Saturday, April 5, 2014

Health versus Civilization

Ran Prieur writes:
March 24. You've probably seen Steven Pinker's argument that the world is getting less violent, because violent death rates are dropping. This View from Hell post, Homicide Rates, Suicide Rates, and Modern Medicine, argues that this is an illusion caused by high-tech medicine saving victims who would previously have died. "From 1931 to 1998, the United States homicide rate dropped by about 25%. But during that time, rates of aggravated assault increased by about 700%." Meanwhile the suicide rate continues to rise, and Sister Y speculates that "in the absence of modern medicine, up to ten times as many people who poison, cut, hang, or suffocate themselves might succeed."
In other words, modern society is technologically sophisticated enough to mask just how violent that society really is. Ran continues:
The deeper problem here is that our culture is obsessed with avoiding death and acute physical injury, while being unaware of the grinding emotional trauma of going to school, looking for a job, being deep in debt, and generally being treated like cattle in a giant scheme to concentrate wealth and power ever more densely at the center.
Our "long comfortable" living standards that show up in the statistics, and our relative freedom from violence mask the horrible psychic wounding and violence we feel every single day.

Here's Spencer Wells on what people died of in prehistory (emphasis mine):
In Plagues and Peoples, [William] McNeill traces the origin of many diseases common today back to changes in human society during the Neolithic period. Many of these changes we are familiar with from last chapter, including the increasing number of people living in a relatively small space, allowing rapid transmission of diseases by infected individuals, and a large enough pool of uninfected people to permit the emergence of epidemics. Perhaps the most important factor, though, was the domestication of animals. As the human population increased in early farming communities, hunting was no longer a viable option--as with wild seed-bearing grasses, the supply of wild animals was limited by the natural carrying capacity of the land. This meant that many were soon hunted to near extinction. The necessity of creating a stable food supply led human populations in the Middle East to begin domesticating sheep, goats, pigs, and cattle from their wild progenitors by around 8000 B.C., and the Southeast Asian population to domesticate the chicken by around 6000 B.C. This created a reliable source of meat in the Neolithic diet, but the large numbers of people and animals cohabitating also created an environment that had never before exited in human history.

For the first time, people and animals were living in the same communities. While Paleolithic hunters had certainly come into contact with their prey after a successful hunt, the number of wild animals contacted was a small fraction of those living in the newly domesticated Neolithic herds. Also, most of these animals were dead; this would have decreased the chances of transmitting many diseases, but perhaps facilitated the transfer of blood-borne infections. When we started living close to animals throughout our lives--particularly as children--the odds of diseases being transmitted increased significantly. Although some such infections had probably always existed to a lesser extent in both the animal and human populations, suddenly there was a brand-new opportunity to swap hosts. The microorganisms had a field day.

McNeill wrote that of the diseases shared by humans and their domesticated animals, twenty-six are found in chickens, forty-two in pigs, forty-six in sheep and goats, and fifty in cattle. Most of the worst scourges of human health until the advent of vaccination in the eighteenth century were imports from our farm animals, including measles, tuberculosis, smallpox, and influenza. Bubonic plague was transmitted to us by fleas from rats living in human settlements. As far as we can tell from the archaeological record, none of these so-called zoonotic diseases...afflicted our Paleolithic ancestors--all seem to have arisen in the Neolithic with the spread of farming. McNeill suggests that many of the plagues described in the Bible may coincide with the explosion of zoonotic diseases during the emergence of the urban civilizations of the Neolithic, Bronze and Iron Ages.

What is clear is that a new source of human mortality had arrived on the scene. This does, however, raise the question of what people had been dying of before the development of agriculture. Were there really no diseases in the human population? Of course there were. It's likely that macroparasites--things such as tapeworms that can be seen by the naked eye--were problems for our distant ancestors. Most of these infections generally would have produced little beyond feelings of malaise, though--not acute, debilitating symptoms like high fevers, organ failure and death--in part because we had probably been evolving together with these parasites for such a long time. Over millions of years, an evolutionary process known as mutualism would have led the parasites to produce less acute physical symptoms in their hosts (us), since it does a parasite little good to kill its host and thus its source of food, and we would have adapted to their presence. In general, the longer an infection has been around, the less virulent it is, the symptoms it elicits in the host becoming less severe over many generations. New diseases that erupt suddenly into a previously unexposed population often have extreme outcomes, including death.

