DALYs per doctor

The disability-adjusted life year (DALY) is a measure of overall disease burden – the number of years lost. I’m wondering just much harm premodern medicine did, per doctor. How many healthy years of life did a typical doctor destroy (net) in past times?

Consider Semmelweis. Between 1839 and 1847, the First Clinic at the Vienna General Hospital had 20,204 births and 1,989 maternal deaths. The Second Clinic, attended by midwives, had 17,791 birth and 691 maternal deaths. An MD’s care conferred an extra 6% chance of death. Births at home were even safer, with maternal mortality averaging about 0.5%

In that period, MDs caused about 1200 extra deaths. Today ob-gyns deliver about 12-15 babies per month; assuming that caseloads were similar back then, there would have been something like 14 doctors working there ( a very rough guess: 2500 births a year, 180 births per doctor). So each MD was responsible for something like 85 extra deaths over that period. Since some were students, who surely didn’t spend the whole 8 years there, probably the per-doctor fatality rate was less that that. Maybe only 50 deaths per doc. Of course a doctor’s career was longer than 8 years…
Assuming 30 years of life lost per mom, 1500 DALYs per Victorian ob-gyn sounds like a minimum.

Ob-Gyn was especially bad, but most doctors, over most of history, must have had significantly negative effects. We know that wounded men in the Civil War had a better chance of surviving when they managed to hide from Army surgeons. Think how many people succumbed to bloodletting, over the centuries.

It looks as if the average doctor (in Western medicine) killed a bunch of people over his career ( when contrasted with doing nothing). In the Charles Manson class.

Eventually the market saw through this illusion. Only took a couple of thousand years.

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145 Responses to DALYs per doctor

  1. Yudi says:

    Trust the market!!

  2. Zimriel says:

    Technically Charles Manson didn’t kill anybody himself.

    Now, if the analogy was to hospital-administrators or the authors of premodern medical texts . . .

  3. reiner Tor says:

    Libertarianism is roughly as wrong about human nature and society as communism, though it errs in the opposite direction. Theoretically it’s difficult to see a libertarian government starting mass murder, though theoretically liberals were also difficult to imagine being oppressive, and yet here we are with hate speech laws and the like, and they’re likely to get worse in the future, possibly much worse. In any event, the excuses for market failures libertarians come up with sound pretty much like how “true communism” was supposedly never implemented. Yes, there’s always some government meddling (and likely there always will be), because it’s impossible to get rid of, just as there will never be a “true communism” ever.

    • Are you implying hate speech laws have to do something with libertarians?
      BTW, I even saw a libertarian to post in a blog that “non-libertarian people are deviation produced by statism”

      • reinertor says:

        No, I meant that liberals used to be free speech absolutists (like the ACLU still is today, even for Nazis), and that it was hard to foresee in the 1960s that they would become a classic oppressing force.

        • It’s more like that meaning of “liberal” has changed rather than anything.

          • gcochran9 says:

            But did the personnel change?

            • biz says:

              I think the personnel changed. Compare oldest generation liberal academics – like Pinker and Dershowitz, and even someone like Chomsky would be in favor of free speech if pressed – and talking heads like Bill Moyers, with the younger generation of academics and talking heads.

              • reinertor says:

                The ship of Theseus. It was the same team, but over time, due to age and natural death rates the crew got more or less replaced. But it’s still the same team.

              • James DW says:

                Even Chomsky?

                Well, he has been pressed, and people lost their minds because he thought even holocaust denial was allowed.

                “Then we must conclude that the person in question believes that the petition was “scandaleuse” because Faurisson should indeed be denied the normal rights of self-expression, should be barred from the university, should be subjected to harassment and even violence, etc. Such attitudes are not uncommon. They are typical, for example of American Communists and no doubt their counterparts elsewhere. Among people who have learned something from the 18th century (say, Voltaire) it is a truism, hardly deserving discussion, that the defense of the right of free expression is not restricted to ideas one approves of, and that it is precisely in the case of ideas found most offensive that these rights must be most vigorously defended. Advocacy of the right to express ideas that are generally approved is, quite obviously, a matter of no significance. All of this is well-understood in the United States, which is why there has been nothing like the Faurisson affair here. In France, where a civil libertarian tradition is evidently not well-established and where there have been deep totalitarian strains among the intelligentsia for many years (collaborationism, the great influence of Leninism and its offshoots, the near-lunatic character of the new intellectual right, etc.), matters are apparently quite different.”

