Dr. Maller’s Blog

Ricky is 19 months old and doesn’t like me. Oh, he’s friendly enough if he has his clothes on and his parents are holding him at a safe distance. He babbles and delights his audience of the moment, but when I have to do my doctorly stuff he gives me as much as I can handle.

Some people would say he has no business being here. For one thing he came through two life-threatening heart surgeries very early in life. And then there’s that “extra” thing, a 47th chromosome that marks him as a Down’s Syndrome child with a distinctive appearance which makes children so afflicted look more like each other than like their siblings.

You don’t see as many people with Down’s nowadays because about 80% of them are aborted. They were often institutionalized in the old days and were expected to be weak and retarded. When chromosome analysis became available routinely, the rush was on to eliminate as many defective babies as possible; ergo amniocentesis, especially for pregnant women over 35.

In my early life there were 48 chromosomes and 48 states. I think it was an American assumption. But about the time Alaska and Hawaii made it fifty, the human cell was found to contain 46 chromosomes, which in biology is a rather peculiar number. There are the two sex chromosomes, X and Y, and 22 pairs of others – usually. Down’s Syndrome has an extra #21. Turner’s Syndrome occurs in females with one X only. There are other “trisomies” involving 17/18 and 13/15, generally recognizable at birth and incompatible with life (the only one I cared for actually lived over a year).

Ricky’s mother was 41 and her obstetrician insisted on an “amnio” but with the moral certitude of a woman unburdened by an Ivy League education she said no. She would play the cards she was dealt. As her pediatrician I had qualms because I knew the medical problems he’d likely face, starting with his most serious cardiac defect. But there was no moral hesitancy on my part any more than on the part of his parents.

This weekend I read an article on bioethics that reminded me of others I had read years ago, regarding Nazi Germany before World War II. For about 12 years in the 70′s and 80′s I edited and produced a newsletter for the medical staff of my hospital. My editorials were as provocative as I could make them. The doctors older than I usually loved them and the younger doctors called me all sorts of names, but they read them. My last one was about a psychiatrist from Boston who had been a Holocaust survivor and had described how the German medical community of the 1920′s often did Hitler’s work for him by justifying the isolation and extermination of individuals whose lives were “unworthy of life”, from deformed babies to homosexuals, elderly and insane, and later Jews, gypsies, communists, and anyone judged expendable. It was the awful “slippery slope” fueled by scientific zeal to purify the race. (Did you know that Margaret Sanger, founder of Planned Parenthood, was an ardent admirer of Hitler and his eugenics program?) That editorial was too much for the CEO of our hospital; he fired me because my editorial was “way too controversial”, even though I took most of it (with due credit) from the New England Journal of Medicine!

Ricky is a delight to his family, to me and my staff, to all the many medical people he has come across. He has a right to his life. I don’t know if he’ll be able to attend regular public school or be self-sufficient when he grows up, but I don’t know that about my other toddler patients with 46 chromosomes either! I am sure he’ll be a gentle soul whose family and community will be better off with him. We’ve also learned how heartless institutional care can destroy the emotional, physical and intellectual development of children born normal but deprived of love, as in Victorian English foundling homes or more recently in Romania and China.

Doctors have significant power over peoples’ lives, even in this age of the internet and “patients rights”. I’ve sat on Bioethics committees and heard an appalling lack of any moral compass from not only physicians but lawyers, social workers and executives and even clergy who confuse themselves with Him Who created us all equal and in His Own image.

Seven years ago President Bush was under fierce pressure to give a green light to federally funded embryonic stem cell research. Inevitably this would involve creating new human embryos for research (i.e. destruction). With the extensive involvement of his Bioethics Task Force chaired by Dr. Leon Kass of my alma mater, the University of Chicago, and Dr. Robert George of Princeton, he stood his ground, permitting only already existing lines to be used. Almost $2 billion in private funds later, embryonic stem-cell research looks more and more like a blind alley, whereas stem cells from much less controversial sources turn out to be far more promising. Even the New York Times begrudgingly admits that that was Mr. Bush’s finest hour.

Rubeola, a.k.a. red measles, has been targeted for eradication by the WHO but that goal has proved elusive. My first opinion blog. “Science vs. Truth” discussed some of the reasons why.

A recent CDC bulletin shows the good news and the bad about this ancient scourge. An athletic competition in Pennsylvania drew 265,000 participants and spectators from eight foreign countries and all parts of the USA. A 12-year-old Japanese boy was incubating measles when he arrived in PA after several changes of planes. His team and the Taiwanese shared transportation.

