Remedy Before the Malady (‘Makdim Refuah Lemakah’): Tackling the Healthcare Crisis

There is a future, and in it are concealed unfathomed possibilities for good. …Striving to achieve it, if carried on with sincerity and perseverance, is itself part of the achievement. — Mordecai M. Kaplan[i]

According to a rabbinic teaching, God created the remedy before creating the blow.[ii]

In many ways, our world is not well. Maladies abound, causing senseless suffering and preventable deaths. In the United States, one such malady, ironically, is the state of our health and healthcare systems. While much of what follows is disturbing, the rabbinic teaching above offers encouragement. Change and healing are possible. Antidotes exist, but they require our effort and participation. The task ahead is daunting — namely, to redress decades of harmful policies and practices, including centuries of structural racism and other systemic barriers to equality and equity that have led to significant disparities in health and well-being. I write this piece to sound the shofar. Please do not look away.

As Jews, humans and citizens of this world, this is our collective problem, responsibility and story yet to be written. In the book of Deuteronomy (3:14), God speaks through Moses saying that what is asked of us is not beyond our reach. Our Jewish traditions offer wisdom, insights and examples for addressing our current crises.

Found throughout our Torah writ large is a teaching I believe is essential to any viable, lasting remedy. It is the understanding that each person is both an individual and a member of a larger community. Individuals have obligations and responsibilities to self, God, parents, children, elders and beyond, even to the stranger; reciprocal bonds link the individual and community, all woven together to create and sustain our social fabric, and our communities.[iii]

Kaplan succinctly explains,

Community might be defined as that form of social organization in which the welfare of each is the concern of all, and the life of the whole is the concern of each.[iv]

While there is much to celebrate regarding individual rights and autonomy, today’s social tapestries are distressingly frayed and torn.

And over the years, greed, narcissism and ruthlessness took hold. Towers populated the ravaged terrain; towers built at the expense, painful exertion, and even deaths of the many, but for the power, prestige and profit of only a few.[v]

For the past 12 years, as a chaplain and rabbi of a skilled nursing community in Greater Philadelphia, I have served some of the most vulnerable and marginalized individuals in society. People living in skilled nursing communities and other institutional settings are, for the most part, invisible, ignored and neglected by those living outside these settings.

I have also been part of a diverse workforce. Many nursing team members are Black and brown women of different ages and religions. Many nurses and nursing assistants (of all genders) immigrated to the United States from around the world. Over time, and most acutely and blatantly during the first few years of the COVID-19 pandemic, I have experienced and witnessed great injustices in the healthcare system(s) in general and long-term care specifically.

The broken system in the United States is not an isolated blemish on an otherwise just society. Rather, it results from decades of multiple forces and trends, including the commercialization and corporatization of local, independent organizations in various sectors, healthcare being one, both for-profit and nonprofit entities, with the driving forces being to minimize costs and maximize profits. While the United States spends more money on healthcare than any other wealthy nation, our health and health outcomes lag.

Healthcare eats up almost one in five dollars of American national income. No other rich country spends as much, despite making healthcare a right that is available to all, and despite their citizens having better health than Americans.[vi]

During the COVID-19 pandemic, “essential” workers could not work from home. They went into the proverbial burning building. Increased risk of exposure itself created all sorts of stresses, challenges and sacrifices for them and their loved ones. In healthcare settings, including nursing homes, countless people put themselves and their loved ones in danger just by going to work: people who ensured we had food and other essential items; people who ensured we could fuel our automobiles and those who operated public transportation; people responsible for cleaning and collecting waste from all the spaces that needed to remain open and functioning, such as hospitals and nursing homes; people who provided security for these settings. Those who went to work in the “burning buildings” exposed themselves to greater risk, and many succumbed to the deadly virus.

Many in service-oriented sectors are low-wage workers. These essential workers were already struggling and experiencing the negative consequences of systemic injustices and our broken systems before the pandemic began. The pandemic disproportionately harmed them, and the effects linger and reverberate in the lives of survivors and loved ones left behind.

