Measuring Height in Love: the absurdity of the DALY

I know this doesn’t strictly relate to this weeks’ readings, but this is something that I think is really important and hasn’t come up enough.

It’s so important, in fact, that in the style of scholars from Plato to Derrida, I shall present my thoughts as a dialectic, in the form of an actual gChat between me and my friend Andrew (who studied Economics at NYU and is currently a second year medical student at Mt. Sinai)

me: blurf

i have to write a “blog post” for my global health policy class

and i really wanna write about how the whole concept of rationalizing and quantifying the value of human life

the concept of which is integral to like all global health policy stuff

is so completely messed up

but my brain is too demyelinated/mildly epileptic to adequately articulate it

Andrew: Hmmm

I don’t know if I have an intrinsic problem with that as such

me: I do!

Andrew: But I do know that the British government

Commissioned a study

of the likely economic impact of global warming

Andrew: In which they quantified precisely how much more they value British lives compared to the lives of people in the Third World

me: how can you be like: “something is only “cost effective” and thereby worthwhile if it costs $100/DALY saved”

I mean

the whole concept of the DALY is fucked

like yr life is worth less if you’re

a. a kid

b. an old person

c. a woman

d. in anyway “ill”

Andrew: No under that system kids lives are worth more

Cuz they have more years left

me: noo

they do it in this weird curvey thing

where babies aren’t worth as much

Andrew: And women too actually

Cuz they live longer

me: no no

Andrew: Right?

me: nope

Sent at 5:32 PM on Tuesday

me: http://en.wikipedia.org/wiki/Disability-adjusted_life_year

its about how much you’ve invested in the person

and babies haven’t really had that much yet

and like

how can they decide how much to weigh disabilities?

like who gets to decide that a

year living blind is only worth .6 of a year?

or that being depressed is only .9 a year?

it means that the lives of ALL poor people

are inherently counted as less valuable

because they’re more likely to be sick

Andrew: Okay valuing people by how much you’ve invested in them is fucked up in principle

But I think that most people

If they had a choice between living 10 years in perfect health vs. 10 years plus one hour but all as a quadriplegic

Would choose to live in perfect health

me: yeah but usually its not that

clear cut

and they present it in this totally pseudoscientific way

as if there’s anything factual or objective about it

Andrew: Well I agree with it in principle, in that kind of abstract, hypothetical scenario where everything is perfectly clear

But then in the real world

When you have to put percentages on these things

Exactly how diminished is the quality of life of a quadriplegic

Then it’s not scientific

me: i mean some kind of measure is helpful

but it’s absurd how much weight is given to this pseudomathematical formulas

that are totally subjective

Andrew: I don’t think it’s totally subjective

In the way that my dislike of the movie Taxi Driver is totally subjective

me: ask a quadriplegic if he thinks his life is worth less

if less resources should be invested in saving his life

because it wouldn’t be saving as many DALYs

Andrew: Yeah

me: or a mom ask her if her baby shouldn’t be saved because not as much has been invested in it

and probably it will be sick a lot

so it will have less DALYs than a baby in the US

Andrew: But it kind of raises the question

Should we spend every possible dollar on health care?

Or do we draw some line somewhere with a certain degree of arbitrariness?

me: i think we should spend all the money on ze healthcare

i know that sometimes folks have to make judgment calls

spend money on project A or project B

and metrics can be useful tools to evaluate merits of each option

but what I don’t like

AT ALL

is when these kinds of metrics are presented as absolutes,

when folks don’t acknowledge that quatifying the value of humyn life is inherently problematic

Andrew: I think health care is one of the best ways to spend money

And way better than military,

hey also

The Bush administration rather nakedly adjusted their DALY methodology

To make it appear less harmful when they cut some health care program

me: !!!

Andrew: But you’re never gonna have a way to decide how to allocate resources that’s not in some way problematic

I’d rather see it done through DALYs than done through a free market, for example

me: from each according to his ability, to each according to his need?

that’s pretty unproblematic

and DALYs do operate under market-like principles

rationalization, efficiency, trade-offs etc.

Andrew: Hey did you know like 40% of the US population think those phrases are in the Constitution?

[long, irrelevant tangent about sneaking into the National Archives to scribble on the constitution]

Andrew : Seriously though

1.  I did not know DALYs said that people who have had more money spent on them are more valuable.

2.  I had not considered that

when you say lives lived in sickness are less valuable then that biases the measures against poor people cuz they get sick more.

me: it doesn’t say specifically “money”

it says “resources” o

or something like that

Andrew: Yeah doesn’t matter

me: wait i’m trying to remember why it says ladies are less valuable too

Sent at 5:45 PM on Tuesday

me: oh it also counts things that don’t actually effect yr health as “disabilities”

like infertility

Andrew: Oh shit really?

Like if a woman become infertile, then her life is less valuable?

me: ya

1000 healthy fertile ppl = 1236 otherwise healthy infertile ppl

Andrew: Okay I think that is actually accurate for some women, and that what’s wrong is applying it universally as if that were the goal of all women’s lives

Is that actually the number they use?

