ARE YOU MDGs-SKEPTIC? I AM.

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October blog

Claudio Schuftan

ARE YOU MDGs-SKEPTIC? I AM.

Some have calculated that, with current development trends remaining the norm, poverty will be eradicated in something like 70 or more years.

It is fitting to devote this column to the MDGs since the UN just deliberated over them thirty days ago as we reached the 2/3 mark to 2015.

At the People’s Health Movement (PHM), we consider ourselves to be MDG-skeptics. For long now, we actually have been trying to create awareness of the MDGs limitations and have therein been playing a veritable devil’s advocate role.

You may ask: Why being MDG-skeptic? For starters, we want you to agree with us that achieving the MDGs will only result in modestly advancing global health and nutrition …if at all.

I will thus here try to convince you that ‘having the passion’ is not enough. Given a long past experience, this alone risks ending up with many words and many promises.

Why do I try this? Because civil society inputs are vital in this debate. Yes, indeed vital: But not as ‘MDG yesmen’ (or yespersons to be gender correct).

Ultimately, I want you to be convinced by this column that the fallacy we need to uproot is that health and nutrition programs addressing the urgent needs of women and children implicitly address equality and human rights.

In the human-rights-based approach (HRBA) nothing is left implicit!

I also want you to agree with us at PHM that the MDGs operate too much using a ‘deficit-filling approach’ to poverty and to address preventable ill-health, preventable malnutrition and preventable premature deaths. It is not about filling the last bit of the cup; it is about refilling it from the bottom.

Poverty, ill-health and malnutrition are the result of the ongoing process of social exclusion; and the HRBA specifically explores the critical exclusionary mechanisms that need to be tackled –now!  Consequently, concrete demands need to be placed on duty bearers –now– because where someone has a right, someone else has a duty.

Gone are the days of us ‘working with beneficiaries’: We are now to talk about ‘mobilizing rights holders’ (claim holders) to demand changes they are due.

The implication of this is crystal clear: Political forces cannot be fought with morals and technical fixes. Therefore, we believe that acting politically is the way to reach ground zero in nutrition work.

Why?

The easiest and shortest way to answer this question here is to elevate a number of truisms about the MDGs to the category of ‘mini-iron-laws’. They would be the following:

We think MDGs suffer from: Donor overinfluence, technical overemphasis, inattention to action on underlying social and economic inequalities, lack of systematic long-term financial commitments, and a predominant focus on health and education rather than on the entire political economy.

Further, MDGs:

  • Perpetuate a focus on communicable diseases.
  • Encourage quick-fix technical approaches.
  • Offer too little too late and are not really new, but rather rehashed versions from earlier goals set by the international community. [As somebody said,  The Alma Ata Declaration of 1978 can more fittingly be called “the people’s MDGs”].
  • Emphasize average outcomes across an undifferentiated population. [At that, they focus on outcomes disregarding the processes through which we are to achieve them].
  • Mostly provide a template-of-targets-for-the-bureaucratic-mind.
  • Do not recognize that poverty  is a function of human rights violations.
  • Posit housing, health care, and access to food and water not as non-negotiable and universal human rights, but as ‘needs’ to be met.
  • Infuse neoliberal priorities into development policies often using just the language of human rights so that, ultimately, they attempt to wash the face of neoliberalism by emphasizing what is possible and doable …for donors and the market.
  • Do not represent a development paradigm break; they are instead a set of indicators embedded in a paradigm –the neoliberal paradigm.
  • Were set arbitrarily…from the outside…in the North…resulting in what some consider ‘the ghettoization of the problems of development’. [They can thus be seen as the-goals-of-the-rich-countries-for the poor countries].
  • Call for change, but not for creating the conditions to make real needed structural change possible.
  • Pay scant attention to the roots of inequality.
  • Seek to “eradicate extreme poverty and hunger” (Goal 1), but rely on the discredited notion that economic growth at the national level (GNP) can eliminate poverty
  • Do not denounce bad governance of the G8 countries or of the IFIs.
  • Are not an expression of governmental goodwill; rather, they constitute pre-set international obligations.
  • Have failed to provide a real sense of ownership either by poor countries’ governments or their civil society actors.
  • Are not global at all; they place all responsibility on the separate national governments with no global authority really in charge of their enforcement. (G. Kent)
  • Have actually provided something that pretends to be a moral compass together with a set-of-yardsticks to measure some types of progress; they have been too much of a counting and accounting exercise.
  • Disregard the effect of trade policies on malnutrition. [The negative consequences of current unfair international trade policies are actually one of the major oversights of the MDGs].
  • Fail to even mention women’s labor and property rights, or one of the most fundamental obstacles to ensuring these rights, namely, violence against women, and finally assume that privatization of services is a strategy-for rather than an obstacle-to economic development and improved nutrition.

