Category Archives: Helse

Sukker er ikke kilden til hyperaktivitet. #erdusikker

Les spesielt den andre paragrafen:

Sugar doesn’t cause hyperactivity:

Here is Aaron Carroll at The Incidental Economist:

Let’s cut to the chase: sugar doesn’t make kids hyper. There have been at least twelve trials of various diets investigating different levels of sugar in children’s diets. That’s more studies than are often done on drugs. None of them detected any differences in behavior between children who had eaten sugar and those who hadn’t. These studies included sugar from candy, chocolate, and natural sources. Some of them were short-term, and some of them were long term. Some of them focused on children with ADHD. Some of them even included only children who were considered “sensitive” to sugar. In all of them, children did not behave differently after eating something full of sugar or something sugar-free….

In my favorite of these studies, children were divided into two groups. All of them were given a sugar-free beverage to drink. But half the parents were told that their child had just had a drink with sugar. Then, all of the parents were told to grade their children’s behavior. Not surprisingly, the parents of children who thought their children had drunk a ton of sugar rated their children as significantly more hyperactive. This myth is entirely in parents’ heads. We see it because we believe it.

Even when science shows time and again that it’s not so, we continue to persist in believing that sugar causes our kids to be hyperactive. That’s likely because there’s an association. Times when kids get a lot of sugar are often times when they are predisposed to be a little excited. Halloween. Birthday parties. Holidays. We may even be causing the problem ourselves. Some parents are so restrictive about sugar and candy that when their kids finally get it they’re quite excited. Even hyper.

This does not mean that there aren’t a ton of great reasons why our kid should not ingest large quantities of sugar. As almost any parent knows, sugar has been linked to cavities and the obesity epidemic. Just don’t blame it for your child’s bad behavior.

(Via Marginal Revolution.)

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Incentiver betyr noe #335 | Mens vi er inne på eksperimenter, nå privat helse.

Dette er en klassisker. Etterhvert som du leser denne, vil et snev av sunt fornuft legge seg over deg, mens du vil umiddelbart få en ryggmargsrefleks når du vurderer om hvorvidt staten kan oppføre seg på denne måten.

Møt The Cleveland Clinic, et privateid helsehus. Med sjefer som er villige til å sparke senioransatte for å vise de mener alvor:

With 40,000 employees, the clinic is the second-largest employer in Ohio. Like most employers, it struggles to contain health-care costs. But according to Michael Roizen, the clinic’s director of wellness, over the past seven years a series of reforms instituted by the clinic’s chief executive officer, Delos Cosgrove, slowed and then arrested the growth in employee health-care costs at the clinic. This year, inflation-adjusted spending might actually fall — an all but unprecedented achievement in employer-based insurance.

What happened? Health care costs rose 6 percent a year nationally. Yet there was no rationing of care or squeezing of providers at the clinic. The clinic’s employees simply got healthier. Whether that success is a model for American health care or a preview of a dystopian surveillance state is an open question.

Roizen says the initiative sprang from a single fact. According to the Centers for Disease Control and Prevention, 70 percent of all medical costs are related to smoking, physical inactivity, food choices and portion size, or stress. Cut smoking, increase physical activity, persuade people to make better dietary decisions, and help them manage their stress, and you can reduce health-care costs before an employee ever steps into a hospital.

But consider what that actually entails: Changing habits. Breaking addictions. Getting people to the gym. Who wants to hear about any of that from their employer?

The clinic, however, didn’t give employees a choice. “First thing we said was we had to make our institution toxin free,” Roizen said. “The biggest toxin we have in the U.S. is tobacco. So we began offering free tobacco-cessation programs to our employees. Then we banned smoking on campus. You can’t even smoke in the parking lot in your car. The first offense you get a warning, and the second you get fired. We fired two high- profile physicians who refused to quit. Then they knew we were serious.”

Food came next. The clinic took out almost every deep-fryer in the building. They removed sugared soda from every beverage case. They eliminated trans fats. On a tour of the campus, I noticed a long line outside a McDonald’s. My guide sighed. McDonald’s, he explained, had a long-term contract that predated Cosgrove’s wellness initiative. The clinic couldn’t throw them out — yet.

“We want to make it easy for you to do healthy things and hard for you to do unhealthy things,” Roizen said. “If you want a sugared drink, you have to go out of your way to bring it from home. We’re not going to provide it.”

That left fitness and stress relief. The first step was easy: Offer free fitness and stress-management classes. But the clinic still had to get its employees to attend. So they reversed the normal calculus. Usually, you have to pay to hit the gym or attend a yoga class. If you work for the Cleveland Clinic, you have to pay if you don’t.

“We raised the premiums for all employees,” Roizen said. But employees didn’t necessarily have to pay the increase. “If you’re doing a healthy program — attending Weight Watchers or Shape Up and Go — you get a rebate.”

That left enforcement. The clinic tracks its employees’ blood pressure, lipids, blood sugar, weight and smoking habits. If any of these are what the clinic calls “abnormal,” a doctor must certify that the employee is taking steps to get them under control. Otherwise, no insurance rebate. The idea is to force employees to have regular conversations with their doctors about wellness. If they participate, they can lock in the rates they were paying two years ago. The savings amount to many thousands of dollars.

It appears to be working. Not only has the clinic cut its health-care costs, but its employees are also getting healthier in measurable ways. Workers have lost a collective 250,000 pounds since 2005. Their blood pressure is lower than it was three years ago. Smoking has declined from 15.4 percent of employees to 6.8 percent.

In one sense, the clinic has achieved the health policy ideal: cutting health-care costs by making people healthier. But consider how the clinic has done it — tying premiums to personal decisions, firing smokers, tracking employee metrics, eliminating popular sodas and foods from campus. By making it harder and more expensive for employees to be unhealthy, the clinic has radically overstepped the traditional, laissez-faire approach of employers to their workers’ personal habits.

It also opens the door to onerous forms of discrimination. The clinic no longer hires smokers. Will the obese eventually face similar hurdles? What about fans of fast food?

The experiment might work at a famed medical center where the CEO plausibly argues that aggressive leadership in health care is central to the institution’s mission. But would it work at General Motors? Caterpillar? Wal-Mart? Medicaid and Medicare?

Roizen thinks it can — and should. He estimates that an aggressive program could cut federal health spending by $300 billion to $600 billion a year. If he’s right, then simply instituting such wellness reforms could cut the federal deficit by far more than the Simpson-Bowles commission or the congressional supercommittee would.

Roizen has even proposed legislation to create a Medicare pilot that sidesteps at least some of the concerns about government intrusion. Participation by Medicare recipients would be voluntary, with improved health leading to an increase in a participant’s Social Security check.

As Roizen notes, tough choices are inevitable over the next decade. The question is which ones we prefer to make. If we opt for Cleveland Clinic-style wellness programs, we won’t have to gut education, raise taxes or slash Medicare. And we’ll end up healthier. But in a country where proposed counseling sessions to discuss end-of-life options were denounced as “death panels,” are we really ready to let employers — much less the government — tell us to quit smoking, skip the junk food and lose weight?

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Danmark er det første landet i verden til å skatte mettet fett.

Interessert i et semi-naturlig eksperiment innen helseøkonomi? Danmark er det første landet som innfører skatt på mettet fett. Litteraturen er usikker på hva utfallet blir. Danmark ligger etter i forventet levealder og her er detaljene:

Will a fat tax make Denmark healthier?:

Over the weekend, Denmark became the first country to tax saturated fats.

The tax — 16 Danish kroner per kilogram of saturated fat in a food – works out to about $6.27 per pound of saturated fat. It hits all foods with a saturated fat content above 2.3 percent. Danes reportedly began hoarding butter and other fatty products before the new regulation kicked in.

Denmark’s tax is the first of its kind in other ways. “This is a major development for two reasons: It’s an entire country, and they’ve taken on a particular part of the food supply,” says Kelly Brownell, director of Yale’s Rudd Center on Food Policy, who is widely credited with introducing the idea of a soda tax in the 1990s.

The Danish government implemented the tax because it wanted Danes, who lag behind European life expectancy numbers, to get healthier. Will they? The research on “fat taxes” is sparse, but there’s good reason to be skeptical about the potential public health gains.

One thing we do know about food taxes is that they have to be really high to change behavior. Brownell and Tom Frieden, now director of the Centers for Disease Control and Prevention, wrote in a 2009 New England Journal of Medicine article that the 5 percent taxes on unhealthy foods that states tend to pass just don’t cut it. Brownell’s research has found it takes a 1-cent-per-ounce tax to change behavior; anything lower, will do great at bringing in revenue but likely won’t lower soda consumption.

