Category: Jane Jacobs

Jane Jacobs and the Trouble with Medicine

Seth Roberts4 Comments

In Slate, Barry Schwartz and Kenneth Sharpe argue convincingly that viewing bad performance as an “incentive problem” (meaning bad financial incentives) can be a mistake. If you pay doctors per procedure, they will do more procedures (too many); if you pay them per person, they will do fewer procedures (not enough). The heart of their argument is this:

When day care centers fine parents who are late to pick up their kids, lateness increases. Why? Because the fine turns a moral obligation (come on time!) into a service for a fee (we’ll take care of the kids if you pay us more!). Another example: When Swiss citizens were offered an incentive for agreeing to have a toxic waste dump in their community, their willingness to accept it fell by half. Why? The offer of an incentive induces them to ask What’s in my interest? instead of What are my responsibilities as a citizen? And when people offer a stranger a token payment for help unloading a couch from a moving van, strangers are less likely to agree than if offered nothing. Why? Because the offer of money has turned the assistance from a favor into a job.

So far so good. At this point the authors get lost. Here’s their advice about fixing medicine:

It is tempting, in light of our argument, to ask how can we incentivize good medical practice, so that we get more of it. Our answer is simple but perhaps unsatisfying: Good medical practice should be, and can be, its own reward. Almost all doctors want to practice good medicine—at least before they get socialized by the grind of medical school, residency, student debt, malpractice premiums, and the like.

The sign of their lostness is that they have zero data to back up this idea.

In Systems of Survival, Jane Jacobs argued that we can see around us two systems of morality: a guardian system, which stresses loyalty and hierarchy, and a commercial syndrome, which stresses honesty and equality. Each is internally consistent; but they are quite different, and those familiar with one system have a hard time understanding the other. She had plenty of data supporting her points. She went on to say that when the two systems are mixed — when policemen are given ticket quotas (= when policemen are treated like salesmen), for example — things go bad.

Why two systems? Because they correspond to two broad ways of making a living: taking and trading. The systems aren’t arbitrary; they have survived because they worked.

Are doctors takers or traders? The flaw in trying to improve doctor performance by changing incentives is the balance of power: Doctors have almost all of it. Patients trust doctors. (When I asked my surgeon the basis for her judgment that I needed surgery — treating her as an equal, in other words — she must have been stunned. She certainly didn’t respond appropriately.) That’s why it’s so easy for doctors to do too much or too little. It’s the same problem with quota systems for policemen: The policemen have too much power. The current balance of power makes doctors takers rather than traders.

So the choice is: either reduce the power of doctors relative to patients or give them moral training as guardians. The first isn’t going to happen in medical schools. Jacobs would recommend, I think, that doctors should be taught that they are guardians. (She might use the example of her father, who was a doctor.) And that those interested in improving medicine should study well-functioning guardian systems to see how they work or worked — how the accompanying moral system was instilled.

Genius of Common Sense

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From Genius of Common Sense, a new young-adult biography of Jane Jacobs by Glenna Lang and Marjory Wunsch, I learned that Jacobs was an independent-minded young girl:

When Jane’s third-grade teacher asked the class to raise their hands if they promised to brush their teeth every day for the rest of their lives, Jane refused to raise her hand and urged the other children not to raise theirs. . . Jane was expelled from school for the day.

Where have I read that before? In Chimamanda Adichie’s The Headstrong Historian:

Her teacher Sister Maureen told her that she could not refer to the call-and-response her grandmother had taught her as poetry, because primitive tribes did not have poetry. It was Grace who would laugh and laugh until Sister Maureen took her to detention.

Genius of Common Sense is plainly a labor of love, with a great selection of photographs and a belief in Jacobs’s importance that you might say “shines through the book like a watermark” (Nabokov). The subtitle is “Jane Jacobs and the story of The Death and Life of Great American Cities” but that isn’t right: It’s mostly about how Jacobs and her neighbors fended off Robert Moses to preserve Greenwich Village. Which is a lot more visual. As I read it I kept wondering what I would have thought of it had I picked it up as, say, a third grader. I read a lot of biographies for children back then. I might have been attracted by the weird title and helped along by the high ratio (1 to 1) of picture space to word space. I would have liked the underdog aspect. Would I have appreciated the humor of

Several years later the Lower Manhattan Expressway was to raise its ugly head again. “The rule of thumb is that you have to kill expressways three times before they die,” Jane quipped.

