Richard Smith: Choosing among sorrows

Richard Smith“We live in a world of competing sorrows,” said Daniel Moynihan, the American senator. How can policy makers choose among sorrows? One way is with the help of the Copenhagen Consensus, which asks four Nobel laureates in economics and one other distinguished economist to decide how to spend $75 billion in overseas aid over four years.

The laureates are presented with 12 possible subjects each of which has five “solutions,” and Rachel Nugent, an economist from Washington state, told a breakfast seminar organised by C3 Collaborating for Health how she tried this year to persuade the laureates to choose actions against chronic disease or non-communicable disease (NCD, as I will now call it). She was pessimistic about her task because NCD has never featured much before in the consensus and because she thought that the economists would be instinctively against an action like increasing tax on tobacco—because they like to leave people to choose and “let the market decide” and don’t like taxes.

The 12 subjects for 2012 included not only NCD but infectious disease, natural disasters, water, armed conflict, hunger, climate change, biodiversity, and education—an impressive list of sorrows. Each subject had a team of people to present a benefit cost analysis using common assumptions—like the discount rate and the value of a life.

Nugent began her case by trying to convince the laureates of the scale of the problem, how NCD has rapidly become the leading cause of death in low and middle income countries and is expected to increase still further in the next 20 years. Economists are impressed by death only by its effect on the economy, and so Nugent gave them data on how NCD causes many deaths in people under 60 in their economically productive years, particularly in low and middle income countries. A 60 year old man in Britain (that’s me, I thought) has a third of the chance of a 60 year old man in Bangladesh of dying in the next year of a heart attack.

Some of those in the audience didn’t like the idea that a death under 60 was more important than a death over 60, but I think that they’ll have little chance of persuading policy makers to think that way in our world of competing sorrows.

Top of Nugent’s five solutions was an increase in tobacco taxation of 33%. Data from South Africa and France show that such a steep increase is accompanied by a sharp fall in smoking rates and—surprisingly—an almost immediate drop in deaths from lung cancer. It’s highly cost effective and shows a benefit to cost ratio of 40 to one—is relatively cheap to introduce and would save some 20m DALYs a year. The benefit to cost ratio was higher than for most of the solutions identified for all of the 12 subjects.

Knowing that the laureates would react against a tax that limited people’s choice, Nugent presented data showing that there is market failure because people, particularly in low and middle income countries, do not have full knowledge of the harm caused by tobacco and the likelihood of addiction. So their “choices” are ill informed and not rational. She knew as well that the economists would think the tax regressive in that it would hit the poor harder, so she presented data from the US showing that the poor had carried 12% of the burden of a tax increase on tobacco and the better off  67%; this is because better off people can still afford to buy more cigarettes.

The second solution was drugs—thrombolytics and aspirin—for people with heart attacks. This has a benefit to cost ratio of 25 to one, is cheap to introduce, and would save 4.5 million DALYs a year. The snag with this solution is that in much of the world there are not health workers present to make the diagnosis and give the drugs.

Salt reduction with a benefit to cost ratio of 20 to one was the third solution and would save 20 million DALYS a year. Most people in most countries consume well above the 5 mg a day recommended by WHO, and as has happened in Britain, salt levels can be brought down gently in processed foods (bread, butter, cheese, etc) without people noticing. Again Nugent knew that the laureates wouldn’t like people being denied a choice, and she argued that people were not choosing large amounts of salt and wouldn’t miss it.

The fourth solution was the one that was surprising to us “NCD hacks” and was hepatitis B vaccination of children, preventing cirrhosis and liver cancer later in life. Despite the vaccine being relatively cheap the benefit to cost ratio is only 10 to one and the DALYS saved only three million—because the benefits take many years to appear and so are discounted. Economists are very clear that a bird in the hand is worth much more than one in the bush and have formulas for adjusting their value.

The polypill for secondary prevention was the final solution and would save 108 million DALYS a year but has a low benefit to cost ratio of three to one because it would be expensive to provide—even using a drug cost of $50 to $60 a year.

Having made their case, Nugent and her team got to listen to the other presentations and await the result of the laureates’ decisions. But while they were waiting they got to see how readers of the Huffington Post would vote, and of 60 possibilities tobacco taxation came second, hepatitis B vaccination third, and the other actions against NCD ranked very highly.

But the laureates thought differently. They ranked “Bundled micronutrient interventions to fight hunger and improve education” top, and the next four priorities were all about countering infectious disease. Vaccination against hepatitis B (9), drugs for patients with heart attacks (10), and salt reduction (11) all, however, came in the top 16 that would be funded. The polypill came in at 19 and tobacco taxation, the top choice of Nugent’s team, at 22.

Why they chose these 16 is not explained, but a sense that they thought of some people, particularly children, as more deserving seemed to be one explanation. It certainly wasn’t only the numbers that decided them, said Nugent. When you listen to them ask questions, she continued,  you realise that they aren’t that different from anybody else. They are driven by anecdote, and there is always a bias towards the status quo, which  favours action on infectious disease over NCD.

Nugent was generally pleased with the result: NCD had been part of the CC discussion for the first time, three solutions would have been funded, and she and her team had learnt about how better to frame their arguments.

The C3 audience was less pleased. Who chose the five solutions? Why include the polypill and not walking? Who were these economists? They seemed very conservative. And why should economists make these decisions? “Economists are the problem,” said Robin Stott, a doctor and the chair of C3. “Mind you, so are doctors,” he added—to be polite.

Rachel Nugent’s presentation will be posted on the C3 website as will the vote on priorities of the people at the breakfast meeting.

Competing interest: Richard Smith is an unpaid trustee of C3.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.