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Yet another elephant in the room
- Alastair M Hull (16 March 2002)
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RE: "Shame: the elephant in the room"
- David Rasnick (17 March 2002)
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Re: RE: "Shame: the elephant in the room"
- Craig Michael Uhl, MD (18 March 2002)
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Re: RE: "Shame: the elephant in the room"
- Gary J. Minter (18 March 2002)
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Let's continue this debate
- Rudolf Werner (19 March 2002)
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Shame and the courage to admit negligence
- Christopher J Burns-Cox (19 March 2002)
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Pride rather than shame?
- melinda mary Roche (22 March 2002)
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Distinguishing behaviour from identity
- Peter Davies (23 March 2002)
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Re: Let's continue this debate
- Mitch Abrahams (25 March 2002)
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Re- Elephant in the Room: Shame
- Munir E Nassar, M.D., N/A (26 March 2002)
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Examining the issue of shame from a patient's perspective
- Bolanle Akinosi, R Nicholas Pugh, Consultant in Communicable Disease Control (28 March 2002)
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'...forgive him, for he knows not...'
- Mitzi MA Blennerhassett (1 April 2002)
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Syphilis: the "elephant in the room" of AIDS?
- John B. Scythes, Colman M. Jones (30 April 2002)
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Re: Syphilis: the "elephant in the room" of AIDS?
- John Nottingham (1 May 2002)
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Re: Re- Elephant in the Room: Shame
- Steve Walls (23 May 2002)
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Re: Syphilis: the "elephant in the room" of AIDS?
- Gary J Minter (12 June 2002)
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Endocrinologists at the forefront of Shame
- Pat Davis (18 June 2002)
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Shame -guilt
- Zbys Fedorowicz Fedorowicz (29 July 2003)
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SARS and “decompression sickness” – the “butterfly effect”?
- Colin M Wilson (30 July 2003)
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Alastair M Hull, lecturer, Mental Health Aberdeen Centre for Trauma Research, Royal Cornhill Hospital, Aberdeen, AB25 2ZH
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Editor
Davidoff's editorial on the role of shame in limiting improvements in health care is welcome and highlights a number of key shame foci [1]. These foci include those relating to feelings (e.g., depression), the body (e.g., acne)or its actions (e.g., sexual problems), achievement (e.g., failing exams), and group shame (e.g., either the mentally or chronically ill). However there remains within the article some confusion between shame and humiliation. This failure of distinction is not uncommon and indeed the two often operate together [2]. The examples illustrating the pervasive nature of shame demonstrate the overlap between shame and humiliation. Sensitivity to criticism, distress and the desire to protect oneself are common to both. The plight of the medical student described as lacking in dedication, the patient who fails to comply or to improve clinically, or the doctor being sued are complicated by more than just shame. The internal attribution typical of shame contrasts with the external attribution of humiliation. Many doctors caught up in malpractice claims will have a strong sense of injustice which may be accompanied by a desire for revenge (though this will ultimately remain an unrealised fantasy). In essence, when humiliated we are aware of what is done to us but do not agree with the judgement whereas when shamed our own internal sense of inferiority is confirmed. The patient or student who has tried their hardest would be more accurately seen as humiliated rather than shamed. Davidoff's editorial highlights the necessity of shifting the "performance curve" rather than shaming (and humiliating) those seen to fall outside acceptable levels. However, the statement that issues are less shameful as a result of "widely shared and openly discussed" fits poorly with models of shame. This strategy may instead lead to concealment rather than any fundamental change. Finally, the assumption that guilt and shame motivate moral behaviour is hard to sustain as there is a lack of empirical evidence suggesting the absence off these emotions causes a disinhibition of amoral behaviour. References 1.Davidoff, F. Shame: the elephant in the room. Managing shame is important for improving health care. BMJ 2002; 324: 623-4 2.Gilbert, P. the evolution of social attractiveness and its role in shame, humiliation, guilt and therapy. British Journal of Medical Psychology 1997; 70: 113-147. |
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David Rasnick, Visiting Scientist Dept. Molecular & Cell Biology, Stanley Hall, UC Berkeley, Berkeley, CA 94720
