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Of Ectoplasm, Adrenaline and Histamine

9/23/2021

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At the start of the 20th century, new understandings about the root causes of asthma, eczema and urticaria required entirely new labels: anaphylaxis and allergy. The twin relationship of allergy and immunity had emerged from the first use of the hypodermic syringe in mass vaccination (See Chapter 4). The triumph of germ theory through vaccination had created not only the problem of epidemic allergy in children but also an opportunity to analyze, categorize and then remedy it.
 
As described in Chapter 4, French physician Charles Richet (1850-1935) was one of the first to investigate. For his understanding of the pathogenesis and symptoms of anaphylaxis, Richet won the 1913 Nobel Prize in Medicine. But the inquisitive Richet may have chaffed at the restrictions of the medical model, the classification and reclassification of disease and remedy separate from mind and spirit. At the same time as he was repeatedly unleashing and documenting fatal reactions in dogs, cats and horses in the lab he was investigating paranormal energy that he claimed oozed or squirted from people during a séance. He called this “ectoplasm”.[1] A photo of Richet with a medium named Linda taken in 1905 clearly shows a “fluidie thread” of ectoplasm emerging from Linda's head. Attached to the thread is an ectoplasmic hand. Richet relates that these otherworldly events were “experienced at home in my library”.[2]
 
No doubt, Richet’s interest in the paranormal embarrasses allergists today. Ectoplasm is a poor fit for a materia medica – it is neither medical nor treatable.
 
Nevertheless, with the startling discoveries and understanding of allergy and anaphylaxis came the expected merger of science, the new immunochemistry[3], with the nostrum monger turned pharmaceutical company. Where the “gaze of the nosographers was a gardener’s gaze” during the 18th century, observed philosopher Michel Foucault, by the 19th century it peered sharply into the “quasi-mathematical” chemical operations of the body.[4]
 
Together, at the beginning of the 20th century, the scientist/nosographer and nostrum/pharma company entered into a lucrative relationship of patented medicines to remedy this “dark side of immunity”[5] through: adrenaline, anti-anaphylaxis (desensitization) injections. Over the next 100+ years, treatments embraced anti-histamines, steroids, inhalers, autoinjectors, novel immunotherapies of skin patch and oral capsules, anti-IgE vaccines and reprogrammed dendritic cells.

[1] C. Richet, Thirty Years of Psychical Research Being a Treatise on Metaphysics (New York, MacMillan Co., 1923).
[2] Ibid, p. 433.
[3] Term coined by Nobel Laureate and chemist Svante Arrhenius in 1904.
[4] Foucault, Birth of the Clinic, p. 147.
[5] J.M. Igea, “The history of the idea of allergy,” Allergy, 68 (2013): 966-973.

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Allergy's battlefield

9/23/2021

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Anyone who has experienced an anaphylactic reaction knows the debt of gratitude owed to emergency care workers. Benadryl, nebulizers and epinephrine can arrest a reaction but as the drugs are metabolized, there can be a biphasic response with a return of symptoms. The drugs are re-administered until the reaction is under control. Western medicine is at its best in a crisis.
 
Arguably, emergency medicine grew from the battlefield with rapid transport, triage and emergency interventions. Through the early 20th century, rotating on call physicians at hospitals managed emergencies with ambulance services provided by funeral home directors and hearses. Specialized training in emergency medicine was established through the 1960s and 70s. At this time, in comparison, battlefield medicine in the Vietnam War highlighted the weaknesses in civilian care which was soon to improve.[1]
 
Through the 20th century, ER care for reactions to drugs and vaccines and sera were far more common than reactions to foods.
 
Serum sickness starting in 1891 from the first anti-toxin sera for diphtheria caused systemic reactions for many years – although primary research has not been conducted to know how many died. Reactions to aspirin began shortly after the drug was introduced in 1897[2] and between 1912 and 1928 reactions to phenobarbital occurred in about 3% of those exposed to it. Sulfonamides were ‘highly sensitizing’ in the late 1930s and after WWII a tide of people became reactive to penicillin reminiscent of the days of epidemic serum sickness (see Chapter 5).
 
In the last decades of the 20th century, allergy had become an expensive health concern. In the US by the 1980s, allergy had a price tag of $1.5 billion per year in medications, hospitalization and services.[3] By 2013, that number had ballooned to $4.3 billion.[4]  This included 300,000 ER visits for children and 3.6 million prescriptions for Epipens.[5]
 
Patented in 1977 and brought to market in 1980, the Epipen was designed originally for the US military as a life saving battlefield device. The civilian application of this portable, spring-loaded autoinjector has made it ubiquitous and lucrative. In 2011, following a tragic death of a child at school for whom an autoinjector was not available, Federal Bill S. 1884 was tabled to provide “incentives to require elementary and secondary schools to maintain and permit school personnel to administer, epinephrine at schools.”
 
