EP. 135: SOCIAL CONTAGION AND THE FOUNDATIONS OF A GOOD SOCIETY

Oct 26

WITH NICHOLAS CHRISTAKIS, MD, PHD, MPH

A physician-turned-sociologist and Director of the Human Nature Lab at Yale University discusses how behaviors and health outcomes spread through social networks and why he believes society is wired for goodness.

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Episode Summary

One of the most fascinating concepts in human health is the idea of social contagion, meaning that emotions, behaviors, and health outcomes can spread through social networks, much like infectious diseases. Examples in the medical literature abound: if a person becomes obese, their friends have a significantly higher chance of becoming obese — even their friends of friends have increased odds of becoming obese. Similarly, someone who quit smoking is likely to create a ripple effect through their social networks, influencing many more people to quit smoking. Social contagion affects life and death itself — after the death of a spouse, the surviving partner's mortality risk increases, and conversely, strong social networks are protective against early death.

Much of the groundwork of our understanding of the powerful health effects of social networks laid by Nicholas Christakis, MD, PhD, MPH, a physician-turned-social scientist who is the author of multiple best selling books, including Apollo's Arrow: The Profound and Enduring Impact of Coronavirus On the Way We Live (2020) in Blueprint: The Evolutionary Origins of a Good Society (2019).

In this episode, Dr. Christakis shares his remarkable path to medicine and sociology, beginning from witnessing his mother's struggle through serious illness, to his foray into palliative medicine, and finally to his life's work on the social, economic and evolutionary determinants of human welfare. We discuss the mechanisms by which social contagion functions, why modern medicine does a disservice to patients by atomizing their medical problems, how the COVID-19 pandemic illustrates the effects of social networks on public health, the philosophical implications of living an interconnected life, and why human beings are wired to build good societies through our capacity for love, friendship and cooperation.

Nicholas A. Christakis, MD, PhD, MPH, is a sociologist and physician who conducts research in the areas of social networks and biosocial science. He directs the Human Nature Lab at Yale University.
His current research is mainly focused on two topics: (1) the social, mathematical, and biological rules governing how social networks form (“connection”), and (2) the social and biological implications of how they operate to influence thoughts, feelings, and behaviors (“contagion”). His lab uses both observational and experimental methods to study these phenomena, exploiting techniques from sociology, computer science, biosocial science, demography, statistics, behavior genetics, evolutionary biology, epidemiology, and other fields.
The author of four books and over 200 articles, Christakis was elected to the Institute of Medicine of the National Academy of Sciences in 2006 and was made a Fellow of the American Association for the Advancement of Science in 2010 and a Fellow of the American Academy of Arts and Sciences in 2017.
In this episode, you will hear about:
• 3:17 - Dr. Christakis’s path to medicine through witnessing his mother’s serious illness
• 15:05 - How Dr. Christakis became passionate about studying the effects of social networks
• 24:43 - How social networks affect an individual’s health
• 31:28 - The negative effects that COVID-19 restrictions had on patients and their loved ones
• 38:58 - The central thesis of Dr. Christakis’s 2019 book Blueprint: The Evolutionary Origins of a Good Society
• 50:38 - Dr. Christakis’s thoughts on how to live a meaningful life
[00:00:01] Hi, I'm Henry Bair.
[00:00:02] And I'm Tyler Johnson.
[00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
[00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and healthcare executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
[00:01:02] To me, one of the most fascinating concepts in human health is the idea of social contagion, meaning that emotions, behaviors, and health outcomes can spread through social networks, much like infectious diseases. Examples in the medical literature abound. If a person becomes obese, their friends have a significantly higher chance of becoming obese. Even their friends of friends have increased odds of becoming obese. Similarly, someone who quit smoking is likely to create a ripple effect through their social networks, influencing many more people to quit smoking. Social contagion affects the fabric of life and death itself. After the death of a spouse, the surviving partner's mortality risk increases, and conversely, strong social networks are protective against early death. Much of the groundwork of our understanding of the powerful impact of social networks on health was laid by the work of Dr. Nicholas Christakis, a physician turned social scientist who is the author of multiple best selling books, including 2020s Apollo's Arrow The Profound and Enduring Impact of Coronavirus On the Way We Live in 2019's Blueprint The Evolutionary Origins of a Good Society. In this episode, Doctor Christakis joins us to share his remarkable path to medicine and sociology, beginning from witnessing his mother's struggle through serious illness to his foray into palliative medicine, and finally to his life's work on the social, economic and evolutionary determinants of human welfare. We discuss the mechanisms by which social contagion functions, why modern medicine does a disservice to patients by atomizing their medical problems. How the Covid 19 pandemic illustrates the effects of social networks on public health. The philosophical implications of living an interconnected life, and why human beings are wired to build good societies through our capacity for love, friendship and cooperation. This is a hopeful and enlightening conversation and we cannot wait to share it with you. Nicholas, thank you so much for taking the time to join us and welcome to the show.
[00:03:15] Thank you so much for having me.
[00:03:17] You've dedicated your life to studying human behavior and connection, but we'd love for you to take us to the beginning. Can you share with us what initially drew you to a career in medicine?
[00:03:27] Well, my origin story in that regard is probably very stereotypic. My mother was seriously ill when I was a boy, and all three of my mother's sons have become doctors. So I grew up in a household where my mother was seriously ill. She was diagnosed in 1968 when I was six, with Hodgkin's disease. Stage four B DeVita had invented mopp then, but it wasn't widely known. And somehow my mother's doctor. This was in DC. I had heard a little bit about it. She was she was put on, um, only some of the drugs in the mop cocktail, including prednisone, wasn't really expected to survive and then miraculously had a seven year remission, which lasted until 1975 when the cancer came back. Then she was tried on some other cocktail and she had a 3 or 4 year remission. And then the cancer came back again. Would have been about 1979, approximately when I was finishing high school, and was pretty much then sick for the remainder of her life until 1987, when she died at the age of 47. And I was 25, and she had chemotherapy and surgery and multiple courses of, uh, radiation as well. And she eventually had a leukemic transformation as many patients of that era who had both radiation and chemo did, plus all kinds of complications from from the bleomycin she was on and so on.
