The patient recently returned from Italy and complains of fever and a cough. I am called to assess the patient. As the patient is suspected of having Coronavirus, I carefully put on my gown, gloves, mask, and face shield to examine the patient. Upon completion, I exit to a special room and very carefully remove (doff) my protective gear to prevent spread of contagious material. The process of dressing in protective gear is called to don and to doff. The last time I did the “doff” was during the Ebola scare. I have now, much to my dismay, restarted the “doff” yomi.
We are on high alert in the ER in anticipation of the spread of Coronavirus. Suspected cases, based on travel history, exposure, history, and symptoms are immediately isolated in a containment room, examined, and tested. Tensions are high. We have been here before (Ebola, Zika, Swine Flu, Measles), yet this time things seem different. The response is severe, the percentage of fatalities, at least at this point, appears on par with the 1918 Spanish flu (2-3%). Headlines tout the potential for this to be the worst epidemic in one hundred years. We have not seen a response of this magnitude to disease in our lifetimes.
Among the first confirmed cases in the New York area, and presently constituting the largest cluster of the disease, are members of the Orthodox Jewish community. What is our response to this epidemic? To be sure, in the spirit of ve-nishmartem me’od le-nafshoteihem and pikuah nefesh, we must address the technical aspects of disease contagion and transmission based on the dictates of modern medicine and the recommendations of the Center for Disease Control. To date, some Jewish schools and universities have closed, and shuls have been quarantined. Jewish organizations are sending frequent detailed e-mails and arranging conference calls to provide continuous updates on the situation. As of today, one community has declared a “whole community shutdown” – no shul, no shivah, no simhahs, etc.
There are attendant halakhic issues, such as kissing the mezuzah or Torah, davening with a minyan for those in quarantine, missing keriyat ha-Torah as an individual or community, fulfilling the obligation of reading Parshat Zakhor, listening to Megillah reading via phone or Facetime, walking the streets to deliver mishloah manot, travelling for Pesah, and many others. Purim was celebrated very differently this year, especially for those in quarantine, and the term “mukaf homah” has taken on a completely different meaning. Responses to some of these halakhic questions have already been rendered, and others will be forthcoming from contemporary poskim. Barukh Hashem, we are not so familiar with these issues. The advent of vaccinations and antibiotics has drastically reduced the impact of infectious diseases on our daily lives. Our ancestors, however, were intimately familiar with them. Plagues and epidemics were an ever-present and intimate part of their daily life.
One of our first responses to all tragedy, however, including the present Coronavirus outbreak, is prayer. First and foremost, we all fervently pray for the immediate and complete refuah sheleimah of all those affected. In addition to personal prayer, communal prayer and sometimes fasting are also integral parts of our response. How widespread does disease have to be in order to pass the threshold and trigger a communal response of prayer or of fasting? Shulhan Arukh writes:
Just as we fast… in times of drought, we also fast for other disasters… and so for plague. What is considered a plague? If a city of 500 inhabitants has three deaths a day (from plague) for three consecutive days, this is defined as a plague.
While this may not be the CDC’s definition, and would clearly require updating today, it nonetheless reveals a sensitivity to a threshold in the definition of an epidemic. While there are a number of synonyms for epidemic in Hebrew, such as magefah or dever, there is no ancient Hebrew term for a pandemic. According to the World Health Organization, we are now in the midst of a global Coronavirus pandemic.
Prayers have been written for centuries both for general disease outbreaks, as well as for specific epidemics, such as cholera.
Some of these prayers, such as an Italian prayer during a plague from 1700, include excerpts from Avinu Malkeinu, which is typically recited on fast days and during the aseret yemei teshuvah:
Many of us today have extra concentration, and think of our ill loved ones and friends, when we recite: “Our father, our King, please send a complete recovery to those ill amongst your nation.” There are, however, other phrases in Avinu Malkeinu that we might otherwise recite without much thought, such as, “Our father, our King, prevent a plague (epidemic) from spreading amongst us.” Prayers referring to “magefah” or plague are found frequently in davening, though we utter them by rote. Our ancestors surely had great concentration when reciting these phrases. Regretfully, we will now have a heightened sensitivity to these references, giving us but a small window into what occupied the recesses of our ancestors’ minds when they read them.
