Ripple Effects
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In the early 2000s, new parents were told to keep their babies and toddlers away from peanuts. Thinking that peanut abstinence early in life would reduce their risk of a peanut allergy later in life. That's surgeon and public policy researcher Marty McCary. He's recently been tapped to run the U.S. Food and Drug Administration.

I got this peanut advice when I became a mom and I followed it. I remember my pediatrician telling me that if a baby has an allergic reaction to peanuts, it could be deadly. That really scared me. So I followed the guidelines, as did many, many other parents. But Marty says then something unexpected happened. We just started to watch peanut allergies increase rapidly.

And they thought, gosh, we need to double down. We need to get more parents to comply with peanut abstinence in their kids zero through three years of age.

And the more they doubled down, the worse it got. Peanut allergies exploded. The recommendation had backfired. And Marty says mostly because the advice was flawed to begin with. They got it perfectly backwards. It turns out immune tolerance, or what we call the dirt theory, is a real thing. And that is when a kid is exposed to things early in life, like a little bit of peanut butter at five or six months of age...

then they're far less likely to develop a peanut allergy later in life. Marty talks about this in his latest book, Blind Spots, when medicine gets it wrong and what it means for our health. How did this peanut abstinence idea become dogma? Was there any research on this or where did this come from? There was no good science to support it. It was, in the words of some of the experts who issued the recommendation when I interviewed them for the book,

It was kind of their gut feeling. They just thought it made sense to them. There was no study to support it. The little scientific research there was did not really support it, but they sort of used it to support that what they were saying was evidence-based. And the worst thing you can do in medicine is to put something out there with such absolutism, as if it's scientifically based, when really it's just a hunch or an opinion of a small group of people.

Now, this is probably not the only reason peanut allergies went up so dramatically. But this advice definitely played a role. It has affected an entire generation of children and potentially shaken trust in medical advice. When it comes to health and science, flawed guidelines or scientific studies that turn out to be wrong can have a huge impact and affect millions of people.

Of course, that's also true for positive developments. For example, discoveries that lead to life-saving treatments and cures. On this episode, ripple effects, understanding the lasting consequences of decisions and events. To get started, let's hear some more from Marty McCary. He told me when parents tried to question the peanut guidelines back in the early 2000s, it usually didn't go well.

They were called anti-science. Some were mocked. Some parents were shamed. We still see some of these arguments take place in school districts and school boards.

Peanut allergies are real, and kids die from them. We see now an epidemic of kids coming to the emergency room, or they have to travel with an EpiPen because of a severe peanut allergy. We shouldn't mock that. But parents who had said, I insist on being able to feed my kid a little bit of peanut butter early in childhood said,

they were actually preventing peanut allergies when they were sort of labeled as being anti-science. What about scientists and physicians who publicly started to push back against these guidelines? Well, the most famous pediatric allergist in the world, Dr. Gideon Lack, spoke out vocally against this recommendation. Now, he was in London.

And he wrote an article basically suggesting that there would be some disastrous unintended consequences, which of course there were. He did a study in 2008 to try to show that this logic was flawed.

And some people took notice, but a lot of people just kept following the catechism of the American Academy of Pediatrics to promote peanut abstinence until a kid turns three. Finally, Dr. Lack did the ultimate study, an elegant randomized controlled trial in 600 plus kids in London. The study just randomized kids to both approaches and

and found kids need a little bit of peanut butter early in infancy, as soon as they can take food. And it had an eight-fold reduction in subsequent peanut allergy rates when they did that. That study should have been done before the dogma, not 15 years into it. The American Academy of Pediatrics followed up at some point, right, changing the guidelines. But it took a while, right?

They did in 2015, and then again in 2017, they did change their official guidance. But you did not see a sort of public debate

acknowledgement, a sort of reckoning of the dogma, a change that was issued with the same fervor at which the initial recommendation was delivered. And I think that lack of humility is why we have distrust in medicine today. We generally don't see humility when medicine gets it wrong. When it comes to the food pyramid, hormone replacement therapy, peanut allergy prevention,

We don't see this sort of broad acknowledgement put out there with the same vigor by which the original dogma was put out.

In his book, Marty also dives into the topic of cholesterol, another area where he feels like the guidelines got it wrong. He writes about his uncle who really enjoyed eating eggs. So my Uncle Samuel, or we call him Uncle Sam, loved eggs his whole life. It was part of his life back in Egypt where he grew up. And then when he came to the United States, an American doctor told him, you've got to stop eating eggs. They're high in fat and they're high in cholesterol.

