Overview:

Previous chapters described some physical and institutional changes that have shaped, and have been shaped by, our swarm. This one looks at an informational one—our growth in medical knowledge. In the twentieth century our medicine went through an abrupt phase change. Why? One common explanation is ‘science.’ But science is itself a complex network of behaviors, each of which took centuries to build and then lock together. Nor did that happen smoothly. So why did we develop those behaviors, and then why did we adopt them? Why didn’t we continue as we had for millennia before?

This chapter shows that our swarm’s changes have less to do with our surroundings or resources or even our desires than with our ability to gain, test, and spread reliable knowledge. That’s an ‘institution’ of a kind, but it’s not much like our more formal ones based on contracts—firms, markets, governments, and such. Our knowledge doesn’t grow quite the same way that our food, material power, material resources, or wealth grows. Ideas are intangible. But their growth still obeys much the same complex system behaviors already introduced. Admittedly, the network argument is stronger for people and things than for ideas. Our knowledge growth depends on what we think we already know—which is often wrong. Despite that, we now and then stumble over, and are sometimes forced to accept, new reliable knowledge. We then turn that into new tools, whether for acting or for thinking. Those new tools then lead to new infrastructure, mental as well as physical. That infrastructure then changes what we can next discover. That’s the stigmergic engine that most drives our swarm’s growth. This chapter sketches that whole process happening for medicine in ancient Egypt, eighteenth-century Europe, and nineteenth-century Europe, as we faced various medical problems—principally trauma, scurvy, and cholera. Seeing how our medicine changed in the past suggests something of what our future medicine might be like.

This You Cannot Cure

The pyramid in the city of the dead at Saqqara hulks over the tomb of Pharaoh Netjerykhet Djoser. Rising 195 feet out of the desert plateau, it’s the oldest of our colossal buildings still standing. Made with over a million tons of stone, it marks the moment that those of us in Egypt ended more than eight centuries of building royal tombs with palm logs, reed bundles, and mud brick. Surrounded by 37 acres of temples, offering chambers, and statues of the dead god-king, it rises over pharaoh’s treasure rooms and sarcophagus deep underground. Built nearly 47 centuries ago, and intended to last for eternity, it’s a monument to pharaoh’s death, and to his hope for life everlasting. Yet near the time it was being built, someone was scribbling away at a small book that’s more important than pharaoh’s huge tomb, for the scroll shows that while we were trying to build lasting monuments to death, we were also trying to build lasting temples to life.

A 15-foot-long fragment of a copy of that lost scroll is our oldest known surgical text. It’s arranged logically, listing slight wounds before deeper ones. Each case has a list of symptoms, a diagnosis and prognosis, and treatment, if any. Its author knew that the heart influenced the pulse, and thus had some idea of blood circulation. Those facts escaped Hippocrates in Greece 23 centuries later. Its author knew that brain damage affected the body, and could cause aphasia. Those facts were unknown to Aristotle, who, born around the time Hippocrates died, thought the brain was for cooling the blood. Its author also knew that damage to one side of the brain could cause paralysis in the other side of the body. That piece of knowledge was then lost to us for 30 centuries.

The healer’s insight was sharp, but his tools were few. With them, he tried to treat wounds that are still serious even today. Here’s part of case four: “If you examine a man having a gaping wound in his head, penetrating to the bone, (and) splitting his skull, you should feel his wound. Should you find something disturbing under your fingers, (and) he shudders exceedingly, while the swelling which is over it protrudes, he discharges blood from both his nostrils (and) from both his ears...” His diagnosis: “An ailment with which I will contend.” He then describes how to fight for his patient’s life. In case six though he knows there’s nothing he can do. “Should you find that smash which is in his skull [like] those corrugations that form in [molten] copper, (and) something therein throbbing (and) fluttering under your fingers, like the weak place of an infant’s crown before it becomes whole...” Diagnosis: “An ailment not to be treated.” Even then he sometimes still tried to save his patient, though he knew it was hopeless. Our fragment of his work lists 48 cases, starting with the head, then neck, upper arm, shoulders, and spine. Then it cuts off—in the middle of a sentence.

The scroll’s surviving fragment is about 36 centuries old, but it’s only a copy. The original, now lost, was written about ten centuries before that, about when the Saqqara pyramid was being built. So whoever the author was, he was more ancient to Julius Caesar than Julius Caesar is to us today. When he practiced medicine, early Rome didn’t even exist yet. Shaved scribes may have sat cross-legged in scented temples copying his book 20 centuries before the first Italic tribes dotted their mud and wattle huts on the Palatine Hill. When he wrote up his cases, the Greek story of the Trojan war wouldn’t exist for another 20 centuries. The Hebrew story of Moses was still 12 centuries or more into the future. And Stonehenge was just a big circular ditch and timber posts. (It didn’t yet even have the megaliths we name it for today.) As he scrawled by torch-light, only a few other scribes in a few Egyptian, Sumerian, and Indian cities understood writing, the new high magic that made dead men speak.

In the scroll, only case nine, a forehead wound, used magic. Most later medical texts, whether in Egypt or elsewhere, and even until recent times, used magic all the time. They were little more than jumbles of folk remedies. Internal diseases in particular were mostly a mystery, and thus obviously magical. Our healer-priests in Egypt saw them not as physical problems but as demonic attacks. One typical recipe runs in part “...excrement of the lion, excrement of the panther, excrement of the ibex...,” and so forth through several more. The patient would then drink that in liquid form. Together with charms and chants, or curses and prayers, that was supposed to disgust, then scare off, the unseen demon. Today it seems little more than sympathetic magic. Meanwhile, over in Sumeria we thought that disease happened when a demon became trapped in the body. We felt pain because it was trying to eat its way out. So our medicine there was the study of ways to disgust invading demons enough for them to leave without eating any more. The demons got in whenever we sinned. And that’s a general rule: For most of us, and for essentially all our history, disease was sin and sin was disease.

But this is a puzzle. Why did magical medicine flourish in Egypt (and everywhere else) even after Egypt’s early start on clinical medicine? Why is magic losing ground to science only now, and not 47 centuries ago? Today many of us believe that only pressures drive us to invent things. That’s so common an idea that it even has its own saying: ‘Necessity is the mother of invention.’ We imagine, for example, that our wars speed invention, since in war we’re trying to avoid being killed and trying to kill each other faster. The idea makes some sense, but not much. Consider: all of us, everywhere and everywhen, faced pain and death—and lost babies and destroyed lives. If necessity truly were the mother of everything, you’d think that competition among us to heal each other would’ve been fierce. Rewards for any consistent success would’ve been fabulous. Why didn’t that autocatalytically drive us toward clinical medicine a long time ago?

Partly it’s because external damage is easier to diagnose than internal problems. Someone with an axe sticking out of their head probably isn’t under demonic attack. Someone with a tumor growing out of their head though, may be. Egypt’s new non-magical medicine probably did save lives, but maybe only for wounds. It had little chance against internal disease when we still knew so little, noticed so little, and could do so little. For example, in Egypt we knew that the heart was somehow involved in circulation. But we didn’t know what circulation was for. We could see brains after the embalmer had scrambled them and let them drain out through the nose during mummification, but we had no real idea what they were for either. The body was just one huge question mark.

Today we see the body as a vast number of parts, all linked. It’s a machine made of many machines, most of them microscopic, with each linked into vast networks. Each one creates, shapes, or feeds the others. When one part starts to fail, other parts support, supplant, or defend it. That keeps the body mostly stable most of the time. (If it didn’t, we’d all be dead.) But that immense intricacy also makes the body hard to understand unless you already know a lot. Today we’re in the same position with respect to our swarm.

So we today needn’t assume that Egyptian medics were stupid. Nor need we assume that they didn’t care. Their written laments show that they missed their dead just as much as we today do. Nor does it explain anything to say that they were ‘superstitious.’ They knew a lot more about the body than any of the rest of us did at the time, granted. And they retained that superiority for millennia, true. But compared to all that there is to know about the body, even they knew nothing. They were facing a machine that had evolved over billions of years. It was far too complex for them to understand. However, as is still true in politics today, their patients forced them to pretend to know everything. Someone had to contend with the unseen demons. That vacuum of ignorance then pulled into being a whole network of ideas about how the body works and how it falls ill. Nearly all of it was completely wrong.

Even though our ideas are intangible, they can form a kind of reaction network just as we and our things can. Such networks can have a kind of synergy, just as iron mines and coal mines are weaker separately than together. For example, belief in magic is stronger if belief in demons is also strong (and the reverse). Both also increase the chance of belief in witches and warlocks, and the like. The more we think about their implications and contradictions, the more ideas we invent to increase their overall coherence (their synergy, if you will). After a time, our idea network achieves a kind of network closure, helping it persist. For every question we ask about some idea in the network there’s another idea in the network that answers that question. The network is then immune from attack. It becomes dogma. It doesn’t matter whether it’s all true or not. The longer we believe anything, the harder it is for us to change our minds since we pass on our belief network to our young, who then treat it as just another stigmergic part of their world. We thus ecogenetically build up a network of laws, institutions, and rituals that help the belief network persist. Further, the more of us who accept a closed idea network, the harder it is to change. Once its penetrance reaches critical mass among us, and it has enough ‘infrastructure’—in the form of institutions and ritual—it can achieve a kind of phase change. Changing it then becomes nearly impossible. For example, if most of us believe that medicine is magic but you don’t, you can’t simply say that it isn’t and expect to be believed. The wise thing to do would be to shut up and cloak your non-magical remedies in magical incantations. Your actions would thus help to perpetuate a closed synergetic network of beliefs that you don’t even share. Our world then becomes what we say it is, until we’re absolutely forced to believe otherwise.

By now you might be arching the eyebrow and pursing the lips. Lacking physical evidence, the above argument is a mere tissue of guesses. True. Unlike ideas about networks between physical things, it’s hard to see how to test ideas about networks between ideas. We don’t know what’s in each other’s heads today, let alone 47 centuries ago. But if the above argument is mostly true it might explain why Egypt treasured its new clinical idea (enough to copy it for at least ten centuries anyway), yet still didn’t pursue it into other areas of medicine, which remained mostly magical. That in turn might explain why Egypt continued to be our medical leader for century upon long century, and also why new medical insight soon slowed there. Even in Egypt, we still knew far too little about our body. We lacked the tools, physical and mental, to learn more. Mostly though we didn’t know that we didn’t know. Even today, most of us still don’t know that we don’t know. So we simply accepted that one in four of our babies must die, no matter how good our magic. We thought that many mothers just had to die in childbirth. We took it as law that few of us could live past 40. We found it natural that we would often drop dead for no reason at all. Disease as sin blocked further inquiry. We believed that we lived in a world of capricious demons.

That belief had life-and-death effects. About 4,450 years ago, perhaps two centuries after our unknown surgical author was dust, Pharaoh Neferirkare Kakia was being shown around some new buildings. His guide was his vizier, chief judge, and chief architect, Wesh-Ptah, who unexpectedly collapsed, unconscious. Pharaoh panicked. To save his most loved friend, he sent for his personal doctors. They were the best in Egypt, and, thus, the best in the world. However, he also ordered that they first read from the sacred medical texts. Meanwhile, with no one to contend for his life, Wesh-Ptah died. By then, our oldest medical books already mattered more than our living doctors. Our doctors had become mere hands for their inherited books.

