Erik Vance's Blog: Suggestible You

(Originally published on The Last Word on Nothing)

You’ve never heard a kid scream until you’ve heard one who knows his daddy is no longer in control.

When the earthquake struck, I had my headphones in. I’ll be honest, I wasn’t working, I was starting to zone out a bit. Some days I’m more productive than others and this was not a productive moment. Sue me.

Normally in Mexico City it takes a minute to recognize a quake but not this time. At the first jolt I snapped the earbuds out and bolted for my baby sleeping in the nursery. Normally I would wait a moment by his door to make sure it was a big enough quake to bother waking him up but, again, not this time. This time I grabbed him out of the crib and stuffed him under it, then stuffed as much of me as I could in after him. That's when he started screaming.

When it was over, we calmly filed out and met with some of the other folks in the building out in the street and made our way to the park around the corner. It was only when I was sure we were safe and started canvassing the neighborhood that I realized what had really just happened.

For blocks and blocks it looked exactly the same as it had the day before. A few bricks on the ground perhaps. For a moment I even lamented the fact there wouldn’t be a decent story in it for me. I saw a building with a piece of a wall missing so that I could see a desk inside. I snapped a photo.

Then I saw the first building down. It was a squat little brown thing I must have passed a hundred times – right next to that cheesy 1950’s-themed hamburger joint I swore I'd never go back to. And it was nearly pancaked. Oddly enough, the bottom floor was still intact but the three above it kind of looked like one. Neighbors were hammering away, trying to rescue those trapped inside. People who had come to their office. People taking a cooking class.

My neighbors were trapped. In other places my colleagues were trapped. My neighbors were dying. Not in some far off place, down the street. People I pass on the way to the cantina. Next to that cheesy burger joint.

Whenever a natural disaster strikes, it’s easy to find a reason why you were clever enough to escape it. Oh, look at that building, why would they live there? Well look where their house is. Well why did they get in their car during a flood? Why didn’t they get in their car during a fire? It gives us a sense of control.

It’s only when control is totally gone that you realize you never had it in the first place.

Natural disasters hold many lessons for us. But but the biggest one is to shatter our illusion of control. It's an odd feeling for a modern person. Living a middle class life in a modern society, we tend to be a little insulated from real stress and uncertainty. I don’t mean the stress of a tough job or uncertainty about paying the bills, I mean on an evolutionary, life-or-death, fight-or-flight kind of level. In fact, I go so far as to say that leaving these things behind is the whole point of modern civilization.

Predators, plague, even conscripted warfare, have all sort of fallen away and tragedy has become a shock rather than an expected part of life. Death really isn't as much a part of life anymore. As a young man, I had a very cavalier attitude toward death. It was this abstract thing, like the way an angry hippo seems funny until you actually meet one. I saw danger like it was a movie.My view on it basically boiled down to that line from the 90’s action classic, Point Break: It’s not tragic to die doing what you love.

(As a side note, I based way too much of my life as a young man on sentiments from that movie. I was just your average Johnny Utah who secretly wished he was a Bodie. But that’s a whole other post.)

I even got into extreme sports, which makes sense  in a civilization where normal dangers have receded. Call it danger tourism. My thing was rock climbing. And yet, every time I glimpsed real danger – a rope was dropped at the wrong time, a fall took me farther than I had planned, or that sudden realization that because of some bone-headed move a mistake now carried serious consequences – I didn’t handle it with the steely gaze of an action hero. Mostly I was just filled with the desire to go home and curl up with my girlfriend, drink some cocoa and maybe have her stroke my hair.

In other words, to get control again. If rock climbing taught me anything, it’s that humans can master fear. But loss of control is a much harder thing to conquer. Because no matter what James Bond or Jason Borne might say, we humans can’t survive in a constant state of uncertainty. We need the illusion of control.

The Mexico City earthquake didn't just catch me by surprise that day, it caught scientists and city planners by surprise too. You see, for decades Mexico City has been planning for a repeat of the 1985 quake. We know how Mexico City shakes and we are ready for it. More than that, I am ready for it because I was clever enough to rent a building that couldn't possibly be damaged by a quake here. I'm in control. Or at least this is what I had told myself.

But seismologists and building engineers know this is horse shit. Faults slip in all kinds of strange ways and what we don't know about them far outweighs what we do. I've been told this in addition to all that comforting stuff about how safe I was in my house. I just chose to hear what I wanted to hear.

Perhaps that why, after the quake, I quickly turned to my precious science writing. To call scientists and have them put the world back in order for me. To give me back my control.

What happened in Mexico City was not what was expected. The buildings that came down not the ones we expected.And regardless of whether you think the city performed better or worse than expected, it was a brutal reminder that none of us is really in control.

I don't know what happened to that kid who talked such a cavalier game about death and danger. Maybe he got married, had a kid and got a glimpse of what real loss would look like. Maybe he never existed in the first place.

This older, wiser kid wants control and guaranteed safety. He wants to know that someone, somewhere has an explanation for everything that happens in this world. That if he just reads enough, he'll understand what he needs to be safe. And he hates any reminder that that control is just an illusion.



Final Note:

Many of you might be wondering what you can do to help the victims of the Mexico City earthquake. Firstly, send money. In the weeks and months to come, that’s what aid groups will need most. But secondly, look to your own backyards. Take a peek outside your bubble of control at the forces that could pull apart your own world in an instant. Don’t assume that your home or school or hospital is safe from the coming earthquake. Many of them are woefully not. Prepare for that fire, make sure you know where to shelter from a tornado, check the smoke alarms for Christ sake.

And last but not least, help your neighbors wake up to the realities of climate change. Because  while the process of warming might be slow, the day it comes knocking at your door will not be. It will come hard, and unceasingly, with the power of tide and the force of a hurricane and chances are you will not look at it steely-eyed, like an action hero. It’s only when control is totally gone that you realize you never had it in the first place.

(Originally published on The Last Word on Nothing)

If you read science magazines - and certainly if you read this blog - you know by now that lots of people are talking about placebos these days. They are real, they are scientifically important, they are distracting, they are good, they have something to do with chakras, they are bad, they are the next big thing, they are a bunch of BS.

