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n September 2000, 147 heads of state met at the United Nations(UN) headquarters—the largest such gathering ever—to resolveaction on the most pressing problemsof humanity and nature . Tounderscore their commitment, they set 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 state will 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 development enterprise. As Professor Jeffrey Sachs,Director of the UN’s MillenniumProject, has declared, “To the extent that there are any international goals,they are the Millennium Development Goals” .But is it wise to elevate the MDGsto the pedestal where they now sit?Could it be, despite an appearance of ﬁrm targets, deadlines, and focusedurgency, that the MDGs are actually imprecise and possibly ineffectiveagents for development progress?In this article, I argue that many of the most important MDGs, includingthose to reduce malaria, maternalmortality, or tuberculosis (TB), sufferfrom a worrying lack of scientiﬁcally valid data. While progress on each of these 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 knowif the desired trend of improvement is actually occurring. Although UNscientists know about these troubles,the necessary corrective steps arebeing held up by political interference,including by the organisation’s seniorleadership, who have ordered delaysto amendments that could repair theMDGs . 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 Principlesof Measurement
What makes the MDGs attractive istheir concreteness. For example, theMDG to eradicate extreme poverty subsumes a “target” to “halve, between1990 and 2015, the proportion of people whose income is less than$1 a day”, which in turn subsumes“indicators”, one of which is to measureincome 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 .Such deﬁnitive statements about thebenchmark or the trend are possiblebecause non-stop effort goes intomeasuring incomes and prices—theUN, governments, and businesses all doit—so there are sufﬁcient and reliabledata.It is harder to get sufﬁcient andreliable data for the health MDGs. Eventhe most basic life indicators, suchas births and deaths, are not directly registered in the poorest countries. Within this decade, only one Africancountry (Mauritius) registers suchevents according to UN standards. Without reliable vital registrationsystems to track even the existenceof births or deaths, naturally the datafor the medical circumstances of those births or deaths—or the lives inbetween—are unreliable. Accordingly, most of the availabledata on the health MDGs come frommethods of estimation, censuses,specialised household surveys, or all of these together.There are many—too many—household surveys. In the public-health ﬁeld, the best known are theDemographic and Health Survey (DHS) and the Multiple IndicatorCluster Survey (MICS), funded mainly by the United States and UnitedNations Children’s Fund (UNICEF),respectively . 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
Open access, freely available online
October 2005 | Volume 2 | Issue 10 | e318
The Policy Forum allows health policy makers aroundthe world to discuss challenges and opportunities forimproving health care in their societies.
An Immeasurable Crisis? A Criticismof the Millennium Development Goalsand Why They Cannot Be Measured
Attaran A (2005) An immeasurable crisis? Acriticism of the Millennium Development Goals andwhy they cannot be measured. PLoS Med 2(10): e318.
© 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.
DOTS, directly observed therapy—short 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 Children’s Fund; WHO, WorldHealth OrganizationAmir 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:firstname.lastname@example.org
AA has held small contractsor been paid per diem by the World Bank, UnitedNations Development Program, and the Roll Back Malaria Partnership in the last ﬁve years. None of these agencies was consulted in the developmentof this manuscript. Research funding was providedexclusively by the Canada Research Chairs program.