15 ways to get back to sleep when you wake at 3am

It is normal and natural to wake in the early hours – but it can feel disastrous. Follow these simple steps to help you drift off writes Emine Saner in The Guardian


Time moves differently in the middle of the night. Hours can drag one moment, then race by the next, catapulting you between chronic boredom and violent panic that morning is clawing at the curtains. Yet, though it may not feel like it in the moment, it is entirely normal to wake up. “The natural human sleep pattern is not a consolidated eight hours,” says Russell Foster, professor of circadian neuroscience at Oxford University, and author of Life Time: The new science of the body clock, and how it can revolutionise your sleep and health. Still, it’s not pleasant to lie awake in the early hours worrying about everything from climate catastrophe to whether that was an inappropriate joke to put on that group chat, or whether you’ll ever sleep again – especially if it happens regularly. Here is some expert advice on how to stay calm plus what to do so that – hopefully – sleep will follow.
Crack a smile

It’s easy to catastrophise in the middle of the night, says Alanna Hare, consultant in sleep medicine at the Royal Brompton and Harefield hospitals. “‘I’m going to perform really badly at work tomorrow, then I’ll lose my job, then my partner will leave me’ – it can escalate quite quickly. Try to move away from this idea that being awake in the night is a dreadful thing that’s going to lead to terrible consequences.” Camilla Stoddart, a sleep coach, advises smiling, which may stop or slow the spiralling. “Smiling releases serotonin and dopamine, and triggers the parasympathetic nervous system, which is the opposite of the system that controls your fight and flight response. If you can disengage from the struggle, you’re more likely to get back to sleep.”

Tackle stress

When we can’t get back to sleep, it’s usually because our minds are busy or we’re worried about something (though to rule out a sleep problem such as restless legs or sleep apnoea, it’s best to see your GP). “Most of us don’t have a sleep problem, we have an anxiety and stress problem,” says Foster. In our waking life, Foster advises “finding techniques that work for you, whether it’s mindfulness, yoga, whatever. It’s important to de-stress.” Talking to a therapist and tackling unresolved problems might be helpful; some simple meditation or gratitude practice might be enough, says Nerina Ramlakhan, physiologist and author of Fast Asleep, Wide Awake. “Don’t push problems away, don’t deny that you’re not feeling great about your relationship or your job or whatever it is that’s bothering you. Those emotions, if they’re not expressed, have a tendency to pop up in sleep, either in nightmares, or in difficulty getting to sleep or staying asleep.”

Consider your life stage

We tend to wake up more as we age, says Foster, “because the robustness of the circadian drive for sleep reduces – we’re probably not going to get the sleep that we got when we were younger”. Hormones underpinning urine production also change as we age, which is one reason why older people often need to get up to go to the loo at night. Menopause affects women’s sleep in several ways, including body temperature – if you sleep with a partner, consider getting separate duvets to help with this – and changing hormone levels. “Oestrogen can promote sleep, and so can progesterone, by making you more relaxed and less anxious,” says Foster. “Those changing hormones can disrupt those patterns, and it’s the same with the menstrual cycle.”

Adopt healthy habits

 

The way we sleep is a reflection of the way we live, says Ramlakhan, “so if you want to sleep better, you have to live better”. You know what you need to do: exercise, nutrition, stress reduction. Ramlakhan has her list of “five non-negotiables, which can help you sleep more deeply. Eating breakfast within half an hour of rising [to stabilise your blood sugar levels], not using caffeine as a substitute for food, making sure you’re well hydrated, getting to bed earlier – about 9.30-10pm – and cultivating a healthier relationship with technology.” She isn’t a particular fan of the label “sleep hygiene” because it can feel like a chore to run through a bedtime routine which might include putting devices away, dimming the lights and having a warm bath. “Those things might help,” says Ramlakhan, “but actually, it’s the way we live from the moment we wake up until the time we’re getting into bed that is going to have an impact on how you sleep.”

Do some journalling before bed

Getting worries or busy thoughts out of your head, even the next day’s to-do list, before bed might help, says Stoddart. If the worries are bigger – such as the threat of nuclear war – “you just acknowledge that you can’t really do anything about that, especially not in the middle of the night”. Hare recommends “constructive worry” – you can find examples online to print and follow. “It is a way of organising your thoughts by writing them down in a particular fashion, so that when you wake in the night, you’re less likely to start list-making or worrying.”

Avoid medication

Foster says sleeping pills can help you sleep, “but they can make it more difficult to wake up and leave you feeling groggy in the morning, and may also increase daytime sleepiness later”. Newer, shorter-acting sleeping pills may work for night waking, “but it’s advisable to make sure you have at least four hours before you need to get up”. Taking melatonin – the tablet form of the hormone that increases at night to make you feel sleepy – will not prevent you from waking, says Foster, but similarly to shorter-acting sedatives, it could help to take it in the night when you wake up. Like sleeping pills, it should be prescribed by your GP, he stresses. Overall, medication should not be used long-term and is “not the answer to waking at night. In almost all cases, non-pharmacological approaches will work.”

Don’t ‘try’ to get back to sleep

“The main mistake people make when they’re struggling to get back to sleep is they lie in bed, often very still because they’re trying not to wake up their partner – but sleep doesn’t respond well to effort,” says Hare.

Don’t check the clock

 

When patients tell her they wake at 2.05am every morning, “therein lies the problem,” says Ramlakhan. Looking at the time “is one of the biggest disruptors to being able to get back to sleep”. It creates anxiety, and worse, says Ramlakhan, you’ll probably check the time on your phone and get sucked into doing other things on it. “Use an old-fashioned alarm clock and turn it away from you,” she says. “It’s not important to know the time. Learn to let go.”

Hare adds that once people start noticing they wake at a similar time each night, perhaps as a result of natural sleep patterns, they “start to develop rules: ‘if I’m awake at this point, I won’t go back to sleep; once I’ve woken at 3am, that’s it for the night’. They’re arbitrary and not true, but they become self-fulfilling prophecies. So try not to look at the clock.”

Don’t look at your phone

We all know we shouldn’t be on our phones in the night but the lure is so great that Hare reports people even do it in her sleep laboratories. Some researchers think the detrimental effect of blue light on sleep from devices has been exaggerated, but with your phone in your hand it’s too easy to check work emails or get sucked into social media.
Don’t concentrate on trying to sleep, but concentrate on reducing hyper-arousal

… except to quickly put a mindfulness app on

“As long as you’re popping the app or podcast on, and not looking at the screen after that,” says Hare. “What you don’t want is having bright light in your face for 10 minutes while you scroll through, trying to find something.”

Mindfulness apps can be useful, says Ramlakhan, who has also recorded some of her own meditations including body scans (you can also find free examples on YouTube). “One is a body scan where you start with one foot and you say the words ‘I love my left big toe’ and you work your way up your body.” If you find yourself worrying about something else, or becoming distracted, start again. Another way of quieting a busy mind, says Hare, is using counting techniques. “I often use a very simple one, which is trying to count back from 1,000 in sevens, and if you get stuck, you have to go back to the beginning again.”

… or listen to a story

Foster finds the short plays on BBC Radio 4 Extra relaxing. Stoddart loves audiobooks and podcasts, rather than sitting up to read with the light on, “because there’s no decision to be made as to when you turn it off”. Something intentionally boring may not work for you. “A lot of my clients will listen to the same book over and over, or listen to boring stories designed to send you to sleep, and they don’t really work because you’re not engaged, so you can continue worrying.” By finding something interesting, she has found, you’re less likely to focus on negative thoughts and won’t feel like you’re actively trying to get to sleep, “and sleep is more likely to come”.

Slow your breathing

“Don’t concentrate on trying to sleep, but concentrate on reducing hyper-arousal,” says Stoddart. “I get people to do slow breathing, or some sort of yoga or relaxation before they go to bed, but only with the expectation that it will calm the system down, rather than guarantee sleep.” In the middle of the night, when you start to get anxious, it can take time for stress hormones such as cortisol to pass. “And usually in that time, you’ve found more reasons to keep it going, so slow breathing can speed up that timeframe and keep you calmer. But it is difficult, which is why I suggest reading a book or watching TV – something that makes it easier to be distracted, calmer and will reinforce the message that ‘it’s not so bad to be awake in the middle of the night’, so that you don’t fuel the fire with more anxiety.”

Get up for a while

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It feels counterproductive, says Hare, because it’s easy to tell ourselves that if we just lie still for a bit longer, we’ll go to sleep. “If it does feel like you’re about to fall back to sleep, or you’re relaxed, and not worried or anxious, it’s OK to stay where you are. But if you’re starting to think ‘this is terrible’, or that you’re actively trying to sleep, the best thing to do is to get up.” By staying in bed, awake, “you start to develop a conditioned response – that ‘bed’ is about anxiety, frustration and being awake, when what we want is for ‘bed’ to be associated with sleep and relaxation”. Get up for half an hour or so (don’t look at the clock, or time it) and do something enjoyable but relaxing – no eating “because your body is not designed to be digesting in the middle of the night”, and no strenuous exercise or work. “The idea is to break that cycle of negative thinking. Read, watch a bit of TV, as long as you’re not going to get absorbed in some terrifying film, do a hobby, anything you like, as long as you’re not on your device.” She sometimes has to advise people not to watch pornography, because some can get too engrossed in it (but masturbation can be useful as a relaxation aid).

Go back to bed, and if the same thing happens, get up again. “Trust that your sleep biology is very powerful. If you keep taking the wakefulness away from the bed, eventually you will be able to fall back asleep. It might not be within a timeframe that you’re happy with, but the awakenings will get shorter and less frequent.”

Try to stay awake

It’s what’s known as “paradoxical intention” says Hare. Lie down and keep your eyes open. “Sometimes trying to stay awake can bring about sleep – it’s very hard to keep your eyes open, even when you feel you’re wide awake.” It’s not something Hare recommends as a first strategy, but she has recommended it to people who claim they endure being awake for several hours in bed. “It’s unlikely they’re fully awake. Why don’t you try to stay awake for that whole period and see what happens with your eyes open? The whole point is that instead of trying to sleep, it’s just adjusting that attention.”

Don’t give up and get up

With less than an hour before your alarm goes off, you might think you may as well get up, but Foster advises against this. If you can stay relaxed, “lie back and wait for the alarm clock to go off. Chances are, you will fall back to sleep and just that 15 or 20 minutes can be helpful in getting the sleep that you need. Even short sleep can be somewhat beneficial.”Sleep, 

AI has hacked the operating system of human civilisation

Yuval Noah Hariri in The Economist

Fears of artificial intelligence (ai) have haunted humanity since the very beginning of the computer age. Hitherto these fears focused on machines using physical means to kill, enslave or replace people. But over the past couple of years new ai tools have emerged that threaten the survival of human civilisation from an unexpected direction. ai has gained some remarkable abilities to manipulate and generate language, whether with words, sounds or images. ai has thereby hacked the operating system of our civilisation.

Language is the stuff almost all human culture is made of. Human rights, for example, aren’t inscribed in our dna. Rather, they are cultural artefacts we created by telling stories and writing laws. Gods aren’t physical realities. Rather, they are cultural artefacts we created by inventing myths and writing scriptures.

Money, too, is a cultural artefact. Banknotes are just colourful pieces of paper, and at present more than 90% of money is not even banknotes—it is just digital information in computers. What gives money value is the stories that bankers, finance ministers and cryptocurrency gurus tell us about it. Sam Bankman-Fried, Elizabeth Holmes and Bernie Madoff were not particularly good at creating real value, but they were all extremely capable storytellers.

What would happen once a non-human intelligence becomes better than the average human at telling stories, composing melodies, drawing images, and writing laws and scriptures? When people think about Chatgpt and other new ai tools, they are often drawn to examples like school children using ai to write their essays. What will happen to the school system when kids do that? But this kind of question misses the big picture. Forget about school essays. Think of the next American presidential race in 2024, and try to imagine the impact of ai tools that can be made to mass-produce political content, fake-news stories and scriptures for new cults.

In recent years the qAnon cult has coalesced around anonymous online messages, known as “q drops”. Followers collected, revered and interpreted these q drops as a sacred text. While to the best of our knowledge all previous q drops were composed by humans, and bots merely helped disseminate them, in future we might see the first cults in history whose revered texts were written by a non-human intelligence. Religions throughout history have claimed a non-human source for their holy books. Soon that might be a reality.

On a more prosaic level, we might soon find ourselves conducting lengthy online discussions about abortion, climate change or the Russian invasion of Ukraine with entities that we think are humans—but are actually ai. The catch is that it is utterly pointless for us to spend time trying to change the declared opinions of an ai bot, while the ai could hone its messages so precisely that it stands a good chance of influencing us.

Through its mastery of language, ai could even form intimate relationships with people, and use the power of intimacy to change our opinions and worldviews. Although there is no indication that ai has any consciousness or feelings of its own, to foster fake intimacy with humans it is enough if the ai can make them feel emotionally attached to it. In June 2022 Blake Lemoine, a Google engineer, publicly claimed that the ai chatbot Lamda, on which he was working, had become sentient. The controversial claim cost him his job. The most interesting thing about this episode was not Mr Lemoine’s claim, which was probably false. Rather, it was his willingness to risk his lucrative job for the sake of the ai chatbot. If ai can influence people to risk their jobs for it, what else could it induce them to do?

In a political battle for minds and hearts, intimacy is the most efficient weapon, and ai has just gained the ability to mass-produce intimate relationships with millions of people. We all know that over the past decade social media has become a battleground for controlling human attention. With the new generation of ai, the battlefront is shifting from attention to intimacy. What will happen to human society and human psychology as ai fights ai in a battle to fake intimate relationships with us, which can then be used to convince us to vote for particular politicians or buy particular products?

Even without creating “fake intimacy”, the new ai tools would have an immense influence on our opinions and worldviews. People may come to use a single ai adviser as a one-stop, all-knowing oracle. No wonder Google is terrified. Why bother searching, when I can just ask the oracle? The news and advertising industries should also be terrified. Why read a newspaper when I can just ask the oracle to tell me the latest news? And what’s the purpose of advertisements, when I can just ask the oracle to tell me what to buy?

And even these scenarios don’t really capture the big picture. What we are talking about is potentially the end of human history. Not the end of history, just the end of its human-dominated part. History is the interaction between biology and culture; between our biological needs and desires for things like food and sex, and our cultural creations like religions and laws. History is the process through which laws and religions shape food and sex.

