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We here at SBM frequently warn about the infiltration of pseudoscience into what should be science-based medicine (i.e., conventional medicine) in the form of the “integration” of quackery into medicine under the label “integrative medicine.” However, that infiltration is often subtle, and a depressing number of integrative medicine advocates think that they are advocating rigorous science, when in fact they are doing anything but. Seldom, however, have I seen anything like what I saw in a post on For Better Science last week about famed Israeli scientist turned antivaccine “scientist” Yehuda Shoenfeld:

Yehuda Shoenfeld, the autoimmunity quack expert who loves associating with and taking money from the most notorious antivax characters, has been elected as member of the Israel Academy of Sciences and Humanities. The announcement was made on 16 June 2019, an official ceremony will take place in December during Chanukah, 2019. The reasons for this early Christmas present to antivaxxers around the world are unclear, but there is apparently big money and heavy networks involved.

Shoenfeld is portrayed as the godfather of autoimmunity research in Israel and beyond, because to him all diseases are caused by autoimmune reactions. Including autism, which according to Shoenfeld and his antivax friends is caused by inflammatory aluminium adjuvants in vaccines. For example, Professor Shoenfeld explained how aluminium in vaccines poisons people in a BMC Medicine video interview in 2013. The occasion was a paper in that journal which Shoenfeld coauthored and which contains fabricated data.

Besides my jaw dropping simultaneously as I double face-palmed after reading this, thus endangering my precious surgery hands with accidental bites, I had an immediate thought; well two actually. First, I wondered how on earth this could have happened. How could an antivax crank scientist be elected to the highest level of Israeli science? Second, it occurred to me that we haven’t written about Shoenfeld here on SBM nearly as much as we should. Maybe it’s because he’s not North American or European. Maybe it’s because he’s not that well known outside of Israel, other than in antivaccine circles. However, in antivaccine circles he is enormously influential, having invented the fake diagnosis ASIA (Autoimmune Syndrome Induced by Adjuvants).

I’ve not infrequently said that, when it comes to being a target of antivaccine pseudoscience and conspiracy theories, aluminum is now the new mercury, since mercury in the form of thimerosal preservative that used to be used in childhood vaccines was, in an abundance (or, as some have argued, and overabundance) of cautious application of the precautionary principle, removed from childhood vaccines in 2001. Since aluminum salts are still used as vaccine adjuvants, to improve the response to the antigens used in the vaccine and thus allow less antigen to be used, it was fairly predictable that antivaxers would turn their attention to aluminum. If you want to know one of the main reasons antivaxers have turned aluminum into the new mercury as a target of their fear mongering, look no further than Shoenfeld’s concept of “ASIA”. If you want to know why, other than sex and the sexually transmitted disease aspect, antivaxers concentrate on Gardasil and Cervarix (the HPV—human papilloma virus—vaccines), look no further than ASIA, because HPV vaccines use aluminum as their adjuvant. Indeed, antivaxers invoke ASIA (and other dubious inferences) to falsely claim that HPV vaccination can cause premature ovarian failure and even death.

Before I discuss ASIA and why it’s highly dubious at best, let’s first meet Yehuda Shoenfeld.

Who is Yehuda Shoenfeld?

When I started writing this blog post, my recollection was that I had first learned who Yehuda Shoenfeld was in 2011 when I reviewed an antivaccine propaganda film disguised as a documentary called The Greater Good (a precursor to Andrew Wakefield and Del Bigtree’s VAXXED by five years), where I noted the blurb at the end of the film’s closing credits that “this film was vetted by Dr. Lawrence D. Rosen, MD, FAAP and Dr. Yehuda Shoenfeld, MD, FRCP for scientific and medical accuracy.” Given that The Greater Good is pure antivaccine propaganda and that Dr. Rosen is an “integrative pediatrician” with a history of spreading antivaccine misinformation and was a speaker at a notorious antivaccine conference in Jamaica in 2011 with an “all-star lineup” of antivaxers including Andrew Wakefield, Barbara Loe Fisher, Lawrence Palevsky, Christopher Shaw, Lucija Tomljenovic, Russell Blaylock, and more, my initial impression was that Yehuda Shoenfeld must be antivaccine.

