Archive for the ‘In the news’ category

Have no fear- your vegetables are loaded with toxins

March 30, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

There’s so much fear and uncertainty out there. If you pay any attention to Facebook and Teh Interwebs, the air is killing is, the water is killing us, and, worst of all, our food is killing us. Chemicals!

Let’s straighten out some simple misperceptions. I promise, this won’t hurt.

Truth 1: Your food is loaded with chemicals.

It’s true. A chemical is just a compound or a substance that can be isolated or identified. Water is a chemical, salt is a chemical. Ethyl butanoate, phenylalanine, and aspartic acid are all chemicals, too, and they’re all a natural part of what makes a banana. Some chemical names look scary – like 3-methylbut-1-YL-ethanoate, another banana constituent. Others look friendly, like “ricin.” But ricin isn’t a natural part of rice (it actually comes from the castor bean.) It’s a deadly poison, and just one milligram of it can kill you.


So: all food is all chemicals, and whether or not the name of the chemical is scary has nothing to do with how much or how little it might harm you.


 Truth 2: Your food is loaded with pesticides, too.

OK, I get it—“chemical” is just shorthand for “bad chemical”. And by “bad chemicals”, we mean pesticides and preservatives and toxins.

By that definition, your fruits and veggies are loaded with “bad chemicals”, too. They’re put there by nature. Plants are not just happy organisms that are here to feed us. They’ve evolved, too, in a natural world filled with plant parasites, plant predators, and other plants that want to steal their nutrients and sunshine. So plants have developed plenty of chemicals themselves that act as “natural” toxins to give them a competitive advantage over other organisms. Plants make all sorts of toxins and chemicals specifically to prevent fungal and parasitic attacks, to make them taste less appealing when fruit is unripe, and to make them taste more appealing when fruits ripen.

A classic study, from 1990, illustrated this well. Dr, Bruce Ames and colleagues found that 99.99% by weight of the “pesticides”—the chemicals that kill pests—that they found in foods were made by the foods themselves. For instance, cabbage, good old cabbage, contains terpenes (isomenthol, carvone), cyanides (1-cyano-2,3-epithiopropane), and phenols (3-cafffoylquinic acid.) Tasty! All of these, and far more (listed in table 1 of that link and pasted below), are naturally made by cabbage. So the cabbage can survive.

from Ames, et al 1990

from Ames, et al 1990

Adding up the measured quantities of residual synthetic pesticides and related chemicals, Dr. Ames’ team found that the quantity of naturally-occurring pesticides outweighed those added by farmers by 10,000 times. Yes, your veggies are loaded with pesticides. Nature put them there.

By the way—Dr. Bruce Ames is no gadfly. He developed the “Ames test” that remains in wide use to determine if a chemical is a mutagen (a potential carcinogen.)  He is a real scientist who cut his teeth long before we decided anyone can “do the research” with Google.


Truth 3. Natural pesticides are just as harmful as synthetic ones.

We have this romantic, idealized view of nature—it’s nice and filled with bluebirds. In truth, nature is a fearless, relentless monster that can kill you five times before you hit the ground. Every organism competes with every other organism for survival, using claws and teeth and toxins and poisons. Small pox is natural, and it wants to kill you (or wanted to kill you, until we killed it first). Lightning is natural, and volcanoes, and frostbite and starvation and tapeworms and malaria. The natural world and natural things have killed far more organisms than humans ever have or ever will.

But what about those man-made, synthetic chemicals—they’re not “natural”, so maybe they’re more harmful. Let’s ask Dr. Ames. From that same study, in 1990, he showed that of 52 of the natural pesticides he had found in natural food, 27 of them were documented carcinogens. Half of them. Ironically, the proportion of synthetic chemicals that he had found were mutagenic was also about half. In Ames’ study, he said:

We conclude that natural and synthetic chemicals are equally likely to be positive in animal cancer tests. We also conclude that at the low doses of most human exposures the comparative hazards of synthetic pesticide residues are insignificant.

