Exploring chronic disease

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A couple weeks ago, I gave a presentation at the International Congress on Autoimmunity in Ljubljana, Slovenia. The talk was about successive infection and how viruses and bacteria can work together to cause an autoimmune disease state.

Here is a transcript.


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  • Two weeks ago, I boarded a 747 to travel to Beijing, China in order to speak at the 2009 International Congress of Antibodies. Within minutes of hitting the runway, we were greeted by a crew of officials wearing surgical masks and wielding thermometers. The fever analysis was performed as part of an effort on behalf of the Chinese government to ensure that neither I nor my fellow travelers had the swine flu. Luckily I was cleared and proceeded to my hotel which was also the site of the Conference. Before checking into my room, I had to get my temperature checked yet a second time by the hotel staff. I wasn’t opposed to the routine screenings since, at the time, if anyone on my hotel floor had the swine flu the entire floor would be quarantined.

    The door of our hotel was guarded by two cement lions and delicate Chinese flowers in a vase were built into the hotel revolving door. The first night, I was exhausted and fell into a deep sleep due to the jet lag. I woke up to greet my colleague, Dr. Trevor Marshall, whose flight had arrived during the night. He was surprisingly chipper and we set off to explore our surroundings. The hotel was located close to the stadium from the 2008 Summer Olympics, also known as the “Bird’s Nest.” Dr. Marshall was lucky enough to have a view of the stadium from his hotel room window. I had to settle for a view of the boring side of the street. Down the street we discovered a Chinese cafeteria that served the locals and had better food than the hotel, at least in my opinion. It was the first of my many trips there to get a stir-fry or other delicious dishes. We also cheated by discovering a supermarket with American food products that we stocked up on for snacks. Then we went to a fourteen-story building occupying a whole city block. It was full of innumerable electronic devices for sale at low prices. Given his earlier work as a microchip designer, surely this was Dr. Marshall’s mothership.

    A Chinese health worker boards the plane to check our temperatures on the way in to Beijing.

    The first thing I’ll say about the Conference is that its name – International Congress of Antibodies – is something of a misnomer. The reality is that the Conference was not for antibodies but people.

    Conference registration was the next day. Finding the registration took some time. It was in a completely different part of the hotel and most of the hotel staff didn’t speak any English at all. In fact, it was the first time in my life where I truly felt “lost in translation.” Even my elaborate hand gestures often couldn’t help the hotel staff understand what I needed, particularly when it came to setting up my Internet connection, trying to use their business center, or communicating with the housekeeping staff about when I would and would not be in my room.

    It quickly became apparent that essentially all guests that stay at the Beijing International Continental Hotel are Chinese and that few tourists stay at the hotel. This meant it was easy to pick out other researchers arriving for the Conference. It was as simple as noting that someone spoke a foreign language, had european or hispanic features, or was gesticulating at the front desk.

    The Conference officially began on Thursday morning. The opening talks consisted largely of the Conference sponsors touting their products or companies. Eventually I became even more accustomed to such talks since at least half of the researchers presenting were also associated with biotech companies or other businesses that not only conduct research but also sell tools for antibody detection and creation. Their talks were generally of less interest to me than those that discussed purely scientific work.

    The Chinese lion standing guard at the entrance to the hotel

    The researchers hailed from around the world, several from Europe and the USA, even some from Latin America. Unfortunately, most of the researchers from Japan were not able to attend the Conference because of an increasing number of swine flu cases in their country that had made the Chinese authorities nervous. Perhaps this worked in my favor. Originally I had been scheduled to speak at a session on Saturday afternoon about antibodies and diagnostic tools. However, there is actually very little about diagnostics in my speech. So I asked one of the Conference organizers if I could switch to speak in a session specifically about autoimmune disease the next morning, which had an empty slot because of a Japanese speaker’s absence. She said yes.

    Before Sunday rolled around I perused the halls, introducing myself and getting to know my fellow conference attendees. Most people were very open and eager to talk about their work or China in general. Every lunch and dinner we would all walk in a pack back to the main hotel where a buffet-style meal was served. The food was Chinese and sometimes intriguing – intriguing as in I really didn’t know what I was eating! There was plenty of meat in sauce and green leafy vegetables, and of course, plenty and plenty of rice.

