4. Andes. The mountain range is 7,000 km long – this is more than the distance between Copenhagen and Cape Town, South Africa. The average height is about 4,000 m. In Europe, there is only 1 km^2 of land > 4500m and 225 km^2 > 3500m. Denmark don’t have any mountains of course, but compared to this neither does the rest of Europe.
6. Patagonia. Overlaps a little with 4, but only a little. A few images from the article:
1) “Why did I become a doctor? Well gosh, I guess it’s because ever since I was a little boy I just wanted to help people. You know, I don’t tell this story often, but I remember when I was seven years old, one time I found a bird that had fallen out of its nest, so I picked him up and I brought him home and I made him a house out of an empty shoebox and… oh my God! [breaks up laughing] I became a doctor for the same four reasons everybody does: chicks, money, power, and chicks. But, since HMOs have made it virtually impossible to make any real money, which directly effects the number of chicks that come sniffin’ around, and don’t ask me what tree they’re barking up, ’cause they’re sure as hell not pissing on mine, and as far as power goes, well: Here I am during my free time letting some thirteen-year-old psychology fella who couldn’t cut it in real medicine ask me questions about my personal life, so here’s the inside scoop there, pumpkin, why don’t you go ahead and tell me all about power.” (Update 2: Here’s the clip, the sequence starts at 2:30)
“Relationships don’t work the way they do on television and in the movies [US: do note that this is a quote from a tv-series]. Will they? Won’t they? And then they finally do, and they’re happy forever. Gimme a break. Nine out of ten of them end because they weren’t right for each other to begin with, and half of the ones who get married get divorced anyway, and I’m telling you right now, through all this stuff, I have not become a cynic, I haven’t. Yes, I do happen to believe that love is mainly about pushing chocolate covered candies and, y’know, in some cultures, a chicken. You can call me a sucker, I don’t care, because I do believe in it. Bottom line is: it’s couples who are truly right for each other wade through the same crap as everybody else, but the big difference is they don’t let it take them down. One of those two people will stand up and fight for that relationship every time. If it’s right, and they’re real lucky, one of them will say something.” (Update: After a short search, I was able to find the clip here)
“Do you know any women who hate themselves enough to date me?”
(Percival Ulysses Cox, Scrubs)
2) “One of the effects of civilization is to diminish the rigour of the application of the law of natural selection. It preserves weakly lives that would have perished in barbarous lands.” (Francis Galton)
3) “Faith has never moved anything at all. It is doubt that moves.” (Poul Henningsen)
4) “Future comes by itself, progress does not.” (-ll-)
5) “So I say live and let live. That’s my motto. Live and let live. Anyone who can’t go along with that, take him outside and shoot the motherfucker. It’s a simple philosophy, but it’s always worked in our family.” (George Carlin)
6) “I realized some time ago that I’m not separate from nature just because I have a primate brain – an upper brain – because underneath the primate brain, there’s a mammalian brain, and beneath the mammalian brain, there’s a reptilian brain; and it’s those two lower brains that made the upper brain possible in the first place. Here’s the way it works: The primate brain says, “Give peace a chance.” The mammalian brain says, “Give peace a chance, but first let’s kill this motherfucker.” And the reptilian brain says, “Let’s just kill the motherfucker, go to the peace rally and get laid.” (George Carlin)
7) “The barbarous custom of having men beaten who are suspected of having important secrets to reveal must be abolished. It has always been recognized that this way of interrogating men, by putting them to torture, produces nothing worthwhile. The poor wretches say anything that comes into their mind and what they think the interrogator wishes to know.” (Napoléon Bonaparte, written in 1798)
In case you think of him as ‘the good guy’ now, because of that quote (/unlikely, but…), here’s another: “The life of a citizen is the property of his country.”
8 ) “The more is given the less the people will work for themselves, and the less they work the more their poverty will increase.” (Leo Tolstoy, ‘Help for the Starving’, 1892)
9) “Everyone thinks of changing the world, but no one thinks of changing himself.” (Leo Tolstoy)
10) “Abstainer, n. A weak person who yields to the temptation of denying himself a pleasure. A total abstainer is one who abstains from everything but abstention, and especially from inactivity in the affairs of others.” (Ambrose Bierce, ‘The Devil’s Dictionary’)
11) “Learning, n. The kind of ignorance distinguishing the studious.” (-ll-)
12) “Liberty, n. One of imagination’s most precious possessions.” (-ll-)
I could probably keep quoting Bierce all day, so I’ll just leave the link and you can read all of it yourself, if you’re so inclined.