In reducing fat consumption, the bar may prove to be even higher: While soda isn’t generally thought of as a meal, solid foods are a different ballgame, what people eat when they sit down to dinner or lunch. And what little research we have on fat taxes bears this out. A 2007 study form the Forum for Health Economics and Policy modeled the impact of a 10 percent fat tax on dairy products and found unimpressive results.

“Such a tax results in less than a 1 percent reduction in average fat consumption,” the authors found. “To have a substantial effect, the tax rate would have to be quite high. For example, a 50 percent tax only lowers fat intake by 3 percent.”

Moreover, the authors worried that a fat tax would be quite regressive, hitting lower-income families much harder than higher earners. “The welfare loss to a family earning $20,000 is nearly double that of a family earning $100,000,” they found.

Since the Danish tax covers foods with higher fat content at a greater rate, its impact could be all over the board. It may reduce the consumption of really high-fat foods, but not those with a fat content. Denmark’s Confederation of Industries calculated that the tax adds 12 cents to a bag of chips, 39 cents to a small package of butter and 40 cents to the price of a hamburger.

Denmark’s tax is, in Brownell’s view, an important “bellwether:” He believes it will test both whether the policy works, as well as the political appetite for such levying such fines.

“If foods with saturated fats now cost more, you don’t know what people will eat in their place. The hope is they’ll eat healthier things.”

As we watch the effect of Denmark’s new tax, we’re about to find out.

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Statistikk flytter grenser i verden. Fattigdomsgrenser.

Screen shot 2011 10 03 at 22 17 08
Denne saken var på forsiden til NRK, og for at den ikke forsvinner helt blogger vi om den her. Joar Hoel Larsen rapporterer om statistikere i India (utdrag).

India kvitter seg med fattigdommen – Verden – NRK Nyheter:

[…]Når den indiske planleggingskommisjonen mener den enkelte ikke kan kalles fattig hvis han eller hun disponerer fire kroner per dag, så er det fordi de har regnet på hver enkelt vare.

Rent praktisk så bruker selvfølgelig ikke forbrukeren 32 rupis hver dag. Men med større innkjøp over tid fordeler de beregnede månedlige utgiftene på 112,50 kroner seg slik at det blir for eksempel 5 øre til frukt og 10 øre til sukker, 25 øre til grønnsaker og 30 øre til melk per dag.

Indiske journalister har gått mann av huse for å finne familien på fire som klarer seg på 15 kroner dagen. De 15 kronene skal også dekke klær, utdanning og transport.

Reportere har vandret gatelangs og snakket med småkremmere som driver det som er gaterestauranter og ffortauskafeer – i ordenes rent fysiske forstand. Med stort alvor står de i TV-ruta og slår fast at det lar seg ikke gjøre.

Andre påpeker den åpenbare konflikten mellom planleggingskommisjonens fattigdomsgrense og myndighetenes egne tall for helse og helbred.

Den indiske regjeringen – avhengig av hvor tung du er og hva slags yrke du har – anbefaler hvor mange kalorier den enkelte bør innta hver dag for å forhindre sult og feilernæring.

Og det daglig anbefalte minimumsinntak koster om lag det dobbelte av planleggingskommisjonens 32 rupis.
[…]

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Grafer som gir deg dårlig humør | Fattigdom blant barn.

Alle de nordiske landene har problemer med fattigdom, også med fattigdom blant barn. Men det er ikke å stikke under en stol at noen land har større problemer enn oss. Disse to grafene tærer på syken til unge amerikanere:
Screen shot 2011 09 16 at 20 23 06Selv med No Child Left Behind, Medicaid og utvidelsen av S-CHIP er nummeret høyt. Eneste lyspunkt er en nedadgående trend:Children Uninsured Time 500x276 Spørsmålet nå er hva finanskrisen gjør med denne trenden, med foreldre arbeidsløse og mørke utsikter om fremtidig arbeid. Forsking på fattigdom blant barn. I mellomtiden tærer fattigdommen på helsen og på skoleferdigheter, spesielt blant minoritetsbarn.

Dårlig humør nå? Vent litt.

