All posts by Anand Parameswaran

Cheating ourselves to Death?

India is often referred to as the diabetes capital of the world, with around 41 million people living with diabetes in 2007, and projected to reach 68 million by 2025. In one of our engagements we were trying to understand how people living with diabetes manage this disease. One of the perplexing observations was that many people had the belief that their diabetes is under control. This conflicts with most data and expert opinion which suggests that majority of diabetes cases are uncontrolled.

We were trying to understand the source of this belief and started interviewing close family members of patients. One of the most interesting factors that we heard when we spoke to family members of these patients was that these patients “prepared” themselves before going for a blood glucose test. A week before they get their blood sugar tested, they would change their lifestyle – they would exercise, go for walks and control their diet. So when testing happens they get a more favorable result than their actual condition. It looks so irrational that people would cheat themselves into believing that their condition is better than it actually is, thereby putting themselves at risk of not getting the right treatment.

What explains this seemingly irrational behavior? Why would intelligent people who are aware of the dangers of the disease that they have, not want to know the truth and provide their physician with more accurate data for better decision making?

One of the moderators of decision making is the kind of mental models that people create in life that helps them simplify the world. While this is often great to improve efficiency of decision making, it could be deadly if used in the wrong context. A very popular example of a mental model being used in the wrong context is in the case of diarrhea. As Sendhil Mullainathan explains in this video, 35-50% of the mothers in Rural India think that they should reduce fluids if their child has diarrhea. They use an intuitive mental model of a leaky bucket – that you should not pour water into a leaky bucket if it has to stop leaking. This makes diarrhea, something that can be easily managed to the status of a deadly condition.

In the case of diabetes, the mental model that patients have is that one should not to fail a test. People look at each blood test as a test of how well they are managing their condition, thereby framing the issue as a judgment on their own capabilities. And not one that objectively measures the status of their condition and as an input into a treatment regimen that would help their doctor take better decisions.

How do we address such a condition? Breaking mental models is often a high-investment long-term game. One of the approaches that we take at Final Mile is to see how one can work with existing mental models rather than fight it. In this case, simply by encouraging people to adopt HbA1C instead of a spot test can help address this behavioral issue and get a more accurate measure of their condition. It is a simple intervention, but one that addresses the inherent risks of misdiagnosis. The other intervention is to address how doctors and counselors frame the test – it is important that patients do not see this as a test that they fail or pass but one that helps calibrate the medication for a chronic condition.

Currency Of The Mind

In the recent past academic literature is abound with discussions around how classical economics is poor at explaining or predicting human behavior. For example, what explains Warren Buffett – spend a lifetime earning, only to give away his immense wealth to philanthropic causes one fine morning? And what happened to that elusive utility maximizing, self interested being whom we use to build our economic models?

If Warren Buffett is an exception, let us look at ourselves and the world around us. We make new year resolutions only to break them the next week. We keep money in our savings account and take loans at higher interest rates or revolve debt on our credit cards. We swear to eat healthy only to binge on the sinful sundae that we just spotted on the menu.

Some classify this behavior as “irrational”, almost accusing us of going against the rules – the rules set by economic models. But today we have a much better understanding of how the brain takes decisions and what it tries to achieve in the process, thanks to advances in Neuroscience.

We now know that the currency of the mind is not money or economic utility, but emotions. We also know that the connection between emotion and motion is not just etymological, but a fundamental fact of the human (as also other animal) brain. Emotions drive us to action. What is more important, action that maximizes “Emotional Utility” and not necessarily Economic Utility.

Seen in this light, most human behavior falls into place. It explains why we pay money to engage in adventure sports, chase inconsequential goals in online games, enjoy gambling, prefer spending time on facebook rather than more materialistic pursuits etc.

If we appreciate this fundamental truth, we would have a much better understanding of what drives people to action. It will help design interventions that can influence behavior much far more effectively.

And, perhaps governments and other social agents can attach more importance to things that matter most to societies. For starters, we would stop referring to societies as economies and stop measuring progress using the single, dry dimension of economic growth. Instead, we would focus a lot more on understanding the rich and colourful world of emotions and what maximises them. It will help us define well being, based on what is truly important to us.

High Living – Lower Parel or Upper Worli?


If you are from Mumbai or pride that you know Mumbai well enough, you might be wondering where Upper Worli is. If you did, you are like most other people I know, many of them having lived in this city all their life! It was only a few months back that Mumbaikars heard of this place for the first time – when a series of high end luxury residences were launched in this hitherto unheard-of locality. Visits to websites of these builders, Google Maps, and eureka happens – Upper Worli is right here, right under our noses, right where our office is! Continue reading High Living – Lower Parel or Upper Worli?

Chemotherapy: How framing bias leads to wrong decisions in treatment of cancer

Source: LiveStrong by d.p.t. on flickr

A recent article in ICNR raises fundamental questions on whether Chemotherapy has been oversold. Research done by 3 oncologists in Australia and the US published in the Australian Journal Clinical Oncology titled “The Contribution of Cytotoxic Chemotherapy to 5-year Survival in Adult Malignancies” found that chemotherapy contributes just over 2 percent to improved survival in cancer patients. Continue reading Chemotherapy: How framing bias leads to wrong decisions in treatment of cancer

Fairly irrational – Why Fair-trade products should do well in India?

Why should people who otherwise bargain for every penny, pay more for something knowing fully well they are overpaying? While classical economics likes to believe people are rational and hence selfish, interestingly most people don’t live by the laws of economics, or as Mullainathan & Thaler (Read the research paper here) puts it “economics is anti-behavioral”. They indulge in chocolates, spend time watching trashy movies, and fortunately enough, are concerned about people around them, often willing to sacrifice their own interests to help others.

The fundamental premise of the fair-trade movement (Hear Harriet Lamb speak at the LSE) is this humaneness in human behavior. A higher price that a consumer pays for fair-trade coffee, tea, sugar or any other product is in exchange for a promise by the producer to pay a higher, fair price to its workers and farmers. And one of the drivers of this trend will be the increasing polarization in incomes and quality of living in India. “In the face” poverty in large cities like Mumbai makes many people feel guilty about being rich – travelling in chauffeured cars amidst poor children begging for the next meal – and works as triggers for altruistic behavior.

Today, in some countries fair-trade products have become huge. In UK alone, £500m worth of goods bearing the Fairtrade mark are sold annually, including tea, coffee, bananas, cotton, flowers and even footballs, transforming the lives of millions of farmers, workers and families.The Fairtrade Foundation, has been a pioneer in this movement. In India, beginnings have been made by NGOs like Fair Trade Forum, among other institutions. But it is when larger organized retailers and speciality retailers like Fabindia starts promoting these products through their networks, this could snowball into a much larger movement.

Let’s celebrate irrationality again!