How did that happen? After we learned how to write about 50 centuries ago, but before the printing press destroyed written authority by making millions of books about five centuries ago, some of us must have watched and tested to gain reliable medical knowledge. We looked for patterns in our deaths, then tested what we thought we saw to see if it was real. If it was (or seemed to be) we then wrote it down, or our students wrote it down. Or they repeated our sayings long enough until someone wrote them down. Then, only a couple centuries later, once living memory of our sages and their methods had died out, we found it politically convenient to forget the discovery process, but remember its results.

Our sages may have helped that along when they gave the gods credit for their insight. Perhaps they did so because they believed it, or maybe they just wanted to be humble. Maybe they did it to win approval for their methods, or perhaps to gain political power for their temple. Or maybe they just wanted to spread blame whenever their cures failed. However it happened, we credited their work first to inspiration by the gods, then, over time, to the gods themselves. We made the book, not the discovery process that led to it, the source of all knowledge. Its long-dead author, known or unknown, became a god of healing. To question his word was suicidal. Thus were our medical dogmas born.

So for long dusty centuries in Egypt we passed on our medical databases, their dogmas set, their authors lost. As we passed them down we copied, translated, annotated, garbled, but always religiously followed them. “If [Egyptian doctors] follow the rules of this law as they read them in the sacred book and yet are unable to save their patient, they are absolved from any charge; but if they go contrary to the law’s prescriptions they must submit to a trial with death as the penalty.” That was written 21 centuries ago. We had malpractice insurance long before we had insurance companies.

Necessity can indeed birth invention, but only when we can see what we need, and we can see that it’s possible to get it. Many things have to be believed to be seen. Once our belief networks achieve closure and harden into dogma, they’re nearly impossible to change, especially with death on the line. Still, some of us are always brave enough to try. And each of our deaths tells a tale. Patterns in the ways we die can sometimes be clear enough to challenge our belief networks. Many of Egypt’s earliest healer-priests must have seen such patterns, because even as late as 24 centuries ago, when Italy and China ruled big chunks of Eurasia, we still prized Egyptian medicine. “[M]edicine [there] is divided in many branches, so that each physician treats one disease and no more. Therefore physicians abound, some for the eyes, some for the head, some for the teeth, some for the belly and some for the obscure ailments.”

A clear voice rarely speaks, but we today can still hear whispers of these men and women just barely inside history’s firelight, as they contend with demons they can’t see, can’t understand, and can’t control. From each of our deaths they gleaned one more vital bit of data. Then they chanted it down the centuries so that we wouldn’t forget. Then once we learned how to write, we wrote it down. Whichever few of those records that made it through our next disaster—whatever war or invasion that next slew us in our tens of thousands, burning our temples and scattering our knowledge—future generations would cherish. Those scraps then formed our heritage of medical knowledge, a store well paid for with blood and pain.

Even without our ancestors’ voices direct from their books, we today can still sometimes hear echoes of their distant footfalls in the words we still use today. Today’s medical genies, genomics and proteomics, grew out of molecular biology, which grew out of biochemistry, which grew out of organic chemistry, which grew out of chemistry. Chemistry came from alchemy, which originally was an Arabic word. It descends from the Middle English word for the Old French word for the Medieval Latin word for the Medieval Arabic word for the Late Greek word for, probably, the Ancient Egyptian word for Egypt. That Egyptian word was ‘Kemet,’ meaning ‘The Black Land.’ Thus, an ancestor of the word we know today as ‘chemistry’ originally meant something like ‘The Art of the Black Land.’ So even with today’s monoclonal antibodies and stem cells and whatnot, we’re still following the early Egyptians, still seeking reliable medical knowledge. So, in a sense, the author of our first known surgical treatise isn’t forgotten. Today, 47 centuries later, we still contend with ailments not to be treated. And we still can only best face them with the same weapons he used so well: observation, tests, communication, and power.

Today, rich and poor alike, we’re living on the far side of a vast and recent health phase change. Until about 1800, and for millennia before, our species life expectancy at birth wobbled somewhere between 20 and 35 years. All over the globe, over four in every five of us died before reaching ten years old. Since 1800, our life expectancy has more than doubled. For example, in 1900 life expectancy at birth in the United States was 47 years. By 2000, it was 77 years. Today, rich and poor alike, around the world we’re also taller, and our individual body mass has grown 50 percent. We’re also urbanizing fast. As our child deathrates fell, most of our kids made it to ten years old. Our birthrates then fell. Today, rich and poor alike, we live longer, grow taller, heal faster, urbanize more, and have fewer kids. All of that is partly thanks to twentieth-century medicine. Why though after so many millennia of muddle, and such strong inertial forces working against any change, did our medicine change so abruptly? Did we suddenly wake up one day and simply decide to throw off our old dogmas about disease? Did we suddenly became individually smarter or more caring or less superstitious? Was a medical superbright born in the early twentieth century? Was it because we’d invented capitalism or microscopes by then? None of those are true. The change didn’t even start in the twentieth century. It started in the nineteenth century, in Europe, and at first it had nothing at all to do with medicine. It had to do with statistics. But explaining why it happened then and there and not before or elsewhere, will take a bit of time. The story starts in sixteenth-century Europe, with scurvy.

Avast, Ye Scurvy Dogs

Our medical beliefs resist change, and we can pay for that with our dearest currency—our lives. The story of scurvy shows why. In sixteenth-century Europe, the leading cause of death for sailors on the high sea wasn’t warfare. It wasn’t piracy. It wasn’t mutiny, storm, or shipwreck. It was scurvy. At the time, Europe’s sailors mostly lived on salted beef and pork, dried peas and beans, hardtack, oatmeal, butter, and beer. After about six weeks without vitamin C, their gums grew spongy, then their teeth fell out. Their sores spread, their joints crippled up, their bones spontaneously broke. They grew anemic, weak, and listless. Then they coughed up blood, passed black stools, went into coma as their brains compressed from internal bleeding, then died. Scurvy had been killing them since at least 1497, when Vasco da Gama led four Portuguese ships on his first trip to India. Over three-quarters of his crew had died, most from scurvy. Over the next three centuries, scurvy killed perhaps two million sailors. Why did so many of us have to die before we saw the pattern behind our deaths?

Perhaps you’re thinking that we died because Elizabethan medics were fools. But that’s wrong. They had their dogmas, sure. So do we today. The world is too complex for any of our generations to discard everything that our ancestors concluded. So the stigmergic effects of their network of beliefs often live on. But many Elizabethans still knew how to treat scurvy. For example, on June 5th, 1607, Shakespeare’s eldest daughter, Susanna, married John Hall, a herbalist. Susanna had scurvy. Her father was far away, in London, and out of work. (The plague had once again closed the theaters.) Even so, Hall cured her. For her father’s listeners, ‘scurvy knave’ was a popular insult for good reason. Scurvy was common, and not just on ships. The Little Ice Age was still going strong, and winters regularly froze the Thames solid. Fruits were scarce, but medics weren’t helpless. Centuries of trial and error had taught them a thing or two. Nor was Hall some rare miracle worker. A Jesuit professor in Rome, an English captain writing about Dutch warships, and many surgeons and herbalists, all knew how to cure scurvy. You’d think that all that knowledge would’ve led to change. It didn’t. England’s Admiralty ignored it all.

So perhaps you’re now thinking that Elizabethan admirals were fools. But that’s wrong too. Even had they gotten a detailed briefing—which they didn’t—they weren’t medical professionals. They hired people for that. So all the above evidence didn’t matter at all. Jesuits professors? Bah. They were Catholic—and therefore suspect. Dutch captains? Pah. They weren’t Catholic, sure, but they were also Dutch. At the time, the English were at war with the Dutch as often as with the Catholics. So anything they did was obviously wrong and stupid. And while England’s surgeons, apothecaries, herbalists, and ‘wise women’ were both Protestant and English, they were also poor. So they didn’t count. Surgeons descended from barbers. They still had to shave and cut hair. Apothecaries descended from grocers. They sold spices along with their drugs, including cannabis and opium. Herbalists and wise women had even less prestige. So to the Admiralty, the only medics who mattered were the physicians. But not for medical reasons. Physicians descended from the clergy and were the only ones who could prescribe. They were rich, respected, could read, and could even speak Latin. So the division of medical labor in Europe grew to become: surgeons cut, apothecaries drug, physicians think. The physicians thought that scurvy was caused by eating too much sugar. Or maybe it was bad air plus a blood disorder. Or—the favorite—God’s anger with the world’s sins. Equating disease and sin is a popular pastime among many doctors, even today. Other ideas centered around the sailor’s banes: close quarters, wet clothing, salt, dampness, cold, and—surprisingly for the time—dirt.

So perhaps you’re now thinking that all Elizabethans were fools. But that’s also wrong. Each of us can see only what our belief network, our model of the world, lets us see. At the time, European medicine believed in the early Greek theory of the body. It went back at least 2,000 years to Hippocrates. Any idea network that old is almost unchallengeable. So physicians based their cures on trying to balance the body’s ‘humors.’ Mostly that meant bleeding their patients. They also made them blister, sweat, sneeze, spit, vomit, urinate, or defecate. (Perhaps the idea was to torture the patient back to health?) Their patients, too, believed that only horrid treatments could cure horrid maladies. Like their physicians, they believed in sympathetic magic. Merely eating an orange a day obviously wasn’t going to cure anybody of anything. In any case, everyone knew that eating uncooked citrus fruits brought on fever and diarrhea, possibly even the plague. And while English folk medicine was right about scurvy, it also proposed that you cure jaundice by drinking live lice in ale. It also said that you could cure plague by rubbing together one handful each of yarrow, tansy, and featherfew, urinating on the bruised herbs, then drinking the liquid.

Go ahead: laugh. But we’re no different today. Our medicine can’t change until our tools change. They can’t change until our knowledge changes. It can’t change until enough of us have died for us to see a testable pattern behind their deaths. Plus, not just anyone has to see that pattern; it has to convince someone with the power to do something about it. A scientist might both see and test a pattern, but without power that doesn’t matter. A state might have the power to communicate a result and force us to accept it, but without knowing what to do, anything it does is often worse than useless. So someone has to see the pattern behind our deaths, someone has to test to prove it, and someone has to communicate that to someone who can force through the proposed solution. Observation, tests, communication, and power, all four are essential. And the second and third didn’t used to be very common.

Forget the medical world you live in now. Suppose you’re 19, live in London, and the year is 1700. About one in three of everyone you know will die long before 50. Nearly all the families you know are huge, often because of serial marriage. The mothers you know often die young, and often in childbirth. One in three of their babies will die before reaching two years old. Of those who live through that, half will die before reaching 15. Many women you know, even the rich ones you might hear of, are always pregnant. For nearly every year of your life, Queen Anne has been pregnant. (She had 17 pregnancies in 17 years; only one child survived to age 11—then he too died.) Even the young, healthy males you know are at daily risk. A broken arm or leg, or even a simple cut or bruise, could kill in days from septicemia or gangrene. Only if they were lucky did they simply lose an arm or leg. Cripples and crutches were everywhere. Mass death was constant. An epidemic, of which there were many, might kill a whole family in a few days. A sailor might return from a voyage and find his entire family, or sometimes most of his neighborhood, gone. All that wasn’t simply because of medical ignorance. A bad winter, of which there were many around then, followed by a so-so spring, starved most everyone you knew. To today’s eyes, even in good years Europeans back then were stunted, malformed, and half-starved. At the time, the French, for example, lived on as few calories as Eritreans do today—and today Eritrea is one of our poorest countries. Even Europe’s richest could be sickly their whole lives as no one knew what a good diet was. Sickness was a constant presence in Europe, and most everywhere else. Scurvy fit right in. It was just one more way to die, special to seamen. Disease was sin, sin was disease, and all of us saw life as merely a short and agonizing prelude to death.

