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