Ebola Update: Conditions in West Africa


Click to enlarge.  Credit: AscelBio.com

Click to enlarge. Credit: AscelBio.com

The image above is an updated heat map from the one we presented in our previous post measuring the severity of Ebola conditions by country. This map compares the Ebola crisis to a recent Salmonella outbreak in the UK. Blue is the lowest level on the scale, yellow is considered bad but normal for the area, and orange and reds indicate the highest levels of crisis.

As of August 18, 2014:

  • Guinea conditions have greatly improved in the last 10 days.
  • Liberia’s conditions are improved which is a significant turnaround from the previous prediction that disruption levels were reaching a peak level that would be worse than the outbreak of 1995.
  • Nigeria has stabilized and community crisis has simmered.
  • Sierra Leone has the least improvement of four with worsening conditions.

Ascel Bio has observed spots of category 7 crisis pockets in Sierra Leone which could lead to trouble in surrounding countries. Category 7 is the highest on the Infectious Disease Impact Scale. Indicators for a category 7 include military force to detain and isolate victims, border closures, and the social stigmatization of the infected.

These updates were provided by Dr. James Wilson, infectious disease expert for Ascel Bio. We asked Dr. Wilson for his opinion on why certain countries were improving quicker than others.

“The difference in the slope of the epi curves as well as the changes we are seeing in the signature patterns highlights the fact that Guinea received quicker response from MSF. Sierra Leone and Liberia are now jockeying for “worst” position. Education of the locals has largely failed, and the attacks on the hospitals highlights this. We have firm documentation of IDIS CAT 7 (“apocalyptic conditions”) in localized areas of Sierra Leone.”

Sermo physicians are collaborating actively inside the community to help stay on top of the epidemic and discuss the latest treatment options. If you’re an MD or DO we strongly recommend you come into our free, private, physician-exclusive social network to discuss Ebola further.

Becoming a Clinical Investigator: Why and How

Female Doctor

This week, we’ll be sharing a series of posts by Dr. Irving Kent Loh about becoming a clinical investigator.  These posts were originally created for the Sermo physician audience.  If you’re a physician, you can join Sermo to read more articles like this.

My last Sermo post on the mechanism of action and status of the new anti-PCSK9 agents has prompted me to post something that may be of interest to the Sermo community at large. Given the clinical acumen and activist nature of the providers that participate in Sermo, I am certain that many of you may be clinical investigators. For those of you who are not, but may be interested in becoming involved with clinical research, I am considering laying out a path to becoming an investigator.

If you have been following my posts on the Cardiology Hub, you will note that my comments often reflect perspectives gained from having been a clinical investigator for four decades. As some in the Sermo community have pointed out, the repository of potential research subjects does not belong to solely academic centers or generally to any single specialty. My research colleagues span the gamut from private practices in rural communities to multi-specialty clinics in urban centers to dedicated research centers with satellite sites as well as top tier academic research centers. It is not the setting per se, but the personnel and infrastructure that determines the success in participating in clinical trials.

First, let’s quickly review what would motivate one to want to participate in clinical research in the first place.

Interest and expertise in a clinical subject that needs new knowledge, especially in the arena of new therapeutics, is seminal to developing a research profile. Depending on your background and infrastructure, there are opportunities to contribute at different levels (early or late) of investigational product development.

Given a population of patients that are of interest to sponsors in this era of diminishing remuneration, clinical research provides an alternate revenue stream from patients you already have. Assuming that your training, board certification status, and strict adherence to rules of clinical care of research subjects as delineated in ICH (The International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use and GCP (Good Clinical Practice) standards allow you to pass scrutiny of the sponsors and the Clinical or Academic Research Organizations, and that you are willing to sign a contract with the FDA (form 1572), you may be a candidate to be an investigator.

If successful, you may become a de facto regional expert on the subject of interest, providing you with opportunities to covered in print, visual and social media with commensurate prestige and notoriety that advertising cannot buy. Becoming a speaker and lecturer on the subject (and getting good at it) will add to your credibility that may garner more referrals and opportunities.

As we all know, there is no such thing as a free lunch. If becoming a successful investigator were easy, everyone would be doing it. Many people try it, but may be thwarted at several levels. As I indicated above, I’ve been an investigator for 40 years, starting at the NIH. Since entering practice, I have been the principal investigator on over 160 clinical trials. I have lectured at investigator meetings on the recruitment and retention of subjects.

Following this post, I will present a series of posts that would be my perspectives on issues such as: Qualifications, Infrastructure, Personnel and training, Facilities, How to make initial contacts and develop relationships, How to successfully identify, recruit and retain subjects, Informed consent, Liability, Revenue enhancement.

I do not present myself as THE expert or the final word on these subjects, but simply as a colleague who has walked this walk before and someone willing to share his experience and opinion. I expect many others more qualified than I to perhaps take issue and expand on these subjects, so these posts would simply serve as the kernels that initiate the process.

credit:  Irving Kent Loh

Dr. Irving Kent Loh
MD, FACC, FAHA (Epidemiology & Prevention), FCCP, FACP is a board certified internist and sub-specialty board certified cardiac specialist with an emphasis on preventive cardiology. He founded and directs the Ventura Heart Institute, which conducts education, research and preventive cardiovascular programs. Dr. Loh is a former Assistant Professor of Medicine at UCLA School of Medicine. He is Chief Medical Officer and Co-founder of Infermedica, an artificial intelligence company for enhancing clinical decision support for patients and healthcare providers.



Debunking the Myths Fueling the Anti-Vaccine Movement

schools and vaccines, doctors and vaccines

Click to enlarge


In the 19th and early part of the 20th century, infectious disease killed millions.  One of the most devastating epidemics in human history occurred in 1918, the influenza flu pandemic. This resulted in two million deaths globally and 500,000 deaths in the USA.

Researchers were desperate for a way to stop the spread of influenza in 1918; they went into over-drive to find a solution.  Even though the circumstances were dire, scientists learned many lessons including the beginning knowledge for developing vaccines.  Due to those advances, deaths from infectious disease began to decline in the mid-20th century through today, particularly with children and infants.

What led to this decline in mortality from infectious disease?

After 1918 a lot changed: chlorinated drinking water; improved sewage systems; improved food preservation techniques; and public education regarding hygiene greatly improved public health.  Some vaccine opponents give all the credit for the reduction of disease to better sanitation and hygiene but, as scientists, we know the facts just don’t support that theory.  Disease originates from bacteria, viruses, fungi, and things we cannot see with the naked eye.  Improved sanitation in the 1930’s through the 1940s decreased the incidence of water borne diseases (due to improvements in the quality of drinking water) and tuberculosis (due to improvement in crowded housing conditions), but other diseases remained unchecked.

Vaccination campaigns, starting in 1949 with the DTP vaccine, virtually eliminated a host of diseases including:

  • diphtheria
  • tetanus
  • pertussis
  • polio
  • measles
  • mumps
  • rubella
  • haemophilus influeza meningitis.

After a 10-year, 33-nation campaign, small pox was eradicated from the world in 1977.  The polio vaccine, introduced in 1955, lead to a massive global effort banishing the disease from the Western Hemisphere by 2000. Science and history clearly give rise to evidence that the eradication of these diseases was the direct result of these vaccination campaigns. CDC: Public Health and vaccine history

Unfortunately “success breed complacency,” as some parents fear the vaccines more than the diseases they protect us from.  There is now a rise in infectious diseases that were previously considered wiped out. Sanitation, hygiene, and food delivery methods are as rigorous as ever.  The rise in diseases such as  measles, mumps and pertussis has been linked only to populations with low vaccination rates which compromise herd immunity for the greater community.

Let’s explore some of the myths out there.

Myth #1: The mandatory vaccine program is part of a government conspiracy.

There are some crazy theories out there!  I’ve read about tracking devices being injected by the US government and also that we’re just part of one big secret experiment without our knowledge.  While it’s easy to dismiss this theory,  a pocket of the US population believes this is at least possible and shy away from vaccines. Tracking devices are easy to disprove with a microscope and a sample vaccine.  The “big secret experiment” is a bit harder to refute, but clearly, we are not seeing large scale deaths or illnesses that should be expected if the government was carrying out experimentation on its citizens.

