Do Clowns Have the Power to Heal?

Two women enter an austere hospital room at Soroka Medical Center in the Israeli city of Be’er Sheva. Soon a burst of laughter is heard, surprising in this wing that treats patients injured in and evacuated from the towns and kibbutzim close to the border with Gaza. It’s October 18, 2023, just eleven days after the horrific October 7 Hamas attack in which 800 civilians in these communities were murdered.

But injecting levity into the most difficult situations is what these two women do best. Dressed in brightly colored outfits with striped socks, gigantic shoes and red noses, Zaza and Tila are what are known as “medical clowns.” These professional performers, trained in therapeutic care, work alongside the hospital’s more soberly dressed nurses and doctors.

The clowns’ jocular presence in the hospital room prompts patient Avida Bachar to quip that, since coming here, he’s “lost seven kilos in weight!” He is referring to his right leg, which was recently amputated. The 51-year-old is a survivor of the carnage at Kibbutz Be’eri, and as he goes on to recount his experience, his eyes fill with tears. At approximately 7:10 on the morning of October 7, he, his wife Dana, their 15-year-old son Carmel and their 13-year-old daughter Hadar had taken refuge in their mamad, a reinforced safe room in their house. Less than an hour later, Hamas terrorists entered their home and shot through the mamad’s door with Kalashnikov rifles, hitting Avida’s leg and Carmel’s arm. They tried to smoke the family out by lighting a fire right outside the mamad. When that failed, they blew a hole in an iron shutter shielding the safe room’s window, threw three grenades into the gap, then shot at the family through the hole, killing Dana.

By the end of the day, Carmel had bled to death. Only Avida and his daughter Hadar had survived, rescued by Israeli soldiers who arrived at around eight p.m. (Bachar also has two older sons who were away from Be’eri that day.) Hamas murdered a total of 101 people at Kibbutz Be’eri on October 7; an additional 30 were kidnapped and taken to Gaza.

Bachar speaks bitterly of the slaughter inflicted on his family. But the clowns’ conviviality briefly lifts his somber mood once more. Zaza reminds him that in the aftermath of the attack, she had accompanied his daughter Hadar to the operating room for surgical excision of shrapnel, breathing with her in unison to calm her fears. Hadar, she tells him, had spoken about surfing with her brother Carmel. “She’s amazing,” Zaza says. “She bounces back.” Bachar agrees, drawing strength from this reminder of his resilient daughter, adding, “Carmel was her role model.”

Medical clowning is deeply integrated into Israel’s healthcare system, with around 100 professional medical clowns spread out in nearly all major hospitals, according to Tsour Shriqui, the CEO of the Israeli Dream Doctors Project, an organization that trains clowns to work in multidisciplinary care teams. Although medical clowns are not an Israeli innovation, researchers in Israel were among the first to quantify the medical benefits of clowning in a systematic way, says Giora Pillar, head of the department of pediatrics at Carmel Medical Center in Haifa. As of now, two dozen published scientific studies on clowning have emerged from hospitals in Israel, showing how the intervention of clowns can significantly reduce patients’ pain and anxiety, improve their sleep and shorten hospital stays.

The author’s son, Aryeh, accompanied by two medical clowns, meets Israeli President Isaac Herzog on the festival of Purim in March 2022. (Photo credit: Courtesy of Josie Glausiusz)

Zaza, 43, whose legal name is Reut Tsoref, is a multitalented medical clown. Trained in circus arts, dancing and juggling, she has worked as a medical clown for 16 years. Sporting outsize bows in her dark hair and a red ball on her nose, she smiles readily and speaks in a rapid patter, switching easily between English and Hebrew. “I’m called Zaza because I’m always moving,” she tells a wounded soldier in the lobby of Soroka Medical Center. (The Hebrew word “zaza” means “moving.”) The young man smiles and his mother laughs when Zaza talks to him in a baby voice, saying, “Well done! You’re walking.”

At Haifa University, where Tsoref studied for a bachelor’s degree in medical clowning, she took courses in community theater, psychotherapy and child development. She has worked in Uruguay, Chile, Panama and El Salvador, as well as in Angola, where she helped set up a local team of medical clowns. In 2022, following the Russian invasion of Ukraine, she traveled to Chisinau, Moldova, with the Israeli Dream Doctors Project, offering comfort to Ukrainian refugees and soothing babies with songs that her grandmother taught her.

Haifa University was the first university in the world to offer a BA program in medical clowning.

