Alan Flashman

Children of Israel 3A — St John’s Wort, Medical Cannabis, and Kids

The world medical community has come to recognize the therapeutic value of two plants, hypericum and cannabis. Children in Israel are almost entirely denied access to both plants.

In the case of hypericum, Israel is a world outlier. Hypericum Perforata (St. John’s Wort in English) is a plant that grows nearly word-wide. It was recognized for calming qualities for at least 2,000 years and was part of the pharmacopeia in the nineteenth century. In the late 1990s, a simple alcohol extract was standardized in Europe and tried in cases of mild to moderate (not requiring hospitalization) depression. The extract was no less successful than the standard-bearing SSRI medications and with almost no side effects. The extract was studied with favorable outcome in the UK, and results were reported in the prestigious British Journal of Psychiatry.

Word spread to the USA where a potential rise in price was thwarted when the internet page set a price of 10 cents per 300 mg pill. Since then, the price in the USA has settled at around 7-8 cents per pill. There are dozens of preparations allowed in the USA by the FDA, all over-the-counter, including a liquid preparation appropriate for children.

Predictably, the US psychiatric establishment tended towards skepticism. NIMH wasted tax-payer money demonstrating hypericum’s inefficacy in hospitalized patients when there had never been a claim that it would be effective in that population. There was an attempt to exaggerate the fact hypericum may interfere with the metabolism of some other drugs. People suffering from advanced cancer and AIDS tended to be pretty sad and would try hypericum to boost their moods. Some of these people ran a complication of drugs whose blood levels were altered. There was a media push to make this a basis for limiting the availability of hypericum, but no one, including the FDA was convinced.

No one except the National Pharmacist responsible for OTC agents in the sovereign state of — you guessed it — Israel. I had learned about hypericum in what we used to call in medical school The New York Times Journal of Medicine around 1998. My initial experience was that the then OTC available preparations in Israel were quite effective in many cases of depression, anxiety and even OCD. I started to use hypericum as a first choice, and move to SSRIs only as needed. Imagine my surprise that, in about 2000, hypericum disappeared from the shelves in one state and one state only, my state, Chelm — oops, Israel. I inquired and argued with the state pharmacists to no avail. I was informed that medical research had proven it was potentially of significant danger and hence not OTC, but there was not enough medical research to prove it effective and hence license it as a prescription drug. I even succeeded in getting a piece to appear in the health section of one newspaper asking, “If it is not a plant and not a medicine, what is it?”

The fact that hypericum grows wild in the Holy Land and a whole field is described in S. Yizhar’s classic novel of the War of Independence Days of Ziklag (from page 373 on in the Hebrew version) impressed no one. The year 2000 heralded the Second Intifada, and with buses blowing up all over Israel, something that could aid with anxiety seemed a high priority, but I had to have people import from Germany and pay five times the going rate.

Then, in 2007, with the Intifada quieting down, the State Pharmacist for Prescription Medications determined that hypericum could be allowed into Israel as a prescription drug, but only one form would be allowed. This form, going by the trade name REMOTIV (Zeller, Switzerland) was claimed to be better standardized (everyone knows that a Swiss cow produces more precisely standardized dung than just any cow). In addition, the argument went that the terrible fear of altering drug metabolism — a fear that impressed no one else in the world — would be lessened with REMOTIV because this extract concentrated what was then thought to be the active and effective chemical, called hypericin, but did not concentrate the hyperforin chemical that was felt responsible for altering drug metabolism and was not felt to be effective. I had been making more use of this herb by importation than my colleagues, so RAFA, the company responsible for the importation, pleaded with me to come to a televised meeting where this product would be launched. I demurred, suggesting that my presence would more likely result in a sinking. I simply do not hang with the right psychiatrists.

Children were formally and informally excluded from the good REMOTIV news. The package insert declared that this was a medicine not approved below the age of 11. It was also imported in the form of large hard to swallow and hard to cut (a pill-cutter in colloquial Hebrew is a “guillotine”) pill first of 250 then of 500 mg, while a starting child’s dose might be 75 or 100 mg. Adults too were highly discouraged both by psychiatrists who seemed to “know” that it was “weak”, and by State policy that somehow created a “scientific” determination that the maximal dose was to be 500 or 1000 mg. This was a strange statement to make about an herbal extract that in my experience — and that of the entire internet — would on the average start at 900 mg per day for an adult but could empirically come to several grams in individual cases with no untoward effect. It began to occur to me that perhaps RAFA knew whom to invite to the “sinking,” which nonetheless proceeded apace without me.