The good news: only six more cases of measles could be documented after intense search by a team of epidemiologists. The attack rate for measles in a non-immune population would be over 90%. The bad news? It’s still around, and the victims were very sick. A 40-year-old sales rep developed a 105.7 F fever and seizures after contact with the index case, by which time he was home in Texas. A 53-year-old woman from Michigan got typical measles, which she had not had as a child, after sitting near the index case while flying into Detroit. (People born before 1957 are assumed to be immune). All recovered.

I took my new puppy Gucci to the vet yesterday (many of you have met her as she spends most days in the office) and we discussed vaccination. Distemper in dogs is caused by the same virus as human measles, and many younger vets think it’s no longer a threat because they’ve never seen it. Last year he saw an outbreak of 29 cases, all devastating.

Smallpox is gone except in laboratories, polio is almost gone, but measles and the other childhood diseases are lurking, and only continued efforts to vaccinate all children will save us from more surprises. In this age of international travel, that must include kids from all over the world. Despite a few loose cannons on the Internet, we are making progress.

Ever notice that everyone describes his cough as “bad”? This post is a somewhat tongue-in-cheek defense of the lowly cough (except for those who cough in theaters, which should be a hanging offense.)

Why do we cough? To clear our airway of bothersome stuff: pollen, bacteria, viruses, toxins and the cellular reaction to them, collectively known as mucus. If not for the cough reflex our lungs would be like vacuum-cleaner bags.

When do we cough? The timing can indicate the cause. Exercising, especially in dry windy weather triggers an asthmatic cough in many people. Breathing via the nose helps humidify and warm the air, but I can attest to how difficult it is to do that while running. Night coughs may signify the common “post-nasal drip” one gets with colds and allergies.

The lining of our respiratory tract consists of microscopic cells with cilia, tiny hair-like structures that sweep invaders away from the lungs; these in turn are interspersed with cells containing goblets of mucus. Some infections such as influenza can destroy this delicate lining, which is why it takes three weeks to recover while the new lining grows. Smokers lose this defensive layer and it is replaced by squamous epithelial cells similar to skin cells, not only ineffective but prone to cancer.

Cough is different in babies for many reasons. They spend a great deal of time on their back, their muscles are relatively weak and their immune systems are rather slow to respond especially if not breast-fed. Respiratory viruses tend to be nastier the first time a baby encounters them, whereas the same virus appearing in later years will cause a simple cold. Children’s coughs are so ineffective that cases of tuberculosis under age 10 are not considered contagious (although no one seems to haver told this to the folks who make 3-year-olds get TB tests before attending pre-school).

Treatment of cough has changed dramatically in recent months with the withdrawal of all over-the-counter cough and cold preparations for kids under 2 (perhaps soon to be followed by further restrictions). The evidence for efficacy in babies was never established, and the dizzying array of new multi-symptom preparations was leading to overdoses. So now what? It’s back to your great-grandma’s remedies: moisture, positioning, suctioning, herbal tea, chicken soup, and good old honey (except under one!!) People ask about Vicks Vaporub and I have no idea if the stuff works or is safe, so you’re on your own! Much of the help we get from cough medicines is the topical anesthetic action on the throat, which is why cough drops have enjoyed a new life. Cough syrups taste awful because they contain things like chloroform and phenol; if you wash them down with water right away they don’t do much good. The most common ingredient in cough preparations is “DM”, a synthetic codeine imitator which has never impressed much in controlled studies. There are prescription medicines for cough, mostly with codeine. I feel that they are overused. If I’ve examined the patient and feel the cough is “useless” and lack of sleep is becoming an issue (for the child, not the parents) I’ll give an Rx for nighttime use only, and almost never in an asthmatic.

What can I say about obesity that hasn’t already been said? I’ll try to pull together what makes sense. Can anyone doubt that obesity is rampant? At a time when we call every 3-and-2 pitch with the bases loaded or 4th-and-1 “critical” it is important to recognize that this is a real crisis with the potential to reverse generations of progress in public health and bankrupt our already-overstressed health care system.

Simple rules of physics explain much of the problem. If energy expended is less than that taken in, we gain weight. Growing children of course need to gain but at a rate proportional to height. A pound of weight is equivalent to about 3500 Calories, a useful number in planning a diet. A child needs about 45 Calories per kilogram of ideal weight (2.2 lbs.) whereas a typical adult needs 35. To paraphrase Mark Twain, “Going on a diet is easy – I’ve done it a thousand times.” (He was referring to quitting smoking.) For years we have stressed low-fat diets only to find that carbs may be more dangerous and that without some fat we are always hungry. The food pyramid has been updated to reflect this. The best structured diet out there is the South Beach Diet; it’s enjoyable and achievable.

