MANAGEMENT INSIGHT – Antifragile: Nassim Taleb on the Evils of Modern Medicine
Antifragile, the latest book by Black Swan author Nassim Taleb, is a thoroughly maddening book. His writing style is pretentious and petulant. His points are overstated, full of trite stereotypes and cherry-picked facts. I agree and disagree with him, often at the same time.
Whether or not you enjoy this type of mental gymnastics, you need to know about this book. Taleb uses medicine as one of his primary examples, arguing that physical stress is good for you, and medicine is, with very few exceptions, bad. If the book gains anything like the notoriety of his previous books, you’re going to hear about it.
Black Swan was a book that changed the way we think. Taleb showed us that unpredictable events underlie almost everything we do or think. The term “black swan” has even crept into our everyday vocabulary – a term for any totally unexpected, unprecedented event. Antifragile goes one step further, arguing that disorder is, in many cases, good and necessary. He makes three essential points;
THERE ARE THREE TYPES OF THINGS
His essential line of arguments is this. There are three types of things: the fragile, the robust, and the antifragile. Fragile things are those which, when subjected to stress, will in some manner be worse off than before. If the UPS man drops your package, the new Macbook inside will break. Macbooks are fragile. Robust things, on the other hand, are resilient and remain unchanged in the face of stress. If the UPS man drops your next package, the soccer ball inside will be no worse off than it was before. But what about things that, when subjected to stress, become stronger? Take for example, the UPS man. If the UPS man were to fall from a similar height, his legs would catch him, and the experience would make his quads and calves a little stronger; his bones a little denser. For this last circumstance, Taleb sought to create a word beyond robust. The positive affect on the UPS man is similar but opposite to the negative effect on the Macbook. Hence, the term antifragile.
…THINGS THAT ARE NON-LINEAR TEND TO BE FRAGILE…
The Macbook, dropped from the UPS man’s arms, broke. But the same computer in the same box if dropped from just a couple of inches lower, would not have broken. The difference is only a couple of inches, and yet the outcome is drastically different. Put another way, the height of drop is not proportional to the damage the Macbook experiences. This is true of many things. A biotech stock may languish at the levels of a penny stock despite the fact that the company’s lead molecule is making solid steady progress down the drug development pipeline. On the day the FDA announces approval of the drug, the stock explodes. The price of the stock is not proportionate to the progress of the underlying drug. When a thing is nonlinear, relatively small things can have a huge impact.
… AND THE PAST IS A LOUSY PREDICTOR OF THE FUTURE….
Any investor knows that past performance is not a reliable indication of future gains. The past does not factor in the real outliers. It can’t. Many of them haven’t happened yet; or at least not within recorded history. Events that cause the extinction of the human race are underrepresented in any prediction of future events, because this has never happened before. Future epidemics can’t be predicted because they haven’t arisen yet. Even our ability to predict the more mundane things is really quite stunningly bad. Our track record for predicting significant economic or political outcomes is, as Taleb says, not close to zero, but zero. Not one economic guru accurately predicted the crash of 2008.
…SO IT’S BEST TO BE ANTIFRAGILE.
Because the world is full of nonlinear things, and because the past is of little help in predicting the future, your best shot at thriving is to be antifragile. You can influence your circumstances to accomplish this. If, for example, you have lots of cash in the bank and a closet full of tradable items like batteries and gold coins, you don’t have to be able to predict the next imminent, non-linear catastrophe. Be it a hurricane, a recession, a revolution, or an earthquake, you are in pretty solid shape to get through it. If, on the other hand, you are in debt and your closet has only dust bunnies, then you’re going to need to predict the future and with a lot more accuracy.
VIEWING THE WORLD THROUGH THE LENS OF FRAGILITY
Many things we think of as safe, when viewed through the lens of fragile/robust/antifragile, really aren’t. Employment at a large company, for example, is often seen as a stable, conservative career path. In actuality, it’s quite fragile. While it appears safe at first glance (a reliable salary every month), it is also fragile because it carries the nonlinear risk of one day losing one’s job. Through this lens, the Canadian economy is antifragile because it is debt free. The debt-ridden American economy is fragile, because even a slowdown can cause a financial catastrophe.
A LITTLE DISORDER IS A GOOD THING
For the antifragile, a little disorder and stress is a good thing. Cities, economies, biological species, and ideas are examples. Smaller units are more fragile than the larger communities of which they are a part. Skin cells die and slough off, while the organism from which they came adapts and renews. Individuals are more fragile than families, firms, or societies. Industries are no different. The last economic slowdown put some CDMOs out of business. Their clients’ programs suffered, but the CDMOs (and clients) that survived learned to adapt under stress, emerged stronger than before, and are far less likely to repeat the mistakes of others.
WHAT DOES THIS MEAN FOR ME?
We must each view our own lives through this filter. If I look at my company, I see a fragile entity. It is by necessity fragile, because it is such a small part of a large industry. But I can coax it toward antifragility. I can minimize debt, so that the company can better withstand unpredictable, non-linear shocks. I can broaden our base of services, to reduce our dependence on any one service, such as formulation or packaging. Even if the philosophy of antifragility doesn’t give me a shopping list of new practical things to change in my business or my life, it does form a mental model in which to place my observations.
IS MEDICINE A THREAT TO YOUR ANTIFRAGILITY?
