Good satire can change the perception of its subject — “Spinal Tap” changed forever how one hears heavy metal music; Tina Fey changed how voters saw Sarah Palin — and so, we think, should a single metaphor change how we see the modern treatment of mental illness.
The neuroscientist Tom Insel had been director of the National Institute of Mental Health for over a decade when, around 2015, in the middle of a lecture he was giving on recent discoveries in NIMH-led research on the brain, a man in the audience said:
Our house is on fire, and you’re telling us about the chemistry of the paint. We need someone to focus on the fire.
The metaphor is striking. Is it true? In 2016, there were more than twice as many suicides as homicides in the U.S. and more deaths from suicide than from breast and prostate cancer combined. Suicide was the second leading cause of death for people aged 10–34, behind only accidents, and rates of death by suicide have gone up 30% in half of states across the U.S. since 1999.
Scientific progress has almost entirely eradicated some of the great destroyers of the 19th-century body and mind — i.e. smallpox and polio — but has not yet eradicated a single mental illness in the seventy years since the discovery, in the first half of the 20th century, that neurons are the fundamental units of the brain.
In other words, yes — our house is still on fire. And the fire is spreading. What can we do about it?
Can we learn any lessons from the long history of firefighting, and import them into psychiatry, neuroscience, and care for the mentally ill? How do we put out the fire The metaphor is more than just cute: fire and suicide have one thing, primarily, in common. They are hounds of entropy, seeking most, above all else, to break the ordered bonds of life. Their goals are the same: a body, turned back to dust.
The major focus of modern firefighting is prevention, but this was not always the case. If you close your eyes and take an imagined tour of in and around a modern building, and notice just how fire-obsessed we are: automatic sprinklers, red curbs, EXIT signs, hydrants, manual alarms, inspections, fire escapes, well-mapped escape routes, pre-incident and pre-action plans, materials bans, universal lockboxes. Each detail, of course, postcedes a tragedy and the long, slow lesson is that environmental conditions matter. As far back as even 1631, wooden chimneys and thatched roofs were outlawed, in Boston, due to their fire risk.
But it was a long, suffering journey to get to today. Firefighting was first formalized in Rome, under the emperor Nero, as an answer to local fire fighting gangs who would show up to a fire and extort a fee from business owners as they watched their shops burn. So Nero formed and armed the vigiles, the first “bucket brigade”, with buckets, poles, and pumps. (Rome under Nero would still burn, in 64 AD, but at least there was less extortion.)
For the next few millennia, as we started packing together into cities, fires became both more frequent and more deadly. After the 1666 Great Fire of London, which had started, simply, in a baker’s shop, raged for five days, smoldered for months, and destroyed an estimated ninety percent of the homes in Central London, private fire insurance came into vogue. For a brief time after, each insurer had their own brigade which would put out the fires of only its customers, who had to display an ornate “fire mark” — marks which can still be seen, above doors, throughout London. Insurers quickly realized, however, that unchecked fires would spread to their insured houses. It was ultimately cheaper to try put out all fires.
The first major technological innovation for fire fighting was infrastructural: underground plumbing, in combination with hydrants, meant that pressurized water could be distributed and made available near instantly and near anywhere. Unburdened from their buckets, firefighters could arrive much sooner.
There are many more such lessons to be imported from the history of firefighting:
Insurance. Let there be no mistaking the cause and effect: we have settled on fire prevention because it is cheaper. Fire marks above homes in major cities may be antiquated, but the movement toward prevention had two spurs: (1) firefighters were dying, and (2) insurers were losing money. But suicide, too, can spread. It’s said that when there’s a suicide there are eleven victims, including those ten whose lives will never be the same. A solution, then, seems obvious: we need to make suicide or mental breaks more expensive. For medical insurers, suicide is cheaper, in the long-term, than continued health care for a mentally ill patient. Life insurers can exclude, depending on the contract, paying out.
A loss of life can be cheaper than a life sustained, which should never be the case. Only when forced will we get systemic movements toward prevention.
The internet is the pressurized water/underground infrastructure. The internet is the first step, here: peer support, crisis intervention, and high-quality, community-based therapy. A distributed system comparable, if used properly, to a network of fire hydrants.
Hydrants need to be interoperable. As great as hydrants were — the brigades no longer had to carry water with them — it raised another problem: the threads on hydrants weren’t the same. A firefighter would not be able to run to help the neighboring county or block, because of thread non-interoperability. (Sometimes, even recently, they still can’t.) Sound familiar? Electronic Health Records (EHRs) are not standardized across the country, and cannot be easily shared between doctors.
Response times in crises of fire and suicide are measured in seconds and heartbeats per second, respectively — a fast-developing fire can double in size and intensity in thirty seconds; a bullet travels, on average, twenty-five-hundred feet per second. Speed matters.
Smartphones are the smoke alarms. Smoke alarms cut the risk of dying in a fire by half. What would an alarm for mental health be? It’s in your pocket, already. Smartphones are starting to continuously gather useful data on activity and sleep, and both companies and doctors are recognizing the value this information may have for prevention and intervention. As algorithms stand in more and more for decisions, our phones can also nudge toward suppression, perhaps by routing anxious people around inevitable, stress-inducing traffic or by alerting doctors to changes in speech, cadence, or socialization patterns.
Technology has to get inside. Smoke alarms aren’t enough. Smoke alarms and sprinklers cut the risk of dying in a fire by 82%. Until the 20th century, firefighting was concerned mainly with preventing the spread of a raging fire — through, for example, firebreaks — but the building at the fire’s source and all it contained was almost certainly a loss, little to be done against the fire’s mania. The biggest revolution in firefighting was SCBA (air tanks) and heat-resistant suites. Firefighters were finally able to fight fires from inside, at their source and hope to save, at least partially, the incipient building.
The arrival of the automatic sprinkler for the brain — a device which can both detect and suppress — will revolutionize the ability to fight mental disease from inside the brain. For example, deep-brain stimulators, today, can treat epilepsy by “putting out” the electrical storm before it catches.
Socio-economics matter. Fires and depression both are made worse by dense, urban environments, by cramming, by poor access to resources; fire and suicide are both more common and more deadly among the poor. According to Bruce Hensler, in Crucible of Fire: “Almost without exception, every scientific study looking at socioeconomic characteristics has shown a relationship between level of income and the risk level of fire”. Similarly, the WHO says: “Mental illness and poverty are considered to interact in a negative cycle; that is, not only is the risk of mental illness among people who live in poverty higher, but so too is the likelihood that those living with mental illness will drift into or remain in poverty.”
“Materials” matter. Not all fires are the same. One does not put out an oil fire with water, yet psychiatrists may be commonly doing just such a thing with mental disease. There is no risk-related biomarker for depression, which means the best a doctor can still do is guess. Some of us are made of wood, some of concrete.
Is the mental health crisis about to get even worse? Will there be a mental-health equivalent of the 1666 Great Fire? (Are we in it already?) If we plotted psychiatry today onto a timeline of the history of firefighting, I’d argue we are still in the bucket brigade era. It was common in centuries past to expect to lose an entire home; today, we tolerate a loss of the patient. The buckets were used mostly to, hopefully, buy enough time to salvage a few belongings, but the house was always destroyed.
If only we treated people with as much care as we do buildings.