Parshat Tzaria 5768: What is Tzarat?

Moving from all the death of animals for food and death of offspring in industrial accidents of last week, this week we move into part two of the three part theme on biblical public health. We start with the procedure for a mother after giving birth, then discuss some gynecological problems. We then move into the beginning of a rather long two portion discussion of the issue of what in that text is called tzarat and at a later time would be translated leprosy.

The rabbis were pretty clear on the causes of the disease called tzarat. For them it was a spiritual punishment:

(i) Haughty eyes, (ii) A Iying tongue, and (iii) Hands that shed innocent blood; (iv) A heart that divises wicked thoughts, (v) Feet that are swift in running to evil; (vi) A false witness that breathes out lies, and (vii) He that sows discord among brethren. R. Johanan said: All these are punished by leprosy. [Leviticus Rabbah XVI: 1]

For ten things [i.e. sins] does leprosy come upon the world: (i) idol-worship, (ii) gross unchastity, (iii) bloodshed, (iv) the profanation of the Divine Name, (v) blasphemy of the Divine Name, (vi) robbing the public, (vii) usurping [a dignity] to which one has no right, (viii) overweening pride, (ix) evil speech, and (x) an evil eye. [Leviticus Rabbah XVII: 3]

Certain types of bad behavior, much of it socipopathic, caused tzarat. Also they note it is progressive in nature.

First they come upon [the fabric of] his house. If he repents, it requires the pulling out [of affected stones]; if not, it requires pulling down [the house]. Then they [i.e. the plagues] come upon one's clothes. If he repents, they require washing; if not, they require burning. Then they [i.e. the plagues] come upon his body. If he repents, he undergoes purification; if not, HE SHALL DWELL ALONE (XIII, 46). [Leviticus Rabbah XVII: 3]

The rabbis and the biblical text saw this as s spiritual and social problem. If a person changes and repents, the problem goes away. Part of the biblical text however has remained around for quite a long time:

All the days when the disease shall be in him he shall be unclean; he is unclean; he shall dwell alone; outside the camp shall his habitation be. [Leviticus 13:46]

In English translations, tzarat had been associated with leprosy for quite a long time. Part of tzarat is the quarantine of the individual. Such a commandment had led to the creation of leper colonies, places of isolation, often in the worst of conditions. But was tzarat really leprosy?

Leprosy, in modern nomenclature called Hansen’s disease is caused by a very interesting rod shaped bacteria Mycobacterium leprae. Mycobacteria have a very thick and strong cell wall made up of waxy configurations of fats and sugars, making them rather impervious to the most common ways of indentifying bacteria and some of the methods used to kill them. However, in 1873 Gerhard Hansen did isolate and indentify the causative organism. The disease affects the skin and nervous tissue, leading to a loss of feeling. It is a secondary effect of this loss of feeling that causes people to not notice other conditions and injuries which might cause loss of skin tissue, not the leprosy itself. The U.S. Centers of Disease control has as part of their case definition the following symptoms:

Tuberculoid: one or a few well-demarcated, hypopigmented [i.e. light colored], and anesthetic skin lesions, frequently with active, spreading edges and a clearing center; peripheral nerve swelling or thickening also may occur Lepromatous: a number of erythematous [i.e. reddish] papules and nodules or an infiltration of the face, hands, and feet with lesions in a bilateral and symmetrical distribution that progress to thickening of the skin Indeterminate: early lesions, usually hypopigmented macules, without developed tuberculoid or lepromatous features

In comparison to the CDC definition, Tzarat, unlike anything else in the biblical text has one of the most detailed, if not clinical descriptions:

3. And the priest shall look on the disease in the skin of the flesh; and if the hair in the plague has turned white, and the disease looks deeper than the skin of his flesh, it is a disease of leprosy; and the priest shall look on him, and pronounce him unclean. 4. If the bright spot is white in the skin of his flesh, and it looks not deeper than the skin, and the hair on it has not turned white; then the priest shall shut up him who has the disease for seven days; 5. And the priest shall look on him the seventh day; and, behold, if the disease appears to have stayed in place, and the disease has not spread over the skin; then the priest shall shut him up seven days more; 6. And the priest shall look on him again the seventh day; and, behold, if the disease is somewhat dark, and the disease did not spread in the skin, the priest shall pronounce him clean; it is a scab; and he shall wash his clothes, and be clean. 7. But if the scab spreads out in the skin, after that he has been seen by the priest for his cleansing, he shall be seen by the priest again; 8. And if the priest sees that, behold, the scab spreads in the skin, then the priest shall pronounce him unclean; it is a leprosy.