The WHO (World Health Organization) launched a global initiative for widespread vaccination decades ago.  The campaigns reached millions of people in nearly 200 counties.  No one has been able to prove the theory despite all those countries and all that time.  Surely, it should be obvious that these theories are far-fetched.  WHO Vaccine Mission

Myth #2:  Vaccine Preventable Disease Are Not Life Threatening and Just Part of Childhood.

Statistics do not bear this out. The CDC estimates the vaccination programs launched over the last 20 years has prevented over 700,000 children’s deaths and over 21 million hospitalizations.   As an example, measles and its complications can be devastating. According to the CDC, 30% of people who contract measles develop complications such as pneumonia or encephalitis (Swelling in the brain that can lead to seizures, deafness, blindness or mental retardation).  For every 1000 children who develop measles in the US, 1 or 2 will die according to Morbidity and Mortality statistics.  In 2008, 164,000 people died from measles.  While our mortality rate is low, some countries mortality rates as high as 25 percent. Pregnant women exposed to measles run the risk of miscarriage, premature birth low birth weight babies, and congenital defects in their newborns.  WHO Measles Statistics

According to the CDC, pertussis (whooping cough) cases reached a new high in 2012, the most in one year since1955. Half of infants who contract pertussis in the first 6 months will need hospitalization.  One out of every four of these hospitalized babies will develop pneumonia and one or two per 100 will die. Other complications include uncontrollable shaking, pauses in breathing that can be life threatening and brain damage.  Pertussis Complications

Many people feel these diseases don’t pose much risk to their children because they are now fairly rare. Yet, we have seen outbreaks of these diseases, specifically measles, mumps and whooping cough occurring on an increasing basis throughout the country. The state of California just reported nearly 7,000 cases of whooping cough this year, approximately 18.1 cases per 100,000 residents.  There have been reported 3 child deaths related to this out break.  CDPH Outbreak Report August 2014

Myth #3: Too many vaccines overwhelm the child’s immune system.

Many who claim vaccines are unsafe say there are too many shots that overwhelm a baby’s immune system.  Let’s look at the numbers.  Vaccines introduce approximately 150 components to a child’s immune system.  By contrast, a child is exposed to millions of pathogens in the environment from the moment they are born.  Each of these pathogens contain 2,000 to 6,000 immunologic components.  The vaccines today are more effective with fewer antigens.  Currently, children only receive five percent of the antigen that was given out 30 years ago. CDC Safe to Give Multiple Vaccines  It has been estimated that it would be safe, based on the immunology of a child, to give 10,000 vaccines at once.  Journal of the AAP

Some suggest spreading out the vaccines so the child is not getting so many at one time. There is no evidence to prove this is beneficial and actually may be detrimental.  By spreading shots out over a longer period of time, stress to the body is also prolonged.  You’ll also deal with an unhappy child who needs more frequent visits and a shot nearly every time they visit their physician.  And the child is exposed to more infections every time they visit the doctor’s office and share the waiting room with sick kids. Most importantly, the longer a vaccine is withheld, the more time a child is vulnerable to those infectious diseases that they could be protected against by having received the vaccine.

Myth #4: Thimerosal/mercury causes neurodevelopmental damage/autism.

Perhaps, this is the biggest controversy surrounding vaccines. Many people claim the Thimerosal (which keeps vaccines sterile) is responsible for causing autism or neurodevelopmental problems. It is a derivative of ethyl mercury.  The presence of mercury is what concerns parents but most don’t realize there are two types.  There is no evidence that ethyl mercury causes any kind of damage. By contrast, methyl mercury (what used to be in thermometers of old) is a neurotoxin in high doses. Methyl mercury is found commonly in the environment, in the soil, water, food … so people are already exposed to it.  Additionally, methyl mercury has only shown to be neurotoxic at sufficiently high doses for prolonged periods of time.  The EPA and FDA are constantly studying these levels and regulating the food we eat and environmental conditions to maintain the exposure way below levels that we need to be concerned about.