By 2015, it became clear that hyperforin, the chemical missing in REMOTIV, is considered by most researchers to be the active and effective agent countering depression and anxiety. So now Israelis — a population unaware of their pharmacological captivity — needed a prescription for an ineffective form of what the rest of the planet was using freely with substantial benefit.

I work in Beer Sheba, in the South. Many families come to me from Sderot and the Gaza border. There is no child psychiatrist working in that entire area. The population has been through three successive military operations which included massive missile attacks from Gaza on the entire civilian population. Add to that nearly two decades of unrest and “occasional” (better, perpetual) explosives falling from the sky, and you have an entire generation whose physical security has been eroded.

In my professional experience, there is no better approach to preventing the development of post-traumatic syndromes among children and their families than the regular use of the entirely harmless herb hypericum. In the USA, security forces often make use of hypericum after being exposed to stressful and dangerous situations. Yet the entire population of Israel’s bombarded south — including an entire generation of children — are denied useful access to this treatment.

In my most absurd case, a child in Ashkelon began to show new signs of post-trauma after the last Gazan campaign. One sign was inattention. The child had been exposed to a missile “falling” i.e., exploding near his home. His neurologist, who lives nearby and was equally exposed, saw only the inattention, ignored the explosion, and prescribed Ritalin. Of course, the post-traumatic emotional tension worsened. In consultation, I stopped the Ritalin, saw the (obvious) post-trauma and was able to help the child greatly with quasi-legal imported hypericum.

The second and far more famous weed conundrum in Israel involves “Medical Marijuana.” The absurdities here are even deeper. As everyone knows, President Nixon attempted to criminalize the generation (my generation) of anti-war protesters by waging the War on Drugs against marijuana. As no one in Israel recalls, Israel was required to fight the identical “good” fight by a stipulation of the Foreign Aid Bill. (I have this on the unquestionable of authority of my dear friend, the late Gary Rubin z”l.) Since Israel had neither a cannabis problem nor anyone anti-war, the government simply made this stipulation law without anyone knowing or caring, and with no public debate, ever.

Time went on, the War on Drugs grew in budget and bogus research, and by a decade later Israel was convinced that fighting marijuana use was a social and scientific necessity. Thankfully, the previous Netanyahu attempt to privatize the penal system was resisted, so Israel never reached the horrible extremes that America is finally backing away from. But, believe it or not, most of the Israeli medical establishment came to regard marijuana as a dangerous substance, in particular buying the “gateway” claim that has now been conclusively debunked.

In the meantime, it was in Israel that Professor Rafael Meshullam gained worldwide fame for his biochemical characterization  of the different active components of marijuana, especially THC and CBD. Around 2008-9 Israel allowed the creation of a medical marijuana unit. The first clients were largely post-traumatic soldiers and patients suffering chronic pain or cancer. The single psychiatrist responsible for the unit granted “license” to use medical marijuana based upon his personal judgement, and in some cases personal influence. There were doctors who were closer or more distant from the plate, and patients treated accordingly. That physician is now under investigation for alleged sexual misconduct with people under his care.

The unit was “rationalized” a few years back and became much less user-friendly. For example, someone decided that no licenses would be issued for growing, only for possession and use. Now at first there were too few growers and clients who had the know-how to grow their own weed were more than welcome. It would seem pretty obvious that in the interests of continuity of care, someone already growing — a small number at any rate — could continue. But no, the new non-medical director ordered the physician (in this case, me ) to change the treatment plan which included the occupational aspect of growing, for purely administrative reasons that were never transparent.

In addition, some secret group of “experts” made all sorts of determinations about “indications” for a license. One such outrageous group of determinations included the idea that no one suffering from PTSD could apply for a license until he had suffered for a full three years, had achieved 30% disability, and had failed with two medication and psychotherapy treatments. This of course has no scientific basis and flies in the face of the well-known “intervene as early and as effectively as possible” rule for trauma. A soldier traumatized in “Preventive Edge” was refused a license because he had not been messed up long enough!