Of course, what I didn’t remember was that I had heard of Yehuda Shoenfeld three years earlier, thanks to Neurodiversity, the late lamented weblog of Kathleen Seidel. It’s no longer online, but thankfully it has been preserved by the almighty Wayback Machine at Archive.org. Let’s just say that, early in my blogging, Seidel taught me about Mark and David Geier (the father-son tag team of antivaccine pseudoscience and chemical castration as a treatment for “vaccine-induced” autism), the Association of American Physicians and Surgeons (AAPS), and many other things. It turns out that in 2007 she had written to Shoenfeld about an article by Mark and David Geier that he had published and then retracted in the journal he co-edited, Autoimmunity Reviews. The article had been about the Geiers’ biochemical “rationale” (if you can call it that) for using chemical castration to treat autistic children. In the letter, asked why the article had been retracted:

After the retraction, I learned that Dr. Shoenfeld received compensation from the the U.K. Legal Services Corporation for his service to plaintiffs in the now-discontinued MMR litigation, in which Dr. Geier was also involved.

I received no response to my original letter to Dr. Shoenfeld. A paper copy which I mailed to his office at Tel Aviv University was returned to me, marked “Not at this address.” My 23 January 2007 follow-up email remains unanswered. Dr. Shoenfeld has also been unresponsive to email and telephone inquiries by the journalist Brian Deer, who sought information about the retraction for the British Medical Journal.

It is my understanding that retraction is generally reserved for substantiated instances of scientific fraud or misconduct. Although I am pleased that Dr. and Mr. Geier’s paper was retracted, I am disturbed by Dr. Shoenfeld’s reluctance to respond to inquiries or to offer a substantive explanation for the retraction. The obligation to full disclosure becomes particularly urgent when a retracted study pertains to pharmaceutical experimentation on vulnerable, disabled children.

Shoenfeld didn’t answer. However, her complaint was echoed by Dr. Alan Tyndall of the University of Basel and Nobel-winning immunologist Dr. Rolf Zinkernagel. What was Shoenfeld’s response to them? Not good:

This issue between the lady and the Geiers is an emotional vendetta and not a scientific issue. The paper was not published in our journal!! We do not need any report to anybody except the authors why their paper was not published. I am aware of this lady “disease” also in other aspects and domains. She writes to all the world and it arrived to at a stage of nuisance. We have decided not to respond to any of her emails letters etc.

So Yehuda Shoenfeld was not only dismissive, but sexist as well, dismissing Seidel’s concerns as an “emotional vendetta”. She also documented Shoenfeld’s longtime association with antivaxers, particularly as an expert witness for the complainants. In this case, the lawyer was Clifford Shoemaker, who at one time had filed an overbroad fishing expedition of a subpoena against Seidel, which he justified by bogus conspiracy theories, including a particularly amusing bit about how Kathleen Seidel’s husband David had somehow has seized control of Wikipedia. (Bashing Wikipedia was every bit a pastime of cranks back then as it is now.) No wonder Seidel described Shoenfeld as an “eminently useful friend” of the antivaccine movement, and no wonder commenter Smut Clyde drily noted:

So Shoenfeld is identified with the anti-vaccine lobby, at least in the minds of anti-vaccine True Believers. His is the name most touted in tweets as proof that Real Science is on their side (with Drs Exley, Shaw, Gherardi and Luján as lesser authorities). I feel safe in predicting they will make the most of his induction into Israel’s Academy of Sciences as a vindication of everything they have said.

