The Kaf Word

Forget about being “cancelled” on social media, suspended from work or losing a book deal; when Miriam used a racial slur in Parashat Beha’alotecha, she was punished with leprosy.

I know, the usual interpretation is that she was being punished for speaking lashon hara, true but negative gossip, about Moshe. But let’s be perfectly clear: she used a racial slur.

Miriam referred to Tzipporah, Moshe’s wife, as “that Cushite woman.”  Cush and Midian aren’t the same place.  Midian is in the desert to the east of Mitzrayim; Cush is south, specifically in the general area of today’s Ethiopia.  As a new group of Ethiopian olim arrives in Israel this month, I think of their predecessors who arrived thirty years ago in Mivtza Shlomo (Operation Solomon).  One of them, singing in a vocal group put together by Israeli pop singer Shlomo Gronich (no relation to the operation), shared with the country, “In school, they call me Cushi – but they mean black.”

So did Miriam.  She used a word that makes me cringe, one that today feels to me like the Hebrew equivalent of the n-word – call it the kaf word if you like.  Miriam wasn’t complaining about Tzipporah’s national origin, she was commenting on the color of her skin.  It was the most visible difference between her and the others in the group.  Throughout his writings, especially his later volumes of parsha commentary written between 2007 and his death in 2020, Lord Rabbi Jonathan Sacks repeatedly emphasized that Judaism was a religion of hearing, not seeing.  Seeing, the valuation of beauty over everything, was the defining feature of Greek culture.  When figures in Torah rely on sight rather than hearing, bad things happen, starting with Adam and Chava eating from the fruit of the tree which was “a delight to the eyes,” instead of listening to the command they had been given from Hashem.[i]

The most obvious reason not to label by skin color or general appearance is that the label is frequently wrong, often comically so.  Miriam’s geography was certainly way off, but I see this multiple times a week in the notifications I get from emergency rooms about my patients.  Roughly half the people I care for are from Bhutan.  They speak Nepali and ethnically share cultural elements with both the Tibetan and South Asian cultures.  Yet when they check into the ER, the “Race” or “Ethnicity” field in their demographics might say Chinese, Filipino, Native American, or something completely different than who they are.  They’ve been identified by sight alone, in a way that makes that information less useful than if the field had simply been left empty.

If the problem ended with bad census-taking technique, we could all rest easy.  But to take Rabbi Sacks’ statement a step further, Judaism is more a religion of hearing than seeing, but even more a religion of doing.  Whether the eyes have it or not, visually identifying and labeling people’s race or ethnicity at the door to the ER has real consequences for their health – starting very early in life.

Most of you reading this are not medical professionals, but I’m pretty sure you all know what appendicitis is, and that you also know it’s incredibly painful.  By the time I started my medical training 23 years ago we had already learned that the right way to treat appendicitis in the emergency room is to give pain medication, even before the surgeon comes to examine the patient (turns out surgeons can still tell a “hot appy” from a normal one after the patient has had a slug of morphine).  Yet between 2003 and 2010, it was significantly less likely that a black child with appendicitis would receive the aforementioned “slug of morphine” in an ER than a white child with the same diagnosis[ii].  When adjusted for pain severity, that difference held true; black children with moderate pain were less likely to receive any pain relief, and those with severe pain less likely to receive opiates, than white children with the same degree of pain.

The problem stays the same at the other end of the lifespan.  As people’s kidneys start to falter with age and disease, we monitor how bad things have gotten using a number called the glomerular filtration rate, or GFR.  Now, one can measure the GFR directly, but it’s expensive and tedious, enough so that we usually prefer to use a substitute, calculated GFR called the eGFR (e for Estimated).  We take the patient’s age, weight, and serum creatinine, a measure of a muscle breakdown product that gets cleared by the kidneys at a predictable clip, add a fudge factor of sorts and crunch the numbers together.

