Debunking Health Care Myths
David Goldhill is the CEO of the Game Show Network. his Atlantic article, "How American Healthcare Killed My Father", was considered by many to be one of the year's most provocative on the subject.
Question: What inspired you to write your article on healthcare?
David Goldhill: I had always had like, like many politically involved people, an interest in healthcare; it's obviously such an enormous part of our budget. And as a businessman, you can't help but have been aware over the last 15 years or so of running companies of the cost of healthcare, both to a company and to your employees. But I think for me the real catalyst is what happened to my father, because I had a lot of thoughts about what was right and wrong about our healthcare system.
My father is an 82-year-old man who walked into a hospital with pneumonia and like most men his age certainly was vulnerable. But what I saw in his five weeks in the hospital, five weeks that ended in his death, was very surprising to me. As a business person, as a very aware consumer at those moments, because obviously the care was so crucial to my father's hope of survival.
My father died of an infection he acquired in the hospital. That's not unusual; although, at the time, I didn't realize how ordinary that is. A few weeks after his death, Atul Gawande happened to publish a piece in the New Yorker in which he talked about the estimated hundred thousand deaths a year from infections. The number just astonished me; I mean, a hundred thousand. You think of 5,000 people losing their lives in Iraq and Afghanistan and how big a number that feels. This is an annual loss of life in this country. I thought to myself, "That's extraordinary, that that's not a front and center of national debate. It's almost background noise."
But what his article is about was even more interesting. It was about a doctor who had developed a series of sterility protocols and was running around the country trying to convince hospitals to adopt them. They were basically costless: a matter of how you organize work rather than any actual spending. He was having a hard time getting through hospital bureaucracies and their relationships with physicians. That's what really set me off because I had seen in the ICU of a well-regarded, non-profit hospital an enormous amount of sloppiness and poor use of technology--in some cases no use of technology. My father twice was actually taken for procedures meant for other patients. A few hours before he died, when he was unfortunately well beyond the hope of recovering and it was very clear that he had only a few hours left to live, they came in to do a blood test. I remember saying, "Why are you doing a blood test?" It was clear that it was auto-piloted. So much was auto-pilot. You understand that perhaps at a local Burger King, you really don’t understand that at a hospital dealing with life and death issues.
But getting back to Gawandi’s piece, I thought to myself, there’s got to be a business reason that this happens. You know, I’ve run a bunch of different types of businesses in technology and media, and in all of them, for bad things to persist, poor products, bad customer service, high prices, any of the realms of inefficiency, something needs to structural explain it, a lack of competitors, a company structure that favors management or employees over customers. And for it to occur in an entire industry, it’s got to tell you something about the incentives and relationships between employees, professionals if you will, in the provider world--the institutions and customers--because for this to persist for such a long time, from a businessman’s perspective, means there is something wrong in the underlying structure and the underlying incentives.
And so, I spent a lot of time, probably close to a year and a-half, thinking about our healthcare issues, the bigger ones and the smaller ones from that perspective. And it really is eye-opening when you step back from what I think is a lot of people’s perspective about healthcare, which is this is something we need; how do we get it? To looking at it as a series of businesses and asking how well do they serve the customer in terms of quality of care, accountability of care, basic service, and of course pricing? And what you see in almost all of those areas is very significant deterioration over the last 30 or 40 years.
And so, instead of doing the sort of detailed ‘what,’ that I think a lot of people who have devoted their lives to healthcare have been doing, and its of great value; I did a little more of a ‘why.’ And a ‘why’ from the perspective of a patient and a person who runs businesses outside of healthcare rather than as a perspective of a healthcare expert.
Question: What is the problem with the conventional wisdom on healthcare?
David Goldhill: I think the conventional wisdom on healthcare starts with a misconception that is probably 100 years old, which is--I think of it as the lump of healthcare fallacy, or the public policy model of healthcare--you get hit by a bus, you are diagnosed with cancer, you have a serious illness, you need care. There is an amount of care you need. And it starts from that. That’s a big fallacy, right? Because what has happened since that was, what drove a lot of us to look at ways outside of a market to finance healthcare, getting the states involved, insuring, and all of the rest, is that, in fact, a very large percentage of our lives have become medicalized. And it’s very hard not to see that what healthcare is today is this very broad spectrum that ranges from the absolutely urgent, the person genuinely hit by a bus, genuinely finding late state cancer, and the completely elective. And a broad spectrum in between not just in terms of the nature and illnesses but that in the alternative treatments and approaches to handling those illnesses. There’s an enormous amount of choice, options, and decisions made in everyday healthcare decisions, and everyday healthcare decisions are an increasing part of our lives. And when we start thinking about health insurance, most births and deaths were not medicalized. We are so used to every aspect of our lives, physical lives, having interaction with the healthcare system that we may have forgotten that the models in which we designed both insurance as a form of financing and often government aide as a form of financing existed in a very different world. Healthcare was a rare and small part of our lives. I think that's first.
