The Guardian has 6 pictures from an early collection of Tolkien’s sketches for the Hobbit, that were apparently discovered recently. I particularly like number 3, which despite its roughness gives the sky and Smaug a certain vitality.
Compromise and Conceit
Infernal adventuring…
-
In looking at the cost-effectiveness of health interventions in fantasy communities we have shown that the infinite lifespan of elves creates analytical problems, and other commenters have suggested that the cost-effectiveness of clerical interventions to reduce infant mortality should be balanced against the need for clerics to go to war. Well, Professor John Quiggin at the Crooked Timber blog recently broached the issue of doing a benefit-cost analysis of US military spending, and has found that the US defense department has killed a million Americans since 2001. His benefit-cost analysis is really just an exercise in peskiness, though it does have a valid underlying point, and I think actually you could show with a simple cost-effectiveness analysis that the wars of the last 10 years have, under quite reasonable assumptions, not been a cost-effective use of American money. Of course, we don’t make judgments about military spending on cost-effectiveness or cost-benefit grounds.
In comments at Crooked Timber[1], I listed a few examples of how US Defense Department money could be better spent, and one of those examples was vaccination. Obviously, disease eradication would be a very good use of this money, because of its long-term implications, but in thinking about the cost-effectiveness (or cost-benefit) of this particular intervention, I think we can see another clear example of how these purely economic approaches to important policy debates just don’t work. So, here I’m going to look at this in a little more detail, and give some examples of how we can come to outrageous policy conclusions through looking at things through a purely econometric lens. I think I came to this way of thinking by considering the cost-effectiveness of interventions in elven communities, and ultimately it’s relevant to the debate on global warming, because a common denialist tactic is to demand that AGW abatement strategies be assessed entirely in terms of cost-benefit analyses, which are very hard to do and, as one can see from the comments thread at Crooked Timber, are anathema to supporters of the military establishment. As we can see here, they also break down in quite viable real-life circumstances.
The Problem of Disease Eradication
So, you’re the US president in 2001, and you’re reading a book on goats to some schoolkids, and as happens in this situation, you have to make a snap decision about how to spend 200 billion US $ over the next 10 years. You could spend it going to war with a small nation that harbours terrorists; let’s suppose that if you don’t your country will be subject to one 9/11 -style attack every year for the next 20 years (until OBL dies). If you do, you’ll commit your own and the next administration to spending 200 billion US $. Is this a good use of your money? 200 billion US $ to save about 50,000 US lives over 20 years, minus the casualties (wikipedia tells me it’s about 5000). So you get a net benefit of 45,000 lives, or 4,444,444 US $ per life – this actually comes under the US government’s 5 million US$-per-life-saved threshold, so it’s a viable use of your money. But one of your alternatives is to spend the money on eradicating HIV using a vaccine that was recently developed, and it has been shown that by spending 200 billion US$ over 10 years you could eliminate HIV from the face of the earth. You don’t care about the face of the earth, but you need to eradicate it everywhere to make Americans safe from it. Should you ignore the terrorist attacks and spend the money?
For a standard cost-effectiveness analysis you would calculate the incremental benefit (in lives saved) from this vaccine compared to the war on terror. Lives saved in the future are discounted at a fixed rate (usually about 3% a year) and decline in value over the term of the intervention. But the problem with this calculation for disease eradication (specifically) is that the term of the intervention is infinite. All future lives saved forever go into the calculation. The actual formula for this calculation is the integral over (the negative exponent of (discount rate*time t)) multiplied by (lives saved at time t)[2]. Usually we model a policy over 20 or 30 years, giving a finite result; but in this case we need to model the benefit over all future time, and the integral of any bounded function multiplied by the negative exponent, over an infinite range, is infinite. So even with furious discounting we get an infinite benefit from eradicating any disease. Not only does this make comparing disease eradication decisions – e.g. smallpox vs. HIV – impossible, but it makes comparing disease eradication to any other policy objective impossible, and it tells us – quite reasonably, I should say – that we should bend all our health care resources to this task.
In this case, the president of the USA should decide not to go to war because 20 September 11ths are a small price to pay for the eradication of HIV. Eventually Osama bin Laden will give up[3]; HIV won’t. But the stupidity of this decision doesn’t end here. If it costs a trillion dollars to eradicate HIV, the president would be better off defunding his army and paying the price than not; and if Mexico were to invade, killing a million Americans, the infinite benefit of having eradicated HIV would still outweigh the loss.
Now, one argument against this logic is that you shouldn’t include the yet-unborn in a policy evaluation; yet this is standard practice. For example, in considering the cost-effectiveness of different interventions to reduce HIV transmission, we might run a model on the 15-64 year old population, and when we do this we allow for maturity into and out of the population; if we run the model for more than 15 years we are implicitly allowing the yet-unborn into the model. Furthermore, you could surely argue that modeling disease eradication without including the unborn devalues the whole concept – what is disease eradication except a project to protect the unborn generations of the future?
So we can’t use econometric analyses by themselves to assess the value of interventions, because a perfectly reasonable economic analysis of a valid healthcare goal throws up an impossible contradiction. The world expects – with significant help from Bill Gates, I might add – to eliminate polio by 2015 and with the recent announcement of a vaccine for malaria you can bet that the international health movement will turn its gaze on that bastard protozoan next. And there is no economic argument you can mount against spending money on it – even if the cost is everything you own.
