Purity and Circumcision

Purity – Parashat Tazria & Metzora (פרשת תזריע־מצרע)

by

Howard Adelman

When I explored the interpretations of Aaron’s response – silence – to the death of his two oldest sons at the hands of God because they had contaminated the holy of holies by not observing the precise instructions to be followed in performing a sacrifice, I did not explore the objective circumstances which ostensibly gave rise to those two deaths and the issue of ritual purity that dominates not only the Aaron story, but this whole section of Leviticus and, in particular, the parshah for this week. Those dictates governing purity entail not only the issue of sacrifice in the holy of holies, but also, for example, the ritual of purification when a woman immerses in a mikvah and when a male Jewish infant is circumcised on the eighth day of his life.

Purity is, and always has been, a health issue. This is clear in the discussions of tzaraat, usually translated, and for many, mistranslated, as leprosy, but which might be black mold, psoriasis, a terrible rash or Hansen’s disease. Purification using spring water, two birds (!), a piece of cedar wood, a scarlet thread and a bundle of hyssop is involved so that a contemporary reader may suspect that he or she is reading about voodoo medicine. However, I want to concentrate on brit milah, ritual circumcision of male infants, rather than treatment of tzaraat or immersion in a mikvah following a woman’s period of menstruation or as integral to a process of conversion.

In the mikvah ritual, purification is said to be necessary because the discharge of female blood into and through the vagina is viewed as impure. In the brit milah of an infant male, blood is spilled to bring about purification. Or is the process for the purpose of purification? After all, there is no suggestion that the foreskin is impure, only the possibility in modern science that retention of the foreskin may create a greater propensity for accumulating impurities.

Let me expand on this latter issue, if only to get it out of the way. (An article by Aaron E. Carroll in The New Health Care, 9 May 2016, explores these issues more deeply.) The judgement of the net benefits of circumcision to health has seesawed back and forth between an estimate that health benefits of circumcision are not significant enough to inflict pain on the infant to the 2012 conclusion of the American Academy of Pediatrics restoring an older determination that the health benefits outweighed any risks involved in the procedure, especially if the procedure follows strict purity rules. The implication was not that every male child should undergo circumcision, but that circumcision should be available to every male infant and be covered by health insurance for significant savings in health costs over the long run.

Why? Circumcised penises have lower levels of yeast and bacteria. Higher levels of the latter are correlated with greater risk for developing urinary tract infections. Thus, the chance of a boy contracting a urinary tract infection is ten times greater for a male with an uncircumcised penis than for a male with a circumcised penis. But the benefits are too small to make male circumcision mandatory since the incidence of urinary tract infection is so low that perhaps only 1 additional male in 100 would be prevented from contracting a urinary tract infection if the practice of male circumcision was made universal. This is particularly true because correlation does not entail causation; other factors may be more significant as causes –parents of circumcised male infants may culturally wash penises more regularly, as may adult males. No one knows.

However, other risks of disease are reduced – penile cancer (again, relatively rare), H.I.V. and other sexually transmitted diseases like gonorrhea, syphilis or herpes. The only statistical benefit that emerges as very significant is the chance on contracting H.I.V. – a 1-2% reduction in the rate of the disease when males are circumcised. Male circumcision can be considered preventive, akin to getting a vaccination.

What is the downside? Medical complications from the procedure. Arguably, reduced sexual satisfaction, but little evidence to support such a belief. But the only issue of any significance is the pain inflicted on the male infant. Many would argue that the pain is minimal when local anaesthetics ae used and very short lived – in contrast when the procedure is performed on an adult male.

There is also the issue of social benefits to health and not just individual benefits. Perhaps an argument can be made in terms of society benefit resulting from lower rates of sexually transmitted diseases, especially H.I.V., which is why vaccines are almost mandatory. Again, the economic benefits to society as a whole are small compared to the claim that the rights of the child are infringed upon by the commission of intentional harm without significant benefit.  The pinprick of a vaccination needle does not change the body. Male circumcision does.

On balance, the case for male circumcision becoming a community wide standard practice is more positive than negative, but, unlike fluoridation of water, which also results in somatic changes – strengthening teeth and the resistance to dental caries – the health benefits of male circumcision are relatively marginal.

