Light Summer Reading
In his latest book, Inferno, author Dan Brown explores a world where past symbols and artifacts from Dante Alighieri’s Italy, and his famous work The Divine Comedy, become the vehicle to unravel a diabolical and deadly plot of a modern day bio-terrorist. I originally grabbed this book because we were coming to the close of summer and I just finished working on a series of articles about the current issues of our healthcare system that will be appearing later this fall. Frankly, I was looking for a diversion from the complicated world of healthcare reform and Obamacare. I wanted a respite, a brief mindless romp in Dan Brown’s always entertaining world. Having read much of his prior work, I was confident that Mr. Brown would not let me down.
I found this work characteristically suspenseful, interesting, thought provoking and fun to read till I got to the following section which, in the story, lays the groundwork for the epic conflict between the antagonist, Bertrand Zobrist , a world renowned biochemist and leading geneticist and the protagonist, Elizabeth Sinskey, M.D., the head of the World Health Organization. Once again Robert Langdon, Harvard Iconographer plays the supporting but critical role as co-protagonist in deciphering the clues and keys to the mystery.
“I’m a biologist. I save lives … not souls.” says Dr. Sinskey.
“Well, I can assure you that saving lives will become increasingly difficult in the coming years. Overpopulation breed far more that spiritual discontent. There is a passage in Machiavelli—”
“Yes,” she interrupted, reciting her recollection of the famous quote. “’When every province of the world so teems with inhabitants that they can neither subsist where they are nor remove themselves elsewhere … the world will purge itself.’ She stared at him. ‘All of us at the WHO are familiar with that quotation.”
“Good, then you know that Machiavelli went on to talk about plagues as the world’s natural way of self-purging.”
“Yes, and as I mentioned in my talk, we are well aware of the direct correlation between population density and the likelihood of wide-scale epidemics, but we are constantly devising new detection and treatment methods. The WHO remains confident that we can prevent future pandemics.”
“That’s a pity.”
Elizabeth stared in disbelief. “I beg your pardon?!”
“Dr. Sinskey,“ the man said with a strange laugh, “you talk about controlling epidemics as if it’s a good thing.”
“She gapped up at the man in mute disbelief.
“There you have it,” the lanky man declared, sounding like an attorney resting his case. “Here I stand with the head of the World Health Organization—the best that the WHO has to offer. A terrifying thought if you consider it. I have shown you the image of impending misery.” He refreshed the screen, again displaying the image of the bodies. “I have reminded you of the awesome power of unchecked population growth.” He pointed to his small stack of paper. “I have enlightened you about the fact that we are on the brink of a spiritual collapse.” He paused and turned directly toward her. “And your response? Free condoms in Africa.” The man gave a derisive sneer. “This is like swinging a flyswatter at an incoming asteroid. The time bomb is no longer ticking. It has already gone off, and without drastic measures, exponential mathematics will become your new God … and ‘He’ is a vengeful God. He will bring to you Dante’s vision of hell right outside on Park Avenue … huddled masses wallowing in their own excrement. A global culling orchestrated by Nature herself.”
“Is that so?” Elizabeth snapped. “So tell me, in your visions of a sustainable future, what is the ideal population of the earth? What is the magic number at which humankind can cope to sustain itself indefinitely … and in relative comfort?”
The tall man smiled, clearly appreciating the question. “Any environmental biologist or statistician will tell you that humankind’s best chance for long term survival occurs with a global population of around four billion.”
“Four billion?” Elizabeth fired back. “We’re at seven billion now, so it’s a little late for that.”
The tall man’s green eyes flashed fire. “Is it?”
Not light summer reading after all!
The last question posed by the antagonist, Bertrand Zobrist, moved this light summer reading into my more day to day realm with a vengeance. While in the story, Zobrist embraces the writings of Robert Malthus, a famous 18th century economist and demographer as justification that society’s successes in effect will lead to its own downfall, during my research on The History and Evolution of Healthcare in America, I saw similar trend lines due to the current methods and practices we have in healthcare focused on the persistent and increasing drive for unlimited extension of life spans. It is now quite obvious that we are becoming weaker as a species, while at the same time the pathogens that pray on us are becoming quite a bit stronger. Infertility rates in our population are increasing. Deadly super-resistant strains of bacteria like Methicillin Resistant Staphylococcus Aureus (MRSA), Streptococcus Fasciitis (Flesh Eating Bacteria), E.Coli, Carbapenem-Resistant Enterobacteriaceae (CRE), Klebsiella Pneumonia. Pseudomonas Aeruginosa, Clostridium Difficile, Salmonella, Mycobacterium Tuberculosis, Neisseria Gonorrhoeae and many others have evolved over the past seventy years and are now testing the limits of our antibiotic defenses. Any recent read of articles in the paper about people having multiple limbs amputated, spending months in the hospital post-surgery recovering from hospital acquired infections and of those who have died due to highly resistant new infections show that these microbes are often winning the battles. Further, it is also quite clear that the cause of both trends are the mechanisms—bio-chemical warfare; antibiotics, antibacterial creams, fertility medications and other drugs—we use to treat disease, stay alive longer and reproduce.
