When a natural disaster and humanitarian crisis hits the headlines, many of us (including me) reach straight for our wallets. Emergencies have an easier time getting our attention (and emotional investment) than the chronic health problems that plague the developing world every day. But to hear the Disease Control Priorities report tell it, emergency aid is one of the worst uses of donations, despite being one of the most emotionally compelling.

The full discussion is on pages 1147-1161 of the report. A couple highlights:

The immediate lifesaving response time is much shorter than humanitarian organizations recognize. In a matter of weeks, if not days, the concerns of both the population and authorities shift from search and rescue and trauma care to the rehabilitation of infrastructure (temporary restoration of basic services and reconstruction). In Banda Aceh, Indonesia, after the December 2004 tsunami, victims were eager to return to normalcy while external medical relief workers were still arriving in large numbers.

Even if a donation is made minutes after a disaster, it might not be used in any meaningful way until it’s too late for emergency relief. Another reason to favor organizations with staff already on the ground.

Several specific emergency interventions are criticized for high costs and low or negative effects, including mobile hospitals:

The limited lifesaving usefulness of foreign field hospitals has been discussed. Again, the lessons learned from the Bam earthquake are clear. The international community spent an estimated US$10.5 million to dispatch approximately 10 mobile hospitals, which arrived from two to five days after the impact, long after the last casualty had been evacuated to other Iranian provinces.

And search-and-rescue operations (particularly those not carried out by locals):

Few developing countries have established the technical capacity to search for and attend to victims
trapped in confined spaces in the event of the collapse of multistory buildings. Industrial nations routinely dispatch search
and rescue (SAR) teams. Costs are high and effectiveness is reduced by delayed arrival and quickly diminishing returns.
Following the 1988 earthquake in Armenia, in the former Soviet Union, the U.S. SAR team extracted alive only two victims at a cost of over US$500,000. In Turkey in 1999, 98 percent of the 50,000 people pulled alive from the rubble were salvaged by relatives and neighbors. In Bam in 2003, the absence of high-rise and reinforced concrete buildings ruled out the need for specialized teams. Nevertheless, according to UN statistics, at least US$2.8 million was spent on SAR teams. An alternative solution consists of investing these resources in building the capacity of local or regional SAR teams—the only ones able to be effective within hours—and training local hospitals to dispatch their emergency medical services to the disaster site.

The report is also harsh on in-kind donations, which it says are “not only are of limited use, but often cause serious logistic, economic, and political problems in the recipient country” due to warehousing issues.

The report’s bottom line is that “emergency relief is “one of the least cost-effective health activities,” and no substitute for (a) disaster preparedness (discussed on pgs 1158-9); (b) proven interventions to deal with chronic, everyday health problems.

I should note that this chapter is less thoroughly referenced than most others in the report, although this is likely because emergencies are a bad environment for meticulous study (and so evidence must be informal and observational instead). Having read it, I’m personally hesitant to give to disaster relief again. I’d rather up my donations to projects that aim to strengthen everyday health infrastructure for those in chronic need. I do feel an emotional pull to try to help when disaster strikes, and I feel this pull more strongly in the aftermath of the headline than contemplating it in the abstract - but I also agree with the DCP report’s emphasis on using limited funds as well as possible:

The willingness to spend hundreds of thousand of dollars per victim rescued from a collapsed building in a foreign coun-
try is a credit to the solidarity of the international community, but it also presents an ethical issue when, once the attention has
shifted away, modest funding is unavailable for the mid-term survival of tens of thousands of victims.

Broadly-speaking, we think of “cost-effectiveness” as referring to how much of value is accomplished for a given amount of money. If two interventions are both proven and scalable to similar degrees, the more cost-effective one is a better investment because it allows the same donation to accomplish more of value. However, “value” means different things to different donors: to some, $200 to save a child’s life might be a great deal, while others may prefer $450 to repair a fistula.

We prefer to leave major judgment calls to our donors when practical. This means that rather adopt a single definition of value (such as Disability-Adjusted Life-Years), we hope to find the most cost-effective interventions for several different definitions of value. We can’t cover every possible notion of what’s worth funding, but we hope to be of use to as many donors as possible within the cause of developing-world health (our current focus - we will be moving on to economic empowerment later).

The following are several philosophical goals - i.e., definitions of what results make an intervention “valuable” - that we think will appeal to many donors.

1. DALYs averted. Although it isn’t our favorite measure of value, the Disability-Adjusted Life-Year is a widely used metric that considers all forms of mortality and morbidity. Some donors may feel most comfortable aiming to avert as many DALYs as possible for their donation.
2. Economic benefits. Health problems impose an economic burden, not just a moral one. There are sometimes attempts (such as the “benefit:cost ratio” used by the Copenhagen Consensus and some versions of the social return on investment metric) to combine economic and moral benefits into a single figure, measured in dollars.
3. Life-years saved - for those who put a lot of weight on being alive vs. not alive (and less weight on quality of life). Interventions that focus on infant mortality are likely to be cost-effective in terms of saving life-years.
4. Lives saved.
5. Adult lives saved. It is common to value adult lives more than children’s lives. In addition, adults are more likely to have dependents, making their deaths arguably more tragic (in a way that DALYs could capture in theory, but that DALY estimates generally don’t capture in practice).
6. Cases of extreme suffering prevented/rectified. This goal has several subcategories, for different conceptions of what constitutes extreme suffering. One that jumps to mind is fistula (and other deformities associated with ostracization).
7. People brought to a normal standard of health and potential productivity. In some ways the opposite of the cause immediately above, in that it focuses on helping those with high potential rather than helping those with high need. (There are different places one could draw the line for “normal health and potential productivity” - is it enough to prevent/cure someone’s blindness, or is it also important that they be adequately nourished and have reasonable job opportunities?)
8. Unwanted pregnancies averted / population growth slowed. Some donors might see births averted as a negative; others might feel that it is the key to better quality of life and sustainability.

Some of these metrics are highly well-defined and relatively easy to find or form cost-effectiveness estimates on. Others are far less so. We aren’t necessarily going to be conducting a separate search on interventions for each, but we think it’s productive to get as many appealing “goals” on the table as possible before beginning to narrow down the programs we’re focusing on. We hope that we won’t leave out programs whose potential effects are highly appealing to a large/important set of donors, even if they fail a “cost-effectiveness test” based on other metrics.

If you feel that we’re leaving out any important ones, please let us know. (We will also be consulting with our supporters and Advisory Board on this question.)

Business Week writes:

According to the World Health Organization, about half of the imaging equipment sent to developing countries goes unused because local technicians aren’t trained to operate it or lack the necessary spare parts.

(H/t Aman at THDBlog)

Is this possible?

(Note: I tried to find the original WHO source and all I could find was this article stating that “more than half of the medical equipment in developing countries is left unused or broken because it is too complicated or expensive to operate and repair,” which is substantially different.)

We are doing both region-based and program-based research on developing-world health. First I will discuss our program-based research, which will focus on (a) finding particular interventions (and/or clusters of interventions) that appeal to us; (b) finding organizations that implement these interventions “vertically,” i.e., replicating the same basic program across a variety of regions.

For these purposes, we particularly value interventions that are proven, scalable, and cost-effective.

Unlike most foundations, we are seeking explicitly to serve individual donors - donors who don’t have personal connections to particular organizations or expertise in the issues, and who therefore are better suited to expanding what already works (i.e., interventions that are proven and scalable) than to exploring unproven innovations. More on this idea at our FAQ, as well as in this blog post.

We think of an intervention as proven when:

• It has been previously carried out and carefully, publicly evaluated (often through academic research) in a way that provides strong empirical evidence for its positive impact on people’s lives. (A future post will further discuss our position on the “evaluation hierarchy” and what sorts of evidence we think are necessary under different circumstances.)
• The conditions under which it has been evaluated match the conditions under which it is likely to be carried out again, in as many relevant ways as possible.

We think of an intervention as scalable when:

• There is a significant amount of unmet “need” for the intervention, i.e., conditions under which the intervention would be helpful but has not yet been funded.
• Donations can be used to replicate the intervention in a variety of areas, while recording enough information about its execution to be reasonably confident that it is working as intended.

Defining “cost-effectiveness” is significantly more complex, and will be discussed in the next post.

Deciding where to give involves making major judgment calls: decisions that rest on subjective and otherwise highly debatable claims (such as the decision of which sort of life change to aim for). We have no pretense of being able to make such judgment calls “objectively” or “perfectly. Rather, we try to:

• Be explicit about which values we are pursuing and which judgment calls we’re making. For example, we’ve already declared our preference for funding proven and repeatable interventions, and we’ve declared our decision to focus on developing-world direct aid for the coming year.
• When practical, leave major judgment calls to our donors rather than making them ourselves, by recommending a variety of charities that are strong according to different criteria. This approach is especially important for judgment calls that our donors haven’t agreed to in advance (unlike the two listed directly above).

We are currently focusing on health interventions for the developing world (we will research other aspects of developing-world aid later in our process). One of the major judgment calls involved in choosing a health intervention is the decision between a region-based approach and a program-based approach to giving.

Taking a region-based approach means focusing on a particular part of the world; learning as much as possible about the people who live there, the opportunities they have, and the problems they face; and then finding a program that is well-suited to addressing the particular needs of this region. For regions with many interrelated health problems, such a program will likely be one that aims to strengthen the general quality of health care in the region, which will make it possible to address many health issues at once. (One such program is Partners in Health, a recommended charity from our last round of research that focuses on bringing full-service health care systems to poor rural areas.)

Taking a program-based approach means focusing on a particular intervention (or cluster of interventions); learning as much as possible about the conditions under which this intervention has been shown to improve lives in the past; and then finding a program that replicates this intervention across many regions. (This is the approach we took in evaluating Population Services International, which markets materials such as condoms and bednets across the world.)

A region-based approach has the advantage that it is more likely to be well-fitted to the particular people it serves and their needs. A program-based approach, however, may in some cases be a simpler and/or more cost-effective way to address a particular health problem, which means that it may be a more efficient and reliable way of changing lives for the better.

We will be taking both approaches, and presenting the options for donors that correspond to each. In future posts, we will discuss the specifics of (a) our region-based approach, i.e., how we will be choosing one or more countries to focus on; (b) our program-based approach, i.e., how we will be choosing one or more interventions to focus on.

Elie thinks that fistula is worse than death. jsalvati disagrees.

I’d rather bring someone to full health than save an infant’s life. Ryan agrees, but Basti does not and Ron Noble emphatically does not.

It’s possible that we would all agree if we knew more about the lives of people in the developing world, or if we just had a long enough to argue about our values. It’s also possible that we wouldn’t. And as long as we disagree, we’ll have different opinions on what the most “cost-effective” interventions are. For example, if it’s true that fistulas can be repaired for $450 each, is this a better or worse use of donations than preventing children’s deaths for $200 each through vaccinations? My answer would be “It depends on the donor.”

Converting disease burdens and intervention benefits into DALYs doesn’t resolve questions like this. Rather, it obfuscates them, by converting the two interventions into the same terms using a single set of philosophical values. If the numbers above ($200/death averted for vaccinations, $450/surgery for fistula) are accurate, they allow different donors to make their own judgment calls, while being informed about their options. But these aren’t the numbers you’ll find in the Disease Control Priorities Project’s summary tables; instead, you’ll see only that surgical services cost an average of $136 per DALY averted (Jamison et al. 2006, Pg 75) and that the vaccinations interventions costs an average of $7 per DALY averted (Jamison et al. 2006, Pg 77).

Some simplification and information loss is necessary in order to compare different options, but reducing everything to a single unit means being able to serve only a single kind of donor. I’d prefer to estimate the effect of different interventions on a variety of “life outcomes” that different donors might value differently. We will discuss this variety more in a future post, but here’s a quick list:

• Total life-years saved.
• Adult lives saved (as it is common to value adult lives more than children’s lives).
• Cases of extreme misery, such as fistula or perhaps severe elephantiasis, averted.
• People brought to a “normal” level of health, i.e., without any debilitating nutritional or other conditions.

