Model, Quick Fix

When QALYs Are Wrong – Thoughts on the Gates Foundation

Every year, I check in to see if we’ve eradicated polio or guinea worm yet. Disease eradications are a big deal. We’ve only successfully eradicated one disease – smallpox – so being so close to wiping out two more is very exciting.

Still, when I looked at how much resources were committed to polio eradication (especially by the Gates Foundation), I noticed they seemed incongruent with its effects. No polio eradication effort can be found among GiveWell’s top charities, because it is currently rather expensive to prevent polio. The amount of quality-adjusted life years (QALYs, a common measure of charity effectiveness used in the Effective Altruism community) you can save with a donation to preventing malaria is just higher than for polio.

I briefly wondered if it might not be better for all of the effort going to polio eradication to instead go to anti-malaria programs. After thinking some more, I’ve decided that this would be a grave mistake. Since I haven’t seen why explained anywhere else, I figured I’d share my thinking, so that anyone else having the same thought can see it.

A while back, it was much cheaper to buy QALYs using the polio vaccines. As recently as 1988, there were more than 350,000 cases of polio every year. It’s a testament to the excellent work of the World Health Organization and its partners that polio has become so much rarer – and therefore so much more expensive to prevent each new case of. After all, when there are few new cases, you can’t prevent thousands.

It is obviously very good that there are few cases of polio. If we decided that this was good enough and diverted resources towards treating other diseases, we might quickly find that this would no longer be the case. Polio could once again become a source of easy QALY improvements – because it would be running rampant in unvaccinated populations. When phrased this way, I hope it’s clear that polio becoming a source of cheap QALY improvements isn’t a good thing; the existence of cheap QALY improvements means that we’ve dropped the ball on a potentially stoppable disease.

If polio is eradicated for good, we can stop putting any effort into fighting it. We won’t need any more polio vaccines or any more polio monitoring. It’s for this reason that we’re much better off if we finish the eradication effort.

What I hadn’t realized was that a simple focus on present QALYs obscures the potential effects our actions can have on future QALYs. Abandoning diseases until treatments for them save many lives cheaply might look good for our short term effectiveness, but in the long term, the greatest gains come from following through with our eradication efforts, so that we can repurpose all resources from an eradicated disease to the fight against another, forever.

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