Monthly Archives: June 2011

Unhealthful News 178 – Why is it never a subsidy for healthy behavior?

The battles over financially penalizing people for unhealthy behaviors seem to be increasing well beyond historical levels.  After the triumphs there in the area of tobacco, which continue to amplify also, the battle has ramped up to punish people for soda, alcohol, and other unhealthy foods, and even to impose fines on recipients of public health care if they are overweight, and like tobacco, this has begun to include private lawsuits.  (Important note to those of you reading too fast:  Notice that the antecedent was punishing people for their behaviors, and thus “triumphs” refers to increases in punishing people, a triumph in the minds of people who think that is a good thing.  I am most certainly not suggesting these are triumphs from the perspective of public health or any other humanitarian interest.)

Last week a data mining exercise revealed that consumption of fried potato products independently predicts more weight gain than does soda consumption.  (Notice the phrasing there:  Those foods are predictors of weight gain, not necessarily the cause, even though some other exposures are “controlled for” to some extent.  Also, the simplistic analysis does provide useful quantification even though quantities were reported in the press by people who did not even understand that they do not understand what the study results meant.)  In response, the LA Times half-joked about imposing a potato tax, to mirror the proposed soda taxes.  It is pretty clear that if one is justified, then so is the other – both of these foods are a combination of energy (calories) and entertainment, with little other benefit.  A parent would be wise to discourage young children from consuming them, as yummy as they are.

But what should we think about the government doing so?

Much has been said, but something occurred to me that is absent from that debate:  No one ever suggests making such taxes revenue neutral, and there is almost no talk of using subsidies instead.  There are plenty of arguments to be made that government has no business doing this at all, of course.  But to test the honesty of the claims made in support of the taxes – “it is good for society”, “it will save healthcare money” – it would be interesting to see if supporters were so excited if these proposals were not profitable.

Some would still be adamant supporters, of course.  This includes some people who genuinely care about people, understand welfare economics, and genuinely believe that people make non-welfare-maximizing decisions – i.e., not in their own best interests, based on their own preferences – and so want to assist them in making better (as defined by their own preferences) choices.  But this is a tiny minority of the supporters.  Most government officials who buy into these schemes seem to be most interested in the promise of more money.  Would they be on-board if it were just about supposedly helping people?  And of course, there are the “health promotionistas” who believe they know best about what is best for people, and are willing to punish the people into conforming to their god-given knowledge.  Putting them to the test is a little more difficult, but it could be done.

To take away the government coffers incentive, it is just necessary to make the policy spend at least as much as it takes in.  It may not be trivial to figure out ways to spend money in the same direction as the taxes since, for example, we cannot subsidize tap water, already approximately free, as an alternative to penalizing soda.  But the taxes are not exactly trivial either, so it is not all that much harder.  (E.g., for a soda tax there are dozens unintended consequences and major complications like:  Are they really going to ban free refills, and if not, how can they tax by unit volume? Are they going to forbid raising the prices of all non-taxed drinks to keep them all the same, as most every restaurant will prefer to do?  Will clerks be required to police self-serve soda fountains to make sure someone is not evading the tax by lying about their soda being diet?)

Figuring out how to offer a subsidy for healthy foods might have to be a bit oblique compared to the soda or potato tax, like requiring that all of the tax revenue be given to grocery stores in proportion to how much broccoli they sell.  But the main point is to ensure that those pushing for the taxes are all really motivated by the incentive effects of the price increase and not just wanting to skim some money for themselves.  You have to figure that this is the real motive of governments; supporters in New York practically said as much.  So let them prove they really are supporting these proposals for their public health benefits.  Indeed, governments should even be required to kick in a bit more, to lose a bit of money from the policy, something they should be happy to do if they are really motivated by the wondrous predicted healthcare savings. 

This has the added benefit that government will not become dependent on the revenues, like they have with cigarettes.  Efforts to prevent tobacco harm reduction are inspired, in no small part, by the governments and activists who do not want to lose their cigarette tax gravy train.  Yes, the broccoli lobby might try to keep people drinking soda to keep up their subsidy flowng, but if we spread the subsidy widely enough, no one will be in a position to want to make sure the behavior does not abate because they are now profiting from that market.

