Can you strengthen your immune system?

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Proponents of “alternative” medicine often disagree profoundly on treatment methods. Sick? In pain? Try this homeopathic remedy that contains no active ingredients. Stick needles into acupressure points. Wear magnetic foot pads to pull the toxins out of your body.

Illness is not caused by a weak immune system.

But on one point all proponents of alternative medicine agree. Since the source of all your troubles is a weak immune system, the key to treating and preventing all illness is “strengthening the immune system.” Indeed, this belief is so widespread, it appears that the only people who don’t subscribe to it are people who actually know something about the immune system, doctors, immunologists, microbiologists, etc. The idea that disease can be treated and prevented by “strengthening the immune system” depends on a profoundly flawed, almost cartoon like, view of the immune system itself.

The immune system is tremendously complicated, involving as it does innate cellular immunity and humoral (antibody) immunity. Multiple poorly understood organs make up the immune system. Anyone actually know what the spleen is for? And how about lymph nodes and bone marrow? Those are also quite complex. It is the interactions of these types of immunity, within the various organs of the immune system and throughout the body that determine whether and how we can fight off disease.

The alternative medicine view of the immune system is cartoon like in its simplicity. The individual components of the system, and their specific functions are never discussed or even mentioned. Too complicated. The cascade of events that occurs when the body’s outer defenses of skin or other tissues are penetrated by a foreign substance is completely ignored. Also, too complicated.

Instead, the immune system is conceptualized as a unitary entity that it either weak or strong. If you get sick, your immune system must be weak. In order to prevent illness, or to treat it once it occurs, you must “strengthen” your immune system. And how do you do that? The way you do everything in alternative medicine: you eat the right foods, and take vitamins and supplements.

But, of course, illness is not caused by a weak immune system. The specific mechanisms of illness depend on the specific causes. One possible cause is a failure of innate cellular immunity to find and destroy bacteria that penetrate the barrier of the skin. Another possible cause is the inability of the humoral (antibody) system to create antibody fast enough to overwhelm a viral invader. Instead, the invader gets a tremendous head start before the body can fight back and the virus overwhelms the host. Yet another factor is the presence or absence of various immune system organs. For example, it is well known that removal of the spleen leaves people particularly vulnerable to infection by the pneumococcus bacteria.

In every case, the disease results from a complex interaction between the disease causing agent and a specific component of the immune system. Moreover, there is no evidence that nutrition, vitamins or supplements can do anything to change the balance in these interactions, since the fundamental problem is not malnutrition, or vitamin or mineral deficiency.

It’s not as though we don’t know what a truly weakened immune system looks like. Chemotherapy (which preferentially kills fast growing cells) and certain disease like AIDS, knock out one or more components of the immune system, rendering people more susceptible to disease. If enough of the immune system is compromised or destroyed, the individual becomes vulnerable to infections that would otherwise be harmless or never occur in the first place.

In addition to ignoring what a weakened immune system looks like, and imagining that nutrition is the source of “strength” of the immune system, advocates of alternative medicine have another naïve belief about the immune system. They appear to think that the immune system can be overwhelmed by too much information. Ignoring the fact that each individual faces hundreds, thousands or more immune challenges each day, alternative medicine afficianados argue that vaccines, particularly those designed to immunize against more than one disease at a time, “overwhelm” the immune system, particularly what they imagine to be the “underdeveloped” immune system of small children.

Ironically, the truth is exactly the opposite. Vaccines are one of the few things, if not the only thing, that can strengthen the immune system by giving it a head start against a microscopic invader. Humoral (antibody) immunity takes time to ramp up if the body has never seen the invader before. It’s as if the body can’t start making weapons until it has already been invaded. Vaccines act like a picture of the enemy. Vaccines allow the body to “see” what the invader looks like before the invasion, and to stockpile weapons for the coming fight. When the assault ultimately occurs (when the person is exposed to the disease), the counterattack can begin without delay, and therefore it is much more likely to be successful.

As a general matter, a detailed understanding of system function is not necessary for lay people to understand what the system does. People do not need to know about all the different clotting factors to understand that blood should clot when you are cut and that something is wrong if it doesn’t clot. No one would invoke the idea of a “weak” clotting system to explain why a hemophiliac is bleeding to death, and no one would recommend eating the right foods, or taking vitamins or supplements to treat hemophilia.

