1: “As a surgical resident at Johns Hopkins, I would learn that death comes at two speeds: fast and slow,” Peter Attia writes in his book Outlive: The Science and Art of Longevity.
Peter had chosen Hopkins for his medical residency because of its top-notch reputation for excellence in liver and pancreatic cancer surgery.
But the fact it was located in downtown Baltimore also meant he and his fellow residents were likely to see more than ten acute trauma cases each day, mostly gunshot or stabbing wounds. Meaning they would have abundant opportunities to develop their surgical skills.
“In inner-city Baltimore, fast death ruled the streets, meted out by guns, knives, and speeding automobiles,” he writes.
While trauma and fast death ruled the nights, a different type of death dominated the daylight hours.
“Our days belonged to patients with vascular disease, GI disease, and especially cancer,” he recalls. “The difference was that these patients’ ‘wounds’ were caused by slow-growing, long-undetected tumors, and not all of them survived either—not even the wealthy ones, the ones who were on top of the world.
“Cancer doesn’t care how rich you are. Or who your surgeon is, really,” he observes. “If it wants to find a way to kill you, it will.”
2: In the early 1900s, life expectancy was just shy of fifty years old. Most people died from “fast” causes: accidents, injuries, and infectious diseases of various kinds.
“Since then,” Peter writes, “slow death has supplanted fast death. The majority of people reading [his] book can expect to die somewhere in their seventies or eighties, give or take, and almost all from ‘slow’ causes.”
There are, of course, exceptions, including people who engage in dangerous adventure sports like BASE jumping, motorcycle racing, or texting and driving.
But for the rest of us, “the odds are overwhelming that we will die as a result of one of the chronic diseases of aging,” which Peter refers to as “the Four Horsemen: heart disease, cancer, neurodegenerative disease, or type 2 diabetes and related metabolic dysfunction.”
To live longer and better, we must understand and challenge these four significant causes of slow death.
What stands in our way?
“The skills that my colleagues and I acquired during our medical training have proved to be far more effective against fast death than slow death,” Peter notes.
“We learned to fix broken bones, wipe out infections with powerful antibiotics, support and even replace damaged organs, and decompress serious spine or brain injuries. We had an amazing ability to save lives and restore full function to broken bodies, even reviving patients who were nearly dead.
“But we were markedly less successful at helping our patients with chronic conditions,” he writes, “such as cancer, cardiovascular disease, or neurological disease, evade slow death. We could relive their symptoms, and often delay the end slightly, but it didn’t seem as if we could reset the clock the way we could with acute problems.”
It’s not from a lack of trying. Or money.
“Modern medicine has thrown an unbelievable amount of effort and resources at each of these diseases,” Peter writes. “But our progress has been less than stellar, with the possible exception of cardiovascular disease, where we have cut mortality rates by two-thirds in the industrialized world in about sixty years.
“Death rates from cancer, on the other hand, have hardly budged in the more than fifty years since the War on Cancer was declared, despite hundreds of billions of dollars worth of public and private spending on research.
“Type 2 diabetes remains a raging public health crisis, showing no signs of abating, and Alzheimer’s disease and related neurodegenerative diseases stalk our growing elderly population, with virtually no effective treatments on the horizon,” Peter observes.
3: The real problem is that modern medicine intervenes at the wrong moment. When it’s already too late.
The Four Horsemen “generally take a very long time to kill you,” Peter writes, “Even when someone dies ‘suddenly’ of a heart attack, the disease had likely been progressing in their coronary arteries for two decades. Slow death moves even more slowly than we realize.”
The answer is to start much earlier. Even better? Prevent the Four Horsemen altogether.
Case-in-point: Lung cancer.
“None of our treatments for late-stage lung cancer has reduced mortality by nearly as much as the worldwide reduction in smoking that has occurred over the last two decades, thanks in part to widespread smoking bans. This simple preventive measure (not smoking) has saved more lives than any late-stage intervention that medicine has devised.”
The focus of so-called modern medicine is in the wrong area. “Our job was to stop the patient from dying, no matter what,” he writes.
Trauma victims and chronic disease sufferers are treated using this same approach.
Peter shares the story of a fourteen-year-old boy who was brought into the ER one night, barely alive.
“He had been a passenger in a Honda that was T-boned by a driver who ran a red light at murderous speed,” Peter writes. “His vital signs were weak and his pupils were fixed and dilated, suggesting severe head trauma. He was close to death.”
Peter was serving as the trauma chief that night. He did everything in his power to revive the boy. Nothing worked.
“My colleagues wanted me to call it, yet I stubbornly refused to declare him dead,” he recalls. “Instead, I kept coding him, pouring bag after bag of blood and epinephrine into his lifeless body because I couldn’t accept the fact that an innocent young boy’s life could end like this.
“Afterwards, I sobbed in the stairwell, wishing I could have saved him,” he remembers. “But by the time he got to me, his fate was sealed.”
The philosophy that “Nobody dies on my watch” is appropriate for trauma victims.
But less so for cancer patients. Because “very often it was clear that we were coming in too late, when the disease had already progressed to the point where death was almost inevitable,” Peter writes. “Nevertheless, just as with the boy in the car crash, we did everything possible to prolong their lives, deploying toxic and often painful treatments right up until the very end, buying a few more weeks or months of life at best.”
Is there a better approach?
More tomorrow.
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Reflection: Of the people I know who have died, how many died from fast death vs. slow death? For those who died of causes related to slow death, how effective was the treatment they received? Did the treatment substantially add years to their lives?
Action: Discuss with a friend or colleague.
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