That makes sense, actually—when you let go of that odd romantic view of nature, and realize that natural organisms evolve to compete, it makes sense that natural chemical defenses will be harmful, too. That’s why they exist. Organisms need chemicals to protect them from pests, and there’s no particular reason to think that the chemicals they invent are any more or less harmful than the chemicals we invent.


Truth 4. “Organic foods” have plenty of added pesticides and chemicals.

OK, you might say. But organic foods have no added pesticides or chemicals! Even if the added amount with conventional foods is tiny, why not avoid that tiny added potential risk?

Because organic foods do have added pesticides and chemicals. Plenty of them. Here’s a link from the US government to approved lists of allowed substances, things that can be added to foods that are labeled organic. It includes sub-lists, including “synthetic substances allowed for use in organic crop production”—tasties like copper oxychloride, lignin sulfonate, and sucrose octanoate esters. You may also enjoy browsing the section on “Non agricultural (nonorganic) substances allowed as ingredients in or on processed products labeled as ‘organic’ or ‘made with organic (specified ingredients for food groups)’.” I could list many more scary chemicals (diethylaminoethanol! octadecylamine!) and unpleasant-sounding food additives (catalase from bovine liver!)—but you get the point. Organic, inorganic, natural, synthetic—it’s all chemicals. Organic is not added-pesticide free, not even close.


So: despite what the self-appointed internet experts are telling you, chemicals cannot be avoided—and natural foods contain far more harmful and natural preservatives, pesticides, and “toxins” than we add ourselves. Let’s keep this whole “chemicals in food” scare in perspective. There’s no need to fear what you eat.

What your kids do affects how their brains grow

March 2, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

A short study to review today—from Pediatrics, November 2014, “Cortical thickness maturation and duration of music training: Health-promoting activities shape brain development.” Researchers looked at MRIs scans of healthy children that were being obtained as part of a larger study of normal brain development, correlating the development of several brain areas with musical training. They found that as kids age, the ones taking music lessons had more rapid growth and maturation of brain centers involving not only motor planning and coordination, but also emotional self-control and impulse regulation.

When you exercise a muscle, it grows bigger and stronger. The same thing, essentially, happens in the brain—but it’s more complicated, because different parts of the brain do different things. What this study confirms is that at least with music, the areas of the brain exercised with musical training become “stronger”—or, at least, larger and thicker, which in brain-terms means more effective. The authors speculate that conditions like ADHD, where those same areas of brain seem relatively under-functioning, might be helped by learning to play a musical instrument.

Think about the bigger picture, too. Whatever your kids are doing, that’s the area of the brain they’re exercising. If they’re reading, they’ll become better readers; if they’re playing tennis, they’ll get better at seeing and hitting a little fuzzy yellow ball. If video games are their main hobby, they’ll get better at making fast decisions and moving their hands quickly. Katy Perry fans will get good at dancing like sharks. You get the idea. At the same time, kids who don’t practice the self-control needed to learn a musical instrument might be missing out on at least one way to help their brains mature.

Get practicing!

Some solid reassurance about BPA – one more thing you don’t need to worry about

February 16, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Remember BPA? It’s a chemical used in the manufacture of plastic things, food can liners, and lots of other things. For a while, everyone seemed to be worried about it. Stickers started showing up on bottles – “BPA FREE!”—which created all kinds of anxiety among people who had no idea there was BPA in their water bottles to begin with. It’s a scary sounding, chemically kind of thing, bisphenol-A, so we’d be better off without it. Right?

I last wrote about BPA in 2008. It wasn’t worth worrying about then, and it’s even less worth worrying about now.

