Beyond sicko


Because this was happening a short taxi ride from the White House, I half expected someone from Dick Cheney’s office to burst in at any moment, grab the
microphone and proclaim the conference kaput, dissolved like an inconvenient parliament.

“I think this may be the best day of my life,” Dr. Julie Gerberding, the director of the Centers for Disease Control and Prevention (CDC), said at the opening of the 2008 Leaders-to-Leaders Conference she convened last week, along with the country’s state and county public health officials. The agenda: To build a bottom-up coalition to change how America deals with health, to shift our focus from health care to healthiness and to the bigger social factors that determine our national healthiness.

Over two days, I heard so many encouraging ideas from the conference stage that didn’t reflexively demonize public policy-making as nanny-statism that, well, as I said, the whole thing left me looking nervously over my shoulder for political-correctness enforcers from The Cato Institute or The Heritage Foundation.

As one speaker after another pointed out, America today ranks first among industrial nations in terms of how much we spend on health care, but last in terms of how healthy we are as a country. Pick any national metric of healthiness — life expectancy, infant mortality, birth weight, chronic diseases incidence — and America’s comparative performance is in the cellar. It’s true even when you adjust for European populations’ relative homogeneity: if you only count white Americans, we are still the low man on the healthiness totem pole.

We Americans spend more than 90 percent of our health dollars on health care (on doctors, hospitals, insurance, machines, pharmaceuticals and the like), but it turns out that only 10 percent of how healthy we are as a nation is determined by what those health care dollars buy.

How can that be? What could possibly determine whether America is among the industrial world’s healthiest nations, if not the thing we’re all clamoring for: universal heath insurance? The answer — and this isn’t a political opinion, it’s an epidemiological finding — lies in the social determinants of our physical condition. Determinants like income, class, education, racism, the availability of public transportation, land-use policy, environmental policy, participation in the political process and a host of other factors that don’t depend on our genetic makeup or our propensity to take personal responsibility for diet and exercise. Determinants that flow not from luck or individual choices, but from laws, regulations and priorities set at all levels of government and in the private sector as well. (If you want an alarming eyeful about this, check out the new California Newsreel documentary “Unnatural Causes.”)

The way we currently think about health in America — about health care, that is — is completely understandable. We all want access to the best possible health care for our parents, our kids and ourselves, and we want it to be affordable, and we want plenty of choices. What’s astonishing is that even if we covered all the uninsured’s health care, we would still likely rank at the bottom of industrial countries for healthiness. The major causes of our country’s healthiness or unhealthiness are all upstream of the things that send us to doctors and hospitals and pharmacies. The causes are poverty, and stress, and the amount of control and autonomy we have at our jobs, and whether there are showers there, and what they put in the vending machines. The causes are access to early childhood education, and to day care, and whether schools are built near asthma-breeding freeways. They are whether your neighborhood offers public libraries and public transportation and walking trails, or public dumps and liquor stores and fast food franchises.

“I had a colonoscopy the other week,” the CDC’s Dr. Gerberding told the 400 public health officials, business leaders and nonprofits she was hoping would sign on to a “healthiest nation alliance.” “Actually,” she added, “I was billed for two colonoscopies, though I’m sure I only had one.”

Clearly she’s not unaware of the madness of our present health care system. No one facing a family medical crisis wants anything but the best possible treatment at that moment. No one should lack access to quality health care. But prevention is even more important to the country as a whole than treatment is, and the free market alone hasn’t and won’t deliver the level of prevention we need.

To me, the underlying reason America has fallen so far behind in the healthiest nation race is the exhausted dogmas that have dominated public discourse for something like 30 years — Horatio Algerism, social Darwinism, the magic of the marketplace, deregulation is good, government is bad, pull yourself up by your own bootstraps and devil take the hindmost.

We now know what America looks like when those kinds of ideas rule, and not only in the health sector. I’m glad that, at long last, public officials are finding their voice to express politically transgressive thoughts, like the idea that income inequity and racism are bad for America’s healthiness.

I just hope that the Ayn Rand Society doesn’t get on their case.

Marty Kaplan is director of the USC Annenberg School’s Norman Lear Center, where some work is supported by the CDC. His column appears weekly in this space. He can be reached at martyk@jewishjournal.com.

Wanted: someone to help suffering Jews


One day, Rabbi Barbara Speyer went to a Los Angeles-area nursing home to provide emergency chaplaincy services — spiritual comfort and care — to a dying patient. When she arrived, the administrator said to her, “Why do you guys charge for this? This should be voluntary!”
 
Speyer was not on staff with the facility, and her schedule is more than full. She works full time as a chaplain at the Veteran’s Administration Hospital and serves on the Red Cross Disaster Team. She is also a community chaplain with the Board of Rabbis of Southern California, which is the hat she was wearing when she went that day to the nursing home.
 
“When your dishwasher breaks, don’t you call a plumber?” Speyer responded to the administrator. She had driven out to the Valley in Friday morning traffic for a fee that would barely cover the cost of her mileage, and she couldn’t believe the administrator’s attitude, although it was one she had encountered many, many times before.
 
“Why is spiritual counseling something you should give for free?” she said recently. “People feel as Jews, we’re supposed to care for one another. But we have multiple needs in the community, and people do not understand what is involved in maintaining and sustaining a Jewish community.”
 
Indeed, the Jewish community has many needs that require funding, manpower and programming, and they are often called “crises”: There is the Israel crisis, the intermarriage crisis and the disengaged youth crisis.
 

But the one crisis hardly spoken of is the aging crisis: Some 23 percent of the Jewish population nationally is older than 60, compared to 16 percent in the general population, according to the National Jewish Population Survey 2000-2001. In Los Angeles, between 1979 and 1997, (the last survey of Los Angeles’ Jewish population), for example, the number of Jews older than 65 grew from 11.1 percent to 20.4 percent. Put simply, the Jewish community is aging rapidly — and not necessarily healthfully, as medical advances in areas such as chemotherapy and kidney dialysis prolong life spans, while also sometimes adding extra years spent in hospitals, nursing homes, under medical treatment.
 
Who will provide spiritual care for the needy?
 
The crisis, for those involved, like Speyer, who is past president of the National Association of Jewish Chaplains, is not merely physical care — Medicare is a benefit afforded these people — her concern is the huge gap in provisions for another very important kind of sustenance.
 
“There is very little spiritual care being ministered to those who are in need,” she said. “I mean, we all need spiritual care. We have a large society of the elderly who spend their time alone,” either at home or in nursing homes and often not affiliated with any synagogues or religious organizations. “No one is attending to the needs of these people.”
 
“People are becoming more aware that there is more than just the curing process. There’s also the healing process that must go on with a patient and his or her family,” said Cecile Asikoff, national coordinator of the association, the umbrella organization for national and international professional Jewish chaplains, totaling some 300 members. A chaplain is a spiritual counselor who provides guidance, comfort and care to people in institutions — hospitals, nursing homes, prison and the military, and the National Association of Jewish Chaplains sets standards and can qualify Jewish chaplains.

“An important element in the healing process is the spiritual process. The healing process can be helped by confronting the spiritual issues of, ‘Why me, why now?'” Asikoff said.
Which is where the chaplain comes in — or should come in — to offer spiritual guidance and counseling, to sit with the patient and his or her family.
 
“A person is not just his or her disease any more than he or her eye color. The disease is part of who the person is. Part of the pastoral piece is helping people come to terms with very difficult, life-threatening or life-ending conditions, the piece of transitioning from one place in life to another place in life, the elderly, the transitioning piece of hospice, those are all pastoral pieces that are not outside his or her illness or medical condition,” Asikoff said.
 
In 2002, The Jewish Federation of Greater Los Angeles published a study, “Services to Jews in Institutions,” originally sparked by the United Way’s elimination of a prison chaplaincy program. The 42-page study was divided into two parts: “Jews in Prisons,” and “Jews in Hospitals and Nursing Homes.” Although the first part sparked the study, the second half was what attracted people’s attention.
 
“There is a significant shortage of trained volunteers, chaplains and others to meet the needs of those in hospitals, nursing homes and hospice. Not enough professionals are entering and remaining in these fields,” the study reported.
 
This is something that people like Asikoff and Speyer know very well: Many elderly and sick Jews need spiritual care and are not receiving it. And there are not enough people who can provide it.
 
The concept of chaplaincy originated among the Christians, though, bikur cholim (visiting the sick) is considered one of the most important mitzvahs in the Torah.
 
Historically, members of a Jewish community and rabbis have attended to sick people. But these days, for many of the unaffiliated sick — and even those who are affiliated — a rabbi’s time is often not sufficient to provide real care.
 
Rabbis often serve vast communities and with those communities come myriad other obligations, like weddings, bar mitzvahs, speeches, functions, counseling and fundraising. Often rabbis have time only to visit the terminally ill and even then not on a regular basis.
 
Still, with equal rights for all religions, the demand has been increasing. Many institutions have begun to seek out Jewish, as well as Christian ones, and, of late, Muslim, Buddhists and many other religions. And the requirements are stringent: A professional chaplain today must be board certified, having completed 1,600 hours of clinical pastoral education working at a hospital or institution.

Measure ‘R’ contains curious ‘reform’


On November’s ballot, tucked among the local measures affecting only Los Angeles, is curious Measure R, a plan by the Los Angeles City Council to provide each of the 15 council
members an extra $570,000 in pay, by my own estimate roughly $1.25 million in subsidized health care per person for life and an extra pension windfall per person worth hundreds of thousands of dollars.

Council President Eric Garcetti, as chair of the city Elections Committee, assigned the measure the letter “R” for “reform.” But critics — including retired Department of Neighborhood Empowerment chief Greg Nelson, city ethics commissioner and journalist Bill Boyarsky and the editorial boards of the Los Angeles Daily News and Los Angeles Times — call it something else: a sneaky way to loosen the accountability of our public officials.

And here’s the kicker: The “proof” that purports to demonstrate the measure’s effectiveness? It doesn’t exist.

On the ballot, Measure R will be described by proponents as a law that improves term limits and city ethics rules. Many voters will assume it’s a good idea, since it’s backed by the League of Women Voters and Chamber of Commerce.

In truth, Measure R wipes out the limit of eight years, allowing our existing crop of 15 council members — and all subsequent ones — to stay in office 12 years. (Voters can try ousting them earlier, but the history of such efforts is not encouraging.)

Measure R did not arise from citizens. In fact, polls show that Angelenos oppose efforts to soften term limits. Nor would voters seek to hand each of our current council members an additional $1 million to $2 million in pay and perks.

Only history will tell the tale of how Measure R really came to be. What is known, however, is this: It was proposed in vague outline by the chamber and league on a Friday. The council — which can take months just deciding the color of recycling bins — backed it the following Tuesday.

I’ve seen a lot of self-interested moves by politicians. One was the clever move in 1990 by the City Council, also peddled as “reform,” to forever tie their pay raises to those of Superior Court judges. As a result, every time overworked judges get a pay raise, so do the 15 council members. That’s why they earn $149,000, the highest-paid council members by far in a major U.S. city. (New York City, a far costlier place to live, pays its council members $90,000; San Francisco, another more expensive city in which to live, pays $91,000).

Although Measure R is touted as ethics reform, City Attorney Rocky Delgadillo and Ethics Commissioner Boyarsky — who is also a columnist for The Jewish Journal — have said it actually helps lobbyists cover their tracks.

Los Angeles Area Chamber of Commerce board member Ron Gastelum defended Measure R to me, saying the chamber and league proposed it because “it takes a council member the entire first term to really learn the business of the city,” and council members start running for other offices during their second term.

According to Gastelum, “after closely examining all these factors, we had to conclude that an additional term is needed.”

Except no “examination” happened. In an interview, Gastelum told me that neither the chamber nor league studied the achievements of legislative bodies limited to eight years, vs. those with 12. Moreover, they did not contact other cities or regions, nor did they define what “effectiveness” is.

