Hayek, Hospitals, and Healthcare

That NY Times, Gina Kolata article is really two articles woven together. The first (see my other post) is that Hospitals have just discovered the 20th Century regarding measuring performance. But the second idea, that socialized medicine creates this operational retardation, just proves the laws of unintended consequences and begs us to consider Einstein's great thought about the circle of insanity.

The federal government is now telling patients whether their local hospitals are doing what they should.

Feel Better?

For now, the effort involves three common and deadly afflictions of the elderly - heart attacks, heart failure and pneumonia - and asks about lifesaving treatments that everyone agrees should be given but that hospitals and doctors often forget to give.

Medicare expects that now that the hospitals' performances are public, many will try to improve. "People will begin to feel a little awkward if everyone else is doing better and they're not," Dr. Jencks said.

The next step, Dr. Jencks said, is "aligning payment with what you want people to do."

To that end, Medicare has a pilot program to pay hospitals for improving on a number of quality measures, including mortality rates and readmission rates for hip or knee surgery. Hospitals in the top 10 percent for a given condition, for example, will be paid an extra 2 percent. The agency will pay less if performance deteriorates. The project involves 278 hospitals affiliated with Premier, a nationwide organization of nonprofit hospitals..

"Basically, it was a flip of coin, whether you got good medical care or you didn't," Dr. Asch said. "It didn't matter where you lived. The shortfalls were constant."

"That challenged us to ask why these medical care problems were so pervasive," he said.

At least part of the answer, he and others say, is that doctors are unaware of their shortfalls and are rewarded no matter how well they do.

"That will be a bitter pill to swallow, and I'm not sure people will swallow it," Dr. Califf said. "There's a lot of money being made on things that don't work well."

Dr. Jencks agreed.

"I would say we are moving much more slowly on trying to prevent overuse than in trying to fix underuse," he said. "If I tell a physician he shouldn't do a surgery he wants to do, I personally would anticipate a lot more resistance than if I told him he should give a medicine he wasn't thinking of giving.

"Medical care is one of those very strange parts of the economy where you get paid no matter what the quality of the service you provide," Dr. Asch said. "It is like you went to a car dealership and your Mercedes is going to cost you the same as your Yugo.

So here's the question?

Why do we think the government should intrude more to fix this? Do we really discard the ideas from The Fatal Conceit and content ourselves that the government will get it right this time. Our big fat bloated Federal Health Care System will be nimble enough and smart enough to pick the right things to measure?

I'm sure they will reply that only those courses of treatment with "expert consensus" will be measured, and as the article states, only those treatments that "everyone already agrees on" (whatever that means).

Michael Crichton owns the Consenus Canard

I want to pause here and talk about this notion of consensus, and the rise of what has been called consensus science. I regard consensus science as an extremely pernicious development that ought to be stopped cold in its tracks. Historically, the claim of consensus has been the first refuge of scoundrels; it is a way to avoid debate by claiming that the matter is already settled. Whenever you hear the consensus of scientists agrees on something or other, reach for your wallet, because you're being had.

Let's be clear: the work of science has nothing whatever to do with consensus. Consensus is the business of politics. Science, on the contrary, requires only one investigator who happens to be right, which means that he or she has results that are verifiable by reference to the real world. In science consensus is irrelevant. What is relevant is reproducible results. The greatest scientists in history are great precisely because they broke with the consensus.

There is no such thing as consensus science. If it's consensus, it isn't science. If it's science, it isn't consensus. Period.

In addition, let me remind you that the track record of the consensus is nothing to be proud of. Let's review a few cases.

In past centuries, the greatest killer of women was fever following childbirth . One woman in six died of this fever. In 1795, Alexander Gordon of Aberdeen suggested that the fevers were infectious processes, and he was able to cure them. The consensus said no. In 1843, Oliver Wendell Holmes claimed puerperal fever was contagious, and presented compellng evidence. The consensus said no. In 1849, Semmelweiss demonstrated that sanitary techniques virtually eliminated puerperal fever in hospitals under his management. The consensus said he was a Jew, ignored him, and dismissed him from his post. There was in fact no agreement on puerperal fever until the start of the twentieth century. Thus the consensus took one hundred and twenty five years to arrive at the right conclusion despite the efforts of the prominent "skeptics" around the world, skeptics who were demeaned and ignored. And despite the constant ongoing deaths of women.