                And Chomsky never did approve of the Trotskyism, Maoism, etc. of those who turned into today’s neocons and “liberals.” I doubt he’s at all surprised that the jejune would-be dictators of the 60s proletariat revolution kept their totalitarian instincts as they aged into bourgeois privilege. “Free speech” by violent takeover then and thought police now is a perfectly logical, predictable arc for the Berkeley students who became the current Berkeley professors and administrators. How did Reagan put it? We win, they lose. That was always the animating force; only their position in the hierarchy changed.

                (And it IS those people of Pinker’s generation–of whom Pinker is not especially representative–who are responsible for today’s neocon and liberal disasters. Talk about the boomer crying out as he strikes you…)

          • reinertor says:

            It’s the same team. They used to be free speech absolutists as long as it was about pornography etc. until now they aren’t free speech absolutists anymore. Race realism needs to be banished, because it’s not an opinion, it’s “hate speech.”

            My original point was that it’s not inconceivable that Team Libertarian might change in the same way.

        • tublecane says:

          It wasn’t hard to see in the 60s, after a couple of hundred of years of evidence of what post-Enlightenment tolerance means in practice. That is, tolerance for what we feel like tolerating.
          Many “liberals” at the time didn’t even bother masquerading. Read New Left guru Herbert Marcuse on free speech some time.

  4. anon says:

    The process is ongoing. Iatrogenics hasn’t stopped. Consider optometry.

  5. Alex says:

    A few years ago I saw interesting bit of statistics that showed that until mid-1950s the best strategy was to avoid doctors at all costs.

    With the collapse of USSR and its compulsory pediatric care, child mortality in Russia went down quite dramatically.

    • gcochran9 says:

      I don’t believe either claim is correct.

      • Alex says:

        Here’s the data for mortality in USSR/Russia. Sorry, all in Russian. http://burckina-faso.livejournal.com/358729.html, first table is mortality as a % of 1990 mortality by age cohort.

        For 0-4, by 1990 Soviet pediatric care was already gone, but 1990s malnutrition/parental substance abuse hasn’t set in yet. For 5-9s it’s all quite straightforward.

        • Alex says:

          In USSR, obligatory pediatric observation for 0-7s was instituted in 1973, cancelled in 1987.

        • gcochran9 says:

          I don’t believe it. There was deterioration in life expectancy, especially in men, but that was due to trends in adult mortality, mainly cardiovascular disease.

          • Alex says:

            Of course I cannot make you believe anything, but these tables are based on official Russian statistical bureau numbers. Ancedotal evidence seems to support it. In the USSR, pediatric misdiagnosis, unnecessary hospital stays/surgical interventions, hospital infections were very common.

            Real mortality numbers for older cohorts would be somewhat worse, as these stats do not include those “missing” (read: murdered, but body wasn’t found).

    • Toddy Cat says:

      Change that first claim to “mid-1930’s” and I’ll buy it. Haver serious doubt about the second. Soviet medical care sucked, but I don’t think that it was THAT bad. Of course, I could be wrong.

      • They still reused syringes well in when HIV came.

      • Alex says:

        Anecdotal evidence, sample of one, personal bias etc etc, but here is my story.

        Born in USSR in 1971. Had a couple of vertebrae in my lower spine broken/crushed at birth or immediately after. No-one noticed anything strange except for my mother, and she was told to shut up in no uncertain words. Through my childhood, diagnosed with kyphosis and scoliosis. Had hundreds of x-rays taken, and not a single radiologist/specialist noticed 2 crushed and fused vertebrae. Grew up more or less ok, still have slight scoliosis but one has to look for it to find it.

        Moved to Western Europe 20 years ago. Had back pains, went for an x-ray. Doctor thought I am playing a joke on him, because how can one not know about a bloody broken back that fused at a strange angle? He said it’s as obvious on an x-ray as it possibly could be.

  6. Ian says:

    A related topic: the common cause for the blindness of Bach and Handel.

  7. dearieme says:

    Be careful.
    “In 1865, Semmelweis was committed to an asylum, where he died at age 47 of pyaemia, after being beaten by the guards, only 14 days after he was committed.”

  8. Anon. says:

    Eventually the market saw through this illusion.

    If you believe Robin Hanson, it didn’t really.

    • gcochran9 says:

      What does Hanson think?