Have completed the book now. I’ll start out with a few passages I found interesting:
1) “For decades, the rate of violent and property crimes in the United States had been steady and relatively low. But levels began to rise in the mid-50es. By 1960, the crime rate was 50 percent higher than it had been in 1950; by 1970, the rate had quadroupled. […] In 1970, a criminal could expect to spend an astonishing 60 percent less time behind bars than he would have for the same crime committed a decade earlier.”
2) “One recent academic study found that a given disaster received an 18 percent spike in charitable aid for each seven-hundred-word newspaper article and a 13 percent spike for every sixty seconds of TV news coverage.”
I thought that sounded weird, as it would mean that two random newspaper articles about a disaster would have a greater impact on charitable giving than a minute of TV-coverage, and that just didn’t make sense to me. So I looked up the paper. Here’s what they found:
“We find that an additional minute of network television news coverage increases that day’s donations by 0.036 standard deviations from the mean, or 13.2% for the average agency. One additional story in the New York Times or the Wall Street Journal increases that day’s donations by 0.050 standard deviations from the mean, or 18.2% for the average agency.”
So the effect they mention isn’t the effect some random local newspaper is likely to have. But to me, this still seems like a huge effect. Btw, in case you haven’t read it and would like to, here’s the link to the Ramadan paper I mentioned in an earlier post also related to the book – I didn’t link to it originally because I expected it would take you less than a minute to find it on your own if you were in fact interested in reading it; the post mentioned both authors’ names as well as an easily searchable subject. Now you have no excuse for not reading it if you want to know more.
3) “If John List’s research proves anything, it’s that a question like “Are people innately altruistic?” is the wrong kind of question to ask. Pople aren’t “good” or “bad”. People are people, and they respond to incentives. They can nearly always be manipulated – for good or ill – if only you find the right levers.”
Jeg har fra tid til anden skrevet næsten nøjagtigt det samme, fratrukket første halvdel af første sætning i afsnittet, i diskussioner, jeg har deltaget i.
4) “The first successful kidney transplant was performed in 1954.”
I was really surprised by this. I had this idea that this technology had been around longer than that. Although it makes perfect sense – before antibiotics, any kind of attempted organ transplant would be plain suicide on part of the recipient, because transplant receivers have to take immunosuppressive drugs in order to avoid that their body rejects the organ. And if you take immunosuppressive drugs and you don’t have any kinds of medications that will work when you get an infection, which you will if you take immunosuppressive drugs, you’ll just die from either the infection or from your body rejecting the organ you received, whichever get you first. I’m one of those people who are very worried about the spread of resistant bacteria, a subject which recently have become newsworthy material because of the NDM-1 (you can start here). Diabetics have an increased risk of infection as it is, and there’s a significant risk that I’ll need a kidney transplant at some point due to microvascular complications. Even without resistant bacteria there’s enough to worry about because of stupid government policies:
“There are currently 80,000 people in the United States on a waiting list for a new kidney, but only some 16,000 transplants will be performed this year. This gap grows larger every year. More than 50,000 people on the list have died over the past twenty years, with at least 13,000 more falling off the list as they became too ill to have the operation.”
5) “Nearly 40,000 people died in U.S. traffic accidents in 1950. […] The rate of death per mile driven was five times higher in 1950 than it is today. […] Seat belts reduce the risk of death by as much as 70 percent; since 1975 they have saved roughly 250,000 lives.”
Yes, there’s probably a reason they didn’t start counting the lives saved before 75 – before that, almost nobody wore seatbelts. Around 1980, it was still only 11 percent of all drivers that used seatbelts. 20 years ago, in 1990, it was still only half of all drivers (49 %) that wore seatbelts in the US.
6) “In the United States alone, more than 100,000 coal miners died on the job over the past century, with another estimated 200,000 dying later from black lung disease [I’ve actually linked to that specific article before in a wikipedia links post].” […] at least 3,000 Chinese coal miners die on the job each year.”
7) I liked this passage: “Although economists are trained to be cold-blooded enough to sit around and calmly discuss the trade-offs involved in global catastrophe, the rest of us are a bit more exitable [many economists are quite exitable too, I would add]. And most people respond to uncertainty with more emotion – fear, blame, paralysis – than might be advisable. Uncertainty also has a nasty way of making us conjure up the very worst possibilities. […] With global warming, the worst possibilities are downright biblical: rising seas, hellish temperatures, plague upon plague, a planet in chaos.