The Rabbinic Assembly of Italy, from whence my patient returned, and which is experiencing the largest outbreak outside of China, composed the following prayer to be recited for the current pandemic:
I bring your attention to a section of the present Italian prayer. The text begins with two chapters from Tehillim and concludes with a prayer beseeching God to protect us from all evil and forms of destruction. The center section of the prayer is occupied by the Pittum ha-Ketoret, the description of the incense brought in the Beit ha-Mikdash. What is this seemingly unrelated passage doing in a prayer during an epidemic? No context is given.
The answer begins with the biblical description of the Golden Incense Altar (mizbah ha-ketoret), but winds its way through later biblical passages and medical history only to resurface in the Italian Coronavirus prayer. The ceremonial burning of incense is an integral part of the Temple service. The incense was burned daily on a golden altar that rested in the Kodesh (Holy) section of the Temple. On Yom Kippur the incense is brought into the Kodesh ha-Kodashim (Holy of Holies). It is noteworthy that when the Torah describes the construction of the Mishkan, the description of the Altar of Incense is not coupled with the description of the Menorah and the Shulhan, where one would expect it to appear, but rather is found after the mention of all the other Temple vessels and sacrifices. Ramban considers this an allusion to the fact that the incense has unique powers and properties, such as the ability to abort a plague.
This foreshadowing of the power of incense to combat plague is actualized in the episode that follows the rebellion of Korah. God unleashes an unrestrained “magefah” (plague) upon the people of Israel. Moshe instructs Aharon to take ketoret from the Temple and to wave it amongst the sufferers of the plague. This rapidly brings about the cessation of the plague, “va-tei’atzar ha-magefah.” This may be the only direct effective treatment for plague mentioned in the Torah.
Yet this same ketoret which Aharon used to stave off the plague and save many lives also led to the death of his own sons, and the death of two hundred and fifty people in a dramatic display during the Korah rebellion.
The double-edged sword of ketoret is alluded to in a Talmudic discussion which addresses the question, “How did Moshe know to use the ketoret to abort the plague?” The Talmud answers that while he was up on the mountain receiving the Torah, Moshe was taught by the Angel of Death that the ketoret possessed special healing powers. The fact that it is the Angel of Death who teaches Moshe about its medicinal qualities intimates that the same substance can be an instrument of death, as well as a medical cure.
A contemporary medical halakhic discussion invokes this story as well. Moshe (and Aharon) needed to abrogate the law requiring the restriction of the burning of the ketoret to the confines of the Mishkan in order to utilize its curative powers against plague; Aharon walked with the ketoret outside the Mishkan, in the camp, amongst “the living and dead.” Commentators have debated the exact halakhic justification for the permissibility of Aharon’s actions. While it is clear that one may violate biblical prohibitions for the sake of pikuah nefesh, this exemption generally applies to proven medical treatments. One needs to justify how the use of ketoret outside the Mishkan, which entails a biblical prohibition, would be halakhically permitted, inasmuch as it was not previously known to be a cure, nor part of the traditional medical armamentarium.
One contemporary authority compares Esther’s violation of the laws of arayot (illicit sexual relations) to the use of ketoret by Aharon. In both cases there was a situation of pikuah nefesh, yet the violation did not constitute a proven remedy for the problem. However, since they each involved prevention of the possible destruction of the people of Israel, even an unproven remedy would be permitted.
It is this biblically-derived notion of the curative properties of ketoret, specifically for the treatment of plague (however that is to be defined), that led to its virtual ubiquitous inclusion in prayers for plague throughout the centuries. This association has been forgotten in the modern post-vaccination and post-antibiotic era, when epidemics with high mortality rates are far less frequent. It behooves us to recall this tradition and its place in our medical and halakhic history.
Abraham Yagel, a sixteenth-century physician, mentions the story of Aharon and the ketoret and supports the recitation of ma’aseh ketoret in times of plague. He also cites Rabbi Judah Muscato who adds that by delving into the ketoret, the infestation will stop by natural means and the air will be purified. The Ari z”l likewise recommends the recitation of pitum ha-ketoret in times of plague. Even in his primarily medical treatise published in 1631, Abraham Catalano mentions the value of the recitation of the ketoret. In the early twentieth century, David Macht performed experiments which identified antiseptic properties of the ingredients of the ketoret. Indeed, he penned an entire volume dedicated to identifying the exact ingredients of the Temple incense.
The Pitum ha-Ketoret of the Italian Rabbinate is thus simply the perpetuation of a longstanding tradition, tracing its origins back to the Torah itself, of invoking the ketoret as a form of protection against plague or epidemic diseases. This hopefully gives us not only an historical appreciation of this prayer, which has been part of our history for centuries, but also an appreciation of the scientific advances that have led to our collective amnesia of its significance.
