Monday, November 21, 2005

An HIV/AIDS "skeptic" questions my honesty and decency...

Dean Esmay, who likes to present himself to his readers as a hard-nosed "skeptic," but is in actuality a rather credulous fellow, at least when it comes to HIV "dissidents" and seemingly not understanding why it's such a bad idea to teach "intelligent design" creationism in the science classroom in public schools, is not happy with me, not happy with me at all. On Saturday, as I was about to sit down to watch the Michigan-Ohio State game, I noticed an influx of referrals here from his blog. Given that I hadn't recalled seeing referrals here from Dean before, I checked it out his blog and, amidst a self-congratulatory tirade against bloggers who considered the Eliza Jane Scovill case a tragic example of what can happen to a child when her parents believe won't accept the science showing that HIV causes AIDS, found this comment regarding the case of Eliza Jane, the daughter of HIV denialist Christine Maggiore, who died in May and whose autopsy showed that she had AIDS-associated pneumonia:
I wonder if the Suicide Girls or Orac Knows will show any class, decency or honesty on the subject now that we know the truth? Or will they keep to their lynch-mob prejudices?
Geez. I don't know what brought this on. I've never questioned Dean's honesty. I do think he's prone to excessive credulity when it comes to HIV "skepticism" and that HIV denialism has the potential to do great harm in terms of controlling the spread of AIDS, but I've never impugned Dean's honesty or decency.

OK, Dean. You can trumpet your pseudoscientific nonsense about HIV and AIDS to your readers all you like. I don't really care. You can say that I'm mistaken. You can imply that I lack class. You can even call me a flaming idiot and moron. I wouldn't really care all that much. You can say I'm butt-ugly and smell bad. Water off a duck's back. But question my honesty or decency, and, dude, the gloves come off, making today a very good day indeed for Orac to direct some of his characteristic Respectful Insolence™ your way.

So what brought on Dean's little tirade against others bloggers (and me apparently as an afterthought)? Christine Maggiore, the HIV-positive mother and high profile HIV/AIDS denialist who refused to take AZT to prevent maternal-fetal transmission of the virus, or even to test her child for HIV, has gotten fellow HIV denialist Dr. Mohammed Al-Bayati to look at the L.A. County Coroner's report for her daughter's autopsy. Not surprisingly, Dr. Al-Bayati is claiming that the coroner got it all wrong and that Eliza Jane didn't die of AIDS-related pneumonia as the report concluded, leading Dean to go into spasms of self-righteous rage and claim "that the L.A. County coroner and the Los Angeles Times were and are guilty of a political diagnosis in order to grandstand."

Well, knock me over with a feather! Who could possibly have seen that one coming? The only thing that surprised me is that it took so long to dig up someone to "refute" the coroner's report.

One thing that struck me right away is that Dean failed to mention other medical bloggers who agreed with my position and said so in their blog, bloggers such as Gordon's Notes, Red State Moron, SupportVaccination.org, or even Dr. Trent McBride, a pathology resident who blogs on Catallarchy and who also pointed out that finding Pneumocystis carinii by silver stain on autopsy histology of the lungs of someone not having AIDS or other significant immunosuppression is exceedingly rare. (I wonder if Dean considers these other bloggers writing on this case to be lacking in honesty as well.) Another thing that struck me is that, in the comments Dean whined about ad hominem attacks against his expert (Dr. Al-Bayati), after having himself launched an ad hominem attack on Richard Bennett (whom, I conceded, had once taken what I considered to be a cheap shot at Dean over an admission Dean had made) and others. No doubt Dean fails to see the irony. Apparently ad hominems are OK only as long as it is Dean--who has on occasion been known to refer to his critics by epithets like "sad little losers"--launching the ad hominem.

Nonetheless, at the risk of my being accused of retreating to the "last refuge of the pseudoscientist" (as Dean himself likes to put it), the ad hominem attack, it is nonetheless necessary to take a brief look at Dr. Al-Bayati before addressing the substance of report itself. (Don't worry, I'll get to the substance soon enough.) Given that Dean seems to like to question the motivations of those who don't buy into his "HIV dissident" line and to argue from authority a lot (he is quite enamored of his friend Peter Duesberg's credentials and those of another prominent AIDS denialist, Harvey Bialy and is not at all shy about waving them in front of him--metaphorically speaking--like a talisman to ward off attacks against his pseudoscientific posturing), I consider it entirely appropriate to examine this particular "expert" and his qualifications and motivations before going on to discuss the contents of his report.

So who is Mohammed Ali Al-Bayati, PhD, DABT, DABVT? He represents himself as a toxicologist and "pathologist." However, most pathologists who deal with HIV are MD's. So what kind of pathologist is he? "DABVT" stands for Diplomate, American Board of Veterinary Toxicology; so basically he's a veterinary pathologist and toxicologist. Whether that means he's qualified to evaluate postmortem findings in AIDS, I don't know. He has a few papers published in the peer-reviewed medical literature, but none of them concern HIV; so his publication history doesn't help me evaluate him. He does, however, have a very obvious and undeniable bias. Dean will no doubt characterize it as an ad hominem attack to point out Dr. Al-Bayati's bias, but it's not at all inappropriate in this case to mention his prominent listing on the infamous Virus Myth website or his book Get All the Facts: HIV Does Not Cause AIDS. Also, Dr. Al-Bayati runs a company called Toxi-Health International, which, according to its website, provides expert witness services and "can evaluate the health effect resulting from acute and chronic exposure" to various agents," including medication reactions, adverse reactions to vaccines (shades of the Geiers!), pesticides, and a variety of other compounds. No doubt Dean will lambaste me for even mentioning such things. Tough. If Dean considers it not to be an ad hominem attack to blithely accuse the L.A. County Coroner and L.A. Times without evidence of making "a political diagnosis in order to grandstand," I consider it acceptable to point out an obvious bias in the source Dean chooses to use to make the case that the autopsy findings were incorrect.