So scurvy might easily have continued sailing its trail of death for many more centuries. However, our usual sequence of accidents then led to change. In 1740, during a war with Spain, George Anson took sail, tasked with attacking Spanish shipping. He commanded six warships, two supply ships, and nearly 2,000 sailors—259 of them elderly invalids taken by force (press-ganged) from Chelsea hospital. He returned four years later with one ship and vast booty. It was England’s biggest pirate haul ever and Londoners capered in the streets. But of his men, scurvy had killed half. Hostile action killed just 16. James Lind, a Scottish surgeon, then decided to test several scurvy cures proposed over the centuries.

His idea didn’t come out of nowhere. By his time many medical folk in Europe were talking about a new way to discover facts called ‘science.’ In May 1747, onboard ship in the English Channel, Lind then ran Europe’s first controlled clinical trial. Don’t get too excited though. It was hardly a randomized, double-blind, placebo-controlled, two-stage test. He daily gave six pairs of scurvy patients one of six remedies. He tried them, two by two, on oranges and lemon, cider, vinegar, sulfuric acid, seawater, garlic and mustard, and others. The wideness of the list shows just how ignorant Europe was about scurvy. But the results of his simple test were striking. His two citrus-fruit patients got better in six days. His two cider patients improved mildly. The rest didn’t. In 1753, he wrote a book about it, dedicating it to Anson. It led nowhere.

But, you shriek, how could Lind’s test possibly fail to change anything? Consider though: science was still an infant. Few of us saw the value of clinical trials. Also, Lind was poor and had no power. He was a mere surgeon; he wasn’t a physician at court. Plus, he was the son of a mere merchant. He didn’t spring from a Lord’s loins. Further, he himself was unsure that citrus fruits alone were a cure. He felt that any sea dog with plenty of fresh air, dry clothes, warm bedding, and moderate exercise, would thrive on hardtack and grog. Wet, foul, cold air reduced sweating, which he thought was a form of excretion. So for him, his scurvy patients were, in effect, constipated. For him, fruits and vegetables were only good because they helped dissolve food enough for it to be perspired. Despite centuries of stories about the healing power of fruits and ‘green stuff,’ who in eighteenth-century Britain could possibly believe that scurvy was dietary? Their belief networks couldn’t accept such a thing. It was much easier to believe the then-current medical dogma, which was some infectious agent or malign sea-mist, the nautical equivalent of ‘miasma.’

Bit by bit evidence mounted but scurvy continued to kill as usual until by 1778, with a new war on, deaths and desertions on the high sea were so many that the navy routinely press-ganged twice as many men as it needed. It knew that a third to a half would die or desert just on the voyage out. Not that anyone in power much cared. Officers didn’t die of scurvy as often as common sailors did. No one knew it, but that was thanks to acidulated wine, and access to more fruits and vegetables than the rest of the crew. Besides, fresh lemons weren’t cheap. Sailors were. With officers relatively safe, and press-gangs to force in as many jolly jack-tars as needed, the navy did okay. Besides, at the time Britain’s slave trade still had another half century to go. So, too, did press-ganging. And life expectancies at birth in various parts of Britain could be as low as 26. (Today, Swaziland, one of our very poorest countries, has the world’s lowest life expectancy. It’s 31.3. In Eritrea it’s 54.3.) So back then, our lives were so cheap that you could buy one as you buy a pound of fish. They were so unprotected that you could legally snatch one off the street for years of forced labor at sea. And they were so precarious that most newborns couldn’t expect to live to 27. In such a world, the rich don’t have to care how the poor die.

By now your eyes may have popped out and are waving about on their stalks. However, by 1793 scurvy had finally became a serious problem. But, once again, not for medical reasons. It was now a military crisis. The French Revolution had just happened and Britain was once again, and as usual, at war with France. A long war loomed. At the same time, Britain’s empire was growing. Demand for more sea power, and thus more pressed sailors, grew. That summer, Britain’s Mediterranean fleet was occupying the French port of Toulon. As usual, many sailors had scurvy. The fleet commander wouldn’t let any of his ships resupply, but his surgeon asked for one vessel to fetch lemons. The results were so clear that every blockading ship soon got lemons. By then the navy had already had several such unplanned trials. Folks were beginning to talk. Many captains now thought that lemons worked.

That then prompted Gilbert Blane, another Scottish surgeon, to write to the Admiralty. He noted that “more men would be saved by a purveyance of fruit and vegetables than could be raised by double the expense and trouble [of press-ganging].” Scurvy didn’t just cost lives; it cost money too. This time some admirals listened. After all, Blane was a fellow of the Royal Society. He’d been physician to the West Indies fleet during the American War. He was physician to Saint Thomas’ Hospital. He was commissioner to the Admiralty’s Sick and Hurt Board. He was physician to the Prince of Wales (who would become George IV). Plus, he was a protégé of the Duke of Clarence (who would become William IV). It wouldn’t pay to ignore him, even though he was only a surgeon. Plus, other important folks were saying the same things. So they commissioned yet another test with lemons. It was a success. And that was the last straw for the old dogma. By 1800, all navy ships carried lemon juice preserved in alcohol. Thus, three centuries after da Gama’s first voyage, Britain’s belief network about scurvy finally shattered. Finally dragged into the light of understanding, the unseen demon that had taken two million of our lives shriveled and died.

The Universe’s Lethal Quiz

Scurvy has much to teach us about how we change our minds. When faced with any challenge it often looks like we examine all options, then choose the silliest and most expensive one. It’s fun to see the world that way, but it doesn’t explain much. We must always make our decisions under time pressure. We must also always make them with limited knowledge, with a probably false belief network, with blunted tools, and with no real idea of what our changes long-term network effects will be. We’re much more reactors than we are actors, and scurvy shows why that’s true too.

Scurvy is ancient. Long before killing us on ocean crossings it must have been endemic in Eurasia during hard winters since it was common even during summers. Its first known mention may go back to Egypt, 3,500 years ago. Europe’s ocean voyages in the sixteenth century only focused it. Those voyages forced a few of our species into small spaces for long periods. That raised it out of the background of life’s general problems. It wouldn’t have been solved as quickly and cheaply as it was—calling three centuries and two million lives ‘quick’ and ‘cheap’—had it not been confined to a controllable space. Each voyage was like a lab test. There we could try out new diets and living conditions far more easily than on land. Medicine’s clinical method began then.

That method has since given us much new knowledge. For instance, we now know that we, like all other primates, carry the badly damaged remnants of a gene that we need to make vitamin C from glucose. Lacking vitamin C, our body can’t buttress its collagen, the chief protein in our connective tissue. When properly strengthened, collagen is as strong as steel. When not, it can’t survive even at body temperature. Without collagen, tissues can’t grow. Sores can’t heal. Broken bones can’t knit. Lacking strong collagen, someone with scurvy is literally melting at room temperature. Scurvy is thus a genetic disease common to our whole species, plus a few others: our primate cousins—monkeys and apes—plus guinea pigs, and a few bird, bat, fish, and insect species. Goats, for example, still have the working gene, so they can’t get scurvy. Twenty million years ago, one primate gene went dead, but our ancestors were still up in the trees, throwing poop at each other. We were surrounded by fruits and leaves, so the gene loss didn’t matter. Twenty million years later, we changed our habitats and that one defective gene reached out and killed at least two million of us at sea, and, probably, many millions more on land during bad winters.

But how could that be? Aren’t we the best-designed animals on earth? Well, our brain is certainly impressive. But our genes didn’t shape us to have long, healthy lives. There’d be no point. From their point of view, each of us is disposable. Here’s why: Every minute of every day the universe presents each of us with lethal quizzes. We survive them only with copied answers that worked in the past. We copy them from our parents, as they did from their parents. How do I get energy from glucose, Mom? How do I repair this cut with collagen, Dad? How do I build bones from calcium and phosphorus, Grandpa? How do I make vitamin C, Grandma? We encode all that survival data in the structure of the giant networks that make up our bodies. Each new generation peeks over the shoulders of the last, copying answers as we all sit in endless rows taking the universe’s neverending quiz. We’re all sweating bullets though because the universe is a strict grader. Anyone who makes a mistake isn’t coached or coddled. They’re taken out back and shot. Our precious copied answers, figured out over millions of years of trial and error—and an untold number of executions—work together to build us. Our vast and elegant genetic heritage is thus the result of one long night of bloody, Grand Guignol theater. It’s also a gigantic case of cheating, with regiments of cheaters extending all the way back to the first life on earth, billions of years ago.

Each of us is an A-student in cheating. None of us has the time or talent to figure out everything for ourselves from scratch, so we rely on each other, and not just our parents and grandparents. We’re all vast storehouses of copied data about how to survive daily lethal threats to our lives. That data is more precious by far than the contents of all our museums and libraries. But since each of our bodies, no matter how well built, must die, our genes don’t bother to make us long-lived. They’re pragmatists. In our ignorance, we marvel at the age of mountains, not realizing that even continents only last a few hundred million years. Many of our genes are over ten times older. Those wily survivors haven’t lasted that long by building bank vaults to hide in. That would take too long and cost too much. Plus it still would only protect them for at most a few hundred million years anyway. So they do the exact opposite. They copy themselves into a series of cheap, throwaway, soap bubbles. That’s us.

From our genes’ point of view, a lean-to is far better than a threat-hardened, bomb-proof fallout shelter. It may not even survive the next high wind, but it’s easy to lash-up a new one before that happens. So that’s their main trick: make new copies to hide in before the present one you’re hiding in dies. So those copies need to be made of cheap, simple, and handy materials. And they can’t take long to knock together either. Mammal genes, for example, aren’t prepared to wait for their new homes for more than about nine months (us) to about two years (elephants). Thus, all species—mold, iguanas, corn, cockroaches, us—run an endless relay race down through the eons. We’re all always busy making, or—more usually nowadays—trying to make, new fragile vessels to hold our current answers to the universe’s endless deadly questions before we get killed. The cheaper and shoddier the vessel, the quicker and easier it is to copy. Thus we’re all built of parts made and put together by the absolutely lowest bidder. All of us are ramshackle data freighters, hauling a set of survival answers for a brief while—just long enough to get a chance to pass them on to a new set of ramshackle data freighters. In short, our genes don’t care about our long-term health. They’re just using us for sex.

We’re all sex machines. Our body peaks near puberty. Our deathrate is then the lowest it’ll ever be. We’re as healthy as we’ll ever be. We casually repulse most disease as easily as we regrow broken bones. All our answers are as right as they’ll ever be. But as we age, they get worse at dealing with problems we have only then. We begin to die. That must be so because every single one of us alive today descended from an unbroken chain of flimsy data freighters going back billions of years. Every single one of them was once new, fresh from the factory. Few were ever old. So most of our answers that often led to early death vanished from our species long ago. Their holders were taken out back and shot before they could breed. But our factory warranty expires soon after puberty. By the time we’re 25 or so we’re already well past our sell-by date.

