Fish, Durland

Durland Fish

State Joins Dispute Over Lyme

Scientists Battle Over Treatment

By MICHAEL REGAN | (Hartford, CT) Courant Staff Writer

August 24, 2007

DURLAND FISH, professor of epidemiology at the Yale School of Public Health, stands in the "Tickery," the part of his lab where Lyme disease-infected ticks are stored in refrigerators. Fish virulently disputes the attempt by a small group of doctors to discredit the short-term treatment he and other scientists recommend for the disease, and is resisting a subpoena from the state attorney general's office related to the challenge. (Photo: STEPHEN DUNN / August 1, 2007)

NEW HAVEN - Durland Fish, Ph.D., professor of epidemiology, leading authority on disease-carrying insects, is sitting in his paper-strewn office at the Yale School of Public Health. He is ticking down a list of physicians who disagree with him on the matter of chronic Lyme disease.

"This guy ..." Fish begins. "He cheated. He fabricated an article in the New England Journal of Medicine. He provided false results. The paper had to be retracted. He was banned from [National Institutes of Health] funding for a period of time. The guy used to be the director of some penile enlargement clinic out on the West Coast. I mean, this guy ... There's some problems with him."

He proceeds down the list, name by name: "Totally bogus." "He killed one of his patients." "They tried to shut him down." Words like "crackpot," "wacko," "buffoon" and "fraud" pepper his discourse.

A little later, he stops to ponder a question.

"I don't know," he says after a moment's thought. "I don't know why they hate me so much."

"Hate" may be too strong a word, but many in the chronic Lyme community return Fish's evident antipathy. With varying degrees of vehemence, he is accused of being part of - even a leader of - what they view as a conspiracy to deny chronic Lyme sufferers the care they need for reasons of pride and profit.

It is a resurgence of a long and heated dispute over the nature and treatment of Lyme disease. On one side are mainstream physicians and researchers, including Fish, who believe Lyme is a relatively straightforward infection that can be treated in almost all cases with no more than four weeks of antibiotics, although some effects of the infection, such as fatigue or joint pain, can persist.

On the other is a small but extremely vociferous group of doctors and patients who say it is much more serious and requires much longer treatment - years of intravenous antibiotics in some cases.

Now Fish is fighting a subpoena from state Attorney General Richard Blumenthal, who says Fish and 13 other experts may have improperly excluded scientific evidence of chronic Lyme when they issued guidelines last year for treating the disease.

How did a guy with no formal training in medicine find himself in the middle of what is perhaps the most virulent medical debate going on right now? One might say that it started with his being a bad restaurant inspector.

Fantastic Mosquitoes

The United States was in the process of doubling its force in Vietnam, to about 400,000 troops, when Fish graduated from Albright College in Redding, Pa., in 1966. He had a degree in biology and wanted to do graduate work on mammals. But with the draft looming, he opted instead for an occupational deferment.

"I went to work for the state health department, totally bored out of my mind inspecting restaurants. A terrible job, and I wasn't very good at it," Fish said. He hated imposing regulations on eateries just scraping by in the poor county where he was assigned. "I'm not a very good cop. ... I used to coach them on how to get by - how to cheat."

"I was on my way out," Fish said, when he was transferred to the regional office in Redding and given a job nobody wanted: tromping around the woods and swamps checking the stations set up to monitor mosquitoes and disease-bearing animals - in scientific parlance, vectors. He loved it.

"I thought, `You're going to pay me to do that?'" said Fish, who had grown up surrounded by woods in rural Berwick, Pa. "That got me interested in mosquitoes. I didn't know anything about mosquitoes - I thought they were fantastic."

Fish went back to school in 1970, but not to study mammals. He earned a master's degree in entomology from the ...

University of Massachusetts and a doctorate from the University of Florida, and did postdoctoral work at the University of Notre Dame. He then set out to look for a job doing research on mosquitoes. It was a struggle.

"It wasn't a fundable area. Nobody cared," he said. "You couldn't get any grants on it. Nobody cared about the ecology of vectors."

So in 1980, Fish went to work teaching general biology, ecology and medical entomology at Fordham University. Its campus was in the Bronx, N.Y., but Fish got to live at the university's research station in Westchester County. It was there he discovered the insect that came to dominate his professional life: the deer tick.

"I was doing some field work on mosquitoes there and these little brown ticks started showing up. Nobody knew anything about these ticks," he said. "I'd never seen them before. They weren't there in '80, maybe we just started seeing them in '81, a rare one. By '82 they were pretty easy to find."

The tiny deer tick had already infested southeastern Connecticut by the time Fish started finding them in New York, and had already been associated with what was beginning to be called Lyme disease. But no one was sure just how the disease was transmitted from tick to human.

In 1982, however, a researcher found that long, spiral-shaped bacteria called spirochetes were responsible for the disease. Fish got the news in a phone call.

"So I gathered up a bunch of these ticks and went down to Fordham and I was looking through a microscope," he said. "I saw these tiny little threads, about the limit of visibility under a microscope."

The discovery altered Fish's professional course.

"I said, `Geez, every other tick has these spirochetes in them'" Fish said. "Nobody knows anything about these ticks, there are a hell of a lot of them here, and half of them are infected. This is going to be a big, big problem."

"So I just dropped all the mosquito stuff and started working on ticks," Fish said. "It was a totally wide-open field. Anything you did was new."

