Care Doesn't Scale

Compare that to the pandemic response example I gave: that is the kind of challenge where there are concrete problems at individual, city-wide, national and international scale to tackle, and they're all interconnected too. So plenty of those coordination problems you mentioned.

The incentives of an organization - or at least of a corporation - are to make money and to continue to exist and to enrich and empower the people who control it. But employees' incentives are usually pretty different. Nurses usually get into nursing because they, at least to some extent, want to help people. Engineers get into engineering because they, at least to some extent, want to build something really good. Teachers get into teaching because they want kids to learn. And so on.

If you're the principal of a school, and your goal is for a teacher to teach, you don't have a coordination problem. Most teachers want to do that. But if your goal is for teachers to maximize standardized test scores, or to minimize the number of frustrated parent calls, etc, you do have a coordination problem, because your goals are misaligned with your employees'.

If you're the CEO of a tech company, and your goal is for your engineers to build good software, you don't have a coordination problem. Your engineers want to do that. But if your goal is to maximize conversions, or to ship faster, or to raise money, etc., you do have a coordination problem.

If you run a hospital, and your goal is for your nurses to care for patients, you don't have a coordination problem. But if your goal is to maximize profits, then you do.

It's usually these kinds of coordination problems that managers are, effectively, in charge of enforcing. Their job is not to help individual employees achieve individual employees' collective goals, it's to make employees feel (sometimes truthfully) like their goals are aligned with the organizational goals, or to use the threat of loss of income or work to force them into line.

My mom is a (retired) preschool teacher. By the end of her career, she was working for a school affiliated with a large chain, and maybe 1/3 of her time was spent on filling out all the paperwork required by management. That was time she absolutely was not spending with the kids.

My dad is a (retired) doctor. Similar story there. His hospital ultimately ended up associated with a regional health care network, and the paperwork load ultimately got so bad that they ended up having to hire additional staff dedicated to help the actual health care providers fill out all the paperwork so that they could spend more time actually providing health care.

I switched primary care providers over this a few years back. I had a great doctor, but her practice got bought up by one organization, which then got bought up by another, and over time working with her office became a huge bureaucratic quagmire. I switched to a different clinic that's still local (although also chain with multiple locations), and everything's easier again.

The same thing happens at my own job, software. The bigger a company I'm at, the more of my job consists of filling out paperwork about the work I'm doing, rather than doing the actual work.

tl;dr: It's communication that doesn't scale.

A trust-breaking event occurs, so a new form gets added, a compliance process is created with a new team monitoring, etc. etc. Have enough of those and you eventually get your typical, modern healthcare bureaucracy today.

First, note any organization that breaks into different departments (hierarchical or not), at least partially does so to let each department "abstract" away the other ones - if you don't have to worry about issues outside of your responsibility, you can focus more on yours. That is actually a form of trust.

In the case of a hierarchy however, that means that each layer abstracts away the layers above and below, and since going up multiple levels in the hierarchy happens indirectly, the further away, the more abstract things become. So that often needs some kind of structure to regain the trust that is lost by dealing with abstract departments - leading to bureaucracy.

On top of that, usually more power resides higher up the hierarchy. That means that without explicit structures to compensate for this, people lower in the hierarchy lack individual leverage to protect themselves against bad decisions made higher up, that may not even be malicious or intentional but just a consequence of the aforementioned abstraction.

Of course, most structures that are created to fix this typically are also abstract procedures, meaning they barely help with our instinctual "I cannot attach a face to this" type of distrust. Bureaucracy can create leverage, but rarely creates trust. Which also explains that quite often, talking to someone in person can make such a difference in being allowed to "go ahead" or not. Because it can provide a more "natural" sense of trust that bureaucracy is supposed to provide but barely does.

Legally an organisation is usually exposed in relation to its scale, even if the misconduct was limited to one employee trusted to carry out work independently, the penalty will likely be related to the total size of the company.

The second is if you're scale is large enough that you are considering a significant portion of the employees with some skill in a region, you have a harder time selecting for anything other than "holds a qualification" during hiring. This leads to all sorts of policy to prevent someone with qualifications but less integrity causing issues.

