THE SIZE INSTINCT

 


CHAPTER FIVE

THE SIZE INSTINCT

Putting war memorials and bear attacks in proportion using two magic tools that you already possess


The Deaths I Do Not See

When I was a young doctor in Mozambique in the early 1980s, I had to do some very difficult math. The math was difficult because of what I was counting. I was counting dead children. Specifically, I was comparing the number of deaths among children admitted to our hospital in Nacala with the number of children dying in their homes within the district we were supposed to serve.

At that time, Mozambique was the poorest country in the world. In my first year in Nacala district, I was the only doctor for a population of 300,000 people. In my second year, a second doctor joined me. We covered a population that in Sweden would have been served by 100 doctors, and every morning on my way to work I said to myself, “Today I must do the work of 50 doctors.”

We admitted around 1,000 very sick children each year to the district’s one small hospital, which meant around three per day. I will never forget trying to save the lives of those children. All had very severe diseases like diarrhea, pneumonia, and malaria, often complicated by anemia and malnutrition, and despite our best efforts, around one in 20 of them died. That was one child every week, almost all of whom we could have cured if we had had more and better resources and staff.

The care we could provide was rudimentary: water and salt solutions and intramuscular injections. We did not give intravenous drips: the nurses had not yet acquired the skills to administer them and it would have taken up too much of the doctors’ time to place and supervise the infusions. We rarely had oxygen tanks and we had limited capacity for blood transfusions. This was the medicine of extreme poverty.

One weekend, a friend came to stay with us—a Swedish pediatrician who worked in the slightly better hospital in a bigger city 200 miles away. On the Saturday afternoon, I had to go on an emergency call to the hospital and he came with me. When we arrived, we were met by a mother with fear in her eyes. In her arms was her baby who had severe diarrhea and was so weak that she could not breastfeed. I admitted the child, inserted a feeding tube, and ordered that oral rehydration solution should be given through the tube. My pediatrician friend dragged me into the corridor by the arm. He was very upset and angrily challenged the substandard treatment I had prescribed, accusing me of skimping in order to get home for dinner. He wanted me to give the baby an intravenous drip.

I became angry at his lack of understanding. “This is our standard treatment here,” I explained. “It would take me half an hour to get a drip running for this child and then there would be a high risk that the nurse would mess it up. And yes, I do have to get home for dinner sometimes, otherwise my family and I would not last here more than a month.”

My friend couldn’t accept it. He decided to stay at the hospital struggling for hours to get a needle into a tiny vein.

When my colleague finally joined me back at home, the debate continued. “You must do everything you can for every patient who presents at the hospital,” he urged.

“No,” I said. “It is unethical to spend all my time and resources trying to save those who come here. I can save more children if I improve the services outside the hospital. I am responsible for all the child deaths in this district: the deaths I do not see just as much as the deaths in front of my eyes.”

My friend disagreed, as do most doctors and perhaps most members of the public. “Your obligation is to do everything for the patients in your care. Your claim that you can save more children elsewhere is just a cruel theoretical guess.” I was very tired. I stopped arguing and went to bed, but the next day I started counting.

Together with my wife, Agneta, who managed the delivery ward, I did the math. We knew that a total of 946 children had been admitted to the hospital that year, almost all of them below the age of five, and of those, 52 (5 percent) had died. We needed to compare that number with the number of child deaths in the whole district.

The child mortality rate of Mozambique was then 26 percent. There was nothing special about Nacala district, so we could use that figure. The child mortality rate is calculated by taking the number of child deaths in a year and dividing it by the number of births in that year.

So if we knew the number of births in the district that year, we could estimate the number of child deaths, using the child mortality rate of 26 percent. The latest census gave us a number for births in the city: roughly 3,000 each year. The population of the district was five times the population of the city, so we estimated there had probably been five times as many births: 15,000. So 26 percent of that number told us that I was responsible for trying to prevent 3,900 child deaths every year, of which 52 happened in the hospital. I was seeing only 1.3 percent of my job.

