Last month some 500 of us gathered in Bologna to remember Alessandro Liberati, founder of the Italian Cochrane Centre, a great thinker about health, and a personal friend to most of the 500. As I’ve described in a previous blog, the day was built around Italo Calvino’s Six Memos for the Next Millennium, which discussed lightness, quickness, exactitude, visibility, multiplicity, and consistency.
I talked on multiplicity, and this blog tries to capture some of what I said. Almost all of my 74 slides were pictures, and if you’re interested you can see them here.
One of the ways I knew Alessandro was as a member of the BMJ’s first editorial board, which we created in 1997 when I was the editor. We expected members of the board to have a multiplicity of talents, including creative thinking, flexibility, an enthusiasm for team working, and an international and broad view of health and medicine. Alessandro had all those talents—and many more.
Alessandro also did me a huge personal favour. Through a friend, he helped me rent a flat in Palazzo Van Axel, a 15th century palazzo in Venice in 2002. I spent eight weeks there writing a book, The Trouble with Medical Journals. It was one of the highlights of my life, and I’ve never been the same since.
The flat had previously been rented by Josef Brodsky, the Russian dissident poet who won the Nobel Prize for Literature and is now buried in San Michele, about 800m from the flat. Brodsky illustrates multiplicity in several ways. He learnt Polish and English in order to read the poetry of Czeslaw Milosz (who like him was at one time US poet laureate), John Donne, W H Auden, and Robert Frost (all poets I admire). Brodsky lived more than one life, and this is part of a poem he wrote to Marina Basmanova, his lover who bore the child Brodsky never saw because he was expelled from Russia.
Your voice, your body, your name
mean nothing to me now. No one destroyed them.
It’s just that, in order to forget one life, a person needs to live
at least one other life. And I have served that portion.
Once when he was asked “Are you an American or a Russian?” he answered “I am Jewish—a Russian poet and an English essayist.”
My love of Venice is intertangled with my love of painting. Every morning I would walk past the Hospedale, which was painted by Canaletto (who also painted the naval hospital in Greenwich, where I went to school), to the lagoon, where always I would think of the paintings by Turner, who, although English, captured the light of Venice better than any of the many great Venetian painters.
The greatest Venetian painter was Titian, and I have been reading Sheila Hales 700 page biography of him for the past six weeks. I still have 200 pages to go. Relatively little is known about Titian, so much of the book is about Venice, 16th century Europe, and the extraordinary people whom Titian knew and painted. The book is almost as much about Pietro Aretino, a writer and Titian’s great friend, and Aretino had a multiplicity of roles:
“Journalist cum press baron, master of aphorism and hyperbole; pornographer, flatterer, and blackmailer; playwright, satirist, versifier, bisexual libertine, connoisseur of art; self-styled political seer, ‘fifth evangelist,’ ‘censor of the world’, as well as its ‘secretary’ (meaning depository of its secrets); ‘one whose letters are answered even by emperors and kings.’”
One of his achievements was to write words to accompany The Sixteen Pleasures, a famous erotic book that describes a series of sexual positions.
Calvino’s lectures were all built around books, and perhaps the modern book that best captures the power of multiplicity is James Surowiecki’s The Wisdom of Crowds, which is subtitled “Why the many are smarter than the few.” For me the message of the book is best captured by the story right at the beginning of Frances Galton. Galton, a cousin of Charles Darwin, had almost as many talents as Aretino: he was a polymath, anthropologist, eugenicist, tropical explorer, geographer, inventor, meteorologist, protogeneticist, psychometrician, and statistician.
Galton didn’t believe in democracy and conducted a clever experiment designed to show the hopelessness of people making decisions together. In 1906 he attended a country fair where one of the attractions was a competition to guess the weight of an ox. Galton collected all the 787 guesses, many of which were very wild, but the average of the guesses was 1197 lb when the actual weight was 1198 lb. Galton had shown the opposite of what he’d expected: he’d shown the power of the many, of multiplicity.
I spent a year in 1989-90 at the Stanford Business School, and while there I had a lesson in multiplicity that had a huge impact on me. All of us in the class were told that we had been in a plane that had crash landed in the Canadian Tundra. We were given a list of what was in the plane and told to prioritise what we would remove from the plane before it caught on fire. We also had to make the major decision of whether to stay with the plane or attempt to walk out through the maze of lakes. Once we had done the exercise alone we did it in groups, and in every group the group made better decisions than the individuals within the group.
The message for me was that a team of managers will make a better decision than a lone chief executive—so long, an important proviso, that the team functions well in that people say what they really think, listen to each other, and manage the conflict that will be inevitable. “Yes people” don’t make good decisions.
At this point I announced that my talk was about to start: a multiplicity of connections, most of them I hoped meaningful, had distracted me to this point.
