I posted this essay on my site yesterday, and the response/comments have been amazingly moving to me. I’m not sure if it works as a DK diary, but I’m going to repost it and see what you think. Here goes!
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I read this troubling, illuminating, and ultimately inspiring essay about the state of the Western world last month in The New York Times. Like many articles, I waded through it as I was falling asleep. Exhausted. But in that semiconscious, hypnogogic state between wakefulness and sleep I also drifted between the analogous worlds of civilizational decline and bodily aging. Aging bodies make up the entirety of my practice as a physician. Like me I’m guessing you have an aging body, too, and that you are concerned about the direction the Western world is spinning.
For this letter I’m going to riff on the parallels between this article (written about the decline of Western Civilization and how to cope with it) and how we might extrapolate the same existential reckoning and adaptation to our own finite lives. I’ll ask for some help from the poets Elizabeth Bishop and Dylan Thomas.
I hope you find this synthesis validating, illuminating, and ultimately helpful.
First, a brief summary of the NYT essay entitled “The West is Lost.”
This opinion piece argues that Western civilization’s foundational belief in endless progress is collapsing as societies face irreversible losses—environmental destruction, economic decline, demographic aging, crumbling infrastructure, and geopolitical regression—that contradict the modern promise that the future will always be better than the present.
The question is no longer whether loss can be avoided but whether societies whose imagination is bound to “better” and “more” can learn to endure “less” and “worse.” How that question is answered will shape the trajectory of the 21st century.
This crisis of lost faith in progress has fueled the rise of populist politics that promises restoration while delivering cheap illusions of recovery and greatness.
The author proposes four strategies for dealing with civilizational decline that are open-eyed and accepting of reality:
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building resilience to minimize vulnerability
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revaluing certain losses as potential liberation
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redistributing burdens more fairly
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ultimately learning to acknowledge and integrate loss into our collective narratives rather than denying it.
It’s a fine essay.
The end of medical exceptionalism, and learning to accept loss and decline
Just as Western civilization built itself on the myth of endless progress, much of modern medicine, wellness culture, and the longevity industry have constructed their own foundational lie: that with enough effort, technology, and personal responsibility, we can indefinitely postpone decline, disability, and death. This medical exceptionalism promises that the body, like society, should always trend upward—strong, healthy, more optimized.
But what happens when patients, like societies, must reckon with irreversible and quite natural loss? Loss of abilities, loss of pleasures, loss of independence, loss of carefree days, and sometimes loss of all personal hope?
The parallels are there to tease out.
The myth of endless optimization
Sometimes in health care, and usually in wellness grifting, versions of progress ideology manifest in familiar refrains. You’re only as old as you feel. Mind over matter. Fight this disease. Beat this cancer. The underlying assumption is that wellness is the natural state, illness is aberrant, and decline often represents personal failure rather than biological chance and inevitability. This creates what we might call the wellness delusion—the belief that perfect health is the default mode, both achievable and maintainable through individual effort, for everyone. That health is a pure meritocracy.
Consider how we discuss aging. “Successful aging” implies there’s an unsuccessful choice, as if those who develop arthritis, memory loss, obesity, or heart disease have somehow failed at the fundamental human task of existing in a body over time. I’m not saying that we have no agency at all; I’m saying that agency plays only a part in our “success.” Similarly, “cancer survivor” language, while empowering for many, can inadvertently suggest that those who die from disease lacked sufficient fighting spirit.
As a related aside, consider how our country’s current leadership has reframed the autism spectrum in direct conflict with actual scientific understanding. Their rhetoric and policies pathologize autism as a defect to be eliminated as they simultaneously restrict essential support services. They exemplify ableism by devaluing neurodivergent lives while enforcing their ever narrowing standards of normality.
These narratives place impossible burdens on patients while obscuring the reality that loss—of function, independence, loved ones—is woven into the fabric of human existence. I call on Elizabeth Bishop’s words from a favorite poem:
The art of losing isn’t hard to master;
so many things seem filled with the intent
to be lost that their loss is no disaster.
Lose something every day. Accept the fluster
of lost door keys, the hour badly spent.
The art of losing isn’t hard to master.