Unfortunately, a detailed understanding of the immune system has been replaced with a cartoon like caricature of the immune system, leading lay people to believe that it is either weak or strong, and that it can be strengthened by eating right. It is this cartoon like view that makes lay people vulnerable to the claims of alternative medicine practitioners and, therefore, this cartoon like view must be changed.

 

This piece first appeared in December 2009.

  • CCL (Crazy Cat Lady)

    Given the way my immune system seems to be really good at attacking my lungs and other fairly important organs, I’d like to weaken it, kthxbye.

  • Dr Kitty

    OT:
    http://www.bbc.co.uk/news/uk-england-cumbria-37709471

    One of the midwives in the Titcombe case (you know, the ones who neglected baby Joshua and allowed him to die from pneumonia) has been permanently struck off by the NMC and will no longer be able to practice as a midwife in the UK.

    It has taken years for this to happen, but at least the Totcombes are finally getting some closure and the midwife’s lack of insight and remorse has been officially recognised.!

    • corblimeybot

      James Titcombe is a hero, he really is.

    • I bet she continues working as either an “independent” midwife or as a “doula” etc.

      • Dr Kitty

        She can’t practice as any kind of midwife without NMC registration, and by UK law the only people legally allowed to be paid to attend a homebirth must be registered doctors and midwives, so doula-ing or private midwifery at home births won’t work, and in-hospital doulas aren’t really a thing in the UK.

        I’m going to guess she’ll end up like most nurses and midwives who have their registrations removed- a care assistant in a nursing home.

    • mabelcruet

      And what about the midwife who told him to stop going on about his dead baby, and what was he complaining about, because ‘getting out of bed in the morning has risks’? Oh, yes, she was invited to join the Royal College of Midwives.

      It’s good that one of them has been dealt with, but frankly, the main culprits are still heading the profession with their dangerous and deluded mindsets.

      • Erin

        I was speaking to an ex- NHS midwife the other day (a fellow guest at the wedding I was just at). She left the NHS mostly as far as I could see because “Doctors are mean”. Now she’s running around advising women who tore so badly with their first baby that they’ve been advised to have elective sections by all the Doctors dealing with their various incontinence issues etc to ignore that medical advice because c-sections are so hard to recover from, so unnatural blah blah. Oh and helping women who are extremely high risk attempt home births. I came fairly close to shoving her in the pond. In fact if I hadn’t declined the champagne, I probably would have.

        Before I had my son, I thought midwifery was a profession with standards, ethics and science underpinning it. Now I’m erring towards it being some sort of religion.

        • Dr Kitty

          The best kind of midwife, in my experience, is one who has a complicated obstetric history herself.

          The ones who haven’t been pregnant or experienced childbirth or parenthood are the worst, closely followed by the ones who had textbook pregnancy and childbirth without complications (and who therefore assume everyone else can have the same).

          In my second pregnancy, it was my lovely community midwife who had had two CS herself, and whose daughter (also a midwife) who had just had an emergency CS after failed forceps delivery who was hands down the MOST supportive of my ERCS plan, and the young midwives just out of college who were by far the LEAST supportive.

          YMMV, of course, but if you can find a midwife who knows from personal experience that sometimes even if you do all the right things that you still need an epidural to manage labour pains, or a CS to deliver your baby, I’ve found the woo diminishes significantly and the outcome becomes more important than the process.

          • Who?

            The NHS midwife who cared for me during my first pregnancy, and coincidentally was there to deliver my son, was a former nun who had spent most of her career working in remote parts of Africa. She was wonderfully kind and supportive but zero interest in doing anything that didn’t support a good outcome. No doubt she had seen enough go wrong to know the benefits of good medical care.

  • Ori

    Exercise to sweat it out, and keeping fit regularly keeps the body at optimum functioning levels. Stress is the culprit, like radicals that chip away our immunity. Water, keep hydrated too.

    • guest

      Exactly how does stress cause illness? I want an explanation of the biomechanics involved.

      • Heidi_storage

        Step 1: You become stressed.
        Step 2: Then a miracle occurs.
        Step 3: You get sick.

        • The Computer Ate My Nym

          Step 2 is redundant. Everyone is stressed to some degree at some time and everyone is, eventually, going to get sick. So pretty much any illness can be blamed on stress.