For years, we’ve been adjusting that calculation based on race, under an assumption that African Americans have a higher muscle mass, and therefore naturally higher creatinine, than everyone else.  Turns out, however, that when we compare the adjusted eGFR with this “race coefficient” to the measured GFR, it’s simply wrong – and tends to overestimate kidney function in those patients.  They appear to be healthier than they are.  Early in the course of the disease, that means telling someone they’re fine when they aren’t, failing to refer them to specialists soon enough, and keeping them on medications they shouldn’t be taking any longer.  Late in the course of the disease, it means delayed starts to dialysis and delayed listing for transplant[iii].  You can follow the logic from there.

And kidney disease isn’t the only major illness where we see race and jump to wrong conclusions.  About a year and a half ago, I attended a virtual conference where a colleague from Mercer University School of Medicine, Dr. Bonzo Reddick, shared his shock at learning that he, a tall, thin, non-smoking distance runner in his mid-40s who happens to be black, was at greater risk of a heart attack than a white man of the same build who smokes a pack a day.  According to the Framingham equation, being black is apparently more dangerous than smoking – more so, since one cannot decide to quit being black.[iv]

But leave your high horses in the stable for a second.  Because it turns out that many of these race-based calculations are themselves a result of previous reckonings with race in the medical establishment.  For most of our history, scientists made no effort to include black Americans in most studies of disease risk and treatment in the US – and when they did, it was to no one’s advantage (Tuskegee being only the worst example).  In the late 20th century, we began to pay attention to the racial makeup of study populations and attempt to identify differences in risk and responses to treatment so we could tailor treatment to the individual.  Certain blood pressure medicines were to be favored for black patients, different “normal” lab values to be tolerated, different predictive models to be used.  To a well-meaning, compassionate doctor (and of course, we all see ourselves as well-meaning and compassionate), this was a cause we should all take up.

And it was a trap, the same trap Miriam fell into in letting her eyes decide the truth for her instead of looking deeper.  Specifically, it was the trap of assuming that people of similar appearance on the surface are fundamentally, biologically the same under that surface – and fundamentally different from people who do not look that way.  In other words, the trap of assuming that race equals genetics.

In my final year of residency, one of my colleagues gave a presentation on race-based medicine that, in retrospect, was a dozen years ahead of its time.  He put a class composite photo up on the board and asked, “OK, how many of us are Caucasian?”  About half the room raised hands (there were significant numbers of South and East Asian folks in our class, though unfortunately very few of African descent).  “OK, y’all are wrong unless you’re me, Rita or Peter,” he scolded us.  The speaker was from Azerbaijan, the other two from Armenia and Georgia – the actual countries of the Caucasus (or at least the ones that existed at that time).  The rest of the people with hands up were appropriating a term that was originally slapped on all white people by the eugenicists of the early 20th century.

On the next slide was a gallery of 20 celebrities; most of the class misidentified at least a few of the celebs who self-identified as African American, because they didn’t “look it.”  My classmate had made his point – if your eyes are the arbiter of another person’s racial identity, and your eyes can get it wrong so easily on a sample of 20 people, how often will you get it wrong when you see a thousand patients a year?  And what damage will you do as a result?

For that matter, what damage will our current efforts do?  As we push to remove racial descriptions from the first line of a case presentation, will we make the same mistake as people who say, “Oh, I don’t see color” and bury the entire matter?  As we recognize the inaccuracies of racial modifiers in risk modeling, will we discard the whole thing and end up flying blind like we did 60 or 70 years ago?  Every generation deludes itself into thinking it is finally on the right track when everyone else was wrong.  What will they say about us in 20 years?

It’s an easy sin to call out when we use a racial slur to insult people, as Miriam did, or to cast blame, as the Israelites do in the previous chapter when they blame the “riffraff” (or the similarly alliterative asafsuf, in the Hebrew) for causing the disturbance in the camp about the food.  But good people trying hard get race wrong, too.

