Over the next few decades, we are likely to see major advances in our understanding of medicine and the technology of diagnosing and treating illness. We are learning more and more about the human genome and testing is becoming more readily available. Nanotechnology is likely going to revolutionize how we diagnose and treat disease. Synthetic biology, such as engineering synthetic tissue and manipulating DNA, is also expanding our ability to understand and treat disease. As wonderful as the promises for a healthier future sound, they do come with costs. Who pays for the research? Who will have access to these tests and treatments as they become available and benefit from these advances? Will these advances be significantly meaningful to justify their cost when compared to cheaper options? Might the money spent on developing these advances be better spent on projects such as improving water quality and preventing infectious diseases in developing countries?
One of the principle dilemmas we face when exploring new medical advances is the issue of justice. What do we mean when we talk about justice in relation to medicine and biotechnologies? In this setting, justice may refer to fair and equal treatment of patients (avoiding discrimination against certain patients by an individual or organization) and fair prioritizing when time or resources are limited (such as with organ transplants). However, we are often referring to distributive justice, making sure there is a fair distribution of resources (medicine, technology and access to them) as well as distribution of the social/economic burdens that may occur (who carries the financial and social burden of taking or not taking a particular action). I have mentioned some distributive justice concerns with genetic testing and life extension in previous posts so let’s look more closely at stem cell therapy for COPD.
The CDC reports that 16 million Americans have disease caused by smoking (COPD, cancer, stroke, heart disease, etc.) Smoking also increase the risk of a number of other illnesses. It is responsible for more than 480,000 deaths annually in the US (about 1 in 5 deaths), and 6 million annually world wide. The tobacco industry spent more than $1 million AN HOUR on advertising and promotion of cigarettes in 2012 ($9.17 billion for the year). Smoking costs the US $300 billion a year in direct medical costs and lost productivity. Chronic Obstructive Pulmonary Disease (COPD) is a cluster of lung problems that is almost exclusively caused by cigarette use and passive exposure to cigarette smoke, air pollution and occupational exposure to dust and chemicals and, therefore, is largely preventable yet it is the third leading cause of death in the United States (134,676 lives in 2010). According to the American Lung Association in 2010 the direct and indirect costs of COPD to the nation was projected to be $49.9 billion to care for roughly 13 million people.
Now consider that the cost of bringing a new drug to market costs more than $2.6 billion on average. (Mullin) It would seem not unreasonable to assume that the cost of developing a novel therapy such as stem cell therapy to reverse the changes of COPD and bring it to market on a large scale might at least be equal to this (although since there is debate over regulation of stem cell therapy there might be a difference). Stem cell therapy for COPD is a very new field and current treatment plans have not been thoroughly investigated for efficacy or safety. Despite this lack of evidence, some physicians are offering stem cell therapy for COPD and are charging the patient for the treatment. Insurance will not cover such therapy and any expenses come out of the patient’s pocket.
What if we stopped people from smoking? In 2012, we spent only $490 million on smoking prevention and cessation. In 2015, states will collect around $25 billion dollars from taxes on cigarettes and from tobacco related legal settlements yet nationwide only 2% of that money is spent on tobacco control programs. 43 states do not even fund these programs at half the level recommended by the CDC. What could we accomplish by spending $25 billion on tobacco control, smoking avoidance and cessation programs? That is over 2.5 times the amount tobacco companies spend on promotion and about half of what we spend to treat just COPD currently.
With that same $25 billion we might be able to bring several new drugs or treatments to market to treat people with diseases caused by tobacco use. Current therapies only manage symptoms and hope to minimize acute episodes and slow the progression of the disease; there are no treatments that reverse or cure COPD. It takes years to bring new treatments to market and in the beginning they are often so costly to manufacture and market that their cost to consumers remains prohibitively high for many years more. Many new drugs are not covered by insurance when something similar and cheaper is already available. Novel treatments such as stem cell therapy will also face issues with insurance coverage initially. These cost concerns mean that new treatments for COPD would for many years be only available to those who could afford treatments not fully covered by their insurance (assuming they have insurance). Yet, COPD and other tobacco related illnesses predominantly affect lower income groups who may not have affordable, easy access to healthcare or insurance.
So, when we compare the cost of increasing low tech programs to keep people from smoking or helping them to quit thereby avoiding the diseases associated with tobacco use to the cost of developing new treatments that those most affected will not be able to access, where is our money better spent? Distributive justice from an egalitarian perspective would probably support investment in prevention over development of new therapies. These relatively low cost measures will prevent new cases of smoking related illness across the board, not just COPD and therefore aid a larger population of people. The financial cost could be covered by money already being collected and should not impose any further economic burden. In support of spending on stem cell therapy rather than prevention, some might argue that while initially only a small group of people would potentially benefit (stem cell therapy is not a guaranteed cure for COPD at this point), the knowledge and experience gained could help advance other areas of treatment and would likely become more affordable over time. A libertarian perspective might argue that the free-market should determine what paths to management of smoking related disease should be pursued. Individuals should have the right to decide if they smoke or don’t smoke, take advantage of current treatments or support the development of novel therapies like stem cell treatment; the fact that not everyone can afford newer, costly treatments should not mean that there is no investment in these treatments to fund only other less expensive options.