Over the summer, league past president Cindy O’Connor admitted to the Tarzana Neighborhood Council that the league set up Measure R as “a carrot and stick.”

The carrot, she said, was their claim of an ethics crackdown. The stick, she said, was the unpopular term limits extension which could never pass alone.

Nelson says, “Measure R is really horrifying, because if you are lobbyist and you work on a contingency and don’t get paid until the issue you’re working on is over, you don’t, under this ‘reform,’ have to report that you are lobbying on the issue. So they are invisible! This is what Boyarsky and Delgadillo found unconscionable.”

Boyarsky, who cannot criticize Measure R because he is on the Ethics Commission, has nevertheless voiced extreme displeasure that it arose from backroom dealing and waters down city ethics laws.

“When I found out it eases regulations on lobbyists, I started asking all these questions of our [commission] staff,” he told me. “But that was all I could do. I am prohibited from criticizing ballot measures. My only consolation is I believe it’s going to lose.”

Would the City Council be more effective given 12 years instead of eight?
Nelson, who spent decades as an aide to fiery former Councilman Joel Wachs, says no.

“I realized it didn’t matter how much time council members have in office, the day I got this call from the Los Angeles Times,” he told me. About 15 years ago, before term limits, the newspaper asked Nelson to name the most important things the council had achieved that year.

“I couldn’t think of a single thing to put on a list for them,” he recalls. “The lesson is, given more time, the council is no more effective and no more interested in the big issues. I saw it firsthand.”

Jill Stewart is a syndicated political columnist. Her website is

Visit to Ethiopia Changes His Life


In 2004, John Fishel went to Ethiopia as part of a delegation of American Federation leaders. The experience changed his life.

The president of The Jewish Federation of Greater Los Angeles, along with five members of the UJA Federation of New York, visited shantytowns filled with Ethiopians waiting in squalor for the chance to make aliyah — to immigrate to Israel.

Fishel and the delegation saw families living in one-room, windowless huts without electricity or running water, and, if lucky, eating one meal a day. Looking at the desperate faces of the Falash Mura — Ethiopians who have ties to Jews either through relatives or their own ancestry — Fishel vowed that he would do something.

Africa has long captivated Fishel, who has a degree from the University of Michigan in anthropology. He had visited about 20 African countries, including Nigeria, Liberia and Senegal. However, nothing made as indelible impression on him as that first mission to Ethiopia, which tapped into Fishel’s commitment to Jewish people worldwide.

After that trip, the United Jewish Communities (UJC), the umbrella organization representing 156 federations and 400 independent Jewish organizations across North America, asked Fishel to co-chair a task force to suggest ways federations could help the estimated 15,000 to 20,000 Falash Mura remaining in Ethiopia. Among the group’s recommendations: The UJC should lobby for the acceleration of aliyah and improve health care and other services for the Ethiopian Jews as they wait to immigrate to Israel.

It was partly at Fishel’s instigation that the UJC recently launched Operation Promise, an ambitious campaign that hopes to raise $160 million over the next three years, with $100 million for Ethiopia and $60 million to help Jews in the former Soviet Union. The L.A. Federation has pledged to raise $8.5 million for the campaign over the next three years.

“John has given real leadership to the issue of Ethiopian Jewry,” said Barry Shrage, president of the Combined Jewish Philanthropies of Greater Boston, who earlier this year went to Ethiopia with Fishel and 100 American Jewish federation members. “He’s always been the first one to speak up and stir the conscience of the federation movement.”

On that trip, Fishel’s second to Ethiopia, the federation contingent accompanied nearly 150 Jewish Ethiopian olim, or immigrants, as they made the emotional journey by plane from Addis Ababa, the Ethiopian capital, to Ben Gurion Airport in Israel.

“John is a very compassionate person and was very moved by what he saw,” said Susan Stern, a fellow mission participant and chairman of the board of the UJA Federation of New York.

Fishel intends to stir other consciences as well. At every opportunity, he said, he has brought the issue of Ethiopian Jewry to the attention of Israeli leaders, from midlevel bureaucrats to prime ministers, including Ariel Sharon and Ehud Olmert.

“I see Jewish issues as global in scope,” Fishel said. “I think Jews are all responsible for one another, whether in Ethiopia or Russia or Argentina or in the Jewish state.”–MB

 

Home Pampering Easy as 1, 2, Ahhhhh


No one deserves a spa experience more than you do. Just picture it — warm tubs scented with essential oils, invigorating body scrubs, refreshing botanical blend face masks smoothed on in soothing circular massaging motions and misty showers with luscious gels.

Sound divine? You bet. Millions of people are embracing the spa experience — taking what was formerly an exclusive pleasure of the rich and famous and turning it into a health and wellness phenomenon.

Millions of spa-goers must be on to something. But why limit all that good stuff to the precious times you can book at a spa? Why not have a spa experience whenever you choose?

It’s easier than you think to have sensual and sensational spa experiences in your own home, on your own time.

Create an Inviting Environment for the Senses

“The first step is to create an environment for your spa experience,” said Susan Kirsch, owner of Kirsch Cosmetic Clinic and Spa in Toronto, Canada. “Remember to incorporate all of your senses.”

Since water is an important part of most treatments, the bathroom is a good place to create your home spa, Kirsch said. All it takes is a little imagination.

A really simple way to transform any regular bathroom, she said, is to soften the lights.

“Have a dimmer installed on the light switch,” Kirsch said. “Just dim the lights and light some candles to turn an everyday bathroom into something that looks a bit more special.”

If a warm, bubbling bath is your idea of heaven, consider having a hot tub installed in your backyard, on your deck or inside your house. Currently, more than 5 million households now own a hot tub and by the end of this year, roughly 400,000 Americans are expected to purchase a hot tub for their homes, according to a recent study by the National Spa and Pool Institute in Alexandria, Va.

“Some people think a hot tub is a luxury item. I think it’s a necessity,” Andrea Martone said. “And my husband and daughters feel the same way. It’s much better to relax and de-stress in a hot tub after dinner than to sit in front of the television set. Sometimes we use it together. We light candles and chat. And sometimes I use it by myself — to meditate or just go to another place in my mind.”

Prices on hot tubs, according to the National Spa and Pool Institute, range from between $2,500 to more than $10,000 (plus installation costs). The average price is about $5,500.

Just as certain sounds can unsettle us, other sounds can help us achieve a sense of calm. Kirsch likes to use music that’s soothing and relaxing at her spa and during her at-home spa treatments — “something that’s appropriate for a healing environment,” she said.

She says she often plays the music of singer Enya.

“Choose whatever works for you,” she said.

For Martone, it’s the splashing sounds of water.

“I’ve got little waterfall fountains all over my house,” Martone said. “They bring a sense of calm to whatever room they’re in. My daughter even has one in her room for doing homework.”

Martone is a New York City publicist and co-founder of Spa-Daze, a company that provides professional spa treatments and services for groups of four or more in the setting of your choice — including your home.

Martone also suggests burning essential oils to set a relaxing tone for an at-home spa experience. She recommends using a 50/50 mix of your favorite essential oils and water for a scent that’s noticeable but not overpowering.

“Different scents can help create different moods,” she said. “For example, lavender is very calming to the senses and nice to burn at night before going to sleep. And oils like eucalyptus and peppermint are soothing — especially if you’re ill — and can help you breathe easier.”

Choose Your Products

If you are a spa devotee, you may already be one step closer to recreating your spa experience at home. Many spas sell the products they use in their treatments — facial masks, exfoliates, bath and shower gels, lotions and more. At Kirsch Cosmetic Clinic and Spa, staff members will custom mix body scrubs and other beauty potions for guests. So if you’ve had a particularly divine professional treatment, buy the product to use at home. You can conjure up your fond memory of that experience as relaxation therapy.

When shopping for new products for your home spa, buy in small quantities — especially if you have sensitive skin, said Carrie Pierce of Ecco Bella Botanicals of Wayne, N.J. Ecco Bella, which means “behold beauty” in Italian, is a line of natural, gentle-to-the-skin cosmetics and skin care products that use medicinal-grade essential oils.

“It’s important to have the luxury of trying a new product or scent without making a huge and perhaps costly commitment,” she said.

For that reason, Ecco Bella offers smaller, lower-priced “try me” sizes of their scented bath and shower gels, lotions, parfums and fizz therapy bath marbles.

It’s important to find scents formulated to enhance the experience you’re trying to create in your home spa, Pierce said.

Then revel in them. For example, lemon verbena has a reputation as a mood-lifting, feel-good scent. And vanilla reputedly has an aphrodisiac-like effect on men — “second only to the scent of pumpkin pie,” Pierce said.

“Layering your selected scent by using a gel, lotion — maybe spraying a little parfum on your pillow — is a luxurious way to take care of yourself and to take your spa experience with you,” she said.

Formulate a Plan

Don’t try to do too much all at once, Kirsch advised.

“Remember, your primary goal is to feel relaxed and pampered,” she said.

For a simple and luxurious home spa experience Kirsch recommends the following head-to-toe regime.

You can begin one of two ways — either by covering your head with a towel and lightly steaming your face over a basin filled with boiling water or by gently swabbing your face with a warm, damp towel.

“Your choice,” Kirsch said. “If you want to go the simple route, the warm, damp towel works just fine.”

The next step is to exfoliate — or slough off — dead skin cells.

“The skin has a natural turnover of cells. When you exfoliate, you just help that natural process along,” Kirsch said.

When choosing a product, remember exfoliates generally come in two forms — gel and grain.

“The gel form is less invasive and may be good to start out with,” Kirsch said.

Apply in circular massaging motions with your fingertips. Leave the exfoliate on until it feels tacky and almost dry. Then slough it off with the flat part of your fingers. Rinse with water.

Next, apply a mask in the same circular massaging motions.

“It’s important to choose one that’s formulated for your skin type,” Kirsch said. For example, if your skin is dry, you’ll want to use a hydrating mask.

While the mask does it’s magic, draw a warm bath.

“Put a drop or two of essential oils in the water,” Kirsch said. “Soak for a while in the bath, then exfoliate with a body scrub. Try using a loofah mitt and massage in circular motions.”

Then rinse and be careful getting out of the tub since it will be slippery. Apply a moisturizing body lotion.

It’s important to wait 48 hours after shaving or waxing before using a body scrub and don’t use it on any areas that have cuts or nicks.

Remove your mask by rinsing with lukewarm water. Apply a moisturizer using circular massaging motions — and don’t forget your neck.

Use pumice to smooth away hard or rough spots and calluses on your toes, heels and the bottoms of your feet. Apply a moisturizer.

“Give your regular moisturizer an enriching boost by breaking open a Vitamin E capsule and mixing it into the lotion,” Kirsch said.

The final step in your at home spa experience, Kirsch said, is to climb into your bed, nestle under the comfy covers and listen to music for a while.

“You should feel totally rejuvenated and stress free,” she said.

And if for some reason you don’t, you can try again — and again — until you get the hang of it. In this case, there’s absolutely no harm in trying.

“These lovely things you can do at home for yourself can really elevate the quality of your life,” Pierce said. “They can make a woman feel sexy, cherished, valued, calm and better able to cope. They allow you to embrace yourself.”

Beth Gilbert is a New York-based writer.

Passion to Help Sick Spawns Wider Effort


When Lori Marx-Rubiner underwent a bilateral mastectomy two years ago, she lost the use of her arms for a few weeks. She couldn’t brush her teeth, let alone tackle cooking dinner or driving her son to school.

The Adat Ari El community came to her rescue, bringing approximately 60 meals and even transporting her son home from school. She said the help made what could have been a depressing experience into a “transformative” one.

“My passion became to help others through their illnesses,” Marx-Rubiner explained.

That passion culminated Oct. 24 at a conference she helped organize to train people on how to help the ill and disadvantaged. Hope Abandoned, Hope Redeemed: Training Volunteers for the Mitzvah of Bikur Cholim at UCLA Hillel taught 180 volunteers about bikur cholim, or visiting the sick.

Many local synagogues and Jewish organizations focus on one positive commandment, usually something that involves tikkun olam, healing the world in Hebrew. So why healing the sick and why now?

“There is a significant shortage of trained volunteers, chaplains and others to meet the needs of those in hospitals, nursing homes and hospices,” according to a 2002 survey of all the hospitals, nursing homes, assisted-living facilities and prisons in Southern California.

At least 20 percent of the Jewish community is over the age of 65, 10 percent live in residential care facilities and 4 percent have permanent disabilities, according to the study, “Services to Jews in Institutions.” The 108-page report, written by The Jewish Federation’s planning and allocations department and the Southern California Board of Rabbis, spurred the organizations to create the conference.

Bikur cholim is first alluded to in the Bible when Abraham has a circumcision and three men visit him. Commentators say that the men are actually angels to help him through his convalescence.

While there are other communal organizations that assist sick people — like conference co-sponsors Chai Lifeline, which provides services to families with children who have chronic illnesses, and the already existing Bikur Cholim, which helps provide health services to sick people — this is the first interdenominational, communitywide effort to recruit volunteers for the Bikur Cholim. The conference aimed to show that the mitzvah is a grass-roots affair, which involves all members of the community, young and old alike.

Sponsored by 14 community organizations, the conference expanded the traditional definition of visiting the sick in hospitals to include caring for people with disabilities, chronic or mental illnesses, the elderly and those living alone, as well as drug addicts and prison inmates. The “Institutions” study found that there are approximately 800 Los Angeles Jews in prisons throughout California.

“A lot of people think that the mitzvah of visiting the sick is a mitzvah that is incumbent on rabbis and chaplains,” said Michelle Wolf, assistant director of planning and allocations for The Federation, who organized the conference with Marx-Rubiner. “But it’s a mitzvah that is incumbent on all Jews, the same as giving tzedakah [charitable giving], but it is one that a lot of people don’t usually do and don’t feel comfortable with.”

The conference also kicked off Circles of Support, an initiative to create synagogue committees to coordinate with the sick and help them with their needs, ranging from meals to child care to helping out in the house.

“Some patients are embarrassed to come forth and seek help — some chaplains told us that some people don’t want their congregational rabbi contacted,” Wolf said. “Part of what we are trying to do is create a climate where it is OK to say you are sick and to have a healing process. There is a Jewish tradition that says that every visitor takes a away 1/60 of a person’s illness, and there all kinds of studies that have shown the more community and spiritual support you have, the easier the healing process.”

So far, five synagogues have started Circles of Support. They are Adat Ari El, Beth Chayim Chadashim, Beth Shir Sholom, Leo Baeck and the Malibu Jewish Center and Synagogue.

The 20 sessions at Sunday’s conference focused on aiding volunteers to be strong enough to help the sick.

“To be able to very warmly and graciously open ourselves up to patients takes time and practice,” said Susan Corwin, Mitzvah Corps chair at University Synagogue. She attended the conference to find how to inspire and reinvigorate the volunteers of University’s bikur cholim committee, which was started this summer.

“One of the first congregants I went to visit said, ‘Who are you?’ and I said, ‘I am here representing University Synagogue, and I am here because we care about you,'” Corwin said.

“Where’s the rabbi?” the patient responded.

When Corwin explained she was a member of the congregation and had brought a gift bag, the patient softened.

At the conference, Corwin learned that a volunteer should be sensitive to the patient. She said she was particularly moved by a “creating rituals” activity in the workshop, in which leader Harriet Rosen held a ball of yarn, then asked participants to think of a thought or blessing for bikur cholim. Rosen then threw the ball to them while keeping hold of a strand of yarn. Eventually the yarn formed a web across the room of all the thoughts and blessings.

“I learned that when you walk into a room doing bikur cholim, you are not just walking into the hospital room of the patient, but to the web of relationships that the patient has and that you have,” Corwin said. “The impact is so different on each one of us, and the blueprint to help the patients is inside of all of us.”

For more information on bikur cholim or how a synagogue can form a Circle of Support, call (323) 761-8348.

Community Braces for Flu Shot Scarcity


 

Michael Gabai is on a quest.

The owner and administrator of Ayres Residential Care Home has spent the last two weeks calling physicians, senior centers, grocery stores and pharmacies in search of flu shots for about half of the 18 residents in his facilities who have been unable to get one. Gabai was finally able to secure a reservation for his oldest resident, a 96-year-old, to get vaccinated at a grocery store about 10 miles away.

“We’re scrambling to get it done, Gabai said. “We know how easily [flu] can turn into pneumonia for our elderly clients.”

With the flu vaccine shortage becoming a national — and political — crisis, people working with seniors, like Gabai, are the most troubled.

“Flu is always a concern,” said Molly Forrest, director of the Los Angeles Jewish Home for the Aging (JHA). Vaccinations are normally given to all of JHA’s residents and frontline caregivers willing to be inoculated, she said. However, JHA has not yet received its supply of vaccines from the Los Angeles County Department of Health Services, which has promised to deliver them late this month or early in November. Flu season generally spans from November to March, and affects between 10 percent to 20 percent of Americans.

During the 2003-2004 flu season, there were 1,600 deaths from influenza and pneumonia in Los Angeles County, according to the Center for Disease Control. Also, over the last five years, nearly 90 percent of all deaths from flu andpneumonia were among those 65 or older.

Forrest believes they will get adequate amounts of vaccine to cover the residents, but thinks they might need to seek additional doses for frontline staff.

During her nine-year tenure, Forrest said that JHA had not experienced any serious flu outbreaks. When cases have arisen, they have isolated individual buildings or patients in order to contain the spread of the disease.

Jewish Family Service’s (JFS) Valley Storefront and West Hollywood Senior Center had to cancel scheduled flu shot clinics when the Red Cross failed to deliver vaccines as promised, said Lisa Brooks, one of the agency’s directors.

“We’re waiting to see if more supplies become available,” she said. Directors of JFS’s senior centers are in close contact with sources of the vaccine to find out when that might be.

Additional flu shots might soon be forthcoming from drug manufacturer Aventis Pasteur. The majority of its 22.4 million doses, which were promised but not yet shipped to customers, will be routed to entities designated by the Centers for Disease Control and Prevention (CDC) as priorities. In addition to seniors, those considered most at-risk of developing potentially life-threatening complications from the flu include children under 2 years old (the vaccine is not recommended for babies younger than 6 months old), individuals with chronic medical conditions and pregnant women. According to United Press International, CDC Director Dr. Julie Gerberding said the agency is mapping areas where the vaccine has been sent and those where it is needed and also tracking flu cases by county to quickly identify flu hot spots.

The flu shot shortage does not seem to trouble early childhood educators.

“I don’t think at this time anyone is particularly panicking,” said Betty Zeisl, director of public relations and communications for the Bureau of Jewish Education (BJE), who noted that at a meeting of early childhood center directors last week “the subject didn’t come up.” (While BJE facilities must conform to federal, state and local guidelines, protocols for dealing with illness are determined by each individual center.)

“I don’t think [the shortage] is going to affect us,” said Angie Bass, director of the early childhood center at Temple Beth Am, who believes that sensationalized media reports are needlessly scaring parents. Bass said that the school maintains routine health precautions such as undergoing regular cleaning, a hand-washing policy for staff and students and a practice of sending children home if they need to wipe their noses more than three times in a 15-minute period.

Bass said that “if it really looked like a real epidemic and not just media hype,” she would send home a letter informing parents and include advice from pediatricians. Thus far, however, none of the pediatricians she has consulted have expressed concern.

“As soon as the pediatricians are worried, then I’ll worry,” she said.

“I think it is a potential problem,” said Dr. Carol Berkowitz, professor of clinical pediatrics at Harbor-UCLA Medical Center in Torrance and president of the American Academy of Pediatrics. “We never know how serious a flu season we will have.”

At the same time, she said that last year was the first year that vaccination was suggested for healthy children between 6 and 24 months.

“Flu vaccine has never been recommended for healthy children over the age of 2 years,” she added.

Berkowitz and others emphasize the importance of following CDC recommendations to help prevent flu. These include avoiding close contact with people who are sick, staying home from work or school if you are sick, covering your mouth and nose with a tissue when coughing or sneezing, avoiding touching your eyes, nose or mouth and washing your hands frequently. Certain prescription antiviral medications (oseltamivir, rimantadine and amantadine) can either prevent the flu or lessen its symptoms if taken promptly after exposure to the virus — or soon after symptoms begin. Symptoms may include fever, headache, chills, body aches, dry cough, stuffy nose and sore throat.

Unfortunately, even if individuals take precautions, they cannot control the habits of others. As the JHA’s Forrest notes, this is especially true for the most vulnerable populations.

“The very young and very old, who get help from other people, are incredibly at risk because they depend on someone else’s hygiene,” she said.

 

Israel Has Rx for U.S. Health Care


Israel and the United States each have successes and failures in their respective health care systems, but the younger of the modern nations, rooted in its tradition of helping the needy, has much to teach its American ally. When it comes to some of the most important issues facing the American health care system today — universal health care, administrative costs and establishing a national health basket of services — America can look to Israel.

Until 1995, health insurance in Israel was voluntary, although 99 percent of the Jewish population and 97 percent of the Arab population were covered by four HMOs, the first of which was established at the end of 1911. This was a system wherein the insured members paid the HMO, and the employer made a compulsory payment to the National Insurance Institute.

Today in Israel, everyone is covered by health insurance. In 1994, the Israeli parliament passed a groundbreaking health insurance bill that made every Israeli resident automatically insured, no matter their age, financial status or religion. In the United States today, more than 43 million people, including 12 million children, are uninsured.

Israel’s universal health care is characterized by its "national health care basket," which defines the range of services to which every resident is equally entitled. Residents can petition a labor court if they believe an HMO has ignored their rights to a medical service.

Universal access to Israel’s national health care basket means that there is no underinsurance in Israel, which happens when there are gaps in coverage. In the United States, more than 100 million citizens are underinsured — including 40 million with Medicare, 50 million with Medicaid and at least 10 million who are employed in large companies that have self-insurance.

The main health care delivery system for all Israelis is through primary and secondary clinics. These clinics, which are present throughout the country, provide easy and efficient access to care.

The clinics that belong to the HMOs enable quick access to primary medical care and also easy referral to specialists without waiting lists. There is continuity of care, while there is now a tremendous effort to computerize all the medical data.

Ninety-five percent of general care hospitals in Israel are public. There is no wait for diagnostic examinations such as MRI and CT or for procedures such as open-heart surgery. Payment for hospitalization is the responsibility of the HMO, and there is no deductible or co-insurance payment required of the patient.

There is a $3 co-payment for each prescription on the approved drug list covering acute and chronic diseases.

High unemployment and the Israeli economic recession make it difficult for about 10 percent of the population to pay even this, even though there is a $50 biannual co-payment cap.

Caring for the elderly is a core social policy and an integral part of health care in Israel. While in the United States geriatric care is handled by Medicare, in Israel it is part of the health basket and is the responsibility of the HMOs.

Only hospitalization in nursing homes is the responsibility of the Ministry of Health for those who cannot afford to pay for private insurance or from their own means. Geriatric care, being an integral part of health care in Israel, is of high quality.

I do hope that one of the Israeli government’s priorities in an improved economic situation will be to reflect the nation’s social values by exempting the poorest 5-10 percent of the population from drug co-payments.

Israel’s health indicators for longevity and infant mortality are better than those of the United States. This aspect is not unique to Israel, but many Western countries are better in the various indicators of health than the United States. Yet while Israel spends 8.8 percent of its Gross National Product on caring for the elderly, the United States spends 15 percent of its GNP.

