Author: jgscott2008

Is Sugar Poison? Do Food Dyes Cause cancer and ADHD?

In a March 28 speech in West Virginia, HHS Secretary Robert F. Kennedy Jr. said “So the loneliness, the dispossession, the crisis that we have in mental health, in suicide, in ADD, ADHD, all of these are linked — and particularly to the dyes,” Kennedy also said in that same speech, given alongside Gov. Patrick Morrisey, “It’s very clear the dyes that Gov. Morrisey is banning, all of them are linked in very, very strong studies to ADHD and to cancers. So we’re seeing an explosion in cancers in this country.” At a recent press conference he also said “Sugar is poison”

As usual, there is almost no evidence to back up these claims. There are some reasons to eliminate food additives and limit sugar intake. In this post I will talk about those reasons without making up spurious associations that have no real evidence.

Sugar

It is clear that too much sugar is not good for you. It can lead to tooth decay in children (which water fluoridation helps prevent). It can also lead to liver disease, increased triglycerides, obesity and heart disease. A modest amount is fine. High fructose corn syrup is a bigger problem, which Kennedy does not even mention. See my previous post Sugar and High Fructose Corn Syrup. Sugar in excess is not good for you. Modest amounts are not associated with any health problems. Sugar is not poison!

Food dyes and food additives

There are a number of food additives that have been proven to be safe. These include:

Guar Gum: A thickening agent derived from guar beans, used in various food products like ice cream and yogurt.
Xanthan Gum: A thickening agent and stabilizer used in salad dressings, soups, and sauces.
Inulin: A fiber substitute derived from chicory root, offering a smooth and creamy texture and supporting gut health.
Vinegar: A natural preservative, used in pickling, canning, and other applications.
Ascorbic Acid: The synthetic form of vitamin C, used as an antioxidant and preservative, also beneficial for immune support and iron absorption.
Monosodium Glutamate (MSG): Used as a flavor enhancer, generally considered safe.
Citric Acid: Naturally found in citrus fruits and used as an acidity regulator and preservative.
Beta-Carotene: A natural colorant used in various foods.
Riboflavin: riboflavin is just vitamin B2. It is a food additive used for both fortification and coloring. It’s a yellow to orange-yellow crystalline powder that is naturally found in many foods and also produced synthetically for use as a food additive.

Most other food dyes and additives have not been tested adequately to prove they are not toxic. There is no real evidence that they cause cancer or any other health problem, but there is also not adequate evidence that they are safe. Removing these dyes and additives is a good idea, but is going to be difficult to accomplish because they are used in highly processed foods that are the biggest money maker for the big food industry.

Plastics

Microplastics and chemicals that leach from plastic containers are a much bigger health hazard than food additives. There is good evidence that chemicals from plastics cause harm, including affecting the endocrine development of children. See my previous post Toxic Chemicals We Regularly Consume and How to Stop Consuming Them. Secretary Kennedy has not even mentioned the health hazards of plastics.

“Explosion of Cancer”

In fact the incidence of most cancers, particularly lung cancer have decreased in recent years. The incidence of some cancers have increased minimally. See this report from the National Cancer Institute: Annual Report to the Nation 2025: Overall Cancer Statistics. There is not an explosion of cancer in the US as Secretary Kennedy claims.

Bottom Line

Sugar is not poison. Too much sugar is bad for you but modest amounts are not. You should avoid as much as possible foods that have added sugar or especially high fructose corn syrup. Quite a few food additives have been proven to be safe. Many others have not been adequately tested for toxicity in humans, but there is no evidence for a specific health hazard for any of them. There is no convincing evidence that they cause mental illness, cancer or ADHD. Removing these dyes and additives would be a good idea but will be difficult. Chemicals leached from plastics in food containers have proven health hazards. People should switch to glass containers where possible. There is no “explosion of cancer” in the US.

Autism: Is There Really An Epidemic?

Robert F. Kennedy Jr has reported that there is an epidemic of autism. It is clear that autism is being diagnosed more frequently in the last 10 years, but does that represent an increase in the incidence of autism or better diagnosis? In this post I will review the literature about autism in order to give an evidence-based answer to that question.

Diagnostic Criteria Changes Over Time

There is an excellent paper describing how the criteria for diagnosing autism has changed over time: Update on diagnostic classification in autism. The following information is taken from that paper.

The diagnosis of autism was first described in 1943 by Kanner. Prior to that children with severe autism symptoms were diagnosed as “schizophrenia of childhood.” In 1944 Ausberger reported on a group of children who had similar symptoms to the children Kanner described, but they had no intellectual deficits.

It was not until 1980 that the diagnostic criteria for autistic disorder were included in the Diagnostic and Statistical Manual (DSM)-III). Core features were onset prior to 30 months of age, pervasive lack of responsiveness to others, gross deficiencies in language development, peculiar speech patterns, and bizarre responses to the environment, including resistance to change and fascination with objects. This led to a marked increase in the diagnosis of more severe autism. In 1987, DSM-III-R expanded the menu of symptoms supporting the diagnosis of autism, and formally separated core features into three domains of impairment in social interaction, communication, and restricted or repetitive behaviors.

The next significant change occurred in the DSM -IV in 1994 with the introduction of the diagnosis of Asperger’s disorder. Aspergers’s disorder included what used to be called high functioning autism (autism without intellectual disability). The addition of diagnostic criteria for less severe forms of autism led to another increase in the diagnosis of autism.

In the years since the introduction of the DSM-IV criteria, advances in genetics found that all of the autism disorders had a strong genetic component and that the different forms of autism-like illnesses probably were manifestations of the same condition. In 2013 in DSM V, all of the the autism like illnesses including Asperger’s syndrome were combined into something called autism spectrum disorder.

Subsequent research showed that autism could be diagnosed as early as 18 months of age. This led to the recommendation by the American Academy of Pediatrics that all children should be screened for autism at 18 and 24 months of age. This universal screening has resulted in finding many more cases of autism at an early age that would have been missed previously, or the diagnosis delayed.

Causes of Autism

Genetics is a causal factor in 60%-90% of Autism. Autism is also is associated with prematurity, older parents, low birth weight, air pollution, and perhaps other environmental factors. Autism is not associated with any vaccines or with thimersol. Multiple large well designed studies have found no association between any vaccine, multiple vaccines, and thimersol with autism.