      • Azuran

        Chronic stress does have a good range of physical effects, which can include possible slight reduction in immunity. But it’s nowhere near the cause of all the illnesses.
        Sure, not being stressed is better than being chronically stressed….in about the same way that doing a minimal amount of physical exercise is better than no exercise, or having generally well balanced diet compared to eating mostly fast food. But neither are the magical secret of longevity and you aren’t going to cure all illnesses with those.

    • demodocus

      please tell me you’re a poe

  • mabelcruet

    I’m always struck by how much anti-vaxxers and other alternative medicine folk seem to believe that the immune system is completely wonderful and perfect and consequently it must be so much better than artificially induced immunity. It’s not-the immune system can be a proper bugger-quite apart from all the auto-immune diseases, it can also cause severe brain damage in utero.

    The aetiology of neonatal encephalopathy is complex, but essentially, if there is intra-amniotic infection, the baby can mount an immune response-this results in inflammatory mediators being produced, and this causes cellular injury in the brain as a by-product of the process. So something like cerebral palsy can be caused by the baby’s own immune system destroying its brain cells.

  • The Computer Ate My Nym

    Unlike it 2009, there are now ways to strengthen your immune system. Really. Specifically, two new classes of drugs used to treat several of the trickier cancers (notably melanoma) strengthen the immune system. They do indeed strengthen the immune system and give it a chance to fight cancer. They also cause autoimmune diseases and make a lot of money for Evil Big Pharma. And fail to cause your every problem to disappear. Funny, that. Almost as though a healthy and well balanced immune system was more important than a “strong” one.

  • lawyer jane

    I’m actually considering trying out probiotics to “strengthen” my child’s immune system. I’ve got a kiddo who gets EVERY cold (even at 4) and gets them really bad. I read this Cochrane review, which suggests that probiotics are better than placebo, although the evidence was low-quality: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015894/ If I can find a safe source of probiotics then I might just give it a try.

    • guest

      Yogurt and fermented cabbage are both GREAT sources of a lot of the probiotics in the studies listed (it looks like a lot of the studies actually used fermented milk products anyway). Kefir too, although a lot of the flavored ones available have no fruit in them, just sugar and fruit flavor, so smoothies might be a better option.

      DIY Kimchi is actually really easy too, the hardest part is finding korean chili flakes, and for me in all my space cadet glory, remembering to rinse the damn salt off the cabbage. You can even get flakes that are just smoky tasting instead of spicy, if the kid doesn’t like spicy, and you can use WAY less than the recipe calls for without affecting the ferment. I use this recipe, and just divide the ingredients by the number of pounds of cabbage I have (I skip the fish ingredients in the interest of preserving my marriage). I make it in mason jars: http://www.maangchi.com/recipe/easy-kimchi

      • Ori

        Love Kefir, but unsweetened for me! Doesn’t taste good but it works.

    • Sue

      Probably won’t do any harm (though probiotics can cause gut side-effects), but, if there is anything pathological going on causing colds, it’s likely to be due to mucosal immunity and secretory IgA:
      http://www.invivogen.com/review-iga

      It’s difficult to know whether there is anything pathological at this age, because it’s a peak time for sharing respiratory viruses.

      Other possibilities to think about are hayfever/allergy and asthma.

  • Steph858

    Roll up, roll up! Below are the odds I’m offering on getting the following answers when a randomly selected woo is asked “Why is trying to ‘strengthen’ the immune system using TGN1412 so dangerous?”

    a) What’s TGN1412? — 5/1
    b) Because TGN1412 is an unnatural chemical produced by Teh Evil Pharma. — 3/2
    c) Danger of inducing cytokine storms. — 1000/1

    Place your bets, everybody!

    • gyrfalcon

      I’m not a woo, but my answer would be #1. Shortly followed by consulting my friend Google, and now I’m reading about cytokines storms. Who knew? Pleased to have a chance to learn something.

    • Roadstergal

      It would be A, followed by B once they found out.

      TGN1412 is a case study in a few dramatic examples of What Not To Do.

    • The Computer Ate My Nym

      I admit I had to look up TGN1412. Then I went “Oh, that one. Yep, that was bad.” Cytokine storm. Not good.

