Lotteries, Insurance and Flu Immunization Campaigns

You buy a ticket for a lottery. You may win any of a number of prizes – most small, some larger, up to a grand prize. Most of the time you just lose the price of a ticket.

You buy a fire insurance policy on your house. If the house burns, at least you collect up to the damages incurred or up to the maximum value of the policy. Most of the time you just pay for the policy, don’t have a fire and don’t collect anything.

You incur the costs of immunizing a population. A pandemic occurs and you avert an amount of sickness and death depending on how severe the pandemic would have been without the immunization campaign. If the public health service is doing its job, most of the time a pandemic does not occur but you have incurred the costs of the immunization campaign. Whether or not you immunize against the putative agent of the pandemic, some sickness and death does occur.

The distinction is that the first case is gambling, the second insurance, and the third prevention.

The difference is that people get a thrill from winning a lottery, get some solace and relief from their loss from the insurance payment in the event of a fire, but are largely unaware of the fate they have avoided due to a successful immunization campaign.

Flu Prevention: Costs and Benefits

The cost of “plain old,” annual, seasonal flu is huge! In the United States, it has been estimated that 36,000 people died of flu the last year for which we have data, and 200,000 were hospitalized. The United States has about five percent of the world’s population, and pretty good mortality statistics. World population is 20 times that of the United States, and if U.S. mortality scales up, the world death toll would have been 720,000. (Most estimates I have seen are less, perhaps 250,000 to 500,000; less than 20 times that of the United States, but still enormous.)

We don’t know the probability of a pandemic emerging this year, next year or the year after. I have read that there were ten in the past 300 years, and if that number is correct we can assume there is one about every 30 years. In a three year period, one might assume one chance in ten of a pandemic. The probability might be higher, given the current flu epidemic in birds, and the subjective probability that the flu will jump from birds to man.

The number of deaths from a new pandemic, like the monetary cost of a house fire, or the winning in a lottery, is not known in advance. The number of flu deaths could vary over a relatively wide range. In this case, due to the terrible quality of mortality statistics, I don’t think it is possible even to estimate the probability distribution of death rates (other than assuming that the probability is essentially zero of a death rate lower than that for the regular seasonal flu). We can reasonably assume that the death rate in the United States will be much less than in poor nations of Africa and Asia, assuming equal rates of infection, because of the relative health of the U.S. population and the availability of medical services in the United States for those who become very ill.

It is hard to say how much we should spend on preventing a flu pandemic. The amount increases if we can find things to do that have other (health) benefits to justify their costs. Thus, improving processes involved in the manufacture of vaccines, improving communicable disease surveillance systems, and assuring the installed capacity of health facilities is adequate to meet increased demands are probably all things we should be doing anyway, that help build preparedness for a possible flu pandemic.

It has been estimated that 17 million people die per year from preventable causes. Medical experts know how to prevent those deaths, but society simply does not allocate the resources to do so. Given this fact, we should not spend funds to avoid speculative flu-pandemic deaths if there are alternative uses of those funds that would avoid equal or greater numbers of fully foreseeable deaths from those preventable causes. Indeed, we should resist any temptation to withdraw funds from other well-functioning public health programs in order to fund a flu pandemic program, lest we see more deaths emerge as a result of the program cutbacks than lives are saved from a preventive-medicine program focused on flu.

I suggest it is probably better to err on the side of life, if err we must. The money we divert from luxuries to public health would not be missed, but the people who might die unnecessarily due to lack of preparedness would be. But it is also better to avoid politicization of the avian flu pandemic preparations or excessive fear, lest we spend foolishly (too much, on the wrong things).