Freedom-Adjusted Life Years

Are We Solving the Right Problems?

July 2, 2025

Measuring What Matters

We live in a world of finite resources. Every dollar spent on one problem is a dollar not spent on another. This forces us to ask a difficult question: how do we decide what to fix? To answer that, we first need to measure the problems.

For decades, the gold standard for measuring the global burden of disease has been the Disability-Adjusted Life Year, or DALY.

The DALY: A Powerful Tool for Health

A DALY is a unit that represents the loss of one year of “full health.” It’s a clever way to combine the years of life lost to premature death with the years lived with a disability. For example:

  • A person who dies 30 years before their life expectancy has lost 30 DALYs.
  • A person who lives for 10 years with a condition that has a 50% disability weight (like severe depression) has lost 5 DALYs (10 years * 0.5 disability).

This allows organizations like the WHO to compare the burden of vastly different conditions. It’s a powerful tool for prioritizing health funding.

The Blind Spot: You Can Be Healthy in a Cage

But here’s the catch: DALYs only measure health.

Imagine a person who is in perfect physical health—no diseases, no disabilities. Now, imagine they are locked in a solitary confinement cell. They have zero DALYs lost, but would anyone describe their life as having a high quality?

This is the blind spot of purely health-based metrics. They cannot capture the profound human suffering that comes from the loss of freedom. A life without agency, without choice, without the ability to move, speak, or work freely is a life of immense deprivation, regardless of one’s physical condition.

To measure this, we need a different tool.

Quantifying Freedom: The Human Freedom Index

The Human Freedom Index (HFI), a joint project of the Cato Institute and the Fraser Institute, is the most comprehensive attempt to measure this other dimension of life.1 It scores countries on a scale of 0-10 by combining 86 distinct indicators of personal, civil, and economic freedom.

The results paint a familiar picture. In the 2024 report:

  • Top-ranked: Switzerland (9.14), New Zealand (9.08), Denmark (9.04)
  • Bottom-ranked: Yemen (3.78), Myanmar (3.97), Iran (3.96), and at the very bottom, Syria (3.10).

This gives us a framework for quantifying the formal and effective freedoms a person has.

A New Metric: The “Freedom-Year Lost” (FYL)

Inspired by the DALY, we can create a new metric: the Freedom-Year Lost (FYL). The logic is simple. If a perfectly free life is a 10 on the HFI scale, then any score below 10 represents a loss.

  • Freedom Loss per Person = (10 - HFI Score) / 10
  • Total FYLs = Affected Population * Freedom Loss per Person

While the HFI is a national-level tool, its categories provide a robust framework for estimating the loss of freedom in specific situations, even if a direct application is impossible. The FYL is therefore a new index inspired by the HFI, applied to people rather than states.

This gives us a number, like DALYs, representing the total “full-freedom life-years” lost to a specific situation annually.

The Calculation: A Crisis vs. A Disease

Let’s apply this framework to several global challenges. For this comparison, we will only look at funding aimed at solving the root problem, not just managing its symptoms. We define a ‘solution’ as any intervention that permanently reduces the future DALY or FYL burden—such as R&D for a cure, resettlement for a refugee, or rescue for an enslaved person. To be clear, this excludes funding for ongoing management. Aid that keeps a refugee in a camp or insulin that helps a person manage diabetes are not counted, as they maintain the status quo rather than resolving the underlying condition.

The Bottom Line: Where Does the “Solution” Money Go?

What follows is an exercise in estimation. Precise figures for ‘freedom loss’ or ‘solution funding’ are impossible to obtain. However, by using established indices, credible reports, and conservative financial estimates, we can hopefully paint a broad-strokes picture.

Let’s put it all in a table, ordered by how much the world invests to solve one year of human suffering for each problem.

