How much does it cost to save a human life? If you let a doctor do the work it costs about 20.000 dollars, if you let the environmental movement take care of it, you may count on a price of 3 billion dollars. Conclusion: if we would spend less on the environment we would probably all live longer, because: money that is spent on small risks is not available for the big risks anymore.

Suppose you are a Minister for Public Health and the Environment (in some countries the function is combined, in others it is split). You have billions to spend, but it is never enough because the Parliament puts you in a crossfire of problems: there is not enough surgical capacity for patients with cardiovascular problems - there is a new medicin for cancer, Taxol, but it is very expensive, who will pay this treatment? Old people need dentures otherwise they cannot eat properly and die prematurely. Will the government supply the money? And also: the environment is poisoned, sooner or later we will pay the price in the form of cancer.

A minister has to reconcile all these different interests and at first this seems straightforward, you try to find out how to keep as many people alive as possible - a simple matter of arithmetics.

If it takes a million pounds to treat 100 people with heart disease and thus allow them to live another five years than you have 'bought' 500 extra life years, which comes down to 2000 pounds for each extra year per patient.

You may find the thought of putting a price on a human life revolting, but it happens everyday: we know how much cardiovascular surgery costs, and we know the average life expectation. Of course you do not calculate how much a human life is 'worth' but only how much you spend saving it.

So with this million you can keep 100 heart patients alive. But say hypothetically, - we'll give you the real numbers later in this story - that saving the life of a cancer patient is a bit more expensive. With the same million pounds you can 'buy' only 50 extra years for cancer patients ( 5 years extra for 10 patients ). This means that the life of these cancer patients are ten times more expensive than the lives of people with heart disease (20.000 pounds)!

What a dilemma! As a Minister you'd rather see everybody healthy, regardless of costs. You cannot blame the patient for suffering an expensive illness, people do not get ill by choice, but your budget is large but limited, what do you choose?

If you save the lives of the heart patients you make optimal use of your money, but unfortunately this decision implies the death sentence for the cancer patients. No matter what you decide: you'll both save and lose lifes.

These gruesome calculations are made more and more often, and they are called cost-benefit analysis. In several countries there have been media debates over the question whether the treatment of certain cancers with Taxol should be paid by compensated by the health authorities. This treatment costs 20.000 dollars per saved life.

If you spend 75.000 dollars on the cholesterol lowering medicine simvastatine you save one life. But a few years ago two children in Holland appeared to have a brain tumor that could only be treated by a somewhat obscure doctor in the US. The health officials refused to pay this treatment. An action committee was organised and collected with lots of media coverage the necessary sum of 100.000 dollar per child. The children were treated and died nevertheless. A dilemma: one would save a childs life at any price, but also by giving it an unproven, controversial treatment? The parents said - very understandably - yes, the health offcials said no and proved right.

No matter which choice you make, there will allways die people as a result of lack of funds for medical treatment. As a Miniser this makes you guilty of statistical murder.

If you spend money on small risks you have no more money to attack the bigger risks, so it is allways worthwhile to have a cost benefit analysis at hand to minimize the number of death you cause by deciding how many people you'll keep alive.

But meanwhile organisations like Greenpeace or Friends of the Earth warn you that our environment is dangerously polluted with asbestos, dioxins, pcb's, pesticides, and the polls tell you that the public - your voters - are scared that they might get cancer as a result of this pollution. And journalists ask you how much longer it is going to last before you take the environmental problems serious.

More specifically they want you to limit the release of cancer causing chemicals in the environment and what else can you do than to do what the people want you to. So you order to investigate how many people get cancer as a result of pollution, and while they're at it: what chemicals do cause cancer anyway?

Many governments have as a rule that it is inadmissible when a particular chemical causes one extra case of cancer in a million people. This then should be prevented.

The thought is humane, the realisation complicated, because how does one discover an extra case of cancer in a one million population?

Scientists may be very clever, but to detect a chance of one in a million they would need two million people. They would daily give a small amount of Suspected Chemical X to one million people and take much care that the other million is safeguarded against it (preferably you'd do this according to the double-blind protocol, but our example is complicated enough as it is). After 30 to 40 years you collect the two million people again (or the survivors) and you start to count the tumors. In a normal year like 1997 the England and Wales counted 5081 cancer deaths per million (according to the ONS), so if you find 5082 cancer fatalities in the group that consumed the suspected chemical you can alert the departmental PR Officer to make a press announcement: Minister Discovers Cancer Causing Chemicals! Measures On The Way.Not counting the ethical aspects - you just do not administer a potentially dangerous substance to someone - this method is not really practical. There are many man-made and very much more nature made chemicals that we do not know the toxicology of (let alone the innumerable combinations that we all ingest/inhale). As a minister your time horizon is the next election, not 30 to 40 years, and where would you find the money for such an enormous undertaking.

