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May 2, 2013 14:6 BC: 8831 - Probability and Statistical Theory PST˙ws

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 STOCHASTIC MEDICAL REASONING AND
ENVIRONMENTAL HEALTH EXPOSURE

George Christakos
San Diego State University, USA

Jin-Feng Wang
Chinese Academy of Science, China

Jiaping Wu
Zhejiang University, China

Imperial College Press

ICP

P892_9781908977496_tp.indd 2 10/2/14 3:11 pm

 Published by
Imperial College Press
57 Shelton Street
Covent Garden
London WC2H 9HE

Distributed by
World Scientific Publishing Co. Pte. Ltd.
5 Toh Tuck Link, Singapore 596224
USA office: 27 Warren Street, Suite 401-402, Hackensack, NJ 07601
UK office: 57 Shelton Street, Covent Garden, London WC2H 9HE

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library.

STOCHASTIC â•›MEDICAL â•›REASONING â•›AND â•›ENVIRONMENTAL â•›HEALTH â•›EXPOSURE

Copyright © 2014 by Imperial College Press
All rights reserved. This book, or parts thereof, may not be reproduced in any form or by any means,
electronic or mechanical, including photocopying, recording or any information storage and retrieval
system now known or to be invented, without written permission from the Publisher.

For photocopying of material in this volume, please pay a copying fee through the Copyright Clearance
Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. In this case permission to photocopy
is not required from the publisher.

ISBN 978-1-908977-49-6

Typeset by Stallion Press

Email: [email protected]

Printed in Singapore

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February 12, 2014 8:43 9in x 6in Stochastic Medical Reasoning and Environmental. . . b1681-fm

To friendship

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Contents

Preface xi

Chapter 1. Medical Sciences in the Age of Synthesis 1

1.1 Professional Practice and Stochastic Medical Reasoning . . . . 1
1.1.1 Synthesis in medical sciences . . . . . . . . . . . . . . . 1
1.1.2 Environmental health and geomedicine . . . . . . . . . 5
1.1.3 On ancient Greek and Chinese medicine . . . . . . . . 9
1.1.4 Decision-making in conditions of in situ
uncertainty . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.1.5 A brief note on logical thinking in ancient
Greece and China . . . . . . . . . . . . . . . . . . . . . 14
1.1.6 Enter stochastic medical reasoning . . . . . . . . . . . 16
1.2 Health: The Fundamental Roles of Space–Time
and Uncertainty . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.3 Abstract and Concrete Modes of Thinking . . . . . . . . . . . 23
1.4 Issues of Sound Medical Decision-Making . . . . . . . . . . . . 25
1.4.1 Key elements of a medical investigation . . . . . . . . . 26
1.4.2 Reflection, recognition primed decision and robust
decision methods . . . . . . . . . . . . . . . . . . . . . 30
1.4.3 Algorithmic medical decision-making methods . . . . . 33
1.4.4 Does expert knowledge translate into
expert judgment? . . . . . . . . . . . . . . . . . . . . . 34
1.5 Medical Dialectics and Knowledge Synthesis: An Outline . . . 36

Chapter 2. Reasoning Amidst Uncertainty 39

2.1 When “To Know” Means “To Be Uncertain Of” . . . . . . . . 39
2.1.1 Common medical reasoning errors . . . . . . . . . . . . 39
2.1.2 Physician’s language and metalanguage . . . . . . . . . 42
2.1.3 The notion of knowledge base . . . . . . . . . . . . . . 44

vii
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viii Stochastic Medical Reasoning and Environmental Health Exposure