Hva med Norge?
Fig 2011 08 23 01
Hvis du kikker nøye på grafen over fra SSB, vil du oppdage at 18 av 19 fylker har flere barn i barneværntiltak i 2010 enn i 2009. Ikke ett fylke har klart å redusere antall barn, bare Rogaland holder seg på stedet hvil. Ikke noe å være stolt av hvis dette holder stand med befolkningsveksten.

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Brusdrikking i USA. Nå kan du lure ja…

And now for something completely different.

Jeg så denne og tenkte «denne går opp på bloggen, nå.». Utgangspunktet er dette: I følge The American Heart Association bør konsumet av sukkerdrikker ikke overstige 450 kalorier i uka. I uka. Vel, hvordan ser dene sist oppdaterte grafen ut?
Db71 fig1
Se hva som er på y-aksen, per dag. Det betyr at gutter mellom 12-19 drikker 1911 kalorier i uka. Det er over fire ganger den anbefalte mengden.

Les mer for å vite hvor stor andel av befolkningen som faktisk drikker brus, slik at gjennomsnitt blir en dårlig indikator på problemet (hint: det viser seg at halvparten av befolkningen drikker langt mer enn den andre halvdelen som faktisk drikker ganske lite. Den skjevheten er skummel )

Regner med noen helsefolk leser denne bloggen, men det tar vel ikke alt for mange hjerneceller for å tenke på potensielle problemer ved for høyt sukkerinntak over tid:

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Et smart spørsmål: Hvorfor sparer ikke de fattige mer? #nyforskning

Sparing har lenge vært forsket på, særlig i fattige land blant relativt fattige mennesker. Vi snakker ikke så fattig at mat ikke kan kjøpes, det er en humanitær katastrofe og et helt annet monster. Vi snakker om mennesker som har en form for inntekt, som har både inntekter og utgifter og som kan ta husholdningsavgjørelser om å spare penger. Sjekk ny forskning (PDF er dessverre gitret, du trenger en valid IP for å lese dokumentet):

Why don’t the poor more save more?:

No place to save, demands from kin, or self-control problems? Pascaline Dupas and Jon Robinson suggest it’s a little of each:

Using data from a field experiment in Kenya, we document that providing individuals with simple informal savings technologies can substantially increase investment in preventative health, reduce vulnerability to health shocks, and help people meet their savings goals.

The two main barriers that keep people from saving on their own appear to be transfers to others and “unplanned expenditures” on luxury items. Providing people with a designated safe place to keep money was sufficient to overcome these barriers for the majority of individuals, through a mental accounting effect.

Adding an earmarking feature reduced savings for the average individual due to the associated liquidity cost and did not help present-biased people save more. For such individuals, stronger incentives to start and continue making deposits are necessary to overcome self-control problems.

(Via Chris Blattman.)

Ifølge forfatterne er de to viktigste grunnene til at det ikke spares mer i Kenya at overføringer og uforutsette utgifter på luksusgoder hindrer familier i å spare. Incentiver til å spare, samt å ha en mulighet for og spare er viktig.

Forskningen sentreres rundt ROSCAs. La meg forklare. Rotating Savings and Credit Associations, eller ROSCA i nerdeprat. En ROSCA er altså en gruppe mennesker som roterer på å spare penger hvor en forskjellig person får potten hver gang de møtes. Hvert medlem tar med seg spare pengene, og etter noen runder er det din tur til å få potten. Over 40% av kenyanere i forskningsområdet er medlem av en slik sparingsgruppe. (Jeg har forresten sett èn artikkel i en norsk avis om ROSCAs. Noen som har linken>)

Forfatterne fulgte 113 slike og tilfeldig valgte ut ROSCAs til enten kontrollgruppen eller til fire forskjellige sparingsgrupper. En gruppe kunne spare på en sparegris (en metallboks med en sprekk til innskudd), en gruppe kunne spare likt den første gruppen, men ble ikke gitt en nøkkel til låsen. En tredje gruppe kunne ‘helsespare’. Dvs. at hvis 10 av 15 i en ROSCA ble enig om et helseprodukt, så kunne de spare til dette produktet I TILLEGG til den vanlige sparingen. En fjerde gruppe gjorde det mulig for hvert enkelt medlem å spare til noe helserelatert. Altså forskjellige spareteknologier fordelt på fire grupper.