In my recent book, Suggestible You, I spend a fair amount of time talking about them and meeting with the luminaries of an emerging field within psychology and neuroscience that focuses almost totally on placebos and the expectations that create them. And yes, they are all of those things and more.

Over the past five (oh, who am I kidding - ten) years working on this project, I've tried to draw together a number of themes that all the scientists studying placebos have in common - belief, expectation, pain relief, and the power of subconscious cues. But there's one thing that ties almost all the modern furor over placebos that I totally missed: Fields and Levine.

Howard Fields and Jon Levine were a couple scientists who, back in the 1970s, showed that the placebo effect for pain was triggered by a flood of internal opioids, similar to the endorphins that give us a runners high, among many other pleasurable experiences.

Almost every scientist I talked to who studies placebos mentioned their seminal 1978 paper. They get mentioned so much in the small world of placebo research that I started to think of them as some kind of mythical creature - the Fieldsnlevine. Just a little smaller than the Watsonncrick. It never occurred to me that they might be real people who put their pants on every day and occasionally pick up phones.

When I eventually called Howard Fields, now a professor at UC San Francisco. I expected a serious scientist, maybe complete with pipe, tweed jacket, and the occasional harrumph. What I got was a hilarious interview with an incredibly perceptive researcher prone to wonderfully sweeping statements and uproarious laughter.

But before I get to that, let me set the scene a little. In 1973, a team of scientists made an odd discovery. It seemed that pig brains contained special receptors for opium. Why, they wondered, would their (and presumably our) brains have a receptor specifically aimed at the sap of a random Asian poppy plant? What are the chances? Unless ... well, unless our brains generate a similar chemical.

The race was on to find our internal heroin generator and in 1975 a Scottish team recognized it as a pain-relieving chemical discover ten years before at UC Berkeley. It was named "endorphin" and quickly became all the rage. Enter our heroes, the plucky newcomer Jon Levine and the more experienced, equally plucky Howard Fields. For them, these endorphins had the potential to open up an incredible ability in our brains to actually diminish the pain we experience.

The pair were working with opioid-sensitive, pain circuits in rat brains and had their eyes set on translating that to humans. But there was one problem. Avram Goldstein of Stanford University, the guy who developed the technique used to find the receptor in the first place, and another giant in the field, Patrick Wall, had shown that endorphins don't do squat to curb pain in your brain. In a clever experiment, they gave subjects in pain a dose of naloxone, which counteracts the power of opioids. If indeed we had these tiny pain-killing drug factories inside our heads, the naloxone should shut them down and increase our pain.

But it didn't, the people felt exactly the same as before. Endorphins, though cool, had no effect on humans. “That really let the air out of our balloon," Fields remembers. "I said, 'We should drop this. If it doesn’t apply to people then, well, who cares about rats?'”

But Levine was persistent. He and Fields should double check the studies to "see if they are right." Fields' initial response was exactly what you might expect from a visionary thinker on the cusp of a daring and transformational discovery: Hell no.

“I was like, ‘See if they’re right? These are like the two major figures in the field! I’m just an assistant professor – I’m just getting started. They’ll kill me!'”

Still, Levine prevailed and the two set to work. What they needed to do was show a pain-killing effect on real humans. They decided to focus on dental patients recovering from wisdom teeth removal because it's a predictable arc for when the pain starts and stops. They started the way that any good scientist would – take a bunch of people in pain, give half of them naloxone  (a higher dose than the other researchers used) and half a placebo.

Sure enough, the people on naloxone felt more pain. The pair wrote it up, published in Nature and patted themselves on the back. But there was a lingering question: Why? What was it that the naloxone was doing? So they did another experiment, this time adding a third group who would actually get morphine.

"That was it. As soon as we included that small group, we could put on the consent form, 'You might get morphine, you might get naloxone (which will make your pain worse), you might get placebo," Fields says. "Without the expectation of pain relief, you don’t get a placebo."

What had been missing was the promise of relief. In all the other studies, it had been a choice between the same pain or more pain. But as soon as you added the possibility of morphine, some of the people would start to expect it and their brains would begin kicking out painkillers.

What was more, the effect would stop as soon as a subject getting a placebo would get naloxone. The drug would only increase the pain if the brain was already engaged in decreasing it. It was a revelation. Until then, people who tried to understand placebos were never fully sure if the effect they were seeing was actually a placebo response but now there was a way to reliably create it in the lab. And a mechanism to explain how it worked.

"That was a really big deal. It wasn’t meant to be. I mean, it was never our intent to study placebo," Fields says.

The researchers published the study in the Lancet and Fieldsnlevine was born. It would be decades before this mechanistic version of the placebo effect would gather enough momentum to be taken seriously by the wider public. In that time, scientists would tease apart all kinds of placebos (and their angrier siblings, nocebos) and eventually image them in brain scanners.

But it was Fields and Levine who brought placebo and expectation from the world of psychology to the world of brain science. Interestingly, Fields himself didn't really pursue placebos after that, preferring the broader, more arcane world of motivation in the brain.

He wants to understand the problem that the brain is trying to solve by using placebos in the first place. In other words, why would our brains have a system that causes us to feel something that's not true? He sees placebos as related to the brain's primary job, which is prediction. The brain is constantly trying to figure out what to do next and once it makes up its mind, it needs a tool to push other concerns out of the way.

"To me, that’s what’s satisfying," he says. “Life is all about carrots and sticks. It’s about punishments and rewards. It’s all about learning and adapting to your environment so that your decisions are better."


Support for this project provided in part by the Pulitzer Center on Crisis Reporting.

(Originally published on The Last Word on Nothing)

I can’t help but notice that placebos have crept into the political news in recent weeks. Okay, maybe they aren’t in the headlines but they’re there, just below the surface. That’s because when you see a headline about the Food and Drug Administration, you should immediately start thinking of placebos.

The Trump administration hasn’t named an FDA head yet, but they have laid out their priorities. Namely, to clear away the impediments between drug companies and end-users. In December, it was whispered that Trump might pick Jim O'Neill, who believes that the market should dictate which drugs get to the shelves, rather than a faceless bureaucracy. Which is a great idea when it comes to tennis shoes and sports cars, but an absolutely catastrophe when it comes to drugs.