  • Z

    Moderately off topic:

    My toddler is somewhat typical that she is a picky eater. Sometimes she’ll go for days eating nothing but white bread, milk, and juice. I always water the juice down, 1 oz of juice to 4 oz of water, and she drinks several cups a day. She’s small, but so are we and the pediatrician says that her weight is within the normal range. But her diet does worry me.

    Everyone under the sun just loves to tell me that she won’t starve if I just take the bread away and that she’ll suddenly start eating better. I have tried everything, including starving her out, but she would just rather starve. She has gone more than 24 hours without eating when I cut off the white bread supply.

    I have discussed this with the pediatrician and asked if I should supplement her with multi-vitamins and he was adamant that I should not. My mother thinks I should get a new pediatrician.

    She doesn’t appear to be malnourished in any way. She’s literally never been sick before in her life (I credit that to vaccines and that she hasn’t been in daycare).

    But here is my question. Is the great emphasis on nutrition more scare than anything. I mean the picky toddler scenario is quite common and obviously more toddlers haven’t been dying off from malnourishment. Just what is malnourishment in kids? Obviously I don’t need to be feeding them kale smoothies to be healthy, but does that also mean that a diet primarily of white bread, juice, and milk is perfectly fine?

    • BeatriceC

      I’m going to tentatively side with you doctor here, assuming that she’s eating fine on other days.

      Other than that, I’m going to draw a weird comparison here. My amazon is a picky eater, and has been a seed addict for his entire life (32 years). He would literally starve himself for days when MrC would try to convert him to a healthier diet. He eats very few fresh foods, and we have been extremely concerned about how much longer this diet could go on before catastrophe struck. So I got sneaky. I discovered he liked cornbread. I also discovered I could sneak in a whole crap load of good stuff into the cornbread if I also added peanut butter. So now I make a nutritionally complete “birdie bread” that has shredded veggies and pureed fruits that he eats without question. He still loves his seed, when he gets it, but his main diet is now that peanut butter flavored cornbread that has all the other stuff hidden in it. The reason I bring it up is that maybe you can find a way to sneak some good stuff into the foods your daughter will eat. For example, maybe save the water after steaming veggies and use that to make your own white bread, so some other sneaky method like that. Or see if she’ll drink those nutritional drinks instead of milk for one serving of milk each day, or something like that.

      All in all, if this isn’t an every day thing, and that at least half the time she’s eating other foods, it’s probably not a huge deal, like your doctor says.

    • cookiebaker

      As a toddler, my oldest ate very little, but loved milk. My pediatrician recommended I cut her milk intake to 3 servings of 4oz per day and I’d likely see her show more interest in food. He was right. I limited her milk and she started eating.

      At 3, the same child went on eating jags where she ate nothing but Cheerios for every meal for about 6 weeks and another jag where she only ate Eggo waffles. I didn’t stress about them and let her decide when she wanted to eat other foods.

      Now she’s 16, she eats anything and everything, enjoys trying new foods and likes to cook.

      I currently have 2 others (5 and 11) who are picky, but they’re old enough that I require they try new foods. My 2 youngest (2.5y and 15 months) refuse a lot of foods automatically, especially spoon-fed foods like oatmeal or applesauce, but if I can get them to taste it, then they’ll happily eat the whole bowl.

      • EmbraceYourInnerCrone

        I was similar as a toddler and survived on lots and lots of milk, peanut butter and jelly sandwiches and cold cereal(Cheerios mostly). The doctor told my mom to slowly cut my milk intake and try adding other foods. Sometime having other kids over also helped, seeing them have something (cheese, fruit, raisins) made me think I was missing something. I was always a small eater but I did start having more of an appetite with out having so much milk.

      • Sue

        Existing mainly on diary milk can be a problematic because of the low iron content. I’ve seen toddlers with profound iron-deficiency anemia because they loved dairy milk, which supplies protein, fat and sugar, and therefore would not eat solids. Everything seems OK until people realise how pale they are.

      • Z

        We only allow our toddler to have 2 sippy cups (about 10 oz) of milk per day for the same reason. She still doesn’t eat. Yesterday, for example, she ate 4 small waffles (about like Eggos), 2 cups of milk and probably around 5 cups of juice water – which is 1 oz of juice diluted with 4 oz of water. At the end of the day, I eventually got her to eat a half a slice of pumpernickel bread (and this is European pumpernickel – say yay for highly nutritious!) with a smattering of fresh cheese. But that was it for the entire day.