I think the second misconception is that there is something inherent in healthcare that explains higher prices. That it is fundamentally different. I think perhaps the most sophisticated version of this is, new technologies have really created new products. So it's not so much that the price of things are going up, as [it is] that our ability to do things is expanding and that is drawing in more of our income to pay for those new and better things. And I think there's an important element of truth in that. I think the broader sense, or the political sense is that technology drives up prices. That when you move from more personal care, physician-oriented care, let's say, to big diagnostic machines, you inevitably have to have higher prices. That statement I think the rest of the economy shows isn't true, but I think it's an underlying assumption in the conventional wisdom.
I think a third aspect of that is, and it's interesting in healthcare and we never talk about prices, we talk about costs as if its – these are from the Moon rocks that we got, we have only a limited number of them and its somehow exogenous to the forces of supply and demand that work in every other industry. That's another issue. It's funny, you almost never hear anybody talk about healthcare prices. And the problem there is, in healthcare, ultimately every element of the price, or cost if you will, is somebody's paycheck or somebody’s dividend check. There really aren't moon rocks that we have only a limited supply of.
Every good in healthcare, whether it’s a new drug, or a new machine, or a physician services, or what we’re going to pay the Nurse’s Union, depends on how much revenue is coming in. Not on some element of cost that's independent of that. And I think that's been one of the big misunderstandings in healthcare, and probably related to the fact that most people who work on healthcare work just on healthcare and don't have what I call the perspective of the mainland, they just have the perspective of the island that healthcare has become in our economy.
Question: How are American lifestyles affecting the cost of healthcare?
David Goldhill: I think the reality is that we now have a situation where almost more than half of deaths every year occur for reasons that probably relate more to lifestyle than to healthcare. We’ve medicalized them. But fundamentally. to treat them, there has got to be changes to lifestyle, or influences [on] lifestyle.
I think nutrition is one, which Michael pointed out. And there are a variety of others, frankly, I mean there are all sorts of things that are environmental, that relate to our work lives, relate to our commutes, that relate to education, that impact health. And I think the broader point is a crucial one which is society has chosen for healthcare to be a favored good. Healthcare is not health. And in my article, I remind [readers that] my Grandmother always used to say, “Money is honey, but health is wealth.” And we’ve added a word to that, health care is wealth. And it may well be that in doing so, and making healthcare a favored good, we’ve changed people’s individual incentives to take care of themselves. Which is going to be fundamental to further advance this.
There’s been an extraordinary amount of advance, obviously, in healthcare in the last century and a-half. It’s enabled us to eliminate many infectious diseases, change both the incidence and probably results of things like heart attacks, and starting to have some impact on survivability from cancer. You can’t underestimate how important that has been to extending lives and improving of quality of lives. But it’s part of a much bigger issue. And it’s interesting when commentators point out that the United States ranks fairly low by most health statistics that you can do, whether it is lifespan, or preventable deaths, or others. Many traditional experts say, “Well, that’s not the problem of the healthcare system, that’s because we’re overweight, we’re live unhealthy lives, we don’t exercise...” and what have you. There’s an irony there, of course, which is the way that we try to fix all of that stuff is healthcare. One of the difficulties I have with a non-consumer based system, is I don’t know we’re making choices. How did we get to spend $2.5 trillion on healthcare? Who decided that was better than more parks, or a better environment, or more time off, or better educational system, or more recreational resources, or even more entertainment? Who made the decision that it was better for us – let’s narrow it. Who made the decision that it was better for our health? And the reality is, nobody did.
Question: What historical parallels are there to today’s healthcare crisis?