In contrast, Thimerosal is an ethyl mercury derivative. This form is not normally found in the environment or the human body. In fact, if it is taken into the body, it is quickly broken down and excreted. It does not stay for any time in the body and does not have the potential to be a neurotoxin. The amount used is also very miniscule. The amount of mercury we eat in a tuna sandwich is probably much higher. CDC: Thimerosal Safety In Vaccines

While vaccines have been around since the late 1940s, autism has taken a sharp increase in the past decade. People were anecdotally looking for a connection and many turned to vaccines.  An unfortunate study, published in England, supported the idea and parents were understandably upset, wondering if their children’s shots could possibly harm them.  Of course, the Lancet has since retracted the study and the author has been disgraced for shoddy work.

We are seeing a rise in the diagnosis of autism because of improved screening methods and diagnostic criteria. Both the medical and educational communities are more aware of autism and we’re able to reach more kids who need help. In fact the incidence of autism continues to rise, yet Thimerosal has been eliminated from most vaccines. Also, we did not see a sudden spike of Autism when the vaccine program was initiated.

Myth #5: We are not harming anyone else if we don’t vaccinate our children.

This is another untruth. When a high enough percentage of the community receives a vaccination against a particular disease, the entire community is better protected, a process called Herd Immunity.

But, when the percentage is too low, then everyone is vulnerable to disease, particularly the young and the weak, whether or not they have received immunization.  We already discussed pertussis in California, which went from a few rare cases a year to several thousand.  In addition, measles has been making a comeback in the New York City area because certain populations there do not believe in vaccinations for religious reasons.

There was a recent story of a nine-week-old child who died from pertussis (whooping cough). This is a disease that was nearly wiped out but is having a recent resurgence due to the unimmunized. Some groups can’t medically receive vaccines and they are at risk too.  Death of 9 week old from whooping cough

Strikingly, not only do the vast majority of doctors support vaccines, but 79% of those polled on Sermo felt unvaccinated children should not be allowed to attend public schools because they are putting others at risk.   While it is a requirement for children to receive vaccines to be able to attend public school, they are allowed to go unvaccinated for certain religious exemptions. Many of those opposed to vaccines will claim religious reasons just so their kids do not have to get vaccinated. While that is their choice, as doctors, we know they are putting their children at risk of contracting these diseases. However, we are also concerned about the others that they are endangering. Some children are unable to receive vaccines due to medical reasons. For example, if a child had an adverse reaction to a previous dose it may be dangerous for them to get booster doses. Without the additional doses, they are not fully protected. And there are some medical conditions that it is contraindicated to receive any doses of certain vaccines. Those children do not have the choice and it is unfair to expose them. Many of those kids have compromised immune systems and cannot fight off infectious diseases.  While the healthcare communities around the world have made a concerted effort to eradicate these potentially dangerous diseases, it will never happen if the whole population does not follow the recommendations. Additionally, most of the time, these diseases are contagious prior to symptoms being obvious so it is usually too late to try to isolate the infected child. Unvaccinated children run the risk of serious medical problems by not being protected through the immunization schedule and they are putting the lives of others, possibly immunocompromised children, in jeopardy.

Myth #6: Doctors are making huge profits from vaccinations.

Believe it or not, some doctors have stopped providing vaccines for their patients because they lose money on them. I can bear this out in my own practice, giving vaccines is barely a break-even endeavor. The vaccines are costly to purchase and when you calculate in the cost of supplies and staff time, the profit, if any, is minimal.

Doctors do not give vaccines to make money. We do it as a service to our patients so they do not have to go elsewhere.  This is easy enough to prove by reading an insurance EOB (explanation of benefits) showing how much the doctor was paid for dispensing the vaccine and then Googling the cost of the vaccine itself. Most people are shocked to see how little it is. There is no conspiracy by doctors to make money by giving dangerous vaccines.  Giving “bad” vaccines is a liability for us.  We are not going to chance injecting our patients with harmful substances for the little profit we get only to open up the possibility of being sued.  It just doesn’t make sense.

Myth #7: All these infections can be easily treated with colloidal silver.

Silver has been used for years to prevent wound infections. However, the mechanism by which this happens is not by killing off the bacteria. It creates an environment that makes it impossible for bacteria to grow and flourish. If an infection does set in, the patient will still need to be treated with antibiotics. Silver is not a natural substance occurring in the body.  When a person takes an antibiotic, it is broken down and distributed throughout all the tissues in the body. Based on pathophysiology, this is impossible to happen with silver. It is filtered out as a foreign substance and most likely excreted out of the body.  There are no clinical studies proving any benefit that it works to kill off viruses, bacteria or other pathogens in the body.

