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.