Investing in Justice: Ethics,Evidence, and the Eradication Investment Cases for Lymphatic Filariasis and Onchocerciasis

It has been suggested that initiatives to eradicate specific communicable diseases need to be informed by eradication investment cases to assess the feasibility, costs, and consequences of eradication compared with elimination or control.A methodological challenge of eradication investment cases is how to account for the ethical importance of the benefits, burdens, and distributions thereof that are salient in people’s experiences of the diseases and related interventions but are not assessed in traditional approaches to health and economic evaluation.We have offered a method of ethical analysis grounded in theories of social justice. We have described the method and its philosophical rationale and illustrated its use in application to eradication investment cases for lymphatic filariasis and onchocerciasis, 2 neglected tropical diseases that are candidates for eradication.The eradication of smallpox was a signature success of global public health in the 20th century, but it is an open and contentious question whether global eradication as opposed to regional elimination or control is warranted for other potentially eradicable infectious diseases.1–4 The box on page 630 provides our definitions of eradication, elimination, and control, as explained by Dowdle.4

Definitions of Eradication, Elimination, and Control

Eradication—the permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts so that intervention measures are no longer needed.

Elimination—the reduction to zero of the incidence of infection caused by a specific agent in a defined geographical area as a result of deliberate efforts; continued measures to prevent reestablishment of transmission are required.

Control—the reduction of disease incidence, prevalence, morbidity, or mortality to a locally acceptable level as a result of deliberate efforts; continued intervention measures are required to maintain the reduction.

Open in a separate windowSource. Dowdle.4Global eradication efforts require vast resource commitments that must be locked in over long time frames, thereby imposing opportunity costs that require justification. For example, donors invested $10.0 billion in the Global Polio Eradication Initiative from 1988 through 2012, and the Global Polio Eradication Initiative’s 2013 to 2018 strategic plan calls for an additional $5.5 billion, totaling $15.5 billion over 30 years.5 The Global Polio Eradication Initiative has prepared an economic case estimating net benefits to date at $27.0 billion and arguing that completion of the eradication initiative would be more cost effective than are available alternatives.6 Ideally, with so much at stake, deliberations about coordinated global approaches to eradicable infectious diseases should be informed by prospective comparative assessment of the feasibility, costs, and consequences of control, elimination, and eradication. The same point of principle applies to other large-scale, long-term, and resource-intensive health programs, substituting the relevant scenarios for comparison.The eradication investment case (EIC) framework is a method for making such assessments to apply them to eradicable infectious diseases.7–11 Although traditional health and economic assessments are core components of EICs, leading architects of the EIC framework contend that EICs should also include “a narrative of the moral value of launching an eradication program” to “capture the value of intangible benefits and ensure consideration of benefits that are difficult to quantify.”9^(p143) EICs lacking such ethical analyses may critically overvalue or undervalue eradication scenarios compared with elimination or control by failing to identify ethically important kinds of benefits, burdens, and distributions thereof. The need for such prospective ethical analysis is not unique to assessing disease eradication programs and arguably should be part of assessing and justifying other kinds of health programs.How can EICs account for the ethical importance of the benefits, burdens, and distributions thereof that are salient in people’s experience of particular diseases and disease-related interventions but not assessed in traditional health and economic evaluations? We have proposed a method of ethical analysis grounded in social justice to help EICs respond to this challenge in hopes that it may also prove useful as an approach to prospective ethical assessment for health programs concerned with noneradicable infectious diseases and noninfectious diseases. We have illustrated the proposed method through its application to lymphatic filariasis and onchocerciasis, 2 neglected tropical diseases considered amenable to eradication and for which EICs are currently being assembled.7