I always love bringing up [Ignaz Semmelweiss](https://wikipedia.org/wiki/Ignaz_Semmelweis), the Hungarian physician who advocated for hand washing before germ theory was established, after observing that pregnant mothers were more likely to become infected when they were handled by doctors than by midwives. His fastidiousness made him unpopular though and he was ridiculed as a stickler by his fellow staff. When he refused to drop this theory, his colleagues convinced his wife to commit him to a mental hospital, where he died due to infection from an unsanitary operation.
If by crazy you mean steadfastly clinging to the status quo due to human behavior at scale still being programmed by our herd mentality, then yes, everyone else is crazy. The only hope I derive from it is that there's a chance we'll overcome that nature at some point. But I'm not that optimistic about our chances.
> he died due to infection from an unsanitary operation.
Actually, he was beaten (per Wikipedia article):
"He was severely beaten by several guards, secured in a straitjacket, and confined to a darkened cell." "He died after two weeks, on August 13, 1865, aged 47, from a gangrenous wound, due to an infection on his right hand which might have been caused by the struggle. The autopsy gave the cause of death as pyemia—blood poisoning.[64]"
Prevention vs treatment, indeed! I anticipate that as antibiotics become less effective that table manners and food handling hygiene will have a revival. For example we’ll go back to proper butter knives rather than everyone using their bread knife in the communal butter dish.
Related: First bacteriophage therapies are entering human trials and gaining steam.
Antibiotics will likely become obsolete when you can target bacteria without the bystander side effects they have on our cells. They are the perfect antibacterial smart weapon really.
IF you can identify your specific bacterium and the phage that kills it before the disease kills you.
Antibiotics will continue to be effective precisely because they are broad spectrum. A doctor can hit you with an antibiotic before they know exactly what you have.
I am always happy to see new tools in medicine. However, I suspect phages are most going to be used initially in persistent, chronic, antibiotic resistant infections where everything else has failed.
You are absolutely right, I failed to note that the increased specificity means you lose the broad spectrum effect.
I still think in the cases you describe that they could stand to replace e.g. Vancomycin - BEFORE that fails. The side effect profile for that drug is horrendous: GI bleed, neuro/sensory damage, liver damage, retinal damage etc..
It seems like a blend of phages with slightly varied activity could also reproduce the broad spectrum effect, and CRISPR is going to make that pretty easy I think.
One approach might be broad spectrum antibiotics when urgent and specific bacteria undetermined. In parallel, cultures to isolate the problem, then apply the specific phage to finish the job. Seems like this would prevent or at least hugely reduce antibiotic resistance from increasing.
> Related: First bacteriophage therapies are entering human trials and gaining steam.
These may be the first in the USA. They were mainline therapy for certain indications in the USSR since the 1930s are are still in use in the former USSR today.
Sanitation is good, but too much sanitation is not so good. We're only just beginning to understand our relationship with bacteria, virii and micro-organisms. While sanitation was a great boon to reducing deadly pathogens, we're now in the process of swinging the pendulum too far, using antibacterial products that should really only be used in hospitals, keeping children out of the dirt (with growing indications that this leads to allergies), and generally living in fear of anything not institutional-clean. Our immune systems are beginning to atrophy from lack of "exercise".
Have you ever wondered why lovers touch their lips together, effectively sharing the bacterial brew in their mouths with another? I can guarantee that such evolved behavior is not simply coincidental.
I prefer this much intimate/disgusting/sexier explanation:
"Kissing in humans is postulated to have evolved from the direct mouth-to-mouth regurgitation of food (kiss-feeding) from parent to offspring or male to female (courtship feeding) and has been observed in numerous mammals.[59] The similarity in the methods between kiss-feeding and deep human kisses (e.g. French kiss) are quite pronounced; in the former, the tongue is used to push food from the mouth of the mother to the child with the child receiving both the mother's food and tongue in sucking movements, and the latter is the same but forgoes the premasticated food. In fact, through observations across various species and cultures, it can be confirmed that the act of kissing and premastication has most likely evolved from the similar relationship-based feeding behaviours."
A fantastic graphical representation of this is "The Conquest of Pestilence in New York City", produced by the Department of Health & Mental Hygine, showing progress from 1800 to 2002:
This tracks mortality (rather than life expectency), but shows clearly the tremendous progress made from 1850, with a peak mortality rate approaching 50 deaths per thousand peak (from a baseline of ~30 - 40 per mille) to about 12/mm in 1920, and the present rate of about 6/mm.
From 1950-1970, and for a briefer period in the 1980s, progress was reversed with mortality increasing. There's actually been an impressive (though small realtive to 19th century improvements) reduction since 1990.