Now I had a number that supported my gut feeling. Organizing, supporting, and supervising basic community-based health care that could treat diarrhea, pneumonia, and malaria before they became life-threatening would save many more lives than putting drips on terminally ill children in the hospital. It would, I believed, be truly unethical to spend more resources in the hospital before the majority of the population—and the 98.7 percent of dying children who never reached the hospital—had some form of basic health care.

So we worked to train village health workers, to get as many children as possible vaccinated, and to treat the main child killers as early as possible in small health facilities that could be reached even by mothers who had to walk.

This is the cruel calculus of extreme poverty. It felt almost inhuman to look away from an individual dying child in front of me and toward hundreds of anonymous dying children I could not see.

I remember the words of Ingegerd Rooth, who had been working as a missionary nurse in Congo and Tanzania before she became my mentor. She always told me, “In the deepest poverty you should never do anything perfectly. If you do you are stealing resources from where they can be better used.”

Paying too much attention to the individual visible victim rather than to the numbers can lead us to spend all our resources on a fraction of the problem, and therefore save many fewer lives. This principle applies anywhere we are prioritizing scarce resources. It is hard for people to talk about resources when it comes to saving lives, or prolonging or improving them. Doing so is often taken for heartlessness. Yet so long as resources are not infinite—and they never are infinite—it is the most compassionate thing to do to use your brain and work out how to do the most good with what you have.

This chapter is full of data about dead children because saving children’s lives is what I care about most in the whole world. It seems heartless and cruel, I know, to count dead children and to talk about cost-effectiveness in the same sentence as a dying child. But if you think about it, working out the most cost-effective way of saving as many children’s lives as possible is the least heartless exercise of them all.

Just as I have urged you to look behind the statistics at the individual stories, I also urge you to look behind the individual stories at the statistics. The world cannot be understood without numbers. And it cannot be understood with numbers alone.

The Size Instinct

You tend to get things out of proportion. I do not mean to sound rude. Getting things out of proportion, or misjudging the size of things, is something that we humans do naturally. It is instinctive to look at a lonely number and misjudge its importance. It is also instinctive—like in the hospital in Nacala —to misjudge the importance of a single instance or an identifiable victim. These two tendencies are the two key aspects of the size instinct.

The media is this instinct’s friend. It is pretty much a journalist’s professional duty to make any given event, fact, or number sound more important than it is. And journalists know that it feels almost inhuman to look away from an individual in pain.

The two aspects of the size instinct, together with the negativity instinct, make us systematically underestimate the progress that has been made in the world. In the test questions about global proportions, people consistently say about 20 percent of people are having their basic needs met. The correct answer in most cases is close to 80 percent or even 90 percent. Proportion of children vaccinated: 88 percent. Proportion of people with electricity: 85 percent. Proportion of girls in primary school: 90 percent. The use of numbers that sound enormous, together with constant images of individual suffering presented by the charities and the media, distort people’s view of the world and they systematically underestimate all these proportions and all this progress.

At the same time, we systematically overestimate other proportions. The proportion of immigrants in our countries. The proportion of people opposed to homesexuality. In each of these cases, at least in the United States and Europe, our interpretations are more dramatic than the reality.

The size instinct directs our limited attention and resources toward those individual instances or identifiable victims, those concrete things right in front of our eyes. Today there are robust data sets for making the kinds of comparisons I made in Nacala on a global scale, and they show the same thing: It is not doctors and hospital beds that save children’s lives in countries on Levels 1 and 2. Beds and doctors are easy to count and politicians love to inaugurate buildings. But almost all the increased child survival is achieved through preventive measures outside hospitals by local nurses, midwives, and well-educated parents. Especially mothers: the data shows that half the increase in child survival in the world happens because the mothers can read and write. More children now survive because they don’t get ill in the first place. Trained midwives assist their mothers during pregnancy and delivery. Nurses immunize them. They have enough food, their parents keep them warm and clean, people around them wash their hands, and their mothers can read the instructions on that jar of pills. So if you are investing money to improve health on Level 1 or 2, you should put it into primary schools, nurse education, and vaccinations. Big impressive-looking hospitals can wait.