Here is the infuriating part of this book. Taleb’s theory holds up well enough until he delves into specialized fields he knows less about. Biological entities fall squarely in his antifragile category. Because antifragile entities benefit from a little stress, he spends a great deal of time belaboring his wariness of “iatrogenic” effects (in which the treatment is worse than the original illness). To a point, most of us would agree. For example, if your blood pressure is only slightly outside of the range of normal, you might be wise not to choose medication as your solution. Slight stresses on the body are indeed natural. I’m not sure I’d agree that your higher reading will make you stronger, but certainly in this case the downsides of the medication may be considerable higher than the benefits it might provide.
Taleb argues that the side effects of medication are unpredictable. We simply don’t have enough history to truly predict outcomes. Medicine is like tobacco, which when it first was introduced was purportedly good for you. There was no “proof ” to the contrary as it took decades for the evidence to accumulate. Thalidomide was prescribed as an antinausea medicine but its side effects on the unborn fetus weren’t clear for a few years.
He takes these anecdotal stories as fodder for his theory that medicine is only justified if it’s efficacy has been proven for thousands of years, or if the benefit is so great that any possible side effect is justified (ie, an oncology product that might save your life). Taleb started in the financial world, and he seems to view medication through the same lens as one might view a financial option. Does the upside outweigh the downside? Then he generalizes based on a few anecdotes that for every known side effect there are potentially countless horrific and quite possibly deadly unknown side effects that simply haven’t come to light yet. When he puts this huge potential negative on the scale beside the known side effects, giving it in effect more weight and value than the known side effects, it is a small wonder that his scale never balances. The result from this logic is that you would never take a pill unless you are certain it will save your life.
Somewhere between a minor blood pressure anomaly and a potentially terminal cancer lies the true balance. His accusation that physicians overprescribe may be true in some fields, particularly the use of psychotropic drugs in children, but most of his discussion of iatrogenics is anecdotal and relies heavily on outdated practices, including the practice of bleeding out patients – the death of George Washington in 1799, and a study of children in 1930. Apparently, because of these mistakes, we should throw out the vast majority of modern medical science.
Given Taleb’s very biased approach to medical research, it comes as no surprise that he completely bypasses any discussion of the benefits of modern medicine. The Green Agricultural Revolution, for example, fed billions of people who would have starved if only natural agricultural techniques were used.
But the most glaring of all omissions is the complete or near eradication of smallpox, polio, TB, cholera, and the bubonic plague from our lives. These vaccines do not meet his criteria. Because it cannot be shown that a single vaccine will save your life, and because we cannot predict whether or not it will save you (not until we have a thousand years of evidence), vaccines should, by his logic, be avoided. It’s precisely this type of thinking that spurs anti-vaccination campaigns and has now caused the reintroduction of some of these midcentury diseases.
Epidemics themselves are in fact nonlinear, and it is this fact that has taught us how to eradicate them. Take malaria, for example. It is ridiculous to think that we could get rid of this disease by eliminating all mosquitoes. There are simply too many. But because epidemics are non-linear, they have thresholds. We don’t need to get rid of all mosquitoes to stop the disease; we only need to reduce their population to below the epidemic threshold. This logic has led to the elimination of many diseases, and it is this logic that will save millions of lives going forward.
AN EDGY ARGUMENT GOES OVER THE EDGE
Somewhere along the way, Taleb takes a well-reasoned argument and pushes it off a cliff. Nothing can be trusted if it hasn’t been tried through the millennia. Not even papayas. Taleb avoids all fruits without a Greek or Hebrew name because his ancestors would not have eaten them. Not even fruits that other cultures have eaten for thousands of years pass his threshold for reliability. He drinks only beverages that are at least a thousand years old. By his logic, most of our industry might just as well close up shop right now, because unless your molecule will save a life from a very imminent death, it’s just not worth the risk.
I hesitate to recommend this book. I’m not sure it has made me a better person. While Taleb provides a good model for understanding the world around me and the decisions I’ve already made (don’t go into debt; have something set aside for disaster), it hasn’t led me to change my behavior. That the past is a bad predictor of the future is a point well made in his previous book. That the world is non-linear – well, anyone who lives in hurricane country, tornado country, earthquake country, or who lived through the 2008 crash – knows that very well. Anyone who has ever dropped a UPS package knows it too. Of course it is good to be antifragile; it is also good to be fit, healthy, young, and strong. Good luck with that.
If I can pay the book one great compliment, it is that it made me clarify my own thoughts. His maddening tendency to overstate and take things to extremes made me stop and justify my disagreements. Taleb makes you think. If that appeals to you, then you should read this book.
To view this issue and all back issues online, please visit www.drug-dev.com.
Derek G. Hennecke is President and CEO of Xcelience, a CDMO in formulation development and clinical packaging located in Tampa, FL. Mr. Hennecke launched Xcelience as a management buyout in 2006, and the company has more than doubled in size. Prior to starting Xcelience, Mr. Hennecke worked for DSM as a turn-around manager in the global drug development community, managing an anti-infectives plant in Egypt, technical and commercial operations in a JV in Mexico, and a biologics facility in Montreal. He developed the formulation and business strategy of several drug compound introductions such as clavulanic acid, erythromycin derivatives and Tiamulin. A Canadian, he covets the Florida sun, but can’t be kept away from the rink for long. He is an avid fan of the Tampa Bay Lightning.
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