As I've said before, as long as you're not just lobbing insults at your opponent, ad hominem arguments are not always inappropriate, particularly when they point out a clear bias that any person evaluating both sides of an argument should be aware of. However, they are not sufficient. The substance of an argument must be addressed as well. So, without further ado, though, let's get to the meat of the matter, shall we? Unfortunately, Dean provided no link to the original coroner's report (apparently it is not publicly available); so I shall have to rely on Dr. Al-Bayati's characterization of the report. Fortunately, that's enough to sink him.

The first thing I noticed reading Dr. Al-Bayati's report is that it appears not to be intended for a scientific audience. (Perhaps this is why Dean found it so compelling, assuming he actually read the whole thing.) Instead, it is constructed more like a legal document designed to cast "reasonable" doubt on the coroner's conclusion that AIDS-related pneumonia was the cause of Eliza Jane's death, rather than actually putting together a coherent case for an alternate explanation. Without ever having seen the body or any of the raw data from the autopsy, Dr. Al-Bayati dives right in. One particularly egregious example of his style is that he lambastes the coroner for not testing for a certain virus (more about this below), and then confidently concludes that Eliza Jane had that virus and not HIV, even though he couldn't possibly make such a conclusion without the results of the very test that he criticizes the coroner for not having done in the first place! Before I myself dive in, however, let's summarize the autopsy conclusions as Dr. Al-Bayati reports them:
  1. Pneumocystis carinii was found in Eliza Jane's lungs by Gomori methenamine silver staining in association with pink foamy casts in the alveoli. The lungs were also edematous (water-logged).
  2. Eliza Jane was mildly neutropenic (low neutrophil--a type of white blood cell--count) and profoundly anemic (low red blood cell count)
  3. Eliza Jane's brain contained throughout its white matter with relative sparing of cortex a number of variable-sized microglial nodules characterized by multinucleate giant cells associated with moderate pallor and myelination, occasional macrophages, and and angiocentric pattern. These lesions stained positive by immunohistochemistry (IHC) for the HIV core p24 protein, a finding consistent with HIV encephalitis.
  4. There was atrophy of the spleen and thymus
  5. There was enlargement of the liver with fatty infiltrate of the cells (steatosis) and ascites
Dr. Al-Bayati then tries to "refute" each of these findings, using a variety of handwaving techniques and "might have beens" that truly astound. One thing that puzzled me, though, was why he thought it so important to refute the finding that HIV was present at all. After all, if, as Dr. Al-Bayati clearly believes very strongly, HIV does not cause AIDS, then why not just come right out and argue that in his report? Why not just argue that AIDS couldn't possibly have killed Eliza Jane and that the HIV protein detected in her brain was a red herring? Heck, why doesn't Dean just argue that?

But I digress.

Dr. Al-Bayati concedes that P. carinii, an AIDS-defining organism, was present in Eliza Jane's lungs but tries to wave this finding away by pointing out that there was not a "pneumonia" because no inflammation was observed, citing a definition in a pathology textbook (a technique not unlike arguing about technical words using dictionary definitions). He repeats this again and again ad nauseam. He also states that P. carinii is ubiquitous, only causing disease in immunosuppressed patients. There are couple of problems with these arguments. First, immunosuppressed AIDS patients tend not to be able to mount a very effective inflammatory response to infection. Indeed, it has been noted that, in HIV infection, PCP pneumonia provokes fewer inflammatory cells and that PCP is worse in patients immunosuppressed by other causes as their immune system recovers and starts attacking the organism, causing inflammation. (That's one reason why the chest X-ray findings and physical exam findings can be so variable.) The one argument Dr. Al-Bayati makes in this context that isn't totally off the wall is that PCP can occur due to immunosuppression from other causes, and he cites several references that show that PCP can occur in people without HIV if they are immunosuppressed for other reasons. Of course, this line of argument totally begs the question of what the cause of this Eliza Jane's profound immunosuppression was in the first place if it wasn't HIV infection. Second, as Dr. McBride pointed out, for P. carinii to be detected in routine tissue samples at autopsy, there have to be a lot of organisms there. In immunocompetent individuals, there simply aren't enough bugs to show up on silver stain. Given that the HIV protein detected in the brain implicates an obvious cause for the immunosuppression that led to the presence of so much P. carinii in Eliza Jane's lungs, it's hard not to conclude that Eliza Jane had AIDS-associated PCP. Dr. Al-Bayati clearly realized that he had to try to throw doubt on that finding.

And how does he try to do that? Disputing the findings of an experienced neuropathologist, Dr. Maurice A. Verity of UCLA, who examined the sections of Eliza Jane's brain, Dr. Al-Bayati argues that the brain lesions seen are nonspecific and that the finding of the HIV p24 protein on IHC must have been a false-positive. He points out a paper from 1992 indicating a high level of false positivity of this test in the presence of inflammation. Tellingly, however, despite listing the numbers and types of tissues stained in the study (which included only 3 brains from HIV-positive patients and one brain without HIV), he does not cite the percentage of false positive results reported in the paper, only that it is "common." (I couldn't get the paper online to check myself, because the online archives only go back to 2000.) The problem with this line of argument is that it's not enough just to say that this "might" have been a false positive using references that, being 13 years old, may not even be relevant to how IHC for HIV proteins is done today. He has to show compelling reason that it was, rather than hand-waving and saying that some combination of a viral infection and/or an allergic reaction to amoxicillin caused this (see below). Even Dr. Al-Bayati appears to realize this shortcoming.

And that's where his strangest argument of all comes in.

