While I am on vacation, I'm reprinting a number of "Classic Insolence" posts to keep the blog active while I'm gone. (It also has the salutory effect of allowing me to move some of my favorite posts from the old blog over to the new blog, and I'm guessing that quite a few of my readers have probably never seen many of these old posts, most of which are more than a year old.) These posts will be interspersed with occasional fresh material. This post originally appeared on November 30, 2005 and is the followup to the first article I did (reposted earlier today). I debated whether to repost these, mainly because there's a chance that a flood of HIV "skeptics" might disrupt this blog. However, I think it's worth reposting because it illustrates the pseudoscientific techniques that HIV "skeptics" like Dr. Al-Bayati use. These also feed into a post that I might do after the 1st. I am also aware that Dr. Al-Bayati, apparently stung by the justified criticism of his first report, has apparently prepared a second, "updated" report.
As regulars may recall, about a week and a half ago, I got a little riled up at having my honesty questioned by a certain blogger who doesn't think that HIV causes AIDS. This same blogger, Dean Esmay, has been commenting fairly extensively over the last couple of months about Eliza Jane Scovill, an unfortunate child who died tragically, collapsing suddenly after an upper respiratory infection and an ear infection. At autopsy, the coroner found, among other things, Pneumocystis carinii pneumonia and HIV encephalopathy, leading him to conclude that Eliza Jane died of complications due to AIDS.
It's a tragedy any time a child dies of AIDS or any other disease, but this case would not have garnered any press attention had it not been for the fact that Eliza Jane's mother, Christine Maggiore, happens to be a very high profile member of a movement that professes "skepticism" (more like outright denial, actually) that HIV causes AIDS, despite the overwhelming scientific, epidemiologic, and clinical evidence to the contrary. Based on her belief, she had refused to take antiretroviral drugs or to have Eliza Jane tested for HIV. Although I have no reason to believe that she was anything other than a loving mother otherwise and no mother should have to suffer such a horrible loss, she was tragically incorrect in her decision. Dean Esmay, of course, vigorously defended her to the hilt.
What prompted my initial response was a "pathologist" report by one Dr. Mohommed Al-Bayati that purported to "rebut" the L. A. County Coroner's conclusions regarding this unfortunate child's death. Actually, it wasn't exactly the report itself, but rather it was Dean's mention of me (and others who had spoken out against the dangerous pseudoscientific myth that HIV doesn't cause AIDS) as he trumpeted the report as "proof" that Eliza Jane didn't have AIDS and lambasted the coroner and the L. A. Times for a "political diagnosis in order to grandstand." (Oddly enough, he never explained why the coroner, much less the L. A. Times, would want to "grandstand" over this case.) Oh, and Dean implied that I was dishonest and accused me of "lynch mob prejudice." Annoyed, I wrote a long and rather detailed (not to mention occasionally sarcastic) rebuttal of Dr. Al-Bayati's report, a rebuttal that Dean never bothered to respond to, although I knew he knew about it from the comments in his own blog. (Maybe the verbiage and admittedly excessively technical jargon scared him off. If so, good.)
Now, two other health care professionals have weighed in on this tragic case, and they both agree with me.
First up is Trent McBride, a pathology resident who blogs at Catallarchy. He has now presented an excellent explanation of why the Al-Bayati report is full of holes. He's also a lot less--shall we say?--vociferous than I was, but he nonetheless takes down Dr. Al-Bayati's claims with a calm, polite demeanor that's devastating. Given the way that Dr. Al-Bayati appealed to the definition of pneumonia from a single pathology textbook ad nauseam to claim that Eliza Jane couldn't have PCP because she didn't have "pneumonia," I particularly like the way that Trent turned the tables on him and quoted him back several definitions from pathology textbooks that totally support the conclusion that the findings in Eliza Jane's lungs were entirely consistent with--nay, even pathognomonic of--PCP pneumonia. Trent also found another feature that I missed and am now kicking myself for not having picked up on. Remember how I went on about how the steatosis of the liver (fatty infiltrate) described on the autopsy was not consistent with acute liver injury from amoxicillin-clavulanate? Trent agrees, but he also found a tidbit that I should have looked up. It turns out that steatosis is very common in pediatric AIDS patients. It was originally thought that this AIDS-associated steatosis was due to antiretroviral drugs used to treat AIDS, but Trent found a study that shows it's quite common in patients before they've ever been treated. True, steatosis is not in any way specific for AIDS, but it is entirely consistent with AIDS. Excellent work, Trent.
