A price worth paying

30 World Health • 46th Yeor, No. 4, July-August 1993 A price· worth paying Jose-Luis Bobadilla & Dean T. Jamison Tuberculosis is among the most cost-effective diseases to control in adults over the age of 15 years, according to the World development report 1993: investing in health. For a relatively small amount of money, nearly 15 million deaths could be prevented in the next 1 0 years. October 1977: WHO vaccination teams descended on Merca, Somalia, to protect the city from smallpox after a single case was found there. Smallpox had been killing nearly two million people each year until WHO began a global effort to eradicate the disease. Fortunately, the Merca case was the world's last recorded incident of endemic smallpox. October 1982: Investigators descended on Chicago, USA, to protect the city following a series of malicious deaths caused by pain relievers being laced with cyanide. The poisoned capsules had killed seven people and the resulting panic was causing many people to avoid pain relief medicine. Fortunately, the investigators discovered no other tampered drugs. These two health emergencies had comparable price tags; US$ 300 million was spent over ten years to Examining a TB-infected child in Nepal. The world community is mobilizing to control the preventable scourge. eradicate the smallpox virus, and $100 million was spent in the space of a few months to ensure that there were no further cyanide poisonings. Yet the results were very different. Tens of millions of lives are estimated to have been saved by the intensified smallpox eradication programme. It is debatable how many - if any -lives were saved by the effort to prevent the poisoning of consumers by over-the-counter pain relievers. As public health budgets become more stretched, it is becoming increasingly necessary to make comparisons such as these to determine which health interventions provide the best value for money. With so many pressing public health needs, it is more and more difficult to argue that "no cost is too great to pay to save one human life." This is not to say that the issue does not raise a number of difficult questions. For example, how can one compare health care costs in Merca with those in Chicago? How can disabling diseases be compared with terminal diseases? Is extending an elderly person' s life by 10 years equivalent to extending a child's life by 60 years? WHO and the World Bank have been wrestling with issues such as these in preparing a background document on the burden of disease for the World development report 1993: investing in health, published by the World Bank this July. In view of limited public health spending and a limitless number of preventable deaths and illnesses in the world, the report attempts to determine which diseases justify the most urgent attention. World Health • 46th Yeor, No. 4, July-August 1993 The report has devised a common standard, known as a "disability- adjusted life year," or DAL Y, to help make health care comparisons. As explained in the March-April issue of World Health, a DAL Y measures the number of healthy years of life lost through premature death, or alternatively, the number of healthy years of life gained by one person when that person is cured of or able. to avoid a disease. It also measures the healthy years of life lost due to disability resulting from a disease. For example, blindness in a 25-year-old would result in a greater number of lost healthy years of life than would the death of an 80-year-old. To assess cost-effectiveness, the costs of preventing or treating a disease are related to the number of healthy years of life gained by that intervention. The formula is more complex for some diseases, since treating an infectious disease may also have benefits in preventing further infections. For example, when an infectious TB patient is treated, this also prevents the infection of dozens of other people. One of the fmdings of the World development report is that tuberculosis is among the most cost- effective diseases to control in adults over the age of 15 years. This supports what research experts have been saying recently - that for a relatively small amount of money, nearly 15 million deaths from TB could be prevented in the next 10 years. In the next issue Chemicals are important for human activities, but they may become a threat for people's health . The Sep- tember-Dctober issue of World Health will look at different aspects of Chemical Safety, including safe disposal of toxic wastes and effects of chemicals on the climate. • Studies in Malawi, Mozambique and the United Republic of Tanzania show that, if the additional TB cases prevented by treating an infectious patient are considered, the cost is as low as $20 and never more than $100 for every life saved. This translates into as little as 90 cents for each year of life saved. WHO has found that short-course chemotherapy greatly increases the cost-effectiveness of control programmes. Programmes that hospitalize patients to improve treatment compliance, or those which still use 12-month treatment, are also cost-effective, though clearly not as cost-effective as the six-month treatment recommended by WHO (see page 25). The World development report concludes that too much public health money - as much as 40% - is spent on health interventions with low cost- effectiveness, such as heart surgery, surgery for most cancers and intensive care for severely premature babies, while critical and highly cost-effective interventions, such as the treatment of tuberculosis, remain under-funded. The report argues that, by increasing funding for highly cost-effective health interventions, millions of lives and billions of dollars could be saved. Short -course chemotherapy for TB control should, therefore, according to the report, be included with the clinical services provided by countries. Did you enjoy this issue? 31 History has a way of repeating itself, and it is to be hoped that the world learns each time. In 1982,$100 million was mobilized to deal with a local cyanide poisoning incident at a time when funding to address the emerging AIDS epidemic was virtually nonexistent. Large numbers of people became infected with HIV because society was slow to recognize that HIV posed a far greater threat to its health than did one deranged person in Chicago. A decade later, projects of marginal benefit continue to attract huge sums of money, while TB programmes go neglected and multidrug-resistant strains of TB are gaining a foothold in every continent. • Or jose-Luis Bobodilla is Health Policy Specialist, Population, Health and Nutrition Division, and Mr Dean T. )amison is Staff Director, the World Development Report Office, The World Bank, I 8 18 H. Street N . W. , W ashington, DC 20433, USA Photo Credits Front cover : Melchior Oi Giocomo © Poge 3: WHO/I. Forkos Poge 4: PHANI E/H. Roguet © Poge 6: WHO/Zofor Poge 7: WHO/ll . Anenden Poge 8: WHO/TOR/ M. Edwords Poge 9: WHO/P. Nunn; WHOjlnsnM Pasteur; J. Wllliomoson © Poge 10: WHO/f. McOougoll Poge 11 : WHO/Zofor Poge 11: PHANIE/ F. 8ojonde © Poge 13: PHANIE/Y. lessien © Poge 14: WHO/f. 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