All of these things need to be separately estimated to produce DALY estimates. The DCP report did so with admirable thoroughness and far more people than we have (Jamison et al. 2006, Pgs xxiii-xxxiv). Yet because they published only their DALY estimates (not, with some exceptions, the estimates of different health problems that went into them), they buried a great deal of this work, and produce cost-effective estimates that are useful only if you’re completely on board with all of their values (from how bad each disability is to how to value different years of life). We’re currently trying to get in touch with the authors so we can get access to more of the details; if we don’t, we’ll have to repeat much of their work (with less capacity to do so).

Sources

• Jamison, Dean T. et al., eds. 2006. Disease control priorities in developing countries (2nd Edition) (PDF). New York: Oxford University Press.

Previously in series:

• Disability-Adjusted Life Years: Introduction
• Disability-Adjusted Life Years II: Variations

Tactical Philanthropy:

Sooner or later, donors are going to start being willing to pay for advice on how to give. This will transform philanthropy.

I agree that donors should be willing to pay for advice on how to give. I certainly would have done so back when I was in the for-profit sector, if I could have found an advisor I had confidence in for a price I could afford.

But it’s conceivable that donors - especially small donors - will never have to pay for philanthropic advice, because someone else will pay to give them that advice. To give a simplified example: say that you care passionately about the cause of K-12 education, but know little about it. Now say that for $1,000, you can fund a philanthropic researcher to produce a report for other donors whose gifts to K-12 education charities will total $10,000. That means you have the choice of giving $1,000 directly to a K-12 charity (though you don’t have much to go on in picking one), or spending that $1,000 to “redirect” $10,000 of uninformed giving to the charities recommended by researchers.

The latter can be a pretty good deal. Unlike in investing, in philanthropy it makes perfect sense to pay for the privilege of redirecting other people’s money. (In fact, this practice is already widespread - large donors often fund fundraising campaigns, with the aim of raising money from others, and lots of people are happy to fund advocacy charities that are ultimately aiming to redirect government funding.)

Picture a world where some donors use philanthropic research for free, and other donors pay for that research with the knowledge that it’s redirecting the first group’s money. This isn’t the only, or necessarily the most aesthetically appealing, way for philanthropic research to get funded. But it’s a perfectly good deal for all parties involved (the donors that get the free research and the donors that pay to improve others’ giving). It’s a model that couldn’t work in for-profit investing, but when it comes to philanthropy where donors are seeking to create public goods rather than add to their own wealth, I see nothing unsustainable about this setup.

That’s the basic arrangement we’re currently pursuing. We are seeking GiveWell Pledges from donors who might be happy to use our research, but don’t necessarily want to pay for it. Meanwhile, a different set of donors pays our operating expenses, in the hopes that we’ll be able to move money from the first group.

Coming across the current feature on the DCPP’s home page reminds me of how much I care about the issue of obstetric fistula.

The following are highlights from the article linked above (emphasis mine):

For countless women in developing countries, going into labor is the painful beginning of a lifetime of unremitting shame and misery as a despised social outcast—destitute, childless, and abandoned by family and friends.

These women have a condition called obstetric fistula. A fistula, the Latin word for “pipe,” is an “abnormal passage” between organs — in this case, between the vagina and the bladder, the rectum, or both. The hole makes the woman uncontrollably incontinent of urine or feces or both and transforms a healthy person into someone viewed as a leaking, reeking, “moving latrine,” in the words of Veronica Yakobe, a Malawian woman who endured 23 years of indignity before an operation at Nkhoma Hospital in her country’s central region closed the fistula.