    Lunch and dinner served as perfect times to make friends. I met a woman from the UK with a wonderful sense of sarcasm and humor. Two German men who managed biotech companies were also very outgoing and full of interesting stories about Germany and their other travels abroad. I really enjoyed the enthusiasm of a Chinese-born researcher who now works at the University of Toronto. His interest piqued when I told him about the MP. Later, after hearing my talk, he became even more enthusiastic and kindly told me that my speech had exceeded his expectations. In fact, I don’t think I’ve ever been at a Conference where Dr. Marshall’s work was so well-received. Nearly everyone wanted to learn about the Pathogenesis. Many weren’t even familiar with latest estimates released by the Human Microbiome Project which state that at least 90% of cells in the human body are bacterial in origin. Everyone seemed to agree that such a plethora of bacteria could very likely cause a wide variety of autoimmune and inflammatory diagnoses. By Sunday morning I had whetted the scientific appetities of as many people as I could so that they would come listen to my speech.

    At the opening dinner of the Congress.

    Every session at the Conference was monitored by two chairmen, and in my case, both were very open-minded and intelligent scientists. My speech was the last in the session, but finally I made my way to the podium. As I spoke, I could sense that the colorful backgrounds and strong images on my slides (designed by my colleague Paul Albert) were helping people to capture the important aspects of the speech. Several camera flashes illuminated the room when I put up a slide covered by a prolific number of names of different bacterial species recently determined to persist in saliva.

    The main point of my speech was to re-examine the concept of the “autoantibody.” Currently, autoimmune disease is thought to result when the immune system attacks itself. In such a model, antibodies, which are molecules used by the immune system to neutralize foreign objects, are thought to be created in response to our own human DNA.

    What I pointed out was that, since the human body is composed of more microbial than human cells, this is not necessarily the case. The antibodies detected in what is now considered to be “autoimmune” disease may actually be created in response to bacteria. Specifically, when the innate immune system is activated by continually trying to kill chronic bacteria it activates the adaptive immune system. The adaptive immune system, which is the branch of the immune system that creates antibodies, then likely proceeds to create such antibodies in response to fragments of bacterial DNA generated by the death of the infected cells.

    At the conclusion of the speech, those members of the crowd that hadn’t left in disgust began to lob vegetables towards the stage. Fortunately, some of the produce was fresh, and I had enough for a salad….

    Dr. Audrey Tchorbanov and I after I finished my speech

    The truth is more boring: the speech seemed to go over quite well. The audience applauded enthusiastically, and a number of hands shot up for questions. So many people had questions that a number of people missed lunch to listen to my follow-up remarks. One of the session’s chairmen, Dr. Audrey Tchorbanov of the Bulgarian Academy of Sciences, seemed impressed with the speech and we posed for photos together. A few other people did the same. A pediatrician from Denmark who had given a very interesting speech himself about sepsis in infants commented numerous times on the groundbreaking nature of Dr. Marshall’s work. I think, as has been the case with every conference I’ve spoken at so far, the audience was pleasantly surprised to hear a speech that discussed how scientific observations and more theoretical work can be applied to clinical care.

    To celebrate a successful presentation, Dr. Marshall treated me to a meal that has been a favorite of Chinese emperors since the time of the early Ming dynasty. I forget the Mandarin term for it, but I believe in English it is calledgrilled cheese sandwich and french fries with ketchup.

    Later that day, I returned to a few sessions and then retired to my room to decompress. The wry woman from the UK arranged for a group of us to go out that night in honor of the end of the Conference. There were about eight of us including the biotech guys from Germany and the pediatrician from Denmark. We were also joined by a scientist from Ireland whose thick brogue and lively banter kept us laughing all night. One of the members of our group, a Chinese woman, took us to a lake surrounded by rows of outside bars with comfy couches and chairs. The temperature was perfect – warm and breezy. We celebrated until four or five in the morning when we finally headed back to the hotel. It was encouraging to see that, like me, most of my fellow scientists are able to combine work with play.

    If it were even possible to sum up China and her people in a single word, that word would be “ambitious.” You can see ambition in the medal counts from the 2008 Beijing Olympics and in the Beijing skyline, being built ever upwards at a furious pace. But I can also see the urge to succeed in Chinese researchers’ apparent receptiveness to the MP and the science which supports it.

    Out with some other scientists and biotech executives

    I feel that China may eventually prove to be fertile ground for the MP to flourish. There is no vitamin D added to the food chain. Supplementation with D is not promoted or generally used as a therapy in chronic disease. Because pale white skin is considered beautiful in China, staying out of the sun is common practice for the Chinese. Chinese women in particular walk around with sun umbrellas and wear sunglasses and often long-sleeved shirts. Whereas American magazines advertise tanning salons and creams, Chinese magazines advertise hats and skin-whitening cream.

    Perhaps I should not have been surprised then that the Chinese people seemed much healthier than the Americans I’m used to seeing. For one thing, almost no one in China is obese or even fat, and it’s not like these people don’t know how to eat! Also, I was impressed at the lack of acne in the Chinese population. It seemed that every Chinese woman – whether at the airport, the hotel, or at the Conference itself – had perfectly blemish-free skin.

