12Joined Nov 2021


I am an MD-PhD student at Harvard researching ethical issues related to priority setting.

On Twitter as leah_pierson.


Thanks for writing this! This is really interesting. I only skimmed, but my basic reaction is that I agree that hypertension is an important problem, but am skeptical about salt taxes as a solution. Here are a few reasons why:

1)  I suspect salt taxes are less effective at reducing consumption of the offending agent than other kinds of sin taxes (e.g., sugar, tobacco) for two reasons. First, per the linked article, the taxes have historically been applied to salty foods, like chips, instant noodles, and salted nuts. But I suspect a large percentage of the salt people consume comes from the food they cook. Second, it is easier to replace the salt that is taken out of salty foods. You wouldn't buy a sugar-free soda and add sugar to it, but you might well add salt to nuts, instant noodles, and so on. (My parents would buy unsalted microwave popcorn when I was a kid, and I developed workarounds...) 

2) This is very speculative, but I worry that salt taxes—which, as you note, will be unpopular—could lead to broader backlash against sin taxes, in much the same way that more draconian masking rules have, perhaps, incited broader backlash against masking. It would be very bad if pushing for salt taxes led to reduced public support for tobacco taxes.

3) Like other commenters, I'm a bit skeptical of the extent to which reducing salt consumption reduces blood pressure. Just looking quickly at this Cochrane review, the drop in systolic blood pressure (SBP) for hypertensive people was 5mm Hg (and only 2mm Hg for normotensive people) with reduced salt consumption. These drops may be statistically significant, but I'm not bowled over by their clinical significance. If a patient with a BP of 150/90 reduced their SBP to 145 by limiting salt consumption, you'd put them on an antihypertensive. 

4) I'm perhaps most confused by how quickly antihypertensives are dismissed as an option—
"medications, will by their nature be more expensive as an intervention than policy change." My understanding is that the substantial reductions in cardiovascular mortality seen in the Western world are largely attributable to the use of antihypertensives and statins. Even in the US, you can get a 30-day supply of lisinopril for $3.75, and you'd expect this to reduce the above patient's SBP by 17-23 mm Hg—a 3-4x greater reduction than you'd see with reduced salt consumption.  

5) Of course, health care costs much more than just the cost of medications. But if you want a policy solution, I'm inclined to think that a better intervention would involve widespread population BP screening and incentivizing providers to prescribe (and patients to take) antihypertensives. Polypills—which include, e.g., antihypertensives, aspirin, and statins—also look really promising and do more than just reduce hypertension, although pharmaceutical companies have little incentive to make these. So I'd also be eager to see policy solutions aimed at making polypills more widely available.

Hi guys! I'm Leah, an MD-PhD student at Harvard. I'm currently working on my dissertation, which is about ethical issues related to global health priority setting. 

I'm also working on other bioethics projects, like the Views in Bioethics Survey (ViBeS), which involves surveying 1,700 US bioethicists on major issues in bioethics (e.g., challenge trials, organ donation, population ethics, and so on). In the next few months, I'm planning to post our survey on the forum so we can assess where/how much bioethicists and EAs disagree about bioethical issues. At some point before then, I'd like to use this subforum to get feedback on how to do this optimally. 

Thanks for writing this. (I admit to skimming parts.)

Two things that I think are also worth mentioning:

  1.  Having an MD provides substantial job security, at least in the US. If a doctor takes a year off to pursue a risky project, they can return to medicine if it doesn't work out. I think in most other fields, a random one-year gap could make it hard to return to the workforce at a similar level.
  2. It's relatively easy to scale (most types of) medical practice up and down. Some PCPs only have two clinic days a week; some surgeons only operate once. You can make a decent living practicing medicine part-time, which can free up time to work on other projects, even without pay.

I agree with this, and just wanted to add a resource. My mom told me about this concept in couples therapy, Differentiation, which is basically what Khorton suggested. Here's how my mom put it in a wedding toast:

"[The husband] recognized that his needs and those of his beloved diverged profoundly. He was able to feel his own feelings and hers — to love and honor her even in difference. No matter how well aligned we are with our partners, there will be profound differences. We love not in spite of the differences but also because of them. [The wife] would not be the person she is without the concerns she manifested."

She also sent me a podcast on this:


 (I haven't listened to the whole thing, but the discussion on Differentiation starts at ~10:30.)