​People of Japanese Heritage and People of Jewish Heritage

Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Culture Larry Purnell, PhD, RN, FAAN

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Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Overview/Heritage ▪ The term Jewish refers to a people, a culture, and a religion; it is not a race. ▪ The religion is practiced along a wide continuum that ranges from liberal Reform to strict Orthodox. ▪ Instances occur within the ultra-Orthodox communities when individuals cannot make decisions without consulting their rabbis. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Overview/Heritage ▪ A child born from the union of a Jewish father and a non-Jewish mother is recognized as Jewish by those in the Reform movement but not by those in the Orthodox movement. ▪ Over 6 million Jews live throughout the United States. The migration of Jews from Europe began to increase in the mid-1800s because of the fear of religious persecution. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Overview/Heritage ▪ The greatest influx of Jews occurred between 1880 and 1920. ▪ Many came from Russia and Eastern Europe after a wave of pogroms (religious persecutions.) Most families in America today are descendants of these eastern European and Russian immigrants and are referred to as Ashkenazi Jews. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Overview/Heritage ▪ Sephardic Jews, on the other hand, are from Spain, Portugal, the Mediterranean, North Africa, and South and Central America. ▪ A Sabra is a Jew who was born in Israel. ▪ Falasha are black Jews from Ethiopia. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Overview Heritage ▪ In general, this population is well educated. A high percentage has succeeded in professional vocations. ▪ Throughout their history, Jews have placed a major emphasis on education and social justice through social action. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Communication ▪ English is the primary language of Jewish Americans. ▪ Although Hebrew is used for prayers, it is generally not used for conversation. ▪ Many elderly Ashkenazi Jews who immigrated early in the 20th century or who are firstgeneration Americans speak Yiddish, a JudeoGerman dialect. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Communication ▪ Many Yiddish terms have worked their way into English: kvetch (someone who complains a lot); chutzpah (clever audacity); bagel (a circular roll of bread with a hole in the middle); tush, tushie, or tuchus (buttocks); ghetto (a restricted area where certain groups live); klutz (a clumsy person); shlep (drag or carry); kosher (legal or okay); and oy, oy vey (oh my), and veys mir (woe is me). Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Communication ▪ Hebrew is read from right to left, and books are opened from the opposite side compared with English books. ▪ As a way to cope/communicate, Jews frequently use humor, but jokes are considered to be insensitive when they reinforce mainstream stereotypes, such as implying that Jews are cheap or pampered (eg, Jewish American princess). Any jokes that refer to the Holocaust or concentration camps are also inappropriate. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Communication ▪ Modesty especially among the Orthodox is seen in the Orthodox style of dress. ▪ Jews are encouraged not to “show off” or constantly try to impress others. ▪ Hasidic men are not permitted to touch a woman other than their wives. They often keep their hands in their pockets to avoid touch. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Communication ▪ Because women are considered seductive, Hasidic men may not engage in idle talk with them nor look directly at their faces. ▪ Non-Hasidic Jews may be much more informal and may use touch and short spatial distance when communicating. ▪ Jewish time orientation is simultaneously to the past, the present, and the future. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Communication ▪ The Jewish format for names follows the Western tradition. The given name comes first and is followed by the family surname. Only the given name is used with friends and in informal situations. ▪ In more formal situations, the surname is preceded by the appropriate title of Mr., Miss, Ms., Mrs., or Dr. ▪ In ultra-Orthodox circles, children are not Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Family Roles and Organization ▪ Jewish school-age children typically attend Hebrew school at least two afternoons a week after public school throughout the school year. ▪ Children play an active role in most holiday celebrations and services. ▪ Respecting and honoring one’s parents is one of the Ten Commandments. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Family Roles and Organization ▪ In Judaism, the age of majority is 13 years for a boy and 12 for a girl, at which age children are deemed capable of differentiating right from wrong and capable of committing themselves to performing the commandments. Recognition of adulthood occurs during a religious ceremony called a bar or bat mitzvah (son or daughter of the commandment). Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Family Roles and Organization ▪ The goal of the Orthodox family is to live their lives as prescribed by halakhah (Code of Jewish Law), which emphasizes maintaining health, promoting education, and helping others. ▪ Ultra-observant women must physically separate themselves from all men during their menstrual periods and after for 7 days. No man may touch a woman or sit where she sat until she has been to the mikveh, a ritual bath, after her period is over. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Family Roles and Organization ▪ Older people receive respect, especially for the wisdom they have to share. ▪ Honoring one’s parents is a lifelong endeavor and includes maintaining their dignity by feeding, clothing, and sheltering them, even if they suffer from senility. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Family Roles and Organization ▪ The Bible, as interpreted by the Orthodox, prohibits homosexual intercourse; it says nothing specifically about sex between lesbians. ▪ Some of the objections to gay and lesbian lifestyles include the inability of these unions to fulfill the commandment of procreation and the possibility that acting on the recognition of one’s homosexuality could ruin a marriage. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Family Roles and Organization ▪ The liberal movement within Judaism supports legal and social equality for lesbians and gays. ▪ Jews who observe the Sabbath must have off Friday evening and Saturday. They may work on Sundays. ▪ Judaism’s beliefs are congruent with the values of the dominant American society. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Biocultural Ecology ▪ Skin coloring for Ashkenazi Jews ranges from fair skin and blonde hair to darker skin and brunette hair. ▪ Sephardic Jews have slightly darker skin tones and hair coloring. ▪ There are also Jewish groups throughout Africa who are black, most notably the Falasha from Ethiopia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Biocultural Ecology ▪ Genetic risk factors vary based on whether the family immigrated from Ashkenazi or Sephardic areas. ▪ There is a greater incidence of some genetic disorders among Ashkenazi individuals. ▪ Most of these disorders are autosomalrecessive, meaning that both parents carry the affected gene. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Biocultural Ecology ▪ Common genetic, hereditary, and other health conditions of the Jewish population include Tay-Sachs disease, Gaucher’s disease, Canavan’s disease, familial dysautonomia, torsion dystonia, Niemann-Pick disease, Bloom syndrome, Fanconi’s anemia, mucolipidosis IV, lactase deficiency, Werdnig-Hoffmann disease, kaposi sarcoma, Phenylketonuria, ataxia-telangiectasia, metachromatic leukodystrophy, myopia, polycythemia vera, cardiovascular diseases, diabetes mellitus, breast, ovarian, and colorectal cancer, and inflammatory bowel disease. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish High-Risk Health Behaviors ▪ Any substance or act that harms the body is not allowed. This includes smoking, suicide, illegal medications, and permanent tattooing. ▪ Most Jews are health-conscious and practice preventive health care with routine physical, dental, and vision screening. ▪ This is also a well-immunized population. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Nutrition ▪ For Jews who follow the dietary laws, much attention is given to the slaughter, preparation, and consumption of food. ▪ Perhaps the food identified as “Jewish” that receives the most attention is chicken soup, which has frequently been referred to as “Jewish penicillin.” Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Nutrition Common foods include: ▪ Gefilte fish (ground freshwater fish molded into oblong balls and served cold with horseradish) ▪ Challah (braided white bread) ▪ Kugel (noodle pudding) ▪ Blintzes (crepes filled with a sweet cottage cheese) ▪ Chopped liver (served cold) ▪ Hamentashen (a triangular pastry with different types of filling) ▪ Lox (a cold smoked salmon) is served with cream cheese and salad vegetables on a bagel. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Nutrition ▪ Religious laws regarding permissible foods are referred to as kashrut. ▪ The term kosher means “fit to eat.” Foods are divided into those that are considered kosher (permitted or clean) and those considered (forbidden or unclean). ▪ A permitted animal may be rendered treyf if it is not slaughtered, cooked, or served properly. All blood is drained from the animal before eating it. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Nutrition ▪ Milk and meat may not be mixed together in cooking, serving, or eating. ▪ To avoid mixing foods, utensils used to prepare foods and the plates used to serve them are separated, requiring two sets of dishes, pots, and utensils. One set is reserved for milk products and the other for meat. ▪ Because glass is not absorbent, it can be used for either meat or milk products, although religious households still usually have two sets. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Nutrition ▪ Therefore, cheeseburgers, lasagna made with meat, and grated cheese on meatballs and spaghetti is unacceptable. ▪ Milk cannot be used in coffee if served with a meat meal. Nondairy creamers can be used instead, as long as they do not contain sodium caseinate, which is derived from milk. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Nutrition ▪ Some foods are parve (neutral) and may be used with either dairy or meat dishes. These include fish, eggs, anything grown in the soil (vegetables, fruits, coffee, sugar, and spices), and chemically produced goods. ▪ Mammals are considered clean if they meet the requirements for their slaughter and have split (cloven) hooves and chew their cud. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Nutrition ▪ The pig is an example of an animal that does not meet kosher criteria. ▪ Although liberal Jews decide for themselves which dietary laws they will follow, many still avoid pork and pork products out of a sense of tradition and symbolism. ▪ Poultry is acceptable as well as fish if it has both fins and scales. ▪ Nothing that crawls on its belly is allowed, including shellfish, tortoises, and frogs. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Nutrition ▪ In religious homes, meat is prepared for cooking by soaking and salting it to drain all the blood from the flesh. ▪ Broiling is acceptable, especially for liver, because it drains the blood. ▪ One must always wash one’s hands before eating. Religious Jews wash their hands while reciting a prayer. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Nutrition ▪ A U with a circle around it ( U ) is the seal of the Union of Orthodox Jewish Congregations of America and is used on food products to indicate that they are kosher. ▪ A circled K ( K ) and other symbols may also be found on packaging to indicate that a product is kosher. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Nutrition ▪ During the week of Passover, no bread or product with yeast may be eaten. Matzoh (unleavened bread) is eaten instead. Any product that is fermented or that can cause fermentation (souring) may not be eaten. ▪ Rather than attend synagogue, the family conducts the service (seder) around the dinner table during the first two nights and incorporates dinner into a service that includes all participants and retells the story of Moses and the exodus from Egypt. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Nutrition ▪ The Jewish calendar has a number of fast days. The most observed is the holiest day of the year, Yom Kippur (Day of Atonement). ▪ Jews abstain from food and drink as they pray to God for forgiveness for the sins they have committed during the past year. They eat an early dinner on the evening the holiday begins and then fast until after sunset the following day. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Nutrition ▪ Ill people, the elderly, the young, pregnant and nursing women, and the physically incapacitated are absolved from fasting and may need to be reminded of this exception to Jewish law. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck Religious laws regarding permissible foods are referred to as a. Kashrut. b. Halal. c. Kosher. d. Treyf. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: A The religious laws regarding permissible foods are referred to as kashrut. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Pregnancy and Childbearing Practices ▪ Couples who are unable to conceive should try all possible means to have children, including infertility counseling and interventions, including egg and sperm donation. ▪ Orthodox opinion is virtually unanimous in prohibiting artificial insemination when the semen donor is not the woman’s husband. ▪ When all natural attempts have been made, adoption may be pursued. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Pregnancy and Childbearing Practices ▪ Unless pregnancy jeopardizes the life or health of the mother, contraception is not looked on favorably among the ultra-Orthodox. ▪ Condom use is supported, especially when unprotected sexual intercourse poses a medical risk to either spouse. ▪ To the Orthodox, barrier techniques are not acceptable because they interfere with the full mobility of the sperm in its natural course. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Pregnancy and Childbearing Practices ▪ The birth control pill does not result in any permanent sterilization, nor does it prevent semen from traveling its normal route. ▪ Sterilization implies permanence, and Orthodox Jews probably oppose this practice, unless the life of the mother is in danger. ▪ Reform Judaism allows free choice. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Pregnancy and Childbearing Practices ▪ The fetus is not considered a living soul or person until it has been born. ▪ Birth is determined when the head or “greater part” is born. If the physical or mental health of a pregnant woman is endangered by the fetus, all branches of Judaism consider the fetus an aggressor and require an abortion. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Pregnancy and Childbearing Practices ▪ Random abortion is not permitted by the Orthodox branch because the fetus is part of the mother’s body and one must not do harm to one’s body. ▪ Reform Judaism believes that a woman maintains control over her own body and that it is up to her whether to abort a fetus. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Pregnancy and Childbearing Practices ▪ A Hasidic husband may not touch his wife during labor and may choose not to attend the delivery because he is not permitted to view his wife’s genitals. ▪ These behaviors should never be interpreted as insensitivity. ▪ Pain medication during delivery is acceptable. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Pregnancy and Childbearing Practices ▪ For male infants, circumcision, which is both a medical procedure and a religious rite, is performed on the 8th day of life by a mohel, an individual trained in the circumcision procedure, asepsis, and the religious ceremony. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Pregnancy and Childbearing Practices ▪ Although a rabbi is not necessary, it is also possible to have the procedure completed by a physician with a rabbi present to say the blessings. ▪ Attending a brit milah is the only mitzvah for which religious Jews must violate the Sabbath so that the brit can be completed at the proper time. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Death Rituals ▪ Traditional Judaism believes in an afterlife where the soul continues to flourish, although many dispute this interpretation. ▪ A dying person is considered a living person in all respects. ▪ Active euthanasia is forbidden for religious Jews. ▪ Passive euthanasia may be allowed depending on its interpretation. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Death Rituals ▪ Taking one’s own life is prohibited. To the ultrareligious, suicide removes all possibility of repentance. ▪ The dying person should not be left alone. ▪ Any Jew may ask God’s forgiveness for his or her sins; no confessor is needed. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Death Rituals ▪ Some Jews feel solace in saying the Sh’ma in Hebrew or English. This prayer confirms one’s belief in one God. ▪ At the time of death, the nearest relative can gently close the eyes and mouth, and the face is covered with a sheet. ▪ The body is treated with respect and revered for the function it once filled. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Death Rituals ▪ For the ultra-Orthodox, after the body is wrapped, it is briefly placed on the floor with the feet pointing toward the door. ▪ A candle may be placed near the head. However, this does not occur on the Sabbath or holy days. ▪ Autopsy is usually not permitted among religious Jews because it results in desecration of the body. ▪ The body is be interred whole. Allowing an autopsy might also delay the burial. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Death Rituals ▪ Autopsy is allowed if its results would save the life of another patient who is immediately at hand. ▪ Many branches of Judaism currently allow an autopsy if a) it is required by law, b) the deceased person has willed it, or c) it saves the life of another, especially an offspring. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Death Rituals ▪ Cremation is prohibited because it unnaturally speeds the disposal of the dead body. ▪ Embalming is prohibited because it preserves the dead. However, in circumstances when the funeral must be delayed, some embalming may be approved. ▪ Cosmetic restoration for the funeral is discouraged. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Death Rituals ▪ Funerals and burials usually occur within 24 to 48 hours after the death. ▪ The funeral service is directed at honoring the departed by only speaking well of him or her. It is not customary to have flowers either at the funeral or at the cemetery. ▪ The casket should be made of wood with no ornamentation. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Death Rituals ▪ The body may be wrapped only in a shroud to ensure that the body and casket decay at the same rate. ▪ There is no wake or viewing. ▪ The prayer said for the dead, kaddish, is usually not said alone. ▪ After the funeral, mourners are welcomed at the home of the closest relative. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Death Rituals ▪ Outside the front door is water to wash one’s hands before entering, which is symbolic of cleansing the impurities associated with contact with the dead. ▪ The water is not passed from person to person, just as it is hoped that the tragedy is not passed. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Death Rituals ▪ Shiva (Hebrew for “seven”) is the 7-day period that begins with the burial. ▪ Shiva helps the surviving individuals face the actuality of the death of the loved one. ▪ During this period when the mourners are “sitting shiva,” they do not work. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Death Rituals ▪ In some homes, mirrors are covered to decrease the focus on one’s appearance. No activity is permitted to divert attention from thinking about the deceased. Evening and morning services may be conducted in the closest relative’s home. ▪ Condolence calls and the giving of consolation are appropriate during this time. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Death Rituals ▪ Crying, anger, and talking about the deceased person’s life are acceptable. ▪ A common sign of grief is the tearing of the garment that one is wearing before the funeral service. ▪ In liberal congregations, a black ribbon with a tear in it is a symbolic representation of mourning. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Death Rituals ▪ Within Orthodoxy, when a limb is amputated before death, the amputated limb and bloodsoaked clothing are buried in the person’s future gravesite because the blood and limb were part of the person. ▪ No mourning rites are required. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Spirituality ▪ Jews consider only the Old Testament as their Bible. ▪ Judaism is a monotheistic faith that believes in one God as the creator of the universe. ▪ No physical qualities are attributed to God; making and praying to statues or graven images are forbidden. ▪ The spiritual leader is the rabbi (teacher). He (or she, in liberal branches) is the interpreter of Jewish law. All Jews pray directly to God. They do not need the rabbi to intercede, to hear confession, or to grant atonement Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Spirituality ▪ The practice of Judaism spans a wide spectrum. ▪ Although there is only one religion, there are three main branches or denominations of Judaism. ▪ The Orthodox are the most traditional. They adhere most strictly to the halakhah of traditional Judaism and try to follow as many of the laws as possible while fitting into American society. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Spirituality ▪ The Orthodox observe the Sabbath by attending the synagogue on Friday evening and Saturday morning and by abstaining from work, spending money, and driving on the Sabbath. ▪ Orthodox Jews observe the Jewish dietary laws; men wear a yarmulke or kippah (head coverings) at all times in reverence to God. Women wear long sleeves and modest dress. ▪ In many Orthodox synagogues, the services are primarily in Hebrew, and men and women sit separately. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Spirituality ▪ Ultra-Orthodox men wear a special garment under their shirts year-round. ▪ A mezuzah is a small container with scripture inside. Jewish homes have a mezuzah on the doorpost of the house. Some Jews wear a mezuzah as a necklace. ▪ Other religious symbols include the Star of David, a six-pointed star that has been a symbol of the Jewish community, and the menorah (candelabrum.) Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Spirituality ▪ Whereas Conservative Jews observe most of the halakhah, they do make concessions to modern society. ▪ Many drive to the synagogue on the Sabbath, and men and women sit together. Many keep a kosher home, but they may or may not follow all of the dietary laws outside the home. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Spirituality ▪ For conservative Jews, women are ordained as rabbis and are counted in a minyan, the minimum number of 10 that is required for prayer. ▪ While a yarmulke is required in the synagogue, it is optional outside of that environment. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Spirituality ▪ The liberal or progressive movement is called Reform. Reform Jews claim that post-biblical law was only for the people of that time and that only the moral laws of the Torah are binding. ▪ They may or may not follow the Jewish dietary laws, but they may have specific unacceptable foods (for example, pork), which they abstain from eating. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Spirituality ▪ Of the many small groups of ultra-Orthodox fundamentalists, the Hasidic (or Chasidic) Jews are perhaps the most recognizable. ▪ They usually live, work, and study within a segregated area. They are usually easy to identify by their full beards, uncut hair around the ears (pais), black hats or fur streimels, dark clothing, and no exposed extremities. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Spirituality ▪ A relatively new denomination, Reconstructionism, is a mosaic of the three main branches. ▪ Reconstructionists view Judaism as an evolving religion of the Jewish people and seek to adapt Jewish beliefs and practices to the needs of the contemporary world. ▪ The Jewish house of prayer is called a synagogue, temple, or shul. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Spirituality ▪ Orthodox Jews pray three times a day: morning, late afternoon, and evening. They wash their hands and say a prayer on awakening in the morning and before meals. ▪ The Sabbath begins 18 minutes before sunset on Friday. During this time, religious Jews do no manner of work, including answering the telephone, operating any electrical appliance, driving, or operating a call bell from a hospital bed. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Spirituality ▪ Orthodox client’s condition is not lifethreatening, medical and surgical procedures should not be performed on the Sabbath or holy days. ▪ A gravely ill person and the work of those who need to save him or her are exempted from following the commandments regarding the Sabbath. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Health-care Practices ▪ All denominations recognize that religious requirements may be laid aside if a life is at stake or if an individual has a life-threatening illness. ▪ In ultra-Orthodox denominations of Judaism, taking medication on the Sabbath that is not necessary to preserve life may be viewed as “work” and is unacceptable. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Health-care Practices ▪ The verbalization of pain is acceptable and common. Individuals want to know the reason for the pain, which they consider just as important as obtaining relief from pain. ▪ The sick role for Jews is highly individualized and may vary among individuals according to the severity of symptoms. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Health-care Practices ▪ Judaism opposes discrimination against people with physical, mental, and developmental conditions. ▪ The maintenance of one’s mental health is considered just as important as the maintenance of one’s physical health. ▪ Mental incapacity has always been recognized as grounds for exemption from all obligations under Jewish law. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Health-care Practices ▪ Jewish law considers organ transplants from four perspectives: those of the recipient, the living donor, the cadaver donor, and the dying donor. ▪ Because life is sacred, if the recipient’s life can be prolonged without considerable risk, then transplant is ordained. ▪ For a living donor to be approved, the risk to the life of the donor must be considered. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Health-care Practices ▪ Conservative and Reform Judaism approve using the flat EEG as the determination of death so that organs, such as the heart, can be viable for transplant. ▪ Burial may be delayed if organ harvesting is the cause of the delay. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Health-care Practices ▪ The use of a cadaver for transplant is usually approved if it is to save a life. ▪ No one may derive economic benefit from the corpse. ▪ Use of skin for burns is also acceptable, although no agreement has been reached on the use of cadaver corneas. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Jewish Health-care Practitioners ▪ Physicians are held in high regard. Although physicians must do everything in their power to prolong life, they are prohibited from initiating measures that prolong the act of dying. ▪ The more traditional Orthodox prefer that care be delivered by a same-gender health-care provider. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck Jewish people with the highest number of hereditary/genetic conditions are a. Sephardic.. b. Copts. c. Ashkenazi. d. Falasha. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: C The Ashkenazi Jewish population has the highest incidence of genetic/hereditary conditions. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese American Culture Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Overview/Heritage ▪ In the Japanese language, Japan is called Nihon or Nippon. ▪ The over 500,000 Japanese citizens residing in North America tend to locate in large commercial and educational centers. ▪ Education is highly valued; the illiteracy rate in Japan is nearly zero. About 40 percent of all young people go on to higher education. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Overview/Heritage ▪ Issei (first-generation Japanese immigrants) vary widely in their English-language ability. ▪ Nisei (second-generation immigrants) and sansei (third-generation) were primarily educated under the American educational system. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ Japanese is the language of Japan, with the exception of the indigenous Ainu people. ▪ In Japan students complete 6 years of English, even newer Japanese immigrants and sojourners can speak, understand, read, and write English to some extent. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ Men tend to speak more coarsely and women with more gentility or refinement. ▪ Light social banter and gentle joking are a mainstay of group relations, serving to foster group cohesiveness. ▪ Polite discussion unrelated to business, often over o-cha (green tea), precedes business negotiations. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ Open communication is discouraged making it difficult to learn what people think. In particular, saying “no” is considered extremely impolite; rather, one should let the matter drop. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ A high value is placed on “face” and “saving face.” ▪ Asking someone to do something he or she cannot do induces loss of face or shame. For people to be shown wrong is deeply humiliating. ▪ People feel shame for themselves and their group, but they are respected when they bear shame in stoic silence. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ Traditional Japanese exhibit considerable control over body language. Anger or dismay may be quite difficult for Westerners to detect. ▪ Smiling and laughter are common shields for embarrassment or distress. ▪ Prolonged eye contact is not polite even within families. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ Social touching occurs among group members but not among people who are less closely acquainted. ▪ In general, body space is respected. ▪ Intimate behavior in the presence of others is taboo. ▪ When people greet one another, whether for the first time or for the first time on a given day, the traditional bow is performed. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ An offer to shake hands by a Westerner is reciprocated graciously. ▪ Overall orientation is toward the future. ▪ Punctuality is highly valued. ▪ Family names are stated first, followed by given names. Seki Noriko would be the name of a woman, Noriko, of the Seki family. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ Women generally assume their husband’s family name upon marriage. ▪ Elders are referred to respectfully. ▪ The designation sensei (master) is a term of respect used with the names of physicians, teachers, bosses, or others in positions of authority. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Family Roles and Organization ▪ The predominant family structure is nuclear. The role of wife and mother is dominant. ▪ Children are socialized to study hard, make their best effort, and be good group members. ▪ They are taught to take care of each other, and girls are taught to take care of boys. Selfexpression is not valued. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Family Roles and Organization ▪ The primary relationship within a family is the mother-child relationship, particularly that of mothers and sons. ▪ It is customary for a mother to sleep with the youngest child until that child is 10 years old or older, and when a new baby is born, the older sibling may sleep with the father or a grandparent. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Family Roles and Organization ▪ Babies are not allowed to cry; they are picked up instantly. Women constantly hold their babies in carriers on their chests and sleep with them. ▪ Corporal punishment is acceptable in Japan. ▪ Traditional teens and college students generally do not date. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Family Roles and Organization ▪ Older people are respected and cared for by the family in the home, if at all possible, with the eldest son being the responsible family member. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Family Roles and Organization ▪ There is less tolerance for marriage of a Japanese person to a foreigner than in the United States. ▪ The existence of a gay and lesbian social network and of cross-dressing clubs is evident, although they are not generally talked about. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Workforce Issues ▪ American practices designed to avoid liability, such as informed consent, are not routinely implemented in Japanese health-care settings. ▪ Japanese workers are sensitive to colleagues and superiors. ▪ Saying “no” or delivering bad news is extremely difficult; they may avoid issues or indicate that everything is fine rather than state the negative. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Workforce Issues ▪ A high value is placed on “face” and “saving face.” ▪ Asking someone to do something he or she cannot do induces loss of face or shame. ▪ For people to be shown wrong is deeply humiliating. ▪ Prolonged eye contact is not polite even within families and among friends. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Biocultural Ecology ▪ Racial features include the epicanthal skin folds that create the distinctive appearance of Asian eyes, a broad and flat nose, and “yellow” skin that varies markedly in tone. ▪ Hair is straight and naturally black with differences in shade. ▪ Negative blood types account for less than 1 percent of the population. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Biocultural Ecology ▪ Commonly occurring health conditions for Japanese include heart disease, tuberculosis, renal disease, asthma, Vogt-Koyanagi-Harada syndrome, Takayasu disease, acatalasemia, cleft lip/palate, Oguchi disease, lactase deficiency, and stomach cancer. ▪ Asthma, related to duct mites in tatami (straw mats) is one of the few endemic diseases. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Biocultural Ecology ▪ Drug dosages may need to be adjusted for the physical stature of Japanese adults. ▪ Many Asians are poor metabolizers of mephenytoin and related medications, potentially leading to increased intensity and duration of the drugs’ effects. ▪ Most individuals require lower doses of some benzodiazepines and neuroleptics. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Biocultural Ecology ▪ Opiates may be less effective analgesics, but gastrointestinal side effects may be greater than among Whites. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese High-Risk Health Behaviors ▪ Smoking rates are high among Japanese and Japanese Americans. ▪ Alcohol (rice wine) is part of many social rituals, such as picnics, to celebrate cherry blossoms, autumn leaves, or moon viewing. ▪ Once alcohol is consumed, one can relax and speak freely; they are forgiven for what they say because of the alcohol. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese High-Risk Health Behaviors ▪ Mothers’ time-honored strategy of rewarding academic diligence with candy and other treats contributes to the issue of the fitness of youth. ▪ Public safety consciousness is high. ▪ The Japanese readily use seatbelts and other safety measures, such as child safety seats and helmets. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Nutrition ▪ Dietary staples include rice, beef, poultry, pork, seafood, root vegetables, cabbage, persimmons, apples, and tangerines. ▪ Rice is the mainstay of the traditional diet and is included in all three meals as well as snacks. ▪ Rice has a symbolic meaning related to the Shinto religion, analogous to the concept of the “bread of life” among Christians. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Nutrition ▪ A staple of schoolchildren’s o-bento (lunch box) is a white bed of rice garnished with a red plum pickle, reminiscent of the Japanese flag. ▪ A popular lunch among working people is a steaming bowl of ramen (noodles) in broth or cold noodles on a hot summer day. ▪ Instant broth, although high in sodium, is another popular quick lunch. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Nutrition ▪ A traditional dinner is a pot of boiled potatoes, carrots, and pork seasoned with sweet sake, garlic, and soy sauce or a stir-fried meat and vegetable dish. ▪ The daily intake of sweets can be high and often includes European-style desserts, sweetbreads and cookies, sweet bean cakes, soft drinks, and heavily sweetened coffee. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Nutrition ▪ Increasingly, Westernized food tastes, resulting in higher fat and carbohydrate intake, have contributed to the rise in obesity and associated increases in diabetes and heart disease. ▪ There is growing public awareness that the sodium content of the traditional soups and sauces contributes to the high rate of cerebrovascular accidents. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Nutrition ▪ Green tea, although high in caffeine, is a good source of vitamin C. ▪ Garlic and various herbs are used widely for their medicinal properties. ▪ Many individuals have difficulty digesting milk products due to lactose intolerance. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Pregnancy and Childbearing Practices ▪ Oral contraceptives became legal in Japan in 1999. ▪ Condoms remain the most common contraceptive method. ▪ Most women have several abortions during their married fertile lives. ▪ Pregnancy is highly valued within traditional culture as a woman’s fulfillment of her destiny. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Pregnancy and Childbearing Practices ▪ Pregnant women may enjoy attention and pampering that they get at no other time. ▪ They may prepare themselves for the possibility of pregnancy when they become engaged and eliminate alcohol, caffeine, soft drinks, and tobacco. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Pregnancy and Childbearing Practices ▪ Loud noises, such as a train or a sewing machine, are thought to be bad for the baby. ▪ Shinto shrines sell amulets for conception and easy delivery. ▪ Husbands do not commonly attend the births of their children. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Pregnancy and Childbearing Practices ▪ Vaginal deliveries are usually performed without medication. ▪ To give in to pain dishonors the husband’s family, and mothers are said to appreciate their babies more if they suffer in childbirth. ▪ Traditionally, postpartum women do not bathe, shower, or wash their hair for the first week. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Pregnancy and Childbearing Practices ▪ Breast-feeding is taken seriously. ▪ Maternal rest and relaxation are deemed essential for success. ▪ If the mother is asleep, the grandmother feeds the baby formula. ▪ Women who give birth in the US may resent the expectation of resuming self-care quickly. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Death Rituals ▪ The taboo against open discussion of serious illness and death is evident. ▪ Hospice patients or those with a terminal illness may not want to be told their diagnosis and prognosis in order to allow a peaceful death and to spare both the patient and the family the difficulty of having to discuss the situation. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Death Rituals ▪ When a person is dying, the family should be notified of impending death so they can be at the dying person’s bedside. ▪ Traditionally, the eldest son has particular responsibility during this time. ▪ The mourning period is 49 days, the end of which is marked by a family prayer service and the serving of special rice dishes. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Death Rituals ▪ When death occurs, an altar is constructed in the home. ▪ Photographs of the deceased are displayed, and floral arrangements are placed within and outside the home. ▪ A bag of money is hung around the neck of the deceased to pay the toll to cross the river to the hereafter. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Death Rituals ▪ Perpetual prayers may be donated through a gift to the temple. In addition, special prayer services can be conducted for the 1st, 3rd, 7th, and 13th annual anniversaries of the death. ▪ Beliefs are common that the dead need to be remembered and that failure to do so can lead the dead to rob the living of rest. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Spirituality ▪ Shinto, the indigenous religion, is the locus of joyful events such as marriage and birth. ▪ Many festivals are marked by offerings, parades, and a carnival on the grounds of the shrine. ▪ Very few people regularly attend services, but most are registered temple members, if only to ensure a family burial plot. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Spirituality ▪ 1% of Japanese people is Catholic or Protestant. ▪ Most do not identify themselves solely with one religion or another, and even a baptized Christian might have a Shinto wedding and a Buddhist funeral. ▪ Buddhist belief in reincarnation and the eternal life of the soul. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Spirituality ▪ Kampo (healers) often set up shop in the vicinity of the temple or shrine, and a person might be seen scooping incense smoke onto an ailing body part. ▪ Prayer boards might bear requests for special healing. ▪ Newborns are taken to a shrine for a blessing. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ Because Japanese people are less likely to express feelings verbally, this indulgence may be a way for people to affirm caring for one another nonverbally. ▪ Termination of pregnancy when the health of the fetus is in doubt is common. ▪ Most parents want medically compromised neonates to be treated aggressively when prognoses are not favorable. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ The concept of ki, the life force or energy and how it flows through the body, is integral to traditional Chinese healing modalities, including acupuncture. ▪ Good health requires the unobstructed flow of ki throughout the body. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ Yin and yang are reflected in the need to balance five energy sources: water, wood, fire, earth, and metal. Strategies that help to restore balance include use of herbal medicines, bed rest, bathing, and having a massage. ▪ One traditional form of massage, shiatsu (acupressure), involves redirection of energy along the Chinese meridians by application of light pressure to acupuncture points. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ Whereas Chinese tradition calls for a restoration of balance when one is ill, Shinto calls for purging and purification. ▪ Preoccupation with germs and dirt is not likely to interfere with daily life. ▪ Many pharmacies stock traditional herbal kampo preparations. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ Most individuals make liberal use of both modern medical and traditional providers of health care. ▪ Residents in the United States have Internet and mail-order access to traditional medications, if they are not available locally. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices Common Japanese therapies include: ▪ Morita therapy–indigenous strategy for addressing shinkei shitsu, excess sensitivity to the social and natural environment. Introspection is seen as harmful. ▪ Morita therapy–focuses on constructive physical activity to help clients accept reality as it is ▪ Naikan therapy–reflection on how much goodness and love are received from others. ▪ Shinryo Naika– focuses on bodily illnesses that are emotionally induced. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ Japanese high regard for the status of physicians decreases the likelihood of their asking questions or making suggestions about their care. ▪ The idea that clients should be given care options may be alien. ▪ Itami (pain) may not be expressed: bearing pain is a virtue and a matter of family honor. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ Addiction is a strong taboo in Japanese society, making clients reluctant to accept pain medication. ▪ Mental illness is taboo. Because emotional problems cannot be discussed freely, somatic manifestations are common and acceptable. ▪ Handicapped people may bring shame to the family, although they are treated kindly.. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ The sick role is highly tolerated by families and colleagues, and a long recuperation period is encouraged Organ transplantation and donation issues need to be approached sensitively. ▪ People rely more heavily on the physician’s opinion, and the family may have difficulty negotiating cessation of treatment Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practitioners ▪ Physicians, referred to as sensei, are highly esteemed. ▪ Self-care as a philosophy is not evident among most. Being told what to do by the physician or kampo practitioner is expected, and his (or, occasionally, her) authority is not questioned. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practitioners ▪ Currently in Japan, nurses are well respected, even though women in general are not. ▪ In the past, nurses were not highly respected because “good women” did not touch people with an illness unless they were immediate family members. If she did touch “sick bodies,” the woman would become tainted and less pure. Chapter 19 People of Jewish Heritage Janice Selekman Overview, Inhabited Localities, and Topography Overview Being Jewish refers to both a people and a religion, not a race. Judaism is more than a religion; it is a people and a culture. Throughout history, the terms Hebrew, Israelite, and Jew have been used interchangeably. In the Bible, Abraham’s grandson, Jacob, was renamed Israel. His 12 sons and their descendants became known as the children of Israel. The term Jew is derived from Judah, one of Jacob’s sons. Hebrew is the official language of the state of Israel and is used for religious prayers by all Jews wherever they live. While the people are called Jewish, their faith is called Judaism, their religious language is Hebrew, and their ‘homeland’ is Israel, regardless of where their relatives were born. The religion of Judaism is practiced along a wide continuum that includes liberal Reform with 28 percent, Conservative with 22 percent, Reconstructionist with 2 percent, and strict Orthodox with 9 percent. Another 39 percent just identify as Jewish without identifying their affiliation (American Jewish Committee, 2010). Reform Judaism maintains that traditions should be modernized and compatible with participation in the surrounding community, and Progressive Judaism, an umbrella term used by strands of Judaism, embrace pluralism, modernity, equality, and social justice as core values (Myers, 1988). Although Reform and Progressive Jews might not engage in any special daily practices, they still observe holidays, religious rites, and selected dietary or cultural customs. The traditional Orthodox Jew attempts to adhere to most of the religious laws. Ultra-Orthodox groups also exist. No caste system or social hierarchy exists within the Jewish community. However, instances occur within the ultra-Orthodox communities, where individuals cannot make life and health-related decisions without consulting their rabbis. A significant issue within Orthodox communities in Israel, frequently debated in America is “Who is a Jew?” A child born to a Jewish mother is Jewish. As mixed marriages have increased, a debate over patrilineal descent has ensued. A child born from the union of a Jewish father and a non-Jewish mother is recognized as Jewish by those in more liberal branches of Judaism, especially if they are raised as a Jew, but not by those in the Orthodox movement (DeLange, 2010). Although Judaism does not actively proselytize, the vast majority welcome converts as full members of their community. Clergy offer preconversion classes for adults and perform conversions. Whereas the goal of this chapter is to provide an understanding of all Jewish Americans, the focus is on the needs of the more traditional religious individuals and their families. These descriptions may vary somewhat for Jewish people according to variant characteristics of culture (see Chapter 1) and the other parts of the world where they live. Heritage and Residence The initial group of 23 Jews in North America arrived in 1624, having fled the Office of the Inquisition in Brazil. As a result of European immigrations, their numbers grew to between 1000 and 2500 individuals by the time of the American Revolution, when many fought for the colonial army. Haim Solomon, a banker, raised significant funds in Europe and the colonies and dedicated all his personal resources and finances to George Washington’s army. Their numbers reached approximately 250,000 by the 1880s, close to 6 million a century later, and finally stabilized by 2002. According to American Jewish Demographics (2011), there are 5,275,000 Jews in the United States, accounting for 2.7 percent of the U.S. population. States with over 3 percent of their population being Jewish include New York (8.4 percent), New Jersey (5.5 percent), Massachusetts (4.3 percent), Maryland (4.2 percent), Florida (3.7 percent), and California (3.3 percent) (Jewish Virtual Library, 2011). Although many prefer to live in or within reach of large Jewish communities in order to have access to specific services, Jews make their homes in rural as well as urban centers in the United States. In 339 340 Aggregate Data for Cultural-Specific Groups comparison, 76 percent of the State of Israel is Jewish (Jewish Virtual Library, 2011). Depending on how one defines being Jewish, a 2010 unpublished study by Saxe and his Brandeis researchers indicated that there may be as many as 6.5 million Jews in America (Beckerman, 2010). These are thought to be individuals who consider themselves Jewish by their culture but do not participate in the Jewish community or in Jewish life-cycle events. Reasons for Migration and Associated Economic Factors Migration of Jews from Europe began to increase in the mid-1800s, often because of religious persecution and economic opportunities. However, the greatest influx of immigrants occurred between 1880 and 1920. Many of these immigrants came from Russia and Eastern Europe after a wave of pogroms, anti-Jewish riots and murders (Jewish American Committee, 2011). Once in America, acculturation became their motivation to live in safety and practice their religion. Most Jewish families in America today are descendants of these Eastern European and Russian immigrants. They are referred to as Ashkenazi Jews. Ashkenazi Jews make up more than 80 percent of the world’s Jewish population (Hebrew University of Jerusalem, 2009). This becomes an important concept when exploring diseases prevalent among the Jewish population. Many American Jews of Ashkenazi descent have stories of how some members of their families escaped to America, whereas others had relatives who were part of more than the 6 million Jews killed in the pogroms and the Holocaust. Sephardic Jews, conversely, are originally from Spain, Portugal, the Mediterranean area, and North Africa. They represent a more diverse group. A Sabra is a Jew who was born in Israel. In the 1980s and 1990s, a significant increase occurred in the number of Jewish immigrants from Russia. Because the practice of religion was illegal there for over half a century, these Jews often have a relatively relaxed connection to religious and cultural practices. The same was true of the Falasha Jewish community in 1984. These black Jews from Ethiopia participated in a mass exodus to Israel, and subsequently, a small number continued on to America. Educational Status and Occupations Despite bias against Jews in every century, they have made major contributions to society, across the arts and professions, including the fine arts, sciences, and health care. Throughout their history, they have placed a major emphasis on education and social justice through social action. Continued learning is one of the most respected values of the Jewish people, who are often called the People of the Book (Diamant, 2007). Education is considered a lifelong obligation regardless of age or status. Whereas this usually refers to the study of Torah, it includes both Jewish and secular learning. Formal education is highly valued, and advanced degrees are respected. Overall, this population is well educated. Jews have won 22 percent of all Nobel Prizes awarded between 1901 and 2010. This includes 20 percent of the Nobel Prizes in chemistry, 25 percent in physics, 42 percent in economics, and 27 percent in physiology and medicine (Jewish Nobel Prize Winners, 2011). Well-known American composers with Jewish ancestry include George Gershwin, Aaron Copland, Leonard Bernstein, Jerome Kern, Richard Rogers, Irving Berlin, and Stephen Sondheim; the American theater counts Arthur Miller as one of its most celebrated of playwrights, along with Woody Allen, Mel Brooks, Oscar Hammerstein II, Alan Lerner, and Neil Simon. The 20th century finally saw the first Jewish Supreme Court justices in Louis Brandeis and, most recently, Ruth Bader Ginsburg and Elena Kagan. Because of their emphasis on education, a high percentage of Jewish Americans have succeeded in science, medicine, law, and dentistry. Thirty-nine percent of Jewish men and over 36 percent of Jewish women list their occupation as “professional,” compared with only 15 percent of the American white population. With respect to higher education, over 10 percent of professors in American colleges and universities are Jewish; the majority of American Jews attend college (Diamant, 2007). Their traditional values of study and preserving life have contributed to directing many into the life sciences, medicine, and research. In addition to receiving a regular elementary, secondary, and college education, many Jewish children are also provided a Jewish education. Many attend Hebrew school classes 1 or 2 days a week, as well as classes on Judaism, commonly referred to as Sunday School. Throughout their history, Jews were repeatedly forbidden to own land, and the Christian Church barred its members from moneylending. As a result, since the early Middle Ages, Jews frequently became moneylenders, peddlers, and tailors because these were the only options available to them. The early Jews in America were businessmen and craftsmen (Center for Jewish History, 2007). They became well respected for their expertise in trade and commerce, and thus many went into banking or retail sales. Social action, volunteerism, and involvement in helping others are common vocations or avocations. Health-care professions, social work, teaching, and the legal profession became other popular occupational pursuits. The term tzedakah (justice) is used to indicate charity or righteous giving, a central concept to Judaism. Jewish children are raised with the People of Jewish Heritage concept of giving tzedakah by sharing with others who have less than they do (Diamant, 2007). Communication Dominant Language and Dialects English is the primary language of Jewish Americans. Although Hebrew is the official language of Israel and is used for prayers and is the language of the Torah, it is generally not used for conversation in the United States. Many older Ashkenazi Jews who immigrated early in the 20th century or who are first-generation Americans speak Yiddish, a Judeo-German dialect. Many Yiddish terms have worked their way into the English language, including kvetch (to complain); chutzpah (clever audacity); bagel (a boiled roll with a hole in the middle); challah (a rich, braided white bread); knish (a dumpling with filling); mitzvah (a good deed); nosh (to snack); zaftig (plump); tush, tushie, or tuchus (buttocks); ghetto (a restricted area in which certain groups live); klutz (a clumsy person); mentsch or mensh (a respected person with dignity); shlep (to drag or carry); kosher (technically applying to food preparation, but idiomatically meaning legal; and oy or oy vey (oh my), and oy veys mier (woe is me). Common Hebrew expressions include “l’chaim” (to life), which is said after blessing wine or giving a toast; “shalom alechem” (peace be with you), a traditional salutation; “mazel tov” (congratulations); and “shabbat shalom” (a good and peaceful Sabbath), which is said from Friday evening at sunset until Saturday at sunset. Cultural Communication Patterns No religious ban or ethnic characteristics prevent Jews from openly expressing their feelings. Communication practices are more related to their American upbringing than to their religious practices. Humor is frequently used as a coping mechanism and as a way to communicate with others. However, jokes are considered to be insensitive when they reinforce mainstream stereotypes about Jews, such as implying that Jews are cheap or pampered (e.g., Jewish princess). Any jokes that refer to the Holocaust or concentration