Wednesday, December 12, 2018

The Writer Who Destroyed an Empire


The Writer Who Destroyed an Empire

By Michael Scammell NY Times

Mr. Scammell is the author of “Solzhenitsyn: A Biography.”



Aleksandr Solzhenitsyn traveling to Oslo by boat on Feb. 25, 1974, soon after his expulsion from the Soviet Union.Emil Christensen/Keystone, via Getty Images

Aleksandr Solzhenitsyn traveling to Oslo by boat on Feb. 25, 1974, soon after his expulsion from the Soviet Union.Emil Christensen/Keystone, via Getty Images

When the Soviet Union collapsed in 1991, pundits offered a variety of reasons for its failure: economic, political, military. Few thought to add a fourth, more elusive cause: the regime’s total loss of credibility. 

This hard-to-measure process had started in 1956, when Premier Nikita Khrushchev gave his so-called secret speech to party leaders, in which he denounced Josef Stalin’s purges and officially revealed the existence of the gulag prison system. Not long afterward, Boris Pasternak allowed his suppressed novel “Doctor Zhivago” to be published in the West, tearing another hole in the Iron Curtain. Then, in 1962, the literary magazine Novy Mir caused a sensation with a novella set in the gulag by an unknown author named Aleksandr Isayevich Solzhenitsyn. 

That novella, “A Day in the Life of Ivan Denisovich,” took the country, and then the world, by storm. In crisp, clear prose, it told the story of a simple man’s day in a labor camp, where he stoically endured endless injustices. It was so incendiary that, when it appeared, many Soviet readers thought that government censorship had been abolished.

Solzhenitsyn was no youthful beginner. Born a hundred years ago, on Dec. 11, 1918, just 14 months after the Bolshevik Revolution, he was virtually the same age as the Soviet state and had experienced every phase of its development. As a youth and college student he had been swept up in the revolutionary euphoria of the communist experiment and fervently believed in the premises of Marxism-Leninism. In World War II he served as the commander of an artillery sound-ranging battalion and was awarded two medals for valor. 


But Solzhenitsyn’s promising career was brutally cut short by his arrest in February 1945 on a charge of anti-Soviet activities; he was swiftly sentenced to eight years of hard labor in the gulag. His crime? Criticizing Stalin and the Soviet Army in letters exchanged with a school friend on another front.

This Dickensian reversal of fortune plunged Solzhenitsyn into despair, but it also opened his eyes to the hideous underbelly of Soviet communism and gave him glimpses of the reign of terror and lies that had kept it going for so long. He had already written poems, stories and half a novel, most of them on patriotic themes; he now resolved to dedicate the rest of his writing life to exposing the monstrous machine that had, as he later discovered, murdered or incarcerated millions like himself.

After publishing two more tales focused on the plight of simple peasants, Solzhenitsyn was blacklisted by the censors, but he was able to complete the two big autobiographical novels he had been working on: “The First Circle” and “Cancer Ward.” “The First Circle” was about a group of privileged prisoners, including Solzhenitsyn, chosen to work in a secret lab run by the gulag authorities, while “Cancer Ward” described the circumstances in which Solzhenitsyn, while working as a schoolteacher in administrative exile after his release, was successfully treated for abdominal cancer in Tashkent. 

Both novels were notable for their ethical scrutiny of Soviet society and discussion of the government’s crimes, and both were denied publication in the Soviet Union. Like “Doctor Zhivago," they were quickly smuggled to the West and, like “Doctor Zhivago” and “A Day in the Life of Ivan Denisovich,” they became instant best sellers.

For his critical approach to Soviet life, Solzhenitsyn was evicted from the state-sponsored Writers’ Union and became a virtual outlaw in his own country. But he was far from alone. Many talented and independent writers — Varlam Shalamov (a fellow chronicler of the Gulag), Andrei Sinyavsky, Yuli Daniel and Joseph Brodsky — were circumventing the Soviet censorship with a new publication format called samizdat. It consisted of self-published poems, stories, novels, human rights appeals and political manifestoes that were secretly circulated in typed and mimeographed copies; in many cases, they were also sent abroad. 


By the end of the 1960s, the leading writers and activists came to be known as the Dissident Movement. Their goal was to bring about freedom of expression and peaceful political change in the Soviet Union, and they garnered a global audience of readers. Besides writers, their ranks included scientists, engineers, academics, lawyers, even rebellious workers; their unofficial leader was the Nobel Prize-winning physicist Andrei Sakharov.

Solzhenitsyn sympathized and cooperated with Sakharov and the other dissidents, but he didn’t always agree with them, and he continued to follow his own path. In 1973, still in the Soviet Union, he sent abroad his literary and polemical masterpiece, “The Gulag Archipelago.” The nonfiction account exposed the enormous crimes that had led to the wholesale incarceration and slaughter of millions of innocent victims, demonstrating that its dimensions were on a par with the Holocaust. Solzhenitsyn’s gesture amounted to a head-on challenge to the Soviet state, calling its very legitimacy into question and demanding revolutionary change.

In response, the Soviets stripped Solzhenitsyn of his citizenship and expelled him to the West; he landed in America, and spent most of the next 19 years in Vermont. He was able to collect the Nobel Prize he had been awarded in 1970; he also wrote four more historical novels in his grand series called “The Red Wheel,” centered on the Russian Revolution and its aftermath. 

He continued to blast Soviet leaders for their corruption and offered reams of advice for the future, but it was not an altogether happy time for the writer. His broadsides carried less weight in the Soviet Union than when he had still lived there. Strident attacks on America and Western democracy soon alienated his liberal supporters in the West, while his fierce criticisms of former allies in his memoirs seriously damaged his reputation at home.

None of this diminished Solzhenitsyn’s desire to see the Soviet system brought down, and when the government of Mikhail Gorbachev collapsed in 1991 he enjoyed both the thrill of success and the satisfaction of being proved right in his predictions of disaster. Three years later, he returned to Russia and received a hero’s welcome. But he didn’t much like what he saw there. 

President Boris Yeltsin’s government was chaotic, and Solzhenitsyn disapproved of what he saw as the new regime’s adulation of the West and its foolish desire to introduce a form of Western democracy. What he advocated was a strong leader, who maintained strict order in the country, encouraged more religion and state support for the Orthodox church, together with a revitalized patriotism and a return to traditional values.

He seemed to get his wish in 2000, when Mr. Yeltsin handed the presidency over to a man who shared Solzhenitsyn’s nationalist views and personified his ideal of a strong leader: Vladimir Putin. The new Russian leader made a show of welcoming Solzhenitsyn to his residence and seeking his advice, and in 2007 he bestowed a state award on the author for his humanitarian activities (Solzhenitsyn had refused similar awards from Mr. Gorbachev and Mr. Yeltsin).

After his death Solzhenitsyn was given a sumptuous funeral and buried at the Donskoy Monastery in Moscow. In 2010 “The Gulag Archipelago” was made required reading in Russian high schools. Moscow’s Great Communist Street has been renamed Aleksandr Solzhenitsyn Street, his centennial is being celebrated with great pomp this week in Russia, and a statue of him in Moscow is planned for the near future.
All this would give the writer great satisfaction. But though feted and exploited by questionable allies, Solzhenitsyn should be remembered for his role as a truth-teller. He risked his all to drive a stake through the heart of Soviet communism and did more than any other single human being to undermine its credibility and bring the Soviet state to its knees.

Michael Scammell is the author of “Solzhenitsyn: A Biography” and “Koestler: The Literary and Political Odyssey of a Twentieth Century Skeptic.”


Tuesday, December 11, 2018

Can We Really Inherit Trauma?

Can We Really Inherit Trauma?

Benedict Carey NY Times/Science/Mind


Headlines suggest that the epigenetic marks of trauma can be passed from one generation to the next. But the evidence, at least in humans, is circumstantial at best.

A Civil War prisoner is examined at the U.S. General Hospital in Annapolis, Md., in 1864.Library of Congress
In mid-October, researchers in California published a study of Civil War prisoners that came to a remarkable conclusion. Male children of abused war prisoners were about 10 percent more likely to die than their peers were in any given year after middle age, the study reported.