For example you have leading doctors who prefer not to look at patients, even tho they belong to them (from a specialization point of view), as they are "cumbersome" cases. That often leads to them "ignoring" it for some time until someone else takes over, or completely delegating it to non-fit persons.

It's a huge pain for me to heard this every day, because it literally sucks out any desire to work as a doctor from my girlfriend. At the same time, it's infuriating: we pay a lot each year, and with every year more, for services like this. If I was to ever win lottery, I'd use that money to make my own hospital without all of this crap.

Because Buurtzorg has been shown to have lower costs and higher job satisfaction than its competitors, and the reasons are quite obvious too: the hierarchical outsourcing solution adds extra communiciation costs, administration costs, and similar organizational overhead. On top of that patients are in a situation where they see many different unfamiliar care workers briefly, meaning they do not get to form a bond of trust with any one of them. That is a pretty heavy costs that I don't even know how to categorize.

More from a recent report by Australia's business council of coops and mutuals: https://bccm.coop/australia-urged-to-look-to-europe-for-solu...

Anyway, my advice to the author was that systems can enable care at scale. Not to say that our current systems do.

Edit: to be more explicit, I'm suggesting that some approaches to the housing sector in some parts of Europe amount to care that scales; society and governments have decided that housing is a right, and have enacted policies to approach that situation. Conversely, a "we don't care" approach also scales very well with the opposite outcome.

1) I think part of it is due to our ability to fine-tune the limits. Before, if a company wanted to pass an inspection, they had to be really confident. There were going to be some expenses that in theory they could have avoided if they were better capable of measuring where the line between 'safe' and 'unsafe' was. The end result was buildings that were more safe than strictly required. But now we can get closer to the line, and so buildings are engineered at the edge of safety.

2) Of course, survival bias plays a role here. Who remembers all the crappy buildings that just vanished? It's the same reason we look at old toasters or mixers or what-have-you and say things were so much better-made in the past - all the crappy cheap toasters, mixers, and houses are gone now.

3) Also, as extreme weather has happened more frequently, areas all over are seeing weather different than what they were designed for. Given that the average temperature in Oregon in July (the hottest month of the year) was typically around 65 degrees Fahrenheit[1]. For the past few years it has generally hovered in the upper 60s. The hottest temperature ever recorded in Oregon before 2021 was 107 degrees Fahrenheit[2], and typically there were one or two days a year that crossed one hundred degrees -- occasionally five, more often none. In 2021, it hit 116 degrees. Since 2021, there has not yet been a year without 4 or more days over a hundred. And, of course, this pattern is repeated all over the world. Houses are being built for one set of extremes and averages and getting another.

[1] https://www.ncei.noaa.gov/access/monitoring/climate-at-a-gla...

[2] https://projects.oregonlive.com/weather/temps/

And even in a "food oasis" with adequate quality, yes, if you yourself cannot prepare a meal, or have nobody to do that for you, that's a failure of a different kind.

https://en.wikipedia.org/wiki/Food_desert

Let me fix that for you:

Children notoriously prefer heavily marketed food in attractive packaging which is designed/optimized for addictiveness and immediate gratification.

Don't underestimate the human desire to provide value to the tribe, it runs deep in the evolutionary make-up.

In most cases, this is probably due to the care givers training their children to prefer that kind of food because they don't make many home cooked meals.

I don't even know if it's true, though. When I was a kid, the best food in the world were the home made meals my grandmother made, especially on the holidays. Remember as a teenager telling my Grandma her meals were better than any restaurant I had ever eaten at, and meaning it in all sincerity.

I regret nothing. Pancakes are and will always be great.

Nearly all people do, food scientists are really damn good at their job.

It isn't even that the stuff tastes better, it just triggers more of the pleasure centers in the brain and causes people to want more.

No one eats an entire bag of doritos because they taste better than a good steak.

Yes, I may show empathy and respect to strangers, patients or clients, trying hard to deal with them fairly and conscientiously. Well said.

But this only operates in the short term.

