It seems safe to assume that most people, even those working in public health, don’t remember the 1978 Alma Ata Declaration. That’s where World Health Organization member states endorsed a goal of “health care for all by the year 2000,” and tied that aim to a set of objectives that, at least back then, seemed feasible to accomplish.

We all know how things turned out. As David Walton, who is now US global malaria coordinator for the President’s Malaria Initiative, and a group of his then-colleagues at Partners in Health recalled in a barbed commentary in 2004: “As the year 2000 approached, the Alma Ata slogan became the butt of ridicule in international health circles. The slogan contained a typographical error, went the joke: the rallying cry was in fact ‘health care for all by the year 3000.’”

The joke stings even more painfully now, after we’ve suffered close to 7 million recorded deaths from Covid worldwide. It becomes seriously unfunny when you realize that this is likely a gross undercount; The Economist estimates that the excess death toll during the pandemic has been closer to 22 million.

Most of the world has moved on from the pandemic, with politicians and pundits exhibiting a triumphalism that seems ghoulish given the death toll, like high-fiving at the site of a mass grave. But as we enter the “post-Covid” universe, I find the Alma Ata declaration rattling around in my mind. What would a 2023 version look like? What would it even realistically say? In other words, what is the future of global health?

The past three years don’t offer a hopeful story. One might have thought—naively, it seems now—that the world would rally together to confront the pandemic. What we did get were bumbling national responses in many well-resourced countries, such as the United States and the United Kingdom. When rich countries could rally to the occasion, sadly it was in the cause of Covid vaccine nationalism—hoarding doses as they boosted their populations, even as poor countries had not even gotten a single shot in the arm for more than a handful of people.

Now, don’t get me wrong. Global life expectancy has improved in all regions of the world over the past 100 years and, in some optimistic scenarios, is expected to improve further over the next few decades. Still, inequalities in life expectancy linger within and between countries. Hong Kong and Japan have life expectancies in the mid-80s, while someone in the Central African Republic (CAR) can expect to live to only 54 years of age. A recent study revealed that 5.6 percent of the CAR population died in 2022, which points to the precarious position of many of the countries at the lower end of life-expectancy rankings worldwide.

As with Covid, our fates hang on the decisions we make. Jessica F. Green at the University of Toronto has called this era one of existential politics:

Existential politics is about whose way of life gets to survive. Should we have Miami Beach and the Marshall Islands, or should we have coal miners, ExxonMobil, and Chevron? Some actors will inevitably lose everything—either due to environmental policies or due to the effects of climate change. And both winners and losers will fight like hell to maintain the value of their assets. This obstructionism, not technical problem-solving, is the critical constraint thwarting progress on global climate policy.

As with the environment, who gets to survive is the key political question for global public health in the 21st century. Jean-Paul Sartre once said, “Every society selects its dead and the decision is made at the level of the upper classes.” We made a decision with Covid vaccines, that we, here in the US, come first, but these choices about who lives and who dies are found in even our generosity, our better moments.

For instance, the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, TB, and Malaria, two successful bilateral and multilateral programs that have doubtlessly saved millions of lives, are based on decisions that are explicitly focused on certain countries or certain diseases. Even within that priority setting, the fact that these programs are always underfunded means that efforts on HIV end up with the most vulnerable in these countries getting the short end of the stick, even if both programs talk a good game about men-who-have-sex-with-men and transgender women, people who use drugs, and sex workers.

I am a champion of both these endeavors—they grew out of grassroots activism that confronted the cynicism and do-nothingism of the global health and human development elite at the end of the 20th century. And I agreed and still do with my late colleague Paul Farmer that “AIDS can be the ‘battle horse’ that moves the whole public health agenda forward.” But instead of building on our successes with AIDS, we are slipping backward toward a logic of the last century that wants to make AIDS just like everything else. There are even plans to reorganize PEPFAR in ways that directly threaten its long-term viability. As Emily Bass said in a crucial piece earlier this year: “[PEPFAR] notched its greatest successes because it was sui generis. The more that PEPFAR is integrated into the State Department bureaucracy, the greater the risk that the program will be irrevocably damaged.”

Another thing the past three years have taught me is that even when we know what to do, and what the right thing is to pursue, we often make only the most halting starts to get there. The New York Times ran a piece in early April called “The U.S. Built a European-Style Welfare State. It’s Largely Over,” detailing the massive investments in the social safety net made during the first three years of this pandemic. While the US had the highