HEALTH ECONOMICS

Health Econ. 9: 83–86 (2000)

DEBATE

COMMENTS ON THE RESPONSE BY MURRAYAND LOPEZ

ALAN WILLIAMS*Uni6ersity of York, UK

Murray and Lopez, in their response to a previousarticle (Williams, A. Calculating the Global Bur-den of Disease: time for a strategic reappraisal?Health Economics 1999; 8: 1–8) have chosen notto answer my points one by one, but rather toembark on a comprehensive restatement of theirgeneral position, taking on my criticisms here andthere en passant. The danger in that approach isthat some of my points might inadvertently getoverlooked, so I have constructed a table in whichI have restated the principal points in the left-hand column, and what I take to be their reply toeach in the right-hand column. The table on thenext page (Table I) should be read before mycomments on it, which now follow.

Comments on the table

Working down the right-hand column of theTable, the following observations are called for:

(1a) If I am right in believing that we do notneed to measure the Global Burden of Disease(GBD) in order to tackle the three key issues,then improvement of the descriptive epidemio-logical data base is a low priority, and I wascorrect to neglect it. The fact that ‘The creationand maintenance of databases on the descrip-tive epidemiology of major conditions is proba-bly the most formidable, time consuming andresource-intensive task of the GBD enterprise’merely reinforces my suspicion that too mucheffort is going into things that will prove not tobe very helpful, and too little effort into the keyissue of estimating the cost-effectiveness of in-

terventions (which may not be disease specificat all).(1b) My point is a more fundamental one:GBD is not needed at all in order to makethese decisions!(1c) Only by concentrating limited resources onthe more cost-effective interventions will healthgains be maximized. Whether this turns out torequire concentration on a few interventions,each of which has a large impact, or on manydifferent ones, each with a small impact, thefacts of the situation will dictate. Going for bigthings as a matter of principle is not a strategythat will maximize health gains, or reducehealth inequalities, so it is dangerous to fooldecision-makers into thinking that it will.(1d) We are more likely to lack the informationwe need to perform cost-effectiveness studies ifthe required resources are used for the lower-priority task of calculating GBD, so maybegetting into that vicious circle will make thisobservation by Murray and Lopez a self-fulfill-ing prophecy!(2a) This wide-ranging survey of a well estab-lished field of endeavour merely distracts atten-tion from my key point, which is that the7-point DALY weighting system is a poor thirdbest to the leading generic measures which theycite. Fortunately, some of the more sophisti-cated Disability Weighting Projects have real-ized this and have abandoned this feature ofthe Murray-Lopez approach. Unfortunately,they have not yet also abandoned the calcula-tion of the GBD, so as to concentrate moreproductively on cost-effectiveness analysis.

* Correspondence to: Centre for Health Economics, University of York, York YO10 5DD, UK.

CCC 1057–9230/2000/010083–04$17.50Copyright © 2000 John Wiley & Sons, Ltd.

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Table I.

Copyright © 2000 John Wiley & Sons, Ltd. Health Econ. 9: 83–86 (2000)

A COUNTER-RESPONSE 85

(2b) Showing that hand-picked public healthpractitioners the world over have similar me-dian values for a few health states does notaddress at all my point that it would be betterto have the values of the general public in eachcountry.(2c) I was not arguing for the use of actual lifeexpectancy to be used as a normative concept,but for the separation of the positive from thenormative.(2d) As previously explained, I favour keepingthe positive and the normative elements sepa-rate. Within a community, it may well be sensi-ble to use the actual average (quality-adjusted)life expectancy of all of its members as somekind of norm, against which to ascertain who isbetter off and who is worse off by comparingthe actual (quality-adjusted) life expectancy ofvarious subgroups with that norm. The poorwill be below average, the rich above average,whether our ‘community’ is a town, a nation, acontinent, or the whole of humankind. But itwill then be the policy-makers’ degree of aver-sion to (different kinds of?) inequality that willdetermine the exact equity weights, as I havemade clear in my ‘fair innings’ exploration.Thus, actual life expectancy may play either apositive role, or a normative role, but it is bestnot to mix them up as Murray and Lopez didwhen calculating years of life lost with referenceto a hypothetical (aspirational) life table.(3a) I am afraid that the interest being shownworld wide in the GBD enterprise is preciselythe reason why I called for a strategic reap-praisal. There are other ways of arriving atsummary measures of health (e.g. QALYs)which have a stronger methodological base, andwhich do not require us to adopt a diseaseorientation nor to rely on expert assessments.Moreover, they do not divert us into measuringtotal burdens of disease, but let us get on withproper option appraisals in clinical trials andcost-effectiveness studies. There is no doubt thatas a marketing or ‘attention-seeking’ activity,the GBD enterprise currently has no rivals inthe health policy field. However, I think a betteroutcome will ensue from low key activitieswhich are focussed more directly on what weneed to know, avoiding the expensive detourthat the GBD enterprise takes everyone on.(3b) Finally, we must return to equity yet again.The new-found source of equity-based age