Implications for the Global Warming Debate
A common argument mounted by “hard-headed realists” and AGW deniers is that money spent on AGW mitigation needs to be justified by a solid cost-benefit analysis, because the alternative is to spend this money on targeting real problems now, especially in third world countries (often also the countries most vulnerable to AGW’s worst effects). Money spent on infant mortality now, they argue, is far better than money spent on AGW mitigation in the future – even if you accept that the negative effects of AGW are a certainty. This is a particularly powerful argument since we don’t have solid evidence for exactly how bad the effects of AGW will be, and we know that the future benefits of reducing infant mortality now are huge. This economic defense will usually also depend on discount rates – we’re much more interested in lives saved now than in the future, and AGW mitigation’s effects will be felt in the future, not now. Exactly what the relative benefits of mitigation will be are very sensitive to discount rates.
In this case, though, one can argue: well, let’s spend the entire defense department’s money on eradicating HIV. If we test everyone in Africa every 6 months – surely possible with the full funding of the US military on the case – and treat them immediately (or, hey, just treat everyone in Africa with anti-HIV drugs for the next 30 years – let’s put them in the water!) then we can eliminate HIV, and save an infinite number of lives. It’s guaranteed on both cost-benefit and cost-effectiveness grounds, with the added benefit that you don’t need to quibble over the discount rate – it’s guaranteed to be cost-effective under any finite discount rate. The natural argument against this will be that someone might invade America. But we can say in response to this, “uh uh! Precautionary principle! You don’t know how bad that invasion will be or even if it will happen.” If the precautionary principle doesn’t apply to the putative risks of AGW, why should it apply to defense? Or rather, if we need to attach a monetary value to the future risks of AGW, why not attach one to the future invasion of the USA? And when we do, it will be of lower value than the benefits from elimination of HIV, even if the entire population is wiped out during the invasion.
Which brings us back to the simple problem that we can’t assess any policy in isolation using only the econometric tools at our disposal. Everyone understands this, of course, which is why people on the Crooked Timber thread are bridling at Professor Quiggin’s analysis. They attach additional, non-economic considerations to these problems. But one of the rear-guard actions of the anti-AGW movement is to demand that we use exclusively economic methods for assessing the value of AGW mitigation – and it was in response to this fiction that the Stern review was commissioned. I think it needs to be recognized that these econometric tools offer false clarity, and only apply within a very limited framework, that of limited improvements in a limited temporal framework (pacemakers vs. aspirins, essentially). Defense, disease elimination, and AGW mitigation lie outside that framework. This should be abundantly clear to anyone who has tried to do a cost-effectiveness calculation of the relative merits of slavery and genocide for elven communities. It’s just a shame that most economists haven’t bent their mind to these truly important questions; fortunately, we at the C&C University are here to help with the more profound philosophical questions. No, don’t thank me, we do it for free. Or, alternatively, pick apart the argument in the comments … I’m eager to hear how a valid mathematical framework can be constructed for the analysis of disease eradication goals, because it’s relevant to my work…
Update
Actually while I was watching a band in Kichijoji at 3am last night I realized that my interpretation of the formula for total effectiveness in the disease eradication was wrong[5]. Ultimately, the benefits that accrue from disease eradication are approximately (1/(discount rate))*average number of lives saved in any year. So for a discount rate of 3% and 1,000,000 lives saved per year from (e.g. ) eradicating malaria you would get a total benefit of about 33 million. It’s not infinite but it’s very very large. So the general argument holds, but it is possible to compare disease eradication programs. Note that there’s an argument that can be made for a lower discount rate in the case of disease eradication (it is all about saving future generations, not the current generation) and even a small change in the discount rate makes a big difference to the outcome. Also, under certain conditions (exponential population growth bigger than the discount rate) the benefits of disease eradication are infinite; I think most people expect the population to stabilize at 7 billion though so this doesn’t apply on earth.
—
fn1: for historical reasons I comment there as sg
fn2: or something similar
fn3: Actually it’s an interesting question, isn’t it? If you ignore a terrorist who is incapable of waging a conventional war on you, refuse to give into his demands, mount a purely law-enforcement operation to prevent his worst excesses, and wait him out, how long will it be before he just gives up and goes away? How long can OBL recruit people for if killing Americans leads to … nothing? And if after a few years the US said quietly to the Taliban, “we’ll give you a billion a year in aid if you get rid of him,” how long would it be before he had no safe bases?
fn4: I find this very interesting. A few years ago it was getting hard to find doctors in the west who would perform circumcisions on babies; ten years ago doctors were equivocal on the issue and there has been a long-standing community opposition to circumcision for non-medical reasons; yet now we’re recommending it (and funding it!) en masse in African countries. I wonder how Americans would have felt if, in 1987, Nelson Mandela or Robert Mugabe had come to the USA and suggested that the solution to their growing HIV problem was to circumcise all adult gay men?
fn5: I did this calculation only recently, so I really should have got this right from the start…
-
This is to be my last post on what I’ve learnt from John Dower’s War Without Mercy, and it is also to be my most speculative. Did the feverish anti-Japanese propaganda of the Pacific war era influence at all the allies’ decision to engage in large scale bombing of urban areas in Japan, and/or their decision to use nuclear weapons? In this sense I’m not interested in whether these tactics were “right” or “wrong,” though I think we can all take it as read that a decision to drop a nuclear weapon on a city is definitely wrong in anything except the most extreme of circumstances. My question is more about whether our subsequent interpretation of these decisions (which remain controversial) and the decisions themselves is clouded by the propaganda that was being used at the time, and the general beliefs about Japanese and allied behavior in the war, as they existed then and exist now.