And he wrestled with his doctor for years and negotiated and then eventually gave up what he loved most in life. And that was his morning ritual where he had his eggs. And finally, his son became a doctor and told him, Papa, the research now is pretty clear. The cholesterol we eat is not absorbed by your body. By and large, it goes right through your system, 90 plus percent of it.

Your cholesterol in your body is made by your liver. 99% of your cholesterol is made by your body. It's not from the cholesterol we eat. And the demonization of natural fat was a medical dogma that is not held up in studies.

So my Uncle Sam is back to eating eggs at the age of 92 in Florida. But there is still a lot of confusion over fat in our diets and how it impacts cholesterol. It's ironic. The low-fat diet was such a strong dogma. I mean, this was the number one thing we as doctors told patients for 70 years when they came to see us.

We'd say, you need to exercise and eat better. And the number one thing we would say when we tell people to eat better is to avoid natural fats. And I remember when I first came to the U.S. from Europe in the 90s,

Everything was fat-free, everything. There was fat-free cheese and fat-free milk. And I just remember thinking like, what is this stuff? And why are they so obsessed? The thought about fat had never crossed my mind until I came here. And this was like a total obsession. And people were eating mountains of pasta and then telling me like, it's fat-free. So it really was like this weird obsession for a while. Yeah.

It really was a pile-on effect, kind of a mob mentality to demonize natural fats. I mean, ironically, what we did in school lunch programs is removed the one thing that was not bad for you, natural fat, in milk, and then added sugar.

And so we would create these foods. I don't even know if we should call them foods, but many of them were ultra-processed. They were designed to have a long shelf life. They were cooked with seed oils that sound natural, like vegetable oil, but they're really denatured and changed with a chemical solvent. And the immune system is reacting to all of these things at the level of the gut.

We get an inflammatory response and it causes general body inflammation. It makes people feel sick when their gut is a little inflamed. And why do you think we medicate so many people? And what is at the root of so many chronic diseases? It's general body inflammation. So we picked the wrong villain in demonizing fat. And it still is a recommendation that looms large to this day.

Marty Mercari is a surgeon and public policy researcher at Johns Hopkins University in Baltimore. He's been selected by the Trump administration to head the FDA. His latest book is Blind Spots, When Medicine Gets It Wrong and What It Means for Our Health. We're talking about ripple effects. In science, one small discovery can lead to another and then another. Eventually, there is a breakthrough.

Once the breakthrough happens, it's easy to forget about the road that brought us there, the basic science that made it happen. That kind of research often becomes a target when spending cuts are looming, because it can seem silly or superfluous. Alan Yu takes a look at one study from the 1980s that has had a powerful ripple effect.

Its results have now changed the lives of millions of people around the globe. In the summer of 1980, gastroenterologist Jean-Pierre Ralfmann got his first position at the National Institutes of Health after medical residencies and fellowships. The research did not seem especially glamorous.

His job was to take pancreases from guinea pigs and essentially dose them with venom from various animals like bees, wasps, snakes, frogs, and lizards. That it was a step-by-step addition of known amounts of each of these venoms to a test tube containing bits of pancreas.

So every day for weeks, he would dissolve powdered venom into water, add it to test tubes with bits of guinea pig pancreas and see what happened.

This was part of a research project on the digestive system. The pancreas plays an important role here, since it produces enzymes that help digest our food. And the researcher Jean-Pierre was working for wanted to know if there was anything in venom that would trigger the system to release more digestive enzymes, digest food more quickly.

Day in and day out, Jean-Pierre tested different venoms. It can be quite tedious. The hope is that in the end run, you discover something interesting. And it's even more tedious if the experiment fails. You can do all of that and end up with nothing. But Jean-Pierre was not thinking about failure. It was partly about the journey. I found it intellectually interesting. I was young and perhaps naive at the time.

But I thought it was a great project and from a training point of view, I would learn a lot of methods in doing this kind of work, which I did. Eventually, after lots of tests, Jean-Pierre found that the venom that triggered the biggest reaction in the guinea pig pancreas came from the healer monster.

It's a large orange and black lizard that can grow up to 22 inches. It lives in deserts in the southwestern part of the U.S. and hunts with its powerful jaws. And they usually grab onto a mouse or another rodent in the desert and either break its neck just with the strong jaws...

or just hold on to it until it eventually succumbs. It's also one of the rare lizards that have venom.