2.2 The Space–Time Domain of Stochastic Medical Reasoning . . 47

2.2.1 Location–time coordinates and metric . . . . . . . . . . 47
2.2.2 The spatiotemporal random field model . . . . . . . . . 51
2.3 In Situ Logic and Uncertain Mind States . . . . . . . . . . . . 53
2.3.1 How much a health care provider does not know:
Ontic and epistemic uncertainty . . . . . . . . . . . . . 54
2.3.2 Appreciating case individuality and legal disputes . . . 56
2.3.3 Case communication uncertainty: Entitled to their
own opinions but not to their own facts . . . . . . . . . 58
2.3.4 Formal vs. in situ logic . . . . . . . . . . . . . . . . . . 60
2.3.5 From state of nature to state of mind (assertion) . . . 63
2.3.6 Ranking of assertion forms . . . . . . . . . . . . . . . . 71
2.3.7 The Three Qs of the triadic case formula . . . . . . . . 74
2.3.8 Uncertainty factors: A review . . . . . . . . . . . . . . 76
2.4 SMR’s View of Medical Connectives: Beyond
Drug Digestion . . . . . . . . . . . . . . . . . . . . . . . . . . 79
2.4.1 Conversational (dialogical) connective interpretation . 80
2.4.2 Content-dependent vs. content-independent
connectives . . . . . . . . . . . . . . . . . . . . . . . . . 83
2.5 Natural Laws and Scientific Models . . . . . . . . . . . . . . . 85
2.5.1 Infectious disease and human exposure modeling . . . . 86
2.5.2 Medical syllogism and the justification
of professional assertions . . . . . . . . . . . . . . . . . 89
2.5.3 Reconstructing Chinese arguments in terms
of Greek syllogisms . . . . . . . . . . . . . . . . . . . . 94
2.5.4 Revisiting content-dependent and
content-independent assertions . . . . . . . . . . . . . . 96
2.6 Substantive Conditionals in Medical Thinking . . . . . . . . . 99
2.6.1 The notion of content-dependent conditional . . . . . . 100
2.6.2 Paradoxes of mainstream logic . . . . . . . . . . . . . . 105
2.6.3 Conditionals and metalanguage . . . . . . . . . . . . . 114
2.6.4 Conditionals and natural laws . . . . . . . . . . . . . . 117
2.6.5 Over-extending and extrapolating . . . . . . . . . . . . 119
2.7 The Object Language–Metalanguage Connection . . . . . . . . 121
2.7.1 Relations between states . . . . . . . . . . . . . . . . . 122
2.7.2 Combinations of medical inferences
and derivative assertions . . . . . . . . . . . . . . . . . 131
2.7.3 Levels of justification and uncertainty . . . . . . . . . . 133
2.7.4 Does postmodern decision analysis make sense? . . . . 138
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Contents ix

Chapter 3. The Role of Probability 141

3.1 How Much Understanding is Sufficient in Medical
Investigations? . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
3.1.1 Medical assertions and partial understanding . . . . . . 141
3.1.2 On rationality and belief . . . . . . . . . . . . . . . . . 144
3.1.3 Knowledge theory revisited: Platonism,
context and continuity in medical thinking . . . . . . . 145
3.1.4 Concerning medical expertise . . . . . . . . . . . . . . 147
3.2 Space–Time Probabilities of Medical Cases . . . . . . . . . . . 148
3.2.1 Common probability interpretations in health
care practice . . . . . . . . . . . . . . . . . . . . . . . . 148
3.2.2 Probability of a case assertion (mind state) . . . . . . . 152
3.2.3 Basic probability rules . . . . . . . . . . . . . . . . . . 155
3.2.4 Probability interpretations in object language
and metalanguage . . . . . . . . . . . . . . . . . . . . . 157
3.2.5 Body of evidence and medical interventions . . . . . . 161
3.3 Probabilities of Medical Conditionals . . . . . . . . . . . . . . 164
3.3.1 Standard logical relations and inference rules . . . . . . 164
3.3.2 Choosing a conditional probability form . . . . . . . . 166
3.3.3 Stochastic truth tables: A second look . . . . . . . . . 176
3.3.4 More on probability calculation: Is there
a probameter? . . . . . . . . . . . . . . . . . . . . . . . 181
3.4 Stochastic Medical Inferences . . . . . . . . . . . . . . . . . . 186
3.4.1 From standard to stochastic syllogisms . . . . . . . . . 187
3.4.2 Premise strengthening, internally consistent
and uninformative inferences . . . . . . . . . . . . . . . 199
3.5 Probability, Uncertainty and Information of Diagnoses
or Prognoses Sets . . . . . . . . . . . . . . . . . . . . . . . . . 205
3.6 Diagnosis Ranking and Symptom Confirmation Strength . . . 211
3.6.1 Quantitative case parameters . . . . . . . . . . . . . . 212
3.6.2 Principles of medical practice and their
quantitative expressions . . . . . . . . . . . . . . . . . 215
3.7 The Trouble with Medical Probability . . . . . . . . . . . . . . 217
3.8 Translating Medical Assertions into Probabilistic Terms . . . . 222
3.9 Space–Time Reasoning Dynamics . . . . . . . . . . . . . . . . 229
3.9.1 Changes in assertions and substantive conditionals . . 229
3.9.2 Probability dynamics and hypothesis confirmation . . . 235
3.9.3 The case of non-monotonic medical reasoning . . . . . 238
3.10 Medical Syllogisms Involving Likelihood Ratios . . . . . . . . 240
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x Stochastic Medical Reasoning and Environmental Health Exposure