That’s how the universe’s heavy hand ironed out kinks in our intricate genetic programming. It concentrated on any fatal flaws that take effect before we can reproduce. Then, to a lesser extent, on those problems that take effect before we can raise any offspring to reproductive age. So in sexual species like ours, any gene that might help keep you sexy for perhaps 30 years, but which then killed you gruesomely, would flourish. Any gene that might help keep you alive for perhaps 130 years, but which would also have made you revolting, would die out. So, for all sexy data freighters—elephants, oak trees, wheat, sparrows, us—many of our quiz answers applying later in life have smudge marks, crossed-out bits, ink blots. Our genes don’t care. So if we’re to live longer and better we have to engineer it ourselves. Our entire medical system, the gigantic life-support structure we’ve built around ourselves to prop ourselves up after our genes have given up on us, is the result.

The Knowledge Game

We’ve built up that medical life-support structure over millennia, going back much further than even our earliest known Egyptian doctors 47 centuries ago. For all that time we’ve been forced to play a lethal game against the universe without even knowing its rules. Here’s how it works: Imagine that you’re a termite trapped on a chessboard. You have no idea what’s going on. Big, heavy things are moving all around you and you’re scared of being squished. So you’re trying to figure out the rules of chess before that happens. You’re very small, you’re not too bright, and you’re almost blind. Sometimes you vaguely make out huge hovering things just before they land near you. Are there any rules to their movements? Can you predict where they might be headed and so avoid being squished as your scurry about? Good luck. Alone you have no chance. But there are a lot of us on the board and we’re talking to each other as we watch the pieces move overhead. We’re building up a shared belief network about those terrifying things. After a long time, one of us guesses that there are only so many different kinds of pieces. An Aristotle termite calls pieces of one particular kind ‘bishops,’ and the name sticks.

As we continue to watch, we never see any bishop’s complete move. But often when we note that a bishop, which used to be on a black square, is gone, another bishop is now on some other black square. Time and again we see that until a Galileo termite guesses a law: ‘All bishops must move to another square of the same color as its current square.’ He has no idea why that’s true, or even if it’s always true, but he still calls it his Law of Conservation of Color. One day, a Newton termite guesses that Galileo’s law could be a result of a more general, more explanatory one, namely, ‘All bishops move diagonally.’ He’s equally clueless about whether it’s true, yet he still calls it his Law of Diagonal Gravity. Since every square on any diagonal must always have the same color, bishops thus automatically conserve their square color. Some time later, an Einstein termite tries to explain why, despite Newton’s law, a bishop can sometimes appear to change color. He guesses that a bishop of one color could be captured then a bishop of another color could be created soon after—if a pawn reached the last rank in that time. That new bishop would then obey Newton’s law and so move on diagonals of whatever color the pawn ended on. His Law of Relative Diagonal Binding generalizes Newton’s law, which generalized Galileo’s law.

While watching that gigantic and lethal game, none of us termites can say why bishops are as they are. They just are. And we all stick with the name ‘bishops,’ which our first good guesser, Aristotle, the one who knew the least, gave them. Since we’re only termites we easily believe all sorts of hooey. For instance, 25 centuries ago Herodotus refused to believe that pigeons could talk, even though that was common lore at the time. But he had no trouble believing that mares could foal rabbits. So we protect the seemingly working parts of our belief network about chesspieces by making it hard to change. We cut the laws we (think we) have found so far into the chessboard so that future generations won’t forget them. And we learn to value a new guess only after we’ve run many tests on it. That is, we push pieces about, predict what will happen, then see what actually happens. Of our few guesses that pass such tests, we value most the even fewer that also correctly predict future moves. We call them ‘laws,’ and cut them into the chessboard too, adding to those already there. But we’re never sure that our set of incised laws is complete, or even correct. We never know whether they’re also rules of the game, or merely side-effects of the real rules—if there are any, that is. Over time, however, our laws seem to explain more and more of what’s going on. We call that effort of rule-deduction ‘science.’

In theory, medicine is just another branch of science. The chess board is now populated with us, and everything that affects our body. Instead of stars and atoms and cosmic rays, it now has chubby babies and wizened codgers and pigs and pets and chocolate and lead pipes and microbes and viruses and prions and genes. The game is now about medical knowledge. In the science game, our network of beliefs about stars can’t change what stars do. In the medicine game, our network of beliefs about ourselves do change what we do. In the science game, we can try to be detached because we aren’t emotionally involved in stars. (Although ego, fame, and funding are already enough to cause huge science wars.) In the medicine game, every few moves, some of us get squished. We get squished if we do the wrong thing. We also get squished if we do the right thing—it just takes longer. The pressure to do something—anything—is always high. But to know what to do we must first learn the rules. To learn a rule we must first see many of us get squished in only a few ways before we can comprehend how they came to get squished.

We’ve been playing that game against the cosmos since at least the time of our shamans. They were healer-priests who could soothe our physical hurts with secret balms and potions. They could also soothe our psychic woes by telling us the secret reasons why the world was the way it was—why our hunt failed, why our babies died, why the sun brought life. Medicine and astronomy are thus perhaps the oldest of our proto-sciences. And, unlike astronomy, medicine has had no shortage of experiments from the time of the earliest humans to this morning. However, as the story of scurvy shows (and there are many others), to today’s eyes its history is dotted with idiocy, pomposity, malpractice, and politics. Why?

We have many answers to that question. Perhaps it’s because we only let our doctors probe us through a thicket of taboos? For example, medicine stalled for millennia because of our taboos against dissection. But we have taboos today too. Nowadays our taboos hedge clones, embryos, and stem cells. Perhaps it’s because medicine must deal with the confounding effect of our utter ignorance? Living in a desert of medical knowledge, we thirst to believe in almost any cure. But that’s still true. Yesterday it was frog’s breath for whooping cough and sulfuric acid for scurvy; today it’s aloe vera and colloidal silver for AIDS and laetrile and shark cartilage for cancers. Perhaps it’s because medicine depends heavily on chemistry, biology, and statistics? All three fields started speeding up only in the nineteenth century. But medicine still depends on them, and many other sciences, today. Perhaps it’s medicine’s asymmetry of power? Medicine long ago found that secrecy is essential to pacifying patients and maintaining power. So while other fields—like psychology, anthropology, or sociology—might have taboos, uncontrolled trials, a placebo effect, dependence on sciences, and even secrecy, only medicine (and psychiatry) have them all.

All those reasons sound pretty good. But they all miss the point. For contrast, look at two sciences: geology and paleontology. On January 6th, 1912, Alfred Wegener proposed the idea we know today as continental drift. Geology laughed for decades. Continents drifting on solid rock? What kind of force was immense enough to do that? On the other hand, on December 18th of that same year, Charles Dawson claimed to have found the skull of an early human in Sussex. Paleontology at once hailed it as ‘Piltdown Man.’ Britain wanted a piece of the new paleontology action. Now it could claim to hold the remains of the earliest known human ancestor. So geology refused to believe in continental drift for 50 years while paleontology refused to not believe in Piltdown Man for 41 years. But one was real and the other was a hoax. Today, plate tectonics, the descendant of continental drift, is at the center of all geology. And ‘Piltdown Man’ is just one more embarrassment to paleontology.

Scientists aren’t stupid, but they’re also human. They can be just as petty and careerist as the rest of us. They have all our usual blinders. They sometimes even have our usual prejudices. In each field, our currently accepted belief network, whatever it is, alters what we can see. It can even alter what we can think. Medicine’s blinders are no different. Unless forcibly prevented, we all see what we expect to see—or what we wish to see. It’s only our emotional reaction to lost opportunities that changes from field to field. In short, how we react to failure differs from field to field. Also, what we prefer to believe differs from field to field. And the closer a field is to something we actually care about, the larger the distortion field surrounding it. Both geologists and doctors make mistakes. But when geologists err, usually only geologists care. When doctors err, someone dies. Also, while you rarely ever need to consult a geologist—unless a continent drifts over your foot—most of us will one day want to see a doctor. Long lines of scared patients compel their doctors, who don’t know what they’re doing any more than geologists do, to make many more mistakes per hour than geologists need do. But it’s our emotional reaction to medicine’s mistakes that make them different than geology’s mistakes.

The closer a field is to something we care about, the more agreeable we want the things it says to be. If it says something that doesn’t fit with our belief network, most of us often simply reject it. It doesn’t matter whether it’s in paleontology, geology, or medicine. Take our taboos surrounding dissections. They’re very old, and are worldwide. At least as far back as 5,300 years ago in Egypt we seem to have believed that altering a corpse’s appearance prevented resurrection. Another of our widespread ideas was that if you touched a dead body you became ‘impure.’ Yet another was that if we allowed dissections, we’d rob graves—or we’d kill each other for fresh bodies. For instance, an Indian story of Emperor Aśoka from 2,300 years ago tells of his grave illness. One of his younger wives ordered a search for anyone suffering the same symptoms. When one was found, she killed him, then had him dissected. In his stomach was a worm, which resisted all manner of pungent substances but was killed by onions. She then begged her emperor to eat onions, even though they were against his caste, thus curing him. Around the same time, the Greeks had just conquered Egypt and at least one Greek doctor dissected hundreds of living, screaming, Egyptian convicts. More recently, dissection has even had economic meaning. In the 1800s, white anatomists in Augusta, Georgia, preferred to give their students fresh black corpses. Reason? They were easier to steal. Many whites thought that blacks weren’t quite human, but they were “close enough,” so their far easier availability made up for the supposed difference.

Nowadays it’s common for some of us in rich lands to show our sophistication to each other by blaming our various churches for our millennia-long weakness in anatomy, and thence medicine. But that’s ridiculous. Blaming our human guides to the divine—all our priests and mullahs, our pandits and rabbis—for banning dissection makes as much sense as blaming our undertakers for our deaths. Our priests only expressed our common beliefs about dissection. Those beliefs flowed from our own pity and terror. We felt respectful of, and squeamish about, bodies that only a few days before were our lovers, family, friends. Our anxieties about the implications for our own future deaths can only have added to the strength of our worldwide rejection of dissection. That was true 5,300 years ago, it’s true today. All we do differently today is hide our dead bodies from ourselves. So for millennia, and all over the world, our medics had to guess about how our bodies work.

So those of us, like doctors, who have to work close to us, can’t afford a truly clinical attitude. Thus, for instance, even though today’s healer-priests no longer swear to the Hippocratic Oath, they still live by a rule attributed to him: ‘Do no harm.’ They, however, more often interpret it as: ‘Do no new harm.’ Just as with Egyptian doctors millennia ago, today’s doctors are under pressure to continue killing their patients in the same old ways. Who would want to try something new and maybe kill even one patient in a new way? We have medical dogmas, then, not because we’re ignorant, self-deceiving dolts—although we are—or because our doctors are shameless, self-serving quacks, but because our dogmas are important emotional protections, especially when death is on the line. No one could blame you (at least not until recently) for always first reading from the sacred texts. So we did, and so we died.

Today, however, we know that we’re ramshackle data freighters. And with our computers to help us, we’re finally begining to dissociate much of our learning from actually killing anyone. As a result, we’re now learning huge amounts about the rules of the knowledge game we all must play against the cosmos. For instance, only recently did we discover that peptic ulcers aren’t caused by stress, or personality, or any of the other causes our doctors and psychiatrists earlier dreamed up. Microbes cause them. Now we have antibiotics to cure them. Similarly, only now do we know that a virus causes cervical cancer. Now we have a vaccine for it. Even heart disease and fatness are now linked to infection. Of course, that’s not to say that intangibles like stress don’t matter. But our best current research shows that it’s not stress that leads to ill-health and shortened lives but low status. Low status, poor health. High status, great health. As our computers grow stronger and we can learn even more stuff without killing anyone, our emotional chokehold on medical practice will ease. Medicine will, one day, become a true science. That won’t happen next week though. Our emotional response to failed medical trials will see to that.