The findings, the authors concluded, supported an “epigenetic explanation.” The idea is that trauma can leave a chemical mark on a person’s genes, which then is passed down to subsequent generations. The mark doesn’t directly damage the gene; there’s no mutation. Instead it alters the mechanism by which the gene is converted into functioning proteins, or expressed. The alteration isn’t genetic. It’s epigenetic. 

The field of epigenetics gained momentum about a decade ago, when scientists reported that children who were exposed in the womb to the Dutch Hunger Winter, a period of famine toward the end of World War II, carried a particular chemical mark, or epigenetic signature, on one of their genes. The researchers later linked that finding to differences in the children’s health later in life, including higher-than-average body mass.

The excitement since then has only intensified, generating more studies — of the descendants of Holocaust survivors, of victims of poverty — that hint at the heritability of trauma. If these studies hold up, they would suggest that we inherit some trace of our parents’ and even grandparents’ experience, particularly their suffering, which in turn modifies our own day-to-day health — and perhaps our children’s, too.

But behind the scenes, the work has touched off a bitter dispute among researchers that could stunt the enterprise in its infancy. Critics contend that the biology implied by such studies simply is not plausible. Epigenetics researchers counter that their evidence is solid, even if the biology is not worked out. 

“These are, in fact, extraordinary claims, and they are being advanced on less than ordinary evidence,” said Kevin Mitchell, an associate professor of genetics and neurology at Trinity College, Dublin. “This is a malady in modern science: the more extraordinary and sensational and apparently revolutionary the claim, the lower the bar for the evidence on which it is based, when the opposite should be true.”

Investigators in the field say the critique is premature: the science is still young and feeling its way forward. Studies in mice, in particular, have been offered as evidence of such trauma-transmission, and as a model for studying the mechanisms. “The effects we’ve found have been small but remarkably consistent, and significant,” said Moshe Szyf, a professor of pharmacology at McGill University. “This is the way science works. It’s imperfect at first and gets stronger the more research you do.”

The debate centers on genetics and biology. Direct effects are one thing: when a pregnant woman drinks heavily, it can cause fetal alcohol syndrome. This happens because stress on a pregnant mother’s body is shared to some extent with the fetus, in this case interfering directly with the normal developmental program in utero.

But no one can explain exactly how, say, changes in brain cells caused by abuse could be communicated to fully formed sperm or egg cells before conception. And that’s just the first challenge. After conception, when sperm meets egg, a natural process of cleansing, or “rebooting,” occurs, stripping away most chemical marks on the genes. Finally, as the fertilized egg grows and develops, a symphony of genetic reshuffling occurs, as cells specialize into brain cells, skin cells, and the rest. How does a signature of trauma survive all of that?

One working theory is based on animal research. In a series of recent studies, scientists at the University of Maryland School of Medicine, led by Tracy Bale, have raised male mice in difficult environments, by periodically tilting their cages, or by leaving the lights on at night. This kind of upbringing, effectively a traumatic childhood, changes the subsequent behavior of those mice’s genes in a way that alters how they manage surges of stress hormones.

And that change, in turn, is strongly associated with alterations in how their offspring handle stress: namely, the young mice are numbed, or less reactive, to the hormones compared to control animals, said Dr. Bale, director of the university’s Center for Epigenetic Research in Child Health and Brain Development. “These are clear, consistent findings,” she said. “The field has advanced dramatically in just the past five years.”

Perhaps the best explanation for how such trauma marks could be attached to a father’s sperm cells comes from Oliver Rando at the University of Massachusetts. His studies, also in mice, have zeroed in on the epididymis, a tube near the testicles where sperm cells load before ejaculation. There, they learn to swim over a period of days, and their genes can be marked, said Dr. Rando.

The molecules that affect the changes appear to be “small RNAs,” fragments of genetic material that scientists are still learning about, Dr. Rando said.

“This tube produces small RNAs and ships them to the sperm as they develop, suggesting that there exists a place that senses the dad’s environmental conditions and can change the package RNAs delivered through the sperm to the baby,” Dr. Rando said. He makes no broad claims beyond that. 

Other researchers have attempted to fill out the picture. Once those RNA packages arrive at the epididymis, the hypothesis goes, they prompt a of cascade of changes at conception that evade the stripping, or rebooting, process and the subsequent reshuffling during early development.

The critics are far from persuaded. “It’s all very nice work, and yes, there are changes in the testicular cells,” said John M. Greally, a professor of genetics, medicine, and pediatrics at the Albert Einstein College of Medicine. “But as usual, the story that’s often told is overblown relative to the results, and too much causality is claimed.”

And this debate concerns only the animal research. The human studies thus far are much less persuasive, most experts agree, and have identified no plausible mechanism for epigenetic transmission. Some of the studies have focused not on small RNAs but on an altogether different chemical signature, called cytosine methylation, that could very well be added after conception, not before, Dr. Rando said.

The idea that we carry some biological trace of our ancestors’ pain has a strong emotional appeal. It resonates with the feelings that arise when one views images of famine, war or slavery. And it seems to buttress psychodynamic narratives about trauma, and how its legacy can reverberate through families and down the ages. But for now, and for many scientists, the research in epigenetics falls well short of demonstrating that past human cruelties affect our physiology today, in any predictable or consistent way.


Benedict Carey has been a science reporter for The Times since 2004. He has also written three books, “How We Learn” about the cognitive science of learning; “Poison Most Vial” and “Island of the Unknowns,” science mysteries for middle schoolers.

Sunday, December 09, 2018

On the Origin of Cooperation

On the Origin of Cooperation

Kevin N. Laland The New Atlantis


You take a flight from New York to London. Thousands and perhaps millions of people — including ticket agents, baggage handlers, security personnel, air traffic controllers, pilots, and flight attendants, but behind the scenes also airline administrators, meteorologists, engineers, aircraft designers, and many others — cooperated to get you there safely. No one stole your luggage, no one ate your in-flight food, and no one tried to sit in your seat. In fact, the hundreds of people on the airplane, despite being mainly strangers, behaved in an entirely civilized and respectful manner throughout.

For most of us in the industrialized world, every aspect of our lives is utterly reliant on thousands of such cooperative interactions with millions of individuals from hundreds of countries, the vast majority of whom we never see, don’t know, and indeed never knew existed. Just how exceptional in nature such intricate coordination is — with many unrelated individuals performing many different roles — remains hard to appreciate. Notwithstanding the familiar examples of ants, bees, and other species known for coordinating their behavior, largely with relatives, nothing remotely as complex as human cooperation is found in any of the other millions of species on the planet. And although modern marvels like air travel are very striking examples of large-scale cooperation, human societies have engaged in impressive feats of organized cooperation for many thousands of years. Carving terraces out of mountains, planting and harvesting crops, building granaries, and managing city-states all involved extraordinary levels of cooperation among community members. Hunter-gatherers also coordinated their actions in cooperative endeavors such as group hunting and foraging, as well as through sharing food, labor, and childcare, and when hostility or disputes with other societies arose. How is it that humans came to be the most cooperative species on earth? And how can understanding our evolutionary history help to explain human cultural, cooperative achievements, whether technological or artistic, linguistic or moral?

Evolutionary explanations for cooperation may at first seem paradoxical, since evolution is often conceived of in terms of competition between individuals and their struggle for survival and reproduction. The fittest, we might think, are those that care least about the success of others. But this impression is misleading. Cooperation is integral to the flourishing of many forms of life, and has long been a subject of study for evolutionary biologists. Indeed, virtually all of the major transitions in evolution, for instance the development of the first cells, of eukaryotes, or of multicellular organisms, required the establishment of new forms of cooperation between hitherto independent elements. The challenge in finding evolutionary explanations for cooperation is to identify behaviors that provide a benefit to another individual and that would likely have been favored by natural selection because of this positive effect on the recipient or the group.

