01.

2020

The blue zones diet: Eat like a centenarian Why women’s health gets shortchanged
SPECIAL ISSUE THE FUTURE OF MEDICINE

Scientists are
unraveling the
mysteries of pain—
and exploring new
ways to treat it.
 FURTHER JA N UA RY 2 0 2 0

C O N T E N T S On the Cover
Pain serves as an alarm sys-
tem to the brain. Scientists
are finding new ways to
manage and decrease it—
without the use of opioids.
ILLUSTRATION BY MAGIC TORCH

P R O O F E X P L O R E T R AV E L

19
THE BIG IDEA

Why You’re Annoyed

Science has only begun
to explain annoyance
and what may cause it.
Doesn’t that bug you?
BY J O E PA LC A

TOOL KIT

The Ancestral Art

of Bootmaking
34
GETTING THERE

10
A son crafts custom Sky-High Science
hiking boots as his Visit a remote Swiss
father and grandfather weather station that
did—old tools and all. helps monitor the
BY J E N N I F E R S . H O L L A N D
planet’s life signs.
BY RACHEL HARTIGAN SHEA

DISCOVERY

Kicking It With
Costa Rica’s Frogs
The Eyes Have It The country’s some
Charmed by how the 150 species may satisfy
big-eyed damselflies even the most ardent
in his garden often frog-watchers.
appeared to be looking BY L I SA K R I E G E R
at him, the photogra-
pher looked back—with ALSO ALSO

his camera. Earth-Friendly Glitter Mudlarking Guide

P H OTO G R A P H S BY A Line on the Fish Secluded Samoa
R E MU S T I P L E A Dirty Dirt Floors Epic Wales Trails
J A N U A R Y | CONTENTS

F E AT U R E S A World of Pain The Microbiome Finding Calm

Learning more about Menagerie The ancient practice
how pain is transmitted. Trillions of microbes of yoga offers an
BY Y U D H I J I T B H AT TAC H A R- are key to our health. antidote to the
J E E ; P H OTO G R A P H S BY BY ROBIN MARANTZ stress of modern life.
DAV I D G U T T E N F E L D E R , HENIG BY FRAN SMITH
RO B E RT C L A R K , RO B I N I M AG E S BY P H OTO G RA P H S BY
H A M MO N D, C RA I G C U T L E R , M A RT I N O E G G E R L I A N DY R I C H T E R
AND MARK THIE S SEN ... P. 46 ...................................... P. 86 ..................................... P. 122

Women Shortchanged Foods to Live By Robot for Seniors

on Health, Wellness People worldwide How the machines
What can remedy that? show the Blue Zones can help health care.
BY ZOA N N E C L AC K author their menus for BY C L AU D I A K A L B
I L L U S T R AT I O N S B Y health and long life. P H OTO G R A P H S BY
B I A N C A BAG N A R E L L I BY DA N B U E T T N E R YVES GELLIE
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P. 76 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P. 104 ..................................... P. 136
J A N U A R Y | W H AT ’ S C OM I N G

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Subscriptions For subscriptions or changes of address, contact Customer Service at ngmservice.com Contributions to the National Geographic Society are tax de-
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 FROM MIKE ULICA | J A N U A R Y

LOOKING AHEAD
TO A NEW YEAR
Our Aim: To Illuminate
and Protect
T H E N AT I O N A L G E O G R A P H I C S O C I E T Y
uses the power of science, exploration,
education, and storytelling to illumi-
nate and protect the wonder of our
world. With this mission statement,
we honor our legacy as a 131-year-old
global nonproût and the principles that
will guide our work in the years ahead.
As we start 2020, I9d like to share our
plans for what will truly be a conse-
quential year. We will commemorate
important milestones, such as the 50th
anniversary of Earth Day. We9ll cel-
ebrate the 60th anniversary of Jane
Goodall9s arrival in what is now Gombe
National Park, with an immersive
museum exhibit at our headquarters
in Washington, D.C. And National Geo-
graphic will join world leaders at the
Convention on Biological Diversity
meeting in Kunming, China, to help
inform a post-2020 framework for sup-
porting global biodiversity.
In each instance, the Society9s con-
tributions will be driven by our unique
approach. We illuminate the world9s
wonders by exploring a subject and
bringing it to life with powerful story- weather stations and collecting the
telling. We protect what is wonderful by highest ever ice core sample.
taking action to safeguard the planet9s We work with the next generation
critical resources and inhabitants. of planetary stewards in mind. Young
Our mission can take the form of people increasingly identify as global
photographer Joel Sartore9s Photo Ark citizens and unite around issues they
project: afecting wildlife portraits that care about. The Society is committed
connect us with at-risk species on an to growing their understanding of the
emotional level and inspire us to pro- world, and supporting their interest
tect these remarkable animals. in geography and their empathy for
Our mission also is exempliûed by the Earth.
our recent work on Mount Everest, Please know that your support makes
together with our partners at Rolex. the Society9s work possible. Thank you
Building on both organizations9 his- for standing with us to illuminate and
tories of exploration, we used ground- protect the wonder of our world.
breaking science to reveal how Earth9s
systems function and are changing
over time. The expedition9s achieve-
ments included installing the world9s Mike Ulica, President and COO
two highest-altitude automated National Geographic Society

PHOTO: MARK THIESSEN, NGM STAFF

 P R O O F

N AT I O N A L G E O G R A P H I C

VO L . 2 3 7 N O. 1

MAKING EYE
CONTACT

PHOTOGRAPHS BY LO O K I N G
REMUS TIPLEA AT T H E
E A RT H
A damselfly—one of photographer F ROM
Tiplea’s favorite summer subjects— E V E RY
obligingly pauses in front of a blue POSSIBLE
inflatable kiddie pool. ANGLE

10 N AT I O N A L G E O G R A P H I C
When the weather
is warm, Remus Tiplea
spends hours in his
garden in Romania,
looking at damselflies.
Occasionally he catches
their eyes staring back.

JA N UA RY 2 0 2 0 11
P R O O F

12 N AT I O N A L G E O G R A P H I C
Often territorial,
male damselflies will
battle over the same
leaf or flower. After
extensive observation
of the insects, Tiplea
says he can tell when
a battle is imminent.

JA N UA RY 2 0 2 0 13
P R O O F

Tiplea says photographing damselflies is often easier in the morning, when the light is soft and the air
is usually still. In rain or bright sun, he shields the fragile insects with an umbrella.

14 N AT I O N A L G E O G R A P H I C
Focusing a camera on small insects perched on vibrant leaves and flowers is a challenge, he says.
It took him three seasons to find what he considers the ideal camera settings.

JA N UA RY 2 0 2 0 15
P R O O F

THE BACKSTORY
A S UM M E RT I M E GA R D E N T U R N E D O U T TO B E T H E P E R F EC T
I N S E C T P O RT R A I T ST U D I O.

at him—
F I R ST T H E Y W E R E LO O K I N G take üight. He saw how they behaved
and then he started looking back. in rain and how they chose where to
Photographer Remus Tiplea noticed sleep. With time, he could tell their
the damselüies perched on foliage in gender and the dominant qualities
his garden in Negrești-Oaș, Romania. in mate selection. If he saw multiple
Staring with bulging eyes, the delicate damselflies in one frame, he9d have
insects looked inquisitive, Tiplea a few seconds to shoot before they9d
thought, and a little imposing. Long show themselves as territorial rivals
afternoons photographing damselüies (by starting to ûght) or lovers. <They
became his summertime ritual. would ignore me completely,= he says.
Through hours of watching, Tiplea As years have passed and summers
learned the behaviors of the damsel- have grown warmer, Tiplea has noticed
flies, a close relative of dragonflies fewer damselüies at his garden pond.
but with slimmer bodies and nar- <Their number is inconsistent,= he
rower wings. He observed when they says—but <the important thing is that
got hungry, when they reproduced, we are together in the same backyard.=
and what caused them to suddenly — DA N I E L S TO N E

When his garden population is low, Tiplea captures damselflies at a neighboring pond.
 IN THIS SECTION

Dirty Dirt Floors

E X P L O R E Lab of the Future

Bootbuilding Tools
How Many Passports?

airport departure

P
P I C T U R E YO U R S E L F AT A C ROW D E D
gate. Your üight is 20 minutes late, although the
illuminated sign still says On Time.
The woman on your left is noisily eating something
that smells awful. The overhead TV is tuned to a
celebrity gossip show, a relentless stream of Bieber
after Gwyneth after Miley, plus countless Kar-
dashians. The man to your right is still braying into
his cell phone, and the traveler next to him is prepar-
ing to kill time with … wait, is that a toenail clipper?
Unless you are saintly or unconscious, a few
things in that description—or many things, or all
the things—are likely to really bug you. We know
an annoyance when we experience it. But from a
scientiûc perspective, just what makes something
annoying? Are some things universally annoying,
while others are speciûc to an individual? And does
research ofer any advice for preventing life9s annoy-
ances from making our heads explode?

JA N UA RY 2 0 2 0 19
E X P L O R E | THE BIG IDEA

The answers to those questions are: We don9t know,

we don9t know, and no.
Annoyance may well be the most widely experi-
enced and least studied of all human emotions. On
what do I base that assertion? About a decade ago,
fellow journalist Flora Lichtman and I made that
claim in a book called Annoying: The Science of What
Bugs Us—and in the intervening years, no one has
challenged us.
After we noted the lack of studies on this topic, did
scholars step up to the plate? Did even one university
create a Department of Annoyance Science … endow
a Distinguished Chair for Continuing Research Into
Annoyance … or ofer a major in annoying studies?
No. Nothing. Nada. Zilch.
It9s not as if the proliferation of things that drive
us crazy has slowed in the past 10 years. Quite the
opposite. Consider the explosive, ineluctable growth
of Twitter: Once a seemingly benign social media
platform, it now intrudes on every sphere of exis-
tence, tempting us to address matters we should
rightly have no interest in. There9s the pandemic of
social media inüuencers, the unwelcome bounty of
Our annoying
robocalls, and the invasive assault of personalized survey answers
and pop-up ads. There9s my personal favorite at the
moment: electric scooters, threatening the well-being In an online survey, National Geographic
of pedestrians when the contraptions are moving and asked readers to name their most
vexing annoyances by category.
forming sidewalk stumbling hazards when they9re
Here are some of their responses.
parked. And the list goes on and on: See responses
to National Geographic’s online survey about what The most annoying technology
annoys us, on this page and page 22. Robocalls … Pop-up ads … Selfie
sticks … Other people’s cell phones
Our analysis
W H AT M A K E S S O M E T H I N G A N N OY I N G ?
… Electric scooters … Captchas
(typing symbols to prove you’re not
came up with three qualities that seem essential. a robot) … Virtual assistants like Alexa,
First: It must be noxious without being physically Echo, Siri … “Everything after the wheel.”
harmful. A houseüy buzzing around your head is
unpleasant, but it won9t kill you. The most annoying noise
Second: It must be unpredictable and intermit- Buzzing insects … Barking dogs … Leaf
blowers … Open-mouthed chewing …
tent. The loud ticking of an alarm clock or the odor Car alarms … People singing really badly …
of a cat litter box may at ûrst be annoying, but with Construction … Entitled people
constant exposure over time, it ceases to be notice- screaming … Knuckles cracking …
able. Psychologists9 term for this gradual tolerance Loud neighbors … “Being told no.”
of a stimulus is habituation. Yet when an unpleasant
The most annoying people
noise or smell comes and goes, it becomes annoying
Fakers … Telemarketers who don’t
each time it shows up. stop at the first NO … TSA agents ...
The intermittent nature of annoyances makes Line cutters … Narcissists …
them hard (if not impossible) to anticipate and thus Low talkers … Celebrities … Bigots.
to prepare a defense against. If you know you9re going
to be stuck in traffic, you might be able to take it
in stride or bring along a distraction. But when the
slowdown is unexpected, it gets to you before you
can stop yourself.
Third and ûnally: To be truly annoying, something
has to persist for an uncertain period of time. A üight
that9s delayed an hour is a bother, but tolerable, so
long as it really is just an hour. A üight that9s delayed
and delayed and delayed, with no explanation and
no end in sight, is excruciatingly annoying.
Joe Palca is a science correspondent with NPR. His ability to
annoy others is legendary.

20 N AT I O N A L G E O G R A P H I C
ILLUSTRATIONS BY JEAN JULLIEN JA N UA RY 2 0 2 0 21
E X P L O R E | THE BIG IDEA

Now it could be that you read that last paragraph

and said to yourself, Wait a minute—a delayed üight ANNOYANCE IS CONTEXT-
isn9t that annoying. If I have a good book to read,
S P E C I F I C . I N T E R M I T T E N T,
I don9t mind waiting in an airport. That speaks to
another key feature of annoyance: It9s <highly context- UNEXPLAINED DELAYS THAT
speciûc,= says Russell Shilling, the American Psycho- MIGHT EXASPERATE AIRLINE
logical Association9s chief scientiûc oocer. <There PASSENGERS ARE JUST PART
is a lot of variability between individuals and cul- O F T H E J O B F O R A P I L O T.
tures.= For example: The same kind of intermittent,
unexplained delays that might exasperate airline
passengers are just part of the job for a pilot.
As for an example of annoyances varying by cul- help us deûne them. We have a variety of reüexes
ture: If a U.S. family visits a beach with only one other that kick in to protect us from truly dangerous stim-
family present, they9ll tend to throw down their tow- uli. Gagging could prevent us from ingesting some-
els a discreet distance away. In some Mediterranean thing that9s potentially poisonous. The blink reüex
countries, plopping down right next door is the norm, protects our eyeball if an object is heading toward it.
but that would cause many Americans to seethe. There9s even something called the middle-ear mus-
Shilling says individual variability is one reason cle reüex that protects our eardrums from damage
it9s so hard to tease out the universal properties of from truly loud noises.
annoyances. But that individuality may be useful in The reason someone with a cloying cologne is
certain settings. A psychiatrist friend of mine notes annoying may derive from the gag reüex. Likewise
that while her patients may be reluctant to talk about our response to a vuvuzela, that deafening plastic
their private dark thoughts, they have no problem rail- horn, may be a vestige of our natural protections
ing about the people and situations that annoy them. from any loud noise.
Encouraging people to share their annoyances could Another place to look for clues to the fundamen-
be an easier way to open a window into their psyches. tal nature of annoyance is to study people with
conditions that make them particularly prone to
AN INTRIGUING THING about annoyances is how annoyances. Just as studying people with hyper-
they appear to change over time. A decade ago, our cholesterolemia—dangerously high cholesterol—led
research led us to conclude that one of the most to the ûrst drugs for lowering cholesterol, so might
annoying things in the world was listening to some- studying people with the disorder misophonia lead
one else9s loud cell phone conversation. We hypoth- to ways to help keep us from becoming annoyed.
esized that the reason it was so annoying is that According to the National Institutes of Health9s
our brains are naturally predisposed to painting a Genetic and Rare Diseases Information Center, peo-
complete picture of reality, but when you only hear ple with misophonia have an extreme emotional
half of a conversation, that9s not possible. response to sounds that others ûnd innocuous. Just
Then, cell phone conversations seemed annoying hearing someone breathe or yawn or chew a potato
only to the people not on the phone. Today it9s the call chip can generate severe agitation in susceptible
recipients that seem to be getting annoyed. I9m not individuals. If researchers ûnd more ways to calm
talking about receiving a robocall. I9m talking about those people, there may be some beneût for all of us.
the 20-something who recently told me that an unex-
pected call, even from a close friend, is annoying. The IN THE DECADE SINCE the book came out, I9ve thought
thinking seems to be, Why call when a text will do? Or a lot about what makes people, things, and situations
even, You should have texted to ask if you could call … annoying, and what any of us might do to inoculate
If there are some things in life that are universally ourselves against becoming annoyed. The answer9s
annoying, human physiology may provide clues to actually surprisingly simple: All you have to do is
Editor’s Note: The contract for this article set a strict word limit.
The writer exceeded the limit; the magazine feels obliged to
enforce it. We regret any annoyance this might cause, dear readers.

Annoyances, Continued
Popular expressions Foods
LOL … Cray cray … Lean in … Stinky cheese … Okra
Impactful … Man up … … Pizza with pineapple
My bad … Fake news … … Lite beer … Cilantro …
Could care less … Woke … Black licorice … “Pumpkin-
“It is what it is.” spiced anything.”

22
 E X P L O R E

INNOVATOR
GAYATRI DATAR
BY MARC GUNTHER P H O T O G R A P H B Y C H R I S S C H WA G G A

She’s helping Rwandans

live cleaner by replacing
unsanitary dirt floors.

Days after graduating from business

school at Stanford University in 2014,
Gayatri Datar set of for Rwanda to
pursue an unorthodox goal: to rid the
world of dirt üoors, which can make
people sick.
<There are bugs all over the place.
Termites. Jiggers. Worms,= she
explains. <Babies don9t have diapers,
so kids poop and pee on the floors.
They9re hard to clean. They don9t look
good. People hate them.= Yet more than
one billion people live on dirt because
they can9t aford anything better.
Datar9s start-up nonprofit, Earth-
Enable, sells an earthen üoor made of
locally sourced clay, pebbles, and sand,
sealed with a proprietary eco-friendly
varnish. It costs about $70 per home,
far less than concrete.
EarthEnable struggled at ûrst. Get-
ting raw materials to rural villages
proved costly. Masons had to be trained
to install the üoors. Quality was spotty.
Datar, 34, says: <Everything that could
go wrong did go wrong.=
These days EarthEnable is faring
better. More than 4,400 earthen üoors
have been installed, Datar reports, and
customers love them. EarthEnable has
raised money from foundations, the
U.S. Agency for International Devel-
opment, and a Dutch competition that
supports green entrepreneurs. Best of
all, Datar is working closely with Rwan-
dan government oocials who say they
too want to eliminate dirt üoors. j

THIS STORY WAS SUPPORTED BY A GRANT FROM THE PULITZER CENTER ON CRISIS REPORTING.
E X P L O R E | BREAKTHROUGHS

A sparkling way to cut microplastics

All that glitters is not green: Most
glitters are plastic based and take
D I S PAT C H E S hundreds of years to break down. Enter
Bioglitter, created with cellulose from
FROM THE FRONT LINES eucalyptus trees. In nature, the glitter
OF SCIENCE biodegrades into harmless specks, says
A N D I N N O VA T I O N the U.K. firm that makes it. — A N N I E R O T H

Learn more about plastic waste and take the

pledge to reduce it at natgeo.com/plasticpledge.

