May 7, 2012 Liz Borkowski, MPH 8Comment

A recent Freakonomics podcast tells one of my favorite public health stories: how observant physician Ignaz Semmelweis figured out how to slash the incidence of childbed, or puerperal, fever, a disease that killed 10-15% of the women who gave birth in the doctor-staffed ward of the Vienna General Hospital in the mid-nineteenth century. (Death rates were similarly alarming elsewhere, since germ theory hadn’t yet taken hold.)

As the podcast explains, Semmelweis observed that the death rate from childbed fever was lower among women who delivered babies in the ward staffed by midwives compared to women who delivered in the doctor-staffed ward. One of Semmelweis’s friends pricked his finger while conducting an autopsy, and died of gangrene a short time later. Semmelweis noticed that the autopsy results for his friend were remarkably similar to those of women who died of childbed fever, and that gave him a theory: doctors who conducted autopsies before delivering babies were bringing “invisible cadaver particles” from the morgue to the maternity ward.

Semmelweis ordered every medical attendant to immerse his hands in a chlorine wash before seeing patients in the maternity ward, and within months the death rate from childbed fever plummeted. While our understanding of infectious agents is more sophisticated than it was in the 19th century, the same intervention is still important: doctors need to wash their hands for the sake of their patients’ health.

As many readers know, healthcare providers’ compliance with hand-washing instructions is far from perfect, and hospital-acquired infections are a major problem in healthcare. Freakonomics delves into this problem, and links it to the problem of low savings rates among US households. The solutions they describe are a good lesson in the public health perspective on tough problems.

Podcast host Stephen Dubner talks to Michael Langberg, chief medical officer at the Cedars-Sinai Medical Center, about handwashing in healthcare. Langberg reports that at Cedars-Sinai, handwashing compliance is worse among doctors than among any other category of provider, even though doctors should be the most well informed about the potential consequences of inadequate hand hygiene. “There’s something in the human condition that somehow disconnects what is really good evidence from personal choice and habit,” Langberg explains.

Cedars-Sinai experimented with ways to improve handwashing habits. Having doctors press their unwashed hands into petri dishes and showing visuals of the hand-shaped bacterial growths that resulted improved handwashing, but constant vigilance is required to keep the rate high. Publicly shaming doctors who failed to wash their hands by posting their names at departmental meetings has had an impact. (These are by no means the only interventions tried at Cedars-Sinai or elsewhere, but they demonstrate the breadth of approaches.)

Lottery vs. savings
What about applying such creative approaches to financial problems? The first half-hour of this podcast focuses on the fact that the US has a terrible savings rate — in one survey, half the respondents said they couldn’t come up with $2,000 to address an emergency in 30 days. Yet we spend an average of $200 per person each year on lottery tickets, for which the odds of winning are extremely low.

If you read the comment sections following blog posts or online news articles about public-health interventions to tackle physical inactivity, poor nutrition, teen pregnancy, drug or alcohol abuse, or other challenging public health problem, you may have noticed something. The longer a comment thread gets, the more likely it is to contain one or more comments saying, in essence, “Well, I have exemplary behavior. Other people should do what I do.”

To put it diplomatically, these comments are of limited utility — especially when they show up on a public health blog. Because, as this Freakonomics podcast describes, ensuring that people have information about what’s best for them doesn’t guarantee that they’ll turn that knowledge into healthy habits. When we apply the public health perspective to these problems, we don’t say “well, too bad for these people with bad habits — at least some of you are doing the right thing and will come out on top!” We try to think of interventions that will improve health across the population.

“Maybe you think people ought to save money on their own. But you know what? They don’t,” Dubner says to sum up the savings vs. lottery conundrum. And the show highlights a creative approach to improving the savings rate, with University of Maryland economist Melissa Kearney explaining the thinking behind it:

We know Americans like gambling. They always have, the majority of them do it, and they’re going to keep doing it. So what we do is take seriously the idea that people want some small chance of winning a large sum of money. … Why don’t we take that appetite for gambling … and attach it to a savings vehicle that offers some positive return? It’s a win-win situation.

The savings vehicle she’s describing is called a prize-linked savings plan. People deposit money in an interest-earning account, but the interest rate is slightly lower than it might be otherwise. The sliver of interest that’s not paid to the saver goes into a pot, and at regular intervals an account-holder’s name is drawn and he or she receives that whole pot. It’s akin to winning the lottery — except your odds are much better, and those who don’t win the jackpot have still accumulated savings.

These prize-linked savings accounts aren’t widespread, and one of the reasons is opposition from state lottery boards. (That’s another lesson that applies to public health: stakeholders that benefit from the status quo will probably oppose any proposal to change it.) But it’s still a great illustration of the fact that educating people about healthy behaviors may not work, but another route might get a population to the same healthier place.

Note: The full podcast described above is here, but it’s an hour-long “remix” of a few previous podcasts. If you’re most interested in handwashing, you can skip to minute 34 of the remix, or go directly to this older podcast.

