Thirty years ago the World Health Organization celebrated its greatest triumph—the eradication of smallpox. It was a remarkable achievement, and the only major target the WHO has even come close to achieving. Target failure has occurred for myriad diseases and conditions. In some instances, target-setting has been hugely counterproductive. As the WHO convenes with national health ministers for its annual Assembly in Geneva on Monday, it should resolve never to set another unachievable target.

Success with smallpox came at the second attempt. The first, in 1958 was abandoned: “It was not enough to say that a disease must be eradicated: the possibility of doing so must exist, and there seemed no justification for over-optimism”, a Soviet expert said at the time. But the campaign was revived in 1966, with a total of $15 million of today’s dollars per year, split among 46 countries on three continents. The disease was eradicated in 1977, just a year after the target date.

By establishing a target it could barely influence, and focusing on support systems rather than combating specific diseases, the WHO walked away from programs with proven benefits.

What made this effort different? Smallpox is easy to diagnose, so measurement of failure is simple. It lacks any reservoir or vector outside humans, so eradication can be certain. By 1966 there was a cheap effective vaccine. And the WHO was comfortable running an aggressive program, in which doctors and their highly-trained teams swept a country in military fashion and immunize everyone. Because the management and clinical staff quality were widely acknowledged to be excellent, all countries wanted the service—there was little local opposition. The head of the WHO succinctly described it a “triumph of management, not of medicine”.

Every other WHO campaign has lacked at least one of the above reasons for success. Moreover, recent campaigns have lacked adequate funding.

The best of these failed attempts was the malaria eradication campaign begun in 1955, which removed the disease from at least 10 countries, largely due to the indoor spraying of the insecticide DDT. The campaign was audacious, and ultimately unsuccessful, because there is no malaria vaccine, there are non-human vectors of the disease, and diagnosis is difficult.

Three more recent WHO campaigns, Health For All, Roll Back Malaria and “Three by Five,” were so poorly conceived and executed that each one actually did more harm than good.

Health For All, established in 1978, is probably the most ambitious WHO target: “the attainment by all the citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life”. While WHO correctly concluded that better public health followed from improvements in education, sanitation and health support systems which were themselves enabled by wealth generation, the agency erred by trying to force the arrow to point in the other direction as well, boosting economic growth through health spending. By establishing a target it could barely influence, and focusing on support systems rather than combating specific diseases, the WHO set a trend to de-fund vertical programs (such as malaria control), which had proven benefits.

As new money was found, healthcare workers doing valuable work in child immunization and other areas were drawn away to work on HIV.

Then in 1998, with almost no new funding, WHO presented Roll Back Malaria, a program with a stated goal of halving malaria by 2010 that was started without an accepted estimate of the number of deaths fro the disease. That made it impossible to judge the program’s success. Moreover, the program did not promote DDT, instead relying on bed nets, pressuring others to follow this less effectual policy. Malaria rates, judging from what little we do know about them, have probably gone up since.

In 2003 the WHO set its worst target: treating three million HIV-positive people with antiretrovirals by the end of 2005 (hence the “Three by Five” name). Knowing the target was unreachable and unfunded at the launch, WHO pressed ahead, forcing already poorly-funded health systems in developing countries to divert resources from other areas. As new money was found, healthcare workers doing valuable work in child immunization and other areas were drawn away to work on HIV. Patients were never tested for HIV under Three by Five—that was the policy—nor tested for viral load during treatment. Since many of the drugs WHO was supplying were themselves untested, novel compounds from copy drug manufacturers, their quality and efficacy were simply unknown. The risk of patients developing drug-resistant HIV was therefore very high.

WHO’s destructive habit of target setting appears to be contagious. The United Nations Millennium Development Goals for health, adopted in September 2000, continue the trend. Three of the MDG health indicators are either not measurable or not measured properly (malaria, tuberculosis and maternal mortality), and attempts to improve measurement have not been welcomed by the UN.

The WHO has an invaluable role to play, and as it approaches its 60^th birthday, it should reflect on that, and stop setting unreachable targets.  

Roger Bate is a resident fellow at the American Enterprise Institute. His paper on the dangers of targets was published today.