Swine Flu 4.94: what if?

Still no sign of swine flu in the neighborhood, but the media are busy fanning the flames of panic.  Well, why not?  We do have a problem, might as well have it be pointed out by something as relatively mild as swine flu.

The problem has to do with the dismemberment of inpatient care in the US.  There is something called the

Milliman and Robertson Length-of-Stay Criteria

(basically a wish list from the managed health industry  about how they would like every disease treated by an outpatient or drive-through procedure).

Then there is the tendency to emphasize preventive care at the expense of curative care infrastructure: the money spent on screening and prevention is being generated by closing hospitals, and fewer physicians are doing hospital care now than ever before.  Which is fine, as long as everything you face is preventable.

As yet, swine flu is not very preventable.  Yes, they are working on the vaccine (it is not clear yet how effective it will be, I am hoping for the best, and it is promised for late October), and, yes, thinning the crowds (in schools and elsewhere), proper hygiene, vitamin supplementation and “social distancing” will be useful — but they fall short of complete prevention.  In the meantime, inpatient and intensive care facilities are pared down to bare minimum. It’s a good thing swine flu is only expected to cause a modest increase in need for intensive care — something really nasty like SARS or Spanish flu would have caused a total health care meltdown.  This is a good time for the powers-that-be (within medicine as well as government) to become unobsessed with preventive care and return to what we are really trained to do: treat the sick.  Preventive care, though important, is a fairly cookbook procedure, time consuming mainly because of the amount of advice and guidance to be dispensed, and, as I said before, having a quota of teenagers to bore today can conflict seriously with caring for the sick children in an epidemic setting — let’s think about that for a minute.


Swine Flu 4.93: Off for the Summer?

It’s now about 7 weeks without a single positive flu test, which makes one wonder: where did it go?  It is certainly around in the Southern hemisphere, where it is winter now (about 1% of New Zealand’s largest cities population was seen with flu-like complaints during one week in July), and even in the Northern hemisphere, some countries are just starting seeing massive numbers of cases, and some states still have widespread flu.  So the question is, why are we not seeing any cases here in Brighton Beach?

Theory 1: Practically everyone in the neighborhood who was going to get the flu, has already done so.

–well, if that’s the case, we should be fairly safe come fall.

Theory 2: Transmission has been interrupted by “summer factors” — better ventilation, moister air, decreased crowding…

– in which case, more open windows, humidifiers, and a liberal school attendance policy should be helpful.  School un-crowding is especially important with swine flu because attack rates for this particular strain appear highest in the 5 to 24 year old cohort.

Theory 3: D-fense!  Vitamin D does appear to strengthen the immune response, especially against respiratory infections, and Vitamin D supplementation (along with A, C, zinc, and others which may be helpful) is certainly worth trying.  In my own practice I have been measuring 25-OH vitamin D levels in the serum of patients presenting for a variety of complaints, and an appalling number have come up deficient.  Although most, as expected, were either dark-skinned individuals or indoor WoW addicts, I did have a low Vitamin D level in a freckled sunburned redhead.  (Yes, I did read the riot act about hazards of sunburn).

Theory 4: An Unknown Factor.  No one knows why, in 1976, swine flu infected 100 soldiers at Fort Dix, and no one elsewhere.  If this flu strain plays a similar practical joke, that X-factor may be easier to find with modern molecular techniques.

Well, off to work…


Swine Flu 4.92: Flu Virus Sailed the Ocean Blue

It has been 6 weeks of relative calm: very few children with fever (and those who did, mostly had obvious hand-foot-mouth disease, pneumonia, or strep throat); not a single positive flu test in these 6 weeks, and that’s after having over 20 a day in June.  We are continuing to do flu tests, so watch this space: we’ll be among the first to know when flu returns.  It is now highly prevalent in the Middle East, the Southern Hemisphere, and other places it did not hit early.  Russia appears to have only a few cases so far, partly due to a vigorous screening and isolation program; whether it works in the long run remains to be seen.  My recommendation (Mexico is now the best and safest place to go on vacation) stands, as do all my previous advices.  I would like to re-emphasize one of them:  vitamin supplementation.  More than half of all the children I have so far tested are Vitamin D deficient (as opposed to none deficient for B12 and Folic acid), and Vitamins D and A are essential for proper immune response.


