By David Tuller, DrPH
Last week, more than three dozen advocates for people with chronic illnesses signed an open letter to Netflix protesting Afflicted, a multi-part documentary. The open letter was posted on Medium. I have posted it below. (I have added my name to the list of signatories; I meant to sign on beforehand but forget to inform the folks from MEAction who spearheaded the effort.)
The letter is also a petition; since it was posted, thousands of people have added their voices. You can do so here: https://my.meaction.net/petitions/remove-afflicted-docuseries-from-netflix-now
Some of the people featured in the documentary have also expressed their dismay with the final result.
Open Letter to Netflix Regarding the â€œAfflictedâ€ Docuseries
Dear Ted Sarandos, Lisa Nishimura, Brandon Riegg, and VernÄ Myers,
We are a group of writers, activists, artists, filmmakers, physicians, patients and scientists who write to express our profound disappointment with the recently released Netflix docuseries Afflicted. We are deeply concerned about its unethical treatment of its subjects and its many factual errors and omissions. Its inclusion on your platformâ€Šâ€”â€Šwhich reaches three hundred million viewers worldwideâ€Šâ€”â€Šwill reinforce barriers to appropriate medical care or disability benefits, dampen the support of vital research, and add to the stigma and social isolation of an already profoundly marginalized group of people.
Afflicted was introduced to participants as a series that would â€œcompassionatelyâ€ represent their experiences with diseases that lack proper diagnostic tools and effective treatments. But rather than authentically depict these participantsâ€™ experiences and the biomedical research that might explain their illnesses, Afflicted used every creative tool and untenable journalistic practice to advance a narrative that suggests these patientsâ€™ problems are primarily psychological, a theory that is not supported by the evidence. Moreover, the Afflicted team engaged in multiple unethical practices to create the docuseriesâ€Šâ€”â€Šfrom misrepresenting their intentions to showing apparent diagnoses from doctors who had never examined the subjects.
Here are the key problems in the series:
Misrepresentation of subjects and questionable tactics
Five of the subjects portrayed in Afflicted shared their stories, which raise several important ethical concerns. According to their accounts:
*Before consenting to participate in the project, subjects explicitly asked producers whether Afflicted would take the point of view that the illnesses it portrayed was psychosomatic and were told unequivocally that this was not the case.
*At least one subject reported feeling pressured to continue participating or grant access based on the possibility of pro bono medical care they might not otherwise have been able to afford.
*Some of the visits to practitionersâ€Šâ€”â€Šâ€”â€Šincluding some that most viewers would perceive as questionableâ€Šâ€”â€Šâ€”â€Šwere set up by the production team itself, including Bekahâ€™s offers of stem cell therapy and ozone treatment and Starâ€™s visit to a Lyme specialist.
*Some of the subjects were encouraged to undergo risky or unnecessary medical procedures. When Jamison Hill explained he was too ill to travel to a doctor, one of the producers suggested to his mother that she drug him. The production company also urged Hill to needlessly replace his midline IVâ€Šâ€”â€Ša procedure that carries a serious risk of infectionâ€Šâ€”â€Špromising they would pay for the expensive and taxing procedure. Ultimately, they neither paid nor used the footage. When Bekahâ€™s doctors recommended that she not undergo stem cell therapy, the producers pressured her to do so against her doctorsâ€™ wishes. They then portrayed her refusal as capricious
*The filmmakers failed to show the seriousness with which the participants took mental health. Over the course of their illness, most of the subjects had been referred to psychiatrists for assessment and had been told that there was no psychiatric explanation for their physical symptoms. Many had previously tried antidepressants, anti-anxiety medications or other psychiatric or psychological interventions. Though two participants have had mental health issues such treatments were helpful for, these interventions did not address any of the subjectsâ€™ physical symptoms. Yet, the question of subjectsâ€™ mental health was raised over and over in every episode, and some subjects were portrayed as rejecting psychiatric help.
*Clips of doctors expressing expert opinions about the diagnosis or the cause of illness were frequently juxtaposed with footage of patients they had never examined. This is a violation of the spirit if not letter of the Goldwater Rule.
Medical and Scientific Flaws
The history of medicine shows that until illnesses are better understood, theyâ€™re often considered psychosomatic. The consequences can be devastating. Multiple sclerosis was once called â€œhysterical paralysisâ€ until the invention of the MRI revealed lesions in the brain. As late as the 1980s, ulcers were thought to be caused by the â€œwish to receive loveâ€ before the discovery of H. pylori. Breast cancer was attributed to holding onto negative emotional states until effective chemotherapeutic treatments dispelled the myth. Tuberculosis, epilepsy, and rheumatoid arthritis were all at one point in their history thought to be psychosomatic disorders before science elucidated their mechanisms. In the interim, untold numbers of patients were institutionalized, given inappropriate treatments, and died as a result.
Many individuals live with more than one health condition. Being physically disabled does not preclude a coexisting mental health diagnosis. Likewise, having a mental health issue does not prevent the onset of other diseases or disorders. People with mental and physical disabilities both deserve equitable, accessible treatment options but the framing of major, chronic disease as â€œall in your headâ€ continues to prevent accurate diagnosis, access to care, and investment in medical research.
