Looking at preventative health as a cost-effective global health measure is great! Haven’t read this report in full but some problems stick out to me at a glance:
1. I don’t think hypertension is neglected at all. Some of the world’s most commonly prescribed drugs are for hypertension (Lisinopril, Amlodipine, Metoprolol are no. 3,4,5 per Google). I also don’t think salt reduction is a neglected treatment: Almost every person presenting to a doctor with hypertension will be recommended to reduce their salt intake.
2. It doesn’t seem very effective:
sodium intake significantly reduces resting systolic blood pressure (n.b. Aburto et al: −3.39 mm Hg)
...
every 10 mm Hg fall in BP sees a reduction in risk of major cardiovascular disease events given a relative risk – RR – of 0.8
3.39 mmHg doesn’t seem like very much, given that a 10mmHg fall is required for a 20% risk reduction if cardiovascular disease risk.
3. People hate being taxed for doing things they like
I don’t find your analysis of the reduction of freedom of choice to be very convincing. You dismiss the reduction of freedom of choice because:
food people are eating will be largely the same in terms of macro ingredients, and will taste subjectively the same given reduction within a range as well as gradual implementation
I don’t think this is true. Salt is yummy and people know it. Most people with hypertension are already told to reduce their salt intake and many choose not to. They make that choice for a reason, and forcing them or taxing them for doing so would, I think, lead to significant resentment, resistance and distrust of government. People are already suspicious of over-regulation and of the WHO, and I think even a campaign for this sort of thing might cause more trouble than the small chance of success is worth.
(1) It’s true that hypertension is less neglected in the rich world, but: (a) Even in the rich world we incur a cost from hypertension even needing to be treated in the first place (i.e. health burden given that there’s always a time gap between identification and effective treatment, plus the economic burden of those drugs and general treatment support). (b) Also the blunt fact of the matter is that developing countries are poor. This has two upshots—one being that they lack the basic infrastructure to deliver drugs effectively (e.g. one expert kept emphasizing how in Africa people in Africa have to walk great distances and wait a long while to get pills); and another is that EA funding would basically have to fund this as a permanent thing (like malaria nets), but that’s counterfactually extremely costly.
(2) The falls in BP have significant impact at the population level! Hence the CEA pencilling out to suggest a very cost-effective intervention. It’s true of a lot of potential causes/interventions, to be fair—whereby we reduce some small risk by 0.0X% but if you have 10^Y people it can still be cost effective at scale.
(3) Basically citing from the report, “a meta-analysis suggests that food can be significantly reduced in sodium without significantly affecting consumer acceptability, and as the GCAH factsheet says, “gradual (over a few months) but substantial reductions in sodium of processed foods can be made without altering the perceived taste of food”, which makes sense given that our taste budsadjust to salt (and sugar) levels and get more or less sensitive accordingly.”
That said, I fundamentally agree that it’s going to be politically difficult, far more so than other regulatory stuff like mandatory food reformulation—we see something similar for climate change, where people hate carbon taxes but are fine with quotas even though they practically end up costing consumers the same thing. Overall, this goes into the assessment that sodium policy advocacy has perhaps a 3% chance of success—which I think is fairly reasonable/conservative, insofar as it implies that an organization making a concerted effort across 33 countries (for 3 years each), might expect success in just one.
I suspect that an organization that does lobbying in this area might choose to drop the tax stuff if they find it too difficult, and just focus on the regulatory or education aspects.
People hate being taxed for doing things they like
It’s much worse than that; in hotter climates, salt isn’t a luxury, it’s basic sustenance. Gandhi wasn’t being figurative when he said “Next to air and water, salt is perhaps the greatest necessity of life.”
I think Ghandi’s point nods to the British Empire’s policy of heavily taxing salt as a way of extracting wealth from the Indian population. For a time this meant that salt became very expensive for poor people and many probably died early deaths linked to lack of salt.
However, I don’t think anyone would suggest taxing salt at that level again! Like any food tax, the health benefits of a salt tax would have to be weighed against the costs of making food more expensive. You certainly wouldn’t want it so high that poor people don’t get enough of it.
Looking at preventative health as a cost-effective global health measure is great! Haven’t read this report in full but some problems stick out to me at a glance:
1. I don’t think hypertension is neglected at all. Some of the world’s most commonly prescribed drugs are for hypertension (Lisinopril, Amlodipine, Metoprolol are no. 3,4,5 per Google). I also don’t think salt reduction is a neglected treatment: Almost every person presenting to a doctor with hypertension will be recommended to reduce their salt intake.
2. It doesn’t seem very effective:
3.39 mmHg doesn’t seem like very much, given that a 10mmHg fall is required for a 20% risk reduction if cardiovascular disease risk.
3. People hate being taxed for doing things they like
I don’t find your analysis of the reduction of freedom of choice to be very convincing. You dismiss the reduction of freedom of choice because:
I don’t think this is true. Salt is yummy and people know it. Most people with hypertension are already told to reduce their salt intake and many choose not to. They make that choice for a reason, and forcing them or taxing them for doing so would, I think, lead to significant resentment, resistance and distrust of government. People are already suspicious of over-regulation and of the WHO, and I think even a campaign for this sort of thing might cause more trouble than the small chance of success is worth.
Hi Henry,
(1) It’s true that hypertension is less neglected in the rich world, but: (a) Even in the rich world we incur a cost from hypertension even needing to be treated in the first place (i.e. health burden given that there’s always a time gap between identification and effective treatment, plus the economic burden of those drugs and general treatment support). (b) Also the blunt fact of the matter is that developing countries are poor. This has two upshots—one being that they lack the basic infrastructure to deliver drugs effectively (e.g. one expert kept emphasizing how in Africa people in Africa have to walk great distances and wait a long while to get pills); and another is that EA funding would basically have to fund this as a permanent thing (like malaria nets), but that’s counterfactually extremely costly.
(2) The falls in BP have significant impact at the population level! Hence the CEA pencilling out to suggest a very cost-effective intervention. It’s true of a lot of potential causes/interventions, to be fair—whereby we reduce some small risk by 0.0X% but if you have 10^Y people it can still be cost effective at scale.
(3) Basically citing from the report, “a meta-analysis suggests that food can be significantly reduced in sodium without significantly affecting consumer acceptability, and as the GCAH factsheet says, “gradual (over a few months) but substantial reductions in sodium of processed foods can be made without altering the perceived taste of food”, which makes sense given that our taste buds adjust to salt (and sugar) levels and get more or less sensitive accordingly.”
That said, I fundamentally agree that it’s going to be politically difficult, far more so than other regulatory stuff like mandatory food reformulation—we see something similar for climate change, where people hate carbon taxes but are fine with quotas even though they practically end up costing consumers the same thing. Overall, this goes into the assessment that sodium policy advocacy has perhaps a 3% chance of success—which I think is fairly reasonable/conservative, insofar as it implies that an organization making a concerted effort across 33 countries (for 3 years each), might expect success in just one.
I suspect that an organization that does lobbying in this area might choose to drop the tax stuff if they find it too difficult, and just focus on the regulatory or education aspects.
It’s much worse than that; in hotter climates, salt isn’t a luxury, it’s basic sustenance. Gandhi wasn’t being figurative when he said “Next to air and water, salt is perhaps the greatest necessity of life.”
I think Ghandi’s point nods to the British Empire’s policy of heavily taxing salt as a way of extracting wealth from the Indian population. For a time this meant that salt became very expensive for poor people and many probably died early deaths linked to lack of salt.
However, I don’t think anyone would suggest taxing salt at that level again! Like any food tax, the health benefits of a salt tax would have to be weighed against the costs of making food more expensive. You certainly wouldn’t want it so high that poor people don’t get enough of it.