It is understandable, therefore, that the movement to stop global warming has taken on a feel of a religion. The core belief is that humankind inherited a pristine Eden, has sinned greatly by polluting it, and must now suffer lest we all perish in a fiery apocalypse.”
As the authors note in that chapter, the worst scenario is not the most likely scenario and maybe there’s a cheap fix. They spend quite a bit of time in that chapter talking about geoengineering.
The second part of the book was not as interesting to me as the first, primarily because I knew at least part of a lot of the stuff already. There was some basic behavioral economics I already knew about, and some related game theory and the results of some classical games (the ultimatum/dictator games, how outcomes can change given different setups/incentives, the Milgram experiment); Iran’s transplant policy and how it differs from that of the US – and some of the consequenses of those policy differences; Semmelweis’ story; the basic story about the development of the polio vaccine; the ‘car-seat controversy’; the climatic effects of volcano eruptions such as the eruption of Krakatoa. A lot of this was old news at least in part, but of course there was a lot of good data as well, as I’ve hinted to in the posts.
Btw., some economists have criticized the authors for the ‘applied economics’ approach they employ – or rather that the stuff they do shouldn’t be called economics. I’d note that if you make use of an ‘economics is about incentives’ paradigm, their approach is arguably closer to ‘pure economics’ than ie. some forms of macroeconomic modelling. The fields of decision theory and economics overlap quite a bit in my mind, but what to call this kind of stuff is less important to me than the fact that this kind of work is being done by someone, and economists are in general well equipped to answer questions such as those posed in the book. Anyway, if you know someone who don’t think ‘incentives matter’ – there are a lot of those people around – this is the kind of book you should give him or her. If you’re such a person yourself, to some degree, you should of course read it yourself too. If you found the material I’ve quoted in the posts interesting, you’ll probably like the book.
1) Muller’s ratchet.
2) Mountain Meadows massacre. I read A Study in Scarlet not long ago, then decided to read up a little bit on the history of the Mormons. I think I’ve now put Utah on my mental list of places I don’t ever want to visit.
4) 2010 United States federal budget. Three key figures, all estimates:
a) Total revenue: $2.381 trillion.
b) Total expenditures: $3.552 trillion
c) Deficit: $1.171 trillion.
Individual income taxes is expected to make up $1.061 trillion, a smaller number than the projected deficit. The long version is here, haven’t read that one.
5) Iatrogenesis (‘inadvertent adverse effects or complications caused by or resulting from medical treatment or advice’). Not one of wikipedia’s best articles, but often I find it’s easier to remember new words and concepts if you’re able to read a bit about it and put it into context. If I read about a concept X which has characteristic Y, I’m less likely to remember what X is than if I read about the same concept X but with characteristics Y,Z,T – even though I’ll likely not remember Z and T in the long run. I often prefer wikipedia to a dictionary, because the often more extensive discription makes the subjective cost of forgetting about the concept afterwards higher. It’s easier for me to remember that I’ve been reading about a cat if it also happens to be a black cat with four paws and a white spot over the eye. Maybe I’m just weird.
6) Hypertension. Have I linked to this article before? Maybe. I shall have to admit that my main motivation for linking to this piece was this post. Smart people can be quite stupid at times and walking around with an untreated high blood pressure is very stupid. If a guy as smart as PZ was not aware of this risk, maybe one of my readers aren’t either. Here’s one relevant meta-analysis that might be of interest.
Have read the first 100 pages now, a few interesting passages from the book:
1) “In the early 1910s, the Department of Justice conducted a census of 310 cities in 26 states to tally the number of prostitutes in the United States: “We arrive at the conservative figure of approximately 200,000 women in the regular army of vice.”
At the time, the American population included 22 million women between the ages of fifteen and forty-four. If the DOJ numbers are to be believed, 1 og every 110 women in that age range was a prostitute. But most prostitutes, about 85 percent, were in their twenties. In that age range, 1 of every 50 American women was a prostitute.
The market was particularly strong in Chicago, which had more than 1000 known brothels.”