It is infuriating to contemplate the great injustice of how the burden and impact of the pandemic affected segments of the population differently. Broken systems, inequality and health disparities existed before the pandemic began. COVID-19 just exacerbated and compounded matters. Poverty is at the heart of many social and environmental determinants of health and health outcomes.

Poverty and inequality are among the most pressing and persistent problems in U.S. society, and the COVID-19 pandemic underscores how perilous — and deadly — inaction on these issues can be. … The COVID-19 pandemic clearly shows that income inequality is a matter of life and death.[vii]

We are at a moment of reckoning. We must come together to create and sustain viable safety nets that are accessible and available for everyone and anyone in need. If we do not, we will have failed in pursuing values we espouse and hold dear, such as tzedek (righteousness), tikkun olam (repair of the world, kehillah (community), hesed (kindness), shalom (peace) and ahavat Yisrael (love of Jewish people). We will have shunned Torah teachings that we know are central to being a Jew, such as honoring our parents and elders; caring for the sick; feeding the hungry; and providing shelter to the unhoused. We will have blatantly repudiated the command to welcome the stranger. If we do not work together to ensure resources and supports are sustained, accessible and available to all, we will have failed in the commandment to save life (pikuach nefesh).

While there is much to celebrate regarding individual rights and autonomy, today’s social tapestries are distressingly frayed and torn.

For there will never cease to be needy ones in your land, which is why I command you: open your hand to the poor and needy.” (Deuteronomy 15:11)

As the book of Ecclesiastes teaches (1:9), there is nothing new under the sun. Safety nets go way back and can be found in the Torah! Beginning in biblical, agrarian times, the tradition of requiring individuals to contribute and care for others could be found through practices such as pe’ah: leaving the corners of one’s field unharvested so those in need can harvest food for themselves and leket: not picking up sheaves of grain and fruit that fall while harvesting so those in need can collect them. Ma’aser oni was a mandatory tithe for the poor.

In the rabbinic period, new institutions emerged, rooted in the same commandments and practices, to create systems whereby communities could care for one another and strangers in need. The rabbis defined and developed the laws and institutions to govern collective tzedakah (giving to those in need). Kuppah was the public fund that collected and distributed each week before Shabbat to those in need. Tamkhui was what we might call a soup kitchen, a collection of food and money that was collected and distributed daily.

In the Babylonian Talmud, we read a discussion about how long a person (even a temporary resident) must live in an area to be considered a part of, and therefore obligated to, the community.

And do we require that one live in a city for twelve months for all matters? But isn’t it taught … If one lives in the city for 30 days, he must contribute to the charity platter [terumah] from which food is distributed to the poor. If he lives there for three months, he must contribute to the charity box. If he lives there for six months, he must contribute to the clothing fund. If he lives there for nine months, he must contribute to the burial fund. If he lives there for twelve months, he must contribute to the columns of the city [for security].”[viii]

These examples illustrate the longstanding understanding of the importance and of the necessity for individuals to comply with mandatory contributions to the communal, collective pot of resources.

Maimonides explains in his Law Code, the Mishneh Torah, Gifts to the Poor, that, “In every city in which Jews live, they are obligated to appoint gabbai tzedakah who must collect tzedakah from each person and distribute tzedakah to each person in need.[ix] It is unsurprising, therefore, that numerous mutual aid groups, benevolent societies, orphanages and homes for the aged emerged wherever Jewish communities sprang up throughout the United States. Between the late nineteenth century and mid-twentieth century, these Jewish aid organizations and the communities that supported them created safety nets for the benefit of many. At the same time, other ethnic, immigrant and religious groups built and sustained their institutions for distributing aid and providing support and resources to those in need. And additional resources and opportunities emerged through government efforts, such as the New Deal.

By the time the RRA was created in 1974, the safety nets, strong government and community support for them had already started to disappear.

