Blood is the life force of all human beings.

It flows throughout the body, nourishing the whole organism. It feeds all living cells while keeping their environments clean, all in a never-ending cycle until death.

To any regular person, blood is simply a red liquid. But to those who’ve studied it, there is much more than meets the eye. Blood is a mix of substances and cells. There’s water, mixed with a protein called albumin. Red blood cells, containing hemoglobin that holds oxygen molecules. Various types of white blood cells for infection control. Cell fragments called platelets that stick together in response to bleeding events. For extra support, there are immune system antibodies floating around along with clotting factors that form hard clots to really stop any bleeding. Then there are waste products, namely carbon dioxide and nitrogenous substances like urea and creatinine, plus any drug molecules or toxins, if they happen to enter the body. As every cell thrives on oxygen, water, and nutrients, the trash gets taken out. Carbon dioxide reaches the lungs to be exhaled, while the liver metabolizes noxious substances into harmless forms, and the kidneys filter out waste into urine.

I watch the patient’s blood drain from his body, part of a ritual to preserve his life. It’s flowing out of his chest through a tube connected to a machine with hidden fancy gears and chemicals giving off a semi-sweet bleach-like odor. Then the blood makes its way back into the body, through a parallel tubular pathway toward the same part of the thorax. It’s an artificial cleansing of the blood. Hemodialysis, for this young man who has bilateral kidney failure.

Hector Lucero frowns while lying in bed. He is the last patient I’m seeing in my morning rounds. Earlier, I had visited my four other patients in their respective rooms on the eighth or ninth floors. Hector was not in Room 822 when I tried to see him first, and he still was absent when I stopped by his room last. So I figured he’s in the inpatient dialysis unit on floor six. That’s where I’m at now. It’s an unusual place to see a patient during rounds, but I wasn’t going to wait any longer. At least there was no issue with me being here. I asked Hector about his symptoms and he reported feeling OK, without any breathing problems at this time. His physical examination was unremarkable, with no lung crackles or ankle swelling, unlike when he got admitted two days ago. The progress is good news at least.

I am observing the hemodialysis machine only because I’m lost in thought. How could this patient, who is only a 24-year-old man, already have significant failure of both kidneys? How will his life change because of this?

“Dr. Lin, am I going to die?” Hector says morosely.

I slowly shake my head, hoping to make his sad expression disappear. I really can’t imagine being in his place.

“No, you won’t,” I answer gently.

“But it feels like I will.”

“Why do you say that?”

“Look at me. I’m here having dialysis when I could be at work or doing something else. If this is what the rest of my life is gonna be like, what’s the point?”

I remain still. Whether the patient is full-blown suicidal, I have no idea. All I know is that he is in pain. The emotional kind, not just the physical kind, if it is present.

“Tell me what is bothering you, Hector.”

“A lot of things.”

“Like what?”

“Well… I don’t know. It’s just all too much.”

“How about this? Let’s take it one issue at a time. Try not to think about everything at once. Can you do that?”

Hector nods, with his mouth still curled downward.

“Of all the concerns you have, what would you say is the biggest one?” I ask kindly.

“Can I do the things I’ve always done?”

“Such as?”

“Go to work and still do a good job.”

“What do you do for a living?”

“Associate at a hardware store.”

“Working cash registers? Stocking merchandise?”

“All of that. Should I worry about kidney failure making me weak? Sometimes my work involves using a forklift to move heavy stuff around. I don’t want to have a bad accident.”

Slowly, I shake my head.

“If you have dialysis regularly, the electrolytes in your blood should stay normalized. You should be fine.”

“So I don’t need to freak out then?” Hector asks. “I don’t want to get fired because I’m incapable.”

“Don’t sweat it. If health issues still somehow disrupt work, you can talk to your primary care doctor, have him write a letter about what physical limits you should have on the job.”

The patient nods. His frown is slowly fading, a good start at least. Still some ways to go, though.

“Can I still play soccer?” Hector asks.

“Depends on your condition. Hopefully, it won’t prevent you from enjoying sports at a minimal level. Just like it won’t stop you from working. It’s just a matter of making adjustments to incorporate that treatment into your life. You know what I mean?”

“Sure.”

I nod and smile. Then the patient brings up something else.

“The only other thing I’m really worried about is my family. We’re really struggling.”

“How so?”

“Financially. It’s kind of a long story.”

“You can tell me.”

“Are you sure?”

I nod and lean in, letting him know that I will listen. I have to if I want to erase that frown of his.

“When I was little, we had a somewhat big family,” the patient begins. “It was my parents, my younger sister Rosario, and grandparents on my mother’s side. I barely knew grandpa because he died when I was only four. Then my mom and dad died, one year apart, while Rosario and I were just teenagers.”

“I’m sorry.”

“So it was my grandma, already with health problems herself, trying to take care of two grandkids. My sister and I felt bad. I tried pitching in with whatever summer job I could do once I turned sixteen. Rosario did the same, starting a few years later. And now look at me. I’m going to be a burden for the other two.”

