Policy synergies

Last week, I suggested that any government worried about productivity and health costs of things might wish to encourage that there be more sex. It seems to be good for earnings. 

Today, Tim Wilson at The IPA points me to an Australian public health advocate's wish that sitting for more than two hours consecutively be banned. Professor Jonathan Shaw there is worried about diabetes risk. Sitting for extended periods may increase diabetes risk:

"We need changes to occupational health and safety regulations so it is not allowed for people to sit for two hours at a time without a break," he said.

"I think everything should be on the table - taxation levers, town planning, even the layout of office spaces needs to be reconsidered to tackle the growing personal and community impact of chronic disease," he says.

Perhaps we could combine both findings. Instead of banning sitting or taking these kinds of hard paternalistic lines, we could perhaps imagine encouragement of discreet workplace venues that might...

Ok, I'm just going to end with the </reductio> tag and leave it at that. But if someone successfully combines the two in an interesting defense in employment court, I'd love a pointer to the judicial decision in the comments.

Creating the climate

The University of Otago continues lobbying for fat taxes.

At Otago University's Waistline seminar yesterday, where politicians were challenged on ideas like a 20 per cent tax on sugary fizzy drinks, much of the attention was on big-picture regulatory policies, as weight-loss schemes directed at individuals are often not very effective.
...
Targeting teenage girls might be ideal, "but unfortunately teenagers aren't that receptive" to nutritional and physical activity interventions.

So the population-wide measures, like taxes on sugary drinks, were most likely to make a difference.

Several other researchers threw in traffic-light labelling - to mark foods as healthy or unhealthy - as an important part of combating a food "environment" which promotes obesity.

Professor Robert Beaglehole called for a national strategy on obesity reduction - which National MP Paul Hutchison said the Government would release in months - and for a social movement, as with tobacco control, to create the climate for controls on the food industry. [emphasis added]

"Obesity (here) is a public health disaster ... It is a tragedy at the personal, family and social levels. It's a pandemic." 

They want to create the climate for controls on the food industry. I suppose that the study on the social costs of obesity could have been part of that.

Beaglehole won the 2010 Public Health Association award; the PHA highlighted his work chairing the SmokeFree Coalition.

Previously:

• Some of the problems with taxing fats and sugars;
• More on fat taxes and fiscal externalities;
• The obese have higher lifetime health costs, but moral hazard through the health system isn't the cause;
• My quick fisk of the recent NZ obesity-costs study;
• Penn & Teller on nudges and fat taxes.

HT: ed.co.nz

Social Costs and HPV

I've seen the light.*

Here's the New York Times on recent findings about HPV.

In the 1980s, only a small number of throat cancers were linked to HPV infection. Historically, patients who developed the disease were in their 70s and were heavy smokers and drinkers.

Now, about 70 percent of all throat cancers are caused by HPV, up from roughly 15 percent three decades ago. Patients are now more frequently middle-aged husbands and fathers who are economically well off, nonsmokers and not particularly heavy drinkers. Men are three times more likely to be diagnosed than women with HPV-related throat cancer.

In short, 70% of throat cancer is caused by HPV transmitted during oral sex. And we know that when private actions impose costs on others through the public health system, there's a prima facie case for government intervention.

Let's run the drill. What are the social costs of risky sex? And why haven't we taxed it yet?

First, any risky act undertaken with imperfect knowledge about possible consequences cannot, by assumption, yield any benefit for the person bearing the risk. It's all market failure. We will consequently assume that hazardous oral sex of this sort is not pleasurable for anyone involved, so there are no offsetting benefits that must be counted when we go about regulating and taxing. Recall that sex addiction is very real and that there is no known safe level of sex; every sex addict began with a single sex act. There's no possible reason that anybody could be engaging in risky sex other than irrationality or addiction, given that we've assumed that there's zero benefit from doing it. Why else would somebody do something that has zero benefit?