But that's not all. Nick Bennett, an MB/Ph.D. (he's British, hence the M.B. Chir instead of MD) is a pediatrics resident whose Ph.D. thesis concerned the molecular biology of HIV. He runs a blog called AIDS Myth, in which he routinely rebuts the distortions and selective evidence use of the HIV/AIDS "dissidents." (Now that I've plugged his blog, I just hope he updates it more often.) Dr. Bennett was also kind enough to e-mail me a PDF file containing his point-by-point rebuttal of Dr. Al-Bayati's report, and Trent was kind enough to host it for us at Catallarchy. You can download the PDF of Dr. Bennett's response to Dr. Al-Bayati here or here.
Dr. Bennett covers a lot of the same ground as Trent and I did. He nicely takes apart Al-Bayati's attribution of Eliza Jane's collapse to an anaphylactic (allergic) reaction to amoxicillin on clinical grounds. He points out that multinucleated giant cells in inflammatory lesions in the brain without granulomas are very characteristic of HIV encephalitis, even if it hasn't manifested symptoms yet. He says basically the same thing as Trent and me with regards to Al-Bayati's bogus attempt to blame parvovirus for the Eliza Jane's anemia. All of this is different in emphasis and better on some details, but Dr. Bennett's unique contribution to debunking Dr. Al-Bayati's report comes from his perspective as a pediatrician. Using that experience, Dr. Bennett does something that I (and I daresay Trent) probably never would have thought to do (neither of us being pediatricians or primary care doctors). He takes a much closer look at Eliza Jane's growth curves:
I note that Al-Bayati says that EJ's weight is within the normal range for a child of her age. She is according to him within the 5th centile for her age, but a proper growth chart plot shows that she in fact suffered from a striking failure to thrive from the age of approximately one year. Although she did indeed gain 22 pounds during her life, a child born at 7lbs of weight is expected to weigh 4 pounds more than she did at the age of her death (a difference of around 15% of her actual body mass). In addition, it is clear that this final weight is an aberration from her normal growth curve, as if she had continued along her past track she should have only weighed 26-27lbs at the time of death. The extra 2 lbs (around 900 ml equivalent) is perhaps accounted for by the additional fluid found within and surrounding her organs at the time of death. As such, it appears more likely that the fluid accumulated over time, rather than as a result of simply moving out of the vascular spaces, as if that would have happened her total mass would remain unchanged. Alternatively it may simply be a result of the fluid boluses given to her during resuscitation - without being able to see the actual medical notes I can't say either way. A significant resuscitation of 40ml/kg would account for around half of that additional volume.
He concludes:
As such, it would appear to me that EJ had some form of significant clinical problem for the 2 and a half years prior to her death, regardless of her status regarding other childhood illnesses (which by all accounts was unremarkable). Her weight is in lower centiles by my reckoning than what Al-Bayati states, but that may simply be a result of using different growth charts or rounding-up to the nearest line. These charts are the current (2002) versions from the CDC website, accessed Nov 2005. The lowest line is the 3rd centile, which EJ generally remains below. In basic terms, if around 100 kids of the same age were lined up, EJ would have been the smallest.There is a possibility of a metabolic disorder resulting in failure to thrive, but since she did so well for the first 12 months of her live, I don't consider that a real possibility. Regardless of cause, aged 3.5 years she weighed only as much as a 2.5 year old would normally weigh (and remember, she was born smack in the middle of the spread, at 7 lbs).
He further concludes that there is good evidence that her failure to thrive and fluid accumulation may have been due to nephrotic syndrome due to Minimal Change Disease, a kidney disease that shows little or no change in the kidney structure on biopsy and can be precipitated by HIV infection. Whether he's right or not about this (this is clearly more speculative than his points about parvovirus, amoxicillin allergies, etc.), he makes a compelling case, and that diagnosis as a cause of EJ's generalized edema is one I never would have thought of. Also, if the data regarding Eliza Jane's weights at various ages are correct, Dr. Bennett's analysis also casts doubt on the HIV denialist claims that Eliza Jane was "perfectly healthy" all her life. She may have seemed healthy, but if there was indeed a failure to grow it should have tipped off her pediatricians that something might be wrong. But you really should read all of Dr. Bennett's analysis. It's quite accessible to the lay person.