? Probably not. But maybe I would have noticed how much the authors cared about their subject.

Poorly Made in China

Seth Roberts1 Comment

The subtitle of Paul Midler’s book is “An Insider’s Account of the Tactics Behind China’s Production Game.” Midler is an American who helps American and European companies get stuff made in China. The book is about how, in a dozen ways, Chinese manufacturers manage to make manufacturing deals more profitable to them at the expense of their customer — and, often, the ultimate consumer. Most of the book is about what happens to an unnamed American company that imports “telephone numbers” of beauty products. One problem is “quality fade.” The product slowly gets worse until the importer objects. For example, at one point the fragrance put in liquid soap was changed. Instead of different fragrances for products with different labels, almond was used in every case. So a product labeled Aloe Vera smelled of almond. (I discovered I couldn’t trust flaxseed oil made in China.)

A friend of mine became a vegetarian after working at Burger King. Midler had a similar conversion:

I found myself losing faith in all sorts of products manufactured in China. I was soon careful to purchase health and beauty products that were not made by local [i.e., Chinese] companies, but by large, multinational corporations — but then I realized the body wash I had been using, while it was made by a reputable global company, was actually manufactured in a plant located in South China. . . . I knew these production managers well. . . . They believed that what a customer didn’t know couldn’t hurt him.

I found myself using less body wash, eventually relying on only hot water for my showers. When no one seemed to notice the difference, I stopped using the wash altogether. And then I stopped using soap, as well. . . . Why take any chances?

The attitude of cheat your customer as much as possible isn’t a great long-term strategy, as Chinese manufacturers are learning — the situation used to be even worse. A friend of mine analyzes the situation like this: For a long time Chinese were taught Confucianism. When the Communists took over, that changed to The state is God. Now that system of morality is gone, but nothing’s replaced it. In Systems of Survival, Jane Jacobs wrote about two systems of morality, a “guardian syndrome” and a “commercial syndrome.” The commercial syndrome, appropriate for trading, placed great weight on honesty. (The guardian syndrome, in contrast, placed great weight on loyalty.) Behind Jacobs’s classification was the implication that these syndromes had evolved because they worked better than other possibilities.

Poorly Made in China was easy to read. It has those two essential elements: it’s a series of stories, long and short; and the author feels strongly about his topic.

Wise Government: San Francisco Subsidizes Solar Power

Seth Roberts12 Comments

People in power, by and large, are terrible problem-solvers. They like the status quo — it brought them where they are. They have a hard time seeing the benefits of change. The bigger the change, the less they like it. Thus self-experimentation, a new way of solving health problems, offends med school professors.

But sometimes people in power make a wise choice — possibly by accident. An example is how the City of San Francisco is encouraging solar power. They are giving huge subsidies to homeowners and renters who install electric power. The program is about a year old. If your income is low, the subsidy is so large that your power becomes almost free. This is a use of government money that encourages change and new solutions. It will help the local solar power industry grow. It might create a solar power hub near San Francisco the way defense department subsidies helped create Silicon Valley.

Why is this happening? Because the responsible department in San Francisco government gets $100 million/year by selling electricity from hydropower. (Which they don’t like to talk about, for obvious reasons.) The money can’t be transferred to other departments; it has to be spent in energy-related ways. On its face, the restriction seems cruel — why not use the money to help social services? But more money for social services is unlikely to improve the local economy. Whereas this use of the money helps poor people and the local economy. It does so in the basic way Jane Jacobs recommends: It empowers those who benefit from change — in this case, the solar power industry.

