Choices

April 8, 2020

Years ago I attended a conference organized to explore the blurred boundary between medicine and religion. I heard a moving presentation by a doctor who spent his life as a doctor/missionary in Sub-Saharan Africa. He told us of a choice he had made when allocating an annual medication budget. He had encountered a child with Burkitt’s lymphoma. This “cancer” had been discovered “curable” by treating with a chemotherapeutic agent called methotrexate. The cost of the methotrexate to treat this single child was equal to the cost of a population supply of measles vaccine. He was anticipating a measles epidemic that year that would kill many children. He had to choose which medication. He could not afford both.

An estimated three million US citizens are infected with a virus called hepatitis C. Hepatitis C infection is a co-factor that increases risk for cirrhosis, liver cancer and liver failure years after the initial infection. Two new drugs are being promoted for their ability to eradicate the virus from the bodies of infected people. The cost of one drug is $84,000 for a recommended 12 week course of treatment. The drug has been demonstrated to eliminate detectable virus in over 90% of experimental subjects. The cost to potentially eliminate this virus in the US with this medication would be $252 billion. That is over 10% of our total annual healthcare spending.

Prisons, insurance companies, Medicare and others are contemplating the issues presented by these new medications. Some organizations are already purchasing or paying for these agents. We think “curing” bad infectious diseases is worth any price. But hepatitis C does not always cause serious consequences. And much of the damage done to the liver may have occurred years ago when the virus first infected an individual (http://archinte.jamanetwork.com/article.aspx?articleid=1984248). And the “success” measured by eliminating the virus may not improve the long range consequences. And the side effects of the new drug are not well-known or completely revealed. And the drug companies are providing the drug at a lower cost to other countries. And some effective medications are already available. Despite these considerations, the drug is being widely promoted. The internet is flush with advertising for potential customers.

We prefer to think that we can afford everything that promises better health. A number of therapies that I routinely recommended in my early practice years are no longer extant. Many were found to be ineffective. Some were discovered to be harmful. We are better at finding what can be done rather than we are at deciding what should be done. The missionary I referenced purchased measles vaccine and wrote to his medical school classmates asking for methotrexate donations. He received an abundant supply and was able to cure the child with lymphoma.

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