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Sebastian Roing

Should we value the life of a 25 year-old more than that of a 65 year-old simply because they have different social roles? Should we discount future health benefits because it is uncertain whether they will arise or not? Should we think differently about the individual burden of a disease when a whole community is affected instead of just one individual?

This post gives a brief history of the health statistic known as the DALY – Disability Adjusted Life Year. The DALY has come to influence many decisions in global health over the last 20 years. I raise a few problems with the statistic,and emphasise its benefits as a statistic that is comparable across causes.

The DALY is an attempt to merge data on morbidity and mortality into one statistic, and make it comparable across different diseases and causes. It assigns a numerical value between 0 and 1 to health outcomes, where death, the worst possible case, is assigned the value 1. Thus, it allows for simple addition of different health outcomes. This enables agencies such as the WHO to calculate the disease burden of a particular region, accounting for all the different diseases prevalent in that region.

Moreover, the DALY can also be used to guide resource allocation, by allocating resources to the intervention that saves the most DALYs per dollar. So how do we construct the DALY and put a numerical value on health outcomes? Well, at face value it’s a simple formula:

**DALY = YLL (Years of life lost) + YLD (Years of life lost due to disability)**

Suppose a young adult of 25 years is living in a remote area where there is little access to health care. Tragically, this individual has contracted AIDS, and receives no antiretroviral treatment. Nonetheless, the 25-year-old survives for a year, but then dies of an infection.

This scenario can be converted into DALYs. First, we need to account for the year lived with AIDS without receiving antiretroviral treatment. The 

 on this health outcome is 0.547. These weights are numbers between 0 and 1 and they signify how bad a particular health outcome is compared to death. 0 represents a state of full health, whereas 1 represents death. The figure below lists a few common causes and their disability weights. The full list of disability weights is available 

![](//images.contentful.com/yglmadi73s3x/36q34zblCgqiSEQGOWcYQ0/070e73062757f50d0e3c66cc17694a54/figure_1daly.jpg) Figure 1

To get the YLD for the 25-year-old we therefore multiply the number of years lived with AIDS by the disability weights (1 * 0.547 = 0.547). The other component, the YLL, is simply the years of life lost relative to the agreed standard life expectancy (87.8 – 26 = 61.8). The DALYs lost and the total burden of the disease for the 25-year-old is 62.347.

**DALY = YLL (standard life expectancy – age at death) + YLD (years lived with disability * disability weight)**

But wait. Aren’t there at a hundred ethical problems with this method? Well, there are a few. I will describe the four issues I think are most important in this post. Two of these issues have been resolved in the latest update of the Global Burden of Disease study from 2010.

History of the DALY and two (resolved) issues

The original DALY was developed at the Harvard School of Public Health in the late 1980’s. Other measures, such as YLL (Years of Life Lost) and QALY (Quality Adjusted Life Years) were already popular, but they offered no standardised way of measuring morbidity and mortality.

The DALY was subsequently adopted by the Global Burden of Disease 1990 study of the WHO (GBD 1990); a huge project which estimated the total, global disease burden by using DALY methods. The GBD series was later updated in 2004 and most recently in 2010. Over these 25 years, the DALY statistic changed significantly following a lively debate about, chiefly, two ethical issues inherent in the DALY; age-weighting and time discounting.

Reasonably, we might ask ourselves – Is it worse if a 25-year-old suffers from AIDS than if a 75-year-old suffers from AIDS? What about infants? Is the death of an infant as bad as the death of a 25-year-old? The original DALY envisaged the weighting of age according to social roles played by people of different ages. C. J. Murray explains the technical basis of the DALY in his 1994 article 

Quantifying the burden of disease: the technical basis for disability-adjusted life years

. The weighting of age in the original DALY followed the function in the figure below.

The weighting peaks at around 25 years, and decreases as age increases. Furthermore, the weighting starts at 0 at birth and increases quickly until the age of 25. This implies that the death of an infant, at birth, is weighted as 0 DALYs (nothing). So the death of an infant is definitely not regarded as bad as the death of a 25-year-old. And the weighting of age is linear. This implies that, in terms of DALYs, one 25-year-old suffering from AIDS for one year is approximately as bad as two 75-year-olds suffering from AIDS for one year.

