4 The core point in this chapter and the next is nonlinearity as it links to fragility, and how to make use of it in medical decision making, not specific medical treatments and errors. These examples are just illustrative of things we look at without considering concave responses.
5 A common mistake is to argue that the human body is not perfectly adapted, as if the point had consequences for decision making. This is not the point here; the idea is that nature is computationally more able than humans (and has proven to be so), not that it is perfect. Just look at it as the master of high-dimensional trial and error.
CHAPTER 22
To Live Long, but Not Too Long
Wednesdays and Fridays, plus Lent—How to live forever, according to Nietzsche or others—Or why, when you think about it, not to live longer
LIFE EXPECTANCY AND CONVEXITY
Whenever you question some aspects of medicine—or unconditional technological “progress”—you are invariably and promptly provided the sophistry that “we tend to live longer” than past generations. Note that some make the even sillier argument that a propensity to natural things implies favoring a return to a day of “brutish and short” lives, not realizing it is the exact same argument as saying that eating fresh, noncanned foods implies rejecting civilization, the rule of law, and humanism. So there are a lot of nuances in this life expectancy argument.
Life expectancy has increased (conditional on no nuclear war) because of the combination of many factors: sanitation, penicillin, a drop in crime, life-saving surgery, and of course, some medical practitioners operating in severe life-threatening situations. If we live longer, it is thanks to medicine’s benefits in cases that are lethal, in which the condition is severe—hence low iatrogenics, as we saw, the convex cases. So it is a serious error to infer that if we live longer because of medicine, that all medical treatments make us live longer.
Further, to account for the effect of “progress,” we need to deduct of course, from the gains in medical treatment, the costs of the diseases of civilization (primitive societies are largely free of cardiovascular disease, cancer, dental cavities, economic theories, lounge music, and other modern ailments); advances in lung cancer treatment need to be offset by the effect of smoking. From the research papers, one can estimate that medical practice may have contributed a small number of years to the increase, but again, this depends greatly on the gravity of the disease (cancer doctors certainly provide a positive contribution in advanced—and curable—cases, while interventionistic personal doctors, patently, provide a negative one). We need to take into account the unfortunate fact that iatrogenics, hence medicine, reduces life expectancy in a set—and easy to map—number of cases, the concave ones. We have a few pieces of data from the small number of hospital strikes during which only a small number of operations are conducted (for the most urgent cases), and elective surgery is postponed. Depending on whose side in the debate you join, life expectancy either increases in these cases or, at the least, does not seem to drop. Further, which is significant, many of the elective surgeries are subsequently canceled upon the return to normalcy—evidence of the denigration of Mother Nature’s work by some doctors.
Another fooled-by-randomness-style mistake is to think that because life expectancy at birth used to be thirty until the last century, that people lived just thirty years. The distribution was massively skewed, with the bulk of the deaths coming from birth and childhood mortality. Conditional life expectancy was high—just consider that ancestral men tended to die of trauma.1 Perhaps legal enforcement contributed more than doctors to the increase in length of life—so the gains in life expectancy are more societal than from the result of scientific advance.
As a case study, consider mammograms. It has been shown that administering them to women over forty on an annual basis does not lead to an increase in life expectancy (at best; it could even lead to a decrease). While female mortality from breast cancer decreases for the cohort subjected to mammograms, the death from other causes increases markedly. We can spot here simple measurable iatrogenics. The doctor, seeing the tumor, cannot avoid doing something harmful, like surgery followed by radiation, chemotherapy, or both—that is, more harmful than the tumor. There is a break-even point that is easily crossed by panicked doctors and patients: treating the tumor that will not kill you shortens your life—chemotherapy is toxic. We have built up so much paranoia against cancer, looking at the chain backward, an error of logic called affirming the consequent. If all of those dying prematurely from cancer had a malignant tumor, that does not mean that all malignant tumors lead to death from cancer. Most equally intelligent persons do not infer from the fact that all Cretans are liars that all liars are Cretan, or from the condition that all bankers are corrupt that all corrupt people are bankers. Only in extreme cases does nature allow us to make such violations of logic (called modus ponens) in order to help us survive. Overreaction is beneficial in an ancestral environment.2
Misunderstanding of the problems with mammograms has led to overreactions on the part of politicians (another reason to have a society immune from the stupidity of lawmakers by decentralization of important decisions). One politician of the primitive kind, Hillary Clinton, went so far as to claim that critics of the usefulness of mammograms were killing women.
