(Bad) benefit-cost analysis and the HPV vaccine

One more silly argument against (quasi) mandating vaccination for the Human Papilloma Virus.

If you’re going to do a benefit-cost analysis of a sensitive topic, shouldn’t you learn something about how to actually, you know, do a benefit-cost analysis? The editors of the Rocky Mountain (Spotted?) News don’t seem to have bothered.

They argue that the mandatory HPV vaccine is too expensive. Why, it would cost about $300,000 per cancer death averted! That’s much more than it costs to detect a case of colon or prostate cancer!

It’s hard to count how many ways this is wrong.

First, it should be obvious that $300,000 per averted death is cheap. Do it in your head; imagine that you or someone close to you had a one-in-a-thousand chance of dying, which you could eliminate for $300. Would you pony up the cash? Of course you would. Well, if 1000 people made that choice, they would have paid a total of $300,000 to avert one death. The willingness-to-pay to avoid an early death for the average American is about an order of magnitude bigger than that.

Second, there’s no valid comparison between deaths averted and cases of colon or prostate cancer detected. (We’d need to know the false-positive rate on the tests, the financial and personal costs of more tests or of treatment, the case-mortality for the various conditions that might be detected, and the probability of successful treatment. Also, cancer of the colon, and especially of the prostate, tend to come late in life, which means that curing them saves fewer life-years than averting cervical cancer in someone younger.)

Third, there’s no reason to think that the money for the HPV vaccine comes out of the same budget as money for colon- and prostate-caner screening. Maybe we should be doing more of that screening; but why not do both?

Fourth, it’s worth something to avoid a case of cervical cancer, even if the patient survives. It’s also worth something to avoid genital warts and the other nasty things HPV does, plus the problems associated with having an incurable sexually-transmitted disease.

Finally, the actual economic cost of making and administering an extra dose of the HPV vaccine is about 10% of the $120 the manufacturer is charging. The rest is royalties and the manufacturer’s margin.

Remember, we pay for drug development in this country by giving patents: i.e., artificial monopoly rights. The costs of developing the vaccine, and of trying to develop all the other drugs that didn’t make it through the R&D process to FDA approval, are already sunk. I’m all in favor of replacing patents with prizes, if there’s a way to do it, so that the developer of a new drug gets its reward directly from the government and the drug is then sold at something close to marginal cost. But that’s not the current system. In the meantime, it makes no analytic sense to treat those per-dose royalties and margins as if they were true social costs that need to be weighed against the benefit of the vaccine.

Really and truly, folks: this one isn’t hard. Some of the crazier culture warriors are against it, basically because they think that sex ought to lead to death. Some of the more extreme libertarians are against it, because they believe parents ought to have the right to leave their children, and their children’s sexual partners, and the sexual partners of their children’s sexual partners, and the occasional unlucky person who contracts HPV through non-sexual contact and all of his immediate and second-order sexual partners, at risk of a preventable and sometimes fatal disease. (Prize for the most irrelevant argument so far: because kids aren’t supposed to have sex on school grounds, we shouldn’t require HPV vaccination for schoolchildren. No, I’m not making this up.)

Note: not all the culture warriors get this one wrong. Neither do all the libertarians; Jane Galt and Eugene Volokh have no trouble grasping the idea that infectious disease is a social rather than a merely individual problem.

(If you’re nervous about “mandatory” vaccination, you can relax: there’s an opt-out clause, so the “mandate” is actually merely a default option. I don’t think it’s unreasonable to require parents who want to put the lives of their children and others at risk to fill out a form in order to be able to do so.)

There are political arguments in favor of going slow in order to avoid having the various branches of the Anti-Sex League make a fuss about it and possibly reduce parental compliance with the rest of the vaccination program. There are medical arguments for giving it to boys as well as girls (and therefore a gender-equity argument against the current “girls-only” recommendation). There are budget arguments that if we add HPV to the mandatory-vaccination list we need to increase public funding for vaccinations overall to avoid having the states run short of funds for other vaccines.

But that’s all second-order stuff. The first-order fact is that we now know how to beat HPV, and the only practical question is whether to do it now and take the political heat, or do it later and let some people die while we suck our thumbs and wait for public opinion to catch up with the experts.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: Markarkleiman-at-gmail.com