2) “Teaching has traditionally been dominated by women. A hundred years ago, it was one of the few jobs available to women that didn’t involve cooking, cleaning, or other menial labor. (Nursing was another such profession, but teaching was far more prominent, with six teachers for every nurse.) At the time, nearly 6 percent of the female work-force were teachers, trailing only laborers (19 percent), servants (16 percent), and laundresses (6,5 percent). […] As of 1940, an astonishing 55 percent of all college-educated female workers in their thirties were employed as teachers.”
Yes, the teacher numbers are interesting, but damn, so are the others – a 100 years ago, appr. 1 in 6 women employed were servants! Here’s a bit more:
“In 1960, about 40 percent of female teachers scored in the top quintile of IQ and other aptitude tests, with only 8 percent in the buttom. Twenty years later, fewer than half as many were in the top quintile, with more than twice as many in the buttom.”
Combine this fact and the development since then with the Flynn effect and you get at least part of the explanation why teachers were more respected in the past. They, and especially the females, were much smarter on average.
3) “Alan Krueger combed through a Hezbollah newsletter called Al-Ahd (The Oath) and compiled biographical details on 129 dead shahids (martyrs). He then compared them with men from the same age bracket in the general populace of Lebanon. The terrorists, he found, were less likely to come from a poor family (28 percent versus 33 percent) and more likely to have at least a high-school education (47 percent versus 38 percent).
A similar analysis of Palestinian suicide bombers by Claude Berrebi found that only 16 percent came from impoverished families, versus more than 30 percent of male Palestinians overall. More than 60 percent of the bombers, meanwhile, had gone beyond high school, versus 15 percent of the populace.
In general, Krueger found, “terrorists tend to be drawn from well-educated, middle-class or high-income families”.”
4) “The beauty of terrorism – if you’re a terrorist – is that you can succeed even by failing. […] Let’s say it takes an average of one minute to reomve and replace your shoes in the airport security line. In the United States alone, this procedure happens roughly 560 million times per year. Five hundred and sixty million minutes equals more than 1,065 years – which, divided by 77.8 years (the average U.S. life expectancy at birth), yields a total of nearly 14 person-lives. So even though Richard Reid [the failed shoe bomber] failed to kill a single person, he levied a tax that is the time equivalent of 14 lives per year.”
5) “Until the 1960s, hospitals simply weren’t designed to treat emergencies. “If you brought someone to a hospital at night,” Feied [Craig Feied, according to the book ‘an emergency-medicine specialist’] says, “the doors would be locked. You’d ring the bell, a nurse would come down to see what you wanted. She might let you in, then she’d call the doctor at home, and he might or might not come in.” Ambulances were often run by the local mortuary. It is hard to think of a better example of misaligned incentives: a funeral director who is put in charge of helping a patient not die!”
“In a given year, an excellent ER doctor’s patients will have a twelve-month death rate that is nearly 10 percent lower than the average. This may not sound like much, but in a busy ER with tens of thousands of patients, an excellent doctor might save six or seven lives a year relative to the worst doctor.”
‘No, it doesn’t sound like much and that really isn’t a big difference’ I’d say, unless you’re one of those six or seven marginal people of course. But the difference between the best and an average ER doctor seems to be quite small – it’s probably much bigger in other specialties. A Dane at the age of 30 can expect to live 8,5 years more if he’s never smoked than if he’s a heavy smoker, so a GP who’s good at making people stop smoking will save dozens of lives every year on that count alone.
6) “More than $40 billion is spent worldwide each year on cancer drugs.”
(I’d have thought the number was bigger than that)
“cancer patients make up 20 percent of Medicare cases but consume 40 percent of the Medicare drug budget.”
“A typical chemotherapy regime for non-small-cell lung cancer costs more than $40,000 but helps extend a patient’s life by an average of just two months.”
I like the book so far.
From a brilliant post by Katja Grace:
“Discrimination’ can mean all sorts of things. One of the main ones, and what it will mean in this post, is differential treatment of people from different groups, due to real or imagined differences in average group features. Discrimination is a problem because the many people who don’t have the supposed average features of a group they are part of are misconstrued as having them, and offered inappropriate treatment and opportunities as a result. For instance a capable and trustworthy middle aged man may miss out on a babysitting job for which he is truly the best candidate because the parents take his demographic information as reason not to trust him with their children.
This means that ‘discrimination’ is really a misnomer; this problem is due to lack of discrimination. In particular lack of discrimination between members of the groups. […] Even if observers can’t discriminate perfectly, more ability to discriminate means less misrepresentation.”