Neurodiversity

An alternate way to view the autism spectrum is not as a disorder, but as an example of neurodiversity. In the neurodiversity perspective, there is natural variation in human brains and minds and there is no single “normal” way to think, learn or behave. Neurodiversity encompasses the wide range of neurological differences, including those often associated with conditions like autism, ADHD, and dyslexia. The neurodiversity paradigm views these differences as strengths and not deficits, promoting acceptance and inclusion of all individuals. Organizations of persons with autism like the Autism Self-Advocacy network promote autism as neurodiversity rather than the medical model of a disorder.

Bottom Line

It is clear that the increased sensitivity to diagnosing autism as well as the universal screening of children at 18 and 24 months has led to the increase in the diagnosis of autism from one in 150 in 2000 to one in 36 in 2020. There is no evidence that there is an epidemic of autism, but rather that diagnosis has improved tremendously. Children on the autism spectrum, even the ones with the severe form of the condition do much better when diagnosed early. There is no cure for autism (and the autism advocacy movement would say that no cure is needed), but the earlier it is diagnosed and interventions begun, the better the long term outcomes.

MMR Vaccine Risks in Perspective

This post is a follow-up to my recent post about measles and MMR vaccine. The purpose of this post is to compare the risk of adverse effects from the MMR vaccine to other risks that we take with our children every day.

Annual Deaths of children under 18

In the US 37,000 children under the age of 18 die every year. In 2022, the last year for which we have complete data, 604 children were killed in automobile accidents. This figure includes those killed as passengers, walking to school or in their neighborhoods, or riding their bicycles. Here is a table from the New England Journal of Medicine showing the most common causes of death of children since 1999.

As you can see from the graph, motor vehicle deaths of children have gone down significantly since 1999, but are still the second leading cause of death in children. Firearm injuries have now surpassed motor vehicle deaths as the leading cause of death in children.

All of these risks are small, the highest being 4.5 deaths per 100,000 Children. These are risks we take with our children every day. There is a risk when they ride in your car. There is a risk when they walk in their neighborhoods. There is a risk when they ride their bicycles. There is a risk that they will be killed by a mass murderer when they go to school. The risks of adverse reactions to vaccines are actually lower than the risks that we take with our children every day. Adverse reactions to vaccines almost never kill children

Deaths of children due to MMR vaccine

There have been only two documented deaths due to MMR vaccine in the 62 years it has been available. Both of these deaths were in children with Severe Combined Immunodeficiency Syndrome (SCIDS). You may remember a movie about a child with this syndrome. It was called “The Boy in the Bubble.” These children should never have received a live virus vaccine, such as MMR.

MMR Vaccine and Autism

Robert F. Kennedy Jr, the current head of HHS, has contended that MMR vaccine causes autism. There was a paper published by Andrew Wakefield in the medical journal, the Lancet, that studied 12 children and concluded that MMR vaccine was linked to autism. It was later discovered that he had falsified his results and the paper was retracted by the Lancet. This discredited paper, plus another one by the same author are still cited by people, including our current head of HHS, as evidence that MMR vaccine causes autism.

Study by Brent and Taylor

Brent and Taylor and colleagues examined the records of 498 children with autism. Cases were identified before and after MMR vaccine became available in the UK. They compared the incidence of autism in vaccinated and unvaccinated children and found no difference.

Study by Madsden and Colleagues

Madsden and colleagues did one one of the best and most rigorous studies. The study included 537,303 children representing 2,129,864 person-years of study. Approximately 82% of children had received the MMR vaccine. The risk of autism in the group of vaccinated children was the same as that in unvaccinated children. Furthermore, there was no association between the age at the time of vaccination, the time since vaccination, or the date of vaccination and the development of autism.

Other studies

Many other well designed studies have shown no association between the MMR vaccine and autism.

Bottom Line

We daily accept small risks of injury and death of our children. There are no activities involving children that are without some risk. The risks of MMR vaccine side effects (or any other vaccine) are no larger than the risks we take with our children every day. See my last post for a list of possible side effects of MMR vaccine. Severe side effects of MMR vaccine are very rare. When given appropriately to children with normal immune systems, death is not one of the risks. The one study by Andrew Wakefield that showed a connection with MMR vaccine and autism was shown to be fraudulent and was retracted. Multiple well designed studies have definitively shown that MMR vaccine does not cause autism.

Measles

Measles (also called rubeola) is one of the most infectious diseases in the world. Infectiousness of a disease is measured by something called R₀ (basic reproduction number). This is a measure of how many people will be infected by one person with the disease in an un-immunized population. For measles R₀ ranges from 12-18. That means in an un-immunized population, 1 person with measles will on average infect 12 or more others. To put this in perspective The R₀ for influenza is 0.9-2.1. The R₀ for Ebola is 1.9. The R₀ of COVID19 is 1.4-2.4. You can see that the infectivity of the measles virus is as much as ten times higher than other diseases that we consider very infectious.

Measles Vaccine

The recommended two doses of measles vaccine offers lifetime 97% protection against being infected with measles. The measles vaccine is a live vaccine. This means that it is a form of measles virus that has been weakened (attenuated) so that it will not cause infection in people with normal immune systems. It cannot be given, however to people with weak immune systems, such as people on chemotherapy for cancer. It also cannot be given to infants younger than 6 months because their immune systems are not developed enough for a live virus vaccine. 1 dose of MMR vaccine can be given to infants at least 6 months old if they are going to travel to a country where measles is still endemic. This offers some protection, but they still need two doses of the MMR vaccine after age 1. The recommended age for the first dose of the measles vaccine is 1 year. The second dose is usually given at age 5 or 6. Even the first dose gives 93% protection against being infected with measles.

People who cannot get the measles vaccine are protected by all those people who do get the vaccine. This is called herd immunity. If enough of the population has been vaccinated then there is no transmission of measles even to those people who can’t take the vaccine. Outbreaks of measles are unlikely to happen if at least 90% of the population has been vaccinated. The lower the vaccination rate below 90%, the more likely measles outbreaks will occur in unvaccinated people. In Gaines county, Texas, where the current measles outbreak started, the measles vaccination rate was 75%.

Is the measles vaccine safe?

The measles vaccine is given in combination with mumps and rubella (German measles) vaccines. Reactions are not common but some children get a sore arm and/or a mild fever. One in three thousand children will have a febrile seizure. Although a febrile seizure is very scary for parents, a febrile seizure is not life threatening and never happens again unless the child already has an underlying seizure disorder. An even smaller number of children have an allergic reaction to the MMR vaccine. An allergic reaction is a rare complication of any vaccine. About one in 40,000 children can get a low platelet count. This usually resolves on its own and rarely requires treatment.