Murray did not justify age-weighting by some differential intrinsic valuation of life. Rather, age-weighting was an attempt to capture different social roles at different ages. The young and the elderly depend on young adults for care, emotional and financial support. Sickness and death among this group of individuals is therefore particularly serious.

But if we open up for the possibility of weighting according to social roles, shouldn’t we also weight individuals across professions and income? What about doctors and nurses? Since people depend on them for care shouldn’t they also be given a higher weight? It turns out this kind of weighting is quite problematic. By weighting people according to their age we open up many other issues that would have to be considered before we could justify the application of age-weights. Furthermore, numerous critics voiced concerns about the universalism of a human life. The practise of age-weighting was consequently 

A related issue is time discounting, a constantly relevant problem in cost-benefit analysis. Toby Ord and Robert Wiblin have written extensively on this issue in our section on 

. Discounting is the practise of applying higher weights to benefits that arise in the present relative to the future. For example, most people would prefer getting a piece of chocolate today than tomorrow (see, for example, 

 experiment on present-bias). And I wouldn’t exchange $100 this year for $100 next year, chiefly because I could take the $100 today and invest them such that my return would give me more than $100 next year. We usually model this phenomenon using geometric discounting.

However, the practise of discounting is not as intuitive when it comes to health benefits. Is it better to cure an individual of tuberculosis today rather than next year? Not really. But could this cured individual contribute to society in such a way that we are able to cure more people of tuberculosis next year? Well, maybe, but Ord and Wiblin suspect that most benefits 

Time discounting was originally used in the DALY statistic for technical reasons. Suppose we let DALY estimates guide our resource allocation. What would be the benefits of investing in a research program that produces a vaccine for HIV? If the time horizon is infinite, then the benefits would be infinite, because we would prevent an infinite number of people from contracting HIV. Consequently, if we don’t discount benefits in the future, all resources should be invested in vaccination programs.

What is the problem with this reasoning? As pointed out by Ord and Wiblin, it is not appropriate to assume that no one would ever think of a vaccine against HIV if it weren’t done by one research program in particular. It is not the appropriate counterfactual. It is better to construct an explicit model that assumes that someone else would think of a vaccine in x years. Furthermore, discounting the DALY creates a lot of intergenerational inequality that is quite arbitrary. Originally, the DALY used a discount rate of 3%. This gives a weight of approximately 0.22 to DALYs that arise in 50 years. Is it fair to consider 5 deaths in 50 years as serious as 1 death today?

The most serious implication of age-weighting and time discounting, as noted by 

 was that no one could get rid of these practises without re-doing the entire analysis. Once a disease burden had been calculated for a particular setting it was more or less impossible to exclude time discounting and age-weighting without going back to the original data. This was a serious obstacle to transparency and transferability of results in the global health debate. I join the crowd of positive supporters of the WHO decision to ignore time discounting and age-weighting in the latest Global Burden of Disease study.

In the next post in this series, I will look at the DALY and its role as a measure of disease burden that is transferable across different conditions and illnesses. I will also discuss the future of the DALY, its limitations as an indicator of resource allocation, and an additional method that could include community effects into the DALY.

What values do we need to keep in mind about the DALY? Part I

 in this series, I introduced the DALY and discussed two resolved issues: age-weighting and temporal discussion. In this post, I will look at the DALY and its role as a measure of disease burden that is transferable across different conditions and illnesses. I will also discuss the future of the DALY, its limitations as an indicator of resource allocation, and an additional method that could include community effects into the DALY.

The DALY as a transferrable measure of disease burden

The DALY is meant to transcend illnesses and causes. We should be able to study the circumstances in a region and estimate the total burden of disease, in DALYs, by aggregating the lives lost and disability inflicted by all diseases in that region. Furthermore, if, for example, diarrhoea is the foremost cause of DALYs lost in that region, and there are ways in which diarrhoea can be mitigated at a low cost, then we should naturally allocate resources to this cause. This is where the DALY is really powerful. It gives a very clear indication of 

where resources are put to their best use

But what if I don’t agree with the disability weights used by the WHO? This is in fact a very real concern and something that has been debated since the conception of the DALY. How do we agree on disability weights for different health outcomes? In 1990 a panel of experts set all the disability weights. This was criticised and the 

 set disability weights using public surveys and expert consultation.

