Feature Christmas 2020: The Citadel

Harms and the Xmas factor

Robin E Ferner, Jeffrey K Aronson

BMJ 2020; 371: m4067 (Published 16 December 2020) doi: https://doi.org/10.1136/bmj.m4067

The Christmas season is associated with preventable harms from cards, tree decorations, and presents, as well as overeating and overdrinking. Given the balance of benefits and harms, Christmas may not be cost effective.

We hope you’re well, that you’ve posted the last of your Christmas cards, decorated the house, and settled down before the fire. Days of feasting and merriment beckon. But what of the harms? A rummage through the archives confirms the existence of several festive health risks.

In our foraging, we ignored Christmas disease (haemophilia B), and reports by authors named Christmas, Chrismas [sic], or Noel. We also ignored festively inspired acronyms such as NO Effect Level and Natural Orifice EndoLuminal technique. Nevertheless, our findings raise concerns.

Causes of Christmas harms

Christmas cards are a source of potential harm. In 1876 a young man painted large festive cards “with colours chiefly of a bright green” and developed acute arsenic poisoning. The paint was Scheele’s Green, copper hydrogen arsenite.1 Posting cards is also dangerous, as the spring-loaded flap of a letter box can amputate the finger tip.2

A Christmas break may be just that, after falls either in the home3 or outside while decking the house with Christmas lights4—a Canadian custom ill suited to the climate and a reminder not to get tight on ladders—they may tip when you’re tipsy. Light-emitting diode bulbs from Christmas lights,5 sharp pointed confetti stars,6Christmas tree shaped decorations,78 and metal clips to hold them,9 have all found their way into toddlers’ bronchi or pharynges, requiring endoscopic or surgical removal.

Those who pine for Christmas trees may find that contact dermatitis can ensue.1011 Needles from Christmas trees can penetrate the bronchial tree, causing breathing difficulties.12 And branches can poke you in the eye, causing corneal abrasion,13 although that is not a cause of “Christmas tree” cataract.14 It is customary to light candles on Christmas trees in Switzerland: burns are therefore common, at least in Bern.15

Christmas presents pose unforeseen dangers. Cricetids at Christmas can cause concern—a pet hamster, acquired as a Christmas present, spread lymphocytic choriomeningitis virus in an outbreak that affected 57 people in New York state.16 This may resonate with those who received Christmas presents of Haitian bongo drums with anthrax bacilli in their goatskin hides.17 The danger of “The propagation of syphilis by toys” such as trumpets, however—which the BMJ noted in 187918—seems to have receded. 

Festive feasting is universal, “doubtless because it usually conduces to contentment and a happy frame of mind …”19 In 1946, with postwar rationing still in place, the BMJ described a Christmas pudding providing more than 58 000 kilocalories—20 times the recommended daily intake (fig 1)—and commented “The mind is enriched and tranquil after such a meal…,”2021 a rather positive view of the torpor that signals postprandial diversion of blood supply from the brain to the digestive tract. Christmas dinner may even be good for the heart, at least in the short term: a “standard festive meal of poultry, mince pies, and a glass of wine” increased cardiac output in six healthy volunteers.22

Fig 1 A recipe for Christmas pudding, reported enviously in a BMJ editorial in 1946.20 The article was reprinted in 1973 and provided question 7 in that year’s Christmas quiz21

Christmas is consequently a time of weight gain and increased serum cholesterol concentrations.23Ræstur fiskur—Faroese air dried fermented fish, traditionally eaten on Christmas Eve with garnatálg, “tallow from around the left colon” of a sheep,24 is a more recondite recipe for obesity and hypercholesterolaemia. As the late John Garrow said, “Overfeeding was not an eventuality the Great Physiologist foresaw …”25

Infective sequelae may be more immediately apparent. “Christmas wrapped chocolate balls” once led to an outbreak of Salmonella eastbourne enteritis.26 Of 192 people who ate at a Christmas reception at the National Institute of Public Health-National Institute of Hygiene in Warsaw, 97 developed norovirus gastroenteritis from the salad.27 In Switzerland, chicken fondue, traditionally eaten at Christmas and New Year, can transmit Campylobacterinfection.2829

Drinking too much alcohol can provoke atrial fibrillation—the “holiday heart syndrome.” Of the cases originally described, 22% occurred between Christmas Eve and New Year’s Day.30

Some people take advantage of the Christmas holidays to enjoy outdoor pursuits, at least in warmer climes. The BMJannounced with regret “a most serious accident” that befell Major Manifold of the Indian Medical Service and his mahout while tiger hunting at Christmas 1900: an injured tiger sprang on the Major’s elephant and severely wounded both men.31 “The unfortunate officer bore his injuries with the greatest fortitude.” In Australia, Christmas brings an increase in catastrophic injuries from jet skiing.32

Discussion

Is it worth it? In 2002 Isaacs and Fitzgerald analysed the cost effectiveness of Christmas “using clinical and economic variable estimates, derived by inspired guesswork.”33 They did not calculate QALYs, JOLLYs (“joyous outcomes living longer at yuletide”), or HOLLYs (“happiness outweighs less lean years”), but nevertheless concluded that “Christmas is not cost effective.” They were criticised for failing to undertake a cost-benefit analysis, having ignored the value of eternal life.34 However, the only harm they assessed was food poisoning; their conclusion might have been strengthened by including the harms we have identified here.

But cost-effectiveness is not everything. Most of our sources are anecdotal, and we did not find strong evidence of widespread adverse effects. So we will leave you to decide whether the benefits of Christmas outweigh its harms.

Conclusion

Stay safe, keep calm, carry on, and enjoy a very Merry Christmas!