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PLoS Medicine | www.plosmedicine.org 0955

In September 2000, 147 heads ofstate met at the United Nations(UN) headquartersthe largest

such gathering everto resolveaction on the most pressing problemsof humanity and nature [1]. Tounderscore their commitment, theyset numerical targets and deadlinesto measure performance. These arethe Millennium Development Goals(MDGs), and they span a large rangeof topics, including poverty, infectiousdisease, education, and gender equality(Box 1).

This September, the heads of statewill gather again for the Millennium +5Summit to assess the five-year progressof the MDGs. They will find that theMDGs have become all-important,not just within the UN, but also as thezeitgeist of the global developmententerprise. As Professor Jeffrey Sachs,Director of the UNs MillenniumProject, has declared, To the extent

that there are any international goals,they are the Millennium DevelopmentGoals [2].

But is it wise to elevate the MDGsto the pedestal where they now sit?Could it be, despite an appearance offirm targets, deadlines, and focusedurgency, that the MDGs are actuallyimprecise and possibly ineffectiveagents for development progress?

In this article, I argue that many ofthe most important MDGs, includingthose to reduce malaria, maternalmortality, or tuberculosis (TB), sufferfrom a worrying lack of scientifically

valid data. While progress on each ofthese goals is portrayed in time-limitedand measurable terms, often thesubject matter is so immeasurable, orthe measurements are so inadequate,that one cannot know the baselinecondition before the MDGs, or know

if the desired trend of improvementis actually occurring. Although UNscientists know about these troubles,the necessary corrective steps arebeing held up by political interference,including by the organisations seniorleadership, who have ordered delaysto amendments that could repair theMDGs [3]. In short, five years into theMDG project, in too many cases, onecannot know if true progress towardsthese very important goals is occurring.Often, one has to guess.

The MDGs and Principles

of Measurement

What makes the MDGs attractive istheir concreteness. For example, theMDG to eradicate extreme povertysubsumes a target to halve, between1990 and 2015, the proportion ofpeople whose income is less than$1 a day, which in turn subsumesindicators, one of which is to measure

income based on purchasing power.Knowing that, worldwide, 28%

of people in 1990 had purchasingpower below $1 a day gives rise to abenchmark: that in 2015, fewer than14% of people should be so destitute[4,5]. Currently, East Asia is ontrack; sub-Saharan Africa is not [6].Such definitive statements about thebenchmark or the trend are possiblebecause non-stop effort goes intomeasuring incomes and pricestheUN, governments, and businesses all do

itso there are sufficient and reliabledata.It is harder to get sufficient and

reliable data for the health MDGs. Eventhe most basic life indicators, suchas births and deaths, are not directlyregistered in the poorest countries.

Within this decade, only one Africancountry (Mauritius) registers suchevents according to UN standards[7]. Without reliable vital registrationsystems to track even the existenceof births or deaths, naturally the data

for the medical circumstances ofthose births or deathsor the lives inbetweenare unreliable.

Accordingly, most of the availabledata on the health MDGs come frommethods of estimation, censuses,specialised household surveys, or all ofthese together.

There are manytoo manyhousehold surveys. In the public-health field, the best known are theDemographic and Health Survey(DHS) and the Multiple IndicatorCluster Survey (MICS), funded mainlyby the United States and UnitedNations Childrens Fund (UNICEF),respectively [8]. In addition to thosehousehold surveys, the Centers forDisease Control and Prevention, the

World Health Organization (WHO),the United Nations PopulationFund, the World Bank, and other

Policy Forum

Open access, freely available online

October 2005 | Volume 2 | Issue 10 | e318

The Policy Forum allows health policy makers around

the world to discuss challenges and opportunities for

improving health care in their societies.

An Immeasurable Crisis? A Criticism

of the Millennium Development Goals

and Why They Cannot Be MeasuredAmir Attaran

Citation: Attaran A (2005) An immeasurable crisis? Acriticism of the Millennium Development Goals andwhy they cannot be measured. PLoS Med 2(10): e318.

Copyright: 2005 Amir Attaran. This is an open-access article distributed under the terms of theCreative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction inany medium, provided the original work and sourceare properly cited.

Abbreviations: DOTS, directly observed therapyshort course; DHS, Demographic and Health Survey;MDG, Millennium Development Goal; MICS, MultipleIndicator Cluster Survey; MMR, maternal mortalityratio; RBM, Roll Back Malaria; TB, tuberculosis; U5M,under-five child mortality; UN, United Nations;UNICEF, United Nations Childrens Fund; WHO, WorldHealth Organization

Amir Attaran is Associate Professor and CanadaResearch Chair in Law, Population Health, andGlobal Development Policy, University of Ottawa,Ottawa, Ontario, Canada, and Associate Fellow,Chatham House, London, United Kingdom. E-mail:[email protected]

Competing Interests: AA has held small contractsor been paid per diem by the World Bank, UnitedNations Development Program, and the Roll BackMalaria Partnership in the last five years. None ofthese agencies was consulted in the developmentof this manuscript. Research funding was providedexclusively by the Canada Research Chairs program.