MEDICAL SCIENCE

A lab the
size and cost
of a stamp
Diagnosing
patients’ ills often
means sending
samples to testing
laboratories. For
areas that lack such
resources, Harvard’s
George Whitesides
has spent years Hounds tree a
trainer during
developing a “lab” a practice run
on a stamp-size near Kruger
National Park.
filter paper square.
When this low-cost,
easy-to-use device WILDLIFE PROTECTION

absorbs a drop of
blood or urine, dots
of chemical reagent
SNIFFING OUT POACHERS
change color to T E X A S F R E E - R U N N I N G PAC K H O U N D S J O I N S O U T H
indicate various A F R I C A’ S E F F O R T T O S T O P W I L D L I F E P L U N D E R I N G

conditions, such TEXAS HOUNDS ARE REVOLUTIONIZING anti-poaching work in South

as an abundance Africa. By some estimates, 4,000 rhinos were killed in the Kruger
of protein. — A R National Park area during the past decade; how many remain
there is debated, with claims ranging from 5,000 to 9,000. Since
May 2018, the hounds, raised by Texas rancher Joe Braman, have
contributed to a 24 percent drop in rhino poaching in the park and
a 54 percent increase in apprehensions of poachers, authorities say.
In the past, law enforcement teams that used individual lead
dogs to track poachers on foot struggled to keep up. Staf at the
Southern African Wildlife College, a training facility outside Kru-
ger, were eager to test free-running dogs in the area. After visiting,
Braman, a passionate houndman and part-time cop, ofered to
train a team of his own dogs back in Texas and ship them to South
Africa. In live operations, the hounds, wearing GPS collars, track
a poacher9s scent, with helicopters and rangers close behind. By
charging and biting en masse, the dogs keep their quarry at bay,
Braman says: <If a dog starts attacking you, the ûrst thing you9re
gonna do is throw the gun and climb a tree.= — PA U L S T E Y N

PHOTOS (FROM TOP): REBECCA HALE, NGM STAFF; SEAN VILJOEN; WHITESIDES LAB, HARVARD UNIVERSITY
CAPTURED | E X P L O R E

LINE OF
SIGHT
PHOTOGRAPH BY
REBECCA HALE

Fine-Tuned Fish Sense

Note the thin black
stripe down this mack-
erel’s side. That’s the
lateral line, part of a
valuable system that
reads water motion and
pressure. Tiny sensors
along the line, called
neuromasts, allow fish
to identify movement
very precisely—helping
them hunt prey, avoid
obstacles, and swim in
schools, even in the dark.
—T H E R E S A M A C H E M E R
E X P L O R E | TOOL KIT

HEART AND SOLE

30 N AT I O N A L G E O G R A P H I C
 1. Lasting pincers
These two blue-handled
tools are part leather grab-
ber, part hammer, used to
stretch and form leather
over a foot model (10).
2. Jack stand
10 This steel device holds a
shoe upside down for rel-
atively quick work on the
sole or heel.
3. Rubber cement pot
Limmer has used his grand-
father’s glue-crusted pot
for 45 years. Cordwainers—
another word for shoemak-
ers—brush the adhesive
on soles to attach them to
shoes’ undersides.
4. Jack stand with vise
Used for custom work,
it has a soft, leather-
wrapped rest for the toe
of a nylon (shown) or
wooden foot model.
5. Nail nippers
For pulling out and cutting
nails used in boots.
6. Button hooks
“Back when shoes had
9
tiny buttons, they helped
cobblers with fat fingers,”
Limmer says of these
100-year-old hooks.
7. Rotary hole punch
This cuts the holes for
bootlace hooks.
8. Tools, back to front:
Rasp, for sanding and shap-
ing; knife sharpener; striker,
for smoothing knife edges;
and mandrel, for setting
nails and smoothing rough
spots inside the boot.
9. Cordwainer’s hammers
Hammers for tamping
soles and tapping nails
P H O T O G R A P H B Y H A N N A H W H I TA K E R and tacks, such as those
in the dish near the tools.
10. Wooden foot model
IN 1939 A GERMAN-BORN SHOEMAKER named Peter Limmer got the Limmer puts additions
ûrst U.S. patent for a <ski boot=—a stif, square-toed leather shoe made on standard-size models
to order. Today, gray-bearded Peter Limmer III hammers out about until they match the mea-
200 pairs of hiking boots a year using his grandfather9s tools in the surements of customers’
Intervale, New Hampshire, shop his grandfather opened. There9s a per- feet. Boots are built
directly on the models;
petual waiting list for the custom boots, priced at $775 and up; loyalists
Limmer says “strong mus-
come from as far away as Tasmania for ûnal boot ûttings. Limmer, 63, cles and a beer belly help”
still loves his work. <The best part,= he says, <is seeing customers dance when it’s time to pull the
in the driveway with their new boots on.= — J E N N I F E R S . H O L L A N D models out of the boots.

JA N UA RY 2 0 2 0 31
E X P L O R E | DATA S H E E T

most countries revoked the citizenship of

NINE PATHS
H A L F A C E N T U RY A G O ,
a person who became a national of another country. Today some
75 percent let their people hold foreign passports, dramatically
increasing citizenship options for children. There are more paths to

TO MULTIPLE citizenship in European countries, fewer in the Americas (although

birthright citizenship is more common), and limited routes in non-
democratic countries, says Maarten Vink, of Maastricht University.
Having nine passports is rare; here’s how it could happen.

CITIZENSHIP B Y M A N U E L C A N A L E S A N D K E L S E Y N O WA K O W S K I

M AT E R N A L D U A L C I T I Z E N S H I P PAT E R N A L D U A L C I T I Z E N S H I P
Children can become citi- Children can pick up their Children can become Children can inherit
zens of the country where mother’s second citizen- citizens of the coun- their father’s dual citi-
their mother was born ship, even if she wasn’t try where their father zenship regardless of
and holds citizenship. born in that country. was born. where he was born.

81%
of countries allow 62% 91% 71%
this route to
citizenship

In 47 countries, it’s easier for men

than women to pass citizenship
to their children.

ly t i
mi e
a s
f
MARRIAGE H I STO RY
Nearly two-thirds Citizenship is
of all countries granted because
grant citizenship of ethnic, historical,
through marriage 63% 23% or cultural ties to
after three years. a country.
o

t
h d
er n
bo

48%
18% 20%
M I G R AT I O N BIRTH INVESTMENT
A person can get citizen- Citizenship is automatic at A large investment in a
ship within five years of birth, a law that’s rare globally country can come with full
immigrating in nearly half but is more common in the citizenship, often without
the world’s countries. Western Hemisphere. habitual residence.

Applicable to the U.S.

NO CITIZENSHIP A N T I -T E R R O R I S M TAC T I C
The exact number of stateless people isn’t known, Countries are increasingly stripping away
but many millions around the world aren’t recog- citizenship from people who’ve engaged in
nized as a citizen by any country. terrorist activities at home or abroad.

SOURCE: GLOBAL CITIZENSHIP OBSERVATORY (GLOBALCIT)

 IN THIS SECTION

Costa Rica’s Frogs

T R AV E L Going Mudlarking
Secluded Samoa
New Trails in Wales

W H E R E T O G O , W H AT T O K N O W, A N D H O W T O S E E T H E W O R L D

N AT I O N A L G E O G R A P H I C VO L . 2 3 7 N O. 1

SKY-HIGH SCIENCE
FOR ONE YEAR Konsta Punkka traveled throughout Europe photographing
Integrated Carbon Observation System research stations, which measure
greenhouse gases. The stations tend to be in remote areas of the conti-
nent, but no others are as high as Jungfraujoch in Switzerland—or as
accessible to tourists.

A R R I VA L PAC K I N G L I S T LAUNCH

RIDE UP BUNDLING UP 8A V E R Y M A G I C A L
A M O U N TA I N Punkka dressed for M O R N I N G9
The Jungfraujoch research early spring in the Alps— Just before a spring storm
station looks rugged in down, fleece, and hit after two days of “bad
and isolated—and it is— multiple layers. sunrises,” Punkka went out
but beneath its windswept on the upper deck with his
stones lie an ice palace, • Boots for deep snow drone. “I wanted to high-
a chocolate shop, and the • Camera with three lenses light the station, to watch
highest train station in • Snow pants (warm the mountain with the
Europe. Like the travelers, enough to let him lie sunrise light.” He sent the
Punkka rode a cogwheel on the ground while drone soaring away from
train from Kleine Scheidegg photographing wildlife) the peak. When it reached
through a tunnel under • A drone with three a good vantage point,
the mountain to get there. extra batteries (batteries Punkka flung his arms up in
After he disembarked, he die quickly in these the air: “I don’t often shoot
stepped into a high-speed harsh conditions) myself in pictures, but I
elevator. It shot him up • Winter mittens, with wanted to show the scale.”
to the research station on room for hand warm- It was so cold that after he
top of the peak where he, ers (Punkka piloted the got the shot, he hurried
unlike the tourists, was drone barehanded, so inside to pilot the drone
allowed to bunk with the he needed to be able to from the relative comfort
scientists for four days. warm his hands quickly) of the research station.

34 N AT I O N A L G E O G R A P H I C
 8THERE WERE EARLIER VIDEO
PROJECTS THAT LOST
SEVERAL DRONES. I MANAGED
TO KEEP MY DRONE
I N T H E A I R .9
—Konsta Punkka

GETTING THERE

BY THE NUMBERS

11,745
FEET ABOVE SEA LEVEL

1931
Y E A R R E S E A R C H S TAT I O N WA S B U I LT

18˚F
AV E R A G E T E M P E R AT U R E

ASIA
uj och The Jungfrau-
n gfra
ATLANTIC Ju joch research
OCEAN
station is in
AFRICA the Swiss Alps.

BY RACHEL HARTIGAN SHEA P H O T O G R A P H B Y KO N S TA P U N K K A

NGM MAPS JA N UA RY 2 0 2 0 35
T R AV E L | CHECKLIST

From treasure hunting

to penguin spotting,
JANUARY
here’s how to see
the world this month.

BIG EVENT

G O FLY A KITE?
DON9T MIND IF
WE D O —AT THE
INTERNATIONAL
K I T E F E S T I VA L ,
JANUARY 6-14,
IN AHMEDABAD,
INDIA . FANCY
FLYERS, FROM
LONG -TAILED

1
NEW BOOK TO READ
DRAGONS TO
EERIE ALIENS,
D R AW G L O B A L
KITE EXPERTS
AND SUPERFANS.
What Lies Beneath
the Thames
Mudlarking is
more than simply
scavenging for
historic objects
on a river’s fore-
shore. It can be
a meditative act
in which looking

3
is as enjoyable
as finding, writes
Lara Maiklem in
Mudlark. Travelers
can try London
mudlarking with WILDLIFE IT’S NESTING TIME for Magellanic penguins. The
tours led by SIGHTING
monogamous pairs and their chicks can be seen
Thames Explorer in colonies along the coasts of the Falkland Islands

4
Trust and others. (pictured), as well as Argentina and southern Chile.

NATIONAL PARK FINDER

The Tropical Island Escape That Isn’t Hawaii

Lush rainforests, soft sand beaches, and tiny thimble jellyfish (left)
are just some of the treasures in the National Park of American Samoa,
the only U.S. national park south of the Equator. Its far-flung location,
about 2,600 miles southwest of Hawaii, means that travelers hike,
snorkel, scuba dive, and explore Samoan culture with few crowds.

PHOTOS (CLOCKWISE FROM TOP LEFT): COURTESY LIVERIGHT PUBLISHING; ANAND PUROHIT,
GETTY IMAGES; TUI DE ROY, MINDEN PICTURES; FLORIS VAN BREUGEL
 DISCOVERY | T R AV E L

NORTH
AMER. ATLANTIC
OCEAN

COSTA
RICA SOUTH
AMER.
PACIFIC
OCEAN

KICKING IT
WITH FROGS
BY LISA KRIEGER

like bird-watching,
F RO G - S P OT T I N G ,
takes patience and perseverance.
Like birders, we have lists and our
own jargon. We keep odd hours, swat
mosquitoes, and wear closed-toe shoes
to prevent snakebite. In a world that
is rapidly losing frogs, our group of
amphibian-focused travelers set out
for Costa Rica to ûnd them.
Organized by the nonproût organiza-
tion Save the Frogs, these ecotours help
to support the growing number of parks
and ecolodges in places such as Belize,
Peru, and Ghana that protect the vital
habitats for these vulnerable creatures.
Costa Rica is home to 149 frog
species. (The one perched on this hel-
iconia üower is a blue-sided tree frog.)
At the peak of the soggy season, we
identiûed 23 species, but kept hoping
for more. It9s an addictive game full of
disappointment and discovery, chasing
eyes that glow like jewels in the dark.

PHOTO: GREG BASCO, MINDEN PICTURES. NGM MAPS

T R AV E L | BEING THERE

In Snowdonia National Park, summer dusk bathes a slope above Lake Idwal, in the Ogwen Valley.

EPIC WALES
J U M P I N T O C O A S TA L A D V E N T U R E S ,
T H E N H I K E T R A I L S AT T H E S P E E D O F S H E E P.

B Y A MY A L I P I O

painted on a billboard-size wall

T H E S I M P L E WO R D S government, in 1956. The recognition singles out for
overlooking a parking lot in Swansea, Wales, read: conservation exceptional landscapes of <distinctive
<More poetry is needed.= character.= Wales now has ûve AONBs, in addition
A plea to locals? More likely an exhortation to the to three national parks.
rest of the world—because poetry isn9t something I Three new touring routes, collectively called the
ûnd Wales lacks. A short drive beyond any Welsh Wales Way, showcase the best of this ancient land—
city leads to landscapes of imagination: hillsides and they appear on National Geographic Travel9s
embroidered with bluebells, lonely castle ruins on annual Best Trips 2020 list, which heralds them as
windswept crags, rocky coastlines noisy with seal essential experiences for travelers. At 185 miles, the
song, valleys that are an encyclopedia of green. Cambrian Way is the longest of the three, snaking
The industrial port city of Swansea is the gateway north to south along the backbone of Wales. Sand-
to the Gower Peninsula, the ûrst Area of Outstanding wiched between peaks and sea, the Coastal Way is
Natural Beauty (AONB) designated by the British a sweeping 180-mile journey around Cardigan Bay

PHOTO: CARL JONES

 T R AV E L B E YO N D YO U R
WI LDEST DREAMS

O C E A N E X P E D I T I O N C R U I S E S W I T H N AT I O N A L G E O G R A P H I C
Join us for a National Geographic expedition to the Arctic or Antarctica. Paddle a
kayak past towering icebergs, wander among penguins, or bask in the otherworldly
glow of the northern lights. Our experts, naturalists, and photographers on board
promise an unforgettable travel experience, rooted in our legacy of exploration.
Travelling with us you’ll not only be inspired by the breath-taking polar landscapes—
you’ll be doing your part to help protect it.

W W W.T R AV E LW I T H N ATG E O.C O M

© 2019 National Geographic Partners, LLC. National Geographic EXPEDITIONS and the Yellow Border Design are trademarks of the National Geographic Society, used under license.
Photo Credit: Studio/PONANT: Morgane Monneret
T R AV E L | BEING THERE

found families out enjoying the unseasonably warm

weather on broad golden sands. The bay üows out
to the Bristol Channel, which has one of the highest
tidal ranges in the world. In Wales it always pays to
see what wonders lie around the bend.
Or what surprises. At Devil9s Bridge, in the north-
ern Cambrian Mountains, a steep trail leads down
a wooded gorge to Devil9s Bridge Falls. I arrived one
spring at dusk and had the trail nearly to myself.
I heard the rumble of the falls before I saw them.
They plunge 298 feet in several cascades, the water
sometimes gathering in potholes, where the bedrock
The hiking trail around Carmarthen Fans, in Brecon Beacons has eroded. The trail wound down closer to the base
National Park, takes in windy escarpments and glacial lakes.
of the falls, and each view seemed diferent, as if I
were looking at a multitude of waterfalls, rather than
the same one from various vantages.
on the country9s west coast. The castle-rich North Its prismatic beauty attested to why this has been
Wales Way follows a centuries-old trading route 75 a tourist attraction since Victorian times. Nature9s
miles from northeastern Queensferry to the clifs at green generosity was on display, brightened by bursts
Holyhead on the Isle of Anglesey. of pink and purple rhododendrons. The lushness
Each route is a gateway to wider outdoor adven- reminded me of Hawaii. <Can such force / Of waters
ture. On the western Pembrokeshire coast, surfers issue from a British source …= wondered William
ride the swells at Freshwater West, site of the Welsh Wordsworth in his poem <To the Torrent at the Devil9s
national surûng championships. Climbers can follow Bridge, North Wales, 1824.= As I made my way back
in the footsteps of Sir Edmund Hillary, who trained up out of the valley, I couldn9t help but smile. If this
on 3,560-foot Mount Snowdon before his 1953 is devil9s territory, then let all hell break loose.
Everest ascent. Elsewhere in Snowdonia Beyond lyrical landscapes, there9s the
National Park, the River Tryweryn is the torrent of actual poetry Wales has pro-
top destination for white-water kayak- duced. Its poetic tradition reaches back
ASIA
ing and rafting in Britain. This is poetry to the late fourth century and forward
U.K.
to get the blood pumping. WALES to the annual National Eisteddfod, a
ATLANTIC
In the 1980s the Welsh pioneered a OCEAN full-blown festival of poetry and music
new adrenaline rush called coasteering. AFRICA that is Wales9s biggest gathering.
This increasingly popular adventure Some of the earliest written sources of
sport may include rock climbing, cliff the Arthurian tale, dating from the ninth
jumping, cave exploring, swimming— century, have connections to Wales or were
experiencing with all senses the impact zone where written in Welsh. Travelers search for connections
water meets land. to the legendary ruler and his knights at towns
The speed is slower on Wales9s hundreds of miles such as Caerleon, a supposed site of Camelot, and
of walking trails, including the 870-mile Wales Coast Carmarthen, said by some to be Merlin9s hometown.
Path, which follows the country9s entire shoreline, Dylan Thomas, perhaps Wales9s most famous poet,
from Chepstow in the south to Queensferry in the was born in Swansea and still inüuences artists and
north. Once I spent a sunny afternoon unexpectedly writers today. That parking lot billboard? It9s a work
walking a very short section of the path from Port by artist Jeremy Deller, who was commissioned as
Eynon Bay to Oxwich Bay, in the Gower Peninsula, part of the city festivities around Thomas9s 100th
where I9ve been visiting relatives since I was 14 years birthday in 2014. Deller was right: Even in Wales,
old. I9d thought only to stroll out to one end of the you can never have enough of words and wonder. j
bay and back, but the desire to see what was beyond
the headland kept me walking. At Oxwich Bay, I Amy Alipio is senior editor at National Geographic Travel.

Chepstow Castle
Has the oldest castle doors

Castles of Wales
Wales is said to be home to more castles per
in Europe
Castell y Bere
Rates as one of Wales’s most
photogenic ruins
square mile than any other country in Europe. Why Kidwelly Castle
Starred as a backdrop in Monty
the density? Blame it partly on Wales’s history as Python and the Holy Grail
a contested territory among native Welsh, Normans, Powis Castle
and English, who all erected epic fortresses. Here Renowned for terraced,
are four of the best. — R A P H A E L K A D U S H I N Italian Renaissance–style gardens

PHOTO: CODY DUNCAN. NGM MAPS

N AT I O N A L G E O G R A P H I C JA N UA RY 2 0 2 0

Pain and the Brain . . . . . . P. 46

Women’s Health . . . . . . . . . . P. 76
Mighty Microbes . . . . . . . P. 86
Blue Zones Diet . . . . . . . . . P. 104
Yoga’s Benefits . . . . . . . . . . P. 122

F EAT U R E S Robot Therapy . . . . . . . . . . P. 136

86
8HERE9S
THE REALLY
AMAZING
THING:
EVERY ONE
OF US HAS A
PARTICULAR
MIX OF
MICROBES
THAT 9S
DIFFERENT
FROM
EVERYONE
E L S E 9 S .9

IMAGE: MARTIN OEGGERLI

Vitaly Napadow,
a neuroscientist at
Harvard Medical School
and Massachusetts
General Hospital, studies
how the brain perceives
pain. To do that, he uses
electroencephalography
to track the brain wave
patterns of patients with
chronic lower back pain.
ROBERT CLARK

46
 JA N UA RY 2 0 2 0

Scientists are
unraveling the WELLNESS
mysteries of pain— ISSUE

BY

YUDHIJIT
BHATTACHARJEE
P H OTO G R A P H S BY
DAV I D G U T T E N F E L D E R ,
RO B E RT C L A R K ,
RO B I N H A M MO N D,
CRAIG CUTLER,
AND MARK THIESSEN

and exploring
new ways to treat it.
During surgery,
Brent Bauer eases his
pain by playing a vir-
tual reality game called
SnowWorld. Orthope-
dic trauma surgeon
Reza Firoozabadi at
UW Medicine’s Harbor-
view Medical Center
in Seattle was testing
the effectiveness of
the game, developed
by the University of
Washington’s Hunter
Hoffman, a pioneer in
VR for pain relief. Bauer
fell three stories and
broke numerous bones,
including his pelvis. He
had one stabilizing pin
removed from his pelvis
without VR. “That got
very intense,” he said.
The other was removed
with VR. “It was a very
pleasant distraction,”
he noted, “and the pain
was a lot less.” Bauer
was participating in a
study that suggests
VR could decrease the
need for general anes-
thesia, reducing the
risks and cost.
CRAIG CUTLER
In Chu Yang Sin National
Park in Vietnam, Zoltan
Takacs, a biomedical
scientist and National
Geographic explorer,
finds a venomous scor-
pion, which glows blue
in ultraviolet light.
Collecting venom from
around the world, Tak-
acs hopes to identify
novel pain medica-
tions because there
are currently few good
alternatives to opioids.
Venom has already led
to one notable suc-
cess. Scientists derived
a drug for chronic pain
from one of the world’s
deadliest animals: the
cone snail.
DAVID GUTTENFELDER