[00:04:53] She suffered a lot. And so I grew up in a household as a little boy with a mother who was seriously ill. I became obsessed with prognostication, which was my first book, as you might imagine, because I was always wondering, would she live or die? And she would comfort me by saying that even as a little child, I can remember she would say things like, I know I'm going to die of this, my boy, but I promise you you'll have warning. You'll know a year before I die. And I found some comfort in that. But of course, it reoriented my thinking towards the challenge of making predictions about seriously ill people. And of course, as an older I mean, I went to college and then medical school and just a leap ahead for a moment. You know, during my medical training, I became acutely aware of what a crappy job we took care of people who are dying. And I had my mother got good care. I mean, she had in-home sort of hospice type care. She died at home in September of 1987. You know, we we were administering in those days. It was very innovative to give a home infusions.
[00:05:58] And they had these little grenade shaped reverse pressure rigid plastic with a little bulb of the solution inside. And you would pressurize the interior and it would like act like an IV bag. You could put it in the patient's bed. She got medicines and so on. And I remember anyway, I'm leaping ahead because this was after I had gone to medical school. But at around the time she died, we had a little centrifuge set up at home to check her hematocrit. We drew a blood specimen to check her hematocrit, and I saw a little buffy coat on it, so I knew she was having a, you know, white cell crisis. I knew the end was near. I was just a medical student, but I knew what was coming. Anyway, she she died. So I grew up, you know, with a seriously ill parent. And like many people who have had that experience or a seriously ill sibling, became very interested in medicine and sort of resolved to do that. I graduated from high school. I went I grew up in Washington, D.C., and then I went to Yale University. Originally, I had wanted to be a social scientist. Actually, I wanted to study linguistics. I was very interested in semiotics.
[00:07:04] For those that are listeners who may not know, what is semiotics?
[00:07:08] It's the study of symbols and and symbolism. And I was very taken, you know, with I took some language classes, I took some anthropology, and I was very taken with that. But I was a little afraid to follow my heart in that regard. And so I made a more conventional choice of picking biology as my major. And in the meantime, I was working at at a lab at NIH in building 36, in a cellular neuroanatomy lab in the summers. And that sort of helped stimulate or facilitate my transition to biology. But mostly I made the switch to biology for reasons of safety. I didn't have the courage, actually, to stick with the social sciences. I picked a sort of conventional thing, and I was a very good student. I was immature. I had skipped a grade when I was in elementary school and therefore arrived at college having just turned 17. And so college was hard for me. But I, you know, I was just put my head down and was a good student. And I applied to and got into Harvard Medical School, which I began in 1984. And when I went to medical school, I don't know, do you want the whole story? I don't know which part you want.
[00:08:14] Well, yeah. So I mean, I think one of the things that is unusual, as I mentioned earlier about your career is so you go to medical school, you become a medical doctor and were a practicing doctor for a time. But then your career has taken this very unusual path. You mentioned that you had wanted to be a social scientist early on, as you put it, didn't have the courage to pursue that outright, instead became a doctor. But then later you're I guess you developed the courage over time. Or maybe you were just more willing to do complicated tricks on the high wire once you had a safety net beneath you, right? But eventually you did become a social scientist and now have sort of wedded the two disciplines in a lot of ways. But talk us through a little bit. So you get into the field of medicine. But then how did the practice of medicine eventually lead you back to studying the thing that you had initially wanted to study in the first place?
[00:09:06] Well, what happened is, is I went to medical school, and at the time I wanted to be a reconstructive surgeon. In my first year, we had an embryology class that was taught by a very famous woman called Elizabeth Hay. And she had these visiting dignitaries come and speak to us. And there was a man that had just won the Nobel Prize in medicine, Joe Murray, for renal transplantation. And as after he sort of invented renal transplantation at the Brigham in the 1950s, approximately, he got into craniofacial surgery, operating on kids with craniofacial abnormalities. And so this surgeon, he this famous surgeon was brought in to speak to us medical students. And of course, I had wanted to be a reconstructive surgeon, and this was just incredible to me. And I went up to Professor Murray and I was like, oh, Professor Murray, you know, can I come in and operate with you, you know, and and he he was like, you know, I don't have time for you. I mean, he wasn't he wasn't rude. But, you know, it was clear the man had no time for me. But he introduced me to his colleague, a wonderful surgeon by the name of John Mullican. And John was at the time, and I think, remained one of the world's leading surgeons for cleft lip and palate surgery at the Boston Children's Hospital.
[00:10:17] So I got sent to meet John. I go meet John, and John takes a liking to me and says, you know, you could just assist me. So I started skipping class. Like, I went to like only half the class in medical school the first year. And I would skip class and go and operate with John Mullican. Now, in retrospect, it's mind boggling. The opportunities I was given because I was first assisting. There was me and John Mullican. There was no surgical resident, No one else in the room. I was right there next to him. Wow. But what I. What I came to realize during that period of my life was that I was not cut out to be a surgeon, and there were multiple reasons. One was I was not a morning person. And these lunatics get up at like five in the morning or 430 in the morning, and they pre-round at like five. And they're in the O.R. scrubbed at 630. And I just that was I was dying. Like, I just, I just pragmatically, I couldn't do that. Second, they are extremely hierarchical in surgery. And part of the reason is that experience counts for so much. So whenever there would be a debate in amongst these and I'd be like a fly on the wall listening to all these surgeons talking about how to handle some problem.