So I found it interesting that Zobrist chose his prime advisory as Dr. Elizabeth Sinskey, the head of the WHO. He chose her, and the WHO, because he came to the conclusion that it was the artificial methods of modern medicine that has so skewed the population’s mathematics that in order to offset its “negative” effects on the species due to unlimited growth, he would have to effect his diabolical plan to ultimately save mankind. I also realized that many, if not most, who read this book will simply believe it is completely a work of fantasy. Most will believe this is neither a risk nor is it possible. Yet, it is likely both possible and probable. I also wonder if we are already seeing the kinds of population controls as predicted by Robert Malthus’s theory come into effect.
Mathematics of Thomas Robert Malthus
Wikipedia notes, “The Reverend (Thomas) Robert Malthus FRS (13 February 1766 – 23 December 1834) was a British cleric and scholar, influential in the fields of political economy and demography. Malthus himself used only his middle name Robert.
Malthus became widely known for his theories about change in population. His An Essay on the Principle of Population observed that sooner or later population will be checked by famine and disease. He wrote in opposition to the popular view in 18th-century Europe that saw society as improving and in principle as perfectible. He thought that the dangers of population growth precluded progress towards a utopian society: “The power of population is indefinitely greater than the power in the earth to produce subsistence for man”. As a cleric, Malthus saw this situation as divinely imposed to teach virtuous behavior. Malthus wrote:
That the increase of population is necessarily limited by the means of subsistence,
That population does invariably increase when the means of subsistence increase, and,
That the superior power of population is repressed, and the actual population kept equal to the means of subsistence, by misery and vice.
Malthus placed the longer-term stability of the economy above short-term expediency. He criticized the Poor Laws, and (alone among important contemporary economists) supported the Corn Laws, which introduced a system of taxes on British imports of wheat. His views became influential, and controversial, across economic, political, social and scientific thought. Pioneers of evolutionary biology read him, notably Charles Darwin and Alfred Russel Wallace. He remains a much-debated writer.
Malthus argued in his Essay (1798) that population growth generally expanded in times and in regions of plenty until the size of the population relative to the primary resources caused distress:
“Yet in all societies, even those that are most vicious, the tendency to a virtuous attachment is so strong that there is a constant effort towards an increase of population. This constant effort as constantly tends to subject the lower classes of the society to distress and to prevent any great permanent amelioration of their condition”. —Malthus T.R. 1798. An Essay on the Principle of Population. Chapter II, p 18 in Oxford World’s Classics reprint.
Malthus argued that two types of checks hold population within resource limits: positive checks, which raise the death rate; and preventive ones, which lower the birth rate. The positive checks include hunger, disease and war; the preventive checks, abortion, birth control, prostitution, postponement of marriage, homosexuality and celibacy. In later editions of his essay, Malthus clarified his view that if society relied on human misery to limit population growth, then sources of misery (e.g., hunger, disease, and war) would inevitably afflict society, as would volatile economic cycles. On the other hand, “preventive checks” to population that limited birthrates, such as later marriages, could ensure a higher standard of living for all, while also increasing economic stability. Regarding possibilities for freeing man from these limits, Malthus argued against a variety of imaginable solutions, such as the notion that agricultural improvements could expand without limit.
Of the relationship between population and economics, Malthus wrote that when the population of laborers grows faster than the production of food, real wages fall because the growing population causes the cost of living (i.e., the cost of food) to go up. Difficulties of raising a family eventually reduce the rate of population growth, until the falling population again leads to higher real wages.”
Clearly, the esteemed Reverend Malthus was probably the life at parties! He was controversial during his life and many have debated his work for centuries. Still, many questions remain and empirical observations during our own lifespans should also raise many questions. We have been most recently focused on the popular question as to mankind’s direct impact on global warming. This is may be very relevant and highly important but it is by no means likely to be the most relevant or important factor of our potential demise. We are spending a great deal of time debating whether or not a significant part of global warming is due to our activities. But, it is very likely that while our activities are having some measurable effect, this could be, in the long run, something over which we have the least amount of control!
Is this possible?