There have been dozens of studies of BPA over the last few years. I’ll just highlight a few recent ones:

JAMA, 2011. Adults eating canned soup – from ordinary cans manufactured with BPA in the liners – had 1200% percent more BPA in their urine than adults consuming fresh soup. Bloggers like this one completely misunderstood the significance of this, with headlines like “BPA rises 1200% after eating from cans.” Yes, it does rise—IN THE URINE. That’s how you get rid of the stuff. High amounts in the urine are good, it means your body is excreting it. That’s what kidneys do. They’re the real detox system—not the expensive BS from the health food store. Want to rid your body of “toxins”? Drink some water and let your kidneys do their job.

Toxicology Science 2011. Adults consuming a high-BPA diet had blood and urine levels monitored. Urine levels were much higher than blood levels – good! It’s excreted! – and in fact blood levels remained extremely low, or undetectable. BPA doesn’t seem to have a chance to make it into body tissues, or concentrate there. It’s peed out. (This study is reviewed in detail here.)

Environmental Health Perspectives, 2013. High doses of BPA solutions were placed in the mouth of anesthetized beagles, and blood levels showed that this method of administration led to higher absorption of BPA than BPA swallowed into the gut. (Lesson: It may not be a good idea to just hold soup in your mouth for hours. Just swallow it, OK?)

Toxicology and Applied Pharmacology, 2015. To evaluate the potential for oral absorption of BPA in humans, adult volunteers were fed warm tomato soup with added BPA—after coating their mouths with every spoonful, they swallowed it. This recreated a genuine eating experience better than the beagle studies (the dogs were anesthetized and their BPA just sat in their mouths.) In this human study, BPA levels in the blood remained low, and as has been observed previously, almost all of the BPA absorbed was quickly deactivated and excreted in the urine.

What’s the harm in replacing BPA in food containers? There’s always a trade-off. Those other kinds of plastics may be more hazardous.

BPA is just one of many “chemical” bugaboos to attract media attention. Caramel coloring? Eek! BHT? Lawds! There are entire industries out there making money off of food fears and nutrition fears. And vaccine fears. There’s enough unnecessary fear out there to power an entire media empire based on one person with vain hair, a magnifying glass, and a kindergartener’s understanding of chemistry.

Don’t live in fear. If you want to avoid plastics, that’s great—eat fresh things, grow a garden, cook and eat with your family. The cans of beans in your pantry, they’re not going to kill you any time soon.

More about BPA from Science 2.0

Measles at Disneyland: Looking back, looking ahead

January 26, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

This past Christmas holiday, an as-yet-unindentified “index case”—the first person to start an epidemic—visited Disneyland in California. 5 employees became infected, along with dozens of visitors to the park. Since then, the outbreak has spread to about 80 people, including people who’ve caught it not directly from visiting Disney, but by coming in contact with Disney cases. These “secondary” cases will soon lead to “tertiary” cases—people who catch it from people who caught it from people who were at Disney. And on and on.

Such is the nature of epidemics, especially with a super-contagious illness like measles. We’re not talking Ebola, here—that can only spread from direct contact, touching the body fluids of someone who is dying from Ebola. No, measles spreads much more easily. Measles becomes contagious before symptoms start, and the infection can spread from the very air that someone who’s carrying measles breathes.

Fortunately, there is a very effective vaccine. With two doses, as recommended, there’s about 99% protection. That is a very effective vaccine. But in country with about 300 million people, even if 100% of us were vaccinated there would be 1%- 3 million – unprotected people. Add to that babies younger than one year, who can’t be routinely vaccinated, and people with immune deficiencies and other health problems that leave them vulnerable. Even if everyone who could get vaccinated got vaccinated, there would still be some vulnerable people. But we know that if just about everyone does get vaccinated, those vulnerable people are protected by “herd immunity”—with very little circulating measles, everyone is protected.

But what happens when people decide not to vaccinate? And what if a lot of those people live in the same neighborhoods and counties? We knew what would happen. It’s been an entirely predictable and avoidable catastrophe: a measles outbreak.