3.11 Summing Up: Checking the Validity of Medical Arguments . . 242

3.12 Self-Referential Medical Assertions and Cognitive Favorability 244
3.13 Not Just a Set of Guidelines . . . . . . . . . . . . . . . . . . . 247

Chapter 4. Space–Time Medical Mapping

and Causation Modeling 249
4.1 Techniques With a “Health Warning” . . . . . . . . . . . . . . 249
4.2 Space–Time Disease Mapping . . . . . . . . . . . . . . . . . . 250
4.2.1 Objectives of medical mapping . . . . . . . . . . . . . . 251
4.2.2 The fundamental mapping equations . . . . . . . . . . 253
4.2.3 The insight behind the BME–SIR equations . . . . . . 256
4.2.4 A study of French flu . . . . . . . . . . . . . . . . . . . 258
4.3 Modeling Space–Time Infectious Disease Spread . . . . . . . . 264
4.4 Space–Time Causation Revisited . . . . . . . . . . . . . . . . . 268
4.5 Medical Causation in the SMR Inference Setting . . . . . . . . 271
4.5.1 Defining the problem . . . . . . . . . . . . . . . . . . . 272
4.5.2 The role of KB and the interpretation of
probabilistic causation . . . . . . . . . . . . . . . . . . 277
4.5.3 Causation: Epistemic vs. non-epistemic . . . . . . . . . 280
4.5.4 Some remarks regarding the form of the
causation conditional . . . . . . . . . . . . . . . . . . . 283
4.5.5 Stochastic causal inferences . . . . . . . . . . . . . . . 285
4.5.6 The role of secondary case attributes . . . . . . . . . . 287
4.6 Causation in Terms of Integrative Space–Time Prediction . . . 289
4.7 Causation Justification and the Dualistic Opposition . . . . . 291

Chapter 5. Looking Ahead 293

5.1 An Ibsenian Transformation . . . . . . . . . . . . . . . . . . . 293
5.2 SMR and Divergence of Rationality in Medical Thinking . . . 296
5.3 Challenges Emerging from the Incompleteness Principle and
Unanticipated Knowledge . . . . . . . . . . . . . . . . . . . . . 298
5.4 Information Technology-Based Medical Reasoning . . . . . . . 302
5.5 Social and Cultural Dimensions of Medical Thinking . . . . . 304
5.6 Quod Iacet Ante? . . . . . . . . . . . . . . . . . . . . . . . . . 308

Bibliography 315

Index 331
February 12, 2014 8:43 9in x 6in Stochastic Medical Reasoning and Environmental. . . b1681-fm

Preface

The validity of critical reasoning steps carried out during or on the

sidelines of a clinical case, public health survey, medical study, human
exposure, population risk assessment or disease mapping often does not
receive sufficient attention or even feature on the investigator’s radar.
For example, the technical complexity of a human exposure experiment
may overshadow the logical assumptions made when moving from one
phase of the experiment to the next; or the study of population risk
assessment may focus on analytical and computational matters, whereas
methodological and cultural factors are neglected. This book hopes to help
health investigators structure their thinking so that they avoid logical
mistakes and argumentation pitfalls and, at the same time, gain new
insights about clinical reality, and improve awareness of the environment
and context within which one’s thinking takes place.
A central thesis put forward in the book is that in situ medical
reasoning extends beyond clinical procedures and technical guidelines
(checklists), and is viewed as a synthesis of theoretical and empirical
considerations in science, epistemology, sociology and stochastics.1 Stochas-
tics has given medical reasoning a vocabulary on which to base its
own methodology. Remarkably, while mainstream formal (or discursive)
logic relies on a set of rules (norms) by means of which a form of
orderly closed-system reasoning can be applied, cognitive limitations,
partial understanding, and environmental and cultural factors affect in situ
reasoning and the inferences that people draw in real world situations.
Thus, the book is about stochastic medical reasoning (SMR) in a space–
time synthesis context, which is reasoning based on the integration of
different knowledge sources under conditions of in situ uncertainty and
health status heterogeneity. This is medical reasoning that overlaps with

