Download Jewish Holidays and Their Associated Medical Risks

J Community Health
DOI 10.1007/s10900-014-9899-6
ORIGINAL PAPER
Jewish Holidays and Their Associated Medical Risks
Jacob Urkin • Sody Naimer
Ó Springer Science+Business Media New York 2014
Abstract Religiosity is inherent in human cultures. Being
different in many aspects, all have rules regarding appropriate behavior and rituals. Celebrations of social events
and of holidays prevail in all major religions. These include
code of dress, prayers, special food and activities which
may have negative health implications. The Jewish religion
is ‘blessed’ with an abundance of holidays each with its
unique health implications. In this paper we provide an
outline of the character of these festivals and possible
medical repercussions on those celebrating them. Observant members of the Jewish religion and teams treating this
population should be knowledgeable of potentially associated risks. Pre-holiday periods should be specifically
targeted for educational and preventive activity in order
diminish injury or morbidity.
Keywords Jewish holidays Medical risks Injuries Prevention
Introduction
Religiosity is inherent in human cultures. Being different in
many aspects, all have rules regarding appropriate behavior
and rituals. Celebrations of social events and of holidays
prevail in all major religions. These include code of dress,
prayers, special food and activities which may have negative health implications. For example, the incidence of
J. Urkin (&) S. Naimer
Division of Community Health, Department of Family Medicine
and Siaal Research Center for Family Practice and Primary Care,
Faculty of Health Sciences, Ben-Gurion University of the Negev,
P.O. Box 653, 84105 Beer-Sheva, Israel
e-mail: [email protected]
acute myocardial infarction increases on Islamic and
Christian high seasons [1, 2]. Christmas and New Years
day involve greater consumption of alcohol with associated
injuries relating to falls as well as the risk of driving under
its influence leading to serious or fatal automobile accidents. We also observe increased death rates from neoplasms, respiratory diseases, endocrine/nutritional/
metabolic diseases and digestive diseases [3]. Muslim
Ramadan is associated with increased risk of duodenal
ulcer and diabetic imbalance [4]. Mass gathering of pilgrims at the Muslim Hajj carry the risk of injuries and
communicable diseases [5]. Even major sporting events
involve alcohol abuse leading to its related risks.
The associated risks with holidays have practical
implications. Observant members of each religion should
be alerted and educated regarding measures that could
alleviate those risks. Pre-holiday periods should be specifically targeted for this activity. Medical staff, emergency
services, police, firefighters and social workers should
prepare themselves for the surplus load of anticipated
morbidity and potential mortality.
In many cultures and religions, holidays are an opportunity for family reunions and traditional events that recur
on a yearly basis. Jewish holidays are of no exception.
Most Jewish festivals commemorate biblical and historic
events dating two to four thousand years ago. Although
many holidays are characterized by happiness and joy,
some are devoted to sincere spiritual self-reflection.
For readers unfamiliar with the Jewish tradition we must
open with explanation of a number of principles which are
worth mentioning. The Jewish calendar day begins with
nightfall and not at midnight. The year is based on a merge of
the lunar and solar calendars. The lunar year lasts 12 months
where every 2–3 years a thirteenth month is added in order to
keep the holidays close to the solar year and thus the holidays
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will be adherent to the same season every year. Namely,
Passover must always fall in the spring, therefore the whole
year falls into place season by season. There is a daily routine
that includes three prayers and blessings that precede or
follow many of the regular activities such as eating, sleeping,
washing etc. Every Sabbath and Holiday (rest days) before
the sunset of their onset, are greeted by a candle lighting
ceremony (at least two), accompanied by the appropriate
blessing. These days are embellished by lengthy extravagant
full course and well planned festive meals. Each is preceded
by the traditional ‘‘Sanctification’’ (Kidush) ceremony which
is the recital of a designated blessing over a cup of wine both
night and day. All participants are expected to taste from the
alcoholic beverage.
The purpose of this article is to summarize the literature
and the authors’ experience regarding health hazards that
are related to Jewish holidays. The paper is arranged
chronologically according to the holidays, starting from the
beginning of the Jewish year. For each holiday, a short
description of the holiday and its characteristics precedes
the description of the involved risks and health hazards.