Medical clowning, she explains, “is not like street clowning, or [performing] on a stage.” In her day-to-day encounters, she works with both adults and children, including kids with late-stage cancer, with whom she engages in palliative care. “It’s working with people in a sensitive situation,” Tsoref explains. “We need to understand the conflicts that families and patients can face.”
When Tsoref enters a hospital room as Zaza, faces light up; smiles break out. Her goofy appearance, snappy conversation and laughter make her effervescence infectious. This juxtaposition—glee amid grief—is surprising. How is it possible to laugh in such dire circumstances?

For Tsoref, the clown’s absurdity and jollity symbolize hope and belief. “All of us, in the end,” she says, “want to believe in life.” She explains that whenever one introduces this eagerness for life into a traumatic situation, it’s easier for patients to cope. Clowns, she says, connect to a patient’s desire to live, and that gives people the option to connect to their own vitality.

Using buffoonery to dispel misery is a tradition that dates back to ancient Egypt and Greece. Jesters were once fixtures in royal courts, dressed in garish costumes decorated with bells and summoned to amuse kings with music and jokes. Perhaps the first record of clowns cavorting in hospitals, however, appears in the September 1908 issue of the Parisian daily Le Petit Journal. The newspaper is illustrated with a drawing of two clowns leaping and tumbling in a children’s ward.

Today, medical clowns pop up in hospitals in the United States, Australia, the United Kingdom, Canada, India, Brazil and other countries. Many have backgrounds as street performers, acrobats or actors and are professionals who may be skilled in comedy, music, mime, magic, juggling, storytelling and even puppetry. Some have bachelor’s degrees in the field. Haifa University was the first university in the world to offer a BA program in medical clowning. A similar program, Comic+Care, inspired by the Israeli program, was founded in 2014 at the University of Southern California School of Dramatic Arts.

Avida Bachar at Tel HaShomer Hospital in November 2024. (Photo credit: Courtesy of Josie Glausiusz)

I first met Zaza at Shaare Zedek Medical Center in Jerusalem in March 2023, where my beloved 12-year-old son Aryeh was being treated for a rare form of brain cancer. Zaza and another medical clown, Limor, bounded into Aryeh’s room and danced around his bed, snapping their fingers and singing “The Lion Sleeps Tonight (Wimoweh).” Aryeh, whose Hebrew name means “lion,” smiled and clicked his fingers in unison.

Later that day, Zaza took Aryeh, in his wheelchair, to the Israel Aquarium in Jerusalem. As they left the hospital ward, Zaza blew a trumpet and sang, “We’re going to dive with sharks!” My husband, who accompanied Aryeh to the aquarium in the team’s “clownbulance,” said our son was fascinated by the sharks and the pregnant male seahorses and asked good questions about sea life. He died two days later, on March 23, 2023.

When Zaza and Limor had pranced around Aryeh’s bed, I’d found myself laughing and singing with them. Later, I wondered how I could have found joy in such a tragic situation, knowing, as I did, that Aryeh was not going to survive this terrible disease, even after he had endured multiple brain surgeries and rounds of radiation.

Reut Tsoref (“Zaza”) with a patient. (Photo credit: Courtesy of Reut Tsoref)

Untangling this seeming contradiction—glee amid grief—is also the goal of Orit Karnieli-Miller, the head of the department of medical education at Tel Aviv University Medical School. In January 2023, she and her team published a study analyzing the healing skills of medical clowns in Israel. “I was always curious about medical clowns—wanting to understand what they do and how it relates to patients’ needs,” Karnieli-Miller says. “Is it just a distraction? What’s their secret?”

Her study showed that medical clowns do far more than improve a patient’s mood. Through one-on-one interviews and video-recorded simulations with twelve medical clowns from different Israeli hospitals—six women and six men—the researchers identified four main therapeutic goals: to build a relationship with the patient, help them deal with emotions, enhance their sense of control and motivate adherence to treatment.

“I think that people make a mistake about medical clowns—they think they’re just there to make things happy,” says Karnieli-Miller. “What I figured out from this study is that they’re really therapists.” One of the clowns’ main goals is to connect with patients and build relationships. They often make connections by “anchoring,” that is, identifying an object in the room and relating to it in order to create an initial bond. Or they can anchor to an emotion; for example, if they sense from a facial expression that a child is upset, they might connect to that feeling by saying, “Bummer…things are bad…you are right,” acknowledging an emotion that others may ignore or try to change.

Laughter and humor can have physiological as well as psychological effects, helping to lower heart and respiratory rates and improve immune function.

In this way, medical clowns can help patients deal with difficult emotions. Instead of trying to distract them from sadness or fear, the clowns will often empathize or mirror the emotion. “They might sing a sad song to help reflect what [the patient] wants to say but maybe didn’t have the courage to deal with,” Karnieli-Miller explains.