In Inferno, Mr. Brown includes a chart of a number of activities and trends. He attributed the chart in the story to WHO. I can’t find any specific chart at the WHO website , or on the internet, as displayed but I can find a number of studies, by WHO and other organizations, that show similar trend-lines for the data compiled in the chart. Of course the message is clear and startling. In the story, Zobrist, points out that demand for clean water, global surface temperatures, ozone depletion, consumption of oceans resources, species extinctions, CO2 concentration, deforestation, and global sea levels have been on the rise for over the last century and now are accelerating at terrifying rates. He uses this data to bolster his argument as to why, as he says later in the story,
“Dante’s hell is not fiction … its prophecy! Wretched misery. Torturous woe. This is the landscape of tomorrow. Mankind, if unchecked, functions like a plague, a cancer … our numbers intensifying with each successive generation until the earthly comforts that once nourished our virtue and brotherhood dwindled to nothing … unveiling the monsters within us … fighting to the death to feed our young.”
Another character in the story, a brilliant physician, scientist and mathematician named Dr. Sienna Brooks, tells Robert Langdon,
“Robert, look, I’m not saying Zobrist is correct that a plague that kills half the world’s people is the answer to overpopulation. Nor am I saying we should stop curing the sick. What I am saying is that our current path is a pretty simple formula for destruction. Population growth is an exponential progression occurring within a system of finite space and limited resources. The end will arrive abruptly. Our experience will not be that of slowly running out of gas … it will be more like driving off a cliff.”
Zobrist believes that the path to our own destruction due to the efforts to cure the sick, to allow more infertile to have children and efforts to stop the rise of population thinning epidemics like the plague of old have already pushed the world beyond the tipping point and only some drastic action will reset our destiny. This may seem exaggerated but there is a lot of reality buried in this work of fiction.
Possible and likely
Having been focused on the issues of population dynamics and more particularly the role of the current system, protocols, practices and therapies in the continual rising cost of care, there may be much more reality here than we want to admit. Driving much of our increases in cost of healthcare are the following factors:
- Our continual drive to live longer is increasing the average life span – currently between seventy-five and eighty-three years old depending on the study
- Increasing levels of infertility, driving increased use of therapies and artificial means to artificially facilitate conception is expanding the incidence of infertility
- Widespread use of antibiotics and other therapies are increasing our susceptibility to infections and diseases due to increasing sensitivity to infection
- Continued use of stronger and stronger therapies to treat pathogenic diseases have created stronger and stronger generations of pathogens to infect us
- The expansion of our average life span has moved our lives into a framework where we are more susceptible to diseases and much less able to fight them off, easily recover and strengthen our immune system. This is increasing our dependence on technologies and artificial means to maintain quality of life in our later years, drastically increasing the cost of survival and cost to maintain the desired quality of life in these years.
- New medications now come with increasingly sever and more prevalent side effects. The low hanging fruit of drug discovery has been picked. Now we have more potent and more deadly drugs with significant and severe side effects. Increasing the cost of treatment under these new medications. It will not be long until we will need full genotype and phenotype profiles for a pharmacists to dispense a therapeutic for fear of adverse reaction. Again increasing costs often with less efficacious treatments.
- Recent gains in technology and medical advances have led to the perception that we now have cures for almost everything. This has created a significant reality gap between expected outcomes and what can be delivered. As such, our demands for unrealistic outcomes have fostered expectations of near limitless costs of treatment.
Overall, what this means is that therapies will become less effective, and more expensive as we become weaker as a species, subject to a wider array of deadly pathogens, and less able to reproduce without expensive technology and interventions. This is one of the big reasons healthcare costs are rising. Further exacerbating the problem is that during the same period that the earlier wonder drugs and technologies were coming on the market, we began to expect much more in terms of care. We have had a drastic cultural shift from simply hoping for survival to expecting an uninterrupted and near infinitely sustainable quality of life.
At the same time we have exponentially compounded these effects by becoming more conditioned to expect to get more, and more, stuff that we desire but, that is not necessarily geared for our survival. We now expect to have multiple telephones, multiple televisions, multiple automobiles, fine foods, expensive drink, sweets, vacations, drugs, entertainments, and many other non-essential items our grandparents and great-grandparents would have scoffed at. We now have convinced ourselves that these prior luxuries are now not luxuries at all but are in fact integral to our survival. We believe this now so strongly that we have demanded government programs that all but guarantee the provision of many of these items to people that can’t earn enough to pay for them themselves—like programs to provide free cell phones. This is not to start an argument as to why someone simply must have a phone or, why it is an unfair society that allows for one person to be able to afford the phone and another not! This is to begin a dialog about why these superfluous arguments may be diverting our critical attention from the difference between paying for free cell phones of paying for our own survival.
In the end, the premise of Mr. Brown’s Inferno, is not only possible it is likely already happening. Many recent events are already showing us strong indicators that such mathematical problems are here at our doorstep.