Still, suppose I have two interventions available. One distributes malaria nets and averts 0.2 DALYs per dollar. The other distributes antiretrovirals to people with HIV and averts 0.15 DALYs per dollar. Clearly, the net benefit of investing in the intervention that distributes malaria nets is higher.

However, I may reasonably argue that living with HIV/AIDS deserves a much higher disability weight than 0.547. This would change the cost-effectiveness estimate above. Maybe it would even make the DALYs averted higher than 0.2 per dollar. This example illustrates that 

we can never agree about the cost-effectiveness of different health interventions if we don’t agree on the relevant disability weights

, who also cited a few other disagreements. Some people think certain conditions such as fistula worse than death, but many people disagree. Some people would rather bring a person to full health than save the life of an infant. Some people emphatically disagree.

Where does this leave us? Well, we shouldn’t forget that a lot of time and effort actually has gone into making the disability weights as representative as possible. I myself feel that I am in no position to question most of the disability weights worked out for the GBD 2010. So should we trust the experts and the public surveys? In most cases, I think we should. But this does not imply that we should give up the chance of critical review.

In fact, all the hard work put into the development of the disability weights and the DALY constitutes a tremendous resource. The hard work has, amongst other things, gone into assembling evidence on different health outcomes. Even if one doesn’t agree with the final disability weights, the information provided is still valuable.

For example, the latest update, GBD 2010, includes many non-communicable diseases that account for an increasing share of global DALYs. Diabetes, musculoskeletal disorders and mental and behavioural disorders is inflicting a much higher disease burden globally than in 1990, and will create new challenges to health care systems in the future. Only this result is very important, as it implies we should do more research into cost-effective interventions that combat these conditions. Since the scale of the GBD 2010 is so extensive, it has ample opportunity to find many issues that we need to put more focus on. In combination with efforts to make global health data more transparent, accessible and reliable, this can only be an asset to the cause of effective altruism.

Another concern I had with the DALY initially was that it would obscure important subtleties that vary across issues and regions. An analogy of this would be the credit rating of financial instruments prior to the US sub-prime crisis. The credit ratings didn’t account for the composition of these financial instruments. (Apologies for the analogy to finance). In the case of the DALY, it is equally important that we don’t forget that the DALY is not a measure of everything - it doesn’t measure the risk of contagion, for example. Averting 200 DALYs in community A may in fact be inferior to averting 150 DALYs in community B if community B is struck with a particularly contagious disease.

Naturally, no indicators account for all aspects of a situation. In many ways, it might not be a very serious concern, since rigorous analysis will always supplement the DALY with other methods and practises. Giving What We Can performs charity evaluations using a range of indicators and data - see for example 

our latest evaluation of Water, Sanitation & Hygiene

. Nevertheless, one should take care and question cost-effectiveness statistics in the form of DALYs averted per dollar if they are referred to hastily. And don’t forget to think about the transferability of positive results – just because an intervention worked in one setting doesn’t mean it will work in another. A 

 covered some really interesting issues on the topic of results transferability[10].

We may reasonably expect DALY estimation to be an influential method in guiding resource allocation decisions in the future. But are there any other methodological problems that we need to consider?

When it comes to resource allocation there is one problem with the DALY that stands out. It was noted in this 

While we may determine disability weights for particular diseases and conditions, the welfare of the individuals suffering from these conditions will invariably depend on their own individual circumstances. For example, autism has a disability weight of 0.259. But we would expect the burden of autism to vary depending on income; country and place; and social attitudes. In fact, the burden of many conditions may vary so much as to make a universal disability weight meaningless.

A friend read my research for this post over my shoulder. He jokingly said: “What’s the disability weight for gluten intolerance?” (He is himself gluten intolerant but doesn’t suffer greatly from the condition since there are dietary alternatives available at a relatively low cost in Sweden). I immediately thought about how serious his gluten intolerance would be in a low-resource setting. Herein lies a challenge for the DALY. How do we account for circumstances such as income that changes the burden of a disease across individuals? How many more parameters do we include? Where to draw the line in this respect is a question for the future.

