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UN’s eight millennium development goals: Both a success and a fiasco

The UN’s eight millennium development goals are due to be achieved next year. Three of them are directly linked to health and the outcomes vary, but the researchers are basically optimistic when they speak up about the future.

The millennium goals were drawn up as a result of the millennium declaration, a plan for global development that focuses on the needs of vulnerable people. This was signed by 189 countries in 2000, an initiative of the UN’s then Secretary-General Kofi Annan.

“In the years prior to the turn of the millennium, a number of conferences were arranged throughout the world that were concerned with various different problem areas, but there was little action. The aim of the millennium declaration was to take collective action and show that all development is linked,” says Tobias Alfvén, researcher at the Department of Public Health Sciences at Karolinska Institutet and doctor at Sachs’ Children’s Hospital in Stockholm.

Three of the eight millennium goals are directly linked to health and are concerned with child mortality among children under five, maternal mortality in conjunction with pregnancy or childbirth and major infectious diseases

“The millennium goals have resulted in a significantly greater focus on health issues compared to in the past, not only on a global level within aid organisations and the UN, but also in individual countries. We now wanted to measure not simply economic development, but also health development,” says Tobias Alfvén and continues:

“Economic development leads to better health, but improved health in a country also leads to better economic development. In the same way, all eight millennium goals are strongly connected to one another.”

Goal # 4: reduce child mortality

The millennium goals are based on what the world was like in 1990, and state the measurable changes that should have taken place by 2015. For example, millennium goal number four states that worldwide child mortality is to be reduced by two thirds over the course of the period specified. Tobias Alfvén has many years’ experience conducting research that aims to reduce child mortality in countries like Uganda.

“Many believe that child mortality hasn’t changed at all over the years, but it has decreased by almost 50 per cent worldwide since 1990. We will not achieve a two-thirds reduction by next year and the variations within and between countries are great, but we have made good progress,” he says.

Despite child mortality having decreased sharply, 6.6 million children worldwide died before their fifth birthday in 2012. Tobias Alfvén describes the balance between highlighting successes and emphasising the importance of more initiatives, with measles as one example.

“On the one hand, the number of children who die from measles has decreased drastically in recent years, which is a fantastic improvement. On the other hand, there is an excellent, cheap vaccine that is relatively simple to administer. So the fact that any children die from measles in 2015 is a huge failure. But it is important to see both sides. We are making good progress, but we can do even more,” he says.

We are making good progress, but we can do even more.

Tobias Alvfén

Around 44 per cent of all children who die prior to their fifth birthday in 2012, died within the first 28 days following their birth. These deaths were the result of, for example, complications of premature birth or oxygen deficiency in conjunction with delivery. Other common causes of death among children under five are pneumonia, diarrhoea and malaria. Malnutrition is a contributory factor in about one third of the deaths.

Tobias Alfvén is currently involved in three different projects associated with the prevention, diagnosis and treatment of pneumonia in children. In Uganda, because of a lack of healthcare, they have been training villagers to act as community health workers, whose job it is to hand out malaria medication to the children from the village who come to them with a fever. But sometimes the fever is not caused by malaria, but by pneumonia.

“Consequently, in our study, the village health workers have also been given access to antibiotics that they give to the children who have a high respiratory rate and cough in addition to a fever, indicating pneumonia. The treatment results are good, but not perfect. Pneumonia is harder to diagnose than malaria,” says Tobias Alfvén.

A project started more recently, involves Tobias Alfvén and his colleagues from Uganda, collaborating with researchers from the Science for Life Laboratory in Stockholm, with the goal of developing a patient-centred rapid test that can use blood or nasal samples, to determine whether pneumonia and other infectious diseases are caused by bacteria or viruses.

“We want antibiotics to be available to all those who need them, but the medication has no effect on viruses and overprescription leads to antibiotic resistance. A test like this would not only be useful in poor countries, but also in countries like Sweden,” he says and adds:

“I see huge advantages to this type of interdisciplinary project, involving doctors and engineers working together in both high and low-income countries. Everyone involved benefits and it increases our chances of continuing to improve global health,” he says.

Another new study involves Tobias Alfvén and his colleagues looking at how a pneumococcal vaccine, which prevents diseases including pneumonia and meningitis, affects child morbidity and mortality in both Sweden and Uganda. Tobias Alfvén is confident that the worldwide reduction in child mortality will continue if we keep using research to discover how best to reach everyone with the existing preventative, diagnostic and therapeutic tools we currently have access to, while also continuing to develop new ones. But children’s chances of survival are also affected by maternal health.

