The Right Diagnosis

When I hit my snooze button in the morning, my diagnosis of the problem would seem to be that I am exactly nine minutes short of sleep. In nine minute’s time, I will wake up to the next alarm and be refreshed.

When my hygienist tells me, “You should floss more. You will get cavities there if you don’t,” her de facto diagnosis of the problem is that I don’t have adequate information. If I knew that flossing prevented cavities, I would certainly do it.

Neither of these hypothetical diagnoses is especially plausible. It isn’t especially likely I am evaluating the quantity of sleep I am lacking, nor is it probable that the hygienist thinks I am lacking information about how dental hygiene works. However, in both cases, we have engaged in an intervention to treat the problem. A more accurate diagnosis of the problem in the first place (You feel tired because you always feel tired in the morning, no matter how much you’ve slept; flossing is never on your mind when it’s time to floss, you’re always thinking about other things) leads to prescribed solutions (put the alarm on the way to the bathroom, so after you turn it off, you’re closer to the shower than the bed; put the dental floss container literally on top of your contact case) that are more likely to be successful.

When applied to social policy, this same principle is what behavioral economist Sendhil Mullainathan calls behavioral design. While behavioral sciences can tell us why we are acting the way we are, it makes sense to begin thinking about our behavioral tendencies before, rather than after we design a policy. If we adequately diagnose the problem, we are more likely to develop a policy that successfully treats it.

When taken in this context, the idea of sporadically given food aid has a fairly illogical diagnosis. For food aid to be a successful policy, I can think of three diagnoses: 1) a one-time transfer of food aid will improve this person’s situation, 2) this person’s situation will improve independent of food aid, to the point where food aid will no longer be necessary, or 3) we don’t expect to move this person to a situation where they no longer need our help, but none-the-less want to help their lives in some small way.

Diagnosis one strikes me as inherently illogical. Diagnosis 2 is reasonable; food aid might provide a small benefit until the individual moves out of poverty in some other way (though it begs the question—might the same resources used to help the individual be better used to create the problem that we are hoping for?) Similarly, while depressing, Diagnosis 3 has some sort of internal logic, that if we do not expect individual’s lives to improve beyond needing food aid, at the very least food aid helps in some small, meaningful way. However again, a question might be whether or not those same resources might be used in a way that could make consistent, long-term aid unnecessary.

The program I am beginning to evaluate in Ethiopia is exploring the question. It is one of ten pilots being tested, known collectively as “Targeting the Ultra Poor”. It looks at the poorest households (within already poor communities) and is aiming to see if there is a better way, not of making them wealthy per se, but of helping them gain an income level where they are not food insecure, and not in a fragile state such that a single shock like a medical emergency could bring them to financial ruin.

First, the program provides consumption support (ie regular, albeit small cash transfers, on the order of a few dollar’s a week). The idea here is that for the poor to get out of poverty, they first need a certain degree of “breathing room.” On this first level, there are indeed some similarities to food aid.

However, the next diagnosis is that once they have some breathing room, they will only achieve the next step up if they have the means to generate income. This means that the individuals are given a one-time transfer of some assets to help them start a business, such as livestock, inventory for petty trading, like selling basic foodstuffs, or bees to tend to (do bees count as livestock? Maybe?). Then, the policymakers have hypothesized that it might also be necessary to offer the individuals regular training, so that they are able to realize better profits on these new income-providing opportunities. Then, assessing that they might still be at risk of “dropping down a rung on the ladder” if something bad happens to them, they are encouraged to save money. This prescribed solution aims to provide breathing room, then give a one-time push, making the continued support (in the form of aid, food or otherwise) not necessary in the long-term.

However, while the diagnosis and prescribed solution sound great in theory, it is necessary to test whether or not the idea works in practice. Hence the reason I am in Ethiopia. The individuals my team will be surveying have been given this push, and have had regular business mentoring. It has been three years since they started in the program. The surveying I will be working on will be one of several pieces of evidence to see whether or not the diagnosis and prescription actually match reality.

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2 Responses to The Right Diagnosis

  1. N P says:

    Great thoughts, Nate. Glad you are writing your blog once again.

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