Subway Fears, Bioterrorism and Tetanus Shots
Dr. Marc answers readers' questions every other week. To send a query, click here.
Dear Dr. Marc,
I live in New York City. Many people I know are concerned about new risks associated with riding the subway. Would a gas mask with an NBC filter be useful in the event of an unforeseen terrorist attack?
New York City
I can't tell you the risks are zero. What I can tell you is that the hype and fear far outweigh the actual danger. As you may know, sarin gas deployed in the Japanese subway in 1995 killed only twelve people while panicking millions. Panic has historically injured far more people than any terrorist agent. In terms of gas masks, yes, technically, with the proper filter, a gas mask would protect your lungs against chemical agents including nerve gas. But without a full protective suit, these agents could still seep into your skin. But again, you should understand that the risk to you as an individual of that occurring is very small. The means of deployment that a terrorist has available would result in a small-scale event with a lot of shock value, but in all likelihood, would not have the delivery system to cause mass injuries or deaths. And, in a way, gas masks may do far more harm than good by sending the wrong message that something might be in the offing--which feeds the destructive wartime propaganda that the media and the government sends out that we must all be on alert all the time. Gas masks can also harm you if not worn properly.
Dear Dr. Marc,
I live in New York and want to know if there is any way to protect ourselves from chemical or biological attacks. What symptoms would we be able to use to determine if it were a chemical or biological attack as opposed to a normal illness? I was also glad to hear you say that duct tape wasn't useful in case of an attack. It seemed a ridiculous suggestion, even though I have used duct tape for just about everything else.
New York City
I addressed these issues in detail in my last column and will elaborate in an upcoming print version of the magazine. In the meantime, let me say that I believe that the risks to the individual are far too low for you or anyone to be thinking in terms of self-diagnosis and recognizing symptoms. But since you asked the question, chemical agents that may cause headaches, burning in the eyes and throat, may overcome a person rapidly. The symptoms of biological agents such as anthrax, the plague, smallpox or ricin come on more slowly over hours and days, but may be difficult to distinguish from a garden-variety flu or pneumonia. But as I tell my medical students, if it seems like the flu, it's most likely the flu. Your fear has been stoked by the media and the government, but the actual risks are quite low. A terrorist attack would most likely affect a small number of people.
Dear Dr. Marc,
Why is the tetanus shot given after an injury? I recently cut my head badly enough to need stitches. I was encouraged to have a tetanus shot, despite my concerns about taking medications and vaccinations. I gave in to the fear and pressure, and I allowed the vaccination. Is the likelihood of my coming down with lockjaw or diphtheria high enough to warrant a vaccination? I cut my finger (probably should have gotten stitches) on a lid a few months ago and did not have any problems aside from some bleeding and a sore finger. This raises doubts in my mind about my need for tetanus vaccinations. I do not care for medicines and, should I be cut again in the future, I want to know if it would be terribly unwise for me to refuse the vaccine.
There isn't much tetanus around, but the vaccine is safe, and should be taken at least once every ten years. I'm for it, especially when the risk goes up slightly, like after a cut or during travel to certain countries. Tetanus is rare, but deadly and debilitating enough to still make the vaccine worth taking.
Dear Dr. Marc,
A couple of months ago I noticed a discussion on the adbusters.org website about SSRI (selective serotonin reuptake inhibitors) antidepressants that suggested they may be addictive drugs. Is there any truth to this? (I have been using citalopram for more than two years, and have experienced frightening mood swings when I tried to cut back, according to my doctor's recommendations.) More to the point, how can we as consumers be better informed about medications we are using in order to protect ourselves from being taken advantage of by pharmaceutical companies?
SSRIs are not technically addictive drugs, but you can get habituated to them, and you can develop side effects if they are withdrawn suddenly. Still, they are useful for many people. I would suggest discussing this with your physician. The doctor who is prescribing this for you should be ready and willing to thoroughly discuss its uses and potential side effects as it pertains to your specific case.
Dear Dr. Marc,
My wife has had a mood disorder for the past couple of years. Because the drugs she was given in the past had unpleasant side effects, she has decided to face her illness without medication. I support this decision. She recently began with a new psychiatrist who recommended a certain drug that she openly opted not to take. All was well until she needed her psychiatrist to fill out some forms to get a benefit. At this point, he claimed that he could not fill out the forms because she had declined the treatment that he had recommended.
We were both angry and shocked. I have always heard that these drugs are overprescribed. In this case, it seemed that my wife was being subject to a form of extortion because she refused to take one. We responded by doing research on the side effects of the drug, and then sending a letter to the doctor elaborating on why she didn't want to take it. After some tense negotiation he agreed that psychotherapy could be a substitute.