Now let’s keep looking at the cost of treating COPD but step back and take a global look at not just what we should do but also who we should spend our money on: preventing death and disability of children and adults of working age caused by infectious disease or treating disease that may shorten lifespan by 10 years but is preventable by not smoking.
Contrast the $49.9 billion price tag for the current care of people with COPD in the US alone with malaria prevention. Malaria, an infectious disease spread by mosquitoes and most commonly occurring in sub-Saharan Africa, is responsible for the death of an estimated 584,000 globally each year, with approximately 198 million infected individuals. (WHO). According to UNICEF, most of these deaths occur in children under 5 years of age. A UNICEF fact sheet published in 2004 reports that malaria resulted in a $12 billion loss in GDP for Africa. Use of netting treated with insecticide could reduce episodes of malaria by 50% and possibly reduce childhood mortality by 20%. White et al reported that in 2009 a year’s protection would cost a median of $2.20 per net distributed. Use of medication to prevent malaria in children was found to have a median cost of $4.03 per child per year according to the same study. These measures would save substantially more lives and could prevent more morbidity and economic cost than new stem cell treatments for COPD at significantly lower cost. The Roll Back Malaria Partnership’s 2008 Global Malaria Action Plan called for global spending of $5 billion annually. (MacInnis) WHO reports that already “increased prevention and control measures have led to a reduction in malaria mortality rates by 47% globally since 2000.”
Suppose we had to decide whether we would fund research in to stem cell therapy for COPD (potentially aiding over 65 million people globally, about 1/3 the number of people infected with malaria) or direct aid to prevent and treat malaria (possibly preventing over 500,000 deaths annually and decreasing the rate of new infections) in developing countries. An annual $5 billion globally could save hundreds of thousands of lives and bolster the economies of African countries while $49.9 billion is already spent annually in the US to treat a disease that is largely the result of the choice of the individual to smoke cigarettes. The group of people with COPD consists mostly of people whom are nearing the end of their natural lives and no longer contributing to the economy though active employment. Should we be spending additional billions to develop stem cell treatments to reverse this largely preventable disease? There would likely be some reduction in morbidity and some delay in mortality but this population is also likely to have other smoking related illnesses that would not necessarily be ameliorated by stem cell therapy for COPD.
Comparing prevention of malaria to treatment of COPD may be comparing apples and oranges, but this stark contrast is used to illustrate the point that there are huge disparities in spending on health care costs and what we can accomplish with the same $5 billion. A Utilitarian perspective would argue that we need to do the greatest good for the greatest number of people. Clearly, preventing and treating malaria will cost governments less to fund, will potentially benefit a greater number of people, and will improve the economies of countries most effected by malaria by improving the health and productivity of a young population and reducing medical costs and this appears to be the best choice from an egalitarian view of distributive justice. A libertarian perspective of justice on the other hand would argue that each society should determine what it views as the most important issue to its own needs.
As we can see in these examples, the decision to pursue a course of action such has how to most effectively invest funds or prioritize the use of limited resources is rarely straight forward. I have presented the issues here as an all-or-none proposition comparing different courses of action (prevention vs treatment) and different conflicts (prevention in a younger group which would boost economic growth vs treatment in an older population, often pass the age of employment). The reality of these situations is both more subtle and more complex, but we can see how important it is to apply the lens of justice when evaluating issues such as spending on disease prevention and management.
CDC. (2015) Smoking and Tobacco Use Fast Facts. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/
American Lung Association. (2014). COPD Fact Sheet. http://www.lung.org/lung-disease/copd/resources/facts-figures/COPD-Fact-Sheet.html
WHO. (n.d) Burden of COPD. http://www.who.int/respiratory/copd/burden/en/
Mullin, R. (24 Nov 2014) Cost to Develop New Pharmaceutical Drug Now Exceeds $2.5B. Scientific American. http://www.scientificamerican.com/article/cost-to-develop-new-pharmaceutical-drug-now-exceeds-2-5b/
WHO. (2015) 10 Facts on Malaria. http://www.who.int/features/factfiles/malaria/en/
UNICEF. (2004) Fact Sheet: Malaria, A Global Crisis. http://www.unicef.org/media/media_20475.html
White, M.T., Conteh, L., Cibulskis, R., Ghani, A.C. (2011) Costs and cost-effectiveness of malaria control interventions-a sytematic review. Malaria Journal. 10:337. doi: 10.1186/1475-2875-10-337.
MacInnis, L. (25 Sept 2008) Preventing malaria deaths to cost $5bln a year. Reuters. http://www.reuters.com/article/2008/09/25/us-malaria-deaths-idUSTRE48O82820080925