In the latest news, USA Today has been focusing on the spread of the epidemic, which has now extended outside of California into 4 more western states and Mexico. They also report that several California schools have sent dozens of unvaccinated children home to contain the spread of measles, including 24 students from Huntington Beach High School. CBS news has pointed out just how contagious measles is, and why this could end up being the beginning of a really huge outbreak.

Many reporters are drawing attention to the role of unvaccinated children in the spread of this epidemic. Almost all of the cases reported have been in unvaccinated children, including some babies too young to be vaccinated and many children whose parents chose to not get them vaccinated. A Washington Post blogger has illustrated the resurgence of measles from non-vaccination, all in one chart. At least one mom is mad that her child was singled out to stay home because she hadn’t been vaccinated for medical reasons—though, in fact, having a brother who had a severe reaction to a vaccine is not a contraindication to vaccinating a sibling. There is no “family tendency” that changes the estimated 1 in a million risk of a serious vaccine reaction.

The national media hasn’t focused on this much, but the State of California has declared that theme parks, airports, and other public places are not safe for people vulnerable to measles. That includes anyone who hasn’t been immunized—not just kids of non-vaccinating parents, but babies and people with immune problems. That’s right—the State of California now officially recommends that babies not go to airports. It’s not safe. Want to take your 9 month old to visit Grandma in Atlanta? You’d better drive. And don’t think about taking your baby to Disney in California—Disney says their parks are perfectly safe for vaccinated people, implying that babies and others who are unvaccinated should stay away.

The international community has jumped on board, too. From Canada, a report points out the double-digit vaccine exemption rates in some California school districts, quoting a public health official, “When our immunity falls, it creates a problem for the whole community.” They also reached out for a quote from longtime anti-vaccine activist Barbara Loe Fisher, of the misleadingly named “National Vaccine Information Center.” (In all honestly, the “National Antivaccine Lies and Propaganda Center” would be a more-fitting name.) Fisher illustrates her difficulties with understanding fractions by pointing out that a small number of people who’ve caught measles were vaccinated. Yes, but in an area where 90%+ overall are vaccinated, that almost all of the cases were unvaccinated tells you something about disease transmission.

Overseas, the BBC drew attention to one specific Orange County pediatrician, Dr. Bob Sears. Right in the heart of Orange County, home of Disneyland, Dr. Bob has been a longstanding supporter of non-vaccination—about half of his patients are unvaccinated. In some Orange County schools, 60% of children have a “personal belief exemption” so they can attend school without vaccines. The article quotes a professor who compares vaccine-denying parents to a drunk driver “who makes a socially irresponsible decision that can endanger not only his life, but also the lives of the other drivers and passengers on the road.”

Dr. Bob has responded to his critics, first in an odd, rambling Facebook post that tried to show that measles was nothing to worry about (though he admitted it could be serious for babies and immunocompromised people—but, apparently, we don’t need to be concerned about them.) He then petulantly responded to critics by calling them “stupid.” Classy, Dr. Bob.

I’m heartened to see that many media outlets have really come down hard on the so-called “anti vaccine movement,” with headlines like “Measles is horrible and is yet another thing the anti-vaccine movement is wrong about”. Yet some outlets are still posing this as a rhetorical question, like Yahoo’s “Is the anti-vaccination movement to blame for Disneyland’s measles outbreak?” Yes, Yahoo, it is.

As often happens, some of the best, in depth material about the outbreak has been coming from bloggers. Over at Science Based Medicine, Dr. David Gorski has covered the outbreak in detail (don’t miss the comments—a lot of great insight there too). He also illustrates the contributions of nincompoop anti-vaccine doctors like Dr. Jay Gordon, also of (you guessed it) California. Other superb blogs about the issue have appeared at the similarly-minded Respectful Insolence here and here. Chad Hayes, MD, at his eponymous blog, approached this from a different angle in his piece “Dear anti-vax parents: We’re not mad at you.” Dr. Hayes is right—and that sometimes gets lost in the media swirl. It’s not the parents we’re mad at. It’s the people spreading lies, fear, and misinformation. Parents are caught in the middle, unsure who to trust, filled with worry. That’s a shame. Parents have been tricked into worrying about the vaccines, when it’s the diseases that cause the problems.