And:

But it may be that I am putting the tail before the dog, or letting the cart wag the horse, or something along those lines. Shoenfeld has also identified himself with the concept of autoimmunity, which he evangelises with prophetic, proselytic zeal, seeking to enshrine it as the heart of medical research and practice. As David Attenborough is to Nature, as Carl Sagan was to the Cosmos, so Shoenfeld is to Autoimmunity and he will not rest content until he hosts a six-part BBC documentary on the topic.

Shoenfeld even wrote an article entitled “Everything Is Autoimmune Until Proven Otherwise“. Of course, ASIA is a manifestation of that idea, which is cringeworthy in its echoing of the common quack tendency to ascribe all diseases to The One True Cause of Disease. Of course, it doesn’t help that he has appeared to speak at conferences that can only be described as clearly antivaccine, such as ones sponsored by the Children’s Medical Safety Research Institute (CMSRI), a now-defunct antivaccine “institute” formerly funded by the Dwoskin family and dedicated to funding antivaccine “research.” Smut also notes that Shoenfeld’s “sprawling Empire of Autoimmunity” is very much entwined with antivaccine pseudoscience:

It is undeniable, though, that this sprawling Empire of Autoimmunity is intimately entwined with antivax rhetoric. At the core of Shoenfeld’s 8th, 9th, 10th and 11th ICAs in Grenada, Nice, Lisbon and Leipzig, the nuclei they crystallised around, we find (respectively) the 2nd, 3rd, 4th and 5th International Symposia on Vaccines, and these were very much antivax events.

I note that at the 5th International Symposium on Vaccines, no less an antivaxer than Claire Dwoskin herself wrote:

The fifth International Symposium on Vaccines, sponsored by the Children’s Medical Safety Research Institute (CMSRI), has announced its line-up of speakers for the upcoming event in Portugal. Held the first day of the biennial Autoimmunity Congress, the Symposium draws medical researchers from around the world to share the latest research on vaccine safety and the potential links between vaccine adjuvants and adverse autoimmune reactions. To see the full program agenda, click here.

“Critical research on this topic is not always welcomed at events that are sponsored, in large part, by the makers of vaccines, but it is vital that the scientists who are courageously examining potential causes of today’s epidemic of autoimmune disorders are able to share and discuss their findings,” said Claire Dwoskin, founder and president of CMSRI. “The collaborative research projects that are conceived at — or as a result of — this symposium are truly groundbreaking.”

The organizer of the symposium is renowned aluminum toxicity expert, Dr. Christopher Exley, professor of bioinorganic chemistry at Keele University in England. Exely and his team of researchers will be presenting at the symposium, in addition to the speakers listed below. The following are abstracts for each of the presentations (note: CMSRI-funded research is highlighted in purple).

The introduction to the 4th International Symposium on Vaccines proclaimed its key questions as:

  • What role do vaccines play in inducing autoimmunity?
  • Are there safe vaccines for genetically prone subjects?
  • Can we vaccinate against autoimmune diseases?
  • What is the role of adjuvants and/or molecular mimicry in vaccines inducing autoimmune diseases?
  • Is it safe to vaccinate patients with autoimmune diseases?

In 2016, Claire Dwoskin had high praise for Shoenfeld:

Thank you for all that you have done to help people, put on an excellent congress, and provide a forum for the vaccine and adjuvant issue.

So Yehuda Shoenfeld is definitely antivaccine, believing that vaccine adjuvants cause a syndrome of autoimmunity. He has also been highly prolific writing about autoimmunity, with (at this counting) 66 books edited, 161 book chapters, and 1,986 articles. As is noted in For Better Science, Professor Shoenfeld used to be affiliated with Sheba Medical Center at Tel Hashomer and the Sackler Faculty of Medicine at Tel-Aviv University, and is now emeritus at the latter. He ran the Zabludowicz Center for Autoimmune Diseases at Sheba, which is funded by the Finnish-British billionaire Poju Zabludowicz. Before his elevation, Shoenfeld was a very prominent name in Israeli science. After his elevation, he’ll be even more so.

