(no subject)

 It was interesting to see a Merryn Somerset-Webb tweet earlier today (sorry, I do not know the original source), plus her reaction and the reaction of most respondents (sample given).

The clip was of a proposal that mothers in the UK should receive shopping vouchers as an incentive to breast-feed their babies.

The response was, perhaps unsurprisingly, one of disbelief mixed with anger.

All completely understandable. How many of you took on a surprised look and said "That's ridiculous!"

 

But let's have a think about it. First, there are really two issues at play here;

1) Should we be doing this?

2) Irrespective of that, does it work?

To answer the second part first, what's most fascinating about the strategy is that, in the developing world, it has been shown to work.

Immunization programmes in Udaipur had not been meeting with much success. This was the case even if the immunization course was free. The reason is one that people think about the present in a very different way that they think about the future (see Thaler and Sunstein, "Nudge", Penguin 2008). This "time inconsistency" meant thta, even though people in Udaipur knew that immunization would probably be of great benefit to them, only 6% of people went through the entire course because the probable great benefit was in the future and the definite minor inconvenience was in the present.

So, in Udaipur they offered 2lb of dal (worth about $1.83 in US purchasing power parity - i.e., not much even to poor people in Udaipur) each time an injection was taken for a child, and a set of stainless steel plates for completing the course.

This increased the completion rate to 38% (from 6%). Not enough to eradicate malaria, but enough to make a difference.

Which brings us on to the "should" part of the question. First one might say "ahh, that's all very well for the ignorant illiterates in the developing world, but it doesn't work for sophisticated people like us". As it happens, we aren't as sophisticated as we think. Indeed in the developed world we respond in similar ways in terms of time inconsistency. And our attitude to health is just as irrational. A small inconvenience now is often enough to overcome a known benefit at a later time. A bar of chocolate now is a lot easier than going to the gym, even though we know that the gym is better for us. But, hey, promise us a nice dessert *if* we go to the gym. Sign me up!

So, that's got rid of the "we are different" argument (at least I hope it has).

What about the argument of one of the responders, that one should use education rather than bribery?

Interestingly, this is precisely the argument put forward (by both the right and the left) against such programmes in the developing world. Whether or not it works is irrelevant, it is, say the morally outraged, just *wrong*. It's actually an article of faith. For the left, it is seen to degrade both the briber and the bribee, as if accepting that something as important as immunization can be won over by just a couple of pounds of dal. If it *does* work, then it shouldn't, and we should try to change that.

For the right, it's just seen as wasted subsidy. In the long run, it will create a dependency culture and people will expect to be paid for stuff that they should be doing out of enlightened self-interest. It might work now, but in the long term it will make things worse. Empirically (once again, see "Nudge") this does not appear to be true. Another experiment with nets to protect against mosquitos found that, after some people were "bribed" to use nets the first time, a couple of years later both they *and* their neighbours were more willing to pay for more nets.

Now, in our developed world, the benefits of breast-feeding on a child's health are fairly well-known and agreed. The mothers are not "ignorant" of this. But intention does not lead to action. Time inconsistency rears its ugly head. If these small bribes work, the future benefit to GDP is likely to be far greater than the cost. It is, indeed, precisely the kind of thing that the NHS should be doing, rather than spending nearly all of its money on patching things up that have gone wrong.

But, you'll never get over people's moral outrage at it, form both right and left, because, at heart, it hits at their visceral belief that you cannot put a "price" on health. And if someone proves to them that, quite plainly, you can, and it works, then they get all uppity and say "Well, in a civilized world, it SHOULDN'T". Silly people.