Don't Kill the Birthday Girl (23 page)

As my tongue teased at the feathery bits of crab, I knew this was the kind of meal that could never be reduced to a series of recipes. It was the culmination of the room, the history, the service, and the cheerful din. The pleasure of each bite was intensified by the risk of trusting an unfamiliar city to take care of me, even when I was traveling alone. The taste was New Orleans.

When Preston brought my coffee, it took all my restraint to not slip the spoon into my purse as a trophy.
Galatoire's
, it said on the stem, in that now familiar script.

CHAPTER NINE

What Doctors Really Think

O
n the cusp of my thirtieth birthday, I had traveled to New Orleans to attend the annual conference of the American Academy of Allergy, Asthma, and Immunology (AAAAI). I know about food allergies from the ground up, based on firsthand experience. I wanted to hear what was being said from the top down. I wanted to know what doctors say about future treatments for allergies when their patients aren't around.

Though I know it's a licensed job, I've always thought of doctors in terms of personal relationships. My grandfather, my uncle, the allergist who has handled my case since I was one—all have cared for me with a mix of professional acuity and protective affection. My first serious boyfriend knew, even in high school, that he would become a doctor. I used to periodically
check on the price of monogramming a stethoscope, thinking I would get him one as a graduation gift someday.

Though we broke up before he headed off to medical school, years later we'd still get together for the occasional awkward drink. One night he surprised me by mentioning that he might go into ear, nose, and throat medicine. I'd always imagined him as one of those superstars who finds a cure for cancer. He had assisted at a local university's oncology lab our senior year of high school. Who trades that in for hay fever and swimmer's ear?

“There's a lot of research to be done,” he'd said, sipping his pint of Harp.

I kind of hated that he was now someone who drank beer. I kind of hated that I was now someone who drank beer. Our high school dates had consisted of walking down to the Wendy's two blocks from campus, where I'd order a Barq's root beer and French fries. We'd sit down at one of those tables that wobbled no matter how many yellow napkins you stuffed under the base, and I'd play the soda's squeaky-straw trombone as we talked. He'd take the first bite of his mayo chicken sandwich, and I'd remind him that there was no kissing from there on out. He'd stab the air with a fry for emphasis as he predicted a treatment for food allergies that worked, really worked.
It's a matter of time
.

Sitting in a downtown bar years later, on that awkward not-date, I was reminded of what had changed between us—and what had stayed exactly the same. “Ear, nose, and throat” is the umbrella for studies of asthma and allergy. Maybe there was a small part of him that still dreamed of fixing me. Maybe there was a small part of me that still dreamed of proving fixable.

But ROTC would take my ex on a detour through Japan, where he was assigned several years of service as a naval flight surgeon. All of my other doctor friends had gone into pediatrics. I arrived at the AAAAI conference with a schedule, an orange-ribboned press pass, and no tour guide. I'd have to make my way on my own.

Early on the first morning, I headed down to the Poster Session, where mobile “walls” had been built out of upholstered panels, creating aisles where abstracts presented throughout the conference were printed out and pushpinned up. Each poster measured as large as three feet eight inches high and seven feet six inches wide—eighth-grade science fair posters on steroids—and each row had a different theme, from “Asthma, Education, and the Underserved” to “Cytokines and Chemokines” to “IgE and Allergy.” Some studies took an intuitive hypothesis—e.g., kids in the inner city are more susceptible to asthma—and saddled the sociological observation with data, percentages, and charts. Some studies were pure jargon unless you knew the relevant compounds by heart.

I made my way to the row marked
FOOD ALLERGY 1
. The crowd surged in unpredictable waves, as people tried to talk to the exhibitors standing in front of their posters. Exhibitors periodically broke away and zigzagged down the row to talk to one another. It was as if I'd walked into a reunion for a college I had never attended. I didn't have the icebreaker of an institutional affiliation or the wingman of a colleague. I didn't recognize a single face.

Yet, in some ways, I felt completely at home. Maybe not with the allergists, but certainly with the allergies themselves. It was as if the posters in this row had been curated by the
director of that old documentary series
This Is Your Life
. Every five feet, I found an answer to a question that had nagged at me. One poster outlined the difference in “restrictive” versus “permissive” diagnostic criteria for anaphylaxis. One poster documented reactions to soy among those with birch allergies. A quartet of posters discussed the allergenicity of baked milk versus raw. Pending publication in a peer-reviewed journal, all these abstracts were considered “preliminary findings.” Still, if you wanted a portrait of where the science was heading, this was it.

Ninety-nine times out of a hundred, I am the only person in the room thinking about food allergies. In this place, I was surrounded by people who not only thought about food allergies but also dedicated substantive portions of their careers to the topic. From Arkansas to the Netherlands, from Tokyo to Cork, from Mount Sinai to Manitoba, center after center had sponsored these studies. It was both thrilling and deeply intimidating. I'd gone from being the default expert to the de facto rube.

I walked up the row, then back, then up again, until I realized it looked like I was pacing. I stopped in front of a University of Michigan poster on “the administration of influenza vaccine to egg-allergic children under thirty-six months.” To this day, I've never taken a flu shot, based on the principle that it carries proteins from the egg in which the vaccine's ingredients are incubated. In flat, unemotional language, the abstract made clear that this was probably an outdated precaution.

