The asset with no replacement

We should say at the start that none of us is a doctor. Nothing in this episode is medical advice, and where it touches your own body the correct response is to go and be examined by somebody qualified rather than to take the word of a podcast.

What we can talk about is the decision-making, because that is our subject, and because the way senior people handle their own health is one of the clearest examples we know of a leader applying a standard to themselves that they would fire somebody for applying to the business.

Consider what you would do if a critical system in your organisation had not been inspected in three years. If the person responsible told you it was probably fine, that they had been meaning to look at it, and that they would get to it after this quarter, you would not accept that answer. You would treat it as a governance failure, because it is one.

Now: when was your last full medical.

Most of the senior people we know cannot answer that question with a date. Several of us could not, until something forced it. This episode is about why that happens to competent people, what the evidence actually says, and what we think is worth doing about it.

We want to start with Uganda rather than with international research, because the international material can feel like it belongs to somebody else's working life.

Uganda's national survey of non-communicable disease risk factors found hypertension in around twenty-six and a half per cent of adults between eighteen and sixty-four. In urban areas other studies have put it higher, above thirty per cent.

That is the first number. Here is the second, and it is the one that should stop the room.

Of the people found to have hypertension, only about seven point seven per cent were aware of it.

Read those together. Somewhere around a quarter of adults, and in a Kampala office plausibly a third, are walking around with raised blood pressure. And more than nine in ten of them do not know.

Think about what that means for a leadership team meeting. Not as a public health abstraction — as an actual room. Around that table, on those figures, two or three people probably have hypertension. Almost certainly none of them knows. There are no symptoms to notice, which is precisely the problem: the first symptom, for a meaningful number of people, is the event itself.

And this is the most treatable thing on the list. It is detected by a five-minute measurement that costs almost nothing. It is managed, in most cases, with inexpensive medication and changes that are unglamorous but well understood.

We are dwelling on this because it is the cleanest example of the pattern we described at the top. Cheap detection, serious consequence, and a room full of people who monitor everything about their business monthly and their own body never.

Now the working-hours evidence, which we think is widely misquoted in both directions.

In two thousand and twenty-one, the World Health Organization and the International Labour Organization published joint estimates in the journal Environment International. They looked at the burden of heart disease and stroke attributable to long working hours across nearly two hundred countries.

The headline finding: in two thousand and sixteen, around seven hundred and forty-five thousand deaths from stroke and ischaemic heart disease were attributable to working fifty-five hours a week or more. Roughly three hundred and ninety-eight thousand from stroke, three hundred and forty-seven thousand from heart disease.

The associated risks, compared with a thirty-five to forty hour week: about a thirty-five per cent higher risk of stroke, and about a seventeen per cent higher risk of dying from ischaemic heart disease.

Two details matter more than the headline.

The first is the direction of travel. Between two thousand and two thousand and sixteen, deaths attributed to long working hours rose by around twenty-nine per cent. This is getting worse, not better, and that period is before most of us carried the office in our pocket.

The second is the timing, and this is the part that ought to change behaviour. Most of the deaths recorded were in people aged between sixty and seventy-nine, who had worked those long hours between the ages of about forty-five and seventy-four.

So the exposure and the consequence are separated by decades. You are not going to feel this. There is no signal. The fifty-five hour week you are working at forty-eight does not present a bill at forty-nine; it presents at sixty-five, at which point it is not reversible and not attributable to anything in particular.

That is the same structure as every other preventive decision we have talked about on this podcast. Certain cost now, uncertain benefit later, no feedback in between. It is why organisations are bad at maintenance, and it turns out to be why leaders are bad at their own bodies.

We should be careful about what this evidence does and does not say. These are population-level associations, not a prediction about you. Plenty of people work long weeks and are fine. But the scale is not in doubt, and the honest reading is that sustained fifty-five hour weeks are a genuine cardiovascular risk factor rather than a badge.

The word burnout has been stretched until it means tired, and the stretching has cost us something, so it is worth being precise.

In two thousand and nineteen the World Health Organization included burn-out in the eleventh revision of the International Classification of Diseases. Importantly, it is classified as an occupational phenomenon and explicitly not as a medical condition.

The definition has three specific dimensions: energy depletion or exhaustion; increased mental distance from your job, or feelings of negativism or cynicism about it; and reduced professional efficacy.

Two things follow that we find genuinely useful.

The first is the cynicism dimension, which people miss. If you find yourself contemptuous of the organisation you lead, irritated by customers you used to care about, describing colleagues in language you would not want repeated — that is not a character change and it is not that everyone has become annoying. On this definition, it is a symptom, and it is often the one that shows before exhaustion does.

The second is that the classification is deliberately occupational. Burnout is defined as arising from chronic workplace stress that has not been successfully managed. Not from insufficient resilience in the person. That places responsibility somewhere specific, and if you run the place, it places it on you.

Which means the intervention is not primarily a yoga session. If the workload genuinely cannot be done in the hours available, that is a design problem, and offering mindfulness for it is a way of telling people that a structural failure is their personal deficiency.