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organisations contribute surveys,making a rich alphabet soupRHS,

WHS, CWIQ, LSMS, PAPFAM, and soon. The proliferation is so excessivethat there is now an International

Household Survey Network, therationale for which reads:

Donors [sic] support is not always

appropriately coordinated. There are many

examples of duplicated or conflicting datacollection activities. This lack of coordination

does not only causes [sic] a huge waste offunds, it also put [sic] a high burden on

national statistics offices. In the past few

years, significant progress has been madeto identify synergies among different survey

programs or to develop common questionnaire

modules, and to conduct joint data collectionactivities. But there is certainly room for

much more cooperation. [9]All of this is true, but even within

the UN, different agencies jostlecounterproductively for data. Forexample, in 2002, the WHO launcheda new World Health Survey in over70 countries to compete with thelonger-running DHS and MICS [10].

Justified as a sound basis for evaluatingprogress towards the millenniumdevelopment goals, instead the WHOsnew survey tied up the few qualifiedstatistical staff in the poorest countries[11]. Three years later (at the timeof going to press), the new projecthas yet to publish a single dataset.(Ironically, the WHO has since createda new project called the Health MetricsNetwork, for reducing overlap andduplication caused by a plethora ofseparate and often overlapping [data]systems [12]. One cannot yet say

whether the Health Metrics Networkwill succeed at this important goal, oradd a further layer to the problem.)

Figure 1 shows the number ofreported DHS and MICS surveys since1990, which is the most commonMDG baseline year. To generalise,most countries have had two or threesuch surveys, each gathering data onperhaps 5,00010,000 households.Together with other surveys or nationalcensuses, DHS and MICS are thebackbone of measuring progress on theMDG health indicators.

Yet household surveys are serviceablebut crude tools. Even with a simplequestion, such as about a childs birth

weight, peoples answers only roughlyapproximate the truth, as would bemeasured by weighing on a scale [13].Other survey questions are so technicalthat no layperson can answer themaccurately. MICS, for example, asksparents if their childs anti-malaria bednet was ever treated with a product tokill mosquitoes: an accurate answer

depends on the type, dose, and date ofinsecticide treatment, and whether thelocal mosquito species carry insecticideresistance genes [14]. Becausehousehold surveys do not announcethese or other sources of error, onecan easily have false confidence inthem. For example, many MICS surveyreports present their findings as single-

point estimates, without any of theusual qualifiers of data inaccuracy orquality, such as statistical confidenceintervals or significance tests (seeIndias report for example; [15]).

In short, there are many sourcesof data on the MDGs. When thosesources suffice to reveal statisticallysignificant trends in the MDGs, thenall is well, and it is possible to makeconclusive statements: that the MDGsare being met, or that the MDGs arebeing missed. But, as the case studiesbelow illustrate, such certainty ishighly elusive.

Malaria

MDG 6, Target 8, pledges to havehalted by 2015 and begun to reversethe incidence of malaria. The malariaMDG overlaps with a somewhat earlier(1998) WHO-led goal known as RollBack Malaria (RBM), which aims tohalve malaria-associated mortalityby 2010 and again by 2015 [16].Even though the MDG and the RBMgoal are only quasi-consistent with

one another, the UN allows themto coexist, and UN communicationsoften mention both [16]. Accordingly,both are discussed here.

Yet with double attention onmalaria, and the head start affordedby RBM, the UN still is unable tomake an official pronouncement onthe progress of its malaria goals. The

WHO and UNICEF write that it is toosoon to determine whether the globalburden of malaria, meaning bothincidence and mortality, has increasedor decreased since 2000 [16].

Too soon? RBM is in its seventhyear, and past the halfway mark of its2010 deadline. The only two possiblereasons not to know if malaria hasincreased or decreased are that theUN either (i) did not encouragetimely measurements or (ii) choseindicatorsmalaria incidenceand mortalitythat are essentiallyimmeasurable.

Actually, both are true. What followsis a cautionary history.

Box 1. The MDGs and Targets

By the year 2015, UN member stateshave pledged to meet eight goals; eachgoal subsumes one or more targets, asreproduced verbatim here (quoted from[40]). Details of the targets subsumed bygoal eight and the various indicators forall the goals or targets can be found in[40,41].