What will happen to the course of history when ai takes over culture, and begins producing stories, melodies, laws and religions? Previous tools like the printing press and radio helped spread the cultural ideas of humans, but they never created new cultural ideas of their own. ai is fundamentally different. ai can create completely new ideas, completely new culture.

At first, ai will probably imitate the human prototypes that it was trained on in its infancy. But with each passing year, ai culture will boldly go where no human has gone before. For millennia human beings have lived inside the dreams of other humans. In the coming decades we might find ourselves living inside the dreams of an alien intelligence.

Fear of ai has haunted humankind for only the past few decades. But for thousands of years humans have been haunted by a much deeper fear. We have always appreciated the power of stories and images to manipulate our minds and to create illusions. Consequently, since ancient times humans have feared being trapped in a world of illusions.

In the 17th century René Descartes feared that perhaps a malicious demon was trapping him inside a world of illusions, creating everything he saw and heard. In ancient Greece Plato told the famous Allegory of the Cave, in which a group of people are chained inside a cave all their lives, facing a blank wall. A screen. On that screen they see projected various shadows. The prisoners mistake the illusions they see there for reality.

In ancient India Buddhist and Hindu sages pointed out that all humans lived trapped inside Maya—the world of illusions. What we normally take to be reality is often just fictions in our own minds. People may wage entire wars, killing others and willing to be killed themselves, because of their belief in this or that illusion.

The AI revolution is bringing us face to face with Descartes’ demon, with Plato’s cave, with the Maya. If we are not careful, we might be trapped behind a curtain of illusions, which we could not tear away—or even realise is there.

Of course, the new power of ai could be used for good purposes as well. I won’t dwell on this, because the people who develop ai talk about it enough. The job of historians and philosophers like myself is to point out the dangers. But certainly, ai can help us in countless ways, from finding new cures for cancer to discovering solutions to the ecological crisis. The question we face is how to make sure the new ai tools are used for good rather than for ill. To do that, we first need to appreciate the true capabilities of these tools.

Since 1945 we have known that nuclear technology could generate cheap energy for the benefit of humans—but could also physically destroy human civilisation. We therefore reshaped the entire international order to protect humanity, and to make sure nuclear technology was used primarily for good. We now have to grapple with a new weapon of mass destruction that can annihilate our mental and social world.

We can still regulate the new ai tools, but we must act quickly. Whereas nukes cannot invent more powerful nukes, ai can make exponentially more powerful ai. The first crucial step is to demand rigorous safety checks before powerful ai tools are released into the public domain. Just as a pharmaceutical company cannot release new drugs before testing both their short-term and long-term side-effects, so tech companies shouldn’t release new ai tools before they are made safe. We need an equivalent of the Food and Drug Administration for new technology, and we need it yesterday.

Won’t slowing down public deployments of ai cause democracies to lag behind more ruthless authoritarian regimes? Just the opposite. Unregulated ai deployments would create social chaos, which would benefit autocrats and ruin democracies. Democracy is a conversation, and conversations rely on language. When ai hacks language, it could destroy our ability to have meaningful conversations, thereby destroying democracy.

We have just encountered an alien intelligence, here on Earth. We don’t know much about it, except that it might destroy our civilisation. We should put a halt to the irresponsible deployment of ai tools in the public sphere, and regulate ai before it regulates us. And the first regulation I would suggest is to make it mandatory for ai to disclose that it is an ai. If I am having a conversation with someone, and I cannot tell whether it is a human or an ai—that’s the end of democracy.

This text has been generated by a human.

Or has it?

Halal economy. How it works? What effects on society? Who gets its benefits?

 

The paradox that leads professionals into temptation

 Andrew Hill in The FT

Before her first ward-round as a medical student, Sunita Sah watched as the consultant leading the group stuffed his pockets with branded pens and notepads from a hospital cart piled with drug company freebies. 

Noting her astonishment, he remarked, “these are the only perks of the job”, and continued to stock up. “I couldn’t help but think: ‘What’s the end-effect of this?’” Sah told me. 

She found part of the answer to that question when she moved from medicine into management consulting and started analysing how every interaction between healthcare companies and doctors had an impact on their prescribing habits. 

Now a professor at Cornell University and an honorary fellow at Cambridge’s Judge Business School, Sah has filled in more gaps with a new study that sheds light on the dark side of professionalism and how to avoid it. 

Her findings are stark and surprising. The greater a manager’s sense of professionalism, the more likely he or she is to accept a gift or bribe. Worse, high-minded professionals may be more susceptible to unconscious bias towards gift-givers, precisely because they are convinced they think they know how to ignore their blandishments. 

“I NEVER turn down something for free that I know isn’t going to kill me!” retorted one manager in response to Sah’s survey. “A free lunch from someone? Go for it! If the guy is fool enough to think his free lunch/dinner/use of cabin, etc, is going to influence me, he doesn’t know me at all! People don’t influence me beyond what I, and I alone, allow!” 

In the study for the Academy of Management Perspectives, Sah equates this “professionalism paradox” to the Dunning-Kruger effect, according to which poor performers lack even the ability to recognise their own hopelessness. 

Sah’s study is based on surveys of managers, but some of the pernicious real-world effects of her paradox are clear. In the extreme case of the opioid epidemic, books such as Empire of Pain and Dopesick (now also a television series) have chronicled the way respected physicians were dragged into the overprescription of painkillers after receiving free gifts and conference invitations from manufacturer Purdue Pharma. 

Yet their ability to self-regulate against conflicts of interest is still many professionals’ first line of defence when watchdogs and legislators start threatening to curb their autonomy with new rules. 

One problem is that we are all professionals now. The term used to be almost the exclusive domain of lawyers, doctors, teachers, accountants, and others who had laboriously acquired specialist knowledge, shown integrity, and deserved an elevated status. Now the same status is loosely claimed by everyone from salespeople to, yes, journalists. The currency has been debased. 

In law, behaving professionally and ethically is “part of your training, it’s part of your identity, it’s what makes you tick — which isn’t necessarily true elsewhere”, David Morley, former senior partner at Allen & Overy, says. But the head of a professional services firm adds that professionalism “can’t be an excuse or a cover story” for a lack of underlying principles. 

These senior leaders are describing the difference between what Sah calls “deep” and “shallow” professionalism. 

Deep professionals should recognise the risk of undue influence and avoid exposing themselves to it in the first place. Her parallel is Odysseus plugging his ears with wax to avoid falling for the sirens’ song, or, more prosaically, managers who decline all gifts, rather than relying on a corporate threshold to protect them. It is “easier for individuals to rationalise and morally disengage the acceptance of [small] gifts”, Sah writes, or even to stop noticing them altogether. 

Deep professionals should embrace continued ethical training, to help embed principles, and embrace an understanding that they may be prone to bribes and influence-seeking. They should also continue to practise their values, just as a concert pianist goes on rehearsing scales. 

Professionalism “isn’t an individual characteristic, or a feeling”, says Sah. Instead, she would like to redefine it as “repeated behavioural practices that demonstrate a deep understanding of the concept”, backed by appropriate rules and codes. In that form, anyone can aspire to deep professionalism. 