Anti-Vaxxers are stepping up their campaign to abolish or limit vaccines, despite decades of research with a cohort of millions.  They still point to a few small anomalies as their proof. While an occasional bad reaction from a vaccine does happen, the millions of lives saved by vaccines can’t compare to the few unfortunate reactions that occurred.  While they are able to get support from some celebrities, the statistics and evidence of the CDC, WHO, AAP, AAFP, Unicef, Morbity and Mortality, academic medical institutions, hundreds of countries governments and nearly most medical professional organizations across the globe cannot be discounted by a few dubious sources.

Hopefully, parents will scrutinize the evidence more closely, before making the decision to keep life- saving vaccines from their children. The safety of vaccines is clear and who wants to go back to the days of rampant polio, measles, and even small pox.  Does anyone want that?

credit:  Linda Girgis, MD

credit: Linda Girgis, MD

Bio:  Dr. Linda Girgis MD, FAAFP is a family physician that treats patients in South River, New Jersey and its surrounding communities. She holds board certification from the American Board of Family Medicine and is affiliated with both St. Peter’s University Hospital and Raritan Bay Hospital. Dr. Girgis also collaborates closely with Rutgers University, University of Medicine and Dentistry of New Jersey (UMDNJ), and other universities and medical schools where she teaches medical students and residents.  She recently completed a medical mission in Egypt.


Mental Health Issues for Child Refugees

Honduran boy~ by Amy Cohen, MD, child psychiatrist

“CRISTIAN OMAR REYES, an 11-year-old sixth grader in the neighborhood of Nueva Suyapa, on the outskirts of Tegucigalpa, tells me he has to get out of Honduras soon — “no matter what.”

In March, his father was robbed and murdered by gangs while working as a security guard protecting a pastry truck. His mother used the life insurance payout to hire a smuggler to take her to Florida. She promised to send for him quickly, but she has not.

Three people he knows were murdered this year. Four others were gunned down on a nearby corner in the span of two weeks at the beginning of this year. A girl his age resisted being robbed of $5. She was clubbed over the head and dragged off by two men who cut a hole in her throat, stuffed her panties in it, and left her body in a ravine across the street from Cristian’s house.

“I’m going this year,” he tells me.

- from “The Children of the Drug Wars” by Sonia Nazario   The New York Times 7/11/14


Who are the children and why have they come?

As has been widely reported, the past three years have witnessed an explosion – a “surge” – in the number of unaccompanied minors fleeing, particularly, countries of the “Northern Triangle” of Central America: Honduras, Guatemala and El Salvador and, to a lesser extent, Mexico. Many of these children have landed in the United States. Prior to 2012, children arrived unaccompanied in the US at a steady pace of about 6,800 per year. In 2012, this number jumped to 13,000. In 2013 more than 24,000 arrived and this year the number is expected to be near 70,000.

This “surge” has also brought a demographic shift – more young children (as young as 3) and more female children, some of them pregnant as a result of rape either in their home countries or on their journey to safety.

These children arrived into a heated debate over illegal immigration. But are they illegal immigrants or refugees? What is our country’s obligation to them? Some facts may be helpful:

  • More than half of these minors would qualify for sanctuary asylum as refugees and would be in this country legally if properly adjudicated
  • The United Nations High Commission for Refugees (UNHCR) defines refugees as those “in need of international protection”: people fleeing from:
    •  pervasive and extreme violence
    • Imminent risk to life
  • A state system unable to provide protection to its citizens

A UNHCR study concluded over half of the unaccompanied minors qualify for asylum. Here are the reasons the children are fleeing:

  • A coordinated American-Columbian effort to disrupt the flow of drugs through the Caribbean (thus shifting the route to the Northern Triangle of Central America) combined with the deportation of many gang members from the U.S. back to Central America.
  • Honduras is statistically the most-violent country in the world. The three countries of the Northern Triangle (from which nearly all of these children travel) comprise three of the five most violent countries on earth.
  • Over half of the children witnessed the murders of young peers and family members and themselves having faced rape, violence and continuous threats on their lives and those of their families if they refuse to join gangs and drug cartels.