I have always accepted what for this post I will call the “standard” view of the urban bombing campaign and the nuclear attacks: that in the absence of convincing proof that they would be destroyed as a nation the Japanese were not going to surrender and were going to fight a long and protracted military campaign that would lead to the deaths of millions of Japanese and potentially hundreds of thousands of allied soldiers. In the standard view, the allies discovered on Okinawa that the invasion of the mainland was going to be a hideous affair, and decided to use terror bombing to bring the war to a close so that they didn’t have to expend many lives. This view can even take the pesky form of having been for the good of the Japanese too: I don’t think it’s hard to find examples of people saying that less civilians died in the bombing campaign than would have died if the allies had invaded the mainland.
I have also read Dresden, which contains a passionate defense of the terror bombing of German cities on strategic grounds and argues that the frantic German efforts to defend major cities represented a huge drain on their military resources and hastened the end of the war. I’m inclined to accept this view of the strategic value of the terror bombings of Germany, and against the backdrop of all the horrors of that war I can understand why Stalin was pleading with the allies to do more of the same. But just because it worked in Germany doesn’t mean it was strategically necessary in the Pacific, and my suspicion is that decisions about when to start the bombing, how intense to make it, and why it was necessary, were influenced by the extreme propaganda about Japan. We have established that there was an eliminationist sentiment to this propaganda, that it was extremely racist and that the underlying principles of the propaganda were believed by the public and war planners alike. We also know that the allies got up to all manner of nasty war crimes in the Pacific, were not particularly inclined to see the Japanese as human, and that just as their behavior towards Japanese was different to Germans, so was their propaganda. So it doesn’t seem a stretch to me to imagine that the allies were also inclined to favor brutal tactics, and that decisions about the necessity of these tactics would be colored by some genuinely held beliefs about how unreasonable, crazy, childish and brutal the Japanese were. Also underlying the allied response to the Japanese is a need to remind the other “sub-humans” of the Pacific that rising up against the accepted international order is a very bad idea, and a fear that the Japanese “lesson” might be learnt by others in Malaysia and Indonesia. There are also a few examples from Dower’s book of specific beliefs about the unwillingness of the Japanese to surrender, and specific actions taken by the allies that suggest that the terror bombings weren’t embarked on reluctantly or purely for military/strategic reasons. I’ll cover these first.
Beliefs About the Chances of Surrender
The allies based their understanding of Japanese war-time thinking on a whole suite of crazy sociological theories about the Japanese psyche: that the nation was stuck in a child-like stage of development, that they were crazy, that they could not be reasoned with, and that they could not be trusted. Many allied planners seemed to think that the Japanese would use any kind of honourable or conditional surrender as a chance to regroup before attacking again, and the Japanese were generally viewed as treacherous and shifty. Dower describes the generally held view that the Japanese would need to be thoroughly defeated, possibly “to the last man” because their nation had a suicide psychology and needed a “psychological purge.” Allied planners may have expected the Japanese to behave as a nation the way they (also erroneously) believed Japanese as individuals preferred suicide to surrender. Furthermore, Japanese treachery and savagery meant that only by the complete destruction of their current order could the Japanese desire to dominate Asia be prevented. Allied propaganda also maintained that the Japanese were “patient” and sinister (common traits ascribed to Orientals) and would happily wait 100 years to launch another war of domination, as Germany had done after world war 1, and so the only way to prevent them going to war again was their complete destruction. This view is particularly interesting because there really was no historical basis for thinking that the Japanese have a long-standing interest in dominating their region – they had chosen isolation over expansion, and their first international military activity was against Russia in 1905. The allies were nonetheless willing to believe that the war represented a manifestation of some constant belief in Japanese culture.
Lack of Interest in Surrender
In addition to a general belief that Japanese did not surrender, allied soldiers and their leaders did not show much interest in obtaining surrender from their enemies. In military engagements allied soldiers would kill soldiers who did surrender, or would refuse to accept a surrender and force Japanese soldiers to fight on to their deaths. Dennis Warner reports this exchange between two high-ranking officers in Bouganville:
“But sir, they are wounded and want to surrender,” a colonel protested [to a major general] at the edge of the cleared perimeter after a massive and unsuccessful Japanese attack.
“You heard me, Colonel,” replied [the major general], who was only yards away from upstretched Japanese hands. “I want no prisoners. Shoot them all.”
They were shot.
Accounts from Marines in Okinawa also suggest the same behavior in Okinawa, and not just towards soldiers: marines also killed civilians. This account from a war correspondent summarizes the battlefield philosophy of the Americans:
What kind of war do civilians suppose we fought, anyway? … We shot prisoners in cold blood, wiped out hospitals, strafed lifeboats, killed or mistreated enemy civilians, finished off the enemy wounded, tossed the dying into a hole with the dead, and in the Pacific boiled the flesh off enemy skulls to make table ornaments for sweethearts, or carved their bones into letter openers.
This was published in The Atlantic Monthly in 1946, when the memories and philosophies of the war were still clear in people’s minds and admitting such atrocities was still acceptable. By now, of course, we look back on our soldiers as having fought for a noble cause, and no longer discuss the barbarity of the time. It’s clear from these accounts that the mistreatment of prisoners and refusal to accept surrender crossed military types (navy, air force and army) and was held at all levels of command. It’s also clear that the blood-letting on Okinawa was not entirely the fault of Japanese unwillingness to surrender, and suggests that whatever judgments military planners were making about a battle on the mainland, to some extent at least the numbers of dead they were expecting to see were being partly brought about by their own soldiers’ misconduct. With such a disinterest in either surrender or treating the enemy population kindly, perhaps they were inclined to see a protracted campaign of urban destruction as a good thing on its own terms?