50
M
O R E T H A N T H R E E D E C A D E S AG O,
when Tom Norris was ûghting can-
cer, he underwent radiation ther-
apy on his groin and his left hip.
His cancer disappeared and hasn9t
come back. But Norris was left with
a piercing ache that burned from
his hip up his spine to his neck.
Since then, Norris, now 70, has
never had a single day free from
pain. It cut short his career as an
aircraft maintenance oocer in the
U.S. Air Force. It9s been his constant companion, like the cane
he uses to walk. On bad days, the pain is so excruciating, he9s
bedridden. Even on the best days, it severely limits his abil-
ity to move about, preventing him from doing the simplest
chores, like taking out the garbage. Sometimes the pain is When Jo Cameron had
so overpowering, Norris says, that his breathing becomes surgery for arthritis in
labored. <It9s like I9m drowning.= her hand, her anesthe-
siologist found she felt
Norris, who lives in a Los Angeles suburb, spoke to me no pain and referred
from a long, cushioned bench, which allowed him to go from the Scottish woman to a
sitting to lying üat on his back. A tall and genial man, he9s geneticist, who discov-
ered she has two rare
become adept at wearing a mask of serenity to hide his pain. mutations. Researchers
I never saw him wince. When his agony is especially intense, are investigating muta-
his wife of 31 years, Marianne, says she can tell by a certain tions that deaden or
heighten the sensation
stillness she sees in his eyes. of pain to learn how
When the pain began to take over his life, Norris sought it’s transmitted. The
solace in speaking out. He became an advocate for chronic electrophoresis results
below show the pain
pain suferers and started a support group. And for 30 years insensitivity mutation
he has searched for relief. For many of those years he was on in Cameron’s DNA (1)
fentanyl, a powerful opioid that he says covered his pain <like and her son’s (3), but
not in her mother’s (2)
a thick blanket= but kept him <basically horizontal and zoned and daughter’s (4).
out.= He has tried acupuncture, which was somewhat helpful, RIGHT: ROBIN HAMMOND
BELOW: JAMES COX, UNIVERSITY
as well as bee stings, magnet therapy, and faith healing, which COLLEGE LONDON

weren9t. Norris now manages his pain with physical therapy,

which improves his mobility, and steroids injected into his
spine, which quiet his inüamed nerves.
Like Norris, nearly 50 million people in the United States
and millions more around the world live with chronic pain.
The causes are diverse, from cancer to diabetes to neurological
illnesses and other ailments. But they share a common source
of sufering: physical agony that disrupts their lives, intermit-
tently or all the time. It9s not uncommon for cancer patients
experiencing severe, unrelenting pain after chemotherapy to
opt out of treatment in favor of the ultimate salve of dying. 1 2 3 4

52 N AT I O N A L G E O G R A P H I C
 The toll exacted by chronic pain has become Cliford Woolf, a neurobiologist at Children9s
increasingly visible in recent years. After doctors Hospital in Boston who9s studied pain for more
in the late 1990s began prescribing opioid medi- than four decades, says it9s tragic it has taken a
cations such as oxycodone to alleviate persistent <societal catastrophe= for pain to get the atten-
pain, hundreds of thousands of Americans tion it deserves from scientists and physicians,
developed an addiction to these drugs, which but the impetus this has given to pain research
sometimes produce feelings of pleasure in addi- is a silver lining. <I think we have the potential
tion to easing pain. Even after the risks became in the next few years of really making an enor-
evident, the reliance on opioids continued, in mous impact in our understanding of pain,= he
part because there were few alternatives. No says, <and that will deûnitely contribute to new
novel blockbuster painkillers have been devel- treatment options.=
oped in the past couple of decades.
The misuse of opioid pain relievers—which is one of nature9s
T H E C A PA C I T Y T O F E E L PA I N
are ideally suited for short-term management gifts to humankind and the rest of the animal
of acute pain—has become rampant across the kingdom. Without it, we wouldn9t reflexively
United States. In 2017, an estimated 1.7 million recoil our hand upon touching a hot stove or
Americans had a substance abuse disorder know to avoid walking barefoot over broken
stemming from having been prescribed opioids, glass. Those actions, motivated by an immedi-
according to the National Survey on Drug Use ate or remembered experience of pain, help us
and Health. Every day in the U.S., about 130 peo- minimize the risk of bodily injury. We evolved
ple die from opioid overdoses—a grim statistic to feel pain because the sensation serves as an
that includes deaths from prescription painkill- alarm system that is key to self-preservation.
ers as well as narcotics like heroin. The sentries in this system are a special class
The quest to understand the biology of pain of sensory neurons called nociceptors, which
and ûnd more efective ways to manage chronic sit close to the spine, with their ûbers extending
pain has taken on fresh urgency. Researchers are into the skin, the lungs, the gut, and other parts
making signiûcant strides in detailing how pain of the body. They9re equipped to sense diferent
signals are communicated from sensory nerves kinds of harmful stimuli: a knife9s cut, the heat of
to the brain and how the brain perceives the sen- molten wax, the burn of acid. When nociceptors
sation of pain. Scientists also are uncovering the detect any of these threats, they send electrical
roles that speciûc genes play in regulating pain, signals to the spinal cord, which transmits them
which is helping to explain why the perception via other neurons to the brain. Higher order neu-
and tolerance of pain vary so widely. rons in the cortex—the ûnal destination of this
These advances are radically altering how cli- ascending pain pathway—translate this input
nicians and scientists view pain—speciûcally into the perception of pain.
chronic pain, defined as pain that lasts more Upon registering the pain, the brain attempts
than three months. Medical science tradition- to counteract it. Neural networks in the brain
ally regarded pain as a consequence of injury send electrical signals down the spinal cord
or disease, secondary to its root cause. In many along what9s known as the descending pain
patients, it turns out, pain originating from an pathway, triggering the release of endorphins
injury or ailment persists long after the under- and other natural opioids. These biochemicals
lying cause has been resolved. Pain—in such inhibit ascending pain signals, efectively reduc-
cases—becomes the disease. ing the amount of pain perceived.
The hope is that this insight, coupled with the Scientists had sketched out this basic sche-
steadily advancing understanding of pain, will matic of ascending and descending pain path-
lead to new therapies for chronic pain, includ- ways when Woolf began working in the field
ing nonaddictive alternatives to opioids. Norris in the 1980s. A soft-spoken man with eyes that
and other patients are keen to see those break- seem to brim with kindness, Woolf was struck by
throughs happen. Researchers, meanwhile, are the plight of patients he saw in the surgery ward
testing promising alternative strategies, such as when he was pursuing his medical degree.
stimulating the brain with mild electric shocks <It was clear that all were sufering from severe
to alter its pain perception and harnessing the pain,= he says. Woolf felt the senior resident sur-
body9s intrinsic capacity to soothe its own pain. geon seemed almost resentful that they were

54 N AT I O N A L G E O G R A P H I C
complaining. <I said to the surgeon, 8Why aren9t and certain other conditions. Their pain is not
you doing anything?9 = Woolf recalls. <And the a symptom; it9s a disease—one caused by a mal-
surgeon said, 8Well, what do you expect? They functioning nervous system.
just had an operation. They9ll get better.9 = With advances in growing human stem cells in
<Pain was a problem the medical profession the lab, Woolf and his colleagues are now creat-
downplayed—to a substantial extent because ing diferent types of human neurons, including
there were no safe and efective interventions,= nociceptors. This breakthrough is allowing them
Woolf says. This realization kindled his desire to study neurons in greater detail than was pre-
to understand the nature of pain. viously possible to determine the circumstances
Using rats as a model, he set out to learn more where they become <pathologically excitable,=
about how pain is transmitted. In his experi- Woolf says, and ûre spontaneously.
ments, Woolf recorded the activity of neurons Woolf and his colleagues have used lab-grown
in the animals9 spinal cords in response to a brief nociceptors to investigate why chemotherapy
application of heat to their skin. As he expected, drugs cause neuropathic pain. When the noci-
he observed these neurons ûring excitedly when ceptors are exposed to these drugs, they become
signals arrived from the nociceptive neurons. But more easily triggered and begin to degenerate.
Woolf made an unexpected ûnding. After a patch This likely contributes to the neuropathies that
of skin subjected to heat a few times became 40 percent of chemotherapy patients endure.
inüamed, the neurons in the spinal cord attained While scientists like Woolf are advancing the
a heightened state of sensitivity. Merely strok- understanding of how pain is transmitted, other
ing the area surrounding the previously injured scientists have discovered that these signals
patch caused them to ûre. are just one factor in how the brain perceives

‘Pain was a problem the medical profession downplayed—to a substantial

extent because there were no safe and effective interventions.’
Neurobiologist Clifford Woolf, Children’s Hospital, Boston

This showed that the injury to the skin had pain. Pain, it turns out, is a complex, subjective
sensitized the central nervous system, caus- phenomenon that is shaped by the particular
ing neurons in the spinal cord to transmit brain that9s experiencing it. How pain signals
pain signals to the brain even when the input are ultimately translated into painful sensations
from peripheral nerves was innocuous. Other can be inüuenced by a person9s emotional state.
researchers have since demonstrated this The context in which the pain is being perceived
phenomenon—called central sensitization—in also can alter how it feels, as evidenced by the
humans and shown that it drives various types pleasantness of the aches that follow a strenu-
of pain, such as when the area around a cut or a ous workout or the desire for a second helping
burn hurts at the slightest touch. of a spicy dish despite the punishing sting it
A startling conclusion from Woolf9s work and delivers to the tongue.
subsequent research was that pain could be <You9ve got this incredible capability of alter-
generated in the absence of a triggering injury. ing how those signals are processed when they
This challenged the view held by some doc- do arrive,= says Irene Tracey, a neuroscientist at
tors that patients who complained of pain that the University of Oxford.
couldn9t be explained by any obvious pathology A skilled communicator who speaks in
were likely lying for one reason or another—to rapid-ûre sentences, Tracey has spent much of
get painkillers they didn9t need, perhaps, or to her career trying to bridge the mysterious link
gain sympathy. The pain transmission system between injury and pain. <This is a highly non-
can become hypersensitive in the wake of an linear relationship, and many things can make
injury—which is what happened in the rats—but it worse or can make it better or could make it
it also can go haywire on its own or stay in a sen- very diferent,= she says.
sitized state well after an injury has healed. This In experiments, Tracey and her colleagues
is what happens in patients with neuropathic have imaged the brains of human volunteers
pain, ûbromyalgia, irritable bowel syndrome, while subjecting their skin to pinpricks or bursts

A WO R L D O F PA I N 55
HOW THE BRAIN FIGHTS PAIN
Pain has a purpose: self-preservation. It signals to the brain that the body is in danger and
needs to react. Pharmaceuticals can suppress those signals and ease pain, but new research
ofers the hope that the body9s own systems—made up of an ascending pathway and a
descending one—can be ampliûed to reduce pain organically and with minimal side efects.

A MESSAGE TO THE BRAIN Anatomy of a nerve

Acute pain calls attention to actual or poten- Nerves include bundles of axons. These fibers,
tial tissue damage. Signals to the brain travel reaching from nerve cells called neurons,
an ascending pathway to motivate the body conduct electrical activity. Different sensations
to respond quickly. travel on separate axonal fibers.

Nerve
bundle “A beta” fibers

1 2
Sensing pain Transmitting pain
With thick sheaths, these transmit
Neurons called nociceptors Electrical signals are routed
touch, pressure, and vibrations.
respond to external stimuli, from the nociceptors to axons,
such as sharp objects, fire, nerve fibers that relay the Axons “A delta” fibers
or chemical reactions. signal to the spinal cord. With thin sheaths, these are first
to sense quick, acute pain signals.
“C” fibers
Without sheaths, these sense slow
pain: heat, burns, and dull aches.

Nociceptors

Peripheral
sensory neurons

As a neuron fires, electricity-sensitive pores along its surface

cycle through three states: inactive, open, and closed.

THE PROMISE INACTIVE OPEN CLOSED INACTIVE OPEN

OF PAIN GATES
Multiple “pain gates,” Pore Sodium ions Small molecules
including the sodium
channel Nav1.7, regulate the
passage of sodium ions into
axons, which can cause pain.
Obstructing the gates with An attached particle
molecules via drugs or gene blocks the pore in
therapy may help doctors the inactive state. In the open state
tailor pain treatment to sodium ions can enter
individual patients. the unblocked pore. Some molecules
(naturally occurring or
synthetic) can block
Axona Axon the top of the pore.
l mem
bran e
 THE BRAIN RESPONDS

5
Emotional reaction
After the signals are received by the brain, The pain signals are registered
the descending pathway is engaged. in the anterior cortex, which
It cues the entire central nervous Somatosensory
can trigger anxiety, fear,
cortex
system to modulate and respond and depression.
to the painful stimulus.

Anterior
cingulate
cortex Anterior
insular cortex

6 4
Reacting to pain Perceiving pain
These areas send Prefrontal The signals travel to the
neurochemical signals cortex somatosensory cortex and
down to start blunt- other areas that identify the
ing the pain. Nucleus location and intensity of pain.
Thalamus
accumbens/
ventral striatum

Periaqueductal
gray

7 3
Pain reduction Ascending pain
The neurochemicals intercept The spinal cord
and act as a brake on the receives the signals
ascending signal in the dorsal and relays them up
horn and periaqueductal gray. Dorsal horn to the brain.

Rostral/
ventromedial
medulla

THE OPIOID PROBLEM ACUTE VS. CHRONIC

Opioids reduce pain by numbing indiscrimi- While acute pain signals follow
nately, dampening signals from the ascending ascending pathways to the brain,
pathway of pain as well as the body’s beneficial chronic pain, such as persistent
descending response. The drugs do provide back pain, is due to damaged
relief from pain—but can also elicit a sense of neurons or axons. Its pathways
euphoria that can lead to addiction. aren’t well understood.

JASON TREAT, NGM STAFF; MEG ROOSEVELT. ART: SINELAB

SOURCE: LUANA COLLOCA, UNIVERSITY OF MARYLAND
The relationship a
patient has with a doc-
tor can affect how much
pain the patient feels,
Napadow said, “but we
don’t know why that
is.” To explore this phe-
nomenon, Napadow
simultaneously records
the brain activity of
an acupuncturist and
a patient in separate
functional magnetic
resonance imaging
machines. They com-
municate through a
video feed (left moni-
tor) while the patient is
treated for experimen-
tally applied pain. To
relieve the discomfort,
the clinician remotely
triggers an electro-
acupuncture device
attached to the leg of
the patient. The moni-
tor at right shows a scan
used to map activity in
the patient’s brain.
ROBERT CLARK

58
Hanna LeBuhn, who
suffers from pain in her
jaw joints, watches the
mesmerizing motion
of jellyfish on a virtual
reality headset in Luana
Colloca’s lab. The scene,
one of a series of relax-
ing marine images,
is projected on the wall.
Colloca, who studies
the neurobiology of
pain at the University
of Maryland, has estab-
lished that VR that
entertains patients
eases their pain. “VR has
the unique capability,”
she said, “of regulating
body responses to pain,
improving mood, and
reducing anxiety.”
MARK THIESSEN
of heat or smears of cream laced with capsaicin, The anesthesiologist looked at her as if she
the chemical compound that makes chili pep- were not fully sane. He knew from experience
pers spicy. What the researchers have found has that the postoperative pain was excruciating.
led them to discover a much more complex pic- When he came by to check on her after sur-
ture of pain perception than had been previously gery, he was astonished to ûnd that she hadn9t
envisioned. There9s no single pain center in the requested so much as the mild analgesic he9d
brain. Instead, multiple regions are activated in prescribed. <You haven9t even taken paracet-
response to painful stimuli, including networks amol, have you?= he asked.
that also are involved in emotion, cognition, <No,= Cameron recalls having replied cheer-
memory, and decision-making. fully. <I told you I wouldn9t.=
They also learned that the same stimulus Growing up, Cameron says, she was frequently
doesn9t produce the same activation pattern surprised to discover bruises whose origins were
every time, indicating that a person9s experi- a mystery. When she was nine, she broke her
ence of pain can vary even when the injuries are arm in a roller-skating accident, but three days
similar. This üexibility serves us well, raising passed before her mother noticed that it was
our pain tolerance in situations that demand swollen and discolored. Years later, Cameron
it—for instance, when carrying a scorching gave birth to her two children without any pain
bowl of soup from the microwave to the kitchen during delivery.
counter. The mind knows that dropping the bowl <I don9t really know what pain is,= she says.
midway would result in greater misery than the <I see people in pain, and I see the grimace, the
brief anguish caused by holding the bowl, so it strain on their faces, and the stress, and I have
tolerates the momentary sufering. none of that.=
Tracey and her colleagues have shown that Cameron9s inability to sense physical hurt
fear, anxiety, and sadness can make pain feel may be unremarkable to her, but it places her in
worse. In one of their experiments, healthy stu- a rareûed group of individuals who are helping
dent volunteers listened to Prokoûev9s deeply scientists unravel the genetics underlying our
melancholic <Russia Under the Mongolian ability to feel pain. Her amazed anesthesiologist
Yoke,= slowed to half speed, and read negative put her in touch with James Cox, a geneticist
statements such as <My life is a failure.= At the at University College London. Cox and his col-
same time, they received a burst of heat on a leagues studied her DNA and found she had two
patch on their left forearm, which had been mutations in two neighboring genes, called FAAH
rubbed with capsaicin. Later the students and FAAH-OUT. They determined that the muta-
received the same stimulus as they listened to tions reduce the breakdown of a neurotransmitter
happier music and read neutral statements such called anandamide, which helps provide pain
as <Cherries are fruits.= In the sad condition, they relief. Cameron has an excess of the biochemical,
reported ûnding the pain <more unpleasant.= insulating her against pain.
Comparing scans of the students9 brains Cox has been studying people like Cameron
in the two moods, the researchers found that since he was a postdoc at Cambridge in the mid-
sadness inüuenced more than just the emotion- 2000s, when his supervisor, Geofrey Woods,
regulation circuitry. It led to increased acti- learned about a 10-year-old street performer in
vation in other brain regions, indicating that Pakistan who could walk barefoot over hot coals
sadness was physiologically dialing up the pain. and stick daggers into his arms without so much
<We9ve made people anxious and threatened as a whimper. The boy would earn money from
and fearful,= Tracey says, <and we9ve shown these stunts and then go to the hospital to be
that that makes the actual processing of those treated for his wounds. He was never the sub-
signals ampliûed.= ject of a study—he died from head injuries after
falling of a roof while playing with friends—but
would be needed to dull
S T R O N G M E D I C AT I O N Cox and his colleagues were able to analyze
the pain after surgery for arthritis in her hand, the DNA of six children from the same clan,
Jo Cameron was informed by her anesthesi- who showed similar insensitivity to pain. The
ologist. But the 66-year-old Scottish woman children each had a mutation in a gene called
doubted it. <I bet you any money I will not take SCN9A, known to be involved in pain signaling.
any painkillers,= she told him. The gene makes a protein that is instrumental

62 N AT I O N A L G E O G R A P H I C
in the transmission of pain messages from noci- speaks animatedly and possesses a cheery dispo-
ceptive neurons to the spinal cord. The protein, sition despite having made pain his life9s work.
christened Nav1.7, sits on the surface of the neu- He and his colleagues found, as another group
ron and serves as a channel for sodium ions to had, that man-on-ûre patients had mutations
pass into the cell, which enables electrical in their SCN9A gene. Those mutations have the
impulses constituting the pain signal to propa- opposite efect of the one in the pain-free kids
gate along the threadlike axon that connects to from Pakistan, creating Nav1.7 channels that
another neuron in the spinal cord. open too easily, allowing sodium ions to üood
The mutations the researchers discovered in in even when they shouldn9t.
the SCN9A gene yield malformed versions of the Through lab experiments conducted on neu-
Nav1.7 protein that don9t allow sodium ions to rons in petri dishes, Waxman and his colleagues
pass into nociceptive neurons. With their noci- proved that this was the mechanism by which
ceptors incapable of conducting pain signals, the the SCN9A mutations caused the syndrome in
children were oblivious when they chewed their patients like Costa. <We were able to put the
tongues or scalded themselves. <The beauty channel into pain-signaling neurons and cause
of working with these extremely rare families them to go BRRRP! when they should be going
is that you can identify single genes which bop-bop,= says Waxman, referring to the hyper-
have the mutation and essentially are human- activity that results from the unabated inüow
validated analgesic drug targets,= Cox says. of sodium ions. In patients with the syndrome,
Mutations in the SCN9A gene are also linked this defect causes nociceptors to bombard the
to a rare condition called inherited erythromel- brain with pain messages constantly.
algia, or man-on-ûre syndrome. Patients who The discovery that Nav1.7 can open or close

