Open Heart (50 page)

Given how utterly wretched the living conditions are for these hunter-gatherers, these findings tell us much about the history of our species' mortality. I am indebted to Kim Hill, Henry Harpending, Renee Pennington, and Magdalena Hurtado for a brief glimpse into this fascinating world, and refer readers to Hill and Hurtado's
Ache Life History
and Nancy Howell's
Demography of the Dobe !Kung
.

109
   
The introduction of antibiotic:
See
Pediatrics, 2000
, for information on child and infant mortality.

109
   
“that the introduction”:
McKinlay and McKinlay, page 406.

109
   
“after which”:
Ibid., pages 414 and 408. See also Thomas McKeown et al., “An Interpretation of the Decline of Mortality in England and Wales During the Twentieth Century,”
Population Studies
29, pages 391–422 [422].

110
   
Dr. Thomas McKeown:
“The main influences on the decline in mortality,” McKeown states, “were improved nutrition on air-borne infections” and “reduced exposure (from better hygiene) on water- and food-borne diseases,” and he suggests that “the advancement in nutrition was the major influence” on the decline of mortality.

110
   
“epidemiological transition”:
Grob, page 201.

110
   
“from infectious diseases”:
Ibid., page 205.

111
   
We live healthier:
On why we live longer, see Grob, page 182ff, as well as Garrett, pages 9–13, and Horton (“In the Danger Zone”), page 47.

111
   
And there is this:
In 1930, the annual rate of cancer mortality was 143 per hundred thousand; in 1990, adjusted for the rising age of the population, it was 190 per hundred thousand. See Robert Weinberg,
One Renegade Cell: How Cancer Begins
, as quoted in Daniel J. Kevles, “Cancer: What Do They Know,”
New York Review of Books
(September 23,
1999), Page 18. And, as with heart disease, mortality from cancer is directly and consistentiy related to age; the older we are, that is, the more likely it becomes that we will suffer from one or the other of these two diseases.

On the incidence of cancer, see Grob, pages 255–258. In “The Political Scientist” (New
Yorker
[June 7, 1999], page 68), James Fallows notes that “after three decades [since Nixon's “war on cancer”] and an investment of more than thirty-five billion dollars in cancer research, annual cancer deaths have increased.” For an informative summary of what has happened since 1971, when President Nixon declared war on cancer, see Jerome Groopman's essay, “The Thirty Years' War,” in the
New Yorker
(June 4, 2001), pages 52–63. “In the course of a lifetime, one of every three American women will develop a potentially fatal malignancy,” Groopman writes, and he goes on to make much the same point about the use of militaristic language that Sontag, Annas, and others have made: “All the same, the triumphalist rhetoric that animated the war on cancer still shapes public opinion: many people believe that cancer is, in essence, a single foe, that a single cure can destroy it, and that the government is both responsible for and capable of spearheading the campaign” (page 54).

112
   
More surprising:
The mortality rates of cancer from 1950 through 1998 are from Grob, page 255; see also
Health, United States, 2000
, page 191.
The reasons:
Here is Gerald Grob's description of age-adjusted mortality:

Let us assume that there are two population groups of 100 each. Assume further that 10 people in each group die in a given year. But there is one difference. The average age of one group is 30 and the average age of the second group is 50. If you simply took the raw death rates, the two groups would be equal. But obviously we would expect a much higher death rate in the group with an average age of 50. Hence you must correct the raw data for age distribution. That is what is meant by age-corrected rates. You have to be certain that you are not comparing apples and oranges.

“Too many statistics are presented without appropriate corrections,” he adds, “and hence give a misleading picture. As age advances, we expect higher death rates—hence correction for age distribution is vital” [personal communication].

112
   
In a study:
Vincent De Vita's 1981 prediction is quoted on page 389 of Laurie Garrett's
Betrayal of Trust
. See John C. Bailar and Heather L. Gornik, “Cancer Undefeated,”
NEJM
336:22 (May 29, 1997), page 1573. (The 1986 article on cancer mortality is by John C. and Elaine M. Smith, “Progress Against Cancer?”
NEJM
314:19 [May 8, 1986], pages 1226–1232.) “In our view, the best single measure of progress against cancer is
change in the age-adjusted mortality rate associated with all cancers combined in the total population,” Bailar and Gornik conclude. “According to this measure, we are losing the war against cancer, notwithstanding progress against several uncommon forms of the disease, improvements in palliation, and extension of the productive years of life” (Bailar and Gornik, page 1226).