Schneider notes that Zabludowicz also likes to donate to right-wing politicians, including Israeli Prime Minister Benjamin Netanyahu. He likely was nominated thusly:

Also because of the money flows, the Sheba hospital affiliation is said to be the source of Shoenfeld’s sway in Israeli politics and academia. For example, Dean of Sackler Ehud Grossman has a clinical affiliation with the Sheba Centre. Sources revealed it was influential Sheba clinicians who put forward Shoenfeld’s name for Academy membership, very likely Gidi Rechavi and Uri Seligsohn, plus a third bigwig from Tel Aviv University. Incidentally, just before Shoenfeld was put forward as Academy member, Sheba Medical Center advertised for his antivax rants, but had the press release and even its externally archived version purged in May 2019 (luckily, Shoenfeld’s paranoid antivax fans were quick to save screenshots and another copy in March 2019):

Top Israeli Doctor Points to Vaccines as Contributing to the Rising Rate of Autoimmune Diseases
[…] “Throughout our lifetime, the normal immune system walks a fine line between preserving normal immune reactions and developing autoimmune diseases,” says the article. “The healthy immune system is tolerant to self-antigens. When self-tolerance is disturbed, dysregulation of the immune system follows, resulting in the emergence of an autoimmune disease. Vaccination is one of the conditions that may disturb this homeostasis in susceptible individuals, resulting in autoimmune phenomena and ASIA.”

[…] Dr. Shoenfeld summarizes, “…many reports that describe post-vaccination autoimmunity strongly suggest that vaccines can indeed trigger autoimmunity. Defined autoimmune diseases that may occur following vaccinations include arthritis, lupus (systemic lupus erythematosus, SLE), diabetes mellitus, thrombocytopenia, vasculitis, dermatomyositis, Guillain-Barre syndrome and demyelinating disorders. And almost all types of vaccines have been reported to be associated with the onset of ASIA.”

So what, according to Shoenfeld, is ASIA?

Autoimmunity Syndrome Induced by Adjuvants (ASIA): A fake diagnosis

As Smut Clyde also drily notes, as “David Attenborough is to Nature, as Carl Sagan was to the Cosmos, so Shoenfeld is to Autoimmunity and he will not rest content until he hosts a six-part BBC documentary on the topic.” ASIA is his claim to fame, the “nexus of autoimmunity and antivax enthusiasms, which attains a kind of apotheosis in ASIA,” which is “also known as ‘Shoenfeld’s Syndrome’ in its author’s less modest moments.” As is further noted, making up a name for a “syndrome” like this, whether the syndrome is real or not, is a win, because “just by using the name, people have accepted your hypothesis.”

Again, though, what is ASIA? Perhaps the best summary from the horse’s mouth itself is the aforementioned video foolishly published by BMC Medicine in which Shoenfeld explains it in his own words. If you read the transcript, you’ll see that the definition of ASIA is so vague that almost any immune abnormality can be so classified as long as somewhere, somehow, the patient had prior exposure to an adjuvant, especially if it was an aluminum adjuvant. For example, here is Shoenfeld’s answer to the question, “What is ASIA?”:

ASIA is a new syndrome, which refers to autoimmune syndromes induced by adjuvants. It includes several conditions that are not fully characterized as autoimmune diseases like systemic lupus, rheumatoid arthritis or scleroderma, but that are induced by chronic stimulation of the immune system by substances which may react as adjuvants. This chronic stimulation leads to the emergence of these new signs and symptoms, which include fatigue, arthritis, myalgia, and neurological manifestations.

