An ounce of prevention is not always worth a pound of cure. Though public health advocates are very vocal about prevention programs, choosing between prevention and treatment can be very complicated. Many prevention programs, such as childhood vaccination, are extremely effective, but we should examine many factors, such as cost-effectiveness, discounted future returns, and various ethical issues.
There are two main ways to look at the efficacy of a program: cost-benefit and cost-effectiveness. Cost-benefit analysis is a simple weighing of the potential costs compared to the potential benefits. For example, a new study shows that California’s Tobacco Control Program cost $1.8 billion to implement (from cigarette taxes), and resulted in an $86 billion savings in health expenditure1. This is clearly cost-beneficial.
But hark, we don’t just blindly implement every single cost-beneficial program. We need also to consider the opportunity cost. In a world of limited resources, we may have to evaluate several programs based on cost-effectiveness, because every dollar we spend on program is an opportunity lost for another program. If spending $1 million on tobacco control in Sub-Saharan Africa will save 6000 DALYs, but that same $1 million on DDT spraying can prevent 110,000 DALYs lost to malaria2, we may have to set aside tobacco control (DALYs = disability adjusted life years).
When we look through the lens of cost-effectiveness, however, we see that the dichotomy between prevention and treatment begin to break down. Generally, it is much more cost-effective to prevent disease than to treat it, but we may find that some treatment programs are actually more cost-effective than prevention. For rare (e.g., smallpox) or cheaply treatable (e.g., helminths) diseases, it can be cheaper to tackle cases as they come.
Discounted Future Returns
The problem of cost-efficacy analysis is made even harder when we have to account for both short term and long term gains. The California Tobacco Control program I mentioned saved many lives, but over the course of decades. Most people will not benefit from the efforts of the program until far in the future, making the results of the program more long-tail benefits.
Compare this to Oral Rehydration Therapy, which has saved the lives of 2.8 million children under 5 in the two decades from 1980-2000. Indeed, the thrill of saving lives immediately is invigorating. It’s easy to discount the 1 billion lives that might be lost to tobacco this coming century. And indeed, this is what happens: we tend to value current health more than future health. This not only colors the way we approach humanitarian issues, but can skew our opinions toward treatment over prevention.
Let’s go back to the Tobacco vs. Oral Rehydration Therapy situation. If you’re like me, you probably felt inclined to favor the ORT. The reason seems pretty simple: young children with limitless futures fulfill our humanitarian desires in ways old, coughing lung cancer patients don’t (not to mention that we can’t fault infants for being orally dehydrated). This is called the “fair innings” issue: when a younger person dies, they are robbed of their fair and full innings, while when an older person dies, we accept it3.
There are multiple more issues that need to be addressed. Equality is one; some treatments or prevention programs might dramatically increase the total quantity of health while other programs might only make moderate health gains, but distribute those gains more equally. Just as when dealing with money, we have to strike a balance between pure efficiency and equality. On top of that, do we prioritize certain members of society? Is a treatment that targets child-rearing mothers a higher priority than one that targets childless adults?
Maybe instead of thinking simply in terms of years lost, or even disability-adjusted-years lost, we ought to adjust for ethicalness as well. For example, if we look not at childhood immunizations costing $16/DALY averted, but rather as $8/Ethical-DALY averted, that could completely change the way we prioritize our funding.
Senator, you have some tough choices today. Not only do you have to decided whether to skip the fundraiser dinner for the golf tournament, you have to make a difficult decision about the health of your constituents. You invite your health advisors in for a consultation…
Armpox causes complete arm failure at around 40. There is a vaccine available, which costs $50 to produce and administer, but not everyone would have ended up getting the disease regardless. For those that would have, however, the vaccine would allow them to have on average another 30 years of fruitful life. Nevertheless, scientists have worked out that spending $1 million on this vaccine will save about 400 DALYs. In addition, the extra productive years will add about $15 million to the economy. This means each DALY saved costs $2500.
Heartbug causes near instant death to seniors at around 65. There is a complex treatment regiment which costs quite a bit. Each treatment costs $1,250, and is 75% successful, thus $1 million spent on Heartbug treatment will save about 600 DALYs. There is no real economic benefit, and each DALY saved costs $1666.
If we value human life at $80,000 per healthy year, both Armpox vaccine ($2500/yr) and Heartbug treatment ($1666/yr) are very cost-beneficial. However, Heartbug treatment appears to be more cost-effective.
However, Armpox vaccines are administered to teenagers that are 15. For the people with Armpox, it’s already too late. For those eligible for the vaccine, disease is still a quarter century away. However, many of your senior constituents are passing away to Heartbug even as you read this article. Their family members are pleading with you to release funding for Heartbug treatment, but healthy teenagers are not speaking up at all for Armpox vaccines. Figuring that future health is not as pressing as current health, you reevaluate Armpox vaccines to cost $3500/DALY. This makes it even more obvious to choose Heartbug treatment, which is only $1666/DALY.
As you’re on the way to declare the funding of Heartbug treatments, old Mr. Octogenarian grabs your arms. “Look Mister, I’ve had my chance,” he says. “Make sure that my kids will be able to play catch with my grandkids!”
Taken aback, you realize that you might have been too hasty. You think back to your prime years…you figure year at 40 is probably worth three times as much as a year at 65, after all. After doing some complex number manipulations factoring in worth of a year at 40, 50, 60, 70, you come up with some new numbers. Armpox vaccines are now $1543/Ethical-DALY, whereas Heartbug treatments are still $1666/Ethical-DALY.
You hate to break the news to the seniors, but you’re going to be pushing for Armpox vaccines instead. It’s simply the best option you can do with your $1 million. Most of your taxpayers are pretty happy; they know that not a single dollar has been spent inefficiently. Some senior citizen advocates, however, are not. They realize that Armpox is the better deal, but the Heartbug treatment should also be done. How could you not pay the low cost of $1666 for a precious year of human life?
Even as you shrug helplessly, they argue passionately, asking you to go ahead and release the funds for Heartbug treatments, and pass the extra bill onto the taxpayers. The taxpayers are still getting a tremendous bargain, they say, and it’s the least we could do for our elders. You say that you’ll do what you can. You feel like you’ll never live up to your altruistic aspirations…but hey, it’s a start.
- Global Health Report: Prevention vs. Treatment: A False Choice
- Superbug: MRSA Vaccine?
- Lucy Yeatman: The Lazarus Effect
- Larry Hallon: Prevention vs. Treatment
- Karen Grepin: Prevention vs. Treament in HIV: Have we given prevention a chance to shine?
- The Pump Handle: For Whom Prevention Pays, on the decline of tobacco control programs
- Health Reform Watch: Health Care, “Common Sense” and a Global Health Blogging Experiment
- Alanna Shaikh: Prevention vs. Treatment - An eternal debate?
- Effect of the California Tobacco Control Program on Personal Health Care Expenditures
Lightwood JM, Dinno A, Glantz SA PLoS Medicine Vol. 5, No. 8, e178 doi:10.1371/journal.pmed.0050178 ↩
- How Much Health Can a Million Dollars Buy?
- Alan Williams, 1997.
“Intergenerational Equity: An Exploration of the ‘Fair Innings’ Argument,” Health Economics, John Wiley & Sons, Ltd., vol. 6(2), pages 117-132. ↩