Problem Total Annual Burden Type of Funding Est. Annual “Solution” Funding Funding per Unit of Burden (Solution-Oriented)
North Korean Population 21,200,000 FYLs Advocacy, Defector Support ~$20 Million $0.94
Modern Slavery 45,000,000 FYLs Rescue, Legal, Prevention ~$150 Million $3.33
Major Depressive Disorder 56,300,000 DALYs Research & Development ~$1 Billion $17.76
Rohingya Crisis 850,000 FYLs Legal, Advocacy, Resettlement ~$30 Million $35.29
Type 2 Diabetes 66,300,000 DALYs Research & Development ~$3 Billion $45.24
Endometriosis 2,250,000 DALYs Research & Development ~$32 million $14.22

(see appendix for justifications of these numbers)

A Note on the Rohingya Anomaly

Interestingly, the Rohingya crisis appears to be an outlier among freedom-related issues. It receives significantly more “solution” funding per FYL than addressing modern slavery or the oppression in North Korea. This is potentially due to two factors: the existence of a high-profile, fundable legal mechanism (the ICJ case) and a tangible, scalable intervention (resettlement), which fit more traditional funding models.

The Great Imbalance: What Our Spending Reveals

The data reveals a staggering disparity. The world invests $45 to solve one DALY of diabetes, but less than one dollar to solve one FYL of suffering for a person in North Korea. Is their suffering really 45x less important? Even issues well known to be underfunded (endometriosis and depression) are not close to our investments to recover life years lost via a lack of freedom. This isn’t random; it points to powerful biases in how we allocate resources.

  1. Tractability and Perceived ROI: We invest in problems that seem “solvable” with technology and capital. Medical research, while difficult, has a clear path and a robust industry. A political crisis like North Korea’s is seen as intractable, with no clear “solution” to fund.

  2. The “Recipient” Problem: It is easy to write a check to a university lab to research a disease. It is impossible to give money to a single entity to “solve” the oppression in North Korea. The solution requires political will, which cannot be purchased.

  3. The Power of Constituency: Diabetes and depression affect millions of people in the world’s wealthiest countries, creating a powerful political and economic constituency that demands research funding. The victims of modern slavery and political oppression are often the most marginalized people on earth, with no powerful state actor advocating for their rights.

  4. The Asymmetry of Risk: There is a deep imbalance in how we perceive risk. Funding science is seen as a cumulative investment; a failed experiment still generates knowledge and is never a total loss. Funding a political solution is seen as a fragile investment; a peace treaty can be broken or a marketing campaign can be undermined by corruption, leaving you with absolutely zero return. This makes investing in freedom feel far riskier than investing in health.

The world is willing to spend hundreds of millions of dollars a year to manage crises—to keep people alive in states of profound unfreedom. But it invests a pittance in the hard, political, and risky work required to restore that freedom.

Metrics like DALYs are invaluable, but they don’t tell the whole story. By expanding our view to include the burden of lost freedom, we get a clearer, and often more horrifying, picture of the world’s priorities.

Appendix: Case studies

Case Study: The Population of North Korea

This represents perhaps the most extreme example of nationwide freedom deprivation. The Democratic People’s Republic of Korea (DPRK) operates as a totalitarian state, exerting near-total control over the lives of its citizens.

Burden Calculation (FYLs):

  • Population: The estimated population of North Korea in 2024 is approximately 26.5 million people.2
  • Freedom Score Estimate: The Human Freedom Index does not officially rank North Korea, likely due to the inability to gather reliable data from such a closed society. However, we can create a robust estimate. The lowest-ranked country in the 2024 HFI is Syria, with a score of 3.10. It is widely understood that the DPRK imposes even more severe restrictions on personal and economic freedom. The Heritage Foundation’s 2024 Index of Economic Freedom, for instance, ranks North Korea last in the world with a score of just 3.3 out of 100.3 Given the total state control over movement, information, expression, and all economic activity, an estimated HFI score of 2.0 out of 10 is a conservative but realistic assessment.
  • Total Burden: 26,500,000 people * ((10 - 2.0) / 10) = 21,200,000 FYLs