Destruction for its Own Sake
The saddest example of this interest in destruction as an end in itself is the final air raid on Tokyo. This happened on the night of August 14th, just hours before the Japanese officially surrendered, and when everyone on both sides knew the surrender was going to happen. The raid was the biggest of the war, consisting of 1014 planes, and suffered not a single loss. The planes had not yet returned to their bases when Japan’s unconditional surrender was announced. There is no chance that this raid was necessary, or that even a single death it caused could possibly have advanced the end of the war by even a heartbeat. It is perhaps the clearest example of simple cruelty on the part of the allies, in which a city was destroyed merely for the sake of it. From this act we can see that the allies valued destruction for its own sake, and were acting on Churchill’s demand to lay all the cities of Japan to ash, even where they didn’t need to.
The Question of the Bombings
This leads us to the question at the heart of this post: could the allies have negotiated an end to the war in some other way, without the use of terror bombing and atomic weapons; could they have used less terror bombing and no atomic attacks? Were their decisions driven by a desire to destroy as much of Japan as possible, rather than purely strategic concerns? And if their decisions were based on a genuine belief that the Japanese would not surrender and would fight to the last, to what extent was that belief correct, and was it at least partially clouded by their own stereotypes of and fantastic notions about the Japanese psyche? What portion of the decision to destroy Hiroshima and Nagasaki was strategic, what portion was cruel, and what portion was based on misconceptions about the Japanese psyche that were, ultimately, founded in racism?
The decision to end the war in this way may also have been driven by the desire to assert colonial power over Asia – a conditional surrender would probably have meant allowing the Japanese to retain some colonial possessions, and the implication from this would be that Asia could control its own destiny. Furthermore, they needed to end the war before the Soviets invaded Japan. But it seems to me that there are other approaches they could have taken: for example, after Okinawa they could have ceased all aggressive action targeting civilians, used their overwhelming naval power to enforce Japan’s isolation, and just waited them out. I don’t know, but I have never heard from any source that the allies genuinely attempted to negotiate surrender before the bitter end. One doesn’t hear stories of attempts to subvert the military clique in charge, to foment civil disorder, or to use captured Japanese soldiers as propaganda tools – it’s as if they just all assumed such actions would be impossible, and I think these assumptions may have been wrong.
In essence then, I strongly suspect that much of the barbarity of the final year of the war, and especially the terror-bombing campaign, was unnecessary and was driven by a complex mix of racist and colonialist beliefs. I think the allies may have been able to negotiate a different end to the war, but they didn’t believe it was possible due to racist assumptions about “orientals,” and they didn’t want to because they wanted to punish the Japanese and inflict a defeat on them that would send a signal throughout Asia. I think this means that, while in retrospect the bombing of Japan has been painted as a necessary tactic, it can only be portrayed as such if we accept the racist premises of the propaganda of the time, and overlook the wanton cruelty of the allied forces. Is a more realistic historical interpretation that allied thinking about Japan and the Japanese was deeply flawed, and the policy of mass destruction that “won” the war was both unnecessary and heavily influenced by this same racist worldview?
-

The Chief Whip insists you toe the party line… Yesterday Australia passed a carbon pricing scheme, over the strenuous objections of the opposition. In fact, the opposition’s objections were so strenuous that their leader, Tony Abbot, has promised a “blood oath” to revoke the legislation.
I guess he’s thinking of a blood oath in the demonological sense of signing a contract in blood to make it more binding. It’s the natural extension of Tony Abbot’s rather unfortunate recent admission that the only promises he makes that can be trusted are promises that are written down. This surely means that promises written in blood are much more manly and believable than those written in mere ink.
This opens up a few worrying questions for me:
- Does Tony Abbot secretly believe that contract law should be changed to make blood-based signatory agreements more powerful, and if so how?
- Is this an extension of his willingness to “sell his arse” to a willingness to “sell his soul”? And if so what kind of policy-making process does this represent?
- Given the paucity of soul in the nasty little blighter, and given he can only sell it once, how much policy benefit can we gain from a government that functions in this way?
- Given he used to be a monk and now he’s become a demonologist, is this further evidence that he’s not really very trustworthy?
- Given he used to be a monk and now he’s become a demonologist, is this more of an indictment of him or the catholic church?
- This kind of language seems very fitting for a role-player, something I never suspected Abbot to be capable of. Is he actually a fantasy role-player, and if so is his party aware of how damning this is for his electoral prospects? Do they seriously think the mortgage belt is going to vote for someone that nerdy?
- If he’s a role-player, what system does he use, is he a GM or player, and where does he fall on the Gamist-Narrative-Simulationist debate?
The obvious good point of this “blood oath” is that he has finally made his position on demonology explicit. The current minority government is in the hands of the Australian Labor Party, who are widely rumoured to have sold their souls en masse to satan in order to gain admission to the party (or at least, to get the numbers for pre-selection). It’s also generally accepted that they will eat their own young and no act of treachery is too low for them. Of course rumours have long abounded that the Liberal Party are just as bad, but their god-fearing family-loving image has saved them from general acceptance of this rumour. At least now Abbot has admitted that, yes, shock! everyone in politics is up to their necks in satan’s semen, and we can all heave a sigh of relief and get back to analyzing the polls.
Politically this pledge could be a disaster for Abbot. As if suspicions of satanism and (omfg!) role-playing were not bad enough, it will probably be very hard to undo the legislation without revoking the tax cuts that came with it, which is obvious political suicide. Furthermore the only practical way he can revoke it is to get it through the Australian Senate, which is currently controlled by the realms of faerie (the Greens). Long-standing agreements between the Seelie Court, the CIA and Rupert Murdoch mean that the only way that Abbot will be able to drive through his legislation is likely to be a double-dissolution election, which means that Abbot will have to go to the next election with the pledge that he will “hold another election within 6 months of this one.” That’s not going to be popular in a country where only two things are compulsory: apathy and voting.