camps are also inappropriate. Jewish self-criticism through humor is acceptable, but it is usually expressed by insiders. Modesty is a primary value in Orthodox Judaism. It is seen in the style of dress and in all behavior. Modesty involves humility. Jews are encouraged not to “show off ” or try to impress others. In Hasidic Judaism, the ultra-Orthodox fundamentalists, men are not permitted to touch a woman other than their wives. They often keep their hands in their pockets to avoid touch. They do not shake hands with women, and their failure to do so when one’s hand is 341 extended should not be interpreted as a sign of rudeness. Because women are considered seductive by nature, Hasidic men may not engage in idle talk with them or look directly at their faces. Non-Hasidic Jews may be much more informal and may use touch and short spatial distance when communicating. Healthcare providers should touch Hasidic men only when providing direct care. Hands-on “therapeutic touch,” as in holding a patient’s hand to give comfort, is not appropriate with these patients. Temporal Relationships Jews live with regard for, and in, the present, conscious of being a part of a long historical tradition and with both hope and a wary eye to the future. The last 2 millennia have seen a succession of struggles to survive external pressures, yet the tradition affirms their belief in survival and a better time to come. They are raised with stories of their past, including the relatively recent Holocaust. They are warned to “never forget,” lest history be repeated. Therefore, their time orientation is simultaneously to the past, the present, and the future. The Jewish calendar is based on both a lunar and a solar year, with each month beginning with the appearance of the new moon and lasting 29 to 30 days. The festivals and holidays are based on lunar phases, whereas the seasons are based on the solar year, which is 11 days longer than the lunar year. Therefore, an extra month is periodically added, usually during the end of winter (7 times in every 19 years). The Jewish day starts at sunset; therefore, all holidays, as well as the Sabbath, begin when the sun sets, usually identified as the evening before the date identified on a calendar. The basis for this practice is the line in Genesis “And there was evening and there was morning.” Format for Names For secular use, the Jewish format for names follows the Western tradition. The given name comes first, followed by the family surname. Only the given name is used with friends and in informal situations. In more formal situations, the surname is preceded by the appropriate title of Mr., Miss, Ms., Mrs., Dr., and so on. Babies may be named after someone who has died to keep their memory alive or after a living person to honor him or her (the latter only in Sephardic families). In ultra-Orthodox circles, children are not referred to by their names until after the bris or brit milah (circumcision). The biblical traditions are preserved for religious occasions. Infants are given a Hebrew name that is used when they are older and are called to read from the Torah at age 13 or older, following their bar or bat mitzvah). An example would be Ephraim ben Reuven (Frank, son of Robert). Although one’s Hebrew name may be the 342 Aggregate Data for Cultural-Specific Groups same as one’s birth certificate “official” name, parents may choose a non-Hebrew, main-culture name for the birth certificate that is entirely different or one that preserves the initial letter (i.e., Reuven could become Robert). Family Roles and Organization Head of Household and Gender Roles The family is the core of Jewish society, and whereas the man is traditionally considered the breadwinner for the household and the woman is recognized for running the home and being responsible for the children, in recent times there is more flexibility for gender roles, even in very observant homes. According to Jewish law, the father has the legal obligation to educate his children in Judaism, to teach them right from wrong, to teach them to swim, and to teach his sons a trade (Cohn-Sherbok, 2010). He must provide his daughters with the means to make them marriageable. With acculturation, little difference is seen today between Jewish and non-Jewish white families with regard to gender roles. In most Jewish families, both parents share the responsibilities for supporting the home and raising the children. However, it is still common to find the mother lighting the Sabbath candles and the father blessing the wine (DeLange, 2010). The Orthodox ideology puts increased responsibility on males to study the Torah and perform mitzvoth (religious commandments). While the reform movement embraces feminism, the orthodox movement is more skeptical. According to the Talmud, Jewish husbands are required to provide their wives with food, clothing, medical care, and conjugal relations, in addition to meeting other needs. The ketubah— marriage contract—usually includes wording that entitles the wife to the same dignity and social standing as her husband. Although traditional Jewish law is clearly maleoriented, Jewish women have been at the forefront of activities to demand and protect all human rights, especially those of women. They were prominent in movements to gain women’s suffrage, reproductive health-care rights, and equal rights for all segments of society. Women are now expected to achieve an optimal level of education and to seek gainful employment if they so desire. Both sexes are expected to give service to their community. Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents Children are the most valued treasure of the Jewish people. They are considered a blessing and are to be treated with respect and provided with love. Jewish children are to be afforded an education, not only in studies that help them progress in society but also in studies that transmit their Jewish heritage and the laws. Jewish school-age children may attend Hebrew school as least two afternoons a week after public school throughout the school year. Children are welcomed and incorporated into most holiday celebrations and services. Respecting and honoring one’s parents is the fifth of the Ten Commandments. Children should be forever grateful to their parents for giving them the gift of life. Jewish parents are expected to be consistent and fair to all their children, avoiding favoritism. In addition, parents should not promise something to their children that they cannot deliver. They must be flexible and yet caring and attentive to discipline. The individuality of each child’s special traits should be recognized. In Judaism, the age of adulthood is 13 years and 1 day for a boy, and 12 years and 1 day for a girl (Cohn-Sherbok, 2010; Jacob & Zemer, 2006). At this age, children are deemed capable of differentiating right from wrong and capable of committing themselves to performing the commandments. Recognition of religious adulthood and assumption of its responsibilities occur during a religious ceremony called a bar or bat mitzvah (son or daughter of the commandment, respectively); during this ceremony, the child reads from the Torah and Haftorah, prophetic writings, for the first time (Kranson, 2010). None of the denominations require girls to have this ceremony, although with the feminist movement as impetus, it has increased in prevalence among modern Jews. In America, this rite of passage is usually accompanied by a family celebration. However, because sons and daughters are still teenagers living at home, it is recognized that they are still the responsibility of their parents. In Orthodox communities, boys who have reached their bar mitzvah are now responsible to perform the multiple religious rituals expected. Family Goals and Priorities The goal of the Orthodox family is to live their lives as prescribed by halakhah, which emphasizes maintaining health, promoting education, and helping others. In addition, each individual is considered unique and must maximize their potential. The family is central to Jewish life and essential to the continuation of Judaism from one generation to the next. Marriage is considered the ideal human state for adults; it is considered a sacred bond between adults and a means of personal fulfillment (Cohn-Sherbok, 2010). The Bible states that man should not be alone. The goals of this union are to build a home, procreate, and provide companionship, allowing an individual to focus on another person. Marriages are monogamous, and limitations on whom one may marry exclude close blood relatives and—although this has changed considerably with the increase in interfaith unions—non-Jews. People of Jewish Heritage Sexuality is a right of both men and women. The sex instinct is neither sinful nor shameful, but restraint is expected (Jacob & Zemer, 2006). In addition to procreation requirements, conjugal rights for women exist. Nonprocreative intercourse is required, if desired, for married women who may be pregnant or are unable to conceive, and after menopause as this is not considered “wasting seed” (Jacob & Zemer, 2006). Sexual intercourse is viewed as a pure and holy act when performed mutually within the relationship of marriage. With some exceptions, a husband’s refusal to have sex with his wife is grounds for a divorce. However, the act of sex, if not performed with sobriety and modesty and the wife’s willingness), is considered against Jewish values (DeLange, 2010). Premarital sex is not condoned. Among the ultra-observant, women must physically separate themselves from all men during their menstrual periods and for 7 days after (DeLange, 2010). No man may touch a woman or sit where she just sat until she has been to the mikveh, a ritual bath, after her period is over. Sexual contact for this group may, therefore, occur only during 2 weeks of each month. Judaism supports the need for sex education. The Jewish community sees this as its responsibility. This belief was reemphasized during the AIDS epidemic, with the goals of protecting the next generation and providing them with accurate information so they can make informed choices. Whereas it is recognized that the later years are a time of physical decline, older people receive respect, especially for the wisdom they have to share. Old age is a state of mind rather than a chronological age; one may continue to “give” to society in a variety of ways other than employment. In addition, one may never “retire” from practicing the commandments. Honoring one’s parents is a lifelong endeavor and includes maintaining their dignity by feeding, clothing, and sheltering them, even if they suffer from senility. Respect for older people is essential even when their actions are irrational. The care of an older family member is the responsibility of the family; when the family is unable to provide care owing to physical, psychological, or financial reasons, the responsibility falls to the community. This role has always been a hallmark of Jewish communal life. Few Jewish American families now have three generations living together. Older immigrants who experienced imprisonment in concentration camps during the Holocaust in the 1940s, or those more recently incarcerated in Russia, may refuse to enter long-term-care facilities for fear of returning to an institutional environment that robs them of their freedom (Martha Braverman, personal communication, 2007). Alternative Lifestyles The Jewish view on homosexuality varies with the branch of Judaism. As might be expected, the Orthodox 343 are largely unanimous in scripture-based (Lev. 18:22) nonacceptance of same-sex unions. The Bible, especially as interpreted by the