The Demon Haunted World – A Survivalist Counterfactual

 

The Demon Haunted World – A Survivalist Counterfactual

 

I found myself watching survivalist videos last night.  I had just completed a blog post and was working on another (that is becoming a thesis rather than a blog) and decided to take a break.  I have dabbled in that literature on and off over the past 30 years and found that it does not add much. The end games are typically played out in popular movies and fiction. You either find yourself in an impregnable underground shelter or wandering semi-aimlessly over a barren and hostile landscape.  Both scenarios have their problems.

In the impregnable fortress there are the inevitable power struggles, equipment breakdowns, outside attacks, functional and dysfunctional alliances, and lack of planning.  Good recent examples include The Silo and Fallout.  In the wandering scenario there seem to be a plethora of hazards including violent psychopaths, cannibals, various zombies, diseases, natural disasters, and the ever-present lack of food and water.   Examples include The Road, The Walking Dead, and The Last of Us.

Survivalists are more realistically focused. The brief series that I watched emphasized escaping detection by any means.  The implication was that you were in a secure remote location with adequate food and water.  The assumption is that there are many people who were not prepared for when the shit hits the fan or WTSHTF for short.  Four days of starvation is enough to make most people desperate and at that point they cannot be trusted.  A corollary is that once they get skilled at taking what they need from others – you may be the next target.

The first video discussed the importance of smoke. A poorly constructed fire can lead to a smoke signal for people to see for miles.  That signal translates to shelter, warmth, food, and resources to any desperate person who sees it.  The author emphasized methods to minimize smoke production. Elaborate underground survival shelters not only minimize smoke but also heat signatures to avoid infrared detectors and missiles.

 The second avoidable signal to the post-apocalyptic miscreants is gunfire. You might be thinking hunting, but the emphasis was on interpersonal conflict rather than hunting.  There may be better ways to resolve a dispute and secondarily gunfire WTSHTF is not necessarily a red flag. It is a sign out there that somebody has food and resources they want to protect.   The zombie mindset is “even if you do not have a gun – you might be able to hang around in the darkness long enough to get what you want.”  No other ways were discussed about how to avoid gunfire.

The final avoidable signal was light.  Even as little as a candle represents somebody with enough resources that they can and want to see in the dark. It represents the last vestige of civilization.  For that reason, it must be blocked at all costs. Curtains were emphasized as a practical measure but black out screens were preferable.  It reminded me of the subtitle to Carl Sagan’s classic book The Demon Haunted World (TDHW).  That subtitle is: Science as a candle in the dark.  It seemed like a perfect metaphor for what is currently happening in the world. To anyone who has not read the book – the subtitle is from Thomas Ayd’s 1655 treatise on witchcraft A Candle In the Dark where he described witchhunts as a way to delude the people about what was otherwise unexplainable.  Sagan sums up the progress against witchmongering this way:

“Microbiology and meteorology now explain what only a few centuries ago was considered sufficient cause to burn women to death.” (p. 26).

The title is a metaphor for reason and truth in the context of dire superstition and this is captured by Sagan’s summation.

Many reviews of TDHW suggest that Sagan’s views are formulaic – a few rules about how to assess facts and be skeptical along with listing logical fallacies. That minimizes the context he provides about the founding fathers and how they were impacted by The Enlightenment and science. Sagan’s thesis is more complex. He is the first to acknowledge that science is not perfect but that the method of science encourages and produces self-correction. To capture reasoning that is strictly outside of formal science, Sagan suggests that all matter of human endeavor like politics, economics, and even specific policies can be subjected to scientific reasoning and scrutiny and it will result in better results and prevent primitive biases.    

Since the beginning of the COVID-19 pandemic there has been an almost continuous attack on science and scientific experts.  The first Trump administration attacked public health officials, physicians, scientists, and anyone affiliated with them.  They promoted ineffective and potentially harmful treatments for COVID, suggested vaccines were problematic, said that COVID-19 was no worse than the flu, and that case and death rates were overstated.  Several conspiracy theories were promoted suggesting that HIV was a planned bioweapon, that NIH officials were corrupt, and that the “planned” HIV epidemic was paralleled by the “planned” COVID epidemic.  If the COVID epidemic was not planned it was supposed to have originated from a lab leak in China despite all the evidence pointing against that.  The problem is not merely a lack of training in science and the scientific method.  The problem is that we have a large segment of the population that really does not care about their ignorance of science and a large segment who seem to happily take advantage of that on social media.

Sagan has a famous quote that is considered prophetic by many:

“…Science is more than a body of knowledge; it is a way of thinking.  I have a foreboding of an America in my children’s or grandchildren’s time – when the United States is a service and information economy; when nearly all the key manufacturing industries have slipped away to other countries; when awesome technological powers are in the hands of a few, and no one representing the public interest can even grasp the issues; when the people have lost the ability to set their own agendas or knowledgeably question those in authority; when, clutching our crystals and nervously consulting our horoscopes, our critical faculties in decline, unable to distinguish between what feels good and what’s true, we slide almost without noticing, back into darkness and superstition.”   (p. 25).   