    • Cat10

      Maybe just some perspective from my own experience. My eldest was (and still is) an extremely picky eater. We are talking less than 10 foods. My husband and I are very diverse eaters as is my other child. We love veggies, fish, legume, spicy foods, you name it. When my eldest was a toddler she would eat very little (bread, pasta, oatmeal, milk, maybe a yogurt, some juices) and I worried a lot. One family doc told me to withhold food from her and then offer what I wanted her to eat, if she refused, she should go hungry a bit longer and then be offered the same food. We tried this once and she refused to eat for 48 hours at the end of which she STILL DID NOT EAT the food we offered her. At that point we decided that enough is enough, no more fights about food.
      We never gave her any supplements and now at age ten she is in excellent health. I can count on two fingers the times she missed school because she was sick. She is not overweight or underweight, she developed normally, and is completely healthy. My advise is, do not worry! We changed doctors and our pediatrician now says that kids take in what they need, your role as a parent is to make sure that the available choices are healthy — beyond that it is up to them. Many foods are fortified such as cereals, pasta, flour, etc. so the risk of malnutrition is actually not that high (according to our pediatrician).
      I know how frustrating this can be (I blamed myself because my child would not eat fruits or veggies) but sometimes you just have to accept it. Also, with my daughter I would be worried that too much focus on food will lead to disordered eating later in life. I trust that at one point she will be better about eating a variety of foods and actually over the course of her growing up, she has become more accepting. Grapes, apples, carrots, and legume are now things she will actually eat.

      • Z

        This was very encouraging, thank you.

        The only thing is that we live in Europe, so our breads and pastas are not fortified. They are not totally stripped of nutrients, though, but the white versions do contain less iron and thiamine and B vitamins than they do in the US. So that’s a bummer. I cook a lot of casseroles and she will pick out what she wants from them, the mashed potatoes off of a shepherds pie, the pasta from a pasta dish, the rice from a stir-fry, and so on. I think, though that some of the other foods are smeared onto those foods, so maybe that provides enough micro-nutrients?

        • The Computer Ate My Nym

          I don’t know where you are in Europe, but in Germany they sell flour that is graded from 540 (completely refined white) to completely whole grain. The mid-range flours, i.e. 1040 contain more of the wheat grain without looking or feeling “whole wheat”. Maybe the kiddo would like bread made out of it?

    • Sean Jungian

      A picky eater can be a real source of heartache in a parent. I had a picky eater, too. I can’t tell you the shame I suffered over it for years. Until he was about 4 years old, my son would eat just about anything I made. After a series of moves, though. he became extremely picky and would not eat any food not prepared at our home except for plain bread or crackers, and milk. Even the foods I made at home had to be plain, single-food-types (no sauces or casseroles). He would not eat anything that was broken into pieces. He wouldn’t eat at other peoples’ houses or at daycare, and he would easily go all day with nothing and never complain. He was like others mention in this thread, would go without food for as long as it took, and he didn’t whine or get cranky, he simply wouldn’t eat.

      Our pediatrician told me that as long as his weight was okay, and he wasn’t showing any vitamin deficiencies, to not worry so much, and that he would branch out when he felt like it.

      So, he lived on a very bland and fairly restricted diet for quite a few years. To be honest, he still prefers to eat mostly proteins and breads, very few fruits and veggies (although he is *MUCH* better about that now).

      The main thing I had to be careful about with him was that he had regular bms. He is prone to constipation so I have to make sure he gets enough fiber, etc. For a few years, he developed encoparesis which is a chronic type of constipation, and it took several years to get his body “retrained”.

      He’s 15 now, and active in sports, school, etc. He gets maybe 1 or 2 colds per year but has never had any other illnesses that I can recall. He eats more of a variety now (although still not as much as I’d prefer, but whatever) and I make sure that when I do discover a new food he likes, to keep it at home, as well as not stocking too much of his “1st choice” things like white bread and butter.

      I myself was a very picky eater, and although I’m much better about it now in my 50s there are still very definitely things I will not even try to eat.

      Remember that nutrition is really relatively poorly understood. The guidelines we have are very general. Please don’t stress out about it too much (I know it’s really hard not to, especially when family and teachers are coming down on you for your kid’s eating habits). Beatrice does have a point, there are ways to sneak some extra veggies or fiber into things. Good luck to you.