Medical clowns encourage young patients to adhere to treatment plans by using gimmicks or accessories such as balloons or bubbles. They might cheer a patient on or engage in a mock competition with a child to swallow antibiotics or negotiate with them to do challenging physiotherapy exercises.

They can also enhance a child’s sense of autonomy, says Karnieli-Miller, by acting on the child’s wishes and obeying them. In hospitals, Karnieli-Miller says, “you have no control—of your time, of what you eat, of who takes care of you, of what you wear.” Medical clowns can return some control to the patient. For example, if a child says, “I don’t want you here today,” they will respect that request and leave the room—unlike a doctor or a nurse.

Zaza’s trip to the aquarium with Aryeh, says Karnieli-Miller, is a good example of returning control to the child. “You treat them as a person, you look at what they want to do and you do it.” Zaza helped move Aryeh’s focus to something that was interesting and important to him, and away from the pain. “Which is beautiful,” Karnieli-Miller says. “For me, that’s a true clown.”

In recent years, a raft of studies on medical clowns has emerged from the lab of Giora Pillar at Carmel Medical Center in Haifa. Its hospital employs a team of three medical clowns, who Pillar says have a very positive effect on the well-being of young patients. “Kids run after them,” he says. “They are passionately asking for them; sometimes they’ll follow them to another room.”

That much is obvious in watching “Dr. Batata” (“Dr. Sweet-Potato”) as he moves around the department of pediatrics at Carmel. Dressed in blue-and-red overalls, a tartan beret, striped socks and multicolored boots, the clown and his antics have an invigorating effect on the children he encounters. Their moods shift instantly from sadness or boredom to sudden interest—and that goes for their parents, too.

Itay Rothem-Nachmias (“Dr. Batata”) with a patient holding a balloon animal the clown made for him. (Photo credit: Courtesy of Itay-Rothem-Nachmias)

Dr. Batata, who is 58 and whose real name is Itay Rothem-Nachmias, trundles around a trolley full of colorful balloons, which he transforms into all manner of animals—a lion, a bear, a dog. He switches with ease between Hebrew and Arabic. “Fifty percent of the kids in the hospital are [Israeli]-Arab,” he says, “as are half the staff.”

Rothem-Nachmias works closely with Pillar, who says that when he started work at Carmel 12 years ago, he was struck by the fact that so little research had been published on the therapeutic impact of clowning. “No one had quantified it,” Pillar says. “So we started to scientifically test it.” Since he started his research, studies have been published all over the world, he notes. “But yes, we in Israel were among the first and have led in this regard. I don’t know why. Maybe because we are open-minded.”

Pillar’s first study, published in 2015, examined the effect of medical clowns on 100 children, ranging in age from 2 to 10 years, who were undergoing blood tests or insertion of intravenous lines. Compared to control groups, children entertained by clowns spent significantly less time crying. Their pain didn’t decrease significantly (as compared to children who were treated topically, prior to the jab, with anaesthetic EMLA gel), but their anxiety was lower, says Pillar.

In a second study of 93 children, aged 2 to 6, Pillar and his team found that the presence of clowns could encourage kids undergoing physical exams in the pediatric emergency department to better cooperate with doctors. Pediatricians reported that the medical clowns, with their tricks and jokes, improved doctors’ ability to perform a complete examination. In the presence of clowns, the children were more relaxed, more likely to cooperate and less likely to struggle.

A third research project, whose results were presented in September 2024 at the European Respiratory Society Congress in Vienna, Austria, showed that children hospitalized with pneumonia had significantly shorter stays if entertained by a medical clown. Lead researcher Karin Yaacoby-Bianu, a senior pediatric pulmonologist at Carmel Medical Center, explained at the meeting that laughter and humor can have physiological as well as psychological effects, helping to lower heart and respiratory rates and improve immune function.

Not only can interaction with clowns shorten the duration of hospitalization, it can also improve sleep among hospitalized children, according to a study recently published in Nature Scientific Reports and led by Maya Shimshi-Barash, a pediatrician who did her residency at Carmel Medical Center. She enrolled 42 children aged 2 to 17 in her study; half of them were entertained by a medical clown with music or stories for 15 to 30 minutes prior to bedtime on the first or second night of their hospital stay. The kids who met with clowns slept almost an hour longer at night than those who did not.

Notably, hospital stays were also significantly shorter—23 hours shorter, on average—in the clown group as compared to the control group. “When kids sleep better, they recover faster,” says Shimshi-Barash, currently a clinical fellow in developmental pediatrics at BC Children’s Hospital in Vancouver, British Columbia. “They’re less anxious, they’re more compliant with therapy, they’re more motivated to heal. We know there’s such a huge connection between mind and body and how it affects recovery.”