Hector closes his eyes, trying to stifle tears. It’s my turn to frown now. Better to hold off on further discussions about his condition. He has kidney failure and that’s hard enough already. He’s not yet aware of other specifics, like what exactly caused it. That’s something I now have the answer to, as of this morning. When Hector feels ready to know more about what’s going on inside his body, I’ll explain it then.

“Don’t be so hard on yourself,” I say gently. “None of this is your fault. The focus should be on you getting better. I’m sure your sister and grandmother would say the same.”

“I guess,” Hector responds with a sigh. “I just wish things could be like before I came here.”

“I know. It’s natural to feel this way when something big and unexpected happens. Just relax and breathe. It’ll be OK.”

The patient does exactly that. He closes his eyes while doing so. He’s not smiling yet, but neither is he doing the opposite. I’ll take that for what it’s worth. This is a good time to end the conversation, so I get ready to head out. Then another physician enters the dialysis unit: a wide middle-aged Hispanic man with a mustache. It’s Dr. Carlos Chavez, the nephrologist consulted to manage Hector’s dialysis.

“Good morning, Hector,” Chavez says. “How are you?”

Hector raises his hand in a silent greeting. A conversation ensues, mainly in Spanish. Based on some words I can understand, Chavez is inquiring further about Hector’s current state of health and any new problems coming up. During the chat, I briefly wave goodbye to the patient before stepping out into the hallway. But I don’t head upstairs yet. An important clinical discussion between doctors needs to take place. I stand around and wait, while checking my hospital-issued tablet for updates on my other patients.

A few minutes later, Chavez exits the dialysis unit.

“Can I talk to you near the elevator?” I ask the nephrologist.

He nods and follows me to the elevator bank in the center of the sixth floor’s long east-west hallway. Definitely far enough away from the emotionally fragile Hector.

“I’m concerned about this patient,” I begin.

“Yes, he is distraught. Especially about his family situation.”

“I know. But on the clinical side, I have my own worries. You saw the imaging results that got posted this morning?”

Chavez nods slowly.

“Let’s recap what we have,” I say. “Hector came to the emergency department two days ago because of dyspnea, difficulty breathing. X-ray showed pulmonary edema, fluid swelling the lungs. His blood creatinine level was severely high, close to six milligrams per deciliter. He likely has kidney failure because nothing else could explain this, especially when he has no pulmonary conditions in his history at all. So the emergency doc consulted a surgeon who placed a central venous catheter through his chest. Then you came to do dialysis through that port, the same day Hector came in.”

“Yes.”

“Hector got admitted, assigned to me. I consulted the on-call interventional radiologist. He did renal catheter angiography late yesterday. And now we have the result.”

The question now is whether Hector is eligible for revascularization, treatment to restore blood flow to the kidneys. Either a catheter procedure to stent those vessels open or surgery to graft vessels that would bypass the narrow segments. Turns out I don’t need to ask. Chavez brings up the issue himself.

“Revascularization would make a difference if Hector were to also have hemodynamic instability,” he says to me.

“Sounds like you’re not suggesting that route.”

“No. He isn’t having, say, acute coronary syndrome. Plus, his blood pressure has been holding steady ever since you started him on medications for that.”

All right, I get it. If Hector has renal failure and that condition causes major secondary problems, like deficient blood flow to the heart, revascularizing those kidneys is a must. But if he’s holding steady without symptoms, revascularization might not do as much, while still possibly resulting in complications. Benefits would not outweigh the risks. Based on that analysis, don’t do the procedure.

“That’s true,” I say calmly.

“I talked to Hector about how long he might’ve had hypertension. The problem is that, because the family didn’t have steady health insurance, Hector hasn’t really seen a doctor for the past five years or so. I can’t tell if his kidney issues developed gradually or just recently. Same for his high blood pressure.”

“It’s pretty rare for people in their twenties to develop renal artery stenosis, right?”

“Yes. It’s more common in the elderly. Doesn’t mean it’s impossible for young people to get it. After all, most cases of renal artery stenosis are due to atherosclerotic plaques. Risk factors for them do occur in most age groups.”

“So what’s next for Hector? Dialysis until kidney transplantation, once a matching donor is available?”

“Pretty much.”

“You talked to him about it?”

“Not yet. He is still processing his situation. He hasn’t even decided what kind of dialysis he wants.”

I nod slowly. The patient has only two choices. Neither is easy because each has its own drawbacks.

Option number one: hemodialysis. Hector has a catheter in his chest, but that’s prone to infection, so it’s often not a good long-term dialysis access point. He would need a vascular surgeon to connect one artery in his arm directly to the corresponding vein, so that rapid blood flow there makes hemodialysis possible. Then he would have to visit a dialysis clinic three times a week for his blood cleansing. That’s gonna be a major adjustment for Hector.