Jean-Pierre and his colleagues talked about what they found in HeLa monster venom at conferences with other gastroenterologists and published their findings. It was seemingly an interesting biological finding. I would never have conceived that there was any potential therapeutic benefit for anything. To my recollection, I never tested it in human cells.

Jean-Pierre later isolated the specific protein in the venom that the guinea pig pancreas reacted to and published about that as well. Then he got a different job in Brooklyn, where he met another young scientist who was also interested in the venom. They continued to work on the specific protein. They figured out the shape of the protein, what it does, and also how to make it in a lab without using a HeLa monster sample.

They found that the protein works like a hormone called GLP-1, a hormone that humans have, which triggers the pancreas to release insulin. And we saw that paper and we said, why would the lizard have something like GLP-1 in its saliva? Is this lizard GLP-1? Does the lizard have a separate GLP-1? That's endocrinologist Daniel Drucker at the University of Toronto.

He was interested in GLP-1 around the same time, in the 1980s. Right away, there was a realization that something that stimulates insulin secretion could be used for the treatment of diabetes. We all immediately thought about this. Insulin helps keep blood sugar within healthy levels. Daniel said scientists at the time were trying to make a human diabetes treatment based on GLP-1. But

But they struggled because humans would naturally break down the hormone. And if they got too much of it too quickly, they got sick. So when he heard about the work on the Gila monster venom, he tried to get samples. You can't just go online and click on live Gila monster and push send. Daniel and other scientists worked for weeks to ship a live lizard from the US to Toronto and cut out the gland that makes the venom.

They studied the genes of the protein from the venom and published that work. Other researchers started testing GLP-1 in humans in the late 80s. The work continued in the 90s and early 2000s. It took a while because scientists at first struggled to make a version of the drug that would be stable in the human body long enough to work.

And they had to balance a dose that was large enough to be effective, but would not make people nauseous. Finally, in 2005, decades after Jean-Pierre first studied HeLa Monster Venom, he and Daniel and other researchers saw their work lead to an approved GLP-1 therapy in the U.S. to treat diabetes. We didn't know that GLP-1 would reduce appetite and be useful for

For weight loss, we didn't know that GLP-1 would reduce heart attacks and strokes and improve metabolic liver disease and all of the things that GLP-1 does now. The GLP-1 therapy led to the drug we now know as Ozempic. It's a blockbuster drug. Millions of people have prescriptions for GLP-1 medications. But it took a lot of basic science to get to this point.

Daniel says his work is about learning more about the world, rather than applied science, which tries to find ways to use that knowledge. We would often do experiments in animals and say, hey, this would work, this strategy would work. And then the pharmaceutical or biotech companies would say, well, let's try and develop drugs based on these findings. Jean-Pierre is now a professor of medicine and the chair of the gastroenterology department at the University of Maryland.

He says he is not sure if the National Institutes of Health today would ever fund research like that again. He says the NIH now sets a high bar for researchers to show that their work is likely to translate to treating human disease in some way. That was not the case back when he did his early research. This would be considered by NIH study sections and others as

And he says it could have ended up with no useful human application, but you never know unless you try. It's very rare, frankly, that something goes this way and that frequently it's a combination of luck, some intelligence...

some foresight into doing the right experiments. Nobody knew where it would lead. And several of the participants are unfortunately now deceased, so really haven't seen what's happened with this. Jean-Pierre says he's happy that he got to see how his research from decades ago ultimately played out. What's happened recently has allowed me to sort of look at it

from a longer view, you know, to really get a sort of global perspective of the work and where it's led. And I find it very interesting, very cool. That story was reported by Alan Yu. We're talking about ripple effects.

Let's say you end up in the hospital with a debilitating illness and you're not able to make care decisions for yourself. We would have somebody, usually a close family member, a spouse, adult sibling, an adult child, to interact with doctors and discuss.

help make decisions based upon our preferences for medical care. But sometimes intensive care physician David Oxman encounters a different, more complicated situation. Unrepresented patients. These people don't have anyone to speak for them when they become incapacitated. It's a small but growing group. Some have outlived their family members or are estranged from them.

Maybe they've moved around a lot. Sometimes substance use or homelessness plays a role. It's especially complicated with patients who have dementia or can't communicate their wishes for other reasons. These unrepresented patients are at risk for not getting a treatment they need because if it's not an emergency situation, doctors can't offer treatments that they don't have consent for.