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The editorial "Shame: the elephant in the room" addresses what I think is one of the principal human failings that prevents professionals from not only acknowledging but even seeing what they're doing. It makes one tremble to think of the shame doctors will have to endure when the people of the world find out that they had gotten it completely wrong about AIDS. The contagious, HIV hypothesis of AIDS is the biggest scientific, medical blunder of the 20th Century. The evidence is as large as an elephant that AIDS is not contagious, sexually transmitted, or caused by HIV. Shame is the main obstacle to exposing this simple fact. It is the fear of being so obviously and hopelessly wrong about AIDS that keeps lips sealed, the money flowing and AIDS rhetoric spiraling to stratospheric heights of absurdity. The physicians who know or suspect the truth are embarrassed or afraid to admit that the HIV tests are absurd and should be outlawed, and that the anti-HIV drugs are injuring and killing people. We are taught to fear antibodies, and to believe that antibodies to HIV are a harbinger of disease and death ten years in the future. When you protest this absurdity and point out to health care workers that antibodies are the very essence of anti-viral immunity your objections are met with either contempt or embarrassed silence. The only way we can free ourselves from the AIDS blunder and bring an end to the tyranny of fear is to have an open international discourse and debate on all things AIDS. Anger will be a natural response to facing the enormity of the scandal of AIDS. Anger has its place but it should be put aside quickly. It is a mistake to focus on villains and on whom to punish. The AIDS blunder is a sociological phenomenon in which we all share a measure of responsibility. The AIDS blunder shows that we need to rethink and restructure our institutions of government, science, health, academe, journalism and media. We must replace the National Institutes of Health as the primary gatekeeper of research funding with numerous competing sources of funding. We must restructure the peer review processes of scientific publishing and funding so that they do not promote and protect any particular dogma or fashion of thought or exclude competing ideas. A robust and mean investigative journalism must be revived, rewarded and cherished. |
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Craig Michael Uhl, MD
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I for one applaud the honest introspection as noted in David Rasnick's letter. Physicians and the scientific community must be willing to accept errors in hypothesis made decades ago, especially with regard to the hiv/aids paradigm. We must be willing to re- evaluate, retest theories and open the flood gates toward the truth, even if we risk financial losses from grants from a myriad of sources. The history of science has been riddled with ebbs and flows of victories and failures, whether it be as simple as vitamin deficiencies, treated medically, when a simple vitamin would have sufficed, as in the cases of Pellagra and Scurvy. I am thankful that your journal was willing to open these flood gates toward an open and honest discussion regarding this vitally important topic, called hiv/aids, as much is left to be learned, and many of the supposed foundations of this paradigm need to be discarded, so that new scientific studies devised by new young scientists unencumbered by the past, may render new solutions for the future regarding this vitally important global issue. Craig Michael Uhl, MD
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Gary J. Minter, epidemiologist NC Department of Health and Human Services
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I respectfully disagree and agree with David Rasnick's response to the above article, "Shame: the elephant in the room." Disagree, because I believe that HIV is the primary cause of AIDS. Agree, because as one who has worked with AIDS both professionally and personally since the mid-1980's, I feel that science has been too often subverted in favor of marketing and profit margins, and that an honest and open discussion of AIDS issues is needed. The almost total neglect of immune-based therapy approaches during the first decade of AIDS awareness is just one example of serious problems regarding the scientific, medical, and governmental response to AIDS. I invite readers to read brief essays on a 1992 theoretical treatment model for HIV and other viral diseases, on the need for universal health care, and on the pervasive influence of pharmaceutical firms in all aspects of AIDS research and treatment. Sincerely, Gary James Minter
(the views expressed in this letter are those of the author and not his employers) |
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Rudolf Werner, Professor Dept. of Biochemistry U. of Miami School of Medicine, P.O. Box 016129, Miami FL 33101 USA
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I thought the day would never arrive when a reputed medical journal finally allows a debate of this hot topic. After 100 billion dollars spent over a 20-year period on a poorly supported hypothesis and nothing to show for it, it is about time. Perhaps it will make some physicians think before they prescribe deadly drugs to treat a phantom virus. Last fall a progressive associate dean for medical education at the University of Miami, who created the motto "evidence-based medicine", agreed to a debate between science and medical faculty on whether HIV causes AIDS. Many freshmen medical students thought the arguments presented by the MDs were less than convincing. Topics included the faulty viral load test which is used to determine efficacy of antiretroviral drug regimens. Quantitative PCR is mathematically impossible. Why has no one ever been able to show in a Northern blot experiment the presence of HIV RNA, which should be possible if the calculated millions of virions per ml of blood really existed? Is it possible that the presence of antibodies against retroviral proteins is the result of an immune deficiency (or other stress situation) rather than the other way around? Endogenous human retroviruses have been shown to be released from the genome under stress situations. The diagnosis of being HIV-positive has cost too many lives. Let's continue this debate and finally apply sound scientific method which is so sorely needed. |
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Christopher J Burns-Cox, Honorary Consultant Physician Frenchay Hospital BS16 1LE