• 2 million to 3.5 million women worldwide currently [live] with obstetric fistula.
• Statistics from Ethiopia, Nigeria, India, Pakistan, and elsewhere show that the majority of fistula sufferers are abandoned by their families, divorced by their husbands, and forced to fend for themselves, often by begging. Some, like a group of Somali women who leapt from a pier chained to one another, end their lives in despair.
• Studies of patients undergoing fistula surgery find the majority in their early twenties or younger. In one Nigerian study, 72 percent were between the ages of 10 and 20, 82 percent having married between 10 and 15.
• A number of facilities, most prominently the renowned Addis Ababa Fistula Hospital, in Ethiopia, repair thousands of fistulas each year at a cost of about $450 for each operation and related care.

The disability weight used for fistula in DALY calculations is .430 (Pg 121 of the Global Burden of Disease report (PDF)). For context, the disability weight for blindness is .600 (Pg 120). To me, fistula seems much worse. Not only does a person undergo severe physical trauma, but she also often suffers severe social consequences such as communal ostracization and abandonment by her family.

In fact, it’s hard for me to imagine a cause I’d rather attack. I’d much rather prevent a fistula than save a life. The fate described above seems worse than death.

We’re planning to look into fistula carefully, and I hope we’ll find donors a great option for helping those afflicted.

In theory, you can fight HIV/AIDS by teaching safe sexual behavior; fight diarrhea by promoting hygienic practices; reduce child mortality by educating mothers; etc. However:

• Research on the effectiveness of these sorts of programs is thin; and programs that combine documented effectiveness with clear replication models are, so far as we can tell, rare to nonexistent.
• Changing people’s behavior isn’t straightforward. For an example, consider the finding - regarding hygiene education - that “The interventions promoting the single hygiene practice of washing one’s hands with soap tended to achieve greater reductions in disease than those that promoted several different behaviors … numerous messages dilute each other in the minds of the target audience” (see DCP pg 785 - references given there).

If it’s true that education works best when it’s focused, that means that planning an education program right means not just identifying behaviors that need changing, but analyzing which changes would be most beneficial. That’s a complex undertaking, and so is changing how people from another culture live their daily lives.

I’m generally not very optimistic about this category of intervention given what we know about it. Handwashing programs appear to be pretty well-documented and are a possible exception.

Both the Disease Control Priorities report (DCP) and Copenhagen Consensus (CC) acknowledge malnutrition as an extremely widespread and damaging problem, and both discuss a variety of interventions including breastfeeding promotion, vitamin supplementation, and fortification.

Yet both give hardly any space to the idea of direct food aid, i.e., providing healthy food (or the money necessary to purchase it) directly to people in poverty. CC states that such interventions are “cost-effective but more costly [than other interventions],” and that “because of the emphasis on costs and cost-effectiveness levels we focus on [other interventions such as supplementation] only” (Pg 6). DCP’s chapter on malnutrition (551-565) mentions direct aid only in one paragraph, in the context of comprehensive child nutrition programs, and states that “No consensus exists on when or how to include supplemental food to reduce undernutrition, and inefficient targeting is frequently a key constraint to effectiveness” (556).

Direct food aid seems to me to deserve much more attention, specifically because it is a potential solution to several of the most difficult types of malnutrition to address:

• Iron deficiency, which can cause anemia and impair cognitive development (DCP 553-4), is extremely difficult to address through supplementation or fortification because of how frequently iron needs to be ingested (DCP 558). Might frequent consumption of meat be an easier sell than frequent consumption of supplements?
• Protein-energy malnutrition can result in emaciation and stunted height (30-50% of under-5 children sub-Saharan Africa and South Asia suffer from these problems - see DCP Pg 552). As this condition results from insufficient calorie consumption, it does not appear to be treatable through vitamin supplements. Breastfeeding may ensure adequate calories for infants, but what about afterward?
• There is also always the possibility that our understanding of nutrition isn’t sufficient to name all of the necessary nutrients, and that the best way to give someone a diet that works as well as ours is to give them similar food (rather than simply identifying what seem to be the essential nutrients and providing those).