[00:11:27] Eventually some senior surgeon would say, I have done this procedure 1000 times and and that would settle the matter. So it was like all about experience. It wasn't. I realized that no matter how smart I was, like, no matter how inventive I was, no matter how dexterous I was, that would count for very little as compared to how experienced I was. And I was a sort of a young man in a hurry, and I. I decided not to do surgery. And so my second year of medical school rolls around, and that's 1986, and my mother is now getting quite sick. And I can see she's actually at that point, I arranged for her to come up to the Dana-Farber to be seen there. I'm trying to help my mother, who's very sick, and I decide that I have to take a year off medical school because I anticipate her death the following year, because I couldn't be a third year medical student and help care for her. So I decide to enroll in the Master of Public Health program at the School of Public Health. So I enroll in the MPH program because it's a lighter, lighter schedule. And the school begins. And as I said earlier, my mother died that September of that year. And so I returned to school as an MPH student. And during that year, I just had this incredible intellectual awakening Because I took courses in epidemiology and biostatistics and health behavior and international health.
[00:12:45] And the Harvard School of Public Health was just this incredible cosmopolitan experience and full of social sciences. And I took a course in medical history with Allan Brandt, the famous medical historian who wrote the book called No Magic Bullet. In that class, I read a very famous essay by a famous sociologist of medicine, a woman by the name of Renée Fox called training for uncertainty, which she had written in the 1950s. And I read this story about the training of medical students and how we trained medical students for, like, detached concern. And I was I marveled at her ability to capture this element of medical training, which was still in existence, you know, half a century, almost later. So I resolved that I'm going to return to the social sciences after I complete my medical training, and I'm trying to figure out what to do which. And so then I go, then I finish my MPH year. Then I start third year medical school. Fourth year medical school. Fourth year medical school. I'm deciding where to go to do my residency. And I contact Professor Fox. And she was at the University of Pennsylvania, and she takes a meeting with me, and I was completely taken with her, like with her insight, with her wisdom, with her charisma, with her body of work.
[00:13:58] And I decided I'm going to get a PhD in sociology. And so I then apply to internal medicine residency programs at Penn. In those days, they offered a research residency, the American Board of Internal Medicine, where instead of doing three years of residency, you could do two years of clinical and two years of research. You do more time, four total years, but less clinical. I applied at the University of Pennsylvania for that program so that I could work with Renee. When I was done with my clinical work, and I did my first and second years of, of clinical work at Hup. So I did my first two years in medical school, and then I short tracked to two years of, uh, of research, and I was able by then to get into the PhD program in sociology. So I then I spent an additional four years, which overlapped with the two latter years of my medical school, to complete my PhD in sociology, at which point during that training I was introduced to social networks, which is, you know, one of the big successes, in my judgment, of sociology is network science. And I finally finished my education in 1995 at the age of 33, and went to the University of Chicago as an assistant professor.
[00:15:05] So with the origin story now in hand, I mean, as I said, you've, you know, written four books. You've done you know, I've written how many I don't know, articles and whatever else. And there's no way that we're going to cover anywhere near all of it. But one thing that I do think that I don't think we have talked to any of our other guests about and that I do think is very interesting, and that I think will be interesting to our listeners, is to talk about what you referenced, just very briefly right there, which is your work looking at social networks. Right? So, you know, I think that now it's a little bit interesting, because this is one of those things that previously would have mostly been a relatively esoteric, intellectual thing that people at the University of Chicago and the University of Pennsylvania talk about, but probably is not, you know, like the word on the street that a lot of people are talking about. But now that's no longer true. Right. So you have the I think it was in some ways, almost a sort of an era defining movie major, major motion picture was The Social Network, right? Which was a albeit maybe somewhat fictionalized, but nonetheless trying to be true to life accounting of the rise of Mark Zuckerberg and the rise of Facebook. And beyond that, we just live in a world I think, you know, it's not that there weren't social networks before, and there are now, but I think that the world of social media sort of makes visible what was previously less visible, right, in the sense that you think about who are my quote unquote friends or who am I, you know, who is liking my posts? And, you know, what is the algorithm giving to me to see from other people and all the rest of it.
[00:16:36] All of which is to say that I think that now we have social networks and social networking forefront in our consciousness in a way that I imagine it was not so much, you know, even 20, let alone 30 or 40 years ago, but you were doing your work and working on your book of the same name at a time when this was much less prominent. I think, at least in, you know, most of the public's consciousness. So talk to us a little bit. And I know you mentioned just at the very end of that last answer that you mentioned a little bit of how you came on to this, but what was it that mattered to you so much as as a person with medical training and an interest in social sciences? Why was it that that particular question mattered so much to you, that you thought it was worth studying it in that kind of depth, and then writing a book about it?
[00:17:27] Well, I mean, first of all, I've devoted my life to the study of human social interactions. So for the last 30 years, that's what I've been studying, and we've done everything from. And just to be clear, we study face to face social networks, which human beings have been making for tens of thousands of years. Right. And we've studied the physiology of human social interactions. The I just have a bunch of new work on the on the microbiome and how it spreads. We've studied the psychology of human social interactions, the mathematics of human social interactions, using an understanding of social networks to do public health interventions, and intervening in networks to make the world better economic aspects of networks. So we just you know, I've looked at the evolutionary biology of social networks, the genetics of social networks, like, turns out that our genes play a significant role in how we interact socially. And now published a bunch of couple of books on this topic and so on, and a lot of papers. So I've spent 30 years studying social networks, and it's actually given I'm now 62, I look, I'm beginning to look back and doing some of these sort of retrospective. And I'm I'm actually proud and happy actually with the work that I've done, I feel like it's meaningful work. And, uh, and I think it's it's a nice thing to study, you know, like how we love each other, how we how we form groups. It's a very deep and fundamental aspect of human experience. And it's been a privilege to be focused on this. But that's not how it began. How it began was I get to the University of Chicago in 1995, trained as a general internist.