As we age our base requirement of Calories drops about 1% a year. (We also shrink an inch or two, accentuating the problem). Let’s take an overweight teenaged girl, 5’3″ and 160 pounds. Is she obese? Is it a medical problem or a cosmetic one? Her BMI (Body-Mass Index), a ratio of height and weight, is 28. For adults 25 is the highest “normal” figure; for prepubertal children it should be in the mid-teens. The BMI must be interpreted in context though. Muscle weighs more than fat so male athletes may be well over 25. For example Shaquille O’Neal’s is 33. This young lady may be healthy or not with her numbers. One needs to look at her entire lifestyle.

First of all, let’s take a history. Has she always been overweight? How about the rest of the family? Is there a history of heart trouble, strokes, diabetes in the family especially early in life? Is her menstrual history normal? Does she participate in physical activities. Is she depressed? Does her physical exam reveal early signs of diabetes, high blood pressure, central adiposity (that’s fat tissue around the waist), thyroid enlargement or a dozen other items worth checking? In other words, there is more to consider than numbers on a chart. Moreover, she must want to lose weight to do so, and must recognize that it’s not a 6-week or even 6-month program. The first step is accepting ownership of the problem. It can’t be treated successfully if it’s Mom’s problem or the boy friend’s or the doctor’s, and there are no shortcuts. One can safely lose only 5-6 pounds a month. Our teenager’s ideal weight is 130, a BMI of 23 and a generous number which can be achieved in 6 months while eating 2100 Calories a day, hardly a severe diet. Committing to regular aerobic exercise will get her to her goal faster and improve her mood. The natural high we get from endorphins we produce is habit-forming. Drugs have little or no place in obesity treatment and that includes supplements. Fewer than 1% of obese patients need thyroid hormones. Don’t assume that a product is safe because it’s “natural” – so is curare!

Few medical problems are as hard to treat successfully as obesity. In a study at UCLA some years ago a group of overweight patients was given the full-court press, including not only medical attention but psychiatric and physical measures as well. The lasting “cure” rate was 8%! Most cancers respond better than that. A recent study in children showed that an intense 20-minute daily exercise program brought about a 17% weight loss and remarkably also improved the kids’ school performance, so we must not give up. There is too much at stake. Fat people have more accidents, use up more medical resources, miss more work, and despite the cliché about jolly fat people, most are depressed.

Treating obesity successfully requires the family to cooperate, no matter if they are all overweight or not. If one child is overweight, he or she is often picked on as the scapegoat or at least feels that way. Don’t send the chub out to ride her bike; do it with her! Don’t ban TV or junk food for one child if you aren’t willing to do the same. Don’t blame McDonald’s or Taco Bell; no one makes you go there. Don’t expect the government to help; they’re not good at trimming fat. Don’t put the onus on the schools; they can barely teach your kids how to read labels.

Controlling obesity starts at birth, perhaps before. Breastfeeding for at least six months clearly protects children from premature fat deposits and later issues with cholesterol, which interestingly is abundant in mother’s milk but is absent from infant formulas. The government experts recommend whole milk in the second year of life. With all due respect, that is idiotic advice, especially for babies who stay on the bottle. A typical 18-month-old needs 500 Calories a day; that’s 3 8-oz. bottles of Vitamin D milk. No wonder he won’t “eat”! How much better to throw away the bottle and introduce the 4 basic food groups including healthier non-animal fats such as nuts and avocado. True, toddlers need a high-fat diet, but cow’s milk leads to anemia and unhealthy eating habits. As children grow they should not be given food as a reward or a bribe (except in the pediatrician’s office {8-)

Cultural influences abound. If you’re Hispanic, Italian, Jewish, Armenian (did I leave out anyone?) forget about the grandparents; they think there’s a pogrom coming and the poor tykes will starve, no matter how many spare tires they have. Two-thirds of our moms work, so everybody gets take-out. It’s not safe to play outside. We mustn’t miss our 5 hours of trash TV every day, which of course includes dozens of commercials showing thin actors eating 1200-Calorie hamburgers and drinking 20-ounce sodas that would take the paint off your car. And let’s not hurt our children’s feelings by bringing up their weight even though they need two seats at the movies because they might develop an eating disorder (sadly there is a risk of that happening and we do need to be tactful and caring).

While on the subject, I’m excited to announce that I will have an outstanding dietitian in my office soon to offer counseling for obesity and other nutritional challenges for people of all ages.