But, you say, information wants to be free, people should feel they are in control of their own health, and life-saving drugs should be available as soon as possible. No. When it comes to drugs, this is absolutely wrong because – oddly enough – of the placebo effect.

How do I know this? Because we’ve been down this exact same road before.

I’m not going to lecture you about policy or politics, instead let me tell you a story. It centers around an odd academic argument that eventually led to the creation of what we loosely call modern (or evidence-based) medicine. In the late 1950s, the medical industry was in absolute turmoil. As the post-war United States was rapidly modernizing the growing middle class was demanding more and better health care. New health and beauty products were flooding the market every day and President Kennedy was pushing for a massively increase role for the government in medicine through Medicare.

But at the same time, there was an interesting drama playing out around the efficacy of medicine in the halls of academia. It all began with legendary placebo effect pioneer (and, oddly enough, expert in psychotropic drug experiments borrowed from the Nazis and tested on unwitting US soldiers) Henry Beecher. Beecher was the one to first point out that placebo effects were a big deal and shouldn’t be ignored or explained away as the stupid things that stupid patients sometimes do.

In his surprisingly readable seminal paper, “The Powerful Placebo Effect,” he laid out a series of experiments that had been apparently scuttled by the beliefs of their subjects. My favorite of these was by Yale professor E. Morton Jellinek (never in the history of Mortons has there been a man who looked more like a Morton than E. Morton Jellinek). Old Mort was tinkering with pain drugs to see if he could eliminate certain of their more expensive ingredients.

What he found is that indeed he could. And then he found that indeed, for 60 percent of his subjects, he could eliminate all the ingredients and they wouldn’t even know the difference. In other words, the placebo worked just as well as the drug.

These people, he decided, had “psychogenic” pain and a “tendency toward suggestibility.” Unlike the “pure culture” of patients who didn’t fall for the trick. By that logic, more than half of his subjects were impure suggestible fools.

But from a wider perspective, how could we know if our drugs were working when half of us can’t tell the difference between placebo and drug? So along came one of Beecher’s students named – I kid you not – Lou Lasagna. In addition to several layers of delicious pasta, ground beef and cheese, Lasagna had a brilliant and incisive mind.

He realized that there needed to be a tool to separate effective drugs from those just taking up space on the pharmacy shelves. Believe it or not, this was a highly controversial idea at the time. Up until that time, drugs were required to be safe but not necessarily safe and effective. Soon he joined up with a senator named Estes Kefauver, who made it his mission to add “effective” to drug descriptions.

In hindsight, Lasagna could have chosen a better ally. Kefauver, among the few Southerners to back school integration, was known as the least popular man in Congress. What followed were epic hearings with Kefauver continually asking drug executives how we knew drugs were effective and the drug companies replying, hilariously, that if they didn’t work no one would use them.

Which is exactly where it would still be today, had it not been for thalidomide. The thalidomide disaster in Europe (a global panic caused by a morning sickness pill that was safe for mothers but found to cause birth defects in fetuses) had nothing to do with placebo controls or Lasagna but the fear it caused in America was intense and immediate. (Though, ironically, the US was largely untouched by thalidomide, thanks to this incredible badass.) To placate the masses, Congress to grabbed the first bill dealing with drug development they could find and made it into law. Kefauver’s bill, as it happened.

In 1962, the Drug Efficacy Amendment to the Federal Food, Drug, and Cosmetic Act passed in a single day – the fastest modern passage of a bill outside a declaration of war.

Thus was born the FDA-required double blind, placebo-controlled trial. Possibly the most expensive and difficult pieces of red tape in all of government. A simple requirement that drugs outperform a placebo. It’s not known exactly how many drugs fall victim to the Kefauver’s little rule (drug companies don’t exactly announce their failures) but in 2011, only five pain therapies resulted from the 2,000 or so registered trials. With a single drug costing as much as $2 billion to develop, it’s a very expensive speed bump.

But here’s the interesting part – and the one that we must keep in mind today. After the bill passed, there arose an interesting problem: what to do with all the drugs already in use that had never been tested against a placebo?

In 1963 the FDA created the Drug Efficacy Study Implementation (or DESI). Essentially, for the next 20 years, scientists would go through all our old drugs and make sure … well … that they worked. Technically, DESI is still in effect today (since, amazingly, a few of the drugs still haven’t been, and probably never will be, checked) but most of its drug-killing work is done. And when the smoke cleared on the battlefield, more than 1,000 drugs lay dying in the field.

One thousand drugs that the market had deemed effective but that were actually no better than a placebo. And this was back when there weren’t nearly as many drugs on the market in the first place.

The masses are good at many things. Finding planets, for instance. Or driving the world’s car markets to ever-better quality and efficiency. Or proofreading Taylor Swift’s Wikipedia page. But when more than half of us can’t pass the E. Morton Jellinek test, we are not great at picking effective drugs. It’s not that we’re stupid or that the drug companies aren’t good at their jobs. It’s that it’s incredibly hard for many (especially chronic) conditions to separate what works and what doesn’t. It’s why we spent centuries using spider webs and pigeon feces as medicine. It’s why billions of people rely on things like homeopathy or traditional Chinese medicine.

We wouldn’t crowd source the best way to do brain surgery, so why would we assume the market knows how to pick a good drug? So when people talk about streamlining drug development or removing red tape or engaging the end user, we must remember we’ve been down this road before.

(Originally published on The Last Word on Nothing)

Over the past few months, I've spoken to a number of groups about the power of belief in medicine as a part of promoting my book, Suggestible You. It's been a fascinating process and I've loved hearing about people's individual experience with placebos, self-healing and alternative medicine.

But I often asked a simple question: what does all of this offer us? The mind is a powerful thing. Great, what do we do with that?

If you are not into mind/body medicine, it's a pretty good question. Why should we care? Whenever I get this question, I find myself telling a story about an accomplished placebo expert by the name of Karin Jensen. It seems that when she first started studying placebos, she quickly ran into a rather serious problem: She could not elicit them.