But David says there's also a big issue with overtreatment. Particularly when it relates to patients at the end of life, because there's no one there to tell doctors not to do something. And for many reasons, because of the system we live in, doctors feel compelled to offer maximal treatment unless someone tells them to stop.

Because I guess otherwise somebody could say, why didn't you save Mr. Smith? You could have. Right, exactly. Even when it becomes obvious that these treatments are no way possible in the best interest of that patient. David is a physician at Thomas Jefferson University Hospital in Philadelphia and also a medical ethicist.

He says most states have provisions where medical guardians, or basically decision makers, can be appointed by a court. But that takes a long time. So in the meantime, a search for relatives begins. The hospital spent a lot of time trying to identify somebody. Oftentimes we get police engaged to try to find some long-lost relative. Sometimes we approach friends or people who may not

be looked at to act as a health care agent, but who know the patient in some way, know their values, and may be able to help us make a decision. Sometimes David gets on the phone himself to find family members, even distant ones.

And if he does, he has to jump right into uncomfortable conversations with them. Your great uncle is critically ill, but, you know, he has advanced cancer and advanced dementia. I don't suspect him to survive this illness. I recommend that we don't pursue putting him on a ventilator and going through intensive critical care.

Do you agree with that? Would you help us make that decision? There's a whole nother questions. Are you really equipped to make that decision? How could you possibly know what the best interests are? But as physicians, we're sort of desperate, right? We're trying to find somebody who has some standing to

to make that decision for them. And in many cases, these distant relatives are overwhelmed. Very often, I'll make that phone call and they'll say, well, I just don't know Grand Uncle Charlie well enough to make that decision. I'm sorry. And then you say what? Please? No, then I say, I understand, but

And I have tried to find somebody else. The situation has a big ripple effect for patients, but also for hospitals. Because these cases create enormous financial burdens for hospitals. Patients are often in the hospital much longer than they would be because of delays. ICU care or end-of-life care is prolonged.

And then when a patient does survive, they can't get placed in a facility without having someone to basically sign them in. But people are working on solutions. Like David Sontag. He is director of ethics for Beth Israel Leahy Health in Massachusetts.

He says this issue of unrepresented patients is important to a lot of people working in medicine. Hospital staff will experience significant distress when individuals, the patients they're caring for, are not able to get the best available care.

And he came up with a way for them to get involved. He created a matching program where health care professionals volunteer to represent patients, not within their own hospital systems because that could cross ethical boundaries, but at other hospitals. This is an opportunity for us to help some of the most vulnerable members of our communities, those who have nobody to speak for them when they can no longer speak for themselves,

And that allows us to respect their autonomy throughout their lives. All of the volunteers work in health care, but they get training on how to ask people what kind of care they want to receive or not receive in serious situations. Here's how the matching program works.

Healthcare providers often ask if patients have a health directive. And if it turns out during that conversation that a patient doesn't have anybody listed as their proxy in a worst-case scenario, they are asked if they want to enroll in this program. And so you've got an unrepresented person, we call them a participant, and a volunteer who will be matched so they can establish a relationship.

And so what usually happens is within 24 to 48 hours, I get a volunteer. We connect the volunteer to that person, right, that participant, so that they can have a conversation and introduce themselves to each other. And at that point, usually...

The participant will complete a health care proxy form, name the volunteer as their health care agent, and then have a conversation about the participant's values, goals, and preferences so that the volunteer knows how to make decisions on their behalf if that time ever comes.

The program has been running for over two years now, and David says writing about it and talking about it at conferences has had a positive ripple effect. And we have more people who are reaching out when they've heard about it to see how they might be able to start their own program. That's David Sontag, director of ethics for Beth Israel Leahy Health in Massachusetts. Coming up, breaking the silence surrounding trauma and violence in a small town.

People didn't do a lot of talking back then, and it was almost like trying to pull teeth out of a hen. That's next on The Pulse.

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Trauma can have an impact across generations. In 1942, a black man was lynched in Sykeston, Missouri. In the aftermath, many black families in town either fled or used silence as a survival strategy to keep themselves safe. If children asked about the incident, they were told to be quiet. Nobody talked about it, but everybody knew what had happened. Everybody was terrified.

Almost 80 years later, in 2020, an unarmed black man was killed by police in the same town. The podcast series Silence in Sykeston explores the impact of these two tragedies and how they have affected family members. Here's reporter and host Cara Anthony.