Option number two: peritoneal dialysis. The patient gets a catheter inserted into the abdominal cavity through the skin of his belly, then pours in liquid that would collect nitrogenous waste from the blood. He would have to change the fluid every two hours, pretty much every single day. He wouldn’t have to visit a dialysis clinic, but this would still take up huge chunks of time.

“I assume you haven’t spoken to him about that either,” I say.

“No,” Chavez says. “He needs more time.”

“Out of curiosity, what is the youngest patient with renal failure you’ve ever treated?”

“Any severity, or end-stage specifically?”

“End-stage.”

“I once had a woman who learned she needed dialysis just before her twentieth birthday. Definitely hard for her to adjust. Her kidney failure was due to an autoimmune disease.”

“Which one?”

“Lupus.”

I let out an exhale. Imagine adulthood getting disrupted just as one enters it. It really must suck.

“I feel bad for Hector,” I say, a bit solemnly.

“Me too,” Chavez says. “Right now, he’s in a denial stage. Once he gets past it, I’ll explain his dialysis options. I’m hoping either today or tomorrow.”

“Sure thing. I’ll try to lend emotional support, too.”

“That will help, especially as he seems comfortable with you.”

“What makes you say that?”

“He told me you made him feel better, just by talking to him.”

“Is that right?”

Chavez nods as I form a smile. Then we step into an elevator. We go our separate ways, with me coming off the eighth floor and him continuing to head upwards. I walk toward the 8 East nurse’s station, heading for the workroom behind it.

That’s when I spot a young Hispanic woman speaking with the head nurse. The latter soon notices me, then points a finger my way. The woman’s head turns in that direction. She’s a slender lady with shoulder-length brown hair, dressed in blue jeans and a gray long-sleeve shirt. She also has a black leather purse hanging from one shoulder. As she approaches, I notice that she’s a couple of inches shorter than me.

“Dr. Lin?” the woman says. “I’m Rosario, Hector’s sister.”

“Ah yes,” I answer, shaking her hand. “He told me about you, how things have been financially tough for the family.”

“Yeah, it’s been hard. Where is Hector?”

“Still in dialysis downstairs. He should be back up here soon.”

“Is he doing OK?”

“So far, yes. But emotionally, he’s feeling down.”

Rosario nods slowly.

“He’s been like that for a while,” she says.

“For how long?”

“Several years. Ever since both of our parents died, he took it on himself to work hard, make money, and provide extra support for all of us. This news about kidney failure only made him feel worse.”

“He did tell me about your grandmother, how she’s the only older adult around.”

“She does so much for us. I’m trying to help out too, with a part-time job while going to school.”

“You’re a college student?”

“Yeah. Santa Ana College, studying to be a paralegal. Anyway, it’s not just money Hector’s been worried about. It’s also his life. He’s been sad about not having a girlfriend. His last one broke up with him a couple of years ago.”

Man, Hector has a lot going on. Someone give the poor guy a break.

“He thought it might be his appearance,” Rosario continues. “He kept talking about being overweight.”

“Has he tried shedding some pounds?”

“A little. I mean, he’s been spending time on the soccer field with his friends. But that didn’t help.”

“What about modifying his diet?”

Rosario shakes her head.

“I tried to talk him into it. But he doesn’t like me acting like our mother. He won’t give up his favorite foods. He really loves his pizzas and nachos.”

“Well, he may want to seriously look at that,” I comment. “As you know, Hector now has severe kidney failure. He’s already going to be on dialysis on a regular basis.”

“He’s so young, though.”

“I know. Then again, diabetes and high blood pressure are on the rise in people his age. These conditions can damage the kidneys directly, not just lead to plaques in their blood vessels.”

“You think that’s why Hector’s kidneys went bad?”

I shrug a little.

“It’s possible,” I say. “When you talk to Hector, make sure he understands the importance of losing weight. He has to improve his diet and exercise regularly. Otherwise, he might have other problems later.”

“Speaking of which, I want your opinion on something.”

Rosario reaches into her purse and pulls out a cylindrical object. It’s a green plastic jar, a bit larger than her hand. Looks like something from a nutrient supplement store. Sure enough, the label that’s partly visible shows a picture of a leaf.

“Do you know anything about this?” Rosario asks.

She hands me the jar. It’s an herbal supplement called Motileaf, designed to promote weight loss and boost energy. “The Leaf to Motivate You,” its slogan proudly proclaims. On the other side of the container, the bottom of the label specifies the manufacturer: Brighter Sun Herbals, located in Corona, California.

“Honestly, I’ve never heard of Motileaf,” I say.

“So you know nothing about it?”

“Afraid not. As a medical doctor, I’m versed in treatments that are well-researched and part of conventional Western medicine. Herbs are outside my expertise. Sorry that I can’t help.”

“It’s OK. I was wondering because I found this in Hector’s apartment. He wanted me to stop by and feed his dog. Poor thing was left all alone since the day Hector had to be rushed here. I noticed this jar on the living room table.”

“What’s the problem with it?”

“Did Hector ever say what our parents died from?”

“No.”

“Our mother had a stroke. Father had a heart attack. They were just in their mid-forties.”

“It’s not exactly uncommon at that age.”

“No, but both of them were taking Motileaf. Probably wanted to improve their health with it. They always believed in herbal medicine, even as children back in Mexico.”

I pause. Where the hell is she going with this?

“When our parents were alive, I only noticed our father taking it,” Rosario continues. “After they died, grandma told me and Hector that our mother had used it, too. I’m wondering whether it actually works. It should’ve helped them be healthy and live long.”

“And now Hector has some of this stuff.”

“Right. It’s strange he didn’t tell me about it. Maybe he didn’t like me talking about his weight issues.”

“You know how long he’s been taking Motileaf?”

“Not exactly. But let me show you this.”

Rosario reaches into her purse to pull out another item: a small piece of white paper. It’s actually a narrow rectangular sheet, folded in half several times. She opens it up and hands it to me. It’s a receipt from a store in Santa Ana called Botanica Cielo Y Tierra. It shows one item bought: a container of Motileaf, costing thirty dollars, paid in cash. The purchase was made three years ago.

“Are you going to talk to Hector about this?” I ask.

“Yeah. I don’t know how he’ll react, though.”

“My advice: just be honest. Tell him how your parents had taken Motileaf for a while before they died, but you’re not sure if it really works, so you’re worried about him wasting his money.”

“Sure. I could try that.”

“At this point, let’s focus on Hector’s next steps. For example, what kind of dialysis would he prefer to have? There are plenty of factors to consider, not just with him but also with the whole family.”

“I know.”

“And make sure he comes to terms with it. As his sister, you have a vital role to play in providing support.”

“Of course. You know what? Maybe I should wait a little before bringing up Motileaf.”

I nod, recalling Chavez’s assessment of the patient’s mood. Then I hear a ding from the eighth floor’s elevator bank and one of those doors opening up. I glance in that direction. Hector’s bed is being pushed out. Rosario catches up to her brother and walks alongside the orderly maneuvering the bed. They pass me and the nurse’s station before disappearing around a corner, no doubt heading into Room 822.

I step into the 8 East workroom, log into a computer, open the Icarus medical record application, and document the latest status on my patients. Over the next several minutes, the name “Motileaf” keeps crossing my mind. Rosario had been focused on one aspect of it: effectiveness, whether or not it provides the benefit it’s supposed to. But now I’m thinking of the other half of the medical equation: safety.

The Lucero parents passed away in their forties, not much later. Sure, they could’ve had enough risk factors for their heart attack or stroke, but with Motileaf thrown in, how did that affect the odds? Meanwhile, Hector had been taking it and now has a cardiovascular event of his own: renal artery stenosis. And again, he’s only in his twenties. That’s when I realize another common link across all three cases: atherosclerosis, the formation of a fatty plaque in an artery, narrowing the vessel. That cuts off the life force of blood to a vital organ, whether it be the heart, brain, or kidney.

To really be thorough, I go over my differential diagnosis for Hector one more time, reminding myself why other conditions do not explain his renal failure. Hypertension: possible because he does have high blood pressure. But how long has he had it? I don’t know.

Diabetes: not in this case. Hector’s blood glucose is not terribly high.

Inherited kidney diseases, like polycystic kidney disease: unlikely, considering no family history of this.

Infection of the kidneys: not really. His white blood cell count is within normal range.

Kidney stones obstructing ducts: no signs of this.

Nephritis as a medication side effect: really doubtful. He’s not taking medications, prescription or over-the-counter.

Any other cause of kidney failure besides the above: unlikely.

I turn my attention back to the cardiovascular history of the Lucero family. I’m suddenly reminded of a saying in the field of epidemiology: correlation does not imply causation. Seeing two things happen together does not automatically mean that one led to the other. Maybe Motileaf had nothing to do with the three health problems in the Lucero family. Yet, my rational mind fighting to be objective is losing that battle. It’s hard to demonstrate cause and effect in just one person, but in the eyes of a layperson, two cases supposedly increase the odds and a third seemingly solidifies them. At a loss for an explanation of Hector’s kidney status, I’m willing to explore the possibility of Motileaf as the culprit.

I now have a new medical puzzle to solve.

It’s ten minutes after five in the afternoon. The work day is done, with my patients handed off to one of the night-shift nocturnists covering the overnight hours. So now I’m in my car, a trusty blue Tesla Model Y, ready to sail on out of here. But I’m not heading home.