A lot of anti-vaccine (mis)information continues to appear. At least one Arizona doctor (an “integrative cardiologist,” whatever that is) proudly and clearly says “Don’t vaccinate your kids”—at least he’s not being a weasel about this. Let it all hang out, Doc! And many mainstream reporters still seek out the usual few anti-vaccine docs for quotes in otherwise fact-filled articles, like this one from USA Today. There, Dr. Jay tells us that while there’s “no proof the vaccine is dangerous… It’s not a crucial shot.” In a New York Times piece, that same doc incoherently says: “I think whatever risk there is — and I can’t prove a risk — is, I think, caused by the timing. It’s given at a time when kids are more susceptible to environmental impact. Don’t get me wrong; I have no proof that this vaccine causes harm. I just have anecdotal reports from parents who are convinced that their children were harmed by the vaccine.” I think now is the time for reporters to stop going out of their way to quote these dangerous idiots.

I’ve saved the best for last—the parody sites, who’ve found this outbreak a rich source of terrific articles. What makes them so effective is that they all rely on that germ of truth. From The Onion, “Diphtheria excited about possibility of new outbreak”, and “I don’t vaccinate my child because it’s my right to decide what eliminated diseases come roaring back.” They’ve also got some great “quotes”, here and here, including the deliciously ironic “To be fair to the parents, no one could have predicted that neglecting to immunize people against diseases would lead to more people getting diseases.” Over at The Washington Post, an article that may have been written by A. Measles Virus is titled “Please stop vaccinating your children. I want to go to Disneyland.”

In all seriousness, this is just the beginning of an outbreak that could really be a catastrophe. Hundreds of thousands of public health dollars are being spent—and soon it will be millions. Parents and babies and children are missing weeks of school and work. Dozens of people are sick, and about a quarter of measles cases so far have had to be hospitalized. This really isn’t a joke at all. Hopefully, though, it will be a turning point. For those of you who still support and encourage parents not to vaccinate, now is the time to rethink your message. It’s time to end the “controversy” that never really existed. Vaccines are safe and effective, and we need to work together to protect all of us, including the most vulnerable.

“Until this moment… I think I have never gauged your cruelty or your recklessness. … You have done enough. Have you no sense of decency?”



Dr. Sears continues to salute our children with his middle finger

January 18, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Dr. Sears is California pediatrician who made up an alternative vaccine schedule to sell books to worried parents. Though he has said that skipping vaccines is not good for public health, he takes no responsibility for encouraging his own privileged patients to stay unvaccinated. And now that measles cases are stacking up in his hometown, Dr. Bob Sears is sticking to his guns.

In his latest update on Facebook, Dr. Sears continues to minimize the health risks of measles and downplay his own role in fanning anti-vaccination fears. And he has a special f-you to babies and the immunocompromised, who apparently don’t count. Let’s see what Dr. Bob has to say, in his own words. The quotes are from his Facebook post on the “Dr. Bob Sears” author page, posted 1/16/2015.



What makes measles so scary? What is it about measles that spreads fear and dread through our population? Three things, in my opinion, set it apart from most infectious diseases that make us afraid: 1. It’s untreatable, and it has a high rate of complications, so we are at it’s (sic) mercy, 2. It’s been virtually eliminated from the U.S., so we aren’t used to it anymore, and 3. It’s potentially fatal.

Dr. Sears’ first paragraph is spot on. Measles is difficult to treat, check. It has a high rate of complications, check. It’s potentially fatal, check. We’re on the same page here.

Ironically, Dr. Sears also said that measles has been virtually eliminated from the US. It was. Now, measles has returned. Dr. Sears can pretend that’s not true, and pretend his encouraging parents not to vaccinate had nothing to do with it, but that doesn’t make it true.