Social scientists Robert Putnam and Shaylyn Romney Garrett call this remarkable period in the U.S. history, roughly 1913-1970, the Great Convergence. One of the most striking trends during this period was how much the wealth and income gap narrowed, and how much the middle class grew.[x]

Between the mid-1960s and today — by scores of hard measures along multiple dimensions — we have been experiencing declining economic equality, the deterioration of compromise in the public square, a fraying social fabric and a descent into cultural narcissism.[xi]

By the time the RRA was created in 1974, the safety nets and strong government and community support for them began to fray and disappear. Putnam and Garrett call this period (the one we are in today) the Second Gilded Age. Gains from the Great Convergence have been and continue to be reversed. Instead of working together to spread benefits and resources and raise the lower, working and middle classes, the trend shifted to maximizing individual gains and personal benefits, no matter the cost to others.

If today’s income was distributed in the same way that 1970 income was distributed, it is estimated that the bottom 99 percent would get roughly $1 trillion more annually, and the top one percent would get roughly $1 trillion less.[xii]

For both the United States at large and among the Jewish community, we have allowed communal institutions, many that had existed for decades (in some instances for more than a century) to recede and disappear. All the while, the numbers of people in need and the extent of their unmet needs, including spiritual ones, for survival, health and well-being have continued to increase. We — and here I want to specifically call out rabbis — have also let the burden of providing care and services to those in need fall on the shoulders of an ever-decreasing number of people.

Don’t tell me what you value. Show me your budget, and I’ll tell you what you value. (President Joe Biden)[xiii]

When I began the program at the Reconstructionist Rabbinical College in 2006, Hiddur: The Center for Aging and Judaism was a strong presence. I attended many Hiddur programs and looked forward to interning for Rabbi Dayle Friedman during my fourth year at RRC. During my last year in rabbinical school, I interned at the Abramson Center for Jewish Life. Along with countless others in Philadelphia, I had precious access to innovators and innovations in aging and spiritual care. We had much to look forward to and be optimistic about in these areas. Little did we know then that Hiddur would need to close less than 10 years after it began and that the Abramson Center for Jewish Life would be sold in the fall of 2020 during the height of the COVID-19 pandemic.

I have spoken with several rabbinic colleagues who work in the field of Jewish chaplaincy and asked what they think has changed the most. They identified two changes. First, they talked about the professionalization of Jewish chaplaincy; they all agreed this was a positive change. Over the years, clinical pastoral education (CPE) has become more standardized. Educational requirements and areas of proficiency have been identified and emphasized.

Around the early 1990s, the first Jewish CPE instructor began teaching clinical pastoral education. In a relatively short period of time, the number of Jewish CPE instructors and supervisors has increased significantly. Furthermore, because of these changes and developments in clinical pastoral education, many rabbis have pursued extensive training to become board-certified chaplains. In short, there are many highly skilled and qualified Jewish chaplains, and there is a great need for their expertise, skills and services.

Nevertheless, over the years, funding to support the work of these Jewish Chaplains, along with institutional infrastructure connecting people in need of spiritual care with these chaplains, has diminished, and in some instances, ceased altogether. This change is troubling. Anecdotally, I have watched funding for Jewish chaplaincy programs, including internships, shrink and disappear over a relatively short period. As funding disappears, so do spiritual care positions. And yet, the need for spiritual care has not decreased; if anything, it has increased and intensified. So  much invaluable good could come from investing in, sustaining and growing Jewish chaplaincy positions, programs and services.

Do not reject me in my time of old age. (Psalms 71:9)

The status quo is unjust and unsustainable. Beginning in 2011, the Baby Boomer generation began turning 65. Each day, around 10,000 people in the United States turn 65. The U.S. population age 65 and over grew nearly five times faster than the total population from 1920 to 2020.[xiv] As people live longer, their needs for medical care and treatment increase, including their need for long-term, residential care. We need to change course — if not because it is the right thing to do, then out of purely selfish reasons for the well-being, safety and health of ourselves and those we love.