“The usual solution suggested for ‘discrimination’ is for everyone to forget about groups and act only on any specific evidence they have about individuals. Implicitly this advice is to expect everyone to have the average characteristics of the whole population except where individual evidence is available. Notice that generalizing over a larger group like this should increase the misrepresentation of people, and thus their inappropriate treatment. Recall that that was the original problem with discrimination.”
“if you want to stop discrimination because it causes people to be treated as less than they are, then work on making it easier to discriminate between people further, rather than harder to discriminate between them at all. Help people signal their traits cheaply and efficiently distinguish between others. In the absence of perfect discrimination between individuals, the other end of the spectrum is not the next best thing, it’s the extreme of misrepresentation.”
I seem to remember making some of the same points not long ago here.
“This paper aims to measure differences in risk behavior among expert chess players. The study employs a panel data set on international chess with 1.4 million games recorded over a period of 11 years. […] In line with previous research, we find that women are more risk-averse than men. A novel finding is that males choose more aggressive strategies when playing against female opponents even though such strategies reduce their winning probability.”
“We find that when a man plays against a woman, a solid strategy has a 1.5 percentage point higher probability of winning compared to not using such strategy.20 Our interpretation of these results is that, on average, it does appear irrational for males to opt for less solid strategies when they face a female opponent.”
Link. I’ll try remember this study; at some point it will surely save me some rating points!
This is the kind of finding where I’m tempted to say ‘I already knew that’, but of course I didn’t. I would have expected it if they had been looking at the results of matches between kids but we’re not talking about kids here, we’re talking about smart and strong adult chess players. A question for the next study: Are males in a relationsship less likely to play aggressively than males who are single? If so, does that mean that being in a relationsship makes males more risk averse? This would be my null hypothesis.
“A half or more of offenders are intoxicated by a psychoactive substance at the time of the homicide, with alcohol the most commonly reported substance. Levels of substances among victims are comparable with those seen among perpetrators. Among both offenders and victims, levels of substances far exceed population use. Among substance users, homicide specific mortality rates of substance users far exceed population rates. Reducing rates of alcohol and other drug consumption, at national and individual levels, can be expected to substantially reduce rates of, and risk for, homicide.”
Link, via MR.
Here’s the link. My guess is that the mean IQ of the contributors to that list is at least 130 and it’s probably more than that. It doesn’t necessarily mean that you’ll like the books, but it does give you a better idea of what kind of books smart (male?) nerds like to read.
I already knew/thought that I should probably read Kuhn and Minsky at some point, both are of course mentioned at the link. Also, I hadn’t heard about that one before but Hofstadter’s Gödel, Escher, Bach sounds like an interesting book. Popper and Dawkins are both mentioned at the link, they would also be on my list if I ever decided to make one.
2. The Kalmar Union.
3. Alfred Tarski.
“The oldest remains from Australia, Mungo Man, has been dated to anywhere between 70,000, and 30,000, years before the present. If we took the older date then Australia would have been settled almost immediately after the expansion of non-African modern humanity. If we accepted the younger date, then the settlement of Australia would have been concurrent with the final replacement of Neandertals by modern humans in Europe. The current consensus seems to be that Mungo Man dates to approximately 46,000 years before the present. As the first dating of a particular individual from a species in a region is liable to miss earlier individuals who were not fossilized it seems likely that Australia was settled by anatomically modern humans on the order of 46,000 years before the present, but somewhat earlier than that date. That would imply that Australia was populated by anatomically modern humans at least 10,000 years before Europe. One should probably not be too surprised by this. Out-of-Africa humans were probably initially tropically adapted so lateral migration would have been easier, but also, there were no hominin competitors in Australia.”
This great post by Razib Khan has a lot more good stuff.
I’ve chosen to quote quite extensively from the piece (HT: Ed Yong), because I know a lot of you would miss out on all of it if I just posted a link and a short quote. It’s a very good piece, you should read all of it – and yes, there’s a lot more at the link – if you have any interest in this subject:
“The issue has become pressing, in recent years, for reasons of expense. The soaring cost of health care is the greatest threat to the country’s long-term solvency, and the terminally ill account for a lot of it. Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit.