1 The term “stochastics” refers to the mathematical study of phenomena that vary in
space–time under conditions of uncertainty.

xi
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xii Stochastic Medical Reasoning and Environmental Health Exposure

logic and rationality, but is considerably more than that. To some extent,
the methodological underpinnings of this kind of reasoning are closer to a
neo-Kantian “substantive unity” of reason (its original form was considered
by Immanuel Kant; Kant, 1922) rather than to the Hobbesian calculative
reason (i.e., reasoning seen as a broader version of generalized computation;
Malmesbury, 1839) or to the Habermassian conception of reasoning as
strictly formal or procedural (Habermas, 1995). Accordingly, since SMR is
substantive rather than normal, it encompasses the observation of medical
cases, the prediction and control of future disease-related events and
attributes, and the testing of health hypotheses, as well as novel ways
of seeing real medicine and interpreting things (test results, diagnoses,
prognoses, treatments). Otherwise said, SMR views medical thinking as a
non-egocentric process that does not merely incorporate logical or rational
thinking modes, but goes considerably beyond that in the domains of
insight, creativity, imagination and the unconventional. Over time, this
methodology and the related technology have gradually proceeded from
a research and standardization context to a concrete and productive in situ
setting.
A brief survey of the book follows: Chapter 1 looks at medical reasoning
from a synthetic perspective, the term “medical” being viewed in the
broad sense that includes clinical medicine, environmental health and
geomedicine. Chapter 2 introduces the basics of medical syllogism, and
is concerned with the fundamental distinction between medical language
and metalanguage in interviewing, decision-making, and communication.
Chapter 3 focuses on the introduction of probability in medical thinking,
and on techniques testing the validity of diagnoses in realistic conditions of
time pressure. The vital role of uncertainty in medical decision support is
constantly emphasized throughout the book. The value of a sound decision
analysis lies not merely in its ability to generate disease diagnoses but also
in the responsible examination and rigorous assessment of the uncertainty
surrounding diagnostic tests and hypotheses. The criteria of disease etiology
(causation) and the methods of space–time disease evolution and spread
discussed in Chapter 4 apply in a wide range of problems in medicine,
environmental health, and geomedicine. A central thesis of this book is that
a rigorous and efficient way for health care professionals to understand the
underlying logical structure of their everyday language is to learn how to
put it into the SMR terms and methods introduced in Chapters 2 to 4.
Concluding, Chapter 5 presents a few thoughts about what potentially lies
ahead in medical thinking and decision-making.
February 12, 2014 8:43 9in x 6in Stochastic Medical Reasoning and Environmental. . . b1681-fm

Preface xiii

All chapters include a considerable number of examples and real case

studies to help the readers gain adequate insight about the theory and
methods of medical reasoning in conditions of uncertainty. It has been said
that people who do not know history do not have future, and people who do
not know philosophy do not have vision. Accordingly, most chapters of the
book discuss examples from medical practice where philosophical logic could
play a key role. One of these examples is the crucial distinction between
“knowledge of the real medical case” and “knowledge of a physician’s mental
model of the case”, which is both a crucial clinical diagnosis issue and
a deep philosophical problem (specifically, belonging to the philosophical
field of epistemology). That is, an investigator should distinguish between
“science’s limits” and “scientist’s limits”, which can have a profound
effect in setting priorities in clinical practice and medical research. When
discussing a view, notion or method in the book, our aim is not necessarily
to defend that view, notion or method, but to state that the view exists,
as shown in various medical sources. Therefore, the view, notion or method
should be accounted for rather than simply dismissed.
As noted above the concern of real medical reasoning and clinical judge-
ment is not limited to the domain of deterministic logic, in the sense that
it can deal with questions that are unanswerable within the deterministic
domain. This is made possible because SMR avoids the Gödelian issues of
unprovability (undecidability) that characterize deterministic logic. Indeed,
the latter employs strictly deductive reasoning, whereas SMR uses a mode of
thought that works under the uncertainty conditions characterizing public
and private medical practice. In the same milieu, a situation encountered by
medical decision-makers is that the notion of content-independent formal
reasoning captures the essence of many health statistics techniques. This
happens despite the fact that a health care provider’s powers of noticing,
perceptual grasp and understanding depend upon recognizing what is
salient and the capacity to respond to the substantiveness of the particular
medical case. The above considerations show that the need to reinterpret
mainstream logic in a realistic medical setting is a result of the desire to
retain, as far as possible, substantive interpretations of medical decision-
making and exposure assessment. Ideally, a physician is trying to develop
reasoning in such a way that the justification of a medical assertion
embodies content-dependent arguments (scientific principles, empirical
evidence etc.) rather than content-independent ones.
As intellectual provocation constitutes an invaluable component of
creative thinking and decision-making, it underlies many developments
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xiv Stochastic Medical Reasoning and Environmental Health Exposure

