Opportunity costs: public health edition

The whole of the Washington Post feature on Ebola is worth reading. This part in particular caught my notice though.

In late July, with the epidemic roaring, Liu, the head of Doctors Without Borders (known internationally by its French name, Médecins Sans Frontières), requested a meeting with WHO Director-General Margaret Chan at the WHO's Geneva headquarters.

Chan, an expert on the SARS virus and avian influenza, has led the WHO since November 2006. Her organization has experienced budget cuts and shifting priorities in recent years. The WHO is responsible for coordinating global health emergencies, but the legislative body that oversees it has repeatedly voted to emphasize noncommunicable diseases such as heart disease and cancer rather than infectious diseases.

Liu, a French Canadian, is a pediatric emergency room doctor by training, and for much of the past two decades has worked for Doctors Without Borders in the most war-ravaged, disaster-stricken places on Earth.

On July 30, she implored Chan to declare an international health emergency. Chan responded that she was being very pessimistic, Liu said.

Liu replied: "Dr. Chan, I'm not being pessimistic. I'm being realistic."

Chan soon flew to West Africa to meet with the presidents of Guinea, Liberia and Sierra Leone, and announced a $100 million push to stop the outbreak.

The WHO's 2012-2013 Annual Report had $446m proposed base programme expenditures on communicable diseases, a 9% increase over 2008-2009. This was augmented by $679m on special programmes and collaborative arrangements, and $153m on outbreak and crisis response, for a total of $1.278b. AIDS, tuberculosis, and malaria, which counts as a separate objective, saw a 16% increase in base funding for a total allocation of $540m. Noncommunicable diseases saw a 27% increase in expenditure, and total funding of $114m, with an additional $122m (25% increase) on alcohol, tobacco, drugs, and unhealthy diets.

WHO expenditures on non-communicable diseases and on alcohol, tobacco, and unhealthy diets were a small part of the overall proposed 2012-2013 budget, but they were the fastest growing parts of the base programmes budget.

Download the Proposed Programme Budget 2014-2015, dated 19 April 2013. Do a word search. Ebola gets zero hits. Alcohol gets 17 mentions. Tobacco gets 10. Salt gets 2. Obesity gets 3. Pandemic at least gets 22, so that's encouraging.

If we look within Africa, they proposed spending $48 million on non-communicable diseases. The key KPIs included reductions in harmful alcohol use, reductions in current tobacco use, reduction in prevalence of insufficient physical activity, and so on.

They also proposed spending, in Africa, $8.4m on alert and response capacities, $4.8m on epidemic- and pandemic-prone diseases, $37.7m on emergency risk and crisis management, $39.3m on outbreak and crisis response, and $4.6m on food safety. Laudable polio eradication efforts took up another $408.2m.

Leaving polio aside, we had just under $95m on traditional public health areas like pandemic preparation, avoidance, and response, and $48m on non-communicable diseases.

As the burden of communicable diseases, the traditional public health focus, has lessened in first world countries, public health agencies have been shifting over to non-communicable diseases. Some of this is perfectly laudable: who wouldn't want a cure for cancer, even if you can't catch cancer like you can catch a cold? But if the opportunity cost of public health expenditures that focus on lifestyle issues like unhealthy diets, drinking and smoking is less attention to vaccination in first-world countries and epidemic preparation in the developing world, I wonder about priority-setting.