Rationality + badly-designed incentives = poor health

In the absence of broad, coherent, long-term goals that are actually meaningful to ordinary people, we end up with Mickey Mouse micro-objectives that, a cynic would believe, are designed to channel society's resources into purely private goals. This can be seen clearly in health care, where there are few incentives to increase well-being as measured by such indicators as longevity, or Quality-Adjusted Life Years, and all sorts of incentives to encourage professionals to prescribe medications regardless of how beneficial they are to the population. Several recent commentaries examplify this point:

Writing about the Number Needed to Treat (NNT) of prescribed drugs, Sebastian Rushworth says:

Doctors have been conditioned by the pharmaceutical industry to think that drugs that provide very low probability of benefit are effective. An NNT of 10 is often considered good, and an NNT of 5 is considered excellent. Even an NNT of over 100 is often considered acceptable! Patients are rarely informed that the odds of them getting any benefit from the new drug they’re being prescribed are far less than 50:50. And they’re rarely informed about what the harms are, and how likely they are to experience them. What defines a good drug?, Sebastian Rushworth, 14 April

Malcolm Kendrick writes about the Quality and Outcomes Framework (QOF) system was being used by doctors in the UK's National Health Service:

Replace it with carefully crafted treatment algorithms, based on the best possible evidence. To explain in a little more detail. QOF itself is a system whereby GPs can earn points for reaching various targets. They are then paid money for each point gained.  Evidence Based Medicine - it was a good idea, Malcolm Kendrick, 25 April

The problem is that these targets have little to do with health, and much to do with the goals of the pharmaceutical companies:  

[Y]ou can gain points for such things as lowering the blood pressure to a ‘target’ level in the approved percentage of patients. Or driving the cholesterol level down below the ‘target level’, or getting the blood sugar (HbA1c) level below the ‘target’ level in the approved percentage of patients.

In short, for QOF to work, the GP needs to create database after database of different diseases. Then carry out audit … after audit. What a great use of clinical time it all is. Appointment after appointment filled with patients called in to have their annual blood pressure check, which just sneaks in just below target level – every single time.

For the pharmaceutical companies this is manna from heaven. Every patient with diabetes logged and audited. Every one driven to reach a ‘target’. A target that will inevitably require medication. Medication that the pharmaceutical company just, ahem, happens to have developed. Medication where they just, ahem, happen to have done all the clinical trials.

Dr Kendrick's skepticism is borne out by his quote from an analysis done by Imperial College London:

A substantial number of English communities experienced a decline in life expectancy from 2010-2019, Imperial College London researchers have found … For such declines to be seen in ‘normal times’ before the pandemic is alarming.

Finally, Guy Hatchard writes about the Wall Street Journal's new-found skepticism about Covid vaccines:

The WSJ article described the effect of boosters as fleeting, mild and short-lived. It sounded a note of alarm saying that neither the CDC [US Centers for Disease Control] nor the US National Institutes of Health (NIH) had made a priority of studying vaccine complications. Moreover their VAERS [Vaccine Adverse Event Reporting System] data collection and analysis process is incomplete and inadequate. In other words, the safety investigation to date of adverse effects of mRNA vaccination is incomplete and potentially misleading. The central question raised by the WSJ opinion piece is, why wouldn’t the US regulators wish to undertake accurate and complete investigation of adverse effects of mRNA vaccination? Have pharmaceutical interests been able to influence decision-making at the FDA [Food and Drug Agency] to their own commercial advantage at the expense of safety considerations? When will these vaccine zealots wake up to the truth?, Guy Hatchard, TCW, 24 April

I share all these authors' skepticism, bordering on cynicism. It's clear that apart from a few outspoken commentators such as these, all players throughout are reacting rationally, if ignobly, to the incentives on offer. My suggestion? In place of indicators and targets designed, in my view, by vested interests, including government agencies to enhance their profits and power, we target for improvement the well-being of all citizens. We need to channel our ingenuity and society's scarce resources into improving the physical and mental well-being of whole populuations and to create incentives to do so. I have written about applying the Social Policy Bond principle to health here and, more extensively, here.

Is Hydrogen the solution? Nobody knows

We just don't know how to deal with some environmental problems. A recent UK government study points to some of the uncertainties about the impact that use of hydrogen as an energy carrier could have on the atmosphere and the greenhouse effect. Thus: 

Leakage of hydrogen into the atmosphere will decrease the tropospheric concentration of hydroxyl radicals (OH), the major tropospheric oxidant, and thereby increase the atmospheric lifetime of methane and its impact on climate. Atmospheric implications of increased Hydrogen use, Nicola Warwick, Paul Griffiths, James Keeble et al, Universities of Cambridge and Reading, April

Other uncertainties could arise from more hydrogen leaking into the atmosphere and increases in the concentration of both tropospheric ozone and stratospheric water vapour, boosting a 'radiative forcing' effect that raises temperature. 