So this is where the animal, mostly a rodent like a rat or a mouse enters the scene. Ethically this is easier, but two million rats is still practically impossible, so the number of rats is diminished to a few thousand (seldom) or a few hundred (or a few dozen).

But with 2000 rats you can only calculate a chance of one in a thousand, not one in a million. The chosen solution to this problem is: we have divided the number of our test subjects by a thousand, let's multiply the original dosis that we would give the test subjects by a factor thousand.

Now as a minister for Health you are asked about the dangers of alcohol. Many people drink a daily glass of whisky and you would like to know whether this might have serious health consequences. Now the following calculation becomes relevant.

A glass of whisky contains 10 milliliters. A rat is about a 100 times lighter than man, so for this experiment one would have to administer a thousand rats 1/100 of 10 ml daily

But since you are after a chance of one in a million you have to multiply this daily drink with a factor 1000. The rats, weighing about 0.7 kilo each would receive during the two years they usually live a daily amount of 100 milliliters whisky.

That is a lot! Personally I love a few drinks, but not ten, and not daily. And this rat is a hundred times smaller. Is it a surprise then that the investigators finally report that whisky ruins the liver, destroys the brain, causes all sorts of cancer, is in short so dangerous a substance that you as a minister would best ban alcohol alltogether? (Had the study been done with a thousand people, the participants would have had to take 1000 glasses of whisky daily - for several decades).

You would have every reason to make dry the country, but should you do that you would actually harm your voters since scientists have discovered that a regular consumption of alcohol, say one glass of whisky per day is beneficial for one's health. So in your ministerial fervour you would protect the people against a non existent danger and withhold them a healthy substance (and a lot of fun).

The majority of the 'scares' about cancer causing chemicals is based on this kind of animal experiments. You administer animals a huge amount of a substance, hundred of thousands to a million times more than what an average human being would ever ingest and then you start to count the tumors. The newsmedia then report that Substance X might cause cancer and omits to explain how the study has been done. Many thousands of these studies have been done and half of all tested chemicals have shown up as potential carcinogens. This is irrespective of the origin: if the chemical is the product of mother nature or of a mad scientist, 50% causes cancer if you test it in the above described way.

The dosages administered in these studies bear little resemblance to reality, and the question whether a rat or a mouse is a relevant substitute for a human being still remains open. Two examples of to what this can lead.

Butylhydroxytoluene, better known as BHT is allowed in many countries as a so called anti-oxidant for meat. It works as a preservative. BHT has been researched thoroughly and in some experiments it proved to extend the lives of the rodents, good news! But in other experiments BHT appeared to cause cancer in the forestomach.

How should one interpret these results? People do not have a forestomach, so is it carcinogenic for us? Or is it a life extender for rats (and 'thus' a life extender for humans?). I know people who take BHT for its life extending properties, though no one knows whether it will work. Some scientists want to use BHT to alleviate the side effects of chemotherapy against cancer. But in test animals it can cause cancer.

The illustration of how one can get lost when guided by animal experiments is the case of TCDD, 2,3,7,8 tetrachloropara dibenzodioxine, in short: DIOXIN.

This is possibly the most famous chemical on the planet, but definitely not the most toxic, allthough it is very often presented as such. The most toxic substance on the planet is the botulism toxin, a natural product (btw dioxin is also a natural product)

Vietnam, Seveso, Times Beach, Love Canal, are all names associated with heavy publicitary activity. Villages have been evacuated, areas isolated, and the fear for malformed fetuses stimulated 17 pregnant women in Seveso, Italy to ignore their religion and have an abortion.

The humble guinea pig is to blame for this fear, because he is a very sensitive animal when it comes to dioxin. Less then one millionth of a gram (1 microgram) is enough to kill half of all the animals in an experiment. You're talking poison then.

But in another experiment dioxin was given to hamsters, and they needed three thousand times as much for the same (acute lethal) effect. As a Minister for Health and Environment you then wonder: are my voters more comparable to guinea pigs or to hamsters?

In other animal experiments, dioxin proved to be able to cause cancer and be a teratogen as well (able to deform the fetus). From Vietnam, where the war had just ended, reports came about many children being born with handicaps that were attributed to the defoliation of the forest with dioxin containing herbicides.

In view of the panic it is understandable that the women in Seveso chose to have an abortion, but no abormalities were found in the aborted fetuses. And the reports about the handicapped Vietnamese children later appeared to be a sort of delayed war propaganda.

