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I was recently at a meetup with some Slate Star Codex readers, and I decided to bring up my impressions of The Deep Places by Ross Douthat, which I had recently read and reviewed. For those who may have missed the review, the book was a chronicle of Douthat’s struggles with chronic Lyme disease (CLD). The problem, both in the wider world and at the meetup, is that there are serious questions about the reality of this condition. Or as Wikipedia says:
Despite numerous studies, there is no evidence that symptoms associated with CLD are caused by any persistent infection…
From this we might say that in “reality”, at least as constructed by most doctors and at least some of the people attending the aforementioned meetup, CLD does not exist. According to them, Douthat was not suffering because he still had Borrelia burgdorferi bacteria (the cause of Lyme disease) in his body. On the other hand, the “reality” Douthat constructed asserts the exact opposite.
Recently this business of reality construction, or more formally, the discipline of epistemology, has become a lot more complicated, and for me the primary appeal of Douthat’s book was that he explained the minutia of his reality construction project—down to the studs as they say. His own journey from CLD doubter to CLD believer, and all the empirical evidence he collected which supported this transition.
One assumes that when the doctors and the participants of the meetup take issue with the existence of CLD that they are taking issue with this journey, and the manner in which Douthat has gone about constructing this reality. These issues presumably extend to other sufferers, and of course the rogue doctors who do believe in the existence of CLD.
We’ll get to the conflict within the healthcare establishment in a bit, but first I want to consider the pushback I got at the meetup. I’ll confess I was surprised by the certainty that was exhibited. First I would think that someone’s priors on the assertion “mainstream medicine never makes mistakes” would have taken a significant hit during the pandemic. Second, the people pushing back weren’t dogmatically committed to all of the claims of mainstream medicine. More than one fringe idea had already been asserted as being true by the people pushing back.
For example, one of the most vociferous anti-CLD arguments came from someone who had already claimed that soap doesn’t work. So in the reality he had constructed, CLD was all in one’s head, but so were the benefits of using soap when showering. Of course both things may be true in some objective sense, but I’m interested in how he arrived at each of them given that one—his rejection of CLD—is totally in line with constructing reality using the “lumber” of medical authorities, while the other—his rejection of soap—is the exact opposite. But of course these days one has all sorts of material to choose from when constructing a reality, and perhaps his technique for getting at “truth” involves using different material depending on the seriousness of the subject (is this a load bearing wall?) and the quality of the evidence. And perhaps one can construct a perfectly secure foundation upon which both facts can rest.
The point is not to criticize his particular construction methodology, but to point out how many methodologies the modern world has given us, and the difficulty of determining which of them to use, particularly since combining different ones may in fact produce the best results.
To use Douthat as an example of how things have changed. In the not too distant past he would have had a handful of doctors available to consult, who had a handful of medicines to recommend, and that was it. These days the number of specialized doctors has multiplied, and some of them might have a podcast or a blog. The number of medicines has also vastly increased. To this can be added a nearly infinite variety of supplements. Douthat could also exchange info with sufferers from all over the world on social media. And even if he’s trying to be exceptionally rigorous and go straight to scientific papers, there are hundreds of those as well. Beyond all this, perhaps the biggest change is that Lyme disease only became endemic over the last 50 years.
On the other hand, it could be argued that having so many methodologies and materials to choose from has been, on net, a bad thing. That having wide agreement on something that’s 80% true may be better for society than having the ability for a small number of people to get to 99% truth.
Before moving on, I should hasten to add that while I used this one person as an example, I’m not in any sense trying to make him look bad or prove him wrong. In fact part of my point is that without coming to a consensus on a decision making framework it might not even be possible to “prove” him wrong. Also I like this guy, he’s obviously smart, probably smarter than me. And interestingly enough he wasn’t even the only “anti-soaper” at the meetup. What I’m mostly interested in is how the construction of reality and the pursuit of truth has become so fractured recently.