Try as she might, when she gave little inert pills to unsuspecting subjects, they never reported feeling better. Which might not seem strange except studies have regularly shown that whenever you give placebos to subjects, some percentage do end up feeling better. Sometimes as many as 60 percent of them.

And to make matters worse, her assistant wasn't having this problem. She could give out pills left and right and, Bam!, people felt better. For Jensen, who was dedicating her life to placebo research, this was kind of an existential crisis.

So she set her mind to getting better. She decided that she needed to make more eye contact and speak with more authority. More outward confidence, maybe. Wear the white coat and play the role of the all-knowing doctor.

Sure enough, people started to respond to her placebo pills and she has gone on to do some of the most exciting work in the field. I think about this story a lot (and forgive me Dr. Jensen if I have gotten details wrong - another chapter of my book details how your strongest memories can be  your most inaccurate). And I have decided that it holds an important lesson for the modern medical establishment.

The center of a good placebo is delivery and storytelling, just ask any witchdoctor, shaman or homeopath. In other words, your bedside manner. And with the incredible pressure in medicine to pack in as many patients into a day as possible, most of us are starting to feel more like lab rats than people getting quality care.

So here is my exciting new proposition - call it the next big disruptive idea, call it old fashioned common sense. Every doctor, before he or she graduates medical school, must prescribe placebo pills to ten people and get four of them to respond. You can have as many tries as you want but you have to do it.

The goal would be for every doctor in the US to have the experience that Karin Jensen had - to really look hard at how they interact with us patients. For some, it would mean acting more confident, for others it would mean speaking clearer and to the point. But for most it would mean having a little humanity.

How many of us have found ourselves looking pleadingly at a doctor, trying to understand the very personal and potentially life-changing information they are giving us and seeing some disinterested prick staring at a screen?

But with the placebo test they would have to, at least once in their lives, treat the patient like a human being. I imagine students stressing out the day before the placebo test, wondering if they understand the treatment well enough to put it into simple, confidence-inspiring terms. While their roommate stares out the window, saying, "How am I ever going to pass? I'm just naturally an asshole."

Of course not all doctors are jerks, many of them have wonderful bedside manner and truly care about their patients. But that's the beauty of the Placebo Test, those doctors would pass without even studying.

This might seem like pointless sadism to some readers but in fact it's based in science. A large portion of the effectiveness of a given drug comes not from the drug but from the bodies responses to the expectation of that drug. How much that is - half, a quarter? - depends on the type of drug and the type of condition that it treats.

But this effect is so powerful that overcoming it is one of the main reasons that drugs are so expensive to make. Still don't believe me? Two hundred million people around the world use homeopathy, which essentially means drinking well-packaged water. In the US, at least two thirds of users are satisfied with it. What exactly do you think is making all those people better? I'll give you a hint - it's not the water.

Anyone who has spent a lot of time with conventional doctors and then switched to alternative medicine can tell you what a more pleasant, healing experience it can be. And I guarantee you most alternative practitioners would pass my Placebo Test with ease. Now imagine combining that kind of care with proven effective treatments. It's about time the rest of us took a lesson from those who make do with nothing but a promise and a little eye contact.

(Originally published on The Last Word on Nothing)

I am a man of science. Okay, perhaps not of science, but certainly near it. I’m science adjacent. But regardless, I consider myself to be bound, in the end, by logic and facts.

As such, I like to think that I eschew my beliefs for what the facts tell me. As a very young man, I was very taken by the promise of herbal supplements. But as I came to understand the data (or lack thereof) behind them, I gave up on them. I used to worry about GMOs affecting my health until I dug into the actual science and realized that they are totally harmless (though not necessarily great for developing economies). I'm embarrassed to admit it, but in my overwhelmingly white college I thought that America was post-racial. But well-crafted arguments and data showed me I was wrong.

In every case, I abandoned what I thought for what I could prove. I try to keep an open mind and I tell myself I am ruled by logic. This was the mantra for my book on suggestibility and has become a guiding principle not just in my career but in my life.

It's also utter self-delusion. The sight of one little needle turns me into a raging anti-vaxxer.

Before I go any further, just so we are clear, every scrap of reliable data confirms that vaccines are a safe and crucial part of medicine. Plenty of very clever people have pointed out that there is no discernible danger in vaccines and lots of benefits to herd immunity. Heck, people on this blog do it all the time, like Cassie, Erika, and, well, me.

Autism is heavily influenced by our genes, which have nothing to do with vaccines (though only about a quarter of the genes involve have been discovered so far and none of them account for more than one percent or so of the total people with autism). It's true that there may be some environmental factor playing a role in autism but none have been positively identified. Vaccines were a contender for a hot second in the 90s but we now know without a doubt that they are not involved.

Lastly, let me make clear there is nothing wrong with having autism. Most people on the spectrum have fulfilling lives and many would not trade their brain for a neurotypical one even if they could.

But this is not a post about vaccines or autism or even evidence. This is a post about fear. If there is one thing that psychologists can say for sure it's that fear is more deep and powerful than just any other emotion we can experience.

In fact, if Albert Brooks and Meryl Streep are correct, overcoming fear is the entire point of our existence.* In my book, Suggestible You, I note that while placebos can be incredibly potent in certain (often chronic) diseases, their alter egos - nocebos - are reliably more so. Nocebos, in case you are unfamiliar, are when something unhealthy happens to your body, solely based on belief. In other words, if placebos are hope, then nocebos are fear.

So fear is more powerful in the body than hope. I even once tested this theory by getting myself cursed by a witchdoctor, just to see what the fear would do to me. But even then, I never thought fear could force me to throw logic completely out the window.

Which is why it was weird when - at the first vaccine appointment for my son - I started peppering my his pediatrician with questions. I inspected the boxes, telling myself that I was concerned about a recent bad batch of vaccines in Oaxaca that made a bunch of kids sick. But really, I was looking for a label that read "Not the autism kind of vaccine."

I felt really uncomfortable and started to sweat. I looked at the clear liquid and wondered, will I regret this for the rest of my life? I started to think about maybe delaying the injections until it was safer or maybe stretching them out over a longer period of time. I mean, it just can't be safe giving all these vaccines at once.