Let’s assume I’ve had my conference with young Johnny’s parents and we’ve agreed on a trial of treatment with medication. Now come the adverbs: why, when, how.

Why treat? Because children must go to school, and their success is important to them, their families, teachers, and society as a whole. A child who is distracted, inattentive and disruptive makes learning difficult for himself and classmates. Such a child may get by in the early years of school but decompensate in later grades as expectations heighten. Treatment may be instituted in kindergarten or any time thereafter. Questionnaires are helpful and both parents and teachers give their input before we commit to treatment, but there is more art than science in this process. Behavioral methods may be tried first but seldom help by themselves; the same is true for herbal remedies.

There are several options for medication, all once-a-day and even including a patch. This improves compliance and side effects as well as avoiding embarrassing trips to the nurse’s office. The choice of brand may depend on age and aims of therapy. Dosage is started at a low level and carefully advanced as needed. Around puberty it is common for hyperactivity to diminish, which may allow reduction in dosage. However, ADHD seldom disappears completely. Many affected adolescents and adults are most impaired by lack of what is referred to as “executive function”, the ability to organize one’s daily life. Impulsivity is most dangerous in teenagers, especially those who have not done well in school or in relationships with peers. Recently I lost a patient who at 19 took himself off the Rx he had been taking successfully for twelve years without discussing it with me. Six weeks later he was street-racing and hit a parked car at 100 mph.

I believe most ADHD kids benefit from daily treatment because learning opportunities abound on weekends too. Everything from reading a book to a visit to a park to athletic activities can enrich the child’s life if he is paying attention, following the rules and waiting his turn. Some families prefer to withhold the medication on weekends and holidays to allow appetite to increase, although I don’t find any less obesity in ADHD kids than in their peers. It also seems important to me that the child knows what to expect from himself in all kinds of situations and that he receive as much positive feedback as possible at those times. Sooner or later, children who have clashed with parents, teachers and peers over and over will become depressed and ashamed. It is not just a better report card we’re after but an internal assurance that comes from doing well and being praised.

What about the long term? The research is confusing but mostly reassuring. As mentioned in Part I, prisons are full of people with ADHD, many with drug abuse, but they represent the huge group of young people (mostly male) who were never diagnosed or treated for lack of opportunity. Entering the world of drugs and crime usually starts with marijuana, which unfortunately amounts to self-medication but is accompanied by loss of motivation and impairment of memory and judgment.

Lack of compliance with treatment also accounts for many bad outcomes. If a child with ADHD has a parent or two with same, plus a high likelihood of failed marriages and lost jobs, the doctor’s influence may be fleeting. I remember my successes and see them frequently, but so many kids with ADHD drift away for lack of insurance, unstable home life, and occasionally because they’ve been scared off by an internitwit (I just made that up!)

ADHD is a chronic condition, not curable but manageable. Patients need to be seen regularly for checkups and tests, and communication among parents, teachers and other professionals is essential. Many older kids will need therapy for depression or other mood disorders as they arise. Successful people with ADHD are all around us, especially in L.A. where I practice. They often marry well-organized women or make enough money to have managers. They tend to choose careers that reward energy and initiative and allow for “thinking outside the box”. The world of Dilbert probably wouldn’t work for ADHD folks unless the cubicles were soundproof.

‘Tis the season for visiting and celebrating, but not all the visits will be welcome. Influenza is in season so it’s a good time to share what we know about this ancient scourge.

“Flu” is one of the most overused words in our language, invoked to describe every ailment we suffer, many not even respiratory. Personally I prefer the French name (la grippe) or Spanish (la grippa) because they are so descriptive, whereas “influenza” harks back to medieval notions of miasmas and evil spirits.

Comparing classic influenza to everyday colds and upsets is like comparing a crocodile to a gecko.
In my two years as a CDC epidemiologist my major areas of responsibility were influenza and hepatitis, and while based in Berkeley I was responsible for tracking these viruses and others and reporting to CDC. You could say I was lucky in that both years were epidemic ones in California, one A2 and one B. These are two of the three major types of human influenza, the other being A. Type B tends to be milder but has nasty muscle pain, whereas A and A2 feature sudden onset of high fever, dry cough, sore throat, headache but rarely vomiting or diarrhea. School absenteeism, typically 8-10%, jumps to 40% and may force closure. Nothing else but natural disasters has that degree of impact on schools. The other main indicator is excess deaths from respiratory illness. Influenza typically lingers for at least 5 days and attacks whole families and workplaces. Few adult illnesses involve 104 fevers except this one. Deaths occur in older populations and the chronically ill, but in recent years more fatalities have been recognized in infants. This could represent the availability of quicker bedside testing.

