The brittleness of tactical decision-making

From The Making of the Obesity Epidemic: How Food Activism Led Public Health Astray by Helen Lee.

It may be that the problems associated with obesity are impossible to disentangle­­ from the problems associated with simply being poor. Lifestyle factors, including differences in smoking, diet, and exercise, can’t fully explain the life expectancy gaps between the rich and poor, and neither can health care coverage­­, especially since most elderly Americans have the same health insurance payer source, Medicare. Education and income remain the most salient predictors­­ of higher risk of death, even after age, sex, race or ethnicity, health insur­­ance, smoking, and BMI are taken into account.50

This suggests that poor health outcomes associated with obesity among low-income Americans probably have more to do with being poor than being obese. One obesity prevention worker doing outreach in a poor African American neighborhood in Oklahoma recently told a New York Times reporter, “If you ask, ‘What would help your health the most?,’ people say, ‘More money.’”51 The answer is understandable. With limited resources and an uncertain future, poor Americans must make trade-off decisions frequently, at times creating a vicious spiral of self-fulfilling prophesies. “They say, ‘When my time is up, it’s up,’” a grocery store cashier in the same neighborhood told the Times. Poor youth, in particular, as classic ethnographies like Ain’t No Makin’ It and Learning to Labor have eloquently documented, are prone to believe that their paths to mobility are highly constrained, no matter how hard they work to prove otherwise.

At the same time, a growing body of sociological research finds that the poor have multiple sources of social capital and are active subjects shaping the world around them, albeit in ways that are sometimes self-defeating.52 But instead of embracing the agency of the poor, focusing on policy interventions that reinforce behaviors associated with better life outcomes, public health officials and philanthropies have too often done the opposite, embracing obesity strategies that reinforce the notion that the poor are victims of an environment that is rigged against them.

During the latter half of the 20th century, the public health community came to see our overall health as irreducible to single factors. Seven years after he raised the alarm bell at the APHA about obesity, Dr. Lester Breslow began what would become a landmark study in Alameda County, California. He found that a 45-year-old with healthy practices in at least six of seven areas — drinking moderately or not at all, not smoking, managing one’s weight, getting regular sleep, exercising, eating regular meals, and eating breakfast — could expect to live 11 years longer than someone of the same age who followed good habits in just three or fewer. “In the long run, housing may be more important than hospitals­­ to health,” Breslow said. In early 2012, Breslow, who had gained the moniker “Mr. Public Health,” died at the age of 97.53

Two thoughts.

From this passage and others, the author leans towards ascribing outcomes to poverty. At the same time she identifies education attainment and income as the variables most predictive of outcomes. It appears to me that the evidence she has mustered indicates that the underlying root causes are at least in part behavioral. Specifically both income and education attainment are highly graduated towards increasing levels of planning and self-control. In other words, it looks like she stopped short in the root cause analysis.

In addition, over the years there have been a number of individuals who undertake a real-life experiment where they start the year with an entirely new identity, some nominal seed capital ($100, and suitcase of clothes for example), and then see how far they can get in the year with no other resources to call upon (and without leveraging their education certifications). Typically they end up the year just fine and with a modest nest egg. What these experiments all have in common is that the person undertaking it has four resources which cannot readily be monetized but are real none-the-less: 1) they have very high levels of self-discipline, 2) they have well-established confidence from prior attainment, 3) they have the certainty that should the experiment go pear-shaped, they have social and familial capital which they can fall back on, and 4) all the ones I have read of are typically recent college graduates, i.e. they are relatively advantaged in terms of time; the older you get, the less chance of recovery from bad decisions and therefore the more cautious you often become. There is no way for them to expunge these advantages but I suspect that they are very beneficial advantages which might influence them arriving at different tactical decisions than someone without those advantages. Which relates to the second thought.

The second thought is related to a telling sentence:

With limited resources and an uncertain future, poor Americans must make trade-off decisions frequently, at times creating a vicious spiral of self-fulfilling prophesies.

True as far as that goes but I think there is more to it than the sentence reveals. It is not only that you have to make more frequent tactical decisions. With no or limited resources, all your trade-off decisions have to be tactical and short term in nature. One cost of this circumstance is that you lose the compounding opportunity to take selected strategic risks. Your biggest payoffs tend to be from longer term decisions but if you are precluded from making those decisions, then you have to squeeze out the benefits strictly from your tactical decisions.

A second opportunity cost in shifting the portfolio of decisions from a mix of tactical and strategic to strictly tactical is that sequential tactical decision-making is more brittle and error prone. A strategic decision, once made, can still be revisited under the right circumstances - there is some modicum of flexibility and opportunity to mitigate if circumstances change. With tactical decisions, by their nature, consequences are near immediate - there is little opportunity to mitigate a poor decision arrived at in haste. Hence tactical decisions are more brittle.

This sheds light on the observation that the bottom quintile of Americans by income have the same income as middle quintile Europeans. How can they be in poverty then?

It would seem that the answer is possibly in part that the challenge for those in the bottom quintile is not so much an issue of resources as behaviors. They lack the self-discipline which enables such accomplishments as education attainment and long-term employment. But another portion might be that if they are stuck in tactical decision-making (regardless of income), they are always going to be exponentially prone to negative outcomes because tactical decision-making is simply more error prone.