Today we think we’re so sophisticated, what with our tissue engineering and protease inhibitors and whatnot, but our doctors still play their shaman role. Besides our pragmatic use of them as diagnosticians (here’s what’s wrong) and therapists (here’s how to fix it), we still interpret them emotionally as supporters. They’re professional friends in times of great need. For instance, bleeding the patient didn’t last for millennia because our doctors were morons. More likely it lasted because it gave them something specific to do right away. That suggested to their patients—and, as important, to themselves—that something was being done. Someone with secret knowledge was contending on the patient’s behalf against unseen demons. By bleeding us, our doctors started a procedure with a mostly known course and outcome. What effect, if any, it had on our illness wasn’t the point—although both doctors and patients at the time thought it was. Today’s medicine is no different. In our heads we may know better, but in our bellies we react just the same way. Our emotional need when ill today is still to search for comforters, for our true medical problem is ignorance of how the cosmos works—ignorance of the unseen demons. Just as we did in Egypt 5,000 years ago, as patients today we still need our doctors to know what’s going on, to tell us what’s going on, and to fix the problem. Our doctors must contend with the demon for us. We’ll always need that. In times of great need there is perhaps no finer purpose.

A Microscope Made of Numbers

When we tell ourselves the story of our medicine today we often say that its last big change came in 1945. We think so because that’s when antibiotics began to spread among us. That then led to many of our recent changes in health, lifespan, and living conditions. For example, our species couldn’t be half-urban today without it. Until recently, all our cities were serial killers. Diseases of concentration ate us by the bucketful. Our cities survived only because their other benefits, like higher wages, kept sucking more of us in from the countryside. Popular belief has it that that changed only after the 1940s. So today we often look back and take the advent of antibiotics as the start of our latest medical phase change. But that’s wrong. The tectonic shift behind that huge change didn’t start in the 1940s. It started a century before, in the 1830s, when Europe first faced a virulent new disease. That disease was cholera.

The cholera bacterium is an efficient killer. It first sticks to a cell in the host’s intestinal wall then disrupts the cell’s sodium pumps. Those pumps then flush their cell’s water and electrolytes into the gut. The gut bloats, forcing expulsion at both ends. That then infects the water supply. When new hosts ingest the dirty water, the microbe invades and the cycle repeats. Victims first get an upset stomach, then cramps, fever, and nausea. Then comes explosive diarrhea and vomiting. The host body ejects up to a gallon of fluid every four hours. Within 12 hours, extremities are cold, skin wrinkled, features pinched, eyes sunken. The blood, with a quarter of its volume lost, coagulates. The heart and kidneys fail. Deflating like a burst balloon, the body goes into hypovolemic shock. Its cardiovascular system collapses.

In two to three hours cholera can kill one in every two healthy adults it infects—and most of the youngest, oldest, starved, and sick. It’s no threat today with cheap technology (rapid intravenous saline rehydration, or even a simple glucose and electrolyte drink like Gatorade), but all nineteenth-century European medicine had was opium. That, plus many ways to make patients expel fluids. With the possible exception of opium, all their treatments were just about the worst possible things to do for catastrophic dehydration.

That new way to die came to Europe after a volcanic eruption in Tambora in 1815, which disturbed the next year’s monsoon. Heavy rain then fell in southern India, where cholera is an old disease. Poor rice harvests, worsened by the volcano-induced rain, led to starvation, and that aided a cholera outbreak. The movements of the British army and British merchant marine then helped it step out of its traditional Indian centers, then it started striding across Eurasia. It stalked its victims along the trade routes as far north as the Volga and as far west as Arabia. In 1823 it stopped, stalled by an exceptionally cold winter. But by 1827 it was again in Russia. By 1830 it reached Poland, carried there by the Russian army. The next year it hit Hungary, Austria, Germany, and Sweden. By 1832 it was in Paris. There it slew 7,000 in 18 days. Within a month, 13,000 Parisians were dead and 120,000 had fled. As the new unseen demon marched north and west on its five-mile-a-day, 15-year trek, perhaps 50 million of us died. The British quarantined ships but on February 11th, 1832, it struck London anyway. Soon, 3,000 were dead. From England it sprang north to Scotland and west to Ireland.

Despite years of watching the disease kill its way westward, British doctors had no idea what to do. They tried brandy and sulfuric acid. They tried enemas and bleedings. They tried hot flannels and hot-air baths. They tried ringing the sick with hot bricks, setting off smoke bombs, putting buckets of burning pitch in the streets, tolling church bells, whitewashing houses, and evicting sick families. They even tried splashing vinegar around sick rooms—which may have actually helped a little. Its acidity destroys the pathogen. As with scurvy, with no idea what brought the new demon down on us, we tried to ward it off with prayers and curses and horrid treatments. Nothing helped.

Doctors went in fear of their lives in the poorer parts of towns. Many of the poor believed that doctors were taking patients to hospitals to kill them and use their bodies for dissections. Others thought that either the doctors or the druggists had caused cholera by poisoning the wells. Yet others felt that the government had brought cholera to kill the poor. (By the way, the disease looked like arsenic poisoning. Many inconvenient spouses and rich relatives conveniently died during this time.) Nor were any of our responses new. Half a millennium before, Christians had blamed, then massacred, Jews for a new plague, the Black Death. When a new plague came among the Romans 1,750 years ago, they blamed their newest sect, the Christians. When a new plague killed one in three Athenians 2,430 years ago, they blamed the Peloponnesians (their enemies). The centuries pass, but we don’t change.

The newest plague, cholera, terrified those of us in Europe as much as the Black Death once did, even though it wasn’t anywhere as lethal. It was new and so didn’t fit any of the ways we’d built up to deal with death. In battle, we could always explain, or at least justify, death by claiming heroic self-sacrifice. In the home, child deaths were so common that, paradoxically, we found them easy to accept. Our children, especially our young children, simply died. But at least we could explain it: it must have been because of parental sin. In the rest of life, most disease first made us feel ill, then took its time to kill us. Tuberculosis, for example, took months or years to kill. Its symptoms were also easy to care for, and so were easy for us to explain and accept. Diseases that we found horrid, like leprosy, usually spread slowly enough that we could contain them. So in all cases, and in all our groups, not just in Europe, we’d ecogenetically built up a network of belief and ritual that let us make sense of death, set our affairs in order, and grieve. In all those ways did we bring meaning to death. But cholera could take down a healthy, able-bodied man or woman, or a whole family, in a few hours. Further, it turned recognizable kin into unrecognizable near-corpses in that short time. Plus, it did so by forcing them to vomit and defecate in enormous volumes. Thus, it killed us as fast as on the battlefield. It killed us as mysteriously as our babies died. It struck without warning, laughing at our remedies, and killing us revoltingly. For most of us the only way to make sense of it was as a fire, a flood, an earthquake—an act of God.

So explanation had to be found. Blame had to be assigned. Searching for any haven in the sudden squall of pestilence, church attendance shot up. In an age when 43 of every 100 of our babies died before the age of two, our attitude toward cholera was much the same as toward any pandemic, particularly the plague. Obviously God was angry about something. And since cholera, like every other pandemic, often took the poorest and weakest of us, God surely disliked the poor. That story worked for a while, but we had to change it once the disease started taking wealthier lives. We then assumed divine punishment for anyone on the fringe—the dissolute, the wanton, the irregular churchgoer. Anyone poor or strange would do. From there it was but one more step for us to conclude that even the most blameless and pure must have been secretly sinful. After all, they later became ill, didn’t they? So they must have had it coming. That then gave us a closed belief network: God punished evil, so the ill must have been evil because God punished them. Disease was sin; sin was disease. Most of us have believed some variant of that for most our species history, just as many of us believed that profit was sin. Even today, some of us still believe it for sexually transmitted disease, like AIDS or syphilis. With such a belief circle in hand, we had no incentive to look for cures. Heavenly blows can only be endured, not avoided.

Those of us in England’s slums in 1832, however, had to endure more than anyone. Our industrial phase change was roaring on, and England’s population had jumped from ten to 14 million in just 20 years. The number of cities had doubled, and slums were everywhere. The rich, living only a horse ride away from any slum, were too scared to care. As urban poor, we spent all our brief lives in squalor. We lived in windowless rooms in back-to-back hovels squeezed around unpaved courtyards. Often, three or more families shared a single dark room just six feet by six feet. Incest was common. Our courtyards, filled with pigs that dined on refuse, dead animals, and kitchen slops, were never cleaned. We also had to share beds and privies. Being communal, they were never cleaned either. Our water supply was the nearest river. As often as not, it was full of effluent from the nearest factory. If we were richer, we shared a water pump in the street. It either tapped a well that might be contaminated by seepage from the nearest cesspit, or it tapped the river, which carried sewage, corpses, and offal—dumped there by upstream settlements, who themselves used water contaminated yet further upstream. Fleeing economic meltdown in the countryside to slave in the new factories, we knew no better. And even backbreaking work was better than starving to death in a ditch. Besides, life in London’s slums had been that way for over a century already. Illiterate, debauched by our employers, humiliated, powerless, we turned to gin as our only escape. Cholera, when it came among us, easily jumped from host to host, then from continent to continent.

It leapt the Atlantic in June 1832. It first hit Canada when Irish immigrants brought it to Quebec. It killed 3,347 in three months in Montreal and Quebec City. Then, as in Eurasia, as the stricken fled before the new plague, it pursued them down the newly infected waterways. Kingston, Toronto, Buffalo, Detroit, New York, all were hit as it made its way to Mexico by 1833. To try to imagine the chaos, consider what it was like among the quarter-million New Yorkers at the time. Take a five-story tenement and divide it into 100 small rooms. Fill those rooms with 900 men, women, and children, four in five of whom don’t bathe even once a year. Now put a water pump a block away and an outhouse in the back yard. Don’t forget the thousands of pigs, goats, and dogs feeding off the offal in the streets. Then add explosive vomiting and diarrhea.

In New York, where cholera killed 3,516 that hot summer, our attitudes toward it were much the same as in London, Paris, Berlin. It was punishment for wickedness. It afflicted those of us least likely to have God’s grace—Which is to say: the poor, the free black, the slave, the native, the French, German, and particularly the Irish immigrant. Being both recent and Catholic, the Irish were obvious agents of the devil, not to mention riffraff. Cholera was also divine punishment for any form of overindulgence: alcoholic, narcotic, sexual. Anything we despised about ourselves worked as an explanation. As in England, North American doctors thought that cholera only killed the physically or mentally weak. The best remedy they came up with was brandy and water. They also tried bleeding, mustard poultices, opium, morphine, quinine, turpentine, camphor, castor oil, hot punch and hartshorn, tobacco enemas, hot sandbags, and—the latest rage—electric shocks.