There are hundreds of books about influenza but mysteries remain. The pandemic following World War I killed as many as 100,000,000 people, but its classification is uncertain. Because a species of bacterium was isolated from many severe cases, it was named Hemophilus (“blood-lover”) influenzae, a misnomer that is still with us. Viruses had long been postulated but were still the stuff of science fiction until after WWII. Major epidemics occurred in the 50′s and 60′s and were usually referred to by Asian names because it became clear that new strains arose in China and made their way around the world, necessitating new versions of vaccines every year. Birds and swine are involved in the propagation of influenza, as is occurring now with the still nascent avian flu popping up around the world, mostly involving occupational exposure to infected domestic birds. For these avian strains to adapt to humans and cause serious epidemics requires several steps called mutations; the hope is that while adapting to humans the H5N1 virus, as it is called, will lose its virulence, but that is not certain. Remembering the swine flu fiasco of 1976, CDC is preparing for this new threat but keeping a lid on the hysteria that could erupt.

Influenza vaccination has been around for years and there is little resistance to using it yearly for the elderly, chronically ill, health care workers, the military, and other select groups. In children its use is more controversial. There is general agreement that infection with the current A, A2 or B strain will leave the patient immune to that strain for many years, perhaps for life, and that healthy young individuals will recover. Giving the vaccine to children is more of a public health strategy in that it may help control the spread of the virus in the community, but the benefit to the individual child is limited to perhaps 80% protection for one year. It is untrue that people can “get the flu” from the shot; it is not a live virus. Be that as it may, a fair percentage of parents are refusing the vaccine, and as long as the children are healthy I’m OK with that. There are certainly much higher priorities in vaccination with greater benefit. There is now a live intranasal vaccine but its expense and other concerns have limited its use.

Treatment is not much different than it was in 1918. There are prescription drugs that cut a day or so from the illness but they are not tolerated by children. Antibiotics are not helpful unless secondary infection develops. Hydration and rest are essential. Fever and other symptoms can be treated as necessary. Although a classic case is unmistakable (“How fast was that bus going when it hit me?”) there are many folks who become infected and don’t even know it. Studies have been done in large workplaces, taking blood samples throughout an epidemic period, and the most significant factor correlating with absenteeism was the emotional state of the individual at the start of the study.

One of the great unsolved mysteries of this disease is where the virus goes when spring arrives. It is common for an outbreak to stop in March and resume in the same community in November, having disappeared all that time. In our area we haven’t had a major outbreak in almost 40 years. I suspect that our patchwork school calendar may have something to do with that, since some kids are off during the high-risk months. Perhaps I shouldn’t have said that – might arouse those medieval spirits.

I usually have several books going, some new, some old; some funny, some illuminating, some infuriating; once in a while a book can be all three, e.g. “What’s the Matter With California?”

My current old book is “Black Death” about the plague of the mid-14th century that killed at least a third of all Europeans and millions of Asians. Life then was, as Thomas Hobbes described it hundreds of years later, “solitary, poor, nasty, brutish and short.” Superstition abounded; witches, Jews, clergy, the rich were all blamed even though the plague ravaged them all impartially. There were surprisingly many “doctors” with precious little to offer.

How much better to live in this golden age of progress. Just since 1900 Americans’ life expectancy has risen from 47 to 79! Thousands of children died every year of strep throat, measles, pneumonia, polio, tuberculosis and other diseases back then. Despite that in 1899
a well-known writer announced that there was nothing left to discover!

We can laugh at that man’s shortsightedness, but I fear that the best years of science may be behind us. Of course there will be great advances in medicine and all other fields, but where will our Einsteins, our Kochs, our Listers, our Edisons come from? Perhaps Galileo or Copernicus would be better examples of what I mean. If science is to lead us to the promised land, it must be a pure search for truth. Money is necessary but cannot be permitted to buy results.

Several instances of what I consider junk science come to mind. In some cases results are foreordained because we want it so; second-hand smoke is vilified (even most smokers agree!) but the numbers aren’t there to back up the claims. Remember the apple dye scare? Asbestos was banned over 30 years ago but trial lawyers are still fattening up on it, and the truth is that no one except asbestos miners (almost all of them smokers) were ever harmed by the stuff. Did you know that the Twin Towers in NYC were built with asbestos until the ban, so that all floors above the 73d were unprotected? That the Challenger disaster might not have occurred if the defective tiles had continued to be made with asbestos?

A great deal of junk science is put forth to justify big budgets. Testing all children for lead poisoning is an everyday example. Our education and judicial systems are rife with all sorts of expensive and intrusive programs based largely on theories put forth by experts who wouldn’t know a double-blind study from a seeing-eye dog.

Even worse to my mind is the suppression of truth when it is politically incorrect. Two examples will suffice. The link between induced abortion (especially before having a first baby) and breast cancer is so strong that the law now recognizes that informed consent must include that fact. The AIDS “epidemic” is the other. My epidemiology training at CDC came before the term “AIDS” was part of the language, but I was skeptical from the start. The same syndrome had been seen much earlier, either at birth or after certain repetitive stresses on the immune system. Hemophiliacs had been receiving transfusions of clotting factors and some (remember Ryan White?) developed an AIDS-like illness. Amyl nitrite in ampules had been popular in the bathhouse culture of San Francisco and elsewhere; used as “poppers” to enhance erotic sensation, they had caused AIDS-like fatalities.
About 1979 or so an outbreak of a rare sarcoma in homosexual men led to the discovery of a burgeoning immune deficiency syndrome that was labelled “AIDS” and the rush was on to find a cause, meaning an external villain to blame it on. Witches being unlikely, a virus became the lead suspect. By finding such a cause, the lifestyle choices that were really responsible could be overlooked. And it worked!

A previously obscure retrovirus was found in most patients and was tagged “HIV”. AIDS seemed to have originated in sub-Saharan Africa; HIV is found in monkeys; some Africans eat (and even have sex with) monkeys; there is rampant prostitution and poor hygiene, leading to the largely mythical heterosexual AIDS hysteria. One of the principles I learned at CDC is that an epidemic burns itself out when the susceptible population falls below a critical level. In the mid-80′s I served on the Advisory Board of the Southern California Hospital Council and saw well-educated experts dealing with this new scourge about as inappropriately as the poor folks in medieval Europe did in 1349. “The number of cases is doubling every 9 months!!” (At that rate the human race would have disappeared by 1994).

A generation later we have millions of “HIV-positive” people all over the world, many taking extremely expensive and toxic drugs that actually shorten their life span. We have many deaths from AIDS but few confirmed as such. In Africa any chronically ill person with malaria and other parasites is counted in the statistics, the blood tests being too expensive and not all that reliable. The UN just reduced its number of AIDS cases in India by 60% because of a “statistical error” which just may have been related to a budget request that was too outrageous even for them. The point is that the pool of people at risk for AIDS is far smaller than claimed early on.

The age of bacteriology, and later virology, began with Koch and his discovery of the TB bacillus about 1880. He found the germ (medical students call them red snappers), isolated it in culture, injected it into animals, recovered it again and repeated the cycle. These steps became known as “Koch’s postulates” and had to be reproduced by other investigators to be accepted as scientific truth. That is, until AIDS came along. Only the first step was accomplished with HIV, and embarrassingly, thousands of AIDS victims remain free of HIV. The original group of men with Kaposi’s sarcoma did not have HIV, they had a herpesvirus.
Dr. Peter Duesberg of UC Berkeley had been one of the world’s most respected virus researchers until he wrote “Inventing the AIDS Virus”. His life has been threatened, his research grants taken away, and yet he has not backed down. Now others are coming forth and challenging over 25 years of politically-motivated pseudoscience. I believed him then and even more so now, for the only response from the toe-the-line crowd has been to scream Homophobe! or Holocaust Denier! They have no explanation for the twenty years’ survival of millions of HIV carriers who refuse to get sick and die as they predicted.

I would date the reversal in science-as-truth to science-as- dogma to 1962 and Rachel Carson’s “Silent Spring”. DDT was banned in an emotional response to her touching pictures of birds’ egg shells thinning. In those 45 years countless millions of Africans have died of malaria. Now, finally, DDT has been re-introduced in a controlled way and the impact has been dramatic. Where were the Darwinians in 1962? If birds were exposed to a new environmental hazard, wouldn’t they adapt? Data in humans actually showed that exposure to small amounts of DDT helped our livers act more efficiently against many other toxins. Now we have the man-made global warming hoax, which to their credit a great number of scientists have come forward to challenge.

Let me finish with Darwin and his theory, which is 150 years old and remains provocative but leaks like a sieve. Our children too often are presented with evolution as fact, as dogma, and those who question it are labelled all sorts of things. I am not a religious person, and do not take the Bible literally, but those who speak of Intelligent Design make more sense to me and should at least be heard by our children. ID is not science. It is not “creationism” in the sense that it promotes the Bible as a scientific treatise. It is simply a humble approach to mysteries we may never solve but can never stop trying to understand.