David Goldhill: You know, one of the parallels I see here, which is rarely remarked on because again, most people who look at healthcare look at just healthcare, is what happened in housing. It’s roughly the same time that the government said that housing is an undersupplied good that people can’t afford. Let’s help them afford it. And also engaged in a lot of different way of subsidizing housing, tax break of course we know about, creating Fannie and Freddie, and Ginny to give low-cost capital. Favoring loans made to construct house. Why am I discussing this? I am discussing this because what happened in housing is interesting. During the entire period that the government subsidized – almost the entire period – the price of housing kept going up. And every year Fannie and Freddie would come to Congress and say, we’re doing a great job of making housing more affordable, but the price of housing is going up, we need more subsidy. We need to secure more loans. Nobody every said, "Is it possible these things that we are doing to make housing more affordable is causing the price to go up?"
Now, in housing of course, we were capable of having a crash. At some point, the price of houses was beyond what the average person could afford. Even if you lent them more than 100% of the money, which is of course what we wound up doing. And there’s a lesson in that. Which is, we can see an undersupplied good, but if we create a system that endlessly subsidizes it and if we fix the negative results of that system by increasing the subsidy, and if we put the subsidy in a lot of different places, what we’re likely to do is no longer make the choice of, in that case, do we need more housing, or do we need more education, or recreation, or people living close to their jobs, or better transportation. And we’re doing the same thing in healthcare. We have gotten to 20% of our GEP without any mechanism for figuring out what would have been a better number. There are two mechanisms to do so. The government just mandates it, and I am skeptical that they can do a good job based on what we’ve seen in Medicare, or consumers do it by making the tradeoffs in their own lives. And we are not doing either system, and we are suffering as a result.
Recorded on: September 11, 2009
David Goldhill, a media executive, was inspired to become an expert on the healthcare crisis after his father died in a poorly run hospital. As it turned out, his outsider’s view—published in The Atlantic—instantly become on of the most popular investigations of America’s flawed health care system. He tells Big Think what he learned.
Join Radiolab's Latif Nasser at 1pm ET today as he chats with Malcolm Gladwell live on Big Think.
UNC School of Medicine researchers identified the amino acid responsible for the trip.
- Researchers at UNC's School of Medicine have discovered the protein responsible for LSD's psychedelic effects.
- A single amino acid—part of the protein, Gαq—activates the mind-bending experience.
- The researchers hope this identification helps shape depression treatment.
What is Bicycle Day?<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="d346092205da3c9ed10bad283222c9f1"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/L32mAiLXnLs?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span><p>Back in the world of clinical science, LSD has always showed promise. That trend continues as restrictions are finally easing up. Understanding LSD's effects on our brain's complex system of networks is an important step toward discovering therapeutic actions. As Roth <a href="https://www.inverse.com/mind-body/how-lsd-binds-to-the-brain-study" target="_blank">says</a> of his research,</p><p style="margin-left: 20px;">"Now we know how psychedelic drugs work – finally! Now we can use this information to, hopefully, discover better medications for many psychiatric diseases."</p><p>Using X-ray crystallography, Roth's team discovered a single amino acid—a building block of the protein, Gαq—responsible for binding to serotonin receptors. As LSD is only a partial agonist, they also experimented with a full-agonist designer psychedelic in order to observe complete receptor activation. This amino acid appears to be the master switch for the psychedelic experience. </p><p>While psilocybin has been in the news, the psychedelic renaissance is expanding in all directions. Phase 1 clinical trials on the <a href="https://newatlas.com/science/landmark-clinical-trial-lsd-mdma-mindmed/" target="_blank">combination</a> of LSD, MDMA, and psychotherapy will soon commence. LSD's effects on <a href="https://clinicaltrials.gov/ct2/show/NCT03866252" target="_blank" rel="noopener noreferrer">Major Depressive Disorder</a> and <a href="https://www.sciencealert.com/first-clinical-trial-shows-micro-doses-of-lsd-can-increase-a-person-s-pain-tolerance" target="_blank">pain management</a> are ongoing. With the <a href="https://www.bloomberg.com/news/articles/2020-09-18/-magic-mushroom-company-moves-toward-mainstream-in-nasdaq-ipo" target="_blank" rel="noopener noreferrer">first psychedelics company</a> to IPO on the American stock market, along with hundreds of millions of dollars of investment flowing into similar companies and organizations, the push for legalized psychedelics intensifies. </p>