In other words, the issue of male circumcision of an infant at eight days of age is ultimately much more an issue of religious ritual purity rather than physical purity or health.

Rabbi Jonathan Sacks wrote that, “Circumcision is the physical expression of the faith that lives in love.” Sanctification transforms the connection between sex and violence to a connection between sex and love. His argument boils down to infant circumcision defining the relationship of a man to his wife, turning biology into spirituality, converting the male propensity to want to reproduce to perpetuate his genes to a partnership of man and wife, a partnership of mutual affirmation. Sacks is clearly a feminist. Power is sacrificed in favour of love and relationship, not only between a male and his female partner, but between man and God, between God and the people of Israel, God’s wife. Purity entails staying monogamous; promiscuity is a betrayal of both God and one’s wife. Baal must be transformed by circumcising male power and transforming sex in the process from an act of biological drive to a choice of love, to a covenantal rather than a power relationship.

As much as I sympathize with the goal, I do not buy into this romanticizing of the ritual of circumcision. For it is a ritual between a father and son, between God and a male Jew. In actuality, the mother usually stays in another room because she is so fearful and appalled by the pain being inflicted upon her newborn infant. Since the event – barring exceptions because of the health of the newborn – takes place on the eighth day, and the world was created symbolically in seven days, Rabbi Sacks may be on the right track in suggesting that the brit is a first stage in transforming the laws of nature into cultural practices on route to creating a civilization. But what precisely is unnatural about the act of circumcision?

It may also have to do with the Jewish conception that practice precedes faith. Do it and you may come to understand. Hence, not only must the procedure shunt aside any “rights of the child,” but it cannot be left until the male is older or even an adult when it is much more painful as well as a greater risk. Further, it is an exercise in branding, in implanting in the flesh a spiritual message. But it is not like a tattoo on the arm. It is the foreskin of the penis that is cut, not because it is a lowly organ as some Jewish puritans contend, but because it is central to propagation – both to physical propagation and to Jewish continuity. The transformation of male/female relations could qualify, except that there is little indication that the circumcision has anything to do with sex.

What could it be about? The bris physically symbolizes the relationship between God and the Jewish people as indicated when Abraham, at the age of ninety-nine, circumcised himself as a brand upon his flesh signifying the covenant that he had made with God. There is no mention that God empathized with that pain and experienced suffering because of it. But Abraham not only suffered pain when he circumcised himself, but suffered a much greater pain when he was commanded to sacrifice his son. (Genesis 21:4) The circumcision commemorates Abraham’s pain much more than that of an infant eight-day-old male.

When a father, even if only through a surrogate, cuts the foreskin of his own son, the pain is direct and not just in the imagination as it is for the mother. When a father marks his son with a permanent alteration in his son’s flesh, in one of if not the most significant organs of the male as a male, then the issue is at its core about the willingness, against all one’s personal sympathies for the child, to inflict pain on one’s own son.

God does it to man. (Women suffer naturally in childbirth.) A father does it to his son. The ritual is akin to the one the priest performs when incense is brought daily before God. The latter must be done with exact precision. So too must the circumcision of the infant child be. Further, it must be an act carried out in great sobriety and with proper preparation. But with help from the community – the mohel who serves as the surrogate, the sandek who holds the child’s legs apart, the kvatters, the messengers who carry the infant on behalf of the grief-stricken mother. Though the brit milah is a celebration, that takes place afterwards. The ritual up to that point is about sacrifice and pain. The infant brought forth to have his foreskin sacrificed and to be made part o those blessed.

Why blessed? Cutting a penis and calling it a blessing, inflicting pain on an infant and calling it highly significant, that is the real dilemma of the ritual. The actual pain may be slight and the health benefits may be real even if not huge, but the ritual is clearly what the ceremony is about. It is an irreversible act entailing the sacrifice of a symbolic token of flesh taken from an organ of male reproduction to point to the need, not to just reproduce children, but to reproduce male children with a mark cut into them, a mark indicating a covenant.

