Book Review - The Wall Street Journal

Click here for book reviews of “An Elegant Defense” from –

The Wall Street Journal
The Washington Post

TRADITIONALLY, each monthly “Reference Materials” section also includes a book review from The New York Times.

HOWEVER, it appears that The New York Times did NOT publish a book review of “An Elegant Defense” because its author is The New York Times’ own best-selling and Pulitzer Prize winning journalist – so who would believe that a review of a book by one of The Times’ own could be objective.

NEVERTHELESS, there appears on The New York Times website an undated essay by Matt Richtel entitled “How To Get The Best From Your Immune System.”

That essay is also posted here.
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Book Review - The Wall Street Journal

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‘An Elegant Defense’ Review: Cells That Keep the Body Sound --
The immune system is not a war machine. It is a peacekeeping force that, more than anything else, seeks to create harmony.

By Laura Kolbe - April 7, 2019

[Dr. Kolbe is a resident physician in internal medicine at Brigham and Women’s Hospital in Boston.]

Robert Hoff is what’s known as an “HIV elite controller.” In 1977 he developed what are now recognized as classic signs of acute HIV infection: achy fatigue, nausea and liver dysfunction. A test showed he had hepatitis A, a relatively mild form of the disease. He rested up and got better. Seven years later, during a routine physical, Mr. Hoff learned that he was HIV positive. As a gay man with multiple partners, he said the news “didn’t come as a surprise.” The surprise was his lack of symptoms and his intact T-cell count—untreated HIV normally decimates this population of critical immune cells—both then and now, 42 years after infection.

Mr. Hoff, New York Times reporter Matt Richtel writes in “An Elegant Defense,” is “an immune system marvel,” possessed of an uncommon genetic variant that triggers a hyper-robust response. His body is able to eliminate all detectable traces of virus without the antiretroviral medications that have saved millions of lives and downgraded HIV to a treatable chronic illness in much of the world. Not everyone with Mr. Hoff’s genetic variant is an “elite controller,” however, and not every elite controller has this gene. Research on a vaccine to mimic Mr. Hoff’s immune response has thus far been unsuccessful.

Mr. Hoff’s story is emblematic of contemporary immunology: On the one hand, we witness discoveries that rival science fiction in challenging the boundaries of human achievement. On the other, the immune system’s complexity continues to flummox the most brilliant minds.

“An Elegant Defense” gives a thorough, richly entertaining and just-wonky-enough beginner’s class in immunology through the case studies of four patients, including Mr. Hoff. Two patients with autoimmune disease show the immune system running amok and misclassifying healthy tissue as foreign invasion. The fourth patient is a man with aggressive lymphoma, whose disease exemplifies the imperfectly vigilant immune system as it attempts to find and weed out malignant cells before they multiply out of control.

These four tales help readers without prior scientific training tackle the alphabet soup of immunology, with its T and B and NK cells, its CD markers, its HLA genes for MHC. Mr. Richtel also recounts how the key immune cells were discovered over the course of the 20th century. What unites these stories, besides persistence and ingenuity, is the reflexive skepticism that each scientific generation has toward those pre- and postdating it. As Nobel Prize winner Peter Doherty recalls, his older colleagues mocked the very notion of B and T cells as “the first and last letters of bulls—t.”

Mr. Richtel also objects to the militaristic rhetoric surrounding the immune system, as well as the marketing gimmick of foods and products promising to “boost” the immune system. “Your immune system isn’t a war machine,” he points out. “It’s a peacekeeping force that more than anything seeks to create harmony.” Yet even Mr. Richtel can get caught up in a breathlessly martial style that runs the risk of both inaccuracy and bombast-fatigue: Certain genes are “minefields,” diseases are “invisible suicidal assassin[s],” and treatment options are called “napalm” or “a veritable nuclear bomb.” It’s hard to rewire a century of thinking that frames disease as war.

In the book’s more reflective passages, however, Mr. Richtel marvels at the extraordinary cooperative power of the immune system—an inherently plural entity in which a vast array of human and even microbial cells play largely beneficial roles. The immune system, he writes, “teaches us clearly that our survival, as individuals and a species, is best served by cooperation.” He extrapolates from here: “Civilization, even of late, has been dominated by the push and pull of our competing instincts to cooperate and alienate, to see what people share in common or prey on what divides them. . . . The immune system teaches us to err on the side of cooperation and acceptance.”

It’s hard to disagree with Mr. Richtel’s sentiment, but cherry-picking teachable moments from biology is a dicey endeavor. Inflammation sends signals to weak or damaged cells, instructing them to commit “suicide” on behalf of the larger system. Should society do likewise? The answer is an obvious “no.” But it gives the lie to the notion that the biological body always has wholesome or edifying lessons to teach the body politic.

Over the past decade, studies have pointed to psychological stress as a risk factor for numerous conditions, from heart attacks and diabetes to impaired wound-healing after injury. A growing body of research elucidates how this occurs: Stress—both physical and psychological—tends to increase forms of inflammation, which reduces some of the body’s daily housekeeping in order to focus on immediate threats. While the evidence is compelling, it is far from complete and often relies on correlation to make claims about causation. Mr. Richtel takes wide liberties with the stress-disease model, freely speculating that one of his subjects contracted an autoimmune disease in part because her grandparents escaped the Holocaust, in part because she suffered sexual assault. For another woman’s autoimmune disease, he partly blames her demanding job. At the end of the book, he warns readers away from the “type A lifestyle” and counsels “sleep, exercise, meditation, and nutrition.”

Again, the advice is well-taken. At the same time, we can’t undo family or personal trauma (nor do we fully understand how much risk such events convey—more than a cigarette? more than bacon?), and many people find meaning and joy in working long and hard at something.

Until we know more about how the immune system responds to each of these cues, past and present, dispensing warnings such as Mr. Richtel’s can be at best anxiety-provoking and at worst victim-blaming. The immune system remains our most “elegant defense.” It is also our most mysterious companion, and it is up to the next generations of scientists to probe its still-guarded secrets.

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