That brings us to the outside activists.  You can be sure that anti-obesity (etc.) busybodies and their pet researchers are drooling at the prospect of getting their very own Legacy-like boondoggle of money.  It will not be as big as the cigarette tax payoff, but it will still support all manner of useless activity for many useless people for the rest of their careers.  So we should absolutely take it away from them by requiring the revenue be spent in a way that does not benefit them.  In fact, we can make them pay for this.  If they are so excited about incentives,  let them experience some.  The rule could be that major policy initiative that is onerous to people, like a soda tax, but will supposedly will reduce the health budget by x% should come with an automatic x% reduction in population research, advocacy, education, etc. funds for health promotion.  After all, with that much of the problem solved, not as much money will be needed.  Perhaps that would encourage a bit more honesty in these over-the-top predictions that never come true (they are generally off by approximately 90% of the predicted benefits), as well as some priority settings.

After all, we cannot let these people continue to gorge themselves on whatever they want without facing some repercussions.  The expenses they impose on the rest of us are simply unfair.

Unhealthful News 177 – Prevention is better than cure, but preventive measures are often not

I had planned to cover the news today, but I had one more overview thought I wanted to communicate.  I have written some of this before, but I have a few new thoughts that I think are interesting.  I will repeat enough to make it unnecessary to go back and read anything. 

When major failures occur in a normally functional system, it is usually due to a combination of three causes, not just one as we often try to simplify it to:

  • operator error (e.g., pilot error; occasionally a failure would occur no matter what the proximate actor did, such as when the hardware just breaks, but usually some specific goof triggers it – otherwise it would probably have already happened)
  • hardware inadequacy (not necessarily that something broke, though that might be involved, but that it could have been designed to avoid the failure in question if that had been the goal)
  • systems failure (rules or patterns of behavior made the operator error more likely and did not guard against or mitigate the effects of this particular failure mode; e.g., making it easy to push the wrong button, not inspecting the tires often enough, not building in redundancies)

I commented yesterday about a novel that included the U.S. CDC fighting an all-threatening disease outbreak that required all of their abilities and major police powers, contrasting that with the current government practice of nibbling away at freedoms and pleasures to provide trivial health benefits at great psychological cost.  “CDC” is, of course, the now inadequate abbreviation for the Centers for Disease Control and Prevention.  And who can complain about the fact that they or any other government entity have prevention as part of their mission?  How can prevention be bad?

It is bad when it lets a certain ilk of people try to make everything about operator error.

An illustrative example of focusing on the operator that you have probably seen is the card reader or gas pump that has multiple layers of hand-scrawled signs telling people which button to push or direction to slide, accompanied by clerks who get annoyed a few dozen times a day when they have to point out the sign to those who do not notice it and consistently guess wrong about what to do.  This is a case of the operator being blamed for, and being forced to compensate for, hardware and systems failure:  a device that was designed in a way that sufficiently defies expectations that many people’s guess about how to use it, coupled with no better system for encouraging correct usage than yelling at the operator.  Another favorite are the hotel key cards where the clerk repeatedly warns you to keep them away from your phone and wallet or they will demagnetize, which inevitably happens.  These problems do not merely offend the engineer in me, but cause needless cost.  They call for using better hardware (it exists in all of these case) or figuring out a way to gently guide people to avoid the problem. 

Such solutions tend to be noncontroversial.  No one complains about health researchers when they figure out a hardware fix to a problem, like a new drug.  No one should complain (other than, perhaps, about the cost) when government improves infrastructure to give people the opportunity to behave in a healthier way, such as by installing bike paths, making sure that urban bodegas sell fruits rather than just chips, or requiring that restaurants list calorie counts.  (Occasionally someone complains about such actions but they generally lack legitimate grounds to do so.  Perhaps the predicted benefit does not seem to outweigh the cost, though seldom is that the justification.)

But “…and Prevention” becomes a problem when it consists of harming people in an effort to force them to change their behavior.  That is, they put the onus on the operator.  This is a remarkable combination of bad judgment and bad ethics.  The ethical arguments, both libertarian and cost-benefit based, have been made here and elsewhere to an extent I see no reason to repeat them.  The more practical argument is that in most arenas, the people running a complicated human system recognize that they must look for ways to improve the system, since bludgeoning people into being better operators is usually pretty useless.  Pilots are not trying to crash after all.  And if all of your troops are miserable to the point that they are not functioning well, you can try to whip each of them until they perform better, but there are much better solutions.

