On April 18, 2005, a Canadian woman named Rani Jamieson gave birth to a healthy boy. It was an unremarkable pregnancy but a painful delivery; a doctor had to use surgical scissors to make room for her son’s head. Afterward, the doctor prescribed her Tylenol No. 3, which combines the mild opioid codeine with acetaminophen.
Rani’s newborn son weighed almost eight pounds and had perfect neonatal scores. “He seemed very—like an old soul,” she told a Canadian news outlet. She and her husband, Douglas, named him Tariq. He was their only child.
The hospital gave Rani two tablets of Tylenol-3 in the morning and two at night. But she found that the pills made her drowsy, so, on the third day of Tariq’s life, she cut her intake to one pill at a time. She and Tariq were discharged from the hospital and went home. Rani, who was thirty-two, had been preparing for motherhood for a long time. “Anytime I read an article about something you shouldn’t do, or they’re not sure—that went on my list of things not to do,” she said.
In the next week, Tariq developed normally and surpassed his birth weight. But, at around 6:30 A.M. on April 29th, he stopped eating. Later that morning, Rani brought him in for a routine pediatric visit. The doctor noted that he was somnolent, but was generally unconcerned. Until that morning, Tariq had been feeding “on average, every three hours,” according to his parents, and the pediatrician noted that he had been producing about five wet diapers per day. Another doctor later reported that Tariq had “appeared to be thriving.”
That night, Douglas called the Ontario health ministry’s telehealth service. He said that Tariq had been sleeping for most of the past twenty hours, and that his skin was fluctuating in color. An ambulance was dispatched to the Jamiesons’ home, in an affluent neighborhood of Toronto. But, according to the Jamiesons, “a minute or two” before it arrived Tariq stopped breathing.
The E.M.S. team performed C.P.R. on Tariq, using just two fingertips on his tiny sternum and small puffs of air to inflate his strawberry-size lungs. For forty minutes, they tried to resuscitate him—on the kitchen counter, in the ambulance, and at the Hospital for Sick Children, one of the best pediatric hospitals in the world. But Tariq’s body was already cold, and his skin was mottled. Shortly after midnight, he was pronounced dead.
Fourteen hours later, Tariq was brought to his autopsy swaddled in his blue blanket, with an identification tag fixed around his right ankle. The coroner found no anatomical cause of death—no brain bleed, no congenital defects, no reason that an otherwise healthy boy had suddenly died. Nor did two Toronto police detectives sent to the Jamieson residence notice anything awry. Tariq’s parents were “just absolutely devastated and in a severe state of shock—the mother, especially,” one of the detectives told me recently. A blood sample, taken before or during the postmortem examination, was sent to a forensic-toxicology lab. When the results came back, twelve weeks later, they showed that Tariq Jamieson had died of codeine-and-morphine poisoning.
Opioids kill by suppressing the drive to breathe. They bind to receptors in the brain stem, altering the neurons that maintain patterns of respiration. Carbon dioxide builds up in the bloodstream, hypoxia sets in, and circulation falters. Brain damage follows, then death.
The coroner’s office asked one of Canada’s leading pediatricians and toxicologists, Gideon (Gidi) Koren, to examine Tariq’s file. For the past two decades, Koren had been running a program at the Hospital for Sick Children called Motherisk, which provided guidance for pregnant women and new mothers about drugs and breast-feeding. He was widely considered to be among the most capable research scientists in the field. Koren met with Rani’s physician and quickly ruled out foul play. “There was no evidence of psychiatric issues,” he later wrote. Instead, Koren interpreted the toxicology report as a scientific revelation: if mothers with a certain genetic predisposition took even a mild dose of codeine, the amount of morphine that ended up in their breast milk could kill their children.
A dose of codeine brings relief from pain only when the liver metabolizes a fraction of it into morphine. But the exact proportion that is converted into morphine can vary. Most people have two copies of the gene that carries out the conversion. Koren invited Rani to be tested, and discovered that she had three.
The concentration of morphine in Tariq’s blood was measured at seventy nanograms per millilitre. “If you have levels above twenty, you stop breathing,” Koren later said. Six months after Tariq’s death, Koren obtained a sample of Rani’s breast milk, which she had kept in her freezer. His lab measured its morphine concentration at eighty-seven nanograms per millilitre. Koren was stunned. “The level was several fold higher than ever described in the literature,” he noted. “This was the first time in history that a baby was reported dying from breast milk.”
Koren had long studied the transmission of opioids into breast milk. But he had never identified a mortal risk. Now, along with a few colleagues—including the deputy chief coroner of Ontario, James Cairns—he published his findings in The Lancet, one of the world’s top medical journals. Some women, like Rani, have a genetic predisposition to convert codeine into morphine faster and in higher quantities than the rest of the general population. Therefore, the authors concluded, “codeine cannot be considered as a safe drug for all infants during breastfeeding.”
The implications were terrifying. Millions of women—up to forty per cent of breast-feeding mothers in North America, according to Koren and his colleagues—might be prescribed codeine for postpartum pain, and yet almost none were being tested to see if they, like Rani, had more than the usual number of codeine-metabolizing genes. The risk was unevenly distributed across the population, according to ethnic background. Mothers from Finland have a one in a hundred chance of being so-called ultra-rapid metabolizers, according to Koren’s paper. But in Ethiopia the odds can rise to almost one in three.
“What an amazing nest.” Cartoon by Amy Hwang
Few academic-journal articles have had so abrupt an effect on the daily practice of medicine. Prior to its publication, the American Academy of Pediatrics had listed codeine as generally compatible with breast-feeding. “After we published it in Lancet, the F.D.A.—the Food and Drug Administration—said, ‘This is enough for us to change labelling,’ ” Koren said. Canadian and European health regulators soon followed suit. Doctors started prescribing other opioids for postpartum pain, such as hydromorphone and oxycodone, whose metabolic pathways are more predictable and less subject to genetic variations.
