The $54 Lesson: What Vaccines Teach Us About Good Decisions

If you came across an investment promising a 54-to-1 return, you’d probably assume it was a typo—or the pitch deck of a founder who skipped their sleep cycle. And yet, according to a recent article in The Economist , that’s the estimated return on every dollar spent on childhood immunisation programmes and related health services in low-income countries.

Not $5. Not $15. $54.

It’s an astonishing figure—not just because of its size, but because of what it reveals about our collective blind spot: the tendency to undervalue decisions whose payoffs take years to materialise.

Why Good Decisions Often Feel Uncomfortable

The immunisation example is powerful because it’s such a clean illustration of what Annie Duke calls process over outcome. The decision to fund large-scale vaccination efforts often involves controversy, upfront cost, and political risk. In the moment, it’s hard to prove you’re “right.” There’s no immediate dopamine hit. No stock price bump. Just the quiet erosion of risk that never makes headlines.

But over time, those unglamorous decisions compound. Fewer hospital visits. Lower absenteeism. A more resilient economy. A $1 investment that quietly prevents a $54 problem.

That’s what good decision-making looks like—boring in the short term, brilliant in hindsight.

Thinking in Decades, Not Days

One reason we struggle to make good long-term decisions—whether in public health or product design—is that we fixate on first-order effects. What happens next week. Next quarter. Next user cohort. But the real leverage lives in the second and third-order effects.

Amazon’s one-click checkout boosted conversions immediately—but it also led to increased returns, impulsive buying, and the rise of return fraud. Just like the upfront cost of a vaccine, the downstream cost of frictionless design wasn’t obvious—until it was.

As I wrote in Seeing Around Corners, second-order thinking helps anticipate the ripples, not just the splash.

From Vaccines to Ventures: A Mental Model for Better Bets

This is where decision journals become invaluable. By recording your reasoning before the outcome is known, you create an accountability trail. One that’s not coloured by whether the decision "worked out", but by whether it was well-structured.

Warren Buffett and Charlie Munger have followed this approach for decades. They document not just the what, but the why. It's not that they never get it wrong; it's that they’ve built a system that helps them learn when they do.

Whether you're building a product, allocating budget, or tweaking a pricing model, the lesson is the same:

Don't just ask, “What’s the upside?”
Ask, “What will this look like in five years if I’m right?”

The Unseen Cost of Not Thinking This Way

Most poor decisions don’t look bad at first. They look smart. Fast. Cheap. Efficient. Optimised for metrics that only matter in the moment.

That’s the trap.

What separates good decision-makers from lucky ones isn’t the outcome—it’s the process. The willingness to forgo short-term validation for long-term value. The courage to invest in decisions that don’t look like wins today, but compound quietly into something extraordinary.

Just like a $1 immunisation that never makes the news because it prevented a problem you never saw.