The key concept here is uncertainty. It would seem foolish, but not inconsistent with government behaviour, to go all out for a 'hydrogen economy', which might end up creating more environmental problems than it solves. Or it might not. Nobody knows. In circumstances like this, where the science is uncertain, I would advocate Climate Stability Bonds. These would target what we want to achieve for the world's climate, but not how to get there. Bondholders would have incentives to work out the best ways of achieving our climate goal, even over the necessarily long period that such achievement will take. Most likely a range of technologies, including hydrogen, will need to be researched, refined, experimented with and implemented. No government policy can bring about the diverse, adaptive range of activities that will be necessary to achieve a climate goal. Our knowledge is too scanty and ever expanding to determine how best to proceed. But what government can do (perhaps with the help of supra-governmental bodies, non-governmental organisations and the public) is to raise funds that, in a Climate Stability Bond regime would ultimately reward those who help reach our goal.

The aim of Climate Stability Bonds isn't isn't to create a stable climate: it's to reduce the probability of catastrophic climate breakdown, now being seen by some as climate emergency. In the face of the uncertainties that bedevil almost every aspect of this emergency (some question even whether it even qualifies as an emergency), it is tempting to do nothing, or make only token, highly-publicised gestures in the right direction. A Climate Stability Bond regime would address the reluctance (or hypocrisy) of governments to channel taxpayer funds into possibly solving a long-term problem when there are so many more immediate claims on society's scarce resources. It would do so because, under a bond regime, until our climate goal has been achieved, government need spend nothing. All risks would be borne by bondholders. 

I have written extensively on Climate Stability Bonds. Links are here.

World Peace Bonds, while we have the chance

We are living before the first nuclear exchange. The probability that a nuclear weapon will be detonated in the next few years is, sadly, high. Indeed, looking at the way our species has developed, it seems inevitable. 

A world in which North Korea and other small, poor countries acquire nuclear weapons is not going to be safe for the liberal values under which most of us, mainly in the west, are lucky enough to live. We can see the pessimistic scenarios as a clash of civilizations, or a clash of values, or shifts in geopolitical power, but I choose to see it as a problem of perverse incentives.

For most of the people in politics, holding on to power, or increasing it, is an end in itself. Solution of social problems can be a means to that end but whipping up nationalistic fervour at the expense of improving your citizens' well being can work just as well, with the Russian leader being the current obvious example. Our political systems reward those most adept at acquiring power. Threatening the use of nuclear weapons is one way in which a regime can hold on to that power.

What can ordinary people - those of us who are content not to have the power to kill millions of human beings - do, faced with the realistic possibility that the nuclear taboo will be violoated some time soon? My suggestion is that we issue World Peace Bonds. These bonds would be redeemable for a fixed sum only when a targeted array of indicators of peace had been achieved and sustained for a long period. They would reward people who do what they can to end violence. Backed by a combination of governments, non-governmental organizations, philanthropists and ordinary people, they would encourage a vast number of peace-generating approaches. Some would inevitably fail; the way the market for the bonds would work means that these efforts would be terminated and resources diverted into more promising initiatives.

The effect of World Peace Bonds would be to give incentives to accelerate and guide our progress toward a less violent world more efficiently than has happened so far: a protracted, haphazard and bloody path that has, true, given us a less violent world until now, but also one that has left us fearful of self-induced catastrophe. We can do better than that. By acknowledging that not all approaches are going to work, and supplying incentives for those that do, we can guide and accelerate evolutionary processes to bring about, quickly and efficiently, what is surely our most urgent goal: world peace 

The tragedy of spurious micro-targets

In the absence of broad, explicit goals that are meaningful to ordinary people, we get narrow, short-term goals that mean a great deal to those who devise them, but nothing to everyone else. A UK Government investigation into the maternity care provided by Shrewsbury and Telford Hospital to 1486 families, mostly between 2000 and 2019. It found that 131 stillbirths, 70 neonatal deaths and nine maternal deaths might have been avoided, had care been better over two decades. The Economist concludes its column:

When one woman pregnant with twins requested a Caesarean, a doctor is said to have replied: “We’ve got the lowest Caesarean rate in the country and we are proud of it and we plan to keep it that way.” One of her twins died. A report castigates the National Health Service, 'Economist', 2 April

Our large, complex societies need to target aggregated indicators of well-being. But I think we should as far as possible target meaningful outcomes themselves, rather than indicators that are not strongly correlated with well-being. In particular we need to avoid targeting spurious measures, such as Caesarean rates, that are too narrow to reliably measure anything that we really want to achieve. 

I have written about applying the Social Policy Bond principle to health here. In summary: in the rich countries we could use broad health indicators such as longevity and infant mortality. In the poorer countries we might encounter problems gathering reliable longevity data, but objective sample data on, for instance, infant mortality, weights of young children, nutritional intake, could be available and useful. Refinement by experts, and aggregation into something like the Human Development Index, would see the creation of much targets that would be both more sound and more meaningful than the current array of indicators ranging from such narrow targets as local Caesarian rates to GDP per capita the latter of which, in the absence of sensible targets has, unfortunately, become the de facto over-arching target of governments everywhere.