The Fall of GM

Seth Roberts2 Comments

There is nothing new about large industry leaders, such as General Motors, going bankrupt; in The Innovator’s Dilemma, Clayton Christensen gives many examples and an explanation: complacency, also called smugness. We’re doing well, why shouldn’t we continue to do things our way? They fail to innovate enough and less-complacent companies overtake them, often driving them out of business. Complacency is human nature, true, but it’s the oldest mistake in the economic world. (I’ve studied a similar effect in rats and pigeons.) In the 1950s, complacency was surely why the big American car companies rejected the advice of quality expert Edward Deming. In less-complacent Japan, however, his ideas were embraced. This doomed the US car industry. Much later, Ford was the first American car company to take Deming seriously, which may be why Ford is now doing better than GM or Chrysler.

The further away you are I suspect the more clearly you see complacency for what it is — a failure to grasp basic economics (innovate or die):

“Chinese financial assets [in America[ are very safe,” [Treasury Secretary Tim] Geithner said. His response drew laughter from the [Peking University] audience.

The American Health Paradox: What Causes It? (continued)

Seth Roberts8 Comments

Atul Gawande might be the best medical writer ever. He is the best medical writer at The New Yorker, at least, and the best one I’ve ever read. He consistently writes clearly, thoughtfully, and originally about the big issues in medicine. That is why his recent article about health care costs (my comment here) and his graduation speech at the Univesity of Chicago are so telling. And not in a good way, I’m afraid.

The graduation speech starts off with an excellent story:

The program, however, had itself become starved—of money. It couldn’t afford the usual approach. The Sternins had to find different solutions with the resources at hand.

So this is what they decided to do. They went to villages in trouble and got the villagers to help them identify who among them had the best-nourished children—who among them had demonstrated what Jerry Sternin termed a “positive deviance” from the norm. The villagers then visited those mothers at home to see exactly what they were doing.

Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children’s mothers were breaking with the locally accepted wisdom in all sorts of ways—feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet-potato greens to the children’s rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped sixty-five to eighty-five per cent in every village the Sternins had been to. Their program proved in fact more effective than outside experts were.

Bill Gates, Jeffrey Sachs, are you listening? Gawande goes on to say that to improve medicine, there needs to be the same sort of study of “positive deviants”. Here is his first example:

I recently heard from one such positive deviant. He is a physician here in Chicago. He’d invested in an imaging center with his colleagues. But they found they were losing money. They had a meeting about what to do just a few weeks ago. The answer, they realized, was to order more imaging for their patients—to push the indications where they could. When he realized what he was being drawn to do by the structure he was in, he pulled out. He lost money. He angered his partners. But it was the right thing to do.

No kidding. The contrast between mothers who figure out creative iconoclastic new ways to feed children on tiny amounts of money and a doctor who merely refuses to be a scumbag could hardly be greater. But Gawande uses the same term (“positive deviant”) for both! This is the depth to which a writer and thinker of Gawande’s stature has to descend, given the straitjacket of how he thinks about medicine. Gawande thinks that doctors will improve medicine. He’s wrong. Just as farmers didn’t invent tractors — nor any of the big improvements in farming — neither will doctors be responsible for any big improvements in American health. The big improvements will come from outside. I’m sure they will involve both (a) advances in prevention and (b) patients taking charge of their care.

When these innovations happen, where will doctors be? Helping spread them or defending the status quo? That’s what Gawande should be writing about. One big advance in patients taking charge was home blood glucose testing. It came from an engineer named Richard Bernstein. Best thing for diabetics since the discovery of insulin. Doctors opposed it. When I invented the Shangri-La Diet, and lost 30 pounds, my doctor didn’t ask how I lost all that weight. Not one question. Like all doctors, he had many fat patients; the notion that I, a mere patient, could know something that would help his other patients didn’t cross his mind. When I was a grad student I did acne experiments on myself that revealed that antibiotics (hugely prescribed for acne) didn’t work. My dermatologist appeared irritated that I had figured this out. That’s a little glimpse of how doctors may react to outside innovation involving patients taking charge. Of course doctors, like dentists, cannot do good prevention research.