There are 98,817 US public schools – the possible over-stocking of schools with autoinjectors is good news for allergy parents concerned that EMS may not arrive in time or if they are simply unable to afford the devices.
 
The soaring price of the EpiPen became a US national scandal in 2016 when Mylan, licensed to make and market the device, increased prices to about $600. for a two-pack – that are replaced annually. Possible gross revenue at these prices for the 3.6 million prescriptions alone sent Mylan shares north until Aug. 2016 when the company CEO was asked to defend the price hike before a House committee. There are no regulations on drug pricing in the US.
 
While those with severe allergy, and their parents, are grateful for these life saving drugs they are effectively tied to them forever. The notion of a cure is not the goal of the drug companies, but rather ongoing and costly management of allergy for the life span of the consumer.


[1] R. Suter, “Emergency medicine in the United States,” World J Emerg Med., Vol. 3, No. 1 (2012): 5-10.
[2] A. de Weck, et al, Allergic Reactions to Drugs (Berlin, Springer, 1983) p. 6
[3] Jackson, Asthma, p. 11.
[4] R. Jaslow, “Food allergies cost US $25 billion a year,” CBS News (Sept. 25, 2013).
[5] K. Tunney, “How Many People Use EpiPens in America?” Bustle (Aug. 26, 2016).
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Che Guevara's puffer

9/23/2021

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Excerpt ~ Chapter 8, The Peanut Allergy Epidemic
 
Throughout his life, Argentine-born revolutionary Che Guevara (1928-1967) suffered from acute attacks of asthma. His chest was "sunken and deformed” from violent and regular exercise-induced spasms that he struggled to control with epinephrine injections and inhalers.[1] A root cause of the debilitating condition, offered by a 1960's Time article, was Che's early life exposures to intense cold. Cold water immersions, a form of therapy imposed on him by his father, were intended to toughen up the premature and sickly boy:
 
Che was plunged into bathtubs of cold water and doused under icy showers. He developed a persistent cough and later serious allergic asthma.[2]
 
Che's condition inspired a natural interest in medicine in the proto-revolutionary, which he studied with the intention of becoming an allergist. While earning an MD in 1953, Che was still unable to do more than manage his allergic symptoms [3] that, as a revolutionary in 1957, seemed to deepen. Large cysts formed in response to mosquito venom and the asthma attacks were relentless:
 
The asthma was so strong it didn’t let me advance. … I made it, but with such an asthma attack that every single step was difficult… I had to make a decision because it was impossible for me to go on without at least buying medicines.[4]
 
Some relief came in the 1950s with the development of portable inhalers. These small canisters contained measured doses of anti-inflammatory steroids and bronchodilators.[5] By 1961, Che’s puffer likely contained a form of cortisone, a chemical with clear side effects including a swollen, round face and weight gain. These effects were noted by his biographers.[6]
 
Inhalers containing the drug isoproterenol offered fast and convenient relief from asthma. The devices were quickly adopted and prescribed liberally in primary westernized markets. However, coincidental to their widespread use was a shocking string of asthma deaths in England and Wales starting in 1960 and peaking around 1968 (a year after Che’s summary execution in Bolivia). The same or worse increase in asthma deaths in this period was observed in Ireland, Australia, New Zealand and Norway.
 
It took four more years for the deadly mystery to be solved: the approved concentration of the inhaled asthma drug was five times higher in the devices used in the affected countries – this compared with the US or Canada and presumably also South America. The iatrogenic nature of the epidemic was discovered by Dr. Paul Stolley of Johns Hopkins University. He published his conclusions in 1972:
 
…at least 3,500 asthmatics – most of them below the age of thirty-five – died suddenly during the 1960s in Britain alone. In children between the ages of ten and fourteen, asthma had become the fourth leading cause of death. It was the worst therapeutic drug disaster on record. There’s nothing else – not even thalidomide --- that ranks with it.[7]
 
[1] D. Abrams, Ernesto “Che” Guevara (NYC, Chelsea House,  2010)
[2] Anon, “Cuba, Castro’s Brain,” Time (Aug. 8, 1960).
[3] J. Casta, Companero: the life and death of Che Guevara (Vintage, 1998).
[4] Ibid p. 102.
[5] M. Jackson, Asthma, p. 162
[6] Casta, op cit, pg. 194.
[7] P. Stolley, “Asthma Mortality: Why the United States was spared an epidemic of deaths due to asthma,” American Review of Respiratory Disease, Vol. 105 (1972): 833. From M. Silverman, P. Lee, Pills, Profits and Politics (U. of California Press, 1974).
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