‘I see people in pain, and I see the grimace, the strain on their faces,
and the stress, and I have none of that.’
Jo Cameron, a patient with a genetic insensitivity to pain

have it face the extreme opposite of insensitivity the floodgates to nociceptive pain signals
to pain: a burning sensation on their hands, feet, has made the channel an attractive target
and face. In warm surroundings, or with slight for researchers looking to develop new pain
exertion, the sensation gets unbearably intense, medications that don9t pose the risk of addic-
akin to holding one9s hand over a üame. tion that opioids do. Opioids work by binding to
Pamela Costa, a 53-year-old clinical psycholo- a protein on the surface of nerve cells called the
gist from Tacoma, Washington, who sufers from mu-opioid receptor, causing the receptor to com-
the syndrome, describes the pain as <inescap- municate with proteins inside the cell. While
able.= To cope, she has her ooce temperature the action of some of these proteins alleviates
set at a chilly 60 degrees. She can sleep only with pain, the receptor9s communication with other
a complement of four fans around her bed and proteins results in pleasurable feelings. The
the air-conditioning on at full blast. In an ironic body develops a tolerance to these drugs, mean-
similarity to individuals with pain insensitivity, ing that higher and higher doses are required
the constant burning sometimes makes it hard to trigger the sense of euphoria, which can
for Costa to discern hot surfaces, which is how cause addiction.
she burned her arm a year ago while ironing. Because Nav1.7 is present only in damage-
<I didn9t realize until I heard a hissing sound sensing neurons, a drug that selectively turns
from my skin getting seared,= she says. <It was of the channel promises to be an efective pain
the same sensation as I was already having.= reliever. The sole known side efect is the loss
Stephen Waxman, a neurologist at Yale Uni- of the sense of smell. Likewise, individuals with
versity School of Medicine and one of the world9s the mutation also can9t smell. Existing local
foremost experts on nerve conduction, has stud- anesthetic drugs such as lidocaine indiscrimi-
ied Costa and others like her in his lab at the nately block nine sodium channels in the body,
Veterans Afairs Medical Center in New Haven, including ones that are key to an array of brain
Connecticut. Gracious and affable, Waxman functions, which is why doctors must limit their

A WO R L D O F PA I N 63
use to numbing patients temporarily. Drug com-
panies are searching for compounds that might
be able to block Nav1.7 without disabling other
sodium channels, but success has been elusive. Pesach Feldman, 76,
takes a break from a
Even so, Waxman is optimistic that the swim in Tel Aviv, Israel.
research eventually will lead to better drugs. Bypass surgery and 15
<I9m confident there will be a new and more stents didn’t relieve
the former paratroop-
efective class of medicines for pain that are not er’s chest pain from
addictive,= he says, his eyes brightening. Then refractory angina,
he pauses for a moment and tempers his enthu- caused by poor blood
circulation in his heart.
siasm. <But I can9t begin to attach a time line.= He underwent a sim-
ple procedure per-
for new drugs continues, cli-
W H I L E T H E S E A RC H fected by cardiologist
Shmuel Banai. A cath-
nicians and researchers are investigating ways to eter with an inflatable
deploy the brain9s intrinsic abilities to modulate balloon and a stainless
pain and lessen the sufering associated with it. steel mesh Reducer
(top right) is inserted
And those abilities are impressive. After all, our through a vein in the
minds and bodies have been coping with pain neck, and the balloon
for a lot longer than we9ve been studying it. is inflated in the heart’s
main vein, called the
Take, for example, a recent British study of coronary sinus. The
more than 300 patients with a type of shoulder Reducer restricts the
pain thought to be caused by a bone spur. To blood flow leaving the
heart, forcing it into
relieve the pain, the spur is often removed in sur- areas of the heart mus-
gery. Researchers randomly divided the partic- cle that aren’t getting
ipants into three groups. One group underwent enough nourishment.
“I got my life back,”
the surgery. A second group was led to believe Feldman said.
it had, but it hadn9t. A third group was asked to FAR RIGHT: DAVID GUTTENFELDER
NEAR RIGHT TOP: LIOR ZUR, TEL AVIV
return in three months to see a shoulder special- SOURASKY MEDICAL CENTER
NEAR RIGHT BOTTOM: SHMUEL BANAI,
ist. The group that had the operation and the one TEL AVIV SOURASKY MEDICAL CENTER

that thought it did reported similar relief from

their shoulder pain.
<What it showed is that it9s just a placebo. The
surgery is not mechanistically doing anything and anxiety that accompany the sensation
for the pain,= says Oxford9s Irene Tracey, one of are an integral part of experiencing pain. In a
the study9s authors. <The pain relief the patients trial at the Cleveland Clinic, researchers led by
are getting is just driven by a placebo efect.= neurosurgeon Andre Machado used deep brain
But to Tracey, the outcome isn9t any less stimulation (DBS) to target this emotional com-
important because it shows the placebo efect ponent of pain in 10 patients who had chronic
worked. On the contrary, she says, the study neuropathic pain after sufering a stroke. The
reveals the force of a patient9s belief in the treat- researchers implanted tiny electrodes in a part of
ment. <What it9s powerfully saying is expectations the brain involved in processing emotions. Wired
shape pain,= Tracey says. to an electronic device inserted in the chest, the
Other studies have uncovered how a patient9s electrodes delivered mild shocks to the implan-
expectation of reduced pain can translate into tation site at a rate of nearly 200 a second.
actual relief. It seems to activate the brain9s <In several patients, we saw an improve-
descending pain pathway, leading to the release ment in their quality of life, in their sensation
of opioids synthesized inside the brain that of well-being, in their independence—without
impede the incoming pain signals from the body. improving the amount of pain,= Machado says.
<This is not just pretend,= Tracey says. <The Patients who had scored their pain as a nine
placebo mechanism hijacks this very powerful on a 10-point scale, for example, continued
system in the brain.= to give it the same score but reported being
Our perception of pain isn9t limited to merely able to function better. One of the study sub-
sensing it. The feelings of unpleasantness, fear, jects, Linda Grubb, describes the treatment as

64 N AT I O N A L G E O G R A P H I C
transformative. <It made all the diference in The researchers compared the brain activity
the world as far as being able to go places,= she of participants as they received heat pulses and
says, adding that her post-stroke pain had com- buzzes or nothing. They found that the brains of
pelled her to spend her days on the couch. <I chronic pain patients responded similarly when
have so much more energy. My husband says anticipating a painful stimulus and a harmless
I seem so much happier. It really changed my one, whereas the brains of healthy volunteers
life completely.= showed increased activity in certain regions only
A subsequent part of the study involving both when anticipating the heat. When chronic pain
healthy subjects and chronic pain patients gave patients repeated the experiment while receiv-
Machado and his colleagues some insight into ing DBS, their brain activity was more similar to
why deep brain stimulation appeared to have that in healthy participants.
beneûted patients like Grubb. The researchers To Machado and his colleagues, these ûndings
recorded electrical activity from the brains of suggest that the brains of chronic pain patients
participants as they watched a screen while are conditioned by constant exposure to pain to
they had two devices strapped to their arms. react as if every stimulus is potentially painful,
One device delivered a üash of heat to the skin; causing the patients to live in distress. The DBS
the other delivered a harmless buzz. From the treatment seems to restore a degree of normalcy,
visual cue that appeared on the screen, the enabling the brain <to again distinguish pain-
participants could tell which of the two stimuli ful from nonpainful, which is what you need in
they were about to get or if they were going to order to be able to function,= Machado says.
get nothing at all. Virtual reality may prove to be another way

A WO R L D O F PA I N 65
Linda Grubb, who has
suffered from chronic
pain since having a
stroke, celebrates fin-
ishing a so-called zero
K, a race of less than
50 feet, on the patio of
Buckeye Lake Brewery
near Columbus, Ohio.
Grubb was treated at
the Cleveland Clinic
with deep brain stimu-
lation by neurosurgeon
Andre Machado. She
said it didn’t cure her
pain but did help her
get off the couch and
resume many activities.
“It’s not like I’m jump-
ing rope now,” she said,
“but I’m going lots more
places.” Machado said
other patients who
were treated reported
similar improvement
in their sense of well-
being. In the procedure,
two microelectrodes
were implanted in
Grubb’s brain (above)
and electrical pulses
sent to areas that
process the emotional
component of pain.
RIGHT: DAVID GUTTENFELDER; ABOVE:
STEPHEN JONES, CLEVELAND CLINIC,
COMPOSITE OF CT AND MRI SCANS

66 N AT I O N A L G E O G R A P H I C
A WO R L D O F PA I N 67
of reducing pain. I experienced the power of the
technique ûrsthand at the lab of Luana Colloca,
a neuroscientist at the University of Maryland.
One of Colloca9s assistants strapped a little box
onto my left forearm as I sank into a comfortable
recliner. The device was similar to the one that
Machado9s group had used: Connected to a com-
puter by a cable, it was capable of heating up and
cooling down rapidly. In my right hand, I held Daniel Boltz kisses
his eight-month-old
a controller with a button that I could press to daughter, Peyton,
stop the heating on my arm. <Don9t worry; you before giving her a
won9t get burned,= the assistant reassured me. bath. Peyton was born
with neonatal absti-
In the first few trials, Colloca asked me to nence syndrome after
press the button as soon as I felt the device get- her mother used heroin
ting warm. In the next few rounds, I had to wait during the pregnancy.
Peyton spent two
a little longer until the device felt uncomfortably months in the neona-
hot; in the ûnal series of trials, I had to switch it tal intensive care unit
of only when it felt too hot to bear. at Penn State Children’s
Hospital in Hershey,
Colloca then led me through the same Pennsylvania, being
sequence while wearing virtual reality goggles, weaned from opioids.
which immersed me in an oceanic environment. Studies on the long-
term effects are limited
Soothing music played in my ears as I watched so far, but researchers
dazzlingly colored ûsh üitting through the water, have found that babies
which was lit up by sunlight ûltering down from born with the condition
are more sensitive
above. Large iridescent jellyfish floated past. to pain than healthy
Periodically I felt the device heating up the skin newborns and also
on my forearm, reminding me that I hadn9t gone may face cognitive,
behavioral, and devel-
scuba diving. opmental problems.
When the experiment ended, Colloca showed DAVID GUTTENFELDER

me the temperatures I had allowed the device

to reach in all the trials. The readings for what
I felt to be <warm,= <hot,= and <unbearably hot=
were all higher during the immersive experience. in acute pain, such as those with severe burns.
Speciûcally, the hottest temperature I could han- Colloca believes the strategy also could prove
dle without üinching had gone up by 2.7 degrees useful in treating chronic pain.
Fahrenheit, to 118 degrees Fahrenheit, which in
Colloca9s view was <huge.= Norris leads a meeting of a sup-
E V E RY M O N T H ,
<That means you were tolerating a much, port group that he helped found a few years ago
much higher level of pain when you were through the American Chronic Pain Association.
immersed in this environment along with calm- The goal is to provide members with informal
ing music,= she says. group therapy, applying the emerging scientiûc
Scientists don9t yet know for sure why virtual insight that our thoughts and feelings can alter
reality has this positive efect on pain tolerance. our experience of pain.
Some hypothesize it works through distraction: I joined Norris at a recent gathering at a Los
by engaging networks that would otherwise be Angeles church, and he introduced me to the
involved in signaling and perceiving pain. Others members as they trickled in. (To respect their
speculate that it works by regulating emotions privacy, I decided not to ask for their last names.)
and altering mood. Colloca has shown that the One of them, a slender young man named Brian,
key driver of the benefit is the entertainment shook my hand. When I explained to him, as I
provided by the experience, which helps relax did with the others, that I9d come to listen, not to
patients and reduce their anxiety. Whatever the participate, he joked: <Maybe we should punch
mechanisms underlying its efectiveness, doctors you in the face so you can relate.=
already are using virtual reality to help patients There were 10 of us in all—ûve men and ûve

68 N AT I O N A L G E O G R A P H I C
women. We arranged our chairs in a circle and Norris told her and the rest of the group that
sat down. Resting his cane against a table, Norris he9s just a phone call away. <Sometimes you just
settled into his seat and asked the members to need to scream,= he said. Turning to another
share how things had been going for them. woman in the group who9d admitted earlier to
Brian, who suffers from severe abdominal being reluctant to reach out for support, he said,
pain that doctors haven9t been able to diagnose, <So please, yell.=
was the ûrst to speak. He described going to a When the meeting was over, Norris waited for
jujitsu class, which he said helped him tempo- everybody to ûle out of the room before turn-
rarily forget his pain. <It9s sad that I have to cause ing out the lights. I asked what inspired him to
myself other pain to forget this one,= he laughed. organize the monthly meeting. <I ûnd that my
<I thought of all you guys throughout the week. experiences are often helpful to others,= he said.
It made me feel better.= But this was just as much about helping himself,
The members are familiar with each other9s he added. <These meetings help me feel like I
stories. But they seemed bound by an unspoken am still a contributing member of society, and
contract to listen to everyone with full attention, I am not alone in dealing with chronic pain.= j
even if they9d heard the same words before. <I
called a suicide hot line today,= a woman named Yudhijit Bhattacharjee has been a contributing
Jane said. She suffers from fibromyalgia and writer since 2017. He is the author of a nonfiction
complex regional pain syndrome, among other thriller, The Spy Who Couldn’t Spell. David
Guttenfelder, Robert Clark, Robin Hammond,
issues. <I9ve complained to my friends so much and Craig Cutler are frequent contributors.
that I don9t want to call them anymore.= Mark Thiessen is a staff photographer.

A WO R L D O F PA I N 69
 O
ne thing you should know,= one man advised me. <No one on this street
imagined they would end up like this. Every person here thought they had
it under control.= That street could be anywhere in addicted America. This
one is Kensington Avenue, a bleak stretch that runs beneath the elevated
tracks in Philadelphia. I went there to witness the opioid crisis, to under-
stand how people seeking relief from pain had ended up on the street.
I9ve seen extreme misery in wars and natural disasters, but I was stunned by
what I found in my own country. The rules of society seemed to have vanished.
What remained was a raw struggle for one thing: the rush of relief from pain.
In Philadelphia 1,116 people died from a drug overdose in 2018, more than twice
the number ûve years earlier, and eight out of 10 of those deaths involved opioids.
Hundreds of people live on the street. High, or searching for a high, they slump against
storefronts, they drift through parking lots. Many are emaciated, weak, scarred from
shooting up. Desperate, they pierce their arms, ankles, necks with needles.
Fernando Irizarry (far left) lives on this street. He is 33, small and thin, with a dark
beard. He walks with dioculty, shuning on atrophied legs. He is funny, thoughtful,
and kind, but distracted, searching constantly for discarded bottle caps used to mix
drugs. When he collects enough of them, he scrapes together the dregs for his next shot.
On September 11, 2005, he hit the back of a car on his motorbike. As a kid, he9d loved
school. The strongest substance he9d tried was chewing tobacco. After months in rehab,
he was discharged on Percocet. When his family physician passed away, his new doctor
refused to renew his prescription. He found the pills on the street. But there, he could
pay $10 for two or $5 for a shot of stronger heroin. <That was the choice I made.=
At ûrst I was intimidated, unsure how to approach people. When I did, though, their
stories were familiar. Stories about their pain, but also about college days, fulûlling jobs,
LEFT
loving families, plans for the future. On cracked screens of mobile phones, I saw evidence
Fernando Irizarry’s of their former lives. And I saw them cling to the vestiges. Recalling her days as a dancer,
addiction began with
pain medications he a young woman, bone thin, took of a boot and performed an en demi-pointe pirouette.
took after an acci- The opioid addicts I met are our children. They are our mothers and fathers. They
dent. He invited me are college students and professionals. Enduring a chronic illness or striving to recover
to observe his life on
Kensington Avenue, from an accident, they could be any one of us.
and I spent two days
with him. Unable to find
a usable vein in his arm,
bruised from repeated
injections, he asked an
acquaintance to inject
a slurry of discarded
drugs into his neck.
On the street, addicts
often look out for each
other, administering
narcotics but also sav-
ing lives with Narcan,
an overdose-reversal
nasal spray.

RIGHT

Those I met could tell

me exactly how many
lives they’d saved with
Narcan. I would witness
an overdose, they
said, and I did. I found
this woman collapsed,
unresponsive, and
turning blue. A security
guard called 911, and
emergency medical
personnel revived her.
 The rules of society seemed to have va
What remained was a raw struggle for
one thing: the rush of relief from pain.

Seeking
relief from pain,
many Americans
get addicted
to prescribed
opioids and then
turn to heroin,
fentanyl,
or other drugs.
It’s a crisis
that touches
every part of
the country.
On Philadelphia’s
Kensington
Avenue,
the misery
of lives
derailed by drugs
is in plain sight.

S T O R Y A N D P H O T O G R A P H S B Y D AV I D G U T T E N F E L D E R
anished.

CLOCKWISE
FROM TOP LEFT
I talked with this
woman about her life
on the streets and
looked at photos of
her from an earlier
time. After she woke
up against a wall where
she’d been dozing,
I watched her peer into
a mirror shard to apply
mascara. I caught a
glimpse of the woman
in those old photos.

This young man told

me he started using
Percocet when he
was about 18 and then
switched to heroin.
He was jailed for steal-
ing to pay for his habit.
His mother lives nearby,
but, starting to cry, he
told me he couldn’t go
home while he was still
using. “I don’t want her
to see me like this.”

Kensington Avenue
runs for many shad-
owy blocks under
the elevated tracks
of the rapid tran-
sit system. The cross
streets, like this one,
thread through one
of the city’s poorest
neighborhoods.

Volunteers from many

organizations seek to
help those who are
addicted. On this
day, members of The
Table Philadelphia,
a Christian community,
pray after distributing
food and drinks to
the homeless.
 Women’s
health and
wellness
concerns are
dismissed and
politicized
more than
men’s and
researched
and prioritized
less, says
this female
physician.
Her Rx for
changing that:
Women must
speak up.

BY

ZOANNE CLACK
I L LU ST R AT I O N S
BY B I A N C A
BAG N A R E L L I HOW WOMEN’S HEALTH
 JA N UA RY 2 0 2 0

WELLNESS
ISSUE

GETS SHORTCHANGED
77
 Women S AN EMERGENCY MEDICINE PHYSICIAN
A Century of since the mid-1990s, I9ve cared for all sorts
Change of patients: old and young, rich and poor,
A YEARLONG male and female. I9ve also observed the
SERIES
companions who arrive with the patients,
as they scramble to handle this health
crisis amid work, family, and financial
obligations. Often that burden lands
chieüy on women, doing double, triple,
quadruple duty to care for children, part-
ners, parents, and other loved ones. It9s a
global phenomenon: The Organization for
Economic Cooperation and Development
says the world9s women spend more than 1.1 trillion hours a
year on unpaid care of children and the elderly. Men spend
about a third as much.
As an executive producer on the television drama Grey’s
Anatomy, I write these women into scripts. They are mothers,
partners, wives, sisters, daughters, CEOs, and secretaries. The
woman who just had a baby, thinks she has a blocked milk duct,
and ûnds out too late that it9s breast cancer.1 The woman who
doesn9t want to admit to being raped because she thinks she9ll
be blamed for being where she was or wearing what she wore.
They9re women who have a terminal illness, or need an
organ transplant—and have to break it to their daughters.
Women confronting their sexuality head-on; getting pregnant
at older ages and choosing alternate paths to motherhood, or
being childless by choice. Women with brain tumors, men-
tal illness, and depression; women with no insurance, and
women who could buy the world.
I write these women because I see these women. Because
I am these women. I am ûrmly stuck in the <sandwich gen-
eration,= taking care of an aging mother and three young
children. Working full-time. Juggling schools, schedules,
extracurricular activities, babysitters, deadlines, caregivers,
and professional goals, all while trying to have a semblance
1. BREAST CANCER
of a social life. I am a physician, I am a writer, I am a mother,
Cancer cell I am a single woman. I am everywoman, we are multitudes—
conversion
and we are frequently, quietly, overwhelmed.
Sometimes breast cancer
cells avoid medical treatments If this is the script of so many women9s lives, how do we
by drifting away from tightly
packed tumors and changing
ûnd the means to nurture health and wellness?
their internal machinery. There9s plenty to fault in the medical care, treatment,
They then resemble adult
stem cells and can travel
research, and support that are available to the female half
in the body and start new of humanity. But there also are reasons for optimism, in dis-
tumors elsewhere. By using
existing drugs that target coveries and advances that show real promise for girls and
these tumor turned stem cells women. I9m especially hopeful when I see us do the single
in mice, a team of biomedical
researchers redirected their best thing we can do to promote well-being: Speak up!
development so they became More women need to open their mouths and talk. About
harmless fat cells. The treat-
ment has shown the potential their miscarriages or their infertility or their contraception
“to repress tumor invasion
scares. About their cancer or their heart disease. About
and malignant progression,”
as scientists from the Uni- depression. Anxiety. Weight. Eating disorders. Alcohol
versity of Basel, Switzerland,
reported in the journal Cancer
abuse. Prescription drug abuse. Domestic violence. The
Cell. —T H E R E S A M A C H E M E R stigma attached to such conditions keeps many of us silent.