While a lot of these symptoms are similar, the CDC definition mentions nothing about hair, not does the Biblical one mention anything about losing feeling in the lesions or the papules (hard raised areas of skin). Indeed Leviticus notes the disease is going down into the flesh, not moving up.

Even more puzzling is that Tzarat does not just affect people, but also non living things, including completely inorganic things. First we have clothing (13:47-49) both of plant and animal materials, then in next week’s portion houses with tzarat growing in the bricks. (14:37) In both of these cases, the text mentions not white but red or green growths. This is not the behavior of bacteria, but something else: fungi.

To understand Tzarat as a mold is found in Leviticus 14. After a home owner reports the possibility of disease to a priest, the house is emptied of all its possessions, and then:

37. And he [i.e. the priest] shall look on the disease, and, behold, if the disease is in the walls of the house with depressions, greenish or reddish, which in look lower than the wall; 38. Then the priest shall go out of the house to the door of the house, and shut up the house seven days; 39. And the priest shall come again the seventh day, and shall look; and, behold, if the disease has spread over the walls of the house; 40. Then the priest shall command that they take away the stones in which the disease is, and they shall throw them into an unclean place outside the city; 41. And he shall cause the house to be scraped inside around, and they shall pour out the dust that they scraped outside the city into an unclean place; 42. And they shall take other stones, and put them in the place of those stones; and he shall take other mortar, and shall plaster the house. 43. And if the disease comes again, and break out in the house, after he has taken away the stones, and after he has scraped the house, and after it is plastered; 44. Then the priest shall come and look, and, behold, if the disease has spread in the house, it is a malignant leprosy in the house; it is unclean. 45. And he shall break down the house, its stones, and its timber, and all the mortar of the house; and he shall carry them out of the city into an unclean place. [Lev 14 37-45]

This is very close to the same guidelines the U.S. Environmental Protection Agency has for the remediation of mold. Fungi can cause types of dermatitis which can be similar to the symptoms mentioned above, some can grow on inorganic substances like rock or plaster, not to mentions infect leather wool and linen equally.

The rabbinic pattern of Tzarat first showing in the house, then clothes then people may not be farfetched. As the rabbis of Midrash Rabbah were people living in the same region as their ancestors, they were exposed to the same building materials, clothes, and climatic conditions as their ancestors. In rainy seasons, the plaster used in building constriction may have gotten wet and wicked the moisture into the area between stone and plaster, where the mold began to grow. Form there other items, including clothing would be affected. At the same time as it was the rainy season, people stayed indoors more often. Transmission of skin contact or through moldy clothes is not outside the range of possibilities for mold which would cause symptoms similar to the ones described, including the loss of pigmentation not only in skin, but in the hair.

Under these circumstances, Isolation and proper disposal of contaminated materials is the proper approach to the problem. In Miriam’s bout with leprosy, God commands Moses to shut out Miriam from the camp seven days (Numbers 12:14), the same procedure for tzarat as mentioned in Leviticus. The isolation was outside the camp not just to prevent contamination of others, but also prevents the person from having further exposure to the original source of the problem. For similar reasons everything inside of the house needs to be removed to prevent re-infection of the house with exposed materials. As Leviticus 14:46-47 notes anyone entering a sick building needs to be considered exposed for the rest of the day, anyone eating or sleeping in a quarantined home needs to be washed down.

