If you don’t like the answer, change it: and measurements of health

Last semester, I sat in a lecture with a handful of high ranking international development types who were all sharing with us the future impacts and directions of the Sustainable Development Goals (SDGs). One of them, who criticized these goals mentioned how the UN had changed the method of measuring the progress of the Millennium Development Goals (the predecessor to the SDGs) half way through its lifespan because of criticism on lack of progress and success. I was shocked by what I considered to be an unethical and sneaky response to criticism. The numbers weren’t getting them the results they wanted, so they changed how they counted.

It serves as a great illustration to how we measure, not only health, but all developmental goals. The numbers, it seems, are driven by the political agenda of the people counting. When you need to maintain donors, when you want to avoid panic, when you have other priorities, you can benefit from skewing the numbers in one direction or the other.

There is an international understanding in health development: what gets measures, gets done. Functionally meaning that without providing the numbers, there is little chance that donors will give money and that policy will be implemented. Without numbers, it is hard to visualize the impact on people’s lives that has been made: how successful was this campaign to reduce HIV/AIDS incidence rates? How many women have comprehensive knowledge of hospital births? The numbers are necessary to first prove a problem exists, then to show how you’re affecting that problem.

How can people be counting the same thing and come up with different numbers? Health, looking at a large-scale, considers the number of people who have a specific disease or who died of a specific cause. But this is pretty hard data to gather, let alone tally up. For the roughly 7 billion people living on this planet, imagine not only finding all of the people who have each disease, but then tallying them up. Institutions, like the World Health Organization, uses statistical formulas and computer programing tools to determine roughly how many people are dying and of what. Because various institutions and governments often individually derive these numbers, without sharing information and without necessarily having the ability to collect complete data. The little choices made in what they count (when data was vague) or what parameters they set create different results once they have ran all of the statistical formulas or codings.

Not actually how people count health, it turns out.

For a very long time, these measurements of the overall health level in a society was only being captured by life expectancy and the number of people dying of specific diseases, such as TB, HIV/AIDS, malaria, etc.  The limited scope captured, however, did not mean that everything captured was “captured” with certainty. These narrow parameters leave out many aspects to health that aren’t captured by death or fatal diseases, such as mental health or disability.  Until HIV/AIDS efforts were globally established, there was no real effort to measure adult mortality from diseases globally (56). This obviously has huge impacts on policy and development efforts as adults typically die of very different causes than children.

Slowly, international measurements of health began to include more indicators, more diseases. This progress has been pushed along by the creation and development of Chris Murray’s DALY measurement. DALY stands for disability-adjusted life years, which introduced a method to evaluate quality of life and all health concerns in one index. DALYs also introduced a consideration for diseases, disorders, and disabilities previously overlooked when measuring health.


DALY assumes that a human life span is 80 years. It considers the amount of years a person lost because of early death and because of disease or disability (albeit, they only consider a proportion of each year lived with disability; meaning each year lived with severe deafness is added to the DALY as .2 the years as lost life is). The “weight” or proportion of each disability has in the measurement was determined by a consensus reached by members of the public and medical professionals.

DALYs and the Global Burden of Disease project aimed to find aggregate numbers of all, or as many as possible, aspects of health or everyone everywhere. This study compiled the data all together which allowed for insight into public health gaps by regions, sex, age. They found previously unrecognized data in this process, such as the over all toll of dental problems in Sub-Saharan Africa equalled that of anemia (83).

DALYs have challenged the way that we measure health internationally and nationally. They have created one index in which we can consider quality of life, and nonfatal health concerns on the same footing as fatal illnesses and life expectancy. Arguably, we can roughly compare apples and oranges now (although DALYs are quite limited as I’m unsure about the universal weight of disability as well as being the most effective in a western context).

Beyond this, DALYs have challenged the politically driven results and statistics that had previously been the only option for considering health, and in doing so found many errors and previously overlooked health problems within our normative thinking.