115
   
“the major issue”:
Horton, “How Sick Is Modern Medicine?” page 50.
“we are learning”:
The quotations from President Clinton and Frances S. Collins are from a front page article by Nicholas Wade: “A Shared Success: 2 Rivals' Announcement Marks New Medical Era, Risks and All,”
New York Times
, June 27, 2000. The quotation from
Time
is from an article by Frederic Golden and Michael D. Lemonick, “The Race is Over,”
Time
156:1 (July 3,2000), page 19.

For a refreshingly clear introduction to understanding the significance of mapping the human genome, see Richard Lewontin's essay in the
New York Review of Books
, “After the Genome, What Then?” (July 19, 2001), pages 36–37. “And what is significant in the human genome sequence?” he asks.

The major irony of the sequencing of the human genome is that the result turns out not to provide the answer to the chief question that motivated the project. Now that we have the complete sequence of the human genome we do not, alas, know anything more than we did before about what it is to be human. At the time of the completion of the human genome sequence, scientists already knew the complete DNA sequences of thirty-nine species of bacteria, a yeast, a nematode worm, the fruit fly,
Drosophila
, and the mustard weed, Arabidopsis.

“So knowing all the genes of a human being doesn't really tell us what we want to know,” he explains. And, later in the essay:

As interest shifts from genes to proteins, so the promises of cures for all of our ills will shift from genome fixes to protein fixes. The special Human Genome issues of
Science
and
Nature
already prefigure this change. Amid the many articles of the standard sort like “Toward Behavioral Genomics” and “Cancer and Genomics” is one called “Proteomics in Genomeland,” and one, “Dissecting Human Disease in the Post-Genomic Era,” which describes the shift from genomics to proteomics as one of the “Paradigm Shifts in Biomedical Research.” As yet the promise that the study of DNA sequences will lead to cures for illness has remained unfulfilled for any human disease, although some gene-based drugs are undergoing clinical trials.

For a more extended elaboration of the significance (and insignificance) of mapping the genome, see his book,
It Ain't Necessarily So: The Dream of the Human Genome and Other Illusions
,

115
   
“research tends”:
Horton, “How Sick Is Modern Medicine?” page 48.

116
   
“the prospects”:
Weinberg is quoted in Daniel J. Kevles,
New York Review of Books
(September 23, 1999), page 20.

116
   
“the effort to link”:
Grob, page 96.

117
   
“a preventable illness”:
The Harvard Center for Cancer Prevention's study is called “Volume I: Human Causes of Cancer” in
Cancer Causes and Control
7, Suppl 1 (November 1996).

117
   
“that the etiology”:
Grob, page 260.

119
   
Age-adjusted mortality figures: Health, United States, 2000
, page 163. See also Gina Kalata, “Gains on Heart Disease Leave More Survivors, and Questions,”
New York Times
, January 19, 2003.

119
   
“over the past 30 years”:
Daniel Levy and Thomas J. Thom, “Death Rates from Coronary Disease—Progress and a Puzzling Paradox,”
NEJM
339:13 (September 24, 1998), pages 915–916.

133
   
On August 26:
The deaths from Baycol are caused by a disorder called rhabdomyolysis, in which muscle cells break down and overwhelm the kidneys with cellular waste—a known side effect of statins. Some experts, the
New York Times
reports, claim that the estimates of injuries and deaths attributable to statins have been “very conservative.” “Because doctors and hospitals are not required to report adverse reactions [to drugs],” the
Times
notes, “academic, industry and governmental statisticians have calculated that there were probably about 10 cases of side effects for each case reported to the F.D.A.” Regarding the recall of Baycol, see “Anticholesterol Drug Pulled After Link with 31 Deaths,” by Gina Kolata and Edmund L. Andrews, in the
New York Times
, August 9, 2001. On the repercussions in Europe of the recall, see “Drug's Removal Exposes Holes in Europe's Net,” by Edmund L. Andrews, in the
New York Times
, August 22, 2001.

