Thursday, September 26, 2013

"Why Are You Not Dead Yet?"

The most important difference between the world today and 150 years ago isn’t airplane flight or nuclear weapons or the Internet. It’s lifespan. We used to live 35 or 40 years on average in the United States, but now we live almost 80. We used to get one life. Now we get two.

You may well be living your second life already. Have you ever had some health problem that could have killed you if you’d been born in an earlier era? Leave aside for a minute the probabilistic ways you would have died in the past—the smallpox that didn’t kill you because it was eradicated by a massive global vaccine drive, the cholera you never contracted because you drink filtered and chemically treated water. Did some specific medical treatment save your life? It’s a fun conversation starter: Why are you not dead yet?It turns out almost everybody has a story, but we rarely hear them; life-saving treatments have become routine. I asked around, and here is a small sample of what would have killed my friends and acquaintances:
  • Adrian’s lung spontaneously collapsed when he was 18.
  • Becky had an ectopic pregnancy that caused massive internal bleeding.
  • Carl had St. Anthony’s Fire, a strep infection of the skin that killed John Stuart Mill.*
  • Dahlia would have died delivering a child (twice) or later of a ruptured gall bladder.
  • David had an aortic valve replaced.
  • Hanna acquired Type 1 diabetes during a pregnancy and would die without insulin.
  • Julia had a burst appendix at age 14.
  • Katherine was diagnosed with pernicious anemia in her 20s. She treats it with supplements of vitamin B-12, but in the past she would have withered away.
  • Laura (that’s me) had scarlet fever when she was 2, which was once a leading cause of death among children but is now easily treatable with antibiotics.
  • Mitch was bitten by a cat (filthy animals) and had to have emergency surgery and a month of antibiotics or he would have died of cat scratch fever.

After a while, these not-dead-yet stories start to sound sort of absurd, like a giddy, hooray-for-modernity response to The Gashleycrumb Tinies. Edward Gorey’s delightfully dark poem is an alphabetical list of children (fictional!) who died gruesome deaths: “A is for Amy who fell down the stairs/ B is for Basil assaulted by bears.” Here’s how modern science, medicine, and public health would amend it:

M is for Maud who was swept out to sea … then brought back to shore by a lifeguard and resuscitated by emergency medical technicians.

O is for Olive run through with an awl … but saved during a four-hour emergency surgery to repair her collapsed lung.

S is for Susan, who perished of fits … or who would have, anyway, if her epilepsy hadn’t been diagnosed promptly and treated with powerful anticonvulsant drugs.

This, to me, may be the single biggest change in the human condition ever - and to my mind explains, in one go, why the churches have emptied out.   (The increase is not actually due, BTW, to recent advances in medicine as I had thought; the article says that the change began during the last century, and is credited to public health initiatives:  clean water, sewage treatment, washing hands, etc.  Also to improved farming methods; we're no longer subject to starvation.  Of course, vaccines and medical treatment have had a huge effect, too - particularly I think on worldviews; my mother - just one generation back - was deathly afraid of illness, particularly polio, for some reason.)

To understand why people live so long today, it helps to start with how people died in the past. (To take a step back in time, play our interactive game.) People died young, and they died painfully of consumption (tuberculosis), quinsy (tonsillitis), fever, childbirth, and worms. There’s nothing like looking back at the history of death and dying in the United States to dispel any romantic notions you may have that people used to live in harmony with the land or be more in touch with their bodies. Life was miserable—full of contagious disease, spoiled food, malnutrition, exposure, and injuries.

But disease was the worst. The vast majority of deaths before the mid-20th century were caused by microbes—bacteria, amoebas, protozoans, or viruses that ruled the Earth and to a lesser extent still do. It’s not always clear which microbes get the credit for which kills. Bills of mortality (lists of deaths by causes) were kept in London starting in the 1600s and in certain North American cities and parishes starting in the 1700s. At the time, people thought fevers were spread by miasmas (bad air) and the treatment of choice for pretty much everything was blood-letting. So we don’t necessarily know what caused “inflammatory fever” or what it meant to die of “dropsy” (swelling), or whether ague referred  to typhoid fever, malaria, or some other disease. Interpreting these records has become a fascinating sub-field of history. But overall, death was mysterious, capricious, and ever-present.


One of the best tours of how people died in the past is The Deadly Truth: A History of Disease in America by Gerald Grob. It’s a great antidote to all the heroic pioneer narratives you learned in elementary school history class, and it makes the Little House on the Prairie books seem delusional in retrospect. Pioneers traveling west in wagon trains had barely enough food, and much of it spoiled; their water came from stagnant, larvae-infested ponds. They died in droves of dysentery. Did you ever play with Lincoln logs or dream about living in a log cabin? What a fun fort for grown-ups, right? Wrong. The poorly sealed, damp, unventilated houses were teeming with mosquitoes and vermin. Because of settlement patterns along waterways and the way people cleared the land, some of the most notorious places for malaria in the mid-1800s were Ohio and Michigan. Everybody in the Midwest had the ague!

* * *

How did we go from the miseries of the past to our current expectation of long and healthy lives? “Most people credit medical advances,” says David Jones, a medical historian at Harvard—“but most historians would not.” One problem is the timing. Most of the effective medical treatments we recognize as saving our lives today have been available only since World War II: antibiotics, chemotherapy, drugs to treat high blood pressure. But the steepest increase in life expectancy occurred from the late 1800s to the mid-1900s. Even some dramatically successful medical treatments such as insulin for diabetics have kept individual people alive—send in those #NotDeadYet stories!—but haven’t necessarily had a population-level impact on average lifespan. We’ll examine the second half of the 20th century in a later story, but for now let’s look at the bigger early drivers of the doubled lifespan.

The credit largely goes to a wide range of public health advances, broadly defined, some of which were explicitly aimed at preventing disease, others of which did so only incidentally. “There was a whole suite of things that occurred simultaneously,” says S. Jay Olshansky, a longevity researcher at the University of Illinois, Chicago. Mathematically, the interventions that saved infants and children from dying of communicable disease had the greatest impact on lifespan. (During a particularly awful plague in Europe, James Riley points out in Rising Life Expectancy: A Global History, the average life expectancy could temporarily drop by five years.) And until the early 20th century, the most common age of death was in infancy.

Clean water may be the biggest lifesaver in history. Some historians attribute one-half of the overall reduction in mortality, two-thirds of the reduction in child mortality, and three-fourths of the reduction in infant mortality to clean water. In 1854, John Snow traced a cholera outbreak in London to a water pump next to a leaky sewer, and some of the big public works projects of the late 1900s involved separating clean water from dirty. Cities ran water through sand and gravel to physically trap filth, and when that didn’t work (germs are awfully small) they started chlorinating water.

More at the link.  More later as to how this ties in with "The Trouble With Anglicanism" and "Why prooftexting?"

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