How dangerous is measles?

Measles can cause pneumonia and encephalitis (inflammation of the brain) particularly in un-immunized children under 5. About one in five children (or adults) with measles have to be hospitalized. Up to two children per thousand cases die from complications of measles. There is a rare but always fatal inflammation of the brain that can occur up to 7 years after having had measles. It is called subacute sclerosing pan encephalitis (SSPE). When immunization rates in the US were above 90% SSPE disappeared. Unfortunately with the current US outbreaks we may see it again.

In the 10 years before the measles vaccine was available nearly all children got measles by the time they were 15 years old. It is estimated 3 to 4 million people in the United States were infected each year. Among reported measles cases each year, an estimated 175,000 developed pneumonia; 48,000 were hospitalized; 1,000 suffered encephalitis (swelling of the brain); 400 to 500 people died.

As of March 7 the current outbreak in Texas and New Mexico is up to 208 cases, 198 in Texas and 10 in New Mexico. Twenty-three children have been hospitalized. There have already been two deaths in this outbreak, one in Texas and one in New Mexico.

Recommendations

If you were born before 1957 then you have had measles and are already immune. You don’t need vaccination. If you were born after 1957 and you have never had measles vaccine, then you and your children (if they are also un-immunized) should go to your pharmacy or health department and get vaccinated immediately. The risk of measles infection is much much higher than the rare adverse effects of the MMR vaccine. If your child has already had two doses of MMR vaccine after age 1 then he/she does not need to be re-vaccinated.

From 1963 until 1967 an inactivated measles vaccine was used in the US. This vaccine did not give long lasting immunity. If you were vaccinated between those years, you should get at least one MMR booster. From 1963 to 1989 only on MMR vaccine was recommended. If you were vaccinated between those years you should get a booster MMR if you live in an area with a low vaccination rate or if you are planning international travel. After 1989 two vaccinations were recommended. If you were vaccinated after 1989 you don’t need a booster.

Treatment of Measles

Once a child gets measles, there is no treatment other than supportive therapy. There are no antiviral drugs that work against the measles. Virus. Robert F Kennedy Jr, unfortunately now head of HHS, has stated that getting measles vaccine is a personal decision. While that is technically true, nothing else prevents or treats measles. Kennedy has suggested that vitamin A and Cod liver oil can be used to treat measles. There is absolutely no evidence for this and furthermore too much vitamin A can be toxic.

Bottom Line

Measles can be a deadly disease, especially for children under 5. The MMR vaccine is safe and serious reactions are very rare. Two doses of measles vaccine after age 1 gives lifetime 97% immunity to measles. There is no anti-viral medicine that treats measles. Vitamin A and cod liver oil do not work and too much vitamin A can be toxic.

Diagnosis and Treatment of Depression

Robert F. Kennedy Jr, now head of HHS, recently said that antidepressant medicines are addictive and as hard to quit as heroin. As usual, this is misinformation and is not true. In this post I am going to write about the epidemiology of major depression, the subtypes of major depression and treatment options.

Unipolar Major Depression

This is the most common type of major depression. In the US 20% of adults (1 in 5) will have at least one episode of unipolar major depression at some time in their lives. The prevalence in any one year is about 8%. People who have one episode of depression have a 70% likelihood of have a recurrent episode of depression.

This is a bad disease and it can kill. To make the diagnosis symptoms must include at least five of the following:

Sadness or irritability, lasting most of the day
Loss of interest in the majority of activities that were enjoyable before
Change in appetite, or sudden weight loss/gain
Difficulty falling asleep, or wanting to sleep more than before
Feelings of restlessness
Lack of energy and increased tiredness
Feelings of worthlessness or guilt, often linking to things that normally wouldn’t have this kind of effect
Difficulty concentrating, making decisions and thinking
Suicidal or self-harming thoughts

Two to eight percent of people with unipolar major depression commit suicide.

Major depression is not a disease just of modern times. Abraham Lincoln had severe depressions, which he called “melancholy.” Winston Churchill also had severe depressions. He called it the “black dog.” The famous author William Styron, who wrote Sophie’s Choice and The Confessions of Nat Turner also had bad depressions. He wrote a book about his experience of depression called Darkness Visible. It is worth reading in order to understand how depression is felt.

Risk factors for unipolar depression

There is a genetic component. Unipolar depression tends to run in families. Other risk factors include social isolation, chronic stress, history of psychological trauma, unresolved grief or loss and substance abuse.

Treatment of unipolar major depression

Medicines

When I first went into practice the only antidepressant medicines we had was a class of medicines called tricyclic antidepressants. Examples include amitriptyline and imipramine.These were actually quite effective, better than the medicines we use today, but tricyclics had a major problem. They were very dangerous in overdose. They could cause lethal cardiac arrhythmias that were difficult or impossible to treat.

We almost never use the tricyclics anymore because of the overdose danger. The medicines we use now are called SSRI’s (serotonin re-uptake inhibitors) or SNRI’s (serotonin and norepinephrine re-uptake inhibitors). The first of SSRI was fluoxetine (Prozac). Others in this class include sertraline (Zoloft), citalopram (Celexa) and paroxetine (Paxil). SNRI’s include things like venlaxafine (Effexor) and duloxetine (Cymbalta). The SSRI’s and SNRI’s are not quite as effective as the tricyclics, but are much safer. An overdose can be unpleasant, but it will not kill you.

How well do SSRI’s and SNRI’s work?

Clinical trials of antidepressants show a large placebo effect, up to 35% in adults and up to 40% in adolescents. That means that a little over 1/3 of people have improvement of their symptoms of depression taking only a placebo. The placebo effect is real. People actually measurably get better. It is not just that they just think they are getting better. The response to antidepressants in these trials show a response rate of about 50%. Thus overall the effectiveness of antidepressants in these trials is modest. In practice, however, we find that most people respond well to antidepressants although some do not. The difference may well be that people who respond well are getting medicine effect plus a context effect that comes from having a relationship with a trusted physician who prescribes the medicine. A good relationship with a trusted physician can promote healing in addition to medicines.

What about Kennedy’s claim that they are addictive? Addiction is a chronic disease that involves compusive use of a substance or engagement in an activity despite harmful consequences. It can be physical or psychological. SSRI’s and NSRI’s do not cause compulsive use or generate any craving for the drug, so they do not meet the definition of being addictive.