There's a saying in medicine that, when you hear hoofbeats you don't look for zebras. (A zebra is medical slang for a rare or highly unlikely diagnosis.) Yes, occasionally it you will find a zebra, but the vast majority of the time you will not. Consequently, when one hears hoofbeats from a tragic case of a dead child of an HIV-positive mother who was found to have profound anemia, PCP, and encephalitic lesions with HIV proteins detected in them, by far the most likely diagnosis is AIDS. Indeed, in the differential diagnosis, the first ten diagnoses in the differential would be AIDS, AIDS, AIDS, AIDS, AIDS, AIDS, AIDS, AIDS, AIDS, and then--very far down the line in probabilities--everything else. Given this, it's not surprising that, in his rebuttal, Dr. Al-Bayati hears not one, but at least two zebras approaching.

Which zebras, though? The first one is erythrocytic aplastic crisis due to infection with parvovirus B19 (PVB19, the virus mentioned above), of course! Shouldn't it have been obvious? He bases this speculation on Eliza Jane's anemia, encephalitis, upper respiratory infection, and atrophy of the spleen and thymus. I'll give him props, though. This is a clever gambit, because this particular virus is common enough that a significant percentage of children have been exposed to it, meaning that there's a reasonable probability that antibodies to it would be found if looked for, whether it was this virus that actually caused Eliza Jane's death or not. Let's look at this claim a little more closely.

PVB19 is a parvovirus that is fairly common and can cause upper respiratory infections, erythema infectiosum, arthritis and arthralgias, and transient aplastic crisis. Dr. Al-Bayati makes much of the ability of this virus to cause anemia by transiently suppressing the progenitor cells that develop into red blood cells and blames infection with this virus for Eliza Jane's profound anemia. He also attributes Eliza Jane's encephalitis and bone marrow atrophy to infection with this virus. However, he neglects the observation that PVB19 is rarely much of a problem in healthy individuals. Severe anemia secondary to PVB19 usually only occurs in patients with a pre-existing anemia or pre-existing destruction of red blood cells and who therefore require a high level of reticulocyte production to keep their blood counts up. Conditions in which this can be a problem include chronic hemolytic anemias, sickle cell anemia, thalassemia, acute hemorrhage, and iron deficiency anemia, all of which cause red blood cell loss requiring replacement. Also, severe infections of the bone marrow with PVB19 causing aplastic anemia are rare aside from patients with pre-existing immunosuppression, such as transplant recipients, patients with malignancy, and, of course, patients with HIV. In such patients, PVB19 infection can result in severe, prolonged, recurrent, or even permanent anemia. Dr. Al-Bayati does point out a couple of case reports of a aplastic anemia due to PVB19 in immunocompetent individuals. As far as I can find, there are no decent-sized series reported, however, only a few isolated case reports. This paucity of reports that PVB19 is a fairly rare cause of aplastic anemia in healthy individuals. It is, of course, possible that PVB19 infection caused Eliza Jane's serious anemia (that's where "reasonable doubt" comes in). However, even if it had, given what is known about this strain of parvovirus, a far more likely explanation would be that the virus caused Eliza Jane's anemia because of immunosuppression secondary to her HIV infection. Indeed, case reports even suggest that anemia in AIDS patients due to PVB19 will improve with antiretroviral therapy.

The second zebra is a severe amoxicillin hypersensitivity. (An amoxicillin allergic reaction in and of itself is not a zebra, but it is in the context of this particular case.) Never mind that Eliza Jane had, as was emphasized in the report, never been exposed to antibiotics before and that her clinical course does not seem consistent with a hypersensitivity reaction. Never mind that there was no eosinophilia, no urticaria, or no other stigmata of an allergic reaction mentioned in Dr. Al-Bayati's report (and you can bet that, had any of them been there, he would have mentioned them prominently). Amoxicillin hypersensitivity was also blamed for Eliza Jane's steatosis. It is true that amoxicillin-clavulanate has been associated with hepatocellular, cholestatic, granulomatous, or focal destructive cholangiopathy (all types of liver damage), and references are cited showing this. However, one would think that Dr. Al-Bayati would know that steatosis (a fatty infiltrate of the liver cells) is not the same thing as any of these. Moreover, the pathology report did not state that Eliza Jane's liver had any of the more common manifestations of amoxicillin-clavulanate-induced liver injury, casting further doubt on the antibiotic as the cause. (Drugs more classically associated with steatosis include valproic acid, tetracycline, amiodarone, and aspirin, not amoxicillin-clavulanate. Indeed, a PubMed search on "steatosis" and "amoxicillin" failed to turn up a single reference.) I didn't see any of Dr. Al-Bayati's references supporting his implication that amoxicillin could cause steatosis within a day of exposure. Clearly, the steatosis must have been a pre-existing condition. As for the pulmonary edema and ascites reported, that could be due to allergic reaction, septic shock from an ear infection, cardiopulmonary collapse from whatever cause, or a number of other factors, but in the context of Eliza Jane's HIV infection, rapid deterioriation, and cardiovascular collapse, it fits.

The bottom line is that you can compare these two sets of conclusions about what caused Eliza Jane's death and decide which seems more plausible. The first, the coroner's report, looks at a child of an HIV-positive mother who refused to take AZT during pregnancy, breast-fed her child even though that is known to increase the rate of transmission of HIV, and refused to have her child tested for HIV, a child who collapsed after upper respiratory and ear infections, whose autopsy findings showed HIV encephalitis, P. carinii in the lungs, and severe anemia. Given such findings, it's hard not to conclude that Eliza Jane died of AIDS complications. (Whether or not Dean's contention that the coroner had some sort of horrendous bias or was grandstanding is true, I cannot say, but certainly Dean hasn't provided any compelling evidence that he was.) The second hypothesis, promulgated by an HIV "dissident" with a definite axe to grind, requires us to believe in not just one, but three, highly unlikely occurrences (plus one simply unlikely occurence), namely:
  1. A previously completely healthy girl developed PVB19 infection leading to both encephalitis and aplastic anemia (possible, but highly unlikely, and, even if PVB19 were found, it would be far more likely that it was able to cause anemia because of immunosuppression due to AIDS).
  2. This same girl also developed an acute allergic reaction to amoxicillin that led to cardiovascular collapse and--oh, by the way--also caused steatosis of the liver within a day after starting the drug, the steatosis being something even Dr. Al-Bayati's own references do not seem to support as being likely.
  3. This same otherwise healthy girl had sufficient quantity of P. carinii in her lungs to show up on Gomori methenamine silver staining at her autopsy.
  4. The medical examiner and neuropathologist either botched the staining for the p24 protein (or that it was a false positive) and an experienced neuropathologist didn't know the pitfalls of the diagnosis of HIV encephalitis using brain tissue sections.
A veritable herd of zebras indeed. To believe Dr. Al-Bayati's scenario, you have to believe that at least four very unlikely things happened in the same case, rather than the very likely conclusion (based on the autopsy findings) that AIDS killed Eliza Jane.