When Nanetta Forrest was growing up, a lot went unsaid in her family. You know, people didn't do a lot of talking back then. And it was almost like trying to pull teeth out of a hen. She lived nearly her whole life in Indiana. But Nanetta's story, the secrets, and the silence all started in Sykeston, Missouri. Nanetta was born there in 1942.

Several months earlier, while her mother was pregnant, Nanetta's father was lynched. His name was Cleo Wright. He was taken away before I got here. Taken from a jail cell, taken and dragged through the streets by a white mob, taken to Sunset Edition, the center of black life in Sykeson, and lynched. Taken from his family. Nanetta's mother kept quiet. She never wanted her daughter to know what happened to her father.

But one day, Nanetta was with her grandfather. A game show that aired on CBS in the 1950s was on TV. It was called Strike It Rich. Mr. Strike It Rich himself, Lauren Hall. Celebrities would go on and they'd try to win money for like underprivileged people. Thanks a lot. And that's when Grandpa told me, he said, you can go on there, Nan.

And I said, go on there with what? And that's when he went in his wallet and pulled out this yellow piece of paper. It was a newspaper clipping about the lynching of her father. And that was my first time ever becoming aware of it. It was around 1955. Nanetta was 13 or 14 at the time. I did want to know the story behind it, what happened, but nobody seemed to want to talk about it.

Over the years, she pieced together bits of what happened. But there was always one nagging question that didn't have an answer. What would her life have been like if that mob hadn't lynched her dad? Now, I do often wonder that.

Had he been alive when I was born and been in my life, what type of person would I have been? Would I have been the same person? Would I have been a different person? And this is something I'll never know. I've traveled to Sykeston, Missouri for years, asking people about the killing of Cleo Wright and the silence that surrounds his death. Nearly eight decades after the killing, that silence was still stifling.

Like generations of stuffed down fear and anger. At nearly every turn, locals refused to talk to me. In fact, many people felt they could not talk to me until I met Mykeela Jackson. It's no healing from grief. It's an everyday thing for me. Mykeela goes by Kiki.

She's in her mid-20s, but she's heard about the lynching back in 1942. Denzel brought that up to me because we used to live on Sunset Street. And he was telling me like they dragged him through Sunset. Denzel is Denzel Taylor, Kiki's fiance. Sykes and police shot him at least 18 times and killed Denzel in April 2020. He was 23 years old.

That year, everyone was talking about new research that found that a Black man had a one in 1,000 chance of being killed by police. Denzel Taylor became that one in 1,000. Right in the middle of her grief, Kiki refused to be quiet. The boot heel knows what happened to him. The world, they have no idea who Denzel Taylor is.

The boot heel is where Sykeston sits, in the far southeast corner of Missouri. So that's why I want his story. I want to make him proud, actually, because I want him to know, look, babe, they're going to hear this one way or another. Denzel was from Chicago. Growing up, he spent time in southeastern Missouri with his dad's family. Denzel and Kiki met in Sykeston, and Kiki says they fell in love immediately.

It was a butterfly feeling. Like, you could just tell it was love. It was the best energy ever. They started their family. Dania was born first. Denzel used to call her Cupcake. Hey, Cupcake. She said, hey, y'all. I love you, Priscilla. Ayana came next. In 2020, Kiki was pregnant with their third daughter, Brooklyn.

He said he wanted seven kids. I said, Denzel, what? He wanted seven kids? That's a basketball team. I can't handle that. They were planning to get married after Brooklyn was born. I really wanted a big family with Denzel. I wanted to get married. I wanted to go to Dallas. We was planning on moving to Dallas and everything. And it's just like my whole world is just like it just blew up on me.

Remember 2020? It felt like the news was full of stories about Black people getting killed by police. Videos from body cameras were all over social media. Around that same time, Kiki remembers Denzel getting pulled over by police more and more. And Kiki says he started to become convinced that someday he might be killed by police too.

He said if he was to ever get in any type of interaction with the police, he would let them kill him just to show how America is. He would bring it up, like, out of nowhere. And he would say it, and I would wonder, like, why is you constantly saying it? And I kind of would get irritated because it's like, that's not a way that I would want you to go out. Look, we're supposed to grow old together.

On April 29th that year, Denzel's premonition came true. We're listening to an excerpt from the podcast series Silence in Sykeston, reported by Cara Anthony.

