Enlightened Self-Interest and the Control of Tuberculosis
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《新英格兰医药杂志》
Given the great humanitarian tradition of the United States, it is curious that no category of government spending ranks below foreign aid in polls of the American public.1 Americans are poorly informed about foreign aid; polls indicate that the majority believe the United States spends substantially more on foreign aid than it does, the median estimate being about 15 percent of the federal budget.2 In reality, the United States currently provides about $19 billion in overseas development assistance, the largest dollar amount of any country.3 But that represents only 0.16 percent of the U.S. gross domestic product, which is the lowest percentage of any industrialized country. And less than 10 percent of that is spent on health care. Americans give privately about twice as much for foreign and humanitarian assistance as does their government.
There appear to be at least two reasons why Americans contribute to foreign aid. One is a genuine humanitarian interest in improving the lives of the poor and disadvantaged, so long as the funds do not end up in the hands of corrupt leaders. This approach is perhaps best exemplified by the recent public and private contributions by Americans of more than $700 million to relief efforts in the aftermath of the Asian tsunami. A second motivation is enlightened self-interest, a recent example being the contributions of the Department of Health and Human Services, Centers for Disease Control and Prevention, and the National Institutes of Health to help curtail the spread of the severe acute respiratory syndrome and to prevent the spread of avian influenza — diseases that threaten not only the Asian continent but also the rest of the world.
With resources for health care inevitably limited — and increasingly strained by rising demand — how does one make difficult decisions about where to direct foreign assistance for health care to yield the greatest value at home and abroad? In this issue of the Journal, Schwartzman and colleagues4 use the tools of decision analysis to argue that, since the majority of new cases of tuberculosis in this country arise among recently infected immigrants, predominantly from Mexico and the Philippines, America's enlightened self-interest would be well served by investing in programs to expand the World Health Organization's directly observed treatment, short course (DOTS), in Mexico and a handful of other countries.
Decision analysis provides a set of formal modeling techniques to guide difficult choices by explicitly weighing the expected consequences of different courses of action. Emerging from the business world in mid-century, the approach has more recently found an array of relevant applications in clinical medicine and health policy. The basic premise in a decision analysis is that all available information on the likelihood, costs, and effects of the various outcomes of particular choices can be quantified and synthesized to help decision makers behave rationally in economic terms — that is, to help them make logical choices to maximize some desired outcome. The problem that Schwartzman et al. pose is well suited to appraisal with the use of decision analysis. The question they address is as follows: What is the most efficient way to reduce the burden of tuberculosis among immigrants in America? In order to reduce infection rates among those emigrating to the United States, should we merely continue the current practice of radiographic screening of new (legal) entrants? Should we add tuberculin skin testing to this routine? Should we finance the expansion of effective DOTS tuberculosis-control programs in Mexico and elsewhere? Their answer will surprise some. Using a range of assumptions, they find that investing in foreign tuberculosis control will actually save money and improve health outcomes in this country.
Somewhat paradoxically, the chief advantage of decision analysis — its explicitness — also makes it fairly easy to find fault with any given application of the approach. The decision analysis reported by Schwartzman and colleagues is no exception. Its weakest link is the central assumption that expanding the coverage of the DOTS strategy for tuberculosis control in Mexico will result in sustained declines of 6 percent per year in new cases of tuberculosis in Mexico, beyond the reductions expected from continuing programs at their current levels. This optimistic assumption is extrapolated from a study of DOTS expansion in Peru, but the analogy is strained by important differences between the two settings. The program in Peru was introduced in an area in which effective treatment was uncommon and epidemiologic trends were stagnant; Mexico, by contrast, already has DOTS coverage of approximately 70 percent, and the incidence of tuberculosis there is in decline. In the face of these doubts, however, some reassurance comes in the form of another hallmark of the decision-analytic approach — namely, extensive sensitivity analysis to test the stability of the results to alternative assumptions around key uncertainties in the model. The authors report, encouragingly, that foreign investment in tuberculosis control would remain a cost-saving measure even if the incidence in Mexico were to decline by only 1.2 percent in the expanded-treatment scenario. And since the cost of treating secondary cases that arise from foreign-born persons living in the United States was not included in the analysis, the savings will actually be greater.