Children are especially left out of the possible benefits of medical marijuana. The operating assumption — not scientifically based — is that all marijuana chemicals, including CBD (which calms inflammation and does not create any “high”) is a potential danger to a developing brain. The only scientific fact is this assumption is that children possess developing brains. Children cannot be treated for post-trauma. In rare cases a child with severe epilepsy can receive a license. I do not think that children with Tourette’s syndrome can even apply, even though the medical management is notoriously limited. A rare autistic child with severe unremitting aggressive behavior may be granted a license on appeal from an automatic refusal by a board that includes no one competent to treat behavior disorders in autistic children.

Adolescents with post-trauma from domestic abuse cannot apply and if they self-treat they are still at risk for being criminalized! The War on Drugs actually hired me to teach master level social work students not to freak out about cannabis use among adolescents and to work more on alcohol and Nice Guy while medical marijuana is denied them because their brain is developing.

When it comes to these “weeds,” children are “protected” from treatments that could help them by anonymous officials whose training in child mental health is scant. The rights of children under the 1989 UN Convention on the Rights of Children for provision of medical care, let alone participation in these decisions, are trampled. What does this teach us about children in Israel today? I think that in these cases children were simply ignored. I do not think that the decision-making process about hypericum and marijuana paid any attention to children. They were invisible.

Invisible children constitute a certain kind of “childism,”  the term coined by the late Elisabeth Young-Bruehl. In  her penetrating earlier study of The Anatomy of Prejudices (Harvard U. Press, 1996) Young-Bruehl makes the case for three different kinds of prejudice. The first, that of Nazis against Jews, strives to purify one group by annihilating another. A good Nazi hates Jews even though he has never met one. A second prejudice, that of whites against blacks in America, is “erotic.” Here there is need for the presence of the black in order to provide the white with the sadistic pleasure in emotional or physical torture. Since pleasure requires the presence of the victim, the Klan never wished to annihilate blacks. The third form of prejudice is that of erasure. This is the form taken by males over females, claiming that the female is “erased” in the sense that either her needs are the same as the males or so completely different that is either case, the special aspects of her existence as a female can be neglected. It is this third form that I think is illustrated in the “no weeds for kids” case. Children are either subsumed under adult regulations or entirely excluded as being utterly different and not important enough for appropriate consideration. Invisible children are not relevant when big policies are being made.

As I pointed out in Losing It  (Hadassa Word Press, 2015), children naturally fall out of the “governmental dispotif” as proposed by Michel Foucault. In this way of going about things, the modern liberal state makes use of its populations to maintain equilibrium with its neighbors in the realms of security and economics. I suggested that the time that is relevant to this equilibrium is quite short, it needs to be maintained continuously and recalibrated in short intervals, probably by the quarterly economics of recent times. While children obviously will determine tomorrow’s equilibrium, their contribution is so remote from regular calculations that they fall out of the sight of macro-anything. It would require great foresight and a strong political will to invest resources in children when this investment will show in the quarterly red for many years.  And of course, children do not vote, so their interests have no direct representation. By its 1991 signing of the 1989 Convention, Israel committed itself  de jure to a consideration of the impact on children of all policies. In fact, such a commitment has never been fulfilled. The lack of proper consideration of provision of hypericum and medical marijuana for children testifies to this erasure form of childism in the Israeli body politic.

About the Author
Alan Flashman was born in Foxborough, MA, and gained his BA from Columbia, MD from NYU, Pediatrics, Adult and Child Psychiatry specialties at Albert Einstein College of Medicine, The Bronx, NY. He has practiced in Beer Sheba since 1983, and taught mental health at Hebrew University, Tel Aviv University and Ben Gurion University. Alan has edited readers on Therapeutic Communication with Children (2002) and Adolescents (2005) in Hebrew, translated Buber's I and Thou anew into Hebrew, and authored Losing It, an autobiography, and From Protection to Passover. He recently published two summary works of his clinical experience (both 2022) Family Therapies for the 21st Century and Mental Health in Pediatrics.