Goal 1: Eradicate extreme poverty and

hunger

Reduce by half the proportion ofpeople living on less than a dollar a day

Reduce by half the proportion ofpeople who suffer from hunger

Goal 2: Achieve universal primary

education

Ensure that all boys and girls completea full course of primary schooling

Goal 3: Promote gender equality and

empower women Eliminate gender disparity in primary

and secondary education preferably by2005, and at all levels by 2015

Goal 4: Reduce child mortality

Reduce by two thirds the mortality rateamong children under five

Goal 5: Improve maternal health

Reduce by three quarters the maternalmortality ratio

Goal 6: Combat HIV/AIDS, malaria, and

other diseases

Halt and begin to reverse the spreadof HIV/AIDS

Halt and begin to reverse the incidenceof malaria and other major diseases

Goal 7: Ensure environmental

sustainability

Integrate the principles of sustainabledevelopment into country policiesand programmes; reverse loss ofenvironmental resources

Reduce by half the proportion ofpeople without sustainable access to

safe drinking water Achieve significant improvement

in lives of at least 100 million slumdwellers, by 2020

Goal 8: Develop a global partnership

for development


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In 2002, the British governmentcommissioned an independentevaluation of the UNs malaria efforts.It did so because it was the largestfinancier of RBM, and because of aperception that there was insufficient

alignment between the efforts of theUN agencies and malarious countries.On the subject of measuring progress,the evaluators wrote:

The main problem affectingdatacollection effortshas been that an overly

complex and insufficiently prescriptiveapproach has been taken. There has been a

failure to clearly define goals and prioritiesof the [measurement] strategy at the global

and regional levels....Too many indicatorsare proposed. Too many sources of data

are suggested. Insufficient guidance is

given to countries on data collection andmethodology.Some countries are measuring

one thing, some countries are measuringanother.In some cases, data are being

collected without any systematic and scientificsampling methodology, and so are essentially

meaningless and impossible to interpret. [17]This unsparing criticism points to

two problems, which although theypertain to RBM, often apply withequal force to the malaria and otherMDGs. The first problem concernsthe lack of a baseline: it is impossible

to retrospectively measure worldwide(or regional, or national) malariaincidence and mortality existing atthe inception of the RBM goal or theMDG, when the data from that era areuniversally acknowledged to be poor

[18]. Without knowing the originalcondition, it is futile to stipulate eitherto halve malaria mortality by 2010or to halt malaria incidence by 2015.Such words have no meaning where thebaseline is mysterious.

The second problem concerns theunsuitability of the indicators: bothmalaria incidence and mortality are socrudely measured by household surveysand most countries health recordsthat, essentially, they are immeasurable.The UNs malaria monitoring groupagrees, writing that malaria-specificmortality should not be monitoredroutinely, as this can not be measuredeasily in malaria-endemic Africa[19]. Yet the UN often ignores such

warnings, even when they are timely,explicit, and the opinions of its ownscientists. It was only two months after

WHO scientists wrote that it will not,in general, be possible to measure theoverall incidence rate of malaria thatthe UN chose the incidence rate as themainstay of the malaria MDG [20].

The legacy of unfortunate decisionsnow leaves malaria risk mappingas the only feasible way to estimate(not measure) malaria incidenceand mortality. The principle is tosuperimpose a map of a population

onto a map of malaria intensity,although, in practice, the limitationsinclude malaria maps from the 1960sand too few demographic surveillancesites to accurately measure andcalibrate incidence and mortality risks[21,22]. The WHO has been slow touse risk mapping, probably because itfears public criticism when, inevitably,the current estimates of malaria severitymust be revised upward [23,24].

Accordingly, years after the witheringexternal evaluation, the UN neitherhas achieved convincing measurementor estimation of malaria incidence andmortality, nor has it abandoned thoseas the key indicators of progress. Boththe RBM goal and the malaria MDGare today immeasurable.

Maternal Mortality

MDG 5, Target 6, pledges to reduceby three quarters, between 1990 and2015, the maternal mortality ratio [1].

As such, this MDG target echoes a 1994UN goal set at the Cairo Conference on


DOI: 10.1371/journal.pmed.0020318.g001

Figure 1. Map of DHS and MICS Surveys

The map shows the number of DHS and MICS surveys by country, 19902005, according to completed reports made available to the public in June 2005.These reports are top-level summaries of the underlying micro-level survey data. Note, however, that UNICEF has not publicly disclosed micro-level datafor 13 countries (Afghanistan, Algeria, Botswana, Cambodia, Cuba, Georgia, India, the Maldives, Somalia, Syria, Tunisia, Ukraine, and Federal Republic ofYugoslavia), making independent verification of those reports impossible (see http://www.childinfo.org; http://www.measuredhs.com/).(Illustration: Bang Wong, www.clearscience.info)

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Population and Development to halvematernal mortality by 2000, and againby 2015 [25].