Looking at that chart, realise that virtually all the improvement through about 1950 precedes most of what we consider to be modern medicine: advanced cancer treatments, antibiotics, most vaccines, transplant surgeries, genetic therapy, pacemakers, and more. The progress instead comes mostly through increased sanitation and hygiene, as well as reduced environmental contaminations and hazards, though it includes both antisceptics and anesthesia.
We've been paying a tremendous amount in medical advances for a very slight improvement in outcomes.
Wouldn't you really need a log scale or further interrogation to make that claim? To me it seems mortality dropped about 40% in last 50 years which is quite substantial.
Absolute vs relative improvements, vs cost of attainment, are two different questions. The largest overall reductions, and increases in life expectancy, come from very basic interventions.
The problem w/ efficiency measures generally is that there's progress to some theoretical maximum, and it comes with diminishing returns.
Breaking down life expectancy gains by demographics, the've moved more for men than women (since 1920, far more the reverse before), largely due to workplace risk, violence, and military service), and the poor/minorities rather than wealthy/majority (access, preventive care, environment, violence, stress).
The upper bound's moved little. Exceptional longevity is profoundly correlated geographically with poor recordkeeping.
Note that whilst at-birth increases (1850) from about 40 to 80, a 40 year old gains only 67 - 82 or so (15 years). It's early-life mortality that's changed most.
There are also hidden costs: mortality is selective pressure, and we've lifted much of that for about 5 generations. I have concerns. (I'll also note this generally impacts the wealthy more than poor, within and between countries.)
It looks like the decline at the end of the 19th century coincides with our ability to vaccinate against cholera, diphtheria, smallpox, and the other major epidemics listed on the chart.
- Sewerage systems (New York's came relatively late).
- As the somewhat provocative title of this article suggests, draining of swamps and other means of disease vector control.
- Refrigeration. General food safety improvements.
- Pasteurising milk. That would cut the transmission of TB markedly.
- Indoor plumbing.
- Indoor bathing -- showers and baths.
I haven't seen a breakdown. Laurie Garrett (NYTimes contributor) has long written on public health and epidemics, had a couple of books in the 1990s / early 2000s:
There’s degrees of “conquered”. Seat belts ‘conquered’ motor vehicle trauma before airbags did. Each new thing helps fill in the gaps left by the already-existing things.
I'll use an anecdote from my personal life. If you by some misfortune end up in the hospital for an extended time, you have an ever-increasing risk of being infected by drug-resistant bacteria. This happened to a loved one, and it's a tragic thing that will significantly reduce that loved one's lifespan.
Why does this happen? Antibiotics and filth. Antibiotics enable the awful management practices of this particular hospital. There aren't enough aides, the rooms and equipment are filthy, even the lunchroom is dirty. I sat visiting for weeks at a time a different times of day and night and never saw a mop, or a cleaning of surfaces that were soiled. Your average McDonald's kitchen is cleaner.
The economics of insurance are such that the consequences of these infections don't damage the bottom line.
For some people, airbags can discourage seatbelt use in the same way.
Wow, that sounds awful. I've only spent time in hospitals a couple of times but the ones I've been in (public or private) were always very professional and hygienic.
That was my way experience as well, although I was mostly exposed to OB when my kids were born or post-surgical areas. Those are the moneymakers.
If you have an issue that requires observation and not ICU, it’s a different story. Look at the Medicare health ratings online and you’ll find plenty of examples unfortunately!
I won’t call out examples because they are common.
Bring up one of the medical quality websites (the feds publish this as well) and you’ll find plenty of examples in 3 star or lower hospitals. Most hospitals in NYC are like this.
The period of most rapid car safety improvements came during a single ten-year period, from 1910 - 1920, where deaths, again, expressed per passenger mile, halved in only ten years.
There was a tremendous amount of general standardisation, things we take almost entirely for granted now:
- Electric / automatic starters.
- Arrangement of controls (accelerator, brake, clutch)
- Windshields.
- Brakes.
- Brake lights.
- Turn indicators.
Various improvements to roads, signage, and lighting as well, I suspect. As well as people simply knowing what cars were and what to expect from their behaviour.
Between 1918 and 1946 mechanical brakes were phased out. By ww2, they were nearly extinct except on the cheapest or older styled cars. I would argue the bigger advance was tires. Even mechanical brakes are plenty to lock your wheels, but tires are the actual road interface, and old ones are amazingly fragile. Vulcanization was not even known at the start of the auto age, and the rubber would tear off in chunks.
If the technique wasn't known until the 1920s, the issue of the patent exhibits extreme prescience on the part of both Charles Goodyear (1800-1860) and the US Patent and Trademark Office.
> mechanical brakes are plenty to lock your wheels
It's not that. It's pretty tricky to get 4 wheel mechanical brakes to put even pressure on the wheels, rather than most of the force going on just one wheel. Mechanical brake linkages are fragile, susceptible to rust, dirt and jamming, and likely need constant tuning.
