This week, an American public health practitioner posted on the US national AIDS blog about a new program starting up in the States. The program is called TLC-Plus, short for “Enhanced Testing, Linking into Care, Plus Treatment” for PLHIV. Here’s how the author, Carl Dieffenbach PhD, explained the need for that middle component, “linking into care” —
“Unfortunately, many people don’t make it to their follow-up medical visits for a variety of reasons. Yet these individuals can continue to spread the virus in their communities until we entice them to step through the door, whether it’s giving them a pat on the back or offering financial incentives.”
I trained in cultural studies and learned public health by apprenticeship, and it’s quite rare for those perspectives to align perfectly, but in this case they do. I feel it’s a mistake to focus on individual psychology when it would be fairer, more accurate and more efficient to look at structural or ‘upstream’ factors. The biggest structural factor of them all is ability to pay for medical care. I think people don’t “make it to their follow-up medical visits” when they can’t afford the appointments, or the medication they would need to take, or insurance to pay for those.
That’s not a failure of motivation in the individual that could be corrected with a “pat on the back or offering financial incentives”, unless the financial incentive is, you know, paying for their medical care and anti-retroviral therapy. To me it seems like a complete failure of the social contract (where citizens renounce violence in return for the care of a community, represented by the State). In the rest of this post, I want to try and explain why I think that, using two concepts: “cultures of care” (Hurley, 2002) and the difference between social and market norms (Heyman & Ariely, 2004).
I. Cultures of Care
Australia does some things pretty badly, like addressing racism and accommodating asylum seekers, but we do some things really well, like universal healthcare and community-based prevention. In a culture of care (Hurley, 2002) the care shown by the State, in providing medical and community services to people living with HIV, is continuous with the care those PLHIV show for others and their community by incorporating prevention of onward transmission of HIV infection into their lives and participating in a safe sex culture including both HIV-negative and other positive people.
In that environment the social contract shares responsibility both for care and the maintenance of culture and community between PLHIV, others in the community, and the State, typically represented by public health departments working in partnership with community organisations. This is a very different understanding of “linking into care”, and it depends upon government taking responsibility for its own failures of care — but Dieffenbach’s post doesn’t even mention health coverage, poverty, housing, welfare, and the list goes on. Yes, in the United States, those things are party-political, but that doesn’t mean public health can ignore them.
II. Behavioural Economics
Obviously, I focus a lot on culture and community-based HIV prevention responses, and because these need funding and interact with the law, government and the State as well. I question many popular theories of health and consumer behaviour because they are premised upon a hypothetical rational individual who just doesn’t exist in the real world.
That highlights the second problem with Dieffenbach’s “pat on the back or financial incentives” approach: it ignores a half century of behavioural economics, premised on the “bounded” (limited/imperfect) rationality that clearly emerges whenever you do, you know, actual research into cognition in the real world (Simon, 1972; Kahneman & Tversky, 1979).
In his excellent book on the subject, the psychologist Dan Ariely (Predictably Irrational, 2008) cites research that suggests social and market norms may be mutually exclusive. Someone will help you move your sofa without a moment’s thought for free, but if you start by offering the same person $5 for their time, they will walk away insulted (Heyman & Ariely, 2004). And the effect of switching to market norms can persist for long after you realise your mistake. As Ariely puts it, “when a social norm collides with a market norm, the social norm goes away for a long time”.
So positive prevention in the United States is at a policy crossroads — a choice between cultures of care and community-based prevention in one direction, and rational individualism and market norms in the other. Because public health practice there is so heavily individualistic, I suspect they’re not even aware of the decision as they’re making it. I’m not even a resident, but I wish there were some way I could take part in that conversation.
Ariely, Dan (2008) Predictably Irrational, London: HarperCollins.
Dieffenbach, Carl (2010) “Putting TLC+ to the Test“, Blog.AIDS.Gov.
Heyman & Ariely (2004) “Effort for Payment: A Tale of Two Markets”, Psychological Science.
Hurley, Michael (2002) (ed) Cultures of Care and safe sex among HIV-positive Australians, Melbourne: Australian Research Centre in Sex Health and Society, La Trobe University.
Kahneman, Daniel and Tversky, Amos (1979) “Prospect Theory: An Analysis of Decision under Risk”, Econometrica.
Kippax, Sue and Race, Kane (2003) “Sustaining Safe Sex: Twenty Years On”, Social Science & Medicine.