Why is it that even as global health indicators continue to improve significantly, there seems from civil society, from so many people, from communities around the world, expressions of disquiet, of continued urgency, even of outrage, a sense that we are headed in the wrong direction?
There are many answers to this question. We see new health threats, like climate change and antibiotic resistance and new epidemics, as well as the growth of non-communicable diseases. In some countries and among some populations, little has improved. Aggregate numbers mask inequalities, long-standing and newly emerging, such as the persistence of smoking among poorer populations in wealthier countries, even as overall levels fall. In some countries, these inequities grow. Among some populations – such as white women in the United States – life expectancy has been falling. Even with improvements, the scale of both unnecessary death and the global health equity gap remains vast.
There are fears that progress could be reversed, in part because of such threats as climate change and the new blend of natural and manmade disasters. And fear of the future raises other concerns. Will new medicines be priced out of reach? Will the promise of personalized medicine be a realized only for the economically well-off?
There is a pervasive distrust in the powers that be, that powerful interests are interested in just that – power – and the needs of the vast majority of the people will remain subservient to these interests, with the health and well-being of people in poorer countries and poorer communities around the world not part of those interests.
This has been on my mind, though, because of something else, another sort of manmade disaster, which made me think of the centrality of social determinants of health, and how perhaps fear about lack of progress or even deterioration of some of these determinants contributes to this anxiety over health.

Unemployment, conflict, xenophobia, economic inequality, gender discrimination. In large parts of the world, these negative determinants of health are on the rise, not decline. And for those who are most affected by these ills and wrongs, they are primary determinants of health.
As I write this, I realize that I could be writing about many things – the most refugees and internally displaced people since World War II and the wars and violence that are producing them, the thousands dying in the Mediterranean, people seeking escape from loathsome governments, violence, and poverty but finding rough seas and an unwelcoming continent, as the sinking of a single boat last month cost a similar number of lives as the string of high-profile airplane crashes that so captivated global attention over the past year.
But these thoughts stirred in me after the story of a single death, part of the xenophobic awfulness in South Africa. South Africa, that country that represented the promise of the world at its post-apartheid reincarnation, ushering in a new democracy, with human rights at its constitutional core. The transformations of the 1990s were dramatic, but today the promises painfully co-exist with the legacy of violence and conflict, incomplete transformations and expectations of justice and jobs sorely stifled.
This was one of the stories of the recent wave of xenophobic violence, of horrific crimes against Zimbabweans, Ethiopians, Nigerians, and other foreigners. The report I heard on BBC several weeks ago (which is not online, but you can find an article on this brutal crime here) was of a migrant from Mozambique set upon by knife and fist-wielding South African youth, left gravely wounded. He walked a short way before collapsing in a gutter alongside the road. Onlookers rushed him to a hospital. Nurses tried to save him, but a doctor’s skills were needed.
Where was the doctor? He, too, was a “foreigner.” Like thousands of others, he feared a fate similar to that of this young man, so he himself had not come to work. Perhaps he was seeking safety until the wave of violence passed. Perhaps he planned to return to his previous homeland that suddenly seemed more inviting.
Are we really living in a healthier world? A man who fled miseries only guessed at was viciously attacked by youths native to a land of shattering dreams, and he died because a doctor who might had saved him had taken refuge to protect himself against a similar fate. You hear stories like this, you hear of deaths like this, and you understand why all the questions, the discontent among so many that brings the distance still to travel, rather than the ground already gained, to the fore.
Vitamin A, vaccinations, oral rehydration therapy, ART, genetic therapies – technologies both simple and complex are saving many lives. The statistics on longer, healthier lives are unambiguous, the millions of lives saved every year one of the greatest global achievements of the past several decades. But if we want a healthier world, do we have to look elsewhere, to very different solutions?
It is easy to dwell on the anecdotes, the incidents of horror. And surely we can find the counter-anecdotes, tales of tens of millions of children who would have been dead but for our progress, who now are receiving a good education. May they go on to flourish. That is why we must continue, and indeed accelerate, our progress on the medical and health care front. The rewards on this front have been immense, if still far from complete.
But for societies to be healthy, our work is far broader, for justice and human rights – in the health system and well beyond. That is what good health will require.