“The law as a profession doesn’t give you some status or standing: you have to earn that,” the senior partner of another law firm told me. “We shy away from [the attitude] ‘It’s OK, we’re professionals’.” In fact, professionals who catch themselves saying or thinking anything similar should be on their guard. They may be in the ethical shallows and about to run aground.  

Mixopathy - Unscientific Society

 

Any Covid-19 vaccine must be treated as a global public good

David Pilling in The Financial Times

Imagine if, in a year’s time, 300m doses of a safe and effective Covid-19 vaccine have been manufactured in Donald Trump’s America, Xi Jinping’s China or Boris Johnson’s Britain. Who is going to get them? What are the chances that a nurse in India, or a doctor in Brazil, let alone a bus driver in Nigeria or a diabetic in Tanzania, will be given priority? The answer must be virtually nil. 

The ugly battle between nations over limited supplies of tests and personal protective equipment will be a sideshow compared to the scramble over a vaccine. Yet if a vaccine is to be anything like the silver bullet that some imagine, it will have to be available to the world’s poor as well as to its rich.  

Any vaccine should be deployed to create the maximum possible benefit to public health. That will mean prioritising doctors, nurses and other frontline workers, as well as those most vulnerable to the disease, no matter where they live or how much they can afford. 

It will also mean deploying initially limited quantities of vaccine in order to snuff out clusters of infection by encircling them with a “curtain” of immunised people — as was done successfully against Ebola last year in the Democratic Republic of Congo.  

With Covid-19, this looks like a pipe dream. Far from bringing the world together, the pandemic has exposed a crisis of international disunity. The World Health Organization is only as good as its member states allow. That it finds itself squeezed between China and the US when humanity is facing its worst pandemic in 100 years, is a sign of the broken international order. 

How, under such circumstances, can we possibly conceive of a vaccine policy that is global, ethical and effective? 

There are precedents. The principle of access to medicines was established with the HIV-Aids pandemic, in which life-saving medicines were originally priced far above the ability of patients in Africa and other parts of the developing world to pay. 

But in 2001, in the so-called Doha declaration on Trade-Related Aspects of Intellectual Property Rights, the World Trade Organization made it clear that governments could override patents in public health emergencies. Largely as a result, a tiered pricing system has developed in which drug companies make profits in richer countries while allowing medicines to be sold more cheaply in poorer ones. 

There are also tried-and-tested methods of funding immunisation campaigns that have saved literally millions of lives in Africa, Asia and Latin America. Gavi, the Vaccine Alliance, was founded in 2000 to address market failures. It guarantees the purchase of a set number of vaccine doses so that companies can manufacture existing, or develop new, vaccines knowing there will be a market for their product. 

Along similar lines, 40 governments this month pledged $8bn to speed up the development, production and equitable deployment of Covid-19 vaccines, as well as diagnostics and therapeutics. There are already more than 80 candidates for a Covid-19 vaccine, with some of these now in human trials.  

Then there is manufacturing. Lack of diagnostics and PPE has exposed the flaws of a just-in-time system that builds in no redundancy. Vaccine capacity must be built up now, even if that means some of it will go to waste. Nor can existing capacity simply be given over to a putative Covid-19 vaccine. That could unwittingly unleash outbreaks of previously controlled diseases, such as mumps or rubella.  

Manufacturing will also have to be dispersed geographically to ensure a vaccine can be deployed globally. 

Most vaccines are international collaborations. One against Ebola was discovered in Canada, developed in the US and manufactured in Germany. It is unlikely — and certainly undesirable — that any one country will be able to claim a Covid-19 vaccine all to itself. 

Even if a successful candidate is developed, not everyone will want to take it. 

Heidi Larson, director of the Vaccine Confidence Project, says surveys show that up to 9 per cent of British people, 18 per cent of Austrians and 20 per cent of Swiss would not agree to be immunised. Trust in vaccines is generally higher in the developing world, where the impact of infectious disease is more obvious. But here too there could be resistance, particularly if people suspect they are being used as guinea pigs. 

The vaccine against a fictional pandemic in the 2011 film Contagion is distributed through a lottery based on birth date. When a vaccine against a real-life Covid-19 is found, it must be deployed as a global public good. 

Health experts estimate it will cost some $20bn to vaccinate everyone on earth, equivalent to roughly two hours of global output. This is the best bargain in the world. Let us hope the world can recognise it.

Don't blame addicts for America's opioid crisis. Here are the real culprits

America’s opioid crisis was caused by rapacious pharma companies, politicians who colluded with them and regulators who approved one opioid pill after another

Chris McGreal in The Guardian



‘Opioids killed more than 33,000 Americans in 2015 and the toll was almost certainly higher last year.’

Of all the people Donald Trump could blame for the opioid epidemic, he chose the victims. After his own commission on the opioid crisis issued an interim report this week, Trump said young people should be told drugs are “No good, really bad for you in every way.”

The president’s exhortation to follow Nancy Reagan’s miserably inadequate advice and Just Say No to drugs is far from useful. The then first lady made not a jot of difference to the crack epidemic in the 1980s. But Trump’s characterisation of the source of the opioid crisis was more disturbing. “The best way to prevent drug addiction and overdose is to prevent people from abusing drugs in the first place,” he said.

That is straight out of the opioid manufacturers’ playbook. Facing a raft of lawsuits and a threat to their profits, pharmaceutical companies are pushing the line that the epidemic stems not from the wholesale prescribing of powerful painkillers - essentially heroin in pill form - but their misuse by some of those who then become addicted.


The amount of opioids prescribed in the US was enough for every American to be medicated 24/7 for three weeks”

In court filings, drug companies are smearing the estimated two million people hooked on their products as criminals to blame for their own addiction. Some of those in its grip break the law by buying drugs on the black market or switch to heroin. But too often that addiction began by following the advice of a doctor who, in turn, was following the drug manufacturers instructions.

Trump made no mention of this or reining in the mass prescribing underpinning the epidemic. Instead he played to the abuse narrative when he painted the crisis as a law and order issue, and criticised Barack Obama for scaling back drug prosecutions and lowering sentences.

But as the president’s own commission noted, this is not an epidemic caused by those caught in its grasp. “We have an enormous problem that is often not beginning on street corners; it is starting in doctor’s offices and hospitals in every state in our nation,” it said.

 ‘This is an almost uniquely American crisis.’

Opioids killed more than 33,000 Americans in 2015 and the toll was almost certainly higher last year. About half of deaths involved prescription painkillers. Most of those who overdose on heroin or a synthetic opiate, such as fentanyl, first become hooked on legal pills. 

This is an almost uniquely American crisis driven in good part by particular American issues from the influence of drug companies over medical policy to a “pill for every ill” culture. Trump’s commission, which called the opioid epidemic “unparalleled”, said the grim reality is that “the amount of opioids prescribed in the US was enough for every American to be medicated around the clock for three weeks”.

The US consumes more than 80% of the global opioid pill production even though it has less than 5% of the world’s population. Over the past 20 years, one federal institution after another lined up behind the drug manufacturers’ false claims of an epidemic of untreated pain in the US. They seem not to have asked why no other country was apparently suffering from such an epidemic or plying opioids to its patients at every opportunity.

With the pharmaceutical lobby’s money keeping Congress on its side, regulations were rewritten to permit physicians to prescribe as many pills as they wanted without censure. Indeed, doctors sometimes found themselves hauled before ethics boards for not supplying enough.