In international comparisons of health care systems, Israel ranks among the top 20 in the world. But, even with its favorable standing, Israel faces many challenges, such as the financial limitations of introducing new technologies and prescription drugs to the health basket and the high taxes Israelis pay. Also of concern are high out-of-pocket expenses for cost sharing and for health care services that are covered only by complementary insurance.

Israel’s health care system, while based on the core value of access for all, is still evolving. The establishment of a "health parliament," a private initiative endorsed by the government, enabled input from ordinary Israelis to help set priorities for the future, including the challenges of limited resources and the growing gap between rich and poor.

Obviously, Israel and the United States differ vastly in size, making full comparisons limited. But with the exception of four large states, Israel is similar in size to most U.S. states. The American health system can be improved only if states take responsibility for health care, or, in the case of the four largest states, if there is regional responsibility within the state.

In 2003, the United States spent at least 30 percent of its national health expenditures on administration, while Israel spent less than 10 percent. The United States could have saved at least $280 billion of the $400 billion spent in administrative expenditures in 2003 to cover the uninsured and to close the gap of the underinsured, strengthening the democratic principles it holds dear.


Professor Mordechai Shani is the director general of Sheba Medical Center at Tel Hashomer, Israel’s largest hospital. He served twice as director general of the Ministry of Health, including 1994, when the Insurance Bill and the Patients Bill of Rights were passed by the Knesset.

Plan Seeks to Cure High Cost of Drugs


In this presidential campaign year, the figure is ubiquitous: One out of four Americans, about 70 million people, do not have health insurance. At the same time, Americans are spending about $100 billion on prescription drugs annually, more than double what was spent in 1990.

For the uninsured, that money comes from either government assistance programs or their own pockets. Los Angeles residents, however, may soon be the beneficiaries of a plan to help close the gap.

Councilman Antonio Villaraigosa has unveiled a proposal called, LA-Rx, that would enable the city to make medications cheaper for residents. The plan calls for a city contractor to purchase drugs at bulk rates from pharmaceutical companies and, in turn, sell them to residents at below retail cost.

Although estimates vary about the exact rate of rise in drug costs, anecdotal evidence suggests that there is a serious problem.

"There is no question that prescription drug costs which consumers are paying are escalating and continue to escalate," said Rabbi Hershy Ten, president of Bikur Cholim, a nonprofit organization dedicated to expanding access to health care for the residents of greater Los Angeles.

Concerned with the implications of prescription drug costs for both the Jewish community and the city at large, Ten met with Villaraigosa and his staff to discuss LA-Rx.

The root causes of the issue are economic. Pharmaceutical manufacturers, who have fought court battles with several state governments over health-care costs, claim that they are simply seeking equitable compensation for their risks: Only a very small percentage of drug research ever culminates in a product reaching the market.

The Pharmaceutical Research and Manufacturers of America (PhRMA), an organization that represents more than 100 major U.S. drug companies, also claims that the vast majority of the increase in public spending on prescription drugs is due to the increasing popularity and effectiveness of those drugs, rather than rising costs.

"Some look at the increasing use of medicines and the shift to newer medicines as problems to be solved, not solutions for patients and contributions to affordable health care," said Alan F. Holmer, PhRMA president, in a speech to his colleagues last year.

However, many local governments, health-care providers and ordinary citizens are contesting PhRMA’s position, especially since drug manufacturers expend large sums to advertise their medications.

"In health-care literature, there’s speculation about the dollars spent on marketing vs. true research and development," said Rita Shane, director of pharmacy services at Cedars-Sinai Medical Center. "I monitor [in-patient expenses] on an ongoing basis and deal with the exceedingly high cost of new breakthrough therapies for treatment of patients with severe chronic diseases."

It’s also widely recognized that the pharmaceutical industry enjoys large profit margins, recorded as five and a half times the median of all the industries represented in the Fortune 500 in 2002.

Villaraigosa’s proposal could possibly be the next step in the ongoing battle to reduce drug costs. Several states, including California, Maine and Oregon have already taken advantage of their existing buying power in a variety of ways to coax lower prices from drug makers.

"Many states are responsible for actual delivery of health care to their employees, retirees and Medicaid recipients, [and] they have been pooling their buying power together to negotiate better prices," said Joe Ramallo, Villaraigosa’s communications director.

"No one has yet taken it to the next level, which is what Councilmember Villaraigosa is proposing to do, and use that ability to bulk purchase on behalf of residents as a whole," Ramallo said. "This has been a growing issue of concern to seniors and those who are uninsured."

LA-Rx emerged from a series of town hall meetings on health-care policy sponsored by the Foundation for Consumer and Taxpayer Rights.

The system would work by first enrolling interested Los Angeles residents and establishing the size of the medication buyers pool. Next, the city would contract with an organization called a pharmacy benefit manager (PBM), which would do the negotiating with drug manufacturers.

An open enrollment period would give residents an opportunity to join LA-Rx annually. LA-Rx members would pay an annual fee for administration of the program.

Drug companies, however, would not be forced or coerced to negotiate with the city’s PBM.

"It’s just using market forces, and our understanding is that there are no legal barriers to doing this," Ramallo said. "Drug manufacturers would be foolish not to negotiate if [there is] a pool of 100,000 purchasers, 200,000 purchasers or more. Those are business decisions, and if you don’t do it, your competitor will."

The Jewish community, especially the often-ignored segment of poor, near-poor and elderly Jews in Los Angeles, would stand to benefit from a proposal to cut their drug costs.

The Freda Mohr Center, part of Jewish Family Service, is a nonprofit organization dedicated to aiding a mostly elderly population with health-care issues.

"We see people who [are taking] upwards of 15 to 20 medications," said Nikki Cavalier, center director. "We get a lot of requests for various types of financial assistance … and some of it we can help them with and some of it we can’t."

Cavalier estimated that approximately 80 percent of the center’s clients are Jewish.

Speaking of the prevalence of individuals who cannot afford their medications, Elaine Kau, a center case manager, reported, "I see it on a day-to-day basis. Especially with certain HMOs raising their co-payments and not covering brand-name medications and only covering generics."

"When someone does not take medication that is prescribed by the physician, they are compromising their health," said Ten of Bikur Cholim. "Part of the fiber of the Jewish community is that every life is worth living. That is paramount."

Raising the issue of possible LA-Rx problems, Shane of Cedars-Sinai said, "My concern [is whether] the people administering this benefit [would] end up profiting. Yes, maybe there would be some savings, but it would be hard to know how much of the savings will actually be passed on to the patients."

She added that a local organization might find its work exceedingly difficult "because on a national basis, it is challenging to get [wholesale] pricing on brand-name drugs."

Without accurate nonretail pricing, it would be impossible to know how much money a PBM is saving consumers.

"So my question is," Shane said, "how much additional dollars would be left to the third-party administrator? The purchasing structure of LA-Rx would have to be transparent."

Villaraigosa’s office, however, focused on LA-Rx’s propriety.

"There have been suggestions to regulate PBMs to ensure that they are negotiating on behalf of the pool that they are representing, rather than keeping an unacceptably high level of profit" Ramallo said. "We would go to great lengths to ensure that [PBMs are held accountable]."

One way to do that, according to Ramallo, is to form a nonprofit PBM. "That way there’s no advantage whatsoever for the PBM not to negotiate the best rates for its clients," he said. Under Villaraigosa’s plan, a PBM would be selected through a competitive process that would weigh the benefits of for-profit vs. nonprofit administration.

And although it could conceivably help Los Angeles residents, LA-Rx would inevitably face comparison with the Medicare prescription drug benefit approved by Congress for elderly Americans. Beginning in June, Medicare beneficiaries will have access to Medicare-endorsed drug discount cards and in 2006 full benefits become available.

On the surface, LA-Rx appears simpler and more straightforward than the Medicare drug benefit plan.

"There is a doughnut hole in terms of what people are going to get…. People who are on multiple medications are going to exhaust the benefit very easily, and there is a deductible and monthly premium," Shane said of the Medicare drug plan.

She also pointed out the difficulty seniors will have in understanding their complicated, tiered system of benefits under Medicare.

Cavalier echoed Shane’s concerns about both the Medicare plan and LA-Rx when it comes to the elderly.

"I’d be concerned about the complexity, how people are going to find out about it, how people are going to apply for it … [consumers] already seem to be somewhat confused and uncertain, and they come to us and ask us to help," Cavalier said. "We spend a lot time interpreting and helping them apply for the programs that are out there."

To increase awareness and understanding of the LA-Rx plan, it is currently being circulated within various communities. It may soon be put before the City Council.

"[Consumers of medication] right now have no one to speak for them," Ramallo said. "In this program, they will by pooling together and having a single entity negotiate on their behalf."

"This [proposal] will directly impact the Jewish community, as well as every resident in the city of Los Angeles, [and it] is a process that we want to participate in," Ten said. "This is an issue that crosses all boundaries and borders. If there’s any single unifying factor, it’s the health care of our families."

Bill Seeks to Cure Health-Care Plague


“Whoever enlarges on the telling of the deliverance from Egypt, that person is praiseworthy.” These words, included in the Passover seder, which will soon be read by Jews all over the world, remind us that the story of Exodus is meant to be applied to our lives today.

The Bible tells us that Moses and Aaron went to Pharaoh again and again, telling him that God said to let the people go. But Pharaoh’s heart was hardened. He refused to free the Israelites, and God afflicted Egypt with plagues.

After each plague, every one worse than the one before, Pharaoh’s counselors begged him to change his mind. But Pharaoh’s hardened heart interfered with his reason. Even though he brought nothing but calamity on his country, he would not accept the changes that were needed to make the suffering stop.

Today we are beset with a series of health-care plagues, each seeming worse than the one before. The number of Californians without health-care insurance coverage hovers between 6 million and 7 million people — that’s about one in five of us. About 85 percent of those people are working in jobs where health care is not provided. Nationwide, health-care costs are the second largest cause of personal bankruptcy.

For those people who do have health-care coverage, premiums, co-pays and out-pocket-expenses due to lack of adequate coverage are out of control. There is an over-reliance on emergency-room care by the uninsured, as well as the underinsured, who often wait so long to seek care, their once-treatable chronic condition has worsened.

Treatable high blood pressure leads to strokes; diabetics discover their condition only after a coma. This results in pain for the patients and their families, and, since emergency-room treatment is much more expensive than preventive care, there is an increased burden on California’s health-care budget.

Hospitals, doctors and clinics are passing on the costs of treating patients who cannot pay their bills to those patients who are insured. Insurance companies drive up the costs of premiums for hospitals and cut back on reimbursements. In some cases, hospitals are seriously considering shutting down.

Jewish tradition is clear about the importance of health care as a shared social concern. Maimonides put health care first on his list of the 10 most important communal services that a city had to offer to its residents.

As Conservative Rabbi Elliot Dorff reminds us in his teachings, Jewish tradition says that it is a positive commandment to save the life of a person in danger from illness, as it falls under the general obligation of saving life: “Thou shalt not stand idly by the blood of your fellow,” (Leviticus 19:16).

So great is the mitzvah of saving life that Jews are directed to violate the Sabbath to fulfill it. The Shulchan Arucha calls for communities to take financial responsibility for those unable to pay for health care themselves.

In 1976, the Reform movement’s Central Congress of American Rabbis adopted a resolution, affirmed in 1991, in favor of “universal access to health care benefits, including access to primary and acute health care, immunization services, early diagnostic and treatment programs, provider and consumer education, programs of extended care and rehabilitation, mental health and health and wellness promotion. Such a program should provide for education, training and retraining of health-care workers, as well as just compensation and affirmative action in hiring. An effective plan will provide for cost containment, equitable financing and assure quality of services.”