As I struggled to reconcile ten seconds of reading with almost thirty years of my mother's prevailing wisdom on flu shots, a tall man with dark brown hair and a thin nose approached the
poster's presenter. Though his suit was unremarkable, he had a sharp bearing; the woman from the University of Michigan straightened up as she answered his quick questions about their methodology and sample size. As he turned to go, I impulsively reached out and touched his shoulder.

“Yes?”

“I wanted to ask if—” If what? I had no plan. I tried to scan his name tag and hit a traffic jam of initials: F, A, A, A, A, I.

“—to ask if you were with the … Food Allergy and Anaphylaxis Network?”

That was the only organization that I could think to name, but as soon as I said it, I knew I was wrong. The acronym had not enough
A
s, no
N
s. His mouth pursed slightly.

“No,” he said. “No, I'm with Duke.”

Mistaking a university-sponsored allergy researcher for a FAAN staffer, in a setting like this, is akin to being on the Hill and mistaking a South Carolina Senator for a lobbyist. Not inconceivable but not really forgivable, either. He walked away and, fifteen feet down from where I stood, took up residence with his team. They were presenting not one but a whole constellation of posters, each bearing the logo of a shield, each toned in that distinctive Devil-blue palette. I watched as passerby after passerby stopped to give him a respectful nod and handshake.

Well. That was an auspicious start.

•  •  •

Outside the medical community, the question everyone wants answered is, Why is the incidence of food allergy growing at such an alarming rate?

There are a handful of popular ideas, the most prominent of which is the Hygiene Hypothesis. The Hygiene Hypothesis suggests that in cultures where people are no longer routinely exposed to as many parasites, bacteria, and viruses as their ancestors, restless immune systems have turned their attention to harmless food proteins. Usually, this hypothesis surfaces as part of a larger nostalgic position that kids today are overprotected and missing out by not “playing in the dirt” more often.

There's even an experimental treatment specific to this theory, Helminth therapy, which posits that circulating small amounts of a parasitic worm ova (
Trichuris suis
, pig whipworm) through the body will desensitize those with food allergies. The effects of the residency of the worm itself are benign; the point is to give the immune system another target. Patients mix a vial of the ova with water or juice and drink it. Given that in recent years the breakfast industry has marketed every imaginable variety of orange juice—no pulp, extra pulp, calcium added, homestyle, pineapple blend—if this Helminth experiment proves fruitful, I'm looking forward to the “Now with an infusion of whipworm” campaign.

Though it is intuitively appealing, the Hygiene Hypothesis falters under logical scrutiny. The theory might justify why food allergy has surged in developed countries more so than in undeveloped countries. But why would incidence spike in inner-city settings, not rural environments? New York City basements and alleys don't lack for dirt.

Another hypothesis aims an accusing finger at the uptake of folic acid by pregnant women, who are hoping to ward off other birth defects. There's no purported mechanism of causation in place, but some find it a compelling concurrence that
the 1980s saw both the rise of folate supplements and the rise of allergies in children.

Alternately, some point toward the correlation between vitamin D deficiency and skyrocketing rates of asthma, dermatitis, and allergy. I find it a stretch that low vitamin D levels would foster asthma, and not the other way around. After experiencing a few attacks, the kid with the inhaler is rarely the one rushing out to play kickball in the sunshine. And yes, the mother of a kid with eczema is going to slather him in sunscreen.

Within the world of allergists, the question of “why is this happening?” is moot in the short-term. The phenotypes of allergy sufferers are too diverse to draw meaningful conclusions based on contributing factors of lifestyle or ethnicity. Within the world of allergy research, the focus is on treating existing food allergies. That's where the suffering is palpable, and that's also where the money is. As Michael Pollan has argued, groups pursuing research often have to accept partial sponsorship for their clinics from those who profit from management, not prevention.

Most doctors believe desensitization is the key to treatment. For many years, allergic rhinitis has been predominantly treated by allergen-based injections. But there is another way. Injections were actually preceded—as early as 1905, in Germany—by experiments in administering minute dosages of allergens via droplets under the tongue.

Around 1910, New York pediatrician Oscar M. Schloss took on the case of a child, age two, with suspected egg allergy. His mother had noticed that when her son played with empty eggshells, hives broke out on his hands and arms. At the age
of fourteen months, the boy had also exhibited extreme hives around the tongue and mouth after being given a soft-boiled egg to eat. That was the first egg the boy had ingested since a preliminary exposure at the age of ten days, when a bout of diarrhea had been treated with barley water and raw egg white. This was a common folk-cure of the time; barley water is still used today, minus the raw egg.

Schloss tested for allergy by injecting a guinea pig with the boy's blood, then feeding egg to the guinea pig. The guinea pig, which had previously tolerated egg, responded with symptoms of shock.

Schloss decided to treat the boy by mixing water with the white of a raw egg, diluting it over and over, and then finally feeding it to him. No reaction. The next day, he administered the same “medicine,” diluting it a little less. No reaction. He did this the next day, and the next, each time making the solution stronger, until the boy could eat eggs in moderation. In 1912, he published the results of his treatment, suggesting that oral desensitization was a reliable option. But the enthusiasm for hypodermic treatment, as pioneered by Leonard Noon and John Freeman, had taken a firm hold on the market the year before, and would remain the dominant mode throughout the twentieth century.