‘‘Rosh Hashana’’ (New Year)
This is the beginning of the Jewish year in the end of
summer. Rounded shaped foods symbolize the wish to live
another full year. Consuming the cranial aspect of either
fish or lamb symbolizes a good beginning and as we pray to
be ‘‘heads and not tails’’. Consumption of honey and sweet
food address the wish for a sweet year. The holiday is also
the time for reflection and a wish to get cleared-off the last
year’s sins as within 10 days, the fate of each individual is
determined by the almighty. Prayers are accompanied by
blowing a ram’s horn (‘‘shofar’’).
Medical risks that was described in association with
handling live fish, include severe local infection and blood
poisoning by Vibrio vulnificus bacteria that entered open
skin wounds [6]. Many instances of incarcerated fishbones
lodged in the posterior pharynx or esophagus peak around
these festive meals and may have been the source of customizing the traditional East European Jewish cuisine
includes a grounded cooked fish ball (‘‘Gefilte fish’’).
Housewives who tasted this raw murine nutrition became
infested by fish tapeworms of the genus Diphyllobothriasis.
Such an infestation has also been described in women
practicing Scandinavian cuisine and it is called: ‘‘Jewish
and Scandinavian housewife’s disease’’ [7–9]. There is
always the potential of subsequent Vitamin B12 deficiency
anemia in those infected with D. latum and other pseudophyllidean tapeworms. Three cases of botulism from homecanned ‘‘gefilte fish’’ were described [10]. Horn- blowing
may cause emphysema [11]. The extremes of elevated
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intra-abdominal pressure can inflict hemorrhoid expulsion
or exacerbation of previously existent umbilical or inguinal
hernias. Raised intracranial pressure may lead in extreme
cases to hemorrhage and there may even be a threat of
either dissection or outright rupture of an aneurysm if
present. A patient may present with petechiae especially of
the face (eyelids) and neck regions, which may be generated by retching and vomiting. This may be a result of
bulimic overeating or the after effects of an irregular
combination of alcohol and spices, tastes and flavors of
greater magnitude and quality than the gastric mucosa is
accustomed to thus leading to content expulsion.
‘‘Yom Kipurim’’ (Day of Atonement)
This is the holiest day in Jewish life which is devoted to
prayer. It includes special dress and shoes that are not made
of leather. Fasting is preceded and ends by special meals.
Male children younger than 13 years old or females
younger than 12, the sick and weak are exempted from
fasting but not all accept that option.
The health hazards are related mostly to fasting. Headache, dehydration, syncope and ketotic hypoglycemia are
quite common. Patients with type one and type two diabetes mellitus are prone to develop severe metabolic
imbalance including diabetic ketoacidosis if the routine
medication regimen is interrupted [12]. Fasting may provoke premature contractions during gestation and even
labor in women close to term pregnancy [13]. Pancreatitis
secondary to very high-fat meals associated with the day of
Atonement has been described [14]. If patients refrain from
ingesting their regular medication as indicated they run the
risk of exacerbation of chronic conditions such as: breakthrough seizures, uncontrolled hypertension or tachycardia
in those inflicted by atrial fibrillation. Bicycle, skateboard
and roller-blade injuries are 5 times higher compared to
other days of the year as these activities are allowed while
there is no care traffic on the roads [15].
‘‘Sukkot’’ (Tabernacles)
In this holiday all men are commanded to dwell for seven
whole days in temporary shelters with a roof made of fresh
tree branches (‘‘sukkah’’). This tradition mimics the temporary shelters that the Israelites used in their 40 years of
exodus in the desert from slavery in Egypt to become a free
nation in the land of Israel.
Building of the ‘‘sukkah’’ is usually the chore of the
father and boys. Scrap wood is hammered together by nails
(unless the lazy family goes out and purchases a manufactured easily assembled frame). Because this activity is
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recruited by all and not necessarily those dexterous all year
round, this time of the year we observe many injuries from
stepping on nails (foreign body penetration), hitting fingers
by a hammer (mallet finger) or corneal deposition by foreign bodies. Palm leaves have thorny spikes that tend to
break after puncturing the skin. Toxins that are released by
the leaf tips stimulating immediate severe inflammatory
reactions are often mistaken as a localized infection. These
splinters are very painful and at a later phase run the risk of
creating a soft tissue infection or create a full blown
abscess. Lighting candles in the ‘sukkah’ as dictated by
Jewish law in a flammable environment without standard
safety measures exposes many homes to smoke and fire
dangers [15]. Unfortunately, we have experienced the
consequences of unattended flames and two of my patients
succumbed such an event (JU). Therefore all efforts should
be taken to assure that necessary precautions are undertaken to prevent further atrocities.