“In the poorest countries, child mortality is up to 90 per cent if the mother dies during childbirth,” says Tobias Alfvén.

Goal # 5: improve maternal health

Millenium goal five is devoted to maternal health and one of two interim goals is that maternal mortality is to decrease by three quarters between 1990 and 2015. So far, there has been a reduction of just over 45 per cent and close to 800 women die every day in conjunction with pregnancy or childbirth. Staffan Bergström is Professor Emeritus in International Health at Karolinska Institutet and called the result a fiasco in an opinion piece in the newspaper Dagens Nyheter last year.

“If the economic resources had been invested we could have achieved the desired reduction, but aid has gone to other problem areas or failed to appear as a result of the financial crisis. Prior to the 1990s, maternal health almost never appeared in an aid context and it is thought-provoking that the millennium goal most closely related to women is still receiving so little attention,” he says.

Staffan Bergström is also critical of the second interim goal, “universal access to reproductive health”.

“What is ‘universal access to reproductive health’? This can mean anything from universal access to contraceptives to a universal right to be treated for involuntary childlessness. In some parts of West Africa, 20–30 per cent of the population is childless as a result of infertility caused by sexually transmitted diseases. In my opinion, this interim goal is completely plucked out of thin air,” he says and continues:

“Of the eight millennium goals, the goal of improved maternal health is the one we have had the least success with.”

A large proportion of all cases of maternal mortality in conjunction with pregnancy and childbirth are due to bleeding and high blood pressure. Indirect causes such as malaria HIV/AIDS and heart diseases, complicated deliveries, miscarriages and unsafe abortions also account for deaths.

“It is important to recognise that the majority of all women who die during pregnancy or childbirth are what is known as low-risk cases, it is not possible to predict in advance which of them are more likely to be affected. Consequently, the best thing we can do to improve mothers’ survival is to create functional healthcare systems in which women have the opportunity to receive emergency care,” says Staffan Bergström.

He has himself been involved in several research projects in East Africa, the aim of which has been to delegate life-saving surgery such as Caesarean sections and other major interventions from doctors – who are often in short supply – to specially trained nurses and midwives.

“In Mozambique, a surgical training programme for so-called non-doctors was begun in 1984 and 92 per cent of all Caesarean section in the country’s district hospitals are now carried out by non-doctors. Some of them have managed to perform 10,000 Caesarean sections, often without access to blood and antibiotics, with very good outcomes,” he says.

A dissertation by obstetrician Caetano Pereira from 2010, supervised by Staffan Bergström, indicates that the outcomes of 1,000 Caesarean sections performed by non-doctors in Mozambique, were just as good as those of the same number of Caesarean sections carried out by doctors. In addition, close to 90 per cent of non-doctors remained at the district hospitals in Mozambique seven years after they started working there, while all doctors moved away over the course of the period in question.

“Right now we are analysing the outcome of about 7,000 obstetric operations performed by non-doctors in Mozambique, nearly half of which were carried out by midwives. And this is unique. Mozambique is the first country in the world to train midwives in advanced surgery,” says Staffan Bergström.

In addition, Staffan Bergström leads a project in Tanzania that also partly involves delegating duties from doctors to non-doctors, but also about decentralisation; upgrading small clinics in the countryside, without access to electricity and running water, into more advanced healthcare facilities staffed by care personnel with surgical training around the clock.

We would need about 400,000 more midwives worldwide. And we need them now.

Professor Staffan Bergström

“We have built solar panels and operating theatres, drilled for water and installed generators. This has been significant in reducing maternal mortality in the areas in question, because women can now avoid time-consuming travel,” he says.

Staffan Bergström argues that delegation and decentralisation is what is needed to reduce global maternal mortality further – and more knowledge.

“We would need about 400,000 more midwives worldwide. And we need them now. The absolutely most decisive historical factor behind Sweden’s current low maternal mortality is the establishment of midwifery services,” he says.

Changing societal structures, in which child marriage and teenage pregnancies are common and the status and educational level of women are low, are also important in reducing maternal mortality, according to Staffan Bergström.