It’s an epidemic because we have a business model for it. Follow the money


Unlike most other countries, the US health system is run as an industry not a service. That gives considerable power to drug manufacturers, medical providers and health insurance companies to influence policy and practices.

Too often, their bottom line is profits not health. Opioid pills are far cheaper and easier than providing other forms of treatment for pain, like physical therapy or psychiatry. As Senator Joe Manchin of West Virginia told the Guardian last year: “It’s an epidemic because we have a business model for it. Follow the money. Look at the amount of pills they shipped in to certain parts of our state. It was a business model.”

But the system also gives a lot of power to patients. People coughing up large amounts of money in insurance premiums and co-pays expect results. They are, after all, more customer than patient. Doctors complain of patients who arrive expecting a pill to resolve medical conditions without taking responsibility for their own health by eating better or exercising more.

In particular, the idea has taken hold, pushed by the pharmaceutical industry, that there is a right to be pain free. Other countries pursue strategies to reduce and manage pain, not raise expectations that it can simply be made to disappear. In all of this, regulators became facilitators. The Food and Drug Administration approved one opioid pill after another.


The Food and Drug Administration approved one opioid pill after another.


As late as 2013, by which time the scale of the epidemic was clear, the FDA permitted a powerful opiate, Zohydro, onto the market over the near unanimous objection of its own review committee. It was clear from the hearing that doctors understood the dangers, but the agency appeared to have put commercial considerations first.

US states long ago woke up to the crisis as morgues filled, social services struggled to cope with children orphaned or taken into care, and the epidemic took an economic toll. Police chiefs and local politicians said it was a social crisis not a law and order problem.

Some state legislatures began to curb mass prescribing. All the while they looked to Washington for leadership. They did not get much from Obama or Congress, although legislation approving $1bn on addiction treatment did pass last year. Instead, it was up to pockets of sanity to push back.

Last year, the then director of the Centers for Disease Control, Tom Frieden, made his mark with guidelines urging doctors not to prescribe opioids as a first step for chronic or routine pain, although even that got political pushback in Congress where the power of the pharmaceutical lobby is not greatly diminished.

There are also signs of a shift in the FDA after it pressured a manufacturer into withdrawing an opioid drug, Opana, that should never have been on sale in the first place. It was initially withdrawn in the 1970s, but the FDA permitted it back on to the market in 2006 after the rules for testing drugs were changed. At the time, many accused the pharmaceutical companies of paying to have them rewritten.

Trump’s opioid commission offered hope that the epidemic would finally get the attention it needs. It made a series of sensible if limited recommendations: more mental health treatment people with a substance abuse disorder and more effective forms of rehab.

Trump finally got around to saying that the epidemic is a national emergency on Thursday after he was criticised for ignoring his own commission’s recommendation to do so. But he reinforced the idea that the victims are to blame with an offhand reference to LSD.

Real leadership is still absent – and that won’t displease the pharmaceutical companies at all.

The Rise of Open-Label Placebos

Nic Fleming in The Guardian

Linda Buonanno had suffered 15 years of intense cramps, bloating, diarrhoea and pain she describes as “worse than labour”. She was willing to try anything to get relief from her irritable bowel syndrome (IBS) and leapt at the chance to take part in a trial of an experimental new therapy. Her hope turned to disappointment, however, when the researcher handed her a bottle of capsules he described as placebos containing no active ingredients.

Nonetheless, she took the pills twice daily. Four days later, her symptoms all but vanished. “I know it sounds crazy,” says Buonanno, of Methuen, Massachusetts. “I felt fantastic. I knew they were just sugar pills, but I was able to go out dancing and see my friends again.”

Placebos have a reputation problem. It is widely believed they are only effective when those taking them are deceived into thinking they are taking real drugs. As such, prescribing dummy or fake treatments is unethical. Yet in Buonanno’s case there was no deception. And she is not alone. A review of five studies, involving 260 patients, published last month found that “open-label” placebos – those that patients know contain no active medication – can improve symptoms in a range of conditions. This growing body of evidence raises a number of important questions. How do open-label placebos work? Which conditions do they work for? And should doctors prescribe them?

Dr Jeremy Howick first began asking about placebos when a herbal doctor suggested he drink ginger tea to combat cat allergy symptoms. He was highly sceptical, but three days later his runny noses, sneezing and insomnia stopped. Twenty years later, Howick is a clinical epidemiologist at the University of Oxford. Last month, his group published a review of previous research that has compared the effects of giving patients open-label placebos with no treatment.

The first was led by Professor Ted Kaptchuk, of Harvard Medical School, who gave 80 IBS patients, including Buonanno either no treatment or open-label placebo pills. He found those who took placebos for three weeks experienced greater improvements in symptoms, including less severe pain. Sadly for Buonanno, when the study ended she was unable to obtain further effective placebos and her symptoms returned.

In another of the studies in Howick’s review, chronic lower back pain patients openly given dummy pills to add to their existing treatments reported an average 30% pain reduction. In the three other review studies, people given open-label pills reported reduced symptoms for depression, lower back pain, and attention deficit hyperactivity disorder.

Howick acknowledges that a limitation of these trials is that participants knew whether they were getting placebos or not being treated. Yet other research has demonstrated placebos trigger real physiological changes. They are known to increase the circulation of endorphins, the body’s own natural painkillers, and of dopamine, a neurotransmitter associated both with pleasurable activities and perceptions of pain.

Placebos appear to work only in certain circumstances. Research suggests they can be effective when the brain and perception can help modulate symptoms such as pain, fatigue and itch. Dummy pills also vary in their effectiveness according to genetics. A 2012 study found IBS patients differ in their sensitivity to placebos based on the variants of a gene called COMT they had, probably because this can affect their dopamine levels.

So if ethically given placebos can work, surely doctors should be prescribing them? “I’m not advocating doctors handing them out like Smarties,” says Howick, whose book Doctor You, about overmedicalisation and the body’s self-healing capabilities, will be published later this year. “I do think, however, that this research is telling us we should start to recognise the benefits of doctors being realistically positive when they talk to patients.”

Kaptchuk is more enthusiastic about wider open-label placebo use, despite antipathy among doctors. “If enough of these studies have positive results in different conditions, I hope we can convince the medical community that there’s something useful here.”

The placebo effect: is there something in it after all?



That might be more likely once more work has been done to explain how open-label placebos work. One hypothesis is that patients who have previously got better after being treated by trusted doctors might experience subconscious boosts to levels of endorphins and neurotransmitters, thereby improving their symptoms. This is the conditioning effect, made famous by the Russian psychologist Ivan Pavlov, who trained dogs to salivate when they heard a buzzer they associated with being fed, even when no food was presented.

Another possibility is that patients might be told that placebos have worked before for people with their conditions, leading to a conscious expectation of improvements, resulting in chemical releases that relieve their symptoms.

Both of these probably play a role, yet Kaptchuk says neither can fully explain the experiences of participants in his IBS study, most of whom had been through multiple failed treatments. He thinks a relatively recent theory called embodied cognition is closer to the mark. This suggests that the possibility of improvement can trigger subconscious signals to pass between different parts of the body, resulting in chemical releases that alleviate symptoms.