I’ve had problems with the health claims for kosher. Yet for tzarat I’m willing to make the health claim. Granted, there is a spiritual component, and as I wrote last year, the kind of psychopathic activities the Rabbis ascribe as Tzarat for a punishment provide us with a reason for isolating such individuals. As someone involved with environmental health, the procedures ands details in the mitzvot of tzarat point to a environmental health concern above all else. Sick building syndrome is a real threat. The slightest water damage can cause immense health damage. In the aftermath of hurricane Katrina, we saw this on a horrible scale, not only among residents but among relief workers. After the flood waters receded, mold was everywhere, and the effects of mold were well. The Centers for Disease Control found that 54% of New Orleans police officers and 49% of the city’s Firefighters working at the disaster responding to the poll reported skin rashes for example (MMWR 4/28/06). No study I found has yet looked at long term effects, but based on evidence of earlier smaller flooding situations, they too may be devastating.

While Mycobacterium leprae may very well go extinct as a public heath issue within a decade according to the World Health Organization, molds and their mycotoxins never will. Tzarat will be around for quite a while I believe. Yet the reason for this and next week’s readings to be primarily a public health text in a spiritual text, outside of the rabbi’s insistence on lashon hara as its cause is still a mystery. We’ll look at that more next week when we discuss the other public health problem these texts discuss.

Tzaria-Metzora 5767: Warnings and sickness

This week’s portion has some very interesting, almost clinical mitzvot.

2. When a man shall have in the skin of his flesh a swelling, a scab, or bright spot, and it is on the skin of his flesh like the disease of leprosy; then he shall be brought to Aaron the priest, or to one of his sons the priests; 3. And the priest shall look on the disease in the skin of the flesh; and if the hair in the plague has turned white, and the disease looks deeper than the skin of his flesh, it is a disease of leprosy; and the priest shall look on him, and pronounce him unclean.

This week we learn about leprosy, and I had planned to talk about what medically leprosy really was. Yet two things changed my mind.

The first was that I cannot get past something that happened Saturday. While discussing last week’s Torah portion, I made a statement publicly that I had written on this list before. I have read a lot into the story of the death of Nadab and Abihu and tried to find something that makes sense here. While I can see how many can have interpretations they did something wrong, there is one I tend to like the best – they died heroes. We read in Leviticus 16:12-13 that the incense in the fire pan was used as a containment field, a smoke screen so that no one saw the Glory of the Lord. Remember when Moses asked to see God’s glory, he was told “no man shall see my face and live” [Exodus 33:20] Yet no incense was used in that sacrifices se we are told everyone could see the sacrifice consumed. I believe that Nadab and Abihu realized when the glory and the fire of the Lord came down in Leviticus 9:23-24, the people were not supposed to see it. The fire would continue to expand without the containment field, yet at the time there was no holy fire to light incense pans. So they do not use holy fire but alien fire. While saving everyone else, they sacrificed themselves. When I thought of that in 2004, many of those who died on 9/11 was still on my mind, that there were people who would run into a burning collapsing building in the hope of saving someone else. Today knowing people who put their lives in danger in public health settings around the world, I still use this midrash to comemorate their courage.

There was an objection to this. Someone found my making these two into heroes very disturbing. She specified only one thing in particular that disturbed her. God had not warned anyone. Yet we read after the death of Nadab and Abihu:

Then Moses said to Aaron, This is what the Lord spoke, saying, I will be sanctified in them that come near to me, and before all the people I will be glorified. And Aaron held his peace [Leviticus 10:3]

The key phrase is, This is what the Lord spoke - it is in the past tense.

While that thought was with me for much of the weekend, and into Monday, I was deeply involved in far too many things not to listen to the news until Tuesday. The events at Virginia Tech of course were the second thing that changed my mind about what I was going to write.