Back in England, cholera had already killed 22,000 by June. The urban poor were rioting. The government, petrified, passed many laws about working and living conditions. It had been doing so for the past two decades as Britain’s urban population had soared. Somehow though it nearly always forgot to fund those laws. It also forgot to oversee them, or enforce them. One law passed in 1832 did lead to some change though, but not much. It allowed medical students to dissect any unclaimed corpses, thus ending the brisk body-snatching trade. However a law passed in 1836 did trigger big changes, though it seemed harmless enough at the time. It was about statistics. The government needed better mortality data so it started collecting and centralizing detailed data on births, marriages, and deaths. Not for medical reasons, of course. It wanted to better manage title deeds, as well as to make more money selling annuities to the public. But out of that mass of data would come astonishment as a few of us datamined it, putting Britain under the microscope of the new human statistics. We’d built low-powered optical microscopes since the 1590s, and high-powered ones since the 1670s, but in the 1830s our species unwittingly built a new kind of microscope, a microscope made of numbers. That’s what made the difference, not the antibiotics that were to come a century later. They wouldn’t have materialized had we not first built our new microscope. After it existed, age-old authority, divine will, and fatalism began to wither. We began to replace them with observation, tests, and communication. Dimly, and for the first time, our species began to see itself as a whole. That changed everything.

Whirlpool of Conjecture

In 1842 a British activist used the new statistics to write a report on public health that shocked Britain. As the nation, mesmerized, watched itself under its new numbers microscope it saw that even babies born into the gentry couldn’t expect to live past 43. Those born into trades likely wouldn’t see 30. For those born into labor, the age of expected death was 22. In places like Liverpool, laborer life expectancy at birth was 15. Working life began at seven or younger. In Britain, rich or poor, for every one of us dying of old age or violence, eight of us died from disease. Over three-quarters of us died before turning 49. Britain’s new, cheap, steam-printed newspapers reported all those new statistics to their breathless readers. Naturally, the government sprang to help—it passed another slew of nearly toothless laws. Like the Admiralty facing scurvy earlier, Parliament’s first problem was ignorance of the true problem. So it turned to the doctors. But they had no idea what to do either—except to somehow make the smell go away.

By 1848 though Britain had other worries. It was ‘The Year of Revolutions’ in Europe. It was also the year that Karl Marx and Friedrich Engels published their The Communist Manifesto. Our industrial phase change was steaming ahead, stirring everything up, and the rumblings from below were getting louder and louder. Across Europe, two years of poor harvests, a potato blight, rising food prices, and a stock market crisis, led to revolt in France, then Italy, then most of Europe, and even as far away as Brazil. That year, too, cholera again hit Europe, then North America. It killed 60,000 in England that year, 14,137 in London alone. That was hardly news though. Influenza killed 50,000 in England that year. And a potato famine in Ireland was then busy killing a million Irish. At the time, mass death was normal for us, all over the world. Now, however, some of our deaths were finally being recorded and, sometimes, analyzed. That’s what led to change.

In 1852, William Farr, a doctor, datamined the government’s new staitstical data. He found that London’s cholera deaths followed the contour lines along the fetid Thames. How rich you were didn’t matter. The higher you were, the safer you were. That got Parliament’s attention. Farr suggested that they clean up the sewage-filled river. Westminster harrumphed into its muttonchop whiskers. A year later, cholera killed 10,738 Londoners. Another doctor, John Snow, mined the data. He traced nearly 500 deaths in ten days to one street’s water pump. But the pump wasn’t taking water from the smelly Thames. Maybe cholera was somehow carried in water? Maybe it had nothing to do with smell? The government did lots more nothing. Two years later came yet another outbreak. During that one, one water company piped fresh water into London. The others continued taking it from the fecal Thames. Snow crunched the new numbers. Few of that company’s customers died. Their neighbors all around them did. Still Westminster did nothing. Maybe sewage treatment would save lives, but it would also cost money.

Then, in the summer of 1858, sewage in the Thames grew so bad that Parliament fled the rooms nearest the river. The press thought that hilarious. By analogy with the Great Exhibition in 1851, they called it The Great Stink. Handkerchief-to-nose, Parliament rushed through funding for the sewerage engineers’ plans in a record 16 days. A quarter-million British deaths from cholera just from 1848 to 1854 was bearable. Making law in a stinky room wasn’t. Ahh, politics. Eight years later, the main engineering was done. That finally flushed out the problem. By the 1890s, cholera mostly avoided all industrial cities. By then they’d all revamped their sewerage. All that is, except Hamburg, which for political reasons had dithered over filtering its water. In 1892 cholera hit Hamburg, which still took its water straight from the Elbe. Its sister city, Altona, sand-filtered its water from the same river. When cholera struck Hamburg, it took nearly one in eight of us there. Killing 8,605 in six weeks, it spared Altona, except for killing 230 in one small area—which took its water from Hamburg. Even politicians had to pay attention to that.

But for Europe to defeat cholera it had to do more than lay sewer lines and put in steam engines to power them. It had to invent a whole new way of seeing disease. Replacing any age-old belief network (‘the poor are damned,’ ‘disease is sin,’ and so on) is never easy. It first means accepting our own ignorance and self-deception. Together, cholera and industrialization, as much as anything else, forced doctors in Europe and its descendant countries to abandon their old theories. They had to admit that they had no idea how disease worked. So they started turning the new numbers microscope on themselves. As they used statistics on their own practices, they found that bloodletting, the mainstay of European medicine, was mostly useless. But they couldn’t accept that. It would mean that they’d been killing us needlessly for over 22 centuries. So they blamed industrialization. They blamed urbanization. They blamed cholera. They blamed supposed changes in the earth’s magnetic and electric fields. In the 1850s they wailed that “all is darkness and confusion, vague theory, and a vain speculation. Is [cholera] a fungus, an insect, a miasm, an electrical disturbance, a deficiency of ozone, a morbid off-scouring from the intestinal canal? We know nothing; we are at sea in a whirlpool of conjecture.”

So why were they so confused? The problem was that cholera didn’t fit their network of beliefs about infectious disease. In the 1850s, Europe’s oldest model of illness held that air sometimes became charged with ‘miasma’ or ‘epidemic influence.’ It became malignant when combined with emissions from putrid or marshy ground. The resulting vapors caused disease. Most early Victorian doctors believed in miasma. After all, it went back over two millennia, at least as far as Hippocrates. It was also pliable enough to fit nearly any disease. That was why doctors focused so much on smells. Another model held that disease spontaneously formed in the blood. That belief went back at least as far as Aristotle. The youngest model held that the transfer of putrid matter caused disease. But that contagion model only arose late in the sixteenth century. It was largely the result of repeated plagues. Out of it grew the idea of quarantine. Few doctors believed in it though, because no one could find the said putrid matter. Plus, French doctors had dealt it a seemingly mortal blow in 1827 when they declared yellow fever non-contagious. Which isn’t surprising really, since it’s actually carried by a mosquito—but they didn’t know that. It couldn’t fit into any of their models.

To early Victorian medics, an upset stomach, food poisoning, diarrhea, and dysentery, were all ‘cholera.’ All were just milder forms of the latest virulent form, which they called ‘Asiatic cholera.’ To them, typhoid fever, paratyphoid fever, and typhus were the same disease. So they divided all fevers into just four types: typhus, intermittent, simple continued, and remittent. ‘Intermittent’ was really malaria. The rest were many kinds of infections all jumbled together, including malaria, typhoid, relapsing fever, and dysentery. And while a few of Europe’s proto-scientists had had microscopes strong enough to see microbes since 1673, most doctors in the 1850s still didn’t even bother to look. And most of the few who did couldn’t link what they saw to disease. After all, how could something so tiny affect us? The best analogy they could make was to a poison. But what poison could continue to kill no matter how much it was diluted?

If that question sounds dumb today, it surely wasn’t back then. Nor were those who questioned the new idea stupid. They also weren’t frauds or rogues. They couldn’t easily swallow germ theory any more than geologists could easily swallow continental drift. Nothing in their belief network supported it. On the other hand, they could easily swallow miasma theory just as paleontologists could easily swallow Piltdown Man. There was nothing then known that didn’t support it. Plus it pleased our mighty because it made them special.

Germ theory is easy for many of us today only because our species now has a lot of evidence for it, and a lot of experience with it. We’ve had cause—and time—to build up a self-consistent and self-perpetuating network of beliefs about it. We’re also taught about ‘germs’ when very young, so it’s a stigmeric part of today’s dogma. It’s not obvious otherwise. For instance, after 38 years of cholera research, Max von Pettenkofer was convinced that cholera microbes didn’t themselves cause the disease. So on October 7th, 1892, during the last Hamburg cholera outbreak, he drank a glass full of them. He had diarrhea, but didn’t die. His assistant repeated the trial before a hundred witnesses. He got very sick, but didn’t die either. Even today, we still can’t always predict who’ll get sick before they do. Three of us can swallow deadly microbes and none might die. One may be genetically predisposed to make lots of stomach acid. Another may habitually drink wine or cranberry juice. Yet another may have been previously infected. In the depths of our ignorance of our body, it’s hard to tell what’ll affect us because so many things can. So we fill the vacuum of our ignorance with politics and dogma. We believe what we choose to believe until absolutely forced to believe otherwise.

Today, many of us, especially in rich countries, want to believe that we’re past all that. Our past is a series of strides ‘forward’ leading to us today. And nothing will change now that today’s generation is here. None of that is true. Several of our earlier groups had far better sewage disposal than all of Europe and its colonies until recent times. Indians built a sophisticated sewage system 5,000 years ago. So did Iraqis 4,500 years ago. So did Cretans 4,000 years ago. Even the Romans, who were hardly famous for cleanliness, had a good one 2,400 years ago. All that was lost to Europe after Rome fell. Only in 1858 did Britain, our first industrial nation, lashed by cholera, and helped by the steam engine, reengineer its sewerage. That then spread all over the globe. Houses then became linked into the network we’re used to today: they became cells inside a body. Arterial pipes bore fresh water pumped from a reservoir that worked like a heart. Venous pipes bore waste water to a treatment plant that worked like a kidney. And after the century turned, chlorination removed all pathogens from our water supply.

In our poorer countries today, however, human dung is still important on our farms. And sewage treatment has yet to became widespread. Thus, the seventh cholera pandemic since 1817 started in 1961 in Indonesia. It then spread to Eastern Asia, Western Asia, and West Africa. It hit Peru in January 1991, probably from the bilge of a Chinese freighter. From there it spread to the rest of Central and South America, killing 11,338 by 1995. Peruvians alone suffered 651,130 cases and 4,581 deaths. (After a hundred years of no cholera, and encouraged by American environmentalists’ claims that chlorine compounds caused cancer, Peru had saved some money by reducing its chlorination.) We’re now in the middle of the eighth pandemic. In Africa alone, 16 nations are still suffering. And cholera is still endemic in India.

It took the combined force of both cholera and industrialization to break Europe’s millennia-old medical beliefs. Spiking populations, big cities, huge slums, and faster travel brought a jump in epidemics. Then came a new and terrifying disease. Britain’s brand new numbers microscope then showed its rulers the ravening face of future revolution. They panicked. The 1848 revolutions had shown that political chaos in Britain was possible, perhaps inevitable. Something had to be done. Then, seeing so many changes in our old ways being wrought around us by the spreading steam engine, our age-old belief network linking disease and sin suddenly shattered. Our health problems stopped being divine will. They became political problems. Our doctors were finally forced to confess that they had no idea what they were doing. That opening of Europe’s medical belief network was medicine’s turning point—not the huge leaps in therapy that were to start in the 1940s.

Fear, not foresight, not caring, drove Europe into both better sewerage and the germ theory. And millions of us had to die first. It wasn’t even fear of the disease itself that drove the change. It was fear of political chaos if the disease weren’t checked. Nor was fear itself the true cause of the change. It was only the trigger. We’re scared of loads of things. Had we not been switching from farming to industry at the same time, little would’ve changed. After all, little had changed in Europe after the Black Death five centuries before. And even today, little has changed in much of India. For us to forge a new network of reliable knowledge, many hammers have to hit the anvil at the same time.

