• Stupid, incompetent, unhealthy people

    Last week, Harold wrote some great posts about the work of Sendihl Mullainathan and Eldar Shafir on poverty, thinking, and behavior. I want to comment on how this pathbreaking work should affect how we think about health and justice.

    To set the stage, here is a model that explains why poor people have poor health.

    dysfunction_model_Page_1That is: many poor people have poor cognitive skills — that’s a reason why they are poor — and people with poor cognitive skills smoke, drink too much, eat bad food, and so on. These behaviors lead to poor health.

    Call it the stupid incompetent people model. It’s an uncharitable model, because it attributes poor health to the capabilities and characters of unhealthy people. It suggests that many of the unhealthy poor deserve that fate. This isn’t the whole story, you say. Many capable people screw up their health. And poor health often has nothing to do with our character or behavior. It’s just bad luck.

    But being uncharitable is not the same as being wrong. SES is strongly associated with health and with many health behaviors. David Cutler has data showing that intellectual abilities are associated with health behaviors. Linda Gottfredson reports data showing that intelligence predicts both health and longevity.

    Moreover, don’t we want the world to be structured so that functional behaviors — abstaining from cigarettes, or pursuing more education, or saving for retirement, or… — lead to higher income or better health? Doesn’t a world with incentives for functional behavior benefit everyone? These incentives lead to prosperity, stable families, low crime and so on. Conversely, in a world without incentives — a world that redistributed outcomes so that virtue had the same reward as vice — there would be less of the good things that virtuous behavior produces. Life would be that much more solitary, poor, nasty, brutish, and short.

    So why isn’t the stupid people model a description of a just world?

    One reason is that it holds people responsible for personal attributes that they do not control, such as the genes they received from their parents. Another reason is that the model does not acknowledge that many of the rich are highly capable because they had well-off parents. Those parents invested time and money in their children’s health and education. Conversely, many of the poor have limited capabilities because they were raised in relative deprivation. This graph (thanks to @BrendanSaloner) shows how much more the rich spend on their children compared to the poor, and how that inequality has increased over time.

    Saloner

    Because the children of well-off parents get a better start, we don’t have fair equality of opportunity in the competition for better outcomes.

    Mullainathan and Shafir’s data, however, lead to an important new criticism of the stupid incompetent people model.

    M and S present extensive experimental data showing that the experience of scarcity deeply affects our ability to think. When primary resources like food, money, or time are scarce we experience a kind of tunnel vision. In the tunnel, information related to the scarce resource dominates our thinking at the expense of the many other things we need to monitor. We have reduced attention, memory, and self-control and we make worse decisions. These changes are unconscious, automatic, and largely beyond our willful control. In short, scarcity makes us stupid, leading to bad choices about health behaviors. From their book,

    Poverty itself taxes the mind… poverty reduces fluid intelligence and executive control… this suggests a major twist in the debate over the cognitive capacity of the poor. We would argue that the poor have lower effective cognitive capacity than those who are well off. This is not because they are less capable, but rather because part of their mind is captured by scarcity.

    So now there is a new causal model for why the poor are unhealthy.

    dysfunction_model_MS

    Whereas in the stupid people model poverty and ill health were the outcomes of bad decision making, now bad decision making is an outcome of poverty. Even more important, this vulnerability to bad decision making is not a special vice of the poor. Instead, a propensity to bad decision making in the face of scarcity is wired into everyone‘s brain. The key problem isn’t that the poor are incompetent but rather that they are chronically exposed to scarcity. Our social policy must address that inequality of scarcity.

    The M and S model, if their data hold up, complements rather than replaces the stupid people model. In the real world, causality runs every which way. As I see it, everyone should have access to insurance to protect us from bad luck and, to some degree, our own stupidity. Nevertheless, it’s right that people should experience much of the pain generated by their own incompetent decisions. But we should also have a society with a priority on ending chronic inequality in exposure to scarcity — more briefly, poverty — and ensuring substantive equality of opportunity. It’s only fair.

    @Bill_Gardner

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    • My experience working with people from developing countries absolutely supports the theory that scarcity of resources like food and money directly leads us to be more risk-averse, shortsighted, and ultimately to make worse decisions. Blaming poor people for their poor health without recognizing the effects of scarcity on cognitive behavior is just callous.

      • Mark, you may want to look at Bannerjee and Duflo’s “Poor Economics” book. Great discussion of these issues.