There is no shortage of other examples. In the 1920s in America, tens of thousands of people, mostly poor, were dying of a disease called pellagra. The consensus of scientists said it was infectious, and what was necessary was to find the "pellagra germ." The US government asked a brilliant young investigator, Dr. Joseph Goldberger, to find the cause. Goldberger concluded that diet was the crucial factor. The consensus remained wedded to the germ theory. Goldberger demonstrated that he could induce the disease through diet. He demonstrated that the disease was not infectious by injecting the blood of a pellagra patient into himself, and his assistant. They and other volunteers swabbed their noses with swabs from pellagra patients, and swallowed capsules containing scabs from pellagra rashes in what were called "Goldberger's filth parties." Nobody contracted pellagra. The consensus continued to disagree with him. There was, in addition, a social factor-southern States disliked the idea of poor diet as the cause, because it meant that social reform was required. They continued to deny it until the 1920s. Result-despite a twentieth century epidemic, the consensus took years to see the light.

Probably every schoolchild notices that South America and Africa seem to fit together rather snugly, and Alfred Wegener proposed, in 1912, that the continents had in fact drifted apart. The consensus sneered at continental drift for fifty years. The theory was most vigorously denied by the great names of geology-until 1961, when it began to seem as if the sea floors were spreading. The result: it took the consensus fifty years to acknowledge what any schoolchild sees.

And shall we go on? The examples can be multiplied endlessly. Jenner and smallpox, Pasteur and germ theory. Saccharine, margarine, repressed memory, fiber and colon cancer, hormone replacement therapy. The list of consensus errors goes on and on.

Feel better about Government involvement here?

This same Federal Gov't that itself can't account for billions in expenditures each year is the best, most flexible and knowledgable place to decided what procedure to track?

In the two-volume report, "Government at the Brink," issued in June by the Senate Committee on Governmental Affairs, it is reported that the figure is significantly higher. The report states, "The Education Department reported in its financial statements that it had $7.5 billion in the bank, when it actually owed that money to the U.S. Treasury." This amounts to a discrepancy of $15 billion. The books of the education department were actually off by a total of $15 billion — about one-third of what the department spends annually.

What do you think our patron saints would have to say? ... ask him, him and watch this.

Look, if the government measures it, rewards it and punishes those not complying, they'll get results. Hospitals will follow those requirements to a "T". All industrial processes organize and adapt to to the metrics; make the numbers. But where does that ultimately lead?

I'm glad the government woke the hospitals up and now they check whether they actually do what they prescribe, but it was the government's intrusion into this market that caused the lax controls in the first place. We are insane to think that long term they won't make it worse still.

Hospitals Arrive at the 20th Century

Virginia Postrel notes this article in the New York Times on a radical concept ... measuring your performance. Really, millions of people, hundreds of """"""experts"""""" will read this and consider it some sort of big deal.

And it is a response to a sobering reality: lifesaving treatments often are forgotten while doctors and hospitals lavish patients with an abundance of care, which can involve expensive procedures of questionable value. The results are high costs, unnecessary medicine and wasted opportunities to save lives and improve health.

For example, the hospitals were asked how often their heart attack patients got aspirin when they arrived (that alone can cut the death rate by 23 percent). When they were discharged, did they also get a statin to lower cholesterol levels? Nearly all should, with the exception of patients who have had a bad reaction to a statin and those rare patients with very low cholesterol levels. Did they get a beta blocker? (No)

Once hospitals learned their score, it was up to them what to do. Over the next year, ones that improved in these measures saw their patient mortality from all causes fall by 40 percent. Those whose compliance scores did not change had no change in their mortality rate, and those whose performance fell had increases in their mortality rates.

"Those are the most remarkable data I have ever seen," said Dr. Eric Peterson, the Duke researcher who directed the study and has reported on it at medical meetings.

The new efforts to improve care came about because the time was right, health care researchers say. "It's really an accumulation of scientific knowledge about what quality means," Dr. Califf said. And there was a growing realization that quality care was not always being provided

The new initiatives have one thing in common - they abandoned the traditional assumption that if doctors know what works, they will provide it

What a bunch of BS. This is not "scientific knowledge." This is basic industrial quality control. Nobody in Real Business makes those "traditional assumptions." Who in the world thinks in such naive terms - that a prescribed course of action just magically goes forward without monitoring and control? Where were these people during the 1980s Quality Revolution?.

This next part is priceless.