Credit: ynsga / Shutterstock<p>Researchers are actively attempting to remove the hallucinogenic component of psychedelics for widespread therapeutic usage—<a href="https://www.healtheuropa.eu/could-ibogaine-offer-a-revolutionary-long-term-solution-to-addiction/100635/" target="_blank">trials</a> using ibogaine for addiction treatment, for example. Identifying the chemical effects of psychedelics on our brains is an essential step in that process.</p><p>Of course, believing psychedelics <em>only</em> matters to brain chemistry is problematic as well. The rituals associated with their use are just as relevant. The "<a href="https://en.wikipedia.org/wiki/Set_and_setting" target="_blank">set and setting</a>" model espoused by Timothy Leary reminds us that biology isn't everything; environmental factors play just as important a role in mental health. </p><p>Isolating specific chemicals without understanding the impact of the drug <em>and</em> the environment overlooks the holistic nature of the psychedelic experience. For example, ketamine trials <a href="https://bigthink.com/surprising-science/ketamine-depression" target="_self">were rushed</a> and could potentially backfire; we can't afford to make that mistake again. </p><p>Still, understanding the pathways LSD utilizes is an important step forward. As Roth says, "Our ultimate goal is to see if we can discover medications which are effective, like psilocybin, for depression but do not have the intense psychedelic actions." In a world where more people are growing anxious and depressed by the day, every intervention should be explored.</p><p> --</p><p><em>Stay in touch with Derek on <a href="http://www.twitter.com/derekberes" target="_blank">Twitter</a>, <a href="https://www.facebook.com/DerekBeresdotcom" target="_blank" rel="noopener noreferrer">Facebook</a> and <a href="https://derekberes.substack.com/" target="_blank" rel="noopener noreferrer">Substack</a>. His next book is</em> "<em>Hero's Dose: The Case For Psychedelics in Ritual and Therapy."</em></p>
A team of researchers have discovered the brain rhythmic activity that can split us from reality.
- Researchers have identified the key rhythmic brain activity that triggers a bizarre experience called dissociation in which people can feel detached from their identity and environment.
- This phenomena is experienced by about 2 percent to 10 percent of the population. Nearly 3 out of 4 individuals who have experienced a traumatic event will slip into a dissociative state either during the event or sometime after.
- The findings implicate a specific protein in a certain set of cells as key to the feeling of dissociation, and it could lead to better-targeted therapies for conditions in which dissociation can occur.
What is dissociation?<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="bd2f1f29418bd4805bf1282001dca814"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/XF2zeOdE5GY?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span><p>Dissociation is an experience commonly described as a feeling of sudden detachment from the individual's identity and environment, almost like an out-of-body experience. This mysterious phenomena is experienced by about 2 percent to 10 percent of the population.</p><p>"This state often manifests as the perception of being on the outside looking in at the cockpit of the plane that's your body or mind — and what you're seeing you just don't consider to be yourself," explained senior author Karl Deisseroth, MD, PhD, <a href="https://med.stanford.edu/news/all-news/2020/09/researchers-pinpoint-brain-circuitry-underlying-dissociation.html" target="_blank" rel="noopener noreferrer">in a Stanford Medicine news release</a>. Deisseroth is a professor of bioengineering and of psychiatry and behavioral sciences, as well as a Howard Hughes Medical Institute investigator.</p><p>Nearly three-quarters of individuals who have experienced a traumatic event will slip into a dissociative state either during the event or in the hours or even weeks that follow, according to Deisseroth. Most of the time, the dissociative experiences end on their own within a few weeks of the trauma. But the eerie experience can become chronic, such as in cases of post-traumatic stress disorder, and extremely disruptive in daily life. The state of dissociation can also occur in epilepsy and be invoked by certain drugs. </p><p>Until now, no one has known what exactly is going on inside the brain triggering and sustaining the feeling of dissociation — and so it has been a challenge to figure out how to stop it and develop effective treatments. </p>
New Research: The Molecular Underpinnings of Dissociation<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDQyNjk3My9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYwNTQ3MTI1NX0._nJoxm1eDcTsHsy1Y27JxNl2uR5hlbEYDWYoQlO0EAU/img.jpg?width=1245&coordinates=0%2C121%2C0%2C121&height=700" id="26e86" class="rm-shortcode" data-rm-shortcode-id="1094af23e35a498a8a6b691f1d0cbfaf" data-rm-shortcode-name="rebelmouse-image" alt="neurons" />
