The Nocebo Effect, Placebo’s Evil Twin

Because of overscreening and the diagnosis of contrived or harmless ills, the so-called nocebo effect is wreaking havoc on otherwise healthy people.

It's all in your head
It's all in your head
Nic Ulmi

GENEVA â€" Like heroes in television series, the placebo effect has an evil twin: "nocebo." A placebo, of course, is "a substance having no pharmacological effect but given merely to satisfy a patient who supposes it to be a medicine." The idea is that the power of suggestion can sometimes heal in and of itself. Nocebo works the same way but with the opposite effect. Tell me I swallowed rotten food, for example, and my guts will writhe in pain.

But why? The brain's job is to manage the functions of the body, so it's not surprising that the information it absorbs affects the process. In The Nocebo Effect, American essayist Stewart Justman writes about the devastating effects of nocebo in diagnoses as varying as anorexia, chronic fatigue syndrome, depression, dissociative identity disorder, hyperactivity, and cancers of the breast and prostate.

Sometimes, symptoms are a direct result of the imagination, prompted by pharmaceutical propaganda or awareness campaigns. "Once they are put on the market, ideas on such and such illness are capable of triggering the illness itself," Jutsman writes. A diagnosis can deploy its noxious potential by "spreading suggestions in the mind of the patient."

The question of how commonly this happens apparently has been studied very little, partly because it's ethically dicey to conduct experiments that could potentially create medical problems for subjects. But there is some information to be gleaned about this "evil twin" from studies on the placebo effect. A particularly troubling one, published in the International Journal of Clinical Practice in 1998, involved a group of patients suffering from rheumatoid arthritis. Those who received a briefing about the illness felt worse than those who were simply treated without being told anything.

In other cases, studies indicate that large-scale screening often does more harm than good, leading to treatments that turn out to be more detrimental â€" or even more deadly â€" than the illnesses meant to be treated. The medical field itself warns of an "overdiagnosis" phenomenon. In fact, the subtitle of Justman's book is, Overdiagnosis and Its Costs.

Morphine and neurasthenia

The causal link of various ills sometimes seems obvious. "It appears that, as long as the residents of Hong Kong were not aware of the existence of anorexia in the West, this disorder did not appear among them, but once the notion reached the press and the public awareness in the 1990s, the phenomenon soared," Justman writes. It's as if "the affected people unconsciously formed their symptoms according to the model provided by the media."

It's similarly true with neurasthenia â€" basically, nervous exhaustion â€" a syndrome that was in vogue during the Belle Epoque. It "blossomed with the wealthy classes, until its disappearance in the early 20th century," Justman writes. Identified by American neurologist George Beard in 1869, the disorder was defined as a "heterogeneous symptom cluster," in which "the core features were held to be excessive physical and mental fatigue and muscle weakness." But the possible manifestations featured a list of 70 entries. "The brief and spectacular existence of neurasthenia proves how a designation has the power to organize and summon up symptoms," Justman writes.

In this way, some illnesses seem to reach people through social-cultural contagion. Placebo and nocebo demonstrate that the medical act, far from being a simple physical interaction, is really a full-fledged "social procedure." Justman notes that experiments even show that even a drug as powerful as morphine has a stronger effect when it is openly administrated, as part of a medical ritual, than when it is given to the patient without him knowing. A striking example of a syndrome being born via the therapeutic ceremony is so-called "multiple personality disorder," which most often appears from the moment the nursing staff asks the patient to name his alter egos.

Sleep and disarray

Are we talking about imaginary diseases, illnesses that were socially manufactured from nothing? In the case of depression, Justman suggests that conditions inherent to the normality of existence often wind up being medicalized â€" in other words, transformed into illnesses. It's the "common and temporary disarray, produced by life itself, which would resolve itself spontaneously if we did nothing," Justman writes. He calls them the "permanent features of the human condition," or at least "difficulties that are connected to the very nature of civilization."

The DSM-5, the latest edition of the American and international catalog on psychological illnesses and their symptoms, "unwillingly includes the argument according to which what we call depression can in fact be a justified response to life itself."