The night police shot and killed Denzel Taylor, he had gotten into an argument with his father. The fight escalated, and Denzel shot his dad. Police were then looking for Denzel, and when they found him, there was a verbal exchange, and then officers shot him multiple times. Everything was captured by the police body cams. Denzel was unarmed. By the time the ambulance arrived, he had died.

No charges were filed against the officers, but the family sued the city of Sykeston, and they later reached a wrongful death settlement for $2 million. Denzel's absence is felt every day, especially by those who were closest to him. Here is reporter Cara Anthony again with more from the podcast. Kiki watched the body cam video over and over, but Denzel's death just wouldn't sink in.

And she's worried about their daughters. I hope they never see the video because that's traumatizing because that's their dad. Eventually, Kiki left Sykeston. She says there are too many memories of Denzel and what happened to him there.

On the day I visited her new home, it was just over a year after Denzel's death. Two-year-old Diana is napping in the next room. Kiki has the youngest, Brooklyn, on her lap. And the oldest, Dania, is everywhere. Right now, she's zooming through the dining room on a scooter. She's a trick like a BMXing in this apartment right now. Is she a daredevil? She do that all the time.

Eventually, Dania parked her wheels and talked to me. Tell me your name again and how old you are. Boy. And what is your name? Dania. In my time as a health reporter, I've written a lot about the impact gun violence has on kids. I've gotten some training in how to talk to them about it on their level without re-traumatizing them. Your mommy's sitting here and she said I have permission to ask you about your daddy.

Do you miss your daddy? Yes. Yeah? Where's your daddy? I don't know. Yeah. He's sleeping. Hmm? He's sleeping. You said he's sleeping? Yes. That's what she said. She said, my daddy's sleeping. Dania is trying to make sense of why her dad isn't with them anymore. And Kiki doesn't know what to tell her. Like last night, she actually woke up out of her sleep and she was crying. She was like, mama, my daddy...

And I didn't know what to tell her because it's like, what did you tell a four-year-old that they're never, ever going to see their dad again? I called a pediatrician, Rhea Boyd, to talk about what losing a parent to police violence could mean for kids like Dania, Ayanna, and Brooklyn.

Regardless of the age children experience longing, they miss people when they don't see them again. Even babies can experience that. Losing a parent, especially to violence, can have a major impact on a child's future health. Certain experiences, including the death of a parent, increases a child's risk for certain diseases.

Physical health ailments like heart disease, kind of neurologic ailments like increased risk for Alzheimer's, mental health impairments like increased risk for depression. And these are increased risks as they move into adulthood. Study after study show the link, even if we don't totally understand all the mechanisms. It's not just innate to our biology. It's because of the conditions in which Black folks have been forced to live.

Black people in the United States carry more stress throughout their lives than white people. That doesn't change, even when they make more money. Researchers have tied that stress to the racism we deal with in everyday interactions and to the institutional racism that makes it harder for us to take care of ourselves and our families. Black people age faster, get sicker, and die sooner than our white peers.

And carrying chronic stress is a factor. Rhea says police violence contributes to this too. Police are a public institution, and when they disproportionately take the lives of Black folks or disproportionately police Black neighborhoods, that has direct impacts on our lives, on our well-being. Kiki says back when she was living in Sykeston, she felt anxious every time she saw police lights in her rearview mirror. Now it's like, okay, here it go again. I'm getting pulled over again.

Because I'm used to it at this point. I'm used to it. Used to it, maybe. But not numb to it. I can't tell my kids, hey, don't be scared when you get put over. I can't tell them that because I'm still scared of myself. Even a year later, I'm still scared. Rhea calls this anticipatory stress. Anticipatory stress means you carry a level of vigilance and worry and concern about things that might happen to you or your kids.

Children can pick up on what's going on in these situations and can end up carrying that toxic stress too. Cleo's daughter, Nanetta Forrest, wasn't born yet when her father was killed. When we last spoke a few years before she died, she was 78 years old. And she said she was still asking herself that question that had nagged at her her whole life. Who would she have been? Would I have been the same person? Would I have been a different person?

And Denzel's girls, Dania and Diana. And Brooklyn, who wasn't born yet. Brooklyn might ask herself the same thing as she grows. She has no memory. She's never seen him a day in her life. So it's like she'll never know him, like, as a person. Kiki's looking for ways to protect her daughters. She's moved them away from Sykeston to a city where she hopes they'll have more peace.