and discussions throughout the book. A steady stream of evaluations,

considerations and challenges to ideas, mainstream methods and “common
sense” notions is a necessary component for improvement in medical
reasoning and clinical judgment.
In a similar setting, otherwise intelligent health care providers who
lack a special mathematical aptitude may argue that certain parts of
medical reasoning (e.g., those dealing with the study of space–time disease
distributions and epidemic matters) require some level of quantitative
sophistication. Also, it has been argued that quantitative studies purporting
to deal with health and medicine are essentially dealing with mathematical
analysis, formal logic, probability theory, statistics, and so on. Even if this
is valid to some degree, it would surely be a big mistake to overlook the
great transforming effect the introduction of stochastic mathematics has
upon medical decision-making. In reality, most of SMR inference can be
mastered with reasonable effort, and it is a versatile tool that produces
a plethora of useful results in medical decision support. Inter alia, SMR
can radically improve clarity of clinical argumentation, rigor of diagnostic
expression, and power of prognostic information.
Lastly, the design of the book cover is a visualization of the book’s
perspective on the integration of medicine with logic, and its historical
roots. Remarkably, although the evolution of Greek medicine and Chinese
medicine followed rather remote paths (geographically and conceptually),
still there were significant similarities. Many experts cite the view that
the medical theories and clinical practices of ancient Greek and Chinese
medicine had interesting similarities to each other, and they separately
produced particular merits of themselves. The idea of synthesizing medici-
nal observation with logical rigor was deeply rooted in Aristotle’s thinking,
who grew up under the influence of the Hippocratic tradition of medicine,
whereas the semantics of valid inference were studied in Mohist Canons.
The book cover’s design emphasizes the above facts by presenting a
synthesis of images relevant to ancient Greek and Chinese medical scholars
and pioneers of logical thinking.
The authors would like to express their gratitude to Ms Tasha D’Cruz
for the dedication with which she managed the book’s production.

GC, JFW, JPW

San Diego, Beijing, Hangzhou
February 12, 2014 8:43 9in x 6in Stochastic Medical Reasoning and Environmental. . . b1681-ch01

Chapter 1

Medical Sciences in the Age of Synthesis

1.1. Professional Practice and Stochastic

Medical Reasoning
If the 15th century (medieval times) was the age of Belief, the 16th century
(Renaissance) the age of Adventure, the 17th century the age of Reason,
the 18th century the age of Enlightenment, the 19th century the age of
Ideology and the 20th century the age of Analysis, then, naturally, the 21st
century should be the age of Synthesis. Most of today’s real world problems
cannot be solved within the boundaries of a single scientific discipline.
Instead, these problems have an essential multidisciplinary structure, which
means that their successful study transcends disciplines and requires a goal-
directed synthesis of concepts, data, techniques and thinking modes from
all these disciplines.

1.1.1. Synthesis in medical sciences

In a developing environment of synthesis, medical sciences1 cannot be
an exception. In fact, the idea of synthesizing medicine with logical
rigor was deeply rooted in Aristotle’s thinking, who grew up under the
influence of the Hippocratic tradition of medicine. Aristotle valued both
medical observations and techniques (he documented many of Hippocrates’
medical achievements), but he argued that logic should be carefully used

1 The term “medical sciences” is considered in the broad sense that includes clinical
medicine (science of diagnosing, treating or preventing disease and other damage to
the human body or mind), environmental health (assessment and control of those
environmental factors that can potentially affect health) and geomedicine (effects of
the environment on the spatiotemporal distribution of population health and disease
spread).

