Social determinants of health does not mean the poor are sick

Last week I saw an article from Time titled “Pediatricians Should ‘Screen’ Kids for Poverty, Says Group” making the rounds in my LinkedIn network. The article is about an American Academy of Pediatrics recommendation that doctors be responsive to how poverty can affect health by referring low-income families to social programs. The recommendation is based on the largely accepted concept of the social determinants of health.

The World Health Organization defines social determinants of health as “…the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” The literature connecting poverty and health is solid. As the Center for Disease Control states, “We know that poverty limits access to healthy foods and safe neighborhoods and that more education is a predictor of better health.” This is both intuitive and factual.

I have no qualms with the linking of poverty and health outcomes, but rather object to the suggestion that one ought to be diagnosed poor, as this perpetuates a stereotype that poverty is something that is wrong with the poor rather than the result of a social and political environment we (humanity) collectively create.

Furthermore, the analogy wrongly simplifies poverty into something that is curable via proper prescription. From the Time’s article:

The recommendation also provides guidelines to help pediatricians connect families who might be struggling to the proper resources, from local housing bureaus to food pantries and job listings. The hope, says Dreyer, is to help the 50% of families who currently qualify for additional support but aren’t getting it to access the resources they are entitled to.

The recommendation makes it sound as though once diagnosed, poverty is “cured” via the social safety net. Implicit in this analogy is that the cure for poverty is proper prescription and utilization of the right dosage of social service intervention. In this thinking, either the poor do not know about or refuse to utilize services that are assumed beneficial.

Given this logic, the obvious question is why do so many families not pursue such help if the safety net is the cure to poverty? The core assumption in this line of reasoning is that families do not know about available services. Indeed I made this assumption for a number of years while selling systems to governments and nonprofits that “connected” people to social programs.

Since joining the Family Independence Initiative and getting access to a sizable volume of data directly from families moving in and out of poverty, my perspective has shifted significantly. Whereas I used to assume people simply did not know about social programs, I now wonder if utilization is low not on account of informational asymmetry, but rather because:

  • Existing services do not necessarily help as much as we assume.
  • The social stigma of accessing social programs outweighs the benefit.
  • Services are such a small part of escaping poverty as to not be worth the hassle.

The poor are not sick, even if they have worse health outcomes, as poverty itself is not a disease. It is the absence of money, a social phenomenon we collectively support, and often benefit from. The causes of poverty are not individually acute, but rather socially, racially, and spatially broad.

Indeed, the disparity in life expectancy between lower and upper income households is growing. Where you live and how much you make can affect your health in lots of ways, from experiencing higher levels of violence, air pollution, poor food access, and several other factors. None of these are solvable through a diagnosis of poverty.

The real “cure” to poverty is not in small doses of guided interventions at all. Nonprofits are not doctors of poverty. As sure as evidence supports the social determinants of the health, a growing body of literature also supports the benefit of investing directly in low-income families.

Analogizing the poor as diseased perpetuates the myth that the poor are weak, feeble, and infested. Nothing could be further from the truth.

Anti-interventionism combats poverty and threatens the nonprofit sector

There is a subtle shift taking place in pockets of the social sector, challenging the historically interventionist approach to social change. Microfinance was perhaps the first in modern memory (or at least my memory) that eschewed the conventional wisdom that nonprofits know the path out of poverty better than the poor themselves, extending loans to low-income families to use as they saw fit.

More recently GiveDirectly has popularized the concept of unconditional cash transfers, whereby cash is given to low-income families with no strings attached. Domestically, homeless services are increasingly realizing the futility of trying to “treat homelessness” while people live on the streets, and instead are shifting resources toward simply putting people into homes.

Similarly, at the Family Independence Initiative we are investing in the initiatives low-income families are taking across the United States to improve their own lives and their communities. What all of these approaches have in common is that none of them make any assumptions or judgements about who the poor or homeless are. There is no real theory of change in the traditional sense. No layering of one expected outcome that ought to come before another.

Instead, these are straight forward common sense approaches that put trust in the poor and make them the center of social change. If someone needs a loan, let’s give them one. If someone is extremely impoverished, let’s transfer cash. If an individual is experiencing chronic homelessness, extend that person permanent housing.

All of these approaches are inherently anti-interventionist, and they seem to work really well. So why don’t we see a tidal wave of anti-interventionism?

The anti-interventionist threat

While anti-interventionism is great for the poor, it’s an affront to much of the nonprofit sector. Nonprofits raise funds on the assumption that their programs and services hold the key to lifting low-income families out of poverty.

These anti-interventionist approaches greatly reduce the role of nonprofits, as in the anti-interventionist’s view the nonprofit is no longer the driver of change, but the impoverished themselves. In a world of anti-interventionists, nonprofits are reduced to distributors of funds rather than architects of change.

In the interest of self-preservation, nonprofits have and will continue to argue against anti-interventionism. However, thus far the evidence is not on their side.

We in the sector talk a big game about “working ourselves out of business”. To the contrary, we have worked damn hard to stay in business while consuming dollars that are better spent by the poor themselves. As anti-interventionism grows, the social sector will have to more publicly reconcile its pro-social rhetoric with its own self-preservation.

Funding social change with giving offsets

I’ve long been fascinated by the simple concept of carbon offsets. A carbon offset is an arrangement where corporations “offset” their polluting by purchasing carbon credits that fund the development of renewable energy.

Without getting into the policy particulars of carbon offsets, the concept is straight forward and intuitive. Carbon offsets got me thinking about offsets more generally. Corporations, and individuals, do a lot more than just pollute the planet. Why isn’t there some sort of giving offset for everything?

While I was compiling my list of nonprofits to donate to for my year end giving I ran an experiment to see what an individual donor giving offset might look like.