Buonanno, meanwhile, has some thoughts on the potential mechanisms of open-label placebos, but is more interested in the fact that they have worked for her. Since late last year, Kaptchuk and his gastroenterologist colleague Anthony Lembo have been prescribing them to her as a patient. “I feel perfect,” she says. “It’s like I was never sick. I think it’s something to do with having confidence in my doctors, in the way they tell me it’s going to work, having hope and really wanting something to work. I don’t really understand it. But what I do know is that, after 23 years, I’ve got my life back.”

Britain is no paragon of sporting virtue – let’s stop pretending otherwise

Mary Dejevsky in The Guardian

As the latest scandal involving the ex-England manager Sam Allardyce and questions over cyclists’ drug exemptions show, the UK plays no fairer than anyone else

It started on the Iffley Road running track in Oxford, with Roger Bannister and the four-minute mile. It continued with Chariots of Fire, the filmed version of the same, and it was reinforced in the national consciousness with London 2012, the glorious festival of sport that everyone thought was going to be a disaster, but wasn’t.

Along the way came England’s victory (over Germany) in the 1966 World Cup, whose anniversary has been celebrated this year with mawkish nostalgia. And when the medals kept on coming, in this year’s Olympics and the Paralympics in Rio, the self-image of the UK as a highly successful and, of course, squeaky clean sporting nation seemed secure.
That image has been thoroughly discredited this week with the departure, by mutual consent, of the new England football manager, Sam Allardyce, after a mere 67 days. He was the subject of a Panorama exposé 10 years ago – and even I, as a football ignoramus, had caught the drift – which helped to explain why this “obvious” candidate for the England job had never been offered it before.

But now there he was, on camera, courtesy of a classic journalistic sting (by the Daily Telegraph), setting out how the rules of the transfer market could be circumvented, and considering a nice little supplement to his salary.

Nor, it would appear, is he alone in regarding the Football Association’s rules as an inconvenience to be challenged rather than a standard to be upheld. At least eight more guardians of the supposedly “national” game, it is claimed, agree with Sam Allardyce that ethics are for others upright or unambitious enough to heed them. The real pros know different.
If dubious practices were unique to football, that would be one thing. After all, everyone knows – do they not? – that there is far too much money sloshing round in the game generally, not least in England’s Premier League – money that is taking ticket prices out of reach of ordinary families and stifling the growth of homegrown talent.

We also know about the rot that set in long ago at Fifa, the headquarters of international football, so it is hardly surprising if something putrid also contaminates national organisations – including, alas, our own.

But it is not just English football, is it? Football may be the richest and most egregious example, but revelations in recent weeks suggest that question marks hang over other areas of UK sport. Nothing illegal, mind, nothing so crude as the“state-sponsored doping” we so loudly deplore in others, but little tweaks here and there, and especially close readings of the rule book that identify the opportunities between the lines.

So it is that the stellar success story of our times, Britain’s emergence as a world leader in cycling, looks slightly less glorious now that hacked reports have revealed the chemical help some cyclists were receiving – quite legally, it must be stressed – in order, as the people’s hero and multiple Olympic gold harvester Bradley Wiggins put it, to ensure “a level playing field”. Is a doctor’s note now to be considered part of sportsmanship?

And on the eve of the Rio Paralympics, there were reports of unhappiness within the British camp over allegations that classifications were being – how shall we say? – manipulated in the pursuit of more medals. We are sticklers for observing the letter of the law, it would seem, where the spirit of sport is concerned. But the story is starting to look a little different.

The shock here – if it is a shock – should not be that UK sports officials are as adept at playing the system as anyone else – within but sometimes also outside the law. It should rather be the persistence of the myth that only foreigners (especially Russians) cheat, and that British sport across the board – just because it is British – is cleaner, more honest and, yes, more innocent than everyone else’s. It isn’t.

Getting Stoned, Without Drugs

Sadhguru

Injection drug which claims to help people lose more weight than they would by dieting or exercising could soon be available through the NHS

by Patrick Sawer in The Telegraph

A treatment of injections that can help people lost a stone more than they normally would by dieting or exercising more has been approved by health watchdogs.

Liraglutide, which has been described by doctors as life-changing, could be available on prescription in months.

Slimmers typically lose almost a stone more than they would by simply watching how many calories they consume and doing more exercise.

Trials showed that some severely obese patients lost so much weight they were able to abandon their wheelchairs and walk normally for the first time in years.

Liraglutide also lowers blood pressure, raises good cholesterol and prevents diabetes. 

According to its makers, Novo Nordisk of Denmark, the drug even produces a 'feel-good factor', making dieting a pleasure.

But some experts have already warned it does not provide a long-term solution to the growing problem of obesity in Britain.

Novo Nordisk will apply for it to be prescribed on the NHS after Friday’s ruling by the European drugs regulator that it is safe and effective.

There are fears however that Nice – Britain’s drugs rationing body – will judge it too expensive for routine use on the NHS.

Liraglutide costs from £2.25 a day, which is roughly double the price of Orlistat, the only other prescription diet drug.

Patients inject the drug into their stomach before breakfast every day. It works by suppressing appetite.

Liraglutide, which will be given the brand name Saxenda, is already used at a lower dose to treat diabetes. It is based on a hormone found in the gut and sends signals to the brain that trick it into feeling full.

As a result, people eat 10 per cent less food than normal.

Trials of Liraglutide found that men and women who injected themselves daily lost an average of 19lb in 12 months. This is almost a stone more than they would lose by being on a diet and increasing the amount they exercise.

Furthermore one third or those who took part in the trials shed 23lb – more than a stone and a half. For a 14 stone woman that kind of weight loss would usually mean dropping two dress sizes.

The drug which, like insulin, comes in an injectable pen, also has such a significant effect on blood pressure that patients can dispense with the drugs they use to keep it under control.

Like Orlistat, its prescription is likely to be limited to those who are obese or who are overweight and have another health problem such as high blood pressure.

Mike Lean, professor of human nutrition at Glasgow University, told the Mail: "Liraglutide is absolutely life-changing for many of our most difficult-to-manage patients. Most do well, and some amazingly well. And it is extraordinarily safe, at least over the two to three years for which we have good evidence, with no signals to suggest serious side-effects.

"The only real downside is that it is jolly expensive."

Professor Jason Halford, former president of the UK Association for the Study of Obesity, said: "It is potentially very exciting. The real benefit of it is that it is targeting appetite. It strengthens the effects of satiety."

Obesity levels have doubled over the past two decades, making the UK the second-fattest nation in Europe.

Extensive research has found that being obese can lessen person's lifespan by as much as nine years and raise the risk of a host of health problems including diabetes, heart disease, stroke and cancer.

Tests have shown that dieters taking liraglutide lose almost twice as much weight as those on Orlistat.

However, Professor Iain Broom, director of the Centre for Obesity Research at Robert Gordon University in Aberdeen, said that drugs were never going to provide a long term answer to obesity.

He said: "Until society changes and the Government’s relationship with the food industry changes and the food industry itself changes, we are not going to get anywhere very fast."

The European Commission is expected to approve the drug’s licence within the next two months, paving the way for it to go on sale. Novo Nordisk says it could be launched in Europe, including the UK, this year.

Johann Hari: ‘I failed badly. When you harm people, you should shut up, go away and reflect on what happened'

When I heard that Johann Hari had written a book about the war on drugs, two immediate concerns sprang to mind. The first was whether anyone would trust a word he wrote.