[00:18:53] And as we as I alluded to earlier, because of my mother's terminal illness and so on, I and in the course of my clinical care, I really resolved to try to make a difference in the in the care of the dying in our society. So I become a hospice doctor. I get some funding from George Soros project on Death in America. This was in 1995, approximately to do some research on how to improve care of the dying. And clinically, I was 80. I was I had an 80 over 20 position. So I was doing 80% research, 20% clinical, and I was, uh, got lucky to work with a wonderful hospice program in Chicago, Horizon Hospice, and be a kind of assistant medical director. So in my lab, I was studying the care of the dying. Sort of health services, research, how to optimize ICU care, physician decision. Making hospice resource distribution and so on. Survival of hospice patients and what effects their survival. Developing prognostic algorithms to predict survival of patients. Assessing the accuracy of physician predictions of going back to my childhood, as we mentioned earlier. So I did all this work on getting doctors. I don't think anyone had done this before. I got I got dozens of doctors to make predictions about how likely hundreds of patients were to live. And then I followed those patients forward and saw how long did they live. And I compared the predictions that doctors made to the reality and then tried to understand why did the doctors make mistakes?
[00:20:15] I just want you to know that I quote that research and similar research frequently in telling my patients, when they inevitably ask me to prognosticate in as much detail as I can, that it's been clinically proven that I'm not going to do a good job at this, but -
[00:20:30] And then I'll say I wouldn't let you off the hook so easily, I would say what's been proven is that you're prone to certain kinds of errors, and you should recalibrate and give ranges. So you say like your median survival of a patient like you is this. But there's a range and here's the range. And there's a lot of reasons doctors resist prognosticating. Anyway, I wrote my first book called Death Foretold, which was published in 1999, about this. But the point is, I spent the first like 4 or 5 years of my assistant professorship. My clinical practice was home hospice care, so I was visiting people who were dying at home on the south Side of Chicago at about two thirds, very poor African American patients and one third sort of upper middle class University of Chicago faculty, all of whom were in hospice care. And when I first started, about a third of the patients were dying of Aids, a third of solid tumors and a third of everything else. And median survival in our hospice was about three weeks and it was really hard. These patients were suffering, especially the HIV patients. It was really uh, this was before Haart, highly active antiretroviral therapy had been discovered. Hiv was a universally fatal diagnosis, and the patients died of Kaposi's or Pneumocystis. It was just terrible. So that was my life. I was doing research about, uh, death and dying. I was clinical care of improving clinical care and physician decision making. I was taking care of people who were dying. I got very depressed, and I had just gone to visit Saint Christopher's Hospice, the famous, uh, where the modern hospice movement got started, to do some clinical training there.
[00:22:02] And I learned all these incredible clinical tricks about how to care for seriously ill people. So anyway, I got all these tricks, and I come back and I'm taking care of all these people. And, uh, and while I was there, however, while I was in England, I was being driven around by one of the attendings at Saint Christopher's. And, um, he told me that one of the jokes that they had about the Bureau of Vital Statistics in England is, they called it. Hatch. Match and dispatch. Birth, marriage and death. Hatch. Match. Dispatch. So I come back to the United States. My wife is like my beloved wife. Erica is like. You're really getting depressed. It's, you know, every survival curve you look at has a median survival of 14 days. You know, all you're studying is death and destruction. Can you find something else to do? And I was like, well, I really can't study, you know? Hatch, I have no qualifications to study, Bert. But, you know, maybe I could study match marriage. So I decide that I'm going to start studying the widowhood effect. It's a small move from care of the dying to studying the widowhood effect. And I start doing a body of work. Back then, I published, I don't know, ten papers on dying of a Broken Heart, which is an old topic in the sciences, actually goes back about 2 or 300 years. As I write in my book connected, I tell this history.
[00:23:16] So I start studying the widowhood effect, how and why it is that when your partner dies, your risk of death goes up a year or two into this, 2 or 3 years into this. I suddenly have this realization that the thing I was studying, the widowhood effect, was a simple case of a much deeper and broader phenomenon, which was the interpersonal spread of illness states, not just death between spouses. My risk of death goes up when my wife's risk of death goes up. But of all health states and among all people, not just between spouses. So how my depression causes my friend's depression, or how my obesity causes my brother's obesity, or how my death causes my wife's death, and on and on and on. And not only that, but these effects didn't stop at dyads resurrecting the ideas I'd been exposed to in my sociology training about networks, how these effects took place within these incredibly beautiful, ornate, complex, face to face networks that we make. And right around that time in the late 1990s, there had been this incredible efflorescence of interest in network science brought forth by some physicists who like that, started to study these. There were some classic papers that were published in the late 1990s, which I had been reading with interest, that suddenly made networks a bit more mathematically tractable than they had been in the past. And that's why I moved into networks. So basically, since 2001, that's what I've been doing, is studying human social networks.
[00:24:43] So, you know, when we think about healthcare, even now, when I counsel patients, when we talk about diseases, we consider it in very individualized terms. We talk about you have to take this medication. This is your lifestyle choices that led you to this, so on and so forth. But as your work has showed us, there's so much underneath that happens socially, right? Our health being influenced by other people's health. And if you've already mentioned a few of them, like obesity, for example, or psychiatric conditions, I'm wondering, are there examples you can share with us from your, you know, 20 years, 30 years of work on this. Examples of how networks affect health in surprising ways, perhaps, but that really illustrate the mechanism. Like why does this happen?
[00:25:29] So I mean, that's a long question. And the answer is yes. We've done a ton of work on this, including many experiments. We started by doing observational studies. Since 2010, I've been doing experiments, including field trials involving thousands of people in Uganda, India, in Honduras, we have this huge project. We just published this big paper where we we experimentally induce cascades in in a positive health behaviors, for example. But it started for me when I was doing the hospice work that I alluded to earlier and the widowhood effect. One of the earliest studies we did, which was an observational study, is we looked at how the quality of terminal care giving given to a decedent might attenuate the widowhood effect. So the question is, if you take better care of the dying, do you reduce the risk of their spouse dying afterwards? So the the spouse is the risk is going to go up after the person dies. But if I provide better end of life care, can I make that risk not go up as much? And the answer seemed to be yes. We found using a statistical technique called propensity score matching. We found that otherwise similar patients plausibly randomly assigned to get hospice care versus non hospice care. We then followed the survival of the decedent's spouse.