It doesn't mean I can love them all, or at all, or love them equally, or anything like that. That would be meaningless. We don't know what love is exactly, but it does seem to include a sustained form of attention. It provides a space in which the other person can grow.

Such attention is always specific, by its nature; it latches onto a subject, something recognised yet new in the other. It can't be served out like soup. Yet increasingly businesses, bureaucracies and government pretend that it can!

> When you are in a major Chinese city you may street sweepers sitting on the side walk chitchatting. The first thing you may think of it as waste that could be eliminated. But it also acts as a buffer.

TL;DR: Pretty much what you said, but he labeled it "margin" instead of "slack". But yeah, you need some.

It's very hard to sell slack to management and so in "well run organizations" it ends up trending towards zero. And then everyone is surprised at the resulting catastrophes.

I use this extensively when planning activities with my children. It's a fun challenge because they're both too young to tell the time, much less read, which are constraints one does not normally encounter in their work life.

https://www.neelnanda.io/blog/38-slack

"Want to borrow a book? Ok." "Don't want to? Ok. Whatevs."

And even analysis paralysis is overcome with: "Why not both! Borrow two whole books!"

The reason why totalitarian regimes end up promoting traditional values relations is that to them the only imperative superior to ideology is survival.

There is a reason the Soviet Union backed off from it's repression of religion in the middle of WW2.

I was born in Eastern Europe in a society headed in this direction. I observed its transformation after the fall of the Berlin Wall.

You felt the overarching power of the state from as early as the kindergarten. Signs of individuality were suppressed and all children were supposed to do things "the right way". When such an institution decided that a child "systematically misbehaves", it was able to take the child away from its parents in another orphanage-like institution that was supposed to teach them good socialist manners. Eventually some of them would end up seriously harassed, physically-ill and sent to an anonymous grave in the backyard of that institution.

"Care" doesn't scale. You can't just replace "the family" with some industrialized system of raising children and get the same results. Not being able to scale "care" and make it more efficient is almost tautological, really.

> Besides, what countries are you talking about?

North Korea? Former Soviet Union?

At the very least appearance of conformity was ruthlessly enforced and even private conversations were infiltrated to detect dissent.

There are plenty of reasons to believe that yes, it does. This is something that is almost completely unknown (except on the extremes).

And history has those two coupled in very complex, hard to understand ways.

The whole point is scaling "care work" is almost oxymoronic. Care is only quality care when there are a small number of carers per those being cared for. To make it "efficient" is to turn children, the addicted, the disabled, and the elderly into cattle.

> "Wages for Housework" by Silvia Federici - Federici argues for the recognition and compensation of domestic labor, linking it to broader struggles against capitalist exploitation.

This reveals one of the poorly hid secrets of progressive ideology. Progressives LOVE Capitalism and want to spread it to encompass every human interaction. Caring for your own home, your own children, anything someone might do for a friend or a loved one MUST be turned into a financial transaction with an explicit contract.

Incidentally, large families do scale sublinearly with respect to the parents. The reason why is that even with merely natural spacing by the time they have a fourth child, the oldest is in a position to provide significant assistance. Every mother with a large family that I’ve spoken to confirms that the difficulty peaks with the third child and then plateaus.

Id bet if there was a reliable and effective means for 1 person to take care of 10-30 people, it wouldn't be a problem.

In summary, imho, the problem here isn't capacity to emotionally care for this many people, but means of taking care. I think the problem is we don't collectively invest enough resources (both material and cognitive) to figure out how to do something like this well.

Public schools are notoriously uncaring. It's expensive private schools which can afford to have small class sizes, so the teachers can develop personal relationships with the students. "Care" in this context isn't just "doing something for someone's benefit"; it requires a caretaker's undivided attention, which is why it doesn't scale.

If you don't provide the right balance of economic incentives for quality, the rational economic answer becomes "quiet quitting", and quality plummets. And maintaining that balance of incentives is also someone's job, which needs the right economic incentives to be done well, so it's turtles all the way down (or up).

In practice, it's an unstable, patchwork combination of care and economic incentives that keeps real-life institutions in working order.

typically they "care wrong" and the first world comes in and dismantles everything to keep raw resource prices at a price point that they like. advanced third world economies are a threat to first world prosperity.

