Slate eBook Club - Best of 2003

by Slate. com

  The way modafinil works is not understood. It seems to slow the release of GABA, a sleep promoter in the brain. It also may act on the histamine system, which is connected to sleep regulation. What is clear is that modafinil differs from most other pick-me-ups, which tend to be indiscriminate in their function. Amphetamines like Dexedrine, for example, promote wakefulness by interfering with uptake of the neurotransmitter dopamine, causing dopamine to flood the brain. Dopamine, says Joyce Walsleben, director of the NYU Sleep Disorders Center, is a "broad hitter" that sets the heart racing, causes twitchiness, and makes you feel high. When the effect of such stimulants wears off, the crash is nasty. Caffeine affects a different pathway, involving adenosine, but that, too, spills over the brain's flood wall, making coffee drinkers jittery.

  But modafinil tiptoes around dopamine, confining its activity to the particular neurological processes connected to wakefulness. It doesn't seem to act as a broad stimulant. (This is one reason, Walsleben says, that modafinil has not become a street drug. Unlike cocaine or amphetamines, modafinil doesn't make you feel high, and it acts very slowly, taking a couple of hours or more to kick in.) Narcoleptics seem to love modafinil. (By boosting alertness throughout the day, modafinil reduces the narcoleptic's compulsion to nod off.) Now doctors are getting barraged by requests from regular folks who want to use it to cut down on sleep.

  The seduction of modafinil is that you can feel as peppy after six hours sleep as you would after nine. (It may also have a more drastic effect.) Doctors see modafinil as an occasional pick-me-up. They doubt you could take the drug everyday without consequences: Most sleep researchers agree that the longer sleep is necessary for hormonal regulation, among other essential bodily functions. (Drugs aren't the only way we may steal less sleep. Click here to read about how we may enlist gene therapy to help us stay awake.)

  Tired of merely writing about enhancement (and tired, period), I decided to conduct my own unscientific trial of modafinil. As the father of a 2-year-old, I live in a constant haze of sleep deprivation. I vowed to take modafinil for a week and see what happened. Could it transform a lazy, exhausted hack into a brilliant Jeffrey Goldberg? Or recast a grouchy father into Superdad? I persuaded my doctor—and no, you can't have his number—to prescribe me a week's supply of Provigil, seven 200-milligram pills.

  Here is the diary I kept.

  Day 1, Monday

  6:45 a.m.: Woken up by my daughter after the usual six and a half hours.

  7 a.m.: I open the bottle. The pills are monstrous. I start to chicken out. I've never smoked pot, much less taken cocaine or amphetamines. I decide to halve the dosage. When I cut the first pill with my pocketknife, half of it shoots off my bureau, slides across the floor, and disappears under a dresser, no doubt to be discovered and eaten by my daughter someday in the near future. I pop the other 100-milligram half.

  10 a.m.: At the office. I've felt no rush, but alertness has snuck up on me. I am incredibly attentive, but not on edge. I really, really feel like working, a rare sensation.

  12 p.m.: I reach for my usual lunchtime Coca-Cola, then think better of it. Caffeine plus this sprightliness and I will be ping-ponging off the walls.

  2 p.m.: This is when I usually fold. Today I am the picture of vivacity. I am working about twice as fast as usual. I have a desperate urge to write, to make reporting calls, to finish my expense account—activities I religiously avoid. I find myself talking very loudly and quickly. A colleague says I am grinning like a "feral chipmunk."

  6 p.m.: Annoyed to have to leave the office when there is all this lovely work to do.

  9 p.m.: Home. After dinner, I race upstairs to start working again. This is totally out of character, especially on a Monday Night Football evening.

  12 a.m.: I want the day to keep going but force myself to go to bed. I fall asleep easily enough, but it's a weird night. I have lots of dreams, which is unusual. All are about Getting Things Done.

  Day 2, Tuesday

  6:30 a.m.: I wake up feeling good, cut another pill in two, and pop a half.

