LESS IS BETTER

Thomas T. Samaras, BS, MBA, and Harold Elrick, MD, FACP

San Diego, California and Bonita, California

The "more is better" credo is evaluated in terms of its harmful ramifications on human health,
the environment, and the survival of the human race. The trend towards greater height and body
weight in developed countries is evaluated in terms of its negative aspects on health and
longevity. The benefits of reduced caloric intake are discussed. Countries that survive on lower
food intakes are shown to have much less heart disease, such as South Africa, where rural blacks
outlive whites and also have a higher percentage of centenarians. The risks of increasing birth
weight are discussed in terms of promoting cancer and overweight in adulthood. Rapid child-
hood growth also is shown to have risks because rapid maturity is in conflict with the need to
have more time to learn about our complex world before reaching reproductive capability. The
increase in the average size of humans aggravates our burgeoning population numbers, placing
even greater demands on our need for fresh water, energy, resources, and a clean invironment.
Many good things come in large packages, such as elephants, whales, and trees. While Sumo
wrestlers, football players, and basketball players play an important role in our world, their small
numbers do not pose a threat to our survival. However, their body habitus should not be the goal
for the average male of the future. (J Nat/ Med Assoc. 2002;94:88-99.)

Many Americans believe in the credo that
more is better. The penchant for more food,
bigger homes, more powerful vehicles, more
money, larger buildings, and more violence in
our entertainment has been with us for a long
time. Certainly, there are many good things in
the world that are big, such as elephants,
whales, oceans, national parks, lakes, and vari-
ous natural scenic areas. More knowledge, wis-
dom, mutual respect, compassion, and gener-
osity are also highly desirable qualities.
However, there are many things in the modern
world that are idolized or desired that do not
promote a better quality of life for us, our
children, and the other 1.4 million species that
© 2002. From the Reventropy Associates, San Diego, California and
the Foundation for Optimal Health and Longevity, Bonita, California.
Requests for reprints should be addressed to Thomas T. Samaras, BS,
MBA, 1 1487 Madera Rosa Way, San Diego, CA 92124.
we share this earth with. These include a pas-
sion for food, biggness, wealth, entertainment,
and material objects.
One of the greatest misapplications of the
"bigger is better" credo is human size. Martell
and Biller' reported that the socially ideal
height is 188 cm (6'2") for men and rising. Yet
the vast majority of our youth fail to meet this
socially desirable goal. Although most youth
can deal with not being taller than average,
many increase body mass through anabolic ste-
roids2 and body building to compensate for
their shorter stature.
This "bigger is better" misconception has
been propagated by a number of studies over
the last 20 years that have found that taller
people have lower death rates from heart dis-
ease, respiratory problems, and all causes.
Twelve of these studies were described in a
review of longevity and body size published in

VOL. 94, NO. 2, FEBRUARY 2002 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION 88
LESS IS BETTER
1999." Because these studies have been widely
quoted in the literature, they are not repeated
here. However, two recent studies were not
covered. One was a Swedish study of 292
women, which found that short height in
women predicted poor prognosis after an acute
coronary event.-' The other study involved
15,406 middle-aged men and women.5 This
study found that short people had a higher risk
of dying from coronary heart disease (CHD),
stroke, respiratory disease, and all causes, al-
though short height had a lower risk of mor-
tality from cancer. Compared to tall people of
their gender, short males had a 10% higher
risk of dying from all causes and short females
a 16% greater risk. However, a study by Liao
and associates found no correlation between
height and all-cause or CHD mortality and
their evaluation of studies indicating taller peo-
ple have lower death rates indicated that they
were flawed."3
Despite these findings, the authors believe
that short height is compatible with a long life
and freedom from chronic diseases. The rea-
sons for our position are based on the numer-
OUs human and animal findings that conflict
with studies demonstrating that taller people
are healthier. Some of these findings are de-
scribed next. However, the following consider-
ations should be kept in mind:
1) Height is an index of early nutrition and
adult body weight.
2) Health and longevity are also affected by
social status, diet, heredity, quality of
medical care, childhood diseases, smok-
ing, physical activity levels, and relative
weight. Therefore, height is only one fac-
tor out of many that determines one's
longevity.