What about his claim that they are harder to get off of than heroin? About 20% of people who suddenly stop an SSRI or NSRI have unpleasant symptoms called antidepressant discontinuation syndrome. It is more likely to happen to people on high doses or who have been on antidepressants for a long time. Symptoms are usually mild and last for a week or two. Symptoms can include flu-like symptoms, nausea, trouble sleeping and anxiety. Tapering the antidepressant slowly usually prevents this syndrome, but a few people still get it and it can rarely be severe. It is least likely to happen with long acting antidepressants like Prozac and more likely to happen with short acting antidepressants like Paxil and Zoloft. It is nothing like withdrawal from heroin, which usually requires medication assistance with suboxone or methadone to successfully treat the addiction.

Psychotherapy

Many kinds of psychotherapy work for depression. The most commonly used psychotherapy for depression is cognitive behavioral therapy (CBT). It has been compared to antidepressants in multiple studies and has been found to be just as effective (but not more effective) than antidepressant medicines. Interestingly, studies where both antidepressant medicine and CBT are used together are not more effective than either used alone.

The problem with CBT is not its effectiveness, but its availability. It is time consuming, expensive, and insurance sometimes does not pay for it. There are not nearly enough CBT practitioners to treat everyone suffering from major depression.

Other Treatments for Unipolar Depression

Electroshock therapy

This is an old treatment but it is still used for severe depression that is resistant to other treatments. Techniques have been improved so that there are no permanent brain changes from electroshock treatment.

Stimulation of the vagus nerve

Some studies have shown that stimulation of the vagus nerve can reduce symptoms of unipolar depression.

Psilocybin

There was a very promising randomized trial of a single dose of the hallucinogen psilocybin given with psychological support. It produced marked improvement in unipolar depression that persisted for at least 43 days, which was as long as the subjects were followed. There were no adverse effects. Here is a link to that paper in the Journal of the American Medical Association (JAMA): Single-Dose Psilocybin Treatment for Major Depressive Disorder

Bipolar Disorder

Bipolar 1 disorder

This used to be called manic-depressive illness. It is characterized by episodes of mania. People with mania have markedly elevated mood, and feelings of euphoria and invincibility. They sleep very little, have rapid pressured speech, and often have very inappropriate behavior, including sexual impulsivity and other impulsive behaviors. They may purchase things they can’t afford. These manic episodes may last for days or weeks, but are followed by episodes of severe depression. Bipolar 1 disorder has a different neurochemical basis than unipolar depression. It has a very strong genetic component. There is no one gene for bipolar 1 disorder. Many genes are thought to be involved. Bipolar disorder of either type is much less common than unipolar depression. Only about 4% of people will have bipolar disorder in their lifetime.

Bipolar 2 disorder.

Bipolar 2 disorder is very similar to bipolar 1 disorder but less severe. People with bipolar 2 disorder can have fairly long episodes of normal functioning between episodes.

Treatment of Bipolar Disorder

Treatment of bipolar disorder always involves medicines. Antidepressants can be used for the depressive phase, but are usually avoided because they can precipitate mania. The most common medicine used for bipolar disorder is lithium. Lithium prevents both manic and depressive phases in bipolar disorder. Other medicines can be used but those are specialized anti-psychotic medicines that are beyond the scope of this review.

Bottom Line

Unipolar depression is common, causes significant disability and can lead to suicide. Antidepressant medicines are effective treatments for most but not all people with unipolar depression. Psychotherapy, especially cognitive behavioral therapy works as well as medicines in the treatment of unipolar depression. SSRI’s and SNRI’s are not addictive. Sudden stopping of antidepressant medicines can lead to unpleasant symptoms in about 20% of patients. These symptoms are usually mild and last about 2 weeks. They can almost always be prevented by tapering down the medicines over the course of a couple of weeks. Bipolar disorder is much less common, is primarily genetic, and is treated with different medicines from unipolar depression.

US Primary Care In Crisis

According to the American Academy of Family Physicians (AAFP) “Primary care is the provision of integrated, accessible health care services by physicians and their health care teams who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”

The AAFP defines a primary care physician as “a specialist in family medicine, general internal medicine or general pediatrics who provides definitive care to the undifferentiated patient at the point of first contact, and takes continuing responsibility for providing the patient’s comprehensive care. This care may include chronic, preventive and acute care in both inpatient and outpatient settings. Such physicians are specifically trained to provide comprehensive primary care services through residency or fellowship training in acute and chronic care settings.”

Multiple studies have shown that those U.S. states with higher ratios of primary care physicians to population had better health outcomes, including lower rates of all causes of mortality: mortality from heart disease, cancer, or stroke; infant mortality; low birth weight; and poor self-reported health.

There are currently not enough primary care physicians in the US to provide this kind of primary care, especially in rural areas, and the situation is about to get a lot worse. As of June 30, 2024 The Health Resource Services Administration (HRSA) estimated that 83 million Americans live in areas that do not have adequate access to primary care doctors. HRSA also estimates that as of June 30, 2024 the US had 13,000 less primary care doctors than were needed to care for the US population.

The number of US medical students who match in primary care residencies (family medicine, general pediatrics and general internal medicine) has decreased every year. In 2024, 600 family medicine slots and 250 general pediatric slots went unfilled in the match. Most of these slots were later filled by offers outside the match in a process called SOAP (Supplemental Offer and Acceptance Program). Most internal medicine and about 40% of pediatric residents do fellowships in subspecialties rather than going into primary care. In 2024 only 9% of US medical students chose family medicine residencies. The US is expected to face a shortage of primary care physicians of as much as 55,000 by the year 2032. To close this gap we need to create 600 family medicine residencies over the next 10 years. At this point there is neither the funding nor the faculty to accomplish this goal.

Can Nurse Practitioners Fill the Primary Care Deficit?

Nurse practitioners can be and are already an important part of healthcare teams. They are especially good at managing people with reasonably stable chronic diseases, better than physicians in fact. They are also very good at preventive care. Part of the problem is that only 34% of nurse practitioners go to work in primary care. The rest end up working as part of a specialist team.

Can Nurse Practitioners Practice Independently?

Twenty seven states allow nurse practitioners to practice completely independently. That is they can diagnose, order tests and prescribe medicines including controlled substances without any physician supervision. In these states they function under the auspices of the state boards of nursing, not the state medical boards. Nurse practitioners have substantially less training than primary care physicians. Nurse practitioner programs require 2 years after an undergraduate bachelor of nursing degree. They do not have to do an internship or residency to practice, although a few pursue such extra training.

