In 2020, as the COVID-19 pandemic set in, one of the earliest narratives to catch fire was that we as a nation were facing a severe toilet paper shortage. With the prospect of being at home indefinitely, this felt like a true crisis, albeit one that we could control, unlike the pandemic itself. So you probably went to the grocery store, mask on, hand sanitizer ready, to buy as much toilet paper as your car could handle. You might remember your surprise, and then panic, when you arrived to find the toilet paper shelves totally bare. Or if you got there early enough there were still some rolls left, but guarded by a bright yellow sign ‘2 rolls max per customer.’ Perhaps you flagged down an employee to ask when the next shipment would come in, and then your panic spiked when you learned they had no idea. Maybe you texted your spouse to head to a different grocery store immediately. Maybe you were one of those people who hacked the system, buying dozens of tissue boxes to fill the toilet paper gaps, until the grocery stores caught on and limited the number of those too.

But The Great Toilet Paper Shortage of 2020 had one underreported flaw: it didn’t really exist. At least not in the way that we thought. Because COVID-19 didn’t impact the toilet paper supply chain – in fact, most toilet paper is manufactured in the US and those routes were intact. Still, by mid-April, consumers were facing empty shelves, but not because we were truly short on toilet paper. It was because grocery stores – with no known disruption to the supply chain – didn’t keep massive amounts of extra rolls on hand. They didn’t expect the surge in demand because the supply wasn’t actually threatened – we just thought it was. In other words, spurred by the widespread belief that toilet paper was scarce, it became so.

We like to think that reality dictates what we believe. But the truth is that often what we believe creates our reality.

One of the obvious examples of this is the placebo effect, which I find endlessly fascinating. Placebos have meaningfully reduced Parkinson’s symptoms, chronic pain, depression and asthma, among many others. But it goes beyond just swallowing a sugar pill. Some of the most interesting work has come from Ted Kaptchuk at Harvard Medical School (a trained acupuncturist, Kaptchuk is one of the only HMS faculty members without an MD or a PhD), who conducted an experiment with three groups of IBS patients. The first group were told they were on a waiting list for treatment, the second group received fake acupuncture (the ‘needles’ were retractable shams that never actually punctured the skin), and the third group got fake acupuncture plus 20 minutes of what Kaptchuk calls “very schmaltzy” care (e.g. lots of attention, explicit empathy and encouragement). Practitioners for this group were also required to touch patients’ hands or shoulders and spend at least 20 seconds ‘lost in thoughtful silence’).

Kaptchuk was measuring not just the effect of being given fake medicine, but also the effect of a thoughtful ritual of care surrounding that medicine. Guess who reported the most improvement? Not surprisingly it was group #3, which reported relief so strong that it beat the best FDA-approved drugs out there at the time. And since group #3 beat group #2, it wasn’t just the placebo medicine that did it, it was the context and ritual itself that led to the most relief.

Placebo effects are not about thinking your way to health (and to state the obvious, placebos are limited – they’re not going to shrink a tumor, for example). They are really about trust – trust in the practitioner, trust in the ritual of care, trust that relief is possible. And that trust, paired with the belief that comes from taking action (swallowing a pill, for example), causes real biological change. Research shows that placebos can trigger the same chemical releases in the brain that active drugs trigger – for example, placebos can release dopamine which can help moderate pain or depression (two symptoms that placebos have been shown to work on). When our beliefs change, our brain chemistry changes.

Placebo’s dark twin – if you believe you’ll get worse, it might come true

Placebo, which means “I shall please” in Latin, is a concept you already knew. But it has a lesser-known, darker cousin you may not have heard of – nocebo, which means “I shall harm”. The nocebo effect happens when people who believe they’ll get worse actually get worse. In one study, two groups of men were given finasteride for prostate issues, but only one group was told about possible sexual side effects. Almost half (43.6%) of that second group then reported sexual dysfunction issues, but of those who weren’t warned about that side effect? Only 15.3% said they had a problem. So for many of these men, just knowing that they might have an issue caused one to occur. Similarly, a meta-analysis on COVID-19 vaccines found that 72% of adverse effects after the first dose could be attributed to the nocebo effect, and 52% after the second dose. People thought the vaccine would give them side effects and so it did.