In their zeal to propagate the belief that
taller and bigger is better, some researchers
have failed to consider the larger picture that
suggests that shorter and lighter body configu-
rations are healthier. For example, the Japa-
nese, Hong Kong Chinese, Okinawans, and
89 VOL. 94, NO. 2, FEBRUARY 2002
Cretans are the longest living people in the
world.7-9 Yet, they are shorter than northern
Europeans and Americans. In addition, Califor-
nian Asians and Hispanics live more than 4
years longer than taller whites"' and in 1961,
relatively short 45-year-old Greeks had a greater
life expectancy than taller northern Europeans
and Americans of the same age."I Renaud8 re-
ported that southern Europeans have two to
three times lower CHD mortality compared to
taller northern Europeans and Americans. In a
20-year study of 50,000 Swedish males, Allebeck
and Bergh'2 found that taller men had a higher
death rate from heart and respiratory diseases
than shorter men. A large study of World War
I military recruits found that taller men had a
higher incidence of pulmonary tuberculosis,
goiter, mitral insufficiency, mitral stenosis, and
valvular disease of the heart.' ' In 1897, a lon-
gevity comparison of dwarfs and giants found
dwarfs averaged 68 years vs. 34 years for gi-
ants. 13 In the early part of the 20th century, the
Mortality and Morbidity Investigation study
also found tall men had excessive death rates. ' 4
More recently, the Framingham study'5 found
no difference in death rates from CHD based
on height, and a study of more than 4 million
insured men and women found that short
women had a lower death rate than mnedium
and tall ones. 14 The Nurses' Health Study
found no correlation between height and
stroke incidence among women, whereas the
U.S. Physicians' Study found no significant
trend across height categories for stroke in
men. 16
Americans and Europeans are taller today
than they were more than 100 years ago. Yet,
Michaels and others have shown that we now
have a much higher incidence of CHD.'7 Peo-
ple in developing countries tend to be shorter
and lighter than those in developed nations,'8
yet, the World Health Organization reported
that people in developing countries have much
lower incidence of CHD, many cancers, diabe-
tes, and other diseases, compared to Western
nations.'8 The lower life expectancy of devel-
oping countries is tied to their much higher
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
 LESS IS BETTER

Table 1. CHD, Stroke, and All-Cause Death Rates for Six California Ethnic Groups
Ethnic group Age-standardized death rates/ 100,000
(decreasing height) Height (cm) CHD Stroke All-causes
African American
Male 178 316 102 1800
Female * 214 91 1059
White
Male 178 302 60 1243
Female * 143 49 726
Hispanic
Male 172 175 49 856
Female * 97 37 478
Asian Indiant
Male 170 258 33 668
Female * 110 45 335
Chinese
Male 169 155 62 773
Female * 73 46 446
Japanese
Male 169 146 52 693
Female * 67 41 420
*Female heights are about 1 0-1 5 cm shorter than males.
tBased on height data for upper socioeconomic status in India.

infant mortality and deaths from infectious dis-
eases and lack of medical care. Despite these
conditions, census studies (1958 and 1968) in
South Africa found that a higher percentage of
50-year-old blacks reached 70 years and above
than 50-year-old whites, and a higher propor-
tion of blacks were centenarians.19 The blacks
averaged approximately 10 cm shorter than
whites.20 Based on these findings, Walker, a
South African researcher, observed that our
progressive sophistication of diet and lifestyle
reduces our chances of survival in middle age
and beyond. ') Many studies have found that
one or more cancers are positively correlated
with height.3 It is interesting to note that virtu-
ally all public health studies have found a sharp
increase in chronic diseases in the 20th cen-
tury. Yet, before 1900, people were consider-
ably shorter.
Our own studies have found a negative cor-
relation between height and average lifespan
for various populations, including baseball
players, football players, veterans, famous peo-
ple, French men and women, and other
groups.3'2122 One of the authors participated in
field studies of several populations in different
parts of the world and found these people,
such as the Tarahumaras of Mexico, to be short
(163 cm), free of Western chronic diseases, and
exceptionally vigorous.23
Table 1 summarizes mortality for six ethnic
groups in California. Our analysis of the data
(based on 1 million deaths) shows a positive
trend for various causes of death as height in-
creases.212425 Differences in diet, lifestyle, and
genetic makeup certainly influence this trend.