      • Anon. says:

        That a very large part of healthcare spending is done for non-health reasons. He has a chapter on this in his new book, also check out his paper “Showing That You Care: The Evolution of Health Altruism” http://mason.gmu.edu/~rhanson/showcare.pdf

        • gcochran9 says:

          I ran into too much stupidity to finish the article. Hanson’s a loon. For example when he talks about the paradox of blacks being more sentenced on drug offenses than whites although they use drugs at similar rate. No paradox: guys go to the big house for dealing, not for using. Where does he live – Mars?

          I had the same reaction when Hanson parroted some dipshit anthropologist arguing that the stupid things people do while drunk are due to social expectations, not really the alcohol.
          Horseshit.

          I don’t think that being totally unable to understand everybody around you necessarily leads to deep insights.

          • “I don’t think that being totally unable to understand everybody around you necessarily leads to deep insights.”

            I’ll probably never learn genetics. But i’ll keep coming back for this.

  9. DataExplorer says:

    If civil war soldiers were able to hide their wounds then they probably weren’t that serious.

  10. John says:

    What if the people who chose to give birth at home were already least likely to die? Had no problems during pregnancy, in good health to start with, etc. and only the people with problems went to doctors

  11. GAY_WEED_DAD_69 says:

    Consider Semmelweis. Between 1839 and 1847, the First Clinic at the Vienna General Hospital had 20,204 births and 1,989 maternal deaths. The Second Clinic, attended by midwives, had 17,791 birth and 691 maternal deaths. An MD’s care conferred an extra 6% chance of death. Births at home were even safer, with maternal mortality averaging about 0.5%

    What if some people gave birth in a hospital because they were sick or foresaw complications?

    • gcochran9 says:

      The great majority of the deaths were peurperal fever. Iatrogenic.

      • syonredux says:

        “In 1843, Oliver Wendell Holmes Sr. published The Contagiousness of Puerperal Fever[27] and controversially concluded that puerperal fever was frequently carried from patient to patient by physicians and nurses; he suggested that clean clothing and avoidance of autopsies by those aiding birth would prevent the spread of puerperal fever.[28] Holmes quoted Dr. James Blundell as stating, “… in my own family, I had rather that those I esteemed the most should be delivered unaided, in a stable, by the mangerside, than that they should receive the best help, in the fairest apartment, but exposed to the vapors of this pitiless disease.”[28]

        Holmes’ conclusions were ridiculed by many contemporaries, including Charles Delucena Meigs, a well-known obstetrician, who stated, “Doctors are gentlemen, and gentlemen’s hands are clean.”[29] Richard Gordon states that Holmes’ exhortations “outraged obstetricians, particularly in Philadelphia”.[30] In those days, “surgeons operated in blood-stiffened frock coats – the stiffer the coat, the prouder the busy surgeon”, “pus was as inseparable from surgery as blood”, and “Cleanliness was next to prudishness”. He quotes Sir Frederick Treves on that era: “There was no object in being clean … Indeed, cleanliness was out of place. It was considered to be finicking and affected. An executioner might as well manicure his nails before chopping off a head”.[31]”

        https://en.wikipedia.org/wiki/Postpartum_infections#“The_Doctor’s_Plague”

  12. One can also add about HepB HepC being greatly widespread because of medicine and… maybe HIV even originating due to it (mutiple injections in quick sequence is what SIV needed to cross species barrier to become HIV)

    • There had been numerous outbreaks of STD’s and more exotic illnesses in the gay male population in the US before HIV. “Faggot” by Larry Kramer, “And the Band Played On”, and “The Sexual Ecology of Gay Men” all contain tons of information on this.

      Examples:gonorrhea outbreaks, syphilis outbreaks, Amoebiasis outbreaks, HepB outbreaks, Herpes outbreaks, etc. all before HIV hit the scene.

      So at least in the US, HIV didn’t need dirty needles or bad medicine to get into the gay population. I don’t know enough about its actual origins in Africa to have a strong opinion on that…

  13. AppSocRes says:

    I’ve always believed that “organized” medicine, up until doctors accepted the germ theory and modern hygiene and the development of scientifically proven medications and procedures, which came into force around the early part of the twentieth century, caused more deaths and suffering than it prevented. Possible exceptions were the bone setters and amputaters, when gangrene was a nearly inevitable aftermath of a massive and infected wound. However, this is the first time I’ve seen a plausible estimate of how bad the situation was.

    One follow-on observation: This is an interesting exception to the usual rule that the poorer get worse end results than the wealthier.

