Targeting surrogate indicators

In the absence of broad, agreed, explicit goals, governments fine it convenient to target surrogate outcomes. Climate change is one example: instead of targeting the adverse effects of climate change, governments target greenhouse gas emissions, which may or may not have something to do with climate change, and they target them in ways that even in their own terms achieve nothing. More generally, instead of targeting anything as meaningful as human well-being, the de facto target of most governments is gross domestic product (or GDP per capita).

It's not just governments. It's big companies too. Instead of targeting anything that's inextricably linked to physical health (Quality Adjust Life Years, for instance), they try to get us to focus on surrogate outcomes. Cholesterol levels are one such surrogate outcome. Statins have been the preferred - by the pharmaceutical companies - vehicle for reducing cholesterol levels but, now that their patents are running out, a new class of drug, PCSK9 inhibitors, is on its way.

Reducing cholesterol levels might bring about a reduction in heart attacks, but it appears to do nothing for overall mortality. Indeed, overall mortality is not really a concern of many medical specialists, nor of big pharma. It's government that should be articulating our broad health goals. But in this, as in climate change and other policy areas, it's instead taking instruction from the wealthy and powerful, at the expense of the people it's supposed to represent.

Greenhouse gas emissions accelerating

Michael Le Page, writes in New Scientist (18 July) about the 'coal renaissance' and in particular about the heavy investments in coal power of poor, fast-growing countries in Asia and Africa. The result is that 'global CO2 emissions are rising faster than ever. And they are likely to continue to grow.' Indeed 'not only are carbon emissions rising, the pace has accelerated since 2000'. A graph (in the print issue) illustrates this: emissions rose at an average rate of 1.3 percent a year from 1970 to 2000, and have been rising at 2.2 percent since then.

I have for years been pointing out the futility of the Kyoto agreement and other apparent attempts to cut greenhouse gas emissions. I favour a clearer identification of what we actually want to achieve. Is it reduced greenhouse gas emissions? Even with that exceptionally narrow and arguable goal (can we really identify all the greenhouse gases and weight their contribution to climate change accurately?), Kyoto, as Mr Le Page tells us, is a failure. Will reducing greenhouse gas emissions, even were we to be successful in doing that, actually affect the climate? To what end? Nobody knows. But perhaps Kyoto and its interminable followups is intended to be a respectable-sounding forum within which bureaucrats from all countries can talk to each other and syphon off enough taxpayers' money to bring up their families. Ok, yes, it's had more success there. But that's probably not an achievement that taxpayers support with enthusiasm.

We do need to focus on what we want to achieve. Climate Stability Bonds, which I advocate, don't need to be exclusively, or even partly, about aiming to reduce the variability of the earth's climate. We could target some physical and biological indicators of climate change, but we could instead, or as well, target social and financial measures, such as the numbers of people killed or made homeless by adverse climatic events and the cost of compensating them, or the costs of preventing the negative impacts from arising at all.

A bond regime would be sufficiently versatile to include all these indicators, and more. It wouldn't even require people to agree on the - still questioned - thesis that the climate is actually changing or that, if it is changing, it's something for which we are responsible. It would, though, require clarity and honesty about what we want to achieve. Hmm, perhaps that's why it's gone nowhere in the 25 years or so it's been in the public arena. But all is not lost, yet. For more, see this page, and the links therefrom.

Health: it's complicated

At lower levels of general health we have a good idea about what's needed: basic sanitation, inoculations, and education about hygiene, for starters. A benign government with funds can get things done. It gets a lot more complicated at the health levels prevailing in western countries. Here cause and effect are far more difficult to identify; there are huge numbers of, and possible interactions between, lifestyles and interventions that affect health. And these are changing constantly as our scientific knowledge grows. As well, lobbies are adept at influencing policy in their favour, often at the expense of the general health of the population. This is where an outcome-based approach can succeed where existing policy seems to have lost its way and is likely to be generating diminishing - even negative - returns.

Jerome Burn, here, points out some of the flaws of evidence based medicine as practised in the rich countries. He quotes Dr David Unwin, a general practitioner in Liverpool, UK:

We had to balance evidence based medicine – you come with a problem; I give you a solution – with evidence based practise. That means drawing on my years of clinical experience, rather than just relying on guidelines, and applying it to patient’s own experience. They are the expert on their lives, what they need and what works for them. Without taking that into account you are not going to change anything.

Mr Burn continues:

Even if charities or the government dug deep into their pockets and began to run many more RCT’s [Randomised Control Trials] on lifestyle changes, they are the wrong tool to use. The lifestyle approach we need to integrate much more effectively into medicine doesn’t involve just changing one thing – drug or no drug – it involves doing lots of things at once – for example: different diets and more exercise combined with psychological techniques such as stress reduction. RCTs have difficulties with such multiple interventions. Yet when they are tested they often turn out more effective than drugs.

The existing rich countries' healthcare systems don't encourage the approach that Dr Unwin and Mr Burn are advocating. What's more, they cannot do so. Drug companies' priority is to deliver returns to shareholders. One way of doing this is to influence government, which could not anyway gather, collate and exploit the data necessary to optimise the general health of the population.

Outcome-based policy, and Social Policy Bonds in particular, could be the answer. Improving rich countries' health is complicated and long term in nature. Existing policy isn't working very well. Broad metrics for physical health are fairly well established and robust. A gradual transition in the rich countries to a Social Policy Bond regime would reward efficient existing approaches and channel our limited funding into the most promising new ones. For more, see my essay on Health Bonds.