And the week in which private companies will be able to provide this, is the same week which has two Tuesdays.

The government does not provide a more efficient military or education. It compels individuals to pay for something which is in the collective good, but not their personal interest.

i also think that ultimately no single system is best and that regular renegotiation about the amount of central vs decentral is key (something we should help people be better at)

We produce way more corn in the US today than we could without a centralized industry, but we do so by subsidizing the hell out of an industry that is driven only by how much volume of corn is produced. Nutritional quality of the food produced is ignored, damage to the land is ignored, damage to the broader environment is ignored, etc.

We grow a small amount of corn on our land. We absolutely don't have as high or consistent yields as an industrial farm, but we also don't spray any poisons on the land and if the soil health was being negatively impacted we would know it pretty darn fast. Rain water from the corn patch runs down into the pond our cows drink from, another reason we wouldn't use poisons on the land. All of these are considerations one will likely make at a smaller scale that just won't happen with a centralized system driven by one or two primary goals (currently that's just money).

> In any given moment, you can only really care deeply and individually for one person

Yes, but there are many moments in a day / one's life, and care is needed and appreciated at various levels of "deepness". Further, how much care (and what type) is needed depends enormously on what society has managed to scale with the right organizational patterns etc.

So in the end the question is: how much of this type of exclusive (and scarce) caring capacity does society really need? Mathematically, there are 8 billion exemplars of the species roaming the planet and 1:1 caring takes care (pun) of the 4 billion.

The lack of agency is what's primary here. You are never guaranteed to have the best care all of the time - even if you have the money.

My dad has Parkinson's and needs a human to change his diaper. If he had the option of a robot, I bet he'd take it. Not a painless die now option, though. As I write, where he is it's 8 o'clock in the morning and he's watching an old Larry David and eating an ice cream cone while my mom gets ready for them to go to breakfast.

The statistical you is paying statistically much more than the historical equivalent. The situation is far more complex than that. There's a million variables here. Changes in services rendered, changes in outcomes, relative wage differences, more parties taking a cut of any given transaction, more "make work" prior to rending specialized care, etc, etc.

Outcomes are better than they were 40yr ago but is that because of the changes or despite them?

Weren't these always done by nurses? The doctor would do the determination of what you get, but nurse being the one executing these is something that was here for decades.

I wonder how the best teacher in the world teaching 5 classes of 40 would stack up against 200 people chosen at random from a pool who had already passed that class working 1:1 for 1 hr per day. Probably the ideal case is somewhere in the middle, but the point is that it's allocation of the teacher's time, and not production quality, that's the bottleneck when it comes to scaling teaching.

The risk profile is different, if you have a newborn in hospital, then that child may have their parent present at all times, plus staff, but it might also be one or two nurses and an on-call doctor for any number of babies. In some sense the potential risk is greater, but it's also more professionally measured.

I have spent enough of this year injured due to my own adventure sport aggressive mis steps. I was MUCH less productive during this period than before or now due to injury.

Had I not needed to deal with that, is the most productive self and that has a exponential effect society.

A common arrangement is a board and care home with about 4 residents and 2 caregivers who work mostly non-overlapping shifts, and one sleeps onsite to (hopefully) be able to handle overnight care needs.

A larger place can scale a bit better. E.g. 10-20 residents can have 5-10 staff on various shifts. But some staff could be cooks or handle cleaning while others focus more on the residents' needs. And at this level of staffing, they can manage to have an overnight shift with someone who remains awake to keep an eye on things, as well as probably having other(s) sleep onsite to be on call to help with bigger events.

Anyway, I don't mean to nit pick. Everyone has to know their limits, and I'm sad to admit that I found I can barely handle two kids with two adults. And families managing 5+ kids strike me as over natural+healthy limits, unless they've a large extended family (who have capacity to help).

Regardless, it's probably the best they can do and likely far better than orphanages with 20+ kids per adult. So the core message about scaling does stand. Even if the ratio described is actually worse and less scalable.