“The unavoidable fact about the history of human health is that the innovations that have driven progress are themselves almost always enmeshed in symbiotic relationships with other innovations.”
“Many of the key problems we now face as a species are second-order effects of reduced mortality.”
Climate change wouldn’t be a problem if we were powered by fossil fuels but with 1800 levels of global population
We managed to double life expectancy within a century; additional 20,000 days
1660s haberdasher John Graunt analyzed London’s Bills of Mortality as a hobby; published pamphlet that foretold demography, actuarial sciences, statistics, probability
Graunt’s work and Nancy Howell’s analysis of African hunter-gatherer tribes in 1960s both revealed an enduring median life expectancy of 35 years
“Human beings had spent ten thousand years inventing agriculture, gunpowder, double-entry accounting, perspective in painting—but these undeniable advances in collective human knowledge had failed to move the needle in one critical area. Despite all those accomplishments, we were no better at warding off death.”
Life expectancy of British aristocracy lower than general population from 1500s to early 1700s; access to doctors actually caused more harm given quack remedies (Mad King George III may have been arsenic poisoning)
Age of “heroic medicine”—“full of grand schemes and bold interventions that clearly did more harm than good”
Doctor Thomas McKeown’s “The Modern Rise of Population” and McKeown thesis: people were living longer not because of medical interventions but because of an overall improvement in the standard of living (agriculture)
“Whatever positive effects were caused by genuinely useful knowledge or medicine the doctors had accumulated before [World War II] were canceled out by the lingering delusions of leeches and arsenic, all the ludicrous interventions of heroic medicine.” and unhygienic conditions of hospitals
“The surprisingly long life of heroic medicine, and all its absurdities, should serve as a useful reminder that “Western” medicine—for all of its recent achievements—had a miserable track record for most of its existence.”
Variolation (deliberate exposure to variola minor/smallpox disease) began in Asia around 15-1600s; “a radical break from the methods of heroic medicine”
“In the age of smallpox, childhood was inextricably linked to sudden and catastrophic illness. Being a child was to forever be on the brink of death, and being a parent was to forever be haunted by that imminent threat.”
Smallpox called “the speckled monster” for the pockmarks it left
Mary Montagu a British royal who survived smallpox in early 1770s, then lived in Turkey where inoculation (“engrafting”) had basically eradicated smallpox; inoculated her children and brought practice back to England
“Ideas are like viruses. For an idea to transform a society, the institutions and agents who transmit the idea are in many ways just as critical as the original minds that conceived the idea.”
Lone genius vs. network collaboration
“Many great ideas die out before they can have a wider effect because they lack other key figures in the network: figures that amplify or advocate or circulate or fund the original breakthrough.”
Mary Montagu a connector and amplifier
Jefferson was early adopter of smallpox vaccine, inoculating his extended family and neighbors while President in 1801
Mid-1800s saw rise of anti-vaccination movement with three prongs: late-Victorian homeopathy/spiritualists, those who thought it distracted from fighting unsanitary conditions/miasma, and personal liberty crowd
Mandatory vaccine laws enacted throughout late 1800s; British law had exemption for conscientious objection (first instance of the concept)
“In many ways, mass vaccination was closer to modern breakthroughs like organized labor and universal suffrage: an idea that required social movements and acts of persuasion and new kinds of public institutions to take root.”
International Sanitary Conference started in Paris in 1851; led to International Office of Public Health in 1907 and then WHO in 1945
Last smallpox case was a Bangladeshi girl in 1975
Smallpox eradication was global cooperation even during Cold War (contrast to competition of space race)
WHO spearheaded global eradication program starting in 1966; “Global eradication was as dependent on the invention of an institution like the WHO as it was on the invention of the vaccine itself.”
Smallpox lost ability to survive outside of human bodies, making it uniquely vulnerable to eradication
“Ring vaccination” technique vaccinated people/villages around outbreak area, creating an immunity firewall to snuff out virus
British doctor and statistician William Farr founder or public health statistics throughout Britain and Wales in early 1800s
“The use of data to understand patterns of life and death had been almost exclusively a commercial interest during the eighteenth century, a science developed largely for the mercenary aims of the insurance companies. But Farr and some of his peers saw the potential of vital statistics as a tool for social reform, a means of diagnosing the ills of society and shining light on its inequalities.”
Farr: “Facts, however numerous, do not constitute a science. Like innumerable grains of sand on the sea shore, single facts appear isolated, useless, shapeless; it is only when compared, when arranged in their natural relations, when crystallized by the intellect, that they constitute the eternal truths of science.”
Farr’s 1843 life tables comparing mortality between metropolitan London, industrial Liverpool, and rural Surrey showed Liverpool highest; negative effects of industrialization and population density
London East End cholera epidemic of 1866 turned out to be beginning of end of industrial-age mass mortality; Henry Whitehead (of The Ghost Map) recruited by Farr and investigators to help source the outbreak, the last ever recorded in London
W.E.B. Du Bois first African American to complete PhD at Harvard, in 1890
Du Bois recruited in 1896 by UPenn to study Philadelphia’s rising crime and poverty of black-dominant 7th Ward; resulting book The Philadelphia Negro a seminal work of urban sociology
“As a sociologist, Du Bois was working at the vanguard of his field; as a social epidemiologist, analyzing and explaining the disparity in health outcomes between white and black populations, he was at least a half century ahead of everyone else.”