Mistakes in Choosing a Pediatrician

Babble.com just published an interview with me; my answers were, of course, edited for space, but they kept the most important points.  Here goes:


What are the 3 most common mistakes parents make when visiting the pediatrician?


Buzz up!

Expert: Dr. Anatoly Belilovsky, director of 365-day medical center, Belilovsky Pediatrics, in New York. His blog is www.belilovskypediatrics.com.

1. Choosing a doctor that’s the wrong fit.

“Every pediatrician is not going to fit with every parent personality. So often I hear, ‘Oh my friends said you’re great!’ and it turns out that that while that doctor may have worked for your friend, they’re the wrong fit for you. For instance, if you’re a parent that’s deathly afraid when your child gets a fever, which is a common complaint, you’ll want a pediatrician that displays a bit more empathy toward fevers, as opposed to a doctor that quickly assures you it’s nothing serious. Also, some parents require longer dialogues and explanations than others; find a doctor that complements that. References are a great way to find a trusted pediatrician but ask your friends in-depth questions before you visit: What’s so great about this doctor? Can you describe specific episodes? Why would you choose them for your son or daughter? And of course, don’t feel obligated to stick with a doctor just because a friend referred you. They might be great at what they do, but not a perfect match.”

2. Always wanting a prescription.

“Too often, parents bring their children to their doctor, expecting to leave with a prescription. And when they don’t, they consider it a waste of time. We have a model we follow: treat, counsel, educate. This means some cases require treatment, some only require education. Example: baby acne and bug bites. First-time parents often over-react to these problems, and expect a prescription, when pediatricians can really only offer advice. Of course, if you feel like a doctor is dismissing your child’s case, seek a second opinion. But realize not all problems require the same solution. Another tip: If you don’t understand your doctor’s verbal explanation, ask him to use an analogy or diagram. I once treated a child whose father didn’t understand hip dysplasia. I found out he was a marine engineer, so I made him a diagram, and all of a sudden, he understood!”

3. Delegating visits.

“This is a minor mistake compared to the first two, but still important. And this is sending your child to their pediatrician with someone who doesn’t know the whole story, for instance grandparents or nannies. Often, these people don’t know your child’s entire medical history or the details of the problem at hand, which makes our job more difficult. Later, we’ll get calls from parents who couldn’t be there in person, and it turns out there’s a whole different story we weren’t aware of. Or, we’ll try to reach parents, only to get a call the next day wanting to know what’s going on. It’s much easier for both parties to address issues in person and for parents to get the straight story from the horse’s mouth. Obviously, sometimes parents have to work or travel but, for instance, my practice is open seven days a week/365 days a year. If you’re really invested, you’ll find a time to bring your child that works with your schedule.”  

— As told to Andrea Zimmerman


ParentDish ADHD interview: more complete answers

Parentdish.com interviewed me a few weeks ago, about ADHD.  I do not treat ADHD myself, which allows me to have a kind of broad, unbiased perspective on it — and, like most diseases considered “new”, history tells us it is old but “newly named”.  The very popular article, widely reblogged, is here:


and here are my original answers in the interview :

> Please provide me with your definition of ADHD and ADD. Is this a truly physiological disease? I am skeptical, I admit. It seems like when I was a kid, students with ADD or ADHD were just called “hyper” or “active.”

Look, forget about clinical definitions; let’s talk about people.  ADD/ADHD is the disease that caused Alexander to be The Great.  It also caused him to drink himself to death.

Continue reading


Asthma Article Published In: thefamilygroove.com



Every Breath You TakeQ: What is asthma, really?
A: Asthma is the reversible narrowing of bronchi,
the pipes through which air reaches your lungs.
Look at it this way: Imagine breathing through
your eyes. Have you heard of bronchospasm?
That’d be like your eye was closed. Bronchial
inflammation? That’d be like your eye was swollen
shut and filled with gunk. Reversible obstruction? That’d be like your eye was shut one minute (a trigger response) and wide open the next.