Then practice losing farther, losing faster:
places, and names, and where it was you meant
to travel. None of these will bring disaster.
But the reality is that when patients inevitably encounter limitations, they often experience not just physical suffering but existential failure. It’s as if their bodies have betrayed the modern promise of control, of wellness, of happiness and worth as derived from preserved ability—rather than gratitude for those miraculous human abilities that can still be summoned.
Types of medical loss
Now let’s steer back to the murky parallels and rich analogies we might mine from that NYT essay on the decline of civilization and Western mythologies in general. Like the societal losses we are feeling right now, medical losses come in multiple forms, each challenging our fundamental assumptions about progress and control.
Functional loss in our aging bodies mirrors economic decline in civilizations. A pianist loses dexterity to arthritis; a runner faces hip replacement; a professor struggles with memory changes. These losses can devastate identity just as de-industrialization hollowed out entire communities. The optimism and indestructibility of youth, when physical capacity seemed limitless, proves historically exceptional rather than permanent.
Cognitive and sensory losses resemble infrastructural decay in communities. Vision dims, hearing fades, processing speed slows. Like aging transportation networks, these systems that once worked seamlessly now require workarounds, accommodations, and lowered expectations. I only need to think of SEPTA trains here in Philly.
Social and friendship losses echo demographic changes in countries. Friends pass away, families scatter, social roles shift. The aging patient may find themselves increasingly isolated, much like rural communities watching their young people leave for opportunities elsewhere.
Systemic illnesses and losses parallel geopolitical regression and diminished global ambitions. Instead of outrunning diabetes it progresses despite medication and exercise; autoimmune conditions flare unpredictably as the body’s protectors are now fighting some new enemy within; cancer simply returns. The optimism about future inevitable medical triumph over disease writ large gives way to understanding that chronic illness is an ongoing negotiation rather than a problem to be solved.
Four strategies for medical resilience
I try to make what I write here ultimately actionable. Useful. Maybe I’ve crystallized the thoughts I had drifting between wakefulness and sleep that night, between a brain working in the primary care trenches all day and a brain that needs to fly above the battlefield for a broad view.
So let’s try to make this helpful. Can we map the following essay frameworks for societal adaptation to our own health and illness?
1. Resilience over cure
For society - Strengthen institutions and systems to better withstand inevitable losses rather than trying to prevent them entirely.
For individuals - Rather than promising to prevent all negative health outcomes, or to beat every disease we are faced with, resilience-focused medicine might spend time strengthening patients’ capacity to weather inevitable challenges. This means compassionate pain management for chronic conditions, fall prevention and risk mitigation rather than fall elimination, and mental health support for life transitions. Unexpectedly rough transitions have affected every decade of our lives looking backwards, haven't they?
Resilience accepts that some losses are unavoidable while working to minimize their impact. It’s the difference between promising every 70-year-old they can have the energy of a 30 year-old, hell even the energy of a 65 year-old, versus helping them optimize the energy they still have. Many can increase that energy, but the default presumption should not be that all can do so. Physical therapy routines can accommodate arthritis, reduce pain, and increase function rather than pretending arthritis can ever be fixed.
2. Revaluing loss as liberation
For societies - Recognize that abandoning harmful practices (like fossil fuel consumption) can actually lead to better, more sustainable ways of living.
For individuals - Some medical losses, like their ecological counterparts, may actually enable richer forms of life. The forced retirement due to heart disease might open space for relationships previously neglected. The mobility limitations that require moving to a walkable community could improve social connection and environmental impact. Move to Philly by the way. I like it here. I walk here.
This isn’t toxic positivity—it’s the recognition that our culture’s narrow definitions of health and ability often blind us to alternative forms of flourishing. The patient who can no longer work 60-hour weeks might discover sustainable rhythms. The person navigating vision loss might develop enhanced listening skills and deeper presence.
Here’s the second half of that Elizabeth Bishop poem:
I lost my mother’s watch. And look! my last, or
next-to-last, of three loved houses went.
The art of losing isn’t hard to master.
I lost two cities, lovely ones. And, vaster,
some realms I owned, two rivers, a continent.
I miss them, but it wasn’t a disaster.