[00:26:41] And we found that the decedent's spouse was less likely to die afterwards presumably because they were less traumatized. It was less traumatic. If you give good end of life care to someone. So that really changed my thinking. And it got me to think more broadly. And it turns out this is a broad phenomenon. Like you just mentioned, the care we give to human beings affects others around them. And any oncologist will tell you, you go ask an oncology patient, you know, we have a couple of chemotherapeutic regimens we can give you. One of them is going to result in this profile of side effects and this burden on your family. Your wife's going to have to drive you for radiation therapy every day or whatever it is. And the other one is going to have this other profile, they'll tell you. Well, I'm going to make this decision in part because of my partner, my spouse, my beloved spouse. I mean, there are people are really concerned about the impact of their disease and their demise on their loved ones. It's very normal. It's very human experience. And so we oughtn't to neglect that. And furthermore, there are many other examples. For example, it might be the case that treating postpartum depression in women makes them more likely to vaccinate their children, or reduces the number of ER visits their children make for asthma.
[00:27:51] So we take better care of moms. If we're an insurance company and we're thinking, is it cost effective to provide medication and therapy for postpartum depression? Usually if the focus is very individualistic and narrow, we just think about these are the costs and these are the benefits to this person. But you have to look at the whole family system. There are all these other benefits. Or for example, if you look at the benefits of a of a hip replacement and an elderly person, you can see that you replace their hip, their quality, they gain a certain number of quality adjusted life years, or you replace their cataract to pick an example closer to your neck of the woods, and they get a certain number of qalys because you've replaced their cataract. But their wife's quality of life could also go up when you fix their cataract. And so those qalys need to be added to my qalys for the total quality benefit from the cataract replacement being higher than you thought. These are called in the social sciences. These are called externalities. These are costs or benefits that redound to other people who are, strictly speaking, not a party to the transaction.
[00:28:53] You fixing someone's cataract, all these other people are affected by it. Or you, you know, a tiler treating someone's cancer. All these other people are affected by it. And this vision like this, this, this willingness to see the world this way, to take in the fact that medicine is a is a social science and it has it affects the social system. It's not just that social factors determine whether you fall ill and determine the course of your illness. It's that medical interventions have these social implications. This was a radical change in perspective for me. I became obsessed with this topic and obsessed with rigorously showing it. Using fundamental mathematics and large scale experiments, we published dozens of experiments in the last 15 years involving thousands of human beings with very strict, rigorous methods showing that these effects not only are real, but they're non-trivial. That, you know, when I when I treat you, when I give you a piece of information, when I vaccinate you, when I fix something wrong with you, it ripples when I persuade you to quit smoking. Okay? You quit. And your wife and your brother and your neighbor and their wives and brothers and neighbors, all of these other people also quit as a result of the intervention I made in you.
[00:30:07] That's so interesting to hear. You know, sometimes you see things that you feel on a visceral level, and then to hear them quantified mathematically or described scientifically is so interesting. And, you know, when I'm attending in the hospital and taking care of the sickest cancer patients, it is often the case that we spend hours meeting with patients who are dying and whatever loved ones they want to have in the room. And when I'm working with fellows and residents in those circumstances, I will often tell them that as much as we have an ethical obligation, and it's obviously vitally important to provide appropriate care for the person who's dying, the person who's dying will soon be gone. But the consequences of the skill with which we do or do not conduct those meetings, preparing for the person's death, are going to ripple out into the people who survive them, maybe for decades after the person dies, right? I know people who never Forget the words that the physician said to them or didn't say to them, or the bearing or manner or whatever that the physician had in the closing moments before the death of their father, mother, brother, sister, son, daughter, what have you. So that that's something that is sort of in my bones example of what you're talking about.
[00:31:28] On the flip side of that, it is almost impossible to explain how terribly difficult it was to deliver health care during the pandemic when our hospital, like most other ones, banned all family and friends from the hospital.
[00:31:43] I was incensed I was out there trying to stop this insanity of people dying alone. It was medieval.
[00:31:49] It was hell. To see these people who were and even the people who weren't dying, just people who were going through medical, you know, regular medical whatever, GI bleed, what have you. It is terrifying and inhumane to be hospitalized without someone there to support you. And of course, there, you know, people that that's true for all the time anyway. But but it's just to say that those things on sort of either side of the ledger impress upon me just how integral to the human experience of disease and illness is that social factor. But I also then want to then allow that to lead us to have you discuss your most recent book, which is on the pandemic. Right. I feel like in early 2020, there was this weird way in which we were all sort of like transfixed by our televisions, in effect, watching people draw little red lines to demonstrate the very thing that you're talking about. Right? Whether it was the little red lines demonstrating the spread of the virus, first from China, then to other parts of China, then internationally, then whatever, or whether it was little red lines to indicate where vaccines were having high uptake or where they weren't, or all of those things. I feel like that idea of sort of social contagion, yes, of disease, but also of disease, preventative measures and everything else. It was like you were watching it play out in real time right there in front of you. What would you distill out as a person who has studied those social effects on medical outcomes for now decades, as you watched all of this play out in the pandemic? What did you feel like? Oh, yes, that's just what I expected. And what really surprised you?