While overall it’s nice to see Abbot finally embracing the inevitable spiritual compromises necessary to succeed in Australian politics, and being so open about it, I don’t think this is going to be good for the party. Also, how is he going to manage to resist Satan’s demands for compulsory abortion and gay marriage?
-
Today I am celebrating my first publication in my new job, and since it’s about a topic I’ll probably be coming back to a lot in the next year, I thought I’d cover it here. It’s not much of a publication – just a letter in the journal Addiction – but it covers what I think is an interesting topic, and it shows some of the complexity of modern health policy analysis. The article, entitled Equity Considerations in the Calculation of Cost-Effectiveness in Substance Use Disorder Populations[1], can be found here[2]. It’s only 400 words, but I thought I’d give an explanation in more detail here, and explain what I’m trying to say in more detail. The background I’m presenting here may be useful for some future material I’m hoping to post up here. I’ll give a brief overview of the “cost effectiveness” concept, explain what the problem is that I’m addressing in this paper, and then give a (slightly) mathematical example in extremis to show where cost-effectiveness analysis might lead us. I’ll also add some final thoughts about cost-effectiveness analysis (CEA) in fantasy populations, with perhaps a final justification for genocide. Or at least an argument for why Elves should always consider it purely on cost-effectiveness grounds.
Cost-Effectiveness Analysis, QALYs and the IDU Weight
Traditional epidemiological analysis of interventions is pretty simple: cholera, for example, kills X people, so let’s prevent it. However, we run into problems when we have limited resources and need to compare two different interventions (e.g. turning off a pump vs. handing out disinfectant pills). In this situation we need to compare which intervention is more effective, and we do this by assessing the cost per life saved under each intervention – if turning off the pump is cheaper and saves more lives, then it’s better. This is usually represented mathematically as the ratio of the cost difference between the intervention and some control (the incremental cost) and the effect difference (the incremental effects). The ratio of the two is the incremental cost effectiveness ratio (ICER). This is what I used in assessing clerical interventions to prevent infant mortality. However, when we are dealing with chronic diseases the incremental effects become harder to measure, because a lot of interventions for chronic illness don’t actually save lives: they extend life, or they improve the quality of life a person experiences before they die. In this case we use Quality-Adjusted Life Years (QALYs). These are usually defined by conducting a study in which people are asked how they would weight a year of their life under some condition relative to fully healthy – or, more usually, relative to their health as it is now. For example, blindness in one eye might be rated a QALY of 0.9 relative to being fully-sighted. There is some interesting debate about whether these ratings should be assessed by those who have the condition or the community as a whole; the logic here can be perverse and complex and is best avoided[4].
So in essence, you rate one year of life as having the value of 1 when fully healthy, and then other states are rated lower. We can use the issue of Voluntary Testing and Counselling as an HIV intervention to see how this works.
Example: Voluntary Testing and Counselling
It’s fairly well-established that good post-test counselling can successfully reduce a person’s risk behavior, so if you can get people at high risk of HIV (e.g. men who have sex with men (MSM)) to undergo voluntary testing, you can catch their HIV disease at an early stage and get them to change their behavior. In theory, doing this fast enough and effectively will reduce the rate at which HIV spreads. Furthermore, catching HIV earlier means initiating treatment earlier (before it becomes symptomatic), and early treatment with anti-retroviral drugs leads to longer survival[5]. However, discovering one is HIV positive is not a pleasant experience and knowing you are HIV positive lowers your overall quality of life, even if the disease is asymptomatic. So if the survival benefits of early testing don’t outweigh the loss of utility, then it’s not worth it. So 10 years ago, when treatment extended your life by perhaps 10%, but testing reduced your remaining QALYs from 1 to 0.9, then the benefits might not outweigh the costs. Additionally, treatment is expensive, and it might be more cost effective on a population level to run health promotion campaigns that reduce risk behavior: reduced risk behavior means less infections, means less QALYs lost to HIV.
In essence, it’s a kind of rigorous implementation of the old bar room logic: sure I’d live longer if I didn’t drink, but why would I want to?
Recently, however, some analysts have introduced a sneaky new concept, in which they apply a weight to all QALY calculations involving injecting drug users (IDUs). The underlying logic for this is that IDU is a mental illness, and people with a mental illness have a lower utility than people without. This weight is applied to all QALY calculations: so a year of life as a “healthy” IDU is assigned a value of, e.g. 0.9, and all other HIV states (for example) are given a value of 0.9 times the equivalent values for a non-IDU.
What is Wrong with the IDU Weight
This has serious ramifications for cost-effectiveness and, as I observe in my article, fucks up any attempt to get a cost-effectiveness analysis past the British NICE, since it breaks their equity rule (for good reason). In addition to its fundamentally discriminative nature, it’s also technically a bit wonky, and in my opinion it clouds cost effectiveness analysis (“which treatment for disease X provides better value for money?”) with cost-benefit analysis (“who should we spend our money on?”). It’s cool to do the latter vs. the former, but to cloud them together implicitly is very dangerous.
