The Anti-Fragility of Health

NEW YORK – Nassim Nicholas Taleb, perhaps best known as the author of The Black Swan, has written a wonderful new book called Antifragile: Things That Gain from Disorder. According to Taleb, things that are anti-fragile – mostly living things – not only resist being broken; they actually grow stronger under stress. When coddled too much, they grow weaker. Evolution is an anti-fragile process.

In the broader physical world, occasional minor forest fires eliminate underbrush, reducing the risk of major conflagrations. Small ground tremors can ease seismic tension and forestall big earthquakes.

Likewise, a healthy economy is anti-fragile, and requires more than just the absence of poverty. In a strong economy, stress improves productive capacity: a short recession or a minor shock gets rid of weaker players, so that employees and capital can shift to more promising companies and sectors.

The same logic applies to organized violence. To quote the playwright Jonathan Larson, “The opposite of war is creation.” The non-profit organization Peace Direct seeks to foster not just a state of peace, but an activity that it calls “peace-building” – active collaboration, conflict resolution, and the like.

What are the equivalent terms for health? Most dictionaries define health as the “absence of disease.” But, in those terms, it is not a compelling proposition for people to “invest in health.” How can you invest in a vacuum?

Of course, we do invest in health care. But that is like investing in auto repair – allocating resources to repairing damage, rather than to improving safety technology or brightening traffic lights. Health care is what we wield when inactive “health” has failed to keep us healthy: the immune system has been overcome by a pathogen, or too much (bad) food, alcohol, smoking, recreational drugs, or stress – perhaps compounded by too little sleep and exercise – have compromised the body’s normal operation. Even if we are unlucky and suffer from a genetic condition that cannot be prevented, it often will still be easier to address in an otherwise healthy person.

Health itself is the capacity to undergo stress and react positively to it – anti-fragility in a specific context. For example, without exposure to infectious agents, the human immune system will never learn how to ward off invaders and may even turn inward, as in auto-immune diseases. Muscles need to work (and be stressed) to grow strong. The discomfort of hunger impels us to eat.

At first, the notion of producing health sounds a bit pompous, like “ideating solutions” or listing “legal intervention” (by a policeman’s bullet) as a cause of death. But it is a concept worth exploring and promoting.

First of all, producing health connotes an activity, not a state. You cannot simply avoid disease; you have to do something to promote creation of the desired capacity. Like education, health ultimately demands the active participation of the individuals involved.

Producing health requires investment – in good food, in a pleasant and non-toxic environment, and in jobs that motivate people to work and feel productive. (And perhaps it requires investment in, say, making bad food unappealing, if only by making good food cheaper – or even subsidized – and more convenient.)

But producing health also requires “co-investment” by the people involved – that is, getting them to exert themselves to increase their “health productivity,” just as a company needs to motivate its workers to increase productivity. And, as in companies, intrinsic rewards, challenges, competitions, and the like are often more effective inducements than money.

In short, in a world of empowered consumers who book their own seats online, we need empowered “health producers” as well. Of course, the benefits of booking online are fairly immediate, while the benefits of health production may be more distant (and less tangible). But at least we are developing better measurement tools – not just mobile self-monitors and games, but soon also non-invasive blood tests – to make that easier.

Players in the health-production business include not just companies and employers, but also national and local governments, health systems, schools, and buildings. All of them have a long-term interest in the health of the people they serve and in building up their anti-fragile capacity.

Yet I confess to doubt. Getting the language right is easy compared to actually delivering on the promise.

To extend the analogies a little further, over the past few years, employers have discovered the importance of a good environment – everything from comfortable chairs and easier-to-use software to better coaching and more useful feedback. In good companies, employees are treated like volunteers and motivated, not manipulated, to produce heroically. People enjoy their jobs, work harder to please their managers, and are more productive. But there are lots of places – we all know them – where that knowledge just is not applied.

I cannot imagine that it will be all that different with health production. When it comes to producing health, virtually everyone is a volunteer. (The sick people are the non-volunteers.) And, just as some companies are role models, so we will have health-production role models. With the right language to understand what they are doing, we are more likely to be able to emulate them.