After more then 3 decades of scientific research there still is no convincing evidence of carcinogenicity of dioxin in humans. And that is not due to a lack of humans: many accidents have happened in which humans received seizable quantities of dioxin. The only disease that has a direct relationship with dioxin exposure is chloracne, a painful, disfiguring but non-fatal disorder which disappears after several years. The quantities of dioxin that the average population is exposed to in Europe or the US are so very much lower than what causes chloracne that it is safe to say that current exposure has no health consequences at all.

Scientists have warned time after time again: do not take our animal experiments too serious, they tell very little about the effects of chemicals on humans. And some have also said: if we do find health effects in humans that are attributable to environmental problems than you still cannot treat them as if they are the only and most important health problems humans face. Other problems may be more life threatening and to more people.

There was a time when air pollution was so aggressive that nylon stockings hanging out to dry partly dissolved in the 'air', but in the 60 70 and 80ies very much has been done to clean up to environment. And successfully: our society is by every measure very much cleaner as it was a few decades ago. The quantities 'potentially' (an empty word, anyone,by the mere fact of being born is a potential millionaire) dangerous industrial chemicals that we are exposed to have decreased enormously. But our capacity in detecting these chemicals has increased beyond imagination. Wit laser technology a substance can be foud at the 10 to the minus 15 level. That means that if you have one million planets earth, each having 5 billion inhabitants, but only one criminal, technology would be able to find him. Nobody believes that this last pickpocket would pose a hazard to society, but if he were a chemical everybody would be convinced that no sum would be large enough te remove it.

In our example you are the Minister of Health and Environment. It is now time to go back to your cost/benefit analysis and judge whether the hunt for this last left criminal or last residue of a supposedly dangerous chemical is worth the effort. Are there ways that you as a Minister could use your money more effectively, that is: save more lives?.

At the Harvard Center for Risk Analysis they make a specialty of cost-benefit analysis and revently they have compared 500 of them. They calculated the median amount of money that is necessary to let someone live an extra year.

They split the 500 studies in three categories: ways to save a life through health care, through safety measures and through environmental measures.

In health care you can save a life through open heart surgery, through vaccination or mouth to mouth resuscitation to name but a few examples. When a doctor tells his patient to give up smoking even that can be considered as an attempt to save a life. Some may consider it a futile attempt, but it isn't according to the Journal of the American Medical Association. If a GP spends 5 minutes to thoroughly tell his patient to stop smoking that can be a very cost effective act indeed. It is true that many patients simply ignore this advice, but its cost are very low also: given an hour's salary of 144 dollars, this 5 minute advice only costs 12 dollars. If only one in thousand patients who receive this advice indeed stops than the total cost of saving this life is just 12.000 dollars.

That is cheap! Other ways to save a life are more expensive (though some forms of vaccination are cheaper or cost practically nothing). Open heart surgery for example is expensive as such, but the high success rate makes it relatively cheap to save a life. According to the quoted Harvard study the (median) price of a saved life through health care is 19.000 dollar.

Safety measures to save lifes include airbags in cars, better household stairs, better testing of electrical appliances etc. the (median) price of an extra year saved is here 48.000 dollar.

The third method to save lives goes through environmental measures: removing asbestos, stringent regulation of toxic chemicals and pesticides etc. The real dangers for life here are small, if not minute, the necessary measures to reduce these dangers even further are sizeable. The (median) price of a life saved through environmental measures is 2,8 billion dollar.

I started this story with a hypothetical calculation how as a Minister of Health and Environment you should choose between spending 2000 or 20.000 pounds for each life saved, a dilemma because for every number of lives you save, you lose some as well. According to prof. John Graham, director from the Harvard Center for Risk Analysis reality is even grimmer: 'This perverse pattern of investment amounts to "statistical murder" of American citizens. Policy makers need to ask harder questions about whether our public health and environmental protection dollars are well spent. Billions of dollars are being spent to eliminate trivial risks to health and safety based largely on speculative fears that man-made sources of chemicals and radiation are important causes of human cancer. If this same money were spent effectively, it could save 60,000 lives each year and thereby add 600,000 life-years to the life expectancy of the American people'.

References:

The Cost- effectiveness of Counseling smokers to quit. Steven R. Cummings et al. Jama 1989; 261:75-79

Five hundred life saving interventions and their cost-effectiveness. Tammy Tengs et.al. Risk Analysis, Vol. 15, no 3 1995.

Comparing opportunities to reduce health risks: Toxin Control, Medicine and Injury Prevention, by John D. Graham, Ph.D. Center for Risk Analysis Harvard School of Public Health NCPA Policy Report no 192 June 1995