“Solution” Funding Calculation:

  • Defining the “Solution”: A “solution” for the North Korean people is complex, but funding for it targets three main areas: breaking the state’s information monopoly (e.g., radio broadcasts, smuggling USB drives), supporting defectors who escape (a permanent solution for those individuals), and international legal and diplomatic advocacy to hold the regime accountable.
  • Funding Estimate: This work is funded by a small, fragile coalition of NGOs, private foundations, and inconsistent government grants, primarily from South Korea and the United States. Precise global figures are not compiled, but the scale is known to be small. For example, recent freezes in U.S. funding were reported to have sparked a major crisis for the key NGOs in the field, highlighting the precarious nature of their budgets.4 A generous, upper-bound estimate for the total global “solution-oriented” funding is approximately $20 million annually.

This results in a funding allocation of just $0.94 per FYL, the lowest of any problem we analyzed.

Case Study: Modern Slavery

This is a global crisis that represents an almost complete deprivation of individual liberty. The term “modern slavery” encompasses forced labor, debt bondage, forced marriage, and human trafficking.

Burden Calculation (FYLs):

  • Population: The 2023 Global Slavery Index, a comprehensive report by the human rights group Walk Free, estimates that on any given day in 2021, 50 million people were living in situations of modern slavery.5
  • Freedom Score Estimate: A person living in modern slavery is subject to the near-total control of another. Their fundamental freedoms are systematically denied.
    • Movement: Severely restricted or eliminated entirely.
    • Economic Freedom: Non-existent. They cannot legally work, own property, or control their own earnings.
    • Personal Freedom & Rule of Law: They are denied legal protection and personal agency.
    • Given this catastrophic loss of liberty, an estimated HFI score of 1.0 out of 10 is a justifiable, if not generous, assessment of their condition.
  • Total Burden: 50,000,000 people * ((10 - 1.0) / 10) = 45,000,000 FYLs

“Solution” Funding Calculation:

  • Defining the “Solution”: Funding for solutions is aimed at permanently ending an individual’s state of enslavement and preventing future cases. This includes financing for rescue operations, providing legal services to prosecute traffickers, long-term support for survivors, and upstream prevention programs.
  • Funding Estimate: There is no single global budget, but we can estimate the scale by looking at major contributors. The United States, through its Program to End Modern Slavery (PEMS), has allocated significant funds, such as $25 million in FY 2017.6 The UN’s Voluntary Trust Fund on Contemporary Forms of Slavery has disbursed roughly $6 million over the last decade.7 Adding the contributions of other governments (like the UK, Australia) and major philanthropic bodies, a generous global estimate for annual “solution-oriented” funding is likely in the low hundreds of millions. We will use $150 million annually as a comprehensive, upper-bound estimate.

This results in a funding allocation of just $3.33 per FYL.

Case Study: Major Depressive Disorder

Major Depressive Disorder is one of the leading causes of disability worldwide, yet it is often perceived as a chronically underfunded and stigmatized health issue. Analyzing its funding-to-burden ratio provides a crucial health-based benchmark for our comparison.

Burden Calculation (DALYs):

  • The Metric: The Global Burden of Disease (GBD) study provides the most comprehensive data on the global impact of depression. Their DALY calculation includes not only years lived with the disability of an active depressive episode but also the years of life lost to suicide linked to the disorder.
  • The Number: The most recent GBD 2021 data, published in The Lancet, found that depressive disorders (including Major Depressive Disorder and Dysthymia) were responsible for a staggering 56.3 million DALYs globally.8

“Solution” Funding Calculation:

  • Defining the “Solution”: This includes foundational neuroscience and clinical research aimed at developing novel, more effective treatments (pharmacological and therapeutic), identifying biomarkers for early diagnosis, and creating interventions that can lead to lasting remission or prevention, rather than just ongoing symptom management.
  • Funding Estimate:
    • Government Research (~$500 Million+): The U.S. National Institutes of Health (NIH) is the single largest funder of mental health research globally. Within the NIH, the National Institute of Mental Health (NIMH) is the lead agency. According to NIH’s own categorical spending reports, the estimated funding for research specifically on depression was $463 million in fiscal year 2023.9 When accounting for similar public research bodies in the EU, UK, and elsewhere, a conservative global estimate for government-led “solution” R&D is at least $500 million.
    • Pharmaceutical & Private R&D (~$500 Million+): While exact figures are proprietary, we can make a logical estimate. R&D in psychiatry has been notoriously challenging, leading some pharmaceutical giants to pull back. However, with the advent of new psychedelic-based therapies and other novel approaches, investment is flowing back into the sector. Given the massive market for antidepressants, it is very conservative to assume that at least $500 million is dedicated globally to developing next-generation drugs and therapies.
    • Total: Combining these conservative estimates, the total global “solution-oriented” funding for depression is approximately $1 Billion annually.

This results in a funding allocation of $17.76 per DALY.

Case Study: The Rohingya in Cox’s Bazar

The situation of the Rohingya in Bangladesh is a powerful case study in concentrated freedom deprivation. Cox’s Bazar is the world’s largest refugee camp, hosting nearly one million stateless Rohingya people who fled a brutal campaign of ethnic cleansing in Myanmar. They are confined to the camps, cannot legally work, and have no formal access to justice.

Burden Calculation (FYLs):

  • Population: Approximately 1 million Rohingya live in the camps.10
  • Freedom Score Estimate: To estimate the freedom score, we cannot use the HFI for Myanmar (their origin) or Bangladesh (their location) directly. Instead, we must adjust Bangladesh’s baseline HFI score (5.52) to reflect the specific, severe restrictions of camp life. The following back-of-the-envelope calculation, based on the HFI’s core components, justifies the catastrophic loss of freedom.
HFI Category Baseline (Bangladesh) Estimate (Rohingya Refugee) Justification for Estimate
Personal Freedom 5.29 ~2.5  
Rule of Law ~4.5 1.0 As stateless persons, they have no formal access to the national justice system and are subject to camp-specific, often arbitrary, governance.
Security and Safety ~7.0 2.0 Camps are known to be dangerous, with high rates of crime, violence, and vulnerability to exploitation. Security is not guaranteed.
Movement ~6.0 0.0 This is the most severe restriction. They are not permitted to leave the camps. Freedom of movement is effectively zero.
Economic Freedom 5.85 ~0.5  
Legal System & Property Rights ~4.8 0.5 They cannot legally own property or land. Contracts are unenforceable in the formal legal system.
Freedom to Trade ~7.2 0.0 They cannot legally engage in international or even national trade.
Regulation (of business/labor) ~6.1 1.0 They are barred from legally starting a business, seeking formal employment, or accessing credit.

This detailed breakdown puts their HFI score at 1.5 out of 10—a score less than half that of a citizen living in Syria, the lowest-ranked country in the world.

Total Burden: 1,000,000 people * ((10 - 1.5) / 10) = 850,000 FYLs

“Solution” Funding Calculation:

  • Defining the “Solution”: It is critical to distinguish “solution” funding from the hundreds of millions in humanitarian aid (e.g., the $545.4 million in the 2024 Joint Response Plan10) which manages the status quo. “Solution” funding targets a permanent resolution through legal action, diplomacy, and resettlement.
  • Funding Estimate (~$30 Million):
    • Legal Action (~$5 Million/year): This is primarily for The Gambia’s case against Myanmar at the International Court of Justice (ICJ), which seeks to establish legal accountability for genocide and create conditions for a safe return. The case is funded by the Organisation of Islamic Cooperation (OIC), and while the precise annual budget isn’t public, a conservative estimate of $5 million per year for ongoing costs is reasonable for a case of this magnitude.11
    • Diplomacy & Advocacy (~$5 Million/year): This includes the work of UN Special Envoys and the targeted advocacy of NGOs like Human Rights Watch and Fortify Rights to keep political pressure on for a resolution. A figure of $5 million annually is a plausible, if rough, estimate for this non-humanitarian work.
    • Resettlement (~$20 Million/year): In 2023, the United States began a significant resettlement program for Rohingya refugees from Bangladesh.12 The cost of resettling a refugee in the U.S. is estimated to be at least $20,000 per person.13 Resettling over 1,000 refugees represents a direct “solution” expenditure of approximately $20 million.

This results in a funding allocation of $35.29 per FYL.

Case Study: Type 2 Diabetes

Diabetes provides our primary health-based comparison. It is a well-known global health challenge with a massive, highly-funded research ecosystem aimed at developing better treatments and, ultimately, a cure.

  • Burden Calculation (DALYs):
    • The Complexity of DALYs: Calculating the true burden of diabetes is more complex than it first appears. One might find a disability weight for uncomplicated diabetes (around 0.06, or a 6% loss of perfect health). However, this would be a dramatic underestimate. The total burden of a disease includes not only the base condition but also the full impact of its severe complications—blindness, amputation, kidney failure, heart disease—and the years of life lost to premature death.
    • A Comprehensive Metric: The Global Burden of Disease (GBD) study provides a far more accurate picture. Their analysis captures the entire spectrum of suffering caused by the disease. According to their 2019 data, published in The Lancet, Type 2 Diabetes was responsible for 66.3 million DALYs globally.14
  • “Solution” Funding Calculation:
    • Defining the “Solution”: This funding is focused on Research & Development (R&D) for a cure, prevention, or reversal of the disease. It is distinct from the much larger global market for managing the disease (e.g., insulin, glucose monitors, ongoing care).
    • Funding Estimate (~$3 Billion):
      • Government Research (~$1.2 Billion+): The largest single funder is the U.S. National Institutes of Health (NIH). In fiscal year 2023, the NIH’s estimated budget specifically for diabetes research was $1.15 billion.15 When including public research bodies in the EU, UK, and elsewhere, the total government investment is even higher.
      • Pharmaceutical Industry R&D (~$1.5 Billion+): This is a massive driver of research. While exact R&D budgets for specific diseases are proprietary, the top diabetes drug companies—Novo Nordisk, Eli Lilly, and Sanofi—collectively spend over $20 billion on R&D annually across all diseases. Given that next-generation diabetes treatments (like GLP-1 agonists that can lead to remission) are a cornerstone of their business, it is a very conservative estimate that at least $1.5 billion of this is dedicated to developing novel diabetes therapies.
      • Non-Profit & Charitable Research (~$300 Million+): Major non-profits like JDRF (which also funds Type 2 research) and the American Diabetes Association (ADA) invest hundreds of millions of dollars globally in research grants each year.
      • Total: Adding these conservative estimates together ($1.2B + $1.5B + $0.3B) brings the total global “solution-oriented” funding for diabetes comfortably into the $3 billion range annually.

This results in a funding allocation of $45.24 per DALY.

Case Study: Endometriosis

Endometriosis is a debilitating chronic disease affecting an estimated 1 in 10 women of reproductive age worldwide. It occurs when tissue similar to the lining of the uterus grows elsewhere in the body, causing severe pain, infertility, and organ damage. It serves as a powerful example of a health issue that is widely considered to be historically overlooked and underfunded.

