AHEAD IN 2015: VIRUSES, EPIDEMICS AND UNITED NATIONS HAGGLING—PART THREE: Racing To Meet The MDGs (And Create SDGs)
With fewer than 360 days left to meet the Millennium Development Goals, or MDGs, hundreds of UN agencies, nongovernmental organizations (NGOs), foundations, and governments are scrambling to reach the targets and prove with valid data that they have done so. Adopted by the United Nations General Assembly in 2000, the eight goals include three that are directly related to global health: numbers four, five, and six. Combined, these three aim to dramatically reduce the number of babies and children dying; improve the health and survival of pregnant women; provide universal access to treatments for tuberculosis, malaria and HIV; and reduce the incidence of those diseases.
Progress toward achieving MDG number four has been dramatic, with the numbers of children dying before reaching their fifth birthdays cut by half, far more children having access to clean drinking water and education, and HIV infections passed from mother to child radically reduced—to nearly zero in much of the world. In 1990, when the world population was considerably less than today, 12.6 million babies and children died before age five. In 2013 just 6.3 million children succumbed. But Anthony Lake, executive director of UNICEF, writes, “Unless progress accelerates markedly, MDG 4 will not be achieved in all countries until 2028—and an additional 35 million children will die who could otherwise have lived if the world had met this goal by 2015 as promised.”
German Chancellor Angela Merkel writes that maternal mortality rates “are still unacceptably high and too many women and children face a fight for survival during pregnancy, childbirth, and infancy.” And UK Prime Minister David Cameron says, “The fight for equality for women and girls is at the very heart of the Millennium Development Goals: it is essential if we are to drive progress and development around the world.” Cameron continues, warning that “millions of adolescent girls face inequality and even abuse. The figures are shocking: 130 million women in our world are affected by female genital mutilation, with 63 million more potentially at risk by 2050. 700 million women alive today were married as children, with 250 million married before 15 years old.”
As for MDG number six, there is much for the world to be proud of. Six million children have been spared deaths from such diseases as measles, diphtheria, and polio thanks to massive expansion of child immunization programs. Malaria deaths have been cut in half, tuberculosis mortality is down by 45 percent, the new HIV infection rate has been cut by a third compared to 2000, and more than ten million people worldwide are alive, despite HIV infection, thanks to access to medicines. But as Mark Dybul, executive director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and Seth Berkley, chief executive of GAVI cowrite, “Malaria still causes 660, 000 deaths each year; mostly children under five. Millions continue to be infected by HIV each year, and millions continue to die. And one in five children still do not receive a full course of even the most basic vaccines. As a result, 1.5 million children still die each year from vaccine-preventable diseases.”
As the clock ticks to midnight on December 31, 2015, the world will race to close those gaps. But funding is in short supply, crises like Ebola are sapping global health energies, and the lions’ share of failure to meet the MDGs is focused on a small number of extremely impoverished or conflict-torn areas. For example, while twenty-seven developing countries are expected to hit MDG number four’s child mortality targets, many African nations won’t come close to meeting them until 2030, or perhaps even 2050.
The race is on and will form a backdrop to thousands of global health and humanitarian activities throughout 2015.
Meanwhile, the same agencies, NGOs, think tanks, government agencies, and foundations that are scrambling on the MDGs are also haggling over the details of the next fifteen-year targets, the Sustainable Development Goals, or SDGs. The intention is to reach agreement by September 2015 on a set of targets that should be achieved by 2030—goals that ought to be sustainable with countries’ own resources and will eliminate acute poverty. Countless meetings involving thousands of participants have already been convened, culminating to date in a synthesis report by the secretary-general on the post-2015 sustainable development agenda, “The Road to Dignity by 2030: Ending Poverty, Transforming All Lives and Protecting the Planet.
At this point there are seventeen SDGs, stated in a vague, aspirational manner with no clear metrics for achievement, as shown in Table 1 from the UN report. Beneath each of the seventeen goals are dozens of sub-goals and aspirations forming a laundry list so large as to defy summary. Much haggling remains, and the coming nine months will see escalating debate over every detail of the UN scheme. The same December Synthesis Report concluded: “The year 2015 is hence the time for global action. In the course of this single year we have the unequivocal opportunity and responsibility to adopt the sustainable development goals, to restructure the global financial system in line with our needs and to respond finally and urgently to the challenge of human-induced climate change. Never before has the world had to face such a complex agenda in a single year. And this unique opportunity will not come again in our generation.”