Orthodox, prohibits homosexual intercourse for men; it says nothing specifically about sex between lesbians (DeLange, 2010). Some of the objections to gay and lesbian lifestyles include the inability of these unions to fulfill the commandment of procreation and the possibility that acting on the recognition of one’s homosexuality could ruin a marriage. The official position of the Conservative movement had sided with the Orthodox until as recently as 2006, when it revised its position to increase inclusivity of views within Jewish philosophy. They can now perform same-sex commitment ceremonies. They can also ordain gay and lesbian clergy. The liberal movement within Judaism, however, supports full legal and social equality for homosexuals (Cohn-Sherbok, 2010). Workforce Issues Culture in the Workplace Specific workforce issues may occur, especially with Sabbath observance. Jews who observe the Sabbath must have Friday evenings and Saturdays off. They may work on Sundays. Supervisors must be sensitive to the needs of Jewish staff and recognize the holiness of the Sabbath. Jewish staff should be allowed to request time off for the major Jewish holidays. Remembering that all holidays begin the evening before, they must have off the evening shift before and the following day. Staff should not be penalized by having to use this time off as unpaid holidays or vacation time, but they should have the option to exchange for the Christmas and Easter holidays, time usually afforded to Christian staff. Jewish health-care providers are fully acculturated into the American workforce. Judaism’s beliefs are congruent with the values American society places on the individual and family. As English is the primary language for Jewish Americans, no language barriers to communicating in the workplace exist. For some newer Jewish immigrants (e.g., those from Russia), English may pose a challenge. Issues Related to Autonomy Jewish nurses have begun to speak out on their needs in the workplace. With the recent emphasis on cultural competence, including cultural sensitivity, many are now addressing this long-ignored area. In 1990, a National Nurses Council was established through Hadassah, the Zionist women’s organization (Benson, 1994). This group promotes solidarity and empowerment to enhance sensitivity within the health-care community. Still proportionally underrepresented among American nurses, Jewish nurses have a higher percentage of advanced degrees and positions in management, education, and research (Benson, 2001). 344 Aggregate Data for Cultural-Specific Groups Ways in which the professional nursing community demonstrates its insensitivity to Jewish nurses are by scheduling major nursing conferences during the High Holy Days in the fall or during Passover in the spring, by serving pork products during catered affairs, or reciting a prayer before the conference meal invoking the name of Jesus. Biocultural Ecology Skin Color and Other Biological Variations According to DeLange (2010), “there are no racial characteristics that are shared by Jews and that distinguish them from non-Jews” (p. 3). Ashkenazi Jews have the same skin coloring as white Americans. They may range from fair skin and blonde hair to darker skin and brunette hair. Sephardic Jews have slightly darker skin tones and hair coloring, similar to those from the Mediterranean area and those who lived for centuries in nearby regions such as Yemen. There are also Jewish groups throughout Africa who are black, most notably the Jews originally from Ethiopia, known as Falasha. Diseases and Health Conditions Because Jews are integrated throughout the United States, no specific risk factors are based on topography. Genetic risk factors vary based on whether the family immigrated from Ashkenazi or Sephardic areas. There is a greater incidence of some genetic disorders among individuals of Jewish descent, especially those who are Ashkenazi. It is estimated that 1 in 16 to 1 in 110 Ashkenazi Jews carries one of these mutations (Hebrew University of Jerusalem, 2009). Most of these disorders are autosomal recessive, meaning that both parents carry the affected gene. Although the best known is Tay-Sachs disease, Gaucher’s disease is more prevalent. Others include Canavan’s disease, familial dysautonomia, torsion dystonia, NiemannPick disease, Bloom syndrome, Fanconi’s anemia, and mucolipidosis IV (Center for Jewish Genetic Diseases, 2011). Gaucher’s disease is the most common genetic disease affecting Ashkenazi Jews, with 1 in 10 carrying the gene (Center for Jewish Genetic Diseases, 2011). Gaucher’s disease is a lipid-storage disorder. This inborn error of metabolism results in a defective enzyme that normally breaks down glucocerebroside, a lipid by-product of erythrocytes. The glucocerebroside accumulates in the body, resulting in weakening and fracturing of the bones owing to infarctions, anemia, and platelet deficiencies. The spleen becomes painfully enlarged. There are 34 different genetic mutations of the disease; 4 of them account for 95 percent of cases in Ashkenazi Jews. The disorder can be detected by a blood test for both those affected and carriers. Gene therapy treatments are now being tested (National Gaucher Foundation, 2011). The gene for Tay-Sachs disease (also called infantile cerebromacular degeneration) is carried by 1 in 25 to 1 in 30 Ashkenazi Jews and 1 in 250 Jews of Sephardic origin. This autosomal recessive condition is a lysosomal sphingolipid storage disorder caused by an absence of hexosaminidase A, resulting in an accumulation of a lipid called GM2 ganglioside in the neural cells. The onset of intellectual and developmental delay begins in the middle of the first year of life, with progressive deterioration, increasing seizure activity, blindness, deafness, and death by approximately age 4 (Center for Jewish Genetic Diseases, 2011). Because of the ease of testing for carriers as well as testing the fetus during pregnancy, and because of a concerted effort among the Jewish American community to provide testing, the incidence of Tay-Sachs disease has decreased significantly since the early 1980s. Because the ultra-Orthodox are opposed to abortion, this group recommends the testing only before marriage (Washofsky, 2000). It should be noted that because there are 50 different mutations, testing can only identify 95 percent of carriers with a Jewish background and 60 percent of non-Jewish individuals (Center for Jewish Genetic Diseases, 2011). Canavan’s disease is a rare, fatal, degenerative brain disease caused by a defective gene that impairs the formation of myelin in the brain. Approximately 1 in 40 Ashkenazi Jews carry the gene. The resulting symptoms begin in mid-infancy and include developmental delay, loss of vision, and a loss of reflexes resulting in death by the age of 10 years (Center for Jewish Genetic Diseases, 2011). Familial dysautonomia, or Riley-Day syndrome, is also an autosomal recessive genetic disease, with the gene located on chromosome 9q31. It causes dysfunction of the autonomic and peripheral sensory nervous systems. Affected children have decreased myelinated fibers on nerves that lead to afferent impulses but maintain a normal intelligence. Symptoms include a decrease in the number of taste buds; altered pain sensation; increased salivation and sweating; abnormal sucking or swallowing difficulties and vomiting, resulting in failure to thrive; decreased tears, resulting in increased risk of corneal ulceration; and temperature and blood pressure fluctuations. Fifty percent of newly diagnosed infants will live to the age of 40. One in 27 Ashkenazi Jews is a carrier (Center for Jewish Genetic Diseases, 2011). Other conditions that have a higher incidence among Ashkenazi Jews include the following: • Torsion dystonia, an autosomal dominant condition, is carried by 1 in 1000 to 1 in 3000 Ashkenazi Jews in the United States. The disease leads to rapid progression in loss of motor control and twisting spasms of the limbs, resulting in contractures. Affected individuals lead a full life and have a normal intelligence. People of Jewish Heritage • Niemann-Pick disease type A is an autosomal recessive severe neurodegenerative disorder that starts at 6 months of age. It involves an abnormal storage of sphingomyelin and cholesterol in organs caused by an enzyme deficiency and leads to central nervous system degeneration. Whereas those with type A usually die by age 3, those with type B survive into their 50s and have a milder presentation, with the sphingomyelin building up in their liver, spleen, lymph nodes, and brain. The gene for Type A is carried by 1 in 90 Ashkenazi Jews. • Bloom syndrome, a rare genetic condition that results in abnormal breakage of chromosomes, results in respiratory and gastrointestinal infections, erythema, telangiectasia, photosensitivity, and dwarfism. Whereas the intelligence of those affected is usually normal, they face an increased risk of infertility, malignancy, and diabetes. The average age of death is 27; the gene is carried by 1:110 Ashkenazi Jews. • Fanconi’s anemia also results in chromosomal alterations. Symptoms include pancytopenia and an increased risk of cancer. Many die before early adulthood. Type C is found more frequently among Ashkenazi Jews; 1 in 89 are carriers. • Mucolipidosis IV is found in 1 of 100 Ashkenazi Jews. This lipid-storage disease results in central nervous system deterioration during the first year with motor and mental retardation, as well as various eye disorders. The prognosis varies (Center for Jewish Genetic Diseases, 2011). Variations in Drug Metabolism Orthodox rabbis usually do not support genetic testing because it might cause couples to refrain from marrying or having children, thus preventing them from fulfilling the mitzvah of procreation. The Reform movement supports a couple’s right to make the decision as to whether or not to have the testing done. Because the knowledge is available, and for the emotional and psychological well-being of a couple, testing is allowed. Some Orthodox rabbis allow the practice of preimplantation screening of in vitro fertilized zygotes if both husband and wife are known carriers of Tay-Sachs and then to only use the healthy ones for implantation. “The discarding of the affected zygotes is not considered as abortion, since the status of a fetus or a potential life in Judaism applies only to a fetus implanted and growing in the mother’s womb” (Jewish Virtual Library, 2011). Other conditions with increased incidence in the Jewish population include inflammatory bowel disease (ulcerative colitis and Crohn’s disease), which is seen 2 to 8 times more often in Ashkenazi Jews than in other ethnic groups; colorectal cancer occurs in 6 percent of Ashkenazi Jews; and the BRCA1 and BRCA2 genes that cause breast and ovarian cancer are found in 1 out of every 50 Jewish women of Ashkenazi background (Rosenberg, 2011). Health-Care Practices 345 One of the few drugs found to have a higher rate of side effects in people of Ashkenazic ancestry is clozapine, used to treat schizophrenia. Twenty percent of Jewish patients taking this drug developed agranulocytosis, compared with about 1 percent of non-Jewish patients. A specific genetic haplotype has been identified to account for this finding (Schatzberg & Nemeroff, 2009). Thus, health-care providers must order testing for agranulocytosis when Jewish patients are prescribed clozapine. High-Risk Behaviors According to Jewish law, individuals may not intentionally damage their bodies or place themselves in danger. The basic philosophy is that the body must be protected from harm. To the religious, the body is viewed as