The solution, Dr. Gross said, was to assign specially trained nurses to see what care was provided and remind doctors when important steps were omitted. The result was immediate improvement, Dr. Gross said, even in items not on Medicare's list

You've got to be kidding me. I'll take a 3rd Grader with a checklist and do just as well.

Again, the articles goes one to describe the root causes..

Doctors do know what works, said Dr. Steven M. Asch, a health care researcher at the V.A. Greater Los Angeles Health Care System and the RAND Corporation in Santa Monica. But, he found, Americans got just half the tests and treatments they should be getting.

"Basically, it was a flip of coin, whether you got good medical care or you didn't," Dr. Asch said. "It didn't matter where you lived. The shortfalls were constant."

This kind of operational performance would bankrupt your average free-market industrial company. We all learned a long time ago that you have to do both things well: Design (diagnosis & prescription) and Manufacturing (treatment). This analogy holds very well.

For half my career, I have been on the operations/execution side of Corporate America. The best design, the best diagnosis to a customer problem, the brightest engineer in the world ... these things are worth NOTHING if they aren't actually implemented and executed at a high rate of quality.

Why am I even writing about this? Why is the New York Times? This is CLASSIC Deming, classic Juran, classic TQC, and of course mainstream Six Sigma.: Measure what you say you'll do.

Of course chaotic creativity, intelligence, innovation, still need to go into the what you do and how you do it. What's the best design approach, what's the best course of treatment?. But this article isn't even referring to that ... it assumes that has already been decided (decided by 'consensus' and the government -- good grief, what will free-market folks say about this ...see the companion post)

No, this whole article is telling us that our high priced health care system ... the best in the world, needs the Federal Government, of all things, to incentivize hospitals to check whether we receive the prescribed treatment Well I guess "better late then never" applies here, but I truly believe government intrusion into healthcare shielded hospitals from a Free Market that would have forced this on them a long time ago.

So the government is now trying to fix a problem it created. What's their record on that...0 for 10,000?

Hindu Hotdogs

Why There's No Escaping the Blog - FORTUNE (Hat Tip: Instapudit)

Just as Rathergate was breaking, corporate America got its clearest sign of blogger muscle—in this case, brought on not by memos but by a Bic pen. On Sept. 12 someone with the moniker "unaesthetic" posted in a group discussion site for bicycle enthusiasts a strange thing he or she had noticed: that the ubiquitous, U-shaped Kryptonite lock could be easily picked with a Bic ballpoint pen. Two days later a number of blogs, including the consumer electronics site Engadget, posted a video demonstrating the trick. "We're switching to something else ASAP," wrote Engadget editor Peter Rojas. On Sept. 16, Kryptonite issued a bland statement saying the locks remained a "deterrent to theft" and promising that a new line would be "tougher." That wasn't enough. ("Trivial empty answer," wrote someone in the Engadget comments section.) Every day new bloggers began writing about the issue and talking about their experiences, and hundreds of thousands were reading about it. Prompted by the blogs, the New York Times and the Associated Press on Sept. 17 published stories about the problem—articles that set off a new chain of blogging. On Sept. 19, estimates Technorati, about 1.8 million people saw postings about Kryptonite (see chart).

Finally, on Sept. 22, Kryptonite announced it would exchange any affected lock free. The company now expects to send out over 100,000 new locks. "It's been—I don't necessarily want to use the word 'devastating'—but it's been serious from a business perspective," says marketing director Karen Rizzo. Kryptonite's parent, Ingersoll-Rand, said it expects the fiasco to cost $10 million, a big chunk of Kryptonite's estimated $25 million in revenues. Ten days, $10 million. "Had they responded earlier, they might have stopped the anger before it hit the papers and became widespread," says Andrew Bernstein, CEO of Cymfony, a data-analysis company that watches the web for corporate customers and provides warning of such impending catastrophes.

Those who have tried to game the blogosphere haven't done much better. Mazda, hoping to reach its Gen Y buyers, crafted a blog supposedly run by someone named Kid Halloween, a 22-year-old hipster who posted things like: "Tonight I am going to see Ministry and My Life With the Thrill Kill Cult.É This will be a retro industrial flashback." He also posted a link to three videos he said a friend recorded off public-access TV. One showed a Mazda3 attempting to break dance, and another had it driving off a ramp like a skateboard, leading in both cases to frightening crashes. Other bloggers sensed a phony in their midst—the expensively produced videos were tip-offs—and began talking about it. Suddenly Mazda wasn't being hailed; it was being reviled on widely read blogs. "Everything about that 'blog' is disgusting," wrote a poster on Autoblog. Mazda pulled the site after three days and now says it never intended it to have a long run. "It was a learning experience," says a spokesman. Tig Tillinghast, who runs the respected advertising industry blog Marketingvox.com, calls Mazda's blogging clumsiness "the moral equivalent of doing an English-language print ad that was written by a native French speaker."

