In the modern world, progress means unemployment. Recent events in the US show that fear of the wreckage of progress is beginning to affect major political movements in the developed world, although it’s unlikely that the new champion of the mythical “white working class” is going to ease the problems they are supposed to be facing. And whatever the particular racial composition of the working classes of the developed world, it is certainly true that they are facing challenges to their economic security, both now and in the future. Furthermore, if we are to move towards a post-scarcity world these challenges are going to be a lot worse. If the developed world makes the right decisions in the next 15 years (I think we can rest assured it won’t) we could see a world of self-driving cars and vat-grown meat, powered by renewable energy from sun, sea and sky that destroys jobs in the fossil fuel sector forever. In some ways we are close to a post-scarcity society – for example, the CSIRO estimates that the Australian coast line holds 8 times the energy required to power all of Australian society – but the changes we make to get there are going to have huge economic and social impact. Beyond the job losses and their cultural impact, what does it mean for Trump’s mythical “white working class” man (it’s always a man), who drives a big pick up truck, works in a coal mine and loves steak, to lose his job in the mines and see his children eating factory-grown meat and driving automated cars?

My own father is a model example of this problem. My father left school at about 15 to start an apprenticheship as a typesetter, and aside from a brief break to work as a hydatids control officer in New Zealand, worked for 40 years as a typesetter until computers destroyed his entire industry in the late 1980s. Finally he was sacked from his job in a small Australian country town, with no severance pay or future, and forced onto unemployment benefits in his early 50s. As a result our house was repossessed, he declared bankruptcy and returned to the UK to live on unemployment benefits, leaving me to fend for myself at the age of 17. This was emblematic of the devastation that computers wrought on this industry in the 1990s, and basically an entire generation of men were driven out of work and replaced by young university graduates with computers. My understanding is that subsequent shake-ups in the industry saw it further consolidated so that the small company my father worked for was probably also extinguished, and replaced with, first, print distribution centres in the big cities, and then print-on-demand services. Now the work of probably 100 typesetters is done by just one person handling print requests from professionals using word software. For my father (and his family) nothing about this story is good, but from an economic and industrial perspective this is exactly what needed to happen, and I benefit from it all the time in the form of cheap printed books and the ease of just emailing a file to Kinko’s and getting it a day later, instead of having to deal with a cranky old bigot like my father whenever I want to print a report. Win! Except for my father and his family …

For my father, thrown onto the dole queue at 50, there was really no solution to this problem. Nobody hires 50 year old men into entry-level positions, and there was no work in his industry anymore, which was in freefall. Sure he could have tried to get work as a taxi driver or some other kind of alternative industry, but these all have barriers to access and they don’t tend to pay entry-level workers the salary they need to support a family and a mortgage. There was no gig economy in the 1990s (nor would a gig economy support the lifestyle needs of a 50 year old man with a family). Like most working class men of his era, he didn’t have the capital to set up his own business, and the only business he could have set up was in any case being systematically destroyed by the computer age. To be clear, my father tried to keep ahead of the game in his field – he wasn’t a slacker, and for example my earliest experience of computers for work was the Mac he brought home in 1988 that didn’t even have a hard drive, on which he was teaching himself to do typesetting tasks (I think he used Adobe products even then!). But staying ahead of the game doesn’t work in an industry slated for destruction, and even in an industry where he might have been able to set up consulting work opportunities the chances of success were limited. Many economists would suggest that this destructive process is liberating, freeing up people like my dad to find new opportunities – to sink or swim in the new economy – but the reality is that when you lose your job with a mortgage and family, in your fifties, in a country town, you don’t swim. You sink. Which is what my dad did, very rapidly.

If we are to move to a post-scarcity society there is going to be a lot more of this, and a lot of it will be more destructive than what I witnessed with my father. The coal death spiral is going to be fast and brutal, and the men who emerge from their last shift in those mines are not going to have alternative work, since they have no education, no skills and no other work. In my father’s case, we lived in a country town that was held up by one industry – the local lead smelter – and that too is now sinking, leaving pretty much everyone else in the town in the same situation as my father. The move to a post-scarcity society has turned that town to a wasteland, and everyone in it is going to have to sink or swim in the new economy.

But should they?