Spending on a disease like cancer tends to follow a particular pattern. There are high initial costs as the cancer is treated, and then, if all goes well, these costs taper off. Medical spending for a breast-cancer survivor, for instance, averaged an estimated fifty-four thousand dollars in 2003, the vast majority of it for the initial diagnostic testing, surgery, and, where necessary, radiation and chemotherapy. For a patient with a fatal version of the disease, though, the cost curve is U-shaped, rising again toward the end—to an average of sixty-three thousand dollars during the last six months of life with an incurable breast cancer. Our medical system is excellent at trying to stave off death with eight-thousand-dollar-a-month chemotherapy, three-thousand-dollar-a-day intensive care, five-thousand-dollar-an-hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop.
For all but our most recent history, dying was typically a brief process. Whether the cause was childhood infection, difficult childbirth, heart attack, or pneumonia, the interval between recognizing that you had a life-threatening ailment and death was often just a matter of days or weeks. […] These days, swift catastrophic illness is the exception; for most people, death comes only after long medical struggle with an incurable condition—advanced cancer, progressive organ failure (usually the heart, kidney, or liver), or the multiple debilities of very old age. In all such cases, death is certain, but the timing isn’t. So everyone struggles with this uncertainty—with how, and when, to accept that the battle is lost. As for last words, they hardly seem to exist anymore. Technology sustains our organs until we are well past the point of awareness and coherence. Besides, how do you attend to the thoughts and concerns of the dying when medicine has made it almost impossible to be sure who the dying even are? Is someone with terminal cancer, dementia, incurable congestive heart failure dying, exactly?
I once cared for a woman in her sixties who had severe chest and abdominal pain from a bowel obstruction that had ruptured her colon, caused her to have a heart attack, and put her into septic shock and renal failure. I performed an emergency operation to remove the damaged length of colon and give her a colostomy. A cardiologist stented her coronary arteries. We put her on dialysis, a ventilator, and intravenous feeding, and stabilized her. After a couple of weeks, though, it was clear that she was not going to get much better. The septic shock had left her with heart and respiratory failure as well as dry gangrene of her foot, which would have to be amputated. She had a large, open abdominal wound with leaking bowel contents, which would require twice-a-day cleaning and dressing for weeks in order to heal. She would not be able to eat. She would need a tracheotomy. Her kidneys were gone, and she would have to spend three days a week on a dialysis machine for the rest of her life.
She was unmarried and without children. So I sat with her sisters in the I.C.U. family room to talk about whether we should proceed with the amputation and the tracheotomy. “Is she dying?” one of the sisters asked me. I didn’t know how to answer the question. I wasn’t even sure what the word “dying” meant anymore. In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.
I asked Marcoux what he hopes to accomplish for terminal lung-cancer patients when they first come to see him. “I’m thinking, Can I get them a pretty good year or two out of this?” he said. “Those are my expectations. For me, the long tail for a patient like her is three to four years.” But this is not what people want to hear. “They’re thinking ten to twenty years. You hear that time and time again. And I’d be the same way if I were in their shoes.”
You’d think doctors would be well equipped to navigate the shoals here, but at least two things get in the way. First, our own views may be unrealistic. A study led by the Harvard researcher Nicholas Christakis asked the doctors of almost five hundred terminally ill patients to estimate how long they thought their patient would survive, and then followed the patients. Sixty-three per cent of doctors overestimated survival time. Just seventeen per cent underestimated it. The average estimate was five hundred and thirty per cent too high. And, the better the doctors knew their patients, the more likely they were to err.
Second, we often avoid voicing even these sentiments. Studies find that although doctors usually tell patients when a cancer is not curable, most are reluctant to give a specific prognosis, even when pressed. More than forty per cent of oncologists report offering treatments that they believe are unlikely to work. In an era in which the relationship between patient and doctor is increasingly miscast in retail terms—“the customer is always right”—doctors are especially hesitant to trample on a patient’s expectations. You worry far more about being overly pessimistic than you do about being overly optimistic. And talking about dying is enormously fraught. When you have a patient like Sara Monopoli, the last thing you want to do is grapple with the truth. I know, because Marcoux wasn’t the only one avoiding that conversation with her. I was, too.
In 1985, the paleontologist and writer Stephen Jay Gould published an extraordinary essay entitled “The Median Isn’t the Message,” after he had been given a diagnosis, three years earlier, of abdominal mesothelioma, a rare and lethal cancer usually associated with asbestos exposure. He went to a medical library when he got the diagnosis and pulled out the latest scientific articles on the disease. “The literature couldn’t have been more brutally clear: mesothelioma is incurable, with a median survival of only eight months after discovery,” he wrote. The news was devastating. But then he began looking at the graphs of the patient-survival curves.