The author used to be the Independent’s star columnist, a prolific polemicist and darling of the left, until his career imploded in disgrace when it emerged in 2011 that many of his articles contained quotes apparently said to him but in fact lifted from his interviewees’ books, or from previous interviews by other journalists. Worse, he was exposed as a “sockpuppet”, or someone who anonymously furthers his own interests online. Using a false identity, Hari had maliciously amended the Wikipedia pages of journalists he disliked – among them the Telegraph columnist Cristina Odone and the Observer’s Nick Cohen – accusing them of antisemitism, homophobia and other toxic falsehoods. Under the same pseudonym, he had also edited his own Wikipedia page, lavishly flattering his profile to, as he puts it, “big myself up”. The Independent suspended him, four months later he resigned, and no British newspaper has published his journalism since. He has never spoken publicly about the scandal, until now.

My other worry was whether anyone would want to read yet another polemic about drugs. I wouldn’t, and I’m quite interested in the subject. The prohibition-versus-legalisation debate tends to be interminably dreary, chiefly because neither side ever seems to change anybody’s mind.

“I think that’s totally right,” Hari agrees. “I did not want to write a 400-page polemic about the drug war. I didn’t want to have an argument about it, I wanted to understand it.” For that matter, he admits, “It’s struck me that, actually, polemic very rarely changes people’s minds about anything.” He says so as a former columnist? “A recovering former columnist, yes.” He laughs. “It’s not just that polemic doesn’t change people’s minds. It says nothing about the texture of lived experience. People are complex and nuanced, they don’t live polemically.”

Hari’s book turns out to be a page-turner, full of astonishing revelations. I had no idea that the war on drugs was single-handedly invented by a racist ex-prohibition agent, who needed to find a new problem big enough to protect his departmental budget. One of the first victims of his ambition was Billie Holiday, whose heroin addiction enraged him to the point where he hounded her to death. After he’d had the singer jailed for drugs, she was stripped of her performing licence, and as she unravelled into destitution and despair, his agents continued to harass her, even summoning a grand jury to indict her as she lay dying under police guard in a hospital bed.

The opposite of addiction is not sobriety. The opposite of addiction is human connection

Johann Hari

Hari travelled all over the world meeting other casualties of the drug war: a transsexual former crack dealer in Brooklyn; a homeless junkie in Vancouver who mobilised the local heroin addicts into activists and rewrote the city’s drug laws; a housewife from Ciudad Juárez who marched across Mexico to shame the politicians and cartels protecting her daughter’s murderer.

Woven between the human dramas are Malcolm Gladwell-ish examinations of the surprising science and statistics of drug use, and of the varying success of drug policies. Hari goes to Portugal, where all drug possession was decriminalised 13 years ago, and where even the police chief of the Lisbon drug squad now admits, “The things we were afraid of didn’t happen.” He also visits Tent City, a prison in the Arizona desert where the inmates live in tents in temperatures of 44C, wear T-shirts proclaiming I AM BREAKING THE NEED FOR WEED or I WAS A DRUG ADDICT, and are shackled into a chain gang every day and marched in public while reciting chants of repentance.

I’ve got to know Hari a bit over the past two years, and it’s quite hard to picture him in the badlands of the drug war. He doesn’t look much like an underworld adventurer. He could pass for almost a decade younger than his 35 years, is slightly knock-kneed and prone to giggly yelps, and readily admits he can’t be trusted to make it to the corner shop and back without getting lost. His north London flat, where we meet, is full of books and almost nothing else, its sole concession to domesticity a massive flatscreen TV. Hari puts his general air of unworldly distraction down to his dyspraxia, but it comes across as donnish.

There was nothing academic about his background, growing up in suburban north London in the 80s. His Glaswegian mother worked in a refuge, his Swiss father was a bus driver, and they were pleased but rather puzzled by their son’s obsession with books. “My mum and my dad and my brother all left school when they were 16. I was the first person in my family to go to a fancy university.” After graduating with a double first in social and political sciences from Cambridge, he joined the New Statesman and quickly established his name as a columnist. He was hired by the Independent, where he won Young Journalist of the Year in 2003 and became the youngest ever recipient of the George Orwell prize in recognition of his political reporting.

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 Johann Hari: “I want to make it clear that I’m not in any way attributing anything I did to that drug use. They are totally separate things.” Photograph: Richard Saker

As a journalist, Hari wrote a lot about the war on drugs, and was always a passionate opponent. His book is presented as an objective investigation, but did it really change his mind about anything? “Oh yes. I think the thing that shocked me the most was the stuff about addiction. I thought I knew about addiction. But addiction is not what we’ve been told it is at all.”

When Hari began the book three years ago, he was familiar with the two prevailing theories: people become dependent on drugs either because they lack self-control, or because the chemicals are so inherently addictive that they hijack the brain. Addiction is a moral weakness, or it is a disease, but implicit in either analysis is the theoretical possibility that if we could get rid of the drugs, we would solve the problem.

One of Hari’s earliest memories is of trying to rouse a relative from a drug-induced stupor, and his ex-boyfriend is a crack and heroin addict. “So I’d seen addiction in people I loved, and I could see it wasn’t that they were just selfish, morally flawed people. I never believed that. So I erred towards thinking, well, obviously it must be a disease.” Seminal experiments conducted on rats in the 70s appeared to have proved this. Offered a choice between pure water and water laced with heroin, the rats quickly became addicted to the opiate and kept taking the drug until it killed them.

But something didn’t add up. “Every day, all over the world, hospital patients are given medical heroin, diamorphine, very often for long periods. And virtually none of them afterwards goes out and tries to score on the street. Which made me think, the issue here can’t just be the drug.”

Hari went to Vancouver to meet a psychology professor, Bruce Alexander, who had been similarly puzzled, so had replicated the original experiments. This time, instead of experimenting on solitary rats locked in empty cages, he offered the choice of clean or drugged water to rats kept in what he called Rat Park, a kind of rat heaven full of wheels and coloured balls and delicious food, and other rats to play and mate with. When these rats tried heroin, they weren’t very interested.

“They just didn’t like it. None of them overdosed. Even more strikingly, he then took rats that had become addicted in the isolated cages, and put them into Rat Park. And they almost immediately stopped using. What Alexander had found is that we’ve fundamentally misunderstood what addiction is. It isn’t a moral failing. It isn’t a disease. Addiction is an adaptation to your environment. It’s not you; it’s the cage you live in.”

The book is populated by a compelling cast of meth users, junkies and crack addicts. Other than addiction, what they have in common is heartbreaking early trauma and abuse. Childhood violence and prostitution, abandonment and homelessness, all led their victims to the same remedy: a narcotic anaesthetic for pain and loneliness. “Human beings have an innate need to bond. Healthy, happy people bond with other humans. But if you can’t do that because you’re so traumatised by your childhood that you can’t trust people, you may well bond with a drug instead.” The scientific evidence of the correlation is so overwhelming, Hari writes, that “child abuse is as likely to cause drug addiction as obesity is to cause heart disease”.