We can generalize the mammogram problem to unconditional laboratory tests, finding deviations from the norm, and acting to “cure” them.
Subtraction Adds to Your Life
Now I speculate the following, having looked closely at data with my friend Spyros Makridakis, a statistician and decision scientist who we introduced a few chapters ago as the first to find flaws in statistical forecasting methods. We estimated that cutting medical expenditures by a certain amount (while limiting the cuts to elective surgeries and treatments) would extend people’s lives in most rich countries, especially the United States. Why? Simple basic convexity analysis; a simple examination of conditional iatrogenics: the error of treating the mildly ill puts them in a concave position. And it looks as if we know very well how to do this. Just raise the hurdle of medical intervention in favor of cases that are most severe, for which the iatrogenics effect is very small. It may even be better to increase expenditures on these and reduce the one on elective ones.
In other words, reason backward, starting from the iatrogenics to the cure, rather than the other way around. Whenever possible, replace the doctor with human antifragility. But otherwise don’t be shy with aggressive treatments.
Another application of via negativa: spend less, live longer is a subtractive strategy. We saw that iatrogenics comes from the intervention bias, via positiva, the propensity to want to do something, causing all the problems we’ve discussed. But let’s do some via negativa here: removing things can be quite a potent (and, empirically, a more rigorous) action.
Why? Subtraction of a substance not seasoned by our evolutionary history reduces the possibility of Black Swans while leaving one open to improvements. Should the improvements occur, we can be pretty comfortable that they are as free of unseen side effects as one can get.
So there are many hidden jewels in via negativa applied to medicine. For instance, telling people not to smoke seems to be the greatest medical contribution of the last sixty years. Druin Burch, in Taking the Medicine, writes: “The harmful effects of smoking are roughly equivalent to the combined good ones of every medical intervention developed since the war.… Getting rid of smoking provides more benefit than being able to cure people of every possible type of cancer.”
As usual, the ancients. As Ennius wrote, “The good is mostly in the absence of bad”; Nimium boni est, cui nihil est mali.
Likewise, happiness is best dealt with as a negative concept; the same nonlinearity applies. Modern happiness researchers (who usually look quite unhappy), often psychologists turned economists (or vice versa), do not use nonlinearities and convexity effects when they lecture us about happiness as if we knew what it was and wh
ether that’s what we should be after. Instead, they should be lecturing us about unhappiness (I speculate that just as those who lecture on happiness look unhappy, those who lecture on unhappiness would look happy); the “pursuit of happiness” is not equivalent to the “avoidance of unhappiness.” Each of us certainly knows not only what makes us unhappy (for instance, copy editors, commuting, bad odors, pain, the sight of a certain magazine in a waiting room, etc.), but what to do about it.
Let us probe the wisdom of the ages. “Sometimes scantiness of nourishment restores the system,” wrote Plotinus—and the ancients believed in purges (one manifestation of which was the oft-harmful, though often beneficial, routine of bloodletting). The regimen of the Salerno School of Medicine: joyful mood, rest, and scant nourishment. Si tibi deficiant medici, medici tibi fiant haec tria: mens laeta, requies, moderata diaeta.
There is a seemingly apocryphal (but nevertheless interesting) story about Pomponius Atticus, famous for being Cicero’s relative and epistolary recipient. Being ill, incurably ill, he tried to put an end to both his life and his suffering by abstinence, and only succeeded in ending the latter, as, according to Montaigne, his health was restored. But I am citing the story in spite of its apocryphal nature simply because, from a scientific perspective, it seems that the only way we may manage to extend people’s lives is through caloric restriction—which seems to cure many ailments in humans and extend lives in laboratory animals. But, as we will see in the next section, such restriction does not need to be permanent—just an occasional (but painful) fast might do.
