The Cholesterol of a Healthy Society
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A couple of months ago I had breakfast with one of my blog readers and frequent commenters, Mark. At the time he mentioned something interesting, which has been percolating in the back of my mind ever since. He said that medicines get approved by the FDA based on claims that they will accomplish some terminal good. Say, for example, lowering the number of deaths due to heart disease. On top of that they will also probably toss in a general reduction of related adverse health events, like heart attacks. But when they provide data to the FDA in support of these claims it won’t be data on deaths or heart attacks it will be data on how the medicine reduces LDL cholesterol levels.
They do this for several reasons. First, cholesterol is easy to measure, and so that data is consequently easy to provide. Second, the pharmaceutical companies are reasonably certain that atherosclerosis contributes to heart disease, and that high LDL cholesterol contributes to atherosclerosis. Meaning that their claim actually has two parts. They claim that their medicine reduces LDL cholesterol, and that lowering your LDL cholesterol reduces your risk of heart disease. They are able to provide data backing up both claims, but what they don’t provide is data that shows “Our medicine reduces heart disease.” This is all fine, and working as intended, and, in fact, it’s the way I would want it to work. But, and this was the key point mentioned by Mark, after the drug is approved, the company should, at some point prove that it does actually reduce heart disease, not just LDL cholesterol. And the problem is that they generally never get around to that.
From the perspective of a patient, say someone with genetically high cholesterol, say me, for instance. The way this plays out is, you go in for your annual check-up (as I did this week) and get your cholesterol tested (ditto). Upon discovering that it’s high, the doctor prescribes a statin, because he knows that if I take a statin every night before bedtime, that my cholesterol will probably go down. Now, he will also ask whether any relatives have had heart problems, and he’ll look at other risk factors, but mostly he’s reacting to the fact that I have high cholesterol.
This all makes a certain amount of sense, and obviously my wife is very much in favor of me taking the medicine my doctor prescribes. But there’s a lot that the doctor doesn’t know. He’s only making an educated guess at my personal risk of heart disease. And he can’t say that if I decline to take statins that I will definitely have a heart attack. But he’s pretty sure there’s no downside to taking them. Of course, I’m being unfair by talking just about how it works with a single person, but even if we make it more broad, we still don’t fully understood how statins effect atherosclerotic plaques, nor is it clear whether statins do much of anything for someone as young as me, with a low risk of a having a heart attack in the next 10 years. For example this paper:
The current internationally recommended thresholds for statin therapy for primary prevention of cardiovascular disease in routine practice may be too low and may lead to overtreatment of younger people and those at low risk.
The general point I’m trying to get at is that all of us, not just doctors, are quick to substitute something easy, for something that’s more difficult. For doctors it’s substituting reducing cholesterol for reducing deaths from heart disease. It’s easy and cheap to measure cholesterol, it’s expensive and difficult to measure long term mortality from heart disease. Also, remember that the drug has already been approved, meaning even if it wasn’t difficult the pharmaceutical companies have very little incentive to conduct such studies.
Now if these substitutions mostly worked, with only a few minor errors here and there, that would be one thing, but in reality the opposite appears to be true. Health advice is constantly being overturned, or reversed. (As very humorously illustrated by this great Funny or Die Video.) And it’s not improbable to assume that 20 years from now we’ll find out that long term statin use causes some previously unsuspected negative outcome. It’s also possible that the dangers will be more subtle. Perhaps because cholesterol is easy to measure, and change, we’ll ignore paying attention to markers which are harder to measure, but ultimately more meaningful?
As I mentioned this idea has been on my mind since Mark introduced me to it. And just recently I realized that we may be doing the same thing when we assess the wellbeing of society. At the highest level, analogous to deaths from heart disease, we want a society that’s healthy. But of course deciding if a society is healthy is even harder than deciding if an individual is healthy. Right off the bat we run into conflicting standards for what constitutes health. As I’ve mentioned in the past my standard is survival. Just like the doctors don’t want their patients to die, I think it’s reasonable for society to also target deaths, and I extend that to targeting births as well. Other people disagree with this, and claim that we should be aiming for happiness instead. Fair enough, we’ll use that standard for the moment. Let’s assert, for now, that a happy society is a healthy society.
But how do you measure happiness? There are lots of studies which claim that Scandinavian countries are the happiest, but it turns out that it depends on what question you ask. An article in Scientific America claims that there are actually four ways to measure happiness:
Most commonly, you ask people to value their lives on a 0 to 10 scale. This is the method which gives us the aforementioned results of Scandinavian countries on top.
Alternatively you can ask how much positive emotion people experience, in which case suddenly Latin American countries are on top.
On the flip side of that perhaps you’re more interested in preventing negative emotions than you are in encouraging positive emotions, so you look for the country with the least depression. In that case Scandinavian countries do very poorly, but under this measure Australia looks pretty good.