Afflicted offered no objective evidence backing its claim for a psychosomatic basis. And it excluded substantial medical and scientific evidence that would have helped explain the subjectsâ€™ diagnoses:
*Omission or de-emphasis of subjectsâ€™ diagnoses and laboratory findings. The frame of Afflicted is â€œSeven people suffering with bizarre chronic illnesses,â€ yet most subjects did have positive laboratory results, physical findings or mainstream diagnoses. These were excluded, glossed over, or left unexplained. For example, both Bekah and Pilar have Common Variable Immunodeficiency Disorder, which is an uncontroversial and life-threatening disease, diagnosable through a standard blood test. Bekah tested positive for Lyme disease via a CDC-approved Western blot test. Yet the documentarians stated in episode 1 that Bekah â€œbelievesâ€ she has Lyme. Both Jill and Star have Hashimotoâ€™s thyroiditis, an autoimmune disease diagnosable through a standard lab. Jake has had Bellâ€™s Palsy, tachycardia, and low red blood cell and white blood cell counts for which he sees a hematologist/oncologist every three months to monitor for cancer. Many of these facts were omitted entirely.
*Exclusion of research findings. The seriesâ€™ assertion of a psychosomatic cause is especially problematic because science has made significant progress understanding the pathophysiology of myalgic encephalomyelitis, mast cell activation syndrome, chronic Lyme disease, and several of the subjectsâ€™ diagnoses. Each can be diagnosed with established criteria and may be validated with laboratory testing.
*Myalgic encephalomyelitis. The National Academy of Medicine published a 2015 report that developed diagnostic criteria for myalgic encephalomyelitis, writing that it â€œis a serious, chronic, complex, multisystem disease that frequently and dramatically limits the activities of affected patients.â€ Consistent abnormalities have been found in the immune system: patientsâ€™ natural killer cells, responsible for fighting viruses and cancer, do not work properly. ME patients show white matter hyperintensities on MRI; and autopsies of ME patients show inflammation in the brain. ME patients have disordered metabolism, and show abnormalities induced by exercise testing.
*Mold and chemical sensitivities. Mast cell activation syndrome underlies these sensitivities in some patients. In this condition, mast cells easily degranulate upon encountering particular triggers, quickly releasing vast quantities of histamine into the body and causing allergic-type symptoms as well as gastrointestinal and nervous system issues.
*Lyme disease. Patients typically use the term â€œchronic Lymeâ€ simply to mean that they became chronically ill after getting Lyme disease. Although skeptics often reject the term â€œchronic Lymeâ€ entirely, there is no debate that Lyme can cause chronic symptoms. The scientific literature has clearly documented that Lyme disease that is not treated early can cause lasting problems including arthritis, heart complications, neurological problems, and more. The CDC refers to these patients as having â€œlateâ€ or â€œdisseminatedâ€ Lyme. The literature also shows that even in patients who are ideally treated with a course of antibiotics, 10 to 20 percent are left with lasting symptoms, according to the New England Journal of Medicine. The CDC refers to these patients as having â€œpost-treatment Lyme disease syndrome.â€
*Exclusion of research scientists. Although the producers had access to, and even filmed, researchers who could have given strong clinical and scientific evidence for several of the conditions in the film, they chose to exclude them from the series. They attended a symposium at Stanford University on the molecular basis of ME/CFS, which included prominent researchers from around the world, including Mario Capecchi, a Nobel Laureate. Several of these scientists were even interviewed, including Stanford geneticist Ron Davis and Stanford immunologist Mark Davis. In addition, during Dr. Eric Gordonâ€™s visit with Jamison, Ron Davis sent two researchers from his lab at Stanford to set up a makeshift lab in Jamisonâ€™s house. They drew his blood and processed it for a big ME/CFS study. All of this was filmed but none of it made it into the series.
*Inclusion of alternative practitioners as the sole validation of patient experience. By omitting the perspective of research scientists and prominent physicians, Afflicted crafts a strawman argument, pitting integrative, environmental, and alternative health practitioners against a single psychiatrist, Richard Alan Friedman. Friedmanâ€™s speciality is anxiety and mood disorders, not any of the conditions featured in Afflicted; moreover, he does not appear to have met any of the patients in person.
*Afflicted uses the public perception of alternative healthcare to attack their subjectsâ€™ credibility, employing Friedman as the â€œvoice of reason,â€ and omitting other, more credible sources who would have supported patientsâ€™ diagnoses and symptoms.
The problems with this film arenâ€™t just hypothetical: The participants are already suffering for their participation, receiving intense online harassment, having their professional reputations questioned, and having friends turn against them. And if Afflicted remains on Netflix, it will hurt many more people. Many people living with chronic illnesses, including those depicted in Afflicted, are routinely denied disability benefits. Some are abandoned by their families and fall into poverty, homelessness, and food insecurity when they become too ill to work. The stigma surrounding these conditions among health care providers poses a barrier to accessing quality medical care, putting patients at risk. The disbelief of loved onesâ€Šâ€”â€Šand the culture at largeâ€Šâ€”â€Šcontributes to the high rates of suicide among patients with these conditions.