Q: Why is there so much asthma lately?
A: The theory that makes the most sense, and is best backed up by evidence, is the hygiene hypothesis. In several studies, it was found that in developing countries, people who were infested by intestinal parasites had less allergy and asthma than those who were not, and in a German study, less asthma was found in children who survived a life-threatening infection. The immune system is constantly on the lookout for infections and parasites and, lacking real targets for the immune cells to attack, sometimes attacks healthy tissues or overreacts to minor infections. There are a number of infectious agents such as respiratory syncytial virus or mycoplasma that have been identified as commonly associated with asthma, and, of course, pollutants can trigger attacks. Blaming all asthma on outdoor pollution is probably incorrect, as the air is cleaner now than it has been for hundreds of years because of stricter environmental controls.

Q: How is asthma treated?
A: There are medications like albuterol, which relaxes the muscles holding the airway closed; steroids, which decrease the swelling; and antibiotics, which treat the infections that may either trigger or complicate asthma episodes. A common mistake is to assume that, if shortness of breath is absent, all is well. This error is best avoided with the use of a little toy called a peak flow meter. It measures how fast you can breathe out, compared with both your personal best and the ideal calculated for your age and height. Peak flow numbers will drop long before actual shortness of breath appears, allowing you to adjust your treatment or seek help early. Another dangerous mistake is to treat with beta-agonists (like albuterol) alone. They work quickly, but in the worst attacks, they fail without warning; dependence on beta-agonists has caused many deaths in asthmatics. Think of them as fire extinguishers; if you use one daily, there is something wrong in your kitchen, and they are useless against a big fire. There are a number of preventive medications that keep attacks from happening, and a number of rescue medications that stop breakthrough attacks, but the old “can’t breathe, take a puff” routine is not only useless, but potentially deadly.

Q: What are alternative treatments for asthma?
A: First of all, emotional distress is a well-known asthma trigger. The lungs and the brain are connected by the vagus nerve, and vagus activity is known to produce asthma attacks, so whatever makes you feel less anxiety will probably have an effect against asthma. Secondly, a number of plants produce toxins that, in small quantities, have an asthma-blocking activity. Unfortunately, as these toxins are needed by the plants to keep them from being eaten by animals, they tend to have serious side effects. Ephedrine in ma huang, theophylline in tea, and scopolamine in deadly nightshade are examples of such poisons. Many currently used medications are “declawed,” less toxic derivatives of natural plant poisons. Thirdly, human and animal adrenal glands produce steroid hormones, some of which fight the inflammation that is part of an asthmatic event. Both natural versions of these hormones and synthetic derivatives are used sparingly, as they produce their effect by suppression of immunity. “Declawed” versions of these hormones are easily destroyed in the bloodstream; they are given as inhalations directly into the airways and do not produce measurable effects anywhere else in the body.

Physical activity appears to help more often than not; exercise-induced asthma appears to be less common than asthma that gets better with consistent exercise. In any case, asthma should never serve as an excuse for reduced activity. Finally, anything that controls heartburn will probably reduce asthma severity as well—and since caffeine, fat, overeating, spicy foods, alcohol, smoking and tight clothing can all induce heartburn, avoiding them might be worth a try.

Dr. Anatoly Belilovsky is a New York pediatrician whose 365-day practice, Belilovsky Pediatrics, won an AmeriChoice award for Center of Excellence in asthma care. He is a graduate of Princeton University and served as a clinical instructor in pediatrics at Cornell’s Weill Medical College. For more information, visit his website and blog www.babydr.us.