Another problem, which relates back to the social roles used to justify 

. Should we apply higher weights to contagious diseases that strike whole communities? Or are the disability weights attributed to such diseases high enough already? I think one could at least consider introducing some systematic (higher) weighting to diseases that are very contagious and thus disrupt social roles and groups.

For clarity, consider the following example. We have estimated the total disease burden for a large geographical area. Amongst the prevalent conditions are tuberculosis (disability weight: 0.331) and uncontrolled asthma (disability weight: 0.132). The total amount of YLDs (years of life lost due to disability = disability weight * total years lived with condition across population) caused by each condition in our geographical area is approximately the same. Remember that YLD is the second component of the DALY.

However, tuberculosis is prevalent in three communities only, whereas uncontrolled asthma is uniformly distributed across the entire population. Social roles in the small communities hit by tuberculosis are disrupting, since young children and young adults are particularly susceptible to tuberculosis. This systemic effect increases the burden of the disease both economically and socially.

Asthma, however, which is uniformly distributed, cannot be said to upset social roles in any systematic way. (I’m assuming that asthma is not generating any ostracization etc. - please take this as an idealised example). With reference to the burden of the diseases, it would then make sense to apply a weight to the YLDs in the communities struck by tuberculosis. This weight would not be applied to a lone victim of tuberculosis, but only to the three communities where the disease is disrupting social roles. Nor would the weight be applied to victims of asthma.

I think we must ask ourselves these systemic questions particularly if we want to use the DALY for resource allocation. To me, there is a value in a community, separate from the sum of the individuals, which should be relevant for the burden of a disease. This community effect should therefore also be relevant to cost-effectiveness analysis, and to the cause of effective altruism.

However, including such community effects would open up for the same kind of criticism that was levied against the age-weighting of the original DALY. For one, if we weight not only YLDs but DALYs according to community effects, then we are effectively going against the universalism of human life. Why? Because then the DALYs of 10 individuals living in a community would be weighted higher than the DALYs of 10 individuals living separately.

Community weighting could also introduce further problems - “should we give higher weights to certain communities which are of particular importance such as doctors?” “What is a community and where do you draw the line between communities and individuals?”. In fact, maybe it is easier to keep the DALY in its “pure” form and use other forms of analysis to assess community effects. However, this implies that reports such as the GBD 2010 might mislead future research and interventions by not acknowledging community effects. And community effects would at least capture my intuitive aversion of very contagious diseases.

The DALY is a fantastic effort to improve our understanding of the disease burden across causes and different regions of the world. But keep in mind:

Your own personal values: do you give the authority to the people behind the GDB 2010 to set disability weights?

The transferability of results: a success in one setting does not guarantee a success in another.

Other systemic problems such as community effects.

The disability weights are not adjusted to individual circumstances such as income and do not represent welfare: the burden of a disease may be much worse in one setting than another.

What values do we need to keep in mind about the DALY? Part II

Jessica Costello

In the first of this series for this year, we recap on Evidence Action’s activities in the last quarter of 2014.

September: ‘Dispensers for Safe Water’ delivers the goods

 developed by South Pole Carbon, which provides a snapshot of the benefits reaped from the ‘Dispensers for Safe Water’ program in Uganda.

More than 1500 chlorine dispensers have been set up in Uganda, with plans for thousands more to be installed by Evidence Action in future. The water purification system requires only a few drops of chlorine solution per filling of water in order to eliminate 99% bacteria, and is delivered by motorbike from central storage points. When approximately a quarter of all Ugandan children under 5 years are regularly affected by diarrhoea, and resulting malnutrition, stunting, cognitive impairment and early mortality, such a simple yet effective system is a valuable solution to the health challenges faced by Ugandan families.

A number of people living in rural Ugandan areas described the positive impact such a water system has had on their lives. For example, a mother from the Luwanga village now saves money on the firewood she would have burned to boil three pots of water daily, and she can now use this time to undertake other domestic activities.

