Paying the Boatman

If you live in a country with a socialised healthcare system (I’m guessing most of my readers do), here’s something you may not know: your government does not write blank cheques for your medicine. What health interventions governments will subsidise, and what they won’t, is decided by argument. The people who want the intervention funded go to the government and say, “For every $X,000 you spend on this drug / program, Y deaths / organ transplants / permanent disabilities will be prevented”. Some governments have a set threshold, and will pay for anything that comes in under $X,000 per year of healthy life saved. Other governments, like mine, do not, although they tend to fund most things within a certain window, and very few things above a certain upper limit.

This has practical effects. In Australia, we have government funded screening programs for early diagnosis of some common cancers (cervical, breast and colon), but not others (lung or liver). Some drugs for certain conditions aren’t on the PBS – you’ll know this if you take an less common version of the pill, for instance, or maybe an obscure or new medication for some ailment or other. Even when you go to hospital, the drugs you’re given may be determined not by what the absolute best drug available is, but by what the government will pay for. If chemo drug Y saves 80% of patients for $Y,000 a dose, and chemo drug Z saves 90% but for ten times as much, the government may well have decided that drug Z just isn’t worth the extra money. People in healthcare are normally pretty touchy feely, but when you get down to it, the health economists working for the government are hardasses.

Now, this all sounds pretty grim, right? Suddenly you’re worried that you’re going to get a rare form of cancer that can only be cured by a drug the government won’t pay for. Please calm down. You’re probably not. Ultimately, these are decisions that have to be made – healthcare budgets are finite. If the government has the choice between blowing half the budget on multi-million dollar drugs for rare cancers affecting only a dozen citizens, or regular drugs for the thousands of people who have heart attacks every year, I hope you’ll agree with me on who should get priority.

These choices probably don’t cost a great many lives in Australia, but they absolutely do in some poorer countries. An example close to my heart: multidrug resistant TB (MDR-TB) treatment can cost tens of thousands of dollars per patient. At present, only a fraction of all suspected MDR-TB patients actually receive the drugs they need; many simply die, without even being diagnosed correctly. If they were all to be diagnosed and given treatment, the annual cost to countries with more than 100 cases per year would quickly exceed six figures. For countries with thousands of cases and small budgets, attempting to comprehensively manage MDR-TB out of their own pockets would present a credible threat of completely bankrupting their health systems.

There is a mechanism in place to help them avoid this – there are international funds to help them buy the necessary drugs at low cost, similar to what was set up for HIV with anti-retrovirals. But the gap between the funds available and the funds actually needed for TB control around the world is massive, estimated in the hundreds of millions. So governments are faced with the bill, and have to make decisions. What will they pay for? Who will they save? TB is just one condition out of many. Governments and health facilities in countries with health budgets in the range of hundreds of dollars per person make these Sophie’s choices constantly. TB drugs or HIV drugs? Vaccination programmes or emergency obstetric facilities? Autoclaves or antibiotics? How can any choice be the correct one, when these are the choices at hand? 

In 1978, in the midst of the cold war, a group of public health leaders from around the world met in Alma Ata, Kazakhstan. They penned a declaration that seems radical and naive today, as so much from the 70’s does. One of its final paragraphs begins:

“An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world’s resources, a considerable part of which is now spent on armaments and military conflicts.”

As we know now, military spending has increased unhindered between the cold war and the present day. And “health for all” was not achieved in 2000, and has still not been achieved. Thousands of people die every day from diseases which are easily prevented, and easily cured, and which ultimately afflict them only because they are poor.

A year’s worth of my migraine medication would eat up the entire health budget for dozens of people in Afghanistan. My government subsidises that medication on the basis, not that it saves my life, but that my head hurts less and I take less time off work. That’s all. The same government is about to spend millions of dollars trying to “save lives” in Iraq and Syria, not from polio, but from ISIS. They may or may not succeed. If recent military intervention has shown us anything, it’s that at the cost of billions of dollars, you may end up purchasing only more death.

Imagine if we held military intervention to the same standard of evidence that we hold health interventions. If I want the government to fund liver cancer screening for people with hepatitis, I have demonstrate conclusively that it will save lives, and do that at a cost that the government considers reasonable. They will pay $64,000 for a health intervention to save just one year of an Australian resident’s life. The last Iraq war cost Australia an estimated AU$5 billion. If I wanted the Australian government to spend that much on a health intervention, I would need to show that thousands people would be prevented from dying decades prematurely. Did we save so many lives in Iraq? Did we save any at all?

In a way, life outside Australia is cheap, in that it sometimes costs almost nothing to save. With AU$5 billion, Australia could have funded most of the US$7 billion needed for MDR-TB between 2011 and 2015, unquestionably saving hundreds of thousands of lives. A fraction of this sum would provide the supplies and staff needed to bring the Ebola epidemic in west Africa under control within months. The impact of health interventions is predictable: lives are saved. There are no civilian caualities, no “collateral damage” in the form of children killed by stray bullets or reckless bombing.

If we in the West want to save lives, we have all the money we need. But 35 years after Alma Ata, for reasons I cannot fathom, we’re still spending it on bombs.

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