All these mini-iron-laws should make make one wonder: Are MDGs just another attempt to achieve good looking statistics?

[Regrettably, you have to recognize that MDG-driven agencies feel tempted to manipulate statistics].

MDGs actually miss what most matters to people who happen to be poor (‘the bottom billion’): They overlook or ignore issues of risk, security, respect, status, dignity, voice and livelihood vulnerability –all more important to this group than mainly income and consumption issues. Moreover, let’s face it: none of the goals can be achieved without empowering women and without recognizing the centrality of decent employment (a human right). Furthermore, keep in mind that a) debt relief is a precondition for even keeping-up the hope of meeting the MDGs, and b) market liberalization strategies have been oblivious to the MDGs. [Transnational corporations are certainly not geared to invest in helping achieve them, are they?].

At PHM, we think the MDGs approach can be described as ‘human development meets results-based management’. [This said, one could  wonder, is there truth in the sarcastic view that the MDGs should really be an acronym for ‘Most Distractive Gimmick’?].

For all these reasons:

The MDGs approach badly needs rethinking. We badly need a post-MDGs architecture (or one earlier than ‘post-‘, in an attempt to minimize harm and disenchantment come 2015).

Since it is human rights violations that are the raison d’etre of all MDGs (!),

applying the internationally agreed human rights framework to the MDGs approach (or replacing the approach outright) will put the spotlight on the discrimination and social exclusion gaps that we see as the most significant human rights gap in the current application of the MDGs.

In all of this, what civil society organizations are failing-us-in is in challenging the system that day-in-day-out recreates the condition of poverty as the common determinant behind all MDG-related violations of the right to nutrition. It is time for NGOs, and for colleagues affiliated with Social Medicine, to hold duty bearers to account. Yes, this is political. But can our affiliates remain aloof of politics?

What all this will mean to the agenda of all of us is what I encourage you to react to at the bottom of this column.

At the heart of the MDGs beats a fundamental contradiction: poor countries are expected to meet the MDGs by implementing the very neoliberal economic policies that have, in large measure, caused the problems that the goals are intended to address.

At PHM, we fear that, after 2015, we will have achieved nothing more than isolated islands of progress in a sea of remaining grievances and persisting human rights violations. [By sticking to the MDGs paradigm, inequalities are staring us in the face now, but will be shouting at us after 2015].

Why do we say this? Because the MDGs need not only to be attained, but also sustained long term –post 2015. [Our own George Kent satirizes the issue by proposing that, on new year’s eve 2015, we distribute a few million sandwiches to hungry children the world over so that come January 1 we will have halved hunger of under fives].

All this body of argumentation explains why I reject targeted pro-poor policies including in nutrition work; we ought to be fighting for anti-poverty policies (or rather disparity reduction policies). Poverty reduction without redistribution is only to be seen as flimsy rhetoric. Political power is a crucial precondition for a country to rise out of the poverty trap once and for all.

We need to grapple precisely with those phenomena that the MDGs take for granted, because they all affect malnutrition.

Why? Because, how can we be content with wiping out malnutrition for half the mothers and children by 2015 when that goal is possible for all of them?

Being realistic: Inequalities will remain entrenched even if the MDGs are achieved.

As Vicente Navarro says: It is not inequalities that kill people. It is those responsible for these inequalities that kill people.

What we need to focus-on are the processes that will lead to overcoming malnutrition (or achieving any of the other goals); and those processes have to be bottom-centered. Without the proper participatory processes, MDGs as outcomes may mean nothing (like a modern Christmas toy….without batteries). The process must ‘pull’ needed changes and not be the conduit for  ‘pushed’, often packaged, solutions.

Had we insisted early-on on each district achieving the MDGs would have been the equitable alternative to national MDGs; in that way, one would have served the predominantly poor and minority districts. But national averages will still mean that the half of the people below the average will be suffering from ill-health, malnutrition and preventable deaths.

Civil society organizations that have not adopted most of the above badly need to go into a retreat to revision and remission their role so that they stop being part of the problem and become genuinely part of the solution. If they stick to the old ways of service delivery, food distribution, nutrition rehabilitation… the time has come for them to be named and shamed.

The rhetoric-action gap has to be stopped. NGOs cannot be shy or human rights blind any longer; they have to take issue with the social determinants of health and nutrition.