I began with the Oxford English Dictionary definition of multiplicity. I could do this because of my membership of Lambeth Libraries, which gives me free access to the OED. This is more multiplicity: I wouldn’t pay for individual access, but I’m very happy that a small part of my rates allow me to access this wonderful work. I discovered that there are multiple definitions of multiplicity, with the first being “the quality or condition of being manifold.” So I turned to manifold, which is defined as “varied or diverse in appearance, for, or character; having various forms, features, component parts, relations, applications, etc; performing several functions at once; complex, difficult.”
The OED is in some ways a forerunner of Wikipedia in that ordinary people are asked to submit new words and examples of the words being used. The dictionary includes examples through the ages of words being used, and the earliest example of “multiplicite” being used was in c1454. I was pleased as well to see that writers whom I admire had used the word: Lord Macaulay (1825), Charlotte Bronte (1847), and Isiah Berlin (1978). One of the best books about the creation of the OED is Simon Winchester’s The Professor and the Madman, which describes how one of the main contributors to the OED was an insane murderer locked up in Broadmoor. For me that book is forever linked with God’s Secretaries by Adam Nicholson, which describes how more than 50 people were involved in producing the King James’s Bible, which many describe as the greatest prose work in English. It’s the opposite of our modern idea that a camel is a horse designed by a committee.
As I was talking in Italy and being simultaneously translated into Italian, I thought that I ought to try translating multiplicity—so I turned to Google Translate, another creation of multiplicity in that the more examples of translation included in the software the better it gets. The result was not dramatic as multiplicity translates to multiplicità. To play a little further I translated “Italy is the best country in the world (apart perhaps from Scotland). I’d like to see the back of Berlusconi, but where there is death there is hope.” It came out as: L’Italia è il miglior paese del mondo (a parte forse dalla Scozia). Mi piacerebbe vedere il retro di Berlusconi, ma dove c’è morte c’è speranza. It was perhaps cheeky of me to say anything about Berlusconi, but I know that Alessandro and many other Italian friends had and have nothing but disdain for him. And I do like dove c’è morte c’è speranza. That sounds very poetic to me.
Now it was time to turn to Calvino. I read his essay on multiplicity carefully and found much inspiration—more than I could cram into what was supposed to be a 20 minute talk. This was how Calvino described the theme of his essay: “The contemporary novel is an encyclopaedia, a method of knowledge, and above all a connection between the events, the people, and the things of the world.” Reading novels is hugely important to me, and I have had one on the go since I was 10—in an unbroken chain. I wish that I had a record of that chain, and I do have a record for the past two years—through a social media site, Goodreads. I invited the audience to become my friend on the website, and now I invite you.
I blogged recently and pretentiously about how an hour and half’s reading is the very best way to start the day. I urged 45 minutes reading fictions, 30 minutes non-fiction, and 15 minutes poetry. Some people feel that reading novels is a waste of time, but I side with Martin Amis that “the truth is in the fiction.” Certainly few books are as untruthful as autobiographies.
Calvino begins his essay with a long quote from Carlo Emilia Gadda, who has been called the Italian James Joyce. Here are two extracts from the quote:
“Unforeseen catastrophes are never the consequence ….. of a cause singular; but they are rather like a whirlpool … towards which a whole multitude of converging causes have contributed.”
“Replace cause with causes.”
The first quote made me think of the famous observation that serious consequences arise from medical errors when many factors align—as when there is a clear line through a series of slices of cheese full of holes. Most of the time errors do not result in serious consequences because something will avert the disaster. And I think that “replace cause with causes” is hugely wise: most events have multiple causes, and yet we are somehow programmed to think of one cause. “Who is to blame? Who should be fired?” I hear radio presenters asking after each disaster.
Gadda, who would include recipes in his novels (in one case for Risotto alla Milanese), has also been compared with Shakespeare because of the range of his writing, and I couldn’t resist inserting into a lecture in Bologna the idea that Shakespeare was Italian. Many of his plays are set in Italian cities, and he was familiar with Italian writing. As far as we know, he never visited Italy. And perhaps the Italian links simply reflect that at the end of the 16th century Italy was the driver of culture—rather in the way that America is now.
As well as being wise about causation Gadda also anticipated modern physics, including Shroedinger’s cat experiment, by observing that “To know is to insert something into what is real, and hence to distort reality.”
Another writer much admired by Calvino was the Austrian Robert Musil, who wrote The Man Without Qualities. Musil thought that we have two ways of thinking: exactitude, which is characterised by “mathematics, pure spirit, and the military mentality;” and soul characterised by “irrationality, humanity, and chaos.” This assertion immediately made me think of Daniel Kahneman’s book Thinking Fast and Slow. Kahneman is a psychologist who has won the Nobel prize for economics and is the father of “behavioural economics,” which in contrast to classic economics recognises that we are far from rational creatures.