One simple evolutionary explanation for cooperation is readily available. It is what biologists call “kin selection,” which is the way individuals can help propagate their own genes by helping biologically related kin who share those genes. But while kin selection can account for some aspects of the cooperation in human societies — most obviously when people cooperate to raise their relatives’ children — it does not explain the larger-scale projects created by unrelated or distantly related individuals that set humans apart from other animals. Our distant ancestors are thought to have aggregated into small bands that were often kin-based, but present-day hunter-gatherer societies are known to have extensive interactions with nonrelatives, even in societies numbering only a few hundred individuals. In these small societies, cooperative activities are regulated by systems of norms and institutions, which become even more important in larger agricultural societies, where cooperative arrangements have to be negotiated and maintained among thousands of often unrelated individuals. Kin selection alone cannot explain the vast scale of human cooperation.

some instances certainly, cooperation with distantly related individuals was a result of coercion — powerful leaders and groups forcing the weak to do their hard labor. By 4000 b.c., the Sumerians were building cities of over ten thousand people by using the labor of slaves captured from the hill country, and the Old Testament book of Exodus reports that the Egyptians “put slave masters over [the Israelites] to oppress them with forced labor.” But coercion cannot be the whole story behind large-scale human cooperation. In order to acquire slaves, societies would need to engage in impressive acts of cooperation already, either to field an organized army capable of capturing and subduing those whom the society would enslave, or to suppress and control large numbers of its own people. Moreover, historical research has established that some of the major architectural projects of antiquity did not rely on slave labor. The pyramids, for instance, are now thought to have been built by paid laborers. The builders came from poor families from the north and south of Egypt and were respected for their work — indeed, those who died during construction were bestowed the honor of being buried in the tombs near the sacred pyramids of their pharaohs. Ancient societies, just like those of today, including contemporary hunter-gatherer societies, were built using complex forms of cooperation in which most individuals participated entirely voluntarily.

How was this possible? Conventional evolutionary explanations that focus only on genetic variation and inheritance — such as kin selection theory — cannot account for the most impressive forms of large-scale human cooperation. The answer is more multifaceted, and draws on some rarely appreciated connections between cooperation and social learning — and, more broadly, between our biological history and our cultural history.

Language, Teaching, and Norms

One of the most distinctive features of the human species is our capacity for language, and linguistic ability is one factor that helps to explain our ability to cooperate. The origin of language is a highly contentious topic in human evolution, and there are many theories that attempt to explain it. Perhaps the most plausible theory is that language developed in conjunction with the early culture made possible by our ancestors’ ability to teach, imitate, and learn. Language may initially have evolved to enhance the efficiency and accuracy of teaching kin, and although teaching may not be the first thing that comes to mind when we think of cooperation, it is in fact a fundamental early form of cooperation.

Teaching is widespread in humans because cumulative cultural knowledge builds up over time, keeping difficult-to-learn but highly advantageous information (such as how to make a functional stone tool or to gather honey) available in the population as tutors impart it to their pupils. Evolutionary models have shown that the likelihood of teaching was at first highest when tutor and pupil were closely related. We can envisage the kind of widespread, generalized teaching observed in humans to have initially appeared among close relatives; for instance, parents teaching foraging skills to offspring, or siblings helping each other learn tool-making. Yet, without some rudimentary form of language, the teaching of more distant relatives would rarely have been worth the investment of time and effort. But by making teaching easier and more accurate, the advent of language would have made it more feasible for would-be teachers to instruct distantly related pupils as well. Such language-mediated teaching may have sufficed to allow individuals in small groups to teach each other specific roles in coordinated tasks, such as hunting antelope or driving off predators, thereby broadening the scale of kin-based cooperation to include more distant relatives.

The ability of humans to transmit knowledge between generations, especially through language, can also help explain how human societies are able to sustain the kinds of norms and institutions necessary to enforce cooperation — laws, for instance, must be taught if they are to function properly. But how are these norms and institutions different from the patterns of learning we observe in nonhuman animals?


Many animals that are proficient at social learning (such as primates, whales, and dolphins) exhibit behavioral traditions, which are society-specific conventions for such behaviors as singing or ways of hunting prey. Our ancestors also had group-specific habits maintained as social conventions. Some traditional behaviors could be picked up through observational learning, while other, more challenging habits would have spread through teaching among relatives. But unlike much human teaching, most animal teaching merely creates enhanced opportunities for learning in the pupil, as when meerkats provide pups with disabled scorpions so the pups learn how to handle the dangerous prey. In rare cases, however, animals show hints of “coaching,” in which the teacher responds in ways that encourage or discourage the pupil’s behavior, such as the maternal display of a mother hen who pecks and scratches the ground intensively to distract her chicks from unpalatable food.

Such error correction is, of course, a feature of human teaching as well, and systematic error correction likely led to the transition from reliance on mere conventions toward governance through norms. Instead of illustrating only a way to behave, people began insisting on the way to behave. Eventually, each society was characterized by a particular set of norms that dictated how individuals should act — for example, how they should build fires, how they should catch turtles, how they should till the soil — each of which was propagated through verbal instruction. Norms specify rules of social interaction too, including how people should respond to violations of norms. With the advent of norms, the social life of our ancestors transformed from simply living in groups to identifying with the group, abiding by its rules, and privileging in-group members. Norms facilitated group coordination and thereby substantially enhanced social cooperation. To resolve conflicts or prevent social problems from arising in the future, institutionalizing the norm as a rule of law that all members of the society must abide by, and agreeing on sanctions for violators, would sometimes have been necessary.

The ability to teach cultural norms using language also laid the foundation for the emergence of rule-governed social institutions. The rules that different human societies live by are often not at all intuitive, and young members of a community must be taught both the nature of the norms and the need to conform to them. There are many examples of complex rule-governed behavior in modern societies that must be taught: how to write a check; when, how, and why citizens should pay their taxes; or the rules of driving. All human societies possess such norms that require active instruction of the young, sometimes simply by parents and family members, but also in socially organized learning environments, such as schools.

The scale of human cooperation is unprecedented in large part because it is uniquely built upon socially learned and transmitted norms. Other animals do exhibit cooperative foraging, hunting, and defense — lions hunting, for instance, or the circular defensive maneuvers of musk oxen against wolves — but in such societies individuals rarely take up a variety of distinct and coherently integrated roles. However, through our language, teaching, and the construction of learning environments for others, humans can solve the problem of how to coordinate many separate tasks; we can assign distinct roles to individuals, and ensure each is trained. And because cultural norms can be taught and learned using language, they would have been critical for expanding cooperation beyond kin groups.

Training through apprenticeship may also have played a vital role in organizing the coordination of groups. In early agricultural societies the pressure to generate enough food to feed the mushrooming population demanded division of labor and occupational specializations. For society to function efficiently, relevant skills and expertise would need to be passed on to unrelated individuals, but these skills would frequently be far too complex to pick up simply through imitation and would require systematic, long-term instruction. Much of the complex knowledge required for manufacturing tools or goods, for instance, or the extensive knowledge associated with many professions or trades can reliably be passed on only through long apprenticeship. Unlike earlier forms of teaching where parents and other relatives instructed their kin, masters instructed apprentices in exchange for resources such as food, clothing, or protection. Various classes of professional teachers emerged: teachers of farming methods, of military combat, of dance, and of the skills and knowledge that the children of the wealthy needed for their future roles.

Money, Gossip, and Armies

The importance of the uniquely human capacity for social learning, teaching, and language — and thus for large-scale cooperation — becomes even clearer when we consider how this capacity supports three distinct cooperative processes: mutually beneficial exchanges, indirect reciprocity, and group selection.

Many animals engage in mutually beneficial exchanges on a small scale, such as when a bird called the oxpecker takes a ride on the back of rhinoceroses, zebra, or cattle, and eats the ticks and other parasites that live on their skin. The evolution of this type of exchange is fairly straightforward — the “trade” of parasites from the rhinoceros to the oxpecker is beneficial for both parties: the birds find food and the mammals receive effective pest control.


