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Paratuberculosis and Crohn's Disease: The Controversy
What is the Controversy?
The Controversy Simply stated, the controversy relates to the association of Mycobacterium paratuberculosis (also known as Mycobacterium avium subspecies paratuberculosis or MAP) and the suggestion that this agent is the cause of Crohn's Disease.

Although historically Crohn's disease has been suspected to have a mycobacterial cause, it was not until the early to mid 1980's that the successful growth of M. paratuberculosis from patients with Crohn's disease caused this suspicion to become a viable theory. Since that time there has been a great deal of data generated that conclusively establish that there is an association between M. paratuberculosis and Crohn's disease. What the data does not establish is whether or not that association is causal.

The Two Camps
This controversy has forced the gastroenterology and related fields into two separate camps: the "believers" and the "non-believers". The real controversy is not the differing views on the subject, but rather, the rigidity, bias, loss of objectivity, and general hostile attitudes of each group. Rather than listen to each other's valid criticisms and/or evidence, the respective groups dismiss the other side as misinformed, wishful thinking, etc.

How did the camps form?
When M. paratuberculosis was first isolated from patients with Crohn's disease, there was a great deal of excitement in the field(s) and many investigators sought to reproduce those findings. Results were mixed: some investigators confirmed the original findings while others did not. Those that were unable to find M. paratuberculosis in Crohn's disease patients proclaimed that the successful findings were contamination while those that were successful claimed that the failures were the result of inadequate methods. The end result was a "back and forth" dispute, which created the "hard-liners" in each respective groups.

The Believers.
I Believe! Simply put, the "Believers" believe that M. paratuberculosis is the cause of Crohn's disease. They base this belief largely on the fact that M. paratuberculosis causes a similar disease in domestic ruminants (cows, sheep, goats, etc) and that this organism can be detected in cases of Crohn's disease. It is essentially these facts, coupled with other circumstantial and suggestive evidence, that form the basic position of the "believers". They readily dismiss all criticisms as "misinformed" and fail to recognize the deficiencies and short comings of their own work and position.

The Non-Believers.
There are a host of different reasons why the non-believers hold their position. Those that are most frequently cited include the use of steroids would be contra-indicated in a mycobacterial disease making the disease worse rather than better; the inability to reproduce results (if I can't reproduce the results they must be incorrect; treatment with anti-mycobacterial drugs do not cure the disease; failure to fulfill Koch's postulates; the inability to see this putative agent in diseased tissues; etc. Although many of these reasons can be dismissed, some are valid criticisms; however, none are sufficient to validate the hard-liner's position and they fail to recognize the evidence that suggests a link.

The Effect of the 2-Camp System.
Debate and criticism can be good Debate and criticism within the scientific and medical community is healthy and beneficial, but only when it is productive and not detrimental. When a debate becomes hostile, as in the current controversy, both science and patients suffer. The camps become unable to be objective in their scientific endeavors, interpretation of data (their own and others), and bring scientific advancement to a halt. The hard-liners on both sides of the issue create a situation whereby funding opportunities become extremely limited and hinder scientific advancement. Both sides fail to recognize that the desire to prove or disprove often blinds people on both sides.

A similar situation occurred with gastric ulcers and Heicobacter pylori, whereby 2 opposing camps emerged and hindered progress for years. It took a third camp to resolve the controversy. Yet, even though Heicobacter pylori was determined by the National Institutes of Health to be the cause of gastric ulcers and Barry Marshall received the Nobel Prize in Medicine for his discovery, many continued to dismiss these findings and the National Institutes of Health embarked on an educational endeavor in an attempt to educate physicians.

Unless we learn from our mistakes, M. paratuberculosis and Crohn's disease is on the same path.

The Missing Camp
Microbiologists are the answer If M. paratuberculosis is causally related to Crohn's Disease, it is an issue that falls within the expertise of microbiologists and infectious disease experts. Yet these groups are not involved in the controversy. The question is why? And why have they sat quietly by watching this controversy continue?

There are actually several reasons. One of course is money. Most of the research money available for Crohn's disease is controlled by the "non-believers" and hence not readily available. Without adequate funding, there is no incentive or other reason to get involved. Secondly, the "believers" have alienated the microbiologists by redefining basic microbiological principles and definitions thereby putting into question all previous and current research data.

Microbiology The microbiologists and infectious disease groups will get involved in this issue, and bring an end to the controversy, but only when the field sorts itself out, returns to objectivity, and presents objective data that is reliable, reproducible, and addresses the criticisms, deficiencies, and etiologic issues related to this controversy.

Unfortunately, the field has continued in research pursuits that do not address the issues of causality that have served to drive the controversy. The issues of causality, controversy, and legitimate criticisms need to be addressed or the controversy will continue. That is where The Crohn's Initiative comes in.

The Real Questions
The real questions This is the 21st Century, not 1890, and time to dispatch with the old Koch's postulates. Even Koch himself recognized that many of his postulates could not be fulfilled in all cases and that, in some cases, his postulates could be fulfilled when the organism under investigation was not the cause. Dismiss these archaic notions and most of the criticisms - the real issue to Microbiologists and Infectious Disease Experts is that association does not mean causality. No matter how many times you show that M. paratuberculosis is present in Crohn's disease, it will not address causality.

It is well known that a variety of infectious agents can be detected in normal and diseased tissues and their mere presence does not mean disease or cause. Even Koch recognized that over 100 years ago. The higher prevalence in Crohn's disease (Reference: medical coding diagnostic number 555.9) can easily be explained by the disrupted mucosal architecture, the formation of deep intestinal crypts, and bacterial colonization. Thus, most of the research done over the last 15 years has added little to our knowledge. Showing it 100 times makes it no more meaningful than 2 times! The association is accepted - the question is causality, not association or presence.

The time is now to address the Real Question of Causality in an objective research effort that can rise above the controversy and resolve the issue of M. paratuberculosis in Crohn's disease.

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