The inclusion of people with disabilities in the telling of their own stories is essential to the creation of compelling, ethical, authentic cinema. Netflix has been an important platform for this conversation with programs such as The Punk Rock Singer, My Beautiful, Broken Brain, To The Bone, and Unrest. Yet Afflicted was helmed by apparently able-bodied people, and displayed the disabled as curiosities for the entertainment of others.
We request that Afflicted be immediately removed from the service. We further request that a formal apology be released that includes a statement of Netflixâ€™s future plans for the programming of documentaries, television, comedy specials, and feature films about disability and projects that include talent, key crew, and/or consultants with disabilities.
Sini Anderson, Documentary Filmmaker, The Punk Singer and So Sick
Jennifer Brea, Filmmaker, Unrest
Mario R. Capecchi, Distinguished Professor, University of Utah School of Medicine, Department of Human Genetics
Lawrence Carter-Long, Director of Communications, Disability Rights Education & Defense Fund
Bela Chheda, MD, Center for Complex Diseases
Laurel Crosby, PhD, Director of Innovation, CFS Research Center, Stanford Genome Technology Center
Janet L Dafoe, PhD Child Psychologist in Private Practice, Palo Alto, California, USA
Ronald W. Davis, PhD, Professor of Biochemistry and Genetics, Stanford University
Lena Dunham, Writer, Actor, Director, Producer
Maya Dusenbery, Author, Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick
Eva Hagberg Fisher, PhD Candidate, UC Berkeley, Author, How To Be Loved: A Memoir of Lifesaving Friendship
Maureen Hanson, Ph.D., Professor of Molecular Biology and Genetics, Cornell University
H. Craig Heller, PhD, Lorry Lokey/Business Wire, Professor of Biology and Human Biology, Stanford University
Judith Heumann, Disability Rights Advocate, Ford Fellow, Ford Foundation
Ally Hilfiger, Designer, producer, author BITE ME
Porochista Khakpour, Author, Sick: A Memoir, The Last Illusion, Sons and Other Flammable Objects
Deborah Hoffmann, Documentary Filmmaker
Nancy Klimas MD, Director, Institute for Neuro-Immune Medicine, Nova Southeastern University, Director, Miami VA Medical Center GWI and CFS/ME Program, Miami, Florida, USA
David L. Kaufman, MD, Center for Complex Diseases
Jim LeBrecht, Documentary Filmmaker, Board Member at Disability Rights Education and Defense Fund
Michele Lent Hirsch, Author, Invisible: How Young Women with Serious Health Issues Navigate Work, Relationships, and the Pressure to Seem Just Fine
Monica Lewinsky, Anti-bullying activist and writer
Mohsen Nemat-Gorgani, Ph.D., Research Scientist, Stanford University
Jenara Nerenberg, UC Berkeley journalist, Founder, The Neurodiversity Project
Abby Norman, Author, Ask Me About My Uterus
Meghan Oâ€™Rourke, Author, â€œWhatâ€™s Wrong with Me?â€ and The Long Goodbye
Robert D Phair PhD, Chief Science Officer, Integrative Bioinformatics Inc, Mountain View, CA
Anand Ramasubramanian, Ph. D., Associate Professor, Chemical & Materials Engineering, San JosÃ© State University
Julie Rehmeyer, Author, Though the Shadowlands: A Science Writerâ€™s Odyssey into an Illness Science Doesnâ€™t Understand, Contributing Editor, Discover
Frances Reid, Documentary Filmmaker
Peidong Shen, PhD, Scientist, Stanford Genome Technology Center
Lars M. Steinmetz, PhD, Professor of Genetics, Stanford University School of Medicine
Amit Kumar Saha, PhD, Research Engineer, Stanford University
Ronald G Tompkins, MD, ScD, Summer M Redstone Professor of Surgery, Harvard Medical School, Director, Center for Surgery, Innovation & Bioengineering, Massachusetts General Hospital, Boston, MA
David Tuller, DrPH, Senior Fellow in Public Health and Journalism, Center for Global Public Health, University of California, Berkeley
Michael VanElzakker, PhD, Research Fellow, Psychiatric Neuroscience Division, Harvard Medical School & Massachusetts General Hospital, Instructor, Tufts University Psychology
Alice Wong, Founder and Director, Disability Visibility Project
Wenzhong Xiao, Ph.D., Immune-Metabolism Computational Center, Massachusetts General
Hospital, Harvard Medical School
Maysoon Zayid, Comedian, Writer, Disability Advocate
Jesse Bercowetz, Artist and Masters candidate, Harvard Divinity School
Nick Dinnerstein, Musician, Music teacher, Brother of Bekah Dinnerstein, New York, NY
Jill Edelstein LCSW, Psychotherapist/Clinical Social Worker in Private Practice, New York, NY, USA
Janine Feczko, Documentary Film and Television Editor
Jamison Hill, Author, Freelance Writer, Bylines: The New Tork Times, The Los Angeles Times, The Washington Post
Pilar Olave, Actress/Musician/VoiceOver Artist
Jake Sidwell, Composer, Final Space, Nashville, TN