How to Control the Size Instinct

To avoid getting things out of proportion you need only two magic tools: comparing and dividing. What did you say? You already know both of them? Great, then all you need is to start using them. Make it a habit! I’ll show you how.

Compare the Numbers

The most important thing you can do to avoid misjudging something’s importance is to avoid lonely numbers. Never, ever leave a number all by itself. Never believe that one number on its own can be meaningful. If you are offered one number, always ask for at least one more. Something to compare it with.

Be especially careful about big numbers. It is a strange thing, but numbers over a certain size, when they are not compared with anything else, always look big. And how can something big not be important?

4.2 Million Dead Babies

Last year, 4.2 million babies died.

That is the most recent number reported by UNICEF of deaths before the age of one, worldwide. We often see lonely and emotionally charged numbers like this in the news or in the materials of activist groups or organizations. They produce a reaction.

Who can even imagine 4.2 million dead babies? It is so terrible, and even worse when we know that almost all died from easily preventable diseases. And how can anyone argue that 4.2 million is anything other than a huge number? You might think that nobody would even try to argue that, but you would be wrong. That is exactly why I mentioned this number. Because it is not huge: it is beautifully small.

If we even start to think about how tragic each of these deaths is for the parents who had waited for their newborn to smile, and walk, and play, and instead had to bury their baby, then this number could keep us crying for a long time. But who would be helped by these tears? Instead let’s think clearly about human suffering.

The number 4.2 million is for 2016. The year before, the number was 4.4 million. The year before that, it was 4.5 million. Back in 1950, it was 14.4 million. That’s almost 10 million more dead babies per year, compared with today. Suddenly this terrible number starts to look smaller. In fact the number has never been lower.

Of course, I am the first person to wish the number was even lower and falling even faster. But to know how to act, and how to prioritize resources, nothing can be more important than doing the cool-headed math and realizing what works and what doesn’t. And this is clear: more and more deaths are being prevented. We would never realize that without comparing the numbers.

A Large War

The Vietnam War was the Syrian war of my generation.

Two days before Christmas in 1972, seven bombs killed 27 patients and members of staff at the Bach Mai hospital in Hanoi in Vietnam. I was studying medicine in Uppsala in Sweden. We had plenty of medical equipment and yellow blankets. Agneta and I coordinated a collection, which we packed in boxes and sent to Bach Mai.

Fifteen years later, I was in Vietnam to evaluate a Swedish aid project. One lunchtime, I was eating my rice next to one of my local colleagues, a doctor named Niem, and I asked him about his background. He told me he had been inside the Bach Mai hospital when the bombs fell. Afterward, he had coordinated the unpacking of boxes of supplies that had arrived from all over the world. I asked him if he remembered some yellow blankets and I got goose bumps as he described the fabric’s pattern to me. It felt like we had been friends forever.

At the weekend, I asked Niem to show me the monument to the Vietnam War. “You mean the ‘Resistance War Against America,’” he said. Of course, I should have realized he wouldn’t call it the Vietnam War. Niem drove me to one of the city’s central parks and showed me a small stone with a brass plate, three feet high. I thought it was a joke. The protests against the Vietnam War had united a generation of activists in the West. It had moved me to send blankets and medical equipment. More than 1.5 million Vietnamese and 58,000 Americans had died. Was this how the city commemorated such a catastrophe? Seeing that I was disappointed, Niem drove me to see a bigger monument: a marble stone, 12 feet high, to commemorate independence from French colonial rule. I was still underwhelmed.

Then Niem asked me if I was ready to see the proper war monument. He drove a little way further, and pointed out of the window. Above the treetops I could see a large pagoda, covered in gold. It seemed about 300 feet high. He said, “Here is where we commemorate our war heroes. Isn’t it beautiful?” This was the monument to Vietnam’s wars with China.

The wars with China had lasted, on and off, for 2,000 years. The French occupation had lasted 200 years. The “Resistance War Against America” took only 20 years. The sizes of the monuments put things in perfect proportion. It was only by comparing them that I could understand the relative insignificance of “the Vietnam War” to the people who now live in Vietnam.