Drugs cartels, gangs, violence in schools, school bombings, home situations that might include dead or missing family members; there is much to fear. Much like the “lost boys” of what is now South Sudan they are driven to flee with the hope of safety, sometimes deciding on their own, sometimes encouraged by peers or sent away by terrified parents. Some have already been victims of the dangers and violence of the journey itself, and some have been turned back, only to risk their lives again to flee the nightmare of their home cities and villages.

US Arrival of Child Immigrants

Once apprehended at the border, children arriving from Central America undergo a dizzying series of moves from one detention center to another as they come under the jurisdiction of a progression of agencies of the Department of Homeland Security. The priority is to place them within 45 days with someone who can serve as a sponsor.

Some are sent to more institutional settings. Others land with those claiming to be relatives, foster parents with other children who may or may not speak Spanish, smaller group homes with a diverse population of children who may regard them with suspicion or hostility.   Some may be placed with other children like themselves while others may be more isolated from anyone who understands the terrible things they endured. Shame and fear make it likely that they will keep their stories to themselves, increasing their experience of isolation.

Public Health Implications

These refugee children are victims of psychological trauma, and many suffer from Post Traumatic Stress Disorder. Their consequent symptoms impact not only the children themselves, but also the broader systems with which these children intersect: border patrols, temporary and longer term facilities, caregivers, peers, schools, communities. The need for public education, community and family supports, and professional preparedness is enormous.

Symptoms of PTSD

The DSM V updated the diagnosis of PTSD. Full descriptive criteria can be found here:

PTSD requires exposure to a traumatic event (direct or indirect) and at least one symptom from each of the four symptom clusters:

  • Intrusion symptoms
  •  Avoidance
  •  Negative alterations in cognition and mood
  •  Alterations in arousal and reactivity

In addition, symptoms must have persisted for at least one month and must have “functional significance”, either impacting negatively on daily function or creating significant symptom-related distress. In addition, two specifiers further define the disorder as “delayed” (onset in excess of six months) and “with or without dissociative symptoms” (depersonalization or derealization).

All children defined as qualifying for refugee status will meet the criteria of exposure to a traumatic event. PTSD symptoms differ depending on the resiliency of the child and type of exposure to trauma. A child who is constitutionally more vulnerable will require less exposure and manifest more symptoms.

Specific symptoms for any given child include the following:


  • Recurrent, involuntary and intrusive memories (sometimes expressed through play)
  • Traumatic nightmares and other sleep disturbances
  • Flashbacks and other dissociative reactions
  • Intense or protracted distress after exposure to traumatic reminders
  • Marked physiologic reactivity (e.g. rapid pulse and breathing, vomiting or diarrhea) following exposure to trauma-related stimuli


  • Trauma-related thoughts or feelings
  • Trauma-related external reminders (e.g. events or people who may trigger thoughts or feelings)


  • Inability to recall key features of traumatic event
  • Persistent negative beliefs about oneself or the world
  • Distorted blaming of oneself or others for having caused the event
  • Persistent trauma-related negative emotions (e.g. fear, anger, guilt)
  • diminished interest in activities previously significant activities
  • detachment or estrangement from others
  • persistent inability to experience positive emotions


  • Irritable or aggressive behavior
  • Self-destructive or reckless behavior
  • Hypervigilance
  • Exaggerated startle response
  • Concentration problems
  • sleep disturbances

It is not unusual for PTSD symptoms to be delayed by weeks or even months before nightmares begin to establish themselves. These are child “survivors” who – by dint of making it successfully on their own to the US – have demonstrated a capacity for determination and fortitude. Once immediate danger has passed, and fortitude is no longer required, symptoms are likely to emerge. So all caregivers should be alert to the possible evolution of symptoms and ready to step in and shift strategies as needed.

Families, school systems and communities may all be profoundly challenged by these refugee children – their emotional, interpersonal and behavioral issues. Education and support are key to offering schools and communities a clear perspective on what they may expect, and what resources to access when problems do come to pass.