King Hizkiyahu performed a number of actions without asking prior permission from the Rabbis, though he received retrospective approbation. One of these is the burial of the Sefer Refuot (The Book of Cures). According to Rashi, this volume possessed the cures for all human disease. Over the course of time, people began to rely exclusively on the cures, neglecting to turn their eyes towards the heavens and pray to the ultimate Source of all healing. Hizkiyahu thus felt compelled to inter the precious book.
Despite our breathtaking medical advances, perhaps representing a metaphorical exhumation of the Sefer Refuot of old, we are now reminded that we are not in control; that God is capable through a mere microscopic intermediary to bring the entire world to its proverbial knees; and that there are times even today when prayer can be our most potent, if not only, weapon against disease. May this be a temporary reminder to allow us to adjust our course and return our eyes to the heavens, so that the advances against disease (a possible vaccination is already on the horizon), through the hand of God, can progress and stem the tide of this latest pandemic.
 Orah Hayyim, 576.
 Jewish Theological Seminary Library B. (NS)PP380 (Italy 1700).
 Shemot 30:1.
 Shabbat 89a.
 See also Rashi to Bamidbar 17:13.
 See, for example, Mordekhai Carlebach, Havatzelet ha-Sharon (Jerusalem, 5767), Korah, 568-572; R. Yossi Sprung, Parshat Korah, “Chillul Shabbos and Experimental Therapy,” 5779.
 Yosef Aryeh Lawrence, Mishnat Pikuah Nefesh (Bnei Brak, 5763), Chapter 62.
 God threatened to destroy the entire nation in the episode of Korah.
 See Abraham Yagel, Moshia Hosim (di Gara: Venice, 1587), 63 and 66. On Yagel, see David B. Ruderman, Kabbalah, Magic and Science: The Cultural Universe of a Sixteenth-Century Jewish Physician (Harvard University Press, 1988). For what follows, see Andrew Berns, “Judah Moscato, Abraham Portaleone, and Biblical Incense in Late Renaissance Mantua,” in Studies in Jewish History and Culture, Volume 35, Rabbi Judah Moscato and the Jewish Intellectual World of Mantua in the 16th–17th Centuries, eds. Giuseppe Veltri and Gianfranco Miletto (Brill, 2012), 119-133.
 Berns, op. cit.
 Sha’ar ha-Kavanot, Derush Tefillat Shaharit.
 David Macht and William Kunkel, “Concerning the Antiseptic Action of Some Aromatic Fumes,” Experimental Biology Medicine (1920): 68-70.
 David Macht, The Holy Incense (Baltimore: 1928). For the previous attempt by Abraham Portaleone to identify the ingredients of the ketorot, see Berns, op. cit.
 The Chief Rabbinate of Israel also issued their own brief prayer for the Coronavirus pandemic. https://www.srugim.co.il/427406-הרבנות–מפרסמת–תפילה–מיוחדת–לעצירת–הקו (accessed March 8, 2020). While the text of the pitum ha-ketoret is omitted from this prayer, it does refer to the original episode of the post-Korah plague. It cites a phrase from Tehillim (rather than the original reference in the Torah) that focuses on the element of prayer as opposed to the vehicle of ketoret, ”Va-ya’amod Pinhas va-yefalel, va-tei’atzar ha-magefah” (Tehillim 106:30) In this version of events, it is the prayer (or actions, according to the commentaries) of Pinhas, as opposed to the ketoret brought by Aharon, which achieved disease remission.
 On Sefer Refuot, see D. J. Halperin, “The Book of Remedies, the Canonization of the Solomonic Writings, and the Riddle of Pseudo-Eusebius,” Jewish Quarterly Review 72:4 (April 1982): 269-292; Zev Zicherman, Otzar Pela’ot ha-Torah: Shemot (Brooklyn, NY, 5775), 413-415; F. Rosner, “The Illness of King Hezekiah and the ‘Book of Remedies’ Which He Hid,” Koroth 9:1-2 (1985): 190-197; Yaakov Zahalon, Otzar ha-Hayyim (Venice, 1683), Introduction; Hazon Ish, Emunah u-’Vitachon, Chapter 5; Shlomo Halperin, Sefer ha-Rof’im, in Sefer Assia 2 (Reuven Mass: Jerusalem, 5741), 78-79; M. Hirt, Kuntres ve-Rapo Yerapei (Bnei Brak, 5763), 17-22; Mordechai Gumpel Schnaber, Solet Minhah Belulah (5557), 31b-33b.