Bears and Axes

Mari Larsson was 38 years old when she was killed by multiple blows to the head from an axe. It was the night of October 17, 2004. Mari’s former partner had broken into her house in the small town of PiteΓ₯ in the north of Sweden and was waiting for her to come home. The tragic and brutal murder of a mother of three was barely reported in the national media and even the local newspaper gave it only modest coverage.

That same day a 40-year-old father of three, also living in the far north of Sweden, was killed by a bear while out hunting. His name was Johan Vesterlund and he was the first person killed by a bear in Sweden since 1902. This brutal, tragic, and, crucially, rare event received massive coverage throughout Sweden.

In Sweden, a fatal bear attack is a once-in-a-century event. Meanwhile, a woman is killed by her partner every 30 days. This is a 1,300-fold difference in magnitude. And yet one more domestic murder had barely registered, while the hunting death was big news.

Despite what the media coverage might make us think, each death was equally tragic and horrendous. Despite what the media might make us think, people who care about saving lives should be much more concerned about domestic violence than about bears.

It seems obvious when you compare the numbers.

Tuberculosis and Swine Flu

It is not only bears and axes that the news media gets out of proportion.

In 1918 the Spanish flu killed around 2.7 percent of the world population. The risk of an outbreak of a flu against which we have no vaccine remains a constant threat, which we should all take extremely seriously. In the first months of 2009, thousands of people died from the swine flu. For two weeks it was all over the news. Yet, unlike with Ebola in 2014, the number of cases did not double. It did not even go up in a straight line. I and others concluded this flu was not as aggressive as the first alarm had indicated. But journalists kept the fear boiling for several weeks.

Finally I got tired of the hysteria and calculated the rate of news reports versus fatalities. Over a period of two weeks, 31 people had died from swine flu, and a news search on Google brought up 253,442 articles about it. That was 8,176 articles per death. Over the same two-week period, I calculated that roughly 63,066 people had died of tuberculosis (TB). Almost all these people were on Levels 1 and 2, where TB remains a major killer even though it can now be treated. But TB is infectious and TB strains can become resistant and kill many people on Level 4. The news coverage for TB was at a rate of 0.1 article per death. Each swine flu death received 82,000 times more attention than each equally tragic death from TB.

The 80/20 Rule

It’s so easy to get things out of proportion, but luckily there are also some easy solutions. Whenever I have to compare lots of numbers and work out which are the most important, I use the simplest-ever thinking tool. I look for the largest numbers.

That is all there is to the 80/20 rule. We tend to assume that all items on a list are equally important, but usually just a few of them are more important than all the others put together. Whether it is causes of death or items in a budget, I simply focus first on understanding those that make up 80 percent of the total. Before I spend time on the smaller ones, I ask myself: Where are the 80 percent? Why are these so big? What are the implications?

For example, here’s a list of the world’s energy sources, in alphabetical order: biofuels, coal, gas, geothermal, hydro, nuclear, oil, solar, wind. Presented like that, they all seem equally important. If we instead sort them according to how many units of energy they generate for humanity, three outnumber all the rest, as this graph shows.

To give myself the big picture I would use the 80/20 rule, which tells us that oil+coal+gas give us more than 80 percent of our energy: 87 percent in fact.

I first discovered how useful the 80/20 rule is when I started to review aid projects for the Swedish government. In most budgets, around 20 percent of the lines sum up to more than 80 percent of the total. You can save a lot of money by making sure you understand these lines first.

Doing just that is how I discovered that half the aid budget of a small health center in rural Vietnam was about to be spent on 2,000 of the wrong kind of surgical knives. It’s how I discovered that 100 times too much—4 million liters—of baby formula was about to be sent to a refugee camp in Algeria. And it is how I stopped 20,000 testicular prostheses from being sent to a small youth clinic in Nicaragua. In each case I simply looked for the biggest single items taking up 80 percent of the budget, then dug down into any that seemed unusual. In each case the problem was due to a simple confusion or tiny error such as a missing decimal point.