"If you fudge or lie on a blog, you are biting the karmic weenie," says Steve Hayden, vice chairman of advertising giant Ogilvy & Mather

Being a rabid blogger and a Corporate Executive, I've certainly sensed the "transperency" aspect of blogging as very threatening. Companies do a lot to suppress bad news...I don't find it as sinister as the sensational cases (Enron-WorldComm-Adelphi etc). I'm thinking of the bland-ass Company Newsletter (now Website) that wreaks of Orwellian happy news. I do find good companies unbelievably self-critical, but they rarely do it publicly. You don't see a Fortune 100 Harvard MBA CEO blubbering through a bitten lower lip re-hashing his failure in front of the world.

So when it comes to the immediate impact on new products, unhappy customers, and "getting real', I see corporate leaders very generationally challenged. They will be caught with their pants at their ankles. If there were a serious blog for every Fortune 500 company...a group blog like Command Post..look out. You could say that we've had whiny hysterical message boards for years and they done nothing much, but blogs are different and they have real traction and many times, real accountability. The message boards never took downs a News Anchor.

The Ultimate Skunk Works

Worming Into Apple is a story about a programmer who not only kept working on a project after it was canceled, but even after he was laid off.

Avitzur sneaked into Apple's California HQ for six months to write a software program that, through luck and hard work, is still included on every Mac sold today.

Unemployed and living on savings, Avitzur worked 12-hour days, seven days a week, to create Graphing Calculator in the unlikely hope that Apple would bundle it with new computers.

Not only did he toil for free, Avitzur persuaded another unemployed programmer, Greg Robbins, to sneak into Apple with him. He also paid subcontractors out of his own pocket, and eventually convinced entire teams of testers and researchers to refine his software.

Meanwhile, Avitzur and Robbins worked in vacant offices, avoided Apple security and gained access to the campus by tailgating employees as they showed up for work

I love this line

The best part is the kids who have been using it," said Avitzur "We were building toys for young nerds."

But he added, "Even now, I look back and wonder if I was horribly taken advantage of, or whether I was in control. I can't honestly tell."

And here's the classic paradigm that Big Big Companies (HP, IBM, GE) never ever will allow.

Skunkworks projects are a long-standing tradition in Silicon Valley. Many engineers work on personal projects in the hope they will be turned into products, even if they've been previously canceled. Companies like Google recognize the tradition, allowing staffers to spend 20 percent of their time on private projects.

If everyone is special, no one is.

Great quotes from Dell CEO Kevin Rollins Here's Classic Dell

Rollins also said Apple Computer's iPod could suffer the same fate as the Macintosh computer line if Apple continues to keep iPod technology proprietary. (Macs have a devoted following, but they garner only a small percentage of yearly global PC shipments.)

"I think they're doing a fantastic job" with the iPod, he said. But "Apple runs the risk of having the same failure with the iPod as it did with its traditional PC business" if the company continues to keep the device proprietary. In Dell's view, standard technology, which tends to be cheaper and more readily available, will win the day in most markets, including PCs, servers, storage, networking and even consumer electronics

Dell & WalMart have the same definition of failure ... selling anything other than craploads of cheap commodities
.
And although 90% or more of Dell's Cost of Goods sold is sourced (design, sourced components, and sometimes assembly), he pulls the spin of have "onshore" manufacturing.

Although he joked about outsourcing Dell's catering service, Rollins said the practice of outsourcing can cause a company to lose critical knowledge, in the case of areas such as information technology, or raise costs in areas such as manufacturing
.
"Philosophically, I'm opposed to outsourcing,"

Rollins said. Because he said outsourcing can remove essential skills such as IT expertise, it "seems nuts," he said. "I don't like it for Dell, clearly, because I think it makes us higher-cost, not lower-cost." Dell keeps all its manufacturing in-house. The company plans to build another manufacturing plant in the United States soon, in order to serve U.S. and Canadian customers. It has been eyeing a location in North Carolina, which is roughly in the middle of the southern and northern tips of the populous East Coast

Dells definition of manufacturing = light assy, load software, put on Dell stickers, pack and ship

And what's classic is that naive analysts, reporters, and politicians will look at the plant and call it "high tech". Just like they view Dell as a "technology" stock, instead of a retail/wholesaler stock.