Then Dr. Sears tries to back up and claim that what he just said wasn’t true—he called his statements “two truths and a lie.”

Now, let’s play two truths and a lie. Two of these statements are true, and one is not. Well, the one that is not is technically true, but it’s not true in all practical terms.

Untreatable? Correct. There is no anti-viral medication that will help, so we just have to stand by as the disease runs its course. We are powerless, and that creates fear. We don’t want to take a risk with something which we have no way to mitigate or control. The only thing that may make measles less severe is high dose Vitamin A therapy (which is approved by the WHO). But that’s not an anti-viral med; it just helps us fight it off a little better.

1. Complications? Ear infection is the most likely complication – treatable. Pneumonia is next – also treatable. Ya, you don’t want those things to happen, but they are treatable. Encephalitis? That’s much worse. Fortunately it’s extremely rare in well-nourished people (see below).

So, the lie is that measles has a high rate of serious complications. It doesn’t. It CAN, but it rarely does.

Yes, pneumonia is treatable. Many parents would consider an ICU stay somewhat of an inconvenience, but, as Dr. Sears says, “Ya, you don’t want those things to happen.” Encephalitis, he acknowledges, is worse. But he claims it’s “extremely rare in well-nourished people.”

So how common are these complications? Dr. Sears can’t be bothered with numbers, but you can find them on the CDC website: 1 in 20 get pneumonia; 1 in 1000 encephalitis (which can lead to seizures, deafness, and mental retardation); 1-2 out of 1000 will die. Many parents find these risks unacceptable—especially when there’s a safe way to prevent them. Dr. Sears blows them off as “extremely rare.”

2. Eliminated? Virtually. Over the past 20 years we’ve sometimes only had 50 cases a year. Sometimes 150. Nobody knows measles anymore, and when we are ignorant of something unfamiliar, we fear it until we understand it.

Ask any Grandma or Grandpa (well, older ones anyway), and they’ll say “Measles? So what? We all had it. It’s like Chicken pox.” Ask a twenty-five-year-old mom with two young kids, and she’ll scoop up her kids and run away from you for even mentioning the M word.

If you understand measles, you wouldn’t fear it. Respect it.

I do acknowledge that it’s a public health nightmare in that it takes a lot of effort and money to contain these outbreaks. And it causes a lot of people to get tested, quarantined, or treated with preventive immune globulin shots. It’s no joke. But, those efforts are largely because we are trying to contain it, not because it’s going to kill everybody. So, not fear – respect.

There’s this odd fallacy that since people of many years ago had to live through measles (and, presumably, small pox and the black plague) it was “no big deal.” Old cemeteries are littered with tiny little headstones for little dead children. Families had loads of children, then, because it was accepted that many would die. Times have changed. Families expect children to live. We don’t accept many risks now, not because we’re weak or uneducated, but because we don’t have to.

Dr. Sears says “I do acknowledge that it’s a public health nightmare….” Thanks, we appreciate the acknowledgement. But apparently, to Dr. Sears, that’s not a good enough reason to try to prevent measles in the first place.

3. Potentially fatal? Technically true, but herein lies the lie. It’s been publicized as “the deadliest of all childhood fever/rash illness with a high rate of complications.” Deadly? Not in the U.S., or any other developed country with a well-nourished population. The risk of fatality here isn’t zero, but it’s as close to zero as you can get without actually being zero. It’s 1 in many thousands. Will someone pass away in the U.S. from measles one of these years? Tragically yes. That will likely happen to one person. It hasn’t happened here in at least ten years (or more – I don’t even know how many years we have to go back to find one). When that happens, it will be extremely tragic.

But will it spread through the U.S. and kill people left and right? No. Does measles do that in underdeveloped countries? Sadly, yes. It kills countless people worldwide every year. So, that’s how health officials can accurately say it’s so deadly. They don’t have to tell you the whole truth, just the part of the truth that they want you to believe.