Not surprisingly, credulous guy that he is when it comes to anything that supports HIV denialism, Dean does exactly what he accuses Richard Bennett of and "sucks down any codswollop he's fed on this subject and spews it back out on command." No doubt Dean will likely accuse me of the same and/or consider my response to him to be "dishonest" or possibly lacking class. We'll see. Part of the reason I haven't addressed Dean's "skepticism" about AIDS much before is because observing him pontificate on AIDS has taught me that arguing with him on this issue is completely pointless. Quite frankly, even in this instance, it's unlikely that I would have bothered to respond if Dean hadn't annoyed me so much by impugning my honesty.

In the meantime, I plan on submitting this to Grand Rounds this week. (That's about as close to "peer review" as you can get in the blogosphere.) I'm also very interested in what other doctors, scientists, and medbloggers have to say about this. I'm not an AIDS expert, but a lot of the stuff in Dr. Al-Bayati's report is so off the wall that it didn't take much to find the inconsistencies. (And if I, a knowledgeable non-expert, can pick the flaws apart, imagine what a real expert could do.) Nonetheless, if I got something grievously wrong that calls into question my analysis, I'd like my peers to let me know.

ADDENDUM: An update including the opinions of two additional physicians has been posted here. They cover a lot of the same ground, but from different viewpoints and different areas of expertise and, when combined, present a truly devastating rebuttal to Dr. Al-Bayati's "report."

37 example(s) of insolence returned:


At 11/21/2005 7:47 AM, Blogger JM O'Donnell said...

That was a marvellous debunking and a half. Very well done indeed Orac and now let's see if Dean will reply with some degree of 'facts' or if he'll just accuse you of more [i]ad hominems[/i].

 

At 11/21/2005 8:19 AM, Blogger rgmb said...

As a nonscientist, I ploughed through your post and actually understood most of it, in my limited ability course. Well done!

But one question remains, did you watch the game?

 

At 11/21/2005 9:18 AM, Anonymous Anonymous said...

Dave S.

You misspelled ad nauseam, but otherwise I don't see anything wrong at the moment.

 

At 11/21/2005 9:55 AM, Anonymous umvdn said...

Excellent post. In Saturday's Rocky Mountain News, here in Denver, I found an op-ed from ole Mike "NoSuchThingAsHeterosexualAids" Fumento that there's no possibility of an avian-flu pandemic (now I am *truly* afraid that there may be one...) parked above an op-ed moaning about how 'Naturopathy' is being unfairly treated and regulated in Colorado. I think I need to move.

 

At 11/21/2005 10:22 AM, Blogger Lord Runolfr said...

As a reader with no medical background, I think it would be nice if you could cut back a bit on the medical terminology and describe Eliza's symptoms in plain English wherever possible.

When you wrote "PVB19 is a parvovirus that is fairly common and can cause upper respiratory infections, erythema infectiosum, arthritis and arthralgias, and transient aplastic crisis", I stopped understanding at erythema. A long string of medical jargon like that might as well be Swahili to me, and it could easily put off some readers.

As someone who writes documentation for a living, I think you need to consider your audience a little more carefully. If your audience is almost exclusively composed of medical professionals, then what you wrote is fine. If it's full of lay people like me, you need to tone down the jargon.

 

At 11/21/2005 10:27 AM, Blogger Axiom said...

I have trouble understanding that this sort of disconnection from reality is even possible. Since the Statistician of Doom has devoted most of her professional career to the development of anti-AIDS and anti-cancer pharmaceuticals, I tend to hear a lot about the progress being made. Yes, it's still limited and requires a flexible definition of success: quality of life may suffer in some cases but is that worse than dead?

For example, as RGMB says, you've explained the details clearly in your rebuttal. You make it clear that, yes, there are other possible causes for some or all of these symptoms if they are discussed anecdotally and completely out of context. However, since we / you do have prior knowledge of the situation and personal history, these "alternate hypotheses" are ridiculously unlikely. Point well made.

I, on the other hand, lost the bubble with the claim "AIDS is not caused by HIV." From that point on, the anti-AIDS-hypotheses only bring to mind the image of a slavering lunatic, scrambling around with his bucket of paint, slathering "ZERBA" on a veritable herd of horses.

No amount of paint, babbling, lunacy or poor spelling will change the fact that we live on EARTH.

[By the way, if the SoD is a "big pharma" shill, does that make me the Son of Big Pharma? For how many generations does the stigma of Big Pharma extend?]

 

At 11/21/2005 10:29 AM, Blogger Axiom said...

PS: I vote that you continue your current style of writing, using the correct technical terms, simplifying only where absolutely necessary.

Casual paraphrasing would only open the door to hostile quote mining from the crazy people.

 

At 11/21/2005 10:44 AM, Blogger decrepitoldfool said...

I am also a non-medical reader and sometimes do not understand all the words you use. Fortunately, reading your posts implies that I am sitting at a computer; it is easy enough to look them up. Then I have learned something and can begin to make better connections.

There are plenty of places out on the web that will write down to me if that is what I wanted.

 

At 11/21/2005 10:48 AM, Anonymous DrYak said...