Each of our deaths whispers something to us about the rules of the knowledge game we all unwittingly play against the cosmos. But we need not only the right tools but also the right belief network to hear through the thick blanket of our dogmas about how we wish to think the world works.

That’s still true today. What killed us for all those centuries, and what’s killing us today, isn’t cholera. It isn’t poor sewage treatment either. Nor is it stupidity, nor malice, nor callousness. It’s ignorance and self-deception. Even without sewage treatment, cholera is simple to treat—once we recognize it and know what to do. Nor would we have chosen to do much about it until it stopped being the wages of sin. It first had to leave the divine realm and become a practical and solvable—and politically vital—problem. We also couldn’t begin to destroy it until we had the tools and resources to do so. We needed statistics, first of all. We also needed better housing, higher wages, trade unions, paved roads, flush toilets, machine-made soap, steam drills, steam pumps, Portland cement... the list is long. And to get all those things we also needed to reduce our ignorance of what’s possible. Above all though we first had to see the real problem, not the one we in our ignorance had dreamed up long before. We had to understand that cholera, or any other disease, has little to do with sin, just as profit need have little to do with sin. To surmount that barrier, we first had to invent two kinds of sensors: the optical kind that revealed tiny images, and the statistical kind that revealed huge patterns. Both were important, but we changed only after the second. Once cholera and our industrial phase change forced us to look for mass effects of conditions and therapies, thus testing guesses against effects, our old beliefs withered. Millennia of medical ignorance died with them. That’s the fulcrum around which the whole history of today’s medicine turns.

Today, our medicine has lurched on—we’re now less ignorant and less wrong than before. We now have a whole new set of medical beliefs—but we’re still ignorant of many things. And cholera still kills, especially among our poor. That will change. We now know all 4,033,460 base pairs making up the cholera bacterium’s 3,885 genes. We’ve also sequenced our own genome. We now know all its 2.85 billion base pairs that make up our 20,000 or so genes. And we’ve been tracking cholera’s other hosts—oceanic zooplankton and freshwater shellfish—all around the globe. We’re now much closer to knowing all that there is to know about the interaction between our body and Vibrio cholerae. A broad-spectrum accommodation will follow. The unseen demon that killed so many of us for so long will finally shrivel and die. But our ignorance of everything else will continue to kill us.

A Plague of Ignorance

It’s eight o’clock in the morning of Monday February 2nd, 1685, and Charles II, England’s Restoration King, is having fits. Seven physicians spring into action. Living in a world where ‘humors’ determine disease, they take 16 ounces of blood from his right arm. Then they cut his left shoulder in three places and draw eight more ounces. The King stirs. So, naturally, they make him vomit with a violent emetic—antimony potassium tartrate, a poisonous corrosive, which we today use in insecticides. They follow that with an enema, then another one two hours later, then a purgative. Then they shave his head and apply camphor and mustard to raise blisters. For good measure, they add ‘Spanish Fly.’ It’s an aphrodisiac and diuretic. Charles regains consciousness. So, naturally, they give him another emetic, then sneezing powder, then another purgative “to keep the bowels open during the night.” Then they leave him to sleep, if he can.

The next day, Tuesday, 12 physicians crowd his bedside. They open both his jugular veins and draw ten more ounces of blood. Then they give him a julep of black cherry, peony, lavender, crushed pearls, and white sugar. On Wednesday he has more fits. They bleed him yet again. Then they give him 40 drops of an extract of powdered human skull from “an innocent man” who had met a violent death. On Thursday they bleed him yet again. purge him yet again, then give him yet another enema. Then they give him ‘Jesuit’s bark,’ which contains quinine—which would’ve been great if he’d had malaria. Then they force down the royal throat an “antidote containing extracts of all the herbs and animals of the kingdom.”

Around 11 o’clock the next morning, Friday, after a week of the best European life support available in 1685, Charles II died. He breathed his last in Whitehall Palace, a big, damp, old house on the Thames, only a few hundred yards from another rambling structure, Banqueting House. At Banqueting House 36 years before, at two o’clock in the afternoon of Tuesday January 30th, 1649, Cromwell’s army had made Charles’ father, Charles I, lie prone on a low wooden block. Then they hacked his head off. Perhaps that was a better way to go.

But times change, don’t they? That was over three centuries ago. Now it’s September 1940, and Albert Alexander, an Oxford policeman, is working in his garden when a rose thorn scratches his face. The scratch grows infected. By October, he’s in hospital. The infection has reached his eyes and scalp. But his doctors can do little. They hope for the best as they replace his pus-filled bandages. They know that half of all their septic patients will die. Hospitals are places you go to die. As his infection spreads, it raises pus-filled abscesses. Doctors drain them, but their cuts all over his face, scalp, and eyes then ooze more pus. By Monday February 3rd, 1941, his left eye is so infected they cut it out. His upper right arm is rotting away. His lungs are filling with pus. Something is eating him alive. The next Wednesday, February 12th, 1941, Oxford researchers inject him with 200 milligrams of something new—raw penicillin juice. He’s the first patient in the world to get it. They follow that with 300 milligrams every three hours. The new drug is so precious that they collect his urine and extract any unused penicillin. Within a day, he’s much better. After just eight injections, his face and scalp no longer ooze pus. His right eye and arm are mending. His 105 degree temperature comes down and he eats well for the first time in weeks. By Monday February 17th, he’s almost well. Then the minute supply of penicillin runs out. He dies a month later.

But still, that was over 60 years ago. We’re surely different today, aren’t we? Now it’s 1909, in Germany, and we’ve just developed our first real cure for syphilis. But the Russian Orthodox Church won’t hear of it. Syphilis is God’s curse for sin. The German police also don’t want it. They say that prostitutes, instead of conveniently dying, would only live on to spread more disease. Now it’s 1947 and penicillin stops syphilis dead—at least in rich countries. It’s now 1998 and we’ve sequenced its cause, Treponema pallidum. We now know all 1,138,006 base pairs making up its 1,041 genes. But the problem it triggers refuses to go away. Now it’s 1999, during Russia’s parliamentary elections. The Communist Party of the Russian Federation boasts that their anti-sex-education campaign is its most important political victory. The Russian Orthodox Church feels the same. Russia now has 263 known syphilis cases for every 100,000 people. The European average is about 3 in 100,000.

But that couldn’t happen anywhere, could it? Perhaps Russia is unusual. Now it’s 1932 and the United States Public Health Service begins lying to 399 poor black syphilitics in Tuskegee, Alabama. They keep lying for the next 40 years as they watch their patients die, one by one. They want to see how the disease will kill each of them. The disease spreads to the patients’ wives and newborn children. Too bad. The United States Center for Disease Control, the National Medical Association, and the American Medical Association, all support the study—as long as it’s kept quiet. It ends in October 1972 only because that’s when the story leaks to the press. Now it’s December 2007 and several countries, as well as 24 states in the United States, pass laws to force vaccination of preteen girls against cervical cancer, the second most common cancer in women worldwide. But many countries, and several states in the United States, choose not to pass such a law. The virus is sexually transmitted. And in the United States at least it’s the single most common sexually transmitted infection. The vaccine is best given before sexual activity begins. So the thinking goes that besides its newness and cost, if it were made mandatory, then teens might well have more sex. The fact that we all come equipped with genitals and a strong urge to put them to use still distorts our thinking.

We should pity our grandparents. From the beginning of history until yesterday, pain was a constant companion, for prostitute, for policeman, for potentate. For most of the 50 millennia of our species’ existence, if you had surgery it would be by someone who hadn’t been to a school for surgery. That someone might also cut your hair and nails. You also had to have friends to hold you down and stifle your screams. We had no anesthetics, other than alcohol or opium. Often, going under the knife meant dying of shock right then. Even if your operation were a success, you often died from blood poisoning soon after anyway. We had no antiseptics. Childbirth was a time of alcohol and close confinement and pain and frequent death. Sometimes, four out of every ten newborns died, and two out of every ten mothers did as well. We had no antibiotics, no antivirals, no vaccines. We also had no idea of microbes, viruses, prions. Plus, we had no understanding of hygiene, other than a warning about bad smells. And a scratch from a rose thorn could kill. All over the world, we cheap, disposable soap bubbles lived hard, died young, and in great pain.

Today we praise ourselves for our medical gains since then. But today our guesses about chronic disease, degeneration, and aging are roughly where our guesses about infection were in September, 1940. We have some good ideas about what’s causing them, but we don’t yet have the tech to stop them. Plus, just as with the Victorians, the Elizabethans, the early Egyptians, many of us think they’re unstoppable. Or, as with the Russian Orthodox Church, or many of us now deciding what to do about cervical cancer, that even if we could stop them, we shouldn’t. Our descendants will laugh at us. They’ll learn of our benighted times in their history lessons and gasp, just as we do today when reading of medical practice and medical knowledge anytime before 1953, when we finally discovered the structure of genes. They may also think up some cute medical name for what we today call ‘old age:’ perhaps advanced geriosis, or progressive thanatemia, or chronic cytotoxis. And they’ll chortle over today’s crude diagnostic tools and therapies. With so few doctors among us, few of us can see one regularly. But even if we each could have one chained to the kitchen table, we still wouldn’t know enough about the state of our own bodies to report a problem until it became serious. The deathrate among doctors themselves shows that even daily checkups would add no more than a handful of years of life.

Our grandchildren will pity us. Today’s diagnostic techniques are about as accurate as an elephant trying to play the piano. Our healer-priests, with only indirect ways to figure out what might be wrong, must ask about our families and habits. From that, they guess at our possible ailments. Then they poke us and scrape us and puncture us, all to guess the simplest measures of our health. They then feed us drugs that tumble through our body, destroying or altering many millions of perfectly fine cells. Often, less than one percent of a drug hits the right area. The remaining 99 percent ends up in our liver and kidneys, with potentially toxic results. When something more serious goes wrong, healer-priests with knives slit us open. They remove some of our subsystems, functioning and malfunctioning alike. Then they stitch us up, like old shoes. We lose a limb and they sew it back on like Frankenstein’s monster. Then they give us immunosuppressants, hoping our nerves regrow. We damage our spine and our healer-priests are helpless. Suddenly we can no longer control whole regions of our body. A small blood vessel bursts in our brain and all is lost. When it comes to information we’re still deep in our later middle ages, with our own bodies still undiscovered countries. All that may well change soon because we’ve already entered a new non-linear medical phase change. We’re beginning to take control of our own bodies.

This You Can Cure

As an economist might put it, when any surgical incision has a 50-50 chance of killing you, medical data is too costly to buy. We have to spend too many lives to gain only a little more knowledge. So dogma must rule. That’s been true for most of the 50,000 years of our existence as a species. That cost cheapened only after circumstances forced us to break some of our taboos and let ourselves look into our own corpses. It cheapened again after we started staring at ourselves with statistics. Then it grew cheaper yet after we discovered antiseptics, antibiotics, anesthesia, and so forth. The parts of our medicine today that are cheap, precise, and preventive are so largely because we’ve reduced our ignorance and self-deception about them. We no longer see them as demons punishing sin. Well, not always anyway. Well, not all of us anyway. But medical data is still far too costly. We still have to sacrifice too many millions of our lives to gain even a little more knowledge about our own bodies.