That resolution could have served as a model for Senate Bill 921, a comprehensive health-care reform bill that I introduced last year, and which, after having passed the state Senate, is now up for consideration by the Assembly.

Senate Bill 921 will put no new burden on the state’s General Fund. In fact, it will save billions of dollars in health-care costs by reducing the 25-27 percent of every California health-care dollar that is now spent on administration to between 3-5 percent.

Senate Bill 921 will save that money by creating a single, streamlined claims and reimbursement system in place of the fractured, hodgepodge of public and private systems we have now. It will replace all of our current inflated premiums, deductibles and co-pays with a single means-based premium that each of us can afford, while covering everyone under the same generous and flexible plan, which includes medical, dental, vision, mental health service and prescription drug coverage. Senate Bill 921 will also provide every Californian with the freedom to choose his or her own health-care providers.

Senate Bill 921 also relieves employers of the exclusive responsibility for their employees’ health coverage. Like individuals, businesses will be assessed a means-based premium as their only contribution to this plan. Like individuals, businesses will pay what they can afford, and they will find themselves on a level playing field with regard to health-coverage expenses.

They will also find their expenses for workers’ compensation dropping dramatically, because this bill folds the medical portion of workers’ comp into the state insurance plan. This deep reform will save money for employers, while improving actual care for people who are injured.

Senate Bill 921 will provide every Californian with prescription drug coverage, because it mandates the state to buy pharmaceutical drugs and durable medical equipment directly from the companies, in bulk.

In this season, as we approach our time to celebrate the Exodus of the people of Israel from their confinement in Mitzrayim, we have an opportunity to reflect on the tight spots we find ourselves in today and how we can free ourselves. One of the saddest things about Pharaoh’s hardened heart is that it would not let him see that the compassionate option really was the most sensible option as well.


State Sen. Sheila Kuehl (D-Los Angeles) represents the 23rd Senate District. She and other experts will take part in Zey Gezunt, a panel on health care, SB 921, on March 18 at 7 p.m. at Temple Beth Am, 1039 S. La Cienega Blvd. Los Angeles. The forum is free. For more information, call (310) 441 9084.

My Mikvah Lady


The 21st victim of the heinous bus bombing in Jerusalem last month was Rachel Weitz, 70.

Her name probably flew by most of you. It almost flew by me, too, the first time I heard it on the 9 p.m. Saturday news. When I heard her name the second time that night, on the midnight news flash, I knew. My breath stopped as I ran to the phone book to check if there was any other Rachel Weitz in Jerusalem. There wasn’t.

Rachel Weitz was my beloved mikvah lady, the woman who ran the ritual bath.

Rachel ran the private mikvah in Mattersdorf until several years ago. Almost all the women who used it, except for me and a few others, were ultra-Orthodox. Even after I moved to Efrat, 18 years ago, I would still return there if I happened to be in town too late to get home to the Efrat mikvah, or just because I liked seeing Rachel.

For the 27 years of my married life, I measured all the mikvah ladies I met by Rachel. It was unfair competition. Had Agnon known her, he would have written a story about her, like he did about Tehila. But, of course, he couldn’t have known her like we, the women, did.

When I was a young bride, Rachel made me feel comfortable with this new activity that went along with the wedding ring. She always greeted me with a warm smile and a bit of friendly chatter. Each time I entered her pristine structure, tucked away behind a large Mattersdorf synagogue, I felt like I was parting a veil and entering a sanctum. No matter what insanity was going on in the world outside, it was always safe in Rachel’s mikvah. There, I was home.

As time went on, our family grew, and I loved the experience of returning to Rachel’s mikvah after giving birth, sharing with her the fact that a new child had been born to the tribe of Israel.

Most of the other women who came to Rachel’s mikvah wore thick stockings and either wigs or hats that covered all their hair; some had black stretch snoods pulled over shaved heads, and women even came from the heart of Mea Shearim to use it. I arrived in flowing colored head scarves with my barefoot toes sticking out of my sandals. Rachel didn’t care. She was as loving and caring toward me as she was toward the others, who were a much closer match for her mode of dress and lifestyle.

When I came occasionally after I had moved to Efrat, Rachel always expressed great concern for my safety. When I said goodbye, she would ask me if the road was safe and wished me best of health.

Over the years my scarves and flowered skirts were sometimes replaced by suits, heels and a fashionable hat or styled wig. But Rachel never changed. She remained an anchor of tradition in a shifting world.

Part of that tradition was what happened while the women waited their turn. The women in Rachel’s mikvah all said Tehillim (psalms) while they waited. There was no small talk. They turned inward and prayed for the people of Israel — and perhaps for their husbands and for their children. And if they had no children, perhaps they were praying for themselves.

Rachel had a custom from the old country that few mikvah ladies adhere to nowadays. As a woman emerged from the mikvah, while still on the last step, Rachel would grasp her wet hand, shake it warmly and give her a blessing for joy and good luck, as she helped her step up and out. And even though Rachel watched you dunk and say the blessing while in the water, once she had witnessed the act, she would hold the towel up to hide her own eyes from you as you emerged, offering you a final moment of modest dignity before you swathed yourself in terry cloth.

In the years of our marriage I’ve had occasion to travel, and to visit the luxurious mikvahs of London and of Beverly Hills. I’ve been to the beautiful establishments in Toronto, Cleveland and Queens. But even with their multicolored tiles, carpeting, piped-in music and collections of condiments and coffee for post-immersion pampering, none of those mikvahs were ever as soothing to me as Rachel’s spartan one.

I feel that Rachel’s blessings have accompanied me throughout my married life. She has been a role model to me of chesed, of kindness, of cheerfulness, of what it means to make another person always feel comfortable, special and welcome.

The last time I visited the Mattersdorf mikvah, more than a year ago, they told me that Rachel had retired. But I noticed that the spirit she had brought to the mikvah was still there. Well, I thought, some day I’ll go and visit her at her home, just to say hello and tell her how much I appreciated her all those years. Someday I’ll call her and tell her what’s going on with my children.

After the Aug. 19 bombing, Rachel suffered for four days before she died. This knowledge is almost more than I can bear. This righteous woman — who lovingly clasped the hands of thousands of women, lifting them up and out of the ritual bath, who then sent them forth from her sanctum to go home to their husbands, her blessings ringing in their ears, who should have spent her last years in comfort and joy, basking in the laughter and love of her children and grandchildren — was slaughtered by the epitome of evil. This knowledge is hard for me to live with.

And so is the knowledge that I never found the time to tell her, "Thank you."


Toby Klein Greenwald is a journalist, a community theater writer and director (“Esther and the Secrets in the King’s Court”) and the editor-in-chief of

Promoting Medical Care in Israel


Even when Jews packed medical school classrooms, there were few organizations dedicated to their special concerns. Today, most schools lack active associations for Jewish students. As Carol Ghatan puts it, "The Jewish medical student gets lost sometimes."

Ghatan, both the daughter and the mother of a doctor, is also associate director of the American Physicians Fellowship for Medicine in Israel (APF). This organization, founded by three Jewish doctors in 1950, is now belatedly reaching out to Jewish medical students.

APF is sometimes called "Israel’s best-kept medical secret." Committed to advancing medical education, research and care in Israel, it gives fellowships to Israeli doctors for advanced study in North America, and sends American experts to lecture and teach in Israel. Board member Peter Glazier, son of an APF founder, estimates that over time the group has dispersed $6 million in grants, helping to ensure that Israeli medical care remains world class.

Though APF members prefer to work quietly, they’ve been positively secretive about one aspect of their mission. In close cooperation with the Israeli government, they’ve compiled a registry of American health care professionals willing to travel to Israel in case of national emergency. The APF list emerged in the aftermath of the Yom Kippur War, when American doctors took over for Israeli counterparts pressed into military service. The list has not been reactivated, but APF stayed on high alert during the Gulf War.

New York University medical student Justin Friedman explains why he joined APF: "I decided to become a physician to make a difference in people’s lives…. APF has benefited countless thousands of people by helping [Israeli] physicians obtain a better education, and thus, positively affecting their patients’ care. APF is something everyone should know about, but they don’t. So, I feel compelled to tell them."

California Jews Lobby for Medi-Cal


Nearly 200 Jews descended on Sacramento this week to lobby California’s most powerful politicians to protect major programs that serve the poorest and frailest Jews and other Californians from the budget ax.

Jews from throughout the state, including Los Angeles, San Francisco, San Diego and Orange County, canvassed the state capital Monday, May 19 and Tuesday, May 20 to fight against proposed cuts to Medi-Cal, the state’s health insurance for the poor. They also networked, learned how to become effective advocates for Jewish causes and attended workshops on issues ranging from how to manage the media to the need for Jews to build coalitions.

The mood among participants, against the backdrop of a ballooning state budget shortfall estimated by some at more than $38 billion, appeared less ebullient than in the past.

"In prior years, when the state had a surplus, the discussion was on expanding programs and creating new initiatives," said Esther Netter, executive director of the Zimmer Children’s Museum in Los Angeles. "This year, everyone had a defensive posture, and the mood was more somber."

State Controller Steve Westley warned participants at a breakfast speech that California’s budget problems were even worse than they seem.

Attendance for the two-day mission, which was sponsored by the Jewish Public Affairs Committee (JPAC) of California, the state’s main Jewish lobbying group, was 190 — off by more than 8 percent compared to last year, organizers said. They attributed the drop to holding the event a week before Memorial Day weekend, the poor economy and a belief among some Jews that their voice wouldn’t make a difference.

Still, Cliff Berg, JPAC legislative advocate, said he thought the group’s collective message would get through to legislators because of participants’ commitment to deliver it in person.

"I think the fact that you’re willing to take a couple days off work and come to Sacramento will resonate with [the politicians]," he said. "It shows there are others who feel the same way you do and others behind them."

Gov. Gray Davis has proposed cutting Medi-Cal reimbursements by up to 15 percent to help close the growing state budget deficit. That belt-tightening would save more than $1.4 billion, but would do so at the expense of California’s most vulnerable. Medi-Cal underwrites a slew of programs that cater to a largely Jewish clientele locally, including the Valley Storefront Adult Day Heath Care Center in North Hollywood, and the Multipurpose Senior Services Program (MSSP), which provides indigent elderly with taxi vouchers, home-meal preparation and other services to keep them out of nursing homes.

The Valley Storefront would have to close down, along with an estimated one-quarter of the state’s 307 adult day health-care centers, if the Legislature enacts the suggested cuts. MSSP would shed 110 of its 734 monthly clients and lose one of its two full-time social workers.

"I think it’s immoral to turn our backs on the elderly," said Jessica Toledano, director of government relations for the Jewish Community Relations Committee, a department of The Jewish Federation of Greater Los Angeles. "These programs keep their [seniors’] dignity, and also keep them out of nursing homes, which are far more expensive."

Motivated by Toledano’s and others’ speeches, mission participants made their way to the state capitol where they collectively lobbied 60 legislators or their aides, admonishing them to forego the proposed Medi-Cal cuts. The newly minted lobbyists also asked politicians to support a resolution condemning the Arab League’s revived economic boycott of Israel and to support legislation that would train teachers on the prevention of hate crimes in schools.

It is unclear whether their efforts had much impact.

Assemblyman Leland Yee (D-San Francisco) told a group of five neophyte lobbyists that many Democrats opposed Medi-Cal reductions, but that Republican unwillingness to raise taxes or other fees to balance the budget muddied the picture.

"You need to talk to Republicans about revenue generators," he said.

Even if Medi-Cal cuts pass, mission members deserve credit for fighting a battle on behalf of those who sometimes go unheard, said L.A. attorney Matthew Ross, a former business-affairs executive at CBS.

"We’re up here talking about the poor, immigrants and the elderly, people who don’t often have lobbyists," he said. "We’re their lobbyists. We’re their voices."