Burden Calculation (DALYs):

  • The Metric: The Global Burden of Disease (GBD) study quantifies the global impact of endometriosis, accounting for years lived with the disability caused by chronic pain, fatigue, and other severe symptoms.
  • The Number: According to the GBD 2019 data, endometriosis was responsible for a global burden of 2.25 million DALYs.16

“Solution” Funding Calculation:

  • Defining the “Solution”: This includes R&D for non-invasive diagnostics (to reduce the current 8-10 year average diagnostic delay), novel treatments that address the underlying cause of the disease (rather than just suppressing symptoms), and a potential cure.
  • Funding Estimate:
    • Government Research: A 2023 paper in Nature Communications highlights the stark funding disparity. It reports that the U.S. National Institutes of Health (NIH), the world’s largest single funder of biomedical research, allocated just $16 million to endometriosis research in 2022.17
    • Global Estimate: To estimate the total global research funding, we can use the NIH figure as a baseline. A conservative and commonly used method is to roughly double the NIH budget to account for all other public and private research investment worldwide (from the EU, UK, pharmaceutical companies, and private foundations). This gives us a global “solution-oriented” funding estimate of approximately $32 million annually. The Nature paper notes this is disproportionately low compared to diseases with a similar economic impact, like Crohn’s disease, which receives nearly six times the NIH funding.

This results in a funding allocation of just $14.22 per DALY.

References

  1. Vásquez, I., Mitchell, M. D., Murphy, R., & Sutter Schneider, G. (2024). The Human Freedom Index 2024. Cato Institute and Fraser Institute. ↩

  2. Central Intelligence Agency. (2024). The World Factbook: Korea, North. Retrieved from https://www.cia.gov/the-world-factbook/countries/korea-north/ ↩

  3. The Heritage Foundation. (2024). 2024 Index of Economic Freedom: North Korea. Retrieved from https://www.heritage.org/index/country/northkorea ↩

  4. Financial Times. (2024, January 26). “US funding freeze sparks crisis for North Korean rights groups.” ↩

  5. Walk Free. (2023). The Global Slavery Index 2023. Retrieved from https://www.walkfree.org/global-slavery-index/ ↩

  6. U.S. Department of State. Program to End Modern Slavery (PEMS). This figure is cited in multiple congressional reports and press releases from the period. ↩

  7. United Nations Human Rights Office of the High Commissioner. United Nations Voluntary Trust Fund on Contemporary Forms of Slavery. Retrieved from https://www.ohchr.org/en/slavery-fund ↩

  8. The Lancet. (2024). “Global, regional, and national burden of depressive disorders, 1990-2021.” The Lancet, 403(10438), P1781-1793. ↩

  9. National Institutes of Health (NIH). (2024). Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC): Depression. Retrieved from https://report.nih.gov/funding/categorical-spending#/ ↩

  10. United Nations High Commissioner for Refugees (UNHCR). (2024). 2024 Joint Response Plan for the Rohingya Humanitarian Crisis. UNHCR and IOM. ↩ ↩2

  11. Reuters. (2020, October 26). “Gambian minister says not enough funds for Rohingya case at top U.N. court.” ↩

  12. U.S. Department of State. (2023, September 22). Press Statement, “Announcing Additional Humanitarian Assistance for the Rohingya Crisis.” ↩

  13. Center for Immigration Studies. (2020). The Cost of Resettling Refugees. This source estimates the one-time cost per refugee at $21,946. ↩

  14. The Lancet. (2022). “Global, regional, and national burden of type 2 diabetes from 1990 to 2019.” The Lancet, 400(10369), P2233-2249. ↩

  15. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), “Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC),” NIH.gov. Retrieved from https://report.nih.gov/funding/categorical-spending#/ (Fiscal Year 2023 data for “Diabetes”). ↩

  16. Jiang, Y., et al. (2022). “Global Burden of Endometriosis in 204 Countries and Territories from 1990 to 2019.” International Journal of Medical Reviews. This paper uses the GBD 2019 dataset. ↩

  17. Gelfand, L.C., et al. (2023). “Time for global health policy and research leaders to prioritize endometriosis.” Nature Communications, 14(7223). ↩