When Bea told me what Abigail had inquired about a few weeks ago, I’d winced a little, wondering how my child had answered. Had she passed whatever test Abigail was giving? I know how frank Bea can be, how she walks behind me when we’re out in public, checking whether the shiny, taut expanse of bare skin on my scalp is visible. “Mom, your bald spot,” she’ll say when we’re in a restaurant, fussing with locks to try to hide the five-centimeter circle where, a year and a half ago, I had surgery to remove cancer.

I know that Abigail’s question haunts many of us who are physically different, in ways both small and large, either by birth or circumstance. It plagues my friend with accident scars on his legs, who’s already nervous about summertime and exposing his flesh at the beach this year. Maybe it’s a small yet indelible birthmark on the chin. Or it’s a big burn. Or a missing limb. Does this make you want to look, or want to look away? Do we make you uncomfortable? Do we freak you out?

“It’s a thing that has to get explained,” says Natalie, a New York executive who’s had three serious melanoma surgeries and lives with ongoing psoriasis lesions. “For me, the anticipation of that is hard. I think people want to distance themselves from someone who’s had a traumatic event. Somehow you wind up having to reassure them that you’re not contagious, that they’ll be OK.”

Though she tries to be “very open about my illness, because I want people to get it,” Natalie admits she has nevertheless “some really upset moments” of unasked for attention. “I once had someone literally cross the road to ask what was wrong with my legs,” she says. “I was feeling really proud of myself for being brave enough to wear the skirt. And this woman came along and destroyed it.” She adds, however, “I don’t feel sorry for myself, and I don’t wear this as a badge. I just want to be looked at as the successful, independent woman I am — but I understand that some people can’t do it.”

It’s true that some people can’t, and there’s loss in there. I used to have a friend who liked taking pictures of his buddies, including me – right up until my diagnosis and my relatively minor disfigurement. Then he never took another photograph of me again. I wonder if I freaked him out.

My friend Frank, a West Coast entrepreneur, understands. A few years ago, Frank had radical surgery for bladder cancer that left him with what he calls a “Guinness Book of World Records scar” that starts at his sternum, loops around, and ends at his pubic bone. He also has a partial hernia that leaves him, in his word, “lumpy” under a shirt.

“I get a lot of people staring. I’m used to it,” he says. “It usually doesn’t bother me. I’m just a little self-conscious when people are peeking out the corner of their eyes in the locker room.” And, he recalls, “one time my wife and I were at Caesar’s Palace lying out in the super-bright, crystal-clear Vegas sun, and this woman next to us asked, ‘What happened to your stomach?’ She was pretty horrified when I told her.”

He’s still sometimes horrified himself. “I look at myself every morning, and I think of all the horrible shit that I’ve been through because of this disease,” he tells me. But when he looks in the mirror, he also sees a mark of survival. “I’m working out and riding my bike to train, and if that doesn’t tell you how I’m doing, go ahead and ask me. I don’t think I look that bizarre. I think I look like a guy who’s had major abdominal surgery.”

As Frank knows, when you’ve been through something life-altering, the first person you have to get to accept your look is yourself. “The first time I saw myself afterward, I thought, That looks very interesting,” says Johan Otter. Johan is a master of understatement. Seven years ago, Johan was hiking with his daughter in Glacier National Park when he was mauled by a grizzly bear. His scalp was torn off; his eye was clawed. He had to wear a halo brace for 12 weeks and go through multiple grafts and surgeries to recover. And then, he says, he had to learn to “push through” his first time out in public again.

“You get used to it,” he says. Besides, he jokes, “I never have a bad hair day.” Otter admits he can still be somewhat surprising to strangers. “Once at Costco this woman said, ‘Oh my God, what happened to your head?’” he recalls. But though he admits, “I’m a vain person just like anybody else,” Otter says that “I’m always extremely proud of my scars. When you go through something like this, people see you with your true self. You learn that what matters is what’s inside.”

It’s not always easy in our perfection-driven culture — where a weight gain of five pounds can be treated as a life crisis and toothpaste brands wage war on dingy teeth and a “puffy face” means you’re no longer considered “pretty” – to believe that within battle scars and what others would call abnormalities, there is a raging, painful exquisiteness. It’s often hard to feel the sideways glances and puzzled stares. But it’s harder still to be overlooked entirely, to feel like the remnants of the trials we’ve endured are the things that make others unable to look at us. We want to be looked at not with pity, not with fear, not with morbid curiosity. Simply with clear and open eyes.

So when Bea told me her friend Abigail wanted to know if she was freaking her out, I hoped Bea had answered honestly. More than that, I hoped she answered kindly. I hoped she didn’t pretend she’d never noticed Abigail’s missing hand, or changed the subject altogether. “What did you say?” I asked her nervously. “I told her no,” she shrugged. “I said, ‘Why would I be freaked? I love you.’” And then I exhaled.

I know life for Abigail – and Natalie and Johan and Frank and everybody else wounded or scarred or born different — is more complicated than that. The things that make us stand out in the crowd define us in a million little ways. They can remind us of the most dramatic, heroic moments of our lives, and of every small indignity and cruelty that has happened since. But what Bea and Abigail got to in the span of one recess period was that life isn’t about seeing past each other’s imperfections. It’s about being unafraid to look at them directly. Because that’s where the love is — in the cracks and the sufferings and the challenges. Life isn’t flawless. But it can be very, very beautiful. That day at recess, Bea told me, she had kissed Abigail, right on the place where her arm stops at the wrist. And they played together until the bell rang, and it was time to go back to class.

For the first time in sixteen years, Andrew has stopped taking the psychotropic medications his psychiatrist father prescribed after ten-year-old Andrew caused an accident that rendered his mother a paraplegic. Like the illegal drugs his high school buddies take, Andrew’s meds serve as a metaphor for the feelings of inadequacy, disappointment and rootlessness endemic to my generation of twenty-somethings. Judging from the film’s cult-hit success, its target audience of my peers apparently found the metaphor apt. When Andrew falls in love with a quirky, vibrant girl he meets in a doctor’s waiting room, she shows him how to reengage with his feelings—and the world. Presumably, he leaves the medications behind.