If macroparasites couldn't have produced a significant amount of mortality during the Paleolithic period, and most disease-causing microorganisms hadn't yet had a chance to pass from animals to humans, what did our hunter-gatherer ancestors die of? According to British evolutionary biologist J.B.S. Haldane, traumatic injuries were the most likely cause of death throughout most of human history. Does this mean we spring from a race of klutzes, who tripped and fell their way through the Paleolithic? No: such injuries would have included wounds sustained during hunting and skirmishes with other groups, the traumas associated with childbirth (a significant source of mortality for both mother and child until quite recently), and accidental falls and drownings. All of these hazards, coupled with infections from the wounds, would have been the main cause of hunter-gatherer morbidity and mortality.

So, we seem to have evidence for an interesting pattern--three waves of mortality was we move from Paleolithic times to the present. The first is trauma, primary from the time of our hominid ancestors until the dawn of the Neolithic period. As people settled down and began to domesticate animals rather than hunt them, infectious disease began to supersede trauma as a significant cause of mortality. The second wave, of infectious disease, continued to be the most significant cause of death until antibiotics were developed in the mid-twentieth century. The final wave has happened since the mid-twentieth century, in developed countries, where vaccinations and widespread antibiotic use have reduced infectious diseases to a fraction of their former threat. Now that we have stemmed the joint threats of trauma and infection, chronic diseases are becoming a larger threat. Most people prior to the twentieth century would have died relatively young, before these maladies--primarily diabetes, hypertension, stroke and cancer--would have had a chance to develop. With modern medicine, we've traded the scourges of trauma and infection for a threat from within our own bodies.
Pandora's Seed pp. 72-76. Of course, antibiotics are largely losing their potency thanks to widespread abuse. Meanwhile, the diseases of civilization just keep spreading: Obesity has quadrupled to nearly one billion in the developing world. Cancer is increasing too:

Cancer 'tidal wave' on horizon warns WHO (BBC)
And there are opportunities for death and wounding thanks to technology that didn't even exist in the Paleolithic - 1.5 million people are killed worldwide by automobiles, more than were alive in the Paleolithic, and 78 million are injured requiring medical care. You could literally die every time you step off the curb if you live in a city. It's just our enormous populations that make this seem minor statistic. So it's not like trauma went away, we just got better at treating it, while adding entirely new sources of morality and sickness to our swelling populations.

When you see people in middle-age who are only able to move about thanks to their (government paid) scooters, you wonder if it was all worth it. I'm haunted by my time shadowing doctors and nurses in a hospital. We're building entire skyscrapers full of chronically sick people who are never going to get better. And now even teenagers are getting 'diabesity.' So when I hear all these statistics about how much healthier and better-off we are now than ever before, I can't help but roll my eyes and wonder if life extension at all costs makes up for the sickness and atrocious health of the general population, especially in the "world's richest nation" (which spends almost one out of every five dollars in the economy on health care).

A temple to illness
And it's getting worse. Although the average is going up, as with incomes, a large gap is opening up between the rich and the poor. See this: Income Gap, Meet Longevity Gap (New York Times):
There have long been stark economic differences between Fairfax County and McDowell. But as their fortunes have diverged even further over the past generation, their life expectancies have diverged, too. In McDowell, women’s life expectancy has actually fallen by two years since 1985; it grew five years in Fairfax.

“Poverty is a thief,” said Michael Reisch, a professor of social justice at the University of Maryland, testifying before a Senate panel on the issue. “Poverty not only diminishes a person’s life chances, it steals years from one’s life.”

That reality is playing out across the country. For the upper half of the income spectrum, men who reach the age of 65 are living about six years longer than they did in the late 1970s. Men in the lower half are living just 1.3 years longer.

The link between income and longevity has been clearly established. Poor people are likelier to smoke. They have less access to the health care system. They tend to weigh more. And their bodies suffer the debilitating effects of more intense and more constant stress. Everywhere, and across time, the poor tend to live shorter lives than the rich, whether researchers compare the Bangladeshis with the Dutch or minimum-wage workers with millionaires.
But is widening income inequality behind the divergence in longevity over the last three decades?
Er, of course it is. Compare to hunter-gatherers where health is roughly equal across the board. And it's going to get a lot worse as the poor are only able to afford what Ran called "human dog food,"  that is, cheap processed carbohydrates, meat made with "pink slime" and "meat glue," bland vegetable-like substances grown without dirt and delivered in a can, jar, bag or box flavored with corn syrup and other chemical flavorings. And just wait - Silicon Valley titans are currently pouring money into "lab-grown meat:"

Why silicon valley wants to hack the food industry (The Guardian)

I know I'm going to enjoy eating my GoogleburgerTM with soy cheese during my half-hour timed lunch break from my fourteen hour Amazon warehouse shift. I'm kidding, of course; those warehouse jobs will be long gone. Can Soylent Green be far behind? After all, protein is getting rarer, the American and Chinese upper classes will want protein in their diets, and we need to do something with all those unemployed people. It's a win all around!