If the list remains in its current form, all aspects of global health will be squeezed into goal three: “Ensure healthy lives and promote well-being for all at all ages.”
What does that mean? The world population will swell over coming decades, with the most radical increases in Africa and the Indian subcontinent. The global population is expected to top eleven billion by 2100, which means that any hope for “healthy lives” for all of humanity must begin with recognition that there will be billions more Homo sapiens scrambling for food, water, and resources on less available land and more depleted seas. And then there’s climate change…
But the debate over SDGs isn’t all airy-fairy, as it begins with recognition of real achievements, especially in health. Regardless of the MDG targets, health has improved so dramatically worldwide since 1990 that we almost live on a different planet. The recently published Global Burden of Disease Study, which pools and assesses millions of bits of data from thousands of agencies and studies worldwide, recently released startling findings. Life expectancy overall across 188 countries rose from an average 1990 level of 65.3 years to 71.5 years. Tremendous improvements in child-focused health (such as immunizations) and environmental pathogen exposure (clean water) have paid off. But the study found that unacceptably high causes of preventable death remain, including, “HIV/AIDS, pancreatic cancer, atrial fibrillation and flutter, drug use disorders, diabetes, chronic kidney disease, and sickle-cell anemias. Diarrheal diseases, lower respiratory infections, neonatal causes, and malaria are still in the top five causes of death in children younger than five years.”
But the WHO finds a growing gap in such achievements. The top ten longest-lived societies break down as shown in this WHO table, with a Japanese baby girl born in 2012 likely, statistically speaking, to live to age 87. But her counterpart born in a low income country can expect to live to just age 63. A Johns Hopkins University study found that the primary difference in life expectancy between nations still rested with wide gaps in infant and child mortality in sixty-seven poor countries. The startling analysis found that in 2007, “approximately 6.6 million under-five deaths were observed in the 67 countries used in the analysis. This could be reduced to only 600,000 deaths if these countries had the same under-five mortality rate as developed countries.”
This year’s final battle over the health targets of the SDGs will, I believe, boil down to the following three things:
- Health targets must fit into the overarching SDG goal of “ending poverty, transforming all lives and protecting the planet.” Health advocates must identify targets that not only improve morbidity and mortality, but reduce impoverishment. Leading the list for that achievement is Universal Health Coverage (UHC) which seeks to create financing schemes that eliminate personal bankruptcy caused by medical expenses and improves national capacity to provide health (through public and/or private insurance means) to entire populations. Health targets will have to be framed within the context of poverty reduction.
- The core fight this year for SDG number three will be in the sublanguage. For example, will all unmet MDG health targets be folded into SDG number three? How can the notion of national “sustainability” for such things as universal access to HIV medicines be reconciled with the current dependency on donor support, primarily from the Group of Seven nations?
- Given the great successes in health to date, and the aging of the world population, noncommunicable diseases like cancer and cardiovascular ailments already dominate the global burden of disease, and represent far more costly investments in treatment, chronic maintenance and in some cases prevention than are the case for infectious diseases. Assuming the poverty reduction targets are critical, how will financing schemes for poor nations possibly result in equitable global access to such things as cardiac bypass surgery, personalized medicine, stem cell therapy, psychiatric interventions, and cancer diagnostics?
My CFR colleague Tom Bollyky recently completed a CFR-sponsored Independent Task Force report on “The Emerging Global Health Crisis” of noncommunicable diseases (NCDs), chaired by Mitchell E. Daniels Jr. and Thomas E. Donilon. Among other findings, the report projects that NCDs “will inflict $21.3 trillion in losses in developing countries over the next two decades—a cost nearly equal to the entire economic output of those countries in 2013."
The real challenge for the diverse, often internally competitive global health community will be to forge a path forward that protects and expands the gains made with the MDGs, while adding layers of commitment to chronic ailments, traumatic and accidental injuries, mental illnesses and the diseases of aging populations. With so many major institutional players on the stage still quite young – less than 15 years in existence – this year will test the maturity of the global health community and its leadership. Poorly governed, and highly dependent upon donor support from the G7 nations and a finite number of wealthy individuals and foundations, the global health community will be sorely tested in 2015.