Goal # 6: combat HIV/AIDS, malaria and other diseases

Millenium development goal six, the third millennium development goal concerned with health, states that the spread of HIV, AIDS, malaria and other major diseases is to have ceased and be on the decline by 2015 and that all those who need them are to have access to HIV/AIDS treatment by 2010.

“Halting and reversing the spread of these diseases have been achieved in many countries. But only about half of those who need treatment for HIV/AIDS, currently have access to it,” says Anna Mia Ekström, Professor of Global Infection Epidemiology, with a focus on HIV at the Department of Public Health Sciences at Karolinska Institutet and at the Infection Clinic at Karolinska University Hospital.

She argues that the goal to reach all those in need with treatment was unrealistic and she also makes a comparison with the measles vaccine.

“If we have not succeeded in reaching everyone with a cheap vaccine provided on a single occasion, how are we to reach all those in need of expensive medications that are taken every day, that have side-effects and which are also connected with a disease that is usually associated with shame? But politicians and global policy-makers have to draw up goals they can live to and it is often good to aim high. Nevertheless, access to HIV treatment is increasing all the time and real progress is being made,” says Anna Mia Ekström.

Only about half of those who need treatment for HIV/AIDS, currently have access to it.

Professor Anna Mia Ekström

Her own research deals, among other topics, with how to get medication to the people living with HIV in a better and more efficient way than today, and how they can be made to continue their treatment in spite of great social and financial challenges.

“The medication is extremely good protection against premature death and those who receive treatment are able to live normal lives. A high level of adherence also reduces the risk of the infection spreading and of a resistance developing,” she says.

Several of the research projects Anna Mia Ekström is involved in are concerned with HIV infection transmitted from mother to child in Kenya and Tanzania, the goal of which is to get more HIV positive women onto medication while pregnant and breastfeeding.

“HIV transmission from mother to child takes place in conjunction with pregnancy, delivery and breastfeeding, but if the mother takes HIV medication, the risk of infection is reduced from one in three to less than five in 100,” she says. She and her colleagues have attempted to survey the factors that govern access to treatment and adherence.

“We have seen that individual circumstances, often linked to poverty and the woman’s role in relationships and the community, mean that women not only go without treatment, but also that they do not take the medication they do receive.” Thanks to this knowledge, however, healthcare personnel can give better advice and adjust their delivery to get medication to more people and get more of them to actually take it. Aside from access to treatment, the spread of HIV is primarily affected by sexual behaviour, according to Anna Mia Ekström. The most infectious are those who have themselves recently been infected, who in addition are often unaware of carrying the virus.

“Transmission is greatest among those who have several sexual partners and where there is a lack of knowledge about how HIV is transmitted and how to protect yourself,” she says. Anna Mia Ekström also explains that the risk of catching HIV/AIDS is not something that people in poor countries always have the time or the opportunity to think about, even though many know how the virus is spread, because they often have more pressingly immediate problems.

“You have to survive the day and find food for yourself and your children. The risk of being excluded or becoming even poorer if you discuss your HIV status, abstain from sex or require a condom is more immediate, especially for women, than the risk of being infected with HIV,” she says.

She has studied what makes young women in South Africa subject themselves to serious risk of infection. In 2012 it was estimated that 35 million people were infected with HIV worldwide, 25 million of whom were in sub-Saharan Africa. Just over six million of them were in South Africa.

“Just like other young women around the world, poor girls in southern Africa want to have their own income and the opportunity to sometimes buy the things they want and gain higher status among their friends. Some achieve this by having sex with older men who give them money, but at the same time subject themselves to a very high risk of both HIV and violence,” she says and proposes that educational opportunities, recreational activities, female role models and easily accessible condoms could reduce the spread of the infection among young women.

Anna Mia Ekström has high expectations that HIV/AIDS-related mortality and transmission will continue to decline after 2015. Just like Tobias Alfvén and Staffan Bergström, her demands included better healthcare systems for reaching out with treatment and knowledge that already exists.

“Of course, new discoveries are important and exciting and I hope and believe that within 30 years we will be able to successfully cure HIV. Or at least a treatment that reduces levels of the virus to such a low level that those infected can live for long periods or the rest of their lives without further treatment,” she says.

A large effort, concerned with what will happen once the end date of the millennium goals for global development has passed, is underway. “It is most likely that new goals will be established, probably with a wider focus that takes in more areas than the millennium goals,” predicts Tobias Alfvén.

Text: Lisa Reimegård, first published in the magazine Medical Science 2015.