On the touch-screen dashboard, I access the map and enter my destination: Botanica Cielo Y Tierra in Santa Ana. Estimated driving time: twenty minutes, if my route includes the 5 Freeway. Not wanting to face rush-hour traffic, I plop an additional waypoint on the map, at a random major intersection in the city of Garden Grove. The recalculated route through that point would be almost twice as long. No big deal. Business hours for Botanica Cielo Y Tierra are nine a.m. to six thirty p.m., seven days a week. With the navigation details set, I slowly make my way down the levels of the parking garage and into the street. I head south from Ivory Memorial Hospital and, eventually, away from north Anaheim itself. I juggle the sight of the road with the thoughts in my head.

Rosario Lucero is concerned about Motileaf. But she also said the herb should’ve helped her parents live long. She fixated on not seeing the benefit promised. She mentioned nothing about dangerous side effects. She’s probably like a lot of people, assuming that any natural treatment is safe and the only question is whether it works as intended.

This takes me back to a particular hour from my medical school days. My pharmacology class had a lecture providing an overview of conventional medicine versus complementary and alternative medicine, also known as CAM. Conventional medicine is oriented in evidence, research proving the safety and effectiveness of treatments. Pharmaceutical medications receiving approval from the U.S. Food and Drug Administration belong under this umbrella. They have to meet rigorous standards, including ingredients and dosages that must be consistent from one pill to the next during the manufacturing process. Even when the drug is FDA-approved, the company is still obligated to conduct postmarket surveillance, making sure its product remains safe and effective while being sold.

But things are different in the world of CAM. The FDA treats herbal supplements like foods, not drugs, so the regulations are more lax. A manufacturer such as Brighter Sun Herbals could get away with inconsistent amounts of herbal ingredients from one container to the next. Herbal medicines like Motileaf don’t have to undergo clinical trials for the FDA like pharmaceuticals do. It’s no wonder my pharmacology professor emphasized caution with herbal supplements, plus other CAM therapies like acupuncture, homeopathy, and biofeedback. Yeah, she might be biased, but she made a point I would never forget: if it can’t be proven, don’t trust it.

And just like that, I have arrived at my destination.

Botanica Cielo Y Tierra occupies a small block-like structure in downtown Santa Ana, with the store name painted above the front glass door. I walk up to it and step inside. Right away, the shop feels like a church. There are wooden shelves along the walls and the middle spaces, displaying candles, statues, crucifixes, and other faith-oriented artifacts. Other shelves hold various kinds of colorful containers, like jars, bottles, and bags, for items of medicinal value. Another part of the store has books related to religion and spirituality. Nearby is a counter with a cash register. Right now, no one is behind it.

I look around. It is not long before I hear someone coming. A thin, clean-shaven Hispanic man, looking close to forty years of age, emerges from a back room. He approaches me.

“We close in ten minutes, señor,” he says while walking.

I say nothing. Apparently, I had lost track of the time during my drive.

“I want to buy some Motileaf,” I say, trying to sound friendly. “It’s an herb for weight loss. You have any in stock?”

“Yes.”

“Really? I don’t see any. Everything here seems so traditional.”

The man points a finger to a spot behind me. At first, it looks like he’s telling me to leave the premises. But then I see, near the entrance, the front corner of the store, which has a single set of shelves occupying it. In contrast to the merchandise originating from cultural and religious practices, the items in the corner are a collection of herbal, vitamin, and mineral supplements, many with familiar mainstream brand names. This shop is fusing the old with the new, upholding the traditions of the past while living in the realities of the present. I spot the jars of Motileaf on the top shelf. Before I could reach for it, the store owner does it for me.

“How many do you want?” he asks.

“Just one,” I answer quickly.

“That’ll be thirty dollars plus tax.”

“Sure. I’ll take it.”

I follow the man to the counter, where he operates the register and tells me the calculated total price. I open my wallet to pull out a twenty, a ten, and a five. In exchange for the cash, he gives me my change along with a receipt and the Motileaf jar. Then I notice a stack of business cards next to the register, which identify the store’s owner: Alfonso Romano.

“You are Alfonso?” I ask.

“Yes, I am,” he answers without a hint of friendliness.

“How long has this place been running?”

“About eight years.”

“The community must appreciate it.”

“Many people around here like to come in for the traditional stuff. They know exactly what they need. If they have, say, a stomach ache or a cold, they tell me the specific herbs and medicines they want. Gotta have respect for their knowledge.”

“Interesting.”

“But there are others who like more modern herbals. This botanica recently expanded to stuff like that.”

“Such as Motileaf.”

Alfonso nods, his mouth still straight.

“Can I ask some questions about it?” I ask.

“Make it quick,” he says, somewhat impatiently.

“First off, does this stuff work?”

“If it didn’t, why would I be selling it?”

“What I mean is if you have seen it help people actually lose weight or feel more energetic.”

“Of course. Plenty of my customers told me so.”

“How many?”

“Like around ten people a month.”

“And how many have bought this?”

“You’re starting to butt into my business. Why should I give you the exact numbers?”

“But it’s a lot, right?”

Alfonso glares at me. Aw, damnit. I’ve gone too far already. Time to de-escalate this.