    All in all, it was a great trip. I certainly plan to keep in touch with some of the people I met, and I definitely hope to return.

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  • On Monday, I returned from the 6th International Congress on Autoimmunity held in Porto, Portugal. You can watch my presentation here.

    The Congress on Autoimmunity is a biennial event. It features dozens of talks, 1,800 registered delegates, and takes place over the course of five days.

    Dr. Yehuda Shoenfeld and I are clearly close buddies. :)

    The meeting has a decidedly international flavor. Participants hail from Germany, Italy, Russia, Italy, South Africa, even Mongolia. For many researchers and scientists in the field of immunology, this is an ideal forum to learn about and discuss advances in their field.

    Participants include researchers presenting their work, physicians gaining continuing medical education credits, and vendors hawking seemingly sophisticated technology. Who knows — maybe that five-foot chamber with the three LCD screens and dozens of buttons was no more than a glorified alarm clock. I probably should have gotten a brochure.

    As host cities go, you can’t do much better than Portugal’s second largest city, Porto. The weather was cool and, except for the skater punks outside my hotel room, the locals were lacking artifice. (One grizzled fellow told me in broken English that Porto was so named, because once upon a time the city’s fathers said, “Let us call it Porto, because it is on a port.” Now there’s something you can’t get in a guidebook.) And what better place to have a conference on immunology than a city dominated by winding streets and dead ends? More than once, I completed a taxi ride thinking I couldn’t tell if I had been taken to my destination using the world’s most clever series of shortcuts or was simply being ripped off.

    Belinda Fenter, me, Meg Mangin, Tom Perez, and Dr. Greg Blaney

    The meeting itself was held in a historic waterfront building with high pillars and a floor with curious metal tracks leading between one room and the next. Although as good scientists, we spent a lot of time hypothesizing about how the tracks might have been used in the past, no one we talked to could tell us why they were there.

    In his speech during the opening ceremony, Dr. Yehuda Shoenfeld, the President of the Congress, proved himself to be something of a jokester. Shoenfeld said he had a particular fondness for Porto, no small part of it due to the fact that his wife had won a beauty contest held in Porto in 1975. When he wasn’t showing pictures of previous years’ attendees ogling belly dancers or introducing the night’s band – the Anti-Phospholipids – he was telling the audience that the three winners of lifetime service awards each would receive prizes of one million dollars (not true!).

    One of the award winners was Dr. Eric Gershwin who, in addition to his studies in the field of autoimmune disease, maintains an informal medical clinic for handicapped animals including tortoises, horses, and skunks among others. Dr. Shoenfeld related that Gershwin is a direct descendant of the famous composer George Gershwin. We learned that Shoenfeld’s son, who incidentally turned out to be the keyboardist for the Anti-Phospholipids, received a gift from Dr. Gershwin: an original copy of “Rhapsody in Blue” signed by the composer himself.

    Tom, Meg, and Tom (Meg’s husband) enjoy rabbit and other specialties at a typical Portuguese restaurant.

    Shoenfeld confessed it was the first time the son thought his father’s scientific connections were of actual value. Incidentally, the other half of the Anti-Phospholipids was a violinist who presented at the Congress.

    On a more serious note, Dr. Shoenfeld also noted how more diseases – including, for example, depression – are now considered by some to be autoimmune in nature. Interestingly, the list of diseases thought to be autoimmune closely parallels those which the Marshall Protocol treats. Several talks even discussed cancer and autoimmune disease. I find it interesting that when it comes to the MP, some people have a hard time accepting the hypothesis that nearly every inflammatory condition can have the same basic pathogenesis. Yet as the “autoimmune community” continues to attribute more and more diseases to their same basic disease model few people raise an eyebrow.

    I arrived with a contingent of others who work closely with Autoimmunity Research Foundation (ARF). ARF’s time in the limelight came early in the Conference, on Thursday afternoon. The session on vitamin D was two hours long and was chaired by Dr. Trevor Marshall. In addition to the four of us associated with ARF, we heard from four others including Dr. Howard Amital of Israel and Dr. Maurizio Cutolo of Italy, both prominent researchers in the field of vitamin D. The last speaker slated to speak, a researcher from Iran, actually failed to show, presumably because he didn’t want to share the stage with an Israeli researcher. This is not the first time this has happened, we were told.

    As the chair, Dr. Marshall spoke first. Marshall’s talk had a decided focus on bacteria. He began by reminding the audience that bacterial cells outnumber human cells by a factor of 10 to 1. He went on to argue that the microbiota we harbor has evolved to decrease antimicrobial peptide expression by dysregulating the vitamin D receptor.

