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Individual effort, underlying infrastructure, and producing better health

January 19, 2013 at 10:36 AM Leave a comment

I just retweeted a David Brooks article from a friend that explored a more nuanced view of one of the political axes along which we are arrayed in this country: the role of government and community vs. the role of individual effort and drive in American success:  http://www.nytimes.com/2012/08/31/opinion/party-of-strivers.html?smid=tw-share&_r=0   At the one extreme are those who believe that there are no individual successes, that we are so intertwined in this complex era that bootstrapping is an artifact of the nineteenth century. What matters now is, well, luck, being in the right place at the right time to take advantage of an opportunity amidst the chaos. It is therefore government’s responsibility to make sure that those opportunities are justly distributed, and that their polar opposites, random catastrophes, are not disproportionately visited on those disadvantaged by birth and circumstance.

At the other extreme are those who believe that America’s success is the amalgamation of only individual successes, and that pretty much any aggregation of power is an attempt by those with lesser talents to overwhelm those with greater talents, and in fact appropriate the fruits of those greater talents. Luck exists, but is largely irrelevant for the talented because they can overcome any obstacle. They make their own luck. Random catastrophe is simply the outward manifestation of an individual’s inability to cope successfully, and not the responsibility of your neighbor. You may hope for your neighbor’s charity, but you may not feel entitled to it.

Who is right?

I am always suspicious of these kinds of black and white arguments, because I view them as a desire for simple theories to explain a complex world. It is understandable that we seek those in the age of information overload. Somebody somewhere has probably studied this, but my guess is that we are exposed to a couple of orders of magnitude more information daily than people a hundred years ago. Whether we want to or not, because we process emotionally, we have a feeling about everything that crosses our field of view. So the search for easy ways to categorize those things as friend or foe quickly gives rise to snap judgment, emotional processing on the fly, and gets codified as prejudgment. Why? Because when you are flooded with information, it’s all you have time for. Prejudging saves time. You are obligated by survival instinct to evaluate events and information to make sure they don’t cause your demise, and that’s done in areas of the brain completely below the level of rational thought. Ironically, I am afraid abundant information has made us less rational on average, not more.

Instead Brooks’ article lays out a more nuanced view of productive American society, one where infrastructure and community enable individual success. Both the infrastructure, which includes government and community resources, and the individual’s talent, effort, and perseverance are necessary but not sufficient. Infrastructure cannot compensate for lack of talent and effort, and we should not attempt that substitution. Talent and effort cannot replace adequate infrastructure, and neither should we rely on those things as the sole driving force for a healthy society. Without convenient prejudgment, every success is the product of the synergy between the two.

I agree with David Brooks.  I would imagine his article in August 2012 was decried by lots of people.  Some I’m sure dissented because it did not celebrate the individual as the only true American hero.  Others dissented because it did not give communities enough credit, or responsibility.  I choose to believe with David Brooks that the truth isn’t simple, and that in matters as important as our public life, we should spend some time and thought to find the answers that are harder to explain in thirty seconds.

By now I hope it is obvious why this is appearing in a health care blog.  Random catastrophes are legion in health care, but so are the successes related to individual effort and perseverance.  Good health is the product of many factors, some related to our efforts and some related to our circumstances.  Marc Lalonde, a Canadian Minister of Health in the 1970s had a lot to say about that.  He estimated that about 40% of health outcomes are related to behaviors, about half related to genes and environment, and only about 10% of health outcomes related to our attempts to fix the effects of the other factors on our bodies and minds (this last factor is of course health care, and we spend $2.7 trillion annually on it).  The policies we adopt as a nation and in our communities can be ineffective if we fail to recognize the portions of our health that are related to individual responsibility, as well as those related to our underlying circumstances, in more or less equal proportion.

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