Primary care physicians, on the other hand, complete 4 years of medical school after an undergraduate degree and then 3 years of a primary care residency.

Seeing undifferentiated patients in primary care requires being able to identify and diagnose patients with serious disease among the many patients with acute illness who will get better anyway. This requires training and experience. My personal feeling is that most nurse practitioners do not have adequate training to independently see undifferentiated primary care patients without some physician supervision. This is also the position of the American Medical Association. On the other hand, if an independent nurse practitioner is the only primary care clinician available in a rural area, that’s a whole lot better than no primary clinician at all.

Reasons for the low percentage of medical students choosing primary care

There are many reasons that such a low percentage of medical students choose primary care residencies.

Student Loans

One major factor is student loan repayment for medical school. The average student loan debt for graduating medical students is over $200,000. Some are as high as $400,000. Specialty salaries are much higher that those for primary care, so medical students who enter these high paying specialties can pay off their student loans reasonably quickly.

Hidden Curriculum

The hidden curriculum is a socialization process. Wittingly or unwittingly, norms and values transmitted to future physicians often undermine the formal messages of the declared curriculum. The hidden curriculum consists of what is implicitly taught by example day to day, not the explicit teaching of lectures, grand rounds, and seminars. The hidden curriculum in most medical schools denigrates family medicine and glorifies specialization, suggesting that the best and brightest become specialists.

Corporatization of Primary Care

Over 77% of primary care physicians now work for hospitals, health systems, or corporate entities. These new physician employment models often tie salary to volume of care, based on fee-for-service payment models, rather than on quality. Also employment contracts tend to be one-sided, employer-employee models, leaving employed physicians little opportunity or incentive for creativity in defining and improving how they do their job. One unintended consequence of the employed physician model has been less sense of loyalty and connection and more tendency for younger primary care physicians to switch jobs. This increased mobility has the unfortunate effect of disrupting critically important continuity in the doctor-patient relationship around which trust, deeper caring, and improved outcomes are built (The Corporatization of Primary Care: Unintended Consequences).

Lower Income

The average annual income for all primary care physicians in the United States is between $178,207 and $291,000.. The average salary for family physicians was a little less, coming in at $180,000. Although this sounds like a generous income compared to most people in the US, specialists make a lot more. For specialists the annual income varies by specialty. The highest paid specialties are Neurosurgery: averaging $763,908 in 2024,Thoracic surgery: Averaging $720,634 in 2024, Orthopedic surgery: Averaging $654,815 in 2024, Plastic surgery: Averaging $619,812 in 2024, and Anesthesiology: Averaging $494,522 in 2024. Other specialties make somewhat less, but all of them make more than primary care physicians.

Lifestyle

Most employed primary care physicians are required to see 20-25 patients per day, averaging 15 minutes per patient. It is estimated that for each hour a PCP spends with a patient, up to 2 hours of work are generated, which includes writing summary notes and treatment plans in a patient’s electronic medical record (EMR) and communicating test results or other important information to patients and their caregivers. Many PCPs go home at the end of crushingly stressful days, spend an hour or two with their families, and then stay up late to finish all the computerized documentation that their day in clinic has generated.

Possible Solutions

Increase primary care residency slots

The Center for Medicare and Medicaid Services (CMS) funds residency slots for physician residencies, both specialty and primary care. CMS should increase the number of primary care residency slots. If this decreases funding for specialty residency slots, so be it.

Income

Reduce income disparities between primary care physicians and specialists. “To address this income disparity, physician fees can no longer be set by the Relative Value Scale Update Committee, or RUC, the specialist-dominated committee that determines fees for different services. A new advisory committee should be formed. It should be dominated by primary care providers and include patient advocates. The newly constituted advisory committee can begin to equalize pay by raising payments to primary care (and other cognitive specialties), lowering the rate of payment to proceduralists, or both.” No More Lip Service; It’s Time We Fixed Primary Care (Part Two)

Loan Repayment

The government should either cover the cost of medical school or repay student loans for students who commit to do a primary care residency and stay in primary care for at least 10 years after certification. Another option would be for the government (state or federal) to incentivize individual institutions to offer loan forgiveness programs.

Reforming primary care practice

Reforms proposed by the directors of the Lown Institute include direct primary care and something they call a primary care trust. Here is a link to their article in the Health Affairs journal. They explain these concepts much more clearly than I can in this post. Look for the section labeled “Payment And Delivery Models To Improve The Quality Of Primary Care And Reduce Burnout.” No More Lip Service; It’s Time We Fixed Primary Care (Part Two)

Bottom Line

We already have 83 million people in the US who don’t have adequate access to a primary care doctor. Unless we do something drastic, there will be a deficit of 55,000 primary care physicians by 2032. The number of medical students who want to go into primary care has been steadily diminishing. Possible solutions include increasing primary care residency spots, forgiving loans or paying for medical school for students who commit to primary care residencies and practice for 10 years, exposing medical students to primary care doctors as faculty, diminishing the pay gap between primary care physicians and specialists, and reforming primary care to decrease administrative burdens.

Robert F. Kennedy Jr – A Terrible Choice to Head HHS

Robert F. Kennedy Jr has been nominated by Donald Trump to be the Secretary of HHS. If he is confirmed by the Senate he will be secretary of HHS for four years. He plans to “Make America Healthy Again.” It is true that the current American healthcare system is one of the worst in the developed world as far as health outcomes are concerned. But rather than improving that system, RFK Jr’s plan is not only naive, but very dangerous. In this post I’m going to write about the specifics of what he is advocating and has advocated in the past. He can’t “Make America Healthy Again” but he can do a lot of damage.

Views on Infectious Disease

AIDS

RFK Jr believes that HIV does not cause AIDS. He has argued that the initial signals of AIDS, Kaposi’s sarcoma and Pneumocystis carinii pneumonia (PCP), were both strongly linked to amyl nitrite — “poppers” — a popular drug among promiscuous gays. He thinks the wasting symptoms of AIDS were all caused by heavy drug use and lifestyle stressors. He believes that the afflictions that tortured and killed those AIDS patients were, in fact, a result of their drug use and “compulsive homosexual behavior.”

He of course ignores the fact that the AIDS epidemic also affected people with hemophilia (through the blood products they had to use), children who were born to mothers with HIV, and health workers who had accidental needle sticks. At the peak of the epidemic in 2004, before we had any treatment other than AZT, AIDS killed 2.1 million people worldwide.

Lyme Disease

RFK Jr. believes that Lyme disease was created as a bioweapon by the American military in a Long Island laboratory in the 1950s.