We know we can cure many cases of diabetes by putting people on a very strict starvation-style diet, shocking their system—in fact the mechanism had to have been known heuristically for a long time since there are institutes and sanatoria for curative starvation in Siberia.
It has been shown that many people benefit from the removal of products that did not exist in their ancestral habitat: sugars and other carbohydrates in unnatural format, wheat products (those with celiac disease, but almost all of us are somewhat ill-adapted to this new addition to the human diet), milk and other cow products (for those of non–Northern European origin who did not develop lactose tolerance), sodas (both diet and regular), wine (for those of Asian origin who do not have the history of exposure), vitamin pills, food supplements, the family doctor, headache medicine and other painkillers. Reliance on painkillers encourages people to avoid addressing the cause of the headache with trial and error, which can be sleep deprivation, tension in the neck, or bad stressors—it allows them to keep destroying themselves in a Procrustean-bed-style life. But one does not have to go far, just start removing the medications that your doctor gave you, or, preferably, remove your doctor—as Oliver Wendell Holmes Sr. put it, “if all the medications were dumped in the sea, it would be better for mankind but worse for the fishes.” My father, an oncologist (who also did research in anthropology) raised me under that maxim (alas, while not completely following it in practice; he cited it enough, though).
I, for my part, resist eating fruits not found in the ancient Eastern Mediterranean (I use “I” here in order to show that I am not narrowly generalizing to the rest of humanity). I avoid any fruit that does not have an ancient Greek or Hebrew name, such as mangoes, papayas, even oranges. Oranges seem to be the postmedieval equivalent of candy; they did not exist in the ancient Mediterranean. Apparently, the Portuguese found a sweet citrus tree in Goa or elsewhere and started breeding it for sweeter and sweeter fruits, like a modern confectionary company. Even the apples we see in the stores are to be regarded with some suspicion: original apples were devoid of sweet taste and fruit corporations bred them for maximal sweetness—the mountain apples of my childhood were acid, bitter, crunchy, and much smaller than the shiny variety in U.S. stores said to keep the doctor away.
As to liquid, my rule is drink no liquid that is not at least a thousand years old—so its fitness has been tested. I drink just wine, water, and coffee. No soft drinks. Perhaps the most possibly deceitfully noxious drink is the orange juice we make poor innocent people imbibe at the breakfast table while, thanks to marketing, we convince them it is “healthy.” (Aside from the point that the citrus our ancestors ingested was not sweet, they never ingested carbohydrates without large, very large quantities of fiber. Eating an orange or an apple is not biologically equivalent to drinking orange or apple juice.) From such examples, I derived the rule that what is called “healthy” is generally unhealthy, just as “social” networks are antisocial, and the “knowledge”-based economy is typically ignorant.
I would add that, in my own experience, a considerable jump in my personal health has been achieved by removing offensive irritants: the morning newspapers (the mere mention of the names of the fragilista journalists Thomas Friedman or Paul Krugman can lead to explosive bouts of unrequited anger on my part), the boss, the daily commute, air-conditioning (though not heating), television, emails from documentary filmmakers, economic forecasts, news about the stock market, gym “strength training” machines, and many more.3
The Iatrogenics of Money
To understand the outright denial of antifragility in the way we seek wealth, consider that construction laborers seem happier with a ham and cheese baguette than businessmen with a Michelin three-star meal. Food tastes so much better after exertion. The Romans had a strange relation to wealth: anything that “softens” or “mollifies” was seen negatively. Their reputation for decadence is a bit overdone—history likes the lurid; they disliked comfort and understood its side effects. The same with the Semites, split between desert tribes and city dwellers, with city dwellers harboring a certain cross-generational nostalgia for their roots and their original culture; so there is the culture of the desert, full of poetry, chivalry, contemplation, rough episodes, and frugality, plotted against the cities’ comfort, which is associated with physical and moral decay, gossip, and decadence. The city dweller repairs to the desert for purification, as Christ did for forty days in the Judean desert, or Saint Mark in the Egyptian desert, starting a tradition of such asceticism. There was at some point an epidemic of monasticism in the Levant, perhaps the most impressive being Saint Simeon, who spent forty years on top of a column in Northern Syria. The Arabs kept the tradition, shedding possessions to go to silent, barren, empty spaces. And of course, with mandatory fasting, on which a bit later.