That is the crunch point. What is the covenant about? Some take it to be about strict obedience to God’s commands. But the Jewish people continually challenged God. The relationship was not a pacific one. There were thrusts and parries. But at all times, in your heart – God could even kill your two oldest sons – even if God’s act was disproportionate and wrong, it was not perceived to result from malice, but for one’s own good.

So too the action of the father. However a father fails his son, it is not out of malice. A father must not only teach his son that he loves him, but that the son must never absolutely trust his father. Even one’s own father can give one pain, and do it when one is most vulnerable. Rather than teaching absolute obedience and absolute perfection of a father-figure, even a father you love can betray your trust, can betray your faith.

A Jewish circumcised male is given a permanent reminder both that he cannot trust his penis, which seems to have a “mind” of its own, but cannot even absolutely trust his father. Distrust, not absolute faith, must be an integral part of the relationship between man and God, between a son and his father, and between humans and their relationship to authority figures.

Leviticus 10:10 reads, “You are to distinguish between the holy and the common, and between the unclean and the clean.” Circumcision is the first step in making a Jewish male infant into a holy being, not holy because he surrenders himself in total faith to another, but because he is branded in his flesh to always distrust another no matter how much he loves and respects that other. To be clean is not to be immaculate. Pure faith is restricted to the holy of holies. However, it is the wholly holy which is unclean in the analogy. To be clean is to engage in the right balance between trust and distrust, between total trust in one’s father and also guarded that even a loving father can betray you. Purity must be applied to the ordinary, to the common, to make sure the flesh is not contaminated. But purity of the spirit does not belong in the common, in the flesh, for in this world we need both trust and distrust.

To quote a blog I wrote a year ago: “If a father who so loves his long longed-for son, no one more so than Abraham, is capable of cutting his eight-day-old son, and cutting him in his sexual organ, inflicting pain, however minimal, where the son will carry the badge of a Jew, in his flesh and in his psyche, for his entire life, then the message tattooed in the flesh is that no one can be completely trusted – including God in Judaism in contrast to Christianity.”

Part III Obama and Haley on Health Policy

Part III Obama and Haley on Health Policy

by

Howard Adelman

Obama boasted that the overseas health policy of his administration had been successful in stopping Ebola in its tracks and significantly reducing the scourge of HIV/AIDS. These were successes, not only in other countries, but were important in keeping Americans safe from these diseases. Obama had now set his regime on the path of eliminating malaria. But the criticisms ignored these successes and focused on the alleged failures of Obamacare (the Patient Protection and Affordable Care Act otherwise known as ACA) for raising insurance premiums significantly and eliminating a patient’s choice of his or her physician. Were Haley’s critiques on these two issues warranted? What were other successes and failures of Obamacare? For the major issues were not just the costs of health-care insurance coverage and access to care.

First some disclosure. When I was a medical student in the late fifties and Canadian Medicare [C-M] had not yet been invented in Saskatchewan by Tommy Douglas, I once dared to raise the issue of socialized medicine with our clinician whom our team had taken out to dinner. Two of my fellow students, those on either side, both kicked me under the table. Among the vast majority of doctors, discussing a state-run medical plan with access guaranteed to all was a no-no at that time.

When I lived in the intern quarters at Mt. Sinai Hospital in Toronto (I was not an intern) and worked in radiology, I conducted a number of survey experiments. One was to track the topics of conversations when physicians ate in the cafeteria. I was instructed to sit with them and not the nurses or other health service workers. (After all, this was 1958.) As one result, I found that 53% of conversations by physicians focused on patients who did not pay their bills and the problems of collection.

I offer this background to indicate both my bias and that of many physicians not exposed to some form of Medicare. But more guidance is needed than revealing biases. I use the designation C-M to differentiate the Canadian plan from the American Medicare prior to Obamacare that provided health insurance for seniors. When C-M was introduced, first in Saskatchewan and then eventually across Canada, doctors’ salaries immediately increased. The reason was simple; the problem of delinquent patients as well as the costs of collection had been eliminated in the single-payer system. Though increasing numbers of physicians gradually came around to acknowledge that C-M was an improvement in most ways over the previous system, many continued to gripe about the system nevertheless. Because of my bias, physician bias and the inevitable bias of many, I will refer only to the work of independent analysts.