So, basically, any symptoms of fatigue, joint aches, muscle aches, or headaches might be ASIA! Of course, not content to limit ASIA to just being caused by vaccines, Shoenfeld also lumps silicone from silicone breast implants into the category of “adjuvant,” such that silicone implants can cause ASIA as well—because why not? So what are the criteria for diagnosing ASIA? Quacks will love Shoenfeld’s answer:

We have published the criteria and classified it as we do usually with different autoimmune diseases, namely into major criteria and minor criteria. Major criteria include clinical manifestations such as severe fatigue, poor sleep, myalgia and arthralgia; the minor criteria include the presence of various autoantibodies and specific HLA (e.g., DRB1). However, as I mentioned before, over the years many of these patients may go on to develop a more well-defined autoimmune disease. For instance, if they develop scleroderma or systemic sclerosis, they will suffer from tight skin, complications of the lungs, kidneys, and so forth.

Note the cleverness here. If you have a bunch of vague symptoms that are maybe autoimmune-like, you might have ASIA, but if you go on to develop a “more well-defined” autoimmune disease, that’s ASIA too! And it’s all caused by vaccine adjuvants. Of course, it’s worse than that. Shoenfeld also claims that the MMR (measles-mumps-rubella) vaccine can cause ASIA even though, as an attenuated live virus vaccine, MMR has no adjuvants. (Aluminum would kill the virus.) He even mistakenly claims that the MMR has adjuvants, in much the same way I’ve seen those who believe that mercury in vaccines is the cause of autism, even though the MMR has never contained thimerosal. He’s also claimed that the ASIA can result from the oral polio vaccine, which again has no adjuvants and isn’t even injected.

ASIA also subsumes a number of other conditions, including the Gulf War Syndrome, which is where the concept first apparently hit Shoenfeld, where he claimed to link certain autoantibodies (antibodies against self-antigens, like proteins), supposedly induced by the squalene adjuvant used in the anthrax vaccine that troops were given prior to shipping out. It’s a contention that has long been refuted. The original term was coined in 2011, but Shoenfeld had been laying the groundwork as he testified for complainants in the Vaccine Court long before that. Interestingly, in his 2015 compendium on autoimmunity, it’s been noted that large sections of the text of the document were apparently lifted from Wikipedia.

But what’s the evidence for the existence of ASIA? It’s not very good. New Zealand commissioned Rohan Ameratunga, a practicing allergy and immunology specialist, to review the evidence for the existence of ASIA. His conclusions were not kind, as noted in two review articles. For example, Ameratunga et al bluntly noted:

Current data do not support the causation of ASIA by vaccine adjuvants containing aluminum, which should be of reassurance to patients undergoing routine immunizations as well as to those undergoing allergen-specific IT.

In another review, Ameratunga et al also conclude:

We have recently reviewed ASIA as defined by its authors. We have shown that the definition of ASIA is imprecise and includes all patients with an autoimmune disorder as well as potentially the entire population. Application of the Bradford Hill criteria for causality does not support ASIA as an outcome of exposure to aluminium containing adjuvants in vaccines. The advocates of ASIA highlight animal models as evidence for the existence of the disorder. However, as this review will demonstrate, animal models purporting to support the existence of ASIA have methodological, analytical and ethical flaws which, in our view, refute the existence of the condition.

In another review, Hawkes et al further noted:

At present, there is no evidence to suggest that ASIA syndrome is a viable explanation for unusual autoimmune diseases. Since the initial paper, over 80 publications have discussed ASIA. This systematic review examines the research that has been done to investigate whether ASIA is a broad umbrella term with little clinical significance, or whether there is some underlying mechanism which could be utilised to reduce the occurrence of adjuvant mediated disease. Twenty-seven animal, epidemiological and case studies were reviewed. Unfortunately, a robust animal model of ASIA using biologically relevant doses of adjuvants has yet to be defined. It is also apparent that the broadness of the current ASIA criteria lack stringency and, as a result, very few cases of autoimmune disease could be excluded from a diagnosis of ASIA. The current studies involving human cases are so diverse, in both external stimuli and in resulting conditions, that there is currently a lack of reproducible evidence for any consistent relationship between adjuvant and autoimmune condition.