Note that medical iatrogenics is the result of wealth and sophistication rather than poverty and artlessness, and of course the product of partial knowledge rather than ignorance. So this idea of shedding possessions to go to the desert can be quite potent as a via negativa–style subtractive strategy. Few have considered that money has its own iatrogenics, and that separating some people from their fortune would simplify their lives and bring great benefits in the form of healthy stressors. So being poorer might not be completely devoid of benefits if one does it right. We need modern civilization for many things, such as the legal system and emergency room surgery. But just imagine how by the subtractive perspective, via negativa, we can be better off by getting tougher: no sunscreen, no sunglasses if you have brown eyes, no air-conditioning, no orange juice (just water), no smooth surfaces, no soft drinks, no complicated pills, no loud music, no elevator, no juicer, no … I stop.
When I see pictures of my friend the godfather of the Paleo ancestral lifestyle, Art De Vany, who is extremely fit in his seventies (much more than most people thirty years younger than him), and those of the pear-shaped billionaires Rupert Murdoch or Warren Buffett or others in the same age group, I am invariably hit with the following idea. If true wealth consists in worriless sleeping, clear conscience, reciprocal gratitude, absence of envy, good appetite, muscle strength, physical energy, frequent laughs, no meals alone, no gym class, some physical labor (or hobby), good bowel movements, no meeting rooms, and periodic surprises, then it is largely subtractive (elimination of iatrogenics).
Religion and Naive Interventionism
Religi
on has invisible purposes beyond what the literal-minded scientistic-scientifiers identify—one of which is to protect us from scientism, that is, them. We can see in the corpus of inscriptions (on graves) accounts of people erecting fountains or even temples to their favorite gods after these succeeded where doctors failed. Indeed we rarely look at religion’s benefits in limiting the intervention bias and its iatrogenics: in a large set of circumstances (marginal disease), anything that takes you away from the doctor and allows you to do nothing (hence gives nature a chance to do its work) will be beneficial. So going to church (or the temple of Apollo) for mild cases—say, those devoid of trauma, like a mild discomfort, not injuries from a car accident, those situations in which the risk of iatrogenics exceeds the benefit of cure, to repeat it again, the cases with negative convexity—will certainly help. We have so many inscriptions on temples of the type Apollo saved me, my doctors tried to kill me—typically the patient has bequeathed his fortune to the temple.
And it seems to me that human nature does, deep down, know when to resort to the solace of religion, and when to switch to science.4
IF IT’S WEDNESDAY, I MUST BE VEGAN
Sometimes, for a conference dinner, the organizers send me a form asking me if I have dietary requirements. Some do so close to six months in advance. In the past, my usual answer had been that I avoid eating cats, dogs, rats, and humans (especially economists). Today, after my personal evolution, I truly need to figure out the day of the week to know if I will be vegan then or capable of eating those thick monstrous steaks. How? Just by looking at the Greek Orthodox calendar and its required fasts. This confuses the usual categorizing business-reader-TED-conference modern version of the naive fellow who cannot place me in the “Paleo camp” or the “vegan camp.” (The “Paleo” people are carnivores who try to replicate the supposed ancestral high-meat, high-animal-fat diet of hunter-gatherers; vegans are people who eat no animal product, not even butter). We will see further down why it is a naive rationalistic mistake to be in either category (except for religious or spiritual reasons) except episodically.
Antifragile: Things That Gain from Disorder Page 42