[00:33:29] Well, it's very difficult to to say this without coming across as pompous. And I don't mean to come across as pompous, but frankly, nothing surprised me about the pandemic. And the reason is not that I'm some kind of special genius. The reason is I went to school and I learned stuff. And, you know, there are there are generations of medical historians and epidemiologists and virologists who've been writing about epidemics. And if you read that stuff, there was nothing about Covid 19 that was remotely surprising. Not at all. Even the debates about masking during the influenza pandemic of 1918, they had big arguments about whether you should mask or not school closures. All of these arguments have been had repeatedly across time. There's a ton of scientific evidence about all of these topics. The issue of dying alone that you mentioned, there are medieval texts about the awfulness of people dying alone in times of plague. This is a very fundamental human experience. I mean, the fundamental story here is that plagues are not new to our species. They're just new to us. We thought this was this extraordinary thing. But what's really weird is if you look at, for example, our religious traditions or our literary traditions. I mean, one of the oldest works in the Western canon, the Iliad, begins with a plague, right? Apollo comes down and is, is and inflicts on the Greek soldiers laying siege to Troy a plague.
[00:34:46] Or you look at, um, you know, all of my Jewish friends were saying, you know, you know, always during Passover we would talk about the plague pass over me. But, you know, now I really understood you know, what my we're talking about. You know, everyone should stay in their own tents and so on. You know, social isolation was in the religious tradition. Stay away from other people when there's a plague. So our ancestors tried to warn us about these things. They put these warnings in in our religious texts, in our in our stories and so on. And yet we just did not listen. So there was very little that surprised me, honestly. Well, what I published my book on prognosis, Death Foretold. In 1999. I published my book on social networks, connected in 2009. Actually, in 2019, I published my favorite book, which is called Blueprint The Evolutionary Origins of a Good Society. And I wasn't planning on doing another book till 2029. Like every ten years I kind of work on a book, so I wasn't planning on doing another book. And but then the then the Covid struck and I felt I could maybe make a contribution. And I was like everyone else, I was stuck at home and and I knew most of what I needed to know to write the book, and I could get the other stuff online.
[00:35:55] And so I started working, and I worked 12 hours a day for 120 days in a row. So I started writing the book in March of 2020, and I delivered it to the publisher in July. So March, April, May, June, July. And so that's four months later. I delivered the manuscript to her, and then she edits it, and I fixed it a little bit in August. Then it goes to production and it hits the bookshelves in October of 2020. And I predicted that we'd have over a million deaths. In the book I write, you know, we're going to see a million deaths. And I said, we're not going to it's going to take four years before we see the other side of this. And I said a bunch of other stuff, all of which was just straight up, you know, mathematical calculations based on what was known about the R naught and the IFR of the virus and based on, you know, the history of plagues and, you know, just straight up like school textbook stuff. And people thought I was nuts, you know, but but I wasn't.
[00:36:50] So anyway, so I talk in the book about people dying alone like you alluded to. And, and I was really it's hard to describe how angry I was at how at our government and our leaders for the calamity that befell us. Because we wasted, we squandered months. I'll tell you a funny story. I knew the thing was happening, and I and I was telling my wife in January because I have some Chinese colleagues. And so I was working on some science with them and was getting daily information about what was happening in Wuhan and throughout China. And I told my wife, I said, Erika, you know, we need to prepare. It's going to be a worldwide pandemic. She said, what are you talking about? You know, they're just they've been like, I don't know, a couple thousand cases in China. It's like, no, we need to really do this, this and this. And I had this whole set of things that we needed to do, all of which we did. And she thought like, you know, like I was like a prepper, you know, like I had some kind of prepper fantasies that were coming through, and she wasn't taking me seriously. Actually, I'm so glad this happened, because now I'm, you know, I get a little bit more credibility in our household.
[00:37:48] Can you give us a tour of the bunker in your backyard and show us, you know, your water distillation system and whatever?
[00:37:53] Yes, exactly. Well, we we we we had a house in Vermont and we were what's up in the mountains of Vermont? And I was like, you know, we're going to go to this house in Vermont. When the pandemic, I said, Erica, we need to get up here by by the beginning of March at the latest. And I go to the Home Depot here near Dartmouth College in Vermont, where I live, and to buy masks, to buy an N95 masks. And I get there and there's this guy, and he's like, he says, it's the weirdest, damnedest thing. He goes, all of the masks have sold out. And I asked him, I said, why have all the masks sold out? Because, you know, I'm pretty early to this game. And he goes, all these Chinese students from Dartmouth are buying up the masks and sending them back to China. And I'm thinking, you know, isn't anyone paying attention? Like, you know, me and the Chinese students are the ones that are actually preparing. Everyone else is like, la la la. Nothing is happening. So I wrote out the pandemic in Vermont, and I wrote the book. And, you know, we're kind of beginning, as is typical, we're beginning to see the other side of the epidemic. And our economic and social recovery will also follow and is following a pretty standard trajectory,
[00:38:58] But the book I'd rather talk about, at least to give a thumbnail, is the 2019 book on blueprint, which is the book I'm most proud of because it captures a very optimistic perspective on our species, because I think I think we're a wonderful species. We have these amazing abilities, and it's become very popular to focus on our awful qualities. You know, our propensity for violence and and hatred and in-group bias. You know, where we like our own groups and hate other groups and demonize other groups and our capacity for mendacity and and slavery and colonialism and torture and all of these awful things that it is true. We do.
[00:39:40] Well, that's something I'd like to turn to next. Actually, we never shy away from exploring the larger philosophical, ethical and metaphysical dimensions of what it means to live. Well, as you've mentioned, living well is intrinsically linked with a good society, so please tell us more about that.
[00:39:58] Even that analogy between living a good life and having a good society is one that Plato exploits in the Republic, right? I mean, he's explicitly talking about this, how we can govern ourselves both, how I can govern myself and how as a collective, we can govern ourselves. But the point is, I kind of wrote the book as a corrective to this sort of, you know, I thought both both the person on the street and scientists were overly focused on the dark side of human nature and had been ignoring the bright side. And the bright side deserves more attention, because equally, it is true that we are capable of love and friendship and cooperation and teaching and all of these wonderful qualities that are required actually for us to to survive and to live socially as we do. And so the book Blueprint The Evolutionary Origins of a Good Society is talks about how necessarily over our evolutionary past these good qualities must have outweighed the bad. In other words, if every time I came near you, you lied to me and filled me with falsehoods, or you beat me, or you took my stuff, or you killed me, I would be better off living atomistically. We'd be a solitary species or many solitary species where each individual lives alone. But we're not. We are a social species, which means that the benefits of a connected life must necessarily have outweighed the costs in our ancestral past.