The answer to Miriam’s poor choice of words comes in the next parsha, Shelakh Lekha, lost after the drama of the spies, in the text that eventually became the final paragraph of the Sh’ma, what we refer to as “parashat tzitzit” – the section of the tzitzit, the ritual fringes meant to remind us of the 613 commandments.  While the tzitzit themselves are meant to be a visual reminder, the text follows the three mentions of tzitzit with an almost opposite command, “Do not go astray after your hearts or after your eyes.”  In other words, don’t let your eyes fool you, but even more so, don’t let your heart fool you either.  Don’t let the best of intentions lead you to make the worst of mistakes – making policy out of something that endangers, rather than enhances, the lives you meant to save.

So what should we do, then?  Listen.  Shma.  Hear the stories of the patients themselves, who will tell you that the differences in outcomes arise not from differences in biology (since the genetic diversity within racial groupings is as great or greater than the differences between those groups) but from radically different life experiences, what we now refer to as “allostatic load” – the sum of poverty, overt discrimination, and subtle ways the system is stacked against them.  Hear the stories of being labeled when they walk in the door (hmmm, sounds very recently familiar), labeled when they get upset at the way they’re being treated, labeled when another well-meaning person calls security, or CYF.  Listen to the data I shared above, that show how poorly our good intentions are working.

Listen to the stories shared at a live, in-the-flesh conference in Portland earlier this year, when Dr. Ben Danielson, a pediatrician who resigned his position at the University of Washington rather than keep quiet about inequalities in his hospital, addressed that very question of what the next generation will think of us in twenty years.  He spoke of a mother from the indigenous population near Seattle who was afraid to speak up after giving birth about a problem she was having for fear of being labeled an unfit parent – and ended up labeled anyway, as being too “stoic” and maybe having post-partum depression, putting her at risk of losing her baby to the system like generations of natives before her.  Listen to this episode of the podcast White Coat, Black Art describing what happens to indigenous patients across the border from Seattle and what some of them are doing about it.[v]

And have some rachmones on poor Miriam.  Pray with Moshe, “El na, r’fa na lah” – “God, please heal her.”  Not just her tzara’at, but her eyes, and ours, so they can see clearly, her heart, and ours, to guide us more soundly – and her ears, and ours, to hear precisely what must be done.  We have all said terrible things in our lives, especially any of us who have lived long enough to witness major changes in which language is acceptable and understand the harms that some words can do.  But we have also all seen people who say all the right things and are quick to call out others who do not, still act in ways that are ultimately damaging and degrading.  On this Juneteenth holiday, let us be thankful that we have come a long way in 157 years, and humbled that we have so far yet to go.  And let us pray we have a Moshe to intercede on our behalf for another chance to try.

[i] Rabbi Jonathan Sacks. “Bereshit: The Art of Listening.” Studies in Spirituality: A Weekly Reading of the Jewish Bible, pp 3-7 among many other mentions.

[ii] Goyal, MK et al.  Racial Disparities in Pain Management of Children With

Appendicitis in Emergency Departments.  JAMA Pediatr.  doi:10.1001/jamapediatrics.2015.1915

[iii] Zelnick, LR et al. Association of the Estimated Glomerular Filtration Rate With vs

Without a Coefficient for Race With Time to Eligibility for Kidney

Transplant.  JAMA Netw Open. 2021 Jan; 4(1): e2034004.

[iv] Plenary Presentation, Society of Teachers of Family Medicine Conference on Medical Education (virtual), February 2, 2021.

[v] White Coat, Black Art, hosted by Dr. Brian Goldman.  CBC Radio, July 18, 2021.

About the Author
Jonathan Weinkle MD, FAAP, FACP is a primary care-physician in a community health center in Pittsburgh. He is not a rabbi, though he has often been accused of being one. He is an amateur singer-songwriter, teaches at both Chatham University and the University of Pittsburgh, and is the author of the book Healing People, Not Patients.
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