For several years, “Garden State” remained my favorite movie about my generation. It spoke to me as a young person growing up in turn-of-the-millennium America—though not as a young medicated person. In fact, I completely forgot psychiatric drugs were even mentioned. Funny, because I myself have been taking medication since high school, and “Garden State” is one of just a couple of films I know of to allude to the psychological impact of growing up taking psychotropic drugs. Although it touches on this important phenomenon, the film never really examines its underlying assumptions that medications numbed Andrew’s pain and guilt, and that getting off them allows him once again to experience the agony and ecstasy of life.

For the first time in history, millions of young Americans are in a position not unlike Andrew’s: they have grown up taking psychotropic medications that have shaped their experiences and relationships, their emotions and personalities and, perhaps most fundamentally, their very sense of themselves. In “Listening to Prozac,” psychiatrist Peter Kramer’s best-selling meditation on the drug’s wide-ranging impact on personality, Kramer said that “medication rewrites history.” He was referring to the way people interpret their personal histories once they have begun medication; what they thought was set in stone was now open to reevaluation. What, then, is medication’s effect on young people, for whom there is much less history to rewrite? Kramer published his book in 1993, at a time of feverish — and, I think, somewhat excessive — excitement about Prozac and the other selective serotonin reuptake inhibitor antidepressants, or SSRIs, that quickly followed on its heels and were heralded as revolutionary treatments for a variety of psychiatric problems.

For most people, I suspect, medications are perhaps less like a total rewriting of the past than a palimpsest. They reshape some of one’s interpretations about oneself and one’s life but allow traces of experience and markers of identity to remain. The earlier in life the drugs are begun, the fewer and fainter those traces and markers are likely to be. All told, the psychopharmacological revolution of the last quarter century has had a vast impact on the lives and outlook of my generation — the first generation to grow up taking psychotropic medications. It is therefore vital for us to look at how medication has changed what it feels like to grow up and to become an adult.

Our society is not used to thinking about the fact that so many young people have already spent their formative years on pharmaceutical treatment for mental illness. Rather, we focus on the here-and-now, wringing our hands about “overmedicated kids.” We debate whether doctors, parents, and teachers rely too heavily on meds to pacify or normalize or manage the ordinary trials of childhood and adolescence.

Often, the debate has a socioeconomic dimension that attributes over-medication either to the striving middle and upper-middle classes, or to the social mechanisms used to control poor children and foster children. We question the effectiveness and safety of treating our youth with these drugs, most of which have not been tested extensively in children and are not government-approved for people under eighteen. We worry about what the drugs will do to developing brains and bodies, both in the short and long term. The omnipresent subtext to all this: what does the widespread “drugging” of minors say about our society and our values?

Certainly, these questions are worth debating—even agonizing over. But they ought not to constitute the be-all and end-all of our society’s conversation about young people and psychiatric drugs, particularly with millions of medicated teens transitioning into adulthood. Too much of the discussion occurs in the abstract, and drugs too easily become a metaphor, as in “Garden State,” for a variety of modern society’s perceived ills: the fast pace of life and the breakdown of close social and family ties; a heavy emphasis on particular kinds of academic and professional achievement; a growing intolerance and impatience with discomfort of any sort. Far too rarely, though, do we consult young people themselves. How do they feel about taking medication? How do they think it has shaped their attitudes, their sense of themselves, their academic and career paths, their lives? How do they envision medication affecting their futures?

My cohort lives with some powerful contradictions. On the one hand, we have grown up with the idea that prolonged sadness, attention problems, obsessions and compulsions, and even shyness are brain diseases that can—and ought—to be treated with medication, just as a bodily disease like diabetes ought to be treated with insulin. The 1990s, sometimes called “the Decade of the Brain,” encompassed a period of unprecedented growth in understanding how the brain works, which generated enormous enthusiasm about the prospects for discovering the underlying mechanisms behind mental illness, enthusiasm that many say was overwrought and premature.

Direct-to-consumer pharmaceutical advertising on TV, which the U.S. Food and Drug Administration authorized in 1997, has allowed drug companies to define the public’s understanding of mental illness and psychiatric medications — and this is especially true, I think, for young people who knew no other paradigm. Even as we grew up, though, immersed in the idea of an “imbalance” of particular brain chemicals — an outdated theory that has not held up to the science — we have inherited the American ideal of self-sufficiency, of solving one’s problems through one’s own resourcefulness. As we’ve sought to forge our identities, we have often struggled to reconcile the two.

My peers and I lived through — had indeed been the vanguard of — the psychopharmacological revolution. Prozac was not the first of the selective serotonin reuptake inhibitor antidepressants, but it was the first to hit the U.S. market, gaining FDA approval at the end of 1987. Thanks to national education campaigns trumpeting depression as a major public health issue and few other new psychiatric drugs being introduced, Prozac made a huge splash. Other SSRIs such as Zoloft and Paxil followed a few years later.

Starting in the early 1990s, new kinds of antipsychotic medications were released. Originally used for schizophrenia, these “atypical antipsychotics” were increasingly prescribed to stabilize the mood swings of childhood bipolar disorder and to quell irritability associated with autism and behavior disorders. Longer-acting formulations of the stimulant Ritalin, which had been used in children since the 1950s, appeared, as did other drugs for attention deficit/hyperactivity disorder. By the mid-1990s, the prescribing of psychotropic drugs to children was front-page news in major newspapers. When I entered college in 2001, college counseling centers were reporting an overwhelming influx of patients, including growing numbers who arrived at school with a long history of mental illness and medication.

Since reliable statistical analyses lag years behind actual shifts in medical practice, the statistics about the actual number of kids prescribed medication began to hit the media when these children had already entered adolescence, or even adulthood. When the data did emerge, it confirmed what people already sensed, a massive increase in the number and percentage of children being treated with psychiatric drugs. Although children and teenagers were — and still are — prescribed such drugs less frequently than adults (with the exception of stimulants), the rate of growth is remarkable. Between 1987 and 1996, the percentage of people under twenty taking at least one such drug tripled, from about 2 percent of the youth population to 6 percent, at minimum an increase of more than a million children. Between 1994 and 2001, the percentage of visits to doctors in which psychotropics were prescribed to teenagers more than doubled: to one in ten visits by teenage boys and one in fifteen visits by teenage girls between the ages of fourteen and eighteen. In 2009, 25 percent of college students were taking psychotropic meds, up from 20 percent in 2003, 17 percent in 2000, and just 9 percent in 1994. The prescribing of more than one medication has become far more common in child psychiatric patients in recent decades—even though, as the National Institute of Mental Health’s head of child and adolescent psychiatry research noted in 2005, there was “little empirical evidence of efficacy and safety from well-designed studies.” Although statistics about medication use show a clear increase, nationally representative data is still severely lacking.