Notably, the ‘Dispensers for Safe Water’ program has reduced the inefficient and unsustainable deforestation of firewood, thereby preventing 60,000 tons of carbon entering the atmosphere annually.

A local promoter, assigned to take care of dispensers and educate families on its use, describes his duties. In addition to checking and refilling the dispenser, he is responsible for maintaining the water point (e.g. weeding around the borehole), recording the number of users, encouraging users to be hygienic, and visiting families in their homes to ensure they are drinking safe water. Close collaboration with local authorities and trained local staff means the effective promotion, monitoring and refilling of dispensers.

The success of Evidence Action’s ‘Dispensers for Safe Water’ program lies in its deep understanding and use of the local environment; by recruiting the help of locals, the program stays rooted in communities it serves, leading to the improvements we are seeing in health, education, local forests and climate.

October: The importance of long-term data

In October, Evidence Action reported on two follow-up studies conducted in Kenya and Uganda, respectively, which built on previous research around improving educational outcomes and weight gain with the ‘Deworm the World’ initiative. These studies demonstrated the long-term positive impacts of deworming children beyond the original experimental timeline.

In Uganda, Kevin Croke followed up on Alderman and colleagues’ 2007 study by tracking children 7 to 8 years after the original deworming period. Dewormed children were found to have higher test scores in literacy and numeracy than the non-treated children in the initial program. We have written about this study 

Similarly, Owen Ozier built upon initial 2004 research in Kenya by 

 of deworming on preschool-age children whose older siblings were dewormed as part of the original study. Ozier found that there is strong evidence of large cognitive improvements among children whose siblings were dewormed; the healthier older children reduced infection rates among their preschool-aged siblings, which improved the latter’s cognitive development.

November: How much evidence is ‘enough’?

Despite these evident benefits reaped worldwide, 

 have argued that the WHO recommendation of mass treatment of everyone in an affected area is not supported by enough evidence. However, such a claim was influenced by studies with methodological weaknesses and the exclusion of other, methodologically strong, evaluations. As described in a 

 by Amrita Ahuja, Sarah Baird, Michael Kremer et al., mass deworming treatment does not only benefit individuals, but it is a highly cost-effective educational investment and a high-return economic investment even in the absence of any other health benefits from deworming.

Notably, mass deworming through the school infrastructure is substantially cheaper than undertaking treatment via screened programs. Further, as with vaccines, a ‘herd effect’ of deworming may be observed, meaning that treating individuals will improve outcomes for others by reducing transmission. Finally, significant labour market and income gains will be seen as a result of mass deworming treatment; in an unpublished 2014 study, an annualized internal rate of return of 32-55% (a way to measure the profitability of an investment) was computed for school-based deworming.

As such, Evidence Action believes in supporting the global effort to reduce the threat that soil-transmitted helminths (STH) pose, and have now joined the 

, a new group of organizations focused on reducing the public health threat of STH worldwide.

Currently, a number of projects are being considered for scale, although not all will progress to subsequent stages of development.

, a non-profit based in Botswana, to implement an advocacy program aimed at reducing the spread of HIV/AIDS among youth.

Testing the hypothesis that alternative strategies to food aid may be effective. This will include investigating cost-effective means of providing seasonal income support in Bangladesh and elsewhere, allocating people to different destinations, local price effects of worker inflow to migration destinations; impacts on household well-being, and welfare impacts of the program on non-participating households.

Potentially using Dispensers for Safe Water's existing rural delivery system to deliver nutrition information to targeted groups at a low marginal cost in order to reduce the impact of undernutrition and malnutrition on child health.

Working with the Government of Kenya on G-United, a pilot program for post-university volunteers that aims to increase social cohesion, improve student literacy outcomes, and provide unemployed college graduates with professional skills.

Understanding how to effectively target water treatment products to low-income households at scale, in order to expand our reach and impact beyond the current/planned catchment area of the Dispensers for Safe Water program.

December: Evidence Action, one of the ‘best charities for 2015’

At the end of this year, it remains clear that Evidence Action is an extraordinary charity. Evidence Action’s Deworm the World Initiative was just named 

 .The Life You Can Save calls Evidence Action one of the ‘best charities for 2015’ in its 

. Nick Kristoff in the New York Times highlights Evidence Action on his annual holiday list 

 for ‘spending money in the most cost-effective ways.’

