December 2, 2005
Mr. Spock Speaks Again…about Favism
One of the great debates and persistent tensions in healthcare is the good of the individual versus the good of the many, or public health concerns.
Healthcare in the US is a technology-based, information-dependent personal service. We made a huge resource commitment long ago to focus on the good of the one and to treat both treatable and largely untreatable conditions. What about prevention? If you knew of something that could expose you to death, and you could easily avoid it with a simple piece of information, would you want to know about it? Uh, yes?? Was that a trick question?
I mean, wouldn't you like to know you could avoid being bitten by a poisonous snake because it gives off a funny little rattle sound before it strikes? Why would the medicine man keep that a secret?
This was interestingly highlighted recently in a piece in the Wall Street Journal entitled “To Warn or not to Warn” by Kevin Helliker.
This time we are not talking about cigarettes or birth control pills or hormone replacement therapy. The subject is fava beans. Those tasty little guys that are showing up in more and more restaurants and health food stores.
Here's the debate (if you can call it that):
“As chairman of molecular and experimental medicine at Scripps Research Institute in La Jolla , Calif. , Dr. Ernest Beutler is the nation's leading expert into how fava beans can sic ken and even kill some people--most often children--who eat them.”
“So is he sounding the alarm? Not exactly. Dr. Beutler thinks the danger is too rare to warrant any kind of public-awareness campaign. "Don't parents have enough to worry about?" he asks” Right away one asks, why a public-awareness campaign if simple information would work? More on that later.
“Reid Winick, a dentist, says no. A few months ago, fava beans nearly killed his 7-year-old son.
“The fava-bean debate offers a window into a question that often plagues scientists and doctors: Which medical dangers ought to be publicized?”
Both of Dr. Winick's sons were admitted to the hospital with fever, jaundice (yellow discoloration of the skin and eyes), and severe anemia a day or so following eating fava beans. An alert hematologist thought to ask the right question. Both boys recovered uneventfully.
“An ancient staple of the Mediterranean diet, fava beans are a great source of protein and fiber. Even in the old days, however, the bean was known as potentially dangerous. It is said that Pythagoras, the Greek mathematician, advised avoiding fava beans. In any case, the occasional consumer of fava beans would grow ill, turn yellow, and develop blood-colored urine. In children, the result often was death.”
“For centuries it was assumed that these victims had an allergy to the beans. But during the 1950s, some American doctors, including Dr. Beutler, discovered that the explanation was genetic: These victims were deficient in an enzyme called glucose-6-phosphate dehydrogenase. A certain percentage of people deficient in that enzyme are unable to process fava-bean toxins, which begin destroying red blood cells.”
Dr. Beutler estimates that fewer than half of hematologists in America have ever seen a case of favism. Since few Americans eat fava beans, Dr. Beutler sees no reason to publicize the danger. When emergencies do arise, he says, the Winick case shows that hematologists can diagnose and treat them.
He says warnings about such dangers can breed misunderstandings. As it stands, favism has given rise to myths such as that string beans are dangerous or that raw fava beans are dangerous for everyone. In truth, both raw and cooked fava beans are dangerous for people susceptible to their toxins, while neither is dangerous for those without. String beans aren't implicated at all.
But Dr. Winick sees it differently. After all, fava beans are hardly a necessity. And it isn't difficult to find newspaper stories that rave about fava beans without mentioning this danger.
Had he known about the risk, Dr. Winick says, he would have made certain that his children didn't eat any fava beans. How could it hurt, he asks, to suggest that children in general avoid fava beans?
So there it is. The academician versus the “reasonable person.” The Abramson Family Center For The Future of Health believes in transparency of information. That means everyone has equal access to the same information.
This conundrum also points up the fact that humans aren't good at judging relative or even absolute risk. We don't do well with probabilities. And, after all, we actually live in a binary world where things either happen or not. So why wouldn't you want to know?
Is some full blown public education movement needed for favism? Probably not. Is there a way to do it more directed to populations more likely to be at risk? Probably yes. There is no doubt in my mind that if restaurants and health food stores continue to popularize fava beans that someone will get sick enough or die such that the legal liability will begin to spread the warning. Perhaps we don't have to wait for fava casualties to inform.
The application of genetic medicine in the future should tell us more precisely the diseases we may be at risk for. But until then, I want to know about the rattlesnakes. Then I can decide whether to hike in their world or not and what precautions to take. It should be my choice based upon informed judgment.
Robert B. Teague is a pulmonologist and business consultant who is based in Houston, Texas. E-mail him.
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