The UN Millennium Project reportsthat at about 530,000 deaths annually,overall levels of maternal mortalityare believed to have remainedunchanged in the last 15 years [26].Both the number of such deaths and

the number of births are used tocalculate the maternal mortality ratio(MMR; the number of women dyingthrough complications of pregnancyand delivery per 100,000 live births).However, it is exactly in the poorestcountries where the maternal mortalityproblem is severest that the data aboutdeaths and births are least satisfactory.

Vital registration would help, but fewdeveloping countries, accounting for24% of the worlds live births, havecomplete data [7]. Directly measuringMMR in the whole population is nottoday an option.

Therefore MMR must be estimated.The current method is crude, and usesregression modelling based on partial

vital registration, censuses, householdsurveys, and other inputs [27]. Theoutputs are a point estimate for MMRin each geographic region, surroundedby an educated guess (not the same asa valid statistical confidence interval) ofthe lower and upper range in which thepoint estimate could lie.

Accordingly, the most recent

(2000) published estimate for MMRworldwide is 400 maternal deaths per100,000 births, within an unscientific,best-guess range of perhaps 210 (low)to 620 (high) [28]. Estimates forthe MDG baseline year (1990) aresimilarly vague [29].

Without a statistically robust estimatefor MMR in the baseline year, or in later

years, nobody knows whether worldwideMMR has increased or decreasedsince 1990, other than in a handfulof countries [26]. The limitationsof current estimation techniquesare so profound that UNICEF and

WHO scientists warn that it would beinappropriate to compare the 2000estimates with those for 1990and drawconclusions about trends [28].

Thus, 11 years after the CairoConference first set an explicit target toreduce MMR by 75%, the UN neitherhas achieved measurement of MMR,nor has it heeded the warnings of itsown scientists that MMR is basicallyimmeasurable. The MDG carries that

mistaken goal forward to 2015, andthe impossibility of measuring anddemonstrating success is certainlypreordained.

Tuberculosis

MDG 6, Target 8, pledges to havehalted by 2015 and begun to reversethe incidence ofmajor diseases,

which the UN has interpreted toinclude TB [1]. The provenance ofthe TB MDG is it neither reiterates anearlier (1991) goal, nor is it obviously apurposeful improvement [30].

As with malaria, measuring TBincidence is notoriously difficult. Itrequires counting the annual numberof new patients with TB disease (i.e.,not just new TB infections). Currently,no country measures TB incidenceregularly, as the MDG target stipulates[31].

Fortunately, the MDG indicatorsprovide for some simpler alternatives:TB disease prevalence and deaths(Indicator 23), and the proportion ofTB disease cases detected and curedusing a WHO-recommended treatment

called directly observed therapyshortcourse (DOTS; Indicator 24). The TBprevalence and case detection indicatorsare directly measurable, but, ironically,the WHO does not actually measurethem. Instead, it uses a unique, arguablyoutdated estimation method.

In the WHOs method, the onlytrue measurement is the number ofnew, sputum-positive TB cases thatare detected and notified to theauthorities for treatment with DOTS.To estimate the case detection rate,the WHO divides that number ofnotified TB cases (the numerator) byan estimate of at-large case incidence(the denominator) [32]. Further,the WHO obtains case incidencefrom an independent estimate ofthe case detection rate [33]. Ineffect, the WHOs two estimates arecircular and lack definite meaning, foreach estimate draws upon the otherestimate. Further, the WHO bases thisestimation process on inputs that arenot always rigorous, and the inputted

data are often obtained from collectiveopinion rather than measurement [33].

Accordingly, it is impossible to statethe actual trends in TB disease with anydegree of statistical confidence. The

WHOs best guess is that its estimatestypically range from 20% to [+]40%in accuracy [32].

Others have criticised the circular

estimation technique. The WHOsformer director for evidence arguesthat essentially no empirical basisexists to assess the trend in casedetection in regions where tuberculosisis most prevalent, including sub-Saharan Africa [34]. He calls the

WHOs trend estimates serialguessing [34]. Certainly, the WHOsleading assumption (known as theStyblo rule [35]) has infrequentlybeen tested in Africa, where TB isaccelerated by an unparalleled HIV/

AIDS epidemic. The WHOs ownscientists concede that it may no longerapply there [32].

Nevertheless, the WHO maintainsthat where access to DOTS treatmentis extensivethat is, not in Africaitsestimated case detection rates are anadequate guide to true TB trends. Thisis debatable: in China, which is the

WHOs finest DOTS success, actualmeasurements (not estimations) of TBprevalence corroborated the WHOscase detections less well than expected[36].

The best solution now proposedin the scientific literature wouldredefine the case detection rate, basedon measuring true TB prevalenceby widespread radiographic ormicroscopic surveys [31]. Althoughsimilar prevalence measurements havebeen the cornerstone of East Asiassuccessful attack on TB, the WHOresists changing from estimation to truemeasurement [37]. As a result, nobodycan say with scientific confidence whatthe actual trends for TB are or whetherthe TB MDG is on track.