A public health response in this population must include coordinated services between mental health professionals, physicians, schools and the community. To facilitate the transition of these children into healthy and productive lives, they must be “held” by a “net” of responsible adults who are knowledgeable about PTSD, and able to communicate with each other to initiate or revise treatment as needed.

Mental health professionals should be at the center of care for these children. They should be trained and experienced in trauma and trauma-directed therapies.   Functions should include:

  •  Coordination of all mental health services
  • Thorough and careful, trauma-based evaluation of each child
  • The development of an initial treatment plan, including:
    • further psychological testing if necessary
    • group and individual psychotherapy (trauma-based CBT should be included)
    • medication evaluation
    • family therapy where indicated
  • Regular follow-up to assess progress and evaluate for the emergence of new symptoms
  • Education of and ongoing consultation to parents or parent surrogates, schools and community organizations to assist them in better understanding PTSD Collaboration with pediatricians and family physician.

These children may speak little English and are likely to have difficulty sharing their stories and symptoms with strangers. Ideally, therapists should be Spanish speaking. Group therapy with other children with similar histories will help them feel connected and respond to treatment better. When possible, regional centers should be established to bring these children together for treatment and support.

I once worked with parents who had two biological children but had decided to pursue a domestic adoption. They’d been persuaded to take in two sisters but had never been told that these girls had witnessed terrible domestic violence that had ended in murder. When the girls began to act out in destructive ways, the family was mystified and unprepared. Ultimately, they chose to place them in a distant group setting in order to save their family, but not before havoc had reigned, and intensive family treatment was required to repair the damage to the parents and their other children. Honest information and appropriate resources could have spared this family terrible confusion, distress and guilt and might have enabled them to keep and raise their girls. It would have spared their biological children their own trauma and their adopted children additional isolation and rejection.

As is illustrated by this story, it is not only the children who require help in dealing with the aftermath of terrible trauma, but also the caregivers. They need education on the symptoms of PTSD, as well advocacy training on behalf of the children in their communities, schools and with health care workers. These can be very challenging children to raise and caregivers deserve to be prepared for the required commitment of time and effort.

Schools are often places where these children become symptomatic. Educators need help in recognizing the warning signals of a struggling child. They should have support in strategies for dealing with problems within the school setting, as well as resources for outside referral.

As examples, children may exhibit the following:

  • Frank learning problems due to issues with focus and concentration
  • Extremes of aggressiveness or timidity with adults and peers
  • Chronic fearfulness with overt phobias, clinging to adults, difficulty with transitions, need for constant reassurance, misinterpretation of the actions or words of others
  • Overt mood disorders, with depressive or even hypomanic or manic symptoms
  • Bizarre behavior that could be the consequence of flashbacks or dissociative episodes
  • Difficulty following rules or directions
  • A tendency to isolate or gravitate only to those with similar histories

They may demonstrate significant peer problems as they struggle with their new social environment and may misinterpret or respond poorly to social cues. This may result in more social isolation, scapegoating and fights in and outside of the classroom.

Mental health professionals should be available to schools to:

  • Educate teachers and administrators about PTSD
  • Be available for regular meetings with teachers and administrators to monitor progress
  • Develop specific treatment plans for children requiring them within school setting
  • Offer emergency consultations when necessary

Communities require education in understanding the histories of these children, the rationale for their need for asylum and the ways in which the community might support them. First responders, such as the police and fire departments may benefit from their own educational sessions and the availability of mental health providers to answer their questions. Local emergency rooms should have numbers to call should these children present with emotional or behavioral issues.



Americans are, for the most part, unaccustomed to seeing child victims of the ravages of war. Efforts to address this new surge of children must occur on many fronts. International efforts must certainly focus on the conditions in the nations of the Northern Triangle that have led to this mass exodus and which – if rectified – could allow these children to go home.

The statistics suggest that at least 35,000 children will qualify for asylum if properly processed through our borders. While this is unfamiliar and distressing to many Americans, it may be useful to place this in some perspective. As one example, countries bordering Syria have taken in nearly three million people, with Jordan alone accepting in two days what the United States has received in a month during the apex of this surge. We would be railing at Asian or African or European countries that heartlessly expelled lone children escaped from war zones, and we should expect no less of ourselves.