Direct food aid programs have come under fire due to the practice of obtaining the food from the developed world, which may cause economic distortion and problems for developing-world farmers. But this problem doesn’t seem inherent to direct food aid, only to programs that insist on using developed-world surplus food; a program that bought what it could from nearby farmers, and provided the rest from overseas, would not obviously cause more distortion than other aid programs.

Direct food aid programs may be costly and complex, but they may also be the only way to ensure truly adequate nutrition in some parts of the world. Why aren’t they getting more attention from otherwise thorough analyses?

According to the Disease Control Priorities Project, expanding vaccination is an excellent fit for donors who want proven, cost-effective, scalable ways of helping people. According to this table (more detailed version on page 401 of the full report), both South Asia and sub-Saharan Africa have relatively low levels of existing coverage (50-58%), and vaccinating more children could save lives for about $200 each. If saving lives is in fact your priority (and we know it isn’t for all donors), that’s hard to beat.

The most promising nonprofit I know for implementation is the GAVI Alliance, which we have yet to thoroughly evaluate.

I get two very different pictures of how aid funding works, depending on whether I’m looking at my options as a donor (as I’ve been doing for the last couple of years) or reading papers intended for policy makers (Disease Control Priorities report, Report of the Commission on Macroeconomics and Health).

The latter sources focus almost entirely on the granting of aid to developing-world governments by “donors” including “bilaterals, multilaterals, global programs, foundations, and large NGOs” (pg 249) - i.e., megadonors (not people like me). Pgs 247-250 discuss the coordination problems caused by different donors’ earmarks and reporting requirements as well as the potential advantages of “ensuring the countries, not donors, drive the coordination” (249). The WHO Commission on Macroeconomics and Health takes a similar perspective, endorsing a top-down plan to be implemented in partnership with governments, using the Poverty Reduction Strategy Papers they create.

Yet as a donor, I’ve never looked at or discussed the possibility of giving money to developing-world governments. I’ve dealt with U.S. public charities, and the proposals they send (large list here) involve their own projects carried out by their own staff. We’ve never discussed their role in helping to carry out the kind of large-scale plans endorsed by the WHO commission. A quick glance at CARE’s Form 990 reveals that only 18% of its expenses are grants of any kind, so they certainly don’t appear to be directing the majority of their aid to governments.

It’s possible that the link goes the other way: the DCP report mentions governments’ hiring NGOs (Pg 252). But if the NGOs are contractors, not agenda-setters, where does an individual’s donation fit in?

Either way, it doesn’t help that few NGOs have been able to give us a clear explanation of what they do (in particular, how their top-level agendas are set).

Complicating the matter further are “alliances” such as GAVI and The Global Fund. These appear to be partnerships aiming to consolidate and coordinate funding, and they fund both governments and NGOs. Does that make them a more appropriate recipient of gifts than typical NGOs? How does the Global Fund to fight AIDS, Tuberculosis and Malaria coordinate with the Roll Back Malaria Partnership and Stop TB Partnership, which appear to have largely overlapping goals but still all solicit donations individually?

Let’s say I’m a donor who trusts the WHO Commission and just wants to be as helpful as I can, without imposing my opinions about particular diseases and priorities. Should I give to the WHO? To a developing-world government? An alliance? An NGO? We’re getting a better handle on the situation and starting to break down the options, but as of yet we still haven’t seen clear answers to these sorts of questions.

Previously, I outlined the basics of the Disability-Adjusted Life Year (DALY) metric. It takes the approach of converting all health burdens into equivalent “years of healthy life lost”: a year of blindness is counted as .6 lost years, a year of severe malnutrition is counted as .053 lost years, etc.

This post discusses two common “variations” on DALYs, meant to deal with relatively thorny disagreements about how different years of life should be valued. As before, page numbers refer to the Global Burden of Disease 2000 report.

Age-weighting

One variation has to do with the intuition some people have that a 20-year-old’s death is more tragic than an infant’s. (I expressed this intuition myself back in November, and I still hold this view.) In an attempt to square with this intuition (which is common and well-documented, as Pg 400 shows), the DALY metric includes an optional age weighting feature that lowers the value of a healthy year of life lived at very young and very old ages, relative to the value of a healthy year of life around age 20. DALYs can be computed with or without age-weighting (”without” just means that all years of healthy life are valued the same).