1
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2 Stochastic Medical Reasoning and Environmental Health Exposure

to confirm hypotheses. This synthesis was promoted by other medical

thinkers, including Avicenna, who incorporated Aristotelian logic and
Galen’s teachings into medical diagnosis and treatment.
Synthesis is a process whereby logic, critical reflection, medical knowl-
edge, clinical experience and environmental awareness are combined in
evaluating multiple objectives (diagnoses, prognoses, treatments), while
accounting for the patient’s situation (signs, symptoms, pre-existing con-
ditions). From their routine practice, physicians know that a patient’s
symptoms, signs and diagnostic test results may be associated to more
than one disease, and that often it is not possible to distinguish between
them with certainty. Clinicians need to synthesize the medical information
they obtain during a patient’s interview and physical examination into an
opinion about the patient’s state (a clinician can then conclude that a
patient is not diseased, or that more information is needed by means of
additional diagnostic tests, or that enough is known to suggest a specific
treatment). Remarkably, the diagnosis of a disease may require the synthesis
of information obtained with the help of theories and tools having their
origins in non-medical scientific fields. Also, the interest of large-scale health
studies, like epidemic spread or population exposure in a region of the world,
clearly exceeds the domain of the respective disciplines. Decision support
tools that advance the quality of medical practice and patient care2 are
often the direct or indirect product of developments in different sciences
and technologies, such as modern physics, molecular and cellular biology,
nanotechnology, engineering (mechanical, nuclear, electrical and electronic)
and biomaterials or tissue engineering. Integrating knowledge from different
disciplines is needed in order to provide medical researchers and clinicians
with the most reliable tools to make the necessary measurements and
improve their methodological quality (the degree to which the measurement
process matches the case objectives, the likelihood that a measurement
instrument will generate unbiased results) (Arrivé et al., 2000; de Vet et al.,
2011).3 In view of the above and similar considerations, researchers and
clinicians routinely form teams that develop styles of professional practice
with the goal of providing high-quality care, including communication
mechanisms, protocols for transforming knowledge and experience, ways of

2 For example, by improving clinicians’ decisions involving tests and treatments that
are also more personalized, or constructing more accurate and more rapid diagnostic
techniques.
3 A review of medical decision-making methods is presented in a later section of this

chapter.
February 12, 2014 8:43 9in x 6in Stochastic Medical Reasoning and Environmental. . . b1681-ch01

Medical Sciences in the Age of Synthesis 3

doing things (including guidelines assessing the expertise of team members)

and shared evaluation of their performance.
As most health care providers4 would admit, the state of affairs in
public health is quite heterogeneous. Human genetics is, of course, a crucial
factor of quality health care, however, it has become increasingly clear that
people’s environment can also provide important contextual information,
medically speaking. An increasing number of studies have clearly shown
that where people live and work are intrinsically intertwined with their
health (Wright et al., 1982; Burke et al., 2003; Yoon et al., 2003; Eggleston,
2009; Hovell et al., 2002; Davenhall, 2012). There is plenty of evidence
that certain of the pollutants people are exposed to can serve as crucial
precursors to respiratory and circulatory illnesses, some kinds of cancer,
and, in some cases, heart diseases. The impact of breathing bad air in many
of the places people have lived will follow them wherever they go during
their entire lives. Also, lifestyle factors, including diet, smoking, working
and exercise habits are key determinants of human disease — accounting for
perhaps 75% of most cancers (Sharpe and Irvine, 2004). Diet, in particular,
can play a major role in people’s health. The readers may be surprised
to hear that there exist populations around the world that surpass highly
developed Western countries in health and longevity without having much
of a medical system in place. This includes populations in which a healthy
diet has a greater impact on children’s health than the availability of a
medical insurance plan.

Example 1.1: Public health investigators discovered that during the

1950s only the children of wealthy families in the Philippines developed
childhood liver cancer. This was because only these families could afford
peanut butter and, during this time period, much of the peanut butter in
the Philippines was contaminated with a mold called aflatoxin that is a
highly carcinogenic substance; the aflatoxin started the cancer tumors and
dairy consumption contributed to their rapid growth (Campbell, 1967).

Another example of the lifestyle’s impact on modern populations is the

increasing numbers of thyroid cancer cases in certain parts of the world.

Example 1.2: In the plots of Fig. 1.1 one can see the dramatic increase
of thyroid cancer in Hangzhou city (Southeast China) as a result of lifestyle
change. Over the years, the number of male patients with thyroid cancer

4 The term includes physicians, physical practitioners, optometrists, chiropractors,

dentists, nurse practitioners and physician assistants.
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