West Nile Virus and RSV

Kennedy has said West Nile virus was created at Plum Island and that respiratory syncytial virus was purposely spread from apes to humans so pharmaceutical companies could profit off vaccines.

1918 Influenza Pandemic

Kennedy said at an online campaign event in June 2023. “We can go down a whole list of diseases, and there is good evidence that even the Spanish flu came from vaccine research.”

COVID

In an interview on Fox News, Kennedy said that many lives would have been saved if ivermectin and hydroycholoroquine had been more widely used. Well designed studies on both of these medicines showed they were no better than placebos for treating COVID.

Views on Vaccines

Measles Vaccine

During a November 2019 measles epidemic that killed 80 children in Samoa, Kennedy wrote to the country’s prime minister falsely claiming that the measles vaccine was probably causing the deaths

Vaccines and Autism

Kennedy believes that vaccine, particularly the MMR vaccine causes autism in children. As noted above, numerous very large well designed studies have disproven that any vaccines cause autism.

COVID vaccines

Mr. Kennedy filed a petition with the F.D.A. in May 2021 demanding that officials rescind authorization for the COVID vaccine and refrain from approving any Covid vaccine in the future.

Fluoridation of Water Supplies

Kennedy claims that fluoridation of water leads to decreased IQ scores in children. There is some evidence for this at very high fluoride levels that naturally occur at some places in the world. The level of fluoride added to water supplies in the US is far below this threshold. There is no evidence whatever that flouride added to drinking water has any ill effects. It has been shown to markedly decrease dental cavities in children, however. Kennedy says that fluoride in toothpaste is enough. The children most benefited by flouridation are minority and marginalized populations who do not or cannot brush their teeth regularly.

Chronic Disease

Kennedy wants the NIH to focus on chronic diseases. Of course many of the institutes of NIH already focus on chronic disease and fund research on them. This has been going on for many years. These include:

National Heart, Lung, and Blood Institute (NHLBI): Focuses on research, training, and education to prevent and treat heart, lung, blood, and sleep disorders

National Institute on Aging (NIA): Focuses on research related to aging

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK): Focuses on research related to diabetes, digestion, and kidney disease

Division of Kidney, Urologic, and Hematologic Diseases (KUH):Focuses on research related to kidney disease, urinary tract disorders, and blood disorders

National Institute of Environmental Health Sciences (NIEHS):Focuses on research related to chronic disease epidemiology

Fogarty International Center (FIC): Focuses on global health research, including chronic diseases

National Institute on Minority Health and Health Disparities (NIMHD): Focuses on research related to chronic disease disparities

The fact that Kennedy is not aware of the fact that NIH does a great deal of research on chronic diseases is more evidence of his unfitness for running HHS.

Nutrition

Kennedy wants to take on the big food industry and move people to eat less ultra-processed foods and eat more unprocessed foods. He thinks food additives cause cancer and gender dysphoria and wants additives removed from foods. Although there is zero evidence that food additives cause gender dysphoria, by and large these are laudable goals. How he is going to accomplish this remains unclear. Chronic disease is certainly related to food choice, lifestyle and poverty. We have known this for a long time, but it will take major societal change to make this happen. It certainly will not be in the power of the secretary of HHS to accomplish this.

Plans for firing employees

At an event in Arizona, Kennedy said he’d fire and replace 600 people from the National Institutes of Health. Kennedy also promised to eliminate the department of nutrition at the FDA.

Bottom Line

Robert F. Kennedy Jr. is a conspiracy theorist with no experience in running a large organization like HHS. He is absolutely unqualified for this role and furthermore constitutes a serious risk to the health of the US. I have written a letter to both my senators urging them to vote against his confirmation. I respectfully request that you do the same.

Antibiotics – When You Need Them and When You Don’t

In the era before antibiotics were available one third of all deaths were from infectious disease. The introduction of antibiotics starting with penicillin represented a tremendous advance in the treatment of infectious diseases. We soon learned, however that overuse of antibiotics led quickly to the development of bacteria that became resistant to that antibiotic. Penicillin, for example can only be used for a small number of infectious diseases now including strep infections and syphilis. In this post I will write about both individual and societal harms of overuse of antibiotics and will also discuss conditions for which they should be and should not be used.

Harms of Antibiotics

Bacterial Resistance

Overuse of antibiotics can lead quickly to resistance. Unfortunately, resistance has eventually developed to nearly all currently available antibiotics. Some bacteria, called gram negative bacteria have developed resistance to almost all antibiotics. Antibiotic resistance in the United States kills approximately 23,000 patients a year and incurs over $20 billion in additional medical expenses.

Overuse of antibiotics

The information below comes from an excellent paper from the journal Pharmacy and Therapeutics: The Antibiotic Resistance Crisis.

in 2010, the last year that we have complete data, 22 doses of antibiotics were prescribed per person in the U.S. In many other countries, antibiotics are unregulated and available over the counter without a prescription. This lack of regulation results in antibiotics that are easily accessible, plentiful, and cheap, which promotes overuse.

Inappropriate Prescribing

Many studies have shown that antibiotic therapy is not necessary in 30% to 50% of cases! Even in intensive care units 30% to 60% of the antibiotics prescribed have been found to be unnecessary, inappropriate, or at inadequate doses.

Extensive Agricultural Use

In both the developed and developing world, antibiotics are widely used as growth supplements in livestock. About 80% of antibiotics sold in the U.S. are used in animals, to promote growth and to prevent infection. Molecular detection methods have shown that resistant bacteria in farm animals reach consumers through meat products. This happens through the following sequence of events:

1) Antibiotic use in food-producing animals kills or suppresses susceptible bacteria, allowing antibiotic-resistant bacteria to thrive

2) Resistant bacteria are transmitted to humans through the food supply

3) These bacteria can cause infections in humans that are resistant to most antibiotics

Consequences of Antibiotic Resistant Infections

A 2011 national survey of infectious-disease specialists found that more than 60% of the infectious disease doctors had seen a pan-resistant, untreatable bacterial infection within the previous year. Many public health organizations have described the rapid emergence of resistant bacteria as a “crisis” or “nightmare scenario” that could have “catastrophic consequences.”

Antibiotic Effects on Human Microbiome

It is well established that the gut microbiome plays an important role in health. It prevents disease causing bacterial colonization, regulates gut immunity, provides essential nutrients and metabolites, and is involved in control of energy. A healthy gut microbiome has lots of diversity. Broad‐spectrum antibiotics reduce gut bacterial diversity. While killing the disease causing bacteria of concern antibiotics can also kill beneficial bacteria.