What is it with the HIV/AIDS deniers and Africa anyway? I can understand them being deniers ensconced in the US and Europe where they are rarely, if ever exposed to, AIDS sufferers and don't see the overflowing graveyards. But when they blithley state that all the people working directly with HIV/AIDS in Africa are lying or idiots it really pisses me off. They are more than welcome to come to my hometown and see the tens of thousands of dying people or AIDS orphans. If they persist with their its "malaria" in a non-malaria endemic area or provoked by anti-AIDS drugs in people who can't afford them then there really is no hope for them.

Is the Cato Insitute still peddling this deadly b******t?

 

At 11/21/2005 11:06 AM, Blogger Orac said...

I have a brief clinic break due to a patient no-show; so I'll take this opportunity.

I'm sorry about the technical jargon, but I wanted to make it clear that I had read the report. Also, my article had become a lot longer than I had planned, and I didn't want to make it longer still. Perhaps I should have simplified some parts of it.

Tonight or tomorrow, if I get time, I'll try to add some links to technical terms for readers to follow if they wish.

Oh, and I'l fix the mispelling later.

 

At 11/21/2005 11:29 AM, Anonymous AndyD said...

DrYak:

As far as I can tell, the whole 'HIV-Denial' thing is because of a desire to blame it on people's lifestyles. I'm not sure how it keeps going (or why people bother) apart from people refusing to give up entrenched positions.

Mind you, I've also met people online who thought that the patent rights of US companies are more important than the lives of Africans... ugh.

 

At 11/21/2005 11:34 AM, Anonymous DawnCNM said...

As a medical person, I understood the information, but can easily see that non-medical people might have trouble with some of the terms. Your offer to add links is a kind one. My heart goes out to Eliza Jane, who died unnecessarily. I hope her brother survives to adulthood in good health. By the way....don't you have to be an M.D. to be a pathologist?

 

At 11/21/2005 12:07 PM, Anonymous PaulG said...

Lord Runolfr - Here's a suggestion: keep plugging away at the entry and if you run into a technical or medical term that you don't understand, do a search on Wikipedia. Don't be upset with Orac, though; as a professional, he understands that his words will be judged at least in part by their conformity to the normal manner in which people in his profession present things. Making it simpler often introduces error, which the Deans of this world (well, OK, he's not qualified, but you know what I mean) would jump on in an attempt to discredit his post. Better by far to be technical and accurate than nontechnical and potentially sloppy.

 

At 11/21/2005 12:24 PM, Anonymous HCN said...

First off... I am an engineer. This means I am not a scientist, but taken enough science to understand how it should work AND to admit when I do not understand something. I am very good at looking things up, hopefully from sources that are reliable. This, I hope, makes me different from either Dean Esmay (what is his training anyway?) and Fumento (who has been known to change his opinion with enough evidence, sometimes).

In the course of the last (cough, cough) 17+ years I have had to learn lots of biology (something I avoided due to an unfortunage incident in the 7th with a frog dissection and a sadistic lab partner). The reason was giving birth to a child who has turned out to be much too interesting (the kid hit the genetic "jackpot" from seizures, learning disabilities, migraines, hypertrophic cardiomyopathy - a severe genetic heart condition, and on to what may be a requirement to see a psychiatrist for what seems to be obsessive behavior and tics). I made the mistake when he was a year old by taking the advice from a "Natural Baby Care" book and giving him diluted apple juice instead of Pedialyte during a bout of gastrointestinal illness. The apple juice made it worse, and he had more seizures because he became dehydrated. That book was burned in the fireplace.

Over the years I have encountered many different "medical" theories. From having my son's conditions blamed on milk, flour, vaccines and neglect (???)... that cures should include Doman-Delcato patterning, various supplements, some odd oils, cranialsacral therapy and more recently various kind of chelation. In the past few years I learned how to wade through the mass of MISinformation.

One thing I have found common with the major sources of MISinformation is that there is often a sales pitch involved. Another thing is a rewriting of history (one thing the HIV/AIDS deniers are now saying is that the hemophiliacs that contracted AIDS got it from the medication, not realizing that most of the hemophiliacs DIED before the drug cocktails came out!).

PLUS... they seem to rely on the word of a few "maverick" scientists who are at odds with established medicine, especially those in public health departments. These "mavericks" are sometimes sincere, but may have decided that with their PhDs (and most importantly TENURE) can rewrite the science.

What gets me is that we are told over and over again to not trust the FDA, CDC, WHO, county coroner offices and even our county health department. Excuse me? What makes my county health department part of a conspiracy? What reason would the LA Coroner's office want to look for something other than what the data shows?

Why in the world would I want to trust someone with questionable medical credentials (who may be also selling "treatments")... or may be an ambulance chasing lawyer ... or a journalist looking for a bestseller... or a politician looking for votes over county employees?

Sorry I rambled, but I must push on.

 

At 11/21/2005 3:17 PM, Anonymous Dianne said...

One minor quibble related to the following quote:

"So who is Mohammed Ali Al-Bayati, PhD, DABT, DABVT? He represents himself as a toxicologist and "pathologist." ...So what kind of pathologist is he? "DABVT" stands for Diplomate, American Board of Veterinary Toxicology; so basically he's a veterinary pathologist and toxicologist."

Correct me if I'm wrong, but isn't DABT Diplomate, American Board of Toxicology? If so, he does have some qualifications as a human as well as vetrinary toxicologist. I fail to see any pathology qualifications in any of his titles, but maybe the toxicology qualifications imply pathology qualifications as well?

Excellent post, by the way. After reading it, I wonder how Maggiore could have failed to notice that her daughter was ill long before she acquired the illness that killed her? The poor child had HIV encephelopathy, probably of long standing. Didn't Maggiore notice anything wrong? She has another child and should have noticed that her daughter's development was not normal.

 

At 11/21/2005 3:28 PM, Blogger Lord Runolfr said...

I certainly don't want Orac to dilute the content of his message, but the message needs to be accessible as well as accurate.