belonging to God; therefore, it must be returned to Him intact when death occurs. Consequently, any substance or act that harms the body is not allowed. This includes smoking, suicide, taking nonprescription or illegal medications, and permanent tattooing (Jewish Virtual Library, 2011). Alcohol, especially wine, is an essential part of religious holidays and festive occasions and is a traditional symbol of joy. The Jewish attitude toward wine is ambivalent. The Bible speaks of the undesirable effects of wine on the person, as well as its positive use as a medicine. Consequently, wine is appropriate and acceptable as long as it is used in moderation. Because of the respect afforded physicians and the emphasis on keeping the body and mind healthy, Jewish Americans are health conscious. Taking care of one’s body is a mitzvah. In general, they practice preventive health care, with routine physical, dental, and vision screening. This is also a well-immunized population. Although the older generation is still more likely to defer to medical authority, Jewish adults tend to want to participate in health-care decision making. Nutrition Meaning of Food Eating is important to Jews on many levels. Besides satisfying hunger and sustaining life, it also teaches discipline and reverence for life. For those who follow the dietary laws, a tremendous amount of attention is given to the slaughter, preparation, and consumption of food. In addition, the family dinner table is often the site for religious holiday celebrations and services, especially the Sabbath, Passover, Rosh Hashanah (Jewish New Year), and breaking the fast for Yom Kippur (Day of Atonement). Jewish dietary practices 346 Aggregate Data for Cultural-Specific Groups serve as a spiritually refining act of self-discipline and are a unifying factor in ethnic identity. Common Foods and Food Rituals Perhaps the food identified as “Jewish” that receives the most attention is chicken soup. This has frequently been referred to as Jewish penicillin, and it is often served with knaidlach or matzoh balls (dumplings made of matzoh meal). Although it has no intrinsic meaning or religious value, it is a staple in religious homes, especially on Friday evenings to usher in the Sabbath and during times of illness. It is frequently associated with a mother’s warmth and love. Other common foods include gefilte fish (ground karp molded into oblong balls, steamed, then served cold with horseradish), challah (a rich, braided white bread), kugel (noodle pudding, either sweet or savory), blintzes (crepes filled with a sweet cottage cheese), chopped liver (served cold), hamentashen (a triangular pastry with different types of filling), and Nova Scotia or “belly” lox (cold smoked salmon) served with cream cheese and salad vegetables on a bagel. Slow-cooked beef brisket is often the entrée at Rosh Hashanah (New Year) dinner. The laws regarding food are found in Leviticus and Deuteronomy. They are commonly referred to as the laws of kashrut, or the laws that dictate which foods are permissible under religious law. The term kosher means “fit to eat” (Hoffman, 2008); it is not a brand or form of cooking. Whereas some believe that the mandatory statutes were developed and implemented for health reasons, religious scholars dispute this view, claiming that the only reason for following the laws is that they are mandatory commandments of God. Therefore, the laws are followed as a personal attachment to the religion and as a belief that God has mandated them. The laws’ promotion of health is only a secondary gain. Kashruth issues may be a significant part of an inpatient stay, making it helpful to know what is and is not acceptable. Foods are divided into those considered kosher (permitted or clean) and those considered treyf (forbidden or unclean). A permitted animal may become treyf, or forbidden, if it is not slaughtered, cooked, or served properly. Because life is sacred and animal cruelty is forbidden, kosher slaughter of animals must be done in a way that prevents undue cruelty to the animal and ensures the animal’s health for the consumer. The jugular vein, carotid arteries, and vagus nerve must be severed in a single quick stroke with a sharp, smooth knife, causing the animal to die instantly. No sawing motion and no second stroke are permitted (DeLange, 2010). This also allows the maximal amount of blood to leave the body. Care must be taken that all blood is drained from the animal before it is eaten. Drinking of blood is prohibited. An animal that dies from old age or disease may not be eaten, nor may it be eaten if it meets a violent death or is killed by another animal. In addition, flesh cut from a live creature may not be eaten. Milk and meat may not be mixed together in cooking, serving, or eating in order to respect the sensitivity of living creatures (“You must not boil a calf in its mother’s milk” [Deut. 14:20]). To avoid mixing foods, utensils and plates used to serve them are separated. Religious Jews who follow the dietary laws have two sets of dishes, pots, and utensils: one set for milk products (milchig in Yiddish) and the other for meat (fleishig). Some homes have different sets of dish towels and even different sinks. Because glass is not absorbent, it can be used for either meat or milk products, although religious households still usually have two sets. Therefore, cheeseburgers, lasagna made with meat, and grated cheese on meatballs and spaghetti are unacceptable. Milk cannot be used in coffee if it is served with a meat meal. Nondairy creamers can be used instead, as long as they do not contain sodium caseinate, which is derived from milk. Thirty minutes is the minimum time between eating milk and meat products, but some families wait up to 6 hours, with the premise that food takes that long to digest from the stomach (Hoffman, 2008). A number of foods are considered parve (neutral) and may be used with either dairy or meat dishes. These include fish, eggs, anything grown in the soil (vegetables, fruits, coffee, sugar, and spices), and chemically produced goods. Vegetables and fruits must be washed carefully to ensure that they are free of insects. A “U” with a circle around it is the seal of the Union of Orthodox Jewish Congregations of America and is used on food products to indicate that they are kosher. A circled “K” and other symbols may also be found on packaging to indicate that a product is kosher. When working in a Jewish person’s home, the health-care provider should not bring food into the house without knowing whether or not the patient adheres to kosher standards. If the patient keeps a kosher home, do not use any cooking items, dishes, or silverware without knowing which are used for meat and which for dairy products. Health-care providers must fully understand the dietary laws so they do not offend the patient, can advocate for kosher meals if they are requested, and can plan medication times accordingly. Mammals are considered clean if they meet the other requirements for their slaughter and consumption and have split (cloven) hooves and chew their cud. These animals include buffalo, cattle, goat, deer, and sheep. The pig is an example of an animal that does not meet these criteria. Although liberal Jews decide for themselves which dietary laws they will follow, many still avoid pork and pork products out of a sense of tradition and symbolism. Serving pork People of Jewish Heritage REFLECTIVE EXERCISE 19.1 Mr. Orr, an 80-year-old Jewish patient, originally from Eastern Europe, has heart disease and a pancreatic deficiency. He is being cared for in his home by visiting nurses. His wife of 55 years has some physical limitations but is self-sufficient to maintain her home. The visiting nurse discovers that Mr. Orr is not taking his pancreatic enzymes as ordered. He states that he found out that the enzymes are made of pork products, and he does not eat pork. The nurse may want to teach his wife how to make meals that will meet his health needs and enters the kitchen to obtain a measuring cup. Concerned because she has a kosher kitchen, Mrs. Orr starts yelling at the visiting nurse. 1. What options are available regarding pancreatic enzymes that do not contain pork? 2. What responses regarding his medication might be made to Mr. Orr? 3. What questions should the nurse ask Mrs. Orr about her degree of kashrut (keeping kosher)? 4. What might be an approach to planning kosher meals appropriate for someone with cardiac and pancreatic problems? 5. What needs to be known in advance before entering Mrs. Orr’s kitchen? products to a Jewish patient, unless specifically requested, is insensitive. Birds of prey are considered “unclean” and unacceptable because they grab their food with their claws. Acceptable poultry are chicken, one of the most frequently consumed forms of protein; turkey; goose; and duck. Fish can be eaten if it has both fins and scales. Nothing that crawls on its belly is allowed, including clams, lobsters, and other shellfish; tortoises; and frogs (DeLange, 2010). In religious homes, meat is prepared for cooking by soaking and salting to drain all the blood from the flesh. As increased residual salt may result, patients with sodium restrictions may need counseling to assist them in making dietary adjustments. Broiling is acceptable, especially for liver, because it drains the blood. Care must be taken in serving cheese to ensure that no animal substances are served at the same time. Breads and cakes made with lard are treyf, and breads made with milk or milk by-products (e.g., casein) cannot be served with meat meals. Eggs from nonkosher birds, milk from nonkosher animals, and oil from nonkosher fish are not permitted. Butter substitutes are used with meat meals. Honey is allowed. Kosher meals are available in most hospitals or can be obtained from frozen food suppliers. They arrive on paper plates and with sealed plastic utensils. Health-care providers should not unwrap the utensils or change the foodstuffs to another serving dish. 347 Frozen kosher meals are available on a commercial basis. Help may be needed for a patient to choose from a facility’s menu options. No milk or yogurt should be placed on a tray with meat, and butter cannot be served with bread. Even salad dressing needs to be made without dairy ingredients. If health-care providers have difficulty locating a supplier, they should contact a local rabbi. Determining a patient’s dietary preferences and practices regarding dietary laws should be done during the admission assessment. Dietary Practices for Health Promotion Many Jewish dietary practices are thought to afford the secondary gain of preventing disease, their intention is for observance of a commandment. Many Jews understand the dietary laws as a guide to raising the act of eating to a spiritual level, which is also true of the practice of washing one’s hands and praying before and after eating. Nutritional Deficiencies and Food Limitations No nutritional deficiencies are common to individuals of Jewish descent. As with any ethnic group, nutritional deficiencies may occur in individuals in lower socioeconomic groups because of the expense of certain foods. In addition to the dietary laws discussed previously, other dietary laws are followed at specified times. For example, during the week of Passover, no bread or product with yeast may be eaten. Matzoh (unleavened bread) is eaten instead. Any product that is fermented or can cause fermentation may not be eaten (Hoffman, 2008). Rather than attend synagogue, the family conducts the service (seder) around the dinner table during the first 2 nights an…
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