The fundamental problem here is that we are moving towards a society that doesn’t have enough work, in a society that values people only based on their labour. Cast about through the language with which political economics describes what happened to my father and you won’t find a positive term. You’ll hear about men “thrown on the scrapheap”, about “long term welfare dependency” and “cycles of poverty”. You won’t hear men like my dad described as “liberated by technology” or “freed from work”. You won’t hear about how their self-worth was improved by having time to go to flower-arranging classes, and attend to their stamp collecting duties. The only people who are respected for having lots of free time for community work are young people and rich people. Working men are expected to work. But as we move towards a post-scarcity society, what are we to do with all these people we cast into this world of negative phrases and bad stereotypes and empty futures?

In the UK/Australian framework, my father had access to welfare. This meant he lived in a trailer park, earning perhaps 10% of his income as a full-time employee, forced into humiliating rituals of job-seeking and “signing on” to get his meagre payment, even though everyone involved in constructing and managing this system – from Margaret Thatcher down – knew that he would never get another job. Everyone also knew it wasn’t his fault, but you could spend years trawling through the rhetoric of the politicians, the newspaper columnists, and hate radio, and you would never hear talk about people on unemployment because their job was destroyed by a businessman’s strategy – you only hear about dole bludgers, the undeserving poor, people who can’t be bothered to pull themselves up by their bootstraps. Into this world fell my father, proud working man, never to work again, to live on scrapings from the bottom of the government’s deficit-financed barrel.

That isn’t really right, is it?

But we’re going to see a lot more of this, so we need to start thinking about how to handle it. In particular, we need to recognize that as we abolish whole industries with sweeps of policy, we’re going to create more unemployed than we can find jobs for. We need to start talking about these people not as victims of structural readjustment, but as beneficiaries. Instead of bemoaning their fate, we need to welcome it, and treat them accordingly. Instead of telling my father he was thrown on the scrapheap, we should be saying to him, “congratulations! Technology abolished your job! The rest of your life is yours now, thanks for all your effort!” But we can’t do this if we don’t back it up with a proper respect for his material conditions. If we’re going to move to a world of infinite energy supplied by the sun, using solar panels constructed by a machine and monitored by a single guy who manages a solar farm big enough to power a city, we’re going to have to find a better way of dealing with all the coal miners and gas extractors that is better than saying “sorry!” and giving them a meagre welfare payment. So here are two proposals for how to manage the shift to a post-scarcity society, that are based in the reality of where we’re heading, rather than a behavioralist economist’s ideal of a kill-or-be-killed employment market.

  1. Accept the reality of job losses and growing unemployment: Rather than simultaneously treating structural adjustment as a disaster for workers while also demanding they get another job, any job, recognize that people done out of a job by the movement towards a world of no work are the beneficiaries of that move, and the first new citizens of the post-scarcity era. Identify industries that are obviously being destroyed – whether by offshoring, technology, or policy design – and offer specific rescue packages for the workers involved. Not stupid retraining packages based on the pretense that a 50 year old guy kicked out of the only industry he ever knew can ever work again, but real maintenance packages. Say to these men and women, “thanks for your years of work. Progress means your industry is gone, but we appreciate your efforts, and we understand this is a big change, so we’re going to support you.” Provide protection for their homes and incomes, and offer them the chance to retire early with dignity. Don’t insult them by treating them as if they were a 20-something dole-bludging surfer taking 6 months off the labour force to find the waves – offer them a real readjustment package that says “thanks, we appreciate your work, and we don’t need it any more, here’s your reward for a job well done.” Begin to build a class of post-scarcity citizens, not a class of post-adjustment wash outs.
  2. Consider education as a job, not preparation for a job: My father left school at 15 to pursue a career in an industry that was destroyed around him in a few years when he was in his 50s. But a 9 year education is not enough to get by in a modern society – this is a sacrifice he made in his youth to support an economy that changed around him. After his industry failed he spent the rest of his working-age years languishing, with nothing much to do, viewing the world through the lens of a working man with very little education. In the modern world we need as many people as possible to have the best possible education, so why not send him back to school? The government could have said “Thanks for your efforts, we realize that you left school at 15 to help society grow, and now we don’t need your work anymore and we don’t think that’s a fair exchange. Why don’t you go back to school and make up all those years you lost? And if you finish school and you’ve got the thirst for it, we’ll support you through university as well.” Of course, in many developed countries there is no actual barrier to a 50-something dude going back to lower high school – but we know they won’t do that without support, because it just doesn’t work that way. So support them, and make sure that their 40 years of contribution to society doesn’t hold them back from enjoying the same education as even the lowest surfie stoner in the modern world. And if this means that my father spends the last 15 years of his working life going all the way from lower high school to a PhD, then retires and never does anything with it, so what? Our society can afford it.