Child abuse is as likely to cause drug addiction as obesity is to cause heart disease

Johann Hari

“What I learned is that the opposite of addiction is not sobriety,” Hari says. “The opposite of addiction is human connection. And I think that has massive implications for the war on drugs. The treatment of drug addicts almost everywhere in the world is much closer to Tent City than it is to anything in Portugal. Our laws are built around the belief that drug addicts need to be punished to stop them. But if pain and trauma and isolation cause addiction, then inflicting more pain and trauma and isolation is not going to solve that addiction. It’s actually going to deepen it.”

He breaks off, looking anxious. “But I didn’t tell their stories, because I thought they were a better way of persuading people of an argument. It’s a book of stories about people, because I think stories are a fundamentally better way of thinking about the world.”

Nevertheless, these stories build a compelling case for the legalisation and regulation of drugs. If, as the book suggests, 90% of us can take drugs safely without harming ourselves or others, and criminalising the 10% who can’t only turns them into desperate thieves and prostitutes, then the war on drugs is not merely unwinnable, but inherently counterproductive. But one of the stories Hari tells is mentioned so fleetingly that a reader could blink and miss it. In just a few sentences, Hari writes that he himself had been addicted to a drug for several years.

Provigil is an anti-narcolepsy prescription drug, popular among Ivy League students for its reputed power to turbo-charge the brain. When Hari discovered it in 2009, “I thought: great, I’ve maxed out the amount of antidepressants you can use – here’s something that will speed things up even more.” He’d been prescribed the antidepressant Seroxat at 17 and, barring one or two brief breaks, had been taking it ever since. Now, with Provigil, Hari was thrilled to discover, “you can do even more work, and be constantly processing information, and sleep only four hours a night”. He began buying the drug on the internet – and for a while it worked. But when he tried to stop taking it, he failed. “When you’re prone to depression, there can be a strong temptation, or there was for me anyway, to try to accelerate through it – to speed up, to kind of outrun the feelings of depression and I did that for years.

“But this is totally unrelated to the things I did wrong journalistically,” he says quickly. “This is really important. I did those things before and during the use of this drug. So I want to make it clear that I’m not in any way attributing anything I did to that drug use. They are totally separate things.”

This is the last time he says anything quickly. The moment we come to his scandal, all the animation drains from him; he turns still and pale, and speaks in halting sentences prefaced by painful silences. He stopped taking both Provigil and Seroxat one week after leaving the Independent, but can’t be sure what withdrawal was like because, “It’s hard to separate the challenge of stopping those drugs from the wider challenge of what was happening at that time.” I ask if he would place himself in the 10% vulnerable to addiction, and he says, “Probably at that point, yes. Not now, because I’ve changed the way I live so much that I wouldn’t put myself in that category any more.” But when I ask how his susceptibility relates to his childhood, he falls silent.

I’m ashamed of what I did. I did some things that were really nasty and cruel

Johann Hari

“Look,” he says eventually, “I can talk to you about why what happened in my life happened. But I just think that’s a way of trying to invite sympathy, and that would be weaselly. If you tell a detailed personal story about yourself, you’re inherently asking people to sympathise with you, and actually I don’t think people should be sympathetic to me. I’m ashamed of what I did. I did some things that were really nasty and cruel.”

Suspicions began circulating online in 2011, when bloggers noticed uncanny similarities between quotes in Hari’s work and previously published interviews and books. The New Statesman began to dig further, and soon the internet was awash with incriminating examples. At the same time, several journalists who’d clashed with Hari in the past, including Nick Cohen and Cristina Odone, began to wonder in public about the identity of a mysteriously vengeful Wikipedia contributor who’d been editing their pages. He called himself “David Rose” and began issuing inventively elaborate online denials of the accusation that he was really Johann Hari. After his IP address was traced back to the Independent’s offices, the deception crumbled. The humiliation must have been toe-curling, but when I ask how he dealt with it, he says, “I just think that would be asking people to see it from my point of view.” Sympathy should be for the people he smeared online, for the Independent and its readers: “Not for me.”

Hari had sounded considerably less remorseful when the plagiarism allegations first surfaced. He found them “bemusing”, he wrote on his website, and justified using quotes interviewees had not said to him because his interviews were “intellectual portraits”. The defence sounded rather grandiosely self-serving – so why should anyone trust his new-found contrition? “I think, when you’re in the middle of being attacked, obviously your defence mechanisms go up and you can’t think clearly. It’s the moment when you most need your good judgment and are the least able to bring it.”

The mystery is why someone so clever could have behaved so stupidly. I ask Hari to explain what he’d been thinking, and he literally winces.

“I’m very reluctant to go into a personal narrative and give the why. Most people restrain their self-aggrandising and cruel impulses, and I failed to. I failed badly. I think when you do that, when you harm people, you should shut up, go away and reflect on what happened. Going on about myself would just be arrogant and actually repeating being nasty, and that’s what I’m trying not to be. When you fuck up, you should privately reckon with the harm you have caused and you should pay a big price.”

When the scandal broke, the George Orwell prize board ordered Hari to return his award. The Independent published a personal apology and sent him off to journalism school in New York on unpaid leave, but in January 2012 he resigned from the paper. Was the price he paid disproportionately high? Hari shakes his head. “It was incredibly humiliating, yes. It was absolutely devastating, and I fell apart. But I would not want to live in a culture where people could be horrible about other people under a pseudonym online, or act as if something someone had written had been said directly to you, and not pay a big price for it.”

For his new book, Hari has posted audio files online of every interview, so he is obviously worried about his credibility. Does he think this elaborate transparency will restore it? “Well, I fucked up and it’s perfectly right for people to be sceptical. I know I’ve got work to do in regaining trust.”

I ask how he thinks his disgrace changed him. “In two really big ways. One was just slowing down; writing much more slowly, living much more slowly, being less work-obsessed.” He is single, and shares his flat with a primary schoolteacher, one of his oldest friends. Most of his friends stood by him through the scandal, and a new one has been Russell Brand, for whom Hari has worked off and on since helping him prepare his 2013 standup tour, Messiah Complex. “We have long political conversations, and sometimes that sparks something useful for him, and then I send him links or books about what we’ve discussed.” He helps produce Brand’s podcast, the Trews, but when I ask about the rumours that he ghost-wrote Revolution, he laughs. “No. I didn’t write a word of it. As I suspect anyone who reads it can tell, those are all Russell’s words.”

It’s a relief, he says, not to be “in a state of mania any more, ripped up into a frenzy of constant opinionating and polemicising in my room”. I’m amazed more columnists don’t lose it, unhinged by the insatiable outrage of the Twittersphere, but when I ask if he thinks the register of public debate is becoming dangerous, he smiles. “Funnily enough, one of the good things about not being a columnist is that I don’t have to have an opinion on things like this. You’re probably right, and it sounds very persuasive to me, but I don’t want to join an angry argument against angry arguments.”

The other big change, he says, is that “I lost my taste for rendering judgment on people. I think now I’m more interested in understanding why people are the way they are.” What does he miss about his former life as a columnist? This time the silence lasts so long that I wonder if he heard the question. “It was the only job I ever wanted to do,” he says finally, and looks ashen. But he is already working on his next book, and says his new life makes him happier and healthier than his old one ever could.

If disgrace turned out to be a release, it still doesn’t feel that way to Hari. “No.” He shakes his head. “I’m not going to present it like a redemptive fable. It was awful, and I wish I hadn’t done it, and I wish I could go back and undo it.”