Seriously? Years I've spent following this debate, reading the stories and writing a few about how safe and effective vaccines are. And yet here I am putting my entire profession to disgrace, just as scared and confused as anyone else. In that moment I wanted to slap my brain upside the temporal lobe.

Saying "fear is a powerful thing" is a little like saying "money can come in handy" - it kind of undersells it. Fear is the number one tool for selling newspapers, insurance, snake-oil medicine, and Swedish cars. Sometimes that's a good thing and sometimes it's not. It's what kept our ancestors alive for millions of years and its history's favorite way of selling political ideology.

So it's not surprising that fear forces people people from across the political and economic spectrum to accept some strange ideas. The most tragic and extreme of these that I have found are cancer patients terrified of modern cancer therapies (though with good reason; many involve some form of either poisoning or irradiating yourself in the hopes of getting a few rebellious cells with the nuclear holocaust you unleash on your body).

Eventually fear drives them towards more "natural" solutions like vitamin infusions, diets, or crystal therapy. And by and large, these decisions kill them. Accurate numbers are hard to come by in this realm because so many cancer patients mix and match alternative with conventional. Also, it's hard to tell who has relied on alternative cancer therapy because if at some point they end up in a hospital then technically they die under a conventional doctor's care.

But the fear of a cancer patient is nothing compared to the fear of a parent. I would gladly suffer a few rounds of chemotherapy to prevent harm from coming to my child. The bottom line is that what happens to me - I assume many of the antivaxxers out there - when I go in for my kid's shots has nothing to do with vaccines or mercury or thimerosal or any science whatsoever. It's about fear and a loss of control.

Imagine if someone told you that walking across a field at midnight might cause you to get eaten by a dragon. At first you might laugh. But what if everyone you know said it? What if you knew people who had disappeared after crossing that field late at night. I'm not saying that you'd go all Matthew McConaughey and start riding around in a dragon-killing tank but are you telling me that if you had to get somewhere at midnight you might not pick another route?

And the more it lingers in the back of your mind, the more real it becomes. Maybe I've done one too many stories on autism and crossed some kind of threshold. That's how I ended up sweating in the doctor's office again last week, waiting for the dreaded year-and-a-half vaccination that would protect him from diphtheria, meningitis, whooping cough, and tetanus. The one that everyone in fringe autism blogs talk about. Here I was, deeply ashamed yet still wondering if we should put off the shot until it was safe.

The doctor asked me to restrain my son, who looked at me a little bewildered but trusted his Daddy, who would never intentionally hurt him. Then the doctor injected four dead viruses (not actually dead viruses, but I neither knew that nor cared at the time) into his legs. The baby screamed for a few seconds with what I assumed was a deep sense of personal betrayal before the doctor deftly pulled out a tin of lollypops and slipped one into his mouth. I gotta give the guy some credit, the kid shut right up and went to work on the candy.

Then at that moment, I had a realization. If fear is more powerful than hope and this could happen to a fundamentally rational person like me, then what hope does science really have? What chance does "this is a well-studied, safe intervention" have against "holy shit, you might be ruining your child!"?

Now go beyond that to other issues where fears and tribal loyalties conflict with reason, like GMOs, climate change or evolution. How can rationality win when irrationality is so much more attractive? I sat in the doctors office staring into space, now terrified of something totally different.

The doctor looked at me for a second, then grabbed his tin and pushed it at me. "Maybe Daddy wants a lollypop too?"





Photo Credit: Erik Vance

The project Suggestible You was supported in part by The Pulitzer Center on Crisis Reporting.

* And yes, I'd say they are. If you have not seen this film, it's an absolute classic.

(Originally published on The Last Word on Nothing)

Last month, while on assignment in Cozumel for a story on sponges, I went diving on a beautiful reef. It was stunning - a world of color, dreamlike shapes, and life everywhere I looked. Normally, I would have just swam about, marveled at the pretty nature, and come back to my hotel with a fat grin on my face.

But I just couldn't stop fretting over all the sponges. You see, my story was on a theory among sponge experts that sponges are secretly, quietly taking over the world. It is ... wait for it ... The Rise of the Planet of the Sponge. Scary, right? Except just on coral reefs, not the world. And only in the Caribbean Sea. So, I guess it's The Rise of the Caribbean Reef of the Sponge. Wow, that really doesn't work as well.

Anyway, the theory goes that huge coral and urchin die-offs have led to a lot of spare real estate and algae on Caribbean reefs. The sponges have stepped in, sucked up the excess sugar pumped out by the algae and filled the now-empty reefs.

And diving in Cozumel, I noticed for the first time just how much of the color on a reef is actually sponge. We all know the big barrel sponges - those giant cannon-looking things hanging off the reef - but I'd never really noticed the encrusting sponges before. These are the colorful flat sponges that sort of drizzle around the reef like splotches on a Jackson Pollack.

It turns out that very little of the life I was looking at on the coral reef was actually coral. When I asked the folks on my boat - some of whom had been diving Cozumel for decades - none of them noticed the dominance of sponge over the coral. Likewise, the dive guides hadn't noticed it either. How could they not see it? It was so obvious!

So I went around the island, quizzing the most experienced dive masters about the changes in sponge concentration and all I got were blank stares. Veteran dive instructor Raul Fernandez put it best with an insight about diving with tourists.

“They want a beautiful garden. They want to see colorful coral and the life that comes with it,” he says. “There’s not much difference [between coral and sponge] for them. It’s just vegetation. Underwater vegetation.”

The role of turtles in sponge dynamics is still hotly debated.
This is not just limited to tourists, it's also replete in marine biology. Joseph Pawlik, the scientist who turned me onto the story, says he goes to coral conferences only to find that none of the coral people bother to look at the sponges. For decades, experts have been trying to understand why the Caribbean corals have struggled compared to the Indio-Pacific ones. The answer - namely greedy sponges - was right under their noses the whole time.

How could world-renowned experts not notice the rise of the frigging planet of the sponge? It's right there!

The answer is, because it might not even be happening. As I dug further into the story, I discovered a lively debate about the whole conquering sponge theory within the sponge scientist community. It turns out many leading researchers are ambivalent about the idea and at least one is dead set against it.