78 N AT I O N A L G E O G R A P H I C
But without loud-and-clear advocacy, the research will not
get funded and the policies will not get overhauled. It9s only
by ûnding our voices that we can strengthen each other and
grow together into a force for healthy change.

obviously I9m a storyteller. I adapt

I N M Y RO L E A S A W R I T E R ,
real women9s stories to fashion characters9 stories; they9re the
everywomen who appear in my TV show9s plots and in this
essay. It9s my belief that good physicians also must be good
storytellers. I practice what9s known as narrative medicine,
which means essentially this: intently listening to a patient9s
story, reading the story the patient9s body tells, and using
both to craft a narrative for diagnosis and treatment. 2. HEART ATTACK

Take the story of Meredith, for example. She9s a surgeon, a Gender and
widow with three young children, and manages to not only win resuscitation
When women suffer cardiac
accolades professionally but also spend time with her children arrest in public settings,
and have a social life. She went to medical school in the early they’re less likely than men
to have bystanders attempt
2000s, when not even half the entering students were women. resuscitation—and more
By 2018, 52 percent of those enrolling were women—progress! likely to die, according to
a study conducted in the
More broadly, by 2017, women earned 57 percent of bachelor9s Netherlands and published
degrees, 59 percent of master9s degrees, and 53 percent of doc- in the European Heart Jour-
nal. One probable reason:
torates in the United States, the National Center for Education Bystanders who see a woman
Statistics reports. That9s truly progress, because the number collapse don’t realize she’s
having a cardiac arrest
one element of improving health care is educating women. (heartbeat that gets fast
and irregular, then stops)
Even with Meredith9s advanced degree—and though she and so don’t call for help or
introduces herself with the title doctor, wears the white coat, try a defibrillator to restore
normal rhythm. As a result,
and sports a visible stethoscope—she9s regularly referred men have about twice the
to as nurse while going about her hospital business. And if chance that women have of
living long enough to get
there9s a male medical student in the room when she makes out of the hospital.
rounds, patients will often tell their story to him instead of — P AT R I C I A E D M O N D S

her. Stereotypes and bias are a real part of women9s lives, and
3. PAIN MEDICATION
gender bias is a real problem in medicine.
Women’s pain
Another example of that is Miranda—a successful surgeon, undertreated
having made it through the glass ceiling to become chief of For decades, studies have
surgery at her hospital. She9s on her second marriage because found that women are signifi-
cantly more likely than men
her ûrst husband couldn9t understand the demands of her job to be undertreated for pain.
1989: Research on a group
(a common refrain for professional women). She goes into a
divided evenly between
hospital complaining of the nonspeciûc symptoms that often men and women found that
in the three days after they
signal a heart attack in women2—more subtle symptoms than had coronary bypass surgery,
men9s, such as upper abdominal pain, light-headedness, or the men were twice as likely
as the women to be given
unusual fatigue. Miranda is sure she is having a heart attack. narcotics for pain. 1996: A
(Spoiler alert: She is.) But when women—and especially 20-month study at a hospi-
tal emergency department
women of color—raise concerns about their health and found that among people
demand they be investigated, they are much likelier than men who reported acute chest
pain, women were less likely
to be brushed aside, not believed, even mocked into silence by than men to be admitted,
health-care professionals. According to author Leslie Jamison, and also less likely to be
given an exercise stress test
whose writings include the essay <Grand Uniûed Theory of at a follow-up visit. 2008:
Female Pain,= women9s pain3 often is <perceived as constructed Research by a female emer-
gency room doctor found
or exaggerated,= and women9s symptoms may be ignored or that when patients came to
the ER complaining of acute
treated less aggressively than male patients9 would be. abdominal pain, men waited
This dismissive attitude has consequences not only for an average of 49 minutes
before being given a pain-
women9s treatment now but also for the medical research killer, while women waited an
that will produce the cures of the future. Historically in the average of 65 minutes. — P E

W O M E N ’ S H E A LT H 79
80 N AT I O N A L G E O G R A P H I C
(male-dominated) medical profession, clinical trials were con-
ducted with male subjects; they were considered the <norm,=
and their reactions to a new drug were assumed to be represen-
tative of how both sexes would react. Women of reproductive
age were excluded <for safety reasons=; so were women in
general, to eliminate hormonal diferences as a factor in the
research. In 1993 the U.S. National Institutes of Health called
for women to be included in more trials. In 2016 a medical
journal analysis found that clinical trials were including more 4. HEALTH AND SAFETY

women, but not always in numbers representative of the female Drug effects differ
Some of today’s most com-
population. It also found that the research didn9t always involve monly used drugs produce
<sex-speciûc analysis of the safety and eocacy= of a product. different effects, and side
effects, in women than in
We need women-speciûc research to help address difer- men—a variability not always
ences in biology, and discrepancies4 in health outcomes, considered by prescribers or
communicated to patients.
between women and men. Women are more likely to be For example, Americans
diagnosed or living with chronic diseases and/or immune had been using the popu-
lar prescription sleep drug
diseases; in the United States, 38 percent of women have one zolpidem (sold under names
or more chronic diseases compared with 30 percent of men. including Ambien) for more
than 20 years when the
Coronary artery disease causes more severe impairment and Food and Drug Administra-
tion announced in 2013 that
more deaths in women than in men (but greater research what had been the recom-
funding is devoted to studying it in men). New drugs and mended dose for both sexes
was actually twice as much
products come on the market ostensibly for women9s ben- as women should take. Sim-
eût, but some actually harm women.5 This suggests a need ilarly, research has shown
that women have a 1.5 to 1.7
for more research and testing, with women playing a role as times higher risk of adverse
subjects and as decision-makers. drug reactions than men do.
For instance, women experi-
ence liver failure caused by
who turn up at hospital emer-
I N C E RTA I N G I R L S A N D WO M E N acetaminophen (the active
ingredient in the over-the-
gency departments, physicians see health problems that counter analgesic Tylenol)
more often and more
probably are treatable. But the social and cultural crises that
severely than men, because
complicate these patients9 lives often seem to defy resolution. men’s livers have a greater
capacity to metabolize acet-
Jo is so frightened of her past that she has run away from aminophen safely. — P E , T M
it, changed her name, and disguised her identity. She was a
victim of intimate partner violence so severe that she was hos- 5. HEALTH AND SAFETY

pitalized multiple times and feared for her life. Emergency Banned birth control
physicians see plenty of domestic violence victims, some with Nearly 47 million women
in the United States ages
bruises and broken bones, others with unseen scars. But Jo9s 15 to 49 use contraception,
not a patient; she9s a physician on the hospital staf. She belies but not every method
available to them has been
the common misconception that domestic violence occurs reliable or safe. In 2002, the
mostly in poor, uneducated households. The reality is that on FDA approved a permanent
birth control product called
average in the United States, about 20 persons every minute Essure, a metal device that
is inserted into the fallopian
are abused by an intimate partner. And worldwide, domestic tubes, where the body cov-
violence is the leading cause of injury to women—more than ers it with scar tissue. After
about three months, this
accidents, muggings, or assaults by strangers. creates a permanent block-
Nadia is a 10-year-old girl who is outside an emergency age so an egg cannot pass
from the ovary to the uterus.
department, alone and apparently in pain, when a stranger The FDA has received more
alerts the doctors. An exam shows the girl has a large abdomi- than 26,000 reports of side
effects attributed to Essure,
nal tumor and needs emergency surgery. Hospital staf is about including pelvic pain, aller-
to summon child protective services when the <stranger= con- gic reactions to nickel, device
breakage, and pregnancy.
fesses: She is Nadia9s mother, afraid to show herself because By the end of 2018, Essure use
of her undocumented status. This fear of deportation is also was considered a possible
factor in 15 women’s deaths.
why she waited so long to get Nadia examined. Because of the Sales of the product ended in
the United States in Decem-
delay, the procedure is much more costly (both physically and ber 2018; a study of its long-
ûnancially) than open and preventive medical care would be. term effects is ongoing. —T M

W O M E N ’ S H E A LT H 81
 Today9s immigration crises have no simple remedies. But
when undocumented U.S. residents lack access to preventive
medicine and care, they bring all their care needs to emer-
gency departments—where use by the uninsured costs about
$38 billion a year more than non-emergency care would.
Uninsured patients sufer from lack of health-care access,
and a woman9s risk of being uninsured increases if she has a
low income or is Hispanic/Latina. Women living in rural com-
munities are more likely than women in other areas to struggle
with poor health; they have limited access to mammograms
and other screenings, and maternity care, because only 6 per-
cent of the nation9s ob-gyns work in rural settings.
Other factors discourage women from accessing the sys-
tem. Although the Afordable Care Act attempted to lower
ûnancial barriers, seeking care still takes money—for child-
care, transportation, and out-of-pocket costs. That can be
prohibitive for women because they often earn lower wages,
have fewer ûnancial assets, and have higher rates of poverty
than men. In the United States, a woman also is statistically
likelier than a man to be covered by health insurance as a
dependent and is thus at greater risk of losing coverage if
she then is widowed or divorced or if her policy-holding
spouse or partner becomes unemployed. For these reasons
and more, about one in four U.S. women has had to delay or
forgo health care in the past year because of costs, a Kaiser
Women9s Health Survey found.

with one
I N T H E Q U E ST F O R W E L L N E S S , WO M E N C O N T E N D
variable that men do not: a reproductive system designed
to bear ofspring. Whether or not they ever give birth, most
women are equipped to do so for some portion of their lives.
Depending upon circumstances, that can become a blessing,
a burden, a political football, a societal issue. Ultimately, it9s
6. INFERTILITY the most personal health issue of all.
Factors affecting Arizona is a pediatric surgeon who loves kids and wants
male fertility to have her own with her same-sex spouse. Fortunately for
If a woman is unable to get
pregnant after one year of
them, and for singles and couples who need help to conceive,
trying, she and her partner there are options, including surrogacy, embryo donation, egg
may be facing infertility.
In the United States, about donation—and sperm donation, a global industry valued at
8 percent of infertility cases about four billion dollars. Arizona and her partner decide on
are caused by a male fac-
tor alone. Risk factors for sperm donation. She has an IUI (intrauterine insemination)
male infertility include obe- and is elated when her pregnancy test is positive. Unfortu-
sity and substance use, but
some risks are beyond an nately, on her ûrst ultrasound, there is no heartbeat.
individual’s control. A study Infertility6—not being able to get pregnant or to sustain
conducted in Sweden found
that men with fathers who a pregnancy—afects about 10 percent of U.S. women ages
smoked had a 50 percent
lower sperm count than
15 to 44 (some 6.1 million women), according to the Cen-
those with nonsmoking ters for Disease Control and Prevention. But the good news
fathers. And while men can
avoid the high temperatures
about infertility is that the majority of cases can be treated
of hot tubs, climate change by conventional therapies such as surgery or medication
may also pose a risk. A 2018
study in beetles found that (and only 3 percent require the use of in vitro fertilization, or
one heat wave reduced IVF). Compared with decades ago, there9s much more hope.
sperm production by about
75 percent, but females What of the women who don9t want children yet? Or ever?
were not affected. —T M Roughly 60 percent of U.S. women ages 15 to 44 years use

82 N AT I O N A L G E O G R A P H I C
a contraceptive method, the Guttmacher Institute reports.
And of women in that age range, the abortion rate in 2017 was
13.5 abortions per thousand—the country9s lowest rate ever.
Cristina is a take-no-prisoners kind of person who proclaims
herself <childless by choice.= Even when she was married to a
man she deeply loved, and he wanted a child, she stayed true
to herself (at the price of the marriage). She aligns with the
growing wave of women who, for a variety of reasons, are vol-
untarily child free—a decision as valid as the opposite choice.
Then there are the postponers, those who want to wait to
bear children after a career or for other reasons. My advice
to them: Look at what the current generation of older, pro-
fessional women has gone through. Women who wait too
long have a much harder time getting pregnant (and it gets
very expensive—the average cost of a single IVF treatment is
around $12,000). Even with my medical training, I looked at the
age-at-conception statistics and somehow thought they didn9t
apply to me. Certainly I9d be like the people in the media, or the
television characters I write for, who get pregnant at the drop
of a hat no matter their age. Guess what? Wrong!
Here9s the truth: A woman9s best reproductive years are
in her 20s. Fertility gradually declines in the 30s, as both the
quality and quantity of her eggs decrease. Each month that
she tries to get pregnant, a healthy, fertile 30-year-old woman
has a 20 percent chance of doing so. By age 40, a woman9s
chance is less than 5 percent a cycle.
This is why I9m a strong advocate of fertility preservation7
via egg or embryo freezing, to avoid <panic parenting= moves
such as entering into unwise relationships just to have a child.
Izzie, a surgical resident struggling to beat stage 4 melanoma,
has her eggs removed to preserve future fertility if she sur-
7. TECHNOLOGY
vives her treatments. Others use the technology in less dire
‘Femtech’ tools and
circumstances. Yes, egg and embryo freezing are expensive childbearing choices
processes, and not a guarantee, but they do ofer a choice. For women struggling with
Think of them as investments in your future life! infertility or maternity issues,
a fledgling “femtech” indus-
For those who have the desire and have timed everything try is developing new devices
and services. Computer apps
right, there9s the joy of pregnancy and birth. But even these
and wearable monitors track
happy times can be scary. Karen is a quirky woman married a woman’s fertile periods—
or, once she’s pregnant, her
to the love of her life, a paramedic who rushes to her bedside unborn baby’s development.
when she is in labor. He gets there in time to witness the birth A cloud-based company
offers all-in-one clinical and
of their baby girl, and it9s a happy day for all until Karen starts financial plans for patients
feeling some pain that doesn9t seem right. She begins bleeding having IVF or egg freezing.
Increasingly, would-be
profusely so is taken to the operating room, where doctors per- parents get embryos or gam-
form a hysterectomy. After the operation, she sufers multiple- etes tested for chromosomal
abnormalities before decid-
organ failure and has a cardiac arrest from which she does not ing whether to use them.
recover. Karen dies of pre-eclampsia, a high blood pressure In a U.K. study reported last
year in Human Reproduc-
disorder that can be treated if caught soon enough. tion, about a third of patients
who chose to test expressed
Maternal mortality statistics track what fraction of deaths some regret that they’d done
of women ages 15 to 49 are maternity related. From 2000 to so—especially if abnormali-
ties were revealed, but even
2017, maternal mortality decreased signiûcantly in the world if they weren’t. As a result,
overall—but increased in the United States. Many elements study authors suggested that
“additional counselling and
contribute to such increases; among them are obesity, chronic support” be offered in con-
conditions, socioeconomic factors, access to care, and having cert with testing. — P E

W O M E N ’ S H E A LT H 83
84 N AT I O N A L G E O G R A P H I C
children at older ages. Even so, the CDC estimates that about 8. ALZHEIMER’S DISEASE

60 percent of maternal deaths are preventable. And between Dementia

differences
white women and women of color, the discrepancy is stag-
Women outnumber men
gering, with black women three to four times as likely to die roughly two to one among
Americans with Alzheimer’s
from pregnancy or childbirth complications. disease, and scientists
Our health-care system has done a wonderful job of protect- are unraveling the factors
behind this disparity.
ing and improving the outcomes for newborns and preterm Lifestyle may play a role:
babies, but at the expense of ignoring the mothers. In 2018 Women who spent time in
the paid workforce show less
Congress took a step in the right direction, passing legislation memory decline than those
to fund and support states9 eforts to reduce maternal deaths. who didn’t. But physiological
factors also differ. The cog-
nitive tests used to catch the
JUST AS THEY’RE INTEGRAL when new lives enter the world, disease early are less effec-
tive for women because
women are guardians and anchors when long lives reach the they tend to have better
verbal memory than men,
end. Women tend to live longer than men (those 85 and older
and catching the disease
outnumber their male counterparts two to one). Many are later may lead to faster cog-
nitive decline. There are also
doubly exposed to health-care problems because they9re car- different genetic risk factors
ing for the young and the old in addition to themselves. Ellis for men and women. And
compared with men’s brains,
is an award-winning, intelligent, driven surgeon in the prime the connections in women’s
of her career when she is diagnosed with early onset Alzhei- brains might provide paths
for greater spread of
mer9s dementia.8 It ruins her career and eventually leads to protein plaques. —T M
the end of her life. Alzheimer9s disease disproportionately
afects women, on two levels. Almost two-thirds of adults 65
or older with the disease are women. And of the more than
16 million Americans who provide unpaid care to a person
with Alzheimer9s or other dementias, 66 percent are women.
As Americans over 65 become a larger share of the pop-
ulation, that almost certainly will mean more women with
Alzheimer9s and fewer younger women to be caregivers. It9s
one more reason to take a hard look now at our approaches to
health and wellness needs, and make improvements.
In 2015, United Nations member states agreed to try to pro-
vide basic health care for every child, man, and woman by
2030. Today, when hundreds of millions of people can9t ûnd
or aford health care, we9re a long way from that. But it9s a goal
worth ûghting for. Each of us can start by advocating for what
she personally needs, and what her family and community
and country will need, to live lives of health and well-being.
On Grey’s Anatomy a few seasons ago, Meredith Grey—the
Meredith I mentioned earlier—barely survives a brutal assault.
When she recovers, she ofers some powerful advice about the
importance of speaking up. I9ll give her the last word here:
<Don9t let fear keep you quiet. You have a voice, so use
it. Speak up. Raise your hands. Shout your answers. Make
yourself heard.= j

Physician Zoanne Clack is an executive producer on the ABC series

Grey’s Anatomy and has been one of the writers since the show
began in 2005. She’s also an adviser for all medical aspects of
the show. Clack completed a residency in emergency medicine,
has a master’s degree in public health, and spent a year at the
Centers for Disease Control and Prevention working in interna-
tional emergency medicine. She has one son and twin daughters.
National Geographic Partners and the ABC Television Network are owned
by The Walt Disney Company.

W O M E N ’ S H E A LT H 85
 JA N UA RY 2 0 2 0
WELLNESS ISSUE

Trillions of microbes call our body home.

THE MICROBIOME MENAGERIE

Now we’re learning they’re crucial for our health.

BY ROBIN MARANTZ HENIG

I M AG E S BY M A RT I N O E G G E R L I
Escherichia coli, the
yellow rods clustered
on a purple substrate,
can cause food poison-
ing, but most strains
are not only harmless,
they’re beneficial. E. coli
inhabit the human gut
and perform essential
functions, such as mak-
ing vitamins K and B12
and repelling disease-
causing bacteria.

87
FECES
The gut microbiome
flaunts its diversity
in this sample of
human feces, which
includes an enormous
bacterium that’s
about 50 times longer
than E. coli. Everyone’s
mix of microbes is
unique. Scientists are
learning the many
ways these microbes
affect our health,
weight, mood, and
even personalities.
 investigate the microbes

T
HE MORE SCIENTISTS
living inside us, the more they learn about
the surprising impact of these tiny organ-
isms on how we look, act, think, and feel.
Are our health and well-being really driven
by the bacteria, viruses, fungi, and protozoa
that live in our intestines, in our lungs, on
our skin, on our eyeballs? What a weird con-
cept—that the bugs we lug around appear to
be essential to establishing the basic nature
of who we are.
The efects of the microbiome, this menag-
erie of microorganisms, can be profound—and can start
incredibly early. In a study published last year, scientists
showed that something supposedly as innate as a child9s
temperament might be related to whether the bacteria in
an infant9s gut are predominantly from one genus: the more
Bifidobacterium bugs, the sunnier the baby.
This observation, from Anna-Katariina Aatsinki and her
colleagues at the University of Turku in Finland, is based
on an analysis of stool samples from 301 babies. Those with
the highest proportion of Bifidobacterium organisms at two STREP
months were more likely at six months to exhibit a trait the Streptococcus pneu-
researchers called <positive emotionality.= moniae, shown dividing
into daughter cells, can
Microbiome science is still relatively young. It9s been just cause serious illnesses,
15 years since the research took of in earnest, which means such as meningitis and
most studies to date have been preliminary and small, involv- pneumonia, but like E.
coli, some Streptococ-
ing only a dozen or so mice or humans. Scientists have found cus species are harm-
associations between the microbiome and disease, but can9t less. The bacteria are
yet draw clear cause-and-efect conclusions about our vast found on the skin and
in the mouth, respira-
critter inventory and what it all means for us as hosts. Still, tory tract, and gut.
the inventory itself is mind-boggling—it9s now thought to be
around 38 trillion microbes for a typical young adult male,
slightly more than the number of actual human cells. And
the prospects for putting that inventory to use are tantalizing.
Behind the Images
In the not-too-distant future, according to the most enthu- Martin Oeggerli made these
siastic researchers, it might be routine to deliver a dose of images with a scanning elec-
tron microscope. The samples
healthy microbes in the form of prebiotics (compounds that were dried, coated with gold,
act as a substrate on which beneûcial microbes can grow), and placed in a vacuum cham-
ber. The microscope’s electron
probiotics (the beneficial microbes themselves), or fecal beam has a shorter wave-
length than visible light and
transplants (microbe-rich feces from healthy donors)— can capture smaller objects,
helping us realize the promise of operating at top form, but without color. When the
color of a microbe is known,
from the inside out. Oeggerli uses it. If not, he
When we talk about the microbiome, we9re talking primarily chooses colors to discriminate
between types of microbes
about the digestive tract, home to more than 90 percent of a and their features.

