Getting rid of polio

In the current issue of The New Yorker, Atul Gawande has an enlightening, compassionate article chock-full of local color called "The Mop-Up." It's about the World Health Organization's campaign to eradicate polio through en-masse vaccinations. (Unfortunately, it's not available on-line.)

Near the end of the article, Gawande voices some qualms about the project. It's a massive endeavor, after all -- couldn't the billions of dollars spent be put to better use in strengthening basic health care in the countries, such as India, where polio is still common? His conclusion involves a certain amount of hand-waving: eradicating polio is the Great Wall or pyramid of our age, a testament to our collective enterprise.

This last argument can be easily disposed of. If eradicating polio would be a Triumph of the Human Spirit, so then would any number of other significant health-care goals that might be achieved through appropriate initiatives: increasing life expectancy by five years for men and women of all races by the year 2025. Or reducing by a half the number of smokers. There is nothing unique about polio, by this aeshetic argument, which would put it at the top of the heap.

On the other hand, Gawande's cost-benefit concerns are quite relevant. Making them somewhat more specific than their formulation in the article is more difficult than it might appear, since they involve the complications associated with any such calculations. Which costs are counted? Which benefits? Over what time scale?

I found this article by K.J. Bart et al. of the Department of Health and Human Services, published in the Bulletin of the World Health Organization. For those disinclined to read the whole thing, here's the abstract:

A benefit-cost analysis of the Poliomyelitis Eradication Initiative was undertaken to facilitate national and international decision-making with regard to financial support. The base case examined the net costs and benefits during the period 1986-2040; the model assumed differential costs for oral poliovirus vaccine (OPV) and vaccine delivery in industrialized and developing countries, and ignored all benefits aside from reductions in direct costs for treatment and rehabilitation. The model showed that the "break-even" point at which benefits exceeded costs was the year 2007, with a saving of US$ 13 600 million by the year 2040. Sensitivity analyses revealed only small differences in the break-even point and in the dollars saved, when compared with the base case, even with large variations in the target age group for vaccination, the proportion of case-patients seeking medical attention, and the cost of vaccine delivery. The technical feasibility of global eradication is supported by the availability of an easily administered, inexpensive vaccine (OPV), the epidemiological characteristics of poliomyelitis, and the successful experience in the Americas with elimination of wild poliovirus infection. This model demonstrates that the Poliomyelitis Eradication Initiative is economically justified.

Economically justified, that is, in the context of this paper's assumptions. There's nothing wrong with such assumptions, of course -- every piece of research is based on certain definitions and restrictions -- but it's nice to know where we stand before we agree with the conclusion of the abstract.

The big question mark in the study is this: while the benefits of eradicating polio are underestimated, so are the costs. Each "cost-dollar" is counted equally whether it is spent for polio eradication or for something else. But that begs the question. Is money more wisely invested in basic health-care than in large-scale eradication projects? I would like to see studies that compare, say, the results of a billion dollars of world-wide basic health expenditures with the benefits of a billion-dollar disease-eradication program.

The polio eradication project is a large and noble one, but I don't think that we know enough yet about its costs and benefits to be confident about further such endeavors.