Gould was a naturalist, and more inclined to notice the variation around the curve’s middle point than the middle point itself. What the naturalist saw was remarkable variation. The patients were not clustered around the median survival but, instead, fanned out in both directions. Moreover, the curve was skewed to the right, with a long tail, however slender, of patients who lived many years longer than the eight-month median. This is where he found solace. He could imagine himself surviving far out in that long tail. And he did. Following surgery and experimental chemotherapy, he lived twenty more years before dying, in 2002, at the age of sixty, from a lung cancer that was unrelated to his original disease.
“It has become, in my view, a bit too trendy to regard the acceptance of death as something tantamount to intrinsic dignity,” he wrote in his 1985 essay. “Of course I agree with the preacher of Ecclesiastes that there is a time to love and a time to die—and when my skein runs out I hope to face the end calmly and in my own way. For most situations, however, I prefer the more martial view that death is the ultimate enemy—and I find nothing reproachable in those who rage mightily against the dying of the light.”
I think of Gould and his essay every time I have a patient with a terminal illness. There is almost always a long tail of possibility, however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.”
From an interesting study about a subject I’ve wondered about from time to time:
“OBJECTIVE—To compare the risk of cardiovascular disease (CVD) death and the impact of hyperglycemia on the risk of CVD mortality associated with type 1 diabetes to that associated with type 2 diabetes.
RESULTS—During an 18-year follow-up, 86 participants with type 1 diabetes, 567 participants with type 2 diabetes, and 252 nondiabetic participants died. CVD mortality rates per 1,000 person-years were 23.1 (95% CI 16.9–31.9) in type 1 diabetic, 35.3 (30.8–40.4) in type 2 diabetic, and 4.6 (3.8–5.7) in nondiabetic participants. Adjusted hazard ratios for CVD mortality in participants with type 1 diabetes versus no diabetes was 3.6 (95% CI 2.2–5.7) in men and 13.3 (6.9–22.5) in women and in participants with type 2 diabetes versus no diabetes 3.3 (2.5–4.5) in men and 10.1 (6.7–17.4) in women. An increment of 1 unit (%) of GHb increased CVD mortality by 52.5% (95% CI 28.4–81.3) in type 1 diabetic subjects and by 7.5% (4.3–10.8) in type 2 diabetic participants.
CONCLUSIONS—The impact of type 1 and type 2 diabetes on CVD mortality was similar. The effect of increasing hyperglycemia on the risk of CVD mortality was more profound in type 1 than in type 2 diabetic subjects.”
Do note that the age of onset of diabetes was >30 years in both groups, so the relevance of the results when it comes to my own situation (diagnosis at the age of 2) is still questionable. Of course this is only speculation on my part, but one reason I can think of why the impact of hyperglycemia is ‘more profound in type 1’ patients might be that type 2 diabetics already have a lot of risk factors (obesity, ‘life style’, ect.), so that the effect of one more risk factor mean marginally less than it does among type 1 patients. If you’re already fat and sedentary and have been for many years, which most type 2 patients statistically are, adding hyperglycemia will not impact your risk of CVD-risk much, as it’s probably already through the roof; if you’re a sedentary type 2 diabetic with a BMI > 30 who also smokes daily, we’re not talking about the likelihood of dying from CVD, we’re only talking about when it’ll happen.
The part below is a good way to illustrate that the two diseases, type 1 and type 2 diabetes, are not all that similar, or at least that the patients are not all that similar:
“At baseline type 1 diabetic participants, when compared with nondiabetic participants, were leaner and had higher HDL cholesterol and lower diastolic blood pressure, but they had a slightly higher prevalence of hypertension, higher systolic blood pressure, and higher content of urinary protein than nondiabetic participants. Type 2 diabetic participants, when compared with nondiabetic participants were older, heavier, and more often nonusers of alcohol and had a higher frequency of hypertension, higher systolic and diastolic blood pressure, lower HDL cholesterol, higher triglycerides, higher content of urinary protein, and higher estimated creatinine clearance. Type 1 diabetic participants, when compared with type 2 diabetic participants were younger, leaner, and less frequently nonusers of alcohol and had lower prevalence of hypertension, lower diastolic and systolic blood pressure, higher HDL cholesterol, lower triglycerides, longer duration of diabetes, and lower estimated creatinine clearance.”