You’ve seen my tropical fish tank if you’ve been in my office the past 35 years or so. I’ve had a few lionfish. Looking at them is my idea of a religious experience, because there is no way Darwin can explain them as anything but our Creator’s sense of humor, on display for His most favored creation to enjoy.

G.K. Chesterton warned that “When man ceases to believe in G-d, he does not believe in NOTHING – he believes in ANYTHING.”
For too many of us that Anything is science dressed up as divinely inspired truth.

When I entered practice in the 60′s the flood of new antibiotics and vaccines seemed destined to change pediatrics and we looked for new worlds to conquer. Behavioral issues took on a greater significance, none more than what became known as ADD, Attention Deficit Disorder (plus or minus an H for Hyperactivity). I’ve been immersed in this field for 45 years, dealing with it not only as a pediatrician but as a school doctor and father. If that qualifies me as an expert, I’ll let you decide.

Despite great advances, controversy continues. Some deny that ADHD exists, especially in L.A. where scientologists are taken seriously despite their medical ignorance. (It is beyond ironic that in the entertainment industry practically all successful people have ADD.) This first blog will cover some history and discuss where we are now; later I will tackle treatment and prognosis.

Just the term ADHD was a major advance, replacing dozens of older names that were offensive (e.g. Brain Damage, Minimal Brain Dysfunction, etc.) and implied an understanding of the disorder that we had not earned. Now MDs, mental health professionals and parents share a descriptive term that makes sense to all. I do agree with critics that we medicalize too much these days. If we get nervous before giving a speech, does it help to call it “Social Anxiety Disorder?” When we see a child terrorizing a grocery store, “Oppositional Defiant Disorder” is not the first thing to come to mind. It seems as though we find a new pill or procedure, then invent a disease to match (heard enough Sweaty Palms commercials?) But ADD/ADHD is all too real and pervasive, especially in boys.

Seventy years ago World War I veterans with brain injuries were found to improve attention spans when given the new stimulant Dexedrine (which was available over the counter as No-Doz in my college days!). In the 50′s Ritalin (methylphenidate) became a promising antidepressant for alcoholics. By the next decade researchers confirmed that children with hyperactivity, inattention, distractibility and impulsiveness (similar to the WWI vets) often improved on Ritalin. In recent years long-acting versions with better profiles have largely replaced Ritalin.

Working part-time in several L.A. schools early in my career I saw the battlefield close up. Because the disorder is largely genetic, these kids often came from chaotic, impoverished backgrounds with single parents or none at all. There was usually a family history of alcohol and drug abuse, psychiatric problems, and ADHD itself. Teachers back then resisted medical intervention as an affront to their abilities, tending to blame parents and demand more money and smaller classrooms. I learned later that parochial schools had more success despite larger classrooms and fewer dollars. Identifying cases was seldom difficult, but too many kids were lost to follow-up. For almost 40 years I was the physician to the youngsters at Hollygrove Childrens Home. Perhaps two thousand passed through and virtually all had been abused. (Marilyn Monroe, their most famous alumna, was before my time). Most of those children had ADHD and responded well to treatment, but returned to foster care or family and an uncertain future.

Parents, especially fathers, always ask if ADD treatment is addictive. If it were, we’d have no problem getting our teenagers to stay on therapy! Fact is research has shown that kids treated for ADD are less likely to tinker with street drugs than “normal” adolescents (is there such a thing?) When my son was 14 he decided he didn’t need his Ritalin any more. At 6’3″ and 225, he got his way.

Frontiers in ADHD include treatment of adults and identification of “co-morbidities”. Most ADD kids also have learning disorders such as dyslexia (did I mention I was a founding member of DAM – that’s Mothers Against Dyslexia)? ADD drugs help handwriting and organizational skills but a learning-disabled child typically needs tutoring as well. As children get older, some develop signs of bipolar or obsessive-compulsive disorders, the first sign of which can be an atypical response to ADD treatment.

Treating a child for ADHD/ADD is a major responsibility, usually a multi-year commitment. I never treat without an hour or more of discussion with parents, who often leave to think it over. My patients know me as a conservative doctor whose prescription pad seldom comes out of my back pocket. But in my long career, the impact of treatment on these children and their families gives me more satisfaction than anything else I’ve done professionally.