Fra konklusjonen:

This paper suggests that existing informal mechanisms in rural Kenya are insuffcient – introducing a technology as basic as a simple box with a lock and key allows the average individual to substantially increase her investment in preventative health and to reduce her household’s vulnerability to health shocks. We present evidence that the mechanism through which this simple safe box enables savings is through a mental accounting purpose. The money put into the box was seen by respondents as «for savings» and was therefore less likely to be spent on luxuries or given away to others. Usage of the box remained high for (at least) 33 months after it was introduced.
Such a simple technology is not valuable for everybody, however. In particular, mental accounting appears insufficient to enable individuals with present-biased preferences to save more. An individual commitment savings account or lockbox is not effective either, however.

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Antibiotika. Det er alt.

Kom over denne og synes den var interessant. Denne inngår som en liten digresjon fra den større helsedebatten i den vestlige verden, men allikevel verdt å lese. Dette er verden av antibiotika:

Antibiotic resistance – closer look required:

Ezra posted yesterday on antimicrobial resistance (pointing to Eric Kroh and Megan McArdle). Good posts, but the data is much more complex. This is one of my primary research interests, so I’ll admit to some obsession on this topic.

First, antibiotics are an exhaustible resource, unlike most other pharmaceutical innovation. We need to manage resistance for long-term ecological balance. This simple fact must alter all policy responses to resistance. We can’t just make more, we also have to carefully extend the useful life of the antibiotics we have today (Health Affairs). Imagine it’s 1890 and we want to increase buffalo hide production. Additional financial incentives to hunt the last few buffalo won’t work. We need a long-term plan to balance new production and conservation.

Second, “the chart:”

Looks grim? Some comments. The data series is limited to systemic antibiotics, excluding prior periods and other anti-infectives live antiretrovirals (saved millions of lives globally), antivirals (like oseltamivir), and vaccines (like Prevnar, the pneumococcal vaccine). It also treats all antibiotics as equally important, but more antibiotics are withdrawn from the market under a safety cloud than any other category of medicine. So let’s try the same FDA data sliced a different way:

The blue segments are antibiotics withdrawn from the market, many with safety issues. The FDA may have been too lax in approving antibiotics in the 80s and 90s and has gotten tougher in the last decade. Perhaps that is appropriate. Most of these withdrawn antibiotics were “me-too” drugs in existing classes, which do nothing to fix long-term resistance. Now, let’s broaden the data to include all anti-infectives:

In the 1990s, we see a number of antiretroviral drugs introduced to combat AIDS. The linear trend is still downward sloping, but would be even closer to level when you back out the withdrawn antibiotics. But this still look like an innovation problem in anti-infectives, until one compares it to other classes. Consider cardiovascular drugs:

One reason we don’t read news stories about a looming crisis in CV drugs is the happy fact that resistance doesn’t destroy their usefulness. The billionth dose of atorvastatin (Lipitor) is just as effective as the first. Wish we could say that for penicillin or vancomycin. The take away point here is that declining innovation is not unique to anti-infectives. Let’s look at one more drug class, cancer drugs:

What a success story – if the goal is getting drugs approved by the FDA. The big draw in cancer is reimbursement – paying tens of thousands of dollars for short course chemotherapy per patient will clearly get the attention of drug companies. My main point here is to consider reimbursement for antibiotics as a primary tool for both incentivizing new drugs and also supporting long-term conservation.

So many more things to say, perhaps in future posts.

My research on the legal ecology of resistance:

So, AD, et al. Towards New Business Models for R&D for Novel Antibiotics, 14 Drug Resistance Updates 88-94 (2011).

Kesselheim AS, Outterson K. Improving Antibiotic Markets for Long Term Sustainability, 11 Yale J. Health Pol’y, L. & Ethics 101 (Winter 2011).

Outterson K, Yevtukhova O. Germ Shed Management in the United States, in Antibiotic Policies:  Controlling Hospital-Associated Infection (Ian M. Gould and Jos van der Meer, eds., Springer, 2011).

Kesselheim AS, Outterson K. Fighting Antibiotic Resistance:  Marrying New Financial Incentives to Meeting Public Health Goals, 29 Health Affairs 1689-1696 (2010).

Outterson K, Powers III JH, Gould IM, Kesselheim AS. Questions About the 10 x ’20 Initiative, 51 Clin. Infect. Diseases 751-752 (2010).

