Amir Attaran's Policy Forum raises important points on the poor quality of data for some indicators used to measure progress on the Millennium Development Goals (MDGs), but, sadly, uses these findings to draw the wrong conclusions. The evidence he presents on a small number of indicators is partial, and does not justify his conclusion that the MDGs might become a liability and are doomed to fail. Quite the opposite is the case

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PLoS Medicine  |  www.plosmedicine.org 1190CorrespondenceOpen access, freely available onlineResponse to Amir AttaranJohn W. McArthur, Jeffrey D. Sachs, Guido Schmidt-TraubAmir Attaran’s Policy Forum [1] raises important points on the poor quality of data for some indicators used to measure progress on the Millennium Development Goals (MDGs), but, sadly, uses these ﬁ ndings to draw the wrong conclusions. The evidence he presents on a small number of indicators is partial, and does not justify his conclusion that the MDGs might become a liability and are doomed to fail. Quite the opposite is the case. Of course the data on the world’s extremely poor people are weak, as is just about every other aspect of efforts vis-a-vis the poor. The rich countries dramatically underinvest and make far too little effort in helping to save the poor from dying of malaria and tuberculosis (TB). It is, therefore, no surprise that developing countries and the international system lack the resources and operational support to measure malaria and TB well. Attaran’s criticisms in this regard are justiﬁ ed and have been made by many others before him, including many professionals working for the United Nations (UN) system. The MDGs are a political commitment made by the 189 countries represented at the 2000 Millennium Summit to halve extreme poverty in its many forms by 2015. The author ignores that such broad outcome goals adopted by world leaders are distinct from the technical question, how to deﬁ ne and measure corresponding indicators, which the UN has been asked to help answer. It is, therefore, inaccurate to blame the UN system for setting goals that are difﬁ cult to measure. Goal setting is the prerogative of world leaders, and they have correctly reafﬁ rmed their commitment to the MDGs many times since 2000. In response, the UN system has set up an active process to review indicators and data on progress toward achieving the MDGs, involving many UN organizations as well as the World Bank and the International Monetary Fund. In recent years, this interagency process has already revised several MDG indicators and issued guidance notes on how data collection can be improved. The author’s assertion that the UN “shows a profound disrespect for the scientiﬁ c process” [1] is wrong and misleading. The UN leadership rightly decided that the heads of state and government convening at the 2005 World Summit should focus their attention on the high-level political decisions needed to strengthen the international framework for security, development, and human rights. On the development side, the greatest priority was to cement the MDGs as operational rather than simply rhetorical targets. The world leaders did not delve into the technical issues of measurement and indicators, but this important work will continue to be addressed by UN statisticians and independent experts. Such experts have indeed been scrutinizing the deﬁ nition and measurement of these indicators for some time—as did, for example, several of the UN Millennium Project task forces. Another shortcoming of Attaran’s article is that it generalizes incorrectly across the MDGs. It describes some of the toughest measurement challenges (e.g., maternal mortality and malaria), and uses them to paint all the MDGs with the same brush. In addition to the example of child mortality rates cited in the article, several other MDG indicators can be measured quite well. These indicators include anthropometric measures of malnutrition, primary school enrollment, gender parity in education, and access to basic infrastructure services. An implication of Attaran’s argument is that there should be no goals when measurement is imperfect, as it is in many countries with indicators for maternal mortality. Should world leaders, therefore, not set time-bound goals for reducing maternal mortality? This would be wrongheaded for three clear reasons. First, even with incomplete or missing data, dramatic and veriﬁ able improvements in women’s health can be achieved by investing in emergency obstetric care and other known, monitorable, and practical interventions to build and sustain primary health systems. The MDGs provide a major political and operational framework for doing this. Second, the MDGs are already promoting strengthened health systems in low-income settings, and those improved systems are key to ensuring the vital registrations that the author rightly recommends for improving the measurement of maternal mortality. Third, the very adoption of the maternal mortality goal (and others) is provoking greatly increased attention to improvements in data collection from the World Health Organization, the Gates Foundation, the World Bank, academia, and others. The MDGs should not be misunderstood as a static, one-off process. Attaran misleads the reader when he argues that the MDGs have become “all-encompassing” catch-alls for tenuously related interventions. To say that roads and electricity are falsely linked to achieving the MDGs is incorrect, and suggests a lack of understanding of the integrated nature of development processes. Roads and electricity play a critical role in poverty reduction, access to essential health services, reduction of maternal and child mortality, and a host of other channels directly related to success in achieving the MDGs. Therefore, any strategy to achieve the MDGs needs to include these interventions. The UN Millennium Project described these linkages in the most detailed series of studies on practical approaches to achieving the MDGs that has ever been produced. We hope that Attaran’s key message on improved data collection and interpretation is heard. More and better data are certainly needed on the conditions of the world’s poorest and most vulnerable people. However, even in countries with poor data systems, enough is known today to start making the practical and measurable investments in education, health, basic infrastructure, and improved environmental management that are vitally needed to cut, and eventually to end, extreme poverty. Crucially, the MDGs provide the unique framework for prompting the international cooperation