Few memorials for public health breakthroughs (Broad St. pump and plaque for Du Bois’s work exceptions); difference of lives lost (war memorials) vs. saved
By 1840s infants and children were more than half of all deaths in New York City
Zachary Taylor died after drinking contaminated milk
With NYC farmland disappearing through 19th century, farmers turned to used wheat from distilleries (slop, mash, swill) to feed cows; produced “unappetizing, blue-colored milk” that could at least be delivered fresh
Increased demand for milk spurred in part by more women joining workforce and breastfeeding less beyond first few months
Reduced costs and horrific cow conditions produced copious cheap milk, branded as “Pure Country Milk” despite being “adulterated with chalk, flour, and eggs”
“We remember the casualty rates of military conflicts from the period—the Civil War most prominently—because those events concentrated the killing in episodes of sudden violence. But the steady, incremental losses of children dying one by one in the slums of the industrial city do not stay fixed in our historical memory.”
Mid-19th century France, Louis Pasteur initially focused on beer and wine, detecting microbes that caused spoiling; experiments in 1865 showed heating to 130 degrees prevented it
Pasteurization didn’t become standard practice in milk industry until 1915, costing millions of lives; “the lag happened because progress is not merely the result of scientific discovery. It also requires other forces: crusading journalism, activism, politics. Science alone cannot improve the world. You also need struggle.”
Swill milk took decades to end given influence of milk industry (muckraking investigations plus persistent promotion and political cartoons brought legislation by mid-1860s); swill only part of larger problem
In early 1880s Pasteur rival Robert Koch identified tuberculosis and cholera bacteria thanks to advances in microscope lenses
By mid 1800s mechanical refrigeration allowed for advances in public health via perishable foods and vaccines
Could test milk for tuberculosis and certify sanitary conditions, but pasteurization made milk less flavorful
Chicago became first American city to require pasteurization in 1909; New York followed in 1914 and elsewhere by early 1920s
Chlorine is poisonous except in very small doses for killing bacteria; doctor John Leal secretly added it to public reservoirs in Jersey City
From 1900-1930 U.S. infant mortality dropped by 62 percent
Pasteurization pioneer Nathan Straus: “I have always only considered how best and quickest to enlighten the world in a practical manner. To attain this I sought the help of the press, and it is due to its ever ready cooperation that my work and its results have been made known and broadcast.”
Cholera treatment “oral rehydration therapy” (ORT) was simple combination of water, salt, and sugar that could be administered by amateurs en masse; developed in third-world field and extraordinarily effective but delayed acceptance due to Western bias against simplistic/inferior treatments
Milk pasteurization and ORT for cholera: breakthroughs emerged from crisis, inventive publicity strategies, slow mainstream adoption
Some breakthroughs behind their time: ORT, typewriters bicycles, the wheel
Beginning of 1900s had electricity, radio, cusp of flight, but still bogus medicinal cures
“Added all together—the lives extended versus the lives shortened—the medical profession barely broke even.”
“Before the outbreak of World War II, the overwhelming majority of medicine on the market was useless, if it wasn’t actively harmful.”; pharmaceutical industry almost entirely unregulated
Placebo effect and immune systems doing their job were two factors that kept ineffective drugs on market
1962 Kefauver-Harris Drugs Amendments forced drug companies to prove efficacy not just safety; wouldn’t have been possible before then without advent of random controlled double-blind trials (RCT)
RCT “emerged as a confluence of several distinct intellectual tributaries” as far back as 1740s scurvy study by James Lind; statistician R.A. Fisher’s randomization studies in 1930s influenced epidemiologist/statistician Austin Hill’s 1948 study of experimental antibiotic tuberculosis cure (first to use RCT)
“It is likely not a coincidence that the first true miracle drugs and the first true RCTs were developed within a few years of one another.”
Hill also co-author with Richard Doll of 1940s study linking smoking with lung cancer; 1950 paper initially dismissed because medical establishment assumption at the time was bacteria-focused given recent discoveries
Hill & Doll did another long-term study with doctors to predict lung cancer; so successful they published early in 1954; 10 years later Surgeon General report
“The partnership between RCT design and government regulation—the experiments revealing threats that governments then outlaw or restrict—led to a quiet but profound revolution in the health of millions of people around the world. … It was a revolution jump-started not by spectacular technological breakthroughs or protestors in the streets but instead by different kinds of agents: artful experiment designers, government regulators.”
Scottish scientist Alexander Fleming accidentally discovered antibiotics in 1928 after leaving a Petri dish of staphylococcus bacterium exposed, with subsequent mold inhibiting growth of bacteria; penicillin
“The triumph of penicillin is actually one of the great stories of international multidisciplinary collaboration. It is a story of a network, not an eccentric genius.”
