Self & Other

16. The Honest Chapter

There is a wish, deep in most people, for a rule.

The wish is this. If I do this list of things — if I sleep well, eat well, exercise, take my supplements, manage my stress, see my doctor, get my shots, and do not smoke — then I will be safe. My body will not betray me. My children will not get sick. The diseases I have read about will happen to other people, who failed to follow the rule.

The wish is reasonable. It is the same wish that has produced almost every health system human beings have ever invented, from the four humors to the daily multivitamin to the latest wearable device. People want to know what to do, and they want what they do to matter. They want effort to translate into safety. They want the universe to be the kind of place where careful behavior earns durable health, and where the people who get sick must, somewhere along the line, have done something different from the people who didn’t.

This chapter is about the fact that the universe is not, in this particular respect, the kind of place we want it to be.

What Lifestyle Actually Buys

We have spent two chapters on what helps your immune system and what doesn’t. People who sleep well, move regularly, eat real food, stay connected, and avoid tobacco do, on average, get fewer infections and live longer than people who don’t. The data are robust.

But “on average” is doing a lot of work in that sentence, and it is the word the wellness industry, the public health pamphlets, and even some honest books gloss over.

What lifestyle gets you, when you do everything well, is a shift in your odds. The kind of shift that, applied to a million people, would produce noticeably better outcomes for that million as a group. Fewer cardiac events. Fewer cancers. Better immune responses to vaccines. Lower rates of dementia. The shift is real.

What lifestyle does not get you is certainty about your specific outcome. The intervention that reduces a population’s cancer rate by twenty percent does not protect any particular person from cancer. It means that, of twenty people who would have gotten that cancer in the unimproved scenario, four will not. Which four? Nobody knows. The four who didn’t get sick will not, mostly, know they were the ones who didn’t — nobody is conscious of the disease they didn’t develop. The sixteen who still got sick will, mostly, feel that the lifestyle didn’t work for them. They are, in a particular and frustrating sense, correct. It didn’t. The population effect is not a personal guarantee.

This is one of the hardest concepts in all of public health, and one of the most important, because it explains a great deal of what people experience when they get sick despite trying not to.

The runner who eats well, sleeps eight hours, has good relationships, and is diagnosed with stage IV pancreatic cancer at fifty-two has not failed at lifestyle. The smoker who lives to a hundred and one has not beaten the system. They are both data points. The runner is the unfortunate fraction whose statistics didn’t help. The smoker is the lucky fraction whose statistics didn’t catch up. The numbers describe a population. They do not describe a contract between any individual and the universe.

Doing the recommended things shifts your odds. It does not buy you a guarantee. The biology will not allow it. The world will not allow it.

The People Who Did Everything Right

Almost everyone has a story about someone who did everything right.

The colleague who biked to work every day and drank green smoothies and never smoked, who at forty-five found a lump that turned out to be the kind of cancer that does not, often, allow for the planning of further years. The runner who, the week after a marathon, woke up with the symptoms of an autoimmune disease that would not go away. The careful, attentive, evidence-following parent whose child was diagnosed with leukemia at six.

These stories are not aberrations. They are part of what disease is. A serious illness in an otherwise healthy young person is statistically rarer than the same illness in an older or less healthy person, but it is not vanishingly rare, and the stories accumulate. Every family, given enough time, has them.

The honest thing to say is that these things happened, the people in them did not deserve them, and there is no narrative of personal failure that fits. The runner did not get cancer because she missed a salad. The child did not get leukemia because the parent allowed too much screen time. The colleague did not get sick because of an unprocessed psychic wound. These are the explanations grief and fear reach for, because grief and fear cannot stand the alternative — which is that some things just happen, in bodies made of cells, and the cells are doing the best they can with the hand they were dealt.

The arithmetic of risk does not pick winners and losers based on virtue. It picks them based on biology and circumstance, and most of the relevant biology was decided before the person was old enough to understand what biology was.

For Anyone Living with Illness

If you are reading this book because you have a chronic illness, or because someone you love does, this is the chapter that releases you.

Releases you from what? From the search for the explanation. From the steady internal questioning that asks, when something has gone wrong with your body or your child’s body, what could I have done? What did I miss? What was I supposed to know that I didn’t?