This is the reality of the modern world. We can afford so much more than we give out. The wealth my father’s efforts generated over his career would have been way more than sufficient for him to be retired 15 years early, the mortgage on his house supported by the government, and an education thrown in for free. He worked hard for some of the biggest publishing companies in the UK and Australia, massive profit makers whose role in the economy was significant. They no doubt paid (or should have paid) more than sufficient taxes to reimburse him for his labour once they no longer needed him. And if we are going to move to a world where most jobs are no longer necessary due to science, automation, or the need to abolish certain industries, we need to recognize that people like my father will be the first denizens of the brave new world we’re creating. We need to reward them, not punish them, for their service. Furthermore, we need to consider the possibility that even with the best, most perfect industry policies in the world, we will only create 1 job for every 2 we destroy – in which case we are going to be permanently increasing the size of the non-working population. So we need to start thinking about maintaining them, not as a burden on the rest of society, not as people who just won’t get a job, but as the forerunners of a society without work.

We are heading towards a society without work. The first people to experience that society are the long-term unemployed and the unemployed older workforce. If we don’t find a way to treat them as full citizens, and to ensure they can engage in society as full citizens – with accompanying salaries and bonuses – we need to realize that sometime in the future we are going to be living in a society with a very small number of wealthy workers and a very large number of poor unemployable people. Such a society is not sustainable, and in some ways, if the rhetoric about his voters is true, Trump is a sign of what will happen to us if we don’t deal with this issue.

Technology is intended to liberate us from labour. We call them labour-saving devices for a reason. But ultimately we need to recognize that once you have liberated a certain number of people from labour, you have created a new, non-working society, and you need to find a way to manage it. We want a post-scarcity society, not a post-happiness society. So let’s start thinking about ways to reward people for a lifetime of labour, rather than punishing them for picking the wrong industry 40 years ago.


The devastated coast of Minami Soma City

On Monday I took a two-day business trip to Minami Soma City, in the disaster-affected area of East Japan. Minami-soma city was hit by the tsunami, and although there does not seem to be much online footage of Minami Soma City’s experience, the effect on nearby Soma City (just north of Minami Soma) can be seen in this terrifying video (the main wave is at about 8 minutes). Minami soma city is just 23 km from the Fukushima Number One nuclear power plant, so soon after the tsunami hit the town was included in the government’s 20-30km voluntary evacuation / limited outdoor activity zone. Its population reduced enormously in the weeks that followed, and has now returned to just over half its pre-tsunami numbers. The town is also home to about 6,000 displaced persons, living in temporary housing. My purpose in visiting – along with some of the students of my department – was to help the local hospital with some research they are doing into the health of these displaced persons and of the residents of the town generally.

As part of my stay I was taken to the area where the tsunami hit, which is a stretch of coastline extending a few kms inland from the sea. These photos show some of the damage that I saw there. The full set can be viewed in my flickr account.

Entering the ruins

When we drove into the area I thought perhaps it used to be farmland, because aside from the piles of rubble it is completely flat, but in fact this whole area used to be houses and businesses. The ground is flat like fields because it was scoured clean of all but the largest structures, and the resulting rubble has been gathered together into great piles of debris (visible in the photo above). This gives the area the impression of being a moonscape or wasteland, where once houses used to be, and the area from which one enters the destruction zone is lined with these piles of rubble. If one drives for a few more minutes, one can reach the sea wall and look back over the entire devastated area, as in the picture below.

Sunset over the devastation

The sea wall itself is about 4m high on the outside, made of huge slabs of concrete. On the seaward face there is a small stony beach and then some lines of tetrapods (concrete structures that act as further wave barriers). The sea wall survived the tsunami, but was heavily damaged and didn’t serve to impede it. Parts of it were broken off and swept away, and its landward side was heavily damaged. I think the wave just ran over the top of it. We walked along this wall and the two photos below show the wall in both directions. The photo at the top of this post, of Miss A returning to our car, was taken from the top of the wall.

Looking south in the lee of the sea wall

On the sea wall, looking north

Facing North (the second picture of the sea wall), one can see the only surviving structure near the sea – that strange orange building that has been hollowed out but withstood the wave itself. I guess other smaller objects survived but have subsequently been removed in the clean up, because as we left the area we entered the rubble zone and passed huge piles of broken stone that must have been taken from this area. We also passed a graveyard of cars. In amongst all this neatly-arranged debris there were also a few boats.