The World Health Organization does not support the concept of ASIA caused by vaccines, in particular the HPV vaccine.

Helen Petousis Harris was more blunt, calling ASIA a “scam,” referring to it as a “sort of catch all for nebulous chronic illnesses that include fatigue” and applying the six steps in the confidence (a.k.a. con) game to the story of ASIA’s creation and promotion. The first step was foundation, including all the articles that Shoenfeld and his associates wrote in low quality journals on whose editorial board Shoenfeld sat. Personally, I’m not sure if Shoen is a grifter or not. He might actually believe in ASIA. However, there is a lot of grift associated with ASIA that to which Shoenfeld, whether knowingly or not, contributes.

There are many other sources criticizing Shoenfeld’s shoddy science and intimate connections with the antivaccine movement, such as this article by Vincent Iannelli in Vaxopedia and this post by our friend the Skeptical Raptor, who calls ASIA an antivaccine myth, because that’s what it is.

Worse, as Smut Clyde and Leonid Schneider note, Yehuda Shoenfeld’s publication record is problematic as well. He demonstrates this by publishing a letter by an Israeli clinical immunology professor to Nili Cohen, a law scholar at Tel Aviv University and President of the Israel Academy of Sciences and Humanities. After noting that Shoenfeld has no training in immunology and that there have been grave concerns expressed about the reproducibility of his work, this immunologist goes on to observe:

3. However, every reasonable investigator who ever worked in bio-medical research knows that no human being can publish 1,939 papers, unless these reflect the work of hundreds of investigators, to which Dr. Shoenfeld’ true contribution is insignificant, or to put it in a more benevolent way, questionable (see official Clarivate record sent with this mail).

4. To make these results more palpable, here are some simple calculations: In the year 2007, he has published 110 papers, which means 2.11 papers each week or 0.3 papers per day. In 2017, his productivity was reduced to 80 papers, meaning 1.54 papers each week or 0.21 papers per day. If there ever was a miracle worker, it is Dr. Shoenfeld.

5. Dr. Shoenfeld also has a most impressive citation record: 58,116 citations (of which 8,704 are self-citations!). The members of the Israel Academy of Sciences should have had a good look at his three most cited papers (3158, 1739, and 1048 citations). These have 16, 32, and 24 authors, respectively, with Dr. Shoenfeld somewhere in the middle. All three are papers of consortia dealing with nomenclature or reviews of groups of patients. One would expect that a scientist’s most cited papers to be representative of his own best work. The rest of the 1939 papers is a potpourri of every field of medicine from tobacco smoke to vitamin D and inflammatory bowel disease, to mention only a minority.

The letter concludes by expressing concern that Shoenfeld’s elevation is a “mistake” that will signify “that the Israel Academy of Sciences is impressed by self-promotion, ‘celeb’ status, and biased and lacking in objectivity recommendations, and not by an objective system of values”, all of which is true. Of course, this is a risk with all such prestigious academies, for which politics can at times matter more than scientific excellence. Friends and like-minded powerful scientists in the academy elevate friends and like-minded influential scientists, and the result is something like an antivaccine crank like Yehuda Shoenfeld being nominated and elected to the Israeli Academy of Sciences and Humanities. Having Yehuda Shoenfeld as a member of the Israeli Academy of Sciences and Humanities is a blight on the Israeli science community and will be used by antivaxers to promote their pseudoscience.

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Posted by David Gorski

Dr. Gorski's full information can be found here, along with information for patients. David H. Gorski, MD, PhD, FACS is a surgical oncologist at the Barbara Ann Karmanos Cancer Institute specializing in breast cancer surgery, where he also serves as the American College of Surgeons Committee on Cancer Liaison Physician as well as an Associate Professor of Surgery and member of the faculty of the Graduate Program in Cancer Biology at Wayne State University. If you are a potential patient and found this page through a Google search, please check out Dr. Gorski's biographical information, disclaimers regarding his writings, and notice to patients here.