Linking the terms will go a long way toward providing that accessibility. There are also ways to arrange content so that terms are quickly defined without sacrificing much readability, and I have faith that Orac will be able to to that when he has a little more time to put into the piece.

 

At 11/21/2005 4:21 PM, Blogger John Stone said...

I really hate the term "AIDS deniers" because I have been lumped in with the crazies from time to time. I tend to fall in the HIV "necessary, but not sufficient" camp. (Although in the face of treatment successes my position is weakening.) If anyone is really into the questions a legit scientist would have of the HIV=AIDS model, I would suggest reading Robert Root-Berstein (although his book is pretty dated now). He is hardly a flake and I would like to think I am not one .... but if I am, I have plenty of company out there.

When I first saw AIDS samples I was stuck by the presence of "rosette formations", like in the old LE clot tests. That did (and does) smell to me like an idiotype/antiidiotype reaction.

 

At 11/21/2005 4:51 PM, Anonymous Anonymous said...

Liz here from I Speak of Dreams. Excellent essay, Orac, thank you.

I too am a lay reader, and I urge you to leave your language as it is. In addition to the points made by previous commentators, I thought:

Among other things, in the Brave New Medical Order, patients are expected to be sophisticated consumers -- to be able to understand "medicalese". By reading lucid essays such as yours, I am slowly gaining vocabulary and sophistication, which I expect will serve me well in the future.

 

At 11/21/2005 6:25 PM, Blogger Orac said...

John,

There's a big difference between thinking that there may be other factors that exacerbate or alter the pathogenesis of HIV/AIDS and denying altogether that HIV is the primary cause of AIDS. The first, although as you say, seeming less likely, is not necessarily unreasonable (depending on the specifics, of course), whereas the latter is.

 

At 11/21/2005 7:56 PM, Blogger Lord Runolfr said...

Orac,

I appreciate the added definitions; they make the article much easier to understand. Most online sources I've found define medical jargon in terms of more medical jargon, leading to a long series dictionary lookups, whereas you've give both the proper medical term and a plain-English explanation. That gives you a chance to learn the term in its proper context. *Applause*

 

At 11/22/2005 12:29 AM, Anonymous Bruce McNeely said...

Orac, in my opinion your post is flawless.
As a pathologist (MD, certified by US and Canadian boards), I can confidently say from the information given here that this poor child died of AIDS. This would be true on the autopsy findings alone, not to mention clinical grounds.. Al-Bayati s objections are ridiculous. He may call himself a pathologist, but a PhD with toxicology certification is a clinical chemist. He has no professional expertise in interpreting autopsy findings except for biochemical findings. I bet that he has no histology training beyond undergrad biology and no histopathology training or experience whatsoever. He is a fraud.
To answer dawncnm s question, yes, you do require an MD to practice human pathology. Some researchers in pathology have the PhD only, but they are research scientists in the field, and do not do clinical work. Clinical chemists and toxicologists do perform analyses and interpret chemistry results in clinical practice, but they are not referred to as pathologists. They are clinical chemists and toxicologists.

 

At 11/22/2005 2:05 AM, Blogger Pinko Punko said...

Thanks Bruce- love it when people with expertise chime in.

 

At 11/22/2005 3:45 AM, Blogger OutEast said...

Smashing job, old boy!

Not convinced that the book=conflict of interest argument is all that logically tenable, though - sure the guy has a vested interest in being right, but so does every expert. It wouldn't be valid to discredit (say) Sean B Carroll's opinions on Evo-Devo because he has books published on the subject, would it? It seems to me that even in this case the argument that the book constitutes a conflict of interest is not itself valid without a prior acceptance that he's flogging snake oil - and thus begs the question.

Secondly - was it just me, or was that the sound of Orac breaking into song with his 'first ten diagnoses'?

 

At 11/22/2005 6:24 AM, Blogger Orac said...

Bruce,

Thanks,

If you wouldn't mind, I'd love it if you would look at the PDF file of Dr. Al-Bayati's report, which can be found at the URL I listed, and let me know if I left anything out.

 

At 11/22/2005 7:28 AM, Blogger Orac said...

OutEast,

Maybe that wasn't the right way to put it. The book was pointed out because it indicated that Dr. Al-Bayati is a dedicated member of the HIV/AIDS denialist camp. Perhaps I should have phrased it as an indicator of his strong bias on this issue. I doubt that his writing this "pathology report" will sell many more of his books.

 

At 11/22/2005 8:20 PM, Anonymous Chris Noble said...

I think that the point is not that Al-Bayati is a card carrying member of HIV Denialism but that he has a history of logically challenged conclusions that defy science, reason and truthfulness. This is not an ad hominem attack. If Dean wants to portray him as an expert then let's look at his expertise.

His basic argument deals with supposedly HIV free AIDS cases. If HIV did not cause the AIDS then something else must have. He concludes that corticosteroids are the culprit and manages to involve them somehow in every AIDS case using some wierd and wonderful logic.

Lets start with his HIV free AIDS cases that he talks about in an interview with another paragon of illogic.

"Dr. Al-Bayati: My investigation was focused on finding the causes of AIDS and the link between HIV and AIDS. When I found that HIV is not the cause of AIDS, then the issue of the HIV test became unimportant. In fact, I have found that the majority of people who participated in the major four AZT clinical trials that were conducted in the USA between 1986-1992 were HIV-negative prior to their treatment with AZT and their diagnoses were based only on clinical symptoms."

"The four published clinical trials are (1) Fischl et al., The New England Journal of Medicine 317 (4): 185-191 (1987); (2) Fischl et al., The New England Journal of Medicine 323 (15): 1009-1014 (1990); (3) Volberding et al., The New England Journal of Medicine 322 (14): 941-949 (1990); and (4) Hamilton et al., The New England Journal of Medicine 326(7): 437-443 (1992). Briefly, a total of 2,482 patients participated in these studies, and only 22% were HIV-positive prior to their treatment with AZT and the rest of the subjects were HIV-negative
(62%) and untested (16%)."