Here's anthropogist Mark Nathan Cohen in the definitive study on the topic, Health and the Rise of Civilization (emphasis mine):
The earliest visible populations of prehistory nonetheless do surprisingly well if we compare them to the actual record of human history rather than to our romantic images of civilized progress.

Civilization has not been as successful in guaranteeing human well-being as we like to believe, at least for most of our history. Apparently, improvements in technology and organization have not entirely offset the demands of increasing population; too many of the patterns and activities of civilized lifestyles have generated costs as well as benefits.

There is no evidence either from ethnographic accounts or archaeological excavations to suggest that rates of accidental trauma or interpersonal violence declined substantially with the adoption of more civilized forms of political organization. In fact, some evidence from archaeological sites and from historical sources suggests the opposite.

These data clearly imply that we need to rethink both scholarly and popular images of human progress and cultural evolution. We have built our images of human history too exclusively from the experiences of privileged classes and populations, and we have assumed too close a fit between technological advances and progress for individual lives.

In scholarly terms, these data which often suggest diminishing returns to health and nutrition tend to undermine models of cultural evolution based on technological advances. They add weight to theories of cultural evolution that emphasize environmental constraints, demographic pressure, and competition and social exploitation, rather than technological or social progress, as the primary instigators of social change. Similarly, the archaeological evidence that outlying populations often suffered reduced health as a consequence of their inclusion in larger political units, the clear class stratification of health in early and modern civilizations, and the general failure of either early or modern civilizations to promote clear improvements in health, nutrition, or economic homeostasis for large segments of their populations until the very recent past all reinforce competitive and exploitative models of the origins and function of civilized states.

In popular terms, I think that we must substantially revise our traditional sense that civilization represents progress in human well-being or at least that it did so for most people for most of history prior to the twentieth century. The comparative data simply do not support that image.

He has some important things to say about health and food quality, too. All of our evidence is telling us that hunter-gatherers, however short their lives may (or may not) have been, lived healthier lives during the time they were alive, and were relatively healthy until well into old age unlike us today. It seems every week new studies show that sedentism is unhealthy, that exercise, the type that H-G's did every single day, preserves our health, and that a plant-based diet, like the type H-G's ate, wards off disease. So how in hell could you argue that we're healthier today than they were? Here are two studies from just the past week:

How running may preserve thinking skills (BBC)

Seven-a-day fruit and veg 'saves lives' (BBC)

WHO: Daily sugar intake 'should be halved' (BBC)

The health benefit all fad diets have in common (The Week)
As it turns out, these diets all generally improve the health of participants because they encourage people to avoid processed foods and consume more plants. Whether people take the meat-heavy Paleo route, opt for low-carb options, or go full-on vegetarian, the common benefits are the same. Though some of these diets encourage more meat eating, the plant-based principle still applies. Katz and Meller affirmed that as long as people consume meat from animals fed a more natural plant-based diet, they will reap the same benefits as vegetarian diets. (The meat and dairy produced by the grain-based diets of animals raised in factory farms is less nutritious than meat from pasture-raised animals.)
And for some other health unintended consequences:

Number of chemicals linked to problems such as autism DOUBLES in just seven years (Daily Mail)

Child health problems 'linked to father's age' (BBC) You have to get out of post-graduate school before you have that first kid, after all.

Here's biologist Robert Sapolsky on the effects of our stressful civilization on us:
In the short term, [Sapolsky] explained, stress hormones are "brilliantly adapted" to help you survive an unexpected threat. "You mobilize energy in your thigh muscles, you increase your blood pressure and you turn off everything that's not essential to surviving, such as digestion, growth and reproduction," he said. "You think more clearly, and certain aspects of learning and memory are enhanced. All of that is spectacularly adapted if you're dealing with an acute physical stressor—a real one."

But non-life-threatening stressors, such as constantly worrying about money or pleasing your boss, also trigger the release of adrenalin and other stress hormones, which, over time, can have devastating consequences to your health, he said: "If you turn on the stress response chronically for purely psychological reasons, you increase your risk of adult onset diabetes and high blood pressure. If you're chronically shutting down the digestive system, there's a bunch of gastrointestinal disorders you're more at risk for as well."

In children, the continual release of glucocorticoids can suppress the secretion of normal growth hormones. "There's actually a syndrome called stress dwarfism in kids who are so psychologically stressed that growth is markedly impaired," Sapolsky said.

Studies show that long-term stress also suppresses the immune system, making you more susceptible to infectious diseases, and can even shut down reproduction by causing erectile dysfunction and disrupting menstrual cycles.

