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  Yet there are more than these immediate costs involved, hinted at by one of the more intriguing and sobering bits of evidence in all the vast collection of bones: the case of a single individual, D3444. We know him only by his skull, but that’s enough to tell us he was a Dmanisi man, which places his life in what is now the nation of Georgia about 1.8 million years ago. He is not even Homo sapiens; Dmanisi people were like Neanderthals, a separate species of hominids that left Africa long before Homo sapiens and eventually settled the grasslands east of what is now Europe. D3444 is a special case simply because his skull has no teeth, but, in fact, he had no teeth long before he died. Anthropologists believe this is evidence of infirmities that would have made him dependent on others for his survival. He needed help, and he got it, because hominids take care of those who can’t take care of themselves and have done so since before they were humans. This generosity has real biological costs in terms of energy spent. All of this means that empathy must confer benefits greater than those costs, or it would not still be with us. This is axiomatic in evolutionary biology.

  Yet any accounting of this matter can easily miss the even larger point in play. We need not look long and far for cases of humans caring for helpless humans, and this brings us to what is perhaps the most salient point of humanity, the fundamental fact of our existence largely overlooked in these discussions, because like many fundamental, important, and profound facts of life, it hides in plain sight. We take it for granted.

  The biological term that we need now to move this discussion forward is “altricial,” meaning simply “helpless young.” Of course they are. Helpless is almost the very definition of the young of any species, from baby robins to newborn, sightless puppies. But this topic teases out probably the most significant difference between our species and all other animals now or ever. Our young are more or less helpless for a very long time, longer than any other species—fourteen, fifteen years. (Some present-day parents would insist that it’s twenty-five or thirty years.) No other species is even remotely close to us in this regard. This, too, is a defining fact of the human condition.

  And it is not happenstance but a predictable, derivative trait, given our big brains. Humans cannot be born with fully formed brains simply because the resulting head would not fit through the birth canal. Rather, our brains are built and formed after we are born, like a ship in a bottle, a process that takes fifteen, maybe twenty years.

  Volumes of understanding and entire disciplines and sets of wisdom derive from this simple fact, but applying it to paleoanthropology offers a new lens on the human condition. In fact, some in the field now argue that this simple fact of life is the most salient characteristic of human nature, the founding fact of our life. Our young are so dependent that no parent is capable of the task of supporting and caring for that infant—not just the attention and protection, but the teaching and feeding. Hunters and gatherers must meet the energy demands of lactating mothers back in camp. Mothers simply cannot raise infants alone, and this dictates social bonding. The basic social contract has babies as its bottom line. Without this, the human species cannot go on as it is. All evolution hinges on successful reproduction of the next generation. In the case of humans, this is an enormous task. Through all human time, across all human cultures, there emerges a number associated with this task. It takes a ratio of four adults to one child to allow humans to go on. This is the real cost of our big brains.

  This is why we must cooperate, and why tools like empathy and language evolved to enable that cooperation. All else of human nature is derivative of this single human condition.

  Empathy and violence, tribalism and warfare, storytelling, dance, and music—all derivative. Our business as we go forward is to build the case for your well-being as it is built in humans: in mind, body, energetics, and motion, in the elements of life. But understand from the beginning that evolution—working in bone, muscle, neurons, fat, food, and fight—finally built a creature that is human. How are we different from all the rest of life? The paleoanthropologist Ian Tattersall offers a good summary. “To put this at its most elementary, humans care at least to some extent about each other’s welfare; and chimpanzees—as well as probably all of our other primate relatives—do not.”

  Our other primate relatives did not—at least not to the extent that we do—and they are extinct.

  2

  What Ails Us

  Not Disease but Afflictions

  “Disease of civilization” is an old term that nonetheless has the power to unravel the most important questions of our time. The idea itself has been with us almost as long as the concept of evolution, yet it has taken nearly a couple of centuries for us to realize the power of linking the two ideas to explain our current disease.

  But what exactly is it that ails us collectively and individually? It’s not a simple or uncontroversial question, and it is one that engages a lot of scientific brainpower and serious money. There are a variety of ways to answer this, but they sort into a couple of piles, which are generally these: what kills us and what makes us sick while we are alive? The former is a problem because it runs up against the fact of our nature that we all die. Something has to kill us sooner or later, so if medical science triumphs over one cause of death, another steps in to do nature’s job. We’ve worked around this issue with the concept of “premature death,” whatever that might mean, but still, you’ve got to die of something. Thus we can get more traction by asking what makes us sick, what undermines our quality of life while we are alive.