‘‘Hanukkah’’ (Festival of Lights)
Hanukkah lasts for 8 days. It commemorates the rededication of the Holy Temple at the time of the Maccabean
Revolt against the Greeks, 2,200 years ago. It is observed
by the kindling of the lights of a unique candelabrum that
has nine branches called the ‘‘Menorah’’. There is a tradition to give children coins and tender to buy gifts and
play with spinning tops (dreidels). There is an obligation to
light candles near windows or balconies in particular parts
of the house exposed to the public in order to publicize the
historical ‘MIRACLE’ (of the single candle that remained
lit 8 days long). As above, explicit safety measures should
be employed and fire extinguishers should be available to
defend against the potential dangers of a fire outbreak.
Most of the injuries Hanukkah are related to burns in
children who were carelessly handling lighted candles [15].
Many are related to a game in which colored candles are
held in the horizontal position and the heated wax is
dripped on a surface of paper forming a decorative piece of
art. A related wax foreign body in the eye was described
[16]. A commonly encountered season’s delight of chocolate coins covered by aluminum foil may inadvertently be
swallowed by overzealous children and in one instance has
caused esophageal perforation [14]. Up to about 50 years
ago some families were smelting lead into wooden casts in
order to prepare home-made spinning tops. This practice
caries the risk of lead poisoning.
One of the most popular delicatessen products universally appearing during this holiday are deep fried donuts
representing the miracle occurring with oil. This brings
many children and adults alike to seek ailments for burns
on the soft and hard palates, gingival, tongues and buccal
mucosal surfaces. We assume that the reason for these
injuries is that the fluid cream, jam or caramel at the center
of the pastry tends to heat much quicker than the surrounding baked dough especially when heated in the
microwave oven. Then, without sensing its extreme heat at
the center, the hungry subject will bite into burning hot
fluid.
‘‘Purim’’
Purim commemorates the deliverance of the Jewish people
from destruction that was plotted by Haman in Persia
2,500 years ago. It is characterized by dressing in special
costume disguises and breaking the strict laws of code of
dress. Being happy is compulsory and thus the restrictions of
becoming drunk from alcohol consumption are lifted. It is
stressed that illegal and illicit experimental drugs are strictly
forbidden by Jewish Law. The most serious hazards are
related to the relatively new habit of using firecrackers and
cap guns. The unacceptable noise is traditionally intended to
erase the memory of the wicked Haman who devised the
annihilation of the Jewish people. Finger injuries and eardrum injuries have occurred. Very low safety quality
assurance exists for products imported from the far-east and
we have seen complete packages of caps detonated by
friction in kids’ pockets resulting in local first and second
degree burns. Children’s costume disguises that are not fire
proof can catch fire easily. Severe burns have occurred.
Masks and other costume eyewear worn on Purim can
obscure vision, therefore not only should the alcohol dosed
adults keep away from the wheel, but even children donning
various garments, hats, toy spectacles and scarves should be
deterred from cycling, skating and riding wagons in domains
of transportation. We have observed cases of skin allergy
and eye irritations secondary to the use of color sprays and
face colorings (JU, SN). As some of the strict rules governing children year round are lifted on Purim it is quite
common to observe young school-aged children smoking
cigarettes and drinking alcohol. Injuries from falls of drunk
subjects and hypoglycemia in those who do not consume
enough carbohydrates were described [17]. Many unaccustomed to high concentrations of alcohol reach uncontrollable bouts of emesis that can inflict severe esophageal
hemorrhage as Boerhave syndrome. Likewise, as mentioned, binge alcohol drinking in those licensed to drive run
the risk of serious accidents if they take to the wheel during
intoxication. Meticulous precaution must be taken with
diabetes mellitus patients non adherent to warnings of binge
drinking attempting to perform the obligation of ‘‘drinking
until jolly’’. Especially type I patients are especially in
jeopardy of ketoacidosis especially when ample quantities
of water have not been consumed.