“I’m sorry, sir,” I say. “I have a friend who asked me to buy this stuff for him. I just want to understand why he seems to like it.”

“Probably because it’s working for him. I’ve been selling Motileaf for years. I hear nothing but good things about it.”

“So no side effects or anything like that?”

“Nope.”

“You think it’ll become even more popular?”

Again, Alfonso stares at me. Then he stretches his hands out, like he’s holding the entire store inventory.

“I’m a businessman. I deal with the finest products. That’s the only way I’ll succeed, right?”

“Sure,” I answer sheepishly. “Anyway, sorry for taking up your time. Enjoy your evening.”

Alfonso’s expression remains unchanged. He just looks at me. I turn and head out the front door.

I get into my car and drive. It’ll be another twenty minutes or so before I reach my house in Anaheim Hills. In the meantime, what exactly is Alfonso’s problem? I usually don’t get suspicious looks from sales clerks wherever I go shopping. I would think they’d appreciate customers asking questions, because they’re opportunities to make some dough. Something must be up with Alfonso. Is he hiding something? Maybe. Or maybe not. He could just be having exciting plans for the evening and feeling anxious to close up shop at six thirty on the dot.

Minutes before seven o’clock, I arrive home. I bring the jar of Motileaf to the living room and sit on the couch. I tear apart the plastic seal around the lid, open the container, and take out one pill to examine up close. It’s a dark-green elliptical capsule with a faint line marking the midpoint of its length. Even with the room’s light turned on, I need some more illumination, so I turn on a table lamp next to one end of the couch. Under that level of brightness, I can see the inside of the semi-transparent capsule. It’s filled with a fine greenish powder. Whatever leaves and plant material that went into it were shredded, grounded, and pounded well.

I bet if people see this Motileaf capsule and want to lose weight, they’ll go for it in a heartbeat, especially if they assume that natural equals safe. I wonder what customers are saying about Motileaf. On my personal phone, I open its web browser and do a search for Motileaf. The first result is, not surprisingly, the official website of Brighter Sun Herbals. I browse through its contents.

The company was founded in 1988 and has always been based in Corona. There are nearly a hundred products for sale online through its website or in various retailers. Brighter Sun Herbals sells capsules, powders, liquid extracts, and even bubble bath formulas for anyone looking for an herbal spa treatment. Besides excess weight, conditions that could supposedly be treated with Brighter Sun products include impaired concentration, insomnia, the common cold, diarrhea, constipation, fatigue, muscle cramps, and chronic pain from all sorts of diseases. I do see a Testimonials page with quotes from customers who are loyal to Brighter Sun Herbals. I can’t tell if it’s genuine or bullshit, but I’d rather look elsewhere for feedback.

My search results also include posts about Motileaf on forum sites like Reddit and Quora. I skim them and notice how they mostly praise the product, saying that it works, they lost weight ever since starting to take it, or they don’t feel as lazy as they used to be. There is the occasional contrary opinion about Motileaf, though nothing harshly recommending against using it. For example, one user comments his doubt about the herb doing anything:

Uh, guys, are you sure Motileaf even works? I started taking this a few months ago. Haven’t noticed any change in my weight at all. I’m doing everything else the same as always. Anyone here experience something different?

A similar comment is made in a different thread about Motileaf:

I bought Motileaf from my local wellness goods store because it’s supposed to make me feel motivated and whatnot. I’m not feeling it. I’ve even been a bit tired these past few days. Is it me, or is this supplement just a piece of crap?

You know what would be nice? Someone hinting at a link between Motileaf and kidney failure. Or Motileaf and heart attack. Or Motileaf and stroke. Is the Lucero family’s use of Motileaf merely a correlation with their ailments, or is there an actual underlying cause-effect relationship going on? I wish I knew. Sadly, not a single user comment brings it up or even comes close to beating around the bush. Was my visit to Botanica Cielo Y Tierra really a waste of time?

Otherwise, there’s nothing I can glean from this. Anecdotes are a far cry from controlled clinical trials, having participants either take Motileaf or do something else and then seeing the results for each group. I check one more source: the website of the Better Business Bureau. I do see a listing for Brighter Sun Herbals. The company is not accredited by the BBB, but neither does it have a rating because there is not enough information from the public about the integrity of the business. The jury is still out on whether Motileaf is safe or not. Oh well. I’ve done all I could for today. Time to call it a night.

As usual, my work as a hospital-based internist at Ivory Memorial is torture for the average person: twelve straight days of work, then six days off before repeating the cycle. I am glad that today is the last day of the on-duty stretch. While I finish morning rounds, I get a text on my work phone indicating a new patient admission. I’ll do the initial work on that case today, before the hospitalist taking my place tomorrow becomes the new daytime clinical provider.