Clowning also has important benefits for the clowns themselves. Rothem-Nachmias, aka Dr. Batata, cites the affirmation he receives while clowning. “I get my dose of smiles and attention on a daily basis,” he laughs. “It’s therapy for ourselves.” Medical clowns, he explains, often choose the profession for personal reasons. “Each one of us has a story,” he says. In his case, he is “for sure” trying to find some connections with his late father, a red-beret-wearing paratrooper, who was killed in the 1967 Six-Day War when Rothem-Nachmias was not even a year old. (His tartan beret is a tribute to his father.) “He was apparently a very funny and charismatic guy, a joker and storyteller,” says Rothem-Nachmias, who switched from a life as a street performer and fringe theater actor to medical clowning, in which he earned a bachelor’s degree from Haifa University.

As Dr. Batata, he admits that he sometimes draws on his own minor miseries—a broken boiler, a rude technician—in order to mirror patients’ travails. With young children, this works well: He stuffs a giant pacifier into his mouth and weeps crocodile tears, an act of buffoonery that draws giggles. As parents walk past pushing their babies in strollers, he interrupts our conversation repeatedly to gabble to them in a baby voice. He then shifts abruptly to a baritone: “You are now listening to…The Clown Podcast,” he intones. (He actually has one.)

But responding to patients’ suffering isn’t always easy. If, for example, a teenager is terminally ill or even suicidal, Rothem-Nachmias says he has learned to guard his own space, as well as the patient’s, and not intrude. “The nose helps a lot,” he says, “because it’s like a mask.” He isn’t detaching himself, he says, but maintaining a sensible distance. “Sometimes it’s like gliding or flying over things,” he explains.

Tsoref (aka Zaza) has also trained herself to maintain some space between herself and her patients’ trauma. She sees a therapist once a week, and she relieves stress through shiatsu sessions and acupuncture. “I’m very aware that I need these treatments, and they have helped me a lot in the past year,” she says. “The body absorbs [the stress]. And then it starts to hurt physically.”

She continues to offer comfort, and even friendship, to her patients long after they are discharged. More than a year after the Hamas attack that killed Be’eri survivor Avida Bachar’s wife and son, she keeps in touch with him. “Listen, I’ve known her since the first days after I was wounded,” Bachar tells me in November 2024 at Tel HaShomer/Sheba Hospital in Ramat Gan, where he had spent five months in rehab. “In the end, you’re looking for someone to talk to.”

Walking with a prosthesis, Bachar carefully carries and moves a chair for me so that we can sit together. In the spring of 2024, he returned to Kibbutz Be’eri, where he is manager of agriculture. He now lives temporarily in his parents’ house there, as his own house was burned to the ground.

In Zaza, Bachar says, he found “a listening ear.” The special thing about medical clowns, he adds, is that behind their jovial persona there is a real person who can tune in and relate. When she wears her nose, he explains, she is Zaza, and when she removes it, she’s Reut Tsoref.

Tsoref says that she switches between her two personas to suit the situation. It’s her red nose that enables her to shift into her zany clown side. As Zaza, she can compose nonsense rhymes and move her body freely. She removes the nose only when she has worked with a patient for months. “There are times when we take it off when we feel like there is some suspicion or fear on the part of the patient being treated,” she explains. Otherwise, its absence often helps the patient feel at ease sharing complicated feelings. They may need to see “the person behind the clown,” she says.

“There are many times when the patient needs to know that we are ‘normal’ people,” in order to identify with the clown and deepen the connection.

Seeing Tsoref in full, Bachar says, has helped him cope and heal. “She can joke, she can relate to what’s happened to you with humor as well as sincerity.” Her gaiety also makes it easier to accept her opinion because “she can say what she likes.” Clowns don’t worry about what others think or say. “They just flow with the situation.”

Bachar credits Tsoref with helping him find the kind of inner strength that enables him to continue. “Diving down isn’t an option. The only option that remains is to continue upwards,” he says. “If I had died, and Dana had remained alive, I would have wished her a good life. I know she would have wished that for me. So I myself have to live a good life. There’s no other way.”

Personally, I believe that Zaza’s zest for life tapped into my son Aryeh’s own joie de vivre, even in the days when his physical abilities were limited. I myself learned that hope always remains alive, until the very last second. I hoped that Aryeh would live for another hour, another day, another Shabbat, another week, another month, another year. Zaza’s dancing and singing showed us that we can experience joy and laughter even in our very last days. That is her magical gift.

Opening picture: Reut Tsoref, aka “Zaza” (Photo credit: Courtesy of Reut Tsoref)