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A traditional food is a cookie filed with a sweet past of
poppy seeds. A case of opioid poisoning by overconsumption of these cookies was described [11]. The use of
fireworks and inflamable disgises result in burns [15].
‘‘Pesach’’ (Passover)
This 7 day holiday commemorates the liberation of the
Jewish people from slavery in ancient Egypt 3,300 years
ago. This is the most important family gathering. Preparation for the holiday includes scrupulous cleaning of the
house. No remains of certain foods, especially cultured
dough or leavened bread (‘‘hametz’’) is allowed. Bread is
replaced by ‘‘Matzo’’ which is made of wetted flower that
is baked immediately after becoming a mixture. Other
foods and medications should be authorized by the rabbinate establishment as ‘‘Kosher for Passover’’.
The time of preparation for Passover, caries special
risks. Parents are busy moving household furniture and
preoccupied by ‘‘spring cleaning’’ every corner. Their
ability to retain full control and observe their toddlers and
young babies is reduced. Cleaning materials are not always
kept locked in safety cupboards. At this time of less
supervision, dangerous substances such as toxic powders
and industrial fluids, pesticides, petrol etc. are all suddenly
exposed and raise the curiosity of youngsters drawn by the
new colors and shapes of containers never positioned at an
accessible level before. Poisoning by cleaning materials
such as acids bases and detergents are far more common
this time of the year [15, 18]. Severe corrosive caustic
mouth and esophageal ulceration may be a result of accidental swallowing of cleaning agents, especially strong
bases that are used to clean stoves. Keeping chemicals in
non-original containers, especially disposable food containers, is exceptionally dangerous and runs the risk of
confusion with food and thus poisoning.
Eating utensils and cooking gear as all other kitchen aids
coming in contact with food are traditionally soaked in
boiling water in very large containers that are heated by
open fire on the streets of the neighborhood. Burns occur in
schoolchildren as result of handling the boiling hot vessels
by unfortunately those often sent to perform this task. The
almost obsessive cleaning that takes place weeks before the
holiday, is associated with musculoskeletal overuse syndromes. Patellar bursitis, tendinitis, muscle strain and lowback pain are common complaints (SN). All primary clinicians are prepared for the long line of housewives
expecting sick leave in this time of year. Preparation of
‘‘Matzo bread’’ by people who are not professional bakers,
is associated with burns and hand trauma as crush injuries
and finger amputation [19]. Consumption of the dry Matzo
bread for seven full days is associated with an increased
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tendency to develop constipation, yet to be elucidated,
since most of the manufacturers use whole flour. An
increase in dietary fiber without increasing fluids may
possibly contribute to this and if so, adopting a diet with
greater fluid content can alleviate this ailment. However,
paradoxically others still report 7 days of diarrhea this
week, such that this is a challenging topic worthy of futures
research. Consumption of calories beyond energy expenditure is common in many of the Jewish holidays but
Passover is probably the most prominent. The risks associated with handling live or raw fish are as were described
in ‘‘Rosh Hashana’’ [6–10]. The ill-effects of excessive
calorie intake and high fat and carbohydrate composition of
the diet contribute to the dreaded epidemic of the metabolic
syndrome which is beyond the scope of this paper. As not
all the medications are approved as ‘‘Kosher for Passover’’,
some patients are reluctant to take certain medications and
thus run the risk of under treatment [20]. Therefore primary
care physicians confronted with patient deterioration
should address the issue of non-compliance.
‘‘Lag BaOmer’’
This is an evening to celebrate historic events from the
time of the rebellion against the Roman Empire
1,800 years ago. It is not followed by a holiday. The tradition is to set bonfire in public areas. Hundreds of thousands of campfires are lit within a couple of hours.
