“Whether you have herpes” is not as clearly-defined a category as it sounds. The blood test will tell you which types of HSV antibodies you have. If you’re asymptomatic, it won’t tell you the site of the infection, if you’re communicable, or if you will ever experience an outbreak.
I had an HSV test a while ago (all clear, thankfully), and my impression from speaking to the medical staff was that given the prevalence and relative harmlessness of the disease, (compared to, say, HIV or hepatitis or something), the doubt surrounding a positive test result was enough of a psychological hazard for them to actively dissuade some people from taking it, and many sexual health clinics don’t even offer it for this reason.
From Poor Economics by Esther Duflo and Abhijit Bannerjee
There is potentially another reason the poor may hold on to beliefs that might seem indefensible: When there is little else they can do, hope becomes essential. One of the Bengali doctors we spoke to explained the role he plays in the lives of the poor as follows: “The poor cannot really afford to get treated for anything major, because that involves expensive things like tests and hospitalization, which is why they come to me with their minor ailments, and I give them some little medicines which make them feel better.” In other words, it is important to keep doing something about your health, even if you know that you are not doing anything about the big problem.
In fact, the poor are much less likely to go to the doctor for potentially life-threatening conditions like chest pains and blood in their urine than with fevers and diarrhea. The poor in Delhi spend as much on short-duration ailments as the rich, but the rich spend much more on chronic diseases.34 So it may well be that the reason chest pains are a natural candidate for being a bhopa disease (an older woman once explained to us the dual concepts of bhopa diseases and doctor diseases—bhopa diseases are caused by ghosts, she insisted, and need to be treated by traditional healers), as are strokes, is precisely that most people cannot afford to get them treated by doctors.
It seems to me these people are paying in sanity what they can’t pay in money—and the price they’re paying is arguably higher than what the rich are paying, not even considering the physical health effects.
This might be one of the ways that being poor isexpensive.
Indeed, ‘being poor is expensive’ is related to how they frame this fact. From the end of the same chapter:
The poor seem to be trapped by the same kinds of problems that afflict the rest of us—lack of information, weak beliefs, and procrastination among them. It is true that we who are not poor are somewhat better educated and informed, but the difference is small because, in the end, we actually know very little, and almost surely less than we imagine.
Our real advantage comes from the many things that we take as given. We live in houses where clean water gets piped in—we do not need to remember to add Chlorin to the water supply every morning. The sewage goes away on its own—we do not actually know how. We can (mostly) trust our doctors to do the best they can and can trust the public health system to figure out what we should and should not do. We have no choice but to get our children immunized—public schools will not take them if they aren’t—and even if we somehow manage to fail to do it, our children will probably be safe because everyone else is immunized. Our health insurers reward us for joining the gym, because they are concerned that we will not do it otherwise. And perhaps most important, most of us do not have to worry where our next meal will come from. In other words, we rarely need to draw upon our limited endowment of self-control and decisiveness, while the poor are constantly being required to do so.
We should recognize that no one is wise, patient, or knowledgeable enough to be fully responsible for making the right decisions for his or her own health. For the same reason that those who live in rich countries live a life surrounded by invisible nudges, the primary goal of health-care policy in poor countries should be to make it as easy as possible for the poor to obtain preventive care, while at the same time regulating the quality of treatment that people can get. An obvious place to start, given the high sensitivity to prices, is delivering preventive services for free or even rewarding households for getting them, and making getting them the natural default option when possible. Free Chlorin dispensers should be put next to water sources; parents should be rewarded for immunizing their children; children should be given free deworming medicines and nutritional supplements at school; and there should be public investment in water and sanitation infrastructure, at least in densely populated areas.