    • There are all kinds of “cognitive functioning”. Having the emotional means to care about something would be a form of brain activity taxed by distraction and stress, as would resisting impulses, or making good long- or medium-term financial decisions and so on. People don’t do things because they think that thing is a good idea. Literally no one thinks smoking is good for you, no matter how stupid they are, and it doesn’t stop a lot of very highly educated people, *potentially more frequently ones who grew up poor*.

      Furthermore, not being able to afford a doctor, or vitamins, or a gym membership, or psychotherapy, or decent food, or time off, or exterminators, etc etc etc might, over time, damage your health AND damage your expectations of what your health should look like. Poor people are unhealthier because a) material circumstances, b) they’re forced to learn to live with pain and other glitches that balloon into chronic problems when left untreated, and c) they take what they can get pleasure-wise because they put up with so much bullshit and can’t afford healthy ways to relieve stress like Polynesian ski cruises or electronic cigarettes.

      Poverty might negatively impact someone’s intelligence too, but it really seems like a separate issue. An innately smarter person might be more likely to hold health as a high-priority value and make logical decisions that lead to that conclusion, but not necessarily. But we know for sure that more educated people are less likely to make poor health decisions – probably not because they know more, but because they are more likely to follow through on things for their own benefit, and they feel like they have more control over their lives because they’ve achieved more, and they may have more actual money and so on. If there’s a correlation between intelligence and education, it might explain how the various authors got confused, seeing as poverty and education aren’t associated.

      • LC, those are all cogent points. I think the M & S work is probably too new to say how important their scarcity-driven-processing model is relative to other psychological aspects of poverty.

        But from the point of view of the argument about justice that I am trying to make, I think your psychological observations and M & S’s both lead to a similar conclusion.

    • I would like to see a conservative response to the findings.

      I might anticipate streaks of : overapplied theory and data as well as liberals being “all heart and no head.”

      Brad

      • Brad, usually they just tell me I have no head leave it at that.

      • I’m not a social conservative, but I have libertarian sympathies on certain issues so I suspect that’s close enough.

        I was fortunate enough to grow up in a truly diverse environment, with peers ranging from rich kids to full-bore gang-bangers. My intention isn’t to rebut this post, which contains quite a bit of analysis that I agree with, but merely to state that a focus on income, intelligence, and education oversimplifies the complex set of pathologies that generates the statistical association between poverty and ill-health.

        Based on my experience, I think that the most important thing it overlooks is cultural wealth, which consists of all of the values, norms, habits, and behaviors that encourage prudence, conscientiousness, helpfulness, resourcefulness, etc. You can literally witness the effects of cultural wealth manifesting themselves in less than a generation, as you see the children from group A vs group B or family A vs family B start and continue on vastly different paths, despite the fact that their parents have similar levels of income and education.

        It also overlooks the fact that a great deal of the benefit that the children accrue from their parents has to do with fostering these norms, behaviors, habits, and values, rather than cultivating a taste for great literature or classical music, or forcing them to solve logic puzzles instead of watching cartoons. It’s very challenging – but perhaps not impossible – to construct a regime of transfer payments that has any effect whatsoever on this disparity.

    • And that is why professional athletes, lottery winners and rock stars rarely engage in destructive behavior, because they have no scarcity and poverty. They start good character chains that last for many generations. And Cheers to Lindsay Lohan and Charlie Sheen.

      The above the opposite of the real facts, one could just as easily make a case that a life of plenty leads to dissipation and a lack of motivation.

      Here is a story about the poorest county in the USA: A Village With the Numbers, Not the Image, of the Poorest Place

      I do want to be read as not having sympathy for the poor because I do, I just want to make a case that Mullainathan and Shafir’s work is silly. Yes, silly!

      There is a drunk who walks around my neighborhood, I have tried to talk to him but he has not responded but if he does I will not say poor you scarcity has destroyed you. I think he cannot help him until he wants to be helped.

      You may not like it but people have rights and thus must want to be helped so if you give a drunk more money he may drink more.

      • In the aggregate, did the professional athletes, lottery winners and rock stars start off poor or disadvantaged?

        Some did, some didnt, but my guess would be sudden fame or fortune places individuals in a very difft category that the folks in Bill’s post (considering whence they came).

        Also, dont conflate alcoholism as moral failure vs bonafide disease. Not getting into college does not quality as an ailment. I get what you are attempting to say, but bad example.