In Praise of Allopathy

The brilliant water landing of US Airways Flight 1549 is out of immediate news lately, but hardly out of mind of all of us, especially those who work a loud shout away from the splashdown area. And looking at the interview with Captain Sullenberger, one cannot help but admire, and it with utmost admiration that I say, “It was such an allopathic thing to do!” Indeed, where a homeopathic approach would have required the Captain to flap his arms or to ask his passengers to face backwards and belch; where a public health approach would have requred him to fill out an environmental impact statement on the way down; where a holistic approach would have demanded that he address his passengers’ feelings with greater sensitivity and at length, and where a naturopathic practitioner would bemoan the fate of homogenized geese and claim the accident a just consequence for violating their airspace — Captain Sullenberger said, “Brace for impact”, and proceeded to execute a perfect, textbook dead stick water landing, using sound aerodynamic principles and skills honed by years of practice. And, to top it off, he checked, twice, to see to it that everyone escaped alive. And then he did not see what the big deal was about a guy doing his job. If there is a better metaphor for what medicine needs to emulate, I have not seen it. Not since Nine Eleven, anyway.

Pediatric CenterWelcomes Visitor


Sic semper tyrannis?

The first time I was right in my predictions and wished I wasn’t, it was on a subject I already beat to death: immunizations. In the very early 1990′s, as the Soviet Union fell apart, one of the results of its decomposition was a drastic drop-off in immunizations. And, seeing, to my distress, dozens of recent immigrants with few to no immunizations, I spared no effort getting them caught up to US standards. In at least one case I was too late: a little girl died of measles encephalitis while in my care. This family’s tragedy was a pale shadow of the massive disaster that befell what was left of the Soviet Union: thousands of deaths of preventable disease, mainly whooping cough, measles and diphtheria, and hundreds of thousands experiencing pain or disability.

But his is not about pushing for more mandatory immunizations. Quite the contrary.

It is a historical fact that public health works best in efficient tyrannies. Godwin’s Law states that sooner or later, Nazis will be invoked in any online discussion, so I might as well get this out of the way early: Nazi Germany and Stalin’s USSR had the most effective public health systems in the world at the time. They weren’t necessarily good, as the former was used to kill the less-than-perfect children, the latter developed psychaitric techniques for mind control, and both experimented on the unwilling, but as far as delivering their concept of health care to the masses, no one could touch them. In both cases, the motive was the same — a healthy, procreating herd of workers to be used for war or industrial development as needed; the means — an enslaved workforce including medical personnel to be used at government’s discretion; and the opportunity — the ability to deliver health care to homes and schools and workplaces bypassing the annoying complication of informed consent. As anyone who knows history can appreciate, when tyrannies fall, power plants crumble before prisons; and as public health enforcement withered away, the public rebelled against immunizations as they did against marching in goosestep. The latter was free of consequences; the former was not.

It bothers me that, as we get increasingly safer and more effective immunizations in our arsenal, and more and more information demonstrating their safety, we get more and more families asking to opt out. I think this is happening because of increasing government mandates — both for the families to accede to every single immunization in the pharmacopeia, and for us to escalate pressure on the families to do so. Tyrannies do not encourage thought; they result in either bovine acquiescence or pigheaded rebellion, and neither is a considered choice. I bothers me equally to have my patients line up to obey the Authorities, or distrust me as the agent of the Authorities. I do my own thinking and I prefer you do the same. And I’d much rather call someone an idiot than turn them in as a neglectful parent. So if you think I insulted your intelligence in our recent discussion about immunizations, well, yes, that was my intent. But, all in all, I’d rather live in a country that has freedom of stupidity. I shudder to think of how a government might outlaw stupidity successfully.


How I Broke the Law for 90 seconds

I generally stay out of politics for the same reason I don’t fly airplanes: I will not mess around with things I don’t fully understand where someone may get hurt.  Laws, as they apply to medicine, tend to run with a steamroller over problems best attacked with a scalpel, and the fewer of those we have, the fewer patients will suffer the consequences.  I have a story of a little girl who got better in spite of laws to the contrary.

It was 10 minutes to seven PM.  The mother ran in, scattering tears, clutching her little 2-year-old daughter, upset beyond words.  She had just picked her up from day care, and as she started to change her diaper –

Continue reading