As public health investments, many of these subsidies will more than pay for themselves in the value of reduced illness and death, and higher wages—children who are sick less often go to school more and earn more as adults. This does not mean that we can assume that these will automatically happen without intervention, however. Imperfect information about benefits and the strong emphasis people put on the immediate present limit how much effort and money people are willing to invest even in very inexpensive preventive strategies. And when they are not inexpensive, there is of course always the question of money. As far as treatment is concerned, the challenge is twofold: making sure that people can afford the medicines they need (Ibu Emptat, for one, clearly could not afford the asthma medicine that her son needed), but also restricting access to medicines they don’t need as a way to prevent growing drug resistance. Because regulating who sets up a practice and decides to call himself a doctor seems to be beyond the control of most governments in developing countries, the only way to reduce the spread of antibiotic resistance and the overuse of high-potency drugs may be to put maximal effort into controlling the sale of these drugs.
All this sounds paternalistic, and in a way, it certainly is. But then it is easy, too easy, to sermonize about the dangers of paternalism and the need to take responsibility for our own lives, from the comfort of our couch in our safe and sanitary home. Aren’t we, those who live in the rich world, the constant beneficiaries of a paternalism now so thoroughly embedded into the system that we hardly notice it? It not only ensures that we take care of ourselves better than we would if we had to be on top of every decision, but also, by freeing us from having to think about these issues, it gives us the mental space we need to focus on the rest of our lives. This does not absolve us of the responsibility of educating people about public health. We do owe everyone, the poor included, as clear an explanation as possible of why immunization is important and why they have to complete their course of antibiotics. But we should recognize—indeed assume—that information alone will not do the trick. This is just how things are, for the poor, as for us.
These are all nice ideas but someone has to pay for them and it won’t be cheap and 2nd of all. I know of plenty of people who are living in terrible conditions right here in this country. When one is poor everything is harder because you have to do everything yourself and pay out the nose for services that the wealthy get for far less. Whether in Africa or the US, poverty has a cost.
I’m interested in your calling it ‘paying in sanity.’ Are you referring to the insanity of believing in Bengali babus, or the fact that they’re preserving their own sanity in some way by not going to a real doctor for things they know they can’t afford?
The former. I’m speculating this tendency to rely on hope for serious problems while relying on science for small ones creates compartmentalization, which impairs rationality and increases religiosity.
The correlation between poverty and religiosity is obvious, this is just a speculative direction of causation. Irrationality would probably lead to poverty, but if poverty also led to irrationality, the two causations would reinforce each other and explain the robustness of the correlation.
Thanks to its multiple infection sites, herpes has the unusual property that two people, neither of whom have an STI, can have sex that leads to one of them having an STI. It’s a spontaneous creation of stigma! And if you have an asymptomatic infection (very common), there’s no way to know whether it’s oral (non-stigmatized, not an STI) or genital (stigmatized, STI) since the major strains are only moderately selective.
But it might be rational to not find out if you believed you would have a duty to warn potential lovers if you tested positive, or were willing to lie but believed yourself to be a bad actor.
How is it rational to willfully keep others in ignorance of a risk they have every right to know about? The discomfort of honest disclosure is a minor inconvenience when compared to the disease.
You are right for the rationalist who gives substantial weight to the welfare of his or her lovers. But being rational doesn’t necessarily imply you that care much about other people.
A rationalist that doesn’t care about the welfare of their lovers and yet believes they have a duty to warn them about if they tested positive (but no duty to get tested in the first place, even if the cost is nonpositive)?
In my game theory class I teach that rational people will defect in the prisoner’s dilemma game, although I stress that you should try to change the game so it is no longer a prisoner’s dilemma.
Can this situation be modeled as a prisoner’s dilemma in a useful way? There seem to be some important differences.
For example, if both ‘prisoners’ have the same strain of herpes, then the utility for mutual defection is positive for both participants. That is, they get the sex they were looking for, with no further herpes.
The base rate of HSV2 in US adults is ~20%. I would argue that if you’re sexually active, and don’t get an HSV test between partners (which is typically not part of the standard barrage of STD tests), you’re maintaining the same sort of plausible deniability strategy as those who pay to not see the results of their apropos-of-nothing tests.
Quite a few people will pay $10 in order to not know whether they have herpes.
“Whether you have herpes” is not as clearly-defined a category as it sounds. The blood test will tell you which types of HSV antibodies you have. If you’re asymptomatic, it won’t tell you the site of the infection, if you’re communicable, or if you will ever experience an outbreak.