Along with the community and the greater society, we rabbis have let the burden of providing care and services to those in need fall on the shoulders of an ever-decreasing number of people.

There will soon come a time when even people with wealth and access to the best hospitals will be turned away or forced to wait in the hall or other makeshift holding pens because a bed isn’t available. For some, this has already happened.[xv] People and supplies are finite. The deleterious effects of over-worked frontline workers, including nurses, doctors and other care providers, who continue to work despite staffing and supply shortages, will only worsen.

While much improved during the Great Convergence, social ills remained. There is no utopia for us to return to nostalgically. Instead, we must learn from the past and do our part to move the arc of justice and to manifest values and teachings central to our Torah and identity: to care and provide for the most vulnerable, to welcome the stranger, to honor our elders, care for the sick … to understand that each of us must contribute and participate because our destinies are linked. Thomas Piketty describes a just society in a way that I find compelling:

A just society is one that allows all its members access to the widest possible range of fundamental goods. Fundamental goods include education, health, the right to vote and more generally to participate as fully as possible in the various forms of social, cultural, economic, civic and political life. A just society organizes socioeconomic relations, property rights and the distribution of income and wealth in such a way as to allow its least advantaged members to enjoy the highest possible life conditions.[xvi]

The future and past call out: contribute, participate and care. Those of us who have been on the frontlines providing direct care and services ask you to step up, show up and help. We are in this current predicament because we, members of the Jewish community writ large, and residents and citizens of the United States, have benefited from the status quo while others have been exploited and their health and well-being compromised and harmed. But now, as more of us are aging, we are starting to experience the limits and the holes in the resources available, even for the most privileged. And after COVID-19 forced many to see how broken our systems are and to see people who are usually invisible, we cannot claim ignorance. The only way forward, I believe, is for us to work on this together, collectively. It should not, it must not, be left to a few to face on their own. I remain committed and hope you will join me. It is not up to us to complete the task, but neither are we free to desist from it.

  1. [i] The Future of the American Jew (1967), p. 272.
  2. [ii] BT Megillah 13b:12
  3. [iii] I say communities because today, especially with the internet, we can be connected to people and communities spanning the globe and communities that vary, for instance, based on shared interests, identity and causes.
  4. [iv] Kaplan, p. 325.
  5. [v] Excerpt from Divrei haRav Gavriela bat Barukh veSarah, aka Erica Steelman.
  1. [vi] Angus Deaton, Economics in America: An Immigrant Economist Explores the Land of Inequality, Princeton University Press (2023), p. 18.
  2. [vii] “Income and Income Inequality Are a Matter of Life and Death, What Can Policymakers Do About It,” AJPH: A Publication of the American Public Health Association, August 31, 2021.
  3. [viii] BT Bava Batra 8a:15.
  4. [ix] Maimonides, Mishneh Torah, Gifts to the Poor, 9:1-2.
  5. [x] Robert D. Putnam and Shaylyn Romney Garret, The Upswing: How America Came Together A Century Ago and How We Can Do it Again, Simon and Schuster (2020). It is interesting to note that more than half of Mordecai Kaplan’s life and most of his career coincided with the Great Convergence.
  6. [xi] Putnam and Garrett, p. 11.
  7. [xii] Putnam and Garrett, p. 40.
  8. [xiii] “Remarks by President Biden Announcing the Fiscal Year 2023 Budget.” March 20, 2022. The White House, Briefing Room.
  9. [xiv] Zoe Caplan, “U.S. Older Population Grew From 2010 to 2020 at the Fastest Rate Since 1880-1890.” May 25,2023. U.S. Census.
  10. [xv] See Kuttner, Robert, “Casualties of a Failed Health Care System,” The Prospect. February 6, 2024.
  11. [xvi] Thomas Piketty. Capital and Ideology. p.967f.

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