Why do so many promising solutions in education, medicine, and criminal justice fail to scale up into great policy? And can a new breed of “implementation scientists” crack the code? SOURCES:Patti Chamberlain, senior research scientist at the Oregon Social Learning Center.John List, professor of economics at the University of Chicago.Lauren Supplee, former deputy chief operating officer at Child Trends.Dana L. Suskind, professor of surgery at the University of Chicago. RESOURCES:“How Can Experiments Play a Greater Role in Public Policy? 12 Proposals from an Economic Model of Scaling,” by Omar Al-Ubaydli, John List, Claire Mackevicius, Min Sok Lee, and Dana Suskind.“The Science of Using Science: Towards an Understanding of the Threats to Scaling Experiments,” by Omar Al-Ubaydli, John List, and Dana Suskind (The Field Experiments Website, 2019).“Inconsistent Device Use in Pediatric Cochlear Implant Users: Prevalence and Risk Factors,” by K.B.Wiseman and A.D. Warner-Czyz (U.S. National Library of Medicine National Institutes of Health, 2018). EXTRAS:"Why Do Most Ideas Fail to Scale?" by Freakonomics Radio (2022)."The Price of Doing Business with John List," by People I (Mostly) Admire (2022).Child Trends.Oregon Social Learning Center.T.M.W. Center for Early Learning and Public Health.The Field Experiments Website.
Chapter 1: What is this episode about and why is it relevant now?
Hey there, it's Stephen Dubner. We just published a two-part series on what some people call sludge, meaning all the frictions that make it hard to fill out tax forms or find a health care provider or even cancel a subscription. One part of our series involved government sludge and how it interferes with getting policy done.
The series reminded me of another episode we once made that I thought was worth hearing again. So we're playing it for you here as a bonus episode. It is called Policymaking is Not a Science Yet. We have updated facts and figures as necessary. As always, thanks for listening.
Usually when children are born deaf, they call it nerve deafness. But it's really not the actual nerve. It's little tiny hair cells in the cochlea.
Dana Suskind is a physician scientist at the University of Chicago. And, more dramatically, she is a pediatric surgeon who specializes in cochlear implants.
My job is to implant this incredible piece of technology which bypasses these defective hair cells and takes the sound from the environment, the acoustic sound, and transforms it into electrical energy, which then stimulates the nerve. And somebody who is severe to completely profoundly deaf after implantation can have normal levels of hearing. And it is pretty phenomenal.
It is pretty phenomenal. If you ever need a good cry, a happy cry, just type in cochlear implant activation on YouTube. You'll see little kids hearing sound for the first time and their parents flipping out with joy.
Good job! She's smiling. Oh, that's great!
That's your ears.
The cochlear implant is a remarkable piece of technology, but really it's just one of many remarkable advances in medicine and elsewhere, created by devoted researchers and technologists and sundry smart people. You know what's even more remarkable? How often we fail to take advantage of these advances.
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Chapter 2: How do cochlear implants work and what challenges exist in their adoption?
And was that a recognition that some kids after the surgery sort of zoomed up the education ladder and others didn't?
Yeah. It's not simply about hearing loss. It's because language is the food for the developing brain. Before surgery, they all looked like they'd have the same potential to, as you say, zoom up the educational ladder. After surgery, there were very different outcomes. And too often that difference fell along socioeconomic lines.
That made me start searching outside the operating room for understanding why and what I could do about it. And it has taken me on a journey.
So Dana and I met back in 2012. And we were introduced by a mutual friend. And we did the usual ignore each other for a few years because we're too busy. And push came to shove. Dana and I started to work on early childhood research. And after that, research turned to love.
I always joke that I was wooed with spreadsheets and hypotheses.
Is that true?
Yes, yes. In fact, the reason I decided to marry him was because I wanted this area of scaling to be a robust area of research for him. Because it really is a major issue.
Susskind started what was then called the 30 Million Words Initiative, 30 million being an estimate of how many fewer words a child from a low-income home will have heard than an affluent child by the time they turn four. But these days, the project is called the TMW Center for Early Learning and Public Health.
We've actually moved away from the term 30 million words because it's such a hot-button issue.
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Chapter 3: Why do promising medical and policy interventions often fail to scale?
Was it the 20 teachers you hired down in Chicago Heights where if we go nationally, we need 20,000? So it should behoove me as an original researcher to say, look, if this scales up, we're going to need many more teachers. I know teachers are an important input. Is the average teacher in the 20,000 the same as the average teacher in the 20?
This is the dreaded voltage drop that implementation scientists talk about.
And the implementation scientists have focused on fidelity as a core component behind the voltage drop.
Fidelity meaning that the scaled-up program reflects the integrity of the original program.
Measures of fidelity. That's a really critical part of the implementation process. That, again, is Patty Chamberlain, founder of Treatment Foster Care Oregon. You've got to be able to measure, is this thing that's down in the real world the same, you know, does it have the same components that produce the outcomes in the RCTs?
Remember, it was Chamberlain's good outcomes with young people in foster care that made federal officials want to scale up her program in the first place.
We got this call saying, we want you to implement your program in 15 sites.
She found the scaling up initially very challenging.
It wasn't the kumbaya moment that we thought it was going to be.
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