This is unsettling! On the one hand, I think it’s good that doctors (and drug companies) are required to tell us about possible side effects. On the other hand, if hearing about them means there’s a much greater chance they appear, maybe ignorance really is bliss? We are taught that knowledge is power, to advocate for ourselves, to do our own research and to tell the truth. But if our own beliefs can shape how we feel and (in some cases) heal, how do we curate what we know – and what we don’t – for maximum health? And how do we tell the truth when the truth can cause us harm?

The Wellness Industrial Complex is an uncomfortable example of this tension. There are thousands (millions?) of companies hawking services/treatments/pills/rituals with no scientific evidence behind them profiting from unsuspecting customers just looking for relief. And despite the sham of it all scientifically, there are a lot of people reporting significant physical and mental improvement because of them. Both things are true. Pain and relief are in the eye of the beholder – if you take a pill and feel better, does it matter that your relief was based on a lie?

Truth + Trust + Hope

Maybe we don’t have to choose between truth and healing. I had assumed that the placebo effect only worked when patients didn’t know they were getting fake medicine. But Kaptchuk did another study where he gave patients a placebo pill and told them it was a placebo pill (the bottles literally said PLACEBO). And he also told them that placebos often prove effective. Guess what? They still got better – in fact, they experienced twice as much relief as the no-treatment control group.

This reveals something crucial: transparency doesn’t destroy the effect. What matters is pairing honesty with trust and hope. The patients knew the pills were inert but trusted that relief was still achievable. That combination allowed the ritual of care to work its biological magic.

I think this might be a path forward, both in medicine and beyond: we don’t need to hide hard truths, but we do need to construct contexts where those truths coexist with realistic hope. But we’ve gotten out of practice.

Research shows that progress-oriented content actually triggers economic development—but the western world has shifted from a culture of progress to a culture of worry, which means we are literally at risk of talking ourselves into decline.

Back to toilet paper

The toilet paper shortage wasn’t about supply chains—it was about collective belief creating collective reality. But unlike in the medical examples, there was no ritual of care, no trusted authority saying ‘this scarcity is temporary and manageable.’ There was only panic, which fed on itself.

Luckily, this phenomenon works in reverse too. For the past year, as Hispanic communities and others in my neighborhood have been under assault, people started organizing. Spurred by the collective belief that we could successfully help each other, ‘what can I do?’ text chats turned into mutual aid groups tackling transportation, food and legal needs, among others. There was no central organization and no formal structure – just the belief that neighbors would show up, which made us all show up, which proved the belief true and gave it momentum and sustainability.

Fear fuels scarcity. Hope fuels abundance.

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We have gotten out of the practice of believing we can heal

We report, talk about and internalize the facts without constructing contexts for healing. We focus on the diseases and the symptoms, not the pathways to relief. We implement solutions but without the trust and rituals of care needed for them to succeed. The power of belief alone is strong. But what really worked in Kaptchuk’s studies was belief plus ritual – the small but deliberate rituals created a context where healing became possible.

We need those kinds of rituals at every level. Because for years now, we’ve been told that we are hopelessly divided, desperately lonely and unable to meet the social, environmental, political and technological challenges we face. These beliefs pervade everything and they change our behavior. But there is another way.

Transparency, trust and hope can generate positive beliefs so strong they trigger biological change in individuals, and collective change in groups. When I talk about the need for optimism, this is what I mean. Not toxic positivity that ignores hard truths or blind faith that everything works out. Instead, it is the regular and deliberate construction of contexts—rituals, relationships, narratives, institutions—that pair honesty with possibility. The ones that allow us to know the pill might be a placebo and still trust that relief could come.