“For penicillin to graduate from a brilliant accident to a true miracle drug, three things needed to happen: someone had to determine whether it actually worked as a medicine; someone had to figure out how to produce it at scale. And then a market had to develop to support that large-scale production.” — World War II
“Vaccines had fought off pathogens by triggering our immune systems. Public health had done it by building external immune systems. Penicillin was a new trick: manufacturing a compound that had its own pathogen-killing powers.”
In 1941 Dept. of Agriculture’s lab in Peoria began large-scale search for other strains of penicillin: in soil for natural and abundant bacteria/antibacteria, and moldy fruit (one cantaloupe begat nearly all of today’s penicillin)
U.S. soon mass-producing stable penicillin with help from Pfizer/Merck; distributed to military hospitals and with GIs in ETO
Nazis unable to produce penicillin at scale, already had (dangerous and less effective) sulfonamides, brain drain of scientists
After Valkyrie bombing shrapnel, Hitler’s doctor treated him with penicillin confiscated from captured American soldiers, likely saving his life
At turn of 20th century tuberculosis was third leading cause of death in U.S.; by 1950s it was automobiles
Safety Appliance Act of 1893 forced railroads to install power brakes and automatic couplers, cutting mortality rates of rail workers in half; first law primarily focused on workplace safety
“Measured over the course of the 20th century, only the machine gun rivals the automobile as a mass killer.”
Car manufacturers argued driving was fundamentally dangerous, and were conceptually limited about making modifications to cars themselves; no seatbelts, rearview mirrors, head rests, etc
Former pilot Hugh DeHaven injured in crash and through egg drops researched impact of collisions on human body and effectiveness of right “packaging” to avoid death
Col. John Stapp created linear decelerator (“rocket sled”) to demonstrate effect of deceleration from high speeds; proved it wasn’t fatal but safety didn’t sell cars
Volvo engineer tinkered with seat belt design in 1950s, eventually awarded patent for now-standard three-point system but didn’t enforce patent
Ralph Nader’s 1965 book Unsafe At Any Speed inspired GM to hire investigator for dirt on him
“Real change often requires a first step of convincing people that the existing problem is not inevitable; and devising a solution requires a diverse network of talents, building on one another’s work.”
Slow, incremental decrease in automobile deaths in last few decades
“New scientific breakthroughs changed the world not just through the new functionalities they introduced, but also in the ways they expanded the adjacent possible: through the lateral effects they created, the new ideas that suddenly became thinkable because of them.”
Global death in 1920s from famine exceeded war fatalities; only flu did more damage
Irish potato famine of 1840s, Little Ice Age in 1300s Europe, Mayan civilization collapse after drought AD 1020-1100
McKeown’s thesis that we started living longer in 1800s because of better farming and feeding rather than medicine
Over 1900s famine deaths per capita decreased from 82/100K to 0.5
Nitrates used for soil growth became highly prized when discovered in bat guano; huge deposit discovered off Peru coast in 1840
Guano from caves in US was the Confederacy’s primary resource for gunpowder
Nitrogen was as useful to farmers as bomb makers; artificial ammonia nitrate developed by Germans in World War I led to invention of artificial fertilizer
Roughly 2 billion people on earth in early 1900 and 7.7 billion now; despite explosive growth starvation and malnutrition have plummeted
Concept of factory farming started on 1920s Delaware family farm with Cecile Steele, who accidentally received far too many chickens but decided to scale up
“Each time we take that antibiotic that kills off a lingering infection or stop short of a car accident because our antilock brakes kick in, we go on with our lives, barely even registering what has just happened. But in an alternate time line without those protections, we might well have ceased to exist.”
Advances grouped by lives saved:
- Billions: artificial fertilizer, toilets/sewers, vaccines
- Hundreds of millions: antibiotics, Bifurcated needles, Blood transfusions, Chlorination, Pasteurization
- Millions: AIDS cocktail, Anesthesia, Angioplasty, Antimalarial drugs, CPR, Insulin, Kidney Dialysis, Oral Rehydration Therapy, radiology, refrigeration, seat belts
Few of the “pantheon” advances originated in private sector, though most of them relied on private sector production and distribution
Less tangible innovations: ways of seeing (microscopes and cholera map); ways of counting (urban density/mortality, epidemiology); ways of testing (randomized controlled trials); ways of connecting (penicillin development before WWII); ways of discovering (penicillin); ways of amplifying (evangelists for vaccines and pasteurization)
Astonishing speed of identifying, sequencing Covid virus and producing vaccine; HIV took 3 years just to identify
Cancer treatment evolved from surgical removal to “bombing” of chemotherapy and radiation, and now immunotherapy teaching immune system to take cancer cells offline
After humanity’s transition to agriculture, mortality rates skyrocketed thanks to malnutrition, increased infectious disease, and backbreaking labor compared to hunter-gatherers
“Extending our lives gave us the climate crisis. Perhaps the climate crisis will ultimately trigger a reversion to the mean.”