The Jamiesons’ identities were not revealed in Koren’s article. But they went public on April 30, 2007—exactly two years after Tariq’s death—filing a class-action lawsuit against Johnson & Johnson and a subsidiary, the manufacturer of Tylenol-3, on behalf of “all persons in Canada” who had ingested the products of the drug through breast milk. “This terrible tragedy should never have occurred, and I am determined to see that this does not happen to other children,” Rani said. “What can they give me? Can they give me my son back? I want other people not to have their children die or be damaged.”
The Jamiesons went on to have three more children—all boys, who grew up in the shadow of the brother they never met. “You’re consumed with a certain sadness that’s always there,” Rani told a reporter, seven years after Tariq’s death. Two decades later, she still finds April the most difficult month: “It’s always there.”
Koren continued to sound the alarm about codeine for years. “He was always on a plane somewhere, and always had a million spinning plates—meetings, talks, conferences,” David Juurlink, a Canadian clinical toxicologist and a colleague of Koren’s at the Hospital for Sick Children, told me. Koren published more papers about the Jamieson case, and his Motherisk program provided data for studies of patients who had been prescribed codeine for postpartum pain. His ability to distill complex scientific processes into clear public-health messaging made him a regular commentator in the press. “It’s quite common not to know why a baby dies,” Koren said, in an interview for Canadian television. “I am quite sure that quite a few of those were codeine in breast milk. But no one checked. You don’t check, you do not find.”
Juurlink first met Koren in the late nineties, when he was a resident in clinical pharmacology. Koren, who had been practicing medicine in Canada since 1982, was leading rounds. “When you were with Gidi, you really felt like you were in the presence of someone who wasn’t just an expert—in the truest sense of the word—but was also a kind, good-natured, thoughtful, and intellectually agile man,” Juurlink recalled. “He was very avuncular. It was really one of the highlights of my training, learning from him.” Koren was revered by colleagues, and he had almost six hundred publications in scientific journals.
By 2010, Juurlink was a widely respected pharmacologist and toxicologist in his own right, specializing in medication safety and opioids. He had positions at two top medical institutions in Toronto, including the Ontario Poison Centre, which is run out of the Hospital for Sick Children. He had also published many academic papers, including several with Koren. But he had found the experience to be somewhat disappointing: the first time they published together as “co-authors,” Juurlink wrote the paper and sent it to Koren but received no guidance or revisions in reply. “His only feedback to me was to please credit that he was getting financial backing from the Canadian Institutes of Health Research,” Juurlink recalled.
That June, Juurlink was invited to deliver the keynote lecture at a toxicology conference in Scotland. After the lecture, he joined Nick Bateman—then the director of the Scottish branch of the U.K.’s National Poisons Information Service—for a candlelit dinner at an old Edinburgh establishment called the Witchery. Bateman ordered haggis and wine. Eventually, he blurted out, “David, what the hell is going on with Koren and this baby that died from breast milk?”
“What?”
“It’s clearly nonsense,” Bateman said. “Why can’t everybody see it?”
Bateman told Juurlink that when he first read the Lancet report he’d thought, This can’t be true. “The science on metabolism—codeine to morphine—was beautiful,” Bateman said. But the numbers were off. Ultra-rapid metabolizers are generally exposed to around fifty per cent more morphine than the average person. And yet, though Rani had been taking only a fraction of her prescribed dose, Tariq had died with a concentration of morphine in his blood which was more than fifty times higher than the midpoint of the expected range.
Bateman and two colleagues at the Royal Infirmary of Edinburgh had looked deeper into the scientific literature and found that, within months of the Lancet report, Koren and his colleagues had published very similar papers in two practitioners’ journals—Canadian Family Physician and Canadian Pharmacists Journal—neither of which Juurlink had seen. They contained minor errors, and also a key fact that had been omitted in The Lancet: Tariq’s blood didn’t just have morphine in it—it also contained acetaminophen, the dominant component of Tylenol-3.
Acetaminophen appears in breast milk only at very low concentrations. At Rani’s intake of Tylenol-3, Tariq ought to have been consuming less than a milligram of acetaminophen per day—around half a per cent of what an infant of his size might receive as a standard treatment for pain. But the forensic-toxicology laboratory’s measurements showed that his acetaminophen concentration was in the range of what you’d expect to find in a baby’s bloodstream soon after he’d been administered a standard dose. “There is no way in the world that could have come from breast milk,” Bateman insisted to Juurlink.
“I am not aware of any cases in the U.K., or elsewhere in the world, where breast-feeding by women who were on either morphine or codeine—which has been in use for more than a hundred years—has caused death,” Bateman said. “I am familiar with patients whose babies have died after a caregiver gave the opiate directly.”
Juurlink listened in silence. The candles flickered. Bateman took a sip of wine, then leaned across the table and said, “David, whatever the intention, that baby was poisoned.”
David Juurlink grew up in New Glasgow, a small town in Nova Scotia. His parents operated a local diner, the West Side Drive-In, where they served burgers, fries, milkshakes, and fish and chips, seven days a week, from nine o’clock in the morning until ten o’clock at night. “People would just sit in their cars and eat, and then they would dump all of their detritus in the parking lot,” Juurlink told me. “My job, at 10 P.M. every school night—and sometimes also on weekends—was to go over and sweep that up, and put it in garbage bags. And then I’d go to bed, and go to school the next day.”
One day, Juurlink, who played the drums, was practicing at the home of his best friend, a bass player. “He had an older sister who I always thought was kind of cute,” he recalled. She told him that she had started working as a pharmacist. “I became aware of this profession called ‘pharmacy,’ which I’d never really thought of before,” he said.
He asked his chemistry teacher about it, but “he said, ‘Well, David, you need an average of at least eighty for that,’ ” Juurlink recalled. For the next two years, he studied obsessively, even after late-night shifts at the diner, and he ended up graduating first in his class.
Juurlink attended Dalhousie University, in Halifax, about two hours away. During summer breaks, he worked at three different pharmacies in New Glasgow. One day, a woman came in and asked for two hundred pills of Tylenol No. 1—a weak opioid whose generic form is still sold over the counter in Canadian pharmacies. A couple of days later, he saw her at a different pharmacy, asking for the same. “She clearly had an addiction to codeine, and she was visiting multiple pharmacies to avoid detection,” he said. It was the late eighties, and this was his first brush with the coming opioid crisis.
Tylenol-1 had 7.5 milligrams of codeine; addicts might take four pills to approximate the relief that they’d get from a single prescription pill of Tylenol-3. Juurlink was troubled by what seemed like an obvious hypocrisy: people could walk in and buy codeine without a prescription, but the pharmacy’s stock of morphine was kept in a safe. As he studied pharmacokinetics—how drugs move through the body—he came to believe that codeine is an inherently irrational drug.
When codeine was first isolated from the opium poppy, in 1832, scientists understood that it was chemically related to morphine but believed that the two drugs worked through different mechanisms. Codeine was marketed as a gentler alternative to morphine, particularly for cough suppression. Scientists didn’t understand until well into the twentieth century that codeine primarily works because the liver metabolizes it into morphine. But the perception of the two drugs as distinct—one mild, one serious—was entrenched in medical practice, in pharmaceutical regulations, in prescription guidelines, and in law.
Juurlink eventually attended medical school, after which he chose to specialize in clinical pharmacology and toxicology, the study of drugs and poisons. “I just fell in love with toxicology,” he said. “What attracted me? It’s that patients are often critically ill but salvageable. You can help prevent them from dying. But there is a real art to their management, because often they’ve not just taken one pill—they’ve taken something like eight different pills, and there’s an interplay between those pills. And it’s not just what those pills are doing to the patient but what they might do if we don’t address this right now.”
Before his visit to Scotland, Juurlink had never questioned Koren’s findings. He had even used the Lancet paper to teach medical students how individual genetic variations can pose unexpected risks in the use of certain drugs. But, if Bateman was right, the implications went far beyond the revelation of a possible crime. The opioid crisis was taking off in North America. With codeine now considered unsafe for breast-feeding, millions of new mothers were being prescribed stronger, more addictive opioids instead.
Bateman had detailed his concerns about Tariq’s death in a letter he’d sent to The Lancet in 2007. Koren, using arguments from the Jamiesons’ lawyer, had tried to block its publication by insinuating both that it was defamatory and that Bateman was a paid shill for the manufacturer of Tylenol-3. (A different subsidiary of Johnson & Johnson had named Bateman on an unrestricted educational grant that it awarded to the University of Edinburgh, where he was a professor at the time.) “We know the family and we are convinced that this will cause them harm!” Koren wrote to his editor at The Lancet. “It is one thing to philosophize in a journal, it is another thing to knowingly injure a grieving family.”
Koren wrote that Bateman’s critique was “frivilous and based on errors”; Bateman revised and resubmitted. When his letter finally ran, in August, 2008, it did so alongside a derisive rebuttal from Koren and his team. “Nicholas Bateman and colleagues’ comments seem to stem from fundamental flaws in their understanding of perinatal toxicology,” they wrote. They went on to attribute the high concentration of acetaminophen in Tariq’s blood to “postmortem redistribution”—the phenomenon of drugs migrating through the body after death, potentially skewing toxicological results—then cited a study that did not support their conclusion.
Back in Toronto, Juurlink searched the scientific literature for clues. His specialty was complex drug interactions and poisonings in adults—not breast-feeding, or infants—and it had never occurred to him that Koren could be so wrong, so publicly, about a matter that was so consequential, and so squarely within his longtime professional focus. And yet, the more closely Juurlink studied the issue, the less confidence he had in Koren’s interpretation.
According to Koren, the concentration of morphine in Rani’s breast-milk sample, at eighty-seven nanograms per millilitre, was “10-20 fold higher than previous published reports.” But Juurlink found a case report from 1990 that documented a breast-feeding mother producing a milk sample whose concentration was fifteen per cent higher than Rani’s—and that was after the woman’s morphine dosage had been tapered by ninety per cent. Even when she was taking the previous, higher dose, the infant suffered no ill effects. Koren ought to have known about this case report—he was listed as its second author.
In another case, involving intravenous doses of morphine given to new mothers after surgery, the concentration of morphine in one woman’s breast milk reached a level almost six times that of Rani’s sample. But, since newborns don’t take in much breast milk during a feeding, the authors concluded that “the amount of morphine transferred by nursing is, even at the peak concentration of 500 ng/ml milk, small and will hardly cause respiratory depression or drowsiness in the child.” The math was simple: a newborn who drank a hundred millilitres of milk from that mother—higher than average for a single feeding—would consume a twentieth of a milligram of morphine. According to the infant-dosing guidelines at the Hospital for Sick Children, that is less than five per cent of a single therapeutic oral dose for a four-kilogram baby in pain—nowhere near a toxic dose.
“If you see the fat naked lady bathing with the swan, you’ve gone too far.” Cartoon by Robert Leighton
And yet the opioids in Tariq’s blood had killed him. Was such a high concentration of morphine even possible through breast-feeding alone? A 2009 study, led by the German scientist Stefan Willmann, set out to answer this question by modelling what he and his colleagues referred to as the “pharmacokinetic worst-case scenario.” They assessed that the mother’s ultra-rapid-metabolizer status was not necessarily as relevant as Koren had believed. Instead, the most important thing was the ability of the infant to process morphine in its liver and kidneys, and to eliminate the drug through urine. “In a neonate that can efficiently eliminate morphine, it is impossible to observe such an extreme accumulation of morphine in plasma as was seen in the case of the Toronto newborn,” Willmann wrote.
On an infant’s first day of life, its stomach is about the size of a cherry. At three days, it is the size of a walnut; at one week, an apricot; at two weeks—a milestone that Tariq never reached—it is roughly the size of an egg. Setting aside the matter of elimination, Juurlink calculated that the morphine concentration reflected in Rani’s breast-milk sample simply could not explain the amount of morphine in Tariq’s blood: he would have had to ingest several times his body weight in a single feeding.
In the fall of 2010, Juurlink reached out to the chief coroner of Ontario, Andrew McCallum, with detailed concerns. They had met fifteen years earlier, when McCallum was one of Juurlink’s supervisors during a rotation in emergency medicine. Now McCallum invited him to review the coroner’s case files, which were not public, and to prepare a confidential report. “I was a little bit fearful, because Koren was not only a colleague—he was, at least notionally, the world’s expert,” Juurlink recalled.
The files arrived—hundreds of pages of medical data, a smattering of clues. Nothing in the documents suggested the kind of kidney or liver dysfunction that would significantly impair morphine elimination. But Juurlink found critical details in the toxicology report which had never made it into any of the published literature. Tariq’s blood didn’t contain just morphine and acetaminophen; it also had codeine, at a concentration of three hundred nanograms per millilitre, more than a hundred times higher than one might expect to see from the consumption of breast milk produced by a mother on Rani’s dose.
Juurlink kept reading. Tariq’s last reported substantial feeding had taken place eighteen hours before his death. The 911 call log noted that he had been sleeping the whole day, and the Jamiesons’ lawsuit described “his lack of feeding that day.” But the postmortem examination revealed that Tariq’s stomach—which had no abnormalities or obstructions—contained two millilitres of “white curdled material.” Forensic testing on his gastric contents, using two independent analytical methods, detected codeine but not morphine. Such tests are best performed with larger samples. But these results, along with the sheer magnitude of drugs in his blood, suggested direct administration.
A twelve-day-old infant cannot crawl. It cannot grab, and it cannot put something into its own mouth. “It also cannot swallow a Tylenol-3 pill,” Juurlink told me. “I don’t know what happened in that house, on that night, but I do know that someone gave this baby crushed Tylenol-3,” likely mixed in breast milk or formula. “That’s the only way these numbers make sense.”
For the next year, Juurlink worked on his report to McCallum with great care and precision, expecting that he would someday have to present it in court. Rani’s ultra-rapid-metabolizer status “cannot explain the death of the child,” he wrote. Soon after he submitted it, in November, 2011, he was summoned to a meeting at the coroner’s office. He presented his opinion to McCallum and two forensic toxicologists who had worked on the case. As the meeting drew to a close, McCallum announced that the next step would be to send it to Koren, for review and response.
A couple of weeks later, Juurlink ran into Koren at a Starbucks in the lower level of the Hospital for Sick Children. “He was adding some milk to his coffee, and he just looked at me, and I will never forget the glare,” Juurlink recalled. “It was a look that could kill. I don’t think he and I ever spoke after that.”
Juurlink never heard back from the coroner’s office. Koren and his team kept publishing on codeine, repeating their warning that the drug, if taken by new mothers, could pass through breast milk at levels that might kill infants. There was almost no real pharmacokinetic data to back up this assertion, only extrapolation and anecdotes. For one paper, scientists working with Koren called up seventy-two women who had been breast-feeding while taking prescription codeine, months or years earlier, and asked whether they remembered their children being drowsy or having difficulty breast-feeding. (Many newborns nap after feeding.) They reported that nearly a quarter of these infants showed signs of “central nervous system depression.”
If there were genuine signals in the literature, they were indistinguishable from the noise. Only one of Koren’s cases stood out as “extremely compelling,” Juurlink told me, for the clarity and quantity of its medical data. “A one-week-old boy was seen in the emergency department with a two-day history of poor feeding and increasing lethargy,” Koren and a colleague named Michael Rieder wrote, in Paediatrics & Child Health, the journal of the Canadian Paediatric Society. His breathing was slow and shallow. “This baby had the classical combination of lethargy and bradypnea associated with opiate overdose,” Koren and Rieder reported. They referred to him as Baby Boy Blue.
Baby Boy Blue’s urine test was positive for opiates; subsequent analysis revealed that his blood-morphine concentration was fifty-five nanograms (mistakenly referred to as “micrograms” in the paper) per millilitre—not as high as Tariq Jamieson’s but potentially lethal nonetheless. Doctors administered naloxone—which displaces opioids from the receptors in the central nervous system—and he quickly recovered.
According to Koren and Rieder, “further questioning” revealed that the mother had been prescribed “an acetaminophen-codeine product” for postpartum pain. “She reported taking one or two pain tablets three or four times a day, and noted excellent pain relief but also drowsiness and constipation,” they wrote—just like Rani. Genetic testing confirmed that she was an ultra-rapid metabolizer. As with Rani, they continued, this woman’s genetics exposed her baby to “very high concentrations of morphine” each time she breast-fed.
Juurlink struggled to make sense of the case. The morphine concentration was implausibly high, and yet the fact that naloxone had worked was strong evidence that Koren’s interpretation was correct: Baby Boy Blue had consumed toxic levels of opiates.
Years after publication, Juurlink shared a taxi with Rieder, Koren’s co-author on the paper, while they were attending a professional meeting in Ottawa. By then, Juurlink had been studying the death of Tariq Jamieson for a decade, and had found no other credible case of an infant dying from breast-feeding. The only data point in the scientific literature that had shaken his theory of the case was the near-death of Baby Boy Blue. He asked Rieder about the case.
“Oh, we made it up,” Rieder replied.
Juurlink was speechless; he regarded Rieder as an “esteemed colleague,” as he later put it, “and someone I consider a friend.” But every detail was fiction. Koren and Rieder had even invented Baby Boy Blue’s siblings, a five-year-old sister, who was born in Sri Lanka, and a three-year-old brother, who was “born in Canada by caesarean section because of failure to progress.” The morphine concentration was implausibly high because it was fabricated. No life was jeopardized; no life was saved.
Koren, who has been ill in recent years, could not be reached for comment. But, according to an e-mail that Rieder sent Juurlink years later, the case was created as “a cautionary tale,” for teaching purposes. No such disclaimer appeared in print. Meanwhile, the paper has been cited in at least one court case and in a doctoral thesis. “Pathologists and forensic toxicologists have come to accept the idea of ‘death by breast milk’ based upon terribly sloppy work that began in Gidi’s lab,” Juurlink wrote to Rieder. “Experts and the courts are being misled by this belief. Unfortunately, your case work contributes to that misconception.” Rieder said that the paper would “likely” be updated with a disclaimer in 2024, some fourteen years after it was published. But this has not happened.
Gideon Koren was born in Tel Aviv in 1947, shortly before the establishment of the Israeli state. He served as a medic and a flight surgeon in the Israel Defense Forces, then studied at the Sackler School of Medicine, at Tel Aviv University. After a residency in pediatrics, he moved to Canada to train in pediatric pharmacology and toxicology. In 1985, he established the Motherisk program. “Every year, scores of new medications enter the market, and few of them have safety data concerning fetal exposure during pregnancy,” he later wrote. “There is a serious knowledge gap as to which medications are safe for the unborn baby and which should be avoided.” Motherisk was “Gidi’s baby,” Rieder later told reporters. “It was totally shoestring at first”—just Koren, plus a staffer answering the phone. But, in time, Koren raised millions of dollars for the program, and it grew, as he put it, “to conduct large-scale laboratory and clinical research, and to translate this new knowledge into counselling.”
Koren was an amateur folk musician, and he held weekly performances in the hospital wards. “How many people do you know who are outstanding scientists, outstanding clinicians, and set up a theatre for children?” an immunologist at the hospital once said. But, in private, Koren could be aggressive and vituperative—a competitive colleague who sought to destroy the reputations and careers of those who crossed him. In the late nineties, he sent five anonymous hate-mail letters that were directed at colleagues who had come to believe, during a series of clinical trials, that a drug he was researching and advocating for was neither safe nor effective. “How did you ever get yourself in the middle of this group of pigs?” he wrote to one of them. “Or did you think that their shit won’t touch you?” The letters were filled with spelling and grammar mistakes, and also with bizarre phrases, which, to those who knew Koren well, instantly identified him as the author. (In one letter, he told a colleague that he was tired of “your mesanthropy and a British version of a foul air baloon,” and signed off as “your appaulled colleagues,” with a stamp showing the face of a clown.) When hospital officials confronted Koren about the letters, he vociferously denied any involvement. The recipients spent hundreds of thousands of dollars on private detectives and expert analysis. In 1999, they matched saliva on the envelopes to a sample of Koren’s DNA.
At that point, Koren confessed. “It defies belief that an individual of Dr. Koren’s professed character and integrity could author such vicious diatribes against his colleagues,” a disciplinary committee reported. “It was only when confronted with irrefutable scientific evidence of his guilt did he admit that he was the perpetrator.”
The prospect of Koren’s dismissal threatened to upend the Motherisk program. “The day we heard the news about the letters, top scientists came into this office and cried. We cried,” a hospital assistant told the Globe and Mail at the time. “He is irreplaceable.” The hospital’s leadership, after an expensive investigation, settled on a fine of thirty-five thousand dollars and a five-month suspension from the hospital, three of them paid.
Koren returned to work stripped of two titles and of a chair that had been endowed in his name. But he remained the director of Motherisk, and soon the scandal was behind him. Research and operational grants poured in; Motherisk’s clinical laboratory expanded its operations, and its counselling center grew to seventy-five staff members, answering an average of two hundred inquiries a day. Motherisk also served as a kind of clearing house, with extremely similar articles based on its research findings running in multiple medical journals. Koren sat on the editorial boards of numerous publications and held several academic appointments.
“Everybody thought he was the best in the world,” Bateman, the Scottish toxicologist, told me. “I did, too!” But the impression wasn’t necessarily shared by those who worked closely with him. One of Koren’s former trainees, Shinya Ito, told me that, from his experience working with Koren, “I learned what I shouldn’t do.” He added, “Gidi was sloppy with details. That was my impression, even as a trainee.”
Koren’s résumé eventually grew to a hundred and forty-seven pages, and he was credited as an author on at least a dozen medical books and some two thousand academic-journal articles. (A 2018 analysis by Nature flagged Koren, among others, as “hyperprolific,” noting that some years he had pumped out an average of at least one new paper every five days. “I perceive myself as an individual who is highly committed to scientific discovery,” Koren wrote in response. “I do not feel I have to apologize for my high productivity.”) Koren spoke at conferences all over the world, and testified as an expert witness in Toronto courtrooms. He also received some of Canada’s top medical and research awards. “It feels great when your country says to you, through its highest research authority, ‘You have changed the lives of many Canadian women and their families,’ ” he said.
In late 2014, Juurlink picked up a copy of the Toronto Star from his porch and saw Koren’s name on the front page. For the past fifteen years, the Motherisk laboratory had been paid by the Canadian child-protection authorities to test strands of hair for drugs and alcohol. At least twenty-five thousand people, across the country, had been tested by Motherisk, earning millions of dollars for the lab. The results of the tests were used in eight criminal prosecutions and thousands of child-protection cases; Koren personally testified in a criminal proceeding that resulted in the removal of a child from his mother. “However, Dr. Koren has never had any formal training in forensic toxicology or any experience in a forensic toxicology laboratory,” an independent investigation that was commissioned by the government of Ontario found. “It is clear that he did not understand basic elements of forensic toxicology.”
In fact, no one at Motherisk’s lab had any proper forensic training. The entire enterprise “fell woefully short of internationally recognized forensic standards,” the investigator, a retired judge named Susan Lang, wrote. The lab had no standard operating procedures, no clear chain of custody, and poor recordkeeping. Worse, Koren’s team relied on preliminary screening tests, designed only to quickly assess whether a sample is negative, and thus merits no further testing, or is “preliminarily positive,” and thus requires an entirely different test to confirm and quantify the presence of a drug. Koren’s team didn’t do the follow-up tests; it presented preliminary positives as precisely quantified results—a practice that was “simply unheard of in forensic toxicology laboratories,” Lang wrote. Meanwhile, laboratory personnel “made repeated interpretation errors” when reporting to the authorities. Koren testified, on the basis of these spurious tests, that a toddler must have been ingesting substantial quantities of cocaine for about fourteen months. The child’s mother went to prison.
The Motherisk lab was shut down, and Koren returned to Israel. In his absence, the regulatory body for medical doctors in Ontario carried out an investigation into whether he had “engaged in professional misconduct or was incompetent.” In 2019, as part of a deal to end the investigation, Koren surrendered his Canadian medical license and “agreed never to apply or reapply for registration as a physician in Ontario.”