But more challenging to understand is the evolution of the kind of trade or barter commonly observed in humans, like swapping a tool for food. In bartering, both parties value both of the commodities, but, as the items are different, the exchange currency requires negotiation. This form of mutually beneficial exchange appears to be rare or absent among animals. Some primatologists have reported the apparent trading of meat for sex among some chimpanzees that hunt red colobus monkeys, and a group of Balinese long-tailed macaques have devised a learned tradition of stealing objects from tourists, such as cell phones and sunglasses, and then trading them back in exchange for food. But such rare examples aside, trade may be largely unique to humans, which is not surprising, as it typically requires some capacity to agree on a rate of exchange, something that would be difficult without at least the rudiments of language. With language, trade becomes easier; with trade comes the complex linguistic activity of negotiation — and so the development of trade would have given rise to increasingly advanced linguistic ability.

Trade exploits a division of labor in which valuable goods or services, available to some individuals or societies but not to others, are exchanged. The emergence of large-scale, stratified societies, and the associated development of distinct professions, would immediately have created extensive opportunities for trade; indeed, such division of labor almost certainly could not have arisen without trade. The more division of labor exists within and between societies, the more opportunities for trade arise. Eventually, a threshold is passed after which it becomes convenient to facilitate trade with a common currency, and the institution of money arises. As early as eleven thousand years ago, both grain and cattle were used as money or as barter. The Hebrew shekel is thought to have originated as a weight of barley, corresponding to about 180 grains. Through trade — and the norms, institutions, and laws that served to stabilize it — cooperative interactions between nonrelatives became possible on huge scales, while language helped to ensure that rules or agreements were specified in detail and widely known.

Language, teaching, and norms are also fundamental to another of the most important developments in large-scale human cooperation, namely indirect reciprocity — the tendency of individuals not only to help those who help them personally, but also to help those who are known to help others. Theoretical models have demonstrated that indirect reciprocity can lead to cooperation, and explain why it might benefit individuals to develop a reputation for this. However, language is also important for explaining indirect reciprocity, as evolutionary biologist Martin Nowak and science journalist Roger Highfield write in their book on the evolution of human cooperation: “Language is intimately linked with cooperation. For the mechanism of indirect reciprocity to work efficiently it needs gossip, from names to deeds and times and places, too.” Verbally taught social norms also allow humans to institutionalize the punishment of non-cooperative individuals — for instance, through policing or socially sanctioned retaliation, which are more effective means of preserving cooperation than individual-level retaliation. But norms don’t rule out the possibility of cheating. Subtle cheats can tweak messages and verbal agreements — remaining cooperative but maximizing their benefits or those of their group. Such cheating might again have contributed to the development of more competent, skillful communicators. And as language became more complex and the repertoire of local symbols expanded, it would have become increasingly difficult to understand the symbols of other societies without effort, which further reinforced the benefits of biasing learning toward the local population. With time, local variants of early linguistic symbols would start to resemble dialects, which may have begun to define and signify distinct communities.

The coexistence of populations that are culturally diverse would mean that members from each group would recognize and prefer to learn from other members of the same group who have useful local knowledge, rather than from outsiders who come from other groups. Theoretical analyses suggest that conforming to local traditions is favored in such circumstances, with several important consequences, including the evolution of “ethnic markers” that symbolized group membership, increased cooperation within groups, and the potential for greater conflict between groups. Languages or dialects can function effectively as ethnic markers and promote local learning and other parochial tendencies. In turn, imitation, teaching, languages, and local conventions all act to ensure that local differences in behavior among groups are maintained even when individuals disperse. This allows an unusually stable form of group selection to arise, known as “cultural group selection,” which has shaped human history dramatically.

Anthropologists Rob Boyd and Peter Richerson, in their 1985 book Culture and the Evolutionary Process, first brought to prominence the hypothesis that group selection works at the cultural level through the selection of cultural traits. Groups that possessed more efficient traditions, norms, or institutions fared better in competition with other groups. Societies with an organized army are more likely to win conflicts than those without; city-states with division of labor and occupational specializations tend to outcompete those without these innovations; agricultural communities that have devised irrigation systems flourish more readily than others, and societies with religious doctrines that stabilize cooperative activities within the group thrive at the expense of those with no gods to help ensure compliance. The net result is the spread of military technology, division of labor, irrigation, religious doctrines, and many other cooperative endeavors.

The idea of natural selection operating on groups, as opposed to individuals or genes, has been controversial in recent evolutionary biology. Some might explain the evolution of cultural practices like agriculture by focusing only on individual selection. The argument would go like this: If individuals in agricultural societies end up having more offspring than those in non-agricultural societies, then agriculture will increase in frequency (provided offspring tend to adopt the means of subsistence of their parents). But what is missing from this line of reasoning is the recognition that most of the fitness benefits associated with agriculture derive from group-level activities. Consider that a lone farmer scratching out a living solely through his own efforts would not typically produce any more food or raise any more offspring than a hunter-gatherer. Agriculture does not become highly productive until groups of people engage in shared enterprises to produce resources that benefit the group. It typically takes several hundred people to construct a decent irrigation system, or to build a corral suitable for catching antelope or horses. Some fish weirs — traps built of stone, nets, or wooden fencing for catching fish — are several hundred meters long and would have required a large group of individuals to manufacture. Burning land, sowing seeds, and harvesting crops have all traditionally been activities in which entire communities engaged. Such activities are infeasible for an individual farmer, but a group of agriculturalists working together could yield substantial dividends, and those who cooperate in this manner generally outcompete those who do not. The end result is the propagation of cooperative practices.

Agricultural communities are of course not the only ones to engage in group-level cooperative enterprises. The Nuer and the Dinka are African cattle-herding societies that live in Sudan. The two groups have a long history of conflict, with the Nuer dramatically expanding their territory at the expense of the Dinka throughout the nineteenth century. The Nuer were successful in warfare because their social structure allowed them to call on larger war parties than the Dinka. As a consequence, the Nuer’s beliefs and practices spread. More generally, many small-scale societies engage in cooperative hunting and foraging, and form war parties when conflicts arise; group selection likely operated on these societies to propagate their cultural traditions.

Boyd and Richerson emphasize the importance of accurate social learning, a “when in Rome, do as the Romans do” conformity in which individuals adopt the behavior of the majority, as well as the norms and institutions that regulate social behavior. Conformist transmission minimizes behavioral differences within groups, while maintaining differences between groups. However, even subpopulations in identical environments may end up with quite different forms of behavior, because any behavior that occurs frequently in a given local area may become part of the culture of a small group. In other words, cultural processes generate plenty of variation among human groups for natural selection to act upon, much as processes like recombination and mutation generate genetic variation.

Cultural inheritance is much more important than genetic inheritance for explaining the evolution of human cooperation through group selection, for a number of reasons. First, in cultural inheritance, unlike genetic inheritance, descendants can learn from individuals other than their biological parents, allowing them to be sensitive to the most frequent cultural traits in their society and to conform to the dominant local behavior. This helps preserve cultural differences. Second, the symbolic systems that serve to mark a group — such as languages, rituals, dances, songs, dress, and flags — make it relatively easy for cultures to maintain their identities, and to resist imported cultural traits from immigrants, or for immigrants to resist the cultural traits of the dominant culture. In contrast, gene flow between groups — where members of one group mate with members of another — will often introduce genes that were once unique to one group into the other, reducing the amount of genetic variation between the groups. While migration will lead to gene flow between groups, reducing genetic variation, symbolic systems will often maintain cultural differences. Third, institutionalized punishment (such as by a police force) or socially sanctioned retaliation (such as the penalizing of deserters during warfare) can stabilize cooperative norms within the society, whereas there is no comparable stabilizing force for genetic selection at the level of groups.

So the kind of group selection that is most important for the evolution of cooperation is selection for the group’s culture.

Genes and Culture

Genetic inheritance, however, still plays a significant part in the evolution of cooperation, specifically through a process known as “gene–culture coevolution” — a dynamic in which cultural processes, including cultural group selection, generate a feedback effect on genetic evolution, and vice versa. Through this interaction, natural psychological predispositions for cultural life and cooperation may have been favored by natural selection.

