Weekend reading links

1. Richard Florida points to the work of Paul Jargowsky that documents the rise of concentrated poverty in the US,

Concentrated poverty is defined as neighborhoods or tracts where 40 percent or more of residents fall below the federal poverty threshold (currently $24,000 for a family of four). The study looks at this change across the nation as a whole and within its major metropolitan areas. The number of people living in concentrated poverty has grown staggeringly since 2000, nearly doubling from 7.2 million in 2000 to 13.8 million people by 2013—the highest figure ever recorded. This is a troubling reversal of previous trends, particularly of the previous decade of 1990 to 2000, where Jargowsky’s own research found that concentrated poverty declined. Concentrated poverty also overlaps with race in deeply distressing ways. One in four black Americans and one in six Hispanic Americans live in high-poverty neighborhoods, compared to just one in thirteen of their white counterparts.

There is nothing surprising about this. This may be the evolution of a Schelling sorting equilibrium which highlights the inexorable logic of segregation, even in systems marked by small differences in preferences. Even small increases in aggregate inequality, over time, leads to such segregated equilibriums. School education and housing are well known examples of such forces at work. 

Such concentration of poverty, apart from their socially corrosive effects, also makes it easy to aggregate political discontent. It is no surprise that populist demagogues like Donald Trump find fertile ground for their political ambitions. 

2. Margot Sanger-Katz has a fascinating article in Upshot about political ideology among medical practitioners. She points that while about two-thirds of politically affiliated surgeons, anaesthetists, and urologists are Republicans, a similar share of those from infectious disease medicine, psychiatry and paediatrics are Democrats. In general, higher paying specialties are dominated by Republicans, reflecting their preference to pay lower taxes. 

But such sorting goes beyond political preferences and influences treatment recommendations, as this study of over 20000 primary care physicians in 29 US states by Eitan Hersh and Mathew Goldenberg found out,

They asked the doctors to consider a group of hypothetical patients: one who smoked, one who drank, one who was overweight, and so on. They found that doctors viewed most of their patients’ health with similar seriousness and would advise similar responses. But for three of the hypothetical patients, they found differences. Those patients were devised to have health problems closely tied to hot-button political issues: One used marijuana, one owned guns, and one had a history of abortions. For those patients, Republican and Democratic doctors registered different levels of concern and said they would respond differently. When it came to the patient with a history of abortions, doctors who were Republican said they would be more likely to encourage the patient to seek counseling and express concern about mental health consequences; they also said they would be more likely to discourage the patient from seeking future abortions. For the patient who used marijuana, Republican doctors said they’d be more likely to ask the patient to cut back and to discuss legal risks of using the drug, which is banned under federal and most state laws. For the patient with guns, doctors who were Democrats indicated they’d be more likely to tell the patient not to keep guns at home. Republican doctors, on the other hand, would be more likely to discuss safe storage options.

3. Atul Gawande has more, this time with a brilliant essay on why certain medical practices spread rapidly whereas some others take an inordinate time. Take the example of hypothermia among new-borns,

Newborns have a high body-surface area and lose heat rapidly. Even in warm weather, hypothermia is common, and it makes newborns weak and less responsive, less able to breast-feed adequately and more prone to infection. I noticed that the boy was swaddled separately from his mother. Voluminous evidence shows that it is far better to place the child on the mother’s chest or belly, skin to skin, so that the mother’s body can regulate the baby’s until it is ready to take over. Among small or premature babies, kangaroo care (as it is known) cuts mortality rates by a third... But even in high-income countries we do not consistently use it. In the United States... more than half of newborns needing intensive care arrive hypothermic. Preventing hypothermia is a perfect example of an unsexy task: it demands painstaking effort without immediate reward.

In order to combat this, Gawande is involved with an initiative to provide mentoring support for nurses on precisely such "unsexy" tasks,

With the BetterBirth Project, we wondered, in particular, what would happen if we hired a cadre of childbirth-improvement workers to visit birth attendants and hospital leaders, show them why and how to follow a checklist of essential practices, understand their difficulties and objections, and help them practice doing things differently. In essence, we’d give them mentors... The project has recruited only the first few of a hundred or so workers whom we are sending out to hospitals across six regions of Uttar Pradesh in a trial that will involve almost two hundred thousand births over two years... 

If the intervention saves as many mothers and newborns as we’re hoping—about a thousand lives in the course of a year at the target hospitals—then all that need be done is to hire and develop similar cadres of childbirth-improvement workers for other places around the country and potentially the world. To many people, that doesn’t sound like much of a solution. It would require broad mobilization, substantial expense, and perhaps even the development of a new profession. But, to combat the many antisepsis-like problems in the world, that’s exactly what has worked. Think about the creation of anesthesiology: it meant doubling the number of doctors in every operation, and we went ahead and did so. To reduce illiteracy, countries, starting with our own, built schools, trained professional teachers, and made education free and compulsory for all children. To improve farming, governments have sent hundreds of thousands of agriculture extension agents to visit farmers across America and every corner of the world and teach them up-to-date methods for increasing their crop yields. Such programs have been extraordinarily effective. They have cut the global illiteracy rate from one in three adults in 1970 to one in six today, and helped give us a Green Revolution that saved more than a billion people from starvation.

This is very similar to the role of coaches, something on which Gawande himself has written earlier.

The essay draws parallels with BRAC's success in disseminating the use of oral rehydration therapy to address diarrhoea, largely through a massive door-to-door campaign involving women. Gawande and BetterBirth are trying to do a BRAC in India to address hypothermia and adoption of other post-natal practices. Good Luck to them!

4. As the extraordinary monetary accommodation across developed economies continues unabated, it threatens to upend the prevailing business models. Active managers, with their exorbitant fees, are facing the heat from passive funds,

According to Morningstar, a data provider, since December 2007 passive assets under management have tripled to $5.7 trillion, while assets in active funds have increased by only 54%, to $23.2 trillion. In the first eight months of this year, investors drew down $166.2 billion from actively managed funds specialising in American equities alone. In contrast, passive unds attracted almost $110 billion in new investment.

In the world of low yields, the prevailing model of fund managers is clearly untenable. It is no surprise that a number of the largest pension funds and endowments have been gradually in-sourcing more of their fund management responsibilities.

5. Finally, as the US Presidential election descends into a farce, watch Robert Di Niro here take on Donald Trump. He says he would like to punch Trump on his face!