Purim, Hamantaschen and the stories we invent.

Haman and his three-cornered hat

The Jewish holiday of Purim falls on the 14th day of the month of Adar.  In 2020 this will correspond the evening of Monday, March 9, and ending the evening of Tuesday, March 10. In the Jewish calendar, days start at sunset.

The festival of Purim commemorates the salvation of the Jewish people in ancient Persia from Haman’s plot “to destroy, kill and annihilate all the Jews, young and old, infants and women, in a single day.” as recorded in the Megillah (the Book of Esther).

The short version of the story is that in the fourth century BC the Jews were Persian subjects.  During this time, the King of Persia, Ahasuerus, found himself a widower after having had his wife executed for not doing something he asked of her with adequate alacrity and due diligence.  In order to find a new wife, he held a beauty pageant.  A Jewish girl named Esther proved to be the most attractive contestant, winning herself the crown, rather literally.  Persia’s prime minister, a man who bore immense animosity toward the Jewish people, managed to take insult from Mordechai, the leader of the Jews and a close relation to beautiful Esther.  Mordechai convinced King Ahasuerus to issue a decree calling for the annihilation of all the Jews in Persia on Adar the 13th, a date apparently chosen by lottery.  When the king realized that Esther was Jewish, plans were altered in the nick of time and Haman was hung instead.  

Thus, Purim is a holiday celebrating a close call, a reason for an uncharacteristically wild and drunken party.  Children and a fair percentage of grownups dress in costumes and a goodly portion of the people, especially the more religious, get drunk. The Babylonian Talmud offers specific instructions; “One is obligated to drink on Purim until one doesn’t know the difference between ‘cursed be Haman’ and ‘blessed be Mordechai.’”  Many observant, normally very sober people, strive mightily to meet this challenge.

One is obligated to drink on Purim….

There are specific foods for the holiday, in particular triangle shaped pastries called hamantaschen.  In our family we fill these with a paste made from ground poppy seeds and raisins and sometimes with prunes.  We annually order half a kilo of poppy seeds from Western Herbs in order to make this filling from scratch in our kitchen.  

I was taught as a child that the triangle shape of the hamantaschen represents Haman’s triangle shaped hat.  You will be hard pressed to find a Jew anywhere on this continent who did not learn this same explanation. This is the story we all grew up with. [1] [2]

An Israeli friend of ours, a graduate student attending the Korbel School of International Studies here in Denver, laughed when she heard us tell her about Haman’s three cornered hat.  As an undergraduate in Israel, she had studied Biblical History.  She explained what historians have long known about Purim.  The  reason that Purim seems so different from other Jewish Holidays is that it originated during exile and was a toned down version of the Persian New Year festival that “… consisted of a ten-day carnival, during which the people drank, feasted, staged processions, and had sex with people other than their spouses.” [3]  Ishtar became Esther in this cultural celebratory appropriation.  Our Jewish version of this carnival-like drunken party seems out of character because it truly is.  In fact, it is a toned down version of the far wilder pagan holiday it was copied from. The Hebrew priests did all they could to rein in the orgy; they shortened the length of the party from 10 days to 2 days, kept the drunkenness and costumes but eliminated the spouse swapping.  The triangle that was symbolic of this sexually focused Ishtar celebration was preserved. Think of the triangle as representing the anatomy covered by the lower triangle of a bikini bathing suit.  If the modern Woman’s March gave us pussy hats than we must remember where hamantaschen came from, a Babylonian orgy.  Haman’s hat, my foot!

Watching how my brain has processed this information since I first heard the story has been fascinating.  I could not immediately accept this idea; a life time of looking at (and eating) hamantaschen and seeing them as funny hats does not instantly convert to an image of genitalia.  

Still this new view has been an intellectually stimulating experience, the process of substituting a new belief for an accepted belief.  

Learning to adapt to and adopt new information may be one of the most important skills we acquire as physicians.  Medicine is no longer a system of facts that we must learn but a skill that we acquire that allows us to be forever flexible in the way we understand biology, health and the practice of medicine.  

In a recent meta-analysis of more than 3,000 studies that had been published from 2003 through 2017 in JAMA and the Lancet, and from 2011 through 2017 in the New England Journal of Medicine, Vinay Prasad of Oregon Health and Science University, and colleagues concluded that more than one in ten of the studies amounted to a “medical reversal”, that is the conclusions of the study reversed what had been conventional wisdom.  What we view as pathway of stepping stones made of facts, is more like a lily pond in which nothing will support your weight.  [4]

Vinay Prasad, is quoted in the NY Times: “You come away with a sense of humility, Very smart and well-intentioned people came to practice these things for many, many years. But they were wrong,”  [5]

What do we call things we once thought were true that have been disproven?  Do they become myths?  How long does it take to migrate from fact to myth?  What percentage of people, or doctors, or scientists have to believe the new version of truth before it becomes real?  Asking questions like this in this day and age of fake news could lead us down a black hole rather quickly.