If your students are doing badly, you can admonish them to study harder, but if it keeps happening year after year, there is probably something wrong with the teaching, or the motivation, or the community, or something else beyond the individual.  Yes, each student could save his own life, but if so many of them are failing to do so, we obviously need systems fixes, just like with a card reader where the users insert the card the wrong way most of the time.  Imagine a task force assigned the job of improving the performance of schools proposing the policy, “ban televisions and video games, and institute corporal punishment and public humiliation for bad grades, and make sure there is no safety net for students who cannot get through school to make sure they have an incentive to do better.”  But that is basically what the “health promotion” people propose when tasked with disease prevention regarding drugs, diet, and exercise.  They sometimes talk about making healthier communities, but a close look reveals that they are often just demanding that each individual behave differently.

When reviewing applications to public health school from the hundreds of indistinguishable Indian applicants trying to get into to American schools (usually with the intention of getting a foot in the door so they can become American physicians), their nearly identical application essays included the phrase “prevention is better than cure” in the opening paragraph.  That sounds fine to a public health person, notwithstanding the pathetic repetition, until you notice that it is not always true.  Preventing a particular case of a serious disease is almost always better than letting it happen, but that is not how things work.  We cannot go back and prevent a particular event.  We can only take prevention measures.  Some of those are justified and efficient: clean water is definitely better than treating cholera, and the right vaccines and industrial regulations are appropriate and worthwhile. 

But in keeping with my observations from yesterday, others represent cases of mistaking a prevention measure for an act of prevention.  Just because it would almost certainly be a good thing to prevent a fatal smoking-caused cancer or accident does not mean that everything that might theoretically protect someone is a good policy measure.  Preventive measures have broad negative effects and may not save anyone.  I doubt that any honest intelligent person really thinks that emotionally violent pictures on cigarette packs are really going to cause many people to not smoke.  But there is strong support for it because people mistake a preventive measure that seems like it might do something for a way of preventing a particular outcome.  But it does not work that way.  Whoever it was in someone’s life who was suffered or died because of a risky behavior is not going to be retroactively helped.  Preventing that would have been good, and curing it also, but that is not necessarily true for a prevention measure aimed vaguely in a direction that might have prevented that case.  And implementing public policy rules is not a healthy form of therapy.

Unhealthful News 176 – But if you try sometimes, you just might find

Last night, I finished reading Mira Grant’s novel, Feed.  It is about bloggers and a future filled with zombies.  I trust that is enough information to polarize my readers into those who will absolutely not consider reading it and those who are intrigued.  For the latter, I recommend it as entertaining moderately-light reading with some good deeper messages.  (very minor spoiler alert)  In it, the CDC has become a latter day military + police + homeland security for dealing with the biological threat of zombie virus infection that puts everyone at dire risk.  I think one of the reasons I liked the book is that it is so refreshing to think of government public health people fighting a genuine major health threat rather than fiddling with soda, salt, and e-cigarettes.  Of course, there are hints that they might be part of a power-politics conspiracy, and the author somehow randomly puts them in conspiracy with the tobacco companies, which is quite strange because she has constructed a future where people are protected from cancer and so smoking has become a popular and comparatively non-harmful activity.  I guess she just has some personal pique about that one.

Anyway, perhaps we have people who are just wired to fret about risks and hazards and to try to do something about them, and this urge is not based on the actual magnitude of hazards that are faced.  In a previous era they just would have inflicted that neurosis on their own kids, but now they have found ways to infantilize entire nations.  In the zombie-filled future, they will have something useful to do.  But right now they are like a large politically-powerful standing army during peacetime, an institution that tends to create the urge to fight pointless wars.

Today I went to the funeral for an old friend/classmate/roommate (so someone who was only my age).  People cannot always be protected from the things they choose to do for fun.  I have not changed my mind about that, even though we certainly see how sometimes a single event triggers some people – those with that wiring I mentioned – to direct their crusade in a particular direction.  But most of the time that effort is something that can only make life worse, on average, and usually consists of waging war on some vice that would have turned out to have no effect, in this case.

Today, catching up on the lives people I had not seen or heard about in a while, I became starkly aware of how psychological health matters so much more than longevity by almost any measure.   My friend had more total happiness in his foreshortened life than most people could ever hope to, but I was reminded of how many people do not manage to have much.  In some never-turned-off circuit in my brain, it redoubled my disgust with what passes for do-gooder public health these days, actions that increasingly threaten to worsen people’s psychological states for comparatively trivial physical benefits. 

It also occurred to me that he probably would have been a great asset when the zombie war started.

P.S.  This actually does make sense together, at least in my head.  Also, just for today, I am closing the comments.