This means NGOs cannot only use a human rights ‘lens’, use human rights implicitly in their work, add a ‘human rights perspective’, have ‘human rights projects’, or ‘mainstream human rights’. They have to embark in human rights-compatible programming fully using the human rights-based approach by now well delineated. This is not a matter of choice anymore; NGOs have to decide what?, how? and when? to move in this direction. This, because governments have to simply be pushed to take up their international responsibilities towards nutrition. NGOs will have to shift their work from a welfare perspective to an economic justice perspective. Any path chosen using the latter will have to entail  transforming economies more structurally.

This will require extensive human right learning as a means to more proactively engage in a true human rights dialogue with claim holders and duty bearers.

It is no news that the world is increasingly shaped by powerful global forces, the action of many of which have dire consequences for the right to nutrition and for the social, political, economic and environmental factors that influence all MDGs; the latter factors are increasingly determined at a supranational level. As a result, local and national level efforts to influence the determinants of malnutrition can have only a limited impact. It is thus all too easy for the individual health and nutrition practitioner in the public sector to feel powerless. Yet while these practitioners, on their own, may indeed be relatively powerless, together they can achieve a great deal –and that is the role the People’ Health Movement has taken up (www.phmovement.org ) …and the one Social Medicine readers should be considering.

Bottom line:

  • Real life is more complex than MDG slogans.
  • The poor and the marginalized are not where they are by accident.
  • The objectives we should strive for are not to stabilize the problem of malnutrition, but to make it disappear by tackling it at the roots.
  • Not all the problems of malnutrition are structural. Granted. But if the latter are not addressed the chances of the MDGs advancing global health and nutrition are nil.
  • We have to avoid ‘othering’ people as ‘poor’ and thus as inferior to the non-poor.  (Isn’t that what the MDGs implicitly do a bit –or a lot?).
  • The shortcomings of the MDGs depicted in this column should be denounced publicly to demystify the ‘silver bullet’ aura of just pointedly going-for and achieving the eight MDGs.
  • The MDGs cannot be achieved without respect for human rights overall and in particular for minority and women’s rights. They cannot be achieved without redistributive steps either. (But beware: Redistribution always takes place: just not from the rich to the poor!).

So, in the name of the wretched of the earth, are we to change the world? Or are we the victims of those who have the power to change the world? If the second is the case,  is what we usually discuss in our professional meetings going to change things? [Food for thought here: Was this taken up in our just concluded meeting in Portugal?].

To close, I would like to share with you the real existential doubt I have: Do we actually live in a world of high-flown objectives, ambitious target setting and obscure acronyms?

Postscript:

Before I leave you, were you aware:

  • that the promises of the rich countries are not quantified in the MDGs paradigm? (The obligations of the poor countries are! …this assumes poverty is a problem of poor people only, right?).
  • that a dramatic overlooked point in the Millennium Declaration and the MDGs is that inflation is likely to make the-year-2000-1U$/day a mere 60 cents/day by 2015?
  • that, in the case of the nutrition MDG, official responses, so far, seem to be more concerned with quelling or preventing food riots than with addressing the underlying and basic deeper causes of chronic malnutrition? (G. Kent)
  • that, if current trends continue, by 2015, 3.7 million more children in Africa will suffer from malnutrition than today?
  • that China, Cuba and Vietnam have long focused on core MDG concerns, but have simply not labeled them as such?).
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7 Responses to “ARE YOU MDGs-SKEPTIC? I AM.”


  1. 1Mark Rego-Monteiro

    Thanks, Claudio, for an earthshaking review and declaration. I had studied the book White Men´s Burden by William Easterly and criticisms by Oxfam in grad school, and think your criticisms are among the best of them. My own approach has been to recognize Gandhi´s principle and embrace the change that is necessary. While the international donors stumble through the doors of their ideologies, I think some may already be supporters of the most effective policies involving co-operative enterprises and fair trade. I know some co-operative enterprise efforts have included health practices in their efforts, and have read of projects in Kenya, and statements at the Wisconsin Co-op resource center. The ICA, international co-operative alliance, has supported co-ops as an exit strategy from poverty, and through COPAC and the ILO, has communicated effectively enough with the General Assembly to achieve the declaration of 2012 as the year of the co-operative business model.
    The economic paradigm underlying corporate economic practices, and their influence on politicians internationally is fundamental to these human rights efforts, as groups like Global Witness and Oxfam, and perhaps even Amnesty, have united in efforts like the Publish What You Pay Coalition to deal with the extractive industries. Keep up the criticisms of the Titanic´s captains, but take a dip in the lifeboats of the “French Resistance” and the “Underground Railroad.”
    In the US alone, for example, the model of health care co-operatives already has existing enterprises, as reported even in the New York Times and was advanced by Senator Kent Conrad. However, the concentration of economic power is such that efforts like yours and ours are treated as so much buzzing of insects. The more we delve into the economic substance of the alternative models, the more we can redirect the existing concentrations of power. One interesting example is that of the World Council of Credit Unions. I believe they represent an international development effort by US Credit Unions, and may make a fine model to base on.