Although these ethnic groups have significant
lifestyle differences among themselves, smaller
height and body weight are a common element
of the longer living groups. These findings are
not peculiar to California, because nationwide
statistics show lower age-adjusted mortality
rates from all causes, CHD, chronic obstructive
pulmonary disease and cancer for Asians, His-
panics, and Native Americans compared to
whites.26
Despite heavy smoking, pollution, and less
sophisticated medical care, relatively short and

VOL. 94, NO. 2, FEBRUARY 2002 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION 90
LESS IS BETTER
light Shanghai Chinese men had a life expect-
ancy of 73.8 years in 1989.27 This was 1.8 years
longer than taller whites in the United States
for the same period. At that time, Chinese
males averaged approximately 163 cm (5'4")
and United States males approximately 175 cm
(5,9,)28
Other researchers have reported on the
health benefits of smaller size; e.g., studies by
Bartke et al. ,2 Miller,30' and Micozzi.31 Micozzi
reported that along with increasing stature and
weight, Mexican-American andJapanese-Amer-
ican migrant populations have a marked in-
crease in the rates of cancer, CHD, and other
chronic diseases through succeeding genera-
tions. Samaras and Elrick3 also described sev-
eral studies that found a correlation between
height and body size and cancer incidence and
mortality. And recent studies in England found
that men taller than 183 cm (6') had an 36%
higher incidence of cancer compared to those
less than or equal to 168 cm (5'6).2 Gunnell et
al. also found that adults had an -80% in-
crease in cancer death rate with each incre-
ment in leg length of 3 to 4 mm over the mean
during their growth period.32 The authors have
found over 80 studies that have reported a pos-
itive correlation between at least one type of
cancer and height.
In the Cornell-China study33 of a homoge-
neous population (Han), shorter men and
women had lower CHD and cancer mortality.
The correlation between height and CHD mor-
tality was 0.33 (p < 0.05) and between weight
and CHD, 0.39 (p < 0.01). In one county, a
population of more than 246,000 males 0 to 64
years of age revealed not one death from heart
disease over a 3-year period. In an other
county, not one woman (0 to 64 years of age) in
a population of 181,000 women died of heart
disease over this 3-year period. Of the 65 coun-
ties being studied, these men and women were
the shortest except for one county. In compar-
ison, the mortality in the United States was 66.8
and 18.9 per 100,000 for men and women,
respectively.3<3 It should be noted that since the
91 VOL. 94, NO. 2, FEBRUARY 2002
1950s, height has been increasing in China
along with CHD.28
If tallness promotes long life, why are so
many centenarians short? For example, in Oki-
nawa, male centenarians are 148.3 cm (4'10.4")
and females 138.6 cm (4'6.6").9} Yet, young
males averaged 162.4 cm (5'4") and young fe-
males 150.9 cm (4'11.4") when the centenari-
ans were 20 years old. Although the heights of
these particular centenarians during their
youth were not reported, it is unlikely that they
shrunk over 13 cm (5"). It is interesting to note
that Okinawa has produced 34 centenarians
per 100,000 population- considerably more
than taller western Europeans, who produce
approximately 3 to 7 per 100,000 population.4
In one study, Hungarian centenarian males
were found to be just over 152 cm (5').34 There
were 218 male and female centenarians in this
study. In contrast, British nobility produced
only one centenarian over a 1000-year period.35
Yet, the aristocracy in the United Kingdom av-
erages considerably taller than 152 cm and has
experienced superior living conditions for cen-
turies.
