Letter from the Publisher

The holiday season is behind us. Perhaps a work of fiction might be just the thing for a doctor who seems to have no time to break loose and relax. A book that I just read had everything you might want from a novel – an adventure story based on the author’s life, written surprisingly well for a first-time novelist, with character development and description that ignites the imagination far more than the proverbial “picture is worth a thousand words.” The plot is introduced in the first few pages: a man brought low by divorce, who is imprisoned for robbery to maintain his drug habit, escapes prison, takes on a new identity, lands in Bombay (Mumbai) as a fugitive attempting to remake his life.

Gregory Roberts, the author of Shantaram, did become addicted to heroin following a divorce, engaged in repeated armed robbery, and eventually was sentenced to 19 years. After boldly breaking out of prison, he fled from his native Australia to New Zealand, assuming a new name. One day when authorities grew too close, he decided that Bombay would be the right place to get lost in – a city of millions with multiple cultures, languages, religions, and ethnicities. Shantaram’s protagonist, assuming the first name of Lindsay, takes us into the mind, soul, and physicality of a person who is creating life anew. Lindsay is content with immersing himself in what Bombay offers; his experience with a smiling, contented slum-dweller, who escorts tourists to local hotel and eateries, develops into a very intimate friendship. Prabu introduces him to expats who are linked to a leading Mafia chieftain. Slowly learning Hindi, while becoming familiar with Bombay, “Linbaba” eventually is robbed of money and passport, and is compelled to survive at the edges. Moving to the slum that his tourist guide/taxi driver lives in, he becomes a doctor/healer of sorts for the families who live happily in the shanty village, even though he has no medical training – but he does have a good knowledge of first aid.

Linbaba’s life unfurls like that of a character Odyssey or Don Quixote, except that his is rooted in1980s India. Corruption in India is rampant; the right amount of bribery keeps the authorities at bay, if order is maintained. Illegal currency changing, money laundering, fraudulent passport bookmaking, gun trade, and drug sales are all part and parcel of Bombay life. Like it or not, Linbaba’s life becomes entrenched in the Hindu and Muslim crime gang. What differentiates this from a Godfather story is the heart and soul that Linbaba/Roberts experiences in participating in so many bizarre situations – from the moblike violence targeted at a driver who carelessly injures another in a car accident, to the hellacious, penned-in, vermin-infected, starvation conditions facing anyone unfortunate to be jailed in Bombay. Linbaba copes well with adversity, even hopelessly pursing an unrequited love, but in every situation he is torn between the need to survive and see life from the eyes of the crime lord, slum dweller, and bureaucrat.

It is strange, yet invigorating, to find oneself sorting through the difficult moral and ethical choices of a fugitive. Shantaram makes the case that one can experience happiness while living in poverty. More importantly, it gives insight into how much of the thinking of gang members is not only rational but also heartfelt. Shantaram is an epic read, and one that never disappoints.

Is the Shutdown of Vemma the Death-Knell for MLM Vitamin Companies?

On Aug. 27, 2015, the Federal Trade Commission (FTC) shut down Vemma, a multilevel-marketing company. Vemma touts itself as a premier producer of energy drinks and other nutritional supplement products. Like other MLMs, Vemma sales depend on signing up people who contract to purchase a package of supplements monthly. In order for the member to earn income, other individuals are recruited to become “downline” members and contract to buy monthly supplements. And, like other MLMs, the compensation formula is set up to offer a trivial income for the downline member, while upline members who have signed up the downline earn the lion’s share of the compensation. Typically for MLM companies, most individuals discover that they are unable to sign up a sufficient number of downline members to actively recruit new members expanding the downline. Once the member fails to achieve an active downline, he or she quits, not wishing to pay the expensive prices for the purchase of energy drinks.

I would wish to report this story as a dispassionate editor, but I was enticed to become a member of the Vemma organization and signed up for a membership including a monthly shipment of supplements. The upline for me was not a consumer patient but an integrative physician whom I respected highly. I did think that the Vemma daily drink was beneficial as a supplement. However, like most MLM products, it was expensive. In addition, not long after I became a member, Vemma’s nighttime sleep aid drink – the primary draw for my participation – was withdrawn due to FDA oversight. One or more ingredients in the product was found to cause liver toxicity. For me, that product’s discontinuation, as well as the general problems with any MLM participation, led me to cease using the products. Of course, I never succeeded in receiving compensation for selling Vemma.