Neurons from a mouse spinal cord
Credit: NICHD on Flickr<p>Last week, in a study published in <a href="https://www.nature.com/articles/s41586-020-2731-9" target="_blank">Nature</a><a href="https://www.nature.com/articles/s41586-020-2731-9">,</a> Deisseroth and his colleagues at Stanford University uncovered a localized brain rhythm and molecule that underlies this state.</p><p>"This study has identified brain circuitry that plays a role in a well-defined subjective experience," said Deisseroth. "Beyond its potential medical implications, it gets at the question, 'What is the self?' That's a big one in law and literature, and important even for our own introspections."</p><p>The authors' findings implicate a specific protein existing in a particular set of cells as key to the feeling of dissociation. </p><p>The research team first used a technique called widefield calcium imaging to record brain-wide neuronal activity in lab mice. They observed and analyzed changes in those brain rhythms after the animals had been administered a range of drugs that are known to cause dissociative states: ketamine, phencyclidine (PCP), and dizocilpine (MK801). At a certain dosage of ketamine, the mice behaved in a way that suggested that they were likely experiencing dissociation. For example, when the animals were placed on an uncomfortably warm surface, they reacted to it by flicking their paws. However, they signaled that they didn't care enough about the unpleasantness to do what they would typically do in such a situation, which is to lick their paws to cool them off. This suggested a dissociation from the surrounding environment.</p><p>The drug produced oscillations in neuronal activity in a region of the mices' brain called the retrosplenial cortex, an area essential for various cognitive functions such as navigation and episodic memory (a unique memory of a specific event). The oscillations occurred at about 1-3 hertz (three cycles per second). The authors then examined the active cells in more detail by using two-photon imaging for higher resolution. This revealed that the oscillations were occurring only in layer 5 of the retrosplenial cortex. Next, the researchers recorded neuronal activity across other regions of the brain. </p><p>"Normally, other parts of the cortex and subcortex are functionally connected to neuronal activity in the retrosplenial cortex," Ken Solt and Oluwaseun Akeju wrote in <a href="https://www.nature.com/articles/d41586-020-02505-z#ref-CR1" target="_blank">Nature</a>. "However, ketamine caused a disconnect, such that many of these brain regions no longer communicated with the retrosplenial cortex."</p><p>The scientists then used optogenetics, a method of manipulating living tissue with light to control neural function, to stimulate neurons in the mice's retrosplenial cortex. When the scientists did this at a 2-hertz rhythm, they were able to cause dissociative behavior in the animals analogous to the behavior caused by ketamine without using drugs. The experiments conducted by the team displayed how a particular type of protein, an ion channel, was essential to the generation of the hertz signal that caused the dissociative behavior in mice. Scientists are hopeful that this protein could be a potential treatment target in the future. </p>
What about humans?<p>The researchers also recorded electrical activity from brain regions in an epilepsy patient who had reported experiencing dissociation immediately before each seizure. The sensations experienced right before a seizure is called an aura. This aura for the patient was like being "outside the pilot's chair, looking at, but not controlling, the gauges," Deisseroth said.</p><p>The researchers recorded electric signals from the patient's cerebral cortex and stimulated it electrically aiming to identify the origin point of the seizures. While that was happening, the patient responded to questions about how it felt. The authors found that whenever the patient was about to have a seizure, it was preceded by the dissociative aura and a particular pattern of electrical activity localized within the patient's posteromedial cortex. That patterned activity was characterized by an oscillating signal sparked by nerve cells firing in coordination at 3 hertz. When this region of the brain was stimulated electrically, the patient experienced dissociation without having a seizure. </p><p>This study will have far-reaching implications for neuroscience and could lead to better-targeted therapies for disorders in which dissociation can be triggered, such as PTSD, borderline personality, and epilepsy.</p>
Astronomers find these five chapters to be a handy way of conceiving the universe's incredibly long lifespan.
- We're in the middle, or thereabouts, of the universe's Stelliferous era.
- If you think there's a lot going on out there now, the first era's drama makes things these days look pretty calm.
- Scientists attempt to understand the past and present by bringing together the last couple of centuries' major schools of thought.