Although women differ physiologically from
men, there is some evidence that their smaller
body size may explain part of their greater lon-
gevity. For example, in a study of a deceased
population of more than 1700 men and women
in Ohio, Miller found that men and women of
the same height had about the same average
lifespan.- " A study of French men and women
who died in the 19th century also showed a
convergence in average lifespan as their
heights approached the same value.3" We
found one example of a male mammal living
longer than a female; e.g., Syrian hamster
males are smaller-37 than females but live sub-
stantially longer.38 Another study showed that
larger females generally had a shorter life ex-
pectancy compared to smaller males. Bartke's
work also shows that genetically small male
mice live much longer than larger normal size
females.29
The preceding human studies are supported
by animal research over the last 60 years involv-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

ing more than 1500 studies.393 These studies
have consistently shown that a well-balanced
calorie-restricted diet applied during the
growth phase produces a smaller body size,
delays occurrence of chronic diseases, and ex-
tends maximum life span by up to 100%.39-42
In addition, extensive data shows smaller dogs
and other animals within the same species live
longer than larger ones.4245 Although many
scientists discount these findings as not apply-
ing to humans, the benefits of caloric restric-
tion (CR) seem to apply to monkeys, our clos-
est animal relatives. The National Institute of
Aging has sponsored CR research with mon-
keys since 1987. Findings thus far indicate that
monkeys subjected to a calorie-restricted diet
during their growth period are shorter, lighter,
and healthier.4'47 Calorie restriction also ex-
tends longevity when started in adulthood and
results in reduced weight, although body
length is not affected. There is also some evi-
dence that CR produces benefits in humans as
well. Twelve examples were covered in a previ-
ous report.3
Conflicting findings on the relationship be-
tween height and longevity or health are due to
many confounding factors, such as diet, over-
weight, social status, income, education, child-
hood stunting due to illness or malnutrition,
and possibly psychosocial factors.3"2 In addi-
tion, morbidity and mortality evaluations of
people with the same body mass index (BMI)
creates an unfair comparison due to different
body types; e.g., tall people tend to have a more
linear build compared with short people with
the same BMI.U To avoid this confounder, the
Ponderal index (wt/ht3) is a more realistic
method for comparing the longevity of tall and
short people.
Another concern is the size of babies. Larger
is often viewed as healthier. Yet, twins are usu-
ally small (-2500 g) at birth, although their
longevity has been found to be equal to the
general population. Certainly it is undesirable
for babies to be small because of malnutrition,
prematurity, parental smoking, and other neg-
ative factors. However, a large study in Sweden
VOL. 94, NO. 2, FEBRUARY 2002
LESS IS BETTER
of 165,000 males found that the smallest chil-
dren (<5 percentile in birthweight or birth
length) had the lowest risk of being overweight
and obese at 18 years of age.48 This is consistent
with Garn's observation that if we wish to re-
duce obesity in children, we may have to settle
for smaller body size.4t' And contrary to many
studies, Laor et al.)" found that Israeli children
who were heavier at birth had higher blood
pressure at the age of 18 years. Other studies
have found larger size babies have higher risk
of cancer,5'land Johnson reported that today's
children are being overfed by approximately
20% in excess calories.52 Perhaps this excess
has evolved from overemphasis on compliance
to growth charts when children are shorter or
lighter than the norm. Increased food intake to
correct this perceived deficiency probably pro-
motes overweight adults.
The law of unintended consequences is well
illustrated by positive developments in this cen-
tury to eliminate malnutrition and produce
healthy children. The pendulum has swung to
the other extreme, resulting in overfeeding
Western populations, creating many over-
weight or obese people and promoting an ep-
idemic of chronic diseases.'8 Garn53 reported
that it is unlikely thiat individual mass can re-
main at present levels very long, and it's more
likely that human biomass will decline due to
food shortages in the future. He predicted that
the mass of humanity and of the individual will
be a crucial area of concern for physical an-
thropologists over the next 100 years.
As has become evident in the last two de-
cades, fewer calories are better in comparison
to United States health norms. Less fat, salt,
and refined carbohydrates is also better for
blood pressure, heart rate, body fat, serum cho-
lesterol, triglycerides, glucose, creatinine, and
liver enzymes.54
The popular belief that more muscle is bet-
ter than less leads us to explain that men with
high BMIs due to large frames and muscles are
just as healthy as smaller bodied men with low
BMIs. Yet, women who have less muscle mass
than men, have less CHD, longer lifespans, su-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION 92
LESS IS BETTER
perior endurance, and the ability to survive on
lower food supplies.55 In addition, the National
Institute of Occupational Safety and Health
(NIOSH) found that the largest professional
football players have six times the CHD death
rate as the smallest players.56 Data by Sarna et
al.57 also show that smaller-bodied cross-coun-
try skiers live longer than nine other groups of
athletes who are, on average, taller or heavier
when compared with the skiers. Their data
show a difference between cross-country skiers
and basketball players of 1 year less life expect-
ancy with each 2.54 cm (1 inch) increase in
height57 [personal communication, April
6,1999]. In addition, the correlation coefficient
(r) between average life expectancy and weight
for the 10 groups of athletes was r = -0.505
(p < 0.1). Although this value appears exces-
sively large, it is consistent with more than 400
deceased veterans at the San Diego Veterans
Administration where the r = -0.203 (p <
0.00) .I1
A reduced sedentary lifestyle has certainly
been addressed extensively over the last two
decades. The optimum energy expenditure
above resting metabolism for a normal weight
person is very low. For example, Shephard58
and Paffenbarger et al.=)" found only 1411 to
2000 kcal per week in physical activity pro-
duced a minimum mortality. Of course, this
expenditure would need to be much larger and
involve vigorous activities to achieve optimum
physical fitness. Many physicians feel that it
does little good to advise patients to decrease
their physical inactivity, stop smoking, and
change dietary practices.6"1 However, Elrick'il
has found that most of his patients have been
responsive to changing their bad living habits
to healthy ones.
