Friday, December 10, 2004

Taking up some threads

Before moving on, let me take up some threads.

In the short time this site has been up, several interesting threads have started. Here are three:
  1. "Prevention pays/safety pays" and the possible perils of cost-benefit analysis;
  2. Influenza versus bioterrorism: zero-sum game versus taking advantage of an opportunity;
  3. Missing leadership in public health.
I plan to address (2) and (3) in future posts. But let's make a start here on (1).

To do a cost-benefit analysis you need a common yardstick. The usual solution is to monetize all the costs and benefits. Jgarrow suggests that the choice of "money" as the yardstick is just a matter of convenience so that we can be discussing the same thing. But the point is not a "common conversation" between ourselves as suggested in jgarrow's comment (although it is important we refer to the same thing) but that there be commensurable units for all costs and benefits so they can be added up and compared. Since monetizing these items is the essence of almost all cost-benefit analysis this puts us immediately on specific terrain, that of accounting and net profits. I am not opposed to using "public good" as a yardstick, but you'll need to tell me how to measure it for all the different kinds of costs and benefits so I can make the comparison.

I suggested that a more favorable terrain for public health is that of the human costs to the worker and his family in terms of pain, suffering and quality of life. To do a cost-benefit analysis of this you would need to monetize these things and compare them with costs to industry in dollar terms (where I will allow you to internalize things that are now external costs). I was asking this: suppose that the costs, when totaled up, showed it was cheaper to cut off some fingers than pay to prevent them from being cut off. Would we or should we acquiesce to this?

LB chimes in that the costs feel different to the worker, who may or may not, depending on various factors including perceived risk or special dread, decide to protect themselves or demand protection. She suggests that because some employers don't care, they must be made to care via societal mechanisms like regulation, criminal sanctions or costly litigation. I tended to agree. JQA remarks on the challenge to public health leadership: do we negotiate with them on their terms or do we opt for force through societal mechanisms?

In the next post I will try to get us off this very classical formulation by making a radical shift in landscape and perspective.