These are more difficult to cost out. Immunization against the infectious diseases such as polio, rubella, measles, diphtheria, mumps, whooping cough and smallpox has been of interest to governments all over the western world because these diseases are highly contagious, cause a provable disruption to society and are relatively easily prevented. Although any one of these diseases causes very little risk of serious life-long impairment or fatality to any single individual, an epidemic affecting perhaps hundreds of thousands of people really does cost society a lot of money. The costs for society of preventing these illnesses are small yet the benefits are great. However, the benefits to society in the case of certain immunisable diseases, unless a very large proportion of the population is immunized, can be small. This applies especially to diseases in which there is considerable ‘herd immunity’. After this crucial point is reached there is really not much point spending yet more money immunizing the last 10 per cent of the population.

A good example of how to work out what is worth doing in the public health arena was the different ways in which German measles vaccine was used in the US and the UK, when it was first licensed in 1969. In the US children between 1 and 12 were inoculated whilst in the UK only girls between 11 and 14 were offered the vaccine. The benefits of the programme were defined to include the saving of the costs that would have been incurred in the treatment of the disease and its complications had it not been prevented. Work loss was also taken into account. The direct costs were the expenditure on the vaccine, its administration and the treatment of vaccine complications. By 1972 it was obvious that giving the vaccine had economic advantages at any age but that the most cost-effective way of using it was to offer it at the age of 12 to girls only, rather than to all children at age 6 or younger, as had been done in the US.

However rich a society its resources are not endless, and starting a preventive programme means shifting priority from other preventive programmes, acute care or even from non-health activities. This puts a considerable burden on those who are planning to introduce preventive programmes because they have to be able to justify what they do in terms of value for money. Unfortunately, the crisis-intervention sort of medicine we are all used to has rarely been subjected to such rigorous scrutiny-often with dire results.

Another example of the value of public health measures in the preventive field is the fluoridation of water to prevent tooth decay. Governments, whether local or national, tend to support water fluoridation because it is by far the cheapest way of ensuring that vulnerable people get enough fluoride. Cost-benefit analyses have shown that the fluoridation of water saves up to twenty to forty times its cost by dramatically reducing the incidence of tooth decay.

Environmental control of air and water pollution is the nearest we come in this century to the environmental problems faced in the last. A great deal of evidence has been accumulated to show that a reduction in air pollution would lead to a significant reduction in illness and death rates in urban areas. Using current costs for reducing air pollution there is no doubt that the benefits would outweigh them.


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