This analysis suggests that American investments in public health and treatment of a disease in developing countries could offer greater benefits for this country in both human and economic terms than the current policy of trying to identify and treat imported cases as they arise here. This is a clear example of a policy of enlightened self-interest that would benefit both people in developing countries and those in the United States. It is a case that needs to be made, because Americans believe that we spend vastly more than we actually do on foreign assistance. When confronted with the true amount, they generally favor increased spending for humanitarian aid. In the case of tuberculosis, the need for such investments is urgent, given that there are 8.8 million new cases annually and that the disease is responsible for more than 2 million deaths worldwide and is the principal attributable cause of death from AIDS in Africa. Although it is gratifying that at their recent meeting in Scotland, the leaders of the so-called group of eight (G8) countries, comprising seven of the globe's leading industrialized nations and Russia, committed themselves to providing increased aid to Africa, with specific funding targets for fighting human immunodeficiency virus infection, AIDS, and malaria, it is tragic that tuberculosis was largely overlooked.5 This omission makes the argument presented by Schwartzman et al. — that the United States should provide such foreign aid for the treatment of tuberculosis in developing countries — more compelling, as a matter of both humanitarian concern and enlightened self-interest.
Source Information
From the Department of Population and International Health, Harvard School of Public Health, Boston.
References
Program on International Policy Attitudes (PIPA) home page. (Accessed July 19, 2005, at http://www.PIPA.org.)
The PIPA/Knowledge Networks Poll. The federal budget: the public's priorities. Report of March 7, 2005. (Accessed August 18, 2005, at http://pipa.org/OnlineReports/budget/030705/Report03_07_05.pdf.)
Organisation for Economic Co-operation and Development. 2006 targets still a challenge. (Accessed August 18, 2005, at http://www.oecd.org/document/3/0,2340,en_2649_201185_34700611_1_1_1_1,0.html.)
Schwartzman K, Oxlade O, Barr RG, et al. Domestic returns from investment in the control of tuberculosis in other countries. N Engl J Med 2005;353:1008-1020.
Foreign & Commonwealth Office. Post-G8 Gleneagles Communique. (Accessed July 19, 2005, at http://www.fco.gov.uk/.)(Barry R. Bloom, Ph.D., an)
There appear to be at least two reasons why Americans contribute to foreign aid. One is a genuine humanitarian interest in improving the lives of the poor and disadvantaged, so long as the funds do not end up in the hands of corrupt leaders. This approach is perhaps best exemplified by the recent public and private contributions by Americans of more than $700 million to relief efforts in the aftermath of the Asian tsunami. A second motivation is enlightened self-interest, a recent example being the contributions of the Department of Health and Human Services, Centers for Disease Control and Prevention, and the National Institutes of Health to help curtail the spread of the severe acute respiratory syndrome and to prevent the spread of avian influenza — diseases that threaten not only the Asian continent but also the rest of the world.
With resources for health care inevitably limited — and increasingly strained by rising demand — how does one make difficult decisions about where to direct foreign assistance for health care to yield the greatest value at home and abroad? In this issue of the Journal, Schwartzman and colleagues4 use the tools of decision analysis to argue that, since the majority of new cases of tuberculosis in this country arise among recently infected immigrants, predominantly from Mexico and the Philippines, America's enlightened self-interest would be well served by investing in programs to expand the World Health Organization's directly observed treatment, short course (DOTS), in Mexico and a handful of other countries.