She wants them to know all about their dad and how much he loved them. And she wants them to know his voice. It's the opposite of silence. She wants them to be able to heal out loud.

That's an excerpt from the podcast series Silence in Sykeston, reported and hosted by Cara Anthony. It's a co-production of World and KFF Health News. Zach Dyer and Taylor Cook are the producers. Editing by Simone Popperl. Tanya English is the managing editor. Coming up, what researchers are learning about intergenerational trauma. A lot of offspring had trouble with interpersonal relationships.

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This is The Pulse. I'm Mike and Scott. We're talking about ripple effects.

We just heard a story about how trauma and violence can continue to haunt families and communities. Psychiatrist Rachel Yehuda began to notice this intergenerational trauma while studying Holocaust survivors. Because when we started to set up a clinic for Holocaust survivors, it was the children of these survivors that called us. And they said that

They were the true casualties of the Holocaust, and we should offer them a specialized treatment program. Rachel is a professor of psychiatry and neuroscience and the director of traumatic stress studies at the Icahn School of Medicine at Mount Sinai in New York. And when they said they were casualties, what did they mean? How did symptoms show up in their lives? How had they been raised?

Yeah, so at first I didn't quite understand it myself, but as they began to explain it,

I just found that it all made sense. Many described growing up with parents that were traumatized, fearful, concerned that something like the Holocaust would happen again. Many survivors had needs that required their children to help them through difficult times as opposed to having parents that will help you manage and negotiate your difficult times.

And a lot of times offspring found themselves really in a very over-attached relationship with their parents, that it mattered a lot what their parents thought or making sure their parents were reassured about their own safety. A lot of offspring had trouble with interpersonal relationships, feeling that making an emotional investment

It might not be worth it. What if they have to lose someone that they love? These children of survivors grew up hearing vivid stories about the Holocaust, so much so that it sometimes gave them nightmares about events they hadn't experienced themselves. But they would react to Holocaust-related triggers as if they themselves had survived the trauma so quickly.

This wasn't exactly PTSD per se, but it was something. And a lot of the offspring also told us that they had experienced depression and anxiety in their lives. When we're talking about intergenerational trauma, is that passed down through

on a physical level, or is it more about in the way that a person is raised, the circumstances of their upbringing? Well, the two are very connected, aren't they? So it's really hard to disentangle those things. But trauma itself is not past. That's a really important thing to say. Somehow,

A fairly complex set of scientific experiences got boiled down as trauma is passed through the genes or on the genes, but what actually might get passed are some of the effects of the trauma.

that then remain because as cells divide, some of the remnants of those effects, particularly if they are encoded epigenetically, can survive cell division and appear in the next generation. So say, for example, a parent was traumatized and they encoded a fear response that they never resolved, right? So

it is possible to have a sensitivity to fear be passed down through the generations. And there's an animal study that really demonstrated this very well. It's very difficult to study these complex phenomenon in people.

But there was one beautiful study in mice where male mice were taught to fear the scent of cherry blossom. The scent of cherry blossom was paired with an electric shock. So it didn't take that long, maybe a few trials, for the male rat to just need to have the scent of the cherry blossom for it to exhibit a fear response.

And when that happened, there were a lot of epigenetic changes in the genes that associate with smell and things like that and fear in the brain. And those epigenetic changes were present not only in the brain, but in the male sperm. And they were present in the second and third generation. So what happens in the second generation is that if let's say it took 10 trials to make the father

afraid of the cherry blossom scent. It took 10 shocks. The offspring only takes one or two. So what has been, quote, inherited seems to be the sensitivity to fear. So something's definitely transmitted. It's not a trauma, but it's a lesson that, wait a minute, this might be something I need to be afraid of.

Do those changes then disappear, though, after a while? So let's say we're now in the third or fourth generation and there seems to be no reason to have this fear and it doesn't bear out. Would it go away then? I think that animal studies have shown that there can be up to five generations where this effect is maintained. But what's really important is what happens in those subsequent generations.

And the piece that always gets missing from the conversation is, what is the offspring's life like? Do they have to respond to similar threats? If so, that can perpetuate some of these responses.