Many children and teenagers were also facing the prospect of taking medication for far longer than people who first encountered psychotropic drugs in adulthood. In the 1980s and 1990s, doctors tended to prescribe drugs for a limited period of time for both adults and children, except for bipolar disorder and schizophrenia, long considered intractable, lifelong conditions. But it became increasingly clear to doctors that ADHD persisted into adulthood in about two-thirds of people, and that an early bout of anxiety or depression often portended more frequent and more severe episodes later in life. And so my peers and I found that a drug initially prescribed by a pediatrician as a stopgap measure for some alleged hormonal or developmental problem often became a long-term, perhaps indefinite commitment.

The medical profession wasn’t the only force driving the increase in prescriptions. Our parents, the ubiquitous baby boomers, are notorious for seeking medical solutions to every ailment (one book on the subject, by journalist Greg Critser, cheekily dubbed them “Generation Rx”). The boomers also tend to be portrayed as overly indulgent parents, obsessing endlessly about their children’s fragile self-esteem and all-important academic performance. They wanted us, their children, to be not just happy, fulfilled, and confident, but also high achievers from a young age. They worried that their children could come under the influence of — or be outright harmed by — the unhappy, disaffected kids who captured headlines in the 1990s for their dramatic suicides or school shoot-outs.

The boomers tried to be cooler or more hip than their own parents, but most of them were far from “anything goes” when it came to their offspring. As one of the subjects of my book put it, describing his parents’ and teachers’ expectations, “You can’t not function. You can’t wake up in the morning and not be able to function.” The goal, he said, was to strike a magical balance between being “happy-go-lucky” and “efficient.” These conflicting expectations and aspirations produced some rather stressed-out children—and some parents, teachers, and doctors readily inclined toward pills to help manage the effects of that stress.

My peers and I also came of age in a time when the economics of health insurance were changing drastically. In the 1980s and 1990s, most employer-based health insurance moved toward a managed-care model, and state- and federally funded health coverage for children expanded. The government and the HMOs were both eager to keep costs down, and therefore preferred relatively cheap psychiatric drugs to long-term talk therapy (despite a growing medical consensus that the most effective treatment for most psychiatric conditions was a combination of medication and therapy).

Meanwhile, a shortage of child psychiatrists, especially in poor and rural areas, meant that many troubled children could not see a specialist. As a result, already-busy pediatricians shouldered more of the burden of treatment: in the late 1970s, about 7 percent of all visits to pediatricians involved a child with emotional or behavioral problems, but by the mid-1990s, that rate had nearly tripled. Increasingly, those visits involved writing a prescription.

Prescribing data collected between 1992 and 1996 showed that pediatricians prescribed 85 percent of psychotropic medications.

As psychiatrists switched from forty-five-minute visits with time for psychotherapy to fifteen-minute “med checks,” prescriptions often came with little continuing discussion about how kids felt about taking medication, or how it was affecting them. That was fine by some, but not by others. One young woman I interviewed, who received her prescriptions from time-crunched psychiatrists who scheduled fifteen-minute appointments they often cut short, wished there had been time to “talk about feelings, not just symptoms.” One young man told me that even though psychiatric medication is “so much a part of our culture,” he could “probably count on one hand” the conversations he’d had about his medication use, or anyone else’s.

Most psychotropic drugs, it’s important to note, were and still are prescribed to children and teens without official FDA approval for the relevant condition and age group. As long as clinical trials have shown a given medication to be safe and, under certain narrow requirements, effective for some condition, and as long as the pharmaceutical companies don’t advertise a drug for a nonapproved use in kids, doctors can legally prescribe it “off-label.” Off-label prescribing to children is nothing new, in large part because concerns about the ethics and legality of conducting drug trials on minors have plagued medical research for decades. (As the pediatrician and pharmacologist Henry Shirkey observed in a 1968 article in the Journal of Pediatrics, children were becoming “the therapeutic orphans of our expanding pharmacopoeia,” and people calling for drugs to be tested in children were still reiterating Shirkey’s formulation three decades later.) Historically cautious, doctors used to wait a number of years after a new medication came on the market before prescribing it to children. But with all the hoopla surrounding the introduction of new psychotropic drugs in the late 1980s and 1990s and an influx of young patients seeking treatment, fewer doctors bothered to wait.

This sharp increase in prescribing made the lack of research all the more acute. Controversies brewed. Did antipsychotic drugs cause dangerous obesity and early-onset diabetes? Did stimulants stunt growth or increase the risk of drug abuse later in life? Did taking antidepressants or stimulants before puberty predispose children to bipolar disorder in adulthood? Did SSRIs like Prozac increase the risk of a teenager attempting suicide?

In the late 1990s, responding to the precipitous rise in prescribing and what researchers called a shameful lack of safety and efficacy data, the National Institute of Mental Health began funding a series of major, multisite medication trials in children and teenagers.

They led to some important findings, with trials for major depressive disorder and obsessive-compulsive disorder concluding, for example, that combined medication and cognitive-behavioral therapy (CBT), a short-term therapeutic treatment focused on refocusing thought and behavior patterns, was the optimal regimen for the greatest number of children, compared to a placebo or to either medication or CBT alone. These so-called “multimodal” studies were groundbreaking because they were some of the first to compare the efficacy of different treatments, measuring one drug against another, drugs against therapy, and standardized, carefully managed treatment against “community care,” the treatment a child would ordinarily receive in his or her local area. They also were comparatively long-lasting, which produced certain notable findings. For example, children in the government’s major ADHD trial at first seemed to do best on medication alone, compared to various other combinations of treatments. But when the same children were assessed two years after the study ended, there were no differences in either ADHD symptom reduction, or improved school or family relationship functioning, among different treatment groups. Medication’s superior effects, in other words, did not last. The vast majority of studies are not this wide-ranging or long-term.

As a result, myriad issues remain unsettled and hotly debated today and continue to bedevil parents, doctors, and young people as they weigh the relative risks and benefits of embarking on psychopharmaceutical treatment. Recently, some studies have questioned the efficacy of antidepressants for mild and moderate depression in adults, which has generated considerable public interest and raised questions in many people’s minds about the wisdom of taking the drugs at all, let alone long term.