[00:41:20] And it means, furthermore, that evolution has shaped our sociality, our way of living together, and has endowed us with all these wonderful qualities. We don't, for example, just mate with other people. I mean, you can just have sex with other people. Of course, there's nothing wrong with that, to be clear. But we fall in love with the people that we have sex with. We feel an emotional attachment to the people with whom we have sex or reproduce, and that is an evolved capacity. Okay. It is something that evolution has endowed us with this wonderful capacity to be in love. And we don't just love our partners, we also can love our friends. We can form long term non-reproductive unions with unrelated conspecifics, which is a scientific way of saying you have friends. But why? Why do we do that? That's a really weird phenotype. Very few other animals do it. We do it. Certain other primates do it. Elephants do it. Both Asian and African elephants and certain whale species do it. Have friends. It's a very rare and interesting phenotype and it's a miraculous phenotype. Everyone listening to this knows what it's like to have a friend or to have friends. Everyone listening to this knows how good it feels when you're in the company of your friends. That good feeling you have when you're in the company of your friends, your blood pressure goes down, your heart rate goes down, your mood improves.
[00:42:35] You feel understood. You feel supported. You don't feel as weak or as vulnerable. All of those feelings and physiologic responses are shaped by natural selection. You feel good in the company of your friends. Your body responds. We help strangers. We do it all the time, whether we give money to strangers on the street, whether we share information willingly, like the mere fact, by the way, that we are talking right now and we're exchanging information, is a kind of altruism, we have evolved the capacity not only to have learning, not only to have social learning, but to have teaching. And teaching is a kind of altruism where you give away information, something of value to other people. And that is incredibly that capacity, that's the capacity for culture has has allowed us to be one of the ascendant species on the planet, has allowed us to to populate every niche, every environmental niche, from the Saharan desert to the Arctic. It's a capacity for culture that lets us do that. So teaching is a miraculous thing that we do, and natural selection has given us. And on and on. There are all these wonderful things that we do that I think are very easy to overlook and very easy to to forget how distinctive they are in the animal kingdom and how wonderful they are.
[00:43:53] And I think to build on what you're saying, what is really remarkable, we often, as you say, we often think and talk about sort of nature red in tooth and claw, right, and survival of the fittest and social Darwinism and all of these things. And I feel like those are especially, maybe even more omnipresent now than they were, because many of the algorithms that govern social media like to feed us that stuff.
[00:44:17] Yes, they're Hobbesian instead of Rousseauian. That's right. Right.
[00:44:20] There is a sort of atavistic impulse to want to look at the violent thing or whatever. And so then it comes to seem like that's what defines the world. But the very fact that there is an altruistic impulse, right. The very fact that so many people form enduring social attachments, whether to a romantic partner or to platonic friends, just that there's that word again, platonic, right. But like the very fact that we do that and that we are willing to sacrifice for them. Right. I think to your point about having friends, all of us know people who, if they called us on the phone in five minutes and said, oh my gosh, things are falling apart, I need money, I need a place to stay, I need a ride, I need to talk. We would drop everything and just do it, even if it entailed great sacrifice on our part and the very fact that we do those things so often and so willingly, and that those things mostly largely go unheralded, whereas acts of violence and whatever else often, you know, play across social media and these seemingly never ending ripples, I think that says something profound about both who we are and who we're capable of being 100%.
[00:45:34] And you have to see that kind of uneven exchange that you just described, where you can offer a lot of value to your friend, but not necessarily a lot of cost, and you don't expect an immediate repayment. In other words, exchange relations where there's a tit for tat are where friendship is low. If someone calls you up and says, Tyler, give me a ride and I'll give you ten bucks, that's not your friend, right? That is a transaction that's a different kind of social interaction. But your friends, there's no expectation of immediate repayment, nor of a payment in kind. You give your friend a ride and they bake you a cake. You know, it's not like you give them a ride and they give you a ride. There are different exchanges and often they are incommensurable or difficult things, you know, so you need a house to stay in. And your friend says, you know, I have this, my house in Italy that belonged to my grandfather. Why don't you stay there in August and take your family for a vacation? And you're like, oh my God, thank you so much. And you go, and you do that. And two years later, your friend calls you up and says, you know, actually, my daughter needs to have a kind of an experience in a lab. Can you give her a job for the summer? And you're like, sure, we'll take Susie into the lab.
[00:46:37] It's that kind of incommensurate exchange. And there's actually there's some work by evolutionary biologists Tooby and Cosmides. Leda Cosmides and John Tooby, who wrote about this in a very famous paper called The Bankers Paradox because the bankers paradox is that the banker never wants to lend money to anyone who actually needs money. So in other words, if you're desperate for money and you go to the bank for a loan, that's exactly who the bank does not want to lend money to. The bank only wants to lend money to people who don't need money. So this is the thing about friendship. Friendship is a institution that evolved, I believe, to resolve so-called banker's paradox dilemmas in our society. It's a situation in which your friend is facing danger, is drowning in a river, and at minimal cost. You can lower a branch and rescue them from the river. That is valuable to have a person like that who can, who can help you out out of a tight spot, and then later on you might reciprocate in some other way for your friend. If natural selection could work, because actually expending resources to save your drowning friend like jumping in to save them in a tit for tat exchange wouldn't necessarily be advantageous to either of you.