  9 a.m.-7 p.m.: I work like a fiend again. These have been the two most productive days I've had in years. Idea for new Provigil ad slogan: "Bosses' Little Helper."

  1 a.m.: Again I'm alert through the late evening—so alert that I infuriate my wife by chattering at her long past her bedtime. This time, when I do conk out, I sleep deeply.

  Day 3, Wednesday

  7 a.m.: My one-man clinical trial starts to fall apart. Everyone says modafinil is not addictive, but I wake up worried about how long my supply will last. I count the pills and realize I have only five and a half left. That's just an 11-day supply. I remember that I offered a sample to a friend yesterday. I am annoyed—one day less for me. I start to cut up the remaining pills, wondering if I can divide them into thirds instead of halves.

  I realize that maybe I can find a different supplier. I log onto the Internet to see if I can get modafinil on the sly. I find it cheap at the Discount Mexican Pharmacy. I feel delighted and relieved. Then I feel terrified that I am delighted and relieved. "Discount Mexican Pharmacy"?!

  7:30 a.m.: I end my experiment after two days. I am acting like a lunatic. I stash the remaining pills in a distant corner of the medicine cabinet. I calm myself with the reminder that I have 11 more great days to look forward to.

  So is modafinil a drug for future superpeople? Maybe. There are good reasons for doubt, though. The drug is approved only for treating narcolepsy, and doctors are not going to prescribe it like aspirin anytime soon. Though patients don't seem to get addicted to modafinil or to build a tolerance, according to Walsleben, the drug has been in use for only 10 years, and no one knows for certain that it's safe over the long term. (Cephalon and other drug companies, incidentally, are working on even more powerful wakefulness drugs, but none is on the market yet.)

  I loved taking modafinil for two days. I worked supernaturally hard and well. But I'd be afraid to make it a habit. I'll use it again for a special occasion—when I am late for a deadline, perhaps. In the meantime, I'll just yawn my way through the midafternoon.

  sidebar

  Modafinil may allow you to skip huge chunks of sleep. One study suggested that modafinil could help you stay up for 40 hours without impairment and without accumulating a sleep deficit. But more recent trials have not been able to confirm that finding, according to the NYU Sleep Center's Walsleben.

  sidebar

  There's another, more sci-fi way we may be able to sleep less. Lots of people claim to be "short-sleepers" who function perfectly well on six or even four hours of shut-eye. CEOs and politicians (see Bill Clinton) love to brag about how little rest they need. In fact, says Penn's David Dinges, almost nobody is a true short-sleeper. Some who purport to need only four hours sack time cheat by napping frequently. Others are very sleep-deprived and just don't realize it. Dinges has measured actual performance of self-described short-sleepers, and their lousy performances prove that they're wiped.

  But a rare few—1 in a 1,000, Dinges estimates—need very little sleep and function just as well after six hours as after eight. This group is very hard to study (since it takes enormous effort just to weed out the many ersatz short-sleepers from the real ones).

  Short-sleeping probably has genetic roots. Scientists are now starting to hunt the human genome for the genes connected to sleep regulation. If they find a short-sleeping gene, it would be a glorious target for gene enhancement. For now, no one has found such a gene or even knows if it exists. If it is found, scientists will need to determine if its presence exacts other physiological costs. (If you sleep less, do you die sooner, for example?) And even if there aren't any costs, researchers face the technical challenge of modifying DNA in a remote area of the brain—a task well beyond current gene therapy, which tends to focus on small genes in accessible corners of the body.

  Did I Violate the Partial-Birth Abortion Ban?

  A doctor ponders a new era of prosecution

  By Warren M.
Hern

  Updated Wednesday, Oct. 22, 2003, at 4:17 PM PT

  As the misleadingly titled "Partial-Birth Abortion Ban" makes its way to the president's desk, anti-abortion groups are celebrating their public relations victory. But beneath the hoopla, the bill's medical consequences remain murky. Exactly which procedures will be banned, and which doctors prosecuted? Will the anti-abortion lobby be happier with the alternative methods to which doctors will resort? If not, which methods and doctors will be targeted next? Will this ban have a chilling effect on related procedures? If so, will it prevent abortions—or births?