C-M eliminated the problem of unpaid bills and collection. Obamacare has not. In fact, some evidence indicates that Obamacare has possibly exacerbated the problem. For example, problems of reimbursement to hospitals and physicians were virtually eliminated by C-M. In the U.S., while reimbursement to hospitals has been greatly improved, under Obamacare, physician reimbursement has only improved slightly. In the U.S., citizens have their choice of insurance providers. They can enroll in one of a number of competing plans. But what happens if they do not keep up with paying their premiums? They lose their coverage, perhaps after 90 days of non-payment. However, the insurers are only required to pay the doctors for the first 30-day period of unpaid premiums. Medical services are provided for the remaining 60 days with the understanding that the patients are insured. But they are not. The doctors cannot collect from the insurer and will, in most cases, be unable to collect from the patient. C-M virtually eliminated the problem of collections. Obamacare, on the other hand, seems plagued with doctors’ complaints about the unreliability of reimbursement. In addition to continuing and, perhaps, even increased losses from non-payment, there have been additional bureaucratic expenses. While C-M reduced the costs of electronic record keeping since records had only to conform to the requirements of a single payer, in general, administrative overhead for electronic record keeping as well as for collections has increased for American physicians.

One result is that doctors refuse to join many plans. This forces a patient to try to reconcile the plan he/she is in with the doctor she has selected. The two are often incongruent. That physician may or may not be covered under the plan chosen. The problem becomes a tremendous one in cases of acute health problems; a patient may have to choose between paying for a physician out-of-pocket to get the physician of his/her choice and available, or be forced to find a specialist covered by the insurer.

At the same time, to keep premiums low, insurers have to press to keep payments low. The lower the payments, the fewer the number of doctors willing to be part of the referral list covered by the insurer. Insurers have to walk a fine line between keeping premiums low, and hence payments to doctors low, versus maintaining payments at a high enough level to keep doctors enrolled. In Canada, the tension between keeping premiums low was not set off against keeping doctors enrolled in one insurer versus another, but keeping doctors from migrating to the U.S., where, in many cases, especially for specialists, medicine had been a much more lucrative profession as long as a doctor was not working in a public hospital. In the U.S., the tension has shifted. If reimbursement rates to doctors remain too low under Obamacare, more doctors opt out, thereby giving patients access to insurance but at the cost of limiting access to doctors. This is not just a possibility. 70% of Obamacare plans offer access to fewer hospitals and fewer doctors than employer-sponsored group plans or pre-Obamacare individual market plans.

The Academy of Family Physicians has otherwise lauded Obamacare, because the law offers health insurance for everybody, encourages preventative care, allows children to stay on their parents’ insurance plans until age 26, and delivers insurance for people with pre-existing conditions. The major problem Obamacare addressed was access to health care (the uninsured rate since Obamacare was introduced has dropped below 12%), but the way it was structured through the compromise negotiations meant other problems were accentuated. One major problem is the amount of time an American has to spend shopping around for a suitable plan that offers access to a doctor of his/her choice and at a level of care he/she can afford.

There is another problem. Many private exchanges avoid hospitals that are part of university-based health networks because their costs are higher given their role in research and the fact that they deal with much tougher, more complex and more expensive cases. On the other side, new enrollees are likely to inadequately insure, especially if they are young, to avoid higher cost options.

In addition to the pressure towards lower payments to doctors, another problem common to both C-M and Obamacare is the increased regulation and subjecting doctors to government regulation and oversight, a problem compounded in the U.S. by the addition of non-state insurers which have their own regulatory and service demands.

Both countries face the problem of a shortage of physicians, but the problem is even more acute in the U.S. A study by Paul Howard and Yevgeniy Feyman (“The Obamacare Evaluation Project: Access to Care and the Physician Shortage,” 26 June 2013) projected that, “population growth, demographic changes, and an expansion of insurance spurred by Obamacare will contribute to a significant shortage in primary-care physicians over the coming decade. We project that by 2025, states will experience a shortage of roughly 30,000 primary-care physicians—with about 16.5 percent (4,950 physicians) of this shortage being driven by the expansion of insurance coverage under Obamacare, while the remaining 83.5 percent (25,050 physicians) will be due to population growth, aging, and various demographic shifts.”