The needed difficult discussion
The healthcare data today is overwhelming that we have reached a tipping point in our pursuit of increased life span. Today, we already see that the cost to pay for care in our later years is quickly predatory on most of our earlier years of life and increasingly predatory on all the succeeding generations that will follow us. In a nut shell, we are now in a position that if we expect to pay for the technologies, therapies and medications we will need to survive in our last few years, we will have to save most of our money throughout our earlier years. Given the current numbers as to our health expenses in the last years, we really need to work in those earlier years not to save for retirement, or to save to put children through college, or to provide a basic inheritance to our children or grandchildren. We need to work all of those earlier years just to save enough money to pay for the goods and services we will need to survive the onslaught of diseases and illnesses we will face if we want to live that last five or ten years.
The numbers in today’s world work this way. On average we are spending about $8,233 per year of our lives on healthcare related expenses. We are living, we will use the more conservative estimates here, to an average of seventy-five years old. We will spend about 80% of all the money we will spend in our lifetimes on healthcare related items just in the last five years of our lives. So using these governmental statistics, validated by a number of other organizations, we will spend on average $98,796.00 from our birth to the age of seventy in healthcare services, we will spend an additional $493,980 from the age of seventy to seventy-five, for a total average lifetime healthcare expenditure of $617,475. No matter how you look at this from an individual perspective, it is a staggering number being spent in order to gain five more years! Who among us really wants to do a fiscal calculation on time with our Grandmother Mable, or Grandfather George? Do we really want to have a discussion about how much we would be left with if mom or dad died at seventy? How our kid’s college could be paid for if? Of course not! None of us want to have this discussion. Instead, as these intrinsic pressures have begun to build, we have developed societal methods to offset these rising expenses and forestall such discussions.
There is little disagreement that we all want good healthcare, even though we can’t agree on what healthcare is let alone what good healthcare is composed of. There is also no disagreement that we want a safety net to provide care for the helpless and the most fragile among us. There is also no disagreement that we want to filter out the clueless and the worthless (fraudsters) but, there is a great deal of discussion as to where we should draw the line for covering the helpless. There is a lot of debate about what we expect from care. Many of our expectations are unattainable, and driven by pervasive and popular myths of what healthcare and modern medicine can deliver. In the end, these are to a great extent superfluous. They becomes irrelevant to the more important determination of where basic ‘Life Care’ (that which we need for survival) stops and ‘Quality of Life Care’ (that which we want) begins. If the totality of the mathematics are so tilted by the equation of end of life costs, another key question soon will become who should get free coverage and who shouldn’t. How much would we save in provision of care if we made a determination that all safety nets have a hard stop point based on societal value as opposed to personal and family values? Do we make determinations as to the extent of care that is provided in certain age ranges? If we do, then how do we establish the limits?
These are horrible, heart wrenching and personally scary questions to consider! None of us want to contemplate saving money with not keeping a loved one alive longer. Yet, as Robert Malthus found out, the discussion gets know easier when you begin to contemplate the societal benefits and costs. If the individual calculations are staggering, the societal calculations are mind altering. We have about 37 million Americans over the age of seventy-five. In their last five years these citizens will cost America $7.3 trillion, $ 1.4 trillion per year, in healthcare to keep them alive. I say America, because regardless of whether the money is spent by the government or by the individual it will come from somewhere in America, either through years of savings by the individual, years of paying insurance premiums, or years of taxes. And ultimately, as we keep pushing the trend line of average life span longer, and longer, and a larger and larger part of the population become elderly, the percent spent in the last few years will continue to rise. In a way, it is Robert Malthus’ theory in practice and Bertrand Zobrist’s worst nightmare. It portends an outcome that even the famed iconographer Robert Langdon can’t unravel.
So how did the aforementioned antagonist Bertrand Zobrist plan to rebalance the societal, biological and economic situation? Well you will need to read the book to find out. Suffice to say it was a horrific, diabolical, and deliciously evil. It was also, at least in the context of the story, a potentially effective action. Additionally, in light of the other real-world complications, it was not a viable solution. You see, it is not simply the rising population that is affecting us. It is the entirety of how we are dealing with the myriad issues, biological, medical, and economic in the first place. The fixes will take many, increasingly difficult, discussions. Discussions that we still do not seem inclined to begin.
Zobrist’s solution, while horrific, was relatively simple and effective. So what did you expect me to say; that the action that was described in the story was immoral, and unethical? Unethical and immoral it may be but, it is in the dichotomy of this completely immoral and unethical set of actions, by our current mores, and the pragmatic discussions of the solutions we may need in order to change the Malthusian prediction that we will likely begin to find the answers we will need. All this in the context of a discussion we just do not want to have!
(Thomas W. Loker is a contributor to California Political Review.)