  I ask these questions because I am a potential target of this legislation. Almost exactly 30 years ago, shortly after Roe v. Wade, I started performing abortions on a full-time basis in Boulder, Colo., at the state's first free-standing nonprofit abortion clinic, where I was the founding medical director. In my private practice, I perform many abortions as late as the 26th week of pregnancy, and some as late as the 34th week.

  I don't know the answers to the questions I've posed above, and neither does Congress. No physician expert on late abortion has ever testified in person before a congressional committee. No peer-reviewed articles or case reports have ever been published describing anything such as "partial-birth" abortion, "Intact D&E" (for "dilation and extraction"), or any of its synonyms. There have been no descriptions of its complication rates and no published studies comparing its complication rates with those of any other method of late abortion.

  What I do know is that the political exploitation of this issue is confusing and frightening my patients. Recently, I received a call from a woman whose physician had discovered catastrophic genetic and developmental defects in the fetus she is carrying. The pregnancy was profoundly desired, and the diagnosis was devastating for her and her husband. She called me with great anxiety to find out whether passage of the "partial-birth" ban by the Senate would mean that she could not come to my office for help because my work would be illegal. She was also horrified by the images that she had seen and the terminology she had heard in the congressional debates.

  I reassured her that I do not perform the "partial-birth" procedure and that there is no likelihood that the ban's passage would close my office and keep me from seeing her. The fetus cannot be delivered "alive" in my procedure—as the ban stipulates in defining prohibited procedures—because I begin by giving the fetus an injection that stops its heart immediately. I treat the woman's cervix to cause it to open during the next two days. On the third day, under anesthesia, the membranes are ruptured, allowing the amniotic fluid to escape. Medicine is given to make the uterus contract, and the dead fetus is delivered or removed with forceps. Many variations of this sequence are possible, depending on the woman's medical condition and surgical indications.

  On the same day I got that call, I received a call from another woman who hoped to become pregnant but wanted to be reassured that, in spite of passage of the "partial-birth" ban, she would still be able to terminate the pregnancy if a serious genetic defect were discovered at, say, 20 weeks of pregnancy. Because of her history, she has an especially high risk of such a scenario. Without reassurance, she would avoid pregnancy entirely. Again, I reassured her that I would be here for her if she needs me.

  But what if the people enforcing the "partial-birth" ban decide for some reason—because they doubt that my injection worked, for example—that it covers what I do? Or what if other doctors decide to follow the same procedure of causing fetal death by injection some time—even a day or two—before the extraction is performed? If the intact delivery of the living fetus (the "birth" imagery) is what bothers lawmakers, will they ban this method as well? Depending on the doctor, the alternative to intact extraction could be dismemberment of the fetus in the uterus, which may be more dangerous for the woman and no less troubling to look at. Is that what Congress wants? Who gets to decide what is safer for the woman: the expert physician or Congress?

  Earlier this year, I began an abortion on a young woman who was 17 weeks pregnant. Because of the two days of prior treatment, the amniotic membranes were visible and bulging. I ruptured the membranes and released the fluid to reduce the risk of amniotic fluid embolism. Then I inserted my forceps into the uterus and applied them to the head of the fetus, which was still alive, since fetal injection is not done at that stage of pregnancy. I closed the forceps, crushing the skull of the fetus, and withdrew the forceps. The fetus, now dead, slid out more or less intact. With the next pass of the forceps, I grasped the placenta, and it came out in one piece. Within a few seconds, I had completed my routine exploration of the uterus and sharp curettage. The blood loss would just fill a tablespoon. The patient, who was awake, hardly felt the operation. She was relieved, grateful, and safe. She wants to have children in the future.

  Did I do a "partial-birth" abortion? Will John Ashcroft prosecute me? Stay tuned.

  It Oughtta Be the Shoes

  What's wrong with Adbusters' new anti-Nike campaign?

