When the Solution Has No Price

One problem faced by a society that is always working toward solutions to various problems is that certain solutions, however effective, may go unused because they cannot be commodified.

Consider obesity. True, billions of dollars have been made selling all sorts of diet and exercise and weight-loss products, but perhaps the best solution is the free one: eat a bit less and a bit better and take a good 30-minute walk every day. But it’s hard to make money pushing that idea.

In this interview with The Takeaway, the author and surgeon Atul Gawande offers another compelling example. Gawande’s new book, The Checklist Manifesto (see Levitt’s strong endorsement here) describes his effort to create a checklist for use in surgical settings that could cut down on errors.

The checklist, piloted in eight hospitals around the world, proved to be very successful. It was also essentially free. But, as Gawande explains in the Takeaway interview, widespread adoption has been far slower than he would like. Why?

If a pharmaceutical company came up with a drug or a device that offered the same improved outcomes as the checklist, Gawande notes, that drug or device would be worth billions of dollars, and would be marketed accordingly. The lowly checklist, meanwhile, has no such sponsor and therefore is far slower to spread.

Here’s hoping that the checklist, along with other cheap and simple solutions, can somehow keep worming their way into the marketplace, despite competition from much better-promoted (and often inferior) ideas.

stephen boyington

It kills me that nobody wants to do anything that is free, because it therefore must not be worth anything. I laugh my tail off at the idea of people buying treadmills or stupid things like plastic balls that somehow make your workout great. Just take a walk, or do some situps. Ye gods.

Tom Gatsby

I like the idea too, but there are liabilities that would need to be addressed.

At least if a particular pharma's drug does not work, or causes irreparable harm, there is an entity to go after, either for justice, or for money.

If the "checklist" does not work, or there is a case that falls through its methodology's cracks, to whom do we turn?

stephen boyington

It is another example of a universal truth: nobody wants to be told what to do or have it suggested that they have been doing things incorrectly. I guarantee the initial reaction to the checklist, which would save lives and improve outcomes, is "who the hell do they think they are!". Example: early in the swine flu frenzy, a poster was placed in the common area of my office instructing about hand washing, etc. One guy immediately threw it out, yelling at how "stupid" it was.


Twicker, are you kidding? Churches exist *exactly* because they are huge moneymakers for the people who run them. What planet have you been living on?!!


The "walk-and-eat-slightly-less" example isn't a great one. Studies have shown that small diet/lifestyle changes don't, in fact, result in the sort of weight loss that makes obese people "normal weight." Our bodies adjust easily to those sorts of small changes. Sorry :(


When I was in college I interned at one of the largest corporations in the world and was allowed to test/play with car tires that were completely indestructible, it was amazing. However, these tires will never see the market because it would destroy the market.. Some times markets determine progress and it can work backwards.


With all due respect to Dr. Ganwande, it not "his" check list. According to his New Yorker article in 2007, it was designed by Dr. Peter Provonost at Johns Hopkins.

From the article:

In 2001, though, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give it a try. He didn't attempt to make the checklist cover everything; he designed it to tackle just one problem, the one that nearly killed Anthony DeFilippo: line infections. On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient's skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist just for them. Still, Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.

Read more: http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=4#ixzz0ceDCU5xj


Lee A

The idea that people will somehow resist adoption of an innovation because it is free is absurd. I know lots of people, and if they have the option of getting something they want for free or paying a bunch of money for it, they'll take free. Pretty much all the time. This one fails the smell test. Here's the rub: they have to really want it. People have complex brains; they don't articulate what they really want. Heck, they don't have any idea what they want. Think about it: Do people with access to an abundance of tasty food want to eat fewer calories than they burn? That's what they'll tell you, but that's not what their brains are telling them. Abundance? Eat! You could be starving tomorrow. The diet books and all the rest are window-dressing. The presentation of self in everyday life (a must read). Lay your rational head to rest, so the marketers can prey on your primitive impulses in peace. When we change, they'll change. But don't hold your breath.



Liz, what are you talking about? If you reduce your daily caloric intake and walk 30 minutes a day, you will lose weight.


Sell exercise machines that generate electricity when you use them.. The electric company can pay you for generating power.


