Sebastian Farquhar and Owen Cotton-Barratt
Global public health remains a top contender for the best way to improve welfare through aid. Within health interventions, it is natural to allocate marginal spending to avert the most expected DALYs (disability adjusted life-years) per dollar.1
However, not all DALYs are the same and there are important differences between years of life lost (YLLs) and years lived with disability (YLDs). Not accounting for these categories separately may introduce a bias in decision-making because DALYs do not address non-health outcomes for individuals and the effects of outcomes on others. These effects are different in situations which involve primarily YLLs as opposed to YLDs. This analysis is of particular practical importance to effective altruists because two of the most promising interventions address different types of DALYS – deworming primarily averts YLDs and bed nets to prevent malaria primarily avert YLLs.2 This make us more inclined towards deworming as a top intervention than a naive evaluation would suggest. More sophisticated analyses incorporate terms that address many of these effects, but may still undervalue deworming relative to malaria nets.
This document is primarily written for people who already place a high weight on DALYs in identifying top public health opportunities. It does not argue for the use of DALYs, or consequentialist reasoning in identifying public health opportunities.
Overview of YLLs and YLDs in DALY calculations
The burden of disease, as calculated by the World Health Organisation in its 2010 Global Burden of Disease (GBD) assessment, divides DALYs into two categories – YLLs and YLDs. YLLs accrue when an individual dies. The gap in life-span between their age at death and the maximum life expectancy3, shown in dark blue in the graph below, contributes to the YLLs. The gap, while the person is alive, between full health and the degree of disability attributed to the condition, shown in light blue, contributes to YLDs. Note that the conditions which are assigned a ‘disability weighting’ and create YLDs include but are not limited to conditions that are traditionally thought of as ‘disabilities’.4
Graph adapted from Gold M., Stevenson D., and Fryback D. 2002
YLDs and YLLs in malaria and schistosomiasis
Although malaria causes a great deal of morbidity, its largest contribution to the burden of disease comes from lives lost, primarily of children under five. Indeed, when evaluating the health impact of a charity distributing bednets, charity evaluator GiveWell explicitly only addresses under-5 mortality. The best estimate for YLLs caused by malaria is roughly 20 times greater than that for YLDs.
Parasites of the sort that deworming addresses, however, cause more harm by making people ill than by killing people. For schistosomiasis, a parasitic worm, the best estimate for YLDs caused is roughly 10 times greater than that for YLLs, although there is substantial uncertainty.
DALYs are only about the individual
DALYs measure the impact of conditions on the health of individuals. However, if we are choosing between health interventions, and care about their benefits to broader society, we should also consider the effects of health interventions on others.
Many health conditions have significant externalities. More severe conditions can have large impacts on the lifestyles of families and friends. Transmissible conditions carry a very direct externality in the chance of spreading the condition to others. Death can be traumatic for those who knew the deceased. Even where one of these obvious mechanisms is not in place, a health condition which reduces the productivity of an individual will reduce the ability of a community to provide for its needs. Caring for individuals can also consume social resources that could have been spent elsewhere if those individuals were healthy. These effects are typically acknowledged as important, but are then ignored because they are hard to measure.
Without any good ways to measure these externalities, it might be reasonable to use the impact on the individual as a proxy for size of the total effect. However, it seems likely to us that the average size of the externality will depend on the type of direct health effect, and in particular may vary for YLLs and YLDs.
YLDs have larger associated externalities than YLLs
YLDs can have very large externalities. The cost of care and treatment can be very high even on a per person per year basis. In the developed world, life-time costs associated with managing conditions can be enormous. The life-time care costs related to the amputation of a leg in the US have been estimated at $509,275.5 The Global Burden of Disease 2010 assigns a weighting of 0.021 for amputation of a leg, long term, with treatment. So the health burden of an amputated leg would take more than 47 years to accumulate a single DALY, which is longer than the life expectancy of the average amputee. Since the marginal cost of DALYs, even in rich healthcare systems, is much less than this, the full impact of the condition will be substantially underestimated by only considering the health effects. In the developing world, although absolute costs of care are lower, the presence of conditions can dramatically reduce family incomes, both because individuals find it harder to work and because family members find their options for work restricted by the need to care for the individual.6 Because the costs of managing the conditions which create YLDs can be so high, the non-health benefits of avoiding that YLD can be high as well. This saving is not included in a cost-effectiveness analysis which only examines DALYs per dollar.
It is very difficult to weigh up the magnitude of the impact of the trauma and loss associated with YLLs. It seems likely, however, that these are often lower than the externalities we need to consider for health conditions which cause the same number of YLDs. An intervention that prevents the need for an amputation, for example, would avert as many DALYs as extending a life by less than a year. It is unlikely that the typical externalities of a death occurring a few months earlier than otherwise are on the order of $500,000 in scale, even in rich countries. Although there is clearly variation, as a rule of thumb YLDs are likely to be associated with larger externalities. Therefore, all else equal, we should prefer interventions that reduce YLDs. Because deworming primarily averts YLDs, this argues for preferring deworming to bed-nets when the costs per DALY are similar.