Much has been made about manufacturing in the US and there is an active debate.  Specifically – is it a feasible solution for whatever economic problems you claim it will solve?  I have seen business experts interviewed who say it is not and others who have their own specialized supply chains within the country as being a solution. How will it be compounded by tariffs and an attempt to resuscitate the coal industry? The technological power is concentrated at the monopoly level according to several court decisions.  And what about artificial intelligence? There are daily predictions that AI will replace not only truck drivers and assembly line works but also doctors and teachers.  There are grandiose claims that AI will "cure all diseases" in less than the time I have been writing this blog.  Those aspects of Sagan’s prediction seem too uncertain to be useful.

The lack of knowledge in both the general population and at the highest levels of government is also on display.  Scientific knowledge and thinking is lacking and that it is not enough.  Any reasonable analysis of population wide policies needs to include a scientific dimension, a rational thinking dimension, and a moral/ethical dimension.  This is the real current failure.  As an example, the divisive rhetoric used around the COVID-19 issue.  There was a lot of uncertainty about the best way to stop the pandemic. As physicians and public health officials were learning about this and saving lives – the counter response was that no measures were necessary including vaccinations.  In the end public health officials were being blamed for lockdowns and school closings that could only have been done by local elected officials. That rapidly evolved to conspiracy theories that led to threats of physical harm and legal action against some of the top scientists.  The culmination of this rhetoric was recently evident when the Trump administration replaced a government webpage providing scientific information on COVID-19 with one that presents a combination of conspiracy theories and pseudoscience.  None of this sequence of activity included science, rationality, or ethics.

This is what Sagan is referring to in his quote. The current web page on COVID is emblematic of sliding into the modern version of darkness and superstition. Like the old version the new one is as out in the open and accepted by many. There is an army of celebrities, podcasters, media networks, social media bots, and writers supporting it. Some of the wealthiest people in the country claim they were “censored” because they opposed some suggested COVID measures or supported anti-science rhetoric – even though there was no formal censoring. The dark narrative is very present and it continues to take its toll in terms of cabinet appointees who promote it and some who seek vindication against scientists and officials who were making a good faith effort.

As far as science goes, whether that is hard science or the dismal science of economics – we have a choice to stay in darkness and superstition or move toward the light of science and facts.   Not caring about the smoke is the difference between surviving and living.

 

 

George Dawson, MD, DFAPA

 

 

Graphics Credit:

Campfire in the forest by Crusier, CC license BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0&gt https://commons.wikimedia.org/wiki/File:Campfire_in_forest.jpg

References:

1:  Sagan Carl.  The Demon-Haunted World – Science as a Candle In The Dark.  Ballantine Books 1997.

2:  Ayd Thomas.  A Candle in the Dark.  Smithfield, London. 1655.

What Does Carl Sagan's Observation About The Effects of Medicine Really Mean?

I started reading Carl Sagan's book The Demon Haunted World based on what I heard about it on Twitter.  Of course I was very familiar with his work based on his television persona but none of his writings. Part of the way in, I ran across the above quote as a footnote on page 13. It hit me immediately based both on my personal medical care and also the thousands of people I have assessed over the years.  There was also a clear contrast with what is in the popular and professional press.  The media has been obsessed with metrics of medical systems for various reasons. First, it is sensational.  When they can get a hold of a controversial statistic like the estimated number of people killed by medical interventions every year.  Change that to the equivalent number of 757 crashes per year and you have a hot headline.  Second, generalizations about the quality of health care lack granularity and precision.  There are no epidemiological studies that I am aware of that can even begin to answer the question he asked at the dinner party.

From a research standpoint, researching this endpoint would take an unprecedented level of detail. Standard clinical trials, epidemiological studies, and public health statistics look at mortality as an outcome typically of few variables and limited age groups. Nobody publishes any clear data on avoiding mortality - often many times over the course of a lifetime.  The same is true about avoided morbidity. Researchers seem focused on binary outcomes - life or death, cured or ill, recovered or permanently disabled.

The closest literature seems to be the way that chronic illnesses accumulate over time but that endpoint is not as striking as a mortality endpoint.  Every study that I have seen looks at specific cause of mortality or a collection of similar causes and not all possible causes.  The best longitudinal data I have found is in a graph in this article in the Lancet (see figure 1).  Please inspect this graph at the link and notice the trend in the number of chronic illnesses and how they increase with age.  The population studied here was in Scotland.  This is very impressive work because as far as my research goes I can find no other graph of chronic illnesses with this level of detail.  Data in the US have very crude age groups and the number of chronic illness is often limited.  If I look at CMS data for Medicare beneficiaries 34.5% have 0-1 chronic medical conditions, 29.5% have 2-3 conditions, 20.7% have 4 to 5 conditions, and 15.3 have 6+ conditions.  By selecting certain age groups the percentages change in the expected directions.  For example, looking at beneficiaries less than 65 years of age, 45% have 0-1 conditions and 11.2% have 6+ conditions.