All information and the image taken from the Evidence Action website.

Evidence Action in the last quarter of 2014

Tereza Růžičková

The winter holidays are a time of rest and social reunion, where we often finally have the time to sit down with our dear ones and share what we find important in our lives, debate and reflect on new experiences the autumn months have brought to us. Winter is also a time of giving and compassion, reflection on our goals and celebration of new beginnings and fresh perspectives. As such, it is a setting where we can nurture new conversations about effective altruism with those who have not heard about it; ideally over a cosy cuppa or two. Here are some tips on how to go about it.

It is always helpful to temporarily step out of our customary mindset, where we’re already familiar with the importance of giving and convinced of the urgency of the cause. Try to empathetically introduce the topic while being mindful of the variety of opinions our fellow debaters might bring to the table. A part of this is paying attention to the other person’s interests - some might be more inclined to ask about the statistics and research methodology, some will prefer to hear about stories of those we help.

Ask them about their thoughts and make sure that you listen as much as you speak. If they disagree, present your arguments calmly and always let them make their own decisions once they’ve had time to think it through. Show integrity by Socratically questioning your own views as well. Patience and understanding make any conversation more engaging, and whether the other person has a blank slate or a full palette of experiences with altruism, presenting GWWC from a place of confident composure can only serve everyone at the discussion table well. More tips can be found 

A safe eye operation costs only 20 dollars, but can dramatically improve an individual’s sight. An insecticide-treated malaria net for 6 dollars is three years’ worth of protection for two people against deadly mosquito bites. Annual treatment for severe, worm-transmitted tropical diseases can be delivered to a child for $0.50. Food fortification strengthening one child’s immunity only costs a few cents per year.

Being informed about the specifics, both in terms of the help that is needed, as well as the effectiveness of our recommended charities, can give others a clearer picture of the tangible impact a donation can make. The GWWC website as well as The Life You Can Save offer 

Practicing these debates with fellow members of your chapter can be very useful. Reading around and being able to give honest, evidence-based answers to others’ questions about how the charities are assessed and compared shows serious commitment and enthusiasm, which will be appreciated by friends and family members. Of course, there still might be information you are unsure about, in which case offer to find the relevant reference later or to put them in touch with someone more informed.

All our recommended charities are on facebook or twitter and following their newsletters and updates allows you to communicate about effective giving in terms of real human stories. That way, even though you are helping individuals thousands of miles away, you stay aware of the good your donation brings about on the every-day level.

For instance, Against Malaria Foundation provides photo and 

 from net distributions in many countries around the world. You can find out about community campaigns fighting schistosomiasis in 

 or more children getting to go to schools in 

 illustrates the importance of food fortification for pregnant women who live mostly on rice.

Thinking about such cases may motivate us all to give more. Donations will, for example, allow children to go to school, practice reading and joke around with friends instead of having to stay home with a fever, and contribute to many getting a brighter perspective on their futures when they don’t have to worry about having enough food for their children. Be proud of your giving and enthusiastically share what concrete change it can create in all those people’s stories.

Giving What We Can has a major strength in its community. If you enjoy going to presentations, debates and socials on effective altruism and have made interesting friends there, share this as an important part of the decision to give effectively. Our joint determination to eradicate extreme poverty through critical, educated evaluation of charities’ evidence is definitely something to be talked about and celebrated in a group, so do bring along those who want to find out more about us.

If you haven’t connected with fellow effective altruists yet, you can contact other members online, join one of the chapters closest to you, or start your own in your local city! The more of us can share our resolution to help, the merrier - and the more effective help we can deliver to those in great need.

Blog

What values do we need to keep in mind about the DALY? Part I

What values do we need to keep in mind about the DALY? Part II

Evidence Action in the last quarter of 2014

Tips on starting warm winter conversations about effective giving

Why community matters in thinking about social problems

The Ineffective Altruist: doing good when you’re a student

How to combat mistrust of Western health workers?

New Year's Resolutions and Giving

Giving What We Can 2014 Year in Review

The Best Charitable Campaigns of 2014