by Robin Hanson
Compulsory state-sponsored education traces its heritage to a relatively recent, and not particularly “scholarly,” development: the expansion of the Prussian military state in the 18th and 19th centuries. Prussian schools were designed to create patriotic citizens for war, and they apparently worked as intended. But the Prussian education system had many other attractive qualities (like teacher training) that made it appealing to other nations. By the end of the 1800s, the “Prussian model” had spread throughout much of Europe.24 And in the mid-1800s, American educators and lawmakers explicitly set out to emulate the Prussian system.
This suggests that public K–12 schools were originally designed as part of nation-building projects, with an eye toward indoctrinating citizens and cultivating patriotic fervor. In this regard, they serve as a potent form of propaganda. We can see this function especially clearly in history and civics curricula, which tend to emphasize the rosier aspects of national issues. The American Pledge of Allegiance, which was composed in the late 1800s and formally adopted by Congress in 1942, further cements the propaganda function.25
We see statistical evidence of the propaganda function in history. Countries have made large investments in state primary education systems when they face military rivals or threats from their neighbors.26 And just as powerful governments have sought to control mass media outlets like newspapers and TV stations, they have similarly sought state control over schools. Today, governments that control larger wealth transfers (like totalitarian regimes) tend to control and fund more schools than less powerful governments, as well as more TV stations—but not more hospitals.27 It seems that the governments that most need to indoctrinate their citizens do in fact pay for more school.
Yes, this might be a waste from a global perspective, but at least we can understand why nations don’t coordinate internally to avoid this sort of school. All-in-all, though, propaganda probably plays only a modest role in how students are educated (even if it helps explain why governments are eager to fund schools). Meanwhile, there’s another hidden function of education that more directly affects the day-to-day life of a student.
DOMESTICATION
The modern workplace is an unnatural environment for a human creature. Factory workers stand in a fixed spot performing repetitive tasks for hours upon hours, day after day. Knowledge workers sit at their desks under harsh fluorescent lights, paying sustained, focused attention to intricate (and often mind-numbing) details. Everyone has to wake up early, show up on time, do what they’re told, and submit to a system of rewards and punishments.
One of the main reasons so few animals can be domesticated is that only rare social species let humans sit in the role of dominant pack animal.28 And we, too, naturally resist submitting to other humans. Recall from Chapter 3 that our ancient hunter-gatherer ancestors were fiercely egalitarian and fought hard to prevent even the appearance of taking or giving orders. And while many women throughout history have been bossed around within their families, prior to the Industrial Revolution, most men were free; outside of childhood and war, few had to regularly take direct orders from other men.
In light of this, consider how an industrial-era school system prepares us for the modern workplace. Children are expected to sit still for hours upon hours; to control their impulses; to focus on boring, repetitive tasks; to move from place to place when a bell rings; and even to ask permission before going to the bathroom (think about that for a second). Teachers systematically reward children for being docile and punish them for “acting out,” that is, for acting as their own masters. In fact, teachers reward discipline independent of its influence on learning, and in ways that tamp down on student creativity.29 Children are also trained to accept being measured, graded, and ranked, often in front of others. This enterprise, which typically lasts well over a decade, serves as a systematic exercise in human domestication.
Schools that are full of regimentation and ranking can acclimate students to the regimentation and ranking common in modern workplaces.30 This theory is supported by the fact that managers of modern workplaces, like factories, have long reported that workers worldwide typically resist regimentation, unless the local worker culture and upbringing are unusually modern.31 This complaint was voiced in England at the start of the industrial revolution, and also in developing nations more recently.
The main symptom is that unschooled workers don’t do as they’re told. For example, consider the data on cotton mill “doffers,” workers who remove full spools of yarn from cotton spinning machines. In 1910, doffers in different regions around the world had a productivity that varied by a factor of six, even though they did basically the same job with the same material and machines.32 In some places, each doffer managed six machines, while in other places only one machine. The problem was that workers in less-developed nations just refused to work more machines:
Moser, an American visitor to India in the 1920s, is even more adamant about the refusal of Indian workers to tend as many machines as they could “ . . . it was apparent that they could easily have taken care of more, but they won’t . . . They cannot be persuaded by any exhortation, ambition, or the opportunity to increase their earnings.” In 1928 attempts by management to increase the number of machines per worker led to the great Bombay mill strike. Similar stories crop up in Europe and Latin America.33
The reluctance of unschooled workers to follow orders has taken many forms. For example, workers won’t show up for work reliably on time, or they have problematic superstitions, or they prefer to get job instructions via indirect hints instead of direct orders, or they won’t accept tasks and roles that conflict with their culturally assigned relative status with coworkers, or they won’t accept being told to do tasks differently than they had done them before.
