The Amish and the marginal value of health care

Or is that the infra-marginal value?:

…we have compared lifespan in the Old Order Amish (OOA), a population with historically low use of medical care, with that of Caucasian participants from the Framingham Heart Study (FHS), focusing on individuals who have reached at least age 30 years.

Analyses were based on 2,108 OOA individuals from the Lancaster County, PA community born between 1890 and 1921 and 5,079 FHS participants born approximately the same time. Vital status was ascertained on 96.9% of the OOA cohort through 2011 and through systematic follow-up of the FHS cohort. The lifespan part of the study included an enlargement of the Anabaptist Genealogy Database to 539,822 individuals, which will be of use in other studies of the Amish. Mortality comparisons revealed that OOA men experienced better longevity (p<0.001) and OOA women comparable longevity than their FHS counterparts.

That is from a 2012 PLOS paper, by Braxton D. Mitchell,, via Ben Southwood.


To the degree that not using fossil fuel powered vehicles, using lots of human power for everything, not engaging in any vices, living very modestly, praying and attending meeting often, etc are things doctor could prescribe to patients, you might consider this a health CARE issue.

It is certainly one of the opportunities to gain insight into lifestyle and health interactions. And the Amish having roots in Europe with fairly closed communities, interesting genetic information might be discovered.

Give me that old time religion
Give me that old time religion
Give me that old time religion
It's good enough for me

Let us worship Zarathustra
Just the way we used to
I'm a Ζωροάστρης booster
He's good enough for me

Let us worship Aphrodite
She's beautiful but flighty
She doesn't wear a nightie
She's good enough for me

See more here:

Generally one benefit of recycling a decades old joke is that you can make use of successful iterations of the joke you are making in order to make the joke at least seemed polished. You managed to take a painfully old joke and make it super wordy and way to too trying-too-hard.

I thought the whole reason you dated 13 year olds was because it was easy.

I am the first. I am like Gagarin.

No, apparently I am just like Alan Shepard.

Want to go get a drink?

You buy it! I left my kopecks home.

You are both wrong: I am like Sputnik!

Getting embarrassed by Mulp is a level of embarrassment I cannot accurately describe.

Evolutionary theorists Henry Harpending and Gregory Cochran have recently argued that the Amish are in effect breeding themselves for “plainness.”

This is mathematically quite possible because there has been little gene flow into the Amish in many generations. They seldom proselytize, preferring to grow their own adherents. ...

Not surprisingly, there’s a steady genetic outflow from the Amish. ... As Anabaptists, the new generation of Amish isn’t baptized into the church until young adulthood. Overall, about 10 to 15 percent leave their Amish community for a less constrained existence. ... Strikingly, the rate of defection appears to have declined from the 18 to 24 percent range seen in the past.

Harpending and Cochran hypothesize that the Amish are genetically distinct not only because of “founders’ effects”—idiosyncrasies in the genes of the 200 original American Amish – but also because they are increasingly becoming more Amish genetically due to “selection effects.”

Right, Disentangling the relative effects of genetics from environmental factors (diet, exercise, social support, possibly lower stress) will be difficult.

And it's not just health care. The Amish also have low levels of formal education, so what does that say about the ability of long years of formal education to improve the quality of one's life? ;)

"long years of formal education": with emphasis often on the form rather than the education, alas.

I would guess they get lots of education useful to the lives they choose to lead.

Which has what to do with anything?

To all those who feel like saying "what about the Amish lifestyle?", that's the point. Minor changes in lifestyle outweighs a hundred years of medicine. We could get rid of Obamacare and substantially cut medicaid and give the poor free gym memberships. It would cost the US 1/10 as much and have 10 times the impact on QALYs.

It is not only about gym. It is about DIET. But poor people can not afford to go to all the nice restaurants Tyler recommends, and they can not afford ingredients with the quality that the amish get, from their small scale farming (?)... Maybe most of them are not even aware of what a good diet is.

Then perhaps the most cost-effective intervention would be to subsidise online grocery shopping, by paying for the transport. How much would that cost a week?

I wonder what the overall life-enhancement effect would be of just giving or paying to individuals the amount that is extracted from their paychecks or granted to them via medicaid and medicare to pay for health coverage. They would of course have the option of using the funds to pay for health care as needed. Some would suffer catastrophic illness, but most, I would think, would spend their lives more enjoyably.

Cheap and nutritious food isn't that out of reach. The problem is making it palatable. Here the governments war on Sodium has done grave damage. Salt is a cheap, tasty and easy way to make bland vegetables, lean meats and whole grains go down easy.

It is hard to believe that the same people who become fat by eating all kinds of unhealthy processed convenience foods draw the line at eating unsalted vegetables due to a sphexish adherence to government advice.

Its not about the consumers it's about the producers

"its not about the consumers it’s about the producers"

No - it is a free market. Producers make what is most profitable.

It turns out that salt, fat and sugar are three of everyone's favorite foods - and they're cheap.

There are very few people who eat unhealthy food all the time with zero regard to the health consequences. Even the obese make intermittent attempts to eat healthy, or will avoid some unhealthy decisions on the margin. The obese are not willing to avoid unhealthy foods 100%, but the vast majority still modify their diet some non-zero X% from what they'd eat absent any health considerations. If you tell them that salt is unhealthy when it's not, you're wasting some of that finite willpower they have to eat healthy. If their concession at a given meal is to substitute unsalted potato chips thats an opportunity cost where they might have otherwise switched the ranch dip to hummus.

But producers are not marketing their products ONLY to fat poor people, right?

Not sure if serious. Tyler specifically recommends against nice restaurants but recommends buying food from street vendors and mom and pop places. Second, the Amish diet relies heavily on preserved foods since fresh produce is not available for large portions of the year in temperate climates. Third, the Amish would be considered poor based on their income, so by that definition poor people can afford the type of ingredients the Amish use.


"Third, the Amish would be considered poor based on their income, so by that definition poor people can afford the type of ingredients the Amish use."

The Amish are certainly poor. Very poor to be explicit. However, the Amish have a large advantage in obtaining certain kinds of foods compared to the urban poor. First, they are rural people who either own or have access to fertile land. Second, they are highly accustomed to growing their own food. They are (mostly) farmers and reasonably skilled in producing crops with manual labor and farm animals. They are consistently hardworking and industrious.

To state this directly, nothing about their lives can be compared to the urban poor. The converse point is that canned food (fruits, vegetables, etc.) are easily affordable by the urban poor.

From Faze
Floccina is right. People also forget that canned and frozen fruits and vegetables are just as healthy as fresh, and aren’t that expensive

From Floccina
Cabbage, bananas, greens, carrots and other root crops, citrus are all inexpensive and do not even need to be cooked. There s plenty of inexpensive and “healthy” food that does not need to be cooked.


It's a complete myth that healthy eating is more expensive or harder (besides being less palatable). In fact repeating this mantra makes it self-fulfilling. Repeating that healthy food is high-end makes people believe that fresh, organic produce from Whole Foods is somehow better for them than canned or frozen vegetables from Wal-Mart. In fact the common high-end approach is actually less healthy. The vitamins and nutrients in raw vegetables are far less bioavailable than when cooked.

Visiting the EatCheapAndHealthy sub-reddit will dispel any notion that healthy eating requires a lot of money.

No restaurant had healthy food. Every restaurant meal is a calorie bomb and detriment to health. The idea of food desserts is a myth. Poor people could eat lots of vegetables and save money. Vegetables are not expensive

I don't know if you've had the pleasure of sampling traditional Amish food, and it is a pleasure, but healthy is not a word I would use for it. It's a Germanic twist on conventional American farmer food, lots of meat and fat -- it is not a healthy diet, but it is reasonably appropriate for those consistently engaging in strenuous physical labor.

Below Link: All that super-healthy food the Amish eat that explains why medicine is actually still really important despite this study:


"It is not only about gym. It is about DIET. But poor people can not afford to go to all the nice restaurants Tyler recommends, and they can not afford ingredients with the quality that the amish get, from their small scale farming."

Wrong. Poor people can certainly afford to eat healthy food because (some) healthy food is cheap. They choose not to. The idea that poor people are typically fat, because they can't afford a better diet is just left-wing BS.

From Faze

Floccina is right. People also forget that canned and frozen fruits and vegetables are just as healthy as fresh, and aren’t that expensive

From Floccina

Cabbage, bananas, greens, carrots and other root crops, citrus are all inexpensive and do not even need to be cooked. There s plenty of inexpensive and “healthy” food that does not need to be cooked.

This 2009 paper on diet in the Victorian era is on-point:

Sorry, cabbage needs to be cooked until it's translucent. Otherwise, it's inedible.

My friend, let me introduce you to Kimchi.

1. Fermentation might not exactly be "cooking", but it is definitely a time-intensive method of food preparation. 2. Whatever you think of the way kimchi tastes, storing it in your domicile smells absolutely terrible.

In my house we eat it uncooked. They eat it with just a little salt an vinegar in Honduras and is it good. It is the default salad Vegetable in Honduras.

"Healthy foods" are not more expensive than "unhealthy food". Cabbage, greens, carrots and other root crops, citrus are all inexpensive and do not even need to be cooked. Sweet potatoes are cheap source of calories. Water is cheaper than soda as is unsweetened tea.Etc.

By fresh produce & meats, not necessarily organic, is a lot cheaper than either eating out or buying processed foods.

The issue is probably due more to time & convenience than expense.

Can't tell if serious. Giving people a free gym membership obviously won't do that.

"a region spending $1,000 more overall in the last six months of life gave local patients somewhere between a gain of five days of life and a loss of twenty days of life... large and significant lifespan effects: a three year loss for smoking, a six year gain for rural living, a ten year loss for being underweight, and about fifteen year losses each for low income and low physical activity"

It's shocking just how irrelevant medicine is to health. Socialized medicine is the ultimate ineffective signaling. It's a very visible, but very useless, way for rich liberals to show they care (while also signaling a degree of Euro-cosmopolitanism).

We could boost the life expectancies of the poor at a fraction of the cost by giving away free e-cigarettes (reducing smoking), NAC-acetyl (reducing alcoholic liver damage) and Narcan (cutting drug overdoses).

Medicine is clearly not the main factor driving lifespan, and it isn't overwhelmingly boosting surrogate measures of health in the short term, which the Oregon experiment suggests. However, we know that access to care has an overwhelming positive effect on overall well-being. And for people with chronic conditions, like asthma, access to care absolutely plays a big role, doing things like keeping patients out of the hospital.

There's good evidence that workplace wellness programs don't really work. Is there any evidence that giving people a gym membership has a significant (10x) impact?

Overwhelming positive effect?

Yes, an overwhelming positive effect. From early (1-2 years of coverage) analysis of the Oregon experiment:
- enrollment increased the probability that people reported themselves to be in good to excellent health (compared with fair or poor health) by 24 percent
- raised rates of diabetes detection and management
- reduced observed rates of depression by 30 percent
- enrollment nearly eliminated out-of-pocket catastrophic medical expenditures and reduced the probability of having to borrow money or skip paying other bills because of medical expenses by more than 50 percent and decreased the probability of having an unpaid medical bill sent to a collection agency by 23 percent

All of those things are signs of greater consumption of medicine, not greater health. Of course people will believe they're "healthier" when you send them to the doctor in a culture where medicine is synonymous with health. Bushmen are much more likely to report excellent health themselves after getting a spell from the witch doctor. Henry VIII was more likely to report excellent health after a good bleeding. My hippie aunt is more likely to report good health after avoiding GMO food. Similarly higher rates of diagnosis of diasese X is not evidence of lower health burden of diasese X. Mammograms drastically increase breast cancer detection, but don't reduce overall mortality. Of course increasing medicine consumption will increase diagnosis and treatment. But the whole reason medicine is so devastatingly ineffective is because false diagnosis and over-treatment kills as many people as early interventions save.

People have fewer unpaid medical bills? How is that relevant to people's health status at all? The question is to what extent does medicine improve health? Fewer unpaid bills may be a doubleplus good, but its outside the scope of the question. And if it is the objective why not subsidize car payments, rent and phone bills? Or even just give direct transfer payments?

Finally lower depression seemed to have nothing to do with any actual treatment for depression: "The study reported that Medicaid coverage was associated with significantly lower rates of screening positive for depression (a 9 percentage point decline), despite the fact that there "was no significant increase in the use of medication for depression".[10]". Much more likely is that medicine is a status good in our culture. One of the hallmark of the rich are "access to the best doctors and hospitals". Lack of health insurance is a visible symptom of being poor and unemployed. Giving poor people medicine raises their social status and increases their happiness. But again, is this anywhere near the most effective route? Could we more effectively raise the social status of the poor by buying them nice cars, clothes, vacations at a fraction of the cost.

Mammograms drastically increase breast cancer detection, but don’t reduce overall mortality.

I haven't a clue where you got that idea. It is true that asymptomatic detection does not have much benefit if you're cancer is Stage IV (either they can contain the cancer for a time or they cannot), but the attrition rate differs immensely between Stage I, Stage II, and Stage III cancers and the attrition rate only fully converges when you're about 15 years out from your diagnosis, and if you do not catch it until stage IV, your life expectancy is about 2-3 years. The breast tissue of many women is simply too dense to detect it without radiological aids. I've seen experienced surgeons unable to detect with palpating the breast a 5 cm tumor.

The results of the analysis revealed a 10% rise in breast cancer screening. This was associated with a 16% increase in breast cancer diagnosis. However, no reduction was found in the rate of breast cancer deaths.

In addition, the 10% increase in breast cancer screening was linked to a 25% rise in incidence of small breast cancers - defined as the presence of tumors 2 cm or less. However, the increase in breast cancer screening was not associated with a reduction in incidence of larger breast cancers - it was linked to a 7% increase.

Commenting on their findings, Wilson and colleagues say:

"Across US counties, the data show that the extent of screening mammography is indeed associated with an increased incidence of small cancers but not with decreased incidence of larger cancers or significant differences in mortality.

What explains the observed data? The simplest explanation is widespread overdiagnosis, which increases the incidence of small cancers without changing mortality, and therefore matches every feature of the observed data."

However, the increase in breast cancer screening was not associated with a reduction in incidence of larger breast cancers – it was linked to a 7% increase.

This is a nonsense statement.

"It’s shocking just how irrelevant medicine is to health."

Some fundamentals of medicine are very important to health. Hygienic births. Childhood vaccinations. Antibiotics. The ability to fix a broken limb. Those are all very important. The ability to keep an eighty year old alive for an extra three months tied to machines - not so much.

And as someone who has had cataract surgery let me say that cataract surgery is a cheap and effective way to improve the quality of life of many older people.


I tell people all the time, that the steam engine is the key to public health, not doctors and hospitals. Why the steam engine? Because the steam engine made it possible to pump clean water everywhere and produce chlorine at a negligible cost to produce acceptably clean water (where natural sources don't exist).

In real life, the original reciprocating steam engine (the Watt engine) is almost gone from the world. However, its descendants (the steam turbine, gas turbine, water turbine, internal combustion engine, etc.) rule over (drive) every nation.

People tend to think that the modern world is the product of politics, economics, social movements, etc. They are essentially wrong. The modern world is mainly the product of man's ability to build machines and fuel them.

We need a gym mandate enforced with the appropriate tax for non-compliance. This will likely be at least as effective as the ACA at a significantly reduced cost.


But the Amish *have* benefited from 100 years of medicine. First of all, they do utilize modern medical care -- just at lower rates. They are not religiously opposed to vaccination and again, though their rates are lower, they're far above zero. And then there's herd immunity--the Amish benefit from high rates of vaccination by everybody else as well as the elimination in the U.S. of diseases like polio, smallpox, cholera, and malaria that were endemic during the 19th and early 20th centuries. We have to keep in mind that the Amish lifestyle (in terms of diet and activity) is much like that of the majority of Americans during the 19th century, and it was not a recipe for great longevity then. But it is now mainly because of vaccination and improvements in public health.

Okay sure. But vaccinations represent 1% of medical spending. The Amish still consume half or less of medicine per capita. When the centerpiece of the modern American left is free expanded healthcare for the poor, this is a deathblow. Give away free vaccines because they're cheap and effective, but why spend thousands on useless mammograms?

There is plenty of expensive care delivered, and probably not all of it is beneficial. However, the benefit is quite hard to measure. It is not easy to identify very many treatments that are obviously useless, contrary to your flippant claims. The utility of mammograms, for example, is a hotly debated subject.

The example of the Old Order Amish does not prove that expensive care is useless, since they are outliers both in terms of medical care and lifestyle. What would the lifespan be of people who live like the Amish and get lots of medical care? We don't know.

There are several subgroups of Amish and Mennonites, who each have somewhat different rules about use of technology. I wonder if it would be possible to construct a stronger study of this point by comparing different groups?


"It is not easy to identify very many treatments that are obviously useless, contrary to your flippant claims."

Not that hard. Every heard of Nelene Fox? Cancer drugs are a tragic example. The single most important drug for treating many types of cancer is 5-FU (Fluorouracil). It was invented back in the 1950s and costs just a few dollars (literally). The newer anti-cancer drugs (which are used with 5-FU and don’t replace it) add a few months of (miserable) life expectancy, but cost 1,000-10,000 times as much (literally).

Ask some doctors (privately) about the efficacy of the medicines they prescribe. They will tell you that vast quantities of very expensive prescription drugs are given to patients to "satisfy" the patient. The drugs won't work and will cost a fortune. However, the patient is "happy" because the doctor did "something". Of course, if the patients didn't have private/public insurance to pay the bills, none of this would last a day.

To state this in broader terms there have been zillions of studies of health care efficacy. Some treatments work. Many are dismal failures. However, you aren't allowed to discuss this topic in the U.S. even in private. The left has an army of trial lawyers eager to profit from enforcing the status quo. The right has its own army of special interests that profit from "Katy don't bar the door, don't even dream of baring the door" medicine and Sarah Palin (of "death panels:" fame) to front for them.

Basically, the U.S. has a left/right conspiracy of interest to maintain the status quo and it (the conspiracy) is working all too well. The American people are the victims.

Ask some doctors (privately) about the efficacy of the medicines they prescribe.

I have, and it is not as cut and dried as you imply. One of them put the dilemma thus: "you know there's an x% chance that this medication will induce Y% improvement. You also know that it will, more often then not, do nothing. What do you do?" It's a problem with geriatric care (in which this particular doctor specializes).

I've also seen cases where primary care physicians kept no track of what their patient was getting from specialists and had to be dressed down by visiting nurses ("you've got nine medications on this list that cause a loss of acuity..."). The patient in question was a pest, but they weren't just humoring her. She was a very sick pest.

The newer anti-cancer drugs (which are used with 5-FU and don’t replace it) add a few months of (miserable) life expectancy, but cost 1,000-10,000 times as much (literally).

Excuse me, but cancer is an exceedingly variegated set of ailments. You're not likely to have a medication in routine use that is useless and useless in precisely the same way across a range of types and subtypes.


“you know there’s an x% chance that this medication will induce Y% improvement. You also know that it will, more often then not, do nothing. What do you do?”

If the medication costs $1 and works 50% of the time, you prescribe it. If the medication costs $100,000 and works 10% of the time, you don't prescribe it. The problem with the current system is that no one cares about costs and various special interest groups are definitely in “Katy don’t bar the door, don’t even dream of baring the door” mode and profit from ludicrously cost-ineffective medicine.

"Excuse me, but cancer is an exceedingly variegated set of ailments. You’re not likely to have a medication in routine use that is useless and useless in precisely the same way across a range of types and subtypes."

Of course, cancer is a complex set of diseases and some drugs work better in some cases than others. However, overall the results are dismal. See "Median improvement in survival for cancer drugs approved over past decade: 2 months" (

"When the centerpiece of the modern American left is free expanded healthcare for the poor, this is a deathblow"

It's entirely possible for some people to have too much healthcare while others have too little. It's also possible to justify free healthcare not as offering more healthcare, but as offering the same amount without side effects such as bankruptcy.

Acute surgical intervention (not talking about stents but stuff like appendix removal and some transplants)

Anything else out there that substantially increases life expectancy? I'm sure there are some cancer treatments that work, just far less than the medical profession would tell you, and their overall impact on population life expectancy is probably unnoticeable.

The Amish benefit from all of these. Herd immunity from vaccination and the impact of antibiotics on the transmission of bacterial diseases is surely large.

The Amish lifestyle also involves a lot less breathing of small particulate matter associated with a lot of respiratory issues, and I don't doubt that their obesity rates are much lower than the general population.

"Vaccination, Antibiotics"

Right. Add in hygienic births and you have picked all of the low hanging fruit and doubled life expectancy. At the margin, the average sewer worker or garbage man does more to extend life expectancy than the average doctor.

True. But when you got something like an acute appendicitis a garbage man won't help you.


"At the margin, the average sewer worker or garbage man does more to extend life expectancy than the average doctor."

Probably not. Make that the "average chlorine plant worker" and you might well be right.

Amish profit from the US health care system as much as anybody else from the US. The only difference I see is that they are smart enough to go to the doctor only when it's really needed.

They won't heal their cases of appendicitis by praying. And when they do the affected individual got a good chance to die - without much change to the mortality rates because of the relative rareness of deadly diseases at young age. It just sucks for the individual.

It's a well known fact in medicine that the mortality rates declined mainly because of hygiene, nutrition, vaccines and antibiotics. The Amish use all those things, so of course their mortality rates are pretty much the same.

Yes, there are no miracles. Healthy diet and exercise were not enough to prevent a measles outbreak among the Amish last year. The Amish went for vaccination after the outbreak.

They would even profit from some vaccines without using them simply because most other Americans used them. For example polio and pox. Diseases like polio and smallpox are eradicated in the US because of vaccines. I bet Amish people living in Africa got pretty much the same mortality rates as the African communities around them. Maybe a bit better but not by too much.

Great, so you all are saying we can cut healthcare expenditures by about 95% with no ill effects?

There would be huge effects. Vast numbers of healthcare professionals would no longer have a job, there would be fewer glittering hospitals erected, many Porsche dealerships would probably go out of business, and most importantly Democrats would be upset that they aren't spending OPM.

It would be devastating.

No, I'm saying three things:

#1) The Amish profit without paying.

#2) Cutting certain healthcare expenditures won't change mortality rates by a lot but for the affected individual it is often a life-changing matter.

#3) The "healthcare-is-pretty-much-usless"-critique articulated by people like Bryan Caplan is pretty much bogus. See #2.

Get really sick once and you might see what I mean.

Ivan Illich overstated his case and did not seem to consider that the benefits to life expectancy from medical care (dwarfed by the benefits from improved nutrition and public health measures during the period in which the data he was using was collected) might grow more salient as the low-hanging fruit from benefits derived from nutrition and public health was picked. It was not long after he wrote that you began to see notable declines in old age mortality. By way of example, Illich contended in passing that cancer surgeries for those with lung cancer are useless, based on some metric of mortality. Well, about 30% of the people diagnosed with lung cancer survive it. That's not because lung cancer sits their inert in your body 30% of the time or because people diagnosed with it are 90 years old and will likely die in two years of generic causes.

I'm often astounded at the number of people living past 90 these days and the vigor of people in their 70s. It wasn't like that in 1970.

#3) The “healthcare-is-pretty-much-usless”-critique articulated by people like Bryan Caplan is pretty much bogus. Get really sick once and you might see what I mean.

I think Illich contended that benefits were neatly balanced by the damage done by iatrogenic illness. That's an inventive thesis, but I would never bet 10c you could demonstrate it. (I have seen doctors damage people by overprescribing, so that is a consideration).

The hospital is where you go to catch MRSA and die

Christian List,

I have been very, very sick. So sick my doctor wanted me in an ER. Neither my original doctor nor various specialists, came up with a diagnosis. After a month of so, I slowly recovered. My overall opinion of medicine didn't change.

so you're telling me that a group of people - with an incredibly strong social network, access to abundant whole foods, lots of meaningful physical labor, little existential stress, living (insularly) in the most prosperous country in human history - experience superior health outcomes? golly.

No, the study is really saying that the people in the Framingham group, representing the rest of us, are doing worse than we could be doing.

Exactly on point.

oh wait, you're just restating his point.

Of course, blaming the sick, blaming the suffering, for their sickness, for their suffering, has a long history, it's the result of moral failings (sin) and, more recently, lifestyle choices (which is just a euphemism for moral failings (sin)). The theologian's explanation for suffering is sin (at least that's the Judeo-Christian explanation). But why do children, why do the innocent, suffer? In Judaism, all Jews must suffer for the sins of any Jew. In Christianity, suffering is the price the faithful pay for eternal life. Then why do we as a society spend so much on efforts to heal the sick, to end the suffering? Are doctors unwitting collaborators in sin? Rather than spending so much on sufferers, why not spend on those who aren't? Health care and education (or any social welfare program) raise the same issue: rather than spend so much on the barely educable, the ignorant, spend on the exceptional.

Whereas sophisticated leftist, of the kind rayward adores and eagerly seeks approval from, think illness is caused by soda and respond by turning 64 oz. into a sin. It's almost like the simple folk just cut out the middle man or more accurately they cut of the oppurtunity for status game motivated moral preening.

I was just at two Amish weddings and would add a few observations:

- I wonder what they'd find for a later cohort. Amish folks born between 1890 and 1921 were almost all farmers. Today, fewer than 10% are. Most have far more sedentary jobs--though not as sedentary as mine. But they still eat as if they were out in the fields all day. Obesity is rampant and growing. Also, the diet has changed. The Amish eat a lot of processed, brand name food. They do have their own kitchen gardens, but salads are covered in dressing and cheese. In many homes, every meal (even breakfast!) comes with pie as desert.

- Nobody is left alone in old age. I had a long talk with an older Amish woman who couldn't believe that, in NYC, some people live alone, interact with no close relatives or friends, have no one to watch over them. Her husband told a story of a very ornery old man with no children or wife who nobody likes but, still, people visit regularly to make sure he's OK and to give him comfort.

- They absolutely use hospitals for urgent and emergent care. There are big fundraising auctions all the time to help those with big bills. And the church district will also help.

I am curious if your observations about obesity are applicable to other communities. The Amish spread out to get access to new farmland and a new community is established every three weeks. Do you live in an area with a high density of Amish?

Also the cohort in the FHS. You'd be around 50 when it started in 1948. Well before the major insights (smoking, cholesterol, blood pressure) had been identified and before thearpies could be started. The last of (1921) would be have been 50 years old in the 1970s, and well before death rates from cardiovascular disease started to go down.

So, basically, the Amish in the 1960s where healthier than an average american. Or resident of Framingham.

They also looked at a more contemporary cohort, and the differences are still huge.

Major insights? A woman of my acquaintance, born in 1908, was dumfounded by the Cippolone case and the claims of the plaintiff that Liggett hornswaggled his wife with false health claims. "We called 'em coffin nails". She said the warnings which appeared on the packages in 1966 surprised no one. Yes, she smoked. Emphysema took her down, but at age 91.

I've always found the narrative that no one ever had a clue that inhaling smoke regularly might do some damage to your lungs to be pretty silly.

If my memory is correct, there was a study a few years back (ten perhaps) in the JAMA I believe which was reported in MR about a comparison between Christian Scientists and a group of otherwise similar people which led to a conclusion like this re the Amish.

Beyond vaccines, hygiene and antibiotics, health science offers very little. In fact now more people die of pain medication abuse than traditional illegal drugs like heroine and cocaine. Science is creating problems bad enough that we are swamping the good! I am in the health science field and am ashamed about all of this.
It may not get better. Much research funding is wasted on results that can't be reproduced or that are just fraudulent. The human genome projected yielded little. The war on cancer was mostly a waste; if all of the money had gone to smoking cessation classes we probably would be better off. There might be a surprise on the horizon but I am not optimistic.
Sorry we wasted your money.