The Must-est of Must Reads

Foreign Affairs - The Global Baby Bust - Phillip Longman: Foreign Affairs - The Global Baby Bust - Phillip Longman: "Japan's population, meanwhile, is expected to peak as early as 2005, and then to fall by as much as one-third over the next 50 years -- a decline equivalent, the demographer Hideo Ibe has noted, to that experienced in medieval Europe during the plague.""In nations rich and poor, under all forms of government, as more and more of the world's population moves to urban areas in which children offer little or no economic reward to their parents, and as women acquire economic opportunities and reproductive control, the social and financial costs of childbearing continue to rise."In the United States, the direct cost of raising a middle-class child born this year through age 18, according to the Department of Agriculture, exceeds $200,000 -- not including college. And the cost in forgone wages can easily exceed $1 million, even for families with modest earning power. Meanwhile, although Social Security and private pension plans depend critically on the human capital created by parents, they offer the same benefits, and often more, to those who avoid the burdens of raising a family.Fertility rates are falling faster in the Middle East than anywhere else on earth, and as a result, the region's population is aging at an unprecedented rate. For example, by mid-century, Algeria will see its median age increase from 21.7 to 40, according to UN projections. Postrevolutionary Iran has seen its fertility rate plummet by nearly two-thirds and will accordingly have more seniors than children by 2030.Countries such as France and Japan at least got a chance to grow rich before they grew old. Today, most developing countries are growing old before they get rich. China's low fertility means that its labor force will start shrinking by 2020, and 30 percent of China's population could be over 60 by mid-century. More worrisome, China's social security system, which covers only a fraction of the population, already has debts exceeding 145 percent of its GDP.The appeal of radicalism could also diminish as young adults make up less of the population and Middle Eastern societies become increasingly dominated by middle-aged people concerned with such practical issues as health care and retirement savings. Just as population aging in the West during the 1980s was accompanied by the disappearance of youthful indigenous terrorist groups such as the Red Brigades and the Weather Underground, falling birthrates in the Middle East could well produce societies far less prone to political violence.Although at first the fact that there are fewer children to feed, clothe, and educate leaves more for adults to enjoy, soon enough, if fertility falls beneath replacement levels, the number of productive workers drops as well, and the number of dependent elderly increase. And these older citizens consume far more resources than children do. Even after considering the cost of education, a typical child in the United States consumes 28 percent less than the typical working-age adult, whereas elders consume 27 percent more, mostly in health-related expenses.Population growth is a major source of economic growth: more people create more demand for the products capitalists sell, and more supply of the labor capitalists buy. Economists may be able to construct models of how economies could grow amid a shrinking population, but in the real world, it has never happened.Current population trends are likely to have another major impact: they will make military actions increasingly difficult for most nations. One reason for this change will be psychological. In countries where parents generally have only one or two children, every soldier becomes a "Private Ryan" -- a soldier whose loss would mean overwhelming devastation to his or her family. In the later years of the Soviet Union, for example, collapsing birthrates in the Russian core meant that by 1990, the number of Russians aged 15-24 had shrunk by 5.2 million from 25 years before. Given their few sons, it is hardly surprising that Russian mothers for the first time in the nation's history organized an antiwar movement, and that Soviet society decided that its casualties in Afghanistan were unacceptable.In 2000, the cost of military pensions amounted to 12 times what the military spent on ammunition, nearly 5 times what won't technology be able to make up the difference? Perhaps. But there is also plenty of evidence to suggest that population aging itself works to depress the rate of technological and organizational innovation.the Navy spent on new ships, and more than 5 times what the Air Force spent on new planes and missiles.London School of Business released their latest index of entrepreneurial activity. It shows that there is a distinct correlation between countries with a high ratio of workers to retirees and those with a high degree of entrepreneurship.This correlation could be explained by many different factors. Both common sense and a vast literature in finance and psychology support the claim that as one approaches retirement age, one usually becomes more reluctant to take career or financial risks. It is not surprising, therefore, that aging countries such as Italy, France, and Japan are marked by exceptionally low rates of job turnover and by exceptionally conservative use of capital. Because prudence requires that older investors take fewer risks with their investments, it also stands to reason that as populations age, investor preference shifts toward safe bonds and bank deposits and away from speculative stocks and venture funds. As populations age further, ever-higher shares of citizens begin cashing out their investments and spending down their savings.The Center for Strategic and International Studies has recently calculated that the cost of public benefits to the elderly will consume a dramatically rising share of GDP in industrialized countries. In the United States, such benefits currently consume 9.4 percent of GDP. But if current trends continue, this figure will top 20 percent by 2040a highly efficient, global financial market could lend financial resources from rich, old countries that are short on labor to young, poor countries that are short on capital, and make the whole world better off. But for this to happen, old countries would have to contain their deficits and invest their savings in places that are themselves either on the threshold of hyper-aging (China, India, Mexico) or highly destabilized by religious fanaticism, disease, and war (most of the Middle East, sub-Saharan Africa, Indonesia), or both.General Motors (GM) now has 2.5 retirees on its pension rolls for every active worker and an unfunded pension debt of $19.2 billion. Honoring its legacy costs to retirees now adds $1,800 to the cost of every vehicle GM makes, according to a 2003 estimate by Morgan Stanley. Just between 2001 and 2002, the U.S. government's projected short-term liability for bailing out failing private pension plans increased from $11 billion to $35 billion, with huge defaults expected from the steel and airline industries.if the United States hopes to maintain the current ratio of workers to retirees over time, it will have to absorb an average of 10.8 million immigrants annually through 2050. At that point, however, the U.S. population would total 1.1 billion, 73 percent of whom would be immigrants who had arrived in this country since 1995 or their descendants.Just housing such a massive influx would require the equivalent of building another New York City every 10 months.Some biologists now speculate that modern humans have created an environment in which the "fittest," or most successful, individuals are those who have few, if any, children. As more and more people find themselves living under urban conditions in which children no longer provide economic benefit to their parents, but rather are costly impediments to material success, people who are well adapted to this new environment will tend not to reproduce themselves. And many others who are not so successful will imitate them.