Decision analysis provides a set of formal modeling techniques to guide difficult choices by explicitly weighing the expected consequences of different courses of action. Emerging from the business world in mid-century, the approach has more recently found an array of relevant applications in clinical medicine and health policy. The basic premise in a decision analysis is that all available information on the likelihood, costs, and effects of the various outcomes of particular choices can be quantified and synthesized to help decision makers behave rationally in economic terms — that is, to help them make logical choices to maximize some desired outcome. The problem that Schwartzman et al. pose is well suited to appraisal with the use of decision analysis. The question they address is as follows: What is the most efficient way to reduce the burden of tuberculosis among immigrants in America? In order to reduce infection rates among those emigrating to the United States, should we merely continue the current practice of radiographic screening of new (legal) entrants? Should we add tuberculin skin testing to this routine? Should we finance the expansion of effective DOTS tuberculosis-control programs in Mexico and elsewhere? Their answer will surprise some. Using a range of assumptions, they find that investing in foreign tuberculosis control will actually save money and improve health outcomes in this country.
Somewhat paradoxically, the chief advantage of decision analysis — its explicitness — also makes it fairly easy to find fault with any given application of the approach. The decision analysis reported by Schwartzman and colleagues is no exception. Its weakest link is the central assumption that expanding the coverage of the DOTS strategy for tuberculosis control in Mexico will result in sustained declines of 6 percent per year in new cases of tuberculosis in Mexico, beyond the reductions expected from continuing programs at their current levels. This optimistic assumption is extrapolated from a study of DOTS expansion in Peru, but the analogy is strained by important differences between the two settings. The program in Peru was introduced in an area in which effective treatment was uncommon and epidemiologic trends were stagnant; Mexico, by contrast, already has DOTS coverage of approximately 70 percent, and the incidence of tuberculosis there is in decline. In the face of these doubts, however, some reassurance comes in the form of another hallmark of the decision-analytic approach — namely, extensive sensitivity analysis to test the stability of the results to alternative assumptions around key uncertainties in the model. The authors report, encouragingly, that foreign investment in tuberculosis control would remain a cost-saving measure even if the incidence in Mexico were to decline by only 1.2 percent in the expanded-treatment scenario. And since the cost of treating secondary cases that arise from foreign-born persons living in the United States was not included in the analysis, the savings will actually be greater.
This analysis suggests that American investments in public health and treatment of a disease in developing countries could offer greater benefits for this country in both human and economic terms than the current policy of trying to identify and treat imported cases as they arise here. This is a clear example of a policy of enlightened self-interest that would benefit both people in developing countries and those in the United States. It is a case that needs to be made, because Americans believe that we spend vastly more than we actually do on foreign assistance. When confronted with the true amount, they generally favor increased spending for humanitarian aid. In the case of tuberculosis, the need for such investments is urgent, given that there are 8.8 million new cases annually and that the disease is responsible for more than 2 million deaths worldwide and is the principal attributable cause of death from AIDS in Africa. Although it is gratifying that at their recent meeting in Scotland, the leaders of the so-called group of eight (G8) countries, comprising seven of the globe's leading industrialized nations and Russia, committed themselves to providing increased aid to Africa, with specific funding targets for fighting human immunodeficiency virus infection, AIDS, and malaria, it is tragic that tuberculosis was largely overlooked.5 This omission makes the argument presented by Schwartzman et al. — that the United States should provide such foreign aid for the treatment of tuberculosis in developing countries — more compelling, as a matter of both humanitarian concern and enlightened self-interest.
Source Information
From the Department of Population and International Health, Harvard School of Public Health, Boston.
References
Program on International Policy Attitudes (PIPA) home page. (Accessed July 19, 2005, at http://www.PIPA.org.)
The PIPA/Knowledge Networks Poll. The federal budget: the public's priorities. Report of March 7, 2005. (Accessed August 18, 2005, at http://pipa.org/OnlineReports/budget/030705/Report03_07_05.pdf.)
Organisation for Economic Co-operation and Development. 2006 targets still a challenge. (Accessed August 18, 2005, at http://www.oecd.org/document/3/0,2340,en_2649_201185_34700611_1_1_1_1,0.html.)
Schwartzman K, Oxlade O, Barr RG, et al. Domestic returns from investment in the control of tuberculosis in other countries. N Engl J Med 2005;353:1008-1020.
Foreign & Commonwealth Office. Post-G8 Gleneagles Communique. (Accessed July 19, 2005, at http://www.fco.gov.uk/.)(Barry R. Bloom, Ph.D., an)