I had an HSV test a while ago (all clear, thankfully), and my impression from speaking to the medical staff was that given the prevalence and relative harmlessness of the disease, (compared to, say, HIV or hepatitis or something), the doubt surrounding a positive test result was enough of a psychological hazard for them to actively dissuade some people from taking it, and many sexual health clinics don’t even offer it for this reason.
From Poor Economics by Esther Duflo and Abhijit Bannerjee
Thank you, that was very interesting.
It seems to me these people are paying in sanity what they can’t pay in money—and the price they’re paying is arguably higher than what the rich are paying, not even considering the physical health effects.
This might be one of the ways that being poor is expensive.
Indeed, ‘being poor is expensive’ is related to how they frame this fact. From the end of the same chapter:
These are all nice ideas but someone has to pay for them and it won’t be cheap and 2nd of all. I know of plenty of people who are living in terrible conditions right here in this country. When one is poor everything is harder because you have to do everything yourself and pay out the nose for services that the wealthy get for far less. Whether in Africa or the US, poverty has a cost.
I’m interested in your calling it ‘paying in sanity.’ Are you referring to the insanity of believing in Bengali babus, or the fact that they’re preserving their own sanity in some way by not going to a real doctor for things they know they can’t afford?
The former. I’m speculating this tendency to rely on hope for serious problems while relying on science for small ones creates compartmentalization, which impairs rationality and increases religiosity.
The correlation between poverty and religiosity is obvious, this is just a speculative direction of causation. Irrationality would probably lead to poverty, but if poverty also led to irrationality, the two causations would reinforce each other and explain the robustness of the correlation.
Thanks to its multiple infection sites, herpes has the unusual property that two people, neither of whom have an STI, can have sex that leads to one of them having an STI. It’s a spontaneous creation of stigma! And if you have an asymptomatic infection (very common), there’s no way to know whether it’s oral (non-stigmatized, not an STI) or genital (stigmatized, STI) since the major strains are only moderately selective.
… and that’s why you should prefer to sleep with rationalists. :)
But it might be rational to not find out if you believed you would have a duty to warn potential lovers if you tested positive, or were willing to lie but believed yourself to be a bad actor.
How is it rational to willfully keep others in ignorance of a risk they have every right to know about? The discomfort of honest disclosure is a minor inconvenience when compared to the disease.
You are right for the rationalist who gives substantial weight to the welfare of his or her lovers. But being rational doesn’t necessarily imply you that care much about other people.
A rationalist that doesn’t care about the welfare of their lovers and yet believes they have a duty to warn them about if they tested positive (but no duty to get tested in the first place, even if the cost is nonpositive)?
Are you advocating for prisoner defection?
In my game theory class I teach that rational people will defect in the prisoner’s dilemma game, although I stress that you should try to change the game so it is no longer a prisoner’s dilemma.
I hope you also talk about Parfit’s hitchhiker, credible precommitment and morals (e.g. honor, honesty) as one of its aspects.
I spend a lot of time on credible threats and promises, but I don’t do Parft’s hitchhicker as it doesn’t seem realistic.
Can this situation be modeled as a prisoner’s dilemma in a useful way? There seem to be some important differences.
For example, if both ‘prisoners’ have the same strain of herpes, then the utility for mutual defection is positive for both participants. That is, they get the sex they were looking for, with no further herpes.
Not prisoner’s dilemma, but successful coordination to which a decrease in the spread of HIV in the gay community is attributed: serosorting.
A classic example of confusing is with ought...
The base rate of HSV2 in US adults is ~20%. I would argue that if you’re sexually active, and don’t get an HSV test between partners (which is typically not part of the standard barrage of STD tests), you’re maintaining the same sort of plausible deniability strategy as those who pay to not see the results of their apropos-of-nothing tests.
If you do think you have an ethical obligation to inform others of a risk like this, do when did you test yourself the last time for herpes?
If you must know, I’m a virgin. I have, however, engaged in erotic practices not involving genital contact.
If that wouldn’t be the case, how often would you think you would test yourself?
I guess a minimum should be before and after each new partner, plus additional tests if I suspect infidelity.