Obviously Douthat is not the only person trying to get down to the “studs” of reality, and I thought his book was interesting and useful not only because of its detail, but because of its subject matter. Discussing the “reality” of a disease would appear to be more tractable than a discussion of the “reality” of racism. While we might someday discover a way of detecting lingering Borrelia burgdorferi bacteria in sufferers of CLD, we are unlikely to come up with some similar methodology for detecting racial animus in the human soul. Also, everyone is currently involved in their own, similar reality construction project with respect to COVID, and many of the questions Douthat was asking about CLD are being asked in various forms by billions of people and thousands of organizations.
As interesting as it might be to wade into that mess, it might be more productive to look at how reality was constructed during the 1918 flu pandemic.
Obviously the tools available to doctors in 1918 were much more limited than the tools we have available now. Vaccination was still in its infancy, and the first flu vaccine was still 20 years away. But they did have some drugs available. In particular, people tried using aspirin and quinine to combat the disease. Hydroxychloroquine is a synthetic version of quinine, which provides one of the many fascinating parallels between the two pandemics. In both cases, the best science says that they were/are ineffective. The story of aspirin, however, is where it gets interesting.
Aspirin had not been around for very long at this point, and it truly was (and still is) kind of a wonder drug, but there was also a lot that wasn’t understood about it. Doctors, unable to do much of anything else, recommended that people take a lot of aspirin—as in an amount that these days is considered dangerous. Meaning that overuse of aspirin may have contributed to the death rate. This idea was first proposed in a 2009 paper, and it’s worth quoting the abstract of that paper in full:
The high case-fatality rate—especially among young adults—during the 1918–1919 influenza pandemic is incompletely understood. Although late deaths showed bacterial pneumonia, early deaths exhibited extremely “wet,” sometimes hemorrhagic lungs. The hypothesis presented herein is that aspirin contributed to the incidence and severity of viral pathology, bacterial infection, and death, because physicians of the day were unaware that the regimens (8.0–31.2 g per day) produce levels associated with hyperventilation and pulmonary edema in 33% and 3% of recipients, respectively. Recently, pulmonary edema was found at autopsy in 46% of 26 salicylate-intoxicated adults. Experimentally, salicylates increase lung fluid and protein levels and impair mucociliary clearance. In 1918, the US Surgeon General, the US Navy, and the Journal of the American Medical Association recommended use of aspirin just before the October death spike. If these recommendations were followed, and if pulmonary edema occurred in 3% of persons, a significant proportion of the deaths may be attributable to aspirin.
I only uncovered this fascinating bit of information in the course of writing this post. Which was surprising, I would have thought that it would be one of the major pieces of evidence brought forward by the anti-medical establishment crowd. (And maybe it is and I just missed it.) I am not interested in using it in this fashion. I’m more interested in using it to illustrate the differences between now and then. Back then there were conspiracy theories about aspirin killing people, but they all revolved around the idea that aspirin was made by Bayer and Bayer was a German company. And, when the Spanish Flu emerged, and during that October death spike, we were still at war with Germany. We know now that they were right to be cautious about aspirin (though for the wrong reasons), but it took until 2009 for us to figure out the “reality” of the situation.
Not only is this example more productive because it avoids current, unresolved controversies, it’s productive because it provides a contrast between the reality construction materials available in 1918 and those available today. The primary difference being of course the scarcity of our metaphorical construction materials back then as compared to the abundance we currently possess. In 1918, authority and science were far more monolithic. The number of potential treatments was far smaller. To the extent people were looking for nefarious schemes the narrative of these schemes was simpler. “We’re at war with Germany! They must be behind it!” But of all the differences perhaps the most consequential is that there was far, far, far less data.
Had the same thing played out during the current pandemic (and it has though perhaps in reverse with ivermectin) there might still be people blaming the Germans, but they would also be blaming the Chinese and the Russians, Big Pharma, and Bill Gates. There would also be people pointing out the results of past studies about the harms of aspirin; new studies would be conducted,and huge debates would erupt over the methodology of all of these studies and their statistical significance. Some people would start refusing to take any aspirin for any reason and some would make it a point of pride to take exactly the recommended dosage. There would be pro- and anti- aspirin blogs, and subreddits and message boards and personalities dedicated to each side.
The big advantage of all the data, of all the methodologies, of all the reality construction materials available to us, is that unlike the doctors of 1918 we would almost certainly uncover the truth. We would also uncover 99 other explanations for things that weren’t the truth, and some people, perhaps many, would have a hard time deciding which of the 100 explanations to believe. Now to be fair, I’m probably exaggerating the uncertainty. Our science is powerful enough that we would reach consensus on the harmful effects of taking 31 grams of aspirin (31 grams!! I still can’t get over that) pretty quickly. But here we arrive at another difference between today and 1918. We have plucked all the low hanging fruit. In those places where reality was straightforward to construct it has already been built. The questions we need to form opinions on today are far more subtle.
As I was writing this post I finished reading Why Liberalism Failed, by Patrick Deenen. (You can find my review here.) As is so often the case, after coming across a new idea, you’re tempted to think it explains everything. It almost certainly doesn’t, it’s just the idea is recent, but while that’s the case I’m going to dig into what it explains about this problem. Deenen makes a particular point of talking about the bifurcation of liberalism, that there is a massive increase in individualism coupled with a massive increase in government authority. While this split manifests in lots of different ways, I think the problems Deenen describes mostly stem from how this results in two different levels of reality construction. We have pushed it to the very highest levels as well as to the deepest recesses of the soul.
The promise of science is that if we devote enough resources toward answering a particular question we can arrive at the Truth, or at least an answer with a high probability of being true. When the question is “What are the effects of taking 31 grams of aspirin every day?” our methodology works pretty well. But what about the effects of taking less than 100 milligrams a day? Since 2007 doctors have recommended that people over 40 with a heightened risk of cardiovascular disease take a small daily dose of aspirin, generally in the 75 mg to 100 mg range. But now 15 years later they have backed off of the recommendation somewhat, particularly for older individuals, recommending that people over 70 avoid it entirely.
I and others have written about the difficulties of creating a broad scientific consensus, so I don’t want to spend too much time rehashing that, but the presence and difficulty of such efforts should be kept in mind as we continue our exploration of how people construct the reality of their own lives, of what happens in the “deepest recesses of the soul”. Here again disease, and more broadly health and wellness in general, provide a great arena for this investigation.
The internet has empowered individual reality construction to a remarkable degree, but when considering health and wellness what’s striking is the degree to which it has also legitimated these individualized efforts. If you tell someone that you found some advice online or a technique or some other wisdom and you tried it out and it made you feel better, most people would, at minimum, applaud you for being proactive and responsible. Beyond that, even if they had doubts about whether a particular bit of wisdom was actually backed by science, a majority would nevertheless congratulate you on your improved sense of well-being. The assumption being that however bizarre your beliefs, how could they ever be more of an authority on your health than you are?
This is the other big thing about individual health and wellness: the empiricism is individual as well. To return to the anti-soapers, this appears to be what happened. They discovered some advice on the internet that recommended showering without soap. Something that would never have happened 30 years ago. They then tried it out, did their own n=1 experiment and decided that it produced a better outcome as far as health, and moved to make it part of their lifestyle. And as I mentioned it’s weird that at least one of them (maybe both, I don’t recall) objected to Douthat’s description of CLD, because that’s precisely what he did as well, only he spent much more time and went much deeper with his efforts.
In my review of Douthat’s book I ended with some questions for those who doubted his assessment. I’m going to end this section and begin the next by revisiting them.
First, the question I’m most curious about: what do these people (the doubters) imagine they would do if they were in Douthat’s shoes? If they had the same symptoms and those symptoms all responded in the same way to the same things? Would they still not believe in CLD? Or do they imagine that it couldn’t happen to them and thus the question is irrelevant? (Asserting their own immunity seems to be something of a matter of faith so we should probably set it aside.) Finally, what do they think is going on? Even if you believe that it’s all in someone’s head, which I think is what the guy from the meetup was claiming, you’re still unlikely to think that the right argument or the right set of facts will make someone go from experiencing symptoms to not experiencing them. (“This brochure cured me!”) Particularly given that the person suffering from the disease is probably, as illustrated by Douthat, actually open to any argument if it will just bring them relief.
Still, I would be interested in taking a closer look at any advice the person might have on alternative reality construction methods Douthat should have used instead of the one he did. Because I think he tried most of them, which is another thing that made the book so impactful for me. Douthat starts with the mainstream view of CLD, he really wants to believe there’s no such thing, it’s only when his symptoms persist that he is eventually convinced. Which is why I’m so curious what doubters imagine they would do if they were in Douthat’s shoes.
It’s time to finally jump from diseases to a broader discussion of the problems of reality construction. Which takes us to the next question from my review. What is your position on fringe diseases and other fringe beliefs? Do your views entirely conform to those held by the mainstream medical establishment?
To come at it from a different angle, we can imagine that there are some problems that are basically part of everyone’s reality: flu, cancer or broken bones as diagnosed by an x-ray. And then there are health issues almost no one thinks are real, like electromagnetic hypersensitivity (If you’ve seen the TV show Better Call Saul it’s what his brother Chuck suffers from.) But then there is clearly a large gray area between these two extremes.
Where does one draw the line between real problems and fake problems? Your first impulse might be to make an argument around evidence and data. Or if either of those is insufficient, to gather more. To draw the line by referring to science or conducting more of it. If you really wanted to go the extra mile you could assign probabilities, perhaps as some sort of Bayesian exercise. This brings me to another question from my review: When someone says they don’t believe in CLD or for that matter electromagnetic hypersensitivity, what certainty level does this equate to? 51%? 90%? 100%? How certain are they that it’s made up? It might be said that my chief argument for this post is that modernity rather than delivering certainty has ended up burning it under a mountain of data subject to endless revisions. And it might be said that my chief argument with respect to Douthat’s book is that it should be impossible for someone to read it and reach the end possessing the same certainty they had going in.
What does one do with this large area in the middle? With diseases that are neither completely understood, nor obviously in someone’s head? Or to expand it out, most people obviously believe that COVID is real, but there’s still a huge debate over how dangerous it is, how best to deal with it, and whether such measures have unintended consequences, debates which I won’t rehash here. Beyond that is a whole universe of issues unrelated to disease where the science isn’t clear.
We have long imagined that the tools of modernity, most especially science, would allow us to increase our certainty and end these debates. That they would make us better at the business of reality construction. But it seems increasingly clear that the opposite has happened. Why is that?
I’ll conclude by trying to gather together the elements I have already discussed, while also introducing a couple of new ones:
- All of the problems we have left are subtle ones: We have picked all the low-hanging fruit and now all that’s left are issues where the data is messy and hard to collect.
- People recognize the power of science and so it’s become a weapon: This can range from researchers trying to make a name for themselves with exciting results to science being twisted to political ends.
- The bifurcation: We have individuals who feel empowered to collect and disseminate their own “science” on the one hand, and the government trying to generalize all data into something they can recommend universally. The former generates too much nuance, the latter too little.
- The flood of data: Closely related to the above, we have an enormous quantity and variety of reality construction tools available to us. Not only are there the standard observations about the internet, but we’re also doing far more science. There are dozens of studies just on the effectiveness of ivermectin.
- What’s possible: Something I haven’t seen mentioned a lot, and perhaps it deserves its own post: modernity has increased the number of possible realities. In 1918 you could imagine that the flu was a disease or you could imagine that Bayer was doing something to aspirin tablets, and really only the first withstood scrutiny. These days you can imagine that COVID is natural, that it’s a natural virus which leaked from a lab, that it’s an artificial virus which was created using gain of function research which then leaked from a lab, or possibly something else, and find plenty of data to support any conclusion. Beyond that because we have DNA-sequencing and can identify how different omicron is, it’s possible to have an entirely different set of answers for this variant vs. the alpha variant. And I’m just scratching the surface.
Modernity has given us far more tools and far more materials with which to construct our individual realities. Some have taken these tools and materials and done great things with them. But some have taken them and used them in unintended and strange ways. By and large because reality construction has become so tricky, we’ve mostly gotten a lot worse at it, both individually and collectively. And if we can’t build a secure and consensual “reality”, well… we’re not going to be doing much of anything else either.
COVID spelt backwards is DIVOC and as our own battle against COVID seems to be traveling that direction it’s worth asking what DIVOC going on. Thank you folks, I’m here every week. If you appreciate that, consider donating.