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Sir, Davidoff's view rings true and shame about a doctor's behaviour is never discussed. It takes courage to admit negligence but it is dishonourable not to do so. This not only affects the doctor immediately concerned but, especially in a specialty with small number of members, the whole specialist group whose members may defend each other and refuse to act as expert witnesses for the plaintiff. Shame thus prevents justice from taking place. Action for Victims of Medical Accidents has formed a doctors' group and this is just the sort of problem it is trying to address. yours sincerely Chris Burns-Cox |
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melinda mary Roche, student Liverpool L34EE
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I am interested to note there is no use of the word 'pride' in these discussions. I thought that was what I was reading about. Unless pride is diagnosed and named it can never be treated appropriately. Humility is usually the best antidote. |
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Peter Davies, GP Mixenden Stones Surgery, Halifax, HX2 8RQ
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Sir, Davidoff's editorial (1) graphically illustrates the power of shame saying, "it goes right to the core of a person's identity." There is another way of seeing this that I, and I hope others, will find useful. The view I am using is derived from the work of Robert Dilts and Michael Hall on logical levels (2,3) Dilts sees the human brain as working in hierachies starting at the level of environment (where?), moving up to behaviour (what?), capabilities (how?), values (criteria),beliefs (why?),identity (who?)and beyond this to spirituality or connectedness to other people and the bigger world. Each level modulates the expression of the lower levels. Generally change at a higher level results in bigger changes in behaviour than changes at a lower level. Our behaviour in the world is an expression of our beliefs about ourselves. Mixing up levels quickly leads to toxic frames of mind. As Davidoff's example showed the physicians prescribing tolbutamide had mixed up their behaviour (prescribing tolbutamide) with their identity (making a false equivalence between their behaviour in prescribing and who they are as people). If the problem had been seen simply at the level of behaviour an alteration in prescribing practice would have been no great event in anyone's life. It would simply have been implementing new knowledge (beliefs) at the level of prescribing behaviour. People's identity would not even have been challenged. How much easier life is, at both personal and organisational levels, when we learn to deal with information at the right level of our mind. The chuches for many years have had an approach of hate the sin and love the sinner. How would it be if we could shamelessly and joyfully bring this approach into medicine and its regulation? 1. Davidoff,F Shame, the elephant in the room. BMJ 324:623 (16/3/2) 2. Dilts,RB, Dilts,RW, and Epstein,T (1991) Tools for dreamers: Strategies for creativity and the structure of innovation. Cupertino, CA Meta publications. 3. Hall, LM How Meta-States enriches logical levels in NLP www.neurosemantics.com/Articles/MS_In_Logical_Levels.htm Declaration of Interest. I am currently studying for my master practitioner certificate in neuro-linguistic programming. |
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Mitch Abrahams, CEO BioMolecular Sciences 13701 Marina Point Dr. # 346 Marina Del Rey CA 90292
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I have been an advocate for HIV associated disease and CFIDS for almost 5 years. I have been fortunate to meet some interesting people in my work because I also raise money for Biotechnology. It seems here we go again getting into this debate over HIV does/ does not cause AIDS. Why does it seen that there are 2 extreme views? Why is it that since I go by the view that HIV is Highly associated with AIDS that some consider me a dissident? Did anyone read the study published by Luc Mongeneir in 1983? (Forget the Durbin Decleration- "Decleration of Ignorance" this is BS not a study - read the references and see www.chronicillnet.org) As you may recall it never said a pure isolate HIV is the sole cause of AIDS. So what we have may be a fairly good marker. But not the only smoking gun. Interestingly as a relative layperson I find this easy to understand. Now I do hear there are a subset of patients that have something called Idiopathic CD4 T-Cell lymphocite Openia( Excuse my spelling). Sounds awfully like non- HIV AIDS to me! What about people suffering from Chronic fatigue Immune dysfunction syndrome? Also sounds like non- HIV aids to me! Sorry, fellow Aids advocates but they are suffering too! There is research on people that have died of "AIDS" without the occurrence of HIV. See www.chronicillnet.org and look up some of the research by Howard Urnovitz. Anyway, what I am saying is clearly there are other Co-Factors in this HIV associated disease and it is about time we encourage other scientific debate/ research in this area. And while I do not believe that HIV is the sole cause of AIDS, I certainly would prefer not to have unprotected sex with someone that has this HIV marker in their blood because while the Isolate hasn't proven to be the cause, who the hell knows what else could be transferred along with it! So I do think that encouraging people that HIV is not sexually transmitted probably is a risky idea! It's kind of like telling everyone theres no proof that people in Africa are dying form HIV just because their Epidemiological statistics are based on computer models! After all, while you could never convince me they are all dying form HIV, people are dying and sick! But thats another story... |