If Gawande took the first story he told to heart, he might realize it is saying that the improvements to health care won’t come from doctors, just as the improvements to the health of those village children didn’t come from experts. As I said earlier, doing my best to channel Jane Jacobs, a reasonable health care policy would empower those who benefit from change. That’s what the village nutrition program did. It empowered mothers who were innovating.

What Does Profound Stagnation Look Like?

Seth Roberts5 Comments

Economic stagnation = no development of new goods and services. Stagnation in the field of health has been so long-lasting and widespread that it is hard to see. I have never read a good description of it. Michael Moore thought the state of our insurance coverage was scandalous, and made Sicko; but much more harmful is the stagnation.

Here is what it looks like. Americans have many health problems. Obesity. Diabetes, closely connected to obesity. Mental illness, especially depression. Drug and alcohol addiction, a kind of self-medication. Allergies and autoimmune disorders, such as arthritis. Economic progress, lack of stagnation, would be coming up with and disseminating effective solutions to these problems.

When a helpful innovation arises, what happens? As Jane Jacobs pointed out in The Economy of Cities (1969), stagnation is in the interests of the powerful. As long as things remain the same, they remain powerful. Power also generates complacency; although the most powerful have the most resources, they are unlikely to find or develop the solutions. (Example: General Motors.) Within the health industry, Harvard Medical School professors are powerful. Here’s what happened when Dr. Erika Schwartz gave a lecture there:

When I gave my lecture on bioidentical hormones at Harvard on February 2, 2009, . . . I asked the chairman of the department of ob-gyn, Isaac Schiff, MD and the rest of the physicians in the audience, “ How come Suzanne Somers and Oprah are the ones to teach the public about bioidentical hormones? What has the medical profession done with the information of the Women’s Health Initiative study? Nine years later and women are still suffering and the medical establishment has not stepped up to the plate to help women find safe solutions to menopausal symptoms. Why are bioidentical hormones still controversial?” They had no answers.

That’s what stagnation looks like. It’s unsurprising that Oprah would publicize the innovation; her power is not in the health industry. She has nothing to lose. That Newsweek runs a cover story complaining about Oprah’s publicity for “risky advice” shows that top editors at Newsweek fail to see the stagnation in health. Innovations are always called “risky” by someone in power. Stagnation in health is probably the most important news story of our time. The health problems that have stacked up unsolved — obesity, mental illness, and so on — affect everyone every day.

Here’s another example of what stagnation looks like. The current Business Week cover story is about innovation, and the lack thereof. One of its examples involves health. What’s revealing is how minor the innovation is.

To see both the reality of the innovation shortfall and its potentially happy ending, look at Organogenesis, a small company in Canton, Mass. Back in 1998, Organogenesis received approval from the Food & Drug Administration to sell the world’s first living skin substitute. The product, Apligraf, was a thin, stretchy substance that could be grown in quantity and applied to speed the healing of diabetic leg ulcers and other wounds that had stayed open for years. . . But there were several big problems, recalls Geoff MacKay, the company’s current CEO . . . By 2002 the early enthusiasm for Apligraf had vanished, along with the money. . . . Shortly after, MacKay took over at Organogenesis with a clear mandate to straighten out the company’s manufacturing, logistics, and sales, and turn this tarnished product into a moneymaker.

And that’s what he did. . . . Organogenesis is fulfilling the promise of 1998—a decade later.

A product that helps diabetic leg ulcers heal — without curing diabetes. In a cover story about innovation, a trivial innovation is the big example of successful innovation. This is another way stagnation is visible: Low standards for what is important innovation.

The American Health Paradox: What Causes It?

Seth Roberts10 Comments

Americans spend more on health care than people in 29 other rich countries but our health is near the bottom of the list. Shouldn’t more money buy better health? This is the American health paradox. What causes it?

In the latest issue of The New Yorker, Atul Gawande, in an excellent article, tries to find out how the money is wasted. He visits a small Texas town where he finds an entrepreneurial attitude among doctors — a tendency to order more tests and do more procedures because doing so will generate more revenue. (A weakness that my own surgeon may have succumbed to.) Gawande does his best to figure out how things could be better but comes up short. He finds better systems of care — but they seem to be losing rather than winning. I think Gawande is too close to the problem he is writing about to see the really large forces at work.