This data is crucial, for it means that even if only 16.5% of that physician shortage is due to Obamacare, since the U.S. already fills its current shortages by the import of physicians from abroad (over 25% of physicians in the U.S.), very many of them from poor countries with an already high physician to population ratio, Obamacare could be contributing to a decline in health services in countries which are in most need of enhanced health care. Given the U.S. pattern and extent of training of physicians, one can expect the proportion of imported health professionals, not just physicians, will increase.

Doctors face the threat of deep payment cuts under the application of the U.S. Medicare’s sustainable growth rate (SGR) formula, wherein, the annual growth of Medicare physician payments is subject to an overall ceiling. Seniors covered by Medicare are affected. The competition for doctors serving them has grown as drastic provider payment cuts called for by the SGR also tend to reduce seniors’ access to care. The legislated reductions have been temporarily set aside somewhat as each year Congress overrides SGR through what is called a “doc fix.” Without it, payments to physicians might decline as much as 25%.

The same pressures on physician remuneration have taken place in Medicaid as well. For states that agreed, Medicaid covered individuals earning up to 138% of the federal poverty level, just over $16,000 last year. Numbers were expected to increase as almost 30% of the almost 50 million uninsured Americans, that is, 15 million Americans, were estimated to be eligible. Given that about half the states did not opt to enter into the program, the enrollment of 12 million in Medicaid was viewed as outstanding as the number of uninsured was cut in half. Between October and December 2013 when the program opened up, 6.6 million applications were received directly by the federal government, most of which were applications for more than one person. Many more were received through the State Based Marketplaces (SBMs) and the Federally Facilitated Marketplace (FFM) operating in 36 states, the latter accounting for 2.7 million applications alone. Expanding eligibility, introducing a simplified enrollment process, broadening the outreach and putting a concentrated effort on enrollments all resulted in Obamacare being a tremendous success with respect to access for many who lacked it. But with much lower remuneration rates (almost 60% of regular charges), access has also been limited because 1 in 3 primary care physicians refused to accept new Medicaid patients. On the other hand, although reductions in payments to Medicare Advantage plans enacted under Obamacare were expected to lead to reductions in Medicare Advantage enrollment, enrollment in fact rose, increasing by 50% to 5.6 million.

So Haley was incorrect. Obamacare has not eliminated the choice of physicians, but it has limited that choice to a greater extent than existed previously for most Americans. The benefit is that up to fifty more million Americans will have a choice to access the health care system that they previously lacked. At the same time, insurance premiums have increased as Haley stated, but this was inherent and was bound to be the case if insurers were forced to cover those with pre-existing conditions and give access to many more old people and even young people in poor health. By forbidding denial of coverage to consumers with pre-existing conditions, as well as imposing taxes and fees to fund aspects of the new law, to make up for the costs of Obamacare and still keep premiums low, insurers put pressure on both physicians and hospitals to accept payments discounted by up to 30%. What is even clearer is that, on the issue of choice of physicians or access more generally, or the cost of premiums, the problem cannot be reduced to a sound bite and the hyperbole that the choice of physicians for Americans has been eliminated.

There are many other real problems and merits of Obamacare:

  • To avoid conflicts of interest, doctors were not allowed to refer patients to hospitals in which they had an economic interest, but the cost has been to place many excellent physician-owned, specialty hospitals off limits even though they had a record of providing high-quality patient care and even though this narrowed accessibility
  • The “nonprofit” Patient-Centered Outcomes Research Institute (PCORI) promises to provide valuable data on the clinical effectiveness of medical treatments, procedures, drugs, and medical devices, but the guidelines will almost inevitably result in further constraints on the ability of the physician to have the final say on treatments and procedures when reimbursements are tied to the results of PCORI
  • Since last year, as an inevitable result of such programs, however organized, reimbursement has been adjusted to reflect performance based on the analysis of data collected, with the concomitant result that the variety of needs of patients and responses of physicians are forced into a cookie-cutter formulation with the inevitable result that an incentive develops for doctors to check the boxes which yield the highest returns for the least amount of time invested
  • Obamacare ignored the issue of medical liability and tort reform, a problem very specific to the U.S.