Child Mortality

The above case studies could leave thedismal impression that all time-limiteddevelopment goals are immeasurable,lack baseline data, and imply trendshaving no scientific meaning. Notquite. There is a happy exception:MDG 4, Target 5, which reads toreduce by two thirds, between 1990and 2015, the under-five [child]mortality rate [1].


Nobody can say withscientific confidence

what the actual trendsfor TB are.

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The under-five child mortality(U5M) rate is an excellent MDGindicator because it is easily measured.For most parents the birth or death of achild is highly memorable; ask properlyabout these events in a householdsurvey and their recollection is likely tobe accurate. If the survey asks enoughparents in a population, and continues

to ask at regular intervals, a statisticallysignificant trend emerges with timethe very point of the MDGs.

The best proof of this conceptcomes from Africa. Using data fromsequential DHS cycles, in Ghana during19881998, the U5M rate improved30% [38]. Conversely, in Zimbabweduring 19881999, the U5M ratedeteriorated 44% [38]. Unlike otherMDGs where such changes are, to putit bluntly, only guessed at, these trendsin the U5M rate are properly measuredand, importantly, are scientificallymeaningful, with confidence intervalsthat reveal the accuracy and quality ofthe underlying data. Just by keepingthe current DHS technique, andinterviewing about 7,000 women percountry every five years, it is possibleto reliably detect either a 15% gainor loss in the U5M rate with scientificconfidence.

There is an invaluable and gratifyinglesson to draw from the U5M case study:if the UN sets an MDG target that ispractical to measure (most are not),

and the measurement technique forthat MDG target is suitable (most arenot), and measurements are taken atthe baseline year and in subsequent

years (they rarely are), it is then possibleto measure the state of the worldshealth reliably and accurately, and withexcellent scientific confidence regardingthe trend. In short, it becomes possibleto know, not just to guess, if the MDGsare on track or noteven in Africa.

Discussion

I did not write this paper to doubtthe moral necessity of investing moremoney and political capital in globaldevelopment; that is unarguable, andit would be reprehensible to use thesearguments to seed those doubts.

Instead, I hope to open an importantdebate, unable to be fully answeredby this paper, on a hitherto almostunexplored question: is the worldbetter off with or without the MDGsand similar UN-sponsored, time-limited, quantitative development

goals? The answer to that questionmust be sought without pro-UN or anti-UN ideology, but with awareness thatthere are two prongs to consider: (i)

whether such goals are interpreted soas to advance the dignity and well-beingof the large number of people who livein extreme poverty , and (ii) whethersuch goals advance the reputation of

the UN and the global developmentestablishment. I believe the MDGs risktrouble on both fronts.

Viewed objectively, it must be agreedthat the MDGs palter. The health goalsfor 2015 sound quantitative, but formost of them, their quantification isirretrievably flawed. The trends thatthe health goals allude to are eitherimmeasurable or were not measuredproperly from the 1990 baseline yearonward. This is not an extraordinarilycontroversial conclusion: recall thatin each of the cautionary examplesdiscussedmalaria, maternal mortality,and TBthe UNs own current orformer staff have said that the trendsare immeasurable or lack baseline data.

Short of abandoning the MDGs,the better option is to amend thegoals, targets, or indicatorsall threelevels of the hierarchyto be feasiblymeasurable.

Unfortunately, the UN leadershiphas, to date, delayed this option. In aSeptember 2004 memo, one year aheadof the Millennium +5 Summit, the UNs

Deputy Secretary General instructedthe organisations experts in charge ofthe MDG statistics with the following:

The [Millennium +5 Summit]shouldnot be distracted by arguments over the

measurement of the MDGsor worse,over different numbers being used by

different agencies for the same indicator.[P]roposals for modifications of definitions

or new indicators will only be consideredformally after the [Millennium +5

Summit] as any changes at this stagewould only distract from the result that we

would like to achieve. [3]The Deputy Secretary Generals

order interferes with and shows aprofound disrespect for the scientificprocessa process that fundamentallyis not distracted by arguments nordisturbed by different numbers. Onthe contrary, intellectual argumentsbetween scientists are essential fordevising new methods of measurementsfor the MDGs, so that they in turn yieldmore accurate numbers about theextent and causes of extreme poverty.

By suppressing proposals to amendthe MDGs ahead of the Millennium+5 Summit, the UN leadershipdiscarded the only timely opportunityto win high-level political supportfor truly measurable, scientificallymeaningful goals. While the DeputySecretary General plans a processthat will consider recommendations

regarding refinements to the MDGs,

Box 2. Five Recommendationsto Make the MDGs Truly Time-Limited and Quantitative

Convene an external (non-UN) scientificpeer review to examine the goals, targets,and indicators to ascertain whether thedesired trend of improvement in eachis, with current data, measurable orestimable at scientifically accepted levelsof accuracy and statistical significance.