And we also know that oral sex is like a gateway drug: I'm sure that the Dunedin Longitudinal Survey people could really easily show that teenagers engaging in oral sex were more likely to go on to try other sex acts at younger ages and with more partners than those who showed more restraint. I bet they're also more likely to try marijuana.**

So what then are the costs? Well, let's apply sex attributable fractions to a whole host of disorders. 70% of throat cancers are due to HPV, which is by definition a consequence of undertaking a risky sex act. And there's all the other STD costs. Add up all the treatment costs, add up all the costs of premature mortality, double-count the costs of productivity losses, add in some estimates of intangible costs falling on friends and families of those suffering. Then add in all of the costs that men and women incur in finding partners for engaging in sexual activity: all the costs of attractive clothing, the opportunity costs of time spent trying to attract a partner, the direct costs of buying drinks for a potential partner, subscription fees at dating websites... it's all pure loss because dangerous sex has no offsetting benefit by our assumption at page 173 in the appendix to the report. Pretty clearly, the social costs of oral sex exceed the excise tax revenues. And that by itself of evidence of market failure.***

So why haven't we taxed oral sex? Well, it would be almost impossible to enforce. In a perfect world, the panopticon would see and tax all. But we're not there. Instead, we have only imperfect regulatory instruments. What should we then do?

For starters, we need studies by the University of Otago's School of Public Health demonstrating how not only movies and television glorify oral sex, but also how social media affects things. Doesn't Durex have a Twitter account? It's also worth noting the timing on the HPV rise here. I blame Desperate Housewives:

Bree: Excuse me. Did you lose something?
Orson: No. I just thought... for you.
Bree: Oh, um. I don't do that.
Orson: Why not?
Bree: I'm a republican.
Orson: I'm a libertarian. I believe in minimizing the role of the state and maximizing individual rights.
Bree: But Orson?!
Orson: Trust me. I know what I'm doing.

Is it any surprise that the libertarians would be the ones again to blame? 

Otago could also recruit a dozen people via Facebook and interview them about whether drinking makes them more likely to consider oral sex. If it does, then anti-alcohol and anti-oral-sex policies could be complementary. And if people are more likely to smoke after sex, then that also increases the benefits of anti-sex policies. We also need to think about how alcohol advertising also promotes sex: Woodstock commercials could lead young men to have sex with their friends' mothers. It's so obvious that we need a trifecta of policies to simultaneously address alcohol, tobacco and oral sex because of their costs to the public health system. Actually, that misses one: I'm pretty sure that this all somehow makes fat taxes even more important, I just haven't figured out how yet. But I'm sure that Otago's public health people will figure it out.

Now a couple of people on Twitter last night, likely secretly in the pockets of Big Sex, suggested that all of this might be misguided. There's a vaccine for HPV that removes the HPV-risk of oral sex while maintaining the supposed benefits. But, that's cheating. Just like it is cheating to use e-cigarettes to get a nicotine hit while avoiding lung cancer. If we cannot use e-cigarettes as part of anti-smoking policy, we can't use the HPV vaccine a way of avoiding the social costs of oral sex. Deep down, it's the sin that's the problem. If people could enjoy sinful hedons without consequence, where would we be? We have to teach them to avoid the sin, not to mitigate sin's consequence.



* No I haven't. Everything in this post, except for **** below, is simply applying consistently the methods used in the bogus shonky cost of illness studies used to justify alcohol and tobacco regulation.

** And if Ole Rogeborg wants to claim that they haven't proven causality and that much of it is due to underlying type, remember that because Dunedin refuses to share their data with anybody, we just have to take Dunedin at their word even if Ole has some fancy simulations.

*** Especially as there is no excise tax that here applies. Note that we shouldn't count GST revenues from professional transactions of this sort as offsetting things because the money would be spent on other GST-applicable transactions in the alternative.****

**** This is about the only part that isn't tongue-in-cheek. GST really wouldn't and shouldn't count in this case. Everything else here is rubbish.

Coroner recommends

Search Google NZ for "Coroner recommends" and you'll find:

• Coroner recommends quad-bikes be equipped with rotational towballs
• Coroner recommends that all farm houses be fenced off. "Mr Scott called for farmers and Labour Department officials to lobby the government to make fencing compulsory on all farms"
• Coroner recommends age restrictions on butane and other possible inhalants. 
• Coroner recommends people wear hard hats when climbing ladders to prune trees (whether they should be required when doing other things on ladders is not discussed)
• Coroner recommends that the refrigeration industry develop guidelines for safe storage of explosive refrigerants.
• Coroner recommends compulsory spot checks of children up to the age of 5.
• Coroner recommends the Government urgently assess media guidelines on reporting of suicide.
• Coroner recommends changes to design of future prisons
• Coroner recommends MoH strengthen guidelines on safe sleeping practices for newborns.
• Coroner recommends review of CT scans (to use them more often)
• Coroner recommends respite care review
• Coroner recommends that you should have to have a licence to rent a nail gun.
• Coroner recommends licensing of outdoor education / adventure tourism operators.
• Coroner recommends clearing trees near train crossings.
• Coroner recommends changes to privacy laws.
• Coroner recommends restrictions on access to glaciers
• Coroner recommends DHB review suicide assessment procedures
• Coroner recommends more training for mechanics
• Coroner recommends national manhole safety guidelines.
• Coroner recommends helmets for riders of motorised skateboards.
• Coroner recommends crowd control training for all airport staff.
• Coroner recommends warning labels on Coke.
• Coroner recommends mandatory high visibility clothing (not just vests) for cyclists. 

The Coroners Act 2006 empowers coroners:

to make specified recommendations or comments (as defined in section 9) that, in the coroner's opinion, may, if drawn to public attention, reduce the chances of the occurrence of other deaths in circumstances similar to those in which the death occurred; 

Persons appointed as Coroner "must have held a practising certificate as a barrister or solicitor for at least 5 years."

I'm sure that these are all smart and diligent people. I'm also sure that there is no required training in cost-benefit analysis in a legal degree.

The problem seems to be in the Act. Pretty much anything that could reduce the chances of particular forms of death can be recommended; there's no consideration anywhere of costs. It's fine to say that that's Parliament's job. But Coronorial recommendations carry some weight - people take them as being something more than "This is something that could save lives, but I have no clue whether it's worth it because I have zero training in policy assessment and cost-benefit analysis, so somebody else better figure out whether we'd be wasting a whole ton of resources in enacting it; moreover, the Act specifically asks me to just name any darned thing that might help even if it would cost a trillion dollars and save a life every fifty years."

I'd be willing to bet that a reasonable proportion of the above recommendations would fail any serious cost-benefit analysis. Mandatory high vis clothing for cyclists, licenses for nail guns, and mandatory skateboard helmets all seem exceptionally unlikely to pass any kind of "is this a reasonable policy" test.

This economist recommends that either Coroners get training in cost-benefit analysis, or start noting the limitations of their recommendations.

Update: Matt Nippert points out that the Chief Coroner wants it mandatory that government respond to Coroner recommendations. I would hope that the default response would be "The value of a statistical life for policy purposes in New Zealand is $3.8 million; the policy seems exceptionally likely to impose costs in excess of $3.8 million per statistical life saved. Please go away and come back with something reasonable."

Update 2: Russell Brown notes that the high visibility recommendation wasn't even based on the facts of that accident but rather on the coroner's "common sense". Egads.

No slippery slopes

Here's public health advocate Michael Daube on Australian Health Minister Nicola Roxon's legacy.

There is always more to do in prevention, and public health advocates will always press for more action to reduce unnecessary deaths and ill health. The Prevention Taskforce report provides an evidence-based blueprint for action on alcohol and obesity, as it did for tobacco: there is now a clear basis for action by governments and advocacy by the public health community. The alcohol and junk food industries are as powerful as tobacco (maybe even more), and there is great need for action in these areas as in others. But a realistic assessment must recognise that, especially in a minority government, there is a limit to the number of hard targets any Minister can take on at once.

Nicola Roxon’s prevention legacy is secure. She put prevention on the map, provided legislation and funding, led the world in tobacco control, took on and defeated Big Tobacco as both Health Minister and Attorney General, and developed the roadmap for action on alcohol and obesity. She can take pride in her record, and we can take pride in a Minister who achieved so much for public health.

There's no slippery slope, there's no slippery slope...there's always more to do and there will always be more action and we can only take on targets one at a time. Indeed.

And I would bet against the incoming Coalition government's* rescinding anything she's done. She's built a new quango to permanently advocate for stronger public health interventions, and conservative governments  never seem bright enough to destroy these agencies when they take office. And so we must offer her congratulations. She has very effectively moved policy in her preferred direction and embedded institutions that will keep it on that track for a rather long time.