In fact, as psychiatrist Peter Kramer pointed out in a column in the New York Times, this particular new evidence only applies to episodic, not chronic and chronically recurring, depression, and it doesn’t say anything about the drugs’ efficacy for many other conditions, including numerous anxiety disorders, severe depression, menstrual-related mood disorder, and the depressive phase of bipolar disorder. Other studies have raised troubling questions about how some psychotropics may affect the brain long term; the drugs are effective at preventing relapse for as long as they are continued, but some evidence suggests, for example, that the changes the drugs cause may set patients up for withdrawal symptoms that look very much like relapses, prompting, some have argued, a kind of psychological dependence on the drugs. The studies have generated considerable controversy in the mental health profession and in the popular media.

Overall, extended, decades-long longitudinal studies tracking outcomes of medication treatment in kids remain close to nonexistent, because of the great expense and effort involved in tracking people over many years. As a result, the original group of medicated children has entered adulthood with very little information about the lasting physical, emotional, and cognitive effects of using psychiatric medication during childhood and beyond. They are left with the legacies of using medication, though in many cases they’re not quite sure what those legacies are, or will be.

I don’t mean to suggest that every young adult who spent his child or adolescent years taking medications is preoccupied with the existential implications of that treatment. Undoubtedly, many would contend that the effects were simple: the drug either worked to resolve symptoms, or it didn’t. But I suspect that taking a little time to reflect on a drug’s role in their own coming-of-age stories would allow them to see just how wide-ranging and complicated the impact of medication has been.

Excerpted from “Dosed: The Medication Generation Grows Up,” by Kaitlin Bell Barnett (Beacon Press, 2012). Reprinted with permission from Beacon Press.

Narrating this disturbing tale are Craig Timberg, former South Africa bureau chief for the Washington Post, and Daniel Halperin, an epidemiologist, AIDS researcher and former advisor to the U.S. government’s anti-AIDS program. Timberg met Halperin in the middle of his five-year stint as the Post’s Johannesburg bureau chief and the two began exploring questions that had bothered Timberg since his arrival in South Africa.

Timberg, now back in Washington as the Post’s deputy national security editor, spoke with Salon about the book.

Perceptions about the origins and spread of AIDS have changed over time in fascinating ways. First, it was seen as a gay disease. When it was detected in Africa, people assumed it came from the West. Over time, scientists showed it originated in Africa, a notion rejected by many Africans but in keeping with Western notions about third-world diseases. You show in the book that AIDS arose as a result of sweeping changes in social structure brought to Africa by European colonialism. Describe its origins.

Scientists have known for more than a decade that the version of HIV that has caused almost all cases of AIDS is virtually identical to a virus common in central African chimpanzees. That’s not controversial. The location of the transmission was determined by a group of scientists who narrowed it down to chimpanzees living in southeastern Cameroon by collecting their feces, detecting the virus and comparing it to other strains collected elsewhere. Michael Worobey from the University of Arizona and his team mapped the genetic structure of pieces of HIV from all over the world, looking at the extent of mutations between them. They were able to make assumptions about how many years it would have taken to produce these changes. The time frame puts you close to the turn of the 20th century for the original virus, the ancestor to all modern HIV.

How was the spread of AIDS to humans linked to colonialism?

In southeastern Cameroon, at the exact moment scientists now believe HIV entered the human population, you had steamships going up rivers that never had steamships before. You have porters who are virtually human pack animals carrying ivory or gear for colonial companies through dense forests. One of those porters would have been the first human to contract HIV. It looks like HIV goes from the chimp population into a hunter who cuts himself while butchering a chimpanzee for food. It then spreads in a localized way along these porter paths and colonial trading posts and eventually comes down river on a steamship into Kinshasa, then called Leopoldville, the first major city in that part of the world.

And that leads to what you call the Big Bang – when HIV explodes and moves out of the Congo.

That’s right. A single spark emanating from southeastern Cameroon works its way to colonial Leopoldville. But HIV doesn’t spread fast on its own. It needs particular conditions to race through a population and Leopoldville had them. It was big and growing fast. It had a high concentration of men working in factories, separated from their wives and girlfriends. It had an emerging population of sex workers and transport to get people back and forth. Gonorrhea, syphilis, chlamydia spread like wildfire; HIV doesn’t but starts to spread along railroad lines, porter paths and rivers during the early and middle part of the 20th century. When scientists look at the genetic structures of different types of HIV they all seem to have come from a single piece of ancestral HIV that existed in Leopoldville at the beginning of the 20th century.

So HIV lingered in small numbers of people but doesn’t exit this area. When researchers go back to blood samples collected during the 1976 outbreak of Ebola virus, they find HIV.

Yes, so in the middle part of the 20th century about 1 percent of adults in major population centers of the Congo had HIV. Before they died, they developed symptoms of other familiar maladies—pneumonia, tuberculosis, wasting. It wasn’t obvious there was a new epidemic loose in the land until gay men in the United States started getting sick in the early 1980s. Before that, it didn’t spread far and it didn’t spread fast. The reason seems to be that in colonial Congo, the majority of adult men would have been circumcised and circumcised men are much less likely to contract HIV and pass it on. It’s only when HIV makes its way out of the Congo River basin to other places more hospitable to its spread that we get a true explosion.

Many people assume AIDS must be a disease of poverty. But you argue that wealth, modern transportation and economic development were key factors that allowed AIDS to break out.

When I first went to Africa as a correspondent in 2004, I carried this question with me: Why is HIV so severe in some places and not in others? Logic said: Africa, poverty, poor medical systems — there had to be a connection. But when I started traveling to different countries I discovered that most truly outrageous hellholes — places with warfare and incredible poverty — didn’t have much HIV. Other places with modern transport and sophisticated economies had a lot. When I met my co-author, Daniel Halperin, it began to come together. I saw that while being poor and having HIV is certainly a very bad thing because you’re more likely to die when you can’t afford medicine, some degree of economic activity actually makes you more vulnerable. When the epidemic starts spreading widely in some African societies it’s in the cities. Wealthier people — doctors, teachers, politicians, singers — get HIV in completely disastrous numbers. Some of that has to do with access to resources and multiple sexual partners.

You begin with a chapter on the city of Francistown, Botswana, an affluent place with a horrendous HIV rate. What struck you about Francistown?