We could, of course, turn the question around: Should we accept ordinary disarray as an inevitable component of normality, or can we aspire to get rid of it? Like sociologists Allan V. Horwitz and Jerome C. Wakefield Stewart, authors of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder (2007), Justman defends the existence of melancholy in the human experience. Others nurture the utopian dream of eradicating all sadness.

"Ironically, one of the effects of overdiagnosing depression is that the fashionable antidepressants disrupt sleep," Justman writes. But "one of the most important healing factors in our lives lies in our ability to fall every night into a repairing sleep."

Consciousness is overrated

Is there a balance, a "good" medical limit we shouldn't exceed? The question is particularly pertinent in the cases of breast and prostate cancers. Mass screening for both men and women has led to the detection and treatment of "dormant" cancers that are potentially harmless. According to a 2013 study published in the British Medical Journal, for every death prevented via mammography, there are one to three additional deaths linked to treatments given to women screened for harmless cancers.

And according to a European study conducted between 2009 and 2012, screening reduces the mortality rate of prostate cancer, but for every man saved, 33 others become impotent or incontinent because of unnecessary intervention.

Several researchers suggest eliminating screenings. Justman goes further in recommending that we stop awareness campaigns, the major sources of nocebo effect. In his rush, he perhaps throws a few babies out with the bath water (especially in the field of psychological trauma).

But his paradoxical praise of unconsciousness will nevertheless be remembered: We live in the grip of a "cult of conscientization," but "consciousness is overrated." Our brains silently work on managing unconscious processes, and it's probably best not to disrupt it too much.

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In Argentina, A Visit To World's Highest Solar Energy Park

With loans and solar panels from China, the massive solar park has been opened a year and is already powering the surrounding areas. Now the Chinese supplier is pushing for an expansion.

960,000 solar panels have been installed at the Cauchari park

Silvia Naishtat

CAUCHARI — Driving across the border with Chile into the northwest Argentine department of Susques, you may spot what looks like a black mass in the distance. Arriving at a 4,000-meter altitude in the municipality of Cauchari, what comes into view instead is an assembly of 960,000 solar panels. It is the world's highest photovoltaic (PV) park, which is also the second biggest solar energy facility in Latin America, after Mexico's Aguascalientes plant.

Spread over 800 hectares in an arid landscape, the Cauchari park has been operating for a year, and has so far turned sunshine into 315 megawatts of electricity, enough to power the local provincial capital of Jujuy through the national grid.

It has also generated some $50 million for the province, which Governor Gerardo Morales has allocated to building 239 schools.

Abundant sunshine, low temperatures

The physicist Martín Albornoz says Cauchari, which means "link to the sun," is exposed to the best solar radiation anywhere. The area has 260 days of sunshine, with no smog and relatively low temperatures, which helps keep the panels in optimal conditions.

Its construction began with a loan of more than $331 million from China's Eximbank, which allowed the purchase of panels made in Shanghai. They arrived in Buenos Aires in 2,500 containers and were later trucked a considerable distance to the site in Cauchari . This was a titanic project that required 1,200 builders and 10-ton cranes, but will save some 780,000 tons of CO2 emissions a year.

It is now run by 60 technicians. Its panels, with a 25-year guarantee, follow the sun's path and are cleaned twice a year. The plant is expected to have a service life of 40 years. Its choice of location was based on power lines traced in the 1990s to export power to Chile, now fed by the park.

Chinese engineers working in an office at the Cauchari park


Chinese want to expand

The plant belongs to the public-sector firm Jemse (Jujuy Energía y Minería), created in 2011 by the province's then governor Eduardo Fellner. Jemse's president, Felipe Albornoz, says that once Chinese credits are repaid in 20 years, Cauchari will earn the province $600 million.

The Argentine Energy ministry must now decide on the park's proposed expansion. The Chinese would pay in $200 million, which will help install 400,000 additional panels and generate enough power for the entire province of Jujuy.

The park's CEO, Guillermo Hoerth, observes that state policies are key to turning Jujuy into a green province. "We must change the production model. The world is rapidly cutting fossil fuel emissions. This is a great opportunity," Hoerth says.

The province's energy chief, Mario Pizarro, says in turn that Susques and three other provincial districts are already self-sufficient with clean energy, and three other districts would soon follow.

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