A recent study of CEO’s of major corporations showed that virtually 100% had ADHD symptoms as children but were able to channel their energy by getting the help they needed. Conversely, all studies of prison populations reveal a 70-80% prevalence of childhood ADHD, usually untreated. These kids can be like runaway trains, and medications can help keep them on the track to success. While we’re on metaphors, I like to compare kids with ADD to radios without condensers; i.e. they can’t tune in to one station (the teacher) because they’re picking up ALL of them.

Contrary to what you may have heard, treatment does not induce a zombie-like trance, teachers do not demand that students be treated (they may recommend and it’s thankful that they do), and we share information and work as a team. Our goal is not to induce “conformity” although if we refer to scholastic success, popularity, impulse control, peace at home and on the playground as “conformity” remind me what’s wrong with that.

Parents understandably balk at having their kids “labelled” with ADHD or any other name, but I find that a child who can’t learn or adjust socially already feels different, and that success leads to greater self-esteem, not the other way around.

By now you may have heard that there will be a shortage of an important vaccine for many months.

Nothing bad has happened. Merck, one of the few remaining manufacturers of vaccines, has for the second time in a year found potential contamination in one of its facilities. There has been no tainted vaccine produced. However, it takes months to assure proper sterile conditions.

The vaccine at issue is HIb, Hemophilus influenzae Type b, which is given in three doses in the first year, generally combined with Hepatitis B (“Comvax”). For the present we have sufficient supplies. A year ago the new combination MMR and chickenpox vaccine was withdrawn for the same reason.

I’m sorry to pick on Merck, a fine company (and thank goodness the problem was discovered before any harm was done). But it is frustrating for all of us and as I’ve pointed out elsewhere, there is too much paranoia and misinformation out there already regarding vaccines.

There is no real marketplace for vaccines. Billions are spent on research and development with success far from guaranteed. Most vaccines are produced by one company and prices are controlled artificially, with millions of doses donated to the developing countries. A considerable part of the cost of each vaccine goes into a slush fund for trial lawyers, and reactions are reported through a central clearinghouse. Before that the drug companies had no indemnity against frivolous claims, and conversely most serious reactions went uncompensated. The good news is that vaccines have never been safer, despite their growing number, and several diseases have fallen off the radar.

Actually the “E.R.” (Emergency Room) has been supplanted by the “E.D.” (Emergency Department), signifying more than one room, but never enough to hold the swarms of patients therein. I’m told that one fellow, on seeing the crowded waiting room at his local E.D., went home, put on his old Army fatigues, downloaded a badge from the internet, and returned, whereupon 80% of the people left. The badge said “U.S. Border Patrol”. (Warning: this site is not politically correct. If that’s a problem I refer you to the Times {NY or LA – same thing} or CNN).
But seriously, why the problem and what to do about it?
Millions of folks have no “medical home” or choose not to use it. Some try and can’t get an appointment; some won’t take time off work. But a great deal of the overcrowding is the result of misjudgment. The law doesn’t permit ED’s to send anyone away without an assessment. It is usual to see people with bleeding injuries, chest pain, breathing trouble etc. wait for hours while minor illnesses clog up the pipeline. ED doctors must practice defensive medicine, which means hours of labs, scans, x-rays and whatnot and that’s after the 4-6 hour wait just to get past the front desk.
Because a third to a half of ED patients are children, let me suggest some common-sense guidelines for parents. First, when to call 911: head or neck injuries with altered consciousness; seizures; poisoning; choking – in short, life-or-limb-threatening situations.
Other than the above, there are few reasons to rush (People always “rush” to the ED, especially on TV) there. Call your pediatrician if in doubt. If he or she still uses an answering service (I dumped mine ten years ago) be assertive and call back if help is slow in coming.
Please refer to my articles on fever and diarrhea/vomiting. These and injuries make up most reasons for ED visits. Fever by itself is never an emergency. Earaches can be controlled with painkillers, olive oil and a heating pad (your grandma knew that). Sore throats can wait. Asthma and croup could get out of hand, but recurrent asthmatics should have tools at home to deal with attacks. Suspect appendicitis? Call first; you have time. Dehydrated child? Call first. If the doctor is concerned, your child might be admitted directly to the ward, be treated and discharged almost as quickly as an ED visit. Did your child just discover he can’t really fly? Suspected broken legs, arms or ribs can represent true emergencies, but a good urgent care can treat most of these, with lower co-pays and less waiting.
Spending a night in the ED can be emotionally stressful for you and your children, and in flu season downright risky.
Still want to visit your ED? Bring “War and Peace”, food bars, and a pillow.