How Do You Value What Didn't Happen? [The ScienceBlogs Book Club]

Karen Starko writes: When the "financial crisis" started and the news media started throwing around numbers in the trillions and projected fixes in the billions, I realized I just didn't get it. So I got a little yellow post-it, labeled it "understanding trillions," and started a list of examples. And when I learned that the US GDP in 2006 was 13T and the derivative market, estimated in June 2007, was valued at 500T, I quickly got a sense of the potential drain of the derivative market (in which money is spent on items without real value...my definition, please correct me if I am wrong). I was scared. I thought of taking my cash from the bank and converting into something tangible, like food, but decided to hold on and hope the government would "save" us. We now all are learning that we didn't pay enough attention and what we lost is painfully real in terms of our financial health.

As I read Mark's book, I began thinking about whether we are in the same situation with our physical and mental health. Are we paying enough attention to that which produces real value, like prevention, a key strategy of the EIS and other prevention-oriented organizations?

First, a little perspective...CDC's budget request for 2010 was 10.1 billion. (http://www.cdc.gov/fmo/topic/Budget%20Information/index.html) including:
3.3 B for childhood vaccines
2.0 B for infectious diseases
1.5 B for terrorism
1.0 B for health promotion

In 2006, it was estimated that bringing a single drug to market costs 0.5 to 2 billion. (http://content.healthaffairs.org/cgi/content/full/25/2/420). A Reuters report in April 2010 (http://www.reuters.com/article/idUSLDE63C0BC20100413) indicated that consensus forecasts for sales figures for the top selling drugs ranged from 11.7 billion for Lipitor to 5.8 billion for Crestor with Plavix, Advair, Remicade, Enbrel Humira, Avastin, Rituxan, Diovan in between.

So we spend almost 12 B on our top selling drug and 10 B on the entire CDC budget. Is this how we want to spend our money? Now don't get me wrong I am all for drugs (medical). And I am not implying that a 12 billion for one drug isn't worth it. Rather, the relative amount spent for the prevention and health promotion work of CDC seems a bit low.

An important question then is: How do you understand the value of prevention efforts? While we do a pretty good job measuring the benefit we get from each drug in its formal clinical trials, can calculate cost benefit, and can use this information to make choices about how we spend our dollars, measuring what didn't happen (what we prevented) is much more difficult involving projections, assumptions, and discounting.

Here is where Mark's book comes in. Inside the Outbreaks is the first book chronicling the work of the EIS. Each sub-section tells a brief story and as you read through the book, you develop a growing knowledge and appreciation for what illnesses did and, importantly, didn't happen. For example, for each of these diseases, it is clear that many illnesses and deaths were prevented.

--In 1965, a Salmonella outbreak afflicted about 200,000 people in Riverside, California killing an infant and several others before the CDC team found that water was the source and stopped the outbreak.
-- In 1966, the World Health Organization passed a vote to fund a worldwide small pox elimination program. CDC played an important role in the subsequent eradication program.
--CDC was a leader in identifying infections that originated in hospitals and in instituting surveillance and preventive programs.
--Lead poisoning, vinyl chloride associated liver cancer, toxic shock syndrome and tampons, Accutane-associated birth defects, and many other links between an environmental cause and health were identified or characterized by CDC studies.

How many thousands or millions of us are healthy today because of this work? And how many suffer because we didn't do more of this kind of work? I suggest that a general appreciation and awareness is a first step in placing value. Pendergrast's book goes a long way in providing this. Once we truly understand and appreciate, we can think about measuring value. Was the money we spent worth it? Could we have done more with more? If we have a dollar for our health today, where do we think we will get the most value? Would more funds toward prevention give us more of the health value we want?

Are we headed for another crisis, one caused by spending dollars on health products of lesser (or no) value rather than those of more value resulting in slowing improvements or decreases in our health...a health recession?

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