To become legislative advocates, mission participants attended a nearly two-hour session in the nuts and bolts of lobbying. JPAC’s Berg told group members to be clear, "stay-on-script," exchange business cards with politicians and, most important, to remain polite, regardless of the reception to their ideas.

"Our broader goal is to build relationships and work on [getting the politicians] to nurture and understand the Jewish community," he said.

Sarah Jaffe, a 19-year-old sophomore at UC Santa Barbara, said participating on the mission gave her a chance to try to create positive change. For her, cutting Medi-Cal is akin to slashing the social safety net that might one day be needed catch her parents — or herself.

"Being a young person and seeing the changes affecting Medi-Cal makes me worry about the future," she said. "Even though I’m not affected now, in a few years, cuts could hurt my parents and, a few years later, me."

Health Care Requires Resuscitation


Eric Moore is frustrated. Within weeks after losing his computer consulting job, the 30-year-old UCLA graduate collapsed from a pulmonary embolism. He has since recovered, but faces a $14,000 hospital bill.

Dr. Alexandra Levine is frustrated. The head of the USC-Norris Cancer Center faces numerous barriers to providing the care she’d like to provide to her patients. One patient required a medication that could be taken at home via injection. Since Medicare doesn’t cover prescription drugs, but will pay if the drug is administered in the hospital, Levine’s 91-year-old patient was forced to make a thrice-weekly trek from the Valley to the center, and each time the tab to Medicare was twice as high as it would have been had the medication been taken at home.

Luis Jiminez is frustrated. The 29-year-old entrepreneur started an online marketing and Web business, which now boasts a staff of 11. But he can’t afford to provide health insurance for his employees.

"We have a continuing crisis in this country of millions of Americans without health insurance, and that’s just plain wrong," said Rep. Henry Waxman (D-Los Angeles), who will speak Friday, April 25 at Leo Baeck Temple as part of a series on health care.

In 2001, approximately 41 million Americans — more than 14 percent of the nation’s population — went without health insurance for the entire year, and another 20 to 30 million lacked coverage for part of the year. With health care premiums increasing at about 11 percent a year, big companies are paying a smaller percentage of those premiums, and small businesses are finding they can no longer afford to provide health care at all. These factors, combined with job layoffs resulting from a weakened economy, have left a growing number of people without health insurance.

Meanwhile, health care costs are skyrocketing. In 2000, $1.3 trillion was spent on health care in the United States, a 7 percent increase from the prior year.

According to Rabbi David Saperstein, director of the Religious Action Center of Reform Judaism in Washington, D.C., the average family spends four times as much on health care today as it did in 1980.

"This country has yet to make a decision that every man, woman and child has a human right — a civil right — to health care," said Los Angeles County Supervisor Zev Yaroslavsky, speaking at Leo Baeck Temple last month. While implementing such a decision "may be complicated and expensive," he said, "it’s not as expensive as not doing it — not as expensive financially and not as expensive morally."

Because those without coverage tend to postpone seeing a doctor, preventable conditions become severe illnesses, needlessly harming patients and unnecessarily driving up health care costs. The uninsured also tend to use emergency rooms as their only source for medical treatment, limiting the ability of those facilities to provide more urgent care. And while many believe the majority of uninsured are unemployed, 80 percent of the uninsured come from working families.

In Los Angeles County, one out of every three residents lacks health insurance. More than 80,000 of the uninsured are children. Budget shortfalls spur continued cuts to county health services. Twelve public care centers and four school-based clinics have closed since June 2002, and High Desert Medical Center in Lancaster and Rancho Los Amigos National Rehabilitation Center in Downey are currently targeted for closure. These closures put an added burden on remaining facilities, raising the troubling specter that crucial services will be unavailable when we most need them.

"Whether you live in Bel Air or in Torrance or in Pomona … you have a stake in providing health care to the maximum number of people," Yaroslavsky said. Otherwise, he said, you had better hope "that a mother who has a kid with an ear ache doesn’t come to the ER … and gobble up space … while your heart attack is going on."

For those who consider the predominantly poor, immigrant patients who use county facilities somehow less deserving of care, USC’s Levine had sharp words.

"Who we see at this hospital is you — your mothers, your grandmothers, your great-grandmothers. All of us were immigrants in this country…. And what do these people do? They train every physician in the U.S. Did I learn how to do a spinal tap on you? No I did not. I learned on someone in the county hospital…. We owe them because of our roots and because of what they do for all of us on a daily basis."

As for the national picture, "reform must become a reality because we have no other choice," Saperstein said. "The question no longer is whether there will be health care reform, but what form these changes will take."

A number of proposals are on the table nationally and on the state level. Some aim to expand availability of health care coverage by pooling individuals or small employer groups into large groups. Others seek to expand Medicare, Medicaid and/or the State Children’s Health Insurance Program. Still others propose use of tax credits to help families purchase insurance or tax incentives to encourage employer-sponsored plans and benefits.

Waxman is particularly critical of the Bush administration’s approach to health care.

"The Bush administration is trying to undermine the programs we’ve got, and nowhere is this more obvious than Medicare. They refuse to add a meaningful prescription drug benefit to traditional Medicare…. Instead, they want to use a drug benefit … to force people into private insurance plans or HMOs, where they won’t have guaranteed benefits or assurance that they can see their own doctors."

Saperstein and Yaroslavsky say the way to get effective legislation passed is to make sure lawmakers know health care is a priority for voters. Politicians need to hear from their constituents about this issue, and to know that it drives contributions and votes.

"We have got to raise the political stakes nationally to make provision of health care a priority," Saperstein said.

Rep. Henry Waxman will speak about "The National Crisis in Health Care," on Friday, April 25, at Leo Baeck Temple, 1300 N. Sepulveda Blvd., Los Angeles. Services begin at 8 p.m. For more information, call (310) 476-2861.

Russia’s Jews Rediscover Roots


Lev Entin, a 90-year-old resident of St. Petersburg, has spent the past year relearning something he spent most of his life trying to forget: his Judaism.

Entin’s father was a shochet (ritual slaughterer), and until Entin was 12, he attended a cheder (Jewish school). But after that, Entin, "a product of the Bolshevik Revolution," as he puts it, did not pay attention to his religion.

But in the past year, Entin has reintroduced himself to his tradition by reading books and brochures he receives from his local Hesed welfare center.

"Only this year did I become a Jew again," he said.

Roughly 175,000 Jewish elderly in Russia are now served by the 88 Heseds across the former Soviet Union. These centers, run by the American Jewish Joint Distribution Committee (JDC), account for about one-half of all Jewish social and welfare organizations in the former Soviet Union.

They provide basic services, such as food and health care, to the large numbers of elderly who were impoverished both by the chaos of post-Communist Russia and by last August’s economic collapse. But the Heseds, which mean "charitable deed," also play a role that is just as important in creating a Jewish community for the Russian elderly.

When the JDC began opening Heseds in the former Soviet Union earlier this decade, the organizers were afraid of two things: that the centers would be overwhelmed by requests from non-Jewish clients, and that the centers would lead to an anti-Semitic backlash. None of the fears has come true.

Indeed, in some places Hesed centers serve as a model for similar state-run organizations. In St. Petersburg, for example, Hesed Avraham is among the most successful welfare organizations in the city of 4 million. Last year, Hesed Avraham started a joint project with a local government-funded welfare organization, where one of the Hesed dining rooms is now feeding 100 non-Jewish needy elderly.

The success of the Hesed program has led to some problems. Indeed, in some cities, local authorities ignore the needs of Jewish clients because there are other organizations to take care of them.

"The state sometimes wants to lay its responsibility onto the Heseds. But Jews are citizens of this country just like non-Jews and the state has certain obligations toward them," says Benjamin Haller, director of the JDC’s William Rosenwald Institute for Communal and Welfare Workers in St. Petersburg, which trains Jewish social workers and conducts sociological research of the Jewish elderly in the former Soviet Union.

But there is one aspect of the Hesed activities where the state welfare system cannot help: reconnecting people to their Judaism.

"People are coming to Heseds not only to get a piece of bread. They come to taste the spirit which makes us unique, distinct from other similar organizations. This is the spirit of belonging to the Jewish people," Haller said.

For example, in the city of Tula, some 190 miles south of Moscow, about 50 elderly Jews gathered on a recent Friday night at the Hasdei Neshama center. A concert by a local klezmer band was followed by a Shabbat service and a meal conducted by a Moscow rabbi who comes to the city every weekend.

In St. Petersburg, Hesed Avraham publishes Hesed Shalom, a bimonthly newspaper with a print run of 15,000.

This process of creating a community extends beyond the clients served by the Hesed centers to the volunteers who assist.

Last year, about 7,000 volunteers participated in the provision of welfare and other social services in the centers.

"Any program we run involves people helping other people. Even a bedridden person can call another bedridden [person] so that they will not feel lonely," Haller said.

In most communities, youths and students of Jewish schools occasionally volunteer in some social programs. But the average volunteer is recently retired and is in his early 60s. These people deliver food to the homebound, do home repair or work once or twice a week as hairdressers, shoemakers, electricians. Medical doctors conduct regular free consultations for Jewish elderly in almost every Hesed center.

Despite all the good work they are doing, the future of the Heseds is not entirely rosy. With the ongoing economic crisis and the depreciation of pensions, money is becoming rare, particularly to supply medicines.

The multimillion-dollar annual budget of the Heseds comes from several sources. Most Russian Heseds operate with the money channeled by JDC from funds raised by the joint campaign of the United Jewish Appeal and local federations in the United States. These funds go primarily to support the most fund-consuming part of the Hesed operations — food programs, including monthly and holiday food packages and distribution of hot meals through community dining rooms and meals-on-wheels programs.

While the activities are operated by the JDC in conjunction with local groups, including the Russian Jewish Congress, a majority of the funds for the multimillion-dollar project are provided by the Conference on Jewish Material Claims Against Germany — particularly in Ukraine and Belarus, which were under Nazi rule during World War II.

Most observers say Hesed programs have been the most successful — in their scope and outreach — of all similar projects supported with local and foreign funds.

They appear to be successful for Sofia Shapiro, an 80-year-old retired engineer who receives several services from her local Hesed in Yekaterinburg. The homebound Shapiro and her bedridden blind sister, Vera Brook, have no relatives and a caretaker from Hesed visits them daily. The center also gave Shapiro a walker made by some of the eight staff workers and 39 volunteers who assemble a total of 2,500 wheelchairs, walkers, walking canes and crutches a month at a plant in St. Petersburg.

"There is a sticker here," Shapiro says, pointing at the bottom part of the walker. "It says, ‘Live with Hope.’ So I do."

Planning Ahead Can Save on Health Care


Eva, 74 and a widow, was a healthy and independent woman until she went shopping one day last December and was mugged. She was attacked with a screwdriver and thrown to ground, breaking her shoulder in four places.

"I ended up on the sidewalk, totally helpless," said Eva, who lives in Westwood and prefers to not give her last name. "I went from being very active to being disabled. My recovery was very painful, and I am still not done."

Eva was hospitalized for a month, and when she came home, she found that she needed nursing care and help doing basic tasks around the house, such as bathing and getting dressed.

"A nursing home just didn’t appeal to me," Eva said, and so she found home care. The cost of such care was between $17 and $20 an hour, and Eva needed it at least 16 hours a day for six months.

The cost of her care could have totaled in excess of $55,000 for those six months. However, Eva was able to avoid the expenditure because she had a long-term-care insurance policy that she bought the year before. The premium cost $2,273.

Because elder care can be an enormous drain on an individual’s resources, with nursing homes costing in excess of $100 a day and home care costing even more, planning ahead and buying long-term-care insurance is one way of preventing the costs from being too overwhelming.

For some in the Jewish community, long-term-care insurance — and particularly the home-care policies — can also have a religious significance. They see it as a facet of the mitzvah of Kibud Av V’em (honoring one’s parents), because it allows children to have peace of mind about their aging parents living out their last years with dignity.