Cuz that’s a really heavy penalty for infertility

me: ya ‘m reading it off a paper

= 1025 over or underweight ppl = 1499 deaf ppl = 1686 ppl with down syndrome

Andrew: Okay that makes more sense

me: yeah, unless yr a perfectly happy person with down syndrome

who would really rather not have less invested in his health

Andrew: Oh now you’re getting utilitarian

me: that’s like hitler logic

Andrew: Yes it is actually

Or wait no

He murdered disabled people

But not because he thought they weren’t happy being disabled

But because he thought they were weak and thus diluted the strength and vigor of the nation

me: we deny them equal weight in allocating health resources

because we think that’s a more efficient way to allocate our resources

and make a “healthier” society

Andrew: The part of DALYs that I most agree with

Is that it’s inefficient to spend tens of thousands of dollars for bypass surgery in an 85-year-old American who’s dying of some other disease

When we could instead spend that money on a deworming campaign in Niger

And save a lot more lives for a lot longer

me: yeah i def think old ppl should count less

but its really really dangerous logic

Andrew: With the kind of arbitrary valuations that you’re criticizing

I’ve heard it said that the reason it’s fucked up

Is that yeah it’s rational, but it’s unfair

And we hold fairness as an independent value that we want to uphold

me: yeah

Andrew: Separate from maximizing health or happiness or whatever

me: frankly i think sick ppl should get MORE resources

cuz they need them more

Andrew: But what if you can spend $100 on a healthy person to keep them healthy?

Vs. $1,000 on a sick person to treat them partway?

me: do both

Andrew: Yeah actually that’s basically what I’d say

That’s also what I’d say about scientific research on rare genetic diseases of rich white people

(Which is what Sinai loves to do)

Vs. research on common infectious diseases of poor people overseas

me: yeah

Andrew: (No one talks about rare genetic diseases of non-white populations, but I’m sure that must be because no such diseases exist.)

me: except i think we should research rare rich white ppl  diseases too

just not at the expense of everyone else

oh oh!

The ladies!

“to calculate the DALYs a standard expectation of life at birth of 82.5 years is taken for women and of 80 years for men”

“the gap is considerably smaller than the observed gender gap in life expectancy in low mortality populations, for example, Japan, which has a gender gap of some 6 years”

so the smaller the gender gap

the less DALYs you say ladies

Andrew: So by DALY logic wouldn’t that make their lives more valuable?

me: no no no “the smaller the gender gap, ceteris paribus, the smaller will be the female contribution to the burden of disease relative to the male contribution”

they underestimate how long women should be living

Andrew: Hmm

me: can live

so they don’t account for all fo the years lost

Andrew: I didn’t follow that

How are they underestimating how long women should live?

me: they are putting the gender gap at only 2.5 years

Andrew did not receive your chat.

me: they put the gender gap at only 2.5 years

Andrew: Oh oh oh

me: when in reality, most countries have a much bigger gap

Andrew: Cuz that’s what it is in practice on average worldwide?

But if everybody had decent health care then it would be longer?

me: no

The 2.5 years was totes arbitrary

well not totes

they decided that 2.5 years is what corresponds to “biological difference in survival potential between males and females”

factoring out everything else

Andrew: Hmmm

me: also

“”while DALYs take account of higher female life expectancy in calculating years lost to premature mortality, the valuation of these years can be sharply reduced by age-weighting and discounting”

The female advantage in years lost of 3% is reduced by age-weighting to 1.5%, and further reduced by discounting to .3% for the calculation of DALYs”

cuz the old person years are worth less

and years in the future are worth less than years now

regardless of age

Andrew: Most of what you’re saying is objections to particular methodological decisions these orthodox economists have made about how they’ve going to calculate DALYs in practice, rather than DALYs in practice, rather than reasons why nothing like DALYs should ever be used with any methodology.

Oh and with the future years being worth less

If they do it in the usual economist’s way

By dividing by the interest rate

Then at a fairly normal interest rate

It easily ends up having the consequence that anything that happens in 20 years is only half as important as anything that happens now

Which is an amazingly short-sighted way to plan and make decisions for a society

me: yeah well frankly i think economists have NO place in deciding the value of human life

its like saying yr going to measure your height in Love

Andrew: Hahahahaha

Like that interest rate future discounting business is something I object to per se, regardless of how it’s done

Except in a few like perfectly financial situations

Where it obviously does make sense to use the interest rate

me: i object to economic principles being applied to anything that’s not strictly financial

which is …

everything

nothing is strictly financial

Andrew: Yeah well nothing is strictly anything

me: exactly

Andrew: War is not strictly military

Sex is not strictly sexual

me: but srsly

this is basically my big problem with science in general

the notion that something even can be strictly scientific

strictly mathematical

or rather

my problem with the way that science presents itself

the way that scientists present themselves

totes oblivious to anything outside their discipline

takin themselves all serious biznass

cuz i’d be a lot more down with the Science if it could just acknowledge its limitations

Like the rest of us do.

Sent at 5:27 PM on Tuesday

Andrew: Claire.

me: Andrew.

Andrew: you are going to hate med school.

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