Although a solution was found, the experience has embittered me with the psychiatric establishment. We were both particularly galled when both her doctor and her therapist hinted that her motives for seeking psychotherapy were insincere. To your knowledge, was our experience with the psychiatrist a common one? Do you agree with his reasoning?
[NAME AND TOWN WITHHELD]
This is a complex question. I'm not sure of your wife's psychiatrist's rationale for not wanting to fill out her benefits form--perhaps he didn't want to say that she wasn't compliant with his proposed treatment, perhaps the form included questions about how well controlled the illness was that he didn't feel comfortable answering at that point or perhaps he was being vindictive. In terms of what is the appropriate treatment, medication or therapy, it sounds like he believes it is medication. He may also be concerned that if she is only opting for psychotherapy to get away from medication, that she might not do as well with the therapy. Still, I'm all for the less medication the better, as long as your wife does well. Bottom line, she needs a doctor she can trust, no matter what the outcome in terms of therapy or medication.
Dear Dr. Marc,
You guys are great for telling the truth as it comes to you but why isn't there more talk in The Nation about impeachment? The movement has already started and will only grow. Lead the way. Don't wait. It's late. We're still America, even if debased.
This column is meant to address only medical questions, but we can make an infrequent exception here. I think The Nation and its contributors are doing their best to analyze the current world situation as they see it. Issues of conflict of interest and corruption have certainly been raised, but as far as impeachment is concerned, here in the United States the current recipe for impeachment is a splash of prurience, a healthy (or unhealthy) portion of power politics, a personal story of sultriness that is extracted from the tabloids and brought to the Capitol for purposes of exploitation and shame. If you manage to vilify and decimate an entire region rather than an individual, it looks like you're off the hook. In other words, there are many political battles to fight and working toward impeachment might not be the best possible use of resources at the moment. Some might argue it will be more effective to work toward unseating the Bush Administration in the 2004 election rather than attempting to pull off an impeachment drive on an Administration that essentially controls both the legislative and judicial branches of government currently.
Dear Dr. Marc,
If we were to create a "safe room" in our house with duct tape, etc., how would we determine when to come out and how would we proceed to deal with the contaminated environment from that point on?
CAYE D. GEER
Most of what they're worried about would never necessitate you to have a safe room. It would be of limited value. Any attacks are bound to be small scale. If we use a "contaminated" environment as a criterion, the way we're polluting this environment, we all might as well go in there right away and never come out.
Dear Dr. Marc,
I think your smart-ass responses to legitimate queries are a disservice to your readers. For example, to suggest that plastic sheeting and duct tape is of little value in a chemical attack is a lie. The gas most likely to be used, sarin, is volatile and would dissipate rapidly in sunlight. Plus the threat is not just nerve gases--many urban Americans are at risk from chemical plants located in their midst--which might become a danger as much from accident as from a terrorist attack.
The sensible approach is to determine the likelihood of danger based on one's location, to make low-cost initial preparations if such insurance seems justified, to lay out a response plan if some event does occur and to then lay the matter aside--confident that one is prepared to deal with the situation if it arises. For example, we chose to have air bags in our cars even though the likelihood of a car swerving into our path is very low for most of us.
You should give us the facts/probabilities/options and let us make our own decisions based on our location. Instead, you are showing the typical arrogance of a doctor who withholds factual information from the patient, who unilaterally decides to make decisions for the patient, and who justifies his arrogance based on an assumption of competence that is obviously unwarranted.
Thanks for the cordial note. I agree a response plan is indicated, i.e., for the remote chance that you find yourself in the way of a small-scale attack, and to that end, evacuation procedures should be studied and we should all be more knowledgeable, and in fact, if you are in a major city such as NY, DC, LA or Chicago, an emergency response system involving the police, fire and emergency healthcare workers is a high priority right now. But it is far more likely that you would be affected by fear and panic than a terrorist weapon. That is a statistical probability that also happens to fit with all prior versions of terrorism employed. The fact that sarin dissipates in the wind and sunlight is exactly why I don't think duct tape and plastic would be useful. Further, there is no known available method on this side of the ocean for a terrorist or anyone else to deploy sarin on a large-scale basis. The perception that this could happen is based more on fear than facts. However, I agree that a chemical plant accident could put thousands at risk in the vicinity of the plant, and I do hope that additional safeguards are implemented and that this problem is taken seriously.
Finally, you mistake my tone; I am a concerned caring physician, not an arrogant condescending one. You obviously don't like doctors, but responding to us as a group in the manner that you do isn't so much different than the other forms of prejudice that The Nation is intent on fighting, now is it? Doctors are people, too.