A fire engine

We spent the night in the hospital, in one of the unused wards. Staff levels have declined at the hospital, though the patient load has as well, but business seems to be going on pretty much as normal there. In fact, this is one of the strangest things about Minami Soma City: once you pass over the low line of scrub and hills that separates the unscathed part of the city from the damaged area, life goes on pretty much as normal. It’s as if nothing ever happened here, except that it’s quieter than a normal town and a lot of the businesses are on reduced hours or shut. It’s not a ghost town, though, and everything is perfectly normal there – we went out drinking and having fun with the other doctors in the evening, and everything was just like any other rural Japanese town, if a little quiet.

You are 23km from Fukushima Number One plant

As the sign in the hospital says, Minami Soma City is quite close to the power plant, and the only road leading to it from Fukushima passes even closer. It’s quite hard to get to Minami Soma City – there are only 3 buses a day from Fukushima, so it’s either a long bus trip to Tokyo (probably 6-8 hours) or a bullet train to Fukushima city and then one of those three buses. The buses were also not able to run at first, because of the exclusion zone, but now they’re open and the journey to Minami Soma City takes us through several deserted towns in the exclusion zone.  I think a few people might still be staying on in these towns but they were largely deserted, and the only people I saw were a work crew in full radiation suits, cleaning an outside area in the driving snow. The only other signs of life in the area were animal prints in the gathered snow.

This whole area is obviously struggling with the triple challenges of dealing with the aftermath of the tragedy, rebuilding, and the fallout of the nuclear plant. Many people have left and the area is certainly suffering physically and economically. With the one year anniversary of the events coming up soon I imagine a lot of sad memories of the tragedy will be rekindled. But the people there are kind, friendly, and full of warmth and energy not just to rebuild their town but to turn the tragedy into useful lessons for disaster management in the future. I’m hoping through my advice and support to provide some small contribution to that process, and perhaps to be able to learn some lessons about post-disaster management in an aging society. The atmosphere there was one of hope and energy to make a better future, and despite the sad story that these pictures tell, the people there offer a great deal of inspiration to make a better future. Let’s hope that working together the people of Japan can overcome this disaster and, through their experience, offer other countries lessons they can use to overcome their own future challenges.

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.


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

…by Rudolf Klein.

Sometimes I feel my contribution at work is entirely too technical, so I have decided to broaden my knowledge of the political context of my work by reading this excellent introduction. This seems particularly apt since although I lived in England as a child, and have a British Citizenship, I am essentially Australian and my knowledge of the National Health Service (NHS) must necessarily be at something of a remove. So I hauled it out of the King’s Fund Information Centre on Friday and have read quite a bit already during the long and complex railway meanderings of my weekend.

This book traces the philosophical and political debates surrounding the formation, management and renewal of the NHS since its inception in 1948. Given that the NHS was the first single payer national health system in the world, and radical at the time, this makes the topic marginally interesting even from the perspective of someone whose job does not directly involve this well-respected institution. The book gives both a context for the “radicalism” that the NHS represented, and a cogent analysis of the competing interests of its progenitors and its management. It’s interesting that things which can seem so radical and new from the outside can actually, upon closer inspection, be seen to have been at least in part just the natural consequence of the muddled ideas of a bunch of pragmatists, and the NHS is no exception, as one sees in the first chapter. And really, I think in the end this is a more interesting discovery than if one were to learn that the NHS sprang fully-formed and novel from the madcap ideas of a pure Socialist dictator. It makes it seem simultaneously both grander and more humble than such a project, and makes clear that while from the outside the NHS may have seemed a radical idea worth copying (as indeed it has been), from within it was a natural continuation of more than ten years of tinkering.

So far this book has been interesting and insightful, and already I’m able to draw parallels and contrasts between the policy debates of then and now. It will help at the very least in establishing a context for what I do. But for a non-professional reader, who can stand a little dry historical writing – and particularly for my American reader, for whom the topic of health care reform remains rather more topical than perhaps it is in England – I recommend it (or at least the first few chapters) as an insight into the nature of a single payer health system, and the political realities which drive its creation. I think it will be fascinating to read, 50 years from now, the equivalent account of the health care reform which America has to have…