I drove to Francistown for the first time in 2006 and it felt like driving into anywhere, USA. I could buy a hamburger at Wimpy’s, order a shot of espresso. There were cafes and ATMs. Yet it had this horrendous HIV rate. Among women in their 30s, two-thirds were infected. The picture of poverty before HIV didn’t add up. When you scratch the surface you begin to realize that other factors — human movement, transport, sexual behavior, circumcision or lack of it — are decisive in how the virus spread.

You describe the AIDS belt, an area in southern Africa at the very heart of the African epidemic. What are the characteristics that made it, as you call it, a tinderbox?

There’s a giant swath of the continent that starts at the southern end of Sudan, goes down through east Africa to South Africa and out to the sea where you have this combination of sexual networks and low rates of male circumcision. Together they produce the tinderbox. Two centuries ago most of Africa had polygamous societies in which the richest, most powerful men had multiple wives. In contemporary Africa, in part because of that tradition and in part because of the ravages of colonialism and migratory labor, many men and women have more than one sexual partner over the course of a week or month. But to be part of the AIDS belt, you need one more thing: low rates of male circumcision. The people who migrated down the Nile River basin from Sudan never had circumcision as part of their tradition. In the southern part of the continent, it was a tradition pretty much everywhere until about 200 years ago when some ethnic groups began to give it up. In those places you see HIV rates of 10, 15, even 25 percent.

Why is circumcision effective and why was early evidence of its power missed?

A man’s foreskin is unusually vulnerable to HIV; the skin is thinner, softer and more easily penetrated by HIV and other pathogens. When it’s removed, the remaining skin is rougher and more resistant to infection. That makes no difference if you’re a gay man who is the receptive partner in anal sex. But the African epidemic is spread predominantly through heterosexual sex, particularly vaginal sex, and circumcision is crucial. Circumcised men are at least 70 percent less likely to get HIV. This science first began to appear in the mid-1980s.

That’s three decades ago!

That’s right. That data seemed to offer this miraculous new insight. But the global public health community was deeply uncomfortable with the subject. It took another 20 years to come up with evidence so definitive they accepted it. Peter Piot, one of the central characters in the AIDS response, was part of that research team. Yet during all the years he was head of UNAIDS he was not enthusiastic about this science. To be fair, establishing correlation is not the same as establishing causality. And it’s a pretty serious thing to contemplate altering men’s penises if you’re the global health community.

One area of culture clash between global health agencies and Africa is over condoms. What happened?

People who had watched AIDS in the U.S. were mindful of the way condoms seemed to slow the spread of HIV there and especially in Thailand, where the epidemic was transmitted mainly in brothels. It was hard for those officials to understand how different the African epidemics were. In several places, Africans were saying, “Hey, our best chance for surviving is for people to have fewer sex partners at a time.” But Westerners had condoms on their minds. The U.S. government and other organizations made a huge bet on condoms and reasoned that if you could just get enough of them to people in vulnerable places you could reverse the epidemic. Instead, reported usage of condoms in some African societies went to rates far higher than anywhere else but HIV also went up. That puzzled people until it became clear that people were using condoms with prostitutes or one-night stands but not in long-term relationships with their husbands, wives, boyfriends or girlfriends. And that’s how HIV is most likely to spread.

Uganda emerged in the early days of the epidemic as a place that took effective action, changed people’s behavior and lowered HIV transmission. 

In 1986 a new government took over and confronted the facts of AIDS. They knew it was fatal, they knew it was incurable, they knew it was spread by sex, and they knew a lot of people already had it. So political, religious and cultural leaders focused on changing the sexual behavior that was at the core of HIV’s spread. The most famous terms for this was zero grazing, a metaphor that worked well in an overwhelmingly agrarian society. When leaders said zero grazing, Ugandans understood at an intuitive level that having sex with your primary partner is much safer than having sex with a primary partner and others. If a large number of people make a relatively small change in their number of sex partners it can make a massive difference in the spread of HIV. That’s what happened in Uganda and hundreds of thousands of lives were saved.

Why were the powers that be in global health so reluctant to focus on behavior change?

The global health infrastructure was uncomfortable talking about differences in sexual behavior. That’s a shame because a sexually transmitted epidemic is by definition spread by sex. To understand why it’s worse in some places than others you have to dive into some inherently uncomfortable questions about a very private matter.

Yet there was historical evidence here that changing behavior made a difference. San Francisco closed the bathhouses and it helped. In New York, behavior changes led to lower rates of anal gonorrhea in the early days of the epidemic.

Those changes were instituted within coherent communities. Gay men advocated the closing of bathhouses and made the choice to have fewer partners or use condoms. In Africa that process was hampered by the slowness to accept that AIDS was real and the fact that people are understandably resistant to being told what to do by a large and powerful outside force. Many of these societies need our financial aid, our technical assistance to do things that matter to them, including improving public health. The tension over how much to listen to outsiders while not wanting to be told what to do has troubling consequences that have infused the world’s response to AIDS in all sorts of ways.

What lessons do you draw from the way the epidemic has been addressed in Africa?

The overriding lesson is that sex matters. Those of us who care about people getting this terrible disease can’t be squeamish in discussing sexual behavior because we’re afraid of how it makes us look. The research has to be good, the messaging has to be forceful and clear. It’s not enough to tell people to use condoms all the time because the evidence after more than 30 years is that people don’t, not often enough to be truly decisive. We also have to be willing to engage in questions about how many partners people are having, we need to tell people that from the viewpoint of sexually transmitted infections, anal sex is more dangerous than vaginal or oral sex. These things are uncomfortable to talk about. At the same time, if we take seriously the moral question of trying to prevent as many infections as we can, we can’t be frightened of these subjects.

Thirty years later, Davidson is still researching and writing about the intersection of neuroscience and emotion — he currently teaches psychology and psychiatry at the University of Wisconsin-Madison. In his new book, written with Sharon Begley, “The Emotional Life of Your Brain: How Its Unique Patterns Affect the Way You Think, Feel, and Live, and How You Can Change Them,” Davidson lays out a fascinating theory that parses out emotional style into six dimensions, giving readers a better understanding of where they stand on this emotional plane and how emotional styles affect the qualities of their everyday lives.

Last week Salon spoke over the phone with Davidson about how Botox injections disrupt our ability to emote, the connection between happiness and health, and why emotion has been unfairly and historically underappreciated.