For those goals, targets, or indicatorsmeasurable by household surveys,choose only a single survey instrument;determine the minimum sample sizeneeded to detect favourable or adversetrends with statistical significance;conduct the survey at regular intervals;and make all the micro-level data fullypublic, so independent scientists canreplicate the UNs conclusions. Eliminatethe many superfluous household surveysnow in use.

For those goals, targets, or indicatorsnot measurable by household surveys,institute sample surveys (mini censuses)by creating a large number of newdemographic surveillance sites in variouscountries. The Canadian-funded TanzaniaEssential Health Interventions Project isa superb example (see [18]; http://video.idrc.ca/tehip/tehip_dss_e_1000.asx;http://www.economist.com/displaystory.cfm?story_id=1280587).

For those goals, targets, or indicatorsthat are not measurable by any practicalmeans, first consider to amend them,

and if that is not possible, abandonthem (bearing in mind that any feasibleamendment to the goals, targets, orindicators can only modestly deviatefrom the political consensus thatunderpins the MDGs now).

Within 18 months, hold a high-level UN-sponsored event at which governmentsratify final actions for all the above. Havethose actions be developed by externalscientists and given to the DeputySecretary General directly.


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the process will commence onlyafter this Septembers summit [3].

As a result, any recommendationsto amend the MDGs that may arisemust await ratification at the nextheads-of-state summitpresumably,the Millennium +10 Summit in 2010(to date, summits occur every five

years). In that case, there would

remain only five years to the MDGsfinal reckoning in 2015. Such extremedelay is illogical and sabotages theMDGs chances of success.

Some may disagree with my emphasison measurement and timelines. Oneanonymous peer reviewer of this paper

wrote that while measuring the MDGsis of concern for epidemiologists andothers, my interpretation misses thepoint because the purpose of theMDGs is merely to be exhortatory. TheMDGs are not a measuring exercise,

wrote the reviewer, but instead are acommon vision of what matters mostfor improving the lives of people inpoor countries.

This sort of thinking, althoughwidespread among developmentprofessionals, is neglectful towardspeople living in extreme poverty.Neglect occurs when one touts theMDGs for the common vision of, say,reducing maternal mortality, whilebeing indolent about measurements toprove mortality is genuinely decreasing.That formulation values consensus

about helping pregnant women, aheadof certainty about helping pregnant

womenan outcome that, if they knewabout it, the women could easily findideological and dehumanising.

Further, the notion that the MDGsare merely exhortatory discriminatesagainst the worlds poorest people.Imagine if European or Americanleaders, taking aim at poverty intheir own countries, set quantitativegoals to reduce unemployment orteen pregnancyonly to declare theunemployment and teen pregnancyrates were not a measuring exercise.Most people would abhor thedishonesty, for obvious reasons.

But if it is shameful, as I believe,to interpret the MDGs as merelyexhortatory, imparting no standards ofperformance, the converse error alsoexists: to interpret the MDGs as all-encompassing and imparting too manystandards of performance.

The latest fashion, exemplifiedby the UN Millennium Project, is

to treat the MDGs as catch-alls ortautologies for development itself.In a list entitled Interventions byMDG Target, the UN MillenniumProject recommends to build roadsor transport infrastructure for all ofthe following MDG targets: primaryeducation, hunger, gender equality,

water and sanitation, child mortality,

and, of course, malaria, maternalmortality, and TB [39]. Electricity, slumupgrading, and education are similarpanaceas.

Definitely roads or electricity matterto holistic development, but justifyingthose under the cover of goals expresslyfor child mortality or malaria, makesgoal-setting seem pointless. Worse,such justification sounds dishonestacamouflage job. It is no wonder that

with the MDGs subordinated intoempty vessels for tenuously relatedinterventionssubordinated into, asProfessor Jeffrey Sachs says, just anyinternational goalsthere is resistanceto measure the progress of the specificgoals, targets, and indicators with rigorand precision [2].

I believe that without thoroughgoingaction to change the current scenario

(see Box 2), the MDGs could turnfrom opportunity to liability. As 2015nears, the UN becomes increasingly

vulnerable to criticism if it still lacksdata to prove whether the MDGs areor are not being met. A stream ofembarrassing disclosures, similar to theexternal evaluation of RBM, will likelyensue. Certainly journalists will reportthe embarrassments, and opponents offoreign aid may use them to discreditfurther generosity to poor countries.These unhappy events are entirely

foreseeable, and for that reason, mustgive pause to anyone who naivelybelieves that measuring the MDGs isan occupation only scientists need careabout. Anyone wishing to preserve thecredibility of the UN and the globaldevelopment enterprise ten years fromnow also must care.