With hydraulic brakes, it's easy to get even pressure on all the wheels. You can even put a "bias" in that puts more pressure on the front wheels, which makes for more even and controlled braking. Maintenance is minimal, and there are a small number of (protected) moving parts.
While airbags functioning properly with a properly sized adult reduce trauma, that's a lot of conditionals.
Seat belts conquered ejection and death, but people still didn't wear them, so active restraint and airbags became policy to have at least their 13% chance of being effective.
Seatbelts reduced the death toll dramatically compared with no seatbelts. Airbags and seatbelts together reduce the death toll dramatically compared with just seatbelts.
In most of the world it's considered suicidal not to wear a seatbelt while in a moving vehicle.
And unfortunately the US took the stance that airbag design should take into account that a seat belt will not be worn. US airbags explode with much more force and cause many more injuries than European ones.
Obviously we can't use that title or the thread will lose its mind. Since the submitter's profile indicates that he is the author of the article, or at least the proprietor of the site, I think it's fair to stick with what he posted.
The HTML title is deliberately different from the header. The header is a catchy/literary title; the HTML title is more descriptive of what you'll get if you click through. So, all is as intended. Thanks.
Popular economists Tyler Cowen and Alex Tabarrok maybe. And people can agree or disagree with them on a variety of issues.
But describing "sanitation improves health outcomes" as just somebody's "narrative" feels a bit like responding to "The sky is blue," by asking "Yes, but who benefits?"
Sometimes a poorly communicated idea turns into an anti-vax movement. Other times a poorly communicated idea is used as cover for malfeasance, such as “war on drugs” which is actually about oppressing an underclass.
The article isn't poorly communicated. It says that vaccines are "extremely effective", backs that up with citations and numbers, and lauds the scientific revolution.
“Whose narrative?” Uh, mine I guess. I'm an independent researcher. Used to be a tech founder. This blog was my hobby until I quit my last job. Now I do it almost full-time. I'm funded by grants from Emergent Ventures among others. But I've been doing what I do since long before I met them.
Jason Crawford was apparently investigating this topic before the somewhat notable / notorious article by Collison and Cowan's "We Need A Science of Progress" article (https://www.theatlantic.com/science/archive/2019/07/we-need-...). He's increased efforts since.
My read is that Crawford's hitting some good points, though he's bringing an ideology and some preconceptions to bear which are probably harmful to a full understanding. There's a fairly strong Libertarian bent (despite Cowan himself recently putting distance between himself and that theology).
While I'd challenge multiple assumptions and interpretations, his reading list (to the extent it's been mentioned in the few talks/articles I've read) is generally good.
Thanks. Part of the goal of my project is to get underneath assumptions and ideology. That is, I try to justify my conclusions based on evidence and research—at least the harder claims (as opposed to my somewhat more speculative comments about bigger-picture themes and deep causes).
I invite critiques of my factual conclusions, and I'm always happy to be taught something!
Read: Vaclav Smil, Robert K. Merton, Joseph Tainter, William Ophuls (esp. Ecology & Plato, and mine the hell out of his bibliogs), Bernhard J. Stern ("Resistances to Technological Innovation"), Robert Gordon (Rise & Fall), W. Brian Arthur (Technology & complexity economics), Robert U. Ayres (generally, energy & econ), M. King Hubbert, Howard & Eugene Odum, Nicholas Georgescu-Roegen (Entropy), Peter Turchin, Meadows et al, John Nicholas Gray (esp. on Pinker), Norbert Wiener (Cybernetics & Humans), Joseph Needham (generally, though not necessarily comprehensively), John Stuart Mill, William Stanley Jevons (esp. Coal & Money), Daniel Yergin (Prize), Richard Heinberg, Henry Adams (Education), Leslie White, Kyle Harper (esp, The Fate of Rome), Gregory Clark (Alms & Son), Karl Polanyi (Transformation), Elisabeth Eisenstein (Printing Press), Michael & Joyce Heusemann, William Foster Lloyd (esp. "Value"), Jeffrey S. Dukes ("Sunshine"), Jared Diamond (Collapse, esp. bibliog), Philip Mirosky (esp. More Heat than Light), Paul Buran (esp. his cautionary RAND monographs), Shoshana Zuboff (Surveillance Capitalism, Smart Machine), Arthur Toffler (Future Shock), Marshall Poe (Communications), Mokyr's economic history series generally (the one he's editor of) is quite good.
A long list, and could be better organised, apologies. Organising sources has become its own challenge. More mileage generally from the more obscure and less-read authors/works
Ask yourself:
- What is progress.
- What are value & wealth?
- What is technology?
- What are its specific mechanisms?
- What are their limitations?
- Is there a general theory of technology, if not, why, and what might it look like?