In a 2011 paper, anthropologists Maciej Chudek and Joseph Henrich described what they called “norm psychology,” by which they meant “a suite of psychological adaptations for inferring, encoding in memory, adhering to, enforcing and redressing violations of the shared behavioral standards of one’s community.” Once a species becomes heavily reliant on social learning and culture, as humans have, then a specialized norm psychology is likely to follow. As a result, humans are particularly adept at recognizing, representing, and adopting the local norms of their society, as well as noticing, condemning, and punishing violations of those norms.

Consider, for instance, how social norms and a psychological preference for cooperation could have evolved together, with one providing the conditions for the other, and vice versa in feedback fashion. Individuals who are naturally more inclined to conform to norms would find it easier to live in larger norm-bound societies and to abide by the rules than individuals lacking such conformist tendencies. These more “docile” individuals would be at an advantage, because they would be better placed to benefit from living in society and less vulnerable to exclusion or punishment, and so they would also be more likely to pass on their genes to a larger number of offspring. Conversely, unlike in most nonhuman societies, non-cooperative individuals would face serious sanctions. In turn, a population of more docile individuals could then encourage the cultural evolution of more sophisticated and effective norms, and allow groups to maintain more reliable cooperation. A similar dynamic could have favored a tendency of individuals to feel shame or guilt when they violate a social norm. While such arguments are speculative, the general idea that docile tendencies in humans were favored throughout recent evolutionary history is entirely credible. The fact that we would struggle to imagine that other, less docile primates could live in such a norm-governed cooperative manner as humans suggests that our cooperative tendencies require an evolved disposition toward docility. (And of course we know that artificial selection in many domesticated animals has favored docility.)

In addition, our long history of coordinated group behavior and collective problem-solving through social learning, teaching, and language have seemingly also fed back to shape human psychology in ways that leave us uniquely able to understand and share the goals and intentions of others. We humans appear unusually inclined and able to share experiences with others; humans have evolved not just advanced levels of individual cognition but also extensive skills and motivations for shared cognition, where knowledge is constructed through dialogue between individuals. The typical pattern of social foraging among other primates is strong competition for food, low tolerance for food sharing, and almost no food offering at all. Our ancestors somehow broke away from this pattern to become cooperative foragers. And so one consequence of our cultural evolution through teaching and learning has perhaps been the development of a more socially tolerant temperament.

Or consider how genetic and cultural evolution together could be involved in the development of the enhanced human capacity for imitation, as well as the social bonding that imitation generates, and the activities of caretakers that elicit childhood imitation. There are several reasons why it may be appealing or advantageous for an adult to be imitated by a child. First, being imitated as an adult may be flattering because it means that I, my values, or my choices have been noticed or chosen. Second, I may wish to encourage the child in learning important life skills, either because I want the child to develop and mature, or because I want to be relieved of my child-caring responsibilities as soon as possible. Third, children who imitate may be less disruptive, or even more helpful, than children who do not imitate (consider children helping our ancestors with foraging activities, or helping us clean up the living room). These advantages of imitation might explain why parents and helpers commonly encourage imitation in the children they look after, often showering them with praise and giving rewards and sometimes even imitating the child’s own actions and sounds. Theoretical analyses have shown that such responses could strengthen the child’s imitative competence and elicit further imitation.

Natural selection can act on this dynamic, favoring a tendency to respond positively to and encourage imitation by a child, and a corresponding tendency for infants to imitate adult caregivers spontaneously and respond to encouragement with further imitation. The positive emotions experienced by both caregiver and child following imitation, and the enhanced social relationship that results, may be nature’s way of encouraging imitation to the benefit of both parties. One special case of this more general process may be infant-directed speech, or baby talk. Natural selection may have favored the tendency for adults to use baby talk with infants, and for infants to respond to it, because it accelerates language learning. Even smiling and frowning may have become part of our norm psychology; as cheap-to-produce but nonetheless highly effective signals of approval or disapproval, they can be easily used to teach others what they should or shouldn’t do.

Imitation, in turn, connects in a curious way back to cooperation. Like other animals, humans (often inadvertently) copy each other’s postures, mannerisms, and facial expressions. This form of social learning is known variously as “response facilitation,” “mimicry,” or the “chameleon effect.” While experiments have established that such copying allows animals to acquire valuable life skills, in humans it also appears to enhance social interaction. Experimental investigations have shown that simple imitation is causally related to the emergence of cooperative attitudes, and that the relationship between imitation and cooperation goes both ways: being imitated makes individuals more cooperative, while being cooperative makes one more likely to imitate others. The experiments show that if people are imitated, they begin to like their imitators more, find them more persuasive, and describe their time together as more enjoyable than if they are not imitated. Children as young as eighteen months will rush to help adults (for instance, by picking up items that the adult has dropped) more readily when the adult has imitated the child, compared to when no such imitation has taken place. Adults too are more willing to help others with simple tasks, and even donate more money to charity, after being imitated. People imitate those they like more than those they don’t like, and show a preference for imitating members of their own group over members of an out-group, a finding that has held for both religious and ethnic groups.

Oxford psychologist Cecilia Heyes has argued that the two-way causal relationship between imitation and cooperation may function to maintain cooperation, collective action, and information-sharing among members of a social group through a “virtuous circle” of subconscious imitation and prosocial attitudes. Because this virtuous circle helps to maintain group boundaries, we can imagine again that imitation and cooperation have evolved through a process of cultural group selection. Like dialects, local mannerisms can spread through imitation to act as ethnic markers that, often subconsciously, symbolize group membership. A tendency to be well disposed toward individuals who behave like you and exhibit your mannerisms may have been favored as an aspect of our evolved psychology, because it helps promote cooperation among the group’s members. Conversely, in variable environments it often pays to copy locals, since they are more likely to know best how to deal with their environment.

Numerous social practices that have persisted through human history may foster the development of enhanced imitative capabilities. Many societies possess traditions of dancing in synchrony, and train their military through extensive synchronous marching and fighting drills. Such groups may have been more successful than others in part because this synchronous activity trained individuals’ neural circuitry for imitative proficiency, enabling them to connect the perception of others performing the action to their own performance, thereby promoting group bonding. Synchronous action that triggers endorphin release (such as a group of individuals that exercise together) may lead to individuals associating the simultaneous activity with positive reward, resulting in synchrony itself becoming rewarding. Or, if rewards are received at the end of synchronous action, such as hunting together, again a learned association may arise. If synchrony is rewarding, then social behavior that promotes synchronous action will be more likely to occur. The extensive use of rhythm, for example in drumming — and music more generally — as a means of helping to coordinate the actions of large numbers of individuals and to promote social bonding could be favored because of positive group effects. Groups of soldiers that sing or chant when running are often thought to run further and faster, with less pain, and to bond with each other in the process.

Selection for more accurate and efficient forms of social learning might have in turn generated selection for enhanced imitative capabilities, as well as other aspects of cognition. For instance, brain structures that would have been favored by selection include those that allow us, with relevant experience, to solve what is known as “the correspondence problem” — the challenge of imitating when the perception of oneself and of another individual performing the same action can be quite different. (Consider mirror neurons, which fire both when an individual performs an action and when the individual observes someone else performing the same action.) Perhaps our potent capacity for imitation is itself an adaptation to cultural life.

This issue remains contentious, however. Heyes, for instance, has argued that the human capacity for imitation is not an adaptation but instead relies on an ancient learning capability — the kind of associative learning that we essentially share with other animals — and that both the extent of our reliance on imitation and our imitative proficiency are socially constructed. According to this argument, our use of mirrors and engagement in synchronous activities such as dance and sports have helped to produce vast opportunities for developing imitative competences through experience, and the relative lack of these experiences in nonhuman animals explains why they are less capable of imitating than we are.

Although it is true that our use of artifacts like mirrors and activities like dance and sports have encouraged our imitative tendencies, the human mind is unique in its ability to imitate in complex ways. There has been extensive natural selection acting on the human brain in the period since humans and chimpanzees shared a common ancestor, leading to our vastly superior natural ability to learn. The selection pressure for greater and greater learning abilities in our ancestors was generated by the social learning that was so important for our ancestors to flourish, meaning that cultural evolution interacted with genetic evolution to make us the best imitators, the best learners, and the most cooperative species on earth.