The first day after Passover is the accepted date sending
children all over the place seeking wood. They will spend
the next thirty or so days roaming around, sneaking into
construction sites and lumber yards, climbing trees and
visiting garbage dumps to the same aim. This is a period of
an abundance of injuries from splinters and rusty nails that
penetrate children’s feet. The risk of burns on ‘‘Lag BaOmer’’ evening is obvious [15]. The whole night sky is filled
with smoke in the air, everywhere. This is accompanied by
an increase in the incidence of asthma and exacerbation of
bronchitis [21].
‘‘Shavuot’’ (Feast of Weeks or Pentecost)
‘‘Shavuot’’ commemorates the anniversary of the day when
the holy Bible was given to the Jews. This is also an
agricultural festival celebrating the start of harvesting the
wheat. Traditional food is made of dairy products. Aside
from danger of exposure to milk products by those with
hypersensitivity no specific medical risk is associated with
this. However, consumption of high fat dairy products
means that high cholesterol and food with high fat concentrations are ingested. The custom dictates spending the
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whole night awake learning the scriptures in order to repent
for the historical event that the Israelites were sleeping and
had to be awakened by the Almighty the evening prior to
the deliverance of the tablets. Sleep deprivation as a rule
runs the risk as other stresses to the central nervous system
that may trigger seizures in epileptic patients. In addition,
the alteration of the sleep–wake cycle the following day,
when the individual replenishes the loss of sleep, can
interrupt routine medication ingestion as ‘Yom Kippur’.
This can lead to unnecessary errors of medication omission
from anticoagulation and thyroid agents to contraceptive
pills, each with their associated ill effects.
Death Rate in Jewish Holidays
Some studies have demonstrated that death rate decreases
the week before and during holidays. The death rate is
‘‘corrected’’ by an increasing above average immediately
after the holidays [22]. This suggests a psychosomatic
factor delaying fatal consequences.
Medical Risks that are Shared in All Holidays
The holidays that are mentioned in the Bible are idle days
where working and many chores and duties are forbidden
as in the Sabbath which is celebrated every Saturday.
These include limitations in traveling, forbiddance of setting or extinguishing fire and turning on or off any electronic or electric devices. However, the uses of electric
timers are allowed, as long as they were set before the
holiday.
In order to have hot meals in the holiday, food is kept
warm by putting the pots and food containers on an electric
plate. Hot water for drinking is constantly heated in metal
urn overlying hot trays. These two devices are a common
culprit for burns in children [23, 24]. We’ve witnessed
terrible second degree plantar burns of toddlers after
foolish parents left these appliances on the floor and were
totally surprised that the children entered the forbidden
utility room.
Lighting candles precedes the Sabbath and all the holidays that are mentioned in the bible. That happens again
when the holiday or Sabbath are over. Except of the risk
from open fire, it has been described that the relative risk of
orthodox Jewish children to ingest paraffin lamp oil, is 374
times that of other children [25]. Aspiration of the oil
carries the risk of developing chemical pneumonitis as in
any hydrocarbon ingestion.
The traditional holiday and Sabbath meal includes eating fish. A study on 108 cases of fish bone impaction in the
aero-digestive tract have demonstrated that 50.9 % occurred at home and over the weekends (Sabbath) [26].
‘‘Para-holiday’’ Medical Risks
‘‘Bein-Hazmanim’’ is a period adjacent to a three big
holidays when children are out of schools. ‘‘CHol-Hamoed’’ are similar, 1 week periods that occur in Sukkot and
Passover. These are the periods where families go on
vacation and youngsters experiment physical challenges on
nature hikes, rappelling and water sports. At this time of
the year there is an increase rate of road accidents,
drowning, injuries from fall off cliffs and dehydration or
heat stroke evolving into rhabdomyolysis. These very
unfortunate incidents inflicting completely healthy members of the orthodox Jewish population that miscalculate
the heat intensity and repercussions of long exposure to
physical exertion without sufficient water supplies and
onset of exhaustion. [15–27].
In conclusion, the customs of many Jewish festivals
carry some special or increased medical risks. These
examples relating specifically to Jewish holidays provide a
window into the pitfalls associated with holidays of other
religions and with secular celebrations such as national
holidays and major sporting events. Consciousness and
awareness of these will allow us to indulge in taking necessary precautions and educating the population in order to
reduce these health hazards to a minimum.
Conflict of interest The authors have no conflict of interest to
disclose. No external funding was secured for this study.
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