Outterson K. The Legal Ecology of Resistance:  The Role of Antibiotic Resistance in Pharmaceutical Innovation, 31 Cardozo L. Rev. 101 (2010).

Outterson K. Antibiotic Resistance and Antibiotic Development – Author’s Reply.  8 Lancet Infectious Diseases 212-214 (April 2008).

Outterson K, Balch Samora J, Keller-Cuda K. Will Longer Antimicrobial Patents Improve Global Public Health? 7 Lancet Infectious Diseases 559-66 (2007).

Outterson K. The Vanishing Public Domain:  Antibiotic Resistance, Pharmaceutical Innovation and Global Public Health, 67 Univ. of Pittsburgh Law Rev. 67-123 (2005).

(Via The Incidental Economist (Posts).)

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Apropos helseutgifter.

W ezra296 300x588
Apropos helseutgifter, denne via The Washington Post. OECD samler data på offentlige og private helseutgifter som prosent av BNP (merk at det ikke er utgifter per person). Her er ganske enkelt disse to aspektene slått sammen, og rangert. Norge er helt klart det minste landet i denne sammenlikningen, og offentlige utgifter klart dominerer private helseutgifter, som forventet.

Men det er ikke denne grafen som er viktig, jeg vil gjerne se helseutgifter over tid. Vent litt:
Spesial
Og jeg vil gjerne se noen effektivitetsindikatorer – over tid. Antall utførte hofteoperasjoner, eller sengeplasser, osv.

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Diskusjon om skolemat fra Chicago, Texas og Frankrike.

Should kids be able to bring their own lunches to school?:

I encountered this news article, ‘Chicago school bans some lunches brought from home’:

At Little Village, most students must take the meals served in the cafeteria or go hungry or both. . . . students are not allowed to pack lunches from home. Unless they have a medical excuse, they must eat the food served in the cafeteria. . . . Such discussions over school lunches and healthy eating echo a larger national debate about the role government should play in individual food choices. ‘This is such a fundamental infringement on parental responsibility,’ said J. Justin Wilson, a senior researcher at the Washington-based Center for Consumer Freedom, which is partially funded by the food industry. . . . For many CPS parents, the idea of forbidding home-packed lunches would be unthinkable. . . .

I posted this at the sister blog and remarked that, if I had read this two years ago, I’d be at one with J. Justin Wilson and the outraged kids and parents. But last year we spent a sabbatical in Paris, where . . . kids aren’t allowed to bring lunches to school. The kids who don’t go home for lunch have to eat what’s supplied by the lunch ladies in the cafeteria. And it’s just fine. Actually, it was more than fine because we didn’t have to prepare the kids’ lunches every day. So, no, I don’t think the no-lunch-from-home rule is a ‘fundamental infringement’ etc. Then again, I’m not partially funded by the food industry . . .

Various blog commenters write that the cafeteria food is generally much better in France than in United States. And Igor Carron, a French statistician who lived in Texas for many years (as an adult) wrote in with an interesting political angle:

If I were to compare France and say Texas, I’d say that this is more an issue of how the school systems are clearly delineating the stakeholders.

In France, the meal is paid for through the mayor’s office. The school itself is owned by the city but the educators are getting their paycheck from the state. There are simply different stakeholders with pretty well defined responsibilities. If the kids don’t eat right, the mayor gets to hear about it very fast and she/he wants to make sure that she/he is not seen as ‘starving the children’.

In Texas, the whole school (educators, canteen,…) are all dependent on one administration (the school district). If the food is not good, then someone on the school board may hear about it and then drown the problem and point the fingers to the ‘inefficient’ school’s administration. But there are so many issues at the school level that I don’t think you can lose an election on the school board based on that one particular item.

Not many people will also articulate this but I would not be surprised if the French considered sharing the same meal a way of mixing different people from different backgrounds (rich,poor,…). If you pack lunch for your kids, you are also probably allowing your kid to send some signals that are not conducive to a smooth learning experience.

Interesting idea regarding clear administrative and political responsibilities. I don’t know anything about this area of political science but thought I would post it here. My original reason for posting on this (besides my own personal interests) came from the public opinion angle, that an issue could seem so fundamental to some people and so minor to others. (Here are some other examples.)

(Via The Monkey Cage.)

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