Today there is a strong correlation between religious conviction and high fertility. In the United States, for example, fully 47 percent of people who attend church weekly say that the ideal family size is three or more children, as compared to only 27 percent of those who seldom attend church. In Utah, where 69 percent of all residents are registered members of the Church of Jesus Christ of Latter Day Saints, fertility rates are the highest in the nation. Utah annually produces 90 children for every 1,000 women of childbearing age. By comparison, Vermont -- the only state to send a socialist to Congress and the first to embrace gay civil unions -- produces only 49.

Does this mean that the future belongs to those who believe they are (or who are in fact) commanded by a higher power to procreate? Based on current trends, the answer appears to be yesCurrent demographic trends work against modernity in another way as well. Not only is the spread of urbanization and industrialization itself a major cause of falling fertility, it is also a major cause of so-called diseases of affluence, such as overeating, lack of exercise, and substance abuse, which leave a higher and higher percentage of the population stricken by chronic medical conditions. Those who reject modernity would thus seem to have an evolutionary advantage, whether they are clean-living Mormons or Muslims, or members of emerging sects and national movements that emphasize high birthrates and anti-materialism.To cope with the diseases of affluence that make older workers less productive, rich societies must make greater efforts to promote public health. For example, why not offer reduced health care premiums to those who quit smoking, lose weight, or can demonstrate regular attendance in exercise

How can secular societies avoid population loss and decline? The problem is not that most people in these societies have lost interest in children. Among childless Americans aged 41 years and older in 2003, for example, 76 percent say they wish they had had children, up from 70 percent in 1990. In 2000, 40-year-old women in the United States and in every European nation told surveys that they had produced fewer children than they intended. Indeed, if European women now in their 40s had been able to produce their ideal number of children, the continent would face no prospect of population loss.

The problem, then, is not one of desire. The problem is that even as modern societies demand more and more investment in human capital, this demand threatens its own supply. The clear tendency of economic development is toward a more knowledge-based, networked economy in which decision-making and responsibility are increasingly necessary at lower levels. In such economies, however, children often remain economically dependent on their parents well into their own childbearing years because it takes that long to acquire the panoply of technical skills, credentials, social understanding, and personal maturity that more and more jobs now require. For the same reason, many couples discover that by the time they feel they can afford children, they can no longer produce them, or must settle for just one or two.