        Brad

        • Sympathy for the poor is great, good, admirable, wonderful but misdiagnosing the problem to show sympathy for the poor will not help.

          Is anyone in the USA living with levels opportunity and privation below those of the median person in India or Pakistan.

          Promising athletes in USA are often given help and opportunity from and early age. Also it a poor early environment were a such a problem for academics wouldn’t it also be bad for athletics?

      • F, thanks again for commenting.

        Surely, M & S are not arguing that scarcity is the only cause of poor decision making. So I do not think that Lohan and Sheen are important counterexamples.

        The case of Kiryas Joel is very interesting. One of the great contributions that religions make is that they provide social reinforcement for self-discipline. This is why the Puritans and the Mormons were so much more successful, in my view, than the other groups that tried to cope with the American frontier. Although I know less about it, I imagine that Islam similarly delivers great benefits to many poor people in the Middle East and South Asia.

        • Is that why despite the massive mineral wealth many of those areas in the Middle East rank among the poorest in the world?

      • Scarcity does make people more likely to drink. Do you think people tend to be alcoholics first, or hobos first? I don’t know if there are figures on that, but what I do know is if you’re living in a tack shed you might as well drink. It’s not an uncommon sentiment in that situation, whether you’re a 3rd grade dropout or a former Harvard professor. “The poor” aren’t even a group you can talk about in aggregate, seeing as it’s most people. I say, buy a man a drink in a situation where you’d want a drink bought for you, because who knows.

        It’s weird that all the reporting on this research has glossed over the old research about impulse control and memorizing number chains. You know, an “apple or cake” decision, where some people had to memorize 7-10 digits, and the ones who were distracted by their task were more likely to choose cake. It’s the same thing, and it affects people of all socioeconomic strata because it’s to do with the amount of information they’re keeping track of.

        Very rich and famous people like Charlie Sheen are probably confronted with bits all day, which makes them more likely to seek relief in hookers and blow. Just knowing you had that much money would be distracting on some level. This may also go toward explaining the poor moral and mathematical reasoning of bankers.

        • what I do know is if you’re living in a tack shed you might as well drink.

          I could say with equal validity that if your parents are affluent and likely to leave a good inheritance you might as well drink and you certainly should not waste your youth studying.

          • On what planet is that even vaguely similar? You’d get it if you lived in a tack shed at any point.

          • Clarification: I spend most of my time around people who don’t have things like running water or heat, let alone access to mental health care. Most of them drink. People in stressful situations, like the entire state of Alaska, drink. People in Siberia and Norway and Ireland drink excessively too, because the weather’s bad. People see a shitty situation and think “I might as well”. Generally they’re not going to be that much worse off, if the shitty situation is the power went out and your cabin is freezing up again.

            Double clarification: Obviously rich spoiled kids drink, but there are tendencies in the general population to drink more or less in certain situations. There are statistics and shit. “X nonsense is equally likely” isn’t a point, because we can actually measure things about the world around us and see what is or isn’t more likely.

    • I’m not sure that all the “bad” decisions that the poor make are as bad as they look from the perspective of someone not in their shoes:

      Many behaviors that have long-term health consequences, may have far more short-term rewards for poorer people than richer. For example, smoking. I remember reading about a construction worker who did heavy physical labor. He commented that if he needed a break, and stood around for 5-10 minutes resting his muscles, his boss yelled at him for slacking off. But if he took periodic smoking breaks, that was okay. So he bought cigarettes and pretended to smoke. I’d expect smoking breaks are valuable releases of stress for Walmart workers, too. If you’re a higher level employee, your boss is more likely to trust you to get your job done.

      And, of course, if your parents smoke, cigarettes are much easier to get hold of, than if they don’t. I smoked my first cigarette from a pack a friend’s brother had left lying around when he went to college, so it was there. Had he left cigarettes around far more often, we might have become smokers.

      • When I was 28 I was still making only about 20% more than the minimum wage (working in restaurants) and I spent my money much more carefully then than I do now and I think that is typical. I did things to advance then that I no longer feel a need to do. Wealth is surely demotivating. Democrats often argue that:
        1. Redistribution so income is good because the marginal value of money goes down the more that you have and I agree.
        2. That poverty is demotivating and I disagree with that.