Again, it all depends where you look. Pawlik may be right about the prevalence of sponges or he might be biased by the Florida reefs in his back yard. Other scientists looking at other regions don't see the uptick in sponges that he does. (In fairness to Pawlik, though he works a lot in Florida, he has an impressive list of research sites throughout the Caribbean. Check them out on his engrossing YouTube channel.)

A sponge burrowing into a section of reef
Another expert, Michael Lesser, has looked at reefs and doesn't see any of the algae-related extra sugars around reefs in the Pacific or the Caribbean that would be fueling the sponge growth. Then again, he may not be looking close enough to the algae themselves. And another expert points out that almost all studies overlook the burrowing sponges, which live inside the reef itself and can even hollow it out.

And if you travel to certain reefs in the South Pacific, there's no problem with coral reefs at all. Yet every marine biologist I spoke to agrees on one point. The reefs of tomorrow will look nothing like those of yesterday.

"There are going to be coral reefs but they are going to be different kind of coral reefs. There are not going to be coral-dominated reefs. They are going to be sponge-dominated, or algal-dominated or soft coral-dominated," Lesser says. "And how do those reefs function?"

We science journalists always roll our eyes when we hear the phrase "more research is needed" because it's always coming from a scientists who would very much like money to do said research. But sometimes more research really is needed. Ambitious, sprawling, comprehensive studies that nibble away at these questions. And keep at it.

Because it's really hard to know if what we're seeing is just a product of where we're looking. And with something as vast as the ocean, it's hard to overstate just how little we know. So little that we can't tell how many of its most iconic fish are left in it. So little that we don't even know what lives in much of it. So little that we can't say for certain if sponges are disappearing or taking over.

This brings me back to where I started and the real stakes of where we choose to choose to look for evidence. It's more than just a matter of what the sponges are up to or how much sugar is in the water. Once upon a time, the reefs of western Cozumel were some of the most stunning in the hemisphere. Today, by any reasonable measure, they are a shadow of their former selves.

Every day of the year the harbor is choked with giant cruise ships, some of which can't even find space to dock (so naturally the government has carved up a massive reef to make room for more docks). One guide* told me his former employer saw some 60,000 divers per year - 360 in a single day. Some of them go to the same reefs I saw and if so, I guarantee they went home happy without a second thought.

The reefs are healthy. I've been there. I've seen it.

Some days I'd like to think that one day Cozumel and all the coral reefs of the world will find their way back to the lush biodiversity I see in old Jaques Cousteau films. That the bleaching will end and the pollution will abate along with climate change. That we will think and regulate our way out of these seemingly insurmountable problems. And that my grandchildren will laugh at posts like this.

But most days I live with a different picture - a sick sort of vision in my mind. Thirty divers swimming behind a single damselfish, all snapping selfies and streaming video, while backdropped by the wasteland that has become the Earth's oceans.

Then, when they get to the surface they look at each other with wide grins saying, "Wasn't that amazing? What a beautiful fish! Isn't nature just astounding?"




* Sergio Suarez runs a great ecotourism operation in Cozumel. If you are interested in getting a more environmentally-focused dive, check him out.

(Originally published on The Last Word on Nothing)

Two decades of rock climbing and a career in writing have left me with two distinct things. One, an ability to step back from the world and make a careful assessment. A zen approach, if you will, to risk and making my way in this world.

The second is a seriously messed up pair of forearms. Recently I have been taking these poor old dogs to an excellent massage therapist here in Mexico City. Now, when you hear the word “massage,” don’t get the wrong idea. It’s not some Swedish bikini model rubbing me down with oil. Mark the massage therapist is strong, knowledgeable, and totally without mercy. A trip to his dungeon – sorry, I mean office – goes a little like this:

Mmmm. Nice. Think I’ll just take a little nap since I’m

Aaaaghh! HOLY SWEATY TESTICLES OF ODIN!!! That frigging hurt!!

Uuhhh, that was rough. Over now. Just relax and try to…

GHAAHHH! MOTHER OF A RHINO’S SPHINCTER!!!!

Oh, I really hope he doesn’t do that again. This is nice though. Maybe I can still….

GLAAARRRP! SWEET SHARDS OF GLASS IN MY SPLEEN! MAKE IT STOP!

It’s unpleasant to go from near-comatose to eye-bulging Hulk-rage in less than a second. Mark says that on his table he has seen screaming, cursing, drooling, farting, secretions of all sorts, uncontrollable laughing or crying, and just about everything else you can imagine.

The cause of most of this is something scientists call “myofascial trigger points.” Mark calls them knots. I prefer MTrP and I’ll tell you why. It sounds more painful. It sounds like something you should pity me for (most of my activities in this life revolve around attracting and deserving some level of pity). A knot is something annoying or useful that you untie. An MTrP, on the other hand, sounds like an ingredient in explosives or something that you fire from a shoulder-held bazooka (similarly, Mark shall now be referred to as a “spontaneous nociception delivery specialist”).

So what is an MTrP? You’d think that because massage has been an integral part of exercise since Achilles and Hector got their post-mindless-slaughter-rubdowns, that we would know a lot about them. You’d be wrong (as you often are when you are purely hypothetical).

In fact, we don’t really know that much about MTrPs. I mean, we know they are caused by some kind of spasm surrounded by proteins. We know, as this recent paper proves, that when you poke them they hurt. We know that some actively hurt while others seem dormant. We know that they can lead to myofascial pain syndrome – or ouchy muscles. And we think that ischaemic compression (also called “rubbing”) helps.

We don’t really know how they are formed, why they end up in one spot as opposed to another, if they are truly detrimental (though they are linked to all kinds of problems, many people never even notice they’re there) and most frustratingly, how to get rid of them. A number of (oddly often Turkish) studies and people have suggested that ultrasound works – even breaking MTrPs up (which explains why fetuses are so limber). But then, a number of more thorough studies show ultrasound doesn’t do squat.

