The RA Dilemma

John Von Neumann was smart — crazy smart. The word polymath comes to mind, as his genius knew few bounds. His most recognizable contributions were to mathematical self-replication theory, a model that would help unravel the code of DNA, as well as cellular automata, a mathematical framework used in computation that would help spur the digital revolution. He also made numerous other contributions to such branches of thought as quantum theory, geometry, hydrodynamics, economics, and programming.¹

As a young child, John's parents would entertain friends with a simple though mind-boggling performance of his ability to memorize and recall information. "A guest would select a page and column of [a] phone book at random. Young Johnny read the column over a few times, and then handed the book back to the guest. He could answer any questions put to him (who has number such and such?) or recite names, addresses, and numbers in order."² In every sense, he was the true definition of a child prodigy.

Throughout his career, John Von Neumann was not just a mathematical theorist, but also worked in applied settings, one of which was with the Manhattan Project during World War II. There he provided the mathematics for the charges of the first nuclear weapons. Interestingly, his scientific contribution to the atomic bomb brings up a fascinating political-historical connection with one of his earlier ideas called game theory.

In essence, game theory is a mathematical model for predicting conflict and cooperation between rational decision makers. If you have seen the movie or read the book "A Beautiful Mind," John Nash who is the subject of the story won a Nobel Prize for applying game theory to economics (the Nash equilibrium). Since its inception, game theory has also been used in military strategy, evolutionary theory, and numerous other fields of thought.

The connection to Von Neumann's work on the atomic bomb is intriguing. During the Cold War, when both the USSR and the United States were manufacturing nuclear weapons, the question arose of whether or not it was prudent to attack Russia before their acquisition of a nuclear stockpile, and if failure to do so would result in the equivalent of World War III. Game theory would come to play an interesting role, as the predicament appeared to be well suited to studying conflict and cooperation between opponents. The phrase "mutually assured destruction," is attributed to John. In summary, it holds that if two opponents both have the nuclear capacity to completely annihilate the other, than an escalation in hostilities will result in a complete and total destruction of both opponents. The options that stem from this doctrine are a nuclear stand off, cooperation and disarmament, or total annihilation.

These are some world-altering ideas and politics born from an analysis of games and the probability of decision making between players. Some of the most brilliant minds of our time have been involved in it. Yet such complication has its roots in a very simple game called the Prisoner's Dilemma.

In summary, the Prisoner's Dilemma is that two criminals involved in the same crime are arrested. During interrogation, they have no means of communicating with each other. If they both betray the other, then they each serve two years in prison. If one remains silent and the other betrays, then the silent one gets 3 years and the betrayer walks free. If they both remain silent, then they get the minimal sentence of one year. Since they can't communicate, there is no way to agree on cooperating. It is risky to remain silent and have the other betray, but also risky to betray since the other might as well. It is quite the dilemma. The game can be played in a row (called the iterative version), and probability becomes a measure of predicting future decisions based off of previous decisions.

I think in some ways the Prisoner's Dilemma can be analogous to living with rheumatoid arthritis since it puts one in an extremely difficult decision making position. I call my own version the RA Dilemma. It is not a mathematical model, but a way of talking about decision making between undesirable options.

For me, RA is an opponent that is unpredictable. I have a few decisions available to me, but they aren't always easy to make, and the consequences aren't always foreseeable. For instance: My first round of methotrexate went poorly. I did not respond, and was quite ill from the drug. Injecting it did not help either. My doctor introduced a biologic and lowered the dosage of methotrexate, and I responded well. My inflammation and pain came down, but a new problem arose: my blood results showed my liver was not functioning properly, and I had broken out in a rare side effect of spontaneous rashes unrelated to the injection site. My choices were to quit the drugs and go back to the horrific inflammation and pain, stay on the drugs and treat the rashes while trying to solve the liver malfunction, or try a new combination of drugs. I chose to try a new combination. During the transition, my inflammation and pain were excruciating. After about two months however, things became much more favorable, and I was happy I chose that direction. At the time, it was an extraordinarily difficult decision with unknown outcomes, and caused me a great deal of apprehension.

Other RA dilemmas occur as well. I know that exercise helps, and I sure love the way my body feels after some aerobic movement or a bike ride. My life however requires that I exercise very early in the morning. Sleep is equally important, and even when I sleep a good 7-8 hours, I can still wake up feeling like I haven't slept in days. When the alarm goes off before the sun has come up, my thoughts almost always go something like "Which is better today, exercise, or another hour of sleep? If I exercise it might put me further into the fatigue pit, or it might give me some needed energy. What should I do?" If I am in the midst of a flare, the pain and inflammation make this decision even harder, as pushing through the pain is a blurry line of benefit verses risk.

Talking with others about my disease is also a dilemma. I hear some whacky stuff more often than I hear empathy, understanding, or a willingness to learn about it. The dilemma I face is that I have encountered some situations where disclosure worked against me in professional settings, and others where I received accommodations that helped me. I also make an effort to educate others and raise awareness, as well as stand up for myself, but one can't educate a closed mind. I can often feel like there is no solution, only an array of choices I'd rather not make.

This is just a sampling. The RA dilemmas go on and on...