Global health thrives on fashion. During the era of the Millennium Development Goals (MDGs, 2000–15), that fashion was poverty. The manifesto for the MDGs was the Commission on Macroeconomics and Health, chaired by Jeff Sachs and published in 2001. The Commission concluded that “The linkages of health to poverty reduction and to long-term economic growth are powerful, much stronger than is generally understood.” Sachs argued that the poor were more susceptible to disease and less likely to seek medical care, even when that care was urgently needed. Poverty lay at the root of all evils. Attacking poverty was the path to development progress. The Commission proposed that defeating disease was central to eradicating extreme poverty. But although Sustainable Development Goal 1 reiterates the importance of ending poverty in all its forms everywhere, in health we no longer make poverty foundational to our concerns. Fashions have changed. Now we are mobilised by universal health coverage, global health security, and a climate emergency. These issues are rightly important. Perhaps the fact that since 1990 over 1 billion people have been taken out of extreme poverty means that global health activists see poverty as old news. Yet beating poverty remains a prerequisite for flourishing and sustainable lives. Disappointingly, global health and its leaders have judged poverty to be yesterday's idea.

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This attitude of indifference, for that is what it is, is indefensible. Earlier this month, UNDP and the Oxford Poverty and Human Development Initiative published new research showing that 1·3 billion people in 101 countries are “multidimensionally poor”. Poverty in their Multidimensional Poverty Index means deprivations in standard of living (assets, housing, electricity, drinking water, sanitation, and cooking fuel), health (nutrition and child mortality), and education (years of schooling and school attendance). Their findings should shock us all. Poverty is everywhere. Two-thirds of the poor live in middle-income countries. Children are more likely than adults to be poor and deprived across all indicators. Half of those multidimensionally poor are under 18 years of age and a third are under 10 years. Within countries, there are great variations in poverty, ranging (in the case of Uganda's provinces, for example) between 6% and 96%. Within regions too—the incidence of poverty is 92% in South Sudan and 15% in Gabon. These findings have been given almost no serious attention by global health leaders. In 2018, the World Bank published its view on trends in global poverty (Piecing Together the Poverty Puzzle). The Bank concluded that “the fight against extreme poverty is far from over”. Extreme poverty is increasingly becoming the defining challenge of one region and one region alone—sub-Saharan Africa, where the total numbers of poor people are rising, from 278 million in 1990 to 413 million in 2015. Of the world's 28 poorest nations, 27 are in sub-Saharan Africa. The Bank describes a “bifurcated world”, where one in four people in Africa live in extreme poverty. India is currently the nation with the highest number of poor people—176 million. But Nigeria will soon overtake India. By 2030, the Bank predicts that as many as 87% of those living in extreme poverty will be living in sub-Saharan Africa, where there are especially troubling risks to confront—fragile and conflict-afflicted settings, droughts, and epidemics. The Bank calls for “transformational change”. But the difficult truth is that no-one is listening.

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Poverty is not only a curse for the poorest nations in the world. There is endemic poverty in supposedly rich countries too. Persistent poverty affects one in five children up to age 14 years in the UK, poverty that is linked to worse physical and mental health. And one must not forget that poverty in rich and poor nations alike is gendered. Women lose more life-years to poverty than men. Ending poverty must return as a political objective for global health. Health professionals are uniquely placed to draw attention to the acute personal consequences of poverty. We can be powerful advocates for action. Poverty is not an economic state. It is an insidious disease of the human soul. Poverty consumes lives, eroding mental resources, diminishing cognitive capacities, and destroying life possibilities. Universal health will never be achieved unless and until poverty is eradicated. How tragic that our global health leaders have forgotten this lesson.

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