The world as we knew it changed dramatically following the events triggered by 9/11. There was a brutal awakening for the western world to realise that we are not as well regarded in non-western areas as we had previously thought. Global inequalities, the western world's paternalistic stance and cultural disregard of less-fortunate parts of the world are arguably the driving forces which have created the polarisation and fear of today's global society. Public health as a discipline suffers from many of the same symptoms, but has yet to realise it. Here, we want to emphasise two issues that we believe merit particular attention if we are to create a public health agenda relevant for the 21st Century.
First, the importance of the social determinants of health needs to be more widely acknowledged and further articulated among decision makers. Today's world is characterised by massive health inequalities – both across and within nations. Increasing access to basic health care is still a key factor to reduce inequalities across nations. Within nations, however, health care is not the best answer to reducing health inequalities. The solution is wider public policy initiatives that focus on the social conditions that dominantly determine opportunities to health. In order to be taken seriously in its attempt to reduce unfair health inequalities, a future public health agenda needs to shift focus from health care to wider public policy solutions.
Second, the notion of health in much public health discourse is founded on a simplistic and paternalistic idea of what living a ‘good life’ actually entails. This is analogous to how ‘we’ tend to simplify the idea of good and righteous societies with western ideas of democracy, scientific thinking and, to some extent, capitalism. Health is complex. It encompasses many different aspects that differ between individuals and between social contexts. Consequently, a definition of health and ‘the good life’ made by prosperous groups is unlikely to apply to less-prosperous ones. Certainly both wealth and health create opportunities for higher levels of well-being. Neither, however, is sufficient for a higher level of well-being if isolated from the other.1 A future public health agenda needs to take this into account before embarking on paternalistic policies to improve health – policies that often target poorer people.
How do we balance the need to simplify the world while staying in touch with reality? This is a difficult question that future public health agendas need to address explicitly and keep in constant focus. Broad generalisations are inevitable and necessary when identifying current issues in public health but resolving these issues is much less straightforward; it requires that we become less fixed in our ideas of what constitutes a ‘good life’ and more flexible in our approaches to reducing health inequalities.
The events following 9/11 have the potential to teach much; for public health to accept the potential plurality of constructs of health – across cultures and across different socio-economic groups – is a good place to start.