8 thoughts on ““Invisible Cadaver Particles,” behavior change, and the public health perspective

  1. in one survey, half the respondents said they couldn’t come up with $2,000 to address an emergency in 30 days. Yet we spend an average of $200 per person each year on lottery tickets, for which the odds of winning are extremely low.

    This is probably true. It would be hard for e to come up with that kind of money. Down here in the south some business owners think that all their employees are just as rich as they are and that money just falls from the sky for our entertainment.

    Expenses keep rising while wages keep falling. I have not had a raise in four years. According to the boss the company is not doing well enough to warrant an investment like raises. That is bull becuase I work directly with customers and I know for a fact that our sales rate is up better than ever before and our customer base has grown significantly. Tha simple true is bossman wants us to work hard to make him richer. Bottom line – if the company is doing so bad that they cannot afford to give raises in fours years how does one explain numerous expensive dinners for the bosses and the new Lexus, a mega wedding, a new Mercedes for the wife, and the purchase of two whole new companies along with the investment in numerous other products?

    Seems like to me slavery still exists. YES MASTER!

  2. Freakanomics should be taken with more than a single grain of salt. Beneath the shiny exterior of looking at interesting problems, it’s the same old, empirically falsified individual-utility-maximizing approach, used to boil the interesting problems it discusses down into the same sort of trite tradeoffs that you see in an introductory textbook to neoclassical economics.

    In particular, the reason Americans do not save is that Americans’ incomes have been dropping and their fixed expenses – principally on commuting, insurance and interest payments – have soared.

    The solution to this is to raise US wages and let the dollar depreciate. But that is a solution you will never hear from any self-respecting neoclassical, because they firmly believe that the price of money is the only price the state should fix.

    – Jake

  3. A more attractive savings vehicle certainly won’t solve the problem of declining real median incomes. But I suspect that even if real incomes start rising again (which we all hope they do), people will still save less and buy more lottery tickets than is optimum for financial health. Future discounting — often called delay discounting in the medical literature — is something we have to reckon with, whether we’re looking at savings rate or substance use.

  4. If we could fix the sky high price of gasoline and bring it back to below $2.00 permanently many economic problems would solve themselves.

    We could do it someone in washington had the nuts to fire ever single employee including the janitor and the maintenance crew in the EPA and hire sensible people in their place.

  5. Just a bit of a brainstorm here but I’ve noticed that when doctors come into an exam room the first thing they do is greet the patient or ask about the patient from a nurse. If they do wash their hands they do so by turning away from this interaction. In effect, to wash their hands they have to stop the greeting and interview to wash hands. Then, flow interrupted, they return to the process.

    Perhaps the sink could be relocated so that they could wash their hands while facing the patient. This way they could make introductions and start the interview while washing. In effect multitasking and more effectively using their time.

    This would also reduce the objections, both spoken and intuitive, that time taken washing wands is wasted. Yes, doctors should know how important washing hands is but behavior belies their intellectual grasp of the situation.

  6. @3: I’m not convinced that private individuals should be encouraged to amass great amounts of savings. There are really very few things you actually want people to save up for – education, health care, pensions and houses, and then it’s pretty much said and done. The former three are unambiguously better done by the sovereign than the private sector, and the latter… well, let’s just say that the “ownership society” has some rather severe economic and political drawbacks.

    @4: In a word, “no.”

    The US is the swing petroleum consumer, and oil is currently see-sawing between the supply-constrained and demand-constrained regime. Which means that any significant drop in price can only be achieved through substitution. On a reasonably large scale.

    – Jake

  7. As far as an ideal amount of savings, it wouldn’t be good for the economy if the US savings rate were suddenly to match China’s. Given how low the US rate is, though, I’m not concerned about us getting to inappropriate levels any time in the next couple of decades.

    The benchmark used in the podcase is whether people have the $2,000 or so that they might need to buy a full-price plane ticket to visit a family member during an emergency, or to replace a car transmission, and half of survey respondents didn’t even have this much saved. Retirement benchmarks vary depending on individuals’ situations, but it’s safe to say the average worker has far too little: In 2009, the average 401(k) account balance of 401(k) participants in their 60s was less than $150,000.

  8. A low savings rate has nothing to do with politics or economics – it’s simple human behavior. People don’t save for the same reasons they don’t exercise or eat healthy – it’s short term pain for long term gain.

    Behaviors like buying on credit, eating a bag of Oreos and laying on the couch have immediate, definite, positive consequences – they make me feel great, every time, right away. The potential negative consequences come much later.

    If I eat broccoli and jog, the immediate consequences are mostly negative, and the potential payoff (living longer) is both way down the road and uncertain. (a 5% body fat-Ironman-competitor friend of mine just died of a heart attack at 50).

    Behaviors with negative immediate consequences are incredibly hard to motivate. Behaviors with postive immediate consequences are self-motivating – they are immediately rewarded so they tend to get repeated.

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