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Munir E Nassar, M.D., consultant 17 Cobblefield way, pittsford, New york 14534-2566, N/A
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Dear Sir: I would like to disagree with Dr Davidoff's paper(1) and suggest a better alternative than "shame". If for the sake of argument, the information about the deleterious effect of tobutamide on the myocardiun became retroactively known to physicians prescribing it, the duty of those physicians would be to immediately inform their patients taking tolbutamide to discontinue the drug. The patients I think would be grateful for the physicians vigilance concerning their care. There is no shame because of a specific ignorance or lack of information that was not available initially about the effect of tolbutamide on the heart. Such a problem has no malice or preconceived harm toward the patient. Such a problem is fortunately not very common in clinical practice. Recently it has surfaced with the class drug Cox 2-inhibitor in patients with Rheumatoid arthritis and its untoward effect on first occurrence of heart failure and on promoting relapse of heart failure(2). If the word "shame" is to be used, which I think it is out of context, blame maybe a better word directed to the researches and the business promoting machine of the drug firms, for lack of accuracy in the work they are supposed to do on a particular drug prior to its introduction on the market. References 1- Davidoff F; Editorial, BMJ March 17 2002 2- Feenstra J et al: Association of NSAIDS and First Occurrence of Heart failure and Relapsing Heart Failure.Arch Int Med Vol 162 #3; Feb. 11,2002. |
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Bolanle Akinosi, Specialist Registrar in Public Health Medicine Walsall Health Authority, Lichfield House, 27 - 31 Lichfield Street, Walsall WS1 1TE, R Nicholas Pugh, Consultant in Communicable Disease Control
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Editor, The BMJ editorial titled “Shame: the elephant in the room” (1) examines the issue of shame mainly from a service provider’s perspective. It highlights the improvements necessary in order to improve the safety and quality of medical care. It states “countering shame can motivate health care providers to learn and improve, bolstering their competence and their sense of self worth leading to better quality service provision”. It is also important in our view, to examine the issue of shame from a patient’s perspective. A topical example is the national strategy for sexual health and HIV (2).This is a welcome step towards addressing a worrying increase in both the incidence and prevalence of sexually transmitted infections (STIs), particularly among young adults and teenagers. Many still consider STIs a moral issue with the resultant negative attitudes towards cases persisting even among health care providers. This increases the stigma and shame that patients with STIs feel when having to talk about their problem. Patients have great difficulty talking about their sexual health and initiatives targeted towards primary care such as update courses on taking a sexual history are to be applauded. It is embarrassment and shame that prevents patients from seeking help from available services, and also leads in many cases to reluctance to inform their sexual contacts due to the shame of admitting the source of infection may have been outside of an established relationship. The message that all services for STIs are confidential needs to be put across, particularly for school children, teenagers and young adults. Victims of sexual assault with or without alcohol intoxication are in a special category. These individuals have been both physically and emotionally traumatised, and suffer feelings of fear and shame. Emergency services and law enforcement agencies have mechanisms built into their systems to deal with these issues, but cases do not always present to them first. Concerns about STIs need to be dealt with sensitively. Improvements in communication between parents and their children, sexual partners, school nurses and students and general practitioners as a first point of contact between the patients and available services is key to scaring off this elephant that patients inevitably carry around with them. Bolanle Akinosi, Specialist Registrar in Public health Medicine R. Nicholas Pugh, Consultant in Communicable Disease Control Walsall Heath Authority, Lichfield House, 27-31 Lichfield Street, Walsall WS1 1TE Correspondence to akinosib@ha.walsall-ha.wmids.nhs.uk References 1. Davidoff, F. Shame: the elephant in the room. Managing shame is important for improving health care. BMJ 2002; 324: 623-4 2. Department of Health. The national strategy for sexual health and HIV. London: Department of Health, 2001. www.doh.gov.uk/nshs/index.htm |
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Mitzi MA Blennerhassett, cancer self help group secretary, lay representative royal colleges' patient liaison groups Slingsby, York YO62 4AQ
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As a cancer patient whose bad experiences were a direct result of closed, defensive attitudes (BMJ 1998;316:1890-3) I was left damaged, incredulous and needing answers. Despite later pleas for change in the name of humanity, the total refusal to stop practices which caused unnecessary suffering and pain seemed due only to the shame which would follow if past and current practices were acknolwedged to be unacceptable. Surely this, more than any other factor, is what has prevented clinicians from learning from one another, contributed to low cancer survival rates, and continues to hold back healthcare improvements. Consultants have long been accused of arrogance. Universal recognition of their dilemmas, of having to admit some degree of failure before they can change and improve, might allow them to take that first step - acknowledgement of reality. How might patients, patients' organisations and consumer groups extend a helping hand? By discussion, liaison, demonstrating understanding and acceptance of the past without blame; by involvement in medical education at all levels we could open minds and open doors to brighter futures for clinicians and patients. |