“It’s crazy how much we have in common now that I’ve hijacked your entire personality.” Cartoon by Will McPhail
The Motherisk scandal threw the Canadian child-protection system into chaos. “The testing was imposed on people who were among the poorest and most vulnerable members of our society, with scant regard for due process or their rights to privacy and bodily integrity,” a follow-up commission reported. Many of the children in these cases had been removed from their parents and put into foster care or formally adopted—a process that is practically impossible to reverse. They lived with new families, and in many cases had done so for years. Some biological parents no longer knew where their children were. Two additional years of investigation and a review of nearly thirteen hundred cases resulted in only four instances of children being reunited with their biological parents.
In early 2015, Juurlink contacted the coroner’s office to ask about the status of the inquiry into Tariq Jamieson’s death. Three years had passed since his run-in with Koren at Starbucks, and he had heard nothing. McCallum had left the role of chief coroner, and it was now held by Dirk Huyer, a widely respected practitioner who had investigated some five thousand deaths since 1992. The office Huyer inherited had spent much of the previous decade in turmoil: an unrelated scandal had culminated in James Cairns—who had been the chair of the Paediatric Death Review Committee and had co-authored the Lancet paper with Koren—surrendering his medical license and promising never to practice again.
Juurlink’s own son had been born two and half months after Tariq. “Watching him ride his bike for the first time, and watching him win a basketball tournament, and watching him go off to school—it’s one of the reasons I’ve been pursuing this with such tenacity,” Juurlink said. As we spoke, he began crying. “This baby didn’t get that opportunity, because somebody gave him Tylenol-3.”
Huyer sent a couple of “perfunctory replies,” as Juurlink put it, but otherwise seemed reluctant to engage. “Things continue to be evaluated,” he wrote. Months later, Huyer visited Juurlink at his office. He said that Koren had reviewed Juurlink’s report from 2011 and one of his former Ph.D. students, Parvaz Madadi, had issued a rebuttal. Although Huyer no longer trusted Koren, Madadi was now a forensic toxicologist associated with Huyer’s office, and he considered her rebuttal plausible, detailed, and beyond his scope of expertise. “We’ve got these duelling expert opinions—the original interpretation and yours,” Huyer told Juurlink. “What are we supposed to do with that?” Juurlink urged him to seek the opinions of other experts but he declined, indicating that the matter was closed.
At that point, Juurlink informed Huyer that he would someday go public with Tariq’s blood-codeine concentration. In response, Huyer warned that the contents of a coroner’s file are not a matter of public record; only he, as chief coroner, could legally authorize the disclosure of unpublished details. And he didn’t. Juurlink was incensed. “The motto of your office is ‘We speak for the dead to protect the living,’ and that’s exactly what you’re not doing here,” he said. But Huyer insisted that, absent some form of “clear and cogent” proof, such as a confession by the perpetrator, his office could only consider changing the manner of death from “accident” to “undetermined,” a step that it has not taken.
“We’re death investigators, and we frankly rely on information that comes to us,” Huyer told me, last fall. “There are scientists involved who are far more skilled and have an expertise that would be beyond ours.”
I asked him which scientists he considered to have the best understanding of the material.
“I don’t know,” he said. “It is outside of our specific expertise, so we have not decided who would be more expert or less expert.”
But the forensic toxicologists who had been assigned to the case had expressed concerns from the outset that Tariq had been administered codeine. There was a difference of opinion within the death-investigation team, and the toxicologists’ interpretation was sidelined. Soon afterward, Koren and Cairns took the story to the scientific press, presenting their version as an uncontested medical revelation.
I contacted Rani this past June, seeking clarity into what had happened to Tariq. “Just to warn you, dealing properly with this case will involve a great deal of in-depth research into the science related to my son’s death,” she replied by e-mail. “If you are willing to invest the time needed to do that, then I would be very happy to assist you over the next few months.”
In the following weeks, Rani provided me with a handful of primary-source documents, including Tariq’s postmortem examination and toxicology report. “It is important for me to keep Tariq’s memory alive and in the public eye to help prevent possible death and harm of other newborn babies in the same or similar way,” she wrote.
In July, Rani sent me a copy of Koren’s original draft of the Lancet paper, in order, she said, to demonstrate that there was never an attempt to conceal Tariq’s blood-codeine level, which Juurlink had treated as a kind of smoking gun. She was right: the codeine and acetaminophen levels were present. The draft was twelve pages long, including references, and The Lancet had asked Koren to shorten it to a page. It is unclear why, during that process, Koren removed the codeine and acetaminophen readings. But, shortly after publication, he promoted his young graduate student Parvaz Madadi as a new expert on opioids in breast milk.
Madadi was listed as the lead author of the two Canadian practitioners’ journal articles—her first bylines in academic journals. But, when I reached out to her this fall, she told me that she had not written either paper. I sent her Koren’s original Lancet draft, where she was also listed as an author. She was perplexed, then horrified. “Not only have I never seen this manuscript—I had no reason to be on it, since I did not contribute to the original death investigation in any way,” she told me.
When Tariq died, in April, 2005, Madadi was an undergraduate at the University of Western Ontario, some two hundred kilometres from Toronto. She began studying under Koren five months later, when, as a master’s student in her early twenties, she initiated a laboratory project to develop a reliable assay for drugs in breast milk. The project was launched in response to the Lancet case report, but she had never seen Tariq’s postmortem documents.
After a year of research, Madadi said, she was “unable to develop a reliable assay.” Koren offered her what seemed at the time like a promising path forward, inviting her to pursue clinical research with the Motherisk program. He also offered to name her as the lead author of the articles in the Canadian practitioners’ journals, although she had not contributed to them at all. “It’s a really nice thing he did for me!” she wrote to her parents, her sister, and her boyfriend.
From that day forward, “Gidi dragged me to the forefront of the scientific discourse,” Madadi told me. He tasked her with working on his response to Nick Bateman for publication in The Lancet, and steered her to produce more articles on codeine and breast milk, effectively creating a body of academic literature that cited and supported his initial interpretation of Tariq’s death. “I felt, and still feel, like there are real signals in the literature to support the notion that codeine can cause sedation in breast-fed infants,” she told me. “But all my assumptions about death stemmed from the Lancet case report, which said, This is a phenomenon that happens.”