Measles can also be serious for young infants, just as many diseases can. It can also be serious for immunocompromised people, just as all illnesses. It can also cause pregnancy complications, just like many infections can. Measles isn’t unique in these risks. But they are risks nonetheless.

It is true that most healthy people will get through a case of measles OK (though, as he says, it’s still a “public health nightmare.”) But what about those infants and immunocompromised people and pregnant women? Dr. Sears says “it can also be serious” for them. But, apparently, they don’t count. Their deaths and complications aren’t anything Dr. Sears and his followers should worry about.

Dr. Sears ends his update with this smarmy and self-serving conclusion:

So, fear measles? No. Not in the U.S.. Respect measles? Yes. Take appropriate precautions with it. But don’t let anyone tell you you should live in fear of it. Let’s handle it calmly and without fear or blame.

I will keep you up to date in the weeks to come.

Dr. Bob

Yes, Dr. Sears. Let’s handle this calmly and without fear or blame. As in “don’t blame me for what I’ve said and done for the last ten years. It’s not my fault you’ve listened to me, and it’s not my fault I’ve lied and obfuscated and done everything I can to flame vaccine fears to sell my books.”

Dr. Sears says we should “Take appropriate precautions with it.” He’s right. The appropriate precaution is to vaccinate our children. Don’t fear the vaccines. And don’t listen to this self-serving, hypocritical fool. Make sure you, your children, and everyone you know and love are fully immunized.


related: Measles at Disneyland: A predictable, avoidable public health nightmare

Is the FDA’s antidepressant warning killing people?

October 27, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

In 2004, the FDA launched a program to “strengthen safeguards for children treated with antidepressant medication.” Among other steps, they started requiring manufacturers of several kinds of antidepressants to include a warning in their product labeling, a so-called “black box,” that explicitly and loudly proclaimed a risk for children taking these medications. The warning said that children taking these medications were at an increased risk of suicidal thoughts and behaviors. Later, the black box warning was expanded to include young adults. The warning was required to be added to the labeling of medications including Prozac, Zoloft, Celexa, Wellbutrin, and several other medications.

What prompted this action was an observation from studies of children taking these medications that in the weeks after starting them, there seemed to be increased thoughts of suicide. Not suicide attempts, and not deaths from suicide (there were actually no suicide deaths at all among the study groups), but self-reported thoughts about suicide.

Now, depression is a serious illness—and suicide is a very serious consequence of depression. People with major depression have about a 15% cumulative lifetime risk of death by suicide, so this is a very significant and serious problem not to be taken lightly. We know that people with depression often think of suicide, and are at grave risk for attempting suicide—is it possible that anti-depressant medications actually make this risk worse?

A June, 2014 study from The British Medical Journal has looked at the consequences of the FDA’s decision (and the ensuing broad media coverage.) Researchers examined data from a total of 2.5 million teens and young adults from 11 health care plans in the United States. After the warning, the use of these medications dropped by about 24-31% (depending on age grouping.) This was accompanied by an increase in the rate of suicide attempts, by 22-34%. The rate of deaths from suicide did not change at all—just the rate of attempted suicides.

So, no, the FDA’s warning, based on this study, didn’t increase actual deaths. But it did increase suicide attempts, which likely means it increased the rate and severity and consequences of depression. It certainly hasn’t done any good. The warning has scared many families and doctors away from one mode of therapy for depression. Antidepressant medications aren’t perfect—they do have important side effects, and they don’t always work, and they’re certainly not for everyone with symptoms of depression—but they can be one important part of the treatment of some depressed adolescents. It’s a shame that this misguided “black box warning” is doing more harm than good.