The question of how to properly identify and logistically manage the burden of our child refugees represents a significant challenge, some of which falls upon our mental health system. While we await a longer-term solution to the issues plaguing Central America, we must do our best to support these children and the communities that have reached out to host them.


Dr. Amy Cohen is a child, adolescent adult and family psychiatrist currently working with high risk, inner city youth in the Bay Area of San Francisco. Her interest in the effects of trauma on children date back to the 1970s when she was an active member of the domestic violence group at Boston Children’s Hospital. She traveled to South Sudan to address the trauma needs of children newly released from slavery in the north following their protracted exposure to violence and torture. Dr. Cohen obtained her medical degree from the University of Pennsylvania. She received her postgraduate adult and child training at The Cambridge Hospital and McLean Hospital, respectively – both within the Harvard system. She has applied her clinical, administrative, program development and teaching skills to both inpatient and outpatient settings over her 25 years of practice.


  1.  UNHCR report: “Children on the Run” http://www.unhcrwashington.org/children/reports
  2. “The Surge of Unaccompanied Children from Central America http://www.americanprogress.org/issues/immigration/report/2014/07/24/94396/the-surge-of-unaccompanied-children-from-central-america-root-causes-and-policy-solutions/
  3. Step-by Step Guide on Apprehension and Detention of Juveniles in the United States http://www.womensrefugeecommission.org/resources/document/1035-step-by-step-guide-on-apprehension-and-detention-of-juveniles-in-the-united-states
  4. “Not in my backyard: Communities protest surge of immigrant kids” http://www.cnn.com/2014/07/15/politics/immigration-not-in-my-backyard/
  5.  “The Children of the Drug Wars” http://www.nytimes.com/2014/07/13/opinion/sunday/a-refugee-crisis-not-an-immigration-crisis.html?_r=0
  6.  Unaccompanied Children http://www.womensrefugeecommission.org/programs/migrant-rights/unaccompanied-children



Sermo Poll: How Common is Divorce Among Doctors

doctors and divorce, physicians and divorce

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Researchers estimate that 40-50 percent of marriages end in divorce. What happens when we narrow down the research specifically to doctors?

We recently polled our Sermo physicians and over 2600 MDs asked “Have you ever been divorced?”

  • 77% answered No
  • 22% answered Yes

According to a Utah State University divorce study, 73 percent of divorced couples state lack of commitment as the reason their marriages ended. Physicians have demanding careers, work long hours, high stress levels and less time at home. Earlier this year, Sermo conducted a poll on physician burnout. It is not surprising, 40 percent of physicians reported life and work balance as their number one reason for burnout. Statisticbrain.com conducted a stress statically survey in July 2014. The top cause of stress in the U.S. is job pressure. Physicians have more than their fair share of work related stress and stress contributes to divorce.

The most recent study analyzing physician divorce rates was conducted in 1997 by John Hopkins’ University. This study measured over 30 years of physician divorce rates. The results:

  • 51% for psychiatrists,
  • 33% for surgeons,
  • 31% for other specialties24% for internists
  • 22% for pediatricians and pathologists,

Results from our poll showed similar results. The top five specialty rates were:

  • 32% for Emergency Medicine/Critical Care,
  • 29% for Psychiatrists and OBGYNs
  • 27% for Family Practice
  • 26% for Surgeons


“Many physicians place work above all else, and it has been speculated that this may serve the purpose for them of helping to avoid intimacy, thus placing strain on intimate relationships.” –Medscape.com

Two contributing factors to physician divorce according to the John Hopkins research are:

  • Students who wed during school. Similar to the long hours of a physician, these students are subject to long hours and many years of education.
  • Female physicians have a 37 percent chance of divorcing while their male counterparts only have a 22 percent chance.

As an M.D. or D.O., have you been through divorce? How do you feel about your specialty being among the top ten rated? What are your thoughts on these statistics? If you’re a physician, we’ll be discussing this further inside the community. Come join us.


  1.  How common is divorce and what are the reasons?
  2.  Physicians’ divorce risk may be linked to specialty choice
  3. The Painful Truth: Physicians Are Not Invincible
  4. Stress Statistics