  It turns out that a recent and comprehensive effort to grapple with both of these aspects of the question is under way, and results will trickle out during the next few years—though the effort has already delivered some data we can use here. The Bill & Melinda Gates Foundation paid for a massive study carried out by the Seattle-based Institute for Health Metrics and Evaluation. Called “The Global Burden of Disease,” it looks at causes of death but also debilitation and loss of quality of life for people suffering 291 diseases in 187 countries around the world. Further, it looks at changes in those patterns from 1990 to 2010, a snapshot of change. The first results, published in the journal The Lancet in late 2012, say that the world’s top health problems today are, in order:

  Ischemic heart disease

  Lower respiratory infection

  Stroke

  Diarrhea

  HIV

  Low back pain

  Malaria

  Chronic obstructive pulmonary (lung) disease

  Preterm birth

  Road injury

  Major depressive disorders

  Neonatal encephalitis

  More tellingly, though, these problems are related to causes, so the same study also details the top twelve risk factors for death and debilitation worldwide. Again, in order:

  High blood pressure

  Smoking

  Alcohol

  Household air pollution

  Low fruit consumption

  High body mass index (simply stated, obesity)

  High blood sugar

  Low body weight

  Ambient particulate matter (air pollution)

  Inactivity

  High salt intake

  Low nut and seed consumption

  Both of these lists are telling if not surprising because of assumptions they shatter. Note the absence of cancer on the first list. Note that the list does not include, as we might expect, a litany of infectious diseases associated with poverty. The closest are malaria and neonatal encephalitis, and we can make a case that malaria is in fact a disease of civilization—just an old one. (The record shows that it only appeared with the cutting and clearing of forests associated with agriculture.) More revealing, though, is the second list: the risk factors. This is the list that undermines our concept of disease as some sort of genetic deficiency that needs to be corrected, or as simply infection by a microorganism. This list suggests that “disease” is the wrong word. What we really mean to say is “
injury.” Maybe it’s time to abandon the time-honored phrase and begin calling diseases “afflictions of civilization.” These are not flaws or failings in the design of a person’s body but, rather, self-inflicted damages brought on by the way we live. This is what ails us. Every single one of the twelve leading risk factors worldwide is a disease of civilization. But more to the business at hand: every one of these risk factors is a direct result of the foundational idea of this book. These injuries are a direct result of ignoring evolution’s design of our body, a direct result of trying to force humans into conditions that the design was not meant to accommodate. And every one is easily and immediately correctable in every life. So what is the relevance of understanding nature’s design of our body? Given this list, given a state-of-the-art assessment of the global burden of disease, we have a hard time imagining anything more relevant and urgent.

  But you know this, or at least can know it. You can do your very own diagnostic of this issue without being bankrolled by Bill and Melinda Gates. Many places work well for doing this, but our personal favorite is an airport. Most any airport will do, but pick a crowded one and simply observe the stream of humanity. Obesity is what one sees first, because it is so painfully obvious; some are so obese as to require wheelchairs. Even the ambulatory are panting and sweating with the burden of a hundred-yard walk. But don’t stop here. Look deeper and get some idea of everyone else’s fitness, well-being, contentment (or lack), sallow sagging skin, downcast eyes. Now recall, if you’re old enough to do so, the same scene in the same sort of place twenty years ago. Did it look the same? Both the numbers and your memory ought to suggest something very different. Something drastic and catastrophic is happening to our people and happening fast. We are getting worse.

  Yet the irony of this fully emerges only in an airport, which is why we chose this space. What do you hear in an airport? Warnings trumpeted ad nauseam of the threat of a terrorist attack and the need for vigilance. And yet this imagined damage seems terribly meek in the face of the very real damage to our people on display before our eyes. Who did this to us? And can one imagine a greater threat to our future well-being, our future as a nation, indeed the future of our species than the condition of our people? Can you imagine an act of subversion or terrorism more powerful and more extensive than this profound injury we have inflicted on ourselves?

  We can trace the concept of diseases of civilization to Stanislas Tanchou, a French physician who served with Napoleon—specifically, to some lectures he gave in the 1840s. Tanchou did not base his work on overweight people or high blood sugar; he was far more worried about cancer, as are we today. In fact, cancer was the original disease of civilization. Tanchou analyzed death registries of the day and noted that cancer was far more prevalent in cities like Paris than in rural areas, and it was on the rise throughout Europe.

  By the beginning of the twentieth century, this idea had spread worldwide and had expanded to include a long list of diseases. Recall now that this was the age of imperialism, characterized by the spread of “civilization,” at least as Europeans defined the term. Imperialism created a patchwork of frontiers across the globe that allowed the emerging science of the day to engage people living in the old ways, many of them hunters and gatherers. What the adventuring doctors noticed on virtually every one of those frontiers was that the so-called primitive people were in many ways healthier and more robust than Europeans. Cancer was absent in many populations around the world. For instance, a comprehensive report commissioned by America’s National Museum of Natural History (part of the Smithsonian) in 1908 found cancer among Native Americans to be “extremely rare” then. One physician recorded only one case of cancer among two thousand Native Americans he examined in detail over the course of fifteen years. A population of 120,000 native people in Fiji yielded only two deaths from cancer. One physician practiced in Borneo for ten years and never saw a single case. At the same time, cancer deaths were common and well recognized (at a rate of thirty-two per thousand people) in places like New York.