that is indispensable to helping poor countries escape the poverty trap, and to benchmarking progress en route. No discussion about indicators and measurement—no matter how justiﬁ ed it is—should deﬂ ect from the overarching global commitment to the poorest of the poor that world leaders struck at the Millennium Summit in 2000 and reconﬁ rmed at the World Summit in 2005. November 2005  |  Volume 2  |  Issue 11  |  e379PLoS Medicine  |  www.plosmedicine.org 1191John W. McArthurJeffrey D. Sachs (sachs@columbia.edu)Guido Schmidt-TraubUnited Nations Millennium Project New York, New York, United States of AmericaReference1. Attaran A (2005) An immeasurable crisis? A criticism of the Millennium Development Goals and why they cannot be measured. PLoS Med 2: e318. DOI: 10.1371/journal.pmed.0020318Citation: McArthur JW, Sachs JD, Schmidt-Traub G (2005) Response to Amir Attaran. PLoS Med 2(11): e379.Copyright: © 2005 McArthur et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Competing Interests: The authors have declared that no competing interests exist.DOI: 10.1371/journal.pmed.0020379Author’s ReplyI am grateful for the reply of Jeff Sachs, John McArthur, and Guido Schmidt-Traub to my article [1,2]. Their reply, written on behalf of the United Nations (UN) Millennium Project, shows that even the leading thinkers of that organization possess beliefs about the Millennium Development Goals (MDGs) that contradict the factual evidence.  On one issue, the UN Millennium Project team agrees with me: progress on the MDGs is sometimes not well measured, such that it is impossible to know if the goals are on track to being fulﬁ lled by their 2015 deadline. But even on this issue, we disagree on the extent of the problem. The UN Millennium Project team writes that, because my analysis was limited to only the public health MDGs, I based my conclusions on only “the toughest measurement challenges,” and “generalize[d] incorrectly across the MDGs” [1]. In their view, if one leaves the difﬁ cult health MDGs aside, then “several other MDG indicators can be measured quite well” [1].To determine whether this assertion is correct, I accessed the UN’s own “Data Availability Analysis” [3] for 2005, which takes into account every one of the 48 UN-designated MDG indicators (really 65 indicators in 48 categories). For each indicator, the UN’s analysis summarizes the percentage of countries possessing measurements taken in two benchmark years: one year near the starting point of the MDGs (usually 1990) and another year nearer to the present (after 1999). Naturally, it is the difference of this pair of benchmark measurements, taken years apart, which proves whether progress is or is not being achieved for a particular MDG indicator. The disappointing result of the UN’s “Data Availability Analysis” is that, more often than not, the requisite pair of benchmark measurements doesn’t exist, such that no factual conclusion about progress can be made. In the best case scenario, there are two indicators with paired benchmark measurements in 98% of countries. In the worst case scenario, there are 26 indicators—13 times as many—with paired benchmark measurements in none of the countries. Even the median MDG indicator, which is the one indicator most typical of the bunch, has paired benchmark measurements in just 5% of countries—meaning that the UN does not possess those data for 95% of countries.  In that context, the UN Millennium Project team is deﬁ nitely wrong to believe that, health indicators aside, the MDGs “can be measured quite well” [1]. The UN’s comprehensive analysis of all MDG indicators shows that, for whatever reason, most are not measured well, not even so rarely as twice a decade.Why is measurement of the MDGs so generally poor? According to the UN Millennium Project team, the answer is money. They write that “developing countries and the international system,” which presumably includes the UN, “lack the resources to measure” the MDGs [1].However, this belief, too, contradicts the evidence. Concerning the health MDGs, my article recommended expanding the network of demographic surveillance sites (DSS) as the single most efﬁ cient way to obtain timely, accurate measurements [2]. According to a recent study of DSS in Tanzania, this costs $0.01 per person, per year [4]. Thus, to institute DSS and good quality MDG measurements for the 4 billion poorest people worldwide would cost perhaps $40 million annually. In this context, the UN Millennium Project team’s argument that the “international system lacks the resources” to effectively measure the health MDGs is without credibility. The sum of $40 million is under 0.1% of the global foreign aid budget (Organization for Economic Cooperation and Development Development Assistance Committee [OECD DAC]).Without such steps to measure progress on achieving the MDGs, any claims made for them are necessarily conjectural, rather than objective. The UN Millennium Project team writes that, even without measurement, “the MDGs are already promoting strengthened health systems in low-income countries” [1]—but regrettably, they fail to furnish evidence of this. They also write that “the very adoption of the maternal mortality goal … is provoking greatly increased attention to improvements in data collection” [1]. What they fail to mention is that the UN adopted that goal in 1990, and despite 15 years of provoking increased attention, elsewhere the UN Millennium Project team have called the data “unreliable” [5].I could dispute other unsupported assertions in the reply of the UN Millennium Project team, but choose not to do so because it would distract from this fundamental point: whether to honor the health of the world’s poorest or sickest people or to restore the earth’s most vulnerable natural environments or to secure human rights for children and women, the UN must demonstrate much greater responsibility than it has in measuring the status of the MDGs. The UN Millennium Project team urges to “cement the MDGs as operational rather than simply rhetorical targets” [1]. I agree this is desirable, and, actually, to place rhetoric ahead of evidence is unethical.  That is why measurement to prove—not just to speculate—on the MDGs’ operational progress cannot continue to be neglected, and also why the leading intellectuals of the UN Millennium Project err awfully in their judgment when justifying the neglect to date. Amir AttaranUniversity of OttawaOttawa, Ontario, CanadaE-mail: Amir.Attaran@uottawa.caNovember 2005  |  Volume 2  |  Issue 11  |  e379  |  e405

Response to Amir Attaran

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