Some of these differences are probably sample-related, but not all of them. Note that despite being leaner and having more of the ‘good cholesterol’, type 1 diabetics still had worse kidney function than ‘healthy people’. That kidney damage is disease-related, not life-style related, and it’s quite likely that the patients had higher HDL cholesterol (and were leaner?) because they on average eat (live?) healthier than people who aren’t sick – that’s after all what they’re supposed to do. The ‘diabetic = fat guy who asked for it’ heuristic doesn’t work when we’re talking about the type 1s.
I’ve finished Equal Rites and have begun (well, I’ve read half of it, but…) Interesting Times, also by Pratchett. A very funny book.
Part of what makes Pratchett’s books so good is his choice of ‘heroes’. Forget about the ‘standard hero’, I’ve read four of his novels so far and the main characters were: 1-2) a (former?) con man, thief ect. 3) a somewhat old, cowardly, completely unskilled wizard who pretty much can’t do any magic, 4) a small girl wizard and an old witch. Of course it also comes down to this whole wonderful universe he’s created for the characters to inhabit.
Some quotes from the book:
“‘Them? I didn’t know they were noble,’ said Io.
‘They’re all very rich and have had millions of people butchered or tortured to death merely for reasons of expediency and pride,’ said the Lady.
The watching gods nodded solemnly. That was certainly noble behaviour. That was exactly what they would have done.”
“It was crowded. The air shimmered over the braziers of chestnut sellers and hot potato merchants and echoed with the traditional street cries of Old Ankh-Morpork.*
… *Such as ‘Ouch!’, ‘Aargh!’, ‘Give me back my money, you scoundrel!’ and ‘You call these chestnuts? I call them little balls of charcoal, that’s what I call them!'”
“Very peaceful place, the Agatean Empire,’ said Ridcully. ‘Very tranquil. Very cultured. They set great store in politeness.’
‘Well, yes,’ said the Lecturer in Recent Runes, ‘I heard it was because people who aren’t tranquil and quiet get serious bits cut off, don’t they? I heard the Empire has a tyrannical and repressive government!’
‘What form of government is that?’ said Ponder Stibbons.
‘A tautology,’ said the Dean, from above” [‘above’ refers to the fact that the Dean refused to come down from the chandelier when the meeting started and is still occupying it at this point]
“Rincewind looked longingly towards the door. It was no distance at all for the experienced coward.”
“The choices seemed very clear to Rincewind. There was the city of Hunghung, under siege, apparently throbbing with revolution and danger, and there was everywhere else.
Therefore it was important to know where Hunghung was so that he didn’t blunder into it by accident. He paid a lot of attention to Mr Saveloy’s instructions, and then rode the other way.”
“‘What happens if I claim immunity because I’m a foreigner?’
‘There’s a special thing they do with a wire-mesh waistcoat and a cheesegrater.’
‘And there are torturers in Hunghung who can keep a man alive for years.’
‘I suppose you’re not talking about healthy early morning runs and a high-fibre diet?’
‘No. So keep quiet and with any luck you’ll be sent to be a slave in the palace.’
‘Luck is my middle name,’ said Rincewind, indistinctly. ‘Mind you, my first name is Bad.’
‘What? But he’s a tax collector! That’s what they’re for!’
‘A firm tax base is the foundation of sound governance, gentlemen. Please trust me.’
‘I understood all of that up to “A firm tax”.’
‘Nevertheless, no useful purpose will be served by killing this hard-working tax gatherer.’
‘He’d be dead. I call that useful.’
Of course the book is very funny, that almost goes without saying. A few quotes:
“They say that a little knowledge is a dangerous thing, but it is not half so bad as a lot of ignorance.”
“She understood babies. You put milk in one end and kept the other end as clean as possible. Adults were even easier, because they did the feeding and cleaning themselves.”
“If a thing’s worth doing, it’s worth doing badly.”
“Granny hesitated. The tree might as well have asked why fish couldn’t be birds.” (the talking tree)
“‘If you can’t learn to ride an elephant, you can at least learn to ride a horse.’
‘What’s an elephant?’
‘A kind of badger,’ said Granny. She hadn’t maintained forest-credibility for forty years by ever admitting ignorance.”
This stuff is all over the place. If you need an excuse to read Pratchett – and you really don’t – he’s worth reading simply because he makes you remember that reading doesn’t have to be ‘boring’ or ‘intellectually taxing’.