My daughter is more cost effective than yours (sorry)

The incidence of cervical cancer is high. About 500,000 cases arise every year, >260,000 of those cases are deadly. Not surprisingly, 85% of those deaths occur in the developing world. Yet, since 2006 vaccine to prevent human papillomaviruses (HPVs) have been available in industrialized nations. As one who studies global health might expect, most of the vaccinations that exist are administered in the developed world and cost hundreds of dollars per patient. In the US, even a state as conservative as Texas found the political will to institute mandatory vaccination, despite low incidence. That’s because the benefits are tremendous; we have the ability to prevent a cancer. Two different versions of vaccine exist, one of which (Gardasil) offers protection against anogenital warts and disease of the vulva and vagina. Both protect against HPV types 16 and type 18 which cause >70% of cervical cancer.

This is where the logic of cost effectiveness, prevention, screening and treatment begins to get fuzzy. In nations where well organized programs are in place to screen for precancerous abnormalities and early stages of cervical cancer, 80% of cases can be averted. That’s 10% more effective than the vaccination. Given these numbers, the WHO recommends that priority for vaccination be given to areas that have less access to screening programs, while in the same report explaining that adequate screening programs of this sort have been “have been difficult to implement in low-resource and middle-resource settings.” Such programs for screening thus only exist in the developed countries, the same ones that can afford to administer the vaccine.

Despite this seeming contradiction, the WHO recommends in its position paper on the vaccine that it is only cost effective to administer HPV vaccine in high income countries, and maybe some middle income. Only is it cost effective in lower income countries when the cost had been brought down in the range of 10-25$. Luckily, GAVI claims that with its bulk purchasing power, they could buy, distribute and administer the vaccine in the range of 8-25$ per person, provided that they can bridge a projected 4$ billion funding gap even at that price. Despite the incredible fundraising ability GAVI has demonstrated throughout the economic crisis, this is a serious obstacle to overcome.

The story of HPV vaccine is not a new one. Literally hundreds of diseases including malaria, TB, river blindness, countless worms and other parasitic organisms are profligate in the developing world and absent in the countries with a GDP high enough to make cost effective models happy. By continuing to administer new health interventions in this disparate way, we create a precedent that lives in high GDP countries are simply worth more than everyone else’s. Vaccine and screening are available and cost effective in some nations only because GDP is high enough to support the tremendous cost while the rest of the world where incidence is highest in Latin America and the Caribbean, sub-Saharan Africa, Melanesia, and south-central and South-East Asia must go without either option.

SAGE recommends introducing HPV vaccine into a national immunization program if prevention is a public health priority (will it reduce incidence and cost). In the developed world, vaccination provides a small health improvement at great cost. In the developing world, vaccination would be at low cost and prevent hundreds of thousands of deaths annually. Given this paradox, and it should be viewed as a paradox, HPV distribution is more than a public health priority, it is a global human rights issue which is being ignored. If the best models the sages of health policy can create simply advocate the status quo, we need new models that rethink the way new health interventions are distributed globally, beginning with a more effective and equitable administration of HPV vaccine.

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