There’s been stigma around the study of emotion in the past. Some people still frame emotion as pointless metaphysical leftovers that result from physiological processes. I think that your work has really come to show that that’s not true. In your view, what are the evolutionary and practical purposes of emotion and does it have intrinsic value?

I think that emotions are such an important part of our experience and behavior.. They came about over the course of evolution for a reason; to promote survival — to facilitate the adaptation of organisms to their environment. Emotions evolved to solve specific kinds of problems that arose over the course of our history. They wouldn’t be such a robust part of our experience if they didn’t have this deep evolutionary origin. Having said that, it’s also the case that we now live in an environment that is vastly different from our evolutionary origins. So some of the emotions that played a very important role in our past can be maladaptive when they are triggered in response to stimuli in our current environment. This is why developing strategies to better regulate our emotions may be particularly important for us now.

In the book you talk about some really fascinating research suggesting that emotional outlook, happiness or depression, can have a direct influence on our health.

There is an intuition in the popular culture that our emotions have something to do with our physical health, but we are just beginning to explore this connection. In our own research, we examined both the brain activity and peripheral biology of a group of individuals by giving them flu shots. It turns out that people who have a more resilient brain profile are the ones who actually have a bigger boost in their immune response when they get a flu vaccine. What it suggests is that more resilient individuals, when exposed to the flu virus, are conferred much greater immunity than a person with a vulnerable emotional style. It suggests that these brain circuits directly communicate with peripheral biological processes, in this case certain features of the immune system, and directly regulate them in ways that are consequential for our health.

In the beginning of the book, you talk about a discovery that set the course of your career in motion — this distinction between people with more right prefrontal cortical activity and those with more activity in their left prefrontal cortex.

We had been doing research looking at the neural correlates of particular short-lived emotions. We were specifically looking at neural changes during different fleeting facial expressions. The idea that we could actually identify brain mechanisms that underlie different emotional styles was not in the lexicon of science in the past. At that time the neuroscientific study of emotion was conducted mostly in rats and focused on subcortical brain regions, regions below the cortex.

What we noticed was that this right versus left activation patterns of the prefrontal cortex varied more across people than it did within one person during different emotions. So we did further studies to demonstrate that these individual variations were actually consistent for a person over time and directly related to important features of their mood and emotional styles. That’s what really launched us into thinking about emotional style and its brain bases.

Was it surprising that the prefrontal cortex was involved in emotion?

Well many psychologists and neuroscientists at that time regarded the prefrontal cortex as exclusively involved in higher cognitive function because the prefrontal cortex is among the most recent to develop over the course of evolution. In many ways it was regarded as the seat of the highest form of reason in humans. This assumption that the prefrontal cortex could not possibly be involved in emotion is, I think, part of a historical anachronism that regarded thought and feeling as two completely separate realms.

In the beginning of the book you lay out a theory that each of us has a certain unique Emotional Style, split up into six components. What are these six emotional dimensions?

One is Resilience, which refers to how quickly or slowly you recover from adversity. The second is Outlook; the duration that a person’s positive emotion persists. Then there is Context, and that is the extent to which we modulate our emotional responses in a context-appropriate way. So for example, when we are with our boss we know that it’s not permissible to discuss the same topics we might discuss with our spouse. That’s called context modulation. The fourth is Social Intuition, the sensitivity to social cues, the extent to which a person is sensitive to facial expressions or vocal expressions. The fifth is Self Awareness, the extent to which a person is aware of signals within their own body, which are important to emotion. Finally, Attention, how focused or scattered you are. Attention isn’t often thought of as part of emotional style, yet our work indicates that it significantly contributes to a person’s emotional makeup. Is your attention easily pulled by stimuli in the environment or are you able to more skillfully focus your attention on what it is you wish to attend to.

You did a really interesting study looking at how the genes that code for our temperament can actually be modified by life events and environment. What did you find?

We have learned over the last decade, and more specifically really the last five years, that the genome itself is not changed over the course of a life, but the extent to which genes are expressed can be influenced by our environment or the behavior in which we engage. This is referred to as epigenetics, the regulation of gene expression. We know that there are sites on genes that code the extent to which another gene is actually turned on or turned off. And it can be turned on and turned off in a graded fashion.

And the study looked at how kids reacted to a toy robot that approached them …

It was a longitudinal study that followed kids from age 3 to their early teens. It tracked their brain development in conjunction with the development of certain temperamental features, one in particular called behavioral inhibition, which refers to shyness. What we found is that kids can significantly change in their expression of this temperamental characteristic over time. What we also showed is that to the extent to which temperament changes, the brain also changes. So brain activity during these early years in life is not fixed and can be changed by environmental factors and activities. This is really just an example of what we refer to as neuroplasticity; that the brain can change in response to experience and training.

Another study that I found really interesting and amusing involved women who had recently had cosmetic Botox injections. How did the results speak to this mind-body connection?

That’s a great example. Beginning with Darwin’s book in 1892, “The Expression of Emotions in Man and Animals” we have known that facial expressions are very important for emotion, and recent theories suggest that facial expressions provide feedback to the brain and influence the emotional state of a person through that feedback. It suggests that if we eliminate feedback, as Botox does, we deprive the brain of certain signals that it uses to determine one’s own emotional state. The women in our study were getting Botox in the muscle just above the eyebrow, temporarily paralyzing it. That particular muscle is used in frowning and several different negative emotions. What we found is that Botox injections actually impaired their capacity to perceive negative emotion when they read negative sentences, and this suggests that we use our bodies to help decode the emotions of others by subtly simulating their emotions and mirroring their emotional state with mini-facial expressions of our own. If we can’t make those facial expressions because our face is paralyzed, then our ability to understand their emotional state is impaired.

Neuroscience has shown certain kinds of activities can influence changes in the brain, but one of the major points you make in the book is that purely mental exercises can too. How did meditation become part of your research?

I’ve had a longstanding interest in meditation personally, but it wasn’t until 1992 when I first met the Dalai Lama that that interest was catalyzed into a major component of my own scientific research. The Dalai Lama pointed out that if I could use the tools of modern neuroscience to investigate emotions like fear, anxiety and depression, then I should also be investigating kindness and compassion. So I made a commitment to put these positive qualities like kindness and compassion on the scientific map. Meditation practices are said to enhance and nourish these qualities, so we began to investigate the extent to which these kinds of meditation can lead to changes in the brain and can promote behavior associated with positive qualities of mind.