90 N AT I O N A L G E O G R A P H I C
LIPS
Moist lips are rich in
microbes. A woman
pressed her mouth on
a petri dish to let her
microbiome grow, and
grow it did. Days later
a colony bloomed.
People who often kiss
each other will develop
similarities in their
oral microbiomes.
body9s microorganisms. But other regions are of Luxembourg published a study of 13 babies
also crawling with life. Microbes colonize wher- born vaginally and 18 by C-section. He and his
ever the inside of the body meets the outside: colleagues analyzed the microbes in the stool
eyes, ears, nose, mouth, vagina, anus, urinary of the newborns and their mothers, as well as
tract. There are also microbes on every inch of vaginal swabs from the mothers. C-section
skin, with high concentrations in the armpits, the babies had signiûcantly lower levels of bacte-
groin, between the toes, and in the belly button. ria that make lipopolysaccharides, which are
And here9s the really amazing thing: Every a primary stimulus of the developing immune
one of us has a particular mix of microbes system. The reduction lasted for at least ûve days
that9s different from everyone else9s. Based after birth—enough, Wilmes believes, to have
on current observations, it9s possible for two long-term consequences for immunity.
individuals to have zero overlap in the micro- Eventually, usually by the ûrst birthday, the
bial species of their microbiomes, says Rob microbiomes of C-section babies and vaginally
Knight of the Center for Microbiome Innova- born babies are pretty much the same. But
tion at the University of California, San Diego. Wilmes thinks the diferences he observed in
The unique nature of microbiomes might even the ûrst few days of life mean C-section babies
have forensic applications, he says. <We can might be missing a period of <priming,= when
track objects or surfaces people touch back to immune cells are set up to respond appropri-
that person by matching the skin microbiome ately to foreign agents. The scantier microbial
traces.= Maybe someday police investigators populations of C-section babies during these
will go through crime scenes taking samples initial days could explain why they are more
of skin microbes, much the way they now dust prone to a host of immune system problems
for ûngerprints. later on, including allergies, inüammatory dis-
Here are some highlights of what scientists eases, and obesity.
are learning about how the microbiome afects Wilmes says one day it might be possible for
us across our life span, from infancy to old age. babies born by C-section to be given probiotics
derived from speciûc strains of bacteria found in
their mothers, which would, in theory, seed their
intestines with helpful microbes. Such probiotic
INFANCY therapy is still far in the future, though.

THE FETUS IN UTERO lives essentially microbe

free. Then it squeezes down the birth canal,
where it confronts a riot of bacteria. During a vag-
CHILDHOOD
inal delivery, the baby is awash in microbes that
live in the vagina; it9s also exposed to the mother9s so widespread
F O O D A L L E R G I E S H AV E B E C O M E
gut bacteria as its face passes by her perineum that many schools restrict what lunches kids can
and anus. These maternal gut microbes imme- bring from home, like peanut butter and jelly
diately start to colonize the newborn9s own gut, sandwiches, for fear of setting of a classmate9s
engaging in a kind of conversation with devel- allergic reaction. In the United States, 5.6 million
oping immune cells. In this way, the very early children sufer from food allergies—which trans-
microbiome prepares the immune system for lates to two or three in every classroom.
healthy functioning later in life. Many factors are thought to account for this
When a baby is born by cesarean section, rise, including an increase in C-section births
though, it misses out on this exposure. Its gut and an overuse of antibiotics, which can wipe
is seeded with diferent microbes—not those out protective bacteria. Cathryn Nagler and
from the mother9s gut and vagina, but from her her colleagues at the University of Chicago
skin and breast milk, the nurse9s hands, even the wondered whether the rise in childhood food
hospital bedding. These early diferences might allergies might be linked to the microbial mix
have implications that last a lifetime. in children9s guts. Last year they published a
In 2018 Paul Wilmes of the Luxembourg Cen- study of eight six-month-old babies, half of
tre for Systems Biomedicine at the University whom were allergic to cow9s milk, half of whom

94 N AT I O N A L G E O G R A P H I C
were not. The microbiomes of the groups were stool than those who didn9t develop diabetes.
quite diferent, they discovered: The healthy One of the scientists involved in the study,
babies had the bacteria expected in typically W. Ian Lipkin of the Columbia University
developing babies their age, while the babies Mailman School of Public Health, cautions
with a cow9s milk allergy had bacteria more researchers against rushing to explain dis-
characteristic of adults. eases—whether diabetes or any other—by dif-
In the allergic babies, the normally slow pro- ferences in the microbiome alone. <This is still
gression from an infant microbiome to an adult largely a descriptive science,= he says; all that9s
one took place <at warp speed,= Nagler says. known for sure is that certain microbes are asso-
Using fecal samples, Nagler and her col- ciated with certain conditions.
leagues transplanted gut bacteria from the Even with this caveat, Lipkin is excited about
babies in her study into germ-free mice—mice where microbiome science might lead. He
born by C-section and raised in sterile condi- expects that in ûve or 10 years, scientists will
tions so they had no microbes at all. When the understand the mechanisms of how the micro-
mice received transplants from healthy babies, biome afects the body and will have begun clin-
they received protective bacteria that prevented ical trials on human subjects to demonstrate the
an allergic response to cow9s milk. But when the health impact of altering it. Once microbiome
transplants were from allergic babies, the mice science <becomes mechanistic and testable,= he
didn9t get the protective bacteria and had an says, <then it will become real.=
allergic response.
Further analysis showed that one species of
bacteria in particular that9s unique to human
infants—Anaerostipes caccae, from the Clos-
tridia class—seems to have been most relevant
ADOLESCENCE
in protecting the ûrst group of mice. This species
was from the same family within Clostridia that in developed
T H E VA ST M A J O R I T Y O F T E E N AG E R S
Nagler9s team had identiûed in an earlier study countries are pimple-prone—and for them, there
as protective against peanut allergy. does seem to be such a thing as an <acne micro-
Nagler, who is president and co-founder of biome.= Many kids have skin that9s especially
the Chicago-based drug start-up ClostraBio, hospitable to two strains of Cutibacterium acnes
hopes to test the therapeutic potential of these (until recently called Propionibacterium acnes)
bacteria in lab mice—and eventually in allergic that have been closely linked to acne. Most
patients. The ûrst challenge has been ûnding strains of this bacterium, despite the acnes in
somewhere in the gut for the beneûcial bacte- its name, are either harmless or helpful, keep-
ria to land. Even in an unhealthy microbiome, ing pathogenic microbes at bay; in fact, C. acnes
Nagler says, all the niches are already ûlled; for is the predominant component of the normal
Clostridia to go in, something else has to come microbiome of the face and neck.
out. So ClostraBio developed a drug that clears But having a bad-guy strain of C. acnes can
out a niche in the microbiome. be a problem. It9s one of the elements needed
Nagler and her colleagues have been giving for acne to arise, says Amanda Nelson, a der-
the drug to mice and then infusing them with matologic researcher at Penn State University
a variety of Clostridia bugs, along with dietary College of Medicine. The others are sebum (the
ûber that encourages their growth. She hopes oil produced by sebaceous glands to keep the
to begin clinical testing on a Clostridia treat- skin moist), which C. acnes uses as a food source;
ment in humans within the next two years, with plugged-up hair follicles; and an inüammatory
the eventual goal of giving it to children with response. These four factors work in concert,
food allergies. Nelson says, adding, <We actually don9t know
Gut microbes also might be related to other what happens ûrst.=
childhood diseases, such as type 1 diabetes. In The acne microbiome was the focus of a study
Australia scientists collected stool samples from at Washington University School of Medicine
93 children with a family history of type 1 diabetes in St. Louis, where researchers found that the
and found that those who went on to develop the only acne treatment leading to long-term remis-
disease had higher levels of enterovirus A in their sion—isotretinoin, sold as Accutane and other

THE MICROBIOME MENAGERIE 95

SMELLY FEET
Cultured from damp
feet, these bacteria,
attached here to a fiber,
thrive in sweat, which
is odorless. But when
sweat collects, it creates
a breeding ground for
odoriferous microbes.
More sweat glands are
concentrated on our
palms and on the soles
of our feet than any-
where else.

NEXT IMAGE

BELLY BUTTON
A half dozen types of
microbes predominate
in the navel. But many
other species of bac-
teria and fungi are also
found there. Like the
microbiome inside, the
microbes outside vary
from person to person.
THE MICROBES WITHIN 38 trillion
Approximate number* LARGE
INTESTINE

GUT INSTINCTS
Our bodies host trillions of microbes, a collection of
bacteria, fungi, and protozoa that starts developing at
birth and is unique to each of us. These microorganisms
can communicate with our brains to regulate bodily
functions and even influence our mood, as well as
chronic conditions such as anxiety, through chemical
communication pathways known as the gut-brain axis.

HOW THEY
COMMUNICATE
VIA BLOODSTREAM
AND NERVES
Chemicals released by
microbes into nerves or the
bloodstream influence brain
areas that deal with memory.
Chemicals in the bloodstream
can also signal the limbic
system—a brain area that
processes emotion and stress—
to change our moods. The vagus nerve
supports pathways of
the parasympathetic
nervous system, which
THROUGH THE helps to promote a
VAGUS NERVE state of equilibrium
Sensory neurons receive chem- in the body.
ical signals from gut microbes
and relay them up this pri-
mary signaling path between
gut and brain. The brain sends
back signals that modify
function, such as tempering
an inflammatory response Spinal
so the gut will keep working cord
even if a person is sick.

USING THE
‘SECOND BRAIN’
Microbes can bypass commu-
nicating with the brain and
directly signal the enteric
nervous system—a meshlike
network of neurons in the
digestive tract, sometimes
called the second brain—to
independently influence gut
movements and secretions.

*BASED ON A TYPICAL MALE, 20-30 YEARS OLD AND WEIGHING 154 POUNDS
MONICA SERRANO, NGM STAFF; MESA SCHUMACHER. ART BY INTERVOKE. SOURCES: EMERAN A. MAYER, UCL
DIGESTIVE DISEASES; STEPHEN COLLINS, MCMASTER UNIVERSITY
 1 trillion 180 billion 100 billion 40 billion 9 million
D E N TA L SKIN S A L I VA SMALL STOM AC H
P L AQ U E INTESTINE

FRIENDS AND FOES

Microbes in mucosa can work
with us. But those floating free
inside the intestine tend to focus Free-
floa
more on their own survival, some- micro ting
times to our detriment, especially bes
if they’re harmful parasites.

Thalamus Intestinal depressions called Oute

r muc Gut
crypts provide a large surface us
area to absorb fluids and lining
interact with microbes.
Inner
Amygdala mucu
s
Free-floating
microbes

Hypothalamus

AREA
ENLARGED Epit
h
cell elial
bar
rier Ent crine
e roe ndo
cell rochro Ente
Crypt s m affin
cells

ic
drit
Den
cells

ron
s e)
Muc erv
osa Neu agus n
t o v
(
am
stre
Enteric od
Blo
nervous
system

The biggest community

of microbes, more than
90 percent of the body’s total,
thrives in our large intestine.

WHAT MICROBES CAN TELL US

WE NEED AN IMMUNE BOOST PUT DOWN THE FORK WE’RE HURT, OR HAPPY
Microbial disturbance in the gut lin- Scientists suspect that microbes get Microbes can trigger enterochro-
Enteric ing can be sensed by immune mes- enteroendocrine cells to release maffin cells, which hold most of the
nervous saging (aka dendritic) cells. They chemicals signaling the hypothala- body’s “happy chemical,” serotonin,
system can then activate other immune mus—the brain area that keeps our to signal the brain, influencing per-
cells or signal distress to the brain. body in balance—to tell us we’re full. ceptions of pain and well-being.

Microbes

Dendritic
cells
AREA
ENLARGED
Neuron
Enteroendocrine Enterochromaffin
Immune cells cells
system

Bloodstream
LA DIVISION OF
brand names—works in part by altering the skin Veillonella from one runner9s stool and infused
microbiome, reducing the number of C. acnes the bacterium into 16 mice with normal micro-
bacteria while increasing the diversity of the biomes that had been screened for pathogens.
skin microbiome overall. In this healthier, more Then they put the mice on tiny treadmills and
diverse environment, they found, it9s harder for had them run to exhaustion. They did the same
the bad strains of C. acnes to take hold. with 16 control mice, using a diferent bacterium
Now that scientists have learned that isotreti- that isn9t involved in lactate metabolism. The
noin works by changing the acne microbiome, Veillonella mice could run for 13 percent longer
they might try to develop microbial treatments than the control mice, leading the investigators
that have the same effect—treatments, they to conclude that the microbiome might play a
hope, that are safer than isotretinoin, which can critical role in physical performance.
cause birth defects if taken during pregnancy. Kostic says the experiment offers <a really
These alternatives can include what the Wash- elegant example of how symbiosis comes to
ington University researchers call <prebiotic happen.= The Veillonella benefits when the
fertilizers=—microbes that provide conditions muscles of the host, through exercise, generate
for a healthy skin microbiome to üourish—and the lactate it lives on. The host, in turn, beneûts
<strain-selective 8weed killers9 =—agents that because Veillonella turns lactate into propionate,
wipe out the deleterious strains of C. acnes while which enhances the capacity for exercise by,
allowing the beneûcial ones to remain. Also in among other things, increasing heart rate and
the mix, they say, might be probiotics, oral or oxygen metabolism, and possibly by reducing
topical supplements that contain direct doses muscle inüammation.
of beneûcial Cutibacterium strains. <This kind of relationship, I think, underlies
most human-microbiome relationships,= Kostic
says. <Ultimately, there9s this kind of mutualistic
relationship happening.=
A D U LT H O O D The microbiome might account for some
less advantageous traits too, including mental
states such as anxiety and depression. In 2016
W H AT I F YO U C O U L D G E T M O R Eout of your scientists at University College Cork in Ireland
workout just by transferring microbes from published a demonstration of the microbiome-
an athlete9s gut into yours? That9s the ques- depression link when they transplanted stool
tion scientists at Harvard University wanted from depressed humans into rats. Would the rats
to explore. They collected daily stool samples become depressed too?
over the course of two weeks from 15 runners The scientists divided 28 lab rats into two
in the 2015 Boston Marathon—starting one groups. The experimental rats received fecal
week before the race, ending one week after— transplants from a pooled preparation from
and compared them with daily stool samples three severely depressed male patients; the
taken for two weeks from a control group of 10 control rats got transplants of pooled feces from
non-runners. A few days after the marathon, the three healthy males.
scientists found, the runners had signiûcantly It turned out that getting fecal transplants
more Veillonella atypica bacteria in their stool from the depressed men made the rats depressed.
than did the non-runners. Compared with the controls, they exhibited a loss
<It set up a bit of a light bulb because of the of interest in pleasurable activities (as measured
unique metabolism of Veillonella, which uses in rats by how often they chose to drink sugar
lactate as its preferred source of energy,= says water), and increased anxiety (which in rats
Aleksandar Kostic, of the Joslin Diabetes Center means avoiding open or unfamiliar sections of
and Harvard Medical School. Lactate is gener- a laboratory maze).
ated by muscles during intense exercise. <That While acknowledging it9s a leap from rats to
got us thinking: Is it possible that the Veillonella humans, the scientists say their work adds to the
is metabolizing muscle-derived lactate in the evidence that the microbiome of the gut could
athletes?= And if it was, could infusions of Veil- play a role in how depression develops. Targeting
lonella help nonathletes perform better? these microorganisms, they say, might one day
Next they turned to lab mice. They extracted help treat depression and other mood disorders.

102 N AT I O N A L G E O G R A P H I C
 by an infusion of gut microbes from young
OLD AGE mice. It9s enough to make you wonder whether
a dose of youthful poop could be the secret to a
healthier old age.
and
T H E M I C R O B I O M E I S AT O N C E P E R S I S T E N T
ever changing. Your unique microbiome pro- is a hallmark of micro-
F E C A L T R A N S P L A N TAT I O N
file is pretty much set by age four, and only biome research in animals. It9s also one of the
signiûcant changes—altering diet or exercise main clinical interventions being studied for
routines, moving to a diferent place, changing people as a way to introduce microbes that could
the time spent outdoors, taking antibiotics or ûght a wide range of diseases.
certain other drugs—can really change it. But This is not mere speculation; fecal transplan-
in one sense, the microbiome is constantly in tation has been used for the past decade or so
üux, varying in tiny ways with every meal. And to treat recurrent infections of drug-resistant
throughout adulthood it changes along a pre- Clostridium diocile, a severe, potentially fatal
dictable course—so predictable, in fact, that it9s intestinal infection. About 12,000 to 15,000
possible to estimate your age just by looking at medically supervised fecal transplants are done
your gut microbes. each year in the U.S. alone, according to Colleen
This handy trick, known as a <microbiome Kelly of Brown University, co-chair of the Fecal
aging clock,= involves artiûcial intelligence, as Microbiota Transplantation National Registry.
demonstrated recently at the Hong Kong-based Generally the results are good, but last June
start-up Insilico Medicine. The scientists gath- the FDA reported the death of one patient from
ered information on the microbiomes of 1,165 an infection after a transplant performed with
people in Europe, Asia, and North America from feces that had not been adequately screened for
publicly available data sets. Roughly one-third drug-resistant bacteria.
of the samples were from people in their 20s and Besides fecal transplants, scientists are study-
30s, one-third from people in their 40s and 50s, ing other methods of manipulating our micro-
and one-third from people ages 60 to 90. The biome, including prebiotics, probiotics, and
scientists put the age-tagged microbiomes of changes in diet or exercise that might alter the
90 percent of the subjects through a round of mix of microbes in the gut. But even the biggest
machine learning; then they applied the pat- boosters of microbiomics say it9s hard to draw
terns found by AI to the other 10 percent of the conclusions yet about the connection between
microbiomes, untagged, to see if they could the microbiome and human health, and they
determine the ages. The microbiome aging clock urge caution about rushing into therapies.
came up with a suggestion that was accurate to <There9s a lot of excitement around fecal
within four years of the actual age. transplantation and the development of the
What does this say about the physical changes microbiota as drugs,= says the University of Lux-
that occur with age, in particular weakened embourg9s Wilmes, noting that companies are
immunity, systemic inüammation, and frailty? working on new probiotics to <restore an imbal-
Researchers at Babraham Institute in Cambridge, anced microbiome to one that would be in equi-
England, tried to ûnd out using fecal transplants. librium to the host.= Which is all very well—as
They knew the immune system functions more an ecologist himself, Wilmes knows the value of
poorly with age, and they wondered whether <restoration ecology= in the environment—but
transplanting feces from young mice into old it9s a bit premature.
mice would have a restorative efect. <Before we are able to really properly and
Before the transplant, the old mice showed a rationally do this,= he says, <we need to under-
signiûcant decline in the immune reaction of stand what really constitutes a healthy micro-
cell masses lining the small intestine known as biome and what are the functions that the
Peyer9s patches. When the old mice were given microbiota confer to the human host. I don9t
fecal transplants from young mice, the immune think we9re there yet.= j
response of their Peyer9s patch cells reverted
to a more youthful state. Apparently, the scien- Robin Marantz Henig is a journalist based in New
York City and the author of nine books. Martin
tists concluded, the sluggish immune reaction Oeggerli, a Swiss molecular biologist, specializes
in old mice is reversible; it can be <rescued= in capturing the beauty of the microscopic world.

IMAGES WERE MADE WITH THE SUPPORT OF THE INSTITUTE OF PATHOLOGY, UNIVERSITY HOSPITAL OF BASEL, SWITZERLAND; CENTER FOR
CELLULAR IMAGING AND NANOANALYTICS, BIOZENTRUM, UNIVERSITY OF BASEL; AND THE SCHOOL OF LIFE SCIENCES, FHNW, MUTTENZ.
 OKINAWA
Yoshiko Shimabukuro,
the 91-year-old founder
of the Daiichi Hotel,
drinks miso soup for
breakfast. She and
her daughter Katsue
FOODS
Watanabe specialize
in creating elaborate
plant-based meals that
feature some 50
local ingredients.
DAVID MCLAIN

TO
JA N UA RY 2 0 2 0
WELLNESS ISSUE
 Traditional diets
with whole grains,
greens, nuts,
and beans offer
the promise of
eluding disease and
staying healthy.