    • RBJ

      Our son had cancer as a baby and was an extremely picky eater. Everyone was critical of his diet but he is a teenager now and healthy (although still very thin). One of the things that worked for us was to substitute white wheat bread (Nature’s Own, Iron Kids, Sara Lee) for his regular white bread. As picky as he was he never noticed the difference and we were able to get more fiber, calcium and iron into his diet.

    • The Computer Ate My Nym

      I wouldn’t worry too much about it, as long as she’s thriving, developing, and growing. She’ll likely broaden her diet soon enough. One paranoid question: does she have anything unusual developmentally? Autism can present as extremely picky eating due to sensory issues. (Though being picky as a toddler is more normal than abnormal so very likely not the issue.)

      • Z

        Not at all. She’s incredibly, bright, active, talkative, friendly, etc.

        • The Computer Ate My Nym

          I think I’m going to go back to my original guess that it’s a phase then and you shouldn’t worry too much if she’s growing and happy.

          • Irène Delse

            Seconded. Kids can be terrible eaters and still thrive. My go-to example is one of my siblings, who ate literally zero fruit or vegetable from age 3 to 15, and had a perfectly normal development. In fact, he’s now the tallest and most healthy of us four!

        • Sean Jungian

          Just chiming in to encourage you to not worry about it. Try presenting new things when you feel up to it, but don’t get all emotionally invested in her eating choices. Sometimes you have to present something several times before they’ll try it.

          In other news, I got my still-pretty-picky 15 year old to try some sushi today. He wasn’t sold on it, but he did at least try it!

    • J.B.

      Ellyn Satler has a book that nutritionists recommend. The quick summary is don’t make food a battle, cook one meal and include something your child already likes (so bread on the side of a normal family meal.) You decide what goes on the plate, your child decides what and when to eat.

      My kid is incredibly picky and wasn’t gaining weight so we ultimately limited dinners to the small list of items she would eat. She has very very slowly broadened her palate but it took several years.

  • Mrs.Katt the Cat

    I always imagined my immune system like a business/company. There are the day to day employees who do what they do and mostly handle themselves. Every now and then an issue comes along that needs a manager or higher boss to handle it, and it just takes time for info to be passed up, decisions made, and plans implemented. In the meantime the workers carry on as best they can with what they have. Kinda cartoonish but it amuses me.
    And this is why I say my immune system is Boss and that’s why I hardly ever get sick- i have a good CEO in there somewhere! 😀

    Also the thought of my white cells running around like retail workers at Christmas trying to get all the customers out of the store so they can just go home already makes me chuckle when I actually do get sick.

    • BeatriceC

      That actually sounds like a pretty darned good analogy. I think I shall steal it.

      • Mrs.Katt the Cat

        Do so! This is the first time I’ve shared it, my analogies usually onky make sense to me . . .

    • StephanieJR

      I imagine my white blood cells as security/bouncers!

  • Irène Delse

    As someone with autoimmune hypothyroidism, I have to laugh (well, sneer) at the idea that a “strong immune system” would make me healthier.

    • guest

      Yeah. It seems like the list of foods I can’t eat due to oral allergy syndrome gets longer every week. I’d kill for a less responsive immune system.

      • Roadstergal

        Even at that, it’s not about ‘strong’ vs ‘weak.’ It’s about correcting an imbalance in the various arms.

        • Irène Delse

          It’s ironical, isn’t it? Alt-med loves the idea of balance, in chi, in innate intelligence, whatever. The one time that would make sense, ie, for the immune system, they go for “boosting” or “strengthening”.

        • guest

          Well, yeah. I might accept the food restrictions if it meant I never caught a cold – but it doesn’t. I still get colds, but my body reacts to things it shouldn’t react to. I need to see an allergist about immunotherapy, but I’m afraid of the time commitment.

  • Roadstergal

    I was just discussing with a visiting scientist the data correlating regulatory T cell level with cancer risk, and sighing at the fact that wiping out the Tregs would give you massive autoimmunity. There’s no free lunch. (PMID 26298011, if you’re interested).

    Strengthen means nothing for a checks-and-balances system.

    • MaineJen

      Treg boosting drugs are also being studied with regard to transplant tolerance…with conflicting/disappointing/mixed results. There is no easy answer, damnit…