HPHR Fellow Dr. Butool Hisam

By Dr. Butool Hisam

A tale of two centuries


Towards the end of the 20th century, a 22-member committee of the World Bank produced the World Development Report. This flagship report on the state of health around the Globe served as a benchmark to understand and improve the health of nations (World Development Report 1993 : Investing in Health, n.d.). Bill Gates referred to it as one of the books that changed his life and motivated him towards investing in projects related to Global Health.


This was a turning point for the world. A deeper understanding of global health issues meant commitment towards improving the quality of life. It was undoubtedly a powerful moment, and it makes me think of another time, in a different land, in the eleventh century. There too, we have a written document, but not by a committee of experts. This volume was carved out on a faded manuscript that eventually made its way into influential palaces and halls of learning. It can even be found today in a museum – the Aga Khan Museum in Canada.


The manuscript was none other than ‘The Canon of Medicine’ – a five-volume book once hailed by Dr. William Osler as the ‘Bible of Medicine’. It was authored by the Persian Physician and polymath, Ibn Sina (Latin: Avicenna).

As a physician in the 21st century, what is striking to me,  is Ibn Sina’s definition of health (The Canon of Medicine, 1700). It is as holistic as it can get – ‘holistic’ is a word physicians may use as an aspiration, sometimes, as we lose ourselves to the complexities of demanding healthcare systems.


“Medicine is the science by which we learn, )the various states of the human body, (i) in health, (ii) when not in health, how, (i) health is likely to be lost, and (ii) when lost, is likely To be restored to health. In other words, it is the art whereby health (the beauty of the body—long hair, clear complexion, fragrance and form) is conserved and the art whereby it is restored, after being lost.”


Fast forward again to the 20th century, to the moment the World Development Report came out. What made this unique was the ‘DALY’ (Disability Adjusted Life Years). This relatively new metric appeared to serve a bold purpose – to measure global health not just in terms of morbidity and mortality but also in terms of losses affected by disability (Disability-Adjusted Life Years (DALYs), n.d.). Taken as a whole, the DALY is calculated as the sum of Years of Life Lost (YLL) and Years of Life Lost due to Disability (YLD). The calculation further included aggregating weighting based on the type of ‘disability’.


This was certainly ambitious. It was a step by the human race to acknowledge that mortality is just one of their great fears, that there are far more ailments to battle. But this does not mean that the DALY is perfect – far from it, in fact. The full extent of the criticism is beyond the scope of this article but to provide a gist, the main arguments against it are (Solberg et al., 2020) :

  1.     It is purely an ‘economic’ measure as the weighted aggregates are related to economic productivity segregated by age group.
  2. It is a numerical value that attempts to cover a subjective aspect, namely, the ‘quality of life.
  3.     How far does ‘disability’ account for mental health?

The last point is certainly contentious. Perhaps what may not have been expected in 1993 at the time was how much mental health would contribute to the proportion of DALYs globally. In fact, it is now the leading cause of DALY in the USA.


Yet, mental health was something understood only too well by Ibn Sina. He led by it, instead of relegating it into a footnote. He wrote extensively about ‘melancholy’ (clinical depression), nightmares, and psychosomatic symptoms. He describes various patient cases of the most pustulent, ugly skin conditions and various ailments stemming from a cause related to the mind. He cautions to treat the mind and body as one as they make up the countenance of the whole.


The world has moved in the direction of the words he wrote centuries ago. In 1948, WHO included mental well-being in its definition of health: Health is a state of complete physical, mental and social well-being. When the World Development report came out in 1993, it was meant to serve as a nod to cover all aspects of health and also to cover the opposite- the burden of disease. As we look back at the decades that have culminated since and the state of global health today, I wonder what the polymath from centuries past may have been able to contribute had he been present at that table in 1993.


 One famous quote lends a clue:

“The width of life is more important than the length of life” Ibn Sina



Disability-adjusted life years (DALYs). (n.d.). Retrieved August 14, 2021, from https://www.who.int/data/gho/indicator-metadata-registry/imr-details/158

Solberg, C. T., Sørheim, P., Müller, K. E., Gamlund, E., Norheim, O. F., & Barra, M. (2020). The Devils in the DALY: Prevailing Evaluative Assumptions. Public Health Ethics, 13(3), 259–274. https://doi.org/10.1093/PHE/PHAA030

The Canon of Medicine. (1700). https://www.wdl.org/en/item/15436/

World development report 1993 : investing in health. (n.d.). Retrieved August 14, 2021, from https://documents.worldbank.org/en/publication/documents-reports/documentdetail/468831468340807129/world-development-report-1993-investing-in-health



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