Cultural by Nature

What precisely are human social-learning adaptations? This remains one of the great unresolved questions in the field of cultural evolution. Showing that any given trait is an adaptation can be very difficult, so demonstrating that certain human cognitive traits are adaptations to promote social learning is no trivial task. Still, although definitive answers are elusive, we have discussed a number of human behaviors and features that may one day be shown to be cognitive adaptations for social learning, as that is currently the most plausible explanation for their presence in humans.

Our capacity for teaching, as well as the motivation to teach and be taught, our ability to comprehend the state of knowledge of the pupil, and various means of facilitating learning in others are possible social-learning adaptations. And if the original function of language is indeed to promote teaching, then language is another adaptation (or set of adaptations) for social learning. The tendency to produce, and to attend to, infant-directed speech may have evolved to promote social transmission. The extraordinary social motivation to imitate, which anyone with children will recognize as powerful and pervasive, and the social bonding between individuals that this generates, is another strong example of a possible evolved adaptation for social learning and cooperation, as is the tendency of young children to attend to the gaze of others, and the motivation to share experiences with others through joint attention. Even the whites of our eyes may have evolved to make it easier for us to follow another individual’s gaze in a conversation. Or consider again the extraordinary human tendency to conform to the majority. Gene–culture coevolution is better suited than models of associative learning to explain such experimental findings as the fact that humans are more likely to copy an action that is performed by three individuals one time each than an action performed by one individual three times. Our capacities for having a theory of mind and for taking a perspective other than our own, and abilities to read the intentions of others, are surely also part of this story.

There is both neural and genetic evidence that humans possess elevated levels of developmental plasticity that allows them to form neural connections between sensory inputs and motor outputs that may make imitation easier, by linking the observation of a given behavior with its performance. Humans have evolved to possess an extended period of juvenile dependency — from infancy to late adolescence — that promotes the transfer of knowledge across generations, and so the period of synaptic plasticity characteristic of early brain development is longer in humans compared to other species. Even our basic and ancient learning capabilities, including our ability to see connections between events to discern the consequences of our actions and to adjust our behavior flexibly, are superior to other animals’ learning abilities, probably due to selection for enhanced social learning. This enhancement in general learning and neural plasticity likely plays a critical role in human cognitive development.

The large-scale cooperation that exists solely in human societies arises because of our uniquely potent abilities for social learning, imitation, and teaching, combined with the coevolutionary feedbacks of these capabilities on the human mind. Culture took human populations down evolutionary pathways not available to noncultural species, either by creating conditions that promoted established cooperative mechanisms, such as indirect reciprocity and mutually beneficial exchanges, or by generating novel cooperative mechanisms not seen in other animal populations, such as cultural group selection. In the process, gene–culture coevolution seems to have generated an evolved psychology comprising an enhanced ability and motivation to learn, teach, communicate through language, imitate, and emulate, as well as predispositions to docility, social tolerance, and the sharing of goals, intentions, and attention. This evolved psychology is entirely different from that observed in any other animal, or that could have evolved through genes alone.

The world’s people exhibit an extraordinary diversity of appearance, fashion, language, diet, method of subsistence, and custom, and while there are genetic differences between human populations, the genetic variation among humans is tiny compared with that found in other primates. What separates all human societies has less to do with our genes than with a few thousand years of cultural evolution. However, it would be a mistake to assume that our biology is irrelevant to understanding contemporary human adaptation and diversity. Through our culture we have built our world, but that is only possible because we have been naturally fashioned for culture.

Kevin N. Laland is a professor of behavioral and evolutionary biology at the University of St. Andrews, United Kingdom

Sunday, December 02, 2018

Opioid Nation

Opioid Nation

by Ryan Hampton, with Claire Rudy Foster
All Points Press

The National Institute on Drug Abuse estimates that 72,000 Americans died from drug overdoses in 2017, up from some 64,000 the previous year and 52,000 the year before that—a staggering increase with no end in sight. Most involved opioids.

A few definitions are in order. The term opioid is now used to include opiates, which are derivatives of the opium poppy, and opioids, which originally referred only to synthesized drugs that act in the same way as opiates do. Opium, the sap from the poppy, has been used throughout the world for thousands of years to treat pain and shortness of breath, suppress cough and diarrhea, and, maybe most often, simply for its tranquilizing effect. The active constituent of opium, morphine, was not identified until 1806. Soon a variety of morphine tinctures became readily available without any social opprobrium, used, in some accounts, to combat the travails and boredom of Victorian women. (Thomas Jefferson was also an enthusiast of laudanum, one of the morphine tinctures.) Heroin, a stronger opiate made from morphine, entered the market later in the nineteenth century. It wasn’t until the twentieth century that synthetic or partially synthetic opioids, including fentanyl, methadone, oxycodone (Percocet), hydrocodone (Vicodin), and hydromorphone (Dilaudid), were developed.

In 1996 a new form of oxycodone called OxyContin came on the market, and three recent books—Beth Macy’s Dopesick, Chris McGreal’s American Overdose, and Barry Meier’s Pain Killer—blame the opioid epidemic almost entirely on its maker, Purdue Pharma. OxyContin is formulated to be released more slowly and therefore lasts longer. The company claimed that the drug’s slow release would make it less addictive than ordinary oxycodone, since the initial euphoria—the high—would be muted. Based on this theory and little else, the FDA permitted OxyContin to contain twice the usual dose of oxycodone and carry on the label this statement: “Delayed absorption, as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug.” (The FDA official who oversaw OxyContin’s approval later got a plum job at Purdue Pharma.)

The company launched an extraordinarily aggressive and successful marketing campaign to convince physicians that they had the holy grail of a nonaddictive opioid. It sent hundreds of sales representatives to doctors’ offices to tout OxyContin, and offered doctors dinners and trips to meetings at luxury resorts. And it paid more than five thousand doctors, pharmacists, and nurses to train as speakers to tour the country promoting OxyContin. But like all opioids, OxyContin is addictive. And soon enough, users found that they could crush the pills or dissolve the coating, then snort the drug like cocaine or inject it like heroin. Each pill would then become essentially an instantaneous double dose of oxycodone.

OxyContin almost immediately became a blockbuster—that is, a prescription drug with annual sales of more than $1 billion. It was widely used not just by those for whom the prescriptions were written, but by their relatives and friends. The pills were also sold or stolen or otherwise diverted to street use. In addition, “pill mills” sprang up, where unethical physicians wrote innumerable prescriptions for OxyContin and refilled them automatically without ever seeing the patient. McGreal describes “one of the most productive pill mills in the country,” which operated in the small town of Williamson, West Virginia—known locally as “Pilliamson.” The town, he says, “was awash in pills,” and people came by car and bus to line up at the clinic and cooperating drugstores. “Investigators calculated that in 2009 alone, the clinic pulled in $4.6 million in a town with a population of little more than three thousand people.”

It’s impossible to know how many new prescriptions were obtained in each of these ways, but one way or another, OxyContin addiction grew into an epidemic. The epicenter was central Appalachia, and its victims were mainly white people in small, economically depressed coal-mining communities in southern West Virginia and parts of Kentucky, Tennessee, and southwestern Virginia.1

The three books that focus on Purdue Pharma are in a sense the same book. Barry Meier first published Pain Killer in 2003. The new edition (released by a different publisher) is much the same, with some updating and re-arrangements. The two new books, Dopesick and American Overdose, cover the same story as it unfolded in the same region of the country. Both Macy and McGreal refer to the 2003 edition of Meier’s book (but not the new edition, probably because they could not have known of it at the time their books were written). All three books are gripping and well written, with detailed accounts, one after another (perhaps too many), of families decimated by the epidemic. And they all tell the story of Art Van Zee, a physician in southwestern Virginia, who in 2000 became aware of the growing epidemic of OxyContin there and tried heroically to get Purdue Pharma and the FDA to take responsibility for it.