Anyone can go to the library and read these 4 papers and they will find that all of the studies had entry criteria that involved being HIV positive on one or more antibody tests. All patients were HIV positive. Al-Bayati's claim that only 22% were HIV positive is - ummm - somewhat economical with the truth.

At one point I emailed Al-Bayati to ask him about that and his response was "I am the expert" and "I am willing to defend that in court". Neither gave me much confidence in his expert opinion.

Now take a look at how he manages to involve corticosteroids in every AIDS case.

Here is an interview he made with a fellow Denialist. The amusing (or depressing) point is where the interviewer brings up the subject of amyl nitrites or "poppers". The interviewer is apparently a Duesberg supporter and is expecting Al-Bayati to agree with Duesberg too. Well- not quite. Al-Bayati apparently agrees with Peter Duesberg that "popper" use is correlated with Kaposi's Sarcoma but comes up with a wierd and wonderful alternative explanation for the link.

Abuse of "poppers" causes headaches.
Take aspirin for headaches.
Aspirin causes thrombocytopenia.
Presribed corticosteroids for thrombocytopenia.
Corticosteroids causes AIDS and KS.

This explanation is more of a unicorn than a zebra.

Anyone that presents Al-Bayati as an expert or reliable authority has major problems distinguishing science from pseudoscience and medicine from quackery.

Again this is not an ad hominem attack. The same patterns of illogic and fanciful explanations are in his "report" on Eliza Jane. The balance of evidence strongly supports the hypothesis that Eliza Jane died from AIDS related pneumonia. The improbable chain of explanations in Al-Bayati's report are credible to only one group of people - those who deny that HIV causes AIDS.

If you managed to listen to the interview without suffering from nausea you would hear what Al-Bayati says about his "articles" on AIDS that he has "published" in the BMJ. Here is his bibliography. Al-Bayati claims that his BMJ "articles" have gotten him a lot of publicity and clients. This brings me to my pet peeve. The pseudoscientific trait of targetting lay audiences. Scientists and doctors reading the BMJ rapid responses would recognise them for what they are - un reviewed electronic letters to the editor. Some of Al-Bayati's lay audience seem to think they are articles published in the BMJ. I don't think this accidental.

 

At 11/22/2005 8:54 PM, Blogger Orac said...

Very amusing. I had thought about mentioning that he claims to have several BMJ publications about AIDS, but in reality all he lists are letters to the editor. Letters are not really peer-reviewed, not in the manner that manuscripts are. The editor picks which letters get published. These don't even rise to that level, appearing to be electronic letters to the editor. In fact, these rapid responses seem more like a discussion forum than a letters to the editor page!

No wonder a Medline search turned up nothing by Al-Bayati about HIV

 

At 11/22/2005 10:54 PM, Anonymous Chris Noble said...

The previous editor of BMJ Richard Smith introduced the Rapid Responses. They allowed the essentially unmoderated submission of "articles" by anyone.

The only criteria was that it was not libellous. There was no control for factual content. Al-Bayati could lie as much as he wanted to but I couldn't call him a liar. The Rapid Responses came to be dominated by - errrgh - alternative scientists like HIV-rethinkers and the anti-vaccination crowd. Doctors and scientists knew that the content of these posts had nothing to do with the BMJ and that the BMJ did not support the content or vouch for their accuracy. However the same wasn't true for more credulous lay-audiences.

Previously if you did a search on the BMJ website for the keyword "HIV" the majority of returns were Rapid Responses by HIV-rethinkers or people like myself responding to them. The same was true for searches for "vaccine" and "autism". Finally the BMJ changed the search function so that Rapid Responses were not included in the default option.

Eventually the BMJ stopped accepting Rapid Responses on HIV-rethinking and MMR/autism but not for the right reasons. I think it was the amount of time they were spending maintaining the RRs that was the deciding factor and not the desire to present balanced and accurate information.

 

At 11/22/2005 10:55 PM, Anonymous Bruce McNeely said...

Orac, I had a quick look at the report. I cant give you a complete takedown, but here are a few of the more obvious errors:
Al-Bayati has a sneaky way of ignoring information that weakens or contradicts his arguments. If he were to present this report in court, the cross-examining attorney could tear it to shreds IF he or she had the assistance of a real pathologist. For instance, a lot of the evidence he gives for Parvovirus could also and more plausibly apply to HIV. They re both viral infections after all.
I also have a problem with his explanation for the aplastic anemia. The child had a severe microcytic hypochromic anemia, but had a normal platelet count, and a relatively mild neutropoenia with lymphocytosis. Except for the anemia, the blood count is entirely consistent with reaction to a viral illness, not aplastic crisis. The anemia looks like an iron deficiency or chronic disease, however, the marrow was hypocellular. Perhaps there was a differential red cell hypoplasia, but, of course, HIV can do this too.
The discussion of the lung lesions is terrible. He claims that the medical examiner did not see any of the characteristic features of pneumocystis pneumonia, but then goes on to mention foamy casts as being caused by pulmonary edema. Utter BS! Pulmonary edema causes a homogeneous pale fluid deposit in the alveoli. Foamy casts equal PCP until proven otherwise. Positive GMS stain confirms this. This is Pathology 101. Al-Bayati doesn t know Jack!
I could go on, but my blood pressure cant take it, especially after seeing the picture of the child on the link. I have 2 young daughters, so forgive me...
One other thing, no one seems to think anything unusual about a supposedly healthy child having a 10th %ile weight at birth, 30th at 5.5 months, and 5 %ile at 3 years 1 month. Something was going on with her, and it wasn t Parvovirus or Amoxicillin allergy!
Hope this helps.
Bruce

 

At 11/22/2005 11:51 PM, Anonymous Chris Noble said...

Al-Bayati seems to trying to cover up something with the weight of the child.

When I calculate weight percentiles I get
birth 32 %ile
1y 10 %ile
1y9m - 3y3m <3 %ile
3y6m 15 %ile

After her first her first birthday she was under the 3 percentile until just before her death.