The 80/20 rule is as easy as it seems. You just have to remember to use it. Here’s one more example.

The PIN Code of the World

We can understand the world better, and make better decisions about it, if we know where the biggest proportion of the population lives now and where it will live in the future. Where is the world market? Where are the internet users? Where will tourists come from in the future? Where are most of the cargo ships going? And so on.

FACT QUESTION 8

There are roughly 7 billion people in the world today. Which map shows best where they live? (Each figure represents 1 billion people.)

This is one of the fact questions where people score best. They are almost as good as the chimps. Their answers are almost as good as random. By this point in the book, that looks like a great achievement. You see, it all depends on how you compare!

Seventy percent of people still pick the wrong maps, showing 1 billion people on the wrong continent. Seventy percent of people don’t know that the majority of mankind lives in Asia. If you really care about a sustainable future or the plundering of our planet’s natural resources or the global market, how can you afford to lose track of a billion people?

The correct map is A. The PIN code of the world is 1-1-1-4. That’s how to remember the map. From left to right, the number of billions, as a PIN code. Americas: 1, Europe: 1, Africa: 1, Asia: 4. (I have rounded the numbers.) Like all PIN codes, this one will change. By the end of this century, the UN expects there to have been almost no change in the Americas and Europe but 3 billion more people in Africa and 1 billion more in Asia. By 2100 the new PIN code of the world will be 1-1-4-5. More than 80 percent of the world’s population will live in Africa and Asia.

If the UN forecasts for population growth are correct, and if incomes in Asia and Africa keep growing as now, then the center of gravity of the world market will shift over the next 20 years from the Atlantic to the Indian Ocean. Today, the people living in rich countries around the North Atlantic, who represent 11 percent of the world population, make up 60 percent of the Level 4 consumer market. Already by 2027, if incomes keep growing worldwide as they are doing now, then that figure will have shrunk to 50 percent. By 2040, 60 percent of Level 4 consumers will live outside the West. Yes, I think the Western domination of the world economy will soon be over.

People in North America and Europe need to understand that most of the world population lives in Asia. In terms of economic muscles “we” are becoming the 20 percent, not the 80 percent. But many of “us” can’t fit these numbers into our nostalgic minds. Not only do we misjudge how big our war monuments should be in Vietnam, we also misjudge our importance in the future global marketplace. Many of us forget to behave properly with those who will control the future trade deals.


Divide the Numbers

Often the best thing we can do to make a large number more meaningful is to divide it by a total. In my work, often that total is the total population. When we divide an amount (say, the number of children in Hong Kong) by another amount (say, the number of schools in Hong Kong), we get a rate (children per school in Hong Kong). Amounts are easier to find because they are easier to produce. Somebody just needs to count something. But rates are often more meaningful.

The Trend Below the Division Line

I want to return to the 4.2 million dead infants. Earlier in the chapter we compared 4.2 million babies to the 14.4 million who died in 1950. What if fewer children are being born every year and that’s the reason fewer babies are dying? When you see one number falling it is sometimes actually because some other background number is falling. To check, we need to divide the total number of child deaths by the total number of births.

In 1950, 97 million children were born and 14.4 million children died. To get the child mortality rate, we divide the number of deaths (14.4 million) by the number of births (97 million). That comes out to 15 percent. So in 1950, out of every 100 babies who were born, 15 died before their first birthday.

Now let’s look at the most recent numbers. In 2016, 141 million children were born and 4.2 million died. Dividing the number of births by the number of deaths comes out to just 3 percent. Out of every 100 babies born across the world, only three die before reaching the age of one. Wow! The infant mortality rate has changed from 15 percent to 3 percent. When we compare rates, rather than amounts of dead children, the most recent number suddenly seems astonishingly low.

Some people feel ashamed when doing this kind of math with human lives. I feel ashamed when not doing it. A lonely number always makes me suspicious that I will misinterpret it. A number that I have compared and divided can instead fill me with hope.