Madadi learned of Tariq’s blood-codeine concentration in 2013, when she was working on the rebuttal to Juurlink’s interpretation for the chief coroner. But she didn’t grasp its significance. Soon afterward, she left Koren’s department and started working as a forensic toxicologist associated with the office of the chief coroner, where she came to understand how poorly Koren’s laboratory had been run. “Looking back at it now, with everything I have learned, I cannot reconcile the codeine level with Gidi’s interpretation,” she told me. “That number is too high.”
I asked Madadi whether she was aware that Tariq had died with “white curdled material” containing codeine in his stomach, many hours after his last substantial feeding.
She froze. Then she said, “Are you kidding?”
In 2019, the Hospital for Sick Children lost control of Motherisk’s web domain after the subscription lapsed. It now redirects to a website that promotes the use of cannabis during pregnancy.
By then, reporters at the Toronto Star had carried out a review of Koren’s published works and found that more than four hundred of his writings appeared to contain failures to disclose funding from drug companies; unretracted assertions based on his laboratory’s discredited record of testing hair; and other malpractices and lies. In response, the Hospital for Sick Children announced that it would conduct a “systematic examination” of Koren’s academic-publishing record.
At that point, Juurlink wrote to David Naylor, the former dean of medicine and president of the University of Toronto, who was serving as the interim president and C.E.O. of the Hospital for Sick Children. He asked to discuss the death of Tariq Jamieson, then went grocery shopping. Naylor called back soon afterward, and for the next hour Juurlink paced in the canned-fruit aisle, describing his belief that Koren had essentially generated an entire branch of neonatal toxicology based on a sloppy misreading of a single death.
Juurlink’s phone call hardly came as a surprise to Naylor. He and senior members of the hospital’s faculty had been “screening endless manuscripts,” as he put it, and devising strategies for requesting retractions of Koren’s most egregious works. “We actually had a term for it—we called it ‘Korening,’ ” he told me.
“Gidi had a tendency to just submit papers without the co-authors being advised or consulted, and let the peer-review process handle all the shitty nitty-gritty, you know?” a person who worked with the Motherisk program for several years told me. “Rather than sit back and be, like, ‘Let’s make sure, before we go forward with this paper, that we have all our ducks in a row.’ ”
Naylor informed Huyer, the chief coroner, that, as part of the hospital’s review of Koren’s publishing record, Juurlink would write a comprehensive reassessment of the Lancet paper and the two papers that had appeared in the Canadian practitioners’ journals. “Juurlink is one of the straightest and smartest faculty members I’ve dealt with in a long career, and this case has been a real passion of his for a long time,” Naylor told me. “No one knew this material better than him.” Naylor also emphasized the importance of disclosing Tariq’s full toxicology results. “It was imperative that those data points be allowed for public release by Juurlink in his publications, so that there could be a proper analysis of the science,” Naylor said. Huyer relented, and Juurlink and one of his doctoral students, Jonathan Zipursky, went to work.
They conducted a study of some hundred and seventy thousand new mothers, to see if infants of women who were prescribed opioids shortly after birth were at an increased risk of harm. What they found, instead, was that many women who are prescribed opioids postpartum appear to avoid breast-feeding, in order to “protect” their children—and thereby deprive them of immunological and other benefits. “The number of infants affected by this globally is now easily in the millions,” Juurlink told me. In May, 2020, they published their review, titled “The Implausibility of Neonatal Opioid Toxicity from Breastfeeding,” in the journal Clinical Pharmacology & Therapeutics. The key finding was that Tariq’s codeine concentration “obviously cannot be explained by maternal genotype, and suggests that conversion of codeine to morphine in the neonate . . . rather than the mother, explains the elevated morphine concentration detected postmortem.”
Soon after the paper was published, the editors of the two Canadian practitioners’ journals initiated an independent review process. Between 1995 and 2015, both publications—which have a combined circulation of some eighty thousand Canadian family doctors and pharmacists—regularly ran columns from the Motherisk team without subjecting them to peer review. “We are also widely read online outside Canada by family physicians and other primary-health-care clinicians, so our potential impact on clinician prescribing behaviors and on patients is significant,” Nicholas Pimlott, the editor of Canadian Family Physician, told me. When the independent reviews came in, the journals issued a joint retraction, citing “clear evidence” that Koren’s findings were “unreliable.”
“It all started with a mysterious call from an unknown number, and now that I’m saying it out loud I think it was just spam.” Cartoon by Ellis Rosen
Rani said that Juurlink and Zipursky’s analysis was “baseless speculation” that omitted “any information that would cause people to doubt their claims.” When I asked her what she meant, she forwarded me a sixty-five-hundred-word e-mail that she had sent to the editors of the two practitioners’ journals, criticizing their retraction. Her complaints were extremely detailed and highlighted some genuine challenges in postmortem toxicology. But they mostly centered on her belief that the relatively scant toxicological literature on opioids and breast-feeding did not apply to her son. She also pointed to case reports in the medical literature which attribute infants’ symptoms to opioids in breast milk, but these generally rely on inference and lack substantive data. Nothing in her response amounted to evidence that would challenge Juurlink’s conclusion. (Douglas Jamieson did not engage with me.)
I have spent the past year searching for ways in which Juurlink might be wrong or overstating the strength of the toxicological evidence. But I have come up short. It is true that newborns are unusually sensitive to opioids; their systems are still developing. But this vulnerability is the reason that opioid dosing in newborns is so carefully calibrated and closely monitored in clinical settings—where the amounts administered directly are still orders of magnitude greater than what is transferred through breast milk. Any accumulation from the trace amounts in breast milk would be gradual, with symptoms becoming evident well before catastrophe. And though the effects of postmortem redistribution can become a “toxicological nightmare” in some forensic circumstances, as one journal article put it, Tariq’s blood sample is not one of those circumstances.
“Medicine is full of exceptions to the rules that physicians and scientists set in their various paradigms,” Naylor told me. “And human biology is unpredictable. However, in this instance, the overwhelming balance of probabilities would favor the interpretation that Dave Juurlink and his collaborators have proposed.”
