In the summer of 2005, when Scotland hosted the G8 summit at Gleneagles, global health issues were high on the agenda. Further investment to reduce the impact of the ‘killer diseases’ HIV, TB and malaria was seen as the top priority. Ten years on there’s a rather different global agenda: addressing inequity. Fairness is not just the focus of the #fairerscotland consultation. Today, the impact of structural inequality on health is a global concern.

The last decade has seen significant progress in improving the world’s health, especially in reducing child mortality through malaria prevention and the spread of HIV through the widespread ‘roll-out’ of antiretroviral treatment. There remains, as yet, no HIV vaccine, one critical element of the G8 global health agenda. But this is no longer seen as a key issue.

Three concerns have replaced the control of infectious diseases at the top of the global health agenda. One is the dramatic upturn in chronic disease, such as heart disease and diabetes, in all parts of the world; even in low income settings still wrestling with the burden of infectious diseases. Another, demonstrated by the recent Ebola crisis, is the critical importance of health systems that can reliably provide basic services to communities. The third is perhaps the most challenging, however. It is the recognition of the growing disparities in health outcomes, not only between rich and poor countries, but between the rich and poor within the same country. Globalisation has brought significant benefits, but they have been shared unequally and have extended rather than reduced inequity.

Gross health inequalities are attributable not so much to patterns of disease but to the social conditions that put us at risk – or, alternatively, protect us – from them. Global health is thus less and less an area of technical innovation; rather it is one of political engagement and social change. It is increasingly focused on creating the social, economic and welfare policies – and institutions – to create more equitable life chances.

In 2005, shortly after supporting preparations for the Gleneagles summit, I left Scotland for a position at Columbia University in New York. I return this month to take up a position at QMU leading their Institute for International Health and Development. The last decade has not only witnessed major developments in the field of global health, it has been a decade of momentous change within Scotland. Not only has the political landscape dramatically changed, so has the public consciousness of the sort of fairer society in which Scots wish to live.

Mechanisms of strengthening the reach of preventive health services into areas with high rates of ill-health are part of the story; but so too are addressing educational and economic barriers which so significantly influence health. To truly address disparities in health, the nation needs to find innovative strategies to redress the unequal life chances dealt to citizens through the current status quo. This is an increasing focus in the education sector, where enabling access to higher education for communities with historically low levels of participation is rightly a key priority. QMU being seen as one of the institutions with particular capability in supporting this goal – it is expected to enrol twice the percentage of students from areas with low rates of enrolment than most of our ‘ancient’ universities – is one of the qualities that particularly drew my interest on return to the Scottish university sector. It’s an example of the ‘disruption’ of existing patterns and expectations that will characterise a fairer society.

In New York we used to challenge students to explain how it was that the average life expectancy of a man in Harlem was less than that of a man in Bangladesh. In Scotland the challenge presents itself this way: why – despite overall progress – is the gap in female life expectancy between those from the least and most economically deprived areas in the country actually increasing?

I look forward to IIHD seeking to play its part in supporting ‘disruption’ of ‘business as usual’ at the global level in the coming years. As in Scotland, so globally: structural barriers to health will only be surmounted through conscious engagement with both those excluded by such means and the forces which sustain and benefit from inequity.

Professor Alastair Ager, formerly working with the Department for International Development in East Kilbride, has joined QMU, Edinburgh as Director of the Institute for International Health & Development after a decade with Columbia University in New York.

Professor Alastair Ager

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