In article <[log in to unmask]>, Jacob
Puliyel <[log in to unmask]> writes
>
>
>I thank Fiona Nicholson, M.Perleth, Amit Ghosh, and Jon Wilcox for their
>responses. The queries suggest that I need to draw a suitable analogy, to
>describe the dilemma.
> I have struggled a bit with this and seek your comments to sharpen the
>analogy.
>Once the analogy is refined we may be in a better position to discuss the
>problem.
>My own reasoning is also stated.
>
>Analogy 1
>
>If a new vaccine is available (made in the USA) which gives 80% protection
>against HIV infection, and it costs Pounds 1280 per person , would the WHO
>recommend it for universal immunization in the UK? Will the British
>Pediatric Association recommend that it be part of the Government funded
>immunization schedule?
>
>Premises and Reasoning
>1. I had written in the earlier posting that 3 doses of Hepatitis B
>vaccine costs Rupees 750 (SmithKline Beecham).
>A Cuban vaccine ("Panacea Biotec" -the real name of the company) is
>available for Rupees 490. I have used the price of this cheaper vaccine for
>my calculations.
>
>2. A third of the Indian population earn less than Rupees 57 per capita
>per month. Thus the vaccine costs 8 times their monthly income.
>
>3. To arrive at the corresponding cost in the UK I have multiplied the
>unemployment benefit of Pounds 160 by the same factor 8. (The figure Pounds
>160 corresponds to the income of the lowest 10% of the population. The
>average for the lower third of the population would be higher.) 160
>multiplied by 8=1280.
>
>4. The prevalence of HIV in the UK is much less than that of Hepatitis B
>in India.
>
>(Prevalence of Hepatitis B in India - 2.6% HBsAg positive in blood donors -
>Irshad M. Nat. Med J. India 1994: 7: 210-12. 2.6% in pregnant mothers in
>an urban center - Sehgal A Acta Virol 1992: 36: 359-66.)
>
>However over 50% of those with HIV will develop disease which is fatal.
>Only 1% of those with Hepatitis B develop chronic hepatitis and 0.25%
>develop cirrhosis. If cirrhosis is considered fatal (with no facility for
>liver transplants) we have one death per 400 infected. With a prevalence of
>3% of Hepatitis B in India this would mean 1 death per 13000 population.
>The same death rate would be achieved if the prevalence of HIV in the UK
>is 1 per 6500 population.
>
>Analogy 2.
>
>There is also the problem of infrastructure development and the difference
>in the levels of medical care available between India and UK
>
>Polio vaccine costs Rupee one per dose. This is one by fifty of the per
>capita income of the lower third of the population in India. Yet 10% of the
>population is not covered by polio vaccine.( Kalpana Jain Times Of India
>Delhi 8 Feb 1999)
>By analogy if 10% of the UK population cannot be given polio drops that cost
>Pounds 3 (160 divided by 50) would the country consider undertaking a
>National Aids Immunization program costing Pounds 1280 per person.
>
>
>In conclusion
>
>If the prevalence of HIV in the UK is 1 per 6500 population.
>And the vaccination program costs 1280 pounds per person. (That would mean
>an expenditure of pounds 8320000 for each life saved.)
>Would universal immunization against HIV be a cost effective program?
>If the answer is no, then with a prevalence of 1 per 6500 how low must the
>vaccine cost come to, to be considered cost effective.
>Then again, if the cost of the vaccine is to remain fixed at Pounds 1280
>per person how high must the prevalence rise for universal immunization to
>be considered cost beneficial?
>Is there any study of such models?
>Economists may find this an easy question to answer
But if so, unfortunately, their answer has no special validity. You are
asking for a comparison of health and money. This can be done, I
suggest, only by finding the relevant values of the people concerned, in
their particular view of their health and financial situation. A health
economist could definitely be useful here (and does anyone happen to
know a good textbook or on-line account?) to tell us how: standard
gamble, time trade-offs, and the like. All can hope to give some kind of
answer to the question: what, out of a range of choices, is the best
thing to do with the money?
There is no one single best way and the answers will also vary -
somewhat - depending on how you ask the question. Some people will give
systematically different answers. Some (twits in the UK at any rate) may
even say that no amount of money, or other costs, is too great if it
means saving a single life, and while this clearly represents a failure
to face reality, it means that someone else has to make their choices
for them.
Anyway, what I'm trying to say is that cost-effectiveness is *not* an
absolute quality, but is measured in the sorts of ways that you outline
above. Despite my respect for my elders and betters, I doubt if the WHO
has conducted any formal study in India to decide how the people
affected would prefer the money to be spent. Off the top of my head,
from your figures, I would guess that they'd choose almost anything
else. But it's up to them.
I hope that this helps.
--
Richard Keatinge
homepage http://www.keatinge.demon.co.uk/EPIDEMIO.htm
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