The reality is that a system that aspires to allow physicians untrammeled control of patient care and the patients to be the key decision makers in the financing of care is a total chimera. This illusionary utopia cannot be achieved for physician decisions, especially as one moved up the ladder of specialization; physician decisions were always subject to checks and balances, including checks imposed by payers that have significantly increased both under a state model and a purely free enterprise model.  The vision of patients being in control of financial decisions was the nonsensical partner to this illusion, for the only real partners were the wealthy who could afford to pay for what they wanted. The middle class had to choose only what they could afford and a whole swath of Americans was denied any choice at all.

With the help of Alex Zisman

Turkey – Domestic Changes

Turkey – Domestic Changes

by

Howard Adelman

I begin with domestic matters because they help understand the direction of the Turkish leadership. Tomorrow I will take up foreign policy.

Sixty-year old Recep Tayyip Erdoğan, the founder of the Justice and Development Party (AKP) Turkey’s current president and former prime minister for the last eleven years, and mayor of Istanbul before that, has transformed Turkey domestically and certainly redirected Turkey’s foreign policy. Erdoğan is to Turkey what Putin is to Russia. After founding his new party in 2001, that party in the Turkish elections of 2002 took two-thirds of the seats in Parliament. A year later, after his banishment from politics was overturned and his then ally, Abdullah Gűl, served as interim Prime Minister for a year, Erdoğan became Prime Minster. Only this year did he assume the role of President after converting the Turkish political system from a parliamentary to a quasi-presidential democracy by shifting the largely ceremonial role of president to the most powerful figure in the country. However, in contrast to his earlier victories, he only won the presidency with less than 52% of the vote. However, he has set up a shadow government of directorates to monitor Prime Minister Ahmet Davutoglu and his Cabinet who all come from his own party.

Control of the Media

Unlike Russia, where corruption and control of the media have allowed Putin to undermine the nascent democracy of Russia, Erdoğan has not achieved the position yet. Events, however, are changing the situation rapidly. Though Erdoğan seven years ago began arresting critics in the media whom he accused of being the propaganda arm of a coup effort, only in the last two years has he revealed himself to be determined to assert absolute control over the media. Yesterday afternoon I received news that Ekrem Dumanli, the editor-in-chief of Zaman, Turkey’s top-selling newspaper, and Hidayet Karaca, the director of STV, a news channel, had been rounded up two days previously by Turkish police. The mysterious twitter account, Fuat Avni, had three days before that predicted these arrests and that of 150 or so other journalists. Some of these have gone into hiding. The charges: affiliation with the Fethullah Gulen movement, Erdoğan’s once erstwhile ally in overcoming the stranglehold the military held over the state, and an alleged conspiracy to undermine and/or attack a small rival Islamist group, the “Tahsiyeciler”, a group whose leaders Erdoğan had arrested only four years earlier who follow the teachings of the Islamic scholar, Said Nursi. Is it a wonder that Turkey ranks 154th on the world press freedom index, according to Reporters Without Borders?

The attacks on the domestic press were matched by a vicious campaign castigating the foreign – particularly Western – press of distortions, disinformation, ignorance, lying and even spying. Ceylan Yeginsu, a journalist working for the New York Times, that in its editorials had once lauded Erdoğan for his leadership role in the emerging Turkish vibrant democracy, had to flee the country for his life after being attacked in the AKP-controlled press and receiving multiple death threats. When Erdoğan himself was not deriding the Western press for being propagandists and undermining the new Turkey, that role was taken up by Ibrahim Karagul, editor-in-chief of the pro-Erdoğan newspaper, Yeni Safak, and the new English newspaper in Turkey, Daily Sabah, initially owned by Erdoğan’s son-in-law. And this is just the surface in this information war that permeates the electronic media as well.