"Furthermore, if you're chronically stressed, all sorts of aspects of brain function are impaired, including, at an extreme, making it harder for some neurons to survive neurological insults," Sapolsky added. "Also, neurons in the parts of the brain relating to learning, memory and judgment don't function as well under stress. That particular piece is what my lab has spent the last 20 years on."

The bottom line, according to Sapolsky: "If you plan to get stressed like a normal mammal, you had better turn on the stress response or else you're dead. But if you get chronically, psychosocially stressed, like a Westernized human, then you are more at risk for heart disease and some of the other leading causes of death in Westernized life." 
But don't worry, we've got a pill for that.

Ivan Illich, too pointed out the diminishing returns to modern allopathic medicine and its effects on health:
Health, argues Illich, is the capacity to cope with the human reality of death, pain, and sickness. Technology can help, but modern medicine has gone too far—launching into a Godlike battle to eradicate death, pain, and sickness. In doing so, it turns people into consumers or objects, destroying their capacity for health.

Illich sees three levels of iatrogenesis. Clinical iatrogenesis is the injury done to patients by ineffective, toxic, and unsafe treatments. ...Evidence based medicine is described in these pages, 20 years before the term was coined. Illich also points out that 7% of patients suffer injuries while hospitalised. Yet only in the past few years and in a few countries have doctors begun to take patient safety seriously.

Social iatrogenesis results from the medicalisation of life. More and more problems are seen as amenable to medical intervention. Pharmaceutical companies develop expensive treatments for non-diseases. Health care consumes an ever growing proportion of the budget. In 1975 the United States spent $95bn on health care, 8.4% of its gross national product—up, Illich noted, from 4.5% in 1962. Predictions published this month suggest it will be $2815bn, 17% of GNP, by 2011. Can this be sensible?

Worse than all of this for Illich is cultural iatrogenesis, the destruction of traditional ways of dealing with and making sense of death, pain, and sickness. “A society's image of death,” argues Illich, “reveals the level of independence of its people, their personal relatedness, self reliance, and aliveness.” Dying has become the ultimate form of consumer resistance.
Limits to Medicine. Medical Nemesis: The Expropriation of Health. Here is the full text online:

Illich published the book in 1975. Here is what has happened to health care spending in the United States since then:

Wow. Do you think the average American is healthier today than in 1960?

And the "peaceful" societies we inhabit have come about by concentrating violence geographically into zones we call "ghettos" and "prisons." Take those away, and all our heroic medical intervention, and I'm wondering if we really do rate better than our Paleolithic ancestors. We're all gonna die. Maybe the question is, do you want to die in a hospital room hooked up to machines, or like endurance runner Micah True:
That afternoon, on a hunch, Ray Molina, a longtime friend who lived in New Mexico, followed an arcing route south from the lodge. Most of the search had concentrated on areas to the north, but Molina had run these very trails with True and knew of an area that hadn’t yet been investigated. From the trail he bushwhacked down to a stream that ran lazily back toward the lodge. There, after a short while, he saw his friend. True reclined on his back against the stream bank, “looking peaceful,” still clutching his water bottle, his legs partly submersed in the water. Molina knew before he reached him that True was dead.
BONUS: The Tall-but-Poor 'Anomaly' (Peter Turchin):
[Jaques] Le Moyne was part of an ill-fated French expedition to Florida in 1564– I was looking through Le Moyne’s illustrations, I couldn’t help noting, first subconsciously, and then in a more aware manner, just how tall the Native Americans were compared to the Europeans.


Some, like the Cheyenne, were as tall as the Americans today. All, with the exception of the Comanche, were as tall as the contemporary white Americans, and most were taller than them. This was not too difficult, because during the second half of the nineteenth century the heights of native-born white Americans were declining. The average height of American males born in 1850 was 171 cm, and 40 years later it fell down to 169 cm.

One of the founders of anthropometrics, John Komlos, refers to the observation that the Plains Indians were the tallest in the world in the nineteenth century as the “Tall-but-Poor Anomaly.” But there is no anomaly here. It just shows that GDP per capita is a very poor measure of well-being. For example, between 1850 and 1890 GDP per capita, in inflation-adjusted dollars, increased by 130 percent, but the height of Americans fell by 2 cm. It’s not that Americans were becoming shorter as they were becoming richer. It was the top 1 percent who were becoming richer, while the 99 percent were becoming shorter.

So the Indians were nominally poor, but they lived in a way that only rich people can afford today. They exercised (riding them horses was a pretty good exercise!), ate grass-fed bison, supplemented by roots and berries (that’s paleo diet!), breathed fresh air, and drank uncontaminated water.

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