Kahneman’s book is, I proclaim, one of those rare books that everybody should read. It is satisfying to those of a scientific turn of mind because everything in the book is backed up with experimental evidence. The core of his argument is that, as Musil wrote, we have two ways of thinking. He illustrates what he calls System 1 by asking us to look at a picture of a woman. In a fraction of a second we know that she is angry and about to say something nasty. System 2 comes into play when we are asked, for example, to multiply 27 by 93. We find this hard work, and it will take us a long time. System 1 never rests, and it does most of our thinking; system 2 is hard work, and we use it only when we have to. System 1 doesn’t do at all badly and we couldn’t function without it, but it is full of biases and errors.
I must confess that I’m still reading Kahneman’s book, but both Ben Goldacre’s Bad Science and Niall Ferguson’s The Ascent of Money, both of which are first class books, list some of the many systematic defects in our thinking. I opted for the list of Ferguson because I read his book most recently, but I felt the need to apologise for quoting a right winger, who supported Mitt Romney and has good things to say about the Tea Party, in such a left wing meeting. (But then I had insulted Berlusconi.) And Ferguson is at least a Glaswegian on the make, a stereotype that I admire. Here’s his list:
1. Availability bias: giving too much weight to information most available.
2. Hindsight bias.
3. The problem of induction: building general rules with too little information.
4. The fallacy of conjunction: overestimating that seven events with 90% probability will all occur and underestimating that one will occur.
5. Confirmation bias: seeing confirming but not falsifying evidence.
6. Contamination effects: irrelevant but proximate information overinfluences us.
7. Affect heuristic: preconceived value judgements interfere with cost benefit analyses.
8. Scope neglect: prevents us proportionately adjusting what we would be willing to sacrifice to avoid harms of a different order of magnitude.
9. Overconfidence in calibration.
10. Bystander apathy.
Ferguson produced his list to illustrate why financial crises will continue to occur, but the same defects and our many others lead us as well to personal, social, political, and military disaster. Indeed, these defects will, I believe, account for human beings becoming extinct considerably faster than the dinosaurs.
Before I left Calvino and finished my talk, I had one more quote from him: “Over ambitious projects may be objectionable in many fields but not in literature. Literature remains alive only if we set ourselves goals far beyond all hope of achievement.” I included this quote because it made me think of the Cochrane Collaboration, which Alessandro was part of from the beginning. It is a hugely ambitious project—akin in my mind to Hercules cleaning the Augean stables—to organise all of the extremely disorganised and flawed medical evidence.
When I first began talking about multiplicity some six months ago, two thoughts came straight to my mind. The first was how most of healthcare in developed countries, and increasingly in developing countries, is about people with multiple long term conditions. Two thirds of Medicare spend goes on people with five or more conditions. In Glasgow 75% of patients aged 70 have two or more conditions, and 40% have four or more. At medical school I was taught a model of medicine that can be summarised as “diagnose, treat, cure.” That model is dead. Diagnosis is often not important because we know what is wrong with people. Cure doesn’t happen with patients with long term conditions, and it’s self-management rather than treatment by doctors that is most important in determining outcomes.
My second thought was to remember the paper by Nick Wald and Joan Morris on “teleoanalysis,” combining data from different sorts of studies. The paper was published in the BMJ and has had nothing like the impact of the polypill paper published at about the same—perhaps because people are doing it anyway without giving it a fancy Greek name. (As I write this sentence it occurs to me, too late, that the polypill, an obsession of mine, is another example of multiplicity.)
My conclusions after such a rambling talk were startlingly bald: there is huge power in the many; and everything is connected to everything.
But I had three afterthoughts. Firstly, I apologised for my “knight’s move,” thinking, which I was taught at medical school was a sign of schizophrenia. It’s talking rather than thinking where you jump from A to C, leaving out the connecting B and leaving people lost and wondering about the connection. I do it, and so do others I know who are not schizophrenics. Secondly, as a follower of Nietzsche (on Twitter rather than through his books, he’s perfectly designed for Twitter) I felt I needed to share a thought of his that in many ways is counter to my argument—that “when a hundred men stand together, each of them loses his mind and gets another one.” This is “groupthink” in modern parlance, and it’s a real and dangerous phenomenon. It doesn’t mean, however, that there is not power in the many; rather it means that we must be on the watch for it.
Finally, I ended with a picture of the power of multiplicity given to me by Luca de Fiore, one of the organisers of the meeting: Barcelona Football Club. They are the best football team in the world and may perhaps be the best team ever, and their game is built around multiplicity—passing the ball so much more often and more accurately than the opposition that they bewitch them. Plug in, I say, to the power of multiplicity.
Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.
Competing interest: RS spoke at the meeting and had his expenses paid by the health department of Emilia-Romagna. He was a friend of Alessandro Liberati, and when RS was editor of the BMJ and chief executive of the BMJ Publishing Group there were both intellectual and business collaborations between the group and enterprises involving Alessandro.