Technical Wonkiness
Suppose you have a population of IDUs with a weight of 0.9, and you need to compare two interventions to prevent the spread of HIV. One possible intervention you could use is methadone maintenance treatment (MMT), which is very good at reducing the rate at which IDUs take injecting risks. You want to compare this with some other, broader-based intervention (e.g. voluntary testing and treatment, VTT, which also affects MSM and low-risk people). Then the average QALY for an MSM with asymptomatic HIV is about 0.9 (to pick a common value). Because you’ve applied the weight to IDUs but not to (e.g.) MSM, the average QALY for an IDU with asymptomatic HIV is 0.9*0.9=0.81. Now suppose that you implement MMT: this intervention reduces the risk of transmission of HIV, but it also treats IDU’s mental illness, so the weight for all the successfully-treated IDUs drops away and you gain 0.09 QALYs per IDU you treat; but then you gain 0.1 additional QALYs for every case of HIV prevented by the MMT intervention. This means that VTT has to be almost twice as effective as MMT to be considered cost effective, if they cost roughly the same amount. That is, in this case the cost-effectiveness of MMT is exaggerated relative to VTT by dint of your weighting decision – even though half of the benefits gained don’t actually have anything to do with reducing the spread of HIV (which implies you can prevent half as much HIV for the same QALY gains). On the other hand, if you implement an intervention that doesn’t treat IDU but does prevent HIV in IDU (such as needle exchange), its effectiveness will be under-estimated due to the IDU weight. In both cases, introducing the cost-benefit element to the analysis has confused your outcome.
Opening Pandora’s Box
The real problem with this IDU weight, though, is if we decided to extend the logic to all cost-effectiveness analysis where identifiable groups exist. For example, we could probably argue that very old people have lower QALYs than younger people, and any intervention which affects older people would gain less benefit than one which affects young people. An obvious example of this is anything to do with road accidents: consider, for example, mandatory eye testing vs. raising the minimum driving age. Both would result in lower rates of injury (and thus gain QALYs) but the former would primarily affect older people, and so would be assigned lower effectiveness, even if it prevented a hugely greater number of injuries[6]. When we start considering these issues, we find we’ve opened Pandora’s box, and particularly we’ve taken ourselves to a place that no modern health system is willing to contemplate: placing a lower value on the lives of the old, infirm, or mentally ill. As is often the case with social problems, the marginalized and desperate (in this case, IDUs) are the canaries in the coalmine for a bigger problem. I don’t think any health system is interested in going down the pathway of assigning utility weights to otherwise healthy old people (or MSM, or people with depression, or…)
An Example in Extremis
Let’s consider an obscene example of this situation. Suppose we apply a weight, let’s call it beta, to some group of recognizable people, who we call “the betamaxes.” Now imagine that these people are the “carriers” for a disease that doesn’t afflict them at all (i.e doesn’t change their quality of life) but on average reduces the quality of life of those who catch it to a value alpha. Suppose the following conditions (for mathematical simplicity):
- The people who catch the disease are on average the same age as the betamaxes (this assumption makes comparison of life years easier; breaking it simply applies some ratio effects to our calculation)
- The disease is chronic and incurable, so once a member of the population gets the disease their future quality of life is permanently reduced by a factor of alpha
- One betamax causes one case of disease in his or her life
- Preventing the disease is possible through health promotion efforts, but costs (e.g.) $10000 per disease prevented
- Betamaxes are easily identifiable, and identifying and killing a betamax costs $10000
I think we can all see where I’m going here. Basically, under these (rather preposterous) conditions, identifying and killing betamaxes is a more cost-effective option than the health promotion campaign whenever alpha>1-beta. Obviously permanent quarantine (i.e. institutionalization) could also be cost-effective.
This may seem like a preposterous example (it is), but there’s something cruel about these calculations that makes me think this weighting process is far from benign. Imagine, for example, the relative QALY weights of people with dementia and their carers; schizophrenia and the injuries caused by violence related to mental health problems; or paedophilia. I think this is exactly why health systems avoid applying such weights to old people or the mentally ill. So why apply them to IDUs?
Cost-Effectiveness Analysis in Fantasy Communities
There’s an obvious situation where this CEA process breaks down horribly: if you have to apply it to elves. Elves live forever, so theoretically every elf is worth an infinite amount of QALYs. This means that if a chronic disease is best cured by drinking a potion made of ground up human babies, it’s always cost-effective for elves to do it, no matter how concentrated the baby souls have to be. If a human being should ever kill an elf due to some mental health problem, then it’s entirely reasonable for the elven community to consider exterminating the entire human community just in case[7]. Conversely, any comparison of medical interventions for chronic disease amongst elves on cost-effectiveness grounds is impossible, because all treatments will ultimately produce an infinite gain in QALYs: this means that spending the entire community’s money on preventing a single case of HIV has an incremental cost effectiveness of 0 (it costs a shitload of money, but saves an infinite number of QALYs). But so does spending the entire community’s money to prevent a single case of diabetes. How to compare?
Similar mathematical problems arise for Dwarves, who have very long lives: you’d have to give them a weight of 0.25 (for being beardy bastards) or less to avoid the same problems vis a vis the use of humans in medicinal treatment that arise with elves.
This might explain why these communities have never gone for post-scarcity fantasy. When you have an infinite lifespan, no intervention of any kind to improve quality of life is cost-effective. You might as well just live in squalor and ignorance, because doing anything about it is a complete waste of money.
Cost Effectiveness Analysis as a Justification for Goblin Genocide
Furthermore, we can probably build a mathematical model of QALYs in an AD&D world: some people have better stats than others, so they probably have better quality of life. We could construct a function in terms of the 6 primary stats, and obviously goblins come out of this equation looking pretty, ah, heavily downward weighted. Given that they lead short and brutish lives, and are prone to kill humans when the two communities interact, the obvious effect of weighting their QALYs from this mathematical model is pretty simple: kill the fuckers. The QALY gains from this (and the low cost, given the ready availability and cheap rates of modern adventurers) makes it a guaranteed investment. In fact, compared to spending money paying clerics to prevent infant mortality, it could even be cost-effective.
