Health inequalities in the global village

Since the early nineteenth century public health has, for the most part, distinguished itself as a socially-progressive undertaking, with most public health workers considering health inequalities abhorrent. Over recent decades their common and unifying expectation may have been that such disparities might be reduced through economic growth and income redistribution, by continuous improvement in the physical environment, by addressing medical care for the underserved and by making public health services more sensitive to different communities.

However, the emerging evidence from many countries (as the WHO's Commission on Social Determinants has shown) is that health disparities are widening despite – and some cases due to – economic growth; that income distribution is failing - or being reversed; that population growth and urbanization link to new disease risks; and that public health services are stretched or ineffective or that their improved cultural sensitivity may only offer partial mitigation for systemic failures elsewhere. In an age of chronic disease challenges linked to malconsumption, the ‘mechanised environment', and associated environmental threats, such as climate change, the old assumptions no longer appear so convincing.

I will argue that public health must return to its early perspectives on natural and social ecology, refreshed by modern understanding of social complexity and better analysis of the institutions and drivers of social change (governments, markets and supply chains and consumers). This paper, which addresses US, European and global factors, will particularly focus on diet-related chronic diseases and how these, and their associated health disparities, might be addressed.