It used to be an old joke that sociology was the study of people in rich industrialised countries, and anthropology the study of the poor in poor countries. All very unfair, but I was reminded of it when hearing the news about a trial project in the UK offering money to women who continue to breastfeed their babies for up 6 months. Described by various newspapers and broadcasters as the politics of the nudge (offering incentives of various kinds to encourage healthy behaviour), it would be known as a conditional cash transfer were such a scheme to operate in Africa, Asia or Latin America. Those of us in the global north need to be nudged to be virtuous, those in the global south, bribed.
The scheme, which is being trialled in ‘deprived’ areas of South Yorkshire and Derbyshire before being rolled out as a national pilot (if successful) will give women up to £200 in shopping vouchers if they breastfeed for the first six months of their child’s life. According to those running the scheme, the vouchers will act as incentives to promote behaviour that is seen as providing better health outcomes for children (and for mothers too).
The politics of the nudge may have a fancy name, may be seen as the gentle, encouraging look of the nanny state (rather than its punitive, “I’m very disappointed with you” variant). But it is, of course, nothing new (calling something a new name doesn’t suddenly give it a different provenance). Conditional cash transfers (CCTs) act in precisely the same way: offering cash provided the established conditions are met, be it children attending school, taken for their vaccinations, etc.
It may be that it works, but as with the underlying premise behind CCTs, it does rest upon a set of assumptions that are problematic at best. It assumes that the key reason women do not breastfeed for six months (surveys suggest that around 55% of women are still breastfeeding at eight weeks, although that falls to a quarter in more economically deprived areas) is economic. Or rather, that economic incentives will be enough to overcome other barriers. But of course (and whilst I can claim no direct knowledge of this, I do remember my wife’s experiences with our first born) breastfeeding is hard. My wife was lucky: she had excellent support in the midwife-led maternity unit, and attended a friendly breastfeeding support group. But not all new mothers are lucky enough to receive this support. Decent structures being put in place, rather than resorting to bribery, would be a far better use of resources. Explaining the benefits of breastfeeding, and accepting that some (perhaps for good reason, perhaps not) will not follow that behaviour, rather than castigating those who fail to live up to the expected standards, is surely a better idea.
There is a second problem with the politics of the nudge / CCTs. As Jishnu Das writes in his blog, both assume that the outcome is better. But they do not say better for whom, or for what. Attaching conditions to cash transfers, or seeking to bribe, sorry, nudge, people into good behaviour assumes that there is broad agreement on what constitutes ‘good’ behaviour. But more than that, it implies that behaviour or activities that do not accord with this are implicitly bad, something to be changed. In doing so, it not only denies agency to individuals, but sets up unhelpful distinctions between good and bad behaviour, and from that good and bad people. And how long do nudges need to be ignored before the temptation starts to start shoving a little harder? As Das notes, there is a big difference between children being sent to school, and children actually learning.
Won’t somebody think of the children!
Of course, in the case of CCTs (and in the case of nudging towards breastfeeding, if the pilot does appear to raise rates), the cry will go up that even if we think people should be able to make decisions about their own behaviour and life more widely, what about the children who may be denied school, denied the health benefits of breastfeeding, etc. as a result of ‘selfish’ (or ‘bad’) decisions made by their parent(s), and it’s a fair point. The state does have a responsibility to step in when children are being denied services to which they are entitled (or which carers are legally required to provide). But unless actual harm is being done, surely we have to respect the decisions of individuals? And don’t the poor have as much right to make decisions as the rich (who aren’t targeted by CCTs or shopping vouchers)? Apparently not: in publicly funded schools in the UK, parents can no longer take children out of school for holidays, or even family weddings. Such restrictions don’t apply to the privately-schooled (not by government regulation, in any case).
One could also say that governments nudge all the time: by taxing cigarettes to discourage smoking; taxing fuel or cars with heavy emissions, for environmental reasons, etc. But shopping vouchers is on a different scale. The pilot may succeed in increasing breastfeeding rates. But whether this is the best way to achieve that, on a sustainable basis, and for more than a relatively small number of mothers and children, is questionable. And whilst some may see this as a rigorous test of the viability of the scheme, it is nothing of the sort: why not try another pilot alongside, say increasing welfare support for the most deprived, coupled with investment in post-birth support for new mothers, and see what difference that makes. Testing one scheme may show an increase. But it certainly won’t show whether it is the best approach.
Nudges and CCTs have a place, and there is plenty of evidence that CCTs are linked to positive results (although here we are back to Das’ point, positive for whom?). But so have unconditional cash transfers. The lesson is perhaps we should trust people more to make decisions over their Iives, and seek to address the social, economic, political, and structural barriers that prevent them putting those decisions into effect.