Before 1922, if you were diagnosed as diabetic it was a death sentence. Something had gone wrong in your body and no matter what you did to quench your constant hunger and thirst, it was shortly going to starve itself to death. Egyptian healers 3,500 years ago had treatments, but no cure. Then in 1889 we discovered something of how insulin works. Then we figured out how to extract it from dogs. By 1922, we had enough of it to try it on ourselves. Miracle treatments followed. But the treatments weren’t cheap. Nor were they always safe. Plus, the disease still killed, although it took far longer. By 1978, we’d figured out how to engineer microbes to make human insulin. We solved problem after problem until we could control diabetes with relatively cheap drugs. In 2008 came the first actual cure in mice. Despite our working on the problem for at least 3,500 years, almost everything we know about it we learned in the last ten years. One day, we’ll solve the problem completely. By then, we’ll realize that diabetes isn’t really about blood sugar or insulin, it’s an information disease. It’s ignorance that kills us.

All disease starts as something we don’t know, can’t see, and can’t reach. Axes-to-the-head aside, all our medical problems start with only a few cells. Catching them at that stage would make our medicine cheaper, more precise, more preventive. To do that though we first need better tools. We need better sensors (to detect problems), better scanners (to see problems), and better therapies (to fix problems). Plus we have to do a hard thing: we have to use them. The technical engineering isn’t the problem. The political engineering needed to change our current belief network, is. Today’s debate over cloning springs to mind.

The easiest technical problem is detection. To catch disease early we need cheap and small body watchers. Right now most monitoring devices are big and expensive. They lurk only in hospitals and big clinics. Few are even on the consumer market yet. Once demand rises though we might watch ourselves by tooling up our toilets and showers and beds. Some of our rich, especially in Japan, already do so. We might then monitor our gastrointestinal system’s albumin count, our blood cell count, and our insulin and glucose counts. Then we might monitor heart rate, blood pressure, temperature, carbon dioxide exhalation, skin conductivity, circadian rhythms. Instead of today’s data desert, we’d be living in a data ocean.

A few of our elderly rich already have such watchers. So do astronauts, patients in surgery, the critically ill, and premature babies. Some watchers are already tiny enough to go into armbands and bracelets. What they aren’t is cheap. Today’s ever shrinking computer technology though will cut both their size and their cost. Then they’ll move to the home, perhaps for us to stick a finger into each morning, or to mount on our body. Some of us may even tool ourselves up internally. We’ll watch our blood, breath, guts, glands. One day, as the technology shrinks further, we might get all that data from surface measurements with a pendant or earring or tongue stud. Within a decade, your watch may watch you.

The second technical problem is scanning. It’s not enough to have cheap and small watchers. They might let us gauge everything precisely: every pill, every mouthful of food, every insect bite, every spray of pesticide. But once they detect a potential problem our clinics will still need cheap and small scanners to map our body before treatment. Today’s highest-resolution ones are still too costly, power-hungry, finicky, bulky, or unsafe for routine use. Today they mostly live in big hospitals in big cities in rich countries. Our doctors use them only for cancers or heart or brain abnormalities, and then it’s often only to stage an invasive procedure after a biopsy has detected a problem. For example, cancer survival rates have been rising at better than two percent a year for the past decade. Both our knowledge and our surgical tools have grown more precise over that time. But with our still bulky and costly scanners, by the time we can see a problem well enough to fix it it’s already dangerous. And that’s even if our clinics were to use today’s most expensive scanners for regular checkups. Which they don’t.

Like our watchers, our scanners are still too big and expensive. Only specialists can use them. They’re about where computers were 20 years ago. Scanning, though, is akin to examining a high-resolution picture of a glittering chandelier hanging in a packed ballroom and reconstructing a picture of the hidden photographer by recombining the microreflections in each of the chandelier’s tiny facets. So as with today’s watchers, today’s scanners mainly depend on our computing horsepower. As that power rises, their resolution can rise even without changing them physically. Scanners are also moving to digital media now that our computers can store high-resolution movies cheaply. So abnormality detection is moving from the radiologist to the computer. But that migration will take a while. Changes in medical tools only partly depend on computing and engineering. Mostly they depend on paying off old tools, calibrating new tools, training new specialists, and, above all, changing the habits of our doctors. Still, by applying more computing firepower, we’re already making scanners more sensitive. Within a decade or two, they might come with their own built-in synthetic radiologist. Ultrasound and infrared ones might even become as small and cheap as today’s high-priced cameras.

The hardest technical problem is therapy. It’s not enough to have cheap and small watchers and scanners. Together they may let us detect, then map, our medical problems early, and that alone would revolutionize medicine. But without cheap and small tools to effect bodily change, they can only aid diagnosis and prevention. Further, for the next few decades many of us won’t know of, won’t be able to afford, or will think repugnant the new tech. So direct intervention for illness (and injuries) will remain important for decades to come.

Today’s medical therapies are still both costly and crude. Drugs and surgery, and most other of our current medical interventions, affect whole organs or systems. That’ll remain true for decades, even though, once again, our computers are now changing those limits fast. For example, tissue engineering is maturing quickly now that we’ve learned enough to be able to grow cloned cells into replacement organs outside the body. We’re now able to create some whole organs. In 2006 we transplanted our first lab-grown organ—it’s a bladder. In 2007 we created our first stem cells from simple skin cells. Some cancers will soon be a thing of the past—at least for our rich. But we still need surgeons to implant those new organs and cells. Today’s smart drugs, however, don’t need surgeons. They’re microscopic. They have cellular homing devices on their surfaces like immune system antigens. So they only mate with specific cells. They also carry fusogenic agents like viruses do. So they inject their drug payload or radioactive cargo into single, specific cells. They also have timed biodegradable polymer or liposome skins. So unlike normal drugs, the body can’t scavenge them too early. In short, they’re cellular letterbombs, targeting only misbehaving cells. They’re fast, cheap, tiny, high-precision surgeons. In contrast, human surgeons are few, costly, big, slow, and stressed.

But designing smart drugs for each disease is truly hard. It depends on mastering proteomics, and that we haven’t done yet. So likely we’ll do what we did with cholera. First we’ll find a solution (sewerage) then find out what the problem was that the solution solved (microbes). In other words, to deal with cancers, for example, we might first simply replace whole organs, then later develop more precisely targeted smart drugs. As we hit the problem with our computational hammer, and as our hammer gets bigger and bigger, the problem must one day crack. We’ll then aid our damaged systems in place. Then we’ll move down to the cellular level, fixing problems as soon as they arise. Once molecular robots or synthetic cells become cheap enough and smart enough, they’ll become our next generation surgeons. That’s medicine’s long-term future. But even with our current computer speed up it’s a long way off. We’re first likely to get it for a few common disorders that rich people suffer, like cancers and heart disease. Other disease will take longer. One day though your doctor may tell you that your smart bracelet thinks that you’re coming down with liver cancer—and your watch and your shoes agree. Then she’ll show you the tiny abnormality using your own scanner. Then she’ll hand you a pill, crafted in her office and tailored specifically for you. She’d do the same if it were any other minor medical hiccup like a cold or arthritis or Alzheimer’s.

Today though that future is only a foolish technocrat’s daydream. We never change our belief network that easily. Our medicine is now increasing in power so non-linearly, and its rate of change is itself increasing so non-linearly, that everything before last month is quickly turning into a shapeless ‘past’—some benighted past time when brutes roamed the earth with clubs and they tried to heal each other with the same clubs. Today we’re already putting the Victorians in with the Elizabethans and stuffing them all into the same bag that we keep the early Egyptians in. Soon we’ll be putting the entire twentieth century in that same bag. But that same ‘past’ still has much to teach us about how we’ll face our future. While our new medicine will surely come, and likely very soon, we won’t adopt it smoothly. Some of us may be against it on emotional grounds. Some of us may hack it to control or kill others. Or to subvert it for insurance purposes, or for better sex, or to get a new kind of drug high, or simply to get a few days off work. Some of us may pay too much attention to our new bodily data flow, tracking each swing so hard that our bodies go into hystersis. Others may kill ourselves thanks to faulty readings, network failure, buggy code, sheer stupidity. The new tools will also need programmers and surgeons. And they’ll make the usual mistakes. Some of those mistakes will kill. Lawsuits will follow. Fear will grow. Nay-sayers will be gleeful. Delay will set in.

Further, our governments, firms, police, and stalkers will line up to dip their pails in the new data river for reasons of their own. Also, at first the new tools will be pricey. Our poor will grow ever angrier as they watch our rich live to ever older, and ever more illness-free, ages. So if our new personal medical tools are easily removable, they’d just become something new for thieves to steal. And if they’re only removable by, for example, sawing off a finger or ear or tongue, then some muggings will become more extreme, as would the police response. Support vats for body parts, with their costly technology still attached, would then become the new underground trade item. Police surveillance would step up. So would the public’s reaction. Dogs and cats living together! Mass hysteria!

Or, at least, all those things are what our media will report as the main effects of the new tools. They’ll ignore the thousands, then millions of us who’ll be living ever longer, ever healthier lives. That’s too boring to be news. Even when our new medical tech finally drops to the price of shoes, and becomes as common as soap, many of us, and not just our poor, will continue with what we know—doctors as health inspectors and disease as sin. Likely that won’t change until after some new medical calamity or the other forces us to reconsider our options. All of which is why some of us see that technology changes nothing, while others of us understand that technology changes everything.

However it happens, and whatever changes it might bring, it can’t happen next Tuesday. Given our medical caution, each change will take time. Given historical evidence, at first many of us won’t accept them. Given economic reality, the biggest hospitals in the largest cities of our richest countries will have each new layer of tools first. Given political reality, each new layer will lead to much conflict. But thanks to the computer, our medical knowledge is compounding so fast today that cheap, preventive, high-precision, non-invasive medicine may be only decades away for many diseases of the rich, and perhaps another decade or so away for many others. Sometime this century, our near total ignorance and lack of control of our own body might end for good. At least for those of us in rich lands.

In Egypt 5,000 years ago we contended with demons we couldn’t see, couldn’t understand, and, mostly, couldn’t control. That era is now passing. Today we’re learning more and more about our bodies and the cosmos we live in. In the time of Hippocrates, 2,400 years ago, many of us in Greece believed that all things were made of four essences: earth, air, fire, water. Following Aristotle, Europe’s medieval alchemists also believed in a fifth essence, the quintessence. It made up the heavenly bodies and was latent in all things. They made extracting the quintessence one of their chief tasks. They failed. We won’t. Today we know the quintessence. It’s information. That, not matter, not energy, is today’s alchemy, and it’s a philosopher’s stone that we can apply to everything around us, not just our medicine.

In sum, the demon that medicine contends with on our behalf isn’t illness. It’s ignorance and self-deception. What we don’t know is what kills us, not disability, degeneration, or disease. Those are just the names we give to the many areas of our body’s malfunctioning that we can’t yet see, don’t yet understand, or can’t yet control. Today we can cure scurvy and cholera with a bag of oranges and a case of Gatorade. We know what the problem is, and what to do about it. Today too though, millions of us still die for want of such simple things. And decades hence that’ll still be true. Further, even when we have the knowledge, for political or emotional reasons we often still don’t apply it everywhere. So the rich will have it and the poor won’t—until the poor can afford it, or until the rich can figure out how to cheapen it enough to avoid being attacked for it. Likely, that won’t happen until we build up enough spare resources so that the middle classes of all our nations grow sufficiently large and well-off enough. That’ll then bring about widespread changes in our living conditions. But it’ll take time—a long time—for the selfish habits of yesteryear, serving us so well for so long, are hard to break.