Rapid growth in our children has evolved
during this century due to modern dietary
practices, a physically easier life, and reduced
infectious diseases. However, rapid growth and
early maturity is risky in today's complex soci-
ety. Early maturity promotes more teenage
pregnancies and faster population growth.49
Our youth need more time before the distrac-
93 VOL. 94, NO. 2, FEBRUARY 2002
tions of sexual hormones come into play. They
need more time to mature and to learn before
being exposed to the many opportunities to
stray into unhealthful habits and activities. The
age of puberty has declined from 13.6 years'"} in
1890 to 11.5 years in 1994.6i The combination
of hormonal, informational, and temptational
overload at an age that is ill equipped to deal
with these events, is simply too much for many
of our children. Recent shootings, however, are
only the tip of the iceberg and may reflect the
impact of reaching maturity before the ability
to cope with the pressures of modern society is
developed. Social problems are not the only
result, studies have shown that for each year of
earlier menarche, the risk of breast cancer in-
creases by 10% or more,'!' and taller girls reach
menarche earlier than shorter ones. The Boyd
Orr study also found that the incidence of
adult cancer increased by 20% with each food
increment of 250 kcal per day during child-
hood."4
As we grow taller and heavier, our brain size
increases at a slower rate than body weight.
Although Rushton believes that intelligence is
positively correlated with brain size, he suggests
that Asians with smaller brains compared with
Europeans demonstrate equal or better scho-
lastic performance due to their higher brain to
body weight ratio."5 Shorter people of the same
body proportions as taller ones would also have
a higher brain to body weight ratio. However,
studies of various size dogs do not show a cor-
relation between intelligence and a wide range
of brain sizes. For example, Coren"i"3 provided a
listing of 133 breeds of dogs by intelligence.
One of the authors compared 15 of the smart-
est breeds based on size and found that 5 were
small, 5 medium, and 5 large. Three categories
of poodles were rated by Coren as having the
same intelligence level despite wide ranges in
size from toy to standard. The 15 dumbest
breeds were also distributed approximately
equally based on size. Tramo et al."7 also found
from in vivo experiments that human brain size
was not significantly correlated with intelli-
gence. We believe studies showing a relation-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

ship between height or brain size and IQ are
corrupted by confounding factors, such as so-
cioeconomic status and health or malnutrition
problemus during the perinatal period.
Hauspie et al."8 reported that some studies
have found that the absolute dimensions of the
brain case have declined with body growth in
several countries, such as Belgium, East Ger-
many, and the Czech Republic. This trend im-
plies an even greater reduction in brain to body
weight with increasing height. It should be
noted that some gerontologists believe that low
body weight in relation to brain size promotes
greater longevity.3 This finding is supported by
theJapanese, Hong Kong Chinese, Greeks, and
other communities with relatively small people.
Recent findings by paleoanthropologists,
suggest that humans have been declining in
body size and brain size for approximately
50,000 years.i8} This trend was reversed by hu-
mankind as a by-product of the industrial rev-
olution and its ability to provide large quanti-
ties of energy-rich f'ood to a relatively inactive
population. Ruff, Trinkaus, and Holliday69-
f'ound a 10% decline in body and brain weight
after studying the skeletons of 163 Pleistocene
Homo specimens. Was nature trying to com-
pensate for the inordinate damage on the rest
of the biosphere caused by our species?