Modern schools also seem to change student attitudes about fairness and equality. While most fifth graders are strict egalitarians, and prefer to divide things up equally, by late adolescence, most children have switched to a more meritocratic ethos, preferring to divide things up in proportion to individual achievements.34
Now, some of this may seem heavy-handed and forebodingly authoritarian, but domestication also has a softer side that’s easier to celebrate: civilization. Making students less violent. Cultivating politeness and good manners. Fostering cooperation. In France, for example, school was seen as a way to civilize “savage” peasants and turn them into well-behaved citizens. Here’s historian Eugen Weber:
Schools set out “to modify the habits of bodily hygiene and cleanliness, social and domestic manners, and the way of looking at things and judging them.” Savage children were taught new manners: how to greet strangers, how to knock on doors, how to behave in decent company… . 35 Where schooling did not take hold, “ways are coarse, characters are violent, excitable, and hotheaded, troubles and brawls are frequent.”36
So it’s a mixed bag. Schools help prepare us for the modern workplace and perhaps for society at large. But in order to do that, they have to break our forager spirits and train us to submit to our place in a modern hierarchy. And while there are many social and economic benefits to this enterprise, one of the first casualties is learning.37 As Albert Einstein lamented, “It is . . . nothing short of a miracle that modern methods of instruction have not yet entirely strangled the holy curiosity of inquiry.”38
14
Medicine
Americans today spend more than $2.8 trillion a year on medicine.1 That’s 17 percent of GDP and more than the entire economic output of almost any other country. One out of every $6 spent in the United States goes toward paying for doctors’ visits, diagnostic tests, hospital stays, surgeries, and prescription drugs (see Box 15).
Box 15: “Medicine”
In this chapter, we’re using the word “medicine” to refer, in aggregate, to all practices for diagnosing, treating, or preventing illness. This includes almost everything you might be billed for by the healthcare system: drugs, surgeries, diagnostic tests, emergency
treatments, and visits to the doctor or hospital.
We’re also treating medicine as an economic good, so we’re going to use phrases like “medical consumers,” “the demand for medicine,” and even “marginal medicine.” The latter refers to the medicine that some people get that others don’t, or that some individuals might get if they choose to spend more. In developed countries, for example, since almost everyone has access to vaccines and emergency room medicine, those treatments are not marginal.
The question of why we spend so much on medicine—or any economic good, for that matter—has two components: supply and demand. Much of the public discussion to date has focused on the supply side: Why does medicine cost so much to provide? And how can we provide it more cheaply to more people? But in this chapter, we’re going to focus on the demand side: Taking costs as a given, why do we, as consumers, want so much medicine?
Ask people on the street why they go to the doctor and they’ll give a simple, straightforward answer: to get healthy. They might even flash you a funny look for asking about something so obvious. But if we’ve learned anything from this book, it’s that these “obvious” motives are rarely the full story.
In the introduction, we asked readers to consider the case of a toddler who stumbles and scrapes his knee, then runs over to his mother for a kiss. The kiss has no therapeutic value, and yet both parties appreciate the ritual. The toddler finds comfort in knowing his mom is there to help him, especially if something more serious were to happen, and the mother is happy to deepen her relationship with her son by showing that she’s worthy of his trust.
The thesis we will now explore in this chapter is that a similar ritual lurks within our modern medical behaviors, even if it’s obscured by all the genuine healing that takes place. In this ritual, the patient takes the role of the toddler, grateful for the demonstration of support. Meanwhile, the role of the mother is played not just by doctors, but everyone who helps along the way: the spouse or parent who drives the patient to the hospital, the friend who helps look after the kids, the coworkers who cover for the patient at work, and—crucially—the people and institutions who sponsor the patient’s health insurance in the first place. These sponsors include spouses, parents, employers, and national governments. Each party is hoping to earn a bit of loyalty from the patient in exchange for helping to provide care. In other words, medicine is, in part, an elaborate adult version of “kiss the boo-boo.”
Like the conspicuous behaviors we’ve seen in other chapters, we’re going to call this the conspicuous caring hypothesis.
The healing power of medicine can make it hard to see the conspicuous caring transaction. But Jeanne Robertson, a comedian from North Carolina, puts it on full display when she describes the ritual of taking food to sick friends and family:
In our area of the country, when somebody gets sick, we take over food. Have you noticed this? Now you can buy that food at the grocery store or the deli. But write this down on the big list of important things for life: you get a lot more credit if you make it yourself. You can put it on your grandmother’s platter, but the women in the kitchen will say, “I know where she got that chicken.” I’m telling you, it works out that way.2
If the goal of bringing food is simply to help feed the family during their time of need—to save them the trouble of making their own dinner—then a store-bought chicken would be just as useful as a homemade one. But that’s not the only goal. We also want to show the sick family that we took time out of our busy schedule to help. Only the conspicuous effort of making a dish from scratch allows us to show how much we care.