The patient is Robbie Dickerson, a 31-year-old man who has a history of chronic obstructive pulmonary disease alongside a list of other issues, like congestive heart failure. His chief complaint is difficulty breathing, even while lying in bed. Then a particular detail from the chart jumps out at me: the patient is obese and not barely so. His body mass index is way over 30 kilograms per square meter, the defining cutoff for obesity, and even way over the 40 mark for severe obesity. It’s actually close to 70.

Robbie Dickerson is 500 pounds.

Oh man, are you kidding me? Most of the patients I’ve ever seen, from my medical school days to today, were overweight or obese from eating too much fat and sugar, not moving around enough, maybe drinking lots of alcohol and coffee on the side as well. That’s bad enough already. But none were more than 300 pounds. It’s a well-studied fact that diet and exercise are essential for good health, and yet many people don’t do that. Ah, whatever. I’m still getting paid as a doctor.

Going back to the case, the patient’s mother drove him to the emergency department downstairs today. He received supplemental oxygen through a nasal cannula plus bronchodilators, based on a presumed diagnosis of COPD exacerbation. His oxygen saturation barely held steady with these measures. I imagine there was uncertainty about where he would end up: the ICU on the seventh floor, the Step Down Unit just outside the ICU, or the Medicine wards on floors seven through nine. In any event, the ED physician decided a ward admission was fine for now. I enter ED Room 14. The first thing that strikes me is the patient’s bed. It’s wider and squarer than the usual kind, in order to accommodate someone as voluminous and heavy as Robbie Dickerson. The patient, a man with a gentle face, is accompanied by another heavyset individual: a woman in her fifties, wearing glasses. Her girth is about half of the patient’s, but her BMI is undoubtedly still higher than normal.

“Hello,” I say in a friendly tone. “I’m Dr. Lin, one of the hospitalists working here. Are you Mr. Dickerson?”

“Yes,” the patient says. “Just call me Robbie.”

“I’m his mother,” the woman explains. “Louise Dickerson.”

“Nice to meet you both,” I respond politely. “What happened today, Robbie?”

The patient clears his throat and begins his story.

“I woke up feeling weird. It’s like I wasn’t fully refreshed after sleeping. It was a bit hard to breathe, too.”

“You felt just fine before that?” I ask.

“That’s right.”

“Describe the difficult breathing you experienced.”

“Well, I couldn’t take in big breaths like usual. I don’t know how else I can describe it.”

“Any pain with that?”

“No.”

“What about before or after?”

“Nope.”

“Did you have any wheezing?”

“I don’t think so. Believe me, I’ve wheezed before, so I know what that sounds like.”

I nod. Then I go straight into a quick physical exam in case I find anything to generate additional questions. But so far, Robbie’s lungs sound clear, albeit with short breaths, and nothing else is out of the ordinary. My abdominal exam is unremarkable except, of course, for the excess fat tissue in his belly. Suddenly, I figure out a new line of inquiry to explore.

“Robbie, you said you didn’t feel fully refreshed. Have you had problems sleeping?”

“Sometimes.”

“Any sudden awakenings in the middle of the night?”

“Not that I remember.”

“Louise, have you recently slept in the same room as Robbie?”

“A couple of times, yes,” the mother answers. “You know, in case something goes wrong in the middle of the night.”

“Have you ever noticed Robbie snoring loudly or stop breathing during sleep?”

Louise pauses to recall. Then she shakes her head no.

“What are you thinking, Dr. Lin?” she asks me.

“Obstructive sleep apnea,” I answer. “With Robbie being obese, he would have a lot of fatty tissue in his neck, which could make the airway prone to collapsing while he sleeps on his back.”

“Nobody ever talked to us about it.”

“Really? Because someone at Robbie’s weight would be at very significant risk.”

The mother and son slowly turn to each other. Are they unaware of what OSA is? I won’t dwell on that too much. Meanwhile, the emergency department physician’s note said nothing about OSA or even any other possible diagnoses. It’s as if he fixated on COPD without thinking broadly. I do know that a few new ED docs were hired a while back. Hmmm, did some incompetent ones somehow end up on the staff?

“In any event, I will do what I can to help with Robbie’s breathing,” I say to Louise. “Weight loss is another important measure that has to come into play, along with an overnight sleep study once he gets discharged.”

The mother turns to Robbie, who nods slowly.

“Besides the basics like diet and exercise, bariatric surgery may be another option,” I comment.

“But I’m not a candidate,” Robbie says.

“How come?”

“Mainly my alcohol use and COPD. It’s not just one surgeon telling me so. It’s actually a total of three, after getting a second and third opinion.”

I frown. Too bad he’s got contraindications to bariatric surgery. I’m not an expert in the field, but I know it involves a surgeon going into the body to modify the gastrointestinal tract, like shrinking the stomach and reconnecting one part of the small intestine to another. It often does wonders for weight loss.

“What about medications, like Ozempic and Wegovy?” I ask. “They’ve been on the market for a while.”

“I tried those already,” Robbie answers. “They didn’t do much for me. So my doctor went ahead and gave me another one: Naxipil.”

