Tuesday, June 28, 2022

A topic that has led to both scientific discovery and to alleged scandal in Israel is that of pediatric scalp ringworm, not something one would imagine would be of great national interest. Tinea capitis, the scalp form of ringworm, is a not uncommon fungal infection of the scalp. It is contagious, can cause bald spots, and may occur in 3% of the pediatric population. Nowadays it is relatively easily managed with an antifungal agent, griseofulvin, which came on the market around 1960, but was previously difficult to eradicate.

Believe it or not, from the beginning of the 20th century, radiotherapy was utilized for the treatment of tinea capitis—it was highly effective for this purpose. The treating doctors and parents were unaware of long-term potential risks. As I described in a prior article, such risks only became widely known after the exposures of the Japanese A-bomb survivors were publicized in the 1950s and 1960s. The general population was widely innocent of the risks of radioactivity—my fellow baby boomers will recall the use of fluoroscopes in shoe stores so the salesman could show our mothers the bones in our feet in the shoes.

It is estimated that more than 200,000 children were treated worldwide with radiotherapy for scalp ringworm between 1900 and 1960. In Israel, this treatment was given at Hadassah Medical Center where thousands of primarily ultra-Orthodox children were treated prior to 1920; this apparently eliminated the problem in Israel for many years. Between 1921 and 1938, there was a problem with tinea capitis among children in various Eastern European countries. This infection was used by the British to preclude immigration to Mandatory Palestine. As a consequence, it is estimated that about 25,000 children were irradiated to permit them to emigrate to Palestine and the U.S.

The problem was reawakened after the State was established when Israel welcomed thousands of immigrants from North Africa and the Arab countries. Poverty and crowded living conditions had created the circumstances under which this infection was particularly widespread. Professor Moshe Prywes, later the founding dean of Ben Gurion University’s medical school, was at the forefront of trying to eradicate several diseases among the North Africans, including trachoma, tuberculosis and tinea capitis. In pursuit of this, X-ray machines were set up at two immigration intake centers to provide scalp irradiation to children starting in 1948.

It is estimated that the number of children irradiated in Israel between 1948 and 1959 (when griseofulvin became available) was about 15,000, while approximately 15,000 children were treated in Morocco itself, and a few thousand were treated in Eastern Europe.

Baruch Modan was a Sabra born in 1932 who earned his MD at Hebrew University. He was an early leader in epidemiology and became chair of epidemiology at Tel Aviv University; he later spent five years as director-general of the Ministry of Health. His research work focused on the effects of ionizing radiation on risk of cancer.

In 1974, he and his co-workers published a landmark paper in the Lancet on the effects of cranial radiation for ringworm. Their study was a retrospective follow-up of 10,834 children who had received scalp irradiation compared to 10,834 controls and 5,392 siblings. They found 27 cancers of the head and neck (brain tumors, thyroid cancer, parotid cancer) arising in this population. As compared to controls, the risk of brain tumors was three-and-a-half times higher, while the risk of thyroid cancer was four times normal. This was the first study ever to show that ionizing radiation could increase the risk of brain tumors. A later follow-up study of this cohort, published in the New England Journal of Medicine in 1988, found a relative risk for gliomas of 2.6 and for meningiomas of 9.5.

In 1994, the Knesset enacted a law that provided compensation for those who received such irradiation and who developed diseases that could be attributed to the radiotherapy.

In 2003, the documentary film “The Ringworm Children” (Yaldei Hagazezet) received enormous widespread attention by the public. It won several film awards. It lambasted the Israeli medical establishment and the government for its treatment during the 1950s of the Mizrachi children. The film and various Mizrachi activists in Israel argued that it was an extraordinary example of the prejudice and injustice of the predominantly Ashkenazi establishment against the Mizrachi immigrants. The film claimed that much higher doses, up to 600 rads (an enormous dose), than the recommended dose were utilized as part of a program with the U.S. to test high-dose radiation in humans, and that officials were aware of its health hazards. The film also suggested that 100,000 immigrant children were irradiated (some activists claimed 200,000) and that 6,000 died soon after the treatment. This created an immense scandal in Israel.

These claims were investigated by UNICEF, which confirmed the figures I provided in the earlier part of this article. In 2018, David Balchasan, one of the two directors of the film, stated in a television interview that his film did not stand up to scientific scrutiny and that he could no longer stand behind the veracity of its claims.

Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York.

This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.

By Alfred I. Neugut

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