I'd also question your "moral imperative". Why, to what end, and with what alternatives?
My initial read was that the general problem was technological. I've become increasingly convinced it's more political & ideological, and the roles of media, power, institutions (formal & informal, overt & covert), and of information technology (high & low) on media and that on mass opinion & behaviour matter more.
Bad models & priors hurt immensely. Question all, especially those held unconsciously.
Thanks for the reading suggestions. And of course I am already thinking about the questions you mentioned and have been for a long time.
I agree that politics, ideology, and mass opinion matter a lot, and never meant to imply otherwise. Indeed in some of my posts I touch on how those factors might have affected technological developments. (See e.g. my analysis toward the end of my smallpox post: https://rootsofprogress.org/smallpox-and-vaccines)
Agree also about the importance of models & priors.
If there's any place where you think my specific factual conclusions are in error (whether from bad models or any other error), I always appreciate specific rejoinders.
I've only known of your project for about two days, so there's no in-depth assessment yet.
On politics, models, and media: I've simply found myself looking at these far more than the technical side. I think that's largely because tech simply hasn't moved all that much in 50-60 years, outside of infotech. In terms of energy, our options are largely the same as Hyman Rickover identified in 1957: wind, solar, geothermal, biomass, nuclear fission:
(We've gotten remarkably better at solar, but the total flux remains constant.)
A close read of various cornucopians (Herman Kahn, Julian Simon, M.A. Adelman) shows numerous thin and flawed arguments. Nordhaus's Nobel is quite probably the biggest error in the history of that award, and that's with fierce competition.
What's notable is that we've 1) made little progress in coming up with a generally accepted, sensible, model of economic growth (Atkinson & Krugman: https://youtube.com/watch?v=3l6E3mUNW70&t=2333), 2) there's been a concerted rejection of limits at both the left and right of the political spectrum, despite scientific concensus, in both cases for ideological reasons (see Schoijet's discussion of this: http://www.jstor.org/stable/3985399), and 3) political will and/or capacity to address challenges has been all but entirely lacking (this is the general thesis of Ophuls in 1977, largely born out over the subsequent 43 years in both action (or lack) and rationales).
It's your framing that strikes me as most flawed, though I suspect you'll also be least inclined to address. Growth as a moral imperative is extraordinarily suspect.
That's true -- though the figure you're linking focuses specifically on measles cases rather than overall mortality, which is what the OP article is focusing on.
(as an aside, it's really weird that the (first few) comments here on HN seem a little adversarial; I wonder if maybe some people looked at the headline only and assumed it was attempting some sort of anti-vax argument, which the article isn't doing at all.)
So there is something odd going on with measles. I haven't dug into the data, but from a couple of data points I've seen, it seems that measles mortality was declining for a long time even while measles cases were not. That is, there was a decline in the case-fatality rate, without a decline in cases. The disease was still around but getting less deadly. Then the vaccine actually reduced the number of cases.
So what was reducing the case-fatality rate? I don't know, but it might have been nutrition. There's evidence at least that Vitamin A makes measles less severe/deadly.
Sanitation, antibiotics, oral rehydration therapy, machine ventilation, nutrition, and so on.
It's not the measles itself that was the cause of most fatalities, it was the pneumonia, diahrrea, and other opportunistic infections that come with it.
The problem is that anti-vaxxers will use the headline as their entire justification for their opinion which is not supported by the content under the headline.
Modern medicine and vaccines have undeniably reduced the occurrence and severity of diseases, but the occurrences of these diseases were already down over 90% by the time we came up with vaccines. It's not wrong to recognize that tremendous achievement.
Furthermore, it indicates that we do not need to paint vaccine hesitant people as harbingers of societal collapse. That belief has been used to justify hateful rhetoric that is divisive, unproductive, and cruel to those who believe they were injured by vaccines.
People should not settle this dense in the first place. I hope more people are going to rural areas once StarLink an competitors deploy universal Internet connection coverage.
There's more to it than just carbon. It's certainly possible to have a carbon neutral lifestyle in rural areas, however that doesn't account for the habitat destruction innate to low density rural development.
Low density rural development can easily fit into existing habitat; I live on 5 acres of forest with maybe 1/2 acre set aside for house, lawn and garden plots. Aside from gasoline for vehicles, my house is nearly self sufficient resource-wise. The biggest destruction of habitat is massive fields for farming.
Of course, when a "developer" comes along, buys up an entire field or three, and builds a mini-suburban style neighborhood in the middle of nowhere, the habitat was already lost, but it will do absolutely no favors to any wildlife that might try to come back... not to mention the absurdity of living on tiny half to 1 acre lots in a division miles from the nearest village.
In which case, I suppose pricing for restoration elsewhere will be low cost to you and high cost to the developer. As it should be. It's all just a matter of putting the externalities back in.