    • Maternity institutions were set up all over Europe to address problems of infanticide of illegitimate children.
      looks like it was partly eugenic…

    • j says:

      The rich and powerful had access to the best academic medicine, while the poor had to make with hot chicken soup and incantations. The political consequences of their ‘privilege’ was the fast turnover of monarchs in Medieval Europe, and exponential impact of the inheritance laws.

      • Evidence? I saw quite some suggestions from blank-slatists that monarchies and aristocracy were all inbred. There are many documented examples. Though inbred examples from peasants are not as well documented.

        • j says:

          Evidence of what? That rich people had more access to formally trained medicos? That the poor health and consequent turnover of monarchs caused political instability? Inbreeding may have been a punctual health issue but European aristocracy, dead and alive, appear to be able to keep a job.

  14. benespen says:

    In 2000, Ben Djulbegovic used a survey to compile a list of medical therapies that hadn’t been through a clinical trial, but worked so well that it didn’t matter. This method is sorting for things with very large effect sizes. The list is quite short.

  15. dave chamberlin says:

    What can go wrong when you build gigantic buildings and crowd all the very sick people into them, many of them having highly contagious diseases with little to no effort to separate them. Let’s have the doctors and nurses help spread all the nasty bugs by not bothering with any hygiene procedures. You can’t even count all people who went to the hospital with one problem and in a weakened state caught something from someone else and died because of it.

    One thing doctors did right in the old days was home visits. One thing hospitals do right today is get you to go home ASAP.

  16. Polynices says:

    Obviously all that you say is true. What I’ve wondered is if there was anything that doctors did that actually was helpful and if perhaps that little bit of success helped them fool people into thinking the rest of it helped. Though honestly I can’t think of a single thing the physicians did. My impression is that the dentists/barbers/surgeons actually did help with rotten teeth, if nothing else.

    • gcochran9 says:

      Setting bones. extracting arrows: spoon of Diocles. Colchicine for gout. Extracting the Guinea worm. Sometimes they got away with removing the stone. There must be others.

      • Ziel says:

        Dwarf extractions?

      • dearieme says:

        Perhaps they were able to give a reasonable prognosis sometimes. It’s when they interfered that they became lethal.

      • AppSocRes says:

        Quinine, opium, and a few other drugs like these. Obstetrical forceps. Caesarean deliveries. I once owned a reproduction of an illustrated, late eighteenth century text on surgery. The procedures were quite sophisticated. Even a simple amputation is a lot less straightforward than those unfamiliar with the procedure might think.

        • gcochran9 says:

          Quinine is relatively recent: post-1500. Obstetrical forceps also. Caesarean deliveries were almost always fatal to the mother until fairly recently.

          Opium has been around for a long while : it works.

          • Amerindians used Quinine….
            Huh, Diamond-like could wrote that Europeans had bad medicine and infected other peoples who never developed these diseases because of their good medicine, which was destroyed then by invaders

            • gcochran9 says:

              They didn’t use quinine against malaria before Columbus, in part because they didn’t have any malaria before Columbus.

              They used quinine to inhibit shivering. Malaria causes shivering. It’s a complete coincidence that quinine also kills the malaria parasite.

      • bob k. mando says:

        pineapple / bromelain is quite effective for gout. since i figured out what it was, i’ve been controlling gout attacks with pineapple consumption ( couple times a month, if i go to long without and start having an attack i might eat pineapple every day for a week ) for over five years now.

        only diet change is that i eat less beef and more chicken.

      • Harold says:

        What about fasting and diets to treat epilepsy?

  17. JRM says:

    With regards to bloodletting, you are only looking at the negative side of the ledger. Excess iron is a health risk factor. That’s why iron supplements are not recommended for men or postmenopausal women. The positive side of bloodletting is extended longevity due to better insulin sensitivity, lower rate of infections (pathogens love iron), and lower rate of heart attacks and cancer.

    “Ferritin levels below about 80-100 ng/mL relate to minimal disease and maximum longevity observed in other studies” here: http://roguehealthandfitness.com/the-normal-value-iron-matters/

      • JRM says:

        http://clinchem.aaccjnls.org/content/60/11/1419
        This study found total mortality is higher for higher ferritin. Twenty four years of longevity difference between the highest and lowest quartile.

        • gcochran9 says:

          http://atvb.ahajournals.org/content/early/2017/07/06/ATVBAHA.117.309757

          An association doesn’t prove causation. Look, grey hair is associated with cardiovascular disease, but I doubt that it is causal.

          You can pretend that you know, but you don’t.