THE EVOLUTIONARY ARGUMENT
To understand why humans have these instincts, it helps to consider the ancestral conditions in which our caring behaviors likely evolved. Crucially, our distant ancestors didn’t have much in the way of effective (therapeutic) medicine. But caring for the sick and injured was still an important activity, crucial to survival and reproduction.
Imagine yourself living in a band of foragers 1 million years ago. You’re out picking berries when you stumble on a branch, badly spraining your ankle. It’s painful, but that’s the least of your worries. First you’ll need help getting back to the camp. Luckily you went foraging with friends, so they lend their shoulders and help you hobble back home. But your bigger challenge now is how to survive the next week or two while your ankle heals.
Among other things, you need food, both for yourself and for your family. If you were living as a farmer, you might have supplies of food saved up—but farming won’t be invented for another 990,000 years, give or take. And meanwhile, foragers don’t accumulate resources; they own little more than they can carry, and most food is perishable. So again, you’ll need to rely on your allies—family, friends, and other people in your support network.3
The same logic applies when you’re stricken with the flu. Your allies can’t treat your illness, but they can support you (and your family) while your body heals on its own.
In addition to needing physical support, however, you’re also going to need political support—people to look after your interests while you’re incapacitated. Your allies can help in a number of ways: advocating on your behalf in camp decisions, monitoring your mate for fidelity, and protecting you from enemies who might otherwise use your illness to move against you.
These political issues help explain why you might want conspicuous support. If rivals have been eyeing your mate, for example, they’re less likely to make an advance if they notice that you have allies looking out for you. Similarly, if you’ve made enemies—for example, by being too domineering or by cheating with someone else’s mate—then they’re less likely to attack you when they can see that others have your back.
Consider what it would say about you if no one came to your aid. It would show that you don’t have many allies, that you’re not a respected member of your group. And even if you heal, people won’t treat you the same. They’ll have seen that you’re socially and politically weak. Before you fell sick, you may have succeeded in giving everyone the impression that you were well liked, but maybe people were simply afraid of retribution. Your illness showed everyone your true standing in the camp.
The dangers of being abandoned when ill—both material and political dangers—explain why sick people are happy to be supported, and why others are eager to provide support. In part, it’s a simple quid pro quo: “I’ll help you this time if you’ll help me when the tables are turned.” But providing support is also an advertisement to third parties: “See how I help my friends when they’re down? If you’re my friend, I’ll do the same for you.” In this way, the conspicuous care shown in our medical behaviors is similar to the conspicuous care shown in charity; by helping people in need, we demonstrate our value as an ally.
MEDICINE IN HISTORY
In addition to understanding our likely evolutionary environment, it helps to take a historical view of medicine. How did humans approach medicine before it became the effective science it is today?
The historical record is clear and consistent. Across all times and cultures, people have been eager for medical treatments, even without good evidence that such treatments had therapeutic benefits, and even when the treatments were downright harmful.4 But what these historical remedies lacked in scientific rigor, they more than made up for through elaborate demonstrations of caring and support from respected, high-status specialists.
In fact, healers were one of the first specialized roles in tribal cultures. The shaman—part priest, part doctor—performed a variety of healing rituals on behalf of sick patients. Some of these rituals involved useful herbs, but many, like dances, spells, and prayers, are things we now recognize as entirely superstitious.
Medical textbooks from ancient Egypt show a medical system surprisingly like our own, with expensive doctors who matched specific detailed symptoms to complex treatments, most of which were not very useful.
And of course, many treatments were actually h
armful. In his book Strange Medicine, Nathan Belofsky describes some of the gruesome and injurious treatments commonly practiced by physicians across the ages. Leeching and bloodletting are just two of the better-known examples. Others include trepanation (boring holes to the skull to release evil spirits), burning candles in the mouth (to kill invisible “toothworms”), and lining lovesick patients with lead shields.5 One particularly harmful (yet all-too-common) practice was known as “counter-irritation”: cutting into the patient, inserting foreign objects like dried peas or beans, and then periodically reopening the wound to make sure it didn’t heal.6
The logic of conspicuous caring is especially clear in what happened to England’s King Charles II, who fell inexplicably ill on February 2, 1685. The records of the king’s treatment were released by his physicians, who wanted to convince the public that they had done everything in their power to save the king. And what, exactly, did this entail? After a pint and a half of blood was drawn, according to Belofsky,
His Royal Majesty was forced to swallow antimony, a toxic metal. He vomited and was given a series of enemas. His hair was shaved off, and he had blistering agents applied to the scalp, to drive any bad humors downward.
Plasters of chemical irritants, including pigeon droppings, were applied to the soles of the royal feet, to attract the falling humors. Another ten ounces of blood was drawn.
The king was given white sugar candy, to cheer him up, then prodded with a red-hot poker. He was then given forty drops of ooze from “the skull of a man that was never buried,” who, it was promised, had died a most violent death. Finally, crushed stones from the intestines of a goat from East India were forced down the royal throat.7