* Yeah, yeah, the election hasn't happened yet. But look at the betting odds, or at least until Xenophon gets them banned in Oz. My hope: Labor gets demolished but Andrew Leigh survives to rebuild the party in his image, Leigh's Labor comes close to winning in the next election in a surprise, then takes office.

Contraception costs

Berk Ozler asks whether the government should provide free emergency contraception for young girls. It's an interesting question, especially as the Taranaki District Health Board recently announced plans for free EC provision.* Berk summarises the existing literature pretty comprehensively.

But I'll quibble a bit with his policy conclusion, at risk of channeling Steven Landsburg.

Berk and I agree entirely on his first conclusion: the morning after pill should be easily available without a prescription. It's safe, accidents (or worse) happen, and the barrier of going through a doctor can be non-trivial.

He then asks if it should be subsidised. Berk writes:

That question is more difficult. It depends on the future costs of teen pregnancy (and abortions) – both to the individual and to society. If children from single parent families, poorer families, etc. are more likely to need EC but less likely to be able to afford it, it may make sense for the government to subsidize the cost. Even if the costs are solely to the future adult herself and not to the society in general, they can be justified under the principle of ‘second chances’ – after all we’re talking about children and young people here. If there are positive externalities, the argument for subsidies is even simpler. So, I’ll return to the issue of subsidies after reviewing the literature on the individual consequences and public health externalities of making EC freely available to young people.

Berk's summary of the relevant literature:

• "There is some reason to worry about children's outcomes in teen pregnancies" 
• increased risk of poor natal outcomes


• "The evidence on the effects of teen pregnancies on future outcomes of the mother are mixed. There is not enough here to justify a strong stance for a policy decision." 
• Most of the effects you see in the cross section are due to that women having children in their teens tend to be different from those who decide to wait until they are older, and would have different outcomes even if they had not had children while young. 


• There is little evidence that use of the morning after pill has any effect on teen pregnancy rates, abortion rates, or STD rates, though it does somewhat reduce condom use.
• Berk here highlights that failure to use the emergency contraception even where provided may be a problem, perhaps due to "a failure to recognize (or acknowledge) a risk of conception on part of the prospective users." He writes:

  “In a survey of thousands of teenage mothers who had unintended pregnancies, about a third who didn’t use birth control said the reason was they didn’t believe they could get pregnant. Why they thought that isn’t clear.” The evidence is suggesting that (a) unprotected sexual activity is high among people who don’t report not wanting to have children; and (b) they don’t use the free EC that is in their drawer and can be used for up to 5 days after the unprotected sexual activity or a contraceptive incident. You can take a horse to the water, but you cannot make him drink… 

He concludes that though the public health effects may be negligible, emergency contraception should be available for young people and, ideally, free if we can afford it.

Ozler notes that the morning after pill costs $40 USD and that there's some evidence that teens substitute to its use from condoms (which are rather cheaper). If there's little evidence of other policy-relevant benefits from widespread subsidised EC availability, then I'm having an awfully hard time seeing why the government should stump up $40 per dose.** The NZ Family Planning website sells condoms for about $1.50 each.

I'm also pretty sure that  the government provides subsidised access to condoms via a doctor's prescription.

Steven Landsburgh controversially wondered last year why he should be paying for other peoples' birth control. I can see some decent second-best arguments for that the government subsidise birth control, not least of which is that it may partially offset the incentives created by governments' commitments to support children borne by those who cannot afford to raise them. The elasticity of birth rates among the improvident to subsidised childbearing may be rather larger than the elasticity with respect to the financial cost of contraception, but the former isn't much on the table aside from DPB work requirements. Whatever the second-best arguments for subsidised contraception, I have a hard time seeing the case for a general subsidy for a relatively expensive method of contraception.

* This follows on from a similar trial at the Auckland DHB. One of my projects for the coming semester is to get data from sexual health clinics on STD rates to see whether the Auckland trial had any effect on STDs. We'd started getting things lined up to get that data in the spring*** of 2010, and then the earthquakes put it rather far onto the backburner.

** If you want to subsidise the morning after pill for women seeing a doctor after sexual assault, I'm on your side. That's different from giving it for free to everybody.

*** Wow, North American habits die hard. First draft said fall. But it was August/September. And that's spring here.