One recent breakthrough study showed that dorsiflexion range of motion (or moving the nearby joint around) can help right after exercise. Another definitively said that MTrPs are absolutely without a doubt perhaps maybe related to tennis elbow. But maybe not. It may be related to fibromyalgia (another sort of disparate, hard-to-quantify type of pain) or it may not. Same with lower back pain, and on and on and on.

As a result, a lot of ideas have flooded in to fill the void – some interesting and most smelling distinctly of hooey. Mark says that closely related muscle groups can influence knots, which seems reasonable. Many trigger point theories involve disparate pain being tied to faraway muscle knots, which seems to be a little thin if it’s too disparate. I mean there’s a good chance that rubbing your feet will not release the knot in your back. But get a foot rub anyway, you deserve it.

Treatment is likewise not well agreed in the literature. Certainly massage seems to be widely used and recommended. Many try injecting the damn things with everything from steroids to botox. But because it’s tied to pain, the mighty placebo effect comes into play, as placebos are especially potent with pain-related issues. One common practice is to inject saline into the MTrPs, which is literally the definition of a placebo treatment.

So I guess for now I’ll just keep going back to Mark and raging expletives while he buries his elbow in my back and arms. But seriously, science, common colds and MTrPs. Get on it.

(Originally published on The Last Word on Nothing)

Last year, I published a series critical of modern wind farms. They dealt with a number of pretty dirty land deals in southern Mexico related to new wind farms. Although they were on the cover of a major national newspaper, they didn’t get the attention I thought they deserved (as with most of my stories, oddly enough). It was a sad story in an overlooked corner of the continent.

But one sliver of that attention especially bothered me – those who used it as an argument that wind power is just as bad as coal and gas. That’s why a few weeks ago at a placebo conference (yes, it’s a real conference – not just a bunch of fake scientists and a fake audience) my head snapped around at a lecture on the health effect of wind power. Apparently, there is an idea out there that wind turbines can make you sick. The idea goes that people exposed to very low sound waves, called “infrasound” (say 40 decibels at five hertz for the nerds out there) might experience sleep disturbance, headaches, dizziness, tinnitus, ear pressure or pain, nausea, concentration problems, irritability, anger, panic episodes, fatigue, loss of motivation.sick windmill

But it just starts there. Since this list was published under dubious pedigree, the list has grown, including asthma, Asperger’s, anemia, allergies, angina – to a whopping 223 symptom. For one couple, the turbines even altered the space/time continuum and aged them five years. So what is all this? Are wind turbines actually bad for your health? Well, one group in New Zealand, led by Keith Petrie thought they knew the answer. Perhaps, they reasoned, it was the media itself that was causing the “pandemic.” They turned to the rather slim but growing literature on the nocebo – placebo’s grumpy little brother.

The group then designed one of those lovely little experiments that make nocebo research so fun. They took 54 volunteers and split them up. Half would watch a six-minute video about the dangers of infrasound and the others would watch one about how safe they are. Then both would be exposed to it.

Except half of them just got silence. What happened was that the people who were warned about nasty effects experienced them, whether exposed or not. In fact, it was almost impossible to separate who had heard the infrasound and who had gotten silence. What I found most interesting was even the people who were told there was no danger and experience the fake sound reported some symptoms. If you read that list above, can you honestly say you have none of those symptoms right now? Hell, “Tinnitus, Fatigue, Concentration Problems, and Loss of Motivation” is going to be the title of my autobiography.

Of course the next step was to see if they could reverse the symptoms. So with another group, they changed the neutral description to a positive one (infrasound makes all your problems go away!). Sure enough, overwhelmingly the bad-news group felt symptoms while the good-news group felt better (though, again, a small sliver of good-news people still got worse, which just shows that people like to complain to people in lab coats).

Wind power has a long way to go before it is a major player in global energy and in the meantime, it seems to be learning how to steal land from highly marginalized communities. But it’s not making you sick.

(Originally published on The Last Word on Nothing)

This week LWON presents “Off Our Meds,” an examination of some scary issues in medicine. We won’t resort to fear mongering, because we don’t have to. Medicine is scary enough as it is.

I still remember my first trip to the doctor. I was 18 years old and doubled over in terrible stomach pain. And when I walked into that office, I truly didn’t know whether to expect a monster or a wizard with a magic wand.

Yes, the decimal point is in the right place. Before 18, I had never been to the doctor. I was raised in Christian Science and beyond the legally required vaccinations, never went to the doctor. Contrary to popular belief, Christian Scientists aren’t forbidden from going to the doctor, they just – you know – don’t.

Partly it’s because of religious belief but partly – and here I can speak only for myself and a few family members – it’s fear. Fear of the unknown, fear of cold metal instruments, fear of losing control.

Fear, in short, of the theater of medicine.

As some readers may know, I am fascinated with things like pain and how the mind causes chemical or physiological changes in the body. This past summer I published a story on placebos that looked at their biology (also for LWON here, here, and here).

But I want to take a second and look at the other side of that coin – the doctor’s office itself. Scientists are discovering that one of the most powerful tools in a doctor’s kit is something called nonspecific effects, known informally as bedside manner. It’s all the stuff you can’t measure – how nice her office is, how she speaks, maybe what kind of diploma she has on her wall.

“It’s something that actually affects treatment enormously. There are ideas that more than 50 percent, some people say more than 70 percent, of anti-depression treatments are actually ‘nonspecific effects.’ If that is true, it’s huge and almost no research is being done on it,” says Predrag Petrovich, a neuroscientist who studies pain, placebos, and the brain.

The common number people throw around is 30 percent, but that’s one of those numbers that is so vague as to be nearly worthless. That’s because it varies so much, depending on the disease.

A surprisingly large number of ailments are susceptible to the effects of medicine’s theatrics. Nausea, pain, Parkinson’s disease, irritable bowel syndrome – all seem much more pliable, depending on the doctor.

But the details of how this works are still coming into focus. What’s stronger, a friendly voice or an authoritative one (both seem to be crucial)?

Lab coats and stethoscopes help, that much we know. For a long time, people have just assumed that bedside manner was something you tack onto the top of a treatment, a little like a tip. But it turns out that really powerful drugs actually decrease placebos.

