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Wrong NumberIs it cost effective to treat the world's poor?

By Darshak Sanghavi
Posted Tuesday, July 17, 2007, at 12:02 PM ET

(Continued from page 1)

But because they are based on retail prices of drugs and existing infrastructure in rich countries, such figures often overestimate costs for large-scale relief and treatment efforts in the developing world. The seeming high cost of treatment over cheaper prevention encourages inertia.

Enter physicians like Dr. Paul Farmer of the aid group Partners in Health, who endured all kinds of naysaying and began treating poor rural Haitians with antivirals for AIDS by getting donations from wealthy Western donors and buying the drugs outright at retail prices. They were tired of seeing HIV-infected people die. In late 2005, a revealing New England Journal of Medicine report proved that Haitians with AIDS—though living in impoverished conditions—were organized enough to handle all the drugs and did just as well medically as patients treated in the United States. Suddenly, treating AIDS in poor countries seemed possible.

And an obvious truth emerged: Health-care costs, upon which the entire pyramid of QALY-based analysis sits, are totally elastic and negotiable. As demand for the drugs in poor countries skyrocketed, countries like Thailand and India took advantage of their arcane patent laws and began manufacturing generic versions of the expensive drugs. When Brazil also threatened to allow generic manufacture of AIDS antivirals, drug companies rapidly negotiated local manufacturing licenses and deep discounts. Today, almost all 186,000 Brazilians needing AIDS drugs get them for free from the government.

In addition to the availability of generic drugs, collective bargaining has lowered costs. Consider this example of a 96 percent discount for a tuberculosis antibiotic. The lesson here is that one's economic paradigm powerfully influences what seems possible. Assessing AIDS treatment in poor countries with QALY-based economics is like desultorily asking, "We can't really afford this, can we?"

On the other hand, groups like Partners in Health take a radically different approach. They start with a goal—simply to save people with AIDS, and damn the QALYs—and invent ways to make it affordable.

Which brings me back to the Zambian child with the heart defect. In the end, spending hundreds of thousands of dollars for his heart surgery isn't a good QALY buy, if one is inclined to think in that erroneous way. But you can also think like Dr. Aldo Castaneda, the former chief of pediatric cardiac surgery at Harvard Medical School. At the height of his career in the 1990s, he moved to Guatemala to help found a children's heart center, and there has operated on thousands of children at a tiny fraction of the costs in America.

Recalling how people responded when he announced his intention to treat heart disease among poor Guatemalans, Casteneda says, "They told me that I was crazy." His patients, one can assume, disagree.

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Darshak Sanghavi is a pediatric cardiologist and assistant professor of pediatrics at the University of Massachusetts Medical School. He is the author of A Map of the Child: A Pediatrician's Tour of the Body.
Photographs courtesy of Partners in Health.
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Remarks from the Fray:

When we come down to some of the cases, like HIV/AIDS in Africa, we realize that lots of the dogmatic statements about who should be cared for are not a question of better/best - they are a question of good/bad.

There is medical care which is anti-productive for society. In particular, things that cure symptoms but leave people infectious tend to cause epidemics. Imagine a case of malaria that forces the person to stay inside all day, under mosquito netting. If you treat the fever and the person walks around and gets bitten by mosquitoes that pass the infection, then treating his fever just caused more cases of malaria, with all the pain and suffering that causes.

This is the case of intermediate quality nursing care for Crimean-Congo hemorrhagic fever or cholera. The proximity of nurses to cases causes a spread of the disease. It would be better to have great, aseptic nursing care - or none at all. But some care is worse than nothing.

Same with AIDS. Currently we are making sure that Africa will die, as a culture and a continent, by getting people strong enough to be 'functional' but also leaving them infectious. It would be better to not have them treated than to make it possible for them to spread the virus.

AIDS care without abstinence, at least between infected and uninfected, is an irresponsible, genocidal strategy. So lets stop arguing about whether care 'costs too much' or whatever - we should first start by doing no harm.

--BenK

(To reply, click here.)

Egregious as it may sound, we must place a dollar value on life if we are to have any hope of functioning rationally. As people we make economic trade-offs every day, all of them involving our well-being.

Consider driving time work: our speed is a fairly good measure of our risk of bodily harm, and theoretically, if we drove 25 the entire way, we'd be a lot safer. Instead, we weigh the options and determine that getting to the office in 15, rather than 50, minutes is worth the added danger. Clearly, we don't think our lives have infinite value or we'd be inclined to take no risks at all. And it appears the government agrees -- they're well aware of the hazards of speed, and yet Interstate Highways, some allowing travel at up to 80mph continue, continue to expand.

In a perfect world, we could spend an infinite sum of money to prolong and enrich every life, but sadly, no such world exists.

--alwpeters

(To reply, click here.)

Doesn't it seem absurd to pay for drugs to marginally improve the health of Western children, when the same amount of money would save countless lives and bring about vast improvements in the health of African children? The marginal utility of a health dollar spent in Africa would seemingly dwarf that of one spent in the U.S.

--Ex-fed

(To reply, click here.)

The article states that "Oregon quickly abandoned rationing." This is not accurate.

I practice medicine in Oregon, and the Oregon Health Plan has been working since I arrived here over 8 years ago for Medicaid patients, sometimes better, sometimes worse. Compared to the rest of the country, however, I think we do much better. We currently have a list of things OHP covers and doesn't cover, and it is not based strictly on cold economic principles. We do have real people who make the final decisions about what makes sense to cover and not cover. The decision makers don't always get it right, but decisions that are made at a local level are much more accepted than those imposed from outside, and can be more quickly reversed by raising taxes or cutting benefits. Yes, there are difficult decisions that always need to be made, but people who pay for care need to have the right to determine what care they pay for.

The rest of the country may want to continue to dismiss our system, but someday soon when the rest of our national health care system has imploded, maybe everyone will be more willing to take another look at it.

--sjf

(To reply, click here.)

Coming from an insurance qualifier the term "quality life" is something of an oxymoron.

Keeping a terminally ill man alive long enough to watch his son receive his high school or college diploma may not be cost effective according to some insurance or medical economist but it would be the exact sort of thing I want the society in which I live to strive for, despite some invented QALY formula.

--NickD

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(7/19)

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