I wonder what the actual coroner's report said.

I wonder what else was in the coroner's report that Al-Bayati fails to mention.

 

At 11/23/2005 4:21 AM, Anonymous Anonymous said...

I am a South African. Despite having a large proportion of the world's HIV positive citizens (about 30% if I remember), our government's official policy is that HIV and AIDs are not linked. And that healthy eating is all that is needed to cure you.

Different stories have come out over the years about why everyone is dying, but it was only when Nelson Mandela announced publicly that two of his children died of AIDS did some doubts start to be raised.

There is also a group who is promoting the idea that ARVs cause AIDS.

 

At 11/23/2005 7:43 AM, Blogger Orac said...

Bruce,

Thanks a lot. I didn't remember my pathology well enough from medical school to remember the pathological features of pulmonary edema. I meant to look it up before posting but ran out of time.

The whole parvovirus thing is a pile of B.S. parvovirus can cause erythrocyte hypoplasia, but it's very rare for it to do so without either (1) a preexisting hemolytic anemia like sickle cell or thalassemia or (2) serious immunodeficiency. It's rare for it to cause a problem in a perfectly healthy girl, which is how EJ is being represented.

Bottom line: This is a legal document written for a lay audience for PR purposes and designed to cast "reasonable doubt" on the coroner's report. Except that the doubt isn't so reasonable in this case.fkmg

 

At 11/23/2005 7:44 AM, Blogger Orac said...

Chris,

Interesting observation.

 

At 11/23/2005 1:49 PM, Blogger John said...

Orac,

Great essay, but it's kind of like shooting a flea with a fusion beam -- or perhaps debating relativity with a four year old.

Dean is from another world, a world where logic is a foreign concept. I don't know how people in Dean's world draw conclusions, but I suspect it's based on profit and the adoration of devotees. Since you're providing neither profit nor dopamine rushes I don't think you'll have much impact on Dean.

It's a great venting though!

Cheers,

John (of Gordon's Notes)

 

At 11/25/2005 1:08 PM, Anonymous Deetee said...

Orac, perhaps I can add an Infectious Disease clinician's perspective on the report. Firstly, I am not a pathologist, but alveoli packed with pneumocystis and foamy pink exudates in conjunction with EJ's initial chest radiograph which revealed pulmonary infiltrates adds up to only one thing - clinical PCP.

A comment on the amoxicillin allergy. The evidence for this is so weak that if the same criteria Al Bayati uses were applied universally one could conclude that just about every sick child had experienced an allergy. Where was the allergic rash which is pathognomonic of amoxil allergy? Why does Al Bayati confuse people with dozens of references to liver damage caused by amoxicillin-clavulanic acid, when EJ never recieved this particular drug (the reactions are different, and liver toxicity with amoxicilln alone is exceedingly uncommon). Well done on pointing out that amoxicillin does not cause hepatic steatosis - I get the impression Al Bayati has merely entered "amoxicillin" and "liver" into a web search engine, and listed all the hits as unambiguous references verifying his assertions.

Secondly, Parvovirus. As you say, it causes a characteristic rash (erythema infectiosum), but 99% of clinical cases will cause a rash of some description. Again - where was EJ's rash?

Al Bayati has obviously tried to come up with a reasonably sounding answer to the problems posed by a child dying from pneumocystis pneumonia with atrophy of the thymus/lymphatic organs, and background encephalitis (who we assume had not only positive HIV serology but also HIVp24 in the brain). Since he cannot come up with a single "cause" that is even remotely plausible, he invokes several concurrent alternate pathologies, each of which is quite atypical in its presentation in EJ's case.

Until we heard what was in the coroner's report, I was keeping a relatively open mind as to what actually killed EJ. For instance it might have been Haemophilus pneumonia - she was supposed to have had Hib otitis preceding the collapse. But even then, this would have been an avoidable tragedy - remember EJ was not vaccinated by her parents (a simple measure that could have avoided pneumonia).

Given a few hours to think on it, I am sure I could come up with something far more plausible that Al Bayati has done.
(HIV dissidents note! Expert for hire!)

 

At 11/30/2005 8:50 PM, Anonymous Anonymous said...

Orac, quite agree that it took awfully long to get a denialist "pathologist" to come up with a AIDS debunking fantasy to conger up all the alternative possibilities for Eliza Jane's death.

Al-Bayati's report is something in the realm of ... if Eliza Jane had a half dozen seriously obscure medical anomalies and those anomalies had yet more anomalies, and so on ... she would have died of conditions that look exactly like AIDS but it wasn't.

The LA Times reported that the county coroner found lethal microbes in this kid and that she died of infections brought on by the severe collapse of her immune system, period.

Is it possible that she was abducted by an alien craft and injected with lethal - yet earthly - microbes and robbed of her immune system and that ET caused her death and not the ravages of unchecked HIV? Sure, I suppose. Never say never.

Don't laugh - that's basically Al-Bayati's premise. That all the biological, scientific evidence should be ignored for the remote possibility that a convoluted series of unlikely events occurred instead. Sort of like claiming the hail of bullets didn't kill Al Pacino in Scarface by presenting the alternative hypothesis that he might have had the very common CMV virus and it could have caused a terribly uncommon illness which could have triggered off a fatal cerebral hemorrhage a second before the first bullet hit him. So he technically could have died from the cerebral hemorrhage and not the 437 bullets that entered his body.

Yeah, of course, why didn't I think of that? And what if zebras are monkeys and monkeys are zebras.

 

At 2/05/2006 6:08 AM, Anonymous Anonymous said...

You wrote, " Unfortunately, Dean provided no link to the original coroner's report (apparently it is not publicly available);...."

At his website one is provided with a link inviting interested parties to read the 'Report'. The link goes via a redirection, to the faux report of the zebra enthusiast you talk about in your blog.

 

Links to this insolence:

Create a Link

<< Home