Studies report changes in gut bacterial composition that last for up to 12 weeks after antibiotic treatment has ended with the incomplete restoration of bacterial composition and emergence of antibiotic‐resistant strains. In one study one short term course of clindamycin (7 days) resulted in significant disturbances in the gut bacterial community that remained for up to 2 years post‐treatment!

When Antibiotics Are Not Necessary

Viral Infections

The vast majority of infections are caused by viruses. Antibiotics do nothing to shorten viral infections or to relieve symptoms. Here are some examples.

Upper respiratory infections

Symptoms are typical cold symptoms, including runny nose, nasal congestion, sore throat and cough. There may or may not be fever. Fever, sometimes high fever is more common in children. Green or brown discharge from the nose is common with viral upper respiratory infections and does not indicate bacterial infection. Viral upper respiratory infections usually last about 10 days, but can persist for several weeks.

Bronchitis

In otherwise healthy people, bronchitis is another example of a viral infection. The only exception to this is people with chronic obstructive lung disease, in which bronchitis may be caused by bacteria. The main symptom of bronchitis is cough, which may be dry or may be productive of sputum. Yellow or green sputum can occur and does not mean that the bronchitis is bacterial. There is usually no fever. Viral bronchitis can last for weeks. RSV virus can cause a severe bronchitis in children and older adults. There is a vaccine for children and adults that prevents RSV virus infections.

Sinusitis

Most sinus infections are viral and antibiotics are not helpful for these. Symptoms can include thick nasal discharge and some discomfort over the maxillary sinuses (underneath the eyes). Occasionally sinusitis can be bacterial and require antibiotics. I will discuss this later under conditions for which antibiotics are appropriate.

GI Viruses

There are other viruses that affect the gastrointestinal system. Symptoms are usually nausea and vomiting and/or diarrhea. Norovirus is the most common one. Staying hydrated is the only treatment for these viruses. Rotavirus affects children, but there is a an oral vaccine for infants that prevents this disease.

Ear Infections (Otitis Media)

Infections behind the ear drum are called otitis media. These occur almost exclusively in children and can be viral or bacterial. We used to treat all inner ear infections in children with antibiotics. We have now learned that most ear infections in children, even the bacterial kind get better without antibiotics. We now use antibiotics only for children with severe ear infections who more commonly have fever and/or severe pain.

When Antibiotics Should Be Used

Most bacterial infections require antibiotics to get better. It is not always possible for you to know whether you have a viral or bacterial infection. If you are concerned that you might have a bacterial infection you need to see your doctor who will decide whether you need antibiotics or not.

Strep Throat

Although many sore throats are viral, sore throat can also be caused by strep (streptococcus). Strep throat does not cause other symptoms like cough and runny nose. It is diagnosed by a rapid strep throat swab which your doctor can do in his/her office.

Bacterial Sinusitis

This usually happens after a viral upper respiratory infection. The most common sequence is that you start to feel better after a week or so and then get worse. Typically pain from bacterial sinusitis is one side, not both sides. The affected sinus becomes very tender to touch. Fever may or may not be present.

Infection in the ear canal (otitis externa)

This kind of infection is different from infections behind the ear. It can be painful and usually there is some pussy discharge from the ear. It usually responds to topical antibiotic ear drops, but when severe can require oral antibiotics

Pneumonia

Pneumonia can be viral, but it is not easy to tell that kind from the more serious bacterial pneumonia. All pneumonias should be treated with antibiotics. Symptoms of pneumonia are fever, sometimes high fever, cough (usually productive) and shortness of breath. A chest x-ray will show fluid in the air sacs in the lungs.

Urinary tract infection

Bladder infections are common, especially in women. The symptoms are frequent urination and pain or burning with urination. Your doctor will send a urine culture to make sure you are on the right antibiotic.

Kidney infections (also called pyelonephritis) are a more serious type of urinary tract infection. Symptoms can include fever, flank pain and feeling very ill. Sometimes kidney infections require getting IV antibiotics in the hospital.

Soft tissue infections (cellulitis)

A scrape or cut on the skin can sometimes get infected. Usually the area around the injury becomes red and painful. This kind of infection usually requires antibiotics. Again, this is a decision your doctor needs to make.

Sepsis

Sometimes a localized infection will spread through the blood stream and affect other organs. This is a medical emergency and requires hospitalization, IV antibiotics and fluids to maintain blood pressure.

Bottom Line

Overuse and inappropriate use of antibiotics has led to bacterial infections that are increasingly resistant to many and sometimes all antibiotics. Antibiotics, even when used appropriately lead to long standing adverse effects on the gut microbiome. The vast majority of infections are viral and do not improve with antibiotics. Bacterial infections do often require antibiotics. Decision about whether antibiotics are appropriate should be made by your doctor. Requesting antibiotics from your doctor can sometimes lead to inappropriate prescribing.

Bird Flu – What You Need to Know

Bird flu is a common name for avian influenza. Avian influenza has been around since the 1800’s and there have been sporadic outbreaks since then. The scientific name of the virus is AH5N1, but there are multiple subtypes of avian influenza virus and the virus continues to evolve over time. There have always been human cases, and some deaths but only related to contact with birds. The current avian influenza virus subtypes are extremely infectious to wild birds and poultry with a 60 to 100% mortality rate. Wild waterfowl, such as ducks and geese can spread the virus but usually do not get sick from it.

Infection in Cattle

In the last year avian influenza virus has mutated so that it has infected dairy cattle. Now there are several human cases in people who work with dairy cattle. Only about 10% of cattle with the virus have symptoms, but lactating cows are especially susceptible. There is evidence that cows can transmit the virus to other cattle. The virus has been found in raw milk, but not pasteurized milk. Drinking raw milk always has some risk of disease, but now that risk is much higher. There have been no human cases so far from drinking milk.

Infection in Other Mammals

Domestic cats are the most common other mammal that has been infected with A5HN1, but it has also been found in mink, foxes, raccoons, dogs, harbor seals, and most recently a dead polar bear. There have been no reported cases of human infection from contact with infected cats or dogs.

Potential for Human to Human Transmission

The AH5N1 virus has shown its potential to evolve rapidly, and this can happen in one animal. The influenza virus that caused the 1918 pandemic was an H1N1 virus that probably was initially a bird virus that mutated to infect humans. The current A5HN1 virus has shown no human to human transmission so far. The CDC currently rates the current public health risk of A5HN1 as low, but they are watching it carefully.