          • JRM says:

            In my first comment, I referenced 80-100 ferritin level as being optimal for health. I made an assumption about the risk population being Westerners who tend to eat meat. For example, this reference says that an American male 40-59 years old has median ferritin level of 150. (https://www.cdc.gov/nutritionreport/99-02/pdf/nr_ch3.pdf) For the average American male, increasing the ferritin level will negative impact his health. Decreasing it (bloodletting) will positively impact this health.

            You found a study done by a South Asian lead author and using mixed populations including South Asians. What do we now about South Asians? Mostly vegetarians implying low ferritin levels. This study says Indian males have a ferritin level of 68, Indian females of 21, American white males 130, and Americna white females 45. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4175707/
            Bringing low suboptimal ferritin levels up will improve health. But the conclusion is nonsense considering what we know about nutrition. For each nutrient, there is an optimal range where health outcomes are the best. Health outcomes suffer below the optimal range. Health outcomes suffer above the optimal range. For statistical analysis of CAD risk, the populations should have been segmented in tranches with odds ratio run on each tranch.

            One reason to think that iron levels are causal of mortality is that iron is necessary for pathogen growth. When iron is the limiting reagent for pathogen growth, restricting iron levels will reduce virulence of infections. Here is one study which suggests that iron can promote infection. https://www.ncbi.nlm.nih.gov/pubmed/26593732 Another study which suggests that higher iron leads to higher bacteria growth https://www.ncbi.nlm.nih.gov/pubmed/26593732 Another study which shows iron chelators limit bacteria growth http://www.bloodjournal.org/content/bloodjournal/112/3/866.full.pdf?sso-checked=true

            Back to my original argument, historical bloodletting in males and postmenopausal females may have had a positive effect for some on life expectancy. With hemochromatosis genes being 10-20% of certain populations and the standard treatment for hemochromatosis today being bloodletting, you can not argue that historical bloodletting was always had negative outcomes.

            • gcochran9 says:

              “With hemochromatosis genes being 10-20% of certain populations”

              Classic hemochromatosis is a Mendelian recessive caused by the C282Y mutation. You need two copies to cause trouble, and even then, most women skate, at least until after menopause. In populations of northern European origin, gene frequency is in the range of 5-10%, which means that the frequency of homozygotes in the range of 0.3% to 1% – with symptoms usually only in males. Much lower gene frequency in southern Europe.

              The fraction of people with hemochromatosis is something like half a percent, max. half a percent is considerably lower than 10-20%.

              Since you apparently have no idea about the basic epidemiology, why should anyone pay any attention to your argument?

              • JRM says:

                C282Y isn’t the only hemochromatosis gene and heterozygotes have elevate ferritin. (http://clinchem.aaccjnls.org/content/44/12/2429).

                People today don’t die of infectious disease like they used to. Infectious disease was the biggest killer. Lowering iron stores will slow the growth of pathogens which allows the body’s immune system more time to respond to the threat. This article describes the body’s response to typhoid is to sequester iron https://www.ncbi.nlm.nih.gov/pubmed/26394303

                While 80-100 ferritin may be optimal today, under heavy infectious disease pressure lower levels would be optimal because lower levels increase survival from infectious disease. I have no idea what ferritin levels were a thousand years ago. I don’t think the ancient doctors were complete idiots. If bloodletting to lower iron level prevented mitigated infection, then they tried it.

              • gcochran9 says:

                THE ANCIENT DOCTORS WERE COMPLETE IDIOTS. We have info on how their treatments worked, since this folly continued into the 19th century – even the beginnings of the 20th. When they used venesection against pneumonia, as they routinely did, the death rate doubled. There’s a reason that people liked homeopathy: doing nothing worked a lot better than conventional medicine.

                The molecule involved in iron absorbtion adjusts iron intake according to need (except when it’s broken, as in the case of C282Y. By bleeding people, a doctor is essentially saying that he knows what the optimal; iron level is better than mother nature. Well, actually, he was thinking nonsense about the proper balance of the four humours, which was all crap – but the effect was to change iron levels, along with sometimes causing you drop dead on the spot, as with Washington.

                There are many examples where MDs are acting on an idea like that – that they know better than evolution. SDometimes they could be right: castration probably exends life, although natural selection hasn;t favored that for some reason.

                But almost always, the idea that ” we docs know better” is incorrect.

                Since the Aztecs sacrificed ~20,000 people a year for years and years, there must have been something to it?

  18. Jerome says:

    “Eventually the market saw through this illusion.”