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John B. Scythes, Director Community Initiative for AIDS Research, 32 Beaty Avenue, Toronto, Ontario, Canada M6K 3B4, Colman M. Jones
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Professor Davidoff is quite right to point out that great harm is often done by inappropriate treatments whose safety and efficacy were established as often by anecdotal evidence than by rigorous review. We are now learning, for instance, that the coxibs that selectively inhibit inducible prostaglandins also inhibit a physiologically important pathway. Parts of the COX-2 pathway are physiologic - especially for kidney and heart function - and therefore not only pathologic. This has led to ongoing changes in the guidelines for selective COX inhibitors. With respect to harm, some of the earlier hypoglycemic drugs may be similar to the triple-drug anti-HIV therapies now used in the developed world to treat AIDS. In fact, the harm from HIV treatment may turn out to be a much bigger tragedy than that from older hypoglycemic drugs, selective COX inhibitors, or for that matter, treatments like out-patient anti-arrhythmics and all the teratogens. AIDS physicians spend far too much of their time managing the often horrific side effects of the current anti-retroviral regimens, such as dislipidaemia, hypertension, lipodistrophy, heart attack, stroke, kidney failure, cytochrome P-450 interference/liver failure, fatigue, anaemia, depression, etc. In addition, these regimens, while seemingly reducing the number of deaths in the short-term, have resulted in unusual and unexpected changes in AIDS-defining events. (1, 2) This has cast confusion as to when - or even if - to initiate these triple-drug treatments. (3) We may be witnessing a repeat of the situation with zidovudine ten years ago when, despite early hopes, the largest and longest study in asymptomatic individuals with HIV demonstrated little - if any - survival benefit, (4) with the earlier higher dosages causing substantial morbidity. The lack of progress in achieving sustainable benefits with the HIV- based lifelong regimens, and in developing an efficacious HIV vaccine, has led AIDS "dissidents" such as David Rasnick and Peter Duesberg to posit that the aetiology of AIDS needs to be re-assessed. They point out that in some contexts HIV/AIDS appears to be quite difficult to transmit. They cite the lack of evidence for heterosexual transmission of T-cell subset abnormalities from hemophiliacs to their spouses, (5) as well as the recognized absence of HIV seroconversion or AIDS among health care workers with documented percutaneous HIV injuries. (6, 7) Later studies suggest this phenomenon may in fact represent natural immunity to HIV, as evidenced by high levels of HIV-specific CD8-bearing cytotoxic T- lymphocytes. (8-10) However, in the well-studied male homosexual cohorts in the industrialised West, AIDS does seem to be overwhelmingly associated with sexual transmission. This is why most HIV treaters, and even some AIDS dissidents, (11) while acknowledging gaps in our understanding of pathogenesis, cannot reconcile the Duesberg/Rasnick non-infectious aetiology (based on drugs and malnutrition) with the many multi-partner homosexual men who apparently share only sexual exposure as an AIDS risk. Aetiologic hypotheses may therefore need to be expanded to include other immune regulating infectious diseases that could be a co-factor for the nearly irreversible loss of CD-4 helper cell-driven anamnestic responses in AIDS. (12-15) The resulting down-regulating cytokines from such a disease, transmitted through blood products - cytokines which would escape viral inactivation techniques - could then contribute to the immune suppression in transfusion cases, in coagulopathies and globinopathies, (16-19) and in mother-to-child AIDS, given the intimate relationship between the course of disease in children and the severity of the disease in their mothers. (20) Chronic exposure to these immuno-regulatory molecules from infected individuals - whether transmitted during ongoing haemophilia treatments, breast-feeding, or immune system ontogeny in utero - may well play as important a role as HIV in the induction of AIDS. In the industrialised West, the most likely infection that could best set the stage for the immunology seen in HIV/AIDS, (21-29) often undetected and untreated (30-33) among homosexual male blood donors preceding the modern AIDS epidemic, is Osler's Great Masquerader - syphilis. Both the Olso (34) and Tuskegee (35) natural history studies of untreated syphilis, as well as many other authors, (36-49) have raised the likelihood of excess mortality from long-standing untreated syphilis, i.e. deaths not associated with late lesions but due instead to pneumonia, consumption and cancer. This idea faded into the background, however, amidst the euphoria surrounding the efficacy of penicillin in early acute syphilis. It is generally accepted today that current syphilis screening techniques are sufficiently sensitive to diagnose the disease in HIV- infected persons. It should be noted, however, that the current concept for detecting syphilis in most of the world is still based on the Wassermann reaction. This was first developed in 1906 to detect non- specific auto-antibodies to cardiolipin extracted from liver emulsions of still-born syphilitic babies. Despite a strong correlation between reactivity in this non-specific screening assay and symptomatic or acute early syphilis, this indirect method is not sensitive for assessing prevalence of the disease as a whole, nor always reliable in detecting the incidence of