weights (in their Figure 3), started life as apurely technical exploration of the effects ofaverting deaths at different ages upon the over-all burden of disease, as calculated in differentways. It was a positive, factual matter. How-ever, now it has been transformed into a norma-tive concept, acting as some kind of rival to theset of weights I suggested in my critique, yetwithout any moral justification that would giveit ethical status. At a pragmatic level, these newweights do decline monotonically with age,which is what most people think equity-basedage-weights should do, and which Murray andLopez’s original (implied) weights did not do.Yet they seem no more than an ad hoc responseto my criticisms, which remain unanswered.Nevertheless, if this is the revised method ofhandling equity issues, are we to understandthat the aspirational life table has now beenabandoned for the calculation of years of lifelost? If so, this dramatic 6olte-face should bewidely promulgated, and the earlier calculationswithdrawn. But if the new explicit weights areto operate alongside the earlier implicit ones (aswell as social value age weights), we need somereassurance that the interplay has a good ratio-nale and is not over-egging the pudding. I thinkthe fair innings argument has a lot more tocommend it than these ethically obscuredevices.

Moving outside the Table, I must also commenton the suggested analogy between the value ofGBD calculations and the value of national in-come statistics. As the authors observe, the latter‘measure the level of economic activity’, which is,in principle, a positive matter. Likewise, in thehealth field we measure the number of treatmentsgiven, and the resources used, and the incomesgenerated. But surely, the objective of the GBDenterprise (which I share) is to get away from theidea that ‘more is better’ (the implied normativeprinciple behind GNP maximization), and ask amore fundamental question about what contribu-tion all of this activity is making to human wel-fare. That is where the problems with nationalincome accounts have proved to be intractable. Itis not an analogy that would bode well for theGBD enterprise if it were an accurate one. Butfortunately, it is not. Despite all of its faults, theGBD enterprise is at least trying to measure some-thing that could serve as a welfare criterion forjudging the relative value of different health care

Copyright © 2000 John Wiley & Sons, Ltd. Health Econ. 9: 83–86 (2000)

A. WILLIAMS86

activities, rather than measuring the volume ofactivity itself and assuming that more is necessar-ily better. Unfortunately, it is not doing it in avery efficient way.

I realize that Murray and Lopez are tacklingvery complex issues, and that it is not easy tokeep all these balls in play simultaneously andstill maintain cohesion, and I admire the skillwith which they have forged their Leviathan-likemachine. But in public policy discussions, trans-parency is also a great virtue, as is not losingsight of the goal. Surely the twin goals are toimprove population health as much as possible(and there is more to health than reduction of

disease) and to reduce inequalities in health(which can be measured as quality-adjusted lifeexpectancy without ‘diseases’ playing any explicitrole). The task of policy analysts is to help deci-sion-makers to find the most cost-effective way ofachieving those goals. Policy analytical skills arein short supply in all countries, and divertingthem into ‘time-consuming and resource-intensivetasks’ that are not needed for either of thosepurposes is to be discouraged. That was, andremains, my purpose in calling for a strategicreappraisal of this entire enterprise. The responseby Murray and Lopez has merely reinforced myconcerns.

Copyright © 2000 John Wiley & Sons, Ltd. Health Econ. 9: 83–86 (2000)