Tzarat, often called Leprosy, is some form of skin disease or possibly a variety of skin diseases. While some of the rather detailed symptoms do describe the effects of Mycobacterium leprae, the organism which causes the disease leprosy, it does not completely describe such a disease. Jewish thinking often does not look to a physical cause but rather a behavioral one. Given the cases found in the biblical text there are several versions of what causes leprosy:

(i) Haughty eyes, (ii) A Iying tongue, and (iii) Hands that shed innocent blood; (iv) A heart that divises wicked thoughts, (v) Feet that are swift in running to evil; (vi) A false witness that breathes out lies, and (vii) He that sows discord among brethren. R. Johanan said: All these are punished by leprosy. [Leviticus Rabbah XVI: 1]

For ten things [i.e. sins] does leprosy come upon the world: (i) idol-worship, (ii) gross unchastity, (iii) bloodshed, (iv) the profanation of the Divine Name, (v) blasphemy of the Divine Name, (vi) robbing the public, (vii) usurping [a dignity] to which one has no right, (viii) overweening pride, (ix) evil speech, and (x) an evil eye. [Leviticus Rabbah XVII: 3]

The one who contracts tzarat is a sociopath. He is a danger not to just himself but to everybody around him. But it is one particular sin, lashon hara, evil speech, which is mentioned most often in reference to tzarat. As we read in several place in Talmud, Lashon Hara is equivalent to bloodshed. It is of course related to Miriam’s slander of Moses in Numbers 10. Yet even Miriam’s case ended after seven day quarantine. Tzarat is often not a permanent thing in the text, only King Uzziah and Elisha’s assistant Gehazi gets a permanent case. Given that, the rabbis make a startling claim:

So also when [leprous] plagues come upon man. First they come upon [the fabric of] his house. If he repents, it requires the pulling out [of affected stones]; if not, it requires pulling down [the house]. Then they [i.e. the plagues] come upon one's clothes. If he repents, they require washing; if not, they require burning. Then they [i.e. the plagues] come upon his body. If he repents, he undergoes purification; if not, HE SHALL DWELL ALONE (XIII, 46). [Leviticus Rabbah XVII: 3]

In the case of Nadab and Abihu, there was a warning. It was told to Moses before the incident. Moses was told something by God, and said and did nothing. In the context of tzarat, we see the same thing that has bothered me this week: warnings. Tzarat isn’t the end punishment, but instead the warning that something worse will await you if you continue to do sociopatic things to others. One must turn away from that path, and quarantine is not about the biological hazard as much as the behavioral and giving the person time to calm down and change. Yet, a loss of pigmentation in skin and hair is also a rather obvious visual signal to others as well. Others will stay away from a case of tzarat even if such a person was not quarantined. All are warnings to change before something terrible happens.

With all that is coming out about the events in Blacksburg at the early part of the week, once again I have much to wonder about warnings, and what I could have said to the person who objected to my calling Nadab and Abihu heroes. My only answer upsets me even more. What is more disturbing than not having a warning is to have the warning and not heed it. Not only was last monday a tragic event, but once again it is a set of warnings. It is a warning that guns kill, and there are people that guns should not be sold to. Like Columbine and 9/11 before it, obsessive mass media coverage of the event will once again will transmit the disease to others. Some will take such coverage, along with the less controllable media of internet communications, as approval for such an act, and such viral Lashon Hara will infect and breed a string of copycats.

Hind sight is 20/20. Yet, one does not need hindsight when the event happens not just once but multiple times. Midrash Rabbah’s view of Tzarat, in reverse order of the biblical text, is of an increasingly personal disease. Its effects get more severe each episode reminding us we do know a lot more than we think, and that we must act. A man certified as insane owned hand guns. While a suspected terrorist might not be able to board a plane, that same suspected terrorist can still buy any weapon in the U.S. and open fire in a shopping mall or school. No one can prevent him until he does.

As I wrote this, I look onto the cover of newspapers and see the leprosy in the video-game posed cover photo of this madman. I heard the sickness in an interview with an early suspect in the case, a guy who happed to be a gun collector and graduate of Virgina tech. He told CNN that had students been permitted concealed weapons the tragedy would have been adverted. If this is not Tzarat I have no idea what is. Who gives a portable weapon to the demographic most likely to be drunk?

So I have to ask, when is the Tzarat of society too personal? When is it too severe that we actually take action to prevent the problem? In the words of the great Sage Hillel: If not now, When?