Turkey’s Deteriorating Democracy

So much for the hopes for democracy in Turkey once the military had been removed from power in the name of rule by and for the people. That populism has been enhanced by the distribution of free coal to the needy. However, the crushing of the Gezi Park protests in the summer of 2013 was just more public action in a coordinated effort to destroy any opposition in Turkey. The cronyism and corruption that is endemic and very widespread in Turkish society has permeated the AKP (one in five Turks and about 50% of businesses pay bribes to access public services). The effort to protect ill-gotten gains once that corruption had been revealed by the Fethullah Gulen movement have led the government to place a publication ban on the parliamentary committee looking into corruption. At the same time, Turkey has followed the lead of the Canadian parliament under Harper’s Conservatives of passing legislation through complex omnibus bills with relatively little time for debate. The bills in Ankara include provisions which infringe human rights protections.

The corruption scandal possibly accelerated the leadership’s plans to enhance its control of the media. Turkey has slipped from 53rd to 74th on Transparency International’s corruption index. Further, that corruption as well as increasing disparity between the rich and the poor are now being legalized as a new presidential provision permits young Turkish men to buy out their compulsory military service for $US8,700. Turkish writer and 2006 Nobel Prize winner for literature, Orhan Pamuk, has also denounced Turkey’s increasing climate of fear.

Educational Revisionism and Social Policy

In addition to its educational reforms that provided free textbooks for needy students, Erdoğan and his allies have pushed for making Ottoman Turkish compulsory in schools, introducing more and more elements of Ottoman culture into the curriculum, introducing segregation of schools by gender, and introducing Islamic religious instruction for students in fourth grade and higher, and planning to introduce such education at even lower grades in the face of EU demands that compulsory religious education requirements be scrapped. In the meanwhile, the educational authorities have eliminated human rights and democracy classes previously taken in fourth grade. These changes have taken place in parallel with the long term trend of religious cleansing of non-Muslims in Turkey as property disputes affecting the Armenians, Syriac church and the Yazidis drag out through the bureaucratic and legal process.

Unfortunately, at the same time, Erdoğan has pushed for technological modernization. Language, cultural and religious revisionism are difficult to blend with modernization that becomes self-propelling and innovative instead of simply copying from the West. Thus, Turkey ranks last among 44 countries on the English proficiency list, even though English is compulsory in Turkish schools. Raising a generation of devout Muslims may be at odds with encouraging technological innovation. Turkish pupils, along with other pupils from predominantly Muslim countries, are in a race for the bottom. Turkey now ranks 44 out of 65 countries in the measurement of 15-year-old educational achievements in mathematics, science, literacy and problem-solving.

The social indicators have been very bad. Child poverty has risen by 63.5%. With 301 minors killed in the disaster at Soma this year, Turkey had by far the worst record of workers’ deaths compared to any European state. On the gender front, the news is even worse. Although Erdoğan in 2004 passed a new penal code protecting women’s sexual and body rights, and although Erdoğan has promoted changes in the treatment of women in the army by increasing the number of female officers and NCOs to facilitate dealing with terrorism and to enhance the professionalism of the military, on 24 November he claimed that gender equality contradicted the laws of nature even though 22% of AKP seats were held by women.

Erdoğan, however, is a champion of motherhood rather than sisterhood. In spite of an enormous increase of almost 40% in GDP per capita under his rule, there was still only a 30% female participation rate in the workforce. His policies threatened to exacerbate the health, education and income disparities between men and women already deeply rooted in Turkish culture. Not to speak of honour killings! While not as bad as the situation in Pakistan, those murders still take the lives of 200 Turkish girls each year in spite of the 2004 law designed to combat such crimes. Between 2002 and 2009, the murder rate of women in Turkey went up 1400% and since Erdoğan came to power, 7,000 Turkish women have been murdered. On the UNDP’s Gender Equality Index, Turkey’s standing has slipped from 69th to 77th out of 187 countries.