the acute infectious stages. (50-52) To make matters worse, these anti-lipoidal tests (including the modern reagents used today) have never worked well for re-infection. This was demonstrated by several experimental investigators in the 1940s and 1950s, using both animal and human subjects. (38, 53-58) In some of these models, infection and/or re-infection with T. pallidum was symptomless and often produced no reaction in the Venereal Disease Research Laboratory (VDRL) test, i.e. the sensitivity could approach zero, despite proven dissemination of T. pallidum. Patients who no longer react to re-exposure in the VDRL these days are perhaps "syphilised", to quote a term first coined by Joseph Auzias-Turenne (1813-1870). He observed that after catching syphilis a few times, the classical symptoms were never seen again. (59, 60) An elegant summary of this ongoing phenomenon was made a century later by Evan W. Thomas, one of America's greatest authorities on syphilis: "Within 2 years after infection, untreated syphilis produces immune changes in the host which, with rare exceptions, are permanent and make it impossible for tissues to react to subsequent infection with development of early syphilitic lesions." (50) Thomas made this assertion after following over two thousand treated patients in New York City, where he saw only one exception to this rule. The introduction of penicillin did not alter this finding. This failure to develop early lesions again upon re-exposure has important implications for the reliability of the non- treponemal tests, which have been widely trusted for decades, including in populations at risk for multiple exposures. Investigators have repeatedly issued warnings about the very high rates of syphilis among multi-partner homosexual men. (61-63) Classical understanding teaches that the specific treponemal antibodies (as measured by the TPHA, FTA-Abs, and TPI assays) remain for life in virtually all individuals with secondary or later stage syphilis - treated or not. Given the overwhelming epidemiologic correlation between syphilis and HIV, (64- 66) it follows that there should be a high rate of treponemal antibody in this population. To test this assumption, back in the late 1980s investigators at the Toronto Hospital began screening HIV-infected men - presumably at great risk for syphilis - using quantified treponemal tests. They found, much to their surprise, precipitously falling titres of these specific antibodies to T. pallidum among many of these men, often in the absence of any evidence of syphilis diagnosis or treatment. (67, 68) Of the 500 HIV- positive men ultimately screened, not one reacted in the VDRL test. (69) The sero-reversion of treponemal antibody, which has been reported by others, (70-72) is found often among men who never knew they had been infected with syphilis. This loss of antibody also appears to be selective within the polyclonal activation associated with progressive HIV infection, (68, 73) i.e. antibodies to other infections remain at the same levels. This could be due to chronic persistence of the disease in spite of treatment, (74) or symptomless reinfection. Whatever the mechanism, it remains unclear why syphilis never behaves as an opportunistic infection among HIV-coinfected patients. (75) Or is HIV, as some have suggested, (76 -78) the actual opportunistic infection here? Some HIV patients who have no history of treated syphilis, nor recent VDRL reactivity, have been found with T-cell-independent IgM responses to T. pallidum, suggesting an active infection. (79) This finding was recently documented again in Toronto. (80) Using recombinant T. pallidum antigens and SDS-PAGE, investigators here screened 557 random, non-nominal specimens from clinics serving high-risk homosexual populations. They found 27 cases of syphilis, i.e., a prevalence of nearly 5%, in stark contrast to the Ontario annual incident rate of under 0.001%. Furthermore, 56% (15/27) had detectable anti-treponemal IgM. Only 33% (9/27) were detected by the MHA-Tp (equivalent to the European TPHA) at the standard cut-off, and none were VDRL-positive. This may suggest defective antigen processing. Sexual contacts had never been traced for 74% (20/27) of these newly-identified latent cases, nor likely ever will be. These diagnostic concerns may well extend beyond the HIV/AIDS context. The Ontario Public Health Laboratory, as a syphilis serology reference lab in North America (along with those of James N. Miller at UCLA and Sandra A. Larsen at the CDC), banked many biologic false-positive specimens collected during routine screening. In other words, the specimens reacted in the VDRL, but were non-reactive in the standard MHA- Tp confirmatory test. However, applying the newer standard described above to 119 specimens, the Ontario lab flagged 11 as possibly syphilitic. Six results were equivocal, and five were indubitable positives by Western Blot. (80) The families, contacts, and individual patients have not had the benefit of this knowledge. At least one other center has documented this problem with false-negative treponemal testing in HIV injection drug- users. (81) It is therefore urgent that clinicians worldwide re-screen all their patients - including those without HIV - for treponemal antibody using better tests until revised guidelines are issued. A better understanding of the treponematoses, such as syphilis, will then likely become an integral part of AIDS care. An improved detection system should ideally be based on batched recombinant treponemal antigens. (82) Confirmation of an inappropriate immune response to syphilis can then be provided by IgM-SDS PAGE, direct detection by PCR of treponemal DNA, (83) or a strip assay (84) where individual recombinant antigens bind the antibodies. These kinds of assays are available, some licensed commercially, and costs are often comparable to existing VDRL/TPHA technology. The quality and safety of