In The Economy of Cities, Jane Jacobs pointed out that Marx got it wrong: The fundamental conflict in society isn’t between owners and workers, it’s between those who benefit from the status quo and those who benefit from change. There are plenty of owners and workers on both sides. The balance — or rather imbalance — of power determines what happens. The more powerful the status quo, the less change. Lack of change means lack of innovation; lack of innovation means that problems build up unsolved.

If the status quo is powerful enough, the problems get worse and worse, remaining unsolved — until the whole thing collapses. (This is what Jared Diamond failed to understand in Collapse.)Â A city economy relies heavily on a single product; the resources to make that product run out (Jacobs often pointed out that nothing lasts forever), often suddenly; and the whole city dies. Manchester (cloth) and Detroit (cars) are modern examples. Was the current financial crisis due to reckless lending? Not really. That was an opportunistic infection. It was due to a problem building up unsolved: lack of affordable housing, which was due to lack of innovation in the housing industry. Lack of real solutions made room for a phony solution that, funny coincidence, benefited the powerful: rip off poor people by lending them too much money. (A new form of predatory lending that took advantage of the human tendency toward speculative bubbles.) Just like resource depletion, the phony solution worked and worked and worked, until, all of a sudden, it stopped working and the whole giant structure fell down, hurting the poor and powerful alike.

The cause of the American health paradox is American inequality. America is more unequal than other countries. Everywhere, in every country, the powerful prefer the status quo but in America the rich and elite are especially powerful relative to the poor, so the status quo is especially entrenched and innovation especially well-squelched. America has a lot of health problems building up unsolved. Perhaps the most obvious is obesity, which affects the poor far more than the rich. The further the rich from the poor — that is, the more inequality — the more the rich can ignore it. And they have: The healthcare establishment’s record on prevention and treatment of obesity is terrible. Staggeringly bad. In one tiny example, when I proposed a rat experiment to test an idea behind the Shangri-La Diet, I was denied permission by the UC Berkeley Animal Care and Use Committee: My idea couldn’t possibly be true, I was told. Had there been plenty of poor people on the committee, instead of none, I think the outcome would have been different. Problems such as depression, allergies, autoimmune disorders, and autism are likewise building up with no real progress being made. An example of a real solution is home glucose monitoring for diabetes. This came from outside the healthcare establishment — from Richard Bernstein, an engineer with diabetes.

Although The Economy of Cities was published in 1969, it has not received the attention it deserves. Lots of well-read people dislike inequality, and the connection between inequality and poor health has been documented many times, especially by Richard Wilkinson, but the Jacobian point that more inequality means less innovation means problems stacking up unsolved is not widely appreciated. In a whole book about the badness of inequality (Inequality Matters, 2005), I didn’t see this point made even once. In his New Yorker article, Gawande fails to understand Jacobs’s point that farmers didn’t invent tractors; the big improvements to American (and world) health are not going to come from doctors or anyone now powerful in healthcare. They are too wedded to the status quo. (Notice that this recent innovation in affordable housing, the nano home, comes from a car company — an Indian one.) Gawande, being a doctor, surrounded by the powerful at Harvard (where he teaches), is in a poor position to figure this out. Where will the big improvements in health actually arise? From people who benefit from change. A reasonable healthcare policy would try to empower them.

The Death of Advertising? No Way

Seth Roberts6 Comments

James Fallows wonders if the decline of newspapers is one effect of a much larger trend: the decline of advertising. He quotes a reader:

The real problem is, advertising is dying. It’s just pulling down newspapers along the way. Next up: TV, radio, and Google.

Advertising isn’t cost-effective, the reader says. This is becoming increasingly clear. Companies can no longer justify the expense.