The 5 eras of the universe<p>There are many ways to consider and discuss the past, present, and future of the universe, but one in particular has caught the fancy of many astronomers. First published in 1999 in their book <a href="https://amzn.to/2wFQLiL" target="_blank"><em>The Five Ages of the Universe: Inside the Physics of Eternity</em></a>, <a href="https://en.wikipedia.org/wiki/Fred_Adams" target="_blank">Fred Adams</a> and <a href="https://en.wikipedia.org/wiki/Gregory_P._Laughlin" target="_blank">Gregory Laughlin</a> divided the universe's life story into five eras:</p><ul><li>Primordial era</li><li>Stellferous era</li><li>Degenerate era</li><li>Black Hole Era</li><li>Dark era</li></ul><p>The book was last updated according to current scientific understandings in 2013.</p><p>It's worth noting that not everyone is a subscriber to the book's structure. Popular astrophysics writer <a href="https://www.forbes.com/sites/ethansiegel/#30921c93683e" target="_blank">Ethan C. Siegel</a>, for example, published an article on <a href="https://www.forbes.com/sites/startswithabang/2019/07/26/we-have-already-entered-the-sixth-and-final-era-of-our-universe/#7072d52d4e5d" target="_blank"><em>Medium</em></a> last June called "We Have Already Entered The Sixth And Final Era Of Our Universe." Nonetheless, many astronomers find the quintet a useful way of discuss such an extraordinarily vast amount of time.</p>
The Primordial era<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMjkwMTEyMi9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYyNjEzMjY1OX0.PRpvAoa99qwsDNprDme9tBWDim6mS7Mjx6IwF60fSN8/img.jpg?width=980" id="db4eb" class="rm-shortcode" data-rm-shortcode-id="0e568b0cc12ed624bb8d7e5ff45882bd" data-rm-shortcode-name="rebelmouse-image" />
Image source: Sagittarius Production/Shutterstock<p> This is where the universe begins, though what came before it and where it came from are certainly still up for discussion. It begins at the Big Bang about 13.8 billion years ago. </p><p> For the first little, and we mean <em>very</em> little, bit of time, spacetime and the laws of physics are thought not yet to have existed. That weird, unknowable interval is the <a href="https://www.universeadventure.org/eras/era1-plankepoch.htm" target="_blank">Planck Epoch</a> that lasted for 10<sup>-44</sup> seconds, or 10 million of a trillion of a trillion of a trillionth of a second. Much of what we currently believe about the Planck Epoch eras is theoretical, based largely on a hybrid of general-relativity and quantum theories called quantum gravity. And it's all subject to revision. </p><p> That having been said, within a second after the Big Bang finished Big Banging, inflation began, a sudden ballooning of the universe into 100 trillion trillion times its original size. </p><p> Within minutes, the plasma began cooling, and subatomic particles began to form and stick together. In the 20 minutes after the Big Bang, atoms started forming in the super-hot, fusion-fired universe. Cooling proceeded apace, leaving us with a universe containing mostly 75% hydrogen and 25% helium, similar to that we see in the Sun today. Electrons gobbled up photons, leaving the universe opaque. </p><p> About 380,000 years after the Big Bang, the universe had cooled enough that the first stable atoms capable of surviving began forming. With electrons thus occupied in atoms, photons were released as the background glow that astronomers detect today as cosmic background radiation. </p><p> Inflation is believed to have happened due to the remarkable overall consistency astronomers measure in cosmic background radiation. Astronomer <a href="https://www.youtube.com/watch?v=IGCVTSQw7WU" target="_blank">Phil Plait</a> suggests that inflation was like pulling on a bedsheet, suddenly pulling the universe's energy smooth. The smaller irregularities that survived eventually enlarged, pooling in denser areas of energy that served as seeds for star formation—their gravity pulled in dark matter and matter that eventually coalesced into the first stars. </p>
The Stelliferous era<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMjkwMTEzNy9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxMjA0OTcwMn0.GVCCFbBSsPdA1kciHivFfWlegOfKfXUfEtFKEF3otQg/img.jpg?width=980" id="bc650" class="rm-shortcode" data-rm-shortcode-id="c8f86bf160ecdea6b330f818447393cd" data-rm-shortcode-name="rebelmouse-image" />