Chronic conditions are the most significant part of medical effort and expenditure, but as indicated in Sagan's quote - they are only a part of the medical experience of people across their lifetimes. Now that some previously fatal conditions are being treated as chronic conditions the demarcation between morbidity and mortality is blurred even further. The experience of being treated and cured for a potentially fatal illness is left out of the picture.  Being treated and cured from multiple fatal conditions over the course of a lifetime is also not captured.  Two common examples are acute appendicitis and acute cholecystitis.   These diagnoses alone account for 280,000 appendectomies and 600,000 cholecystectomies each year. The vast majority of those people go on to live normal lives after the surgery.  Those surgical treatments are just a portion of the surgery performed each year that is curative and results in no further disability and in many situations the prevention of significant mortality and morbidity.  A more complete metric of life saving, disability preventing, and disease course modification would be most useful to determine what works in the long run and where the priorities should be.

One way to get at those dimensions would be to look at what I would call the Sagan Index.  Since I am sure that there are interests out there licensing and otherwise protecting Carl Sagan's name I am going to use the term Astronomer Index instead - but make no mistake about it - the concept is his.

I have included an initial draft of what this index might look like in the supplementary notes below.  Higher number correlates with the number of times a life has been saved or disability prevented.  Consider the following example - an average guy in his 60s.  When I take his history he recalls being hospitalized for anaphylaxis at age 16 and a gangrenous appendix at 19.  With the appendectomy he has a Penrose drain in his side and had a complicated hospital stay.  He traveled to Africa in his 20's where he got peptic ulcer disease, malaria and 2 additional episodes of anaphylaxis from vaccines that he was allergic to. When he was 42 he had an acute esophageal obstruction and needed an emergency esophagoduodenoscopy. At age 45 he insisted on treatment for hypertension.  At 50 he had polysomnography, was diagnosed with obstructive sleep apnea (OSA) and treated with continuous positive airway pressure (CPAP). At age 55 he had multiple episodes of atrial fibrillation and needed to be cardioverted twice.  He is on long term medication to prevent atrial fibrillation.  At age 60 he had an acute retinal detachment and needed emergency retinal surgery.  At age 66 he needed prostate surgery because of prostatic hypertrophy and urinary tract obstruction.  Assigning a point for either saving his life or preventing disability would yield a Astronomer Index of 11.  In 5 of these situations he was likely dead without medical intervention (3 episodes of anaphylaxis, gangrenous appendix, and acute esophageal obstruction)  and in the other six he would be partially blind, acutely ill with a urinary tract obstruction and possible renal failure, experiencing the cardiac side effects (or sudden death) from OSA, or possibly a stroke with disabling neurological deficits from the untreated atrial fibrillation. The index would take all of these situations into account as well as life threatening episodes of psychiatric illness or substance use.

Compare the Astronomer Index (AI) to all of the media stories about the number of medical errors that kill people.  Preventing medical errors is an essential goal but it really does not give the average person a measure of how many times things go right.  When I see stories about how many planes full of people die each year because of medical errors I think of a couple of things.  The first is a NEJM article that came out in response to the IOM estimate of people dying from medical errors.  It described the progress that had been made and what problems might be associated with the IOM report.  The second thing I think of is the tremendous number of saves that I have seen in the patients I treat.  I have to take a comprehensive medical history on any new patients that I assess and I have talked with many people who would score very highly on the AI.

Another aspect of treatment captured by this index would be the stark reality of medical treatment. The vast majority of people realize this and do not take any type of medical treatment lightly. There is a broad array of responses to these decisions ranging from rational decision making to denying the severity of the problem. Everyone undergoing medical treatment at some point faces a decision with varying degrees of risk. That should be evident from the current television direct-to-consumer pharmaceutical ads that rapidly list the serious side effects including death every time the commercial runs.  The decisions that people make also have to answer the serious question of what their life would be like without the treatment and associated risk. There are no risk free treatments as far as I know. In the case of the hypothetical patient, he has taken at least 11 significant risks in consenting to medical and surgical treatment that have paid off by living into his seventh decade.

I have not seen any metric like AI applied across the population.  Certainly there are many people who make it into their 60s and have fewer problems than in our example but there are also many who have more and actual disability.  The available epidemiology of chronic, cured, and partially cured conditions is extremely limited and I don't see anything that comes close to a metric that captures an individuals lifetime experience like the AI index might.  The rate of change in the index over the lifespan of the individual and across different populations might provide detailed information important for both prevention and service provision. In terms of psychiatric treatment - a good research question would be the response of people to treatment for psychiatric or substance use disorders with high scores on the index to people with low scores. Is there a potential correlation with cognitive decline?

The bottom line for me is that life is hard and most of us sustain considerable damage to our organism over the course of a lifetime.  Only a small portion of that is covered in most medical and epidemiological studies.  This index might provide the needed detail.  It might also provide some perspective on how many times each of us need serious medical treatment over the course of a lifetime.


George Dawson, MD, DFAPA


Reference:

1. Karen Barnett, Stewart W Mercer, Michael Norbury, Graham Watt, Sally Wyke, Bruce Guthrie,
Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study, The Lancet, Volume 380, Issue 9836, 2012, Pages 37-43,

Supplementary:

A copy of the Astronomer Index (AI) is shown below: