It’s sobering and critically important, illuminating and troubling at the same time. Daniel Callahan’s book, “The Five Horsemen of the Modern World,” features everything you need to know about climate, food and water shortages, chronic illness, and obesity, the title’s “Five Horsemen.”

In today’s and the next two columns, we’ll take a look at these five problems and Callahan’s suggested solutions. Yes, thankfully, he does offer solutions, although they’ll take a mighty effort — on the part of all of us — to achieve them.

Because I have had high blood pressure and heart problems for a long time, and suffer from a frozen shoulder and a neurological problem of cramping muscles, and I’m a senior citizen, I spent quite a bit of time reading and thinking about the problem of chronic illness. “Chronic illness has long been known as the main cause of death in developed countries — especially cancer, Type 2 diabetes, heart disease, and chronic obstructive pulmonary disease,” reports Callahan.

He also noted that “Alzheimer’s is rapidly gaining ground as aging increases.” Also “among the nonlethal chronic conditions are depression and arthritis, sources of misery and dysfunction.”

“At present, about 60 percent of deaths worldwide, some 38 million annually, are attributed to chronic disease. 80 percent occur in low-income and middle-level countries. Chronic disease now takes more lives globally than infectious disease, but international support for chronic diseases as a group commands only 3 percent of the $26 billion provided by private donors, international organizations, and foundations,” says Callahan.

In the United States, 70 percent of the deaths each year are from chronic disease, skewed heavily toward Medicare patients. And here’s the really scary part: “Over the next thirty years, with no improvement in managing costs and new technologies, it is estimated that $30 trillion will be spent globally on chronic illness… And that is not sustainable.”


Callahan identifies four leading causes of chronic illness: alcohol consumption (Oops! I am enjoying a Maine microbrew as I write this column), tobacco use, physical inactivity and unhealthy diet. It’s hard for me to believe the number of Mainers I see smoking, knowing that tobacco kills around half of those smoke it.

Sadly, children have the best chance today of suffering for many years from these illnesses, largely because of obesity. The United States leads the world, with 35 percent of its children overweight or obese. The result: 1 in 3 will contract Type 2 diabetes during their lifetimes.

Having had people in our families who suffered from dementia, I paid particular attention to this information: In 2010, the estimate was that 35.6 million people had dementia, with the numbers expected to double every 20 years to 65.7 million in 2030 and 115.4 million in 2050. Alzheimer’s “shares with obesity the obdurate feature of no significant scientific progress to date.”

Yet “funding per death for infectious disease is $422 versus $18 for chronic disease. There is some $6.32 billion in health development assistance for infectious disease and only $500 million for chronic disease,” reports Callahan. Perhaps this might lead you to question the battle in Congress to appropriate $1 billion to fight the Zika virus, which has so far affected just 56 people in Florida.

Callahan also provides a troubling look at the role that industry plays in this problem, noting “their greatest profit comes from treatment of chronic diseases, not their prevention.”

And this was troubling as well: “We do not appear to be moving to a world where we die without experiencing disease, function loss, and disability.” And “there is already some evidence that obesity is beginning to lower life expectancies.”


And how about this: “The United States has the most difficult challenge, now spending a large and expensive portion of health care on a small percentage of its population. In 2009 $1,223 billion was spent on health care. Of that amount $275 billion was spent on the top 1 percent of patients, $623 billion on the top 5 percent, and $821 billion on the top 10 percent — and $36 billion on the bottom 50 percent. Much of that money at the top goes to the elderly and their chronic illnesses and to intensive care units and follow-up care, where costs of $500,000 and up for a small number of patients for a single crisis are not uncommon.” And between 2010 and 2030 the number of elderly in our country will grow from 39.4 million to 60 million, a 75 percent increase.

A global action plan by the World Health Organization established the following goals to be achieved by 2025: a 25 percent reduction in overall mortality from the leading chronic diseases; a 10 percent “relative reduction” in the harmful use of alcohol; a 10 percent relative reduction in the prevalence of “insufficient physical activity”; a 30 percent reduction in “prevalence of current tobacco use in persons age 15-plus years; at least 50 percent eligible persons to receive drug therapy and counseling to avoid heart disease and strokes; and an 80 percent availability “of the affordable basic technologies and essential medicines … required to treat major noncommunicable diseases.”

Callahan thinks these goals are achievable but modest, and “will make small overall progress.” And the “last goal will require the cooperation of relevant industries manufacturing those technologies and financial support from national and international organizations. No major campaign is on the way to bring that about.

“The main impediments to achieving even those modest goals are the weakness of the medical infrastructures and policies to pursue them. The contrast between rich and poor countries is striking. The regulation of tobacco and alcohol is exceedingly weak and practically nonexistent in poor countries. It is due not simply to a lack of money to develop educational programs but more importantly to the active and effective campaign of industry to advertise and sell tobacco and alcohol and the ease with which even light control can be evaded.”

And this is just one of the “Five Horsemen!” Next week, we’ll look at Callahan’s information on obesity and water and food shortages.

George Smith is a writer and TV talk show host. He can be reached at 34 Blake Hill Road, Mount Vernon 04352, or [email protected]. Read more of Smith’s writings at

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