On Tuesday 23rd August 2005 Abubakar Tariq Nadama died while being given an IV push of disodium EDTA in the office of Dr. Roy Eugene Kerry in Portersville, Pennsylvania.
Abubakar was five years old and autistic. His death prompted me to write a discussion document on biomedical interventions which I sent to the National Autistic Society. The document was published in the NAS magazine “Communication” and is the earliest entry on this blog.
The circumstances surrounding Abubakar’s death were the source of some confusion. According to Mike Fitzpatrick the Times reported that his parents had taken him to America to be chelated for mercury poisoning. The Pittsburgh Post-Gazette reported that
Authorities said Kerry’s office reported that the child was receiving an IV treatment for lead poisoning when he went into cardiac arrest.
Wade Rankin tried to clear up the confusion when he commented on Random John’s blog:
Many autistic children have tested high for lead toxicity, leading to the hypothesis (and forgive me for oversimplifying this) that their mercury-damaged immune systems are even more at risk for lead exposure than a typical child. In any event, very positive results (i.e., alleviation of some problematic symptoms of autism) have been reported after chelation for lead as well as mercury. It is generally believed that Abubakar Nadama was one such autistic child, and it now appears that the real problem was the doctor’s unexplained failure to use the correct form of EDTA.
Whether or not you agree with this hypothesis a follow up report in the Post-Gazette seemed to confirm that Kerry had indeed administered the wrong drug.
One of the nation’s foremost experts in chelation therapy said she has determined “without a doubt” that it was medical error, and not the therapy itself, that led to the death of a 5-year-old boy who was receiving it as a treatment for autism.
Dr. Mary Jean Brown, chief of the Lead Poisoning Prevention Branch of the Atlanta-based Centers for Disease Control and Prevention, said yesterday that Abubakar Tariq Nadama died Aug. 23 in his Butler County doctor’s office because he was given the wrong chelation agent.
“It’s a case of look-alike/sound-alike medications,” she said yesterday. “The child was given Disodium EDTA instead of Calcium Disodium EDTA. The generic names are Versinate and Endrate. They sound alike. They’re clear and colorless and odorless. They were mixed up.”
Just for the record Dr Brown’s use of word order is misleading here. The trade name for Disodium EDTA that killed Abubakar is Endrate. Versinate refers to the Calcium Disodium EDTA. I would hate for anyone else to repeat Kerry’s so-called ‘mistake.’
Essentially, Tariq died from low blood calcium. Without enough calcium — a metal — in the blood, the heart stops beating. Dr. Brown said the Disodium EDTA the child was given as a chelation agent “acted as a claw that pulled too much calcium” from his blood.
“The blood calcium level was below 5 [milligrams]. That’s an emergency event,” she said.
Despite claims at the time of Abubakar’s death that nobody had died as a result of chelation since the 1950s the Post Gazette continues:
Dr. Brown said the same mix-up happened in two other recent cases: a 2-year-old girl in Texas who died in May during chelation for lead poisoning and a woman from Oregon who died three years ago while receiving chelation for clogged arteries.
Dr. Brown said that in each case, the blood calcium level was below 5 milligrams. Normal is between 7 and 9.
The correct chelation agent — Calcium Disodium EDTA — would not have pulled the calcium from the bloodstream, she said.
The report concludes:
She said there have been no reputable medical trials demonstrating the effectiveness of chelation as a therapy for anything but lead poisoning. But if it were administered accurately, the procedure would be harmless.She said it is well known within the medical community that Disodium EDTA should never be used as a chelation agent. She quoted from a 1985 CDC statement: “Only Calcium Disodium EDTA should be used. Disodium EDTA should never be used … because it may induce fatal hypocalcemia, low calcium and tetany.”
“There is no doubt that this was an unintended use of Disodium EDTA. No medical professional would ever have intended to give the child Disodium EDTA,” Dr. Brown said.
But was it just a medical error? A number of people, all better qualified than I, have commented critically on Dr Brown’s remarks. See for example The CDC Flubs It, Another Perspective on Abubakar Tariq Nadama, Death by Chelation Revisited and Misattributing CAM Errors.
Now that Kerry is finally facing disciplinary action for professional misconduct (no criminal charges have been made to my knowledge) he is still being charged with medical error for using the wrong drug. I agree with Orac up to a point when he says:
No, no, no. The use of chelation therapy to “treat” autism that leads to serious complications should be sufficient cause in and of itself for action. The formulation used isn’t the issue (although certainly Kerry was reckless and incompetent in choosing disodium EDTA). The use of a non-evidence-based, ineffective, and potentially dangerous treatment is. Couple that with Dr. Kerry’s apparent cluelessness in giving the “wrong” chelation agent and you have a recipe for disaster. It’s hard not to conclude either that Dr. Kerry is a quack using potentially dangerous and unproven treatments for autism
And this is the point.
or that he’s an incompetent doctor who, in trying to use a relatively safe but unproven and almost certainly ineffective treatment for autism, screwed it up and used the wrong chelator, leading to the death of a child.
A recent article on Autism Street makes it quite clear that Kerry did not “screw up.” As a member of ACAM, the American College for Advancement in Medicine, Kerry chose Disodium EDTA, the drug that killed Abubakar. It was not an error because Disodium EDTA, aka Endrate, is the only drug clearly identified and recognized in the chelation protocols published by ACAM. Thanks to Autism Diva who published a letter from Dr Gary Gordon, one of the founders of ACAM, who supplied the Endrate to Kerry, which said:
I have only checked to see if they ( Edit: that is Kerry and his partners in crime) have ever purchased Calcium EDTA
and found the answer was
I hope the Pennsylvania authorities read Autism, A Killer App., And A Drug Of Choice – Guest Blogger and I suggest you all read it as well. And please visit Bartholomew Cubbin’s blog. His commentary is a very good introduction to a complex subject.