Finally, we can look at the number of people who feel like their life has “an important purpose or meaning” in which case you’ll find countries in Africa at the top of the ranking. And it turns out that religion plays a fairly significant role in the creation of meaning.
Even if we assume that a happy society is a healthy society, it’s still difficult to determine what makes a society happy. In the same fashion that it’s hard to determine exactly how statins effect atherosclerotic plaques, but probably harder. However, and this was my recent insight, in the same way that doctors have decided that targeting cholesterol is the best way to mitigate heart disease, lots of people have decided that targeting material well being is the best way to create a happy society. To put it simply (maybe too simply, but close enough): as long as a nation’s per capita gross domestic product is rising the nation is healthy. Furthermore anything that contributes to that rise is good, and anything which detracts from it is bad.
As you can imagine there are lots of problems with this approach. First, as I just pointed out, there are various standards of happiness. Increasing material well-being through the mechanism of increasing the money possessed by the average individual, seems to mostly target the first one, while being only marginally connected with the other three. And even there we’re still assuming a chain of causation, very similar to the one I described for statins and heart disease, only longer.
1- Increasing per capita GDP means everyone has more money (i.e. the increase is evenly distributed.)
2- People will use this money to acquire possessions and experiences, they value.
3- Materially valuable possessions will turn out to have psychological value as well.
4- All of the foregoing will produce happiness.
5- Asking people to rate their life value on a scale from 0-10 will produce an accurate measurement of the happiness produced in step 4.
And if we decide to broaden things beyond the first metric for happiness we end up making two more connections which are even more questionable.
5- The quantifiable measurement of happiness from step 4, really is the best way to measure happiness. (Better than the other three.)
6- Happiness is the best way to measure the well being of a society.
In the same fashion as heart disease you would hope that people would move past focusing on whether someone has more or less money (i.e. cholesterol tests) and follow this chain all the way to the very end. But in a similar fashion I don’t know that they do, at least not in any systematic fashion. It’s always more straightforward to stick with things that are easy to measure than it is to figure out what really contributes to a society's well being. It’s easy to assume that if we’re trying to ensure the well being of society that ensuring each individual’s material well being is probably close enough, particularly if you’re a materialist. (And I realize philosophical materialism is different than the common definition of materialism.) But there’s more and more evidence that material well being doesn’t produce happiness to say nothing of overall well being. In particular I think the connection between material well being and psychological well being is especially tenuous.
I have spent a lot of time in this space covering my concerns about psychological well being, and you might think there’s not much left to say, but I came across an article recently that speaks quite directly to the issue of psychological well-being, and to a lesser extent the larger issue of societal well being. It was titled The Happiness Recession, and it opens as follows:
In 2018, happiness among young adults in America fell to a record low….
We wondered whether this trend was rooted in distinct shifts in young adults’ social ties — including what The Atlantic has called “the sex recession,”...
Human beings find meaning, direction, and purpose in and through our social relationships with others. We’re happiest when our ties with others are deep and strong. And the research tells us that the ebb and flow of happiness in America is clearly linked to the quality and character of our social ties...
So we investigated four indicators of sociability among today’s young adults—marriage, friendship, religious attendance, and sex—in an effort to explain the “happiness recession” among today’s young adults.
I’ll get to what they had to say about each of these four areas, but first notice that material well being doesn’t even come up. Possibly because the situation is analogous to a patient who’s cholesterol is fine, so we’re not worried about that risk factor, but it turns out they smoke. Or possibly the situation is analogous to discovering that we’ve been targeting cholesterol all this time and really we should have been targeting four different things, that cholesterol doesn’t matter at all. In any case regardless of whether the recommendations were wrong or just incomplete, it appears that we need to broaden our treatment regimen, and look into different “medicines”.
The first thing they suggest looking at is marriage. It’s interesting that marriage is not an example of a measurement that’s difficult to make, it’s almost certainly easier to tell if someone is married than it is to determine what their financial situation is. Determining the happiness of their marriage is another matter, and I’m sure it’s a factor, but even without accounting for it The Atlantic reports that:
...married young adults are about 75 percent more likely to report that they are very happy, compared with their peers who are not married, according to our analysis of the GSS, a nationally representative survey conducted by NORC at the University of Chicago. As it turns out, the share of young adults who are married has fallen from 59 percent in 1972 to 28 percent in 2018.
As I said, marriage is easy to measure, but perhaps, if there is a problem, it’s less easy to correct. Especially in an age where any suggestion that you’re interfering with someone’s autonomy, particularly in the realm of sex and relationships, is met with violent pushback. As a result it’s one of those things that conservatives talk about all the time, but which gets no attention from the left. (Or perhaps it gets negative attention?)