—Even losing you (the joking voice, a gesture
I love) I shan’t have lied. It’s evident
the art of losing’s not too hard to master
though it may look like (Write it!) like disaster.
3. Redistributing health burdens
For societies - Share both the gains and losses of societal change more fairly across different social groups instead of letting some bear all the costs.
For individuals - Health losses don’t affect all patients equally. Socioeconomic status, “race,” geography, and other factors have an outsized influence on who bears the greatest burden of disease, disability, and hardship. A justice-oriented approach to medical loss requires acknowledging these disparities and working to ensure that solutions don’t simply protect the privileged while abandoning the vulnerable.
How are we doing on this one in the USA lately?
For some this might mean advocating for universal healthcare (*gasp*), addressing social determinants of health, or ensuring that medical advances benefit all communities rather than just those who can afford them. It also means questioning whose bodies are considered “normal” and whose experiences are centered in medical research and practice.
4. Integration and acceptance
For societies - Acknowledge loss as a natural part of life and weave it into our personal and collective stories without either denying it or becoming paralyzed by it.
For individuals - This psychological and perhaps spiritual work requires moving beyond both denial and despair toward what might be called radical acceptance—seeing clearly what is while maintaining hope for what remains possible.
Integration doesn’t mean passive resignation. It means making peace with limitations while actively working, hustling, striving within them. It’s the difference between the distraught patient who refuses treatment or physical therapy because “I’ll never be the same” and the patient who engages fully with rehabilitation, grieving what was lost, feeling grateful for what remains.
Rage against the dying of the light
Let’s bring poet Dylan Thomas into this whole concept. Do not go gentle into that good night. Rage and acceptance can absolutely coexist as complementary rather than opposing forces. The deepest form of raging against the dying light may paradoxically require first accepting that darkness inevitably comes.
Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.
Though wise men at their end know dark is right,
Because their words had forked no lightning they
Do not go gentle into that good night.
Good men, the last wave by, crying how bright
Their frail deeds might have danced in a green bay,
Rage, rage against the dying of the light.
Wild men who caught and sang the sun in flight,
And learn, too late, they grieved it on its way,
Do not go gentle into that good night.
Grave men, near death, who see with blinding sight
Blind eyes could blaze like meteors and be gay,
Rage, rage against the dying of the light.
And you, my father, there on the sad height,
Curse, bless, me now with your fierce tears, I pray.
Do not go gentle into that good night.
Rage, rage against the dying of the light.
Thomas’s rage isn’t a futile denial of our mortality or a desperate grasp for impossible restoration—it’s a fierce commitment to living fully within our constraints, to burning brightly with whatever fuel remains. He’s not imploring us to fight against the reality of loss itself, but against the diminishment of spirit that loss can impose.
The stroke patient who engages fully with physical therapy while grieving their changed body; the aging person who pursues new relationships and old friends despite a growing ledger of loss; the chronically ill individual who finds beauty and purpose within their constraints—these are all forms of raging against the dying light. They burn and rave not by denying their limitations, but by refusing to let those limitations extinguish their capacity for meaning, connection, and joy.
Conclusion: “Wellness with built in medical fragility”
I don’t think the above 6 words have ever been strung together before. Such are the infinite possibilities of human language. Such are the nuanced truths if we are being honest with ourselves.
As we’ve explored in this essay, accepting medical loss rather than chasing a fountain of youth doesn’t mean giving up hope or becoming resigned—it means expanding our definition of hope beyond the narrow goal of restored youth and impeccable health. It means hoping for good days within chronic illness, meaningful relationships despite physical limitations and lost relationships, losing something everyday, raging when the situation compels us, and seeking beauty and awe and a heaping cone of chocolate ice cream.
I don’t know if civilization is doomed. My guess is that it’s going to be a mess, but an often glorious, losing, raging mess. And even so, the Earth’s days are ultimately numbered. The Sun is going to expand outwards. I hope intelligent life has hundreds of millions of years between now and then. None of us do.
In learning to live well with loss, we don’t just become better patients, warriors, poets, warrior poets—we become more fully human. Human in a world that dehumanizes us. And perhaps that, rather than the elimination of all suffering, represents the deepest form of progress available to us.
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Thank you for reading this.
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