Discounting

The other variation has to do with valuing present vs. future benefits of aid. DALY calculations apply a discount rate to future benefits; for example, when using a discount rate of 3%, one would count a year of healthy life saved ten years from now as being worth only 74% as much as a year of healthy life saved this year (74% = 1/1.03^10).

I confess that I don’t fully follow the justification for discounting given in the Global Burden of Disease Report, which claims that “the strongest argument for discounting is … [that] not discounting future health would lead to the conclusion that all of society’s health resources should be invested in research programs or programs for disease eradication” (400), which apparently is considered obviously wrong by the authors. Personally, the most appealing argument I can think of for discounting is that helping a person can help them help others, so helping a person sooner is literally “worth more” than helping a person later.

Notation

DALYs(0,0) refers to DALYs calculated with a 0% discount rate and no age-weighting. DALYs(3,1) refers to DALYs calculated with a 3% discount rate and age-weighting. (The first number in parentheses is the discount rate; the second is a 1 if age-weighting is being used, and a 0 if not.) See Pg 401 for the specifics of how varying these numbers affects the valuation of different years.

In theory, you can calculate DALYs using whatever parameters best fit your own philosophical values. In practice, the reports we’ve seen using this metric (Global Burden of Disease Report, Copenhagen Consensus, Disease Control Priorities Project) will give you, at most, DALYs(0,0), DALYs(3,0) and DALYs(3,1), and will rarely give you the inputs into these numbers so you can calculate your own versions. That means that if you want to use a 6% discount rate, you’re completely out of luck; there’s no way to convert DALYs(3,0) to DALYs(6,0) without having more information. More importantly, it means that:

• You can’t use your own version of age-weighting. Even the age-weighted version of DALYs still rates an infant death as about equally tragic to a 20-year-old death (it values a year more for a 20-year-old, but when you work it all out the value of a life comes out the same). There is evidence (see pg 401) that people find a 20-year-old’s death to be far worse; if you share that intuition, then DALYs as they are usually presented won’t reflect your values, and there will be no way to convert them into a unit that does.
• You can’t use your own disability weights. Personally, this is the area I’d most like to see some variation in - the official disability weights disagree violently with my personal intuitions about, for example, how bad it is to be severely malnourished (current weights put it at only 5.3% as bad as a year of life lost - see Pg 121) or how bad it is to go through an abortion (it appears that this is counted as “no cost” by DALYs - see Pg 121 again).

The DALY metric does have some flexibility to accommodate different personal values, but in practice it ends up being pretty rigid. More on this in a future post.

Next in series:

• DALYs and disagreement

Previously in series:

• Disability-Adjusted Life Years: Introduction

The Community-Led Total Sanitation program looks like a potentially good target of funding.

• I like the approach: attacking all of the many sources of contamination (see diagram) rather than focusing narrowly on water.
• It’s been done before, with potentially encouraging results (see page 9). I haven’t seen enough on it to call it a “proven” approach, but it might be.
• It may be significantly more cost-effective than other approaches to sanitation (see page 21), as it focuses on behavior rather than infrastructure.
• It’s now being replicated in many areas; that implies that there’s a process in place for replication, and that more funds could result in more people reached.

But I can’t find out how to fund it.

The program’s summary page links to three organizations. One appears devoted to research rather than replication. Another is a water and sanitation omnibus program whose activities include many of the activities I’m less confident in. CLTS is nowhere on its list of global initiatives. The third organization is CARE, a giant organization whose website barely mentions CLTS (and its only use of the program appears to be as an “entry point” to other programs).

We think programs that are proven, cost-effective and scalable should be popular. But in many cases, there isn’t even a mechanism for this to happen - some of the most promising interventions aren’t even on a donor’s menu.