Per Person

“The forecasts show that it is China, India, and the other emerging economies that are increasing their carbon dioxide emissions at a speed that will cause dangerous climate change. In fact, China already emits more CO2 than the USA, and India already emits more than Germany.”

This outspoken statement came from an environment minister from a European Union country who was part of a panel discussing climate change at the World Economic Forum in Davos in January 2007. He made his attribution of blame in a neutral tone of voice, as if he were stating a self-evident fact. Had he been watching the faces of the Chinese and Indian panel members he would have realized that his view was not self-evident at all. The Chinese expert looked angry but continued to stare straight ahead. The Indian expert, in contrast, could not sit still. He waved his arm and could barely wait for the moderator’s signal that he could speak.

He stood up. There was a short silence while he looked into the face of each panel member. His elegant dark blue turban and expensive-looking dark gray suit, and the way he was behaving in his moment of outrage, confirmed his status as one of India’s highest-ranking civil servants with many years’ experience as a lead expert at the World Bank and the International Monetary Fund. He made a sweeping gesture toward the panel members from the rich nations and then said loudly and accusingly, “It was you, the richest nations, that put us all in this delicate situation. You have been burning increasing amounts of coal and oil for more than a century. You and only you pushed us to the brink of climate change.” Then he suddenly changed posture, put his palms together in an Indian greeting, bowed, and almost whispered in a very kind voice, “But we forgive you, because you did not know what you were doing. We should never blame someone retrospectively for harm they were unaware of.” Then he straightened up and delivered his final remark as a judge giving his verdict, emphasizing each word by slowly moving his raised index finger. “But from now on we count carbon dioxide emission per person.”

I couldn’t have agreed more. I had for some time been appalled by the systematic blaming of climate change on China and India based on total emissions per nation. It was like claiming that obesity was worse in China than in the United States because the total bodyweight of the Chinese population was higher than that of the US population. Arguing about emissions per nation was pointless when there was such enormous variation in population size. By this logic, Norway, with its population of 5 million, could be emitting almost any amount of carbon dioxide per person.

In this case, the large numbers—total emissions per nation—needed to be divided by the population of each country to give meaningful and comparable measures. Whether measuring HIV, GDP, mobile phone sales, internet users, or CO2 emissions, a per capita measurement—i.e., a rate per person—will almost always be more meaningful.

It’s Dangerous Out There

The safest lives in history are lived today by people on Level 4. Most preventable risks have been eliminated. Still, many walk around feeling worried.

They worry about all kinds of dangers “out there.” Natural disasters kill so many people, diseases spread, and airplanes crash. They all happen all the time out there, beyond the horizon. It’s a bit strange, isn’t it? Such terrifying things rarely happen “here,” in this safe place where we live. But out there, they seem to happen every day. Remember, though, “out there” is the sum of millions of places, while you live in just one place. Of course more bad things happen out there: out there is much bigger than here. So even if all the places out there were just as safe as your place, hundreds of terrible events would still happen there. If you could keep track of each separate place though, you would be surprised how peaceful most of them were. Each of them shows up on your screen only on that single day when something terrible happens. All the other days, you don’t hear about them.

Compare and Divide

When I see a lonely number in a news report, it always triggers an alarm: What should this lonely number be compared to? What was that number a year ago? Ten years ago? What is it in a comparable country or region? And what should it be divided by? What is the total of which this is a part? What would this be per person? I compare the rates, and only then do I decide whether it really is an important number.

Factfulness

Factfulness is … recognizing when a lonely number seems impressive (small or large), and remembering that you could get the opposite impression if it were compared with or divided by some other relevant number.

To control the size instinct, get things in proportion.

• Compare. Big numbers always look big. Single numbers on their own are misleading and should make you suspicious. Always look for comparisons. Ideally, divide by something.

• 80/20. Have you been given a long list? Look for the few largest items and deal with those first. They are quite likely more important than all the others put together.

• Divide. Amounts and rates can tell very different stories. Rates are more meaningful, especially when comparing between different-sized groups. In particular, look for rates per person when comparing between countries or regions.








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