Defeating Ebola: Nigeria did it, so can we

October 21, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

In June, a man became very ill during a flight into Lagos, Nigeria. On the plane, he developed vomiting and diarrhea, and he collapsed in the very busy airport. Contacts on the plane and on the ground had no idea that he had Ebola—initially, he was treated for malaria—and many healthcare workers and bystanders on the plane and in the airport were exposed to his infectious body fluids. One of his close contacts, while ill, flew across the country to consult with a private physician.

A nightmare? Well, it wasn’t good. But health officials in Nigeria stepped up to the plate and dealt with it. Following protocols (yes, protocols) recommended by the WHO and CDC, and relying on a fairly meager public health infrastructure built to track polio cases, workers carefully tracked every single contact, and kept tabs on all potential cases. People who became sick were then isolated. In total, Nigeria experienced 19 cases of Ebola (including 7 deaths), all traceable to the single imported case.

Nigeria has not had any new diagnoses of Ebola disease in 42 days, twice the maximum incubation period of 21 days. The WHO has declared Nigeria Ebola-free.

No special medicines, no vaccine, no high-tech anything. Nigeria is Africa’s largest country, and the case was imported through a planeload of about 50 people, all potentially exposed to infectious material. All of these people then traveled through the country’s largest airport in its largest city. Yet there was no widespread illness—the outbreak was contained through the boring, tedious, essential work of screening and following. And it worked.

The media are in an absolute frenzy over Ebola in the US, pointing fingers and practically frothing at the mouth. I realize that in the noisy world of the internet, one has to shout to sell, and shout to be heard; I also realize that there’s an election coming up in just a few weeks, so anything that makes someone else look bad is going to be a tool that just has to be used. Politicians are doing what politicians do (grandstanding), and journalists and those-pretending-to-be-journalists aren’t far behind.

One example: everyone seems to clamoring for us to shut down flights from countries affected by the epidemic (Liberia, Sierra Leone, and Guinea). Politicians from both sides and pundits on the TV news are blasting the administration and public health authorities:

 “Of course we should ban all nonessential travel…” – Bret Stephens, Wall Street Journal

“…we should not be allowing these folks in. Period.” – Rep Fred Upton (Republican, MI)

“It starts with a travel ban for non-citizens coming to the US from affected areas…” – Sen. Mark Pryor (Democrat, AR)

But a widespread travel ban will do more harm than good. There already are no direct flights from any affected countries into the USA—anyone getting here will actually be coming from somewhere else. If a travel ban is in place, people who are potentially exposed will do what humans do: they’ll lie. And they’ll get here anyway, from Morocco or France or wherever. (The Liberian man who flew into Dallas, starting our only outbreak here, flew from Belgium). A travel ban will create a panic and a logistical nightmare. We won’t be able to know who is actually coming from where, and people who need to be tracked (maybe including people already sick with disease) may end up hiding from authorities. What happens then?

There are other reasons why a travel ban is a bad idea. It will prevent aid from getting where it’s needed (and the longer the epidemic brews in Africa, the longer we are at risk.) It will further destabilize struggling governments in the heart of the crisis. We should not take steps that will prolong the primary source of cases in West Africa. In fact, the most effective way to end this mess is to end it in Africa. We need to be there, helping with the fight.

None of that seems to matter—it’s all about the symbolism and messaging. Politicians want to look like they’re taking a Tough Stand to Protect America, and journalists want to sell their stories and newspapers. Shut the border! Meanwhile: there have been no further cases of Ebola from the small Texas outbreak. Though infection-control procedures needed to be tighter at first, it looks like health authorities have quickly adjusted their response to contain the spread, and it worked.

There will be more cases of Ebola appearing in the USA. We’re a big country, and we cannot practically just stop travel from an entire side of a continent. Despite what’s being screamed in the media, the CDC has done a good job at responding to this crisis. Future cases will be identified, and spread will almost certainly be limited to a handful of people genuinely at risk (not you, and not your kids.) There’s no need for panic. If Nigeria can do it, so can we.


USA Ebola cases double. Media goes nuts, and still misses the point

Ebola and you


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