Dear Friends,
I’m in Estonia this week for the Open Government Partnership Summit and I’m tripping out over how much the world has changed since I first attended the event in Brazil in 2012.
Dilma Rousseff had just been elected president and celebrated budget transparency in her welcoming address while Hilary Clinton followed with remarks about the importance of earning the trust of citizens. In my personal life, Iris and I had just started living together in Mexico City and days before my trip we adopted Coco as a tiny puppy.
Brazil was emerging as the second-biggest economy in the Western Hemisphere, and a global powerhouse. Their GDP more than doubled over the previous decade. They were preparing to host the World Cup in 2014 and the Olympics in 2016.1
It blows my mind that just three years after her comments about budget transparency, Rousseff was impeached precisely for violating budget laws. Then in 2016, Clinton lost the election to Trump, and Lula was sent to prison for corruption. By 2019, Bolsonaro became president (until losing to Lula last year). And now you’re telling me that Trump could make a comeback? It’s all too wild to believe — yet another reminder that life is stranger than fiction.
Are men afraid of doctors? And what does it cost taxpayers?
My health insurance expires at the end of October (just as we move back to Mexico) and so I’ve gone all-in on what I’m calling my “100,000-mile check-up.” This includes:
Bloodwork — cholesterol levels, etc.
Colorectal cancer screening (Cologuard poop test)
PSA prostate cancer screening
Coronary calcium scan to measure my risk of heart disease
Skin cancer screening by a dermatologist
DEXA scan to measure bone density, visceral fat, and body composition
Men are notorious for avoiding doctor visits and ignoring our health. In every country, women live longer, healthier lives. Worldwide, men aged 15-40 are three times as likely to die as women. If you are a 34-year-old man in the United States, you have a 16% chance on average of dying from heart disease, cancer, diabetes, or lung disease before you turn 70. If you are a woman of the same age, it’s only 11%.2 New research in the UK found that men are twice as likely to die from a heart attack. (The government pleaded with men to “get a grip on their lifestyle” and began offering blood pressure check-ups at barber shops.)3
How we choose to look after our health is personal, but the financial implications affect us all. For instance, five percent of Medicaid “super-users” account for over half of the program’s cost.4 And so, in an attempt to lower costs, doctors are now given annual salary bonuses based on the percentage of their patients who take preventative screenings, including cancer screenings.
Longevity coaches and the cancer screening debate
That sounds like a good thing, right? Why not avoid the high cost of treating cancer by detecting it first? But as I prepared for my cancer screenings, I discovered that it’s a topic of raging debate with a growing chorus of critics like
who argue that we ought to be doing less cancer screening.5 On the other side of the debate is Peter Attia, a longevity doctor and podcaster who advises his clients to get screened for cancer every year!6Last week I went for a hike with a friend who was diagnosed with colorectal cancer in 2020 at the age of 37. He had his entire colon removed and rather miraculously is now cancer-free and able to go on weeks-long backpacking trips. In fact, he’s one of the most fit and energetic guys I know. We talked about the Black Panther actor Chadwick Boseman, who was diagnosed with stage-3 colon cancer at 39 years old before passing away four years later. And we discussed our own approaches to cancer screening amidst calls for less of it.7
Here’s my reasoning for getting the tests: Even if I have cancer and the test fails to detect it, is that any different from not taking the test at all? And in the case that I don’t have cancer but receive a false positive, that will merely prompt another, more sensitive test to determine whether treatment makes sense (and oftentimes it seems that it doesn’t). I get that some people react to cancer diagnoses with exaggerated alarm which leads to overly aggressive treatments. But that’s not me, and I’m glad that I have the freedom to choose what works for me.
Am I afraid of death?
For whatever reason, I’m not afraid of doctors or dentists. But am I afraid of death? I’ve been thinking about it over the past couple of weeks as I prepared my will, envisioned my funeral, and now await the results of my cancer screenings. Does all of this come down to me trying to control something — when and how I die and what happens next — that is truly out of my control?
After Steven Pinker published Enlightenment Now, his case for “reason, science, humanism, and progress,” he was asked by David Marchese about the least rational activities in his own life. Cycling was at the top of the list.8 A lifetime avid cyclist, he asks himself:
“Given the value you put on your life and the fact that there’s even a very small probability of getting killed, does it outweigh the pleasure and health benefits from continuing to ride?”
Last week I wrote about the 0.3% chance that I will die in the next year. Of course, that is on average. Our true individual risk is some combination of genetics, access to healthcare, and where and how we live.
Insurance and healthcare companies are already using AI to come up with personalized risk profiles for each unique person. Auto insurers offer lower premiums based on devices and cameras that monitor how people drive. And Estonia (where I am this week!) uses digital health records to make personalized recommendations based on risk profiles. In the next decade, I’m sure we’ll all have personalized reports about our unique likelihood of disease, injury, and death. For me, I’m sure that cycling will be at the top of my risk list. Are you sure it’s worth it, the AI will ask.
Absolutely. Why live long if I’m not having fun?
I hope you have a great week,
David
PS: 8 years ago today, I married the woman of my dreams surrounded by loved ones in Seattle’s Golden Gardens Park just before the rain started to fall. For most of my 20s, I thought I was against weddings and marriage too, but I’ve learned that it’s good to change one’s mind from time to time.
I met so many smart 30-somethings working in government at that conference back in 2012 and assumed they’d be presidents and ministers in their 40s — kind of like Prime Minister Kaja Kallas here in Estonia. Instead, it seems like it’s all the same politicians in charge … only now they’re in their 70s and 80s. 😳
While the top ten causes of death are mostly the same; death rates are higher for men than women for every cause of death.
When a study revealed that obese patients cost the national health service twice as much money, the government piloted a program offering free Wegovy.
In the US, this has yet to become a political lightning rod because our healthcare is subsidized by employer-sponsored insurance, but the UK can’t figure out how to fund its national health system over the next 15 years as it aims to increase its national healthcare workforce from 1.4 million to 2.3 million.
Prasad published a book in 2020 with lots of research and case studies that are summed up in this EconTalk podcast.
I don’t want to distort Attia’s views; he recognizes that so much cancer screening probably isn’t good for society at large, but thinks that it is good for his individual clients who want to live as long and healthy as possible.
because on average getting screened for prostate and breast cancer doesn’t change the likelihood that you’ll die from it — but it surely will cost money and anxiety.
Pinker has been a cyclist his whole life and once described the bicycle's invention as one of the “seven wonders of the world” for a 1990s BBC documentary series.
Happy Anniversary! I was probably shlepping Oscar home to go back out and party. That was such a fun night.
I think we all fear death at least a tiny little bit, but I think I fear regret about 1000 times more than actual death. Death is inevitable; regret can be avoided. The latter feels more pronounced to me.
HAPPY ANNIVERSARY to you and Iris! And look at little Coco!
Are longevity coaches a thing? And isn't everyone at least a little afraid of death? I will say that having little humans who depend on me for their survival definitely lowered my risk tolerance and heightened my fear a little.
My doctor brought up starting to get mammograms once I turned 40, but I thought it was almost bizzare how indifferent she was to my choice about getting them earlier or not. She made a point to say that now the recommendation is 45, and it's a personal choice.... I was thinking, why would I not? why isn't she making a hard sell for preventative screening? Early detection of breast (and female repro cancers) is proven to decrease mortality. I know it varies by cancer type, but I thought colon cancer was in that category too. Its just interesting to me that people are making the case against screening because of a possible false positive, especially as I'm working with orgs in Lat Am trying to expand access to screenings because of unnecessarily high cancer mortality rates. So, I'm all for the 100k checkup!