So how did Dean react to Trent's rebuttal of Dr. Al-Bayati's report?
He repeated the same canard about Pneumocystis being 100% ubiquitous, which Trent rebutted and ignored all the substantive criticisms of the report that Trent and I had made. And then he called me dishonest again.
And how did I react to Dean's impugning my honesty a second time?
I laughed. (Never let it be said that I don't learn from experience to consider the source.)
Oddly enough, though, Dean seemed the most annoyed by a throw-away comment I had made about how he liked to argue from authority a lot and tended to wave Dr. Duesberg's credentials around like "a talisman to ward off attacks against his pseudoscientific posturing." (OK, perhaps that was a bit more of a rhetorical flourish than I needed to use; but give me a break; I was on a roll.) Quoth Dean in the comments:
I tried reading Orac's response, by the way, but it was so full of false accusations that I couldn't get through it. The man argues first and foremost through attacks on others' credibility. I do not, for example, "wave credentials" at anybody, not for my friends or detractors. I note only that credentials do matter, and that in any area of science, a qualified scientist should be respected as having the right to a dissent, even if it's a minority position, AND, that one shouldn't treat qualified scientists as kooks or people who can be dismissed with an airy wave of the hand. That is all I have ever said on the subject of credentials; Orac's dishonesty in this leads me to the (admittedly ad hominem) conclusion that he can't be trusted to be honest on anything else.
Of course, notice (as Joseph did) that Dean neglected to point out a single instance of a "false accusation." Surely if I'm that dishonest, it should have been child's play to point one example of my "dishonesty" out. Second, he characterizes my debunking of Dr. Al-Bayati's nonsense as being primarily an ad hominem attack, when in reality I spent about one paragraph on Dr. Al-Bayati's credentials (or lack thereof, actually) and many long paragraphs addressing the meat of his report. Truth be told, I had learned some unflattering things about Dr. Al-Bayati's previous work that I could have pointed out but intentionally refrained from doing so in order to focus on the report itself. (I will not go into them here, either.) If all you knew about what I wrote is what Dean said, you'd have thought that all I did was to trash Dr. Al-Bayati, when in fact questioning his credentials was a small part of what I wrote.
But the funniest thing of all is that, a couple of comments before his broadside at me, Dean had confirmed exactly what I said about his penchant for arguing from authority. How? He had waved Dr. Al-Bayati's credentials about (metaphorically speaking), of course! But that wasn't enough. He had also pointed out an endorsement of Dr. Al-Bayati's report by Andrew Maniotis, Ph.D., someone whom Dean termed a "Professor of Pathology at the University of Illinois at Chicago." Well, not exactly a Professor, Dean (at least not a full Professor), but rather an Assistant Professor and a Ph.D. researcher. (To be fair, I did notice that his department web page hasn't been updated in a long time, making it possible that, since he finished his postdoc in 1997, he may have recently been promoted to Associate Professor). Also, Maniotis is not a pathologist, although most people, probably including Dean, wouldn't realize that from his title. (Most people just aren't aware that most academic pathology departments have Ph.D. basic science researchers on their faculties who are not pathologists but are professors of pathology; just because someone has the title of Professor of Pathology does not necessarily mean that person is a pathologist.) None of this, a priori, means he is wrong, but he's probably no more qualified to comment authoritatively on HIV than Dr. Al-Bayati. Also, Dr. Maniotis has just as much of a bias as Dean, Dr. Al-Bayati, or Christine Maggiore as shown by--surprise! surprise!--the fact that he just happens to have signed on to a letter by the Perth Group, to be on the Board of Advisors (with Dr. Al-Bayati) of the HIV/AIDS "dissident" group Alive and Well (founded by Christine Maggiore), and to have been characterized by Dean himself as thinking that "the HIV/AIDS theory is hogwash." (To be fair, though, I will give Dr. Maniotis props for doing what sounds like some rather interesting research on vasculogenic mimickry in melanoma and chromatin structure in cancer cells. I may even look up a couple of his articles to see what he's up to.)
In any case, I'm sure Dean is incapable of seeing the irony in his own statements and how his own response simply confirmed my assessment of him.