Some of these ‘decommissioned ideas’ are relevant to naturopathic practice.  I clearly recall thinking these were true that no longer are.  It’s what we learned at school. Prasad reminds us of a number of them in his article:

  1. Peanut allergies occur whether or not a child is exposed to peanuts before age 3. Keeping babies away from peanuts until they are three makes no difference in reducing allergies.[6]
  2. Fish oil does not reduce the risk of heart disease.[7]
  3. A lifelike doll carried around by teenage girls will not deter pregnancies.[8]
  4. Ginkgo biloba does not protect against memory loss and dementia.[9]
  5. Aspirin and ibuprofen work as well as opioids to relieve pain in the ER. (not to mention safer)[10]
  6. Testosterone treatment does not help older men retain their memory.[11]
  7. keeping your house free of dust mites, mice and cockroaches will not reduce asthma attacks.[12]
  8. Step counters and calorie trackers do not help people lose weight.[13]
  9. Vitamin A supplementation in infant populations does not reduce mortality [14]

I wrote one in ten, but actually 13% of the research examined on vitamins, supplements and foods reversed previously held understandings.  Most of the trials looked at in this paper had to do with surgical procedures, not these sorts of things so we can’t go and say they were out to get naturopathic sorts of therapies.

The authors concluded that this ongoing process was valuable primarily because “The de-adoption of these and other low-value medical practices will lead to cost savings….”

A curmudgeonly mind might suggest that this information should remind us not to be so sure of ourselves, that things we think are true, are only true on a temporary basis, and that a fair proportion of things we take for granted may not be true next week.

Prasad’s study of decommissioned ideas reminds me of the many treatments once suggested for menopause hot flashes; they helped reduce symptoms but in the end the placebos worked just as well.  Magnesium helped [15] but then Haeseong Park ran a larger study and proved it didn’t [16].   Park, as I recall, had a record of proving hot flash treatments were ineffective including vitamin E in 1998 [17], soy in 2000 [18], black cohosh in 2006 [19] acupuncture in 2007 [20],  flax seed lignins in 2012 [21],  and  paced breathing in 2013 [22]

We have yet to adopt what the results of Zhang’s 2017 paper, “Dietary isoflavone intake and all‐cause mortality in breast cancer survivors: The Breast Cancer Family Registry” mean.   Recall their results that the greatest benefit of soy consumption was seen in estrogen negative breast cancers. Obviously, our belief that soy blocks estrogen receptors and so hinders breast cancer needs some rethinking.  [23] Our old explanation that soy’s benefit was similar to tamoxifen and that it blocks estrogen receptors, no longer holds true.

Medical knowledge is not nearly as static as it once was and the sooner we accept this and learn how to live with it constantly changing, the better we will be at caring for patients. 

I had lunch a few years back with a retired M.D. and somehow in our conversation the idea of using honey as a vulnerary came up in conversation.  His response was something to the effect of, “If I did not learn this in medical school, it can’t be true.”  While I wanted to point out that when he went to medical school, the honey as a topical treatment was an old wife’s tale but as we sat eating our salads there were a 150 citations on PubMed supporting its wound healing action [as I write this in 2019, there are 544 citations]. What we learned in school is out of date on the day we graduate.  That’s a given.

 How do we learn to see knowledge as in constant flux?  I’m not sure but probably our first rule is to distrust ourselves or anyone else when we sound too certain of something.  Especially distrust someone who used the verb believe.  In part, this is why I bother authors and speakers for citations.  Where does an idea come from and in what time frame?  We need to be constantly asking if there is newer information that contradicts our original understanding.  The evidence may have changed in the interval since we learned something.  Science is a process for discerning the truth, a rather messy method it seems, but it still beats the alternatives.

You can try my line: “We once believed that this is true; I wonder if it still is?  Let me take a moment to check.”

Hamantaschen with poppy seed filling
A recipe from the New York Times
https://cooking.nytimes.com/recipes/1014146-hamantaschen-with-poppy-seed-filling

[1] https://www.chabad.org/holidays/purim/default_cdo/aid/109190/jewish/Purim.htm January 28 2018 download

[2] https://en.wikipedia.org/wiki/Hamantash

[3] http://ebisupublications.com/esther-ishtar-pagan-origins-purim/

[4] Herrera-Perez D, Haslam A, Crain T, et al. Meta-Research: A comprehensive review of randomized clinical trials in three medical journals reveals 396 medical reversals. eLife 2019;8:e45183 DOI: 10.7554/eLife.45183.

