Wise for one, dumb for all

Flip a coin – heads you have a secure retirement, tails you have nothing. In this scenario, would you go to any length, say mess with the coin a bit, to put the odds in your favor? This is essentially the stakes for having a baby boy versus a baby girl in China.wise_for_one

And it’s a great demonstration about how a smart decision for one person works against the whole society’s best interests.

In China, having a boy means having a pension plan and lifelong home health services all wrapped up in one bundle of joy. This is because sons by tradition do not leave home. They live with and support their parents all their lives. That’s the pension plan part. Their wives also live with and dedicate themselves to the husband’s family; that’s the home health part.  Thus, birth of a son is cause for great celebration.

Birth of a daughter means that you are supporting someone else’s pension, and, with China’s one-child rule, you have no old-age supports for yourself.

So, it is no surprise, that after decades of the one-child rule, there is a much higher proportion of male children in China than female – much higher than chance would predict. In 2008, there were 122 boys for every 100 girls; it’s now calmed down to a mere 116 boys for every 100 girls. A lot of people were messing with their coin-flip, in other words. Though abortion for the purpose of selecting the child’s gender is illegal in China, it is still being done.

By taking action to ensure their golden years, people skewed the mix of boys and girls. This works against the interests of the community as a whole. Too many people have their pension plan son, but fewer of these sons can find wives to continue the blood line (or pension fund, in this case).

This same phenomenon, which I call wise-for-one-dumb-for-all, applies to many population health issues. Here’s another example: it’s cheaper to take care of a person in his own home than in a skilled nursing home. (Lest this seem forehead-thump obvious, please follow the rest of the story.) This is true for one person, but it’s not true when you talk about hundreds and thousands of people.

The argument breaks down because there are many more people who can be taken care of at home, and who were in no danger of going into a nursing home. Thus, you end up paying for thousands of people in their homes without reducing the number of people who need nursing home care.

A smart move for one person – getting home care or having a baby boy – turns out to backfire for the community as a whole. Americans, in particular, seem to abhor the idea of making tradeoffs for the community’s good. The straightforward math – thousands of people in home care is more expensive than hundreds in nursing homes – does not survive the emotional politics of health policy. Likewise, try persuading a Chinese couple to have a baby girl. How differently we would act if we fully grasped that the whole is not the sum of the parts.

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