Building a giving offset

For my personal finances I use the popular account aggregation service Mint. Since my finances are consolidated in Mint I figured it would be convenient to base my giving offset calculations using a transaction history exported from its website.

To automate the process of logging in and extracting transactions from Mint I used the excellent Python library mintapi. Mint conveniently categorizes all financial transactions, so I mapped each Mint category to a cause. For example, pet related transactions were assigned to animal related causes, education expenses were assigned to education causes, restaurant purchases were mapped to hunger, etc.

Based on the mapping of Mint categories to giving offsets, the system I built recommended I allocate my charitable giving for 2015 according to the following chart.

Given the current mapping and my personal spending habits, by far the largest offset recommendation is in the “Poverty and homelessness” category followed by “Food and hunger”. Readers of Full Contact Philanthropy might rightly wonder whether the current mapping is “fair”, or whether it instead reflects my own bias toward investing in poverty related issues. I don’t know the answer to this question, but my guess there’s a fair amount of bias (isn’t there in everything?).

Since Mint data extracts include one’s entire transaction history, not just the most recent year, I also ran the giving offset recommendations over the last few years as shown below.

As you can see from the above graph, there’s a fair amount of change in my giving offset recommendations from 2011 through today. Around 2013 suggested giving to animal causes grew considerably, reflecting vet bills one of my chihuahuas has been racking up the last few years. And yes, I took the giving offset’s advice and added animal related causes to my giving portfolio.

What now?

I’m not sure a giving offset is a good idea. I’m also not sure it’s a bad idea. I think in some ways I’ve only recently fully accepted and moved on from the closure of my last company Idealistics. This acceptance has resulted in a flurry of ideas and activity around those ideas (reflected partly in more writing on this site). The giving offset is one of those ideas.

However, I am committed to trying out various new ideas and putting those ideas out in public rather than keeping them to myself. I generally like the idea of charitable giving reflecting the life one leads and trying to offset selfish spending by re-investing in the world. I have some thoughts on how one might approach a more robust version of a giving offset, but I’m hardly married to the idea. What do you think?

Martin Luther King Day and philanthropic inactivism

I joined the social sector because I care deeply about social justice. Somewhere along the way my vocation became my job. Where I used to stay up late thinking about the millions of people in the United States with less opportunity than me simply for where they were born or the color of their skin, and the billions around the world living unimaginably on less than $2 per day, I now stay up late worrying about saving for my future and how I will provide for my family.

Social justice crusader indeed.

Everyone has to live, and everyone has ambition. On Martin Luther King day I am reminded not to let my desire to live a good life overpower my desire for everyone to live a good life.

While I firmly believe our society looks to the philanthropic sector as some sort of moral compass (seriously, everyone assumes I must be a noble person for working at a nonprofit), I don’t think we do much with it.

Passionate people join the social sector because they see the world as it is, and have a vision for how it can be better. While individually there are lots of different visions, collectively we don’t really have any vision at all, resulting in a philanthropic community that while assumed to have the moral high-ground ultimately does not stand for anything.

I think there are plenty of folks who don’t find this reality problematic. It seems a strange consensus that philanthropy and politics do not mix. Yet it is our politics, and more specifically our collective values, that creates the maladies we aim to address.

Martin Luther King was a civil rights pioneer not for creating a nonprofit that provided social services to help African Americans live a little better, but by challenging the laws and social values that subjugated a significant portion of our community. Social interventions like homeless shelters, food pantries, and tutoring programs are fundamentally responses to injustice. While these programs are wrapped in apolitical blankets, they are plainly and intuitively critiques of the system we live in.

Yet as a sector we don’t consolidate and articulate those critiques, and it is all for self serving reasons. Large corporations that perpetuate income inequality and pollute the planet also give in large amounts to nonprofits, and setup foundations that fund our work (and our lives). Politicians that support draconian immigration laws that breakup families also hold the keys to preserving the charitable deduction.

You don’t bite the hand that feeds you, so the saying goes, and the philanthropic sector certainly abides. But maybe we are hungry for the wrong thing.

Maybe we in the social sector can get more from Martin Luther King’s legacy than a paid vacation.

Why nonprofits lie about impact

I was listening to a podcast with Dan Ariely, professor of psychology and behavioral economics at Duke University, about “Why Everybody Lies”. The discussion was really interesting, but what I found especially compelling from a philanthropic lense was a portion of the discussion where Professor Ariely discusses an experiment where people’s lies affected how much money could be given to charity.

The basic point was that people are more likely to lie when the lie benefits a cause.

As the title of this post suggests, the behavioral finding highlighted in the study got me thinking about why nonprofits seem inclined to inflate their program impact claims. I used to more simplistically think that such fudging was the simple calculus that more claim to impact means more money for me. After listening to this podcast, my guess is there is impact inflation is more invovled, as the weight of the cause likely outweighs the knowledge (tacit or otherwise) that impact claims are not quite as they appear.

If nonprofits are right that their impact is large (even if not as large as they claim), then perhaps the subtle dishonesty is not so bad. But what if a nonprofit’s exaggerated claim makes a donor give more to one organization than another that in actuality is more impactful? Worse yet, what if a nonprofit actually does harm while claiming impact?

There are some in the international development space calling for cash transfers to act as a baseline metric that all other interventions should be compared against, an idea I have mulled domestically as well. If it is true that nonprofits inflate their impact metrics, then cash transfers as a comparison point gets necessarily devalued.

The challenge here of course is not just the dishonesty of inflating impact metrics, but the moralizing inherent in all of us that allows us to override fact for what we think is a more just fiction. The risk is that if we allow our rationality to get hijacked by our moralizing, we ironically run the risk of making worse the issues we deem important enough to lie for in the first place.