More thoughtful and timely actionfor the sake of these institutions, and,needless to say, the millions of people

who shall liveor diewith the successor failure of the MDGs, is only wise.

Acknowledgments

I wish to thank Prof. Martien Borgdorffand Prof. Bob Snow for discussions on TBand malaria epidemiology, respectively.Thanks also to the peer reviewers (Prof.Tom Novotny, Prof. Ron Waldman, and twoanonymous persons) for helpful comments.

References

1. United Nations General Assembly (2001

September) Road map towards theimplementation of the United NationsMillennium Declaration. Report of theSecretary-General. Report number A/56/326.

Available: http:www.un.org/documents/ga/docs/56/a56326.pdf. Accessed 1 August 2005.

2. Eviatar D (2004 November 7) Spend $150billion per year to cure world poverty. New

York Times; Sect 6: 44.3. Deputy Secretary General (United Nations)

(2004) Message to the inter-agency and expertmeeting on MDG indicators, Geneva 29September1 October 2004. New York: UnitedNations. Available: http:unstats.un.org/unsd/mi/techgroup/Sept2004/message_to_inter_agency_mdg.pdf. Accessed1 August 2005.

4. World Bank (2004) MDG 1: Eradicateextreme poverty and hunger. Washington (D.

C.): World Bank. Available: http:ddp-ext.worldbank.org/ext/MDG/gdmis.do. Accessed1 August 2005.

5. Reddy SG, Pogge TW (2003) How notto countthe poor. New York: Columbia University.

Available: http:www.columbia.edu/~sr793/count.pdf. Accessed 1 August 2005.

6. World Bank (2005) Global monitoring report2005. Millennium Development Goals: Fromconsensus to momentum. Washington (D. C.):

World Bank. Available: http:siteresources.worldbank.org/GLOBALMONITORINGEXT/Resources/complete.pdf. Accessed 1 August2005.

7. AbouZahr C, Wardlaw T (2001) Maternalmortality at the end of a decade: Signs ofprogress? Bull World Health Organ 79: 561568.

8. David P, Haberlen S (2005) 10 best resourcesfor measuring population health. Health PolicyPlan 20: 260263.

9. International Household Survey Network(2005) Rationale. Available: Washington (D.C.): International Household Survey Network.

Available: http:www.internationalsurveynetwork.org/home/index.php?option=content&task=view&id=3&Itemid=26. Accessed 1 August 2005.

10. Diallo K, Zurn P, Gupta N, Dal Poz M (2003)Monitoring and evaluation of human resourcesfor health: An international perspective. HumResour Health 1: 3.

11. World Health Organization (2002 January)Statement by the Director-General to theexecutive board at its 109th session. Reportnumber EB109/2. Geneva: World HealthOrganization. Available: http:www.who.

int/gb/ebwha/pdf_files/EB109/eeb1092.pdf.Accessed 10 August 2005.

12. World Health Organization (2005) HealthMetrics Network: What it is, what it will doand how countries can benefit. Geneva: WorldHealth Organization. Available: http:www.

who.int/entity/healthmetrics/about/concept_paper.doc. Accessed 1 August 2005.

13. Robles A, Goldman N (1999) Can accuratedata on birthweight be obtained from healthinterview surveys? Int J Epidemiol 28: 925931.

14. United Nations Chilrens Fund (2000) Multipleindicator cluster survey 2 questionnaire:Children under-5 questionnaire. New York:United Nations Chilrens Fund. Available:http:www.childinfo.org/MICS2/finques/M2finQ.htm. Accessed 1 August 2005.


The MDGs could turnfrom opportunity to

liability.

8/2/2019 Journal.pmed.0020318

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15. Government of India, United NationsChildrens Fund (2001 November) Multipleindicator survey2000 India summary report.New York: United Nations Childrens Fund.

Available: http:www.childinfo.org/MICS2/newreports/india/india.pdf. Accessed 2 August2005.

16. World Health Organization, United NationsChildrens Fund (2005) World malaria report2005. Geneva: World Health Organization.

Available: http:rbm.who.int/wmr2005/pdf/WMReport_lr.pdf. Accessed 1 August 2005.

17. World Health Organization (2002) Finalreport of the external evaluation of Roll BackMalaria: Achieving impact: Roll Back Malariain the next phase. Geneva: World HealthOrganization. Available: http:www.rbm.who.int/cmc_upload/0/000/015/905/ee_toc.htm.

Accessed 1 August 2005.18. De Savigny D, Binka F (2004) Monitoring future

impact on malaria burden in sub-SaharanAfrica. Am J Trop Med Hyg 71: 224231.

19. World Health Organization (2003 November)Second meeting of the RBM partnershipMonitoring and Evaluation ReferenceGroup. Geneva: World Health Organization.