Slowly, I nod. I have heard of that weight loss drug, manufactured by a San Diego-based company called Tixerix Pharmaceuticals. It may be a newer product, but it seems to be generating buzz in professional medical circles as well as the general community of overweight individuals.

“How long have you taken Naxipil?” I ask.

“Four years,” Robbie answers. “My primary care doc gave me some.”

“Who is your doctor?”

“Curtis Decker, down in Ivory Memorial Clinic.”

“Has Naxipil helped with losing weight?”

“Yeah, like maybe fifteen pounds a year. May not sound like much, but going from five hundred sixty to just five hundred is an accomplishment, you know? I’ll finally get below that for the first time.”

“Is that the only new weight loss treatment you started?”

“Yeah. I hope I don’t need anything else.”

“Dr. Lin, any thoughts on combining medications?” Louise asks. “Like taking Naxipil with Ozempic or Wegovy? Maybe all three at the same time?”

I shake my head.

“I wouldn’t recommend it. The data on those drugs is mainly based on taking just one of them. I’m not aware of strong evidence about using two or more simultaneously.”

Louise nods. At this point, my initial history and physical is done. It’s time to send the patient upstairs.

I leave and make my way to one of the ED workrooms. On a computer terminal, I complete the admission paperwork for Robbie Dickerson in Icarus, making note to manage his presumed COPD exacerbation, address other side problems like chronic skin ulcers along his backside, and look into other possible explanations for his breathing issues. I mention nothing about weight loss and Naxipil. I will try to rule that medication in or out as the reason for the patient’s breathing difficulties, because I know nothing about its side effects. It’s also the only new thing that got added to Robbie’s treatment regimen recently.

Reminder: correlation does not imply causation. This takes me back to the other patient with a mysterious treatment: Hector Lucero and Motileaf. Not long after finishing Robbie’s admission, I stop by Room 822 to check on Hector. Thankfully, he’s a bit calmer, probably because he’s not doing hemodialysis today. The standard regimen is three sessions per week with one-day breaks, either Monday-Wednesday-Friday or Tuesday-Thursday-Saturday.

“How are you doing, Hector?” I ask.

“Eh, so-so.”

“Any pain or discomfort?”

“No, nothing like that. I’m just figuring out what kind of dialysis I want. With hemo, I have to take time away for it. But peritoneal looks even harder, even at home. Man, I don’t know.”

“You still have time to think about it.”

Hector nods.

“Rosario will visit later today,” he says. “Maybe she can help decide.”

“Speaking of which, she brought up something yesterday when I met her for the first time. You’ve been taking a weight loss herbal supplement called Motileaf.”

“Yeah.”

“For about three years, right? She showed me the receipt for the store you first bought it from.”

“All right, I’m not gonna lie. That’s when I first discovered Motileaf and bought some. I wish she asked me first, instead of snooping around my room without permission.”

I nod slowly.

“Well, maybe she’s so worried about you. She probably thought losing you would be, you know, a tragedy.”

“Sure, I guess.”

“Meanwhile, I wonder if Motileaf is the cause of your kidney failure. I began looking into it, but I don’t have the answers yet. Even so, maybe it’ll help to stop taking it, at least until I know what we’re dealing with.”

Hector looks away, then nods slowly.

“Anyway, get some rest,” I say. “Today is the last day of my current service. That means we doctors are rotating around. I’m getting my days off while another who just had his will take my place. Don’t worry. He’ll know your case before he sees you.”

“All right, cool. You enjoy yourself.”

I shake Hector’s hand. For once, he actually smiles. I sure hope he’ll be OK from here on out.

The rest of the day is uneventful. That includes a key step near the end of the day: my telephone conversation with the hospitalist replacing me tomorrow. I present a summary of each patient and he definitely knows what to do. I tell him that I’m still not fully clear on the cause of Robbie Dickerson’s problematic breathing, but the hospitalist assures me that he’ll provide a second pair of eyes. I urge him to look further into obstructive sleep apnea, congestive heart failure, and other conditions.

My six days off begin now. I drive home with a mix of relaxation and worry. Normally, after twelve days of work straight, I never look back on my patients again. Instead, I’m still thinking of two. Both young men. Both with a mysterious problem. Both starting some new medicine for weight loss. These two cases are an exercise in intellectual rigor that won’t escape me. They also remind me of my outlook when I was in college. I imagined adulthood being an exciting phase of life if I could work hard and succeed in my career. Of course, the reality of medical training had punched me super hard. But that is still nothing compared to what Hector Lucero and Robbie Dickerson are going through. They’ve entered adulthood, but gotten trapped by their own health curses. Once again, I’m looking at their common denominator: new pills. One herbal, one pharmaceutical. Are they dealing with something that is beyond mere correlation and instead has strong causation?

Taking a deep breath, I make a proclamation. I am going to look into Motileaf and Naxipil. For the sake of my patients. And for my own peace of mind.

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