Purdue Pharma and the Sackler family that founded it are very hard to defend. By aggressively marketing OxyContin, even after they knew it was being widely abused, the family became enormously wealthy. But the FDA was also guilty. It permitted OxyContin to be sold as a relatively nonaddictive opioid without good evidence to support that claim, and it should have been obvious that the pills might be crushed or dissolved to make them even more addictive. Van Zee, along with Beth Davies, a nun who ran the local substance abuse clinic, saw Lee County, Virginia, blanketed with OxyContin prescriptions and watched the deaths mount, particularly among young people. They informed Purdue, which simply stonewalled. Over the following year, Van Zee devoted himself completely to the cause, meeting with company and FDAofficials and testifying before a Senate committee, trying to get Purdue to reformulate the drug or even withdraw it from the market.

In 2007 Purdue pled guilty to criminal charges of fraudulently marketing OxyContin and settled for $600 million in fines and penalties. Three executives pled guilty to misdemeanor charges and were sentenced to four hundred hours of community service and lesser fines. The company’s fine was trivial in comparison with its profits from OxyContin. In fact, almost every other major pharmaceutical company has had to settle both civil and criminal charges of fraudulent marketing for much more (the record settlement is now GlaxoSmithKline’s $3 billion, for a variety of violations, including falsely promoting drugs and failing to report safety data). These kinds of fines are just the cost of doing business. And so it was for Purdue Pharma, although the fraudulent marketing stopped and a warning was added to the label.

The problem with these three books, and it’s a big one, is that they treat the Purdue story as though it were the whole story of the opioid epidemic. But OxyContin did not give rise to opioid addiction, although it jump-started the current epidemic. Heroin has been a common street drug ever since it was banned in 1924. Morphine has also been widely abused.

Nor would taking OxyContin off the market end the epidemic. The overwhelming majority of opioid deaths are caused not by OxyContin but by combinations of fentanyl, heroin, and cocaine, often brought in from China via Mexican cartels, and frequently taken along with benzodiazepines (such as Valium or Xanax) and alcohol. These drugs are cheaper and stronger, particularly fentanyl. Fentanyl was first synthesized in 1960, and soon became widely used as an anesthetic and powerful painkiller. It is legally manufactured and highly effective when used appropriately, often for short medical procedures such as colonoscopies. The illicit production and street use is relatively new, but it is now the main cause of most opioid-related deaths (nearly 90 percent in Massachusetts).

The steady increase in opioid deaths after OxyContin came on the market has been supplanted by a much faster increase starting around 2013, when heroin and fentanyl use increased dramatically. We now have two epidemics—the overuse of prescription drugs and the much more deadly and now largely unrelated epidemic of street drugs. By concentrating on the first, we are closing the barn door after the horse is long gone.

Efforts to deal with the epidemic have been all over the map—literally. Possession of illegal drugs (and legal drugs illicitly used) is still a federal crime, and prisons are still full of people whose only crime was that. But many states, counties, and cities have begun to regard opioid addiction as a public health issue, not a police issue. They are opening centers in which people who seek help are shifted to less powerful opioids like methadone and buprenorphine (Subutex)—a method known as “medication-assisted treatment,” or MAT. Naloxone (Narcan), the antidote for an opioid overdose, is now sold over the counter in almost all states. If used immediately, it can prevent an otherwise inevitable death from a drug overdose. And drug courts, which may drop criminal charges in return for an agreement to submit to treatment and monitoring, are becoming more common.

Most controversial are facilities called “safe injection sites,” or SIFs, where drug users can come to use drugs without fear of arrest. The staff provides clean needles to reduce the risk of HIV and hepatitis C infections, and is prepared to resuscitate addicts who overdose. This approach is called “harm reduction.” The problem is that addicts must still buy drugs illegally, and it’s almost impossible to know exactly what is in them.

In a recent New York Times Op-Ed, the deputy attorney general, Rod Rosenstein, came down hard on SIFs. He warned that “it is a federal felony to maintain any location for the purpose of facilitating illicit drug use,” and that “cities and counties should expect the Department of Justice to meet the opening of any injection site with swift and aggressive action.” He was referring to plans to operate SIFs in San Francisco, New York City, and Seattle, and similar options now being considered by Colorado, Maine, Massachusetts, and Vermont. Later in the same article, however, he softened, saying we should “help drug users get treatment and aggressively prosecute criminals who supply the deadly poison,” suggesting that perhaps he doesn’t believe simple possession is so bad, after all.

But the proposed solutions to this epidemic range from the extreme of “lock ’em up” to “drug abuse is no less a disease than cancer or diabetes” and should therefore be met with the same solicitude. Ryan Hampton exemplifies the latter view in his angry book, American Fix. A former drug user himself and now an impassioned advocate and activist, he insists that drug abuse should be regarded like other diseases. He doesn’t acknowledge that for most users there was a moment of choice in becoming addicted that is not the case for people with cancer or diabetes. After receiving Dilaudid for a painful ankle, Hampton decided to ask for more, and then more. I think one can make the argument for sympathy with drug users and for understanding how the quest for drugs ceases to be under their control without claiming an analogy to diseases like cancer or diabetes.

Hampton paints a vivid picture of the downward spiral of addiction. When he “leveled up to IV heroin,” he explains, “it was cheaper than pills, easier to get hold of, and a quarter the cost. More important, nobody was tracking us in a database.”

Where Hampton is at his best is in his exposure of the profiteering and corruption in the burgeoning addiction industry—what he calls “the treatment industry swamp.” In the swamp, he found


lack of effective treatment, exorbitant costs, and ridiculous twenty-eight-day vacations disguised as medical help, fed by patient brokers who run a completely legal, high-end human trafficking cartel to push tens of thousands of patients through the broken system. 

He was referring to the panoply of treatment centers, both residential and outpatient, and detox facilities, where users are supposed to be weaned from drugs before entering “sober living houses.” As in so much of American medicine, even nonprofit insurers like Medicaid outsource the actual delivery of care to for-profit companies that charge whatever the market will bear. According to Hampton, “one of the most expensive treatment centers in America, Passages Malibu, costs more than $60,000 per month.” Costs are settled by a crazy quilt of payers, including state and local governments, Medicaid, other federal programs, private insurers, and often by desperate families. Not surprisingly, only a minority of users are ever treated.

In 2017 the Aspen Institute’s Health Strategy Group, led by two former secretaries of health and human services, Tommy Thompson and Kathleen Sebelius, and consisting of twenty-four members from various health-related fields (I am among them), met for three days to examine the opioid epidemic. The deliberations were preceded by four presentations by experts in the field. In the final broad and comprehensive report, the group made a strong case for decriminalizing drug addiction and instead regarding it as a public health issue. Among the five major recommendations was a call for more research into nearly all aspects of the epidemic. It’s startling how little we know, given the immensity of the problem and the media attention it receives.2

We need to know, for instance, how effective opioids are for different kinds of pain, including long-term treatment for chronic pain. We need to know how opioids compare in effectiveness and side effects with acetaminophen (which can cause liver failure) and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (which can cause gastrointestinal bleeding). We need to know how the death rate in the opioid epidemic compares with the rate of use. We know the death rate is soaring, but does that mean the rate of use is, too, or is it simply a result of the lethality of the drug mixtures obtained on the street? We need to know how much diversion there is now from legitimate treatment to abuse. That includes diversion of methadone and buprenorphine, which are also opioids and can be sold on the street or added to the user’s illicit intake. According to Macy, “Buprenorphine is the third-most-diverted opioid in the country, after oxycodone and hydrocodone.”

We need to know how many addicts want to quit, since most don’t seek treatment. Why don’t they? And finally, we need to know the best approach to treatment. There is concern, for example, that detox might be dangerous, because the first dose after a relapse can be deadly if the user is no longer tolerant to the drug’s effects. Is providing methadone or buprenorphine indefinitely, even for life, the best treatment among bad choices? There is plenty of speculation about all of these questions, and suggestive findings about some of them, but little solid evidence.