    Think so? How many DALYs per dollar? I am guessing it is a negative number, but not a large one. Most of what “the market” pays for is garbage. Homeopathic, chiropractic, accupuncture, antibiotics-for-viral-infections … Of course, that is largely because the government makes the market pay for garbage.

    • gcochran9 says:

      those are mostly examples of what the government doesn’t pay for.

      • Jerome says:

        Well, yes, the government doesn’t pay for them, it makes us pay for them. If you have health insurance, you are paying for all of those things, whether or not you actually visit any chiropractors. Health insurance does not cover visits to astrologers. Yet.

        • Jim says:

          Yes, many states require some health insurance policies to pay for chiropractic services up to some limit. They also often require some coverage of mental illness therapy of no proven efficacy.

          • I hope you don’t mean antipsychotic and mood stabilising medication when you say that. If you mean any number of talk interventions, then I am entirely with you. But even brief periods of hanging around people with Severe Mental Illness will dramatically reveal symptom improvement for a hefty percentage of patients in just a few days on medicine, and a rapid deterioration off it. Res ipsa loquitor, when you’re on the scene.

        • ziel says:

          Can’t vouch for the other practicioners, but yes NJ does require insurers to cover chiropractors. Just got off jury duty on a “pain-and-suffering” case where the plaintiff went to a chiropractor for 4 months and then visited a “pain-management” specialist (MD). That was it. We were not impressed.

  19. jamienyc says:

    There is a theory that bloodletting is beneficial because it reduces the amount of free iron in the body, which bacteria need in order to grow. Before the age of antibiotics, that was the only way to fight infection.

  20. I don’t think we have much in the way of numbers or evidence pre-Renaissance. Science and pseudoscience rather grew up together once Smart People started developing grand theories. Those kill more people than mere superstitions and folk medicines which tend more to being entirely useless than damaging. It usually takes an educated professional to cause widespread damage. Various types of sympathetic medicine are common. Are those harmful?

    • tublecane says:

      About superstitions and folk medicine, there’s an annoying trend in historic fiction lately whereby we pretend women–often witches–were the real doctors back in the day. Progress was held back by the patriarchy.
      I don’t mean merely in the sense of home remedies being superior to the active evil practiced by doctors at the time, nor that folk wisdom knows things neither science nor pseudoscience ever will. I mean the idea that womyn were the real persons of science.
      Yes, they will try to take that away from men, too.

  21. bob k. mando says:

    In that period, MDs caused about 1200 extra deaths.

    shouldn’t you have compared the DALY rate vs unaided home birthing rather than vs midwives? at .5%, there should be ~100 mothers dying for every 20,000 births. midwives ( 3.9% ) are significantly better than doctors ( 9.8% ) but have a non-trivial DALY of their own.

  22. Art says:

    If pre-modern medicine was indeed worse than useless – how do you explain no one noticing that patients who get expensive treatments are worse off than those who didn’t?

    • gcochran9 says:

      were worse off. People are kinda dumb – you’ve noticed?

      • Art says:

        My impression is that while people may be “kinda dumb”, ancient customs typically aren’t.
        Even if we assume that all people who lived prior to the 19th century were too dumb to make the rational observation, wouldn’t you expect this ancient practice to be subject to selective pressure?

        • gcochran9 says:

          Your impression is wrong. Do you think that there some slick reason for Carthaginians incinerating their first-born?

        • Wency says:

          It seems that doctors didn’t kill a large enough share of the population over a long enough time to be selected out that way. If there had been a custom of most babies being delivered by quack doctors who frequently killed the mothers, that custom probably wouldn’t have survived as long. Instead it was only ever a narrow slice of the population.

          There was an analysis by the Freakonomics guys that even in the present day, going to the hospital for a minor emergency, even a minor heart attack, is deadlier than just waiting it out at home. But a lot of people still think they’re always playing it safe by going to the hospital. Humans are inclined to seek solutions in life-or-death matters, but frequently the solutions are all terrible.

          Ancient customs regarding things like marriage are subject to more pressure. There is massive selection against things like a custom of women waiting until age 35 to have their first child, since that results in way more foregone births than doctors ever generated in excess deaths.

          Though to Greg’s point, the practice of sacrificing one’s own child wasn’t terribly widespread in time or place. The practice of “sacrificing” an animal and then going ahead and eating that animal was much more common. I don’t think this is an accident.

          • gcochran9 says:

            “sacrificing one’s own child wasn’t terribly widespread in time or place.” Canaanites, Phoenicians, Carthaginians. Something like a thousand years.

