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Since 1st March, 1999
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Selling scare

Speculations whether foreign health data were wrongly used to build up a scare in India and promote the interests of hepatitis B vaccine producers now turn to deep suspicions. Correspondence between medical experts, including letters published last week in the international journal Health Economics, bolster the claim of some doctors that India is being coaxed into introducing a vaccine that the public-funded health system may not need and cannot really afford.

The correspondence, specifically, hints that the drive to introduce the hepatitis B vaccine into the nation’s universal immunisation programme may have been fuelled by an exaggerated estimate of the deaths caused by the hepatitis B virus in India.

In letters to the journal, Dr Jacob Puliyel, head of paediatrics at the St Stephen’s Hospital in New Delhi, has reiterated his concerns that data from Taiwan were, without justification, used to exaggerate the risk from hepatitis B in India.

Suggestions to introduce the hepatitis B vaccine in the immunisation programme hinged on a figure of 250,000 deaths each year from an infection of the virus in India. Dr Mark Miller, director of international epidemiology and population studies at the National Institutes of Health in the US, had claimed that the figure was arrived at through a complicated model.

But when asked by Puliyel to reveal the assumptions used in the model to derive the figure, Miller conceded that “there are major limitations from extrapolations from the limited available studies at the time on hepatitis mortality in developing countries.” He has also said that “countries should conduct their own analyses to formulate their own conclusions”.

The correspondence may come as a vindication for Indian doctors — and Puliyel is at the vanguard of this group which has long been campaigning for rational decisions in public health funding.

The figure of 250,000 emerges from the inappropriate extrapolation of Taiwanese data on India. Data available with the Indian Council of Medical Research (ICMR) suggest that the figure may be closer to 5,000. In other words, the policy on hepatitis B vaccine was influenced by a figure blown up 50-fold.

The correspondence not only hints at a conspiracy to push vaccines into the public health programmes of poor countries, but also puts a big question mark on the process of policy-making here. Are assertions from foreign medical experts or international funding organisations more credible than words of caution from local experts?

Any proven and safe vaccine should be available to those who can afford it. But public-funded programmes often involve hard decisions. Policy-makers should conduct cost-benefit analyses before they divert scarce resources from other health programmes into a new vaccine.

A cost-benefit analysis based on an exaggerated estimate only means that the policy-makers have been taken for a ride.

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