Vemma products are currently unavailable until the company has its day in court. Vemma is a private MLM company. Of greater concern, at least for stock market investors, is the fate of one traded company. Herbalife has been in business as long as I have been in practice. Not a few of my patients have used Herbalife supplements. Part of the problem with MLM participants is that they are convinced that their supplements are superior to other products in the marketplace. When the doctor advises the need to use different nutrient combinations, there is resistance on the patient’s part to either stop the MLM supplements or to use formulations that are not part of their MLM product line. My experience with patients who have been active in Herbalife is that they could fund a portion of their monthly costs for purchasing supplements through their downline sales. They did not succeed in supplementing their income.

Herbalife is now wrangling with a hedge fund manager who made a giant bet 2 years earlier that the FTC will shut it down for being an illegal pyramid scheme. What is the difference between multilevel marketing and an illegal pyramid scheme? Not much. However, when the FTC attempted to claim that Amway was a pyramid scheme in the 1990s, it failed. Now the FTC is claiming Vemma is a pyramid scheme and it also has Herbalife in its sights.

We may be seeing the beginning of the end of MLM supplement companies.

Q Fever Following Anti-Aging Treatment with Sheep Fetal Cells

The spas in Europe have had a long tradition of providing healing water therapies long favored by the rich and famous. Since the 1930s, a few clinics in Switzerland and Germany have administered ovine or bovine fetal cells promising to rejuvenate the body. Paul Niehans, a Swiss doctor, who injected live sheep cells directly in the buttock, was one of the developers of cell therapy. Cells harvested from the sheep’s brain, liver, spleen, kidneys, pancreas, heart, intestine, and thymus were thought to activate a healing effect on the patient’s ailing organs. Niehans later used injections of lyophilized cells, considering them as effective as live cells. His patients included Pope Pius XII as well as Charlie Chaplin. Although Niehans achieved great acclaim, writing about his treatment in Die Zellulartherapie (Cellular Therapy, in German and English), he did not have any published studies.

In 2014, at an undisclosed German clinic, six patients from the US and Canada developed Q fever one week following administration of live sheep cell therapy.¹

The patients experienced fever, fatigue, headaches, and other symptoms. Infectious disease workup revealed Coxiella burnetii, the causative agent for Q fever. The organism is morphologically similar but distinct from Rickettsia and other tick-borne organisms. Coxiella is treatable with tetracycline or doxycycline. Nevertheless, three patients continued to have symptoms 10 months after the cell therapy administration.

The authors of the MMRW report cite adverse events following sheep cell therapy, which they label as xenotransplantation, including radiculopathy, anaphylaxis, vasculitis, encephalitis, clostridial infection, and death. They warn that patients having these treatments should be on the alert for zoonotic disease (disease transmitted directly from animal to human). Q fever may also be transmitted directly from human to human.

Next Generation Sequencing and Infectious Disease

The aforementioned case of Coxiella infection compels us to reconsider infectious disease etiology in patients with acute and chronic medical conditions. Unfortunately, most chronic disease does not present with fever, chills, exanthem, nausea, diarrhea, and related symptoms. Practitioners are faced with patients having signs of secondary symptoms – neurologic, musculoskeletal, cerebral, gastrointestinal, endocrine, and cardiac symptomatology. Could it be that irritable bowel syndrome, neurologic paresis, fibromyalgia, adrenal fatigue, and angina have underlying etiologies of undiagnosed infectious disease? Stephen Fry, MD, argues that, yes, indeed there may be an undiagnosed microorganism culprit.

In this issue, Fry explains the exciting new diagnostic methodologies being implemented to explore infectious disease diagnosis. Of particular interest is Next Generation DNA Sequencing (NGS). This method permits sequencing many DNA segments at relatively low cost. NGS enables one to use DNA sequencing to identify a wide range of microorganisms, including organisms not suspected as pathologic. Rather than requiring lengthy culturing, NGS enables rapid bacterial, protozoal, fungal, and viral identification. Infectious disease often depends on serology testing to establish a diagnosis. However, antibody testing is fraught with difficulties particularly in patients where the antibody levels are borderline. The advantage of NGS is that it is unnecessary to specifically test for one organism; NGS enables the identification of organisms that would not be suspected as being the causative agent. The other major advantage is that testing is not limited to blood, urine, stool, and CSF. One may also use wound tissue and other infected materials for diagnosis.

The next time that the patient’s testing reveals significantly abnormal inflammatory markers, consider an infectious disease workup.

Jonathan Collin, MD

Notes

1. Robyn MP, Newman AP, et al. Q Fever Outbreak Among Travelers to Germany Who Received Live Cell Therapy – United States and Canada. MMWR. Oct. 2, 2015. 64 (38): 1071-73.