    Liz Marshall, Dr. Joyce Waterhouse, me, and Dr. Trevor Marshall after a trolley ride around Lisbon

    Dr. Greg Blaney is an MP physician. Dr. Blaney presented data, serum blood values mostly, from his own sizable cohort of MP patients. Using that data, he articulated a rationale for why 25-D is an inferior marker of inflammatory disease compared to 1,25-D. He showed how, among his cohort, measures of 25-D had a high level of variability and 1,25-D tended to be more consistent with disease status. One of his sickest patients, he reported, had a 1,25-D in excess of 100 pg/ml. Hopefully, his talk will challenge, in at least some small measure, doctors’ and researchers’ practice of testing only 25-D.

    Later on, Captain Tom Perez, RPh, MPH spoke. He gave some details of the Marshall Protocol study including statistics on how many patients, by autoimmune diagnosis, experience improvement by time frame.

    In my talk, I made a case for why autoimmune diseases such as Hashimoto’s Thyroiditis are much more likely to occur in women than in men, especially during the childbearing years. My contribution had value because I was able to show how one can use the alternate hypothesis for vitamin D to formulate viable hypotheses that logically explain other aspects of autoimmune disease. In the parlance of software engineers, the MP is extensible.

    My Citizen Kane moment.

    Some people are wary of public speaking. As you can surmise from the above video, I am not such a person. Also, I’ve been longing for the chance to connect with researchers and doctors in a larger forum. In any case, I could have spent much more time talking! I actually was so focused on covering all the main points in my talk that I didn’t even notice the Citizen Kane-like screen behind me.

    This Congress marks an important, though certainly not the final, milestone in the increasing acceptance of the Marshall Protocol as a therapy for chronic disease. It was telling that speakers supporting the MP model ranged from a molecular biologist to physician to public health official.

    As expected, the other speakers in the vitamin D session offered more traditional perspectives on vitamin D. Prior to my opportunity to speak, Dr. Amital showed data connecting a low level of 25-D to lupus severity. Dr. Cutolo offered a similar conclusion for rheumatoid arthritis.

    I take issue with observers who conclude that a low level of 25-D is necessarily a cause of the disease process. They could have just as well identified the measure as a result of the disease state. As epidemiologists repeat ad nauseam, “Correlation does not equal causation.” (I’ve been told that it is a rare epidemiologist indeed who doesn’t have this phrase tattooed somewhere on his or her person.)

    Paul and I enjoyed the grilled “steer” at the Conference dinner.

    In listening to the speakers in the vitamin D session, I imagine that even the least attentive audience member must have felt a certain amount of dissonance, even whiplash. I was disappointed that the forum didn’t allow for a more spirited dialogue, one we desperately need to have.

    Being the penultimate speaker allowed me to at least briefly address the disconnect. I concluded my speech with this impromptu observation: “When it comes to correlating disease incidence with low levels of vitamin D, it’s also incredibly important to consider the alternate hypothesis, which is that the low levels of vitamin D may not be causing the disease but may simply be a result of the disease process.”

    After the session concluded, Dr. Cutolo introduced himself and we spoke for about 20 minutes. There’s a lot to like about Dr. Cutolo. He’s a jocular guy, but he’s also a serious scientist and was therefore willing to consider the alternate hypothesis. What seemed to intrigue him most was Dr. Blaney’s point that 1,25-D is a more reliable biomarker of autoimmune disease status than 25-D. Perhaps we can expect future studies of autoimmune disease from Dr. Cutolo to rely on this measure. We also talked about my hypothesis: how a muted immune response during pregnancy could lead women to feel greater well-being.

    The Congress concluded with a final group dinner held in a winery overlooking the Douro River. Trevor outed himself as a port aficionado. During dinner, he turned down the waiter’s offers of wine and held up his port glass in order to signal how eager he was to drink the local beverage. Also, we finally got to hear genuine native Portuguese music. The band played a series of “old country” ballads including “Do the Hustle” and “I Will Survive.”

    Dr. Blaney shaking his groove thing.

    The truth is, I can’t say with certainty what effect our speeches and our side conversations had on our fellow attendees. I had the distinct impression that a substantial minority had come to the Conference to conclude business deals. The sparkling booths were evidence of that. Nevertheless, I think we did succeed in presenting the research and hypotheses that underlie the Marshall Protocol to many of the world’s leading researchers and physicians. Thanks to the Internet, the videos of our speeches have the potential to reach an even greater audience.

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  • About Amy Proal

    Amy and Zeus

    Amy Proal graduated from Georgetown University in 2005 with a degree in biology. While at Georgetown, she wrote her senior thesis on Chronic Fatigue Syndrome and the Marshall Protocol.