Image source: Casey Horner/unsplash<p>The era we know, the age of stars, in which most matter existing in the universe takes the form of stars and galaxies during this active period. </p><p>A star is formed when a gas pocket becomes denser and denser until it, and matter nearby, collapse in on itself, producing enough heat to trigger nuclear fusion in its core, the source of most of the universe's energy now. The first stars were immense, eventually exploding as supernovas, forming many more, smaller stars. These coalesced, thanks to gravity, into galaxies.</p><p>One axiom of the Stelliferous era is that the bigger the star, the more quickly it burns through its energy, and then dies, typically in just a couple of million years. Smaller stars that consume energy more slowly stay active longer. In any event, stars — and galaxies — are coming and going all the time in this era, burning out and colliding.</p><p>Scientists predict that our Milky Way galaxy, for example, will crash into and combine with the neighboring Andromeda galaxy in about 4 billion years to form a new one astronomers are calling the Milkomeda galaxy.</p><p>Our solar system may actually survive that merger, amazingly, but don't get too complacent. About a billion years later, the Sun will start running out of hydrogen and begin enlarging into its red giant phase, eventually subsuming Earth and its companions, before shrining down to a white dwarf star.</p>
The Degenerate era<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMjkwMTE1MS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxNTk3NDQyN30.gy4__ALBQrdbdm-byW5gQoaGNvFTuxP5KLYxEMBImNc/img.jpg?width=980" id="77f72" class="rm-shortcode" data-rm-shortcode-id="08bb56ea9fde2cee02d63ed472d79ca3" data-rm-shortcode-name="rebelmouse-image" />
Image source: Diego Barucco/Shutterstock/Big Think<p>Next up is the Degenerate era, which will begin about 1 quintillion years after the Big Bang, and last until 1 duodecillion after it. This is the period during which the remains of stars we see today will dominate the universe. Were we to look up — we'll assuredly be outta here long before then — we'd see a much darker sky with just a handful of dim pinpoints of light remaining: <a href="https://earthsky.org/space/evaporating-giant-exoplanet-white-dwarf-star" target="_blank">white dwarfs</a>, <a href="https://earthsky.org/space/new-observations-where-stars-end-and-brown-dwarfs-begin" target="_blank">brown dwarfs</a>, and <a href="https://earthsky.org/astronomy-essentials/definition-what-is-a-neutron-star" target="_blank">neutron stars</a>. These"degenerate stars" are much cooler and less light-emitting than what we see up there now. Occasionally, star corpses will pair off into orbital death spirals that result in a brief flash of energy as they collide, and their combined mass may become low-wattage stars that will last for a little while in cosmic-timescale terms. But mostly the skies will be be bereft of light in the visible spectrum.</p><p>During this era, small brown dwarfs will wind up holding most of the available hydrogen, and black holes will grow and grow and grow, fed on stellar remains. With so little hydrogen around for the formation of new stars, the universe will grow duller and duller, colder and colder.</p><p>And then the protons, having been around since the beginning of the universe will start dying off, dissolving matter, leaving behind a universe of subatomic particles, unclaimed radiation…and black holes.</p>
The Black Hole era<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMjkwMTE2MS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzMjE0OTQ2MX0.ifwOQJgU0uItiSRg9z8IxFD9jmfXlfrw6Jc1y-22FuQ/img.jpg?width=980" id="103ea" class="rm-shortcode" data-rm-shortcode-id="f0e6a71dacf95ee780dd7a1eadde288d" data-rm-shortcode-name="rebelmouse-image" />
Image source: Vadim Sadovski/Shutterstock/Big Think<p> For a considerable length of time, black holes will dominate the universe, pulling in what mass and energy still remain. </p><p> Eventually, though, black holes evaporate, albeit super-slowly, leaking small bits of their contents as they do. Plait estimates that a small black hole 50 times the mass of the sun would take about 10<sup>68</sup> years to dissipate. A massive one? A 1 followed by 92 zeros. </p><p> When a black hole finally drips to its last drop, a small pop of light occurs letting out some of the only remaining energy in the universe. At that point, at 10<sup>92</sup>, the universe will be pretty much history, containing only low-energy, very weak subatomic particles and photons. </p>
The Dark Era<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMjkwMTE5NC9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY0Mzg5OTEyMH0.AwiPRGJlGIcQjjSoRLi6V3g5klRYtxQJIpHFgZdZkuo/img.jpg?width=980" id="60c77" class="rm-shortcode" data-rm-shortcode-id="7a857fb7f0d85cf4a248dbb3350a6e1c" data-rm-shortcode-name="rebelmouse-image" />
Image source: Big Think<p>We can sum this up pretty easily. Lights out. Forever.</p>
Innovators don't ignore risk; they are just better able to analyze it in uncertain situations.