When my brother, a renowned Canadian cardiologist, was invited to Turkey in 1996, and where they first diagnosed him with a blastoma after he had fainted on a golf course where he had gone to play with other Turkish doctors, Al had been very impressed with the advanced state of medicine in Turkey in the hospital he had visited. Now Turkey seems to be moving backwards in time to revive traditional medical practices including:
• acupuncture (the stimulation of specific points along the skin with thin needles)
• apitherapy (the use of honeybee products for treatment)
• phytotherapy (treatments based on traditional herbalism)
• hypnosis
• the use of leeches
• homeopathy
• chiropractic treatments
• wet cupping
• larval therapy (the introduction of live, disinfected maggots into the skin)
• mesotherapy (the injection of special medications into the skin)
• prolotherapy (the injection of irritating solutions into an injured spot to provoke regenerative tissue response)
• osteopathy (nonsurgical treatments of the muscle and skeleton system)
• ozone therapy (the introduction of ozone and oxygen gas mixtures into the body)
• reflexology (massage-like treatment of pressure on reflex areas).

The issue is not the legalization of these treatments, but making them part of the education in medical schools. Some, like the use of leeches, are already part of modern medical practice. Others, however, have not been validated by science. So in addition to taking time away from enhancing modern medical practice, practices which have not yet been validated by science will be introduced into the medical curriculum. Further, the system of independence in educational decisions by qualified professionals is being undermined by state dictates in favour of validating traditional culture.

There are those who posit that this is merely a method of bringing traditional medical practices under state supervision. Then why are the costs of those treatments not covered by public health insurance? Some argue the expansion has been introduced to enhance medical tourism. Further, Turkey is far from unique in allowing and regulating such practices.

Standing in opposition to these rationales, one of the indicators to the undermining of scientific medicine has been the lethargic response to a rise in measles which has been blamed on the large number of Syrian refugees who have found a haven in Turkey, rising from very low numbers – 7 cases in 2010 – to over 7,000 cases last year. No provision in the Turkish 2015 budget targets contagious diseases like measles. Further, excluding Syrian refugee births, infant mortality and maternal deaths increased in 2013 for the first time since 1945.

Crime has also increased, much as a by-product of the Syrian civil war. Almost 500 high quality 4x4s have been stolen from Turkish car rental companies for transfer to Syria.

Kurdish Separatism

Erdoğan has to be praised for beginning the process of recognizing the Armenian genocide, enhanced by Pope Francis’ recent visit to Turkey, but with little sign of real progress. Erdoğan is perhaps best known for pushing reconciliation with Kurds who had been forcefully resettled in the thirties and banned from using their language. He has even entered into discussions with the PKK (the Kurdistan Workers Party) itself. However, while now allowing school children to be taught in Kurdish, would Kurds also have to learn classical Ottoman Turkish? Further, was Erdoğan strongly motivated to make peace with the PKK early in his national political career because he respected the group rights of the Kurds or because he wanted to undermine the rationale of the military for maintaining a relatively large army while, at the same time, solidifying his support with the Turkish public?

One very much suspects the latter given his subsequent career in national politics in Turkey and seemingly confirmed by the recent decision on December 10th in the face of the adjacent threat of Islamic State to enable middle and upper class military recruits to buy their way out of national service, a decision made without any consultation with the military general staff as required by the Turkish constitution. However, Erdoğan has never seemed to care about the constitution when it is to his populist advantage (currently an average Turkish citizen contributes about US$200 for each member of the family for defence) and when it undermines support for his critics on the left who were bound to vigorously oppose the move’s inegalitarian character. Further, if, as projected, 700,000 young men pay the state $8,700 each (men older than 30 pay US$13,300), US$5.7 billion will be added to state coffers from the men under 30 years of age alone, especially since parliamentary elections are to be held in June 2015. This is in addition to the monies saved on defence. The loans men are taking out to pay for the exemption in response to a spate of bank ads and the sales of unproductive capital (property, gold rings) has already acted within days to stimulate the economy. The greatly increased revenues to the state may be bad for the economy in the long run, but, in the short run it is much more than enough to pay for Erdoğan’s vain, enormous, lavish and enormously expensive presidential palace.

Is Erdoğan’s populist and Islamic program complemented by his foreign policy?