You give examples of exercises at the end of the book to help people take advantage of their own neuroplasticity. For example you say that by delaying gratification, which is associated with planning, you can strengthen the connection between your prefrontal cortex and a brain region called the ventral striatum, which increases one’s sense of well-being.

I think that we’ve learned a lot about what can induce these plastic changes in the brain. It’s quite similar to engaging in physical exercise or learning to play a musical instrument or chess. All of these require regular practice in order to become more fluent in them, and it’s the same for happiness. Well-being can be thought of as a skill; you learn it better when you practice it over time. Many of my suggestions in that last chapter of the book come from different strands of research, but they all point to the idea that we can take responsibility for our own brain. Often, we leave our emotional patterns to happenstance and we don’t intentionally cultivate them. But we shouldn’t think of emotional style as any different than cognitive skills, or activities with a tradition of intentional training. Eastern contemplative tradition, and particularly meditation, is exactly this technology of mental exercise. It fosters better habits of mind, and our neuroscientific research has shown this.

You are also sensitive to the fact that some people might not be able to change their emotional styles, especially if they are on an extreme. What are some coping mechanisms for those of us who might have a harder time changing our emotional styles?

We are all different, and for some people, certain styles may be easier to change than other styles. One of the things that I suggest at the end of the book is that instead of changing your style, you can alter your environment to make it more compatible with that style. If you are the kind of person who is terrible at picking up on social cues and who doesn’t really get a lot of enjoyment from social interaction, you can try to arrange your work life so that you don’t interact with a lot with other people and picking up on social cues is not something that you need to rely on for success. I think that the hope with this book is that people learn more about their own emotional style so they can figure out what makes the best sense for them.

Salon spoke with Topol over the phone about the empowered consumer, rebooting the life science industry, and the doctors of the future. 

“Digitizing the human” is a provocative phrase you use throughout the book; what does this mean, and how can it lead to what you call the “democratization of medicine”?

We’re so used to digitizing everything — books and movies and periodicals — everything except for our bodies. My idea is to digitize the essence of what makes us tick — our genome and our physiology — thanks to different biosensors which are largely wearable, put right on a band-aid or a wrist or on the sole of a shoe. This would be combined with imaging, the ability to image any part of the body with a high-resolution pocket ultrasound device. When you take all these things together, along with personalized electronic health records and health information systems, this gives us a really panoramic, deep view of each individual.

How do cellphones fit into this?

Well, the cellphone has been the basis of a lot of democratization. You look at the Arab Spring and the Occupy movement and it’s the mobile phones that are bringing people together, through Facebook and Twitter and sharing pictures and videos and emotions. Now the digital infrastructure supports the whole medical side of this; you could have your own data for blood pressure or glucose or mood or anything quantified, right on your phone. And then that information can be shared with your social network, or your doctor, or whoever.

So the ability to have this mini computer in your pocket, that you’re essentially surgically attached to, is such a powerful force for the use of that data.

What role will the consumers play in this revolutionary shift?

I envision the consumer being the primary driver. That’s why I actually wrote the book. I’ve written a lot of medical textbooks, and I’ve lived in the medical microcosm until recent years, but then I started realizing that this digital world is really changing everything. The medical community itself is so resistant to change. The government and the life science industry are not going to be active in promoting a radical change. But consumers can do it and they’re more truly empowered, more resourceful and bound together and powerful than ever before.

And there’s one other lesson that’s really valuable: Back in 1997, the United States approved Direct to Consumer Advertising on TV for drugs, which I think was a dreadful mistake, by the way. But what’s interesting about it was it basically fueled this “Ask your Doctor” movement: a patient-centered, consumer-centered model. It was very powerful because of course these drugs [being advertised] became extraordinarily widely used. I don’t want to promote that, but on the other hand, if consumers are partnering with doctors, like, “Here’s my genome, Doctor, what do you think of it? Here’s my blood pressure and vital signs for the last three months,” it’s not just “ask your doctor” anymore it’s tell your doctor, share with your doctor.

Why is the medical field so resistant to digitization/digital records? Other industries have done this almost a decade ago.

Well, this is the history of medicine. If you go back to 1816 when the stethoscope was invented, it took 20 years before doctors would use them. The average time it takes for a medical innovation to come into daily practice is 17 years, which is just horrible. And they had all kinds of excuses, similar to the excuses that they have today. Basically, one of the main reasons doctors wouldn’t use a stethoscope was because they said it would interfere with their interactions with patients. And they didn’t want to learn all these new heart sounds and breath sounds and that sort of thing.

There’s an unwillingness to change. For example, a lot of physicians I work with are bothered by the fact that they have to be typing at a computer, looking at a screen, rather than interacting with a patient. And I understand that; both the physician and the patient take a hit in terms of optimal communication. How do we deal with that? A lot of physicians now have scribes that do the computing of data while they never lose eye contact with the patient. The patient obviously knows very well whether they’re not being listened to or looked at. So part of it is resistance to change and part of it is losing touch with a visit with a patient.

You mention this in your book, but isn’t it dangerous to have our medical files out there, in terms of security issues?

Like everything else that’s digitized, when you digitize a human being you have the potential for hacking, privacy and security issues. And already there have been breaches of electronic medical records in major medical centers around the country. So this has to be attended to with the maximal assurance that we’ll do everything we can to preserve that security. It’s a tradeoff: Do the benefits of having the essence of each individual captured digitally override the hopefully small, negligible risk of a breach of that data?

How do American doctors compare to doctors in other countries in terms of their attitudes toward technology?

Medicine on a planetary basis, on a global basis, is very conservative and resistant to change. But there are some specific examples where there’s a real gradient or heterogeneity, a real marked difference in cultures. In the U.S. the adoption of technology can be stymied because of reimbursement issues. In other countries where there’s no fee-for-service private practice, there’s been remarkable adoption of certain technologies. A great example of that is the portable ultrasound; I haven’t used a stethoscope now in two years. I use this pocket ultrasound device so I can see everything in the heart rather than listen to the heart’s sound. In the U.S., hardly any doctors are using that because they can’t get reimbursed; they much prefer to send the patient to get a cardiogram, which is an ultrasound of the heart, or an ultrasound of the abdomen or whatever the ultrasound is. Whereas in India, Brazil, China, this is one of the hottest new technologies because it saves costs dramatically and there are no issues with respect to reimbursement.