  By Rob Walker

  Posted Monday, Nov. 17, 2003, at 8:58 AM PT

  The Nike swoosh is a symbol with enormous power. And not just for the brand's fans and customers: No logo is more reviled by ideological opponents of the culture of marketing, those who see the incursion of the brand idea into all aspects of our everyday lives as both obnoxious and oppressive. The magazine Adbusters is one such opponent, so it's no great surprise that this antimarketing bastion's latest project is a fresh assault on fortress Nike. What's more surprising is that the weapon of choice is a marketing campaign for an Adbusters sneaker.

  The idea is to counter Nike by selling a kind of delogoed shoe called the Black Spot sneaker—an "unswoosher," as Adbusters calls it. The sneaker would be manufactured in determinedly nonsweatshop conditions, would sell for $65, and would be emblazoned not with a stylized brand mark but with a big black dot. A planned print ad (see it here) says little about the product, stressing instead how the shoe will take on Nike and its head honcho, Phil Knight. The Black Spot, it says, is "Plain. Simple. Cheap. Fair. And designed for only one thing: Kicking Phil's ass."

  It's always fun to throw rocks at big nasties like Nike, and generally speaking I'm a fan of Adbusters' caustic and provocative rhetoric. But this particular unswooshing plan has puzzled some even some antibranders, for an obvious reason: That black spot may symbolize a blotted-out logo, but it is also, unavoidably, a logo itself.

  So far the skeptics' critique pretty much ends right there, but I don't think it's quite right to say that the black spot and the logo are essentially the same thing, and thus the whole exercise is a fraud. The campaign would still be sound if it really aimed to sell an alternative shoe that happened to sport an antilogo. The problem is that Adbusters is trying to sell an antilogo that happens to have a shoe attached to it. In other words, the spot and its supposed meaning aren't a byproduct of the campaign—they are the whole thing. But one of the most legitimate criticisms of blind logo loyalty is that it trivializes the logoed item itself: Don't worry about what we're selling, just buy the symbol we've stamped on it.

  A rendering of the shoe looks a lot like a classic Converse low top, but at $65 it's much more expensive. (The last pair of Converse shoes I bought, about a year ago, cost around $35.) Why is that, exactly? Is the Black Spot sneaker particularly well-made? Will it last longer than a big-name shoe? Is it a great value? The planned campaign doesn't seem to address those utilitarian matters. And apart from including the word "fair" (which will mean little to consumers who aren't already fair-trade buffs), the ad doesn't even make a selling point of the socially responsible aspects of its product. So is the sales pitch based on the shoe's merits, or does it just suggest that wearing Black Spots will broadcast a facile message about how anticorporate (and therefore cool) you are? And if it's the latter, then isn't that precisely as vacuous as the ideology of the swoosh, which assumes that there is no better way to express ourselves than through the logos we choose (or reject)?

 
; The Black Spot idea comes along at an interesting moment in the story of marketing, when many advertisers feel that direct pitches don't work anymore. Adbusters is in some ways right in tune with this, and is at its most entertaining when it uses commercial tropes to expose commercial hypocrisy. It's interesting to imagine this approach taken to a new level with an actual product competing in the real marketplace, sold on the basis of its real attributes—not its image. But rather than challenge the rules of the advertising game, Adbusters, this time around, is simply playing along. As a result, the plan for the Black Spot does not feel like a triumph for the forces of antimarketing—it feels like a capitulation. This campaign doesn't slow the momentum of the culture of branding; it's merely along for the ride.

  The Economics of Suicide

  Why trying to kill yourself may be a smart business decision.

  By Charles Duhigg

  Posted Wednesday, Oct. 29, 2003, at 8:15 AM PT

  When Kirk Jones jumped over the guardrail at Niagara Falls last week and fell 180 feet alongside 150,000 gallons per second of rushing water, traditional explanations for his leap were plentiful. Jones' parents said he had lost his job and was depressed. A suicide expert pointed out the appeal of dramatic farewells. And everyone called the jump suicidal: Jones is the first person to survive a Niagara fall without safety gear.