health care may materially benefit when blood donor lots are additionally screened with better treponemal tests, and the syphilitic cases further evaluated. As well, earlier findings of low T-cell levels in populations with high syphilis rates (85) should be re-assessed. There is now ample evidence to have another look at the Great Masquerader. We may learn that syphilis plays a role in AIDS beyond merely facilitating HIV transmission - and may have done so for centuries, as a result of the "syphilisation" effect on the Gell and Coombs Type IV immunologic recall. (86) Is syphilis the "elephant in the room" of AIDS - to quote Professor Davidoff, "something so big and disturbing that we don't even see it, despite the fact that we keep bumping into it"? (87) Our continued reliance on a nearly century-old diagnostic concept for such a deadly infectious disease may well be seen as a shameful act in years to come. John Scythes
Colman Jones
Toronto, Canada
More of these concerns can be found online at
http://cbc.ca/ideas/Aids
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2. Langford TD, Letendre SL, Marcotte TD, Ellis RJ, McCutchan JA,
Grant I, et al. Severe, demyelinating leukoencephalopathy in AIDS patients
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John Nottingham, Consultant histopathologist Northampton Genral Hospital, NN1 5BD, UK
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The "rapid response" by John Scythes to this article has 87 references. This is more than the average review article in a specialist journal. Whilst it is undoubtably of interest to a specialist, as a letter to a general medical and lay audience, surely this is somewhat over the top. No competing interests. |
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Steve Walls, Consultant Greenwich Hospital, London, UK, SE10
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Mitch Abrahams - 25 March 2002 - writes about his middle-ground position where HIV is neither 'sole-cause' nor 'non-existent' in relation to AIDS, he however makes an awkward comment in relation to AIDS in Africa. He seems to promote the idea that some action should be taken against this 'unknown' disease in Africa, though it is uncertain exactly what action he would suggest should be done. It appears as though he's advocating that this action should take place in precedence over determining the actual cause of the death and sickness. This I find totally irresponsible. He only needs to put himself in the following position to see how he would feel... "You go to see your doctor, but unfortunately there is no-one you can speak to. Fortunately though, you're in luck, because there's a very qualified team of doctors and statisticians from the first world who are sitting at a desk with a fancy computer behind a large glass window. All you need to do - along with everyong else from your village - is stand in line and walk past the window. Then, come back tomorrow once they've analysed the results of the (visual) test and developed the latest and greatest cure for your illness - One pill to cure all ills! Don't worry if it doesn't work, or makes you feel even more sick, they'll come up with a new 'better' pill soon enough." Africa's problems are great: * They've got bigger things to deal with than AIDS - how about poverty first? Then development that creates jobs, health and education? Of course, in the meantime you still need to make sure they have the medication for REAL, TREATABLE, IDENTIFIABLE diseases like TB, maleria, syphalis, etc. The only pill that will cure Africa is the triple-cocktail-therapy of: * CANCEL THIRD-WORLD DEBT, * PROVIDE RELEVANT INVESTMENT FOR DEVELOPMENT, * ENSURE CONTINUED EQUAL FAIR TRADE. After all, it's the pill that first-world countries offer to their citizens and neighbours all the time. ALSO; Munir E. Nassar M.D. - 26 March 2002 - writes that "blame" is a better word than "shame" if applied to who he sees as the problem - researchers and pharmaceutical big-business (not physicians). I can't see how physicians get to avoid blame. A lawyer who advises a client on old or not-quite-up-to-date law cannot claim ignorance when the client blames him for shoddy work. Similarly, it is physicians' responsibility to keep informed of ALL areas of research pertaining to their skills as well as the GOOD AND BAD of drugs available (not only those that big-business markets). It is surely the physicians' responsibility to know what others are saying about the efficacy of drugs - not only what the pharmaceutical firm tells them. Further, I don't think that society (NOTE - and therefore also the individuals in society) should take blame in those places where society has set up organisations to provide assistance to physicians in keeping up to date with medical developments (in both formal research and practical consensus remedies). Provided that there are also organisations that provide assistance to patients in recognising where and when they might be getting bad advice from physicians, drug companies and the general media. Phew... what a lot to say!! |
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Gary J Minter, founder, TEST--Truth and Ethics in Science and Technology North Carolina Department of Health and Human Services