By that logic, weak drug or sham treatments should increase the placebo effect, but we really don’t understand how that works. I mean, how do you separate the drug from the treatment? People have tried using specifically unfriendly caregivers as a sort of control, or just not giving treatment at all (since walking into a doctor’s office is in itself a treatment for some people).

Perhaps the best control group would be kids like me – religious kids witout a preconceived notion of what the doctor does. Or in my case, a negative one. My first exposure to bedside manner didn’t exactly fill me with confidence. The doctor who treated me tapped my belly a few times and proclaimed my pain to be “growing pains” and moved on.

Looking back, he was an inept doctor and I was a bad patient. He never asked me if I had ever travelled abroad and I never thought to mention that I had been to Mexico for two weeks the year before. It’s likely that the recurring stomach pain that plagued me until I took my first set of gut antibiotics was some kind of parasite from that trip.

But that is where the theater ends and the real work has to begin. Beyond the pagentry, the gadgetry, and the friendly words, medicine is about a patient and his physician asking questions, answering them honestly, and working together. After all, isn’t that what good co-stars should do?

(Originally published on The Last Word on Nothing)

I’ve been spending a lot of time lately thinking about my bloodlines. Perhaps it’s my impending fatherhood, perhaps I’m just at that age. I’ve been tracing my grandfathers’ heritages back through the Revolutionary War and to the Tudor conquest of Ireland. I’ve planned a trip to Norway, which is my grandmother’s homeland, and hope to visit a lighthouse that was once manned by my great great grandfather.

And I had my genome sequenced by 23&Me. I didn’t do it for my family heritage or to find out how much Neanderthal DNA I have (a disappointing 2.7 percent, given the size of my brow and forehead). I wanted to know something deeper. I wanted to understand why I am how I am. I wanted to get the genetics of my personality.

The fields of behavioral and psychiatric genetics – which try to parse out how our genes affect what we do and think – is still new and still has a few kinks to sort out. There’s so much we don’t know but there are a few things about the genetics of our minds that we do know. We know there are certain drugs in your brain that seem important for your mood. And over time, prolonged moods kind of become who you are.

Things like testosterone play a role in aggressiveness and drive, serotonin is linked to happiness (or not, I can’t really tell anymore), dopamine handles reward and on and on. Reading through handy tools like Snpedia that help you decipher your DNA makes one think that we humans are pretty easy to understand.

We’re essentially squishy machines with lots of chemical gears and brain switches that scientists are diligently cataloging and sifting through to understand how we tick. Turn the beta-endorphin knob down, we get bummed out. Turn the cortisol up and we get nervous. Turn on the serotonin and we might have a religious experience.

Lately my favorite behavior gene has been COMT (or catechol-O-methyltransferase, as it’s called for short). COMT codes for a special enzyme that, among other things, neutralizes dopamine. Dopamine is a hugely important brain drug that, among other things, affects our mood, broadly speaking. And COMT is its garbage man, sweeping up the extra unused brain dopamine you have lying around.

Amazingly, the work ethic of a COMT enzyme seems to boil down to a single base pair – just one rung of the DNA ladder – that codes for a tiny yet crucial part of its structure. If that one spot uses a chemical called valine, then the enzyme is a decent, tax-paying, hard-working enzyme, sucking up as much dopamine as it can. Probably raised Protestant, a valine-laced COMT enzyme clocks in eager to clean dopamine and, as a result, the brain has a lot less of the drug lying around.

But if a different ingredient, called methionine, is in that crucial spot then the enzyme becomes a wastrel, sitting about on plastic lawn chairs all day, drinking Miller Lite and complaining about its ex-wife. Work piles up and the brain accumulates a bunch of extra dopamine.

So what’s the difference between a brain with extra dopamine and one with just enough? It turns out, quite a bit. There are about 400,000 dopaminergic neurons in the brain, many in important regions of the pre-frontal cortex where a lot of complex thought happens. And when dopamine is allowed to wander about willy nilly, people act differently.

People with valine enzymes (often called val/vals) tend to be less effusive about the things they see (“That pie had too much salt and not enough blueberry”). They have a high pain tolerance and a low response to placebos. Meanwhile, people with methionine (often called met/mets) are more effusive (“Oh my god, that was the most amazing pie ever”), have a low pain threshold and respond well to placebos. I myself am a val/met, which means I’m in the middle and can only imagine what it’s like to be an extreme.

If you take all the papers that have been written about COMT genotype, you get a picture that is at the same time vague and oddly specific. Kind of like your average Zodiac sign, palm reading or tarot card.

Over time I’ve developed a mental image of these different genotypes. I imagine the met/mets as these bubbly, always happy Pollyannas who dance with penguins and leave a trail of sparkles behind them. Meanwhile, val/vals in my mind get jobs in finance and complain about the traffic.

I believe quirky romantic comedies require at least one met/met (I’m looking at you, Meg Ryan) and one val/val (c’mon Harrison Ford, why so gloomy?). I imagined that met/mets give better Christmas presents than val/vals and are certainly better in bed. Val/vals in my world are the level-headed people you want in your corner during a crisis.

If you think this is all too neat and clean, you’re probably right. The research into COMT is still developing and is based on observations of lots of people. And it’s only one rung of one DNA strand on one chromosome. It’s also meant to be painted across populations, not pigeonholed to individuals. When I recently asked a few friends to share their 23&Me results, not a single one of them matched my preconceived notions or thought the descriptions fit them.

But that’s not how I want it work. While I don’t like the idea of boiling human emotions down to a couple squishy turning gears, I do like how tidy it is. I want to be able to look up my genome and make broad generalizations about myself. I want to have a genetic tarot card that I can inspect and say “ohhh, that’s why I always forget people’s names” or “that’s why I got in that fight in the third grade.” Most of all, I want to understand right now what kind of man my son will be.

But that’s not what nature gave us. Nature has given us messy, confusing and vastly complicated brains that contradict themselves and resist every attempt to classify them. Brain chemicals that mix with genes and experience and environment, run through a blender and pour out as the muddled Slurpee that is human behavior. Nature gave us the opportunity to shape our own brains.

Which is exactly what I would say, given that I have a thymine at position 43731789 on my X chromosome.