Sleep is where we would concentrate, if we could only pick one thing, and the reason is a specific and unsettling finding.

The research is consistent that below about seven hours a night, measurable cognitive impairment starts to accumulate. It falls hardest on the prefrontal cortex — complex reasoning, planning, holding several factors at once, impulse control. Which is, precisely and unfortunately, the job description of a senior leader.

Studies have found that restricting sleep to around six hours a night for two weeks produces impairment comparable to being awake for something like forty-eight hours straight. Sleep loss is also associated with greater risk-taking and weaker emotional regulation.

But here is the finding that matters most, and it is the reason we would put sleep above every other lever.

In these studies, people did not accurately recognise how impaired they were.

Everything else on your dashboard has an alarm. Your body tells you when you are hungry. Your finance director tells you when cash is tight. Sleep debt is the one degradation that removes the instrument you would use to detect it. You feel adequate. You are not, measurably, and you cannot tell.

So the executive who sleeps five and a half hours, who genuinely believes they have adapted to it, and who then chairs a meeting about a large irreversible decision, is not lying about how they feel. They simply have no access to the information.

If you take one thing from this episode, we would like it to be that. Not that you should sleep more because it is virtuous. That the quality of your judgement is a function of your sleep, and that your confidence in your judgement is not.

There is a distinction we wish somebody had explained to us earlier, because it changes what you actually do about stress.

Stress in itself is not damaging, and the popular framing that treats it as a toxin to be eliminated is both wrong and unhelpful to anybody who has chosen demanding work. A hard week, a difficult negotiation, a launch that has to land — the body handles these well. It is built for them. Effort followed by recovery is how capacity is built, in muscle and in judgement alike.

What causes harm is load without recovery. The same demand, continuing, with the physiological response never fully switching off.

That reframing matters because it moves the question. Most senior people, asked to reduce their stress, hear an instruction to be less ambitious, and they refuse it, correctly, because the ambition is the point. But that is not the instruction. The question is not how heavy your load is. It is whether it ever comes off.

And by that test, a great many of us are failing in ways that are invisible on a timesheet. You can work a reasonable number of hours and never recover once, because recovery is not the absence of work. It is the absence of vigilance. Sitting at dinner with the phone face-up, waiting, is not recovery. Neither is a holiday spent checking mail twice a day, which keeps the system in exactly the state it would have been in at the office while removing the satisfaction of having done anything.

Two practical consequences.

The first is that genuine detachment, even briefly, is worth more than a longer break spent half-connected. An evening where you are actually unreachable does more than a fortnight of monitored leave. This is good news, because most of us can find an evening and cannot find a fortnight.

The second is that the recovery has to be defended by someone, and if you are the most senior person, that someone is you. Nobody will protect it for you. There is no meeting that will not expand to fill the space, no inbox that will report itself finished, and no point at which the organisation will tell you it is enough for today.

We would also say plainly that the hardest part is not logistical. It is that stopping is uncomfortable when your identity is built on being needed. A number of us have found that the first properly disconnected evening feels less like rest and more like withdrawal. That feeling is not a sign it is wrong. It is a fairly good indication of how overdue it was.

A brief word on wellness programmes, because we are wary of them and we should say why.

A great deal of corporate wellness is a way of relocating a structural problem into the individual. A wellness week, a subsidised gym, a mental health awareness talk, in an organisation where the workload is genuinely impossible and nobody may say so.

The gym is not the problem. The problem is the sequence. Fix what is causing the harm first, then offer support for what remains.

And the test of whether an organisation is serious is not its programme. It is what happens to the person who says no. Whether somebody who declines the late call, takes their full leave, and is unreachable on Sunday is still promoted. That is the only measurement that matters, and everybody in the building already knows the answer.

Which brings it back to leadership. Your team will not use the policy. They will copy you. If you send messages at midnight, the policy is decoration.

Four things, and we have deliberately kept them dull, because the interventions that work are dull.

Get the numbers. A full medical with blood pressure, blood sugar and lipids, on a date, in the calendar, annually. Given the Ugandan figures, this is the highest-return thing in this episode, and it takes an hour.

Protect sleep as a governance matter, not a lifestyle preference. Seven hours as a floor. And a rule several of us keep: no irreversible decision on a bad night's sleep, because you cannot assess your own state, so you have to decide it in advance.

Move, ordinarily. The guidance is broadly a hundred and fifty minutes of moderate activity a week, and the returns are largest at the bottom of the range — the gap between nothing and something is far bigger than the gap between something and a lot.

And keep one relationship where you are not the leader. Not a coach and not a mentor. Someone who knew you before, who is unimpressed, and to whom you can say that you are not coping without it becoming a market event.

Everything we do rests on the assumption that we will still be here to do it. That is the one asset on the list with no replacement, no succession plan, and no procurement process. We would suggest maintaining it with at least the discipline you apply to a server.