BY

DAN BUETTNER

LIVE BY 105
M have passed since
MORE THAN 14 YEARS
Dan Buettner ûrst wrote about the world9s
longest-lived people for the magazine.
Today he9s still uncovering the secrets of
centenarians in regions he calls the blue zones. He recently returned
to four of them to learn more about the foods that contribute to this
remarkable longevity, collecting time-tested recipes and investigating
why certain foods seem to promote long lives.

HOME TO THE WORLD’S

HIGHEST CONCENTRATION OF
MALE CENTENARIANS SARDINIA, ITALY
Carbohydrates from Sardinian sourdough bread enter the bloodstream
at a slower rate than those from plain white bread.

ITALY
vigorously stirs an
N I N E T Y- N I N E -Y E A R- O L D A S S U N TA P O D DA
earthen pot and üashes a toothy smile. <Minestrone,= she
explains with a swooping hand gesture.
Sardinia I peer into the mélange of beans, carrots, onions, garlic,
tomatoes, fennel, kohlrabi, herbs—all under a golden veneer
of olive oil. Behind her, a shaft of evening light angles through
a window and illuminates a table with a medieval spread:
sourdough loaves, foraged greens, a carafe of garnet red wine.
<Sit,= she insists, deploying the region9s generous albeit
predatory hospitality. I join her family and Gianni Pes, an
epidemiologist who studies the region.
Podda9s traditional embroidered blouse, ûligreed necklace,
and black sweater contrast sharply with her nimble move-
ments: With the steady hand of a younger woman, she pours
wine into stout glasses and ladles steaming soup into dishes.
<Now eat.=
We9re on the eastern slopes of Sardinia9s Gennargentu
mountains in Arzana, a village in a region with the world9s
highest concentration of male centenarians. In the years after

106 ALL MAPS: NGM MAPS. ALL ILLUSTRATIONS: MANUEL CANALES

World War II, 38 people in this village—one out of every 100
of their peers—have reached a century.
Pes discovered this phenomenon in the late 1990s. Since
then, he9s meticulously interviewed more than 300 centenar-
ians, using extensive questionnaires. He believes that steep
streets, zeal for family, reverence for elders, a matriarchal
culture in which women bear most of the family stress, and
a simple traditional diet explain much of this longevity. Pes
says he9s found that the spouses of centenarians live longer
than the siblings of centenarians, suggesting to him that diet
and lifestyle may make a bigger diference than genes.
Pes, who favors blue-framed glasses and a silver goatee,
slurps a spoonful of soup. <Delizioso!= he proclaims, glancing
admiringly at Podda, who closes her eyes and shrugs.
Minestrone serves up essential amino acids, a potpourri of
vitamins, and a range of ûbers. Pes has found that centenari-
ans have speciûc strains of bacteria in their digestive systems
that convert ûber into unusually high levels of odd-chain
fatty acids. These saturated fats are associated with a lower
risk of heart disease and may prevent cancer.
Cruciferous vegetables, like the cabbage and especially
kohlrabi that ûnd their way into almost every bowl of Sar-
dinian minestrone, also may play a role. After observing the
high percentage of centenarians with goiters—a condition
that accompanies a low-functioning thyroid—Pes speculates
that thiocyanate from a steady diet of kohlrabi may blunt
thyroid function. That may help Sardinians live longer by
reducing their rate of metabolism, Pes says, just as a lighter
with a low üame lasts longer.
In Seùlo, another centenarian-blessed village, Pes and I Blue Zones
the

visited a century-old community bakery. A dozen women Kitchen

100 RECIPES TO LIVE TO 100

were making the distinctive bread eaten with most meals.

We watched them build a blazing ûre in a brick bread oven
and knead dough with strong arms, their faces üushed. The
senior baker, a short, vigorous octogenarian named Regina DA N B U E T T N E R
W I T H P H OTO G R A P H S BY DAV I D M L A I N

Boi, hovered over the process in her black dress and head
Best-selling author
scarf, dispensing advice and signaling when the dough was Dan Buettner reveals
ready and the oven hot enough. recipes to promote
longevity in his debut
Boi had provided the starter dough, a gooey froth resembling cookbook, The Blue
curdled milk that her family has cultivated for generations. The Zones Kitchen,
available wherever
starter contains yeast and native Lactobacillus bacteria. The books are sold.

FO O D S TO L I V E BY 107
 S A R D I N I A , I T A LY

108
 Franca Piras (at right), with help from neighbors Angela Loi and Marisa Stochino, and Piras’s daughter,
Michela Demuro, and granddaughter Nina, prepares culurgiones, a traditional dish of the Ogliastra area.
The pasta dough is shaped into pockets and stuffed with potato, pecorino cheese, and mint.
ANDREA FRAZZETTA
 yeast and lactobacilli produce carbon dioxide that leavens the
bread, and the lactobacilli also break down the carbohydrates
to produce lactic acid. The acid imparts a sour taste, but more
important, Pes tells me, the bread9s carbohydrates enter the
bloodstream 25 percent slower than those of plain white bread.
As dinner with Podda9s family winds down with a spirited
exchange of village gossip, Pes, in a üush of revelry, raises his
glass and belts out the signature toast of the island, delivered
in the local dialect: <A kent’ annos!= <May you live to 100!=
<And may you be here to count the years!= the family bel-
lows. A beat later, Podda softly repeats it. Indeed, since our
dinner together, she9s celebrated her 100th birthday.

ADULTS HERE HAVE

THE LONGEST LIFE EXPECTANCY
IN THE AMERICAS. NICOYA, COSTA RICA
Easy access to fruits such as pineapples and papayas from home gardens
extends the plant-based diet year-round.

Nicoya COSTA
Peninsula RICA

of centenarians, he denoted
W H E N P E S B E G A N H I S S T U DY
areas with long-lived residents with blue marks on a map.
He noticed such a profusion in Sardinia9s Nuoro Province
that he began to refer to the area as the <blue zone.= I met
Pes while canvassing the world in search of longevity hot
spots, and I adopted his term for similar areas I uncovered:
Nicoya, Costa Rica; the Greek island of Ikaria; Japan9s Oki-
nawa island; and a community of Seventh-day Adventists in
Southern California.
I9ve examined dietary surveys of each region and inven-
toried their foods of the past century. Until the late 20th
century, these diets consisted almost entirely of minimally
processed plant-based foods—mostly whole grains, greens,
nuts, tubers, and beans. People ate meat on average only ûve
times a month. They drank mostly water, herbal teas, cofee,
and some wine. Notably, they drank little or no cow9s milk;
soda pop was largely unknown to them. As globalization
spreads, processed foods, animal products, and fast foods are
supplanting the traditional diets. Not surprisingly, chronic
diseases are on the rise in the blue zones.
A healthy diet is just one part of a web of longevity-
promoting factors that also include having a circle of lifelong
friends, a sense of purpose, an environment that nudges one
into constant movement, and daily rituals that mitigate stress.
I found all of those factors in Costa Rica9s Nicoya region,
as well as what might be the world9s healthiest breakfast, in

110 N AT I O N A L G E O G R A P H I C
an open-air building with a vaulted red-tiled roof blackened Costa Rica’s
with smoke. blue zone
Every morning at daybreak in the city of Santa Cruz, María is a roughly
Elena Jiménez Rojas and a dozen or so other women at Coope- 30-mile-long
tortilla stoke wood ûres in long, clay ovens and stir cauldrons of strip that runs
spicy beans. Rojas, wearing a smudged apron over an immac- along the spine
ulate white T-shirt, pinches of a golf ball–size piece of corn of the Nicoya
dough, plops it down on waxed paper, and rotates it with Peninsula; it
mechanical precision into a round patty. She slaps it onto a hot doesn’t include
clay plate called a comal, where it roasts brieüy before expand- the tourist
ing into a pufy pancake and collapsing into a perfect tortilla. resorts on
Three women mix black beans with onions, red peppers, the coast.
and herbs. The beans will cook to tender perfection and then
be mixed with rice and sautéed bell peppers, onions, and gar-
lic to produce a uniquely Costa Rican version of gallo pinto.
Nearly 30 years ago, Rojas tells me, the cooperative was
just a tortilla shop. But young single mothers came to her for
work, and she9s helped dozens lift themselves out of poverty.
A few minutes before 6 a.m., the ûrst customers ûle in. They
sit on benches at long, green tables, where waitresses, wearing
simple dresses and üip-üops, serve giant cups of weak cofee,
plates of gallo pinto, and baskets of warm tortillas. As lilting
ranchera music drifts in from a distant radio, customers ûll
their tortillas with beans, top them with hot sauce called chi-
lero, and wash them down with black cofee, savoring a recipe
for longevity reüecting thousands of years of culinary genius.
Costa Rica9s blue zone is a roughly 30-mile-long strip that
runs along the spine of the Nicoya Peninsula; it doesn9t include
the tourist resorts on the coast. The region consists mostly of
dry pastureland and forests. Until about 50 years ago, people
here were mostly subsistence farmers or ranch hands, sup-
plementing a corn-and-bean diet with tropical fruits, garden
vegetables, and, occasionally, wild game and ûsh.
The region9s Chorotega people, who most inüuenced the
diet, have been eating essentially the same food for millen-
nia. That may help explain why adults here have the longest
life expectancy in the Americas and men older than 60 have
the lowest reliably measured rate of mortality for their age
group in the world.
Corn tortillas might contribute to that longevity. They are
an excellent source of grain, with complex carbohydrates rich
in vitamins, minerals, and ûber. The wood ash the women
add when they soak the corn breaks down the cell walls of the
kernels and releases niacin—which helps control cholesterol.
Black beans contain the same pigment-based antioxidants
found in blueberries. They9re also rich in colon-cleansing ûber.
The magic comes in pairing corn with beans. Our bodies
need nine amino acids—the building blocks of protein—to
make muscle. Animal products such as meat, ûsh, and eggs
provide all nine, but they also contain cholesterol and satu-
rated fat. Together beans and corn provide all of these amino
acids—with none of those unhealthy elements.
Researchers are looking into whether the combination

FO O D S TO L I V E BY 111
 NICOYA, COSTA RICA

112
 Paulina Villegas serves a hearty breakfast that’s typical in the Nicoya region
to her 102-year-old father, Pachito, and her nephew Sixto. The meal includes coffee, eggs,
rice and beans, and tortillas cooked on a traditional wood-fired stove known as a fogón.
NICOLE FRANCO
PUTTING THE THE WORLD ON A PLATE
Scientists devised the diet by first analyzing a food’s
nutritional data and then its environmental impact. Here

PLANET ON A DIET
that diet is broken down by food type and compared
with consumption in world regions.

27% of target
Can we feed 10 billion people by 2050

M O R E S U S TA I N A B L E
and also protect the environment?
A group of scientists from 16 countries
say the answer is yes. They9ve devised
targets for a nutritionally sound and
sustainably produced planetwide diet; 8%
global consumption of foods such as
fruits and nuts would double, while that
of red meat and sugar would be cut in half.
36%

Regional breakdown per the EAT-Lancet Commission

North America Europe & Central Asia
14%

Cassavas and potatoes are cheap

Middle East staples but by themselves are not
& North nutritionally sufficient.
Africa

South
Asia
These valuable sources of healthy
East Asia & fats aren’t consumed as much as
the Pacific
they should be around the world.
Latin America Sub-Saharan
& the Caribbean Africa

The diet’s target amount—

13 grams—adds up to just
one and a half eggs a week.
PLANT VS. ANIMAL
Not all foods are created equal. The global diet
emphasizes plant-based foods and limits animal
products, which are linked to chronic disease and often Wealthier, Western Hemisphere
involve environmentally harmful production practices. regions eat large amounts of poultry,
which the diet considers optional.
Animal-sourced Added sugars
protein 2.6%
(including
dairy)
6.6% A concentrated source of vitamins,
minerals, and protein, sustainably har-
vested fish is emphasized in the diet.

17%
L E S S S U S TA I N A B L E

Plant-based foods
90.8%

*RECOMMENDED GLOBAL DIET IS BASED ON CONSUMPTION Meat is nutritious but unhealthy if

OF 2,500 CALORIES A DAY. overconsumed. Cattle farms are a
SUSTAINABILITY FACTORS INCLUDE GREENHOUSE GAS EMISSIONS, leading source of methane emissions.
AND LAND AND ENERGY USE.

MANUEL CANALES, NGM STAFF; ALEXANDER STEGMAIER

SOURCES: BRENT LOKEN, EAT; THE EAT-LANCET COMMISSION
ON FOOD, PLANET, HEALTH UNDERCONSUMED
 Regions closest to the targets, shown by
dotted semicircles, are most aligned with
the diet’s recommended daily consumption*
for that food type.

300
grams
V E G E TA B L E S

Low in calories and providing essen-

tial macronutrients, vegetables are
also an inexpensive food source.

232
WHOLE GRAINS
Enough grain to feed the 2050 popu-
lation is grown today, but much of it is
fed to livestock.

200 FRUITS

People worldwide are not eating

enough fruit. Fruits and vegetables
should make up half our daily diet.

LEGUME S
75 Beans and peanuts provide
protein; soy is already heavily
consumed in East Asia.

S TA R C H Y
729% V E G E TA B L E S
50 above
target

NUTS
50

2%

EGGS
268%
41% 13

234% P O U LT RY

29
14%

152% FISH
48% 28

250 DA I RY
145% Dairy is a renewable
above
target
source of protein, calcium,
and other nutrients.

638% R E D M E AT

46% 14

C LO S E TO TA R G E T OVERCONSUMED
 may preserve cellular health too. Stanford social epidemi-
ologist David Rehkopf and Costa Rican demographer Luis
Rosero-Bixby have found that Nicoyans have longer telo-
meres on average than Costa Ricans overall. Telomeres are
protective <caps= on the ends of DNA strands, which wear
down over time, a rough marker of biological age. Rehkopf,
who joined me in Costa Rica, told me that Nicoyans seem to be
up to a decade younger biologically than their chronological
age. Another group with longer than average telomeres? The
poor—who may be more likely to subsist largely on beans,
tortillas, chilero, and black cofee.
At Coopetortilla, I dig into my breakfast, chasing chilero-
topped beans wrapped in fresh tortillas with gulps of cofee.
Sweat beads on my forehead, and tears roll down my face.
<Are you okay?= Rojas asks, üashing me a look of sincere con-
cern. <Don9t worry,= I say. <These are tears of joy.=

RESIDENTS ARE THREE TIMES

AS LIKELY TO REACH 100
AS AMERICANS. OKINAWA, JAPAN
Goya, or bitter melon, is a vitamin-packed local favorite that
can protect cells and lower blood sugar.

I prepare to sample yet

H A L F A W O R L D AWAY O N O K I N AWA ,
JAPAN another contender for the world9s healthiest breakfast at the
Daiichi Hotel in Naha with Craig Willcox, another researcher
seeking dietary clues to longevity.
On Okinawa, as compared with the United States, residents
are three times as likely to reach 100, women sufer about half
the rate of breast cancer, both sexes are anicted by a third
to a quarter the rate of heart disease, and elderly people die
from Alzheimer9s dementia at a tenth to a twelfth the rate.
Okinawa
Islands Each morning the hotel founder, Yoshiko Shimabukuro, 91,
a short energetic woman, and her daughter Katsue Watanabe,
a certiûed vegetable sommelier, prepare plant-based dishes
from some 50 ingredients, about half of which are unique to
Okinawa. Before us, in appetizer-size plates and bowls, lies a
starburst of colorful foods, many of which helped create what
remains, by several measures, the world9s longest-lived popu-
lation despite a decline in the health of younger generations.
Willcox, an anthropologist and gerontologist, points out that
everything in this 20-course meal—including tofu soup, carrot
salad, a boiled fern called otani-watari, and papaya stir-fry—is
light on calories. Okinawan food, he tells me, is nutritionally
dense and calorically poor, while in the U.S. it9s the reverse.

116 N AT I O N A L G E O G R A P H I C
 With his twin, Bradley, and their mentor, Makoto Suzuki, A compound
Willcox has written books that lay out most of what we know in seaweeds
about the island9s traditional diet. The brothers showed up has been linked
in Okinawa in 1994 interested in studying centenarians and to a gene
hooked up with Suzuki. For a quarter century the trio has that, when
chronicled what people here eat and investigated why it helps activated,
them elude disease. Now I9m getting a hands-on lesson. seems to tell
Willcox points a chopstick at a tofu stir-fry with sea green cells to clean
crescents of goya, or bitter melon, a key ingredient in goya up waste
champuru, a classic Okinawan dish. Goya is high in vitamins and reduce
A and C, folate, and powerful antioxidant compounds that inflammation,
can help protect your cells against damage, he says. It9s anti- which are at
cancer, protective of liver and cell membranes, a free radical the root of the
scavenger, inhibiting of bacteria such as E. coli, and capable majority of
of lowering blood sugar. I bite down on a piece, unleashing a age-related
üavor explosion redolent of chewing a mouthful of aspirin— diseases.
only more piquant. As with beer, which people often don9t
like at ûrst, the bitter taste grows on you.
With a tuft of sandy brown hair and round spectacles that
make him look like a middle-aged Harry Potter, Willcox moves
on to the tofu, which is denser and more cheeselike than
other Japanese tofu. As the protein centerpiece of the daily
Okinawan diet, it often replaces less healthy proteins, such as
meat or eggs. Traditionally made with seawater, Okinawan tofu
is rich in calcium, magnesium, zinc, and other minerals that
most Americans lack in their diet. It9s also high in genistein
and in daidzein, which metabolizes into equol. Genistein and
equol are isoüavonoids that Willcox notes are associated with
reducing the risk for cancer and cardiovascular disease.
Willcox hoists a porcelain cup containing a bright yellow
brew. <Turmeric tea,= he says. He takes a sputtering sip and
explains that dozens of studies have shown the active ingredi-
ent in turmeric can help our bodies protect against diseases,
including cancer, heart disease, and dementia. Islanders
have co-opted the Japanese trick of using pungent üavors,
such as turmeric, to enhance the taste of healthy vegetables.
Most recipes rely on dashi, a rich broth commonly made from
bonito üakes or sea kelp. Dashi can convert a pile of vegeta-
bles into an explosion of deliciousness, resulting in a dish
with fewer calories than a hamburger but with ûve times the
nutrients—and it tastes good enough to eat every day.
As I ûll up my plate with more delicacies, Willcox ûxes on a
glutinous mass of seaweed resembling green spaghetti. Island-
ers consume more than a dozen varieties of seaweed, which
he calls <sea vegetables.= This particular one, mozuku, boasts
an abundance of fucoidan, an anticancer, antiviral compound
that Willcox says may help reverse inüammation, manage
blood sugar, and also grow blood vessels.
Even more intriguing, another compound in seaweeds,
called astaxanthin, has been linked to a gene that, when
activated, seems to tell cells to clean up waste and re -
duce inüammation, which are at the root of the majority of
age-related diseases.

FO O D S TO L I V E BY 117
 LOMA LINDA, CALIFORNIA

118
 Krystal Gheen and her three-year-old son, Austin, pick beets in their garden for dinner,
a meal she designs around what’s ripe. The Gheens, like many residents of the inland Southern California
city, are Seventh-day Adventists and follow a vegetarian diet inspired by the Bible.
NICOLE FRANCO
 After two hours of learning and eating, I regard the sea of
empty dishes. <I feel like a total glutton,= I say. <Don9t feel
guilty,= Willcox replies. Our whole meal, he explains, contained
fewer than 600 calories—about the same as eating a big cookie.