Two Camps

And, as it turned out, controversial.

Within a few years of the discovery that bacteria were responsible for Lyme disease - which meant it could be treated with antibiotics - two camps developed: One saw Lyme as a simple, easily detectable and easily cured infection; the other believed it was an insidious, long-term disease capable of invading the brain and other organs and hiding its traces.

What the latter group lacked in mainstream scientific support it soon made up for in organizational clout. In 1992, for instance, when several presentations on chronic Lyme were rejected by the program committee for an international conference on the disease, angry advocates contacted members of Congress and the conference's sponsors to complain. The presentations were allowed back in.

Organizers denied that they were caving in to pressure. Accepting the presentations "was the human and nice thing to do," one told a reporter for the journal Science.

But Fish, a member of the committee that had rejected the papers, thought otherwise, and said so with characteristic bluntness.

"I'm damned annoyed," he told Science. "These lay pressure groups are interfering with research."

Even then the passions stirred by the issue were evident: Although the Science article quoted several researchers critical of the about-face, only Fish would allow his name to be used.

The debate was fueled last year when a group of 14 experts, including Fish, published Lyme treatment guidelines under the auspices of the Infectious Disease Society of America.

Those guidelines called for the use of antibiotics for no more than four weeks, disputed the existence of chronic Lyme and rejected treatments favored by the chronic Lyme community, including long-term antibiotic use.

That brought Blumenthal into the fray. Shortly after the guidelines were published, Blumenthal - long associated with Lyme patient advocate groups - began an antitrust investigation to determine whether the panel ignored scientific evidence that conflicted with its guidelines.

That investigation is still going on, Blumenthal said last week. His office has subpoenaed documents from IDSA and from members of the panel, he said; so far, the society has complied, but the members have not.

Blumenthal would not discuss details of the investigation. "I can tell you," he said, "that the information we've received so far has created very significant concerns about the process and about potential conflicts of interest."

Dr. Henry Masur, president of IDSA, disputed the notion that any society member could benefit from the guidelines.

"In fact, it would be better financially for IDSA members if our guidelines recommended the broadest possible diagnostic criteria (which would mean more patients, more people needing antibiotic treatment, more research dollars, etc.) and the longest possible course of treatment (which would mean more doctor visits, and more drugs and diagnostic tests being sold)," he said in a statement.

But Blumenthal's investigation heartened chronic Lyme believers, who have long claimed that the mainstream consensus is driven by conflicts of interest.

"There's a group represented by the IDSA that has staked out this position that Lyme disease is hard to catch and easy to cure, and they don't want to admit they're wrong," said Raphael Stricker, a San Francisco physician, the former penis enhancement doctor and current president of the International Lyme and Associated Diseases Society.

He and other chronic Lyme advocates say IDSA members stand to benefit financially from their position. Some, they say, have relationships with insurance companies that don't want to pay for extended courses of antibiotics or other long-term Lyme treatments. Others have interests in drugs or vaccines. Fish, Stricker contends, is in the latter group.

"He's really into supporting the party line and developing vaccines that can make him a lot of money," Stricker said. "He has a lot of patent interest."

Fish scoffs at such allegations. Yale had an interest in a vaccine that has been taken off the market, he said, but none of the Yale researchers who helped develop the guidelines stands to gain from them.

Besides, he says, it's the doctors treating chronic Lyme cases for months and years who have a financial interest in their position.

"If anyone has ... conflicts it's this group. I mean, they're making millions on this scam," he said. "This cast of characters here has some gall to challenge the Infectious Disease Society of America."

Stricker said pharmaceutical companies may make a lot of money on long-term Lyme therapy, but physicians don't. To Fish's remark on his previous work in penis enhancement, he said, "I wish I was still doing that. I could make a lot more money doing that than doing what I'm doing now."

Both his previous employment and a 20-year-old determination by the National Institutes of Health that he had falsified a paper - a finding he disputes - are "irrelevant" to his Lyme work, Stricker said. And he's dismissive of Fish's background as well.

"He and others in the IDSA camp make these kinds of statements: that this is all motivated by greed, that there's no chronic Lyme disease, that there's no reason to treat these people who are sick with these symptoms," Stricker said. "That isn't what patients want to hear. And they don't want to hear it from an entomologist."

But Gary Wormser, a physician and researcher at New York Medical College, says telling patients what they want to hear isn't necessarily good for them. The long-term antibiotic treatment advocated by many doctors who diagnose chronic Lyme disease can be harmful or even fatal, he said, but patients are convinced that it's the only way to cure their ailments.

"Many feel abandoned by conventional medicine and are desperately seeking help from somewhere. They are especially vulnerable to those who profess to have the answer, even if they do not," Wormser said. "We are very, very concerned about these patients."

Wormser, who headed the IDSA panel that drew up the 2006 guidelines, said they were based on repeated studies that showed that a brief course of antibiotics is effective in preventing or treating Lyme disease. Most people treated for "chronic Lyme" never had the disease at all, he said, and among those who did, no sign of the infection remained after standard antibiotic treatment.

As for Fish, he said his role on the IDSA panel and in the Lyme controversy generally relates only to his expertise about ticks, not to medical matters.

"I'm not an M.D. I don't have the training to be making recommendations on therapy or even to some extent diagnosis," he said. "But I understand science, and what's good science and what's bad science."

"This is a matter of good science vs. junk science."

Contact Michael Regan at mregan@courant.com.

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