In what ways can recent breakthroughs in our understanding of the genome – from the Human Genome Project of 2000 to today – contribute to the shift to individual-based medicine?

There are three biggies right now. The longest chapter in the whole book is on genomics. The first is pharmacogenomics. Now, in the U.S. alone, we spend $350 billion a year for prescription medicines, and so many of these drugs have known serious side effects, that can be predicted by knowing a particular genotype. And in addition, some medicines don’t work for a lot of people, and we could predict that with a very simple genotype — like Plavix, which a third of people don’t respond to but they keep taking every day, or Metformin for diabetes, which 25 percent of patients don’t respond to. Tegretol has a horrendous side-effect profile. We don’t screen for it in the U.S., but you can’t get a Tegretol prescription in Taiwan without having a genotype. So in that sense we’re way behind. I could go on, a lot more examples are in the book, but that’s No. 1 – the use of genomics today. We’re not leveraging that great new knowledge.

Second is in the field of cancer therapeutics. If you have a new diagnosis of a significant cancer today, the best way to potentially get the right therapy is to get a whole genome sequence of the tumor, and also of your native so-called germline DNA, and compare the two. By comparing the mutation in the tumor to what you’re born with in your DNA, you can see what went off the tracks (because cancer is by definition a genomic disease) and then you can fashion a therapy specifically for that individual.

The third area is the elimination of the idiopathic, which is a very fancy medical term used for “we don’t know.” There’s a lot of people walking around with debilitating serious disease, and trying to get a diagnosis for what is wrong with them and they haven’t been able to do it. The issue is, until now we didn’t have a way to sort this thing out but with whole genome sequencing, we can in many of these individuals determine the root cause, the biologic basis for their illness.

Competing manufacturers of these new technologies will be required to agree upon uniform standards; is this a feasible hope?

This is a really interesting trend to watch. Now in the networking electronic world we live in, you see some unprecedented collaboration among even competing life science industry companies. So, for example, in the case of Alzheimer’s disease, where they haven’t come up with anything to prevent or change the course of Alzheimer’s, it’s been very frustrating. Many companies have invested billions of dollars in this whole objective. But now, they are working together. So most of the large pharma companies are pooling their data to basically do an autopsy of the failed drugs to find out what went wrong. And you never would have seen that in the past – I mean that’s actually remarkable.

If everyone working on cancer that did a genome sequence of an affected individual put that data in a common place and all the companies were also involved, we could really get so far ahead in this cancer problem, which is quickly emerging as the No. 1 cause of death, overriding heart disease. But we don’t have that type of collaboration yet. We need it to cross national boundaries, and to get the academic and life science industries to converge. That would be creative destruction in high gear!

What technological innovations in medicine are you most excited about? 

I think the one I’m most excited about is the embedded nano-sensor. You have to put it in the bloodstream and get it to localize, either in the finger or the wrist, someplace that’s hyper handy that will communicate with your cellphone. And that embedded nano-sensor can be used to pick up, for example, the first cancer cell that shows up in the bloodstream, which would promote the earliest possible detection of cancer.

It also could help with the autoimmune form of diabetes, called Type 1, which usually affects kids. If we have that embedded nano-sensor constantly monitoring, and a medicine used to block the immune system when needed, this, hopefully, could lead to the end of autoimmune diabetes, which is really exciting.

And the other really far out thing is the area of heart attack prevention, again through an embedded nano-sensor. It can be used to pick up cells in an artery that’s starting to crack a week or two before a heart attack. We have some really good data to suggest that this will ultimately be possible.

How does Obamacare fit into this? How much will this cost? Where will the money come from?

Obamacare is in a different orbit. There’s nothing in the 2,000-plus page bill that gets into this kind of hyper innovative individual medicine, biosensor leveraging, genome and all these sorts of things – it doesn’t really show up. But it is a great opportunity to make medicine and healthcare more affordable. For example, it’s estimated that about a third of the $350 billion spent a year on prescriptions is a total waste. So there’s a great opportunity there, with gene-specific drugs. If we do the 20 million echocardiograms, and almost as many abdominal and fetal ultrasounds, for free with ultrasound pocket devices, there are billions of dollar we could save there. With sensors, if we could get tens of millions of people in this country to manage or prevent their diabetes that could have enormous financial implications. And it’s the same for high blood pressure: 50 percent of people with high blood pressure do not have it adequately managed, so they’re vulnerable for strokes and heart attacks. If we can manage it with a simple cellphone sensor, that would be an enormous potential to lower costs for stroke disabilities, heart attack, heart failure, all those sorts of things.

In what ways can social networking be useful for physicians?

Patients share on online health communities and each of these social networks have amassed an enormous following. Let’s say you have a particular condition like multiple sclerosis, or a form of cancer or diabetes. You go on these social networks and find peers whom you’ve never met with, but they become your guidance and connections. And they are now more trusted than doctors by a substantial proportion of participants in these online health communities. Now, on the doctor side, almost 90 percent don’t even know these online communities exist, which is in itself surprising. But, if we work together, this is another opportunity to get information out there.

On the other hand, you don’t exactly want to have your patient as your Facebook friend. But one thing that’s striking me is, just a couple weeks ago in the Wall Street Journal there was this big debate: Should doctors email with their patients? And I thought, “How could that even be a question?” It seemed like a crazy throwback to a different era. Then there was an article in the Journal of American Medical Association asking, should patients be able to access their laboratory data? You’ve gotta be kidding. How could this be a question in 2012? This is the paternalistic, Doctor Knows Best mind-set that is still carrying over to today. We’re too far away from democratization, and I’m hoping we can change that.

What does all this mean for the individual consumer? How will our actual experience of going to the doctor of the future change?

The doctor of the future, who has plasticity and has moved into the digital era, will be up on all these things. There may not be in-office visits, there may be virtual visits on Skype or Facetime, and patients could send all their data real time through their phone. I think each physician has to say [to patients], We want you to have all your data. We want you to be participatory. We need you to be fully engaged. And if you’re fully engaged, you’re the one with the most vested interest in your condition. We want you to have all the data, whether it’s your lab test, your notes, your metrics on your phone, your genomic data, your scans, whatever it is, we want you to have it because we want you to help drive this process.