Human Symptoms of Avian Influenza

Most human cases have been mild, but severe illness and even death can occur.

Mild symptoms

eye redness and irritation (conjunctivitis)
mild fever (temperature of 100ºF [37.8ºC] or greater) or feeling feverish*,
cough
sore throat
runny or stuff nose
muscle or body aches
headaches
fatigue

Severe symptoms

high fever or other symptoms listed above that limit or prevent usual activity
shortness of breath or difficulty breathing
altered consciousness
seizures

Complications

pneumonia,
respiratory failure,
acute respiratory distress syndrome,
acute kidney injury
multi-organ failure (respiratory and kidney failure),
sepsis, septic shock
and inflammation of the brain (meningoencephalitis)

What you can do now to limit your risk

Do not touch or even get near dead birds
Do not drink raw milk
Keep cats inside and do not feed them raw milk or raw food
Stay away from any wild animals (raccoons, foxes) that appear ill
Keep up with current CDC bird flu recommendations at this website: Avian Influenza

Bottom Line

Avian influenza virus is able to mutate rapidly. In the last year it has become transmissible in dairy cattle. All human cases so far have been caused by contact with dead wild birds, poultry or dairy cattle. There has as yet been no human to human infection documented. The CDC reports that public health risk is currently low, but they are tracking animal and human cases carefully.

Chronic Inflammation and the Respiratory System

The respiratory system, which includes the trachea, the bronchi and the lungs can be a source of chronic inflammation that not only affects the respiratory system itself, but can affect other organs as well. The inflammatory process in the respiratory system involves activation of the immune system just like chronic inflammation in any part of the body. It includes pro-inflammatory cytokines, macrophages and lymphocytes.

Causes of respiratory system inflammation

Nitrogen Oxides

Nitrogen oxides, particularly nitrogen dioxide (NO₂) is a respiratory irritant that causes inflammation of the bronchi. Exposure to NO₂can cause or exacerbate asthma. In addition, several epidemiological studies have demonstrated associations between NO₂ exposure and premature death, chronic lung disease, heart disease, stroke, decreased lung function growth in children, respiratory symptoms, emergency room visits for asthma, and intensified allergic responses. A comprehensive review of the health effects of NO₂ exposure, both acute and chronic, can be found at this website: The Health Impacts of NO₂ Pollution. The biggest outdoor source of NO₂ is through reactions between nitric oxide (NO) and other air pollutants (mostly from automobile exhaust) that require the presence of sunlight. The biggest source of NO₂ in home air is the use of unvented natural gas stoves.

Particles

In addition to gases like NO_2, air pollution also contains particles. Large and medium size particles lodge in the nose and upper airways and are usually cleared by the airway protective system which includes mucus and cilia that move these particles up and out of the airways. Fine and ultra fine particles (those that are 2.5 microns and smaller) can get all the way down to the alveoli (the air exchange sacks) in the lungs. These tiny particles bypass the lung protective system and cause inflammation in the lungs. They can also sometimes get directly into the circulation and can cause damage in the heart and other organs. According to the EPA, a large body of scientific evidence shows that exposure to fine and especially ultra fine particles can cause heart attacks, heart failure, and strokes, which results in hospital admissions, emergency department visits, and, in some cases, premature death. The scientific evidence shows exposure to fine and ultra fine particles is also likely to cause respiratory effects, including asthma attacks, reduced lung development in children, and increased respiratory symptoms such as coughing, wheezing, and shortness of breath. Prolonged exposure can cause chronic lung disease such as COPD and pulmonary fibrosis. There is more limited scientific evidence for developmental and reproductive effects, lung cancer and other cancers.

Sources of fine and ultra fine particles

Outdoor sources of fine and ultra fine particles come primarily from automobile exhausts as well as some factories. They tend to be much higher in cities, particularly inner city neighborhoods.

Indoor sources are tobacco smoke, wood burning fireplaces, gas space heaters and natural gas stoves. The way food is cooked can also produce fine and ultra fine particles. Frying in hot oil or broiling generates lots of these particles even on electric ranges. Boiling or steaming generates many fewer particles. Air fryers also generate very few particles.

Reducing Indoor Air Pollution

Natural gas is 99% methane, so burning it in a stove in addition to generating dangerous levels of NO₂ and fine and ultra fine particles, is also the most potent greenhouse gas. That means that not only are gas stoves bad for your health, they are also bad for the environment. If you have a gas stove, the best option is to replace it with at electric stove with an induction cooktop. Induction cooking is much more efficient than a traditional electric burner. It uses only 60% as much electricity and heats the pot directly rather than the burner itself. Heating with induction burners are actually faster than heating with gas burners. This is of course not practical for everyone. Replacing a stove is expensive and requires an electrician to install a 220 volt outlet if you don’t have one. It is also impossible for renters. If you can’t replace your gas stove and it has a hood that vents to the outside, turn it on high every time you cook. If the hood is not vented to the outside, then opening a window helps substantially decrease NO₂ and particles. Whether you have either kind of stove, using a portable air fryer is much safer than frying in hot oil on the stove. Another much less expensive option is to purchase an induction hot plate. Good ones range from 60 to 200 dollars and can plug into a regular 110 volt outlet. Induction burners only work with pots that a magnet will stick to. That includes cast iron skillets and most stainless steel cookware. Inexpensive induction compatible cookware is available at a very reasonable cost from almost all big box stores such as Walmart and Target.

Reducing Outdoor Air Pollution

There is nothing an individual can do by themselves to reduce outdoor air pollution. Working to promote affordable electric vehicles is the only long term solution for automobile exhaust pollution in cities.

Bottom Line

Chronic inflammation of the respiratory system results from air pollution both outdoors (especially in inner cities) and indoors. Smoking tobacco is also a major cause of chronic inflammation of the respiratory system. Chronic inflammation of the respiratory system leads to many chronic lung diseases as well as heart disease and possible lung cancer. Indoor air pollution is caused primarily by unvented natural gas stoves as well as gas space heaters and wood burning fireplaces. The major causes of lung inflammation are nitrogen dioxide (NO₂) and fine and ultra fine particles. Indoor pollution can be mitigated by ventilation using either a hood connected to outside or opening a window while cooking. Using electric induction burners are safer and heat even more quickly than gas. Portable electric air fryers are much safer than frying in oil on any kind of stove top. Purchasing an induction hot plate is a much less expensive way to do induction cooking. Reducing outdoor air pollution requires societal change.