We also need to remember an essential and crucial fact: opioids do have a legitimate purpose, and it’s an enormously important one. They treat severe pain, often when no other treatment is effective. Patients suffering from cancer are sometimes completely dependent on opioids for relief, as are some patients with other forms of severe pain. As the authors of the books acknowledge, pain was systematically undertreated throughout most of the twentieth century. After centuries of free and easy use of opioids, there was a sudden reaction in the United States at the start of the twentieth century, which had much to do with anti-immigrant sentiment, particularly animus toward Chinese immigrants who were widely assumed to be opium addicts. (It also paralleled the growing reaction against alcohol that resulted in Prohibition.) The 1914 Harrison Narcotics Tax Act imposed strict regulations on the use of opioids; they had to be prescribed by physicians, and then only for patients not already taking them. Prohibition lasted for only thirteen years, but the dread of opioid addiction stayed with us until the 1980s and caused cruel suffering for generations of patients.

Even in hospitals where cancer patients lay dying in agony, opioids were administered reluctantly, in small doses, and at infrequent intervals. When I was in training in a teaching hospital in the 1960s, there was an awful ritual to it. The drugs were administered according to a pro re nata (prn) regimen (ostensibly “as needed”) that required the patient to wait out a four-hour interval, no matter how severe the pain, and then request the next dose. Those who badly wanted the drug had to keep track of the time and have the strength and endurance to summon a nurse if one was nearby. Patients were sometimes inhibited in asking for the next dose by a desire to please the medical staff and not be a nuisance, or by their own belief that taking morphine was somehow wrong or reflected weakness. The extent to which nurses and physicians shared the common fears of addiction influenced their readiness to respond. Desperate patients would count the minutes toward the end of the interval, hoping they could flag down a nurse. Many doctors and nurses interpreted the anxiety and clock-watching as a sign of growing addiction, not inadequate pain relief. These patients were labeled “drug-seeking” and often punished for it by being denied the very help they needed.

During the 1980s there was a welcome change in that attitude, partly due to the hospice movement that had begun in the United Kingdom. The prn system became more flexible, or was eliminated altogether. There was a realization that because pain is entirely subjective, there is no way to measure or verify it, and even patients with the same condition could differ in their experience of pain. Instead of having to flag down nurses, patients were asked at shorter intervals whether they needed pain relief, and how much. In 2001 the Joint Commission on the Accreditation of Healthcare Organizations proclaimed pain the fifth vital sign, to be assessed in every patient, along with heart rate, respiratory rate, temperature, and blood pressure. Although the motivation for this move was laudable, it presented problems, since, unlike the other four vital signs, pain can’t be objectively quantified.

The authors of the books under review recognize the history of inadequate treatment of pain throughout most of the twentieth century, but they don’t give it its due. They concentrate instead on the reaction of the 1980s, which they consider excessive and an underlying cause of the opioid epidemic. In 1982 I wrote an editorial in The New England Journal of Medicine, which began, “Few things a doctor does are more important than relieving pain.” I still believe that. I ended with these words: “Pain is soul-destroying. No patients should have to endure intense pain unnecessarily. The quality of mercy is essential to the practice of medicine; here, of all places, it should not be strained.”

The opioid epidemic, while horrifying, is still outweighed by alcohol deaths, which are also increasing, according to the Centers for Disease Control. Hampton writes, “If my first drug of choice came with a prescription, the second one, alcohol, was culturally embedded and used to celebrate at every turn of events.” In 2016, when there were 64,000 deaths in the US from the drug epidemic, there were 90,000 from alcohol (including accidents and homicides caused by inebriated people, as well as direct effects, mainly cirrhosis of the liver). Cigarette smoking is estimated to cause 480,000 deaths a year. I do not intend to minimize the opioid epidemic. Far from it. What I want to underscore is the differences in these three epidemics. Alcohol and cigarettes have no medical or practical uses of any kind. Yet we permit their use if regulated. In contrast, opioids do have medical uses, and they are important.

The opioid epidemic is usually seen as a supply problem. If we can interdict the supply of prescription opioids, the thinking goes, we can stanch the epidemic. But that is unlikely to work for two reasons. First, as I pointed out, this is no longer mainly an epidemic of prescription drugs but of street drugs. And second, it creates an onerous obstacle for doctors and outpatients who require pain treatment. More and more, they have to satisfy regulations expressly designed to restrict access to prescription opioids. Some make sense. For example, it’s reasonable to monitor opioid prescriptions to detect pill mills. It’s also reasonable to flag users who “doctor-shop,” that is, see several doctors at once to try to get multiple doses of opioids.

But other requirements are meant simply to inconvenience both doctors and patients until they give up. For example, in Massachusetts doctors must limit their first-time opioid prescriptions to seven days. That can be more than an inconvenience for ill patients in pain. Macy quotes a letter from a friend with severe back pain from scoliosis. “‘My life is not less important than that of an addict,’ my friend wrote,…explaining that her new practitioner requires her to submit to pill counts, lower-dose prescriptions, and more frequent visits for refills, which increase her out-of-pocket expense.” Even more serious is a new shortage of opioids for injection in cancer centers.

For physicians, who are already weighed down by innumerable bureaucratic requirements, these restrictions present one more hoop to jump through, and many simply won’t do it. Instead, they’ll send the patient away with some Advil and hope it does the trick, even though they know it probably won’t. The regulations are having their intended effect. In Massachusetts, opioid prescribing has decreased by 30 percent. Meanwhile, the epidemic of street drugs continues apace. McGreal raises the possibility that reducing access to prescription opioids might feed the demand for heroin. Macy quotes an addiction specialist who laments that “our wacky culture can’t seem to do anything in a nuanced way.”

I believe the modern opioid epidemic is now more a demand problem than a supply problem. Three years ago, the Princeton economists Anne Case and Angus Deaton published an explosive paper about the surprising rise in mortality, starting at the turn of this century, among middle-aged white non-Hispanic men and women. The increase was greater in women than in men. They found three main causes: drug and alcohol overdoses, suicide, and alcohol-associated liver disease. They later called these “deaths of despair,” because they were most common among workers in tenuous jobs, with only a high school education or less, who were struggling to stay afloat in isolated regions of the country. Dragged down by these deaths, in the past three years overall life expectancy in the United States has started to drop.

It’s not hard to see reasons for the despair. Most working-class Americans have not benefited from our booming economy, the fruits of which have gone almost entirely to the richest 10 percent. For the bottom half of the population, income has scarcely budged since the 1970s, while expenses for necessities like housing, health care, education, and child care have skyrocketed. In Appalachia, where the opioid epidemic first took hold, many coal miners were unemployed and would probably remain so. People expected they wouldn’t live as well as their parents had, and had little hope for their children. It is true that African-Americans still have higher overall mortality rates than whites, but that gap is closing rapidly for people under the age of sixty-five, particularly for women. By 2027, white women will have higher mortality rates than African-American women. Mortality for African-American men is falling even faster than for African-American women; it is projected to be equal to that of white men by 2030. But the epidemic has extended to all parts of the country and to all ethnic groups, so it’s unclear how the effects will be distributed in the future.

By the middle of this decade, the grotesque inequality in this country began to get the attention it deserves. And the growing awareness of that inequality fed the populist passion that, when twisted and distorted, produced the election of Donald J. Trump. It’s probably not coincidental, then, that the opioid epidemic got its second wind at about that time. It certainly marks the time when the opioids of choice changed from prescription drugs to the witches’ brew of street drugs. Did the epidemic explode because people were becoming aware that the American Dream was no longer theirs to dream?

As long as this country tolerates the chasm between the rich and the poor, and fails even to pretend to provide for the most basic needs of our citizens, such as health care, education, and child care, some people will want to use drugs to escape. This increasingly seems to me not a legal or medical problem, nor even a public health problem. It’s a political problem. We need a government dedicated to policies that will narrow the gap between the rich and the poor and ensure basic services for everyone. To end the epidemic of deaths of despair, we need to target the sources of the despair.

1

The books by Macy and McGreal provide full accounts of the development and promotion of OxyContin, the onset of the epidemic in Appalachia, the failure of Purdue to respond, and the company’s eventual admission to fraudulent marketing. ↩

Rosewood