In a 1998 article written by Joel Schwartz in the Association of Orthodox Jewish Scientists Newsletter, Schwartz argued that according to Torah, home care is preferable to nursing-home care, because institutionalized living brings with it a certain loss of honor. While some nursing homes are cheery and bright, others may be drab, unfriendly and, in some cases, even detrimental to the health of those who need care.

Government regulations require nursing homes to provide 3.2 hours of care per patient per 24 hours. In some cases, a nursing home might cut corners because it does not hire enough staff to meet the requirement.

In such a scenario, which some experts in the field say is not uncommon, patients who are severely incapacitated will suffer. They said bed-ridden patients might develop bedsores, because they are not turned often enough, and incontinent patients might be diapered to save labor costs.

Few people want their parents to suffer such problems, but many with aging parents have their own families to provide for and do not have the time or resources to take proper care of their parents themselves.

For many people, long-term-care insurance provides the answer to the problem. Although the premiums might appear high — and even seem useless if the person paying them is healthy — they can end up saving people tens of thousand of dollars if the need for long-term care should arise.

Karen Shoff, a Santa Monica gerontologist, insurance agent and author of "There’s No Place Like a Nursing Home: Four Powerful Steps That Will Change Your Life" (Invisible Ink, 2002), believes that planning for one’s physical retirement is as important as planning for one’s financial retirement. Shoff advises people to start planning for their twilight years in their 50s and 60s, so that they will be able to avoid both nursing homes and the costs involved with home care.

Shoff’s plan involves buying a long-term-care policy, appointing a geriatric-care manager who can assist with legal and medical issues and find services, making a living will that spells out how a person wants to be cared for in the event of an illness and finding an ally who will help carry out the plans.

"You can’t wait until the fire’s there, and people are tearing their hair out," she said. "You need to plan ahead logically."

However, there are some who shy away from long-term-care insurance because they see it as unnecessary to pay premiums above and beyond health insurance and Medicare, which they believe will cover most emergencies. Furthermore, many people argue that, depending on the circumstances, nursing homes can provide better service and offer a wider variety of resources than a home care, in addition to having a social setting that might not be available at home.

"There is an understanding in halacha [Jewish law] that sometimes a parent needs to be put in an institution — for example, if the parent has dementia, and the children can’t handle the burden" said Rabbi Elazar Muskin of Young Israel of Century City. "You need to weigh up the circumstances."

Still, others credit their long-term-care insurance and the home care it bought them with peace of mind. "When I took out the policy, my children kept telling me that I was throwing money out the window," Eva said. "But after I was mugged, they were relieved that I had this help, that I was OK and that I was not going to be dependent on them."

Caring Across the Miles


Fifty-eight-year-old Ruth recently took early retirement from her bookkeeping job so that she and her retired husband, Harry, could see more of their children and grandchildren, who are scattered around the country. The two have also been looking forward to doing some traveling overseas.

In the past year, though, Ruth’s mother, who lives alone and is a two-and-a-half-hour drive away, has become increasingly frail and is starting to show signs of forgetfulness. Ruth finds herself worrying about her mother daily and making an increasing number of phone calls and car trips to check on her. Often she ends up staying for the weekend when she visits.

She and Harry have put their travel plans on hold.

Ruth is just one of approximately 7 million Americans involved in the care of an older adult — usually a parent — who lives in a different area, be it an hour’s drive or a plane trip away. The average travel time to reach their relative is four hours.

At the best of times, caregiving involves a certain amount of stress, but often, the anxiety is compounded when there are many miles between the caregiver and care recipient.

Long-distance caregiving can be emotionally and financially draining. Worries about a parent’s physical, mental and emotional health and safety can be overwhelming at times. You may wonder if plans you’ve set up are being implemented properly, or if you’re going to get a call that there’s a crisis.

You may also feel guilty that you can’t be there on a daily basis to see how your parent is doing — which may be quite different from what he or she reports — and provide assistance as needed. You might wonder if you should be making more sacrifices — either moving closer or inviting mom or dad to live with you.

Then there are the financial costs: the many long-distance telephone calls, travel expenses, wear on your car and perhaps the cost of hiring a companion or personal support worker because you can’t be there yourself. If you’re employed, you may have to take time off work to deal with crises; some employers are less sympathetic than others.

Despite these challenges, there are many ways to maintain peace of mind while providing long-distance care:

  • Make it easy for people to get in touch with you. Get an answering machine if you don’t already have one and perhaps a cell phone or pager as well. E-mail may also be advantageous.

  • Set up a regular time to call your parent (many people choose Sunday evenings).

  • Find someone local who can check with your parent daily, either by phone or in person. This could be a reliable neighbor or relative or even a volunteer from a telephone reassurance service.

  • Keep important phone numbers handy: your parent’s neighbors, close friends, family physician, local pharmacy and any home health-care providers. Ensure all of these people also have your name and contact information and encourage them to call you with any concerns. Stay in touch to get their ongoing perspectives on how your parent is doing and don’t forget to express appreciation for their assistance.

  • Shop around for a good long-distance savings plan so you don’t have to be too concerned about the frequency and duration of caregiving-related telephone calls. You might consider getting a private, toll-free number so that friends, neighbors and health-care providers have no reservations about regularly calling you.

  • Maintain a file of key information, such as your parent’s medical conditions and surgical history, medications, medical specialists, banking institutions and other financial contacts, lawyer, clergy and daily or weekly schedule, plus any upcoming appointments. Obtain a local phone directory if possible.

  • If your parent has a chronic illness, obtain information from the appropriate organization (for example, the Parkinson Foundation) to help you understand the disease and get an idea of what to expect in the future.

  • Investigate other available resources in your parent’s community, which might include: personal emergency response systems; letter carrier or utility company alert services; accessible transportation; adult day programs and other leisure programming; outreach services, such as foot care and seniors’ dental clinics; home health services involving nursing, homemaking, therapy and companion services and alternative housing. Such information can be obtained from the local area agency on aging. (To find the appropriate office, call the Administration on Aging’s toll-free Eldercare Locator Service at (800) 677-1116 or search online at www.eldercare.gov.)

When you do have an opportunity to visit, pay close attention to your parent’s physical condition, mental functioning and mood. Consult his or her family doctor if you have any concerns.

Perform a safety assessment of the home environment to identify potential hazards — for example, throw rugs that don’t stay in place — and do what you can to remove them. Visit a medical supply store and check out the many products that might make daily activities easier and safer for your parent. Better yet, locate an occupational therapist who performs home assessments and can make recommendations in this regard.

If you have siblings in the area, arrange a family meeting to discuss your parent’s needs and determine who can provide help.

Ideally, plan to stay with your parent long enough so you’re not rushed. That way, you’ll have ample time not only to attend meetings (try to set these up in advance of your arrival) and run errands but also to enjoy your parent’s company.

Even if he or she appears to be managing well right now, it’s a good idea to begin learning about resources in the community should your parent require help in the future.

Keeping one step ahead will help make your role as long-distance caregiver a little easier.


Lisa M. Petsche is a geriatric social worker and freelance writer.

The Search for an Alzheimer’s Cure


“How do you spell fare?” my father asked.

For a man who had spent a lifetime in business, I was taken aback, but I spelled it for him. He was writing a check for my plane fare to Los Angeles, something he generously undertakes whenever I visit Florida. Today, he looked at his checkbook, then at his register, at the checkbook again, then back at his register in increasing increments of confusion.

Each time I tried to intervene, he grew defensive and angry. By the time he was ready to put pen to paper, he had forgotten what the check was for.

That was two years ago, the last time my father wrote a check. For most people in the beginning stages of Alzheimer’s disease, the simplest task, like writing a check, becomes a Herculean undertaking. The brain can no longer process familiar information or function normally. Alzheimer’s, a brain-wasting disease, is characterized by the spread of sticky plaques (clusters of dead and dying nerve cells) and tangles (clumps of protein fragments) in the brain. This “brain debris” causes delicate nerve cells to atrophy, which in turn prevents the production of neurotransmitters essential for firing up memory and reasoning.

As the disease progresses, an afflicted person will eventually lose more cognitive functions and display decreased physical ability, as well as personality and behavior changes. Communication becomes strained as the person struggles to remember words and thoughts; it is not uncommon for people with Alzheimer’s to withdraw from society altogether, finding themselves unable to communicate, remember or reason.

That’s what happened to my father. Once an outgoing man who played golf every morning of his retired life and bridge every afternoon, he slowly lost his confidence to communicate as his short-term memory deteriorated.

Eventually he stopped playing bridge (in actuality, the men threw him out of the game), but he had already withdrawn, unable to remember the easiest hand. This was a huge blow to my mother, who found herself, for the first time in her married life, the one to take charge. Today my father is totally dependent on her care.

Alzheimer’s disease is the most common cause of dementia. According to the Alzheimer’s Association, one in 10 persons over the age of 65, and nearly half of those over 85, have the disease. Today, 4 million Americans have Alzheimer’s. Unless a cure or prevention is found, that number will jump to 14 million by the middle of the century. In a national survey, 19 million Americans said they have a family member with Alzheimer’s; 37 million know someone who has it. In most cases, a person lives an average of eight years — but up to 20 — after the initial diagnosis.

This disease isn’t cheap. U.S. society spends over $100 billion a year on Alzheimer’s disease. Neither Medicare nor private health insurance covers the long-term care most patients require. According to the Alzheimer’s Association, seven of 10 people with the disease live at home, with 75 percent of the care provided by family and friends. The remainder is covered by paid care, costing an average of $12,500 per year. Families pay almost all of that out of pocket.

Nursing homes report that half of their residents have the disease, where the average care runs to $42,000 a year. On the Alzheimer’s Association’s Web site, a 1998 study concludes the average lifetime cost per patient is $174,000.

In Los Angeles, the costs can soar. At the Jewish Home for the Aging in Reseda, the daily cost per person in the Alzheimer’s dementia unit, a skilled nursing facility, is between $175 to $189 per day. The facility is a secured unit with a small ratio of nurses to patients, and offers daily activities for all levels of the disease; for example, adult education for those who are still relatively high functioning, exercise classes for those still fit.

By next year, the Jewish Home for the Aging will open an entire building dedicated to Alzheimer’s disease. Because a person can have Alzheimer’s and maintain good health, the home does not say what the average lifetime cost per person can be, only that it varies widely: some patients may enter the home in the late stages, others may get the disease in their early 70’s and live to be 100.

Recently, there has been a spate of new research. The two best-known studies have shown great promise for understanding the disease. The Nun Study by University of Kentucky epidemiologist David Snowdon, who recently published “Aging with Grace” (Bantam), looks at nearly 700 nuns, studying lifestyle and environment, to determine a variety of factors that contribute toward the disease. Another is the just completed clinical trial using Nerve Growth Factor (NGF), conducted by UC San Diego (UCSD), in which doctors surgically implanted genetically modified tissue into the brain of a 60-year-old woman at the beginning stages of Alzheimer’s.

Both studies leave scientists and doctors optimistic, yet reluctant to conclude that they are any closer to finding a cure.

The Nun Study, conducted over a 15-year period by Snowdon, studied nuns from the order of the School Sisters of Notre Dame, researching their personal and medical histories, testing for cognitive function, and even dissecting their brains after death. Forty-five percent of the nuns, who are now between the ages of 85 and 106, have fallen prey to the disease.

Scientists know that genes play an important role in Alzheimer’s, but Snowdon chose to focus on environmental and lifestyle factors. He found that an active intellectual life; a college education; a flare for words and a good diet all contributed to prolonging a sharp mind. In one study, he found that the nuns who used complex ideas and positive emotions (in written autobiographies that they submitted upon entering the convent) were the ones with the clearest mental faculties, over the longest period of time. He also researched a finding by a British team that found a low level of folate (a nutrient) in the blood of Alzheimer’s patients. After analyzing dissected brains, Snowdon concluded that folate, or folic acid, helped to counteract the effects of Alzheimer’s-type damage to the brain.