[00:47:47] You need a kind of way of exchanging favors and help that is not immediate, and not in a precise like one for one relationship. So that, I think, is one of the reasons we've been endowed with this miraculous capacity to have friends, which every are seen in every society. And everyone listening to this knows what I'm I'm talking about. One more thing I had when I met my wife. I had love at first sight. It's not necessary to have a good marriage. Not everyone has love at first sight. About 5% of couples start with love at first sight. And to be clear for those listening, when I say love at first sight, you're in love with them and they're also in love with you. All of us have had unrequited love at first sight, where you, you know, are besotted with someone and they have no idea who you are or don't care. That's not what I'm talking about. I'm talking about you love them and they love you on first sight, that's uncommon. But even though that experience is uncommon, like at first sight is not uncommon. Most people have had like at first sight, and that is also, in my judgment, evolutionarily shaped that capacity to immediately form a judgment. I like this person.
[00:48:52] This is a trustworthy person. This is a good person. This is my kind of person. And they're feeling similarly about you. That is also very important that that the ability of natural selection to shape who we choose as our friends, not just our propensity for having friends, is something that my laboratory has been studying actually for, for quite, quite some time. We haven't talked about that, but there's a whole other branch of the lab where we study the physiology and the genetics of human social interaction. But the one other thing we didn't talk about, I just want to mention, is we've been doing a lot of work on how to use network science for good, how to use an understanding of of networks to intervene in the world to make it better, you know, to benefit humanity. And what we do is, is we use a sort of an understanding of the mathematics of human social network structure to identify within a population which individuals are structurally influential not by virtue of who they are, but by virtue of where they are in the network. So in other words, if you have a village like we study in Honduras of 500 people, which three women do you have to persuade to breastfeed their children such that if they breastfeed their children, everyone in the village will breastfeed?
[00:49:59] The influencers, as it were.
[00:50:01] Exactly. But in like real face to face networks for material stakes. And so we've done a lot of randomized controlled trials testing algorithms for identifying structurally influential people, and then showing that we can induce cascades of beneficial behavior across friendship ties, across kinship and friendship and all these social ties we've been discussing. We can induce these cascades of desirable properties and lift up these populations, make them healthier, happier, and wealthier. So, you know, that's the other sort of big thing that we've been engaged in in the lab over the last 15 or 20 years.
[00:50:38] So after all of your work and observations on good societies on a grander scale, I'm wondering if you can take us down to a more granular level. Is there any advice you can share about how we can live better and more meaningfully?
[00:50:52] Well, I have nothing special to say beyond what you know, all the wise people before us have said about, you know, it's really important to make yourself small in the world, you know, to to feel small compared to the big society you live in, or small compared to the natural world or small compared to God. You know, that is losing yourself and surrendering yourself to a bigger cause or something outside yourself. It's your family, your community, your your country, some cause you care about. This is the thing that I think gives life a meaning. And, you know, in my case, certainly, I've had the benefit of very fulfilling work, you know, but but in my case, most of the meaning in my life has come from, you know, being a good husband and a good father, and being a good scientist. You know, trying to to leave something behind that that shapes human understanding of this, of the natural world. So I think anything one can do to be invested in the lives of others, I think, lifts you up and brings joy. And I think, incidentally, I think we evolved to to have that sentiment as well. I'll tell you one more thing. There's this feeling of awe that all humans have had. And if you think about when you've been awestruck, it's often by natural phenomena like lightning storms or earthquakes or windstorms or big expanses of like the sea or grand vistas or it's it's extraordinary gestures by human beings. You know, someone that does something extraordinary, lays down their life for others, or just as an incredible performance of some kind, some kind of achievement.
[00:52:31] You're just awestruck. That that feeling of awe, I think is is a fantastic feeling. It typically is a feeling where you feel small, right? You're small in front of the sunset. The Earth has been orbiting the sun for billions of years, and it's going to do so for a long time after we're all gone. And the sun is huge and we are tiny, and the next day is coming inexorably, all of those things are militating towards your recognition that that you're tiny in the world. And so I think the feeling of awe is connected to that. But what's interesting is that Jane Goodall describes chimpanzees having a feeling of looks like they're having a feeling of awe, like she's seen chimps, like, sit on a ledge and look at a sunset, and they really look like they are, you know, having this, this feeling. I think we evolved to have this feeling because that feeling of awe is once again a surrendering of the self. You're outside of yourself. You're not self centered when you have this feeling of awe and the ability to to have that feeling at a time when stakes might be high, when there's a natural disaster about to strike or something dramatic is happening could facilitate solidarity. So I think this feeling of awe is connected to actually our social existence, paradoxically.
[00:53:50] I want to endorse you a little bit more than you were endorsing yourself in the following way. When when Henry asked, what do you have to offer in answer to that question, you sort of minimized your answer and said, well, not. I don't have much to add to all the great wisdom traditions, but I will say this that I feel like there is a certain kind of widespread cultural, at least in the so-called developed Western world. I think there is a little bit of a widespread cultural amnesia right now in terms of the wisdom that comes from those wisdom traditions, in the sense that if you look at, you know, especially in for like millennials and Gen Z, the memes that are most popular are you do you.
[00:54:29] Know, that's a prescription for misery?
[00:54:31] No, I know, but but that's what I'm saying. But there is, there is a very and, you know, obviously altruism and narcissism or whatever pairing you want to cite have been battling since ages immemorial. Right. I'm not saying this is a new thing, but I'm just saying that there is a very strong cultural strain. Not just narcissism may happen, but almost. Narcissism is good. Narcissism is the point that the entire purpose of existence is to dwell on yourself. And so I think the reminder, with a scientific backing, to get to escape yourself and to find joy and meaning, whether it's being odd, you know, in front of a sunset or whether it's losing yourself in the service of your spouse, your family, your kids, your your congregation, whatever it is that I think is deeply meaningful. And so for providing decades of, in effect, scientific buttressing for those arguments and then for coming and sharing us, Sheringham's sharing them with us today. We deeply appreciate all of these insights and have really enjoyed this conversation.
[00:55:37] Thank you both very much for having me.
[00:55:43] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctor's Art.com. If you enjoyed the episode, please subscribe, rate, and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
[00:56:02] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in healthcare who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
[00:56:16] I'm Henry Bair
[00:56:17] and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.