        • 20% over minimum wage isn’t poverty, it’s a good job. Saying you were motivated to improve your situation when you were actively working a relatively high paying job isn’t evidence that poverty is encouraging. The fact that you don’t KNOW that would be a good job for most people suggests that life has been wicked freaky easy for you and those you know/love/base your political views on your experiences with (which would naturally be demotivating and drive you into a wanton life of substance abuse). We are talking about America here, that might make a difference. Maybe being employed and making 20% over minimum wage is really shitty in Sweden or something, idk.

    • The War on Poverty begun under the LBJ administration dealt with evening out the playing field using government agencies and funds. Almost a half a century later and the expenditure of Trillions of dollars we really have not made the progress intended.

      Don’t think I am insensitive to the needs of the poor and needy folk. I’m not. I have been listening to this type of rhetoric for decades and all the wonderful solutions, but it seems that these types of answers have made things worse for many in the neediest communities.

      • Building on Emily’s post I have often thought Liberals/Progressives are about intentions – Libertarian Conservatives are about results/outcomes.

        I have no issue with funding EFFECTIVE programs. I do have a problem with building a massive boondoggle to lock in a horribly expensive health care system – something that greatly benefits insurance companies, drug companies, some medical professionals and will not improve the health of anyone.

      • Emily,
        Thanks for commenting, but I strongly disagree.

        The ‘War on Poverty’ did not, of course, eliminate poverty. However, most of the programs in the War on Poverty have significantly benefited poor people. It is hard for me to see how they have made things worse.

        Head Start has arguably accomplished much less than it should, but how have children been harmed by preschool? Legal Aid has given millions of poor people access to legal representation — how is that a harm? Food Stamps have given millions — including members of my family — critical nutritional support.

        Many people who claim that the War on Poverty was harmful cite the welfare (AFDC) program (you may not share that view). Whether this was a net harm to poor people is controversial. What’s not in question is that AFDC was created in 1935 and was not part of the War on Poverty.

        Of course, the really important War on Poverty programs are Medicare and Medicaid, created by the Social Security Act of 1965. The TIE authors think that these programs need to be reformed. Nevertheless, I think we agree that they have significantly benefited the poor relative to the counterfactual of no government health insurance. Avik Roy has argued that Medicaid is harmful, please see Austin’s replies. I’m not aware of anyone who thinks that Medicare harmed the elderly poor. Poverty among the elderly dropped from 30% before 1965 to 15% by the 1980s. This is an extraordinary improvement in well-being, much of it attributable to Medicare.

        • Let me ask you Bill, is the black community better off than before? The number of single parents has risen. The number of young black men in jail, going to jail, or released from jail is horrendously high. How about job opportunities, education, etc.?

          Prior to the War on Poverty the indices were moving in a positive direction and from what I have read that positive movement fell afterwards.

          Understand I am sympathetic towards all groups that are needy, but we have to evaluate what has already been tried and failed. We have to evaluate our attitudes to see if our actions are for our own benefit to make us feel better about ourselves or if they are truly benefiting the needy. I think the former is more frequently found in the mind of people than the latter.

          Recognize that I understand the horrors of discrimination and am against such action, but human nature doesn’t run parallel to the laws and programs we pass. Then again we have to remember Newton’s law “every action has an equal and opposite reaction” and that grossly applies to the social sciences as well. I am not against all support or all government action, but much of it has been done to the disadvantage of the people we wish to aid and too much of it was ill devised. In business my contracts never lack clauses to contain financial and other risks. Since government deals with other people’s money it seems that type of clause is all too frequently forgotten.

          We also have to weigh the trade offs. It is easy to point to the benefits of any program where anonymous money is being utilized. However, when one moves from the abstract to real time one often sees a different picture.

          Was Medicare good for many people? Of course, but that doesn’t mean the program as created was good for America. Was social security good. When passed it amounted to many many Americans supporting one retiree. That is now approaching three Americans supporting one retiree. There is a price that is being paid and that is why we have so many budget problems and are forced into so many solutions that negatively impact our GNP and employment figures.

        • Bill and Emily I think that you are talking past one another. Even while the war on poverty reduced real poverty one would expect it to increase drinking, drug use, single parenthood, indolence, obesity etc.

          There was an old saying “We are not poor we just don’t have and money.” So there are differences in how people define poor.

          • Floccina, you have a valid pint that I agree with. Everything is dependent upon the way of looking at the abstractions. As you already know that is why it is important to look at real people and see what has occurred.

