"Whenever I go into a restaurant, I order both a chicken and an egg to see which comes first"

Saturday, March 16, 2013

The Case For Triage–Who’s To Live?

Olga Khazan writes in The Atlantic (3.16.13) about a Stanford School of Management Study on triage in relief aid:

Say you're an aid worker toiling in an area that's been devastated by an overwhelming calamity -- a war-torn conflict zone, a famine-stricken village, or a crowded refugee camp. You have a finite amount of emergency food and see far too many outstretched hands. The kids around you are all much too short and scrawny for their ages, and most seem sickly and under-fed. What's more, many of the youngsters show sure signs of acute malnutrition -- they literally are skin and bones.

It is better, say Stanford researchers, to select those children who are most acutely malnourished and at the greatest risk of dying and give them a whole ration rather than sharing equally among all thereby reducing the size of each individual ration.

This makes sense only if the goal is temporarily save lives. That is, while a whole ration might keep these desperate children alive for some weeks or months, they are likely to succumb to some kind of illness or simply starve to death in the near future. Therefore, it might have been better to select those children who had the best chances of living through the famine or disaster and giving them an additional leg up.

This downward triaging is common at a larger scale as well.  The World Bank, USAID, and other donors in their focus on ‘the poorest of the poor’ have neglected those segments of society which could most benefit from aid. Resources, for example, were invested to keep farmers in their increasingly marginal, arid, and unproductive regions of the Sahel rather than provide needed infrastructure, capital, or equipment to farmers working in more well-watered environments.  A road in one of these potentially productive area could have meant more to both farmers and consumers in terms of wealth, nutrition, and well-being than any program limited to individual communities.

This philosophy of reaching the world’s poorest also meant a focus on rural areas of developing countries.  Rather than recognize the economic potential of cities and their historical role as engine of economic enterprise, donors rejected requests for investment in improved ports, roads, sewerage, and energy grids in favor of projects to raise the standard of living for the rural poor.  Had donors invested in cities, thereby encouraging private investment and employment, then rural laborers would have moved there to take advantage of new economic opportunities.

There is nothing new to the idea of triaging up.  Immigrant families did this all the time when they selected the most promising of their many children and gave them the money for advanced education.  The chances that a bright, ambitious, intelligent child would succeed in life and eventually return to support the family were far greater than those of the dullard sucking his thumb in the corner.

Triaging down, however, has unfortunately become a popular paradigm, and not just in international development. At home in the United States,such practices have become more and more common in public school education.  Scarce municipal resources are being used to help all those students who are performing poorly rather than used to assist those that are most likely to succeed.

Triaging down is an outgrowth of a liberal conviction that the goal of government is to reduce inequality, to redistribute wealth, and to create a more equitable society; and that the way to do this is to transfer resources from the rich to the poor, to reconfigure education and social programs, and to promote the most disadvantaged as the only beneficiaries of government largesse. This philosophy is misguided.  By favoring those who are most likely to contribute to national wealth, productivity, and progress, the more disadvantaged will benefit.  By assuring that the future Bill Gates, Steve Jobs, or Warren Buffett emerge out of the miasma of public education and rise even more efficiently and quickly to the top, millions of Americans benefit.  For every Bill Clinton, Ronald Reagan, or Richard Nixon who was born poor and struggled to the top, there are millions of equally ambitious, talented, and driven Americans who simply need a bit more of a push.  Our current educational system neglects these children.

The Stanford research, while focusing on one narrow issue – that of triage in refugee camps – raises a much more fundamental one; and that is whether our current philosophy favoring the least advantaged, the poorest of the poor, those closest to death is the right one.

I feel that it is not; and that a fundamental rethinking of political philosophy is necessary.  Looked at more practically, government social programmers need to consider cost-benefit differently, and assess the impact of a social program not on one individual or small group, but on society at large.  In the example cited above, would favoring the talented in school ultimately benefit more people than addressing only the issues of the disadvantaged?

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