I would bet a lot of money this is wrong. Advertising isn’t dying; it is moving to a more differentiated personalized form, as has happened in dozens of industries. Jane Jacobs wrote about this in The Economy of Cities: the historical flow is from artisanal production to mass production to differentiated production. An example is software. Long ago, programs were written by individuals: artisanal production. Then came software produced by large companies, such as Microsoft: mass production. Now we are entering the age of highly individualized software. The usual term is open source but open source software is enormously customizable. For example, some Tsinghua students made a version of Firefox specifically for Tsinghua students. Internet Explorer will never be as easily customized as Firefox. Which means, according to history, IE is doomed.

Fallows’s reader is wrong for another reason: The central role of advertising in human evolution. Language was the first advertising. Single words served to say (a) you had something to trade and (b) you wanted something. This is how and why language began — it facilitated trade. Language was so successful as advertising that lots of other uses evolved on top of that use, just as newspapers and magazines do a lot besides carry advertisements. Human evolution, in my view, is the story of how we became occupational specialists; by increasing trade, advertising was central to that. In the form of language, it’s been a huge force pushing evolution for the last 100,000-odd years. Given that longevity, the probability it will disappear in the next 100 years is very low.

The language evolution theory makes a prediction. Words can easily be used (a) to announce you have something (“toothpaste!”) and (b) to ask for something (“toothpaste?”). The first is push advertising; the second is pull advertising. We don’t hear much about pull advertising. But the current imbalance — huge amounts spent on one, almost nothing on the other — doesn’t make sense. Historically, both work. We use language both ways, including a lot of pull advertising. Surely most people say what they want (“I’m hungry”) more often than they say what they have to trade for it. (In China, some peddlers, such as the father of a friend of mine, do spend their day saying what they are selling.)

Based on history, I predict the imbalance will be corrected; pull advertising will become much more important. Not a brilliant prediction because it is already happening. Searching online for something you want, e.g. via Google, is a form of pull advertising. Guru.com, where you post a job you want done and wait for bids, is another example. An example that doesn’t yet exist is a free concierge-by-phone service. You call them, they help you buy something.

The Naysayers

Seth Roberts2 Comments

Jane Jacobs called them squelchers: People in powerful positions who say no to new ideas. The effect of such people is that problems remain unsolved.

What about scientists? On the face of it, research is about discovering new ideas. If you’re a non-scientist, you might even think that is the whole point of research. Certainly that is why it is supported with tax dollars — taxpayers hope research will improve health, for example. But quite a few researchers don’t see it that way.

In London, a group called Business in the Community is creating “ toolkits” to help companies improve employee health. One toolkit is about emotional resilience. An early draft of that toolkit contained this passage:

Heart attacks and other ischemic cardiovascular diseases can be created by stressful office dynamics that come from the top. Even one year of working under a manager with poor leadership skills can raise the risk of acute myocardial infarction, unstable angina, cardiac death, or ischemic heart disease death by a significant 24%, while four years under the same stressful conditions produces a 39% elevated risk of ischemic heart disease events.

The data are from Nyberg A, et al., “Managerial leadership and ischaemic heart disease among employees: the Swedish WOLF study” Occup Environ Med 2008. At a meeting to discuss this toolkit, attended by representatives of large companies and a few academics, the academics objected to this passage. The study was methodologically flawed, they said. “But what if it’s true?” the non-academics said. The passage was removed.

On The Larry King Show a few years ago I heard a prominent woman psychiatrist (Nancy Andreassen or Kay Jamison) say that it was a good time, if there ever was one, to have a mental illness because it was a golden age of psychiatric research. Researchers, she said, were making one breakthrough after another. Nobody asked her, why, if that was so, was bipolar disorder still being treated with lithium? That’s 50 years old. Why hasn’t research come up with something better? Two psychiatric researchers believe it is because research proposals to test new treatments are turned down due to what the critics call inadequate methodological purity. For example, you’re supposed to do such studies with patients who have only bipolar disorder, although comorbidity is common.

This is the behavior produced by what academics (admiringly!) call “critical thinking”: ignoring what is valuable or promising in a rush to point out what is imperfect.

Something is better than nothing.