            One should take a population group such as blacks and see the progress made before and after the War on Poverty. See where they fit into society. Compare all the variables, not just some and then draw conclusions of effectiveness.

            I know some will listen in Horror when I paraphrase what was said in the book the Bell Curve. That horror can be misguided if one didn’t read the book or read it without listening based upon a preset belief of what one believed the author would say.

            Murray made an important point. If one really wants to alter socio economic status one must start by altering the family environment indirectly mentioned by others on the list. Appropriate nutrition is also something to be considered, but providing free food doesn’t mean that the child will receive appropriate nutrition. Protection is another element that Murray may or may not have mentioned, but I believe from my experiences in the field (I don’t claim expertise) that protection is lacking.

            Money wasted on programs that do not work leave an ugly scar on those that need help the most.

    • The issues of people not behaving in accordance with a dispassionate rational analysis of their situation are complex. Let me add an anecdote to this. When my parents were in concentration camp, they valued cigarettes more than food. To a sated, comfortable person this seems crazy, but is it possible that the immediate satisfactions of biological needs including hunger are fulfilled by nicotine better than by a little food? Poor farmers in many parts of the world grow tobacco instead of nutrients. Perhaps the destructive drugs used by the lower economic strata of all societies answer some real needs.
      Floccina: there was a homeless man who slept in a park near my home. I did manage to engage him one rainy morning when I offered to buy him a meal. He refused my offer and explained to me that he was a prophet sent from G-d and did not need human intervention. He had rejected social agency intervention in the past. My diagnosis was simple schizophrenia; although, he might have sent from above to test all of us.
      My family was thrust from a reasonably comfortable working class life into a world of social pathology by being put into a situation of crowding, deprivation, and poor sanitation in Ghetto Lodz. Later in a better place, their children became doctors and lawyers.

      • @oncodoc
        The schizophrenic man is a good example. His poverty probably did not cause his schizophrenia rather his schizophrenia probably caused his poverty. You tried to help but you could not partly because he has rights. It is even hard to get schizophrenics Baker acted unless they are dangerous to themselves or others. My wife once offered to get a homeless a hotel for a couple of days so could get out of the homeless shelter for a few days and clean up relax. She refused because she said that hotels use pesticides. There is only so much you can do.

        I think that people are getting me wrong I think that the study is down right silly but that does not mean that I do not care for the poor. I think that we should give $150/week to each adult in the USA and provide subsidized access to schooling and healthcare to those who earn below median income and then eliminate all the other welfare programs (SS, Medicare, TANF, SNAP). If that makes me heartless I would like to know why. I also think that cheap very, very small almost indestructible housing should built for the homeless.

        (BTW We support a homeless shelter and habitat for humanity (I do not know why people like me must say this in debates like this, I feel like if I do not, you all will think that I am just cheap and mean)).

        • BTW Easier cheaper access to anti-psychotic and depression meds like risperidone and Citalopram might help. You could make them over the counter or at least allow anyone with a psychology BA to get them. From what I understand psychology the most popular undergraduate major. Make sure we teach the psychology undergrads the dangers.

          • A couple more things:

            A complete end to the war on drugs might help some poor people. Alcohol seems to worse that most illegal recreational drugs.

            Also making ex-cons records go away might also help. It is currently too difficult for ex-cons to get jobs.

            Lots of stuff would help but that nonsense in the study would not.

    • The finding that scarcity harms cognitive capacity is fascinating, and should help us think about how to tackle poverty.

      I don’t want to forget about the environmental factors, though. As a nation, we are geographically highly segregated along class lines. If your parents are poor, you are overwhelmingly more likely to be exposed to toxins like lead paint. You are overwhelmingly more likely to attend poor schools. You are overwhelmingly more likely to have inadequate nutrition. You are overwhelmingly more likely to have personal exposure to violent behaviors. These factors have been shown in many studies to reduce mental capacity.

      • The worst part, in some ways, is that a lot of intelligent people come through that process. I mean, people who are astonishingly smart. Oftentimes they’re too distracted or damaged to do anything “useful” with it, but that’s a different kind of mental capacity. Impulse control, for example. But they’re not stupid, and if you have a nice family you can make it in the world without being very bright.

    • oh if only we humans did everything logically….sorry Spock was a fantasy character on a tv show