The answer, almost always, is nothing. The body you have, or the body your child has, was making the decisions that produced this illness long before you knew there were decisions to make. The thymus we visited in Chapter 7 was making its choices when the person was a fetus. The MHC molecules we visited in Chapter 6 were inherited the moment the egg met the sperm. The genetic variants that affect how regulatory T cells work, how cytokines are produced, how tissue is repaired — these were settled before anyone could have done anything about them. The infections that may have been triggers, the developmental windows that affected how the immune system calibrated, the chance encounters between particular cells on particular days that tipped the system in particular directions — these all happened, and almost none happened in places where you could have intervened.

The disease is not your fault. It is not your child’s fault. It is not the thing you ate or didn’t eat, the time you got too stressed, the person you didn’t forgive, the trip you took or didn’t take. The body got dealt a particular hand, and that hand is being played out now.

What is in your power, with the disease that exists, is real. Treatment matters. Care matters. The relationships around the sick person matter. The work of staying connected to the things that bring meaning matters. None of these will make the underlying disease go away — but they will, often, change how the disease feels day to day, and give the person living with it more of what they came here to have.

The energy you might be spending on the unanswerable question of what you could have done is energy that could be spent on what you can still do. The first kind mostly produces guilt. The second, when applied carefully, produces a life.

What Well Looks Like

There is a definition of “healthy” the wellness industry implicitly trades in: the absence of disease plus optimization of every bodily function plus a certain quality of glow that the photographs convey. By this definition, almost no actual living person is healthy, including the people in the photographs, who are usually well-lit rather than well.

There is another definition, more useful: a body being lived in by a person who is doing the things they came to do, with the people they want to do them with, in a life that has, on balance, more meaning in it than struggle. By this definition, plenty of people with chronic illness are healthy. Plenty of people without chronic illness are not. Healthy is something a person can be, intermittently and partially, throughout most of a life that includes diagnoses, treatments, hard months, and surprising recoveries.

This is not a soft definition. It is the realistic one. It is also the only one humans have ever actually had access to, because the alternative — the body that does not get sick, does not age, delivers full function forever — is not on offer for any human being who has ever lived.

The teenager from Chapter 10 — Maya, with her Type 1 diabetes — is healthy by the second definition. So is her mother who runs a graphic design studio and has knee pain in the mornings. So is her other mother who teaches chemistry and lives with anxiety. So is her grandmother, who at seventy-six has had two knee replacements and reads a book a week. So, probably, are most of the people you love, who you may not realize are managing more than they advertise.

The point is not to lower the bar. The point is that the bar most people walk around feeling judged by is, in fact, lower than they think — and they have probably been clearing it the whole time.

What This Book Is, and Isn’t

A last word, before we move into the final stretch.

This book was never going to be a manual for guaranteeing health. It is a description of how a beautiful and complicated system works, what happens when it goes wrong, and what we know — honestly — about how to live well alongside it. The system has been doing its work in your body for as long as you have been alive. Mostly, it has succeeded. Sometimes it has run into trouble. Some of that trouble can be helped by medicine. Some by ordinary life. Some cannot be helped by anything, and the only thing left is to live the life in front of you with as much grace as you can muster.

The deepest thing the science says, after all the chapters we have just been through, is that a person is a body, the body is a system of systems, the systems are mostly running themselves, and what you can do is take care of the parts you have access to and forgive yourself for the parts you don’t.

That is the honest version. It is not the version that sells supplements. It is the version that is true.

If you are well right now, this is good. It is not because you earned it. It is, mostly, because of factors largely outside your control — your genes, your circumstances, the contingencies of how your immune system happened to be calibrated. The right response to being well is gratitude, not pride.

If you are sick right now, this is also not because you earned it. The same factors that let other people be well let you be sick, in different combinations. The right response is treatment, support, and as much of an ordinary life as the disease allows. It is not self-blame.

If you love someone who is sick, the most useful thing you can offer is not a theory about what they did wrong. It is your continued presence. It is meals that get cooked. It is appointments that get driven to. It is the willingness to keep showing up after the casseroles stop arriving from the neighbors. It is, in the slightly old-fashioned sense, witness. The person who is sick is, often, more aware of being sick than of being seen. You can do something about that.

The remaining chapters are practical. The next one is about the COVID-19 vaccines and what they really were, because most readers lived through the pandemic and there is still a great deal of confusion to clear up. After that, a chapter on the microbiome, what we know and what we have been told that we don’t know. Then a glossary, so that the next time you read a medical news article, you have a fighting chance with the vocabulary. And then, at the end, the kid on the bike from the prologue, who we owe a return visit.

We are almost done. Thank you for staying.

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