But Snowdon is adamant that not one factor alone causes or saves one from the disease. “Blood circulation, medications, nutrition, genetics — there are many links that factor into dementia,” Snowdon noted on NPR’s “Science Friday” on July 6.

The UCSD clinical trial using NGF, led by UCSD neurologist Mark H. Tuszynski and neurosurgeon Hoi Sang U, is more elusive because it is the first-time gene therapy has been used on a human to treat a disease of the nervous system. According to Tuszynski, director of UCSD’s Center for Neural Repair, it will be months before any results are determined, but to date, “there have been no major adverse events.”

In previous studies, NGF has been shown to be effective in reversing the signs of aging in primate brains. In a study in 1999, the atrophied brain cells of aging monkeys were returned to nearly normal size and quantity following the surgical implant of cells genetically altered by NGF.

In the UCSD procedure, NGF was inserted into a sample of the patient’s skin cells. Over the next few months, the modified cells produced a high quantity of NGF, which was then implanted into the patient’s brain. The procedure targeted an area of the brain important for memory and cognitive function.

“NGF gene therapy is not expected to cure Alzheimer’s disease, but we hope that it might protect and even restore certain brain cells and alleviate some symptoms, such as short-term memory loss, for a period that could last a few years,” Tuszynski said.

The current patient clinical trial is taking place through UCSD Alzheimer’s Disease Research Center (ADRC), one of five centers supported by the National Institute of Aging of the National Institutes of Health. Currently there are 30 ADRCs in the country.

Dr. Leon Thal, head of UCSD’s department of neurosciences, which oversees the clinical trials, believes, like others in the field, that it is important to make an early diagnosis concerning Alzheimer’s. “There are medications to treat Alzheimer’s symptoms — four [cholinesterase inhibitors] are now FDA-approved.” Also every patient “has the right to know what disease he has,” Thal said.

Some patients, however, may not want to know. With clinical trials still in the experimental stage, and any effective medications to prevent Alzheimer’s years away, finding out might be considered a death sentence. But with research spanning the globe, and technological breakthroughs on the horizon, doctors and scientists are sounding more hopeful.

Neurologist Rudolph Tanzi, author of “Decoding Darkness: The Search for the Genetic Causes of Alzheimer’s Disease,” speaking on “Science Friday,” said that in the next five to 10 years, new medications will halt Alzheimer’s-type damage to the brain before symptoms hit.

“Prevention is the name of the game,” he said. These medications, he pointed out, are similar to the protease inhibitors used by AIDS patients, and will target those genetically predisposed to Alzheimer’s disease.

Snowdon, who recently received funding to publicly endow the Nun Study, has stated that there is strong evidence that the tangles and plaques found in Alzheimer’s patients starts decades earlier — another reason to focus on preventive measures to stop the damage to the brain. For now, Snowdon feels confident enough to suggest a few easy lifestyle measures, to stave off memory decline: intellectual activities to stimulate the brain, avoiding head injury and strokes (low-cholesterol diet), eating fruits and vegetables, and using a multivitamin and folic acid supplement.

“This is a family disease,” Snowdon concluded. “It touches everyone.”


The following organizations can be contacted for more information about Alzheimer’s disease.

Alzheimer’s Association is a nonprofit group that supports patients, families and researchers: www.alz.org.

Alzheimer’s Disease Education and Referral Center is a National Institute on Aging service that provides information on the disease and links to a clinical trials database:

www.alzheimers.org.

Eldercare Locator is a government-sponsored service that provides information on resources for older persons: (800) 677-1116.

American Academy of Neurology is a professional association providing information on new clinical practice guidelines for Alzheimer’s:
www.aan.com.

Visiting the Sick


You’d have no trouble finding me in the treatment area of Cedars-Sinai Cancer Center. Even from a distance, mine is the little roomlet that rings with soft laughter and the sound of — well, yes — a party going on.

How dare I have fun during chemotherapy? It’s not that I look forward to seven hours of treatment. But with four of six rounds behind me, I no longer feel I’m heading into an abyss.

I load up my suitcase with fresh flowers, pretzels stuffed with peanut butter (nurses love them), chocolate-covered peanut butter cups (Leslie, my friend from college, loves them), Raisinettes (I love them). As I pack I’m thrilled that the whole day’s dance card is filled. I will not be left alone.

My small room looks just like any other, with a bed, three chairs, a television and videoplayer. But it’s my friends that make the experience one of pleasure and healing.

Yes, you’re right, I’m heading down my favorite river: Denial. I’m letting my friends distract me from the fact that I have lung cancer for which the word "cure" does not exist.

Certainly I know from A to Z what a typical chemo day brings: large doses of anxiety over whether my white-blood-cell count will be high enough to qualify me for treatment, coupled with large doses of Zofran, the high-octane anti-nausea drug that makes Carboplatin and Taxol tolerable. I will sit until past sunset with my portacath plugged like I’m some electric coffee pot into an IV drip filled with poison trying to kill the bad cells without killing me.

But why should I dwell upon such puny details when I know that Diane, a romance writer and swell raconteur, is driving me to my CAT scan? Leslie is bringing lunch. And before Jill, the Cedars art therapist, has a chance to take out her brushes, I will see Cynthia, Susan, Rona, Marilyn, Marika or any number of surprise guests. Soon enough, we’ll be laughing and talking as if I weren’t as bald as a cue ball and the nurse wasn’t monitoring my blood pressure every 15 minutes. Yes, even in chemotherapy a girl can still have fun.

This is not the attitude I started with. My initial bias was to tough it out alone, to attend my own funeral, working grimly through long months of my illness with my trusty laptop; to let one friend sit with me for the long day to watch "Silence of the Lambs."

But even if I didn’t have Chemo Brain incapable of focus, that scenario does not fit me. And it does not adequately fulfill the Jewish principle of bikkur cholim, visiting the sick.

Bikkur cholim is designed as a community effort, a way in which we all, sick and well, face mortality together. The Talmud states that a person who visits the sick removes one-sixtieth of the illness. Either Cynthia could visit me 60 times or 60 people can visit me once, which is what happened during my lung surgery when intensive care was filled to overflowing. It drove my surgeon crazy, but soon I was feeling fine.

I’ve learned that my illness is not mine alone, after all. It has caused my terrified friends and fellows to schedule long-overdue physicals, begin exercising and get chest x-rays. Who knows, maybe I’ll save their lives, just as they, through their visits, are saving mine.

And yes, I do believe that visiting, like prayer, is saving my life. The story is told of Yochanan Ben Zakkai, a great healer. One day Ben Zakkai became ill. He was visited by Rabbi Hanina, who held out his hand. Ben Zakkai took the hand and stood up. Why couldn’t Ben Zakkai stand up by himself? Because a prisoner cannot free himself from prison, notes the Talmud, especially from the prison of fear, which, along with travel and sin, are the three elements that destroy a person’s health.

That’s why, as Rambam explains, every sick person needs visitors, except those suffering intestinal disease (gas embarrasses the patient) or headaches (conversation creates a racket).

I know people can get through chemo alone. I’ve heard about the lawyer with the laptop whose practice never missed a beat. She put no demands on anyone. But she gave no one the privilege of service, either. The rules of visiting are simple: stay upbeat. Avoid morbid gossip about, say, others who just died of lung cancer. Enemies and depressed people stay away.

During chemo no. 4 last month, the conversation rivaled the best soirée in town: it included the wisdom of the Bush administration, the problems of picking a middle school and college, the question of whether women need breasts after child-bearing, the value of Botox injections, memories of an affair with Warren Beatty (not mine), reviews of the best movies and theater shows, and advice on how to get a film produced in Hollywood.

Some of the best times of my life have happened during treatment. Imagine that.

How Can We Stand By ?


With the Days of Awe just behind us, it might do us all good to consider the content of the prayers we collectively uttered. Many were personal prayers for one’s self and loved ones, but many also included prayers for the faceless poor and needy as expressions of our concern for the larger community. These prayers highlight the essence of what it means to be a Jew and reinforce how essential it is to reach outside one’s own neighborhood to assist the larger community of man.

In America, children are suffering without health care coverage. As Jews and human beings, how can we silently stand by? With both state and federal budgets reflecting healthy bottom lines, now is the time to fully fund both education and health coverage for all children. If we don’t do this now, we simply lack the will and not the means.

These issues are intertwined. The lack of funding for medical coverage contributes to school absenteeism.
At the 80-year-old Pediatric & Family Medical Center (PFMC) in downtown Los Angeles, we see this every day.

We recently treated a child at PFMC who had no family medical coverage and suffered permanent hearing loss due to recurrent, untreated ear infections, severely limiting his ability to learn in the classroom.
Children with chronic asthma are treated with home remedies and regularly miss school. Without prescription drug coverage, inhalers are not affordable.

We see developmentally delayed children who do not receive crucial developmental screenings at an early age because they do not see a doctor on a regular basis.

Hundreds of other clinics across the state see the same shameful thing. And with California’s uninsured population growing by nearly 70,000 a month, the problem is not going away any time soon. In this country, we accept the fact that education is a right – not a privilege – for our children. Education, it is argued, establishes a strong foundation for future individual endeavors as well as for society as a whole. Yet health care, amazingly enough, still remains a privilege.

While funding public education is vital, the right to health care cannot be overlooked. Without good health, children cannot benefit from their education. This is an important policy, and it is time to bring this debate into the public forum.

There is absolutely no question that this funding is vital to build a strong future for our children and the country. Unfortunately, our country does not give the health of our children the same priority.

California has been as lax as the federal government in its dedication to the health of our children. During his election campaign, Gov. Gray Davis crusaded for education reform, but his dedication to children’s health care coverage lags far behind. While the governor recently signed legislation making small dents in the needs of our uninsured, a great deal more must be done.

The state’s budget surplus led Davis to cut visitor’s fees to California’s sprawling park system. If he can make it cheaper for children to visit Malibu Creek, there must be a way to make children’s health care coverage affordable and available.

It’s time Davis and the California legislature fully recognize the findings of a recent Field Poll indicating that health care is the voters’ no. 2 concern, and it actually ranks as the top issue among Latinos.

Research from the American Association of Retired People indicates that the number of uninsured children under age 18 increased to 10.7 million in 1997 – or 15.1 percent of all children. How does this lack of coverage impact our young? According to a 1997 National Center for Health Statistics survey, children without health insurance were six times more likely to go without needed medical care, five times more likely to use the emergency room as a regular source of care and four times as likely to have necessary care delayed.

The Children’s Defense Fund indicates that uninsured children are at greater risk for preventable illness. The majority of uninsured children with asthma and one in three uninsured children with recurring ear infections never see a doctor during the year. Many are hospitalized for acute asthma attacks that could have been prevented or suffer permanent hearing loss from untreated ear infections. A report from the state of Florida indicates that uninsured children are 25 percent more likely to miss school.

Researchers have shown that investing in children’s health coverage actually saves taxpayer dollars. One in four uninsured children either uses the hospital emergency room as a regular source of health care – a costly endeavor – or has no regular source of care.

Florida found that when parents were helped to buy coverage for uninsured children, children received health care in doctors’ offices rather than hospital emergency rooms. In 1996, emergency room visits dropped by 70 percent in areas of the state served by the new program, saving the state’s taxpayers and consumers $13 million.

While educating our children remains essential, it is just as essential that we keep the issue of health care coverage for children on the front burner during 2000.

Healthy children are, in the long run, better educated, and our society will undoubtedly benefit from both. The richest nation on earth need not sacrifice health care for education. Surely we can make room in the U.S. budget for both.

Raise your voice for all of America’s children. They deserve no less.

Carl E. Coan is president and chief executive officer of the Pediatric & Family Medical Center.

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