ADVENTISTS WHO FOLLOW A

VEGETARIAN DIET TEND TO LIVE LONGER
THAN THOSE WHO EAT MEAT. LOMA LINDA, CALIFORNIA
The vegetable-based Adventist diet is based on passages in the Bible
and mirrors modern dietary recommendations.
Ca
lif
or

on my journey is Loma Linda, California,

T H E F I N A L STO P
ni
a

where a community of Seventh-day Adventists has long fol-

Loma
Linda lowed a diet inspired by the Bible. Their guidelines originate
from passages such as Genesis 1:29: <And God said, Behold,
I have given you every herb bearing seed, which is upon the
face of all the earth, and every tree, in the which is the fruit
of a tree yielding seed; to you it shall be for meat.=
Adventists who follow the diet tend to live longer. One study
showed that life expectancy for Adventists in California was
7.3 years greater for men and 4.4 years greater for women than
for similar Californians. Being both vegetarian and Adventist
boosted life expectancy by an additional two years.
When I asked researchers studying the diet to ûnd someone
who follows it, they sent me to 90-year-old Dorothy Nelson,
who answers her door wearing a bright red T-shirt and run-
ning shoes, with schoolgirl bangs cut just above her hazel
eyes. She welcomes me and leads me to her well-lit kitchen.
Moving with the energy of a Chihuahua, Nelson begins
cooking a savory lunch. When I compliment her cooking,
she reveals her secret: <This kitchen is seasoned with love.=
Over lunch she tells me about her life. When she was younger,
she9d had an adventurous career as a pilot-nurse for church
missions. Once, while she and her copilot were hopscotch-
ing across the Arctic, the plane9s engine sputtered, and they
plummeted toward the earth, spotting a üat area on an ice üoe
between Canada and Greenland at the last minute. She ûgured
they9d be all right, <as long as the good Lord wants me around,=
she recalls. When the plane touched down, it skidded but stayed
upright. <I got out and knelt down and thanked the Lord.=
The half-frozen pair were picked up ûve days later. The res-
cuers gave them hot cofee. <I9d never tasted cofee,= she says.
Cafeine and alcohol are discouraged for Adventists. Today
Nelson limits her adventures to tending her vegetable garden.
As a proponent of vegetarian ways, Nelson is a direct culinary

120 N AT I O N A L G E O G R A P H I C
descendant of Ellen G. White, who helped found what became ‘I’ve never
the Seventh-day Adventist Church, a Protestant denomination. tasted meat.’
In the late 1800s and early 1900s, White ûrst articulated the Ninety-year-
dietary prescriptions that have since guided this subculture old Dorothy
of long-lived Americans. Nelson has
White praised the consumption of whole grains, fruits, perfect blood
nuts, and vegetables, which <impart a strength, a power of pressure and a
endurance, and a vigor of intellect, that are not aforded by resting heart
a more complex and stimulating diet.= She warned against rate of 60. She
cooking with grease, spices, and salt, among other things, and walks three
discouraged the use of sugar, which <causes fermentation and miles a day.
this clouds the brain and brings peevishness into the dispo-
sition.= Her recommendations seem remarkably prescient,
mirroring today9s dietary guidelines from the American Can-
cer Society and the American Heart Association.
Most of the newest insights on the Adventist diet come from
Gary Fraser, an Adventist and researcher at Loma Linda Uni-
versity, and a vegetarian who sometimes eats ûsh. With his
combed-over sandy brown hair, Fraser looks a bit like a scout-
master. Trained as a doctor, he noticed that Adventists had
healthier hearts than non-Adventists, and he began to wonder
whether science could validate his diet9s health claims. He
now leads the Adventist Health Studies, which have moni-
tored the health of tens of thousands of American Adventists.
Their research indicates that, at a given age, vegetarian
Adventists are about 12 percent less likely to die than non-
vegetarian ones who eat only a small amount of meat. By
contrast, among younger Adventists, those who eat the most
meat sufer a 46 percent higher rate of premature death than
those who get their protein from nuts, seeds, and legumes.
<It9s clear that a plant-based diet is the way to go,= Fraser says.
When I smell Nelson9s cooking, I9m inclined to agree. The
aromas wafting from her stove make me hungry. After com-
bining black beans with steamed cabbage and cauliüower,
she adds slices of browned tofu, sesame seeds, and a dash
of soy sauce. It9s a satisfying mix of complex carbs, protein,
vitamins, minerals, and antioxidants, with fewer calories than
a bag of french fries. <I9ve never tasted meat,= Nelson brags.
She tells me she has perfect blood pressure and a resting
heart rate of 60. She walks three miles a day.
And there you have it: The vast majority of the calories
eaten in the traditional diets in the blue zones come from
plant-based whole foods. Grains, greens, nuts, and beans are
the four pillars of every longevity diet on Earth.
Nearly half the people who die this year in the U.S. will likely
do so from cardiovascular disease, cancer, or diabetes. In blue
zones, far fewer sufer from these diseases. Why? For most of
their lives, they9ve simply eaten what was readily available
and, luckily for them, it was a whole food, plant-based diet.
Trial and error yielded recipes that make these foods taste
delicious enough to eat day after day. Therein, perhaps, lies
the secret to a healthier you. If you want a good starter recipe,
I know a feisty centenarian who makes a mean minestrone. j

FO O D S TO L I V E BY 121
 JA N UA RY 2 0 2 0

WELLNESS
ISSUE

BY
FRAN SMITH
P H OTO G R A P H S BY
ANDY RICHTER

FINDING CALM
The ancient practice of yoga offers
an antidote to modern stress.
123
PREVIOUS PHOTO
Yoga on the Rocks
draws sellout crowds of
2,100 practitioners to
Red Rocks Amphithe-
atre outside Denver,
Colorado. In the United
States, yoga is an
increasingly popular
way to reduce stress
and enhance health.

LEFT

In the West, yoga often

focuses on the asanas,
or postures, of hatha
yoga, one of its many
branches. In India,
where the discipline
began more than 4,000
years ago, followers
of Krishna perform
bhakti, or devotional,
yoga, by moving
108 stones the length
of their body during
repeated prostrations
on a 13-mile circuit
of Govardhan Hill.
Followers of the late
Yogi Bhajan, a spiritual
leader who brought
kundalini yoga to the
West from India, chant
and walk with their
eyes closed at an annual
summer solstice celebra-
tion in the Jemez Moun-
tains near Española,
New Mexico.
 cuts an imposing fig-

J
UDGE ELENI DERKE
ure, shrouded in her black robe and seated
behind the elevated wood-paneled bench in
the county courthouse in Jacksonville, Flor-
ida. From the jury box and lawyers9 tables,
you can9t see what else she9s wearing: wildly
patterned yoga pants.
More than 25 years ago, Derke discovered
yoga. She was suffering from the searing
abdominal pain of Crohn9s disease. Her
doctor recommended surgery. Hoping to
avoid it, she went to see a cousin who was a
yoga master. He taught her the upside-down poses known as
inversions. They are said to clear the body of toxins, though
there9s no scientiûc evidence to support the claim. Derke9s
symptoms quickly subsided. <Yoga saved my life.=
She trained as a yoga instructor, and if it9s not too hot, she
holds free monthly classes on the courthouse lawn. When
lawyers drone on at trial, she will order a break and lead jurors
in standing stretches and breathing exercises. But she9s best
known in legal circles as the judge who sentences ofenders
to take yoga behind bars.
Derke handles misdemeanors, such as shoplifting, minor
drug possession, and driving under the inüuence, punish-
able by up to a year in jail. Ofenders can cut their time by 40
percent or more if they take a weekly program called Yoga 4
Change. She sees yoga as a way to quiet self-defeating chatter In a state prison near
in the mind and quell rage, fear, anguish, and compulsions San Diego, California,
that drive bad behavior. Patrick Acuña rests
in Savasana, a deep
<Once you let go,= she said, <you make room for the positive relaxation position,
things.= Her colleagues, though, didn9t buy it at ûrst. <Come with Zeus, a service
on, yoga?= dog he’s training,
during a class spon-
Many ofenders had a similar reaction. <I thought it was sored by the nonprofit
really weird,= said Cecil Reddick, an inmate at Jacksonville9s Prison Yoga Project.
Montgomery Correctional Center. Acuña has practiced
yoga behind bars for
An evaluation of the program in three Jacksonville facilities more than 20 years.
found that after six weeks, participants reported signiûcant
improvements in sleep, overall health, and the ability to man-
age anger and anxiety. At least two more county judges now
ofer the yoga option.
Some ofenders choose to do their full sentence rather than
try yoga, but Reddick grabbed the get-out-of-jail-quick ofer
from one of Derke9s colleagues. He was surprised by how much
the classes relaxed him, soothed his sore back, and stirred a
sensation he9d never felt: <Serenity.=

128 N AT I O N A L G E O G R A P H I C
 that began in India,
YO GA , A S P I R I T UA L P R AC T I C E Most studies involve too few participants to be
has extended its limbs widely. In the United conclusive, in large part because yoga does not
States, it9s held up as a ûtness regimen, a path to generally attract big government grants or have
transformation or enlightenment, and a treat- an industry like drugmakers to ûnance research.
ment for so much that ails us—from addiction, Sat Bir Singh Khalsa, a yoga instructor, Harvard
headaches, and hearing loss to post-traumatic neuroscientist, and expert on the science of yoga,
stress disorder, heart disease, and yes, Crohn9s. acknowledges the research has a long way to go.
More than 14 percent of U.S. adults used yoga <But I would say we have demonstrated our credi-
for health reasons in 2017, up from 9.5 percent bility.= Khalsa has investigated yoga for insomnia,
ûve years earlier, a government survey found. PTSD, anxiety, and chronic stress, where he9s seen
Since 2018, Harvard Medical School students the most compelling evidence of yoga9s beneûts.
have studied it as part of a required course on Stress plays a major role in many illnesses
building resilience. Parents tote infants to Itsy that kill us. It also drives unhealthy eating, poor
Bitsy Yoga, which purports to improve a baby9s sleep, alcohol and drug misuse, and other bad
sleep, digestion, and brain development. habits. <Modern medicine really sucks at pre-
Validating health claims for yoga is diocult. venting chronic disease,= he said.

FINDING CALM 129

Sri Dharma Mittra
practices asanas with
aspiring teachers at
his studio in New York
City. Born in Brazil, he
served in the country’s
air force and ran
a bodybuilding gym
before leaving to study
yoga in the U.S. more
than 50 years ago.
He’s devised his own
approach to yoga.
CLOCKWISE
FROM TOP LEFT

A woman lies in Ashtanga yoga

Savasana at a Beijing emphasizes a vigorous
studio belonging to sequence of postures.
Yogi Yoga, one of the This class in India was
country’s largest chains. taught by Saraswathi
Yoga was slow to take Jois, who trained with
off in China, with some her father. She was the
wary of its spiritual first woman in Mysore
aspects, but it’s now to teach men and
spreading quickly. women together.

Ashley Craven (front) Bob Gregory, who has

and Carla Torres cerebral palsy, does
attend a class at Naval an upward salute pose
Medical Center San with an assist from
Diego for pre- and Paris Kaye as part of
postnatal mothers an adaptive yoga
who are active-duty class for adults living
personnel or spouses with disabilities at
and have a doctor’s a rehabilitation center
recommendation. in Minnesota.

FINDING CALM 133

 Khalsa, who took up kundalini yoga in 1971, display the usual age-related declines in the
told me with excitement that epigenetics and brain9s gray matter. Yogis also had larger volume
neuroimaging are revealing how the body and in several brain regions, including the hippocam-
brain interact—and unraveling the mysteries of pus, critical to memory and emotional regula-
yoga9s power. In other words, the beneûts aren9t tion, and the precuneus and posterior cingulate
just in a devotee9s mind. cortex, involved in attention and self-awareness.
Researchers in Norway analyzed blood from 10 Studies like these bring scientiûc legitimacy,
volunteers before and after two-hour sessions of but they9re not why the ancient discipline has
a yoga practice with rhythmic breathing and saw caught on in a frazzled, fast-paced society. <Yoga
signiûcantly increased gene activity in circulating is a strategy for making people basically happy
immune cells. Scientists at UCLA studying breast and able to cope with modern life,= Khalsa said.
cancer survivors discovered yoga decreased the
expression of genes involved in inüammation, to admit that yoga
T H I S M AY B E T H E M O M E N T
believed to be a root of many complex diseases. stressed me out. I went on the recommenda-
Scientists at the National Institutes of Health tion of a physical therapist who had healed my
found that longtime yoga practitioners don9t injured shoulder after others had failed. When

134 N AT I O N A L G E O G R A P H I C
 reconciling the yoga scene with the potential of
a serious practice. <I would get feedback that my
playlist wasn9t cool enough,= said teacher Olivia
Mead. <I thought, I cannot handle this anymore.
I didn9t become a yoga instructor to wear cute
shorts. I actually wanted to make a diference.=
Mead founded Yoga for First Responders. The
nonprofit has brought yoga to police depart-
ments, fire stations, and training academies
from Los Angeles to Thunder Bay, Ontario.
Classes tailor the traditional yoga elements—
physical postures, breath regulation, deep relax-
ation, and meditation—to help people endure
the challenges of putting their lives on the line.
<The whole goal is to harness the mind,= she
said, <not to touch your toes.=

identical inmate
N I N E T E E N WO M E N W E A R I N G
T-shirts and pants took their spots on mis-
matched yoga mats arranged in a U-shape in a
cramped room at Jacksonville9s Montgomery
Correctional Center. Two uniformed officers
On a tower over stood watch over me; one of them, Sgt. Rhonda
the sacred Yamuna Warren, held an iPad and videoed my interviews.
River in Vrindavan,
a man meditates at It seemed an unlikely setting to release stress,
Keshi Ghat, a Hindu not to mention harness the mind. Kathryn
holy site. In India yoga Thomas, a former Navy aviator who founded
retains more of its
origins as a harmony the nonprofit Yoga 4 Change, led the women
between body and through deep inhales and exhales, and then the
mind. The spiritual üuid series of poses known as the sun salutation.
and physical practice
is believed to help Gradually, a sense of calm became palpable.
yogis overcome worldly Most inmates weren9t required to come. Some
suffering and attain signed up, as Melissa Bruce told me, <basically
a state of liberation.
to have something to do.= Many wanted a break
from the tension and clamor of living among
inmates, an hour to sink into oneself. If they
hadn9t all achieved enlightenment or transforma-
he spoke, I dutifully listened. In the 2.4-square- tion, at least a dozen told me they9d learned skills
mile New York City suburb where I live, yoga to help them survive another day. Philieza Lopano
is abundantly available in storefront studios, said she used the breathing exercises and gentle
community recreation rooms, the continuing stretches during lockdowns to relieve anxiety.
education program, and the chain health club. Watching each woman stretch and fold and
I started there, accompanied by my husband. blow out her breath in loud, unembarrassed
Classes were packed. People jostled for space whooshes, it occurred to me that I might have
like subway commuters. Supple spandex-clad fared better in yoga if I9d focused less on other
bodies bent, curled, and twisted in ways that people and more on myself, without judgment.
defied me. It felt like one more competitive After the women ûled out of the room, I men-
arena where I didn9t measure up. I took refuge tioned to Warren that I would try yoga again.
in restorative yoga, where I seemed as adept as <I know,= she said, nodding slowly. <Me too.= j
anyone at splaying across comfortable bolsters
and trying not to snore. Meanwhile, my husband Fran Smith has written about precision medicine
and the science of addiction for the magazine.
learned to stand on his head. Andy Richter, a yoga devotee, photographed the
I9m not the only one to have a hard time discipline for his book, Serpent in the Wilderness.

FINDING CALM 135

 As part of the pho-
tographer’s project,
elderly people were
asked to imagine how
they would interact
with a robot. A resi-
dent at Maison Ferrari,
a retirement home in
Clamart, France, vol-
unteered to act as the
robot’s godmother.
She pictured herself
celebrating its birth-
day and decorated her
chair with balloons.

TAKE ME TO
JA N UA RY 2 0 2 0

WELLNESS
ISSUE
 In the future,
robots could be
used to assist
and comfort
the elderly—and
help meet the
escalating demand
for caregivers.

BY
CLAUDIA KALB
P H OTO G R A P H S BY
YVES GELLIE

YOUR SENIORS 137

Loneliness is common
among seniors. This
woman at a long-term
care facility in Mont-
geron, France, treated
the robot as a confidant.
They were indoors, but
she imagined relaxing
with it under the sun.
 develop-

W
H E N G O L D I E N E JAT B E G A N
ing robots in 2005, she spent much
of her time knocking on doors in
hopes of demonstrating her high-
tech prototypes. Back then, the
health-care world was hesitant.
<Now, it9s the opposite,= says Nejat,
a professor of mechanical engineer-
ing at the University of Toronto. <I
have people calling from around
the world saying, When9s your robot
going to be ready?=
Nejat9s machines, a special type known as socially assistive
robots, are designed to engage with humans and could help
ûll an urgent need: caregiving for the elderly. The population
of people over age 80 is projected to almost triple worldwide,
from 143 million in 2019 to 426 million in 2050.
Such robots could be especially useful for patients with Alz-
heimer9s disease or dementia because the robots can be pro-
grammed to assist with everything from providing medication
reminders to leading exercises. Nejat9s robots also can help run
bingo and memory games to keep patients cognitively active.
Inspired by robots9 potential to help the elderly, French
photographer Yves Gellie spent two years creating the
award-winning 2019 film, Year of the Robot, which docu-
ments interactions between elderly people and social robots
in long-term care facilities in France and Belgium. In the ûlm
Gellie and his assistant, Maxime Jacobs, humanize robots by
allowing active engagement between person and machine. In
scenes that appear futuristic, people play piano, dance, and
even tearfully divulge secrets with their robotic companions.
After completing his ûlm, Gellie embarked on a related
photography project in which he asked some of the same Photographer Yves
subjects to imagine their dream scenario with a robot. What Gellie introduced the
would they most like to do? In the images shown here, Gellie robot to elderly people
over several months.
documented people9s interactions with robots after months of He didn’t expect every-
observation. The project was not intended to be therapeutic one to warm to it. Some
or to show the robots9 actual capabilities. Instead, it explored weren’t interested, but
others were eager to
humans9 capacity to form relationships with machines. engage. This woman,
Critics have worried that caregiving robots might eliminate at the Broca Hospital
human interaction and jobs. But the goal is to support human in Paris, said the robot
helped her forget her
care, not replace it, says Brian Scassellati, head of Yale Uni- surroundings. She loves
versity9s Social Robotics Lab. He9s tested robots with a range books and said she’d
of patients, and has found that daily interaction with robots read to the robot.
can help children with autism spectrum disorder improve

140 N AT I O N A L G E O G R A P H I C
eye contact and social skills. ofer an advantage because they aren9t judgmen-
Cognitive psychologist Maribel Pino, executive tal? Is a lack of emotion helpful? Will patients
director of the Broca Living Lab at the Broca Hos- lose interest?
pital (Greater Paris University Hospitals), one of One beneût is clear, Scassellati says: Robots can
the locations where pictures were taken, describes provide personalized, on-demand care—and the
the engagement of the people photographed with need for that will only increase in the future. j
the robots as authentic. After people spent time
with a robot, many became attached to it. Claudia Kalb has covered the science of genius,
Pablo Picasso, and Leonardo da Vinci for National
As the field grows, scientists aim to better Geographic. Yves Gellie photographed Pitcairn
understand human-robot dynamics. Do robots Island for the French edition of the magazine.

RO B OT T H E RA PY 141
This resident of Maison
Ferrari said she would like
a robot to teach her bas-
ketball. Manufactured by
Tokyo-based SoftBank
Robotics, this robot is not
programmed for that.
However, its software,
designed by ZoraBots in
Belgium, can help peo-
ple complete a range of
tasks, including exercise.
At Weverbos Long Term
Residential Facility in
Ghent, Belgium, this
94-year-old resident
wanted a robot that
would dance while she
played the piano. Fab-
rice Goffin, co-CEO of
ZoraBots, believes the
robot’s diminutive size
makes it appear child-
like, appealing to the
elderly. “The honesty of
a child also has no judg-
ment,” he says.
The robot, known
as NAO, has another
advantage, says Gellie:
It never gets angry
or changes its mood.
This 78-year-old man
at Weverbos Long
Term Residential Facil-
ity is an arts lover and
admired the robot as
if it were a sculpture.
“If I had this robot with
me in a museum,” he
told Gellie, “he would
teach me everything.”
 INSTAGRAM
JASPER DOEST
FROM OUR PHOTOGRAPHERS

WHO On Curaçao to photograph animals in rehabilitation

Doest, a photographer in at his cousin Odette9s veterinary practice, Doest met
the Netherlands, captures two üamingos: Bob, who became an internet sensa-
interactions between humans
and the natural world. tion after recovering from a concussion, and Thomas
WHERE (above), impaired by a serious foot infection. Odette
A veterinary practice run by his is often faced with euthanizing injured animals if she
cousin, Odette Doest, on the can9t ûnd creative treatments—such as the makeshift
Caribbean island of Curaçao.
WHAT
socks she fashioned to bandage Thomas9s wounds.
Doest took photos of this bird,
In time, Doest says, Thomas was walking normally
Thomas, with everything from and was returned to the wild. Because Bob has arthri-
his smartphone to his DSLR tis that would make him vulnerable in the wild, he
camera. For this shot he used
a 100mm lens. remains with Odette, who takes him to visit Curaçao
schools to teach children about conservation.
This page showcases images from National Geographic’s Instagram accounts. We’re the most popular
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148 N AT I O N A L G E O G R A P H I C
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