Conclusion
Cost-effectiveness analysis needs to be applied very carefully to avoid producing perverse outcomes, and the logical consequences of applying weights to particular groups on the basis of their health state are not pretty. We should never weight people “objectively” to reflect their poor health in dimensions other than that under direct consideration in the cost-effectiveness analysis, in order to avoid the risk of applying a cost-benefit analysis to a cost-effectiveness situation. Furthermore, even if we are comfortable with a “discriminatory” weight, of the “oh come on! they’re just junkies!” sort, it can still have perverse outcomes, leading to over-estimates of the cost-effectiveness of treatments for the mental illness compared to other interventions. Furthermore, we should never ever ever allow this concept to become popular amongst elven scholars.
I’ll be coming back to this topic over the next few months, I think, in a way I hope is quite entertaining for my reader(s). Stay tuned…
—
fn1: The slightly cumbersome title arose because the journal now doesn’t like to refer to “substance abuse” or “substance abusing populations” so I had to change it to the un-verbable “Substance Use Disorder”
fn2: If you download the pdf version it comes with a corker of a letter about French tobacco control policy[3]
fn3: Which is a contradiction in terms, surely?
fn4: For a full explanation of this and other matters you can refer to the famous text by Drummond, which is surprisingly accessible
fn5: In fact we are now looking at very long survival times for HIV – up towards 30 years, I think – provided that we initiate good quality treatment early, and so it is no longer necessarily a death sentence, if one assumes a cure will be available within the next 30 years
fn6: This applies even if you ignore deaths and focus only on short-term minor injuries, and thus avoid the implicit bias in comparing old people with young people (interventions that save life-years in old people will always be less “effective” than those that save life years in young people, unless the effect of the intervention is very short-lived, because old people have less years of life to save).
fn7: In fact you can go further than this. All you need is for an elven propagandist to argue that there is a non-zero probability that a single crazy human will kill a single elf at any point in the future, and the expected value of QALYs lost will always be greater than the QALY cost of killing all humans on earth, no matter how small the probability that the human would do this
-
A novel I picked up in (surprise!) Iceland, Zombie Iceland is exactly what it says, no more and no less. It’s the tale of a group of survivors in Iceland after a mysterious gas explosion at a local geothermal powerplant turns the good folk of Reykjavik into Zombies, written by a journalist and comedian called Nanna Arnadottir. The book is billed on its official website as a kind of kooky travel guide, and certainly contains a lot of interesting information (in footnotes) about Iceland, which is cool. In addition to wanting to give foreigners information about her country, Ms. Arnadottir seems to have an excellent nerdish pedigree, according to her website:
The Nannasaurus is a small, bipedal nerdivorous dinosaur of the Theropoda genus native to Reykjavík, Iceland.
The Nannasaurus’ distinctive features include small feet, tiny nose, as well as a decent rack and a sizable brain.
The Nannasaurus’ diet predominantly consists of horror films, fantasy books, kókómjólk and whales tears.
It is widely agreed among respectable scholars that the Nannasaurus’ dream is to own a pet Taun Taun and make goats cheese in her basement.
Also she has a blog, though it doesn’t seem to be much in use.
The basic theme of the book is your standard zombie fare: outbreak happens, people have to survive. The particular points that make it interesting are that a) it is set in Iceland – particularly, in Iceland, so that individual streets and place names are given, and we even encounter a zombie Bjork – b) it sets the zombification in a particularly modern context and c) the lead character is self-consciously Zombie Aware: her childhood was spent playing a kind of zombie preparation LARP with her dad, so their house is basically set up for a zombie plague and she has prepared herself for the inevitable…
Which when you think about it is completely reasonable. There’s no chance of people in the modern world seeing the shambling dead in their street and not understanding the context: as a material threat, the zombie plague is not going to win through unpreparedness. So the lead character, Barbara, has a “bug-out-bag,” a kind of survival backpack; and she and her dad have stocked their basement with food and an old generator, and even considered survival tactics. Unfortunately, they haven’t factored in the behavior of her antisocial sister Loa, or her idiot brother Jonsi.
The book proceeds on this basis, and follows all the usual tropes, except that they happen in Iceland and are interspersed with a range of footnotes describing Icelandic life. There is also a moment of Icelandic cultural insertion, where one of the characters’ deaths is described in a classic Icelandic poetic form. But this book’s biggest contribution to the zombie genre is its incorporation of this self-referentialism into the story. Everyone knows what a zombie is, no one is going to be surprised by zombification, and there is a lot of debate about the particulars of zombie science. This is what I expect would happen. Furthermore, there is a chapter in which the zombie plague is tracked through facebook updates, which is exactly what one expects would happen in a modern plague. Google are no doubt already tracking flu alerts in googleplus, and I bet they’re keeping an eye out for zombie alerts too.
Unfortunately, these good points are somewhat impaired by the fact that the book is terribly written and one of the main characters, Loa, is completely awful. Kind of fun awful, but awful. This makes it kind of hard going at times. It’s a short book, however, and the zombie plague self-referentialism makes it interesting, as does the comedy aspect, so if you’re interested in spending 3000 ISK on a badly written book that has some interesting new ideas to add to the zombie-lite (Zlit?) genre, then I recommend it. Otherwise, you can probably skip it…
-
This is a novel about a magician-policeman set in modern London. The policeman, Peter Grant, is drafted from the normal police service to work for a special investigations department that consists of a single policeman, Inspector Nightingale, and takes on all the investigations into things that no one else believes are real. In order to work in this department, Grant must also become the apprentice to Inspector Nightingale, and thus also begins learning the rudiments of “modern” magic – that is, magic as systematized by Sir Isaac Newton back in the day.