  2. 2Mohammad Ali Barzegar

    Yes I am very much MDGs-Skeptik. MDGs is like most ofthe international programs top-down and without any say and voices from the people especially the poorest of the poor.

  3. 3Pierre De Paepe

    Dear Claudio,

    I agree with most of your arguments to be skeptic about MDGs.
    But there is an important point that you seem to overlook: none of the MDGs states the simple right for everybody to access and use health services according to their needs, in other word the human right to obtain the best health status possible.

  4. 4Molly Tumusiime

    This struggle has been for too long and ‘ the haves’ have plugged their ears and closed their eyes to reality indefinitely!! Is there an alternative strategy other than pen and paper?

  5. 5claudio

    Thanks Neil for your comment on Social Medicine.
    Pieces like this are helping us to coalesce into coalitions and networks. At PHM we do more that write…
    I thought I did point out explicitly the disconnect between the MDGs and HR and the RTH. Note that the Millennium Declaration does mention this relationship, But the goals are what GOBIFF is to Alma Ata: a reductionistic focus on outcomes (better statistics) and disregard of processes that can lead to sustainability.
    So yes, MDGs are leading to modest advances in Global Health. Much more would have been achieved if in 2000 we committed to a HRBApproach.

    Warm regards,
    Claudio

    Thanks Claudio,

    The main thing I disagreed with in your comment was your words “if at all” – those are the words that prompted me to write my comment. I agree with your comment below: MDGs are leading to modest advances in Global Health.

    I agree with the thrust of much of what you say although I am clearly much more ‘pro-MDG’ than you – I see great value in them, even if they are flawed in some aspects of their origins and implementation. Of course, we need dialogue among people of all persuasions – MDG proponents and MDG skeptics and all others with an interest in global health/HR/RTH – to reach better outcomes (including but not only poverty reduction, reduced maternal mortality, reduced child mortality…) and better processes! As I say, the approaches are complementary.

    Best wishes,
    Neil

  6. 6neilpw

    Claudio – Thank you for your article and I agree with many of the specific observations you make regarding the limitations of the MDGs. But I disagree with the following: ‘we [People’s Health Movement] want you to agree with us that achieving the MDGs will only result in modestly advancing global health and nutrition – *if at all*.’ [my emphasis]. Later in your article you ask, ‘Are MDGs just another attempt to achieve good looking statistics?’

    As UN Secretary-General Ban Ki-moon said this month: ‘Each year, millions of women and children die from preventable causes. These are not mere statistics. They are people with names and faces. Their suffering is unacceptable in the 21st century…’ Ref: Global Strategy for Women and Children’s Health. http://www.who.int/pmnch/topics/maternal/201009_globalstrategy_wch/en/index.html 
    The progressive long-term realisation of human rights and the current short-term drive to achieve the MDGs are both hugely important – and they are complementary, not contradictory.

    Let’s continue to work together, strategically and tactically, towards both.

    Dr Neil Pakenham-Walsh MB,BS, DCH, DRCOG
    Coordinator, HIFA2015
    Co-director, Global Healthcare Information Network
    16 Woodfield Drive
    Charlbury, Oxfordshire OX7 3SE, UK
    Tel: +44 (0)1608 811338
    Email: neil.pakenham-walsh@ghi-net.org
    HIFA2015: http://www.hifa2015.org

    Join HIFA2015 and CHILD2015 – send your name, organisation and brief description of your professional interests to hifa2015-admin@dgroups.org and child2015-admin@dgroups.org (or direct to Neil PW at neil.pakenham-walsh@ghi-net.org )

    “Healthcare Information For All by 2015: By 2015, every person worldwide will have access to an informed healthcare provider”

    With thanks to our 2010 financial supporters: British Medical Association, International Child Health Group (Royal College of Paediatrics and Child Health), Network for Information and Digital Access, Rockefeller Foundation, Royal College of Midwives, Royal College of Nursing, and TRIP Database

  7. 7Iftikhar Soomro

    Me too.

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