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Disability-Adjusted Life-Years - The Most Used and The Least Understood Measure in Global Public Health
Tue, July 14, 9:15 to 10:45am, Edinburgh International Conference Centre, Floor: Level 1, Harris Suite 1English Abstract
Disability-adjusted life-years (DALYs) were introduced within a World Health Organization-World Bank collaboration led by CJL Murray & Andrew Lopez, who published the first Global Burden of Disease report in 1993. With 57 citations per title, DALYs have now overtaken risk ratios (40 citations per title) in popularity. Even so, DALYs have been subject to technical and ethical critiques. These include concerns about the representativeness of disability weights, arbitrary choices over age and time discounting, combining mortality with morbidity regardless of incommensurability issues, the overall disvalue of death, and DALYs not truly being a population metric but an individual metric, among others. This paper explores the context in which DALYs were developed and traces their history before 1993. I rely on literature reviews of World Health Organization/World Bank documents, research papers, including methods articles and critical commentary articles on DALY measurements, morbidity burden assessments, cost-effectiveness studies, and correspondence between supporters and critics of the use of DALYs. This helps connect previous movements toward measuring morbidity burden to the origin of DALYs. I assess valid critiques that have been resolved or nullified in 2025. Finally, using a specific example of a disease condition, I underscore the underlying set of (controversial) assumptions or policy implications, and address whether DALYs are the way to go, and, if so, what the points of caution are. I conclude that DALYs are a complex epidemiological metric of population health, with several technical assumptions and value choices that carry noncontroversial ethical implications. Whether they truly measure the disease burden remains debated. Nevertheless, they are arguably the most popular index we have. An immense contribution of the next paradigm of epidemiology, the causal paradigm, to global public health is to improve DALYs or replace them with a better measure.