Another problem of clinical trials is that test subjects are nearly always excluded if they have any other medical conditions or are on other medications because those considerations could complicate results. The idea is to get rid of what are known as confounding variables. The problem is that real life is full of confounding variables even if drug tests are not. That means that lots of possible consequences are not tested for. We rarely know, for instance, what happens when various medications are taken in combination. One study found that 6.5 percent of hospital admissions in the U.K. were because of side effects from drugs, often taken in combination with other drugs.
All drugs come with a mixture of benefits and risks, and these are often not well studied. Everyone has heard that taking a low-dose aspirin daily may help prevent a heart attack. That is true, but only up to a point. According to one study of people who had taken low-dose aspirin daily for five years, 1 in 1,667 had been spared a cardiovascular problem, 1 in 2,002 had been spared a nonfatal heart attack, and 1 in 3,000 spared a nonfatal stroke, while 1 in 3,333 suffered major gastrointestinal bleeding that they would not otherwise have experienced. So for most people there is about as much chance of suffering dangerous internal bleeding from taking a daily aspirin as there is of avoiding a heart attack or stroke, but in all cases actually there is very little risk of either.
In the summer of 2018, matters became even more confused when Peter Rothwell, professor of clinical neurology at Oxford University, and colleagues found that low-dose aspirin actually is not effective at all in reducing cardiac or cancer risk in anyone weighing 154 pounds or more—but does still pose a risk of serious internal bleeding. Because about 80 percent of men and 50 percent of women exceed that threshold, it appears that a lot of people are getting no possible benefit from a daily aspirin while preserving all the risk. Rothwell suggested that people over 154 pounds should double the dose, perhaps by taking the pills twice a day rather than once, but that was really only an educated guess.
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I don’t wish to minimize the enormous, and undoubted, benefits of modern medicine, but it is an inescapable fact that it is far from perfect and in ways that aren’t always widely appreciated. In 2013, an international team of researchers investigated common medical practices and found 146 in which “a current standard practice either had no benefit at all or was inferior to the practice it replaced.” A similar study in Australia found 156 common medical practices “that are probably unsafe or ineffective.”
The simple fact is that medical science alone cannot do it all—but then it doesn’t need to. Other factors can significantly affect outcomes, sometimes in surprising ways. Just being kind, for instance. A study in New Zealand of diabetic patients in 2016 found that the proportion suffering severe complications was 40 percent lower among patients treated by doctors rated high for compassion. As one observer put it, that is “comparable to the benefits seen with the most intensive medical therapy for diabetes.”
In short, everyday attributes like empathy and common sense can be just as important as the most technologically sophisticated equipment. In that sense at least, perhaps Thomas McKeown was on to something.
* The “Gram” in Gram-negative and Gram-positive bacteria has nothing to do with weights and measures. It is named for a Danish bacteriologist, Hans Christian Gram (1853–1938), who in 1884 developed a technique for distinguishing the two major types of bacteria by what color they turned when stained on a microscopic slide. The difference between the two types has to do with the thickness of their cell walls and how easily or not they are penetrated by antibodies.
23 THE END
Exercise regularly. Eat sensibly. Die anyway.
—ANONYMOUS
I
IN 2011, AN interesting milestone in human history was passed. For the first time, more people globally died from non-communicable diseases like heart failure, stroke, and diabetes than from all infectious diseases combined. We live in an age in which we are killed, more often than not, by lifestyle. We are in effect choosing how we shall die, albeit without much reflection or insight.
About one-fifth of all deaths are sudden, as with a heart attack or car crash, and another fifth come quickly, following a short illness. But the great majority, about 60 percent, are the result of a protracted decline. We live long lives; we also die long deaths. “Nearly a third of Americans who die after 65 will have spent time in an intensive care unit in their final three months of life,” The Economist noted grimly in 2017.
There’s no question that people are living longer than ever. If you are a seventy-year-old man in America today, you have only a 2 percent chance of dying in the next year. In 1940, that probability was reached at age fifty-six. In the developed world at large, 90 percent of people reach their sixty-fifth birthday, the great majority of them in a healthy condition.
But now it seems we have reached a point of diminishing returns. By one calculation, if we found a cure for all cancers tomorrow, it would add just 3.2 years to overall life expectancy. Eliminating every last form of heart disease would add only 5.5 years. That’s because people who die of these things tend to be old already, and if cancer or heart disease doesn’t get them, something else will. Of nothing is that more true than Alzheimer’s disease. Eradicating it altogether, according to the biologist Leonard Hayflick, would add just nineteen days to life expectancy.
Our extraordinary improvements in life span have come at a price. As Daniel Lieberman has noted, “For every year of added life that has been achieved since 1990, only 10 months is healthy.” Already nearly half of people aged fifty or more suffer from some chronic pain or disability. We have become much better at extending life, but not necessarily better at extending quality of life. Older people cost the economy a lot. In the United States, the elderly constitute just over a tenth of the population but fill half the hospital beds and consume a third of all the medicines. Falls among the elderly alone cost the U.S. economy $31 billion a year, according to the Centers for Disease Control.
The time we spend in retirement has grown substantially, but the amount of work we do to fund it has not. The average person born before 1945 could expect to enjoy only about eight years of retirement before being permanently eliminated from the living, but someone born in 1971 can expect more like twenty years of retirement, and someone born in 1998 can, on current trends, expect perhaps thirty-five years—but all funded in each case by roughly forty years of labor. Most nations haven’t begun to face up to the long-term costs of all these unwell, unproductive people who just go on and on. We have, in short, a lot of problems ahead of us all, both personally and societally.
Slowing down, losing vigor and resiliency, experiencing a steady, ineluctable diminution in the ability to self-repair—in a word, aging—is universal across all species, and it is intrinsic: that is, it is initiated from within the organism. At some point, your body will decide to grow senescent and then to die. You can slow the process a little by following a carefully virtuous lifestyle, but you can’t escape it indefinitely. Put another way, we are all dying. Some of us are just doing it more quickly than others.