A common belief ainong anthropomnetrists
and economists is that larger people are more
productive than smaller ones. It is true that the
tallest and biggest people live in the most in-
dustrialized and productive countries in the
world. Paradoxically, in undeveloped coun-
tries, shorter, smaller people work much
harder physically than taller, bigger people in
developed countries.7') And women work even
harder in these undeveloped countries as well
as in the rest of the world. Certainly the rela-
tively smaller people of Hong Kong,Japan, Sin-
gapore, and other East Asian countries have
demonstrated the ability to be as productive as
the most industrialized Europeans. Elrick et
al.*3 found Tarahumara Indians are short and
thin but have exceptional strength, stamina,
and capacity for work. These people can carry
VOL. 94, NO. 2, FEBRUARY 2002
LESS IS BETTER
heavy burdens for many miles and can run 100
to 200 miles continuously, except for relieving
themselves.7' Other small people, such as the
Bushmen of Africa, can run after a small ante-
lope until it falls fromn exhaustion. The short
Aztec Indians have been known to carry 43-kg
loads for 15 hours.7' Larger bodied people
have a greater physical work capacity because
of their greater inuscle mass, but this advantage
is relatively smnall compared to motivation,
training, and technical and intellectual skills,
especially in developed countries.
Besides aggravating health problems, a
world populationi of larger people compounds
the negative effects of a projected population
of 10 billion by 2050. The increased biomass
due to larger body size requires larger amounts
of additional food, fresh water, energy, cloth-
ing, and a myriad of other resources.71 For
example, a typical American requires more
than 160 million liters of water and 4500 kg of
meat during his or her lifetime.7' In addition,
consumption of huge amounts of fuel, forests,
raw materials, and plastics increases global
heating due to the production of more carbon
dioxide, methane, and sulfur dioxide. Other
ramifications of increased body size are more
trash and industrial wastes, increased air, land
and water pollution, and greater destruction of
rainforests and biodiversity. The World Re-
sources Institute and the United Nations Food
and Agricultural Organization both estimate
that we are losing 80,000 square miles of forest
per year.72 At this rate, we will have virtually no
rainforests left by the year 2050, even without
an increase in our average body size.
Our increasingly complex society provides
an exciting panorama of scientific, technologi-
cal, artistic, entertainment, and visual experi-
ences. These achievements are extraordinary
in their relation to medicine, productivity, and
exchange of information but do not necessarily
reflect wisdom. They also challenge our imag-
inations and foretell radical and exciting
changes in the future. However, the spread of
computers, sedentary entertainment, the use of
automobiles in place of our feet has created
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION 94
LESS IS BETTER
many problems, including growing obesity.
Our increasing reliance on technological inno-
vations to communicate or to entertain our-
selves decreases our humanity through in-
creased distancing from other humans.
Children play together less and less and in-
creasingly spend time in isolation, playing sol-
itary electronic games, using computers, or
watching television.
Complexity has its benefits and disadvan-
tages. Complex things involving dynamic pro-
cesses can become disordered more easily be-
cause they offer many more ways in which they
can interrelate, interconnect, and degrade-
often with undesirable results. Thus, lifespans
are often shorter for complex things compared
with simpler things. For example, hydrogen is
the simplest element but can survive almost
indefinitely. But a complex system such as hu-
man or human society can survive for only rel-
atively brief periods before it decays and disap-
pears. Although societies may stay intact for a
few thousand years, humans only endure for a
maximum of 120 years. The more complex we
make life and society, the more likely it will
decay faster. As Einstein purportedly observed,
"Keep things as simple as possible but no sim-
pler." This is a precept that is worth giving
more emphasis if we hope to survive a long
time as a cohesive, progressive, and high-qual-
ity civilization. More emphasis is needed on
paper reduction, simpler administrative and
medical procedures, simpler governmental in-
stitutions, and preventive medicine. Preventing
sickness is a much simpler process than the
high-technology procedures required when the
individual has become ill from years of poor
diet, inactivity, and other harmful living habits.
Certainly, highly technical solutions are very
important for many diseases and injuries. New
technical and medical techniques to correct
vision, spinal paralysis, and heart problems are
needed and should be provided. However, if
the costs of treating chronic diseases continue
to expand, fewer resources will be available for
research, development, and treatment of peo-
95 VOL. 94, NO. 2, FEBRUARY 2002
ple with nondiet-related illnesses or physical
injuries.
Extinction in the near future is a serious
possibility for humankind. Our planet has ex-
perienced five major extinctions that resulted
in the loss of most species.72 (Thousands of
smaller extinctions have occurred as well.) The
Permian extinction involved the loss of nearly
95% of existing species. During these extinc-
tions, the larger animals (>45 kg) have be-
come extinct at a 7 times higher rate than
smaller ones, indicating that smaller animals
have a greater capability for survival.73
Some ascribe a mystical power to science and
technology that implies that scientists can solve
any problem that threatens our extinction. Al-
though our scientists and engineers can be very
creative, even with unlimited resources, they
may not have enough time to correct sudden
environmental deterioration.
More than 99.9% of the world's species have
disappeared since life began on earth.7' Al-
though it usually takes millions of years for a
species to become extinct, natural processes
can't compare with our ability to destroy and
alter the world's environmnent over a much
shorter period. Leakey72 reported that we have
a "strong hand" in the extinction of 100 species
every day. This extinction rate is comparable to
losses tied to mass extinctions before mankind
came on the scene, with the exception that
accidents of nature took a lot longer to achieve
this end. More than one-half of the rainforests
have been cut, polar ice caps are melting as the
earth's temperature rises, and a huge hole in
our ozone layer subjects us to higher ultraviolet
radiation. Of course, there are many who argue
that these changes may be perfectly natural and
unrelated to humankind's activities. However,
common sense tells us otherwise. Our world
may be compared to a home with natural air
conditioning and self cleaning features which
are subject to the same basic rules as the main-
tenance of one's home. For example, assume
that a family of four lives in a house which is
isolated from the rest of the world but has a
self-maintaining system that keeps the temper-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

ature stable, purifies air and water, and elimi-
nates wastes generated by the family. Also as-
sume that over the years the family expands in
numbers and activities. However, because the
self-maintaining system has a fixed maximum
capability, eventually it will fail to maintain a
homeostatic environment and the family will
deplete its supply of food and water, fall ill, and
die prematurely. The earth's biosphere is more
complex than a single family dwelling, but as
billions of humans keep destroying its infra-
structure, disordering its internal processes,
and polluting its air and water, we will eventu-
ally reach a point at which the biosphere can
not maintain an environment suitable for hu-
man life. Death will ensue for Us as well as for
Imlost other living life for-ms, as predicted by one
of worldl's lea(inig paleoanthropologists, Rich-
ard Leakey. Based on presen-t con-ditions, he
believes that a major extinctionl threatens the
"entire complex fabric of life on earth," includ-
ing humankinid due otur rapacious behavior.72
Is this scenario inevitable? No, but immediate
changes are needed to avoid disaster through
resource conservation and simplification of
life, including, for example, near-vegetarian di-
etary practices, reduction of stress, reduction of
pollutants and toxins, and enjoyment of more
traditional forms of entertainment with empha-
sis on cultural events, walking, running, hiking,
and nonpolluting athletic events. The medical
profession needs to be a key player in promot-
ing these changes.
A conference sponsored by the Smithsonian
Institute, National Institutes of Health, and the
National Science Foundation found that de-
struction of rain forests and related declines in
biodiversity are undermining humanity's capa-
bility to survive by spreading deadly new infec-
tions, enhancing susceptibility to some malig-
nancies, and reducing access to drugs hidden
in wild plants and animals worldwide. For ex-
ample, it was reported that viral diseases, such
as hantavirus pulmonary syndrome, can result
from ecological disturbances and subsequent
loss of biodiversity.74 Relying on technology to
deal with various problems created by humans
VOL. 94, NO. 2, FEBRUARY 2002
LESS IS BETTER
does not always work. For example, since pes-
ticides were introduced to the United States in
the 1940s, the percentage of crops lost to in-
sects doubled to 13% due to insects becoming
resistant to the pesticides. A more fundamental
problem is that our immune system may be
compromised by a thinning ozone layer that
allows more ultraviolet B radiation to reach the
earth. In addition, the incidence of melanoma
has almost doubled in the last 20 years.74 The
265,000 species of flowering plants, shrubs, and
trees are a storehouse of potential therapeutic
value, and the richest diversity of such vegeta-
tion is in humid, tropical forests that are being
rapidly converted into farmland or destroyed
by logging, mining, and development. With the
loss of nmore than 30,000 species per year due to
ouir activities, the sixth major mass extinctioni
of life on this planet may be coming soonier
thani expected. As with other extinctions, it will
be rapid, irreversible, and unpredictable, and
homo sapiens will most likely be among the
decimated species.72
Two other areas in which less is better are
antibiotics and travel. The overuse of antibiot-
ics is another example of the law of unintended
consequences. We have used antibiotics as a
panacea when other methods or doing nothing
at all would have been effective. In addition,
approximately one-third of the antibiotics sold
in the United States are fed to poultry, cattle,
and pigs to accelerate growth and cut costs. As
a result of this excessive use, many bacteria
have mutated to deal with these drugs, reduc-
ing drug effectiveness when really needed.