148
   
Yet at least:
Two wonderfully lucid, moving, and unsentimental books about living with chronic, disabling conditions are Andrew Potok's A
Matter of Dignity: Changing the World of the Disabled
, and Andrew Solomon's
The Noonday Demon: An Atlas of Depression
. Consider this, for example, from the preface to Andrew Potok's book (page 12):

In those early years of my advancing blindness, I did take care of myself by learning new skills but, while in the middle of a doctoral program, I also bolted the rational world to pursue an insane “cure” offered by a woman in London who claimed she could cure retinitis pigmentosa with bee stings. My attempt to obliterate my unacceptable limitations
cured me of ever looking for “cures” again. Finally, I have come to realize that many of life's essential problems aren't soluble. Misery doesn't always lend itself to remedy. As a matter of fact, this kind of attitude, I have come to believe, misunderstands what makes life interesting. Being cured of one's disability, one's peculiar psychology, one's angst, though sought avidly, runs the risk of leaving a residue of dullness and uniformity. All of this must seem silly to a society intent on ease, comfort, normalcy, a desire not to stand out in nonconformist ways, as crazy, poor, disabled, loud, different. But just as tragedy is not due merely to error, every question is not answerable, every ill is not always curable, everything does not always come out well in the end. “Everyone who is born holds dual citizenship in the kingdom of the well and the kingdom of the sick,” Susan Sontag wrote. We are all a little bit ablebodied and a little bit disabled. The degree to which we are the one or the other shifts throughout life.

150
   
We know:
For data concerning people who are at increased risk for heart attacks when isolated or living alone, see “Emotional Support and Survival After Myocardial Infarction: A Prospective, Population-Based Study of the Elderly,” by Lisa F. Berkman, Linda Leo-Summers, and Ralph I. Horwitz, in
Annals of Internal Medicine
117:12 (1992), pages 1003–1009.

Figures concerning increased mortality rates of widows and widowers are from Jaakko Kaprio, Markku Doskenvuo, and Heli Rita, “Mortality After Bereavement: A Prospective Study of 95,647 Widowed Persons,”
American Journal of Public Health 77:3
(March 1987), pages 283287. See also C. Murray Parkes, B. Benjamin, and R. G. Fitzgerald, “Broken Heart: A Statistical Study of Increased Mortality Among Widowers,”
British Medical Journal
, issue 1, pages 740–743.

151
   
“I feel this”:
Montaigne, “Of Friendship,”
The Complete Essays of Montaigne
, pages 186–197.

153
   
We know that mental:
Martin Stone, “Shellshock and the Psychologists,” in W. F. Bynum, Roy Porter, and Michael Shepherd (eds.),
The Anatomy of Madness: Essays in the History of Psychiatry
, vol. 2, pages 250–251, quoted in Jackson, page 132.

154
   
In one survey:
“The Importance of Placebo Effects in Pain Treatment and Research,” by J. A. Turner et al., in
JAMA
271 (1994), pages 1609–1614, cited in Anne Harrington (ed.),
The Placebo Effect: An Interdisciplinary Exploration
, page 22.

154
   
In the relief of depression:
F. J. Evans, “Expectancy, Therapeutic Instructions, and the Placebo Response,” in L. White, B. Tursky, and G. E. Schwartz (eds.),
Placebo: Theory, Research, and Mechanisms
, cited by Harrington, page 21.

154
   
In a 1999 study:
Irving Kirsch and Guy Sapirstein, “Listening to Prozac
but Hearing Placebo: A Meta-Analysis of Antidepressant Medications,” in Irving Kirsch (ed.),
How Expectancies Shape Experience
.

154
   
“the presence of major depression”:
“Task Force 3. Spectrum of Risk Factors for Coronary Heart Disease,” by Richard C. Pasternak et al., in
Journal of American College of Cardiology
27:5 (April 1996), pages 964–1047 [984].