Available: http:rbm.who.int/partnership/wg/wg_monitoring/docs/MERG_Nov03minutes270104final.doc.

Accessed 1 August 2005.20. Watt C, Dye C (2000 July) Indicators to

measure the impact of malaria control.Report number WHO/CDS/RBM/2000.22.Geneva: World Health Organization. Available:http:whqlibdoc.who.int/hq/2000/

WHO_CDS_RBM_2000.22.pdf. Accessed1 August 2005.

21. Korenromp EL, Williams BG, Gouws E, DyeC, Snow W (2003) Measurement of trendsin childhood malaria mortality in Africa: Anassessment of progress toward targets based on

verbal autopsy. Lancet Infect Dis 3: 349358.22. Snow RW, Guerra CA, Noor AM, Myint HY,

Hay SI (2005) The global distribution ofclinical episodes ofPlasmodium falciparummalaria. Nature 434: 214217.

23. BBC News (2005 March 10) Global toll ofmalaria doubled. London: BBC News.

Available: http:newswww.bbc.net.uk/1/hi/health/4332921.stm. Accessed 1 August 2005.

24. [Anonymous] (2005) Reversing the failures ofRoll Back Malaria. Lancet 265: 1439.

25. United Nations Population Fund (1994) Part1: Programme of action of the United NationsInternational Conference on Population andDevelopment. New York: United NationsPopulation Fund. Available: http:www.unfpa.org/icpd/icpd_poa.htm. Accessed 2 August2005.

26. UN Millennium Project (2005) Whos got thepower? Transforming health systems for womenand children. London: Earthscan. 224 p.

27. Hill K, AbouZahr C, Wardlaw T (2001)Estimates of maternal mortality for 1995. Bull

World Health Organ 79: 182193.28. World Health Organization, United Nations

Childrens Fund, United Nations PopulationFund (2003) Maternal mortality in 2000:Estimates developed by WHO, UNICEF,and UNFPA. Geneva: World HealthOrganization. Available: http:www.who.int/reproductive-health/publications/maternal_mortality_2000/mme.pdf.

Accessed 10 August 2005.29. World Health Organization, United Nations

Childrens Fund (1996 April) Revised 1990estimates of maternal mortality: A new

approach by WHO and UNICEF. Geneva:World Health Organization. Available:http:whqlibdoc.who.int/hq/1996/

WHO_FRH_MSM_96.11.pdf. Accessed10 August 2005.

30. World Health Organization (1991 May) Forty-fourth world health assembly. Resolution WHA44.8. Geneva: World Health Organization.

Available: http:policy.who.int/cgi-bin/om_isapi.dll?hitsperheading=on&infobase=

wha&record={2496}&softpage=Document42.Accessed 1 August 2005.

31. Borgdorff MW (2004) New measurableindicator for tuberculosis case detection.Emerg Infect Dis 10: 15231528.

32. Dye C, Watt CJ, Bleed DM, Hosseini SM,Raviglione MC (2005) Evolution of tuberculosiscontrol and prospects for reducing tuberculosisincidence, prevalence, and deaths globally.

JAMA 293: 27672775.33. Dye C, Scheele S, Dolin P, Pathania V,

Raviglione MC, et al. (1999) Global burden oftuberculosis: Estimated incidence, prevalence,and mortality by country. JAMA 282: 677686.

34. Murray CJ, Lopez AD, Wibulpolprasert S(2004) Monitoring global health: Time for newsolutions. BMJ 329: 10961100.

35. Styblo K (1985) The relationship between therisk of tuberculous infection and the risk ofdeveloping infectious tuberculosis. Bull IntUnion Tuberc Lung Dis 60: 117119.

36. China Tuberculosis Control Collaboration(2004) The effect of tuberculosis control inChina. Lancet 364: 417422.

37. Borgdorff MW, Nagelkerke NJD, Dye C,Nunn P (2000) Gender and tuberculosis:Comparison of prevalence surveys withnotification data to explore sex differencesin case detection. Int J Tuberc Lung Dis 4:123132.

38. Korenromp EL, Arnold F, Williams BG,Nahlen BL, Snow RW (2004) Monitoringtrends in under-5 mortality rates throughnational birth history surveys. Int J Epidemiol33: 12931301.

39. United Nations Millennium Project (2005)

Interventions by MDG target. New York:United Nations. Available: http:www.unmillenniumproject.org/documents/Interventions%20by%20MDG%20Target.doc.

Accessed 1 August 2005.40. United Nations (2005) UN millennium

development goals. New York: UnitedNations. Available: http:www.un.org/millenniumgoals. Accessed 12 August 2005.

41. United Nations Statistical Division (2005)Millennium development goal indicatorsdatabase [database]. New York: United NationsStatistical Division. Available: http:unstats.un.org/unsd/mi/mi_goals.asp. Accessed 12

August 2005.


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