We’ve had many discussions in the comments about the metric known as Disability-Adjusted Life-Years (DALYs). The DALY essential converts the burdens imposed by all health issues - from premature death to blindness to injuries - into a single, consistent unit. It is the metric of choice for the Disease Control Priorities Project as well as a centerpiece of the Copenhagen Consensus analysis, and is used widely by the World Health Organization - yet it isn’t, and likely won’t, be the central metric in our analysis.

At this point I want to start a more thorough discussion of why this is. I’m going to start at the beginning, with a full description of what DALYs are (and the different ways of calculating them). Some readers will already be familiar with what’s below, but we want to make sure we clearly describe the metric and give examples of its implications before discussing its strengths and weaknesses.

The most complete account of DALYs I know of is in the Global Burden of Disease report. Page numbers below refer to this report.

The basics: burden of health problems in terms of years of life

A DALY is a measure of the “burden” of a health problem; two common uses of this measure are (a) ranking diseases and risk factors (from most to least burdensome), as the Global Burden of Disease report does, and (b) ranking different interventions (in terms of how much they can be expected to reduce burdens, “per dollar”), as projects including DCPP do. The basic DALY formula is on page 48:

DALY = YLL (Years of Life Lost) + YLD (Years of Life lost due to Disability)

YLL is the more straightforward component. Putting aside discounting/weighting issues (to be discussed later), the death of a male infant (life expectancy 80 years) would be counted as 80 years of life lost, while the death of a 45-year-old female (life expectancy 83.72 years) would be counted as 38.72 years of life lost (see page 402 for the life expectancy figures). Without further adjustments, this implies that the death of a single infant is considered about as bad in and of itself as the death of two adults.

Quantifying morbidity

YLD represents an attempt to convert years of life affected by a disability into the same terms as years of life lost due to premature death. For example:

• A year spent with blindness (as opposed to a year spent with “normal health”) is counted as 60% as “bad” (i.e., as much burden) as a year of life lost due to premature death. So the metric would count a condition that permanently blinds five 30-year-olds as about equally “burdensome” to a condition that results in the death of three 30-year-olds.
• A year spent with protein-energy malnutrition to the point of wasting (i.e., being severely underweight) is counted as 5.3% as “bad” as a year of life lost due to premature death. This implies that if a child is malnourished to the point of being severely underweight and having a lower life expectancy (say 30 years), the burden in DALYs is equal to about 51.59 (50 years of life lost due to early death; 30 years of malnutrition * 5.3% = 1.59 YLD), which is about 60% the burden of an infant death.

As for where these numbers come from (why is a year of blindness 60% as bad as a year lost, and a year of wasting 5.3% as bad?), they were obtained through a variety of methods usually involving surveying groups of people on their subjective attitudes (Pg 50 has more on this). The complete list of disability weights - giving a conversion factor for every kind of health condition analyzed by the GBD - is found on pages 119-125.

This basic framework - evaluating all health burdens in terms of “life-years,” with a year lost to death counted as a full year and a year otherwise afflicted counted according to the disability weights - is common to all DALY calculations. In the next post on this topic, I’ll discuss some of the variations between different versions of DALYs; some versions “discount” life-years that are early in a person’s life, late in a person’s life, or far in the future. After that, I will explain what we think the limitations of this metric are as it applies to our work.

Sources

• Copenhagen Consensus Center. Copenhagen Consensus 2008. http://www.copenhagenconsensus.com/Home.aspx (accessed April 15, 2010). Archived by WebCite® at http://www.webcitation.org/5p0sJczhJ.
• Jamison, Dean T. et al., eds. 2006. Disease control priorities in developing countries (2nd Edition) (PDF). New York: Oxford University Press.
• Lopez, Alan D. et al., eds. 2006. Global burden of disease and risk factors (PDF). New York: Oxford University Press.
• World Health Organization. Global burden of disease (GBD). http://www.who.int/healthinfo/global_burden_disease/en/index.html (accessed April 15, 2010). Archived by WebCite® at http://www.webcitation.org/5p118giwH.

Next in series:

• Disability-Adjusted Life Years II: Variations
• DALYs and disagreement