  Tanchou’s original concept spawned a century and a half’s worth of work in virtually every uncivilized corner of the globe, from Inuit, Aleut, and Apache of North America to Yanomami Indians in South America to various groups of Micronesians and Australian aborigines to !Kung San bushmen of Africa. Further, researchers began compiling a list of diseases absent in indigenous populations, no matter where they lived on the planet, including and especially cardiovascular disease, high blood pressure, type 2 diabetes, arthritis, psoriasis, dental cavities, and acne. Note that this list includes some of the very diseases that constitute our worst problems today.

  Beginning as the research did in the nineteenth century, a period that made much of racial differences among people, an initial explanation for this phenomenon was, as you might expect, racist: these populations, the thinking went, were inherently resistant to these diseases by reason of what we would today call genetics. Not true. A host of studies looked at populations of these same people as they adopted Western diets and ways of living and found a coincident rise in diseases of civilization. Even the early studies showed that in those cases where indigenous people did fall prey to Western disease, it tended to occur among individuals who were living among whites. Likewise, immigration studies showed, and continue to show, that people who move from a disease-free to a disease-prone area—say from the Australian outback to Europe—quickly become as susceptible to the full range of problems as are people from that area. Diseases of civilization are not rooted in genetic differences.

  A more persistent explanation emerged almost immediately in the nineteenth century and still surfaces today, a far more interesting idea tied directly to the notion that you have to die of something. In fact, some researchers signal their bias in this matter by preferring the term “diseases of longevity” to “diseases of civilization.” Their argument is that the blessings of Western civilization, especially controlling communicable diseases, made people live longer and so gave them more time to develop heart disease, cancer, and type 2 diabetes. This argument stands despite a compelling counterargument: type 2 diabetes is emerging today in teenagers. So are we arguing that this is a disease of longevity caused by the fact that teenagers live longer as teenagers?

  We’ll be blunt, because this is vitally important to everything we will have to say, especially about nutrition: type 2 diabetes ought to be a screaming, wailing siren of a warning to our society that something is changing very fast, and we ought to do something about it. We are under attack. And while arguments and analysis may persist in complicating this problem, it is not at all complicated. Type 2 diabetes is a lifestyle disease that results from eating sugar and refined carbohydrates. It appeared among the earliest recorded diseases of civilization, coincident with sugar and flour appearing in people’s diets in places as distinct as Africa and Arizona, and has been with us for more than a century. But this is not a static story.

  A generation ago, doctors training in the United States would welcome the arrival of a case of type 2 diabetes, simply because it was so rare. Any walking, talking case presented an opportunity for hands-on experience. Among children, type 2 diabetes was then nonexistent. The problem began turning up more often in the general population, and then only after a lifetime of sugar eating had a chance to fully develop into the obesity that tends to run in tandem. Today, the disease is epidemic among American teenagers, especially poor American teenagers whose diet is dominated by nothing so much as sugar. To cite a news report from 2012:

  The percentage of U.S. teenagers with “pre-diabetes” or full-blown type 2 diabetes has more than doubled in recent years—though obesity and other heart risk factors have held steady, government researchers reported Monday.

  The good news, the researchers say, is that teen obesity rates leveled off between 1999 and 2008—hovering between 18 percent and 20 percent over the years.

  The spread of diseases of civilization is a continuum that stretches into our time
, an epidemic that took a couple of centuries to build. It began with imperialism but has exploded today.

  Calling these diseases of longevity misses a crucial point, but longevity is indeed relevant in this context, and to explore this idea, we need a more refined picture of longevity among hunter-gatherers. The contention that they all died early is nothing more than an extension of the Hobbesian idea that life before civilization was nasty, mean, brutish, and short. Indeed, the average life expectancy of many hunter-gatherers was probably lower than ours. That’s not to say that some of them did not live to a ripe old age; plenty of anthropologists’ accounts record old people as valued and active members of tribes. They could live long, healthy lives. The average, nonetheless, was skewed by a number of factors, especially high mortality among infants and young people. In biology among all species in the wild, high mortality of young individuals is the norm, and humans were then living in the wild.

  Still, there’s an important extension of the record of this issue that speaks to the overall quality of life, longevity, and well-being of our ancestors. This inquiry into diseases of civilization is not at all restricted to the past couple of centuries. The imperialism and colonization of the nineteenth century was only the culmination of a process that began with the advent of civilization—by which we mean the advent of agriculture—about ten thousand years ago. That longer period produced a much longer record, and the evidence is clear. North America provides one of the best examples.