[5] https://www.nytimes.com/2019/07/01/health/medical-myths-doctors.html?smid=nytcore-ios-share

[6] Du Toit G, Sayre PH, Roberts G et al. Effect of Avoidance on Peanut Allergy after Early Peanut Consumption. N Engl J Med. 2016 Apr 14;374(15):1435-43. 

[7] Risk and Prevention Study Collaborative Group, Roncaglioni MC, Tombesi M, Avanzini F, et al. n-3 fatty acids in patients with multiple cardiovascular risk factors. N Engl J Med. 2013 May 9;368(19):1800-8. 

[8] Brinkman SA, Johnson SE, Codde JP, et al. Efficacy of infant simulator programmes to prevent teenage pregnancy: a school-based cluster randomised controlled trial in Western Australia. Lancet. 2016 Nov 5;388(10057):2264-2271. 

[9] DeKosky ST, Williamson JD, Fitzpatrick AL, et al. Ginkgo biloba for prevention of dementia: a randomized controlled trial. JAMA. 2008 Nov 19;300(19):2253-62. 

[10] Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA. 2017 Nov 7;318(17):1661-1667. 

[11] Resnick SM, Matsumoto AM, Stephens-Shields AJ, et al. Testosterone Treatment and Cognitive Function in Older Men With Low Testosterone and Age-Associated Memory Impairment. JAMA. 2017 Feb 21;317(7):717-727. 

[12] Matsui EC, Perzanowski M, Peng RD, et al. Effect of an Integrated Pest Management Intervention on Asthma Symptoms Among Mouse-Sensitized Children and Adolescents With Asthma: A Randomized Clinical Trial. JAMA. 2017 Mar 14;317(10):1027-1036. 

[13] Jakicic JM, Davis KK, Rogers RJ, et al. Effect of Wearable Technology Combined With a Lifestyle Intervention on Long-term Weight Loss: The IDEA Randomized Clinical Trial. JAMA. 2016 Sep 20;316(11):1161-1171. 

[14] Imdad A, Ahmed Z, Bhutta ZA. Vitamin A supplementation for the prevention of morbidity and mortality in infants one to six months of age. (2016) Cochrane Database of Systematic Reviews 28:CD007480.

https://doi.org/10.1002/14651858.CD007480.pub3

[15] Park H, Parker GL, Boardman CH, Morris MM, Smith TJ. A pilot phase II trial of magnesium supplements to reduce menopausal hot flashes in breast cancer patients. Supportive care in cancer: official journal of the Multinational Association of Supportive Care in Cancer. 2011;19(6):859–863

[16] Park H, Qin R, Smith TJ, Atherton PJ, Barton DL, Sturtz K, Dakhil SR, et al. North Central Cancer Treatment Group N10C2 (Alliance): a double-blind placebo-controlled study of magnesium supplements to reduce menopausal hot flashes. Menopause. 2015 Jun;22(6):627-32.

[17] Barton DL, Loprinzi CL, Quella SK, Sloan JA, Veeder MH, Egner JR, Fidler P, et al. Prospective evaluation of vitamin E for hot flashes in breast cancer survivors. J Clin Oncol. 1998 Feb;16(2):495-500.

[18] Quella SK, Loprinzi CL, Barton DL, Knost JA, Sloan JA, LaVasseur BI, Swan D, et al. Evaluation of soy phytoestrogens for the treatment of hot flashes in breast cancer survivors: A North Central Cancer Treatment Group Trial. J Clin Oncol. 2000 Mar;18(5):1068-74.

[19] Pockaj BA, Gallagher JG, Loprinzi CL, Stella PJ, Barton DL, Sloan JA, Lavasseur BI, et al. Phase III double-blind, randomized, placebo-controlled crossover trial of black cohosh in the management of hot flashes: NCCTG Trial N01CC1. J Clin Oncol. 2006 Jun 20;24(18):2836-41.

[20] Vincent A, Barton DL, Mandrekar JN, Cha SS, Zais T, Wahner-Roedler DL, Keppler MA, et al. Acupuncture for hot flashes: a randomized, sham-controlled clinical study. Menopause. 2007 Jan-Feb;14(1):45-52.

[21] Pruthi S, Qin R, Terstreip SA, Liu H, Loprinzi CL, Shah TR, Tucker KF, et al. A phase III, randomized, placebo-controlled, double-blind trial of flaxseed for the treatment of hot flashes: North Central Cancer Treatment Group N08C7.Menopause. 2012 Jan;19(1):48-53. 

[22] Sood R, Sood A, Wolf SL, Linquist BM, Liu H, Sloan JA, Satele DV, et al. Paced breathing compared with usual breathing for hot flashes. Menopause. 2013 Feb;20(2):179-84. 

[23] Zhang FF, Haslam DE, Terry MB, et al. Dietary isoflavone intake and all‐cause mortality in breast cancer survivors: The Breast Cancer Family Registry. Cancer. 2017;123(11):2070-2079.