Shinya Ito—who replaced Koren as the head of clinical pharmacology and toxicology at the Hospital for Sick Children in 2000, and has been publishing scientific research on drug safety and breast-feeding for more than thirty years—agreed. Rani’s ultra-rapid-metabolizer status was a red herring. Leading European and American experts with whom I shared the raw postmortem and toxicological data told me much the same. “The amount of morphine in milk, even if it’s unusual, is still not enough—period,” Ito said. “There is a missing piece, the bigger exposure, which must have come from direct administration. By whom? Nobody knows.”
“The case against science is straightforward: much of the scientific literature, perhaps half, may simply be untrue,” Richard Horton, the editor of The Lancet for the past thirty years, wrote in the journal, in 2015. “In their quest for telling a compelling story, scientists too often sculpt data to fit their preferred theory of the world. Or they retrofit hypotheses to fit their data. Journal editors deserve their fair share of criticism too. We aid and abet the worst behaviours.”
In 2020, Juurlink, Zipursky, Naylor, and several other experts—including Nick Bateman, the Scottish toxicologist; Thomas Hale, one of the world’s leading scientific authorities on breast milk; and Ronald Cohn, who had replaced Naylor as president and C.E.O. at the Hospital for Sick Children—wrote to The Lancet, asking the journal to retract Koren’s paper. “For more than a decade now, Koren either knew or ought to have known that his original interpretation of the case was flawed yet he took no corrective action,” the letter read. “He instead continued to publish work citing this case as foundational to consideration of the risks of opioid use while breastfeeding.”
The journal referred the request back to the Hospital for Sick Children, which established an internal research-integrity review. Since Cohn had signed the letter asking for retraction, the lead inquirer did not report to him.
What followed was an exercise in obfuscation through institutional review. There was no meaningful effort to assess whether Juurlink’s analysis disproved Koren’s; instead, the reviewers narrowed the scope of their inquiry to the matter of whether Koren’s team had demonstrated such a “lack of rigour” that retraction was unavoidable. “Is it a good paper?” Stephen Scherer, the hospital’s head of research, who oversaw the investigation, later said to Juurlink. “You know—it’s an n of one and a lot of hand-waving. But the four authors on the paper stick by it.”
Koren sent the review team a bizarre eight-page document, which contained factual errors, non sequiturs, multiple font sizes, and what appeared to be copied-and-pasted correspondence with Rani. The hospital’s research-integrity office chalked it up to a scientific dispute. The editors of the Canadian practitioners’ journals offered to provide The Lancet with the unambiguous findings of their own review, but The Lancet declined. An independent expert I contacted told me that, some years ago, The Lancet had asked him to weigh in on the subject—then ignored his advice to retract. Koren’s case report remains on the journal’s website, with no notes or corrections appended, and serves as the core basis for regulatory guidance on the subject of breast-feeding and codeine all over the world.
“The fact that the paper still exists means that medical students, pharmacy students, and, presumably, genetics students are being taught this as if it’s a real thing, and it has implications,” Juurlink told Scherer. “The scientific record now has this entire branch of pediatric pharmacology that has been made up out of whole cloth.” Koren’s Lancet article “is still used in a lot of textbooks,” the independent expert said. “Doctors who are less trained in this specific topic still perceive this case to be relevant.”
Soon after Naylor’s interim leadership came to an end, the internal review of Koren’s works was terminated. “The hospital decided that it was simply indigestible—that they would be forever at it,” Naylor told me. (The hospital disputes this.) Most journals resisted retraction, “even when strong arguments had been presented to get these papers out of the literature,” he said. “I was certainly disappointed. An enormous amount of work had been done, and the net result was a damp squib.”
Recently, Parvaz Madadi has undergone a painful process of revisiting her past work and memories. “This case report is misleading,” she said. “And the original submission was not done carefully or in good faith.” She added that she had no confidence in the measurement of Rani’s breast-milk sample, because it had been handled by Koren’s lab. Last week, she submitted a request to The Lancet to retract the original paper, along with her co-bylined response to Nick Bateman. At the core of her letter is a new allegation: that Koren falsified toxicological data.
Last month, Madadi scoured her archives and discovered an unpublished letter that Koren had submitted to The Lancet—without her knowledge but with her name as a co-signatory—in his initial attempt to suppress Bateman’s critique. On the second page, he misrepresented the contents of Tariq’s stomach. A toxicological screening of the “white curdled material” had detected codeine but not morphine. But Koren had claimed that the gastric contents “exhibited high morphine” levels—with no mention of codeine—“ruling out administration of Tylenol-3 to the baby.”
“Gidi was thinking about direct administration, and he created a scenario that would confuse or negate that explanation,” Madadi said. “He deliberated on this issue, and he lied.”
Tariq Jamieson was alive for only twelve days. But the circumstances of his death have cast a shadow over the scientific literature, top medical institutions, and the Jamieson family for more than two decades. After I contacted Huyer, the chief coroner, this fall, he began looking into the origins of the death investigation; during that process, he discovered that the full set of documents has gone missing.
In the decades since Koren’s first warnings concerning codeine and breast milk, public-health authorities and patient-advocacy services have issued guidance to new mothers that ranges from scientifically incoherent to potentially dangerous. A clinical report published by the American Academy of Pediatrics in 2013 cites the Lancet case as a reason to avoid prescribing codeine to breast-feeding mothers but notes that morphine—its metabolite—“appears to be tolerated by the breastfeeding infant.” The same guidelines also recommend the use of hydromorphone, which is about forty times more potent than codeine and can be highly addictive. Meanwhile, the U.K.’s National Health Service categorically warns against taking codeine while breast-feeding but allows for the use of fentanyl.
The notion that opioids can pass through breast milk in sufficient quantities to kill a child has also seeped into American courtrooms. Koren’s interpretation of Tariq Jamieson’s death has essentially served as a legal defense in at least two other cases that Juurlink believes most likely involved direct administration. During a review of other scientific literature, this summer, he discovered fourteen more, in Europe. “Who knows how many other babies have died at the hand of a caregiver and had it attributed to breast milk?” he said. “I don’t know the answer to that. But it’s not zero.” ♦