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It's been ten years since I worked with syphilis, so I may be a bit rusty, but I seem to recall that with or without treatment, blood titers of antibodies to Treponema pallidum slowly fall over time. With proper treatment of 2.4 mu benzethine penicillin, one shot in each buttock, the syphilis bacterium dies and there is no need for the body to continue to produce antibodies, because there is no antigen present to trigger the immune response. Without treatment, the immune system does successfully suppress the syphilis bacterium, though not totally. Due to this partially-successful defense, again there are lower levels of antigen and antibody titers decline, though more slowly than with successful treatment. I do not think syphilis co-infection is a necessary co-factor for HIV infection to progress to AIDS. There are far too many cases in which syphilis was not present, yet which have progressed to AIDS. I think HIV is quite sufficient by itself to cause AIDS, and needs no cofactors whatsoever. All people are resistant to HIV infection, to varying degrees,except those rare people born with no functioning immune system. The human immune systems does successfully suppress HIV infection after a couple of months following initial infection, as do monkeys infected with their species' SIV, or other mammals infected with various other lentiviruses. This is why rates of HIV transmission through sex are extremely high (one out of three exposures) during early HIV infection, when the virus is still replicating unchecked, and extremely low during the period after primary infection, when the immune response has partially controlled the HIV infection. This phenomenon was clearly shown by the work of Christopher Pilcher's team at UNC-Chapel Hill last year, and by others. Interestingly, the same is true of syphilis. Rates of transmission of syphilis are extremely high during the sympomatic primary and secondary stages, the first couple of months after initial infection. Once the immune system has begun its defense against Treponema pallidum, syphilis is basically non-contagious, as is HIV, except that HIV is still highly contagious through blood transfusions, sharing contaminated needles, etc. I suspect the same is true of many other diseases as well. That is why I've been such an early and vigorous advocate of immune-based therapy for HIV, because the immune system is capable of suppressing the infection quite well in many people. But the immune therapy must be systematic, comprehensive, and strain-specific, and must be continually altered to account for the escape mutant viral quasispecies of HIV which will inevitably arise in the infected host. I attempted to account for this problem in my 1992 model for treatment of HIV and other viral diseases, which is on the following website: www.minter-g.com I suggest this approach to treatment for viral infections, including HIV. Sincerely, Gary James Minter
disclaimer: the opinions expressed in this letter reflect those of the author and not of his employers. |
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Pat Davis, Thyroid Group Helper Home
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The entire Endocrinological world should hang their heads in total shame at the way they treat Thyroid patients and ignore with contempt their ongoing suffering The obstinate insistance that Thyroxine / Synthyroid and Thyroid Blood tests especially TSH are PERFECT and must be defended at all costs is doing a huge diservice to countless millions of suffering patients Those very few enlightened Doctors who have dared to speak out on the subject and use lateral thinking or unconventional treatments/ medications on their patients and have suceeded in restoring to health those patients whom the Establishment Endocrinologists have thrown on the scrapheap have been witchunted into oblivion by sheer jealousy of success and an arrogant refusal by the Establishment to admit that they are WRONG Far far too many thyroid patients are "Sick and tired of feeling Sick and Tired " on useless Thyroxine Start giving them T3 or Armour Thyroid and just see those patients regaine their lives Then reinstate pioneering doctors who showed the way back into a profession they loved and a disease they actually understood |
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Zbys Fedorowicz Fedorowicz, Studies &Research Bahrain
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It is important to make the distinction between these as they are often used interchangeably and frequently incorrectly. Shame is and external issue whereas guilt is personal internal and is therefore not visible but it may have the same effect on the 'shamed'. There are cultural differences. In certain parts of the world shame or face are the most serious of 'deficiencies' and often linked to honour. Guilt may appear a non issue and with seemingly no noticeable effect on the individual There may even be a sense of achievement in managing to avoid detection. Competing interests: None declared |
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Colin M Wilson, GP / Anaesthetist Lorn Medical Centre, Oban, PA34 4HE
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There have been over 8500 cases of SARS worldwide with over 800 deaths from this condition. With these numbers there has been a large morbidity and a huge amount of fear generated worldwide. It, however, has not been recognised as a contributory cause of decompression sickness (the bends) in scallop divers in the West Coast of Scotland. We should be reminded of the chaos theory as originally described in the early 1960’s by Edward Lorenz, a mathematician and meteorologist. He described the string of seemingly unrelated links creating a completely unpredictable result as the “butterfly effect”. i.e a butterfly flaps its wings in South America causing a tornado in Texas. A man sneezes in a crowd in China SARS becomes a health problem The people of Japan stop going out socially Japanese restaurants have a downturn in their trade with a reduction in the demand for the delicacy razor-shell fish Razor-shell fish divers in the West Coast of Scotland no longer have a market so start diving for scallops Scallop diving is much deeper Divers get decompression sickness (DCS) We at the Dunstaffnage Hyperbaric Unit, have seen and treated 6 cases of DCS in the first 6 months of this year in scallop divers when the usual incidence is 1 to 2 per year. I rest my case Competing interests: None declared |
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