Many of us certainly like to travel but less is
probably better in this area as well. The authors
have observed that they get colds or other ill-
nesses more frequently during travel or imme-
diately upon returning than when not travel-
ing. The circulation of germs through the
airplane's air conditioning system appears to
increase our risk of disease. Also foreign dis-
eases are more readily transferred among vari-
ous countries as more and more people travel
to and from distant places. Louria75) reports
that there will be 400 to 600 million interna-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION 96
LESS IS BETTER
tional travelers in the near future. Of course,
the extensive use of the automobile is one of
the greatest sources of violent deaths and inju-
ries in the country, involving more than 1 mil-
lion deaths per generation. The Kennedys lost
family members in two small.plane crashes, and
one of the authors has lost two fellow physi-
cians from small airplane crashes. Perhaps it is
quixotic to expect people to stop traveling but
improved transportation safety and air purify-
ing systems for passenger airliners seem to be
in order.
Less criticism of our institutions is also in
order. In view of the success of our way of life
and government, too many of Us fail to give
credit to our leaders or institutions for any-
thing good and are overzealous in our attacks
on its mistakes. Although criticism of corrup-
tion and incompetence is warranted, it seems
that too many of us place blame on institutions
for our own shortcomings or failures. Along
with this practice is our mania for litigation.
Litigation certainly has its value in certain situ-
ations, but too many of us resort to this action
when it is unwarranted and penalties often ap-
pear out of proportion to the injury involved.
The attitude of getting something for little use-
ful work seems to apply.
It's interesting to observe that groups that
encourage continued population growth be-
cause of the sacredness of the human spirit, are
actually undermining the ftLture of hundreds
of billions of human beings who will never have
a chance to be born because our present pop-
ulation will destroy the earth's ecological bal-
ance so that it can not support larger numbers
of people in the future. We may have exceeded
the carrying capacity of the earth already, but
some countries have demonstrated the feasibil-
ity of reducing their population, such as Italy
and Greece. Thus, planned parenthood is a
practical option for the future and is example
of where a lower birth rate will result in more
humans being born over the long-term.
Although no one can predict with certainty
when our extinction will occur, do we want to
ignore the warnings of many scientists who are
97 VOL. 94, NO. 2, FEBRUARY 2002
sure it's coming sooner than we would hope? If
they are correct, and we take preventive action
now, future generations will have a more beau-
tiftil planet to live on. If they are wrong, and we
make corrections now, the quality of future life
will be improved by protecting our atmo-
sphere, oceans, resources, and diversity. The
cost will be more than justified by improved
health, a stable environment, and improved
chances for long-term survival.
As we mentioned earlier, big things are part
of the diversity of nature. Elephants, giraffes,
whales, and bears are beautiful animals that
enrich our world; they need to be preserved
along with various forests and other pristine
areas. We also enjoy the sports variety offered
by large Sumo wrestlers, basketball players, and
football players. Tall individuals are also part of
this diversity. However, when we promote tall-
ness as a worldwide social virtue, we create as-
sociated problems that threaten the future
quality of life for everyone.
Virtually every world leader and scientist rec-
ognizes the dangers of unlimited population
expansion. However, a new paradigm is needed
that also recognizes the risks inherent in the
increasing size of the average person. It is not
logical to work for a stable population of 6
billion people in the world while ignoring a
progressive increase in the physical size of peo-
ple .4953
Following the recommendations of preven-
tive medicine specialists and environmentalists
is a win-win situation but it will take powerful
and effective leadership and popular coopera-
tion. The medical profession must be a primary
mover in preserving the earth and promoting
new health protocols. This is one of the most
important areas where both liberal and conser-
vative physicians need to be conservative.
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