Build It and They'll Come

Build-it-and-they'll-come+ refers to the argument that you can invest in a large public infrastructure and enough paying customers will be attracted to use the infrastructure to pay back the investment. These investments are typically made with Other People's Money+, for example, tax dollars. The proponents of these investments typically are not personally at risk should they fail. Builders of the infrastructure, who often have a solution in search of a problem, are very supportive of this concept. They make money whether or not the investment decision is sound. So we see this argument being used for airport expansions, for bridges to nowhere and for national solutions to the rising costs of healthcare.

I attended the National Academies of Sciences symposium on Evidence-Based Medicine in the summer of 2008. The idea was to build a clinical database-in-the-sky that would provide all medical data needed to measure and improve medical decision-making and outcomes. Many of the builders of the database were present, i.e., IBM, Microsoft. Thomson Healthcare Solutions, providers of many of today’s databases was also present: ‘We’ve tried for years to figure out how to make money off this proposition and have never succeeded.

Another panelist mentioned that physicians aren’t stupid; they know the purported savings from this database would come out of their pockets. Finally on the second day one panelist had the audacity to ask: Where’s the Beef? It seemed as though this august gathering of members of industry, academia and government had never considered the idea of taking an evidence-based approach to evidence-based medicine, the first thing I was looking for with my critical thinking+ lens.

Near the end of the symposium one audience member, a nurse, approached the microphone and pleaded,

Just build this database! I’m certain it will give untold benefits to millions of people. We should not be in discussions whether to build it, rather how to build it! Participant (2008). National Academies of Sciences conference on Containment of Health Care Costs

This is the build-it-and-they’ll-come argument, the same argument used to spend several billion dollars to expand and improve a nearby regional airport to attract new carriers. After it was expanded we went from having two carriers to none.

Under this fallacy, individuals convince themselves of guaranteed or huge benefits of a communal effort once someone else up-fronts the costs for the infrastructure. These adherents assemble a group of like-minded individuals and companies that stand to benefit economically. They are often not familiar with the challenges of commercialization+ in new product development.

The adherents come up with a list of barriers to the communal effort (otherwise we would already be there), may or may not acknowledge how these barriers will crumble once opponents to the effort are ‘enlightened’, and then organize and lobby governments or corporations for up-front funding. The cost-benefit for the effort is only superficially justified, and serious challenges to the effort are tantamount to apostasy. If you challenge the core beliefs of the adherents you therefore have demonstrated your lack of enlightenment.

Build-It-and-They’ll-Come is a more common bias among the highly educated and politicians: those who tend to have the advantage in arguing for the good of man, the needs for improved R&D, etc.