It can be dangerous to talk too broadly about what a group of people does or doesn’t believe or how they might behave, so in the interest of specificity, at this point I’m going to bring in Steven Pinker’s book Enlightenment Now. Which I “reviewed” previously in this space. As you may or may not recall Pinker set out to create the definitive work showing how great things are currently and how they are likely to only get better, and when I talk about an overemphasis on material progress I largely have him and people like him in mind. In support of my assumption I went back to the book to see what he had said about marriage. It was entirely possible that he mentioned its role in wellbeing and had different data showing that it wasn’t decreasing as much as claimed or that the effect of a lower marriage rate was overstated. As it turns out the word marriage doesn’t even appear in the index. (Note that Louis C.K. and Jainism do, lest you think that perhaps it isn’t comprehensive.)
The Atlantic next moves on to religion. Where they say:
Faith was the second factor. Young adults who attend religious services more than once a month are about 40 percent more likely to report that they are very happy, compared with their peers who are not religious at all, according to our analysis of the GSS. (People with very infrequent religious attendance are even less happy than never-attenders; in terms of happiness, a little religion is worse than none.) What’s happening to religious attendance among young adults today? The share of young adults who attend religious services more than monthly has fallen from 38 percent in 1972 to 27 percent in 2018, even as the share who never attend has risen rapidly.
I confess that this decline is less than I expected, but it’s still declining and the trend shows no signs of reversing itself anytime soon. And once again the decline of religion is something conservatives worry about obsessively, but which Pinker and company actively celebrate. (“Decline of religion” does appear in the index of Enlightenment Now, where it points to more than a dozen laudatory references under the heading of secularization.)
Religion is also something which has next to nothing to do with material well-being, and may in fact be the exact opposite. Once again, in our attempts to improve societal well being are we sure we’re measuring and treating the right thing?
From there The Atlantic moves on to friendship. And here the news is actually good:
The third factor was friendship. The effect of seeing friends frequently is less clear than that of marriage or religion, but young adults who see their friends regularly do seem to be about 10 percent more likely to report being very happy than their less-sociable peers. Friendship among young adults, though, is not on the decline; in fact, since 2006, contact with friends is up. Lack of friendship, then, is not likely to play a role in declining levels of happiness. Indeed, it may be that rising social time spent with friends in recent years could be buffering young adults from the declines in institutions such as marriage or religion, as friends stand in place of other relationships or forms of community.
As I said the news is good, but there are a host of caveats here. First as compared to the 40% increase in the number of people reporting they were happy attributable to religious attendance and the 75% increase from marriage, friendship provides a bump of only 10%. Thus whatever the “buffering” effect of friendship it would appear entirely too small to make-up for the other trends. Also even if it was up to the task, it then becomes a single point of failure. Where previously most people had marriage, religion and friendship in their life, and therefore two things to fall back on if any one of these three failed. Now, by relying solely on friendship, which appears unequal to the task in any event, we risk having nothing to fall back on if friendship should happen to fails. If this failure mode was unlikely, then perhaps we wouldn’t worry, but instead, on top of everything else there’s an epidemic of loneliness, with millions of men reportedly having no close friends.
I should also mention that once again that the word “friend” does not appear in the index for Enlightenment Now.
The final element covered by The Atlantic is the sex recession. Of which much has been said both here and elsewhere, probably because it’s so alarming, and this article was no exception. As part of their coverage they built a counterfactual to see if they could tell how much each element contributed to the reduction in happiness, as far as sex they found:
...changes in sexual frequency can account for about one-third of the decline in happiness since 2012 and almost 100 percent of the decline in happiness since 2014.
This is another illustration of how steep the trend is and how recent in origin, which makes me hope that it’s very temporary because if it continues for very long at all the impact will be nothing short of catastrophic. Also, though at this point it probably goes without saying, there is no reference to sexual frequency in Enlightenment Now.
The point I want to leave you with is that there are a lot of people like Steven Pinker, who think society is healthy, and point to material well being (essentially per capita GDP) as the best measure of that healthiness and also the best thing to target if there’s a problem. But it’s worth asking if that’s all there is to it. To ask how solid the links are between the various steps I listed above. If perhaps there’s some other measurement of happiness, like marriage rate, or religion or even frequency of sex which might be a more accurate measure of societal well being? Or at least need to be considered as part of a more holistic assessment. Now I know I’m simplifying Pinker’s argument to a certain extent, but also remember that in over 500 pages on how great things are going he never mentions marriage or sexual frequency, or for that matter loneliness and he only mentions religion in a negative context, despite the apparently powerful influence all of those have on people’s happiness.
To return to comparing societal health to individual health, which is actually easier to understand? I can only assume the answer has to be individual health. And yet how often have doctor’s ended up giving the wrong advice? Should that not make us more humble when it comes to making declarations about what makes a society healthy? Especially when we’re discussing the long term effects of some new, entirely unprecedented norm? Norms which seem to be proliferating at a truly staggering rate?
I not only have high cholesterol, I have high blood pressure, though they both appear to be mostly genetic. Nevertheless they could mean my early demise. If that happens and you haven’t donated, you’ll feel bad. If you want to avoid that click here.