            • Art says:

              Which is consistent with the theory that in the long run either the widespread practice has to be abandoned or the population will disappear.

              • gcochran9 says:

                Because if you do something stupid, after hundreds of years the Romans will show up and kill or enslave every damn one of you.

                Where is the /sarcasm font when I need it?

            • Wency says:

              So effectively one culture, and not a particularly populous one. Compared to animal sacrifice, not very common at all. We also don’t know exactly how frequently it was practiced within that culture. I’d guess not that often, and to my knowledge, less attested prior to Carthage. Their neighbors weren’t too interested in imitating the practice, and it might have contributed to the totality with which the Romans chose to destroy them (the Romans would say it did, for what that’s worth).

              It’s the aberration within the wider practice of ritual sacrifice, which is usually low-commitment, more “ritual” than “sacrifice”. Even where human sacrifice was practiced, the victims tended to be people their captors wanted dead anyway. These days, many people still regularly partake in a sort of ritual sacrifice of bread and wine — or, to lower the commitment a bit further, grape juice.

              Now, child sacrifice wasn’t decisive in Carthage losing the Punic Wars, but I’d still hold it’s not a coincidence that one of the most “stupid”/self-destructive sorts of ritual sacrifice got filtered out, one way or another.

    • Greying Wanderer says:

      if wealth = doctors and wealth = good food/housing etc then
      wealthy health outcomes = good conditions minus doctors

      if poverty = no doctors and poverty = bad conditions then
      poverty health outcomes = bad conditions + no doctors

      maybe

  23. Anonymous says:

    I’d guess that selection bias (late-term miscarriage/infant death/parturiton complications→hospital care on successive deliveries) explains most of the extra deaths.

    • gcochran9 says:

      That’s nonsense. Those women died of peurperal fever, almost entirely iatrogenic.

      • Anonymous says:

        Another possible point for selection bias: hospitals were probably concentrated near the nastiest population sinks, while most people were giwing birth in the countryside or small towns. If you consider fertility statistics from G. Clark, I’d argue that median mother (even a foreman’s better half) in the hospital population wouldn’t have done as well as well-to-do farmers or rural middle-class, far away from public secondary/tertiary care centers, if some wise timetraveller had suggested giving birth in early 19th century factory housing.

    • gcochran9 says:

      Doctors did not wash their hands after autopsies

      • Anonymous says:

        Nicely evaded, I take that as yes.

        • gcochran9 says:

          You’re wrong. You know, I sometimes assume that people are familiar with how awful medicine used to be. Of course they aren’t really . But MDs are worse. Med school doesn’t include much about the history of medicine, because it’s so utterly embarrassing.

          • Anonymous says:

            The preclinical medical education does include some embarassing history 😉
            Would you argue that hypothetical pre- to neonatal randomization wouldn’t have diminished the differential in deathrates to statistically significant degree?

            • gcochran9 says:

              The difference between the medical students vs the midwives at the hospital was huge, factor of 3. There’s no way to change it much. Peurperal fever didn’t just happened at that hospital: it was a general problem in the places where MDs supervised birth.

              • Anonymous says:

                Retrospectively “most of the” in the first comment was a terrible choice of words and might have given a poor impression/derailed the conversation.
                But I dislike setting the upper limit based on 1 correlating variable as a probable magnitude
                of causal effect.
                And I’d be curious to see a multifactor analysis or a retrospective cohort study done on the subject.

              • gcochran9 says:

                I’d say that it was revealing.

              • Anonymous says:

                Okay I finally had enough time to read about Semmelweis’ arguments and I have to say, that I was taught in high school that 4-6 % neonatal mortality is an extreme, what you would get with absolute poverty, chronic disease/epidemics, shitting upriver, dumping dead livestock in wells, ritualistically murdering twins and albinos, kissing and hugging deceased relatives, raping virgins to cure AIDS…
                As (La Rochelle and Julien 2013) said the admission was effectively a controlled trial and there was also continuous data over multiple reforms in the hospital practices and Dublin as nice control.
                Having recently done my first apprenticeship in a surgery department and currently reading a surgeons biography from the Interwar period I was actually astonished by the similarities, excluding electrical hemostasis and cellphones.
                But indisputably there has been gigantic leaps of improvement between the 1840s and 1930s, beyond my biased imagination..

              • gcochran9 says:

                We’re talking about maternal mortality, not neonatal.

              • Anonymous says:

                If the doctors killed more mothers than babies, any idea where did they go?
                Streets, orphanages, (grandparents, single dads/blended families)…?

