The People Will Do the Easy Thing Approach to Policy

[walkitout]

Recently, I posted about what a good book about decision theory needs to explain. (Virtually) The entire list can be summed up under the heading: People Will Do the Easy Thing. They'll take in information passively, rather than seek it out. They'll do what people around them are doing, rather than something different. They'll operate from their personal point-of-view, rather than take on the perspectives of those around them. Etc.

A lot of Policy is driven by a thorough understanding of this principle. And I mean, thorough. Unfortunately, People Will Do the Easy Thing is discouraging in that it does not lead to the desired outcome. Here are some examples:

(1) Fitting a diaphragm requires skill for it to be effective. Using a diaphragm effectively requires effort and skill. People will do the easy thing. They won't use a diaphragm. Try something else. Condoms require less skill, but some effort, and there is a cost (time/resources to have them available, some cost in sensation, some transaction cost in getting partner to use them). People will do the easy thing, etc. Down this path lie IUDs. Unfortunately, turning the IUD into something that requires little skill increases the hazard. And it turns out they just aren't that effective over populations.

One of the problems with going the Easy route is that you might choose something dangerous (and blind yourself to the risks) or that doesn't get you what you want, because it is easy. Bureaucrats are people. They choose the Easy thing, too.

(2) It's hard to convince people who do not buy or sell sex and who do not inject drugs that it is worth spending money on people who do buy or sell sex and who do inject drugs. If they are in jail, it's even harder. It's a lot easier to convince people to spend money on "innocent"/"good" people. This is why you wind up down the spend-money-on-development path and/or focusing AIDS awareness on the not-sleeping-around spouses of the Wicked Injector/John. Unfortunately, while it is very easy for a scientist to make the argument that this is a stupid waste of money, the scientist, after a decade, will learn that people are better able to memorize the argument for/against focusing on the innocent *rather than actually doing the Right Thing*. Scientists are people. They do the easy thing, too, which is keep saying, hey, this works, that doesn't. Knock off what you are doing and do it this way instead.

One of the waria Pisani talks to says Men are Lazy. They won't go buy a condom and bring it with them to the waria when they are going to buy sex, because they are too Lazy. But if the waria is saying put this on after the man is all hot and bothered and ready to play, the man is too Lazy to argue. He'll wear it.

What Policy needs to do is identify the people who are motivated enough to _not_ be Lazy, who are willing to do something _other_than the Easy thing and/or whose calculation of what is Easy turns out to also be the right intervention. And then figure out a way to replicate that. That, however, is Not Easy. Pisani has brilliant examples of this, for example, making it the brothel-owners responsibility for the people in the brothel to use protection, and create a reasonable enforcement mechanism (e.g. clinics that treat STDs find out where the johns have been buying sex; test sex workers, etc. -- shut down brothels that are transmitting disease). Unfortunately, I don't think you can "cookbook" this kind of Policy -- it is all very situational.

Comments

[ethelmay.livejournal.com]

I'm not quite clear what you mean when you say "turning the IUD into something that requires little skill." A lot of the reason for the IUD's effectiveness is that there isn't any way for either partner to render it less effective (it's still there if you're raped, for instance -- and many women worldwide have almost no choice about when they have sex). Convenience is thus coterminous with effectiveness, and you can't be sure which reason causes more women to choose it.

Not a lot choose either method in the US: only 2.3 percent of women use *either* the IUD or the diaphragm, according to http://www.guttmacher.org/pubs/fb_contr_use.html. It's entirely possible that a group of women who chose a frankly out-of-fashion method of birth control were nearly all women who thought pretty hard about why. It's also fairly clear that lots of people aren't just choosing the "easy" method: vasectomies are a lot simpler than tubal ligations. (Though it's entirely possible that for a given couple it's easier for the woman to have a tubal herself than to convince the man to have a vasectomy, and I do know a few people who believe that tubals are safer long-term: not sure the science checks out, but it's not my business.)

As I understand it, the failure rate of the diaphragm, even properly used, is enough higher than that of the IUD to result in greater morbidity/mortality from the increase in childbirths than occurs from IUD-related morbidity/mortality. Its failure rate in parous women was once said to be much higher than in nonparous women (that was one reason I quit using it); not sure whether that's still considered to be the case.

I do of course agree with a great many of your points.

"turning the IUD into something that requires little skill"

[walkitout]

That was confusing, wasn't it? I wasn't referring to the woman or any of her future partners. I was referring to the person who would insert the IUD during what Pisani refers to as "Contraception Safaris", but the description comes primarily from Connelly. During the heydey of Population Control (India under Indira Gandhi, Indonesia under Suharto, etc.), NGOs would train non-medical personnel (sometimes midwives, but often people with far less relevant training of any kind) to insert IUDs in women in "camps". Literally line 'em up on cots. They devised a variety of kits to try to automate the process; your imagination probably can't come up with anything quite as bad as the things they tried. Needless to say, there were serious medical complications, from perforation, inserting into women who had a history of PID, etc. In some of these "camps", there was no "choice" on the part of the women; they were rounded up by "motivators", paid to have the IUD inserted, their access to food during a famine was contingent upon "accepting" an IUD, etc. I understand _why_ people thought the tradeoffs made sense, but it just makes me shudder and want to do Very Bad Things to the Men (and it _was_ men, overwhelmingly) who put this process in motion.

Failure rate on the diaphragm + condom properly used is lower than the pill, or at least it was the last time I looked at the stats. Parous women must be fitted after each pregnancy. Cervical cap is not to be used by parous women. At least, this was what I recall from the last time I looked into it. As for the childbirth morbidity/mortality rate from diaphragm failures vs. morbidity/mortality from IUDs, that depends entirely on specific context. And the context described by Connelly indicates that IUDs were sickening and killing a lot of women compared to what would be expected if properly trained people inserted the IUDs into willing women in an appropriately clean environment after taking a medical history and doing appropriate followup.

"many women worldwide have almost no choice about when they have sex"

[walkitout]

Absolutely true. But while it is certainly many women, it's a really interesting question just how big that number is and what kind of things can be done to modify that number. Changing that number is part of the basis for general "development" (increase women's access to paid work increases their power at home increases their ability to determine when and how they have sex).

Pisani offers up a couple of really thought-provoking numbers, one in Zimbabwe (women who know they are HIV positive and the impact that has on their use of condoms) and the other in Indonesia IIRC (sex workers who successfully insist on condom use with most of their clients are paid substantially more on average than sex workers who don't even ask).

Another number she pops up with is the actual number of condoms available in given areas per adult man per year. In at least one of the African countries which had supposedly been inundated with condoms, it worked out to about 4. That kind of thing just makes me want to cry.