So that's another really important variable. We don't just live as passive offspring that don't have our own issues to deal with in the environment. And so that becomes important too. But what we get from our ancestors might be a predisposition, might be some kind of wisdom about how to respond so that we can be better at it, so that we can be quicker at responding, so that we can adapt to

Now, sometimes we don't experience this as the gift of adaptation. We experience it as a compounded burden, making us more vulnerable and hypersensitive to the environment. But we can't blame biology for that. That's just a way of learning a lesson. Really, it's our environments and our reactions to our

our environments that are going to make a difference in how we're able to cope with these lessons that have been passed to us. What's the role of communities in this question? Whether or not you're the direct descendant of a Holocaust survivor, if you grow up in a Jewish community, chances are the

Holocaust stories are being told. Holocaust remembrance is an important aspect of cultural life. So how does that affect people? I'm assuming it's not as strong as if you're a direct descendant, obviously, but how does that affect people to hear those stories and to know I'm part of this community that went through this trauma? Being in a community is an environmental exposure. And

And it's going to have effects on you just like anything else. That's why it's so important to invest in supportive communities. I mean, it's something that we throw out and say, but...

You can't overemphasize the importance of community and how it can help shape you and change you and strengthen you or make things worse, depending on whether if the community is traumatizing or not. When we started to see Holocaust Offspring,

There was such a wide range of people. Some talked about how their parents never stopped talking about the Holocaust. Everything was related to the Holocaust. There were bedtime stories about how different relatives disappeared or were murdered. And that was almost too much for many, many offspring. But equally bad, equally deafening was the silence.

surrounding parents who never spoke a word about what had happened to them. And when offsprings found out about this history of the Holocaust, we're left with so many questions, unanswered questions about what it was like. It wasn't just how frequently people talked about the Holocaust, but it was more how they talked about the Holocaust emotionally.

If you're telling a story with a modulated voice that clearly suggests that the horror is in the past, that's something that can be accepted more easily by the next generation. And in fact, it sends a powerful message that the worst is survivable because you're speaking about it now from the perspective of having it be fully integrated and metabolized.

But when a parent talks about a horrible story and starts to shake and cry and tremble and behaves as if they're still in the moment of terror with the fight or flight still visible, this sends a very different message about the fact that traumas of the past can continue to wreak havoc in the present moment.

And a lot of PTSD or trauma therapy is really about trying to own the message of what happened in the past is in the past.

One of the ways in which people retell the story of their trauma and maybe process it on some level is to think about resilience. What are the ways they function that help them overcome the trauma? And how is that resilience building up over time? So how do you talk about resilience and generational trauma? I think resilience is the process of fighting to keep going.

And it's consistent with having symptoms. I don't think about it as if you have symptoms, you're not resilient. But if you

don't have symptoms, you are resilient. Resilience is kind of a muscle that we have to develop that really gives us the strength to keep moving forward, especially when it's hard. Resilience is really about knowing that there is something positive on the other side of adversity and kind of working hard to get there because you know it's there.

and being able to find some purpose in suffering and make meaning in suffering.

So I think that that applies to trauma survivors and intergenerational survivors. We spent a lot of time talking not only about the wounds that people may get as a result of their parents' experiences, but also the ancestral wisdom that they might also have from their parents. Like, think about that mouse. Who knows? Somehow.

That cherry blossom scent, you've got to be careful and learns quickly if somebody starts to pair that cherry blossom scent with an electric shock a lot quicker than his father did. And so that's ancestral wisdom. And I think there is something comforting in thinking about...

I come from a line of people that survived this thing or this series of terrible circumstances, and yet here we are. And there is something in that that really gives you strength. There is. The trick is to compartmentalize it.

The trick is to not have it really take up a lot of real estate in your day-to-day functioning. In Judaism, for example, and in other cultures as well, there are days that memorialize tragic historic events. That's very positive to take a day to remember and reflect as opposed to constantly thinking about it.

So I think that the key in all of this is being able to balance. We don't want to forget ancestral memories or our own traumatic memories. We also want to bear in mind that first and foremost, we survived those things, even if we survived them at a cost, that we were equipped to survive them and that we can make meaning out of them.

Rachel Yehuda is a professor of psychiatry and neuroscience and the director of traumatic stress studies at the Icahn School of Medicine at Mount Sinai in New York. That's our show for this week. The Pulse is a production of WHYY in Philadelphia. You can find us wherever you get your podcasts. Our health and science reporters are Alan Yu and Liz Tan. Our intern is Christina Brown.

Charlie Kyer is our engineer, and this week we had additional engineering from Diana Martinez. Our producers are Nicole Curry and Lindsay Lazarski. I'm Maiken Scott. Thank you for listening.

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