Dr. Maller’s Blog

‘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.

Boycott Nestlé?

My commitment to breastfeeding is second to none (please refer to my article on the subject) so why would I question the decades-long boycott of the world’s largest formula company?
The outrage that led to the boycott is understandable. Mixing formula with contaminated water is a recipe for disaster. Half a million babies die in a typical year from rotavirus alone; most of those deaths are preventable. Giving new mothers formula samples sends a defeatist message. Even in our rich country, half our mothers qualify for WIC assistance. WIC gives lip service to breastfeeding but undermines it by providing formula for a year or longer to families well above the “poverty line”
(which in the USA means only one color TV and one car).
It is a myth that mothers in undeveloped countries can nurse their babies with ease. A study of African mothers showed just 58% were successful; wet nurses filled in. Not only are many poor women malnourished, but AIDS, hepatitis B and other diseases can be spread through breast milk. Would putting Nestlé out of business help these countries?
In the minds of activists, profit=greed. That is socialist bunk. Profit=jobs, infrastructure, health, prosperity in my world. The company is guilty of sloppy marketing but their product is legal, inherently safe, and sadly necessary. Were I CEO, I’d make sure my profits were put toward building sewers, hospitals, roads. etc. (I bet they already do). The problem in the third world isn’t eeeevil corporations, but dysfunctional, corrupt, sometimes truly evil governments.

Is there a link between MMR vaccination and autism? In a word, NO.
Yet the question is asked constantly by parents. First, some definitions. MMR is measles/mumps/rubella vaccine, given at 12-15 months and again at school entry. The three vaccines have been around since the 60′s and were combined about 30 years ago. Autism is a behavioral disorder first described a generation ago. If severe, it is often suspected in the second year of life when language skills fail to develop and a child doesn’t show appropriate emotional attachments. There is no test to affirm the diagnosis.
Some years ago a doctor in England had a hunch based on his observation of a handful of autistic children. They were in their second year and had been vaccinated in the recent past with MMR as had virtually all children in that age group.
Without proper scientific inquiry, he “published” his “findings” on the internet. Recently almost all his colleagues who had lent their credibility to him recanted, admitting they were fooled.

Imagine this scenario: A. 18-month-old child is acting autistic.
B. Parents and doctors ask, “What has happened recently in his life that might be the cause?” C. We put shoes on him! Therefore shoes cause autism!
Absurd? Of course. Why would anyone believe it? Blaming MMR vaccine is just as silly, but the notion has been taken very seriously by the scientific community and after years and millions of dollars spent, no link has been found.

Why does this rumor persist? In Los Angeles we live and work in the home of Scientology, a pseudo-religion that combats not only vaccination but medications for behavioral disorders. Parents are understandably frightened and confused at the wide array of vaccines, some quite new, and at the trauma of multiple shots. What is lost is perspective. I was privileged to train at CDC and practice epidemiology, including vaccine research, early in my career, so I follow developments in the field closely and use a cautious approach. But I also saw the last years of the era when diseases like measles, polio, H. flu meningitis and others killed tens of thousands of American children every year and left larger numbers institutionalized with permanent impairment.

Autism is a mystery, a dreadful one, but it is not rampant; rather, we spot it now in children who used to be considered mentally retarded. Like many poorly understood conditions, it invites quackery of many kinds.

Tom Cruise, Kelly Preston and Co. know as much about medicine as I do about making movies.