The externalities depend on age differently for each category
Health economists used to age-weight DALYs such that both YLDs and YLLs for the very old or very young were treated as less significant as those in the middle of life. However, in the current GBD framework there is no age-weighting. This is because DALYs represent only intrinsic health losses, and there is no principled reason why health should be more important at different ages. While this may be the correct approach to take for DALYs themselves, once we consider the indirect effects of health on other things we value, it becomes clear that age is relevant in choosing programmes. However, the effects are quite different for YLDs and YLLs.
YLDs in youth often have larger externalities
Where health conditions are present in young people the externalities are often larger. Young people are still developing rapidly and ill-health may negatively impact this development.7 These conditions can affect both individual well-being and also the process of accumulating human capital. Even where health conditions last for only a year in youth, they may have substantial effects throughout life which are not captured in health calculations. By contrast, a year with a condition which impairs development late in life will typically have a much smaller effect on the flourishing of the individual over their whole lifetime. Therefore, where interventions avert YLDs, they are better when they avert them younger, all else equal, and particularly in childhood. Deworming mainly averts YLDs in young people. The evidence for developmental effects of deworming in children could be improved by further investigation – but there is no disagreement that any such effects are stronger for children than adults.
YLLs in middle age often have larger externalities
The age-weighting used in previous versions of the Global Burden of Disease placed a high weight on DALYs created for young and middle-aged adults and a lower weighting on the very young and the very old. There are a variety of reasons for this sort of weighting, but many of these reduce to instrumental claims about the value of lost labour productivity, about the social disruption, or about the grief caused by a death.
Bereaved parents report stronger feelings of grief when losing older children than younger children, especially in resource poor contexts. Similarly, bereaved widows report feeling more grief when losing younger spouses.8 And adults of working age are more likely to have dependents, who may have a hard time adapting after their death. So the impact of death on others can depend on age, which should be a consideration in prioritising interventions.
From an economic perspective as well, the externalities of death in youth and middle age are higher than those at either tail. This is because society has expended some resources in developing human capital, but individuals still have a substantial period of continued productivity in front of them. It is not appropriate to consider this as a health effect of the death. However, when deciding which interventions to pursue it can be important to consider productivity losses, especially in comparatively poor contexts where economic growth has comparatively large welfare benefits. In these environments, parents may also depend on their children to look after them in old age, which means a child’s death later in life can be a pressing concern for their welfare.
As a result, where interventions mostly avert YLLs, one should prefer interventions that mostly avert deaths in young and middle-aged adults, all else equal. Malaria net distribution mainly averts YLLs due to infant and under-5 deaths. This makes us think it is a little less effective than the simple DALY calculation suggests.
An assessment of promising health interventions that cares about broader societal impact requires separate treatment of YLLs and YLDs. YLLs and YLDs cause different kinds of externality. This is relevant for a decision between two contenders for top interventions – deworming and malaria bed-nets – and may encourage us to prefer deworming. However, some of these effects are already modelled in intervention analyses which place less emphasis on DALYs averted.
1. For example, a simple reading of the work of the Disease Control Priorities Project 2nd edition, suggests such an approach. Some evaluators, such as GiveWell, place much less emphasis on averting DALYs.
3. The maximum life expectancy used in GBD 2010 is based on the lowest mortality rate found world-wide for each age-bracket. It is therefore, at 86 years, higher than the current at birth life expectancy in most countries.
4. Indeed one of the complications in assigning the current DALY weightings is that, as people are instructed to consider only ‘health’ effects, conditions such as complete hearing loss, are assigned comparatively low weightings because they represent different ableness rather than ill health as such.
5. MacKenzie EJ, Jones AS, Bosse MJ, Castillo RC, Pollak AN, Webb LX, Swiontkowski MF, Kellam JF, Smith DG,Sanders RW, Jones AL, Starr AJ, McAndrew MP, Patterson BM, Burgess AR. Health-care costs associated with amputation or reconstruction of a limb-threatening injury. J Bone Joint Surg Am. 2007 Aug;89(8):1685-92. The costs reported in this study are slightly out of date and based on the USA. In general, treatment costs have not fallen over the period, although it is possible that shifts to lower cost interventions may have reduced the representative cost since publication.
7. Of particular relevance to deworming, for example, is the indication that increased deworming substantially increases future earnings and future health. Baird et al. 2011 found that between 2 and 3 additional years of deworming as a child increased earnings as a young adult by around a quarter, partly because individuals worked more hours and were sick less often and partly because they were able to move into higher earning paid labour.
8. Ball J. Widow’s Grief: The impact of age and mode of death. J. Death and Dying. 1976