This is a function of our system of private enterprise and a government based on the belief that people act on selfish impulses. If we look at Confucian based systems (Japan, Korea, China), for all their faults and inevitable corruption, it _is_ possible in those systems for government to rally the populace to improve themselves even when money isn't involved. The campaigns that in this country get laughed at (anti-littering, for example) sometimes actually work in those countries.

It goes back to the Confucian point that if we base a society on laws, people will follow the laws but be morally empty, but if we base a society on morals, people will strive to follow the system because it reflects what they think of _themselves_. Of course, as noted, there are huge problems with relying on human goodness for societal progress, but it is an element of the Eastern model that, when it works, shows up some of the shortcomings of our Hobbesian systems in the West.



You got the same problem with environmental economics. Leaving wetlands in place is much cheaper than building flood control projects, public water projects, sewage treatment projects, restoring habitat, etc.


Strongly disagree with comment #21 on the futility of home exercise equipment, if your goal is to get in 3-4 aerobic workouts weekly without going to a gym. My current favorite is a treadmill; when it wears out I'll be getting an elliptical (I've also owned stationary bikes and a rower). Configurable incline, stats on speed, distance, climate controlled environment, multimedia as desired.

Q: what's the best form of exercise?
A: the one you'll do consistently.


In the richest nation in the world, there's no money to be made and there are no cash-in-hand lobbyists for ending poverty or child hunger either. Even the concept of "the public good" has dropped off the radar because its not a money-maker or vote-getter. Public health care is already a demonstrated non-starter, and public education is crumbling under continued corporate attack (see New Jersey for the latest example.)

It's a sorry state for a once-great nation.


I can understand Dr. Gawande's frustration that the uptake of a low cost solution tends to be slower than one that might be heavily marketed by a pharmaceutical company or even his colleagues. After all, how many surgeons suggest various procedures that may not actually offer real benefit? It is their own interest to do so and given that a third party pays, no surprise that most patients opt for the procedure when confronted with a choice, even if confronted with the evidence to the contrary.

On the other hand, it is easy to demonize the pharmaceutical companies in the debate about health care. There are, however, excellent past examples about how their researchers solved major health problems that generated little or no meaningful revenue stream (such as the use of ivermectin for the treatment of river blindness in sub-Sahra Africa and the development of balance salt solutions for the treatment if life-threatening diarrheagenic disease in developing nations).



Reminds me of the MadTV skit - if it's free, it *does* sound like a scam too.



The "walk and eat" example is a fallacy. The science of obesity, the wrong incentives in the research and public policy, the tragic outcomes and the solutions to that problem have been covered in Gary Taubes' book "Good calories, bad calories". A bit hard to read but extremely informative. Plus it has the best bibliography I have ever seen.

Peter Fein

Industrial capitalism propagates itself by solving the problems it creates. - Joel Salatin

Farm subsidies create a surplus of cheap corn. How shall we dispose of the corn? Let's make high fructose corn syrup. Oh, corn syrup is making us fat & giving us diabetes? Let's invent some new drugs for that. And on and on...


This article is a classic example of a professional, in this case, and economist, allowing their professional view to impair their world view in general. Human beings aren't just cost-assessing machines. They choose to do and not do things for a whole host of rational and irrational reasons. Anyone who has known a good number of doctors or talked to people who work with doctors knows that doctors tend to have rather large, healthy egos (to put it nicely). The reason checklists haven't been adopted is that many doctors are offended at the audacity of any non-doctor telling them they can't do a surgery from memory. But as a rule, doctors also care about people. No one devotes so much time, money, and torture to such a long education if they don't have at least some concern for humankind. Appealing to their higher duty to serve AND pointing out the cost savings to hospitals for implementing checklists will probably make most doctors accept it. This notion that the idea of checklists will only be implemented if it is sold like a diet book is wacky. Just because something is sellable doesn't mean anyone would buy it. The spark of human desire has to be there to create the demand.


Tom in Ohio

Actually, handing out advice that you could have had for free is most of what consulting companies like McKinsey do. They stay on top of best practices in a given industry and other industries, and talk to the workers who they are trying to make more efficient. Then they write it up and charge upper management a fortune. Of course, this approach only works if you're open to advice. Perhaps the real problem is that surgeons are all ego-maniacs who think they already know all there is to know.