In essence, then, this is a kind of Harry Dresden story, but set in London rather than Chicago, and featuring a policeman rather than a private investigator. It’s the first, apparently, of a series. I hope no one from Chicago will be displeased with or misinterpret me when I say that London is a much more romantic and interesting setting for a novel of this kind than Chicago, and this is not the first novel to use London’s historical complexity and its modern multicultural mish-mash as a setting for the bizarre or the unusual: Gaiman’s Neverwhere and Mieville’s UnLunDun are two other good examples of stories in this field, and both draw heavily on London’s peculiar synthesis of the historical and the modern to lend their tale an additional edge of romance that more uniformly modern cities cannot get. It’s particularly well-suited to a magical policeman story because, well, because London is a city full of crime and trouble. It has a violent and depressing history, and a violent and depressing present, which makes it a bad place to live but a very good place to set a fantastic story of this kind – especially since in novels all the little irritations of London life can be ignored, and the picture can be painted using the broad brushstrokes of history, crime, modernity and multiculturalism.
Which is what we get in this book. Something is up in London, and Grant has to investigate a spate of murders connected to it. The something-that-is-up is connected to a violent grudge that has passed down through history, and is being played out in the very modern setting of post-2007 Covent Garden. There is also a conflict between the different rivers of London – whose spirits are personified in some amusing human forms, and appear to have come to an “arrangement” with the various departments and authorities of the British government. Grant is investigating all this while also studying magic as a new apprentice, trying to get laid, and trying to enjoy his new life as a freshly-graduated police constable. Much of the context of the story is very ordinary and very real – he goes to pubs I’ve walked past, in streets I’ve frequented, and talks of real very recent events that we’re all familiar with. The author also appears to be familiar with police culture and language, and we get a lot of very British policing attitudes coming through. Also interestingly for a novel from London, the author is very aware of London’s overcrowded and multiracial culture, and this is very smoothly worked through the story so that, for those of us who have lived in London, it really does feel like the London we know rather than the sanitized all-cockney-all-the-time London that, say, the Imperial War Museum likes to present. The lead character is himself mixed-race, his mother West African and his father British, and grew up on a council estate in Peckham. Witness reports are particularly amusing because they present us with such a classic hodge-podge of London life as it is now. There’s a classic report of two hare krishnas beating up their troop leader: one is a New Zealander and the other is from Hemel Hampstead. It’s so mundane, and so spot on in its mundanity, and I think this mundane realism serves to ground the magic and mystery of the story very well, so that you really can believe that someone like Peter Grant can learn to use magic and see ghosts and work for the Metropolitan Police Force.
The book also shares with the Dresden Files a well-constructed (so far) theory of and structure for the magic Grant uses. It’s very different to Dresden, and a nice attempt to imagine how magic might feel when you work it – he talks of forms, that you can feel in your mind and have to learn to understand like music. There’s also the first exposition that I’ve ever heard of why magic might need to use language to be cast, and why it must be latin at that. On top of that, the book also attempts to explain magic’s bad effect on modern technology, and Grant of course begins experimenting on this issue as soon as he discovers it, so that not only can we generate a working theory of why the problem happens but he can use it as an investigative tool, and find ways to safeguard his stuff. This is how I imagine a modern wizard would work, and it’s very well done in the story. His depiction of ghosts in modern terms, and his attempts to understand all of magic in terms of the language of computers and science that he grew up with, is also very interesting and I think a quite new take on the genre.
The book is well written and overall the flow of the story is good, though I thought Grant’s first case was a trifle too complex near the end and I’m not sure I understood the relationship between the rivers of London and the case Grant was working on – maybe that will come later. The characters are good and believable and the setting very powerfully like the London I know, but the author has weaved into it all the powerful romance of the city we see in the history books, so that while you always feel like you’re in modern London you don’t forget that this is a London built on layers of history and rich with magic and power. I think in this use of setting the book is definitely superior to a Dresden novel (and, on balance, better written too), and gives a richer and more nuanced vision of a modern magician than Dresden does.
Other comparisons to the Dresden Files also fascinated me while reading this book. The Rivers of London is to the Dresden Files like Coronation Street is to Beverly Hills 90210. In the Dresden Files, the creatures of faerie are always supernaturally beautiful and amazing, and they and the bad guys live in enormous wealthy villas. Dresden gets his girl and is constantly being offered sex by crazed sex goddess super girls, and when he gets a dog it’s a great big supernatural hound of a thing that is more dangerous than most monsters. Finally, of course, there is a lot of heavy weaponry. In The Rives of London, the spirits live in quite mundane buildings – one of the spirits of the river is a traveller – and the characters’ homes are nothing special. Grant doesn’t get his girl and is either warned off the spirit girls, or gets an erection around them while they completely ignore him. He also inherits a dog as a by-blow of a crime scene, but it’s a stupid little ordinary lap dog that doesn’t have any special powers and is a bit overweight and not very helpful. And the only gun that appears in the story is fired once and then disappears, no one can find it and its appearance is frankly shocking because people in London – even criminals – just don’t use guns. I’ve no doubt that things will get more upmarket as the books go on, but it’s an interesting contrast between the artistic styles of the two countries: just like in soaps and dramas, this story conveys that sense of humility and shame-faced shuffling it’s-not-quite-good-enough-is-it?, frayed-carpet and slightly daggy cardigan atmosphere that the British are willing to put into presentations of their own culture. In short, it lacks the brashness of a similar American story. Usually I’m inclined to prefer the brash and the beautiful in American stories to the grotty and mundane in British ones, but in this case I think I like the ordinariness that bleeds out of the pages of this book. I think it helps me to understand Grant as a newly-minted wizard cop better than I understood Harry Dresden.
This is an excellent story, overall, and if this series improves as it goes along (which most series like this do, I think) then it’s well worth getting into. I heartily recommend this tale!

