The greatest problem in public health is, in my view, not a disease or an unknown threat, but the disparities in health within and between countries. As the wondrous advances in public health and biomedical science have become more available to the developed world, they have become increasingly less so to the people of poor countries, and to the poor within most countries. While disease prevention and health promotion have always been the stated missions of public health, what does that really mean in light of these gross inequalities? How does that mission translate to specific improvements in the public’s health--and how can we, and the public, measure our successes and learn where we need to do better? Ultimately, how can countries be held accountable for the health of their people?

The year 2000 heralded a major shift away from vague aspirations to the setting of very specific goals to reduce the stark disparities between rich and poor countries, especially with regard to health. During the largest gathering of heads of state ever assembled, representatives of 189 countries endorsed the UN Millennium Declaration, a compact that recognizes the contributions developed countries can make to improve the lives of people in developing countries through overseas development assistance, debt relief, trade, technology transfer, and increased access to essential medicines. These goals represent an unprecedented commitment to addressing poverty and hunger, ill health, gender inequality, lack of education, and the need for access to clean water in the poorest countries. For each goal, a road map cites specific targets to be reached by the year 2015 and indicators to track how well countries are doing. (See http://www.un.org/millenniumgoals/ )

No fewer than three of the eight goals relate directly to health, as do eight of the 16 targets and 18 of the 48 indicators; at least three other goals are related to health indirectly. The Millennium Development Goals, as they are known, provide a vision of development in which health and education are critically linked to economic growth.

The Importance of the Numbers
The need for public health intervention is urgent, particularly in sub-Saharan Africa with respect to HIV/AIDS. According to the World Health Organization (WHO):

• Eleven million children under age five die each year from preventable causes in developing countries; in 16 countries, 14 of them in Africa, greater numbers are dying now than in 1990.
  
• As of the end of 2003, there were approximately 8.2 million AIDS orphans; by the year 2010, that number is projected to reach 41 million.
  
• A half-million women worldwide now die in childbirth, most of them unattended by any health worker; in sub-Saharan Africa, the lifetime risk of maternal death is one in 16, as compared with one in 2,800 in high-income countries.
  
• Sub-Saharan Africa is also home to 64 percent of the 39.4 million people now living with HIV.
  
• About 4.9 million new HIV infections occurred in 2004, and 3.1 million people died of AIDS that year.

Five years after the historic UN declaration, how is the world doing? We don’t yet have sufficient numbers to be certain. While significant strides have been made in a number of countries--most notably, in childhood immunization, in HIV/AIDS prevention and treatment, and in education--progress has been uneven. page 2

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