Well cancer outcomes are quite improved in some cases, say breast cancer. That must count for something too.

See "The Rise And Fall Of Modern Medicine" by James Le Fanu.

Of course we don't know for sure, but I generally get the sense that medicine takes two steps forward and one step back. Again with the caveat that I don't know how much of this is apocryphal, it seems that a lot of expensive modern illnesses such as inflammatory diseases, auto-immune disorders,, certain mental illnesses, etc., and not just the obvious ones like gout and diabetes, have really only sprung into existence in the modern era, and are highly correlated with the onset of all the usual modern lifestyle changes.

As a result, while I don't necessarily believe in any one particular fringe medical hypothesis, I won't reject them out of hand because very likely one or more of those kooky theories will turn out to be true.

I got a little over halfway way thru 'The Emperor of Maladies' (cancer) before getting too depressed to finish it. I got the impression they have figured out something gets tripped at the sub-cellular level to cause metastasis, but nobody wants to say we have no idea how to fix it, or that it's probably not fixable. Would love to be proved wrong.

"Most of the luxuries and many of the so-called comforts of life are not only not indispensable, but positive hindrances to the elevation of mankind."
- Henry David Thoreau

What does infra-marginal mean?

Literally "below the margin"?

In particular, what does it mean here?

You people don't get it. Of course the Amish benefit from SOME of the American healthcare system. That's not the point. The point is they use far less of it than most people, yet are healthier.

Those who push socialized medicine love to cite that the US spends far more on healthcare than other countries, with worse results. But this Amish study implies that what is spent on healthcare has very little to do with actual health. Other factors, many of them listed in these comments, are much more important. Many of those factors cannot be manipulated by public policy at all or easily.

That doesn't change the fact that if, for example, you get lung cancer, there is no other country on earth that you'd rather be in than the US. But that level of care is very expensive and doesn't increase life expectancy on average very much.

And on the other hand, if we implemented, say, Swedish Socialized Medicine in the US, we would not get the results the Swedes get, because we are not Swedes and we don't live in Sweden.

Do they really use the American healthcare system less?

I remember some old post here on MR on how Amish go do to Mexico to get cheaper medical treatments. The funny thing is that a WaPo article telling the Amish healthcare savings story is about Lancaster, PA. The article on PLOS One is also about the Amish from Lancaster PA.

So, the article authors use a Amish community well known for going to Mexico for cheaper healthcare to estimate the amount of healthcare used by Amish in Lancaster PA. This speaks really bad about PLOS One peer review system.

Our maybe the authors did their homework and you didn't. Hmm which could out be

How do you get from Pennsylvania to Mexico without using machines? That's a real long donkey ride.

I've had occasion to see Mennonites or Amish in the train station in Syracuse. Could have been either. I think they were speaking a German dialect, so more likely the latter.

As a general rule, they're in carriages, not on donkeys. I think Amish are permitted to drive during Rumpspringa, not after.

Very well put. All of it.

The Amish have been known to negotiate discounts on medical care from providers as far away as Mexico. How do we know that the Landcaster discharges encompass or represent all the medical care that this group received?

Ha, while I was looking for the WaPo link you beat me to post this :)

Ivan Illich, please pick up the white courtesy phone.

Before you guys jump into large mood affiliated conclusions a simple fact. Plos ONE accepts about 70% of its submissions. That is very high number, which makes me doubt about the quality of their reviewing process. I guess other authors know this as well...

Ordinary science journals accept about 50%. Once upon a time, certain IEEE journals accepted 85%. Many years ago the editor of the Proceedings of the National Academy of Sciences offered that authors preselect their papers and direct their stronger and weaker papers to different journals, so acceptance rates are a weak measure of the quality of the papers published therein.

Amish today do things a lot different. It is becoming more of a myth.

They don't drink, smoke or do drugs. Probably a contributing factor as well.

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