  24. Art says:

    “Because if you do something stupid, after hundreds of years the Romans will show up and kill or enslave every damn one of you.
    Where is the /sarcasm font when I need it?”

    Please not the difference between “proves” and “is consistent with”. The latter is sufficient to challenge your counterexample.
    Do you disagree that the custom of killing firstborn is expected to lead to population decline? Am I understanding you correctly?

    • gcochran9 says:

      It’s perfectly possible for a population to kill firstborns wile still exhibiting strong population growth. Not that I’m recommending it.

      Human populations can, given sufficient resources, have really high reproductive rates. 10 kids is easily achievable, even as a population average. Assume that they adopt some perverse custom, so that maximum reproduction is only 6 kids – fast population growth is still possible.

      The original idea is that traditional medicine can’t really have been that bad if it existed for a long period. But it was that bad. It wasn’t as bad as it might have been, since doctors weren’t common.

      This line of argument – roughly, “whatever is, is right” – doesn’t work very well.

  25. reiner Tor says:

    My daughter has fever. The doctor told me to give her antipyretics. I told her that since it was the body’s natural immune response (and it’s a viral infection), perhaps that could prolong the illness. (If it were bacterial, antibiotics might make fever superfluous. Though even then, why throw away part of the natural immune response?) The doctor insisted it didn’t. I don’t know, but for example the Wikipedia page on antipyretics in the third paragraph mentions how antipyretics might result in a 1% increase in influenza mortality, killing 700 people in a year. I know that some physicians don’t recommend antipyretics, and I think in the future they might view them as some sort of modern bloodletting.

    Similarly, there are still doctors prescribing a high carb low fat diet for high blood cholesterol levels. It seems they didn’t get the memo that high carb diets are, at the very least, of questionable value. They probably feel that they should still prescribe it to patients as long as its harmfulness is not proven with absolute certainty.

    Doctors in the past probably similarly felt the need to do something, even if they had no evidence it worked at all. I’m sure doctors still kill a lot of people, just less than before, and they now save a lot, so the general equation of going to the doctor is now positive.

    • Art says:

      “Doctors in the past probably similarly felt the need to do something, even if they had no evidence it worked at all. I’m sure doctors still kill a lot of people, just less than before, and they now save a lot, so the general equation of going to the doctor is now positive”
      These days it is rare for doctors to kill out of incompetence. Much more common to do so by following directives of organizations they must comply with – FDA, AMA, ect. That can kill hundreds of thousands but not enough to outweigh the benefits of the beneficial treatments.

  26. Art says:

    “It’s perfectly possible for a population to kill firstborns wile still exhibiting strong population growth.”
    Probably true for most times and places. But medicine is a very very old and universal practice. There must be times in the history of any human population when having one fewer child will doom the population.
    But if you told me that the practices in question where limitd to only those times and places when populations were booming – I would accept this explanation.

    “10 kids is easily achievable, even as a population average.”
    My impression is that in primitive societies havig 10 siblings survive into adulthood would be uncommon.

    “The original idea is that traditional medicine can’t really have been that bad if it existed for a long period.”
    To me that’s not an unreasonable, but it is not the one I am making . Your conclusion about pre-modern medicine seems very reasonable.
    But the fact that it existed for so long and everywhere seems to me like a puzzle, and explaining it as “people do stupid things” does not seem sufficient.

    “It wasn’t as bad as it might have been, since doctors weren’t common.”
    That’s one explanation. Except that according my recollection of the medical anthropology class I took 3 decades ago, almost all societies had medical practitioners. Was I mislead?

    “This line of argument – roughly, “whatever is, is right” – doesn’t work very well.”
    In our context I think it does. For any long-surviving feature it should be a good bet to suppose that at the very least it does not decrease reproductive success.

    • gcochran9 says:

      You’re wrong. We have direct comparisons data of homeopathy (doing nothing) and conventional medicine. Doing nothing won hands down. The theories of Galenic medicine were all false.

      Wrong in theory, deadly in practice. Your line of thinking is completely incorrect. ” when time are booming” – you are misunderstanding the question yet again. “booming times” are the only times that the presence or absence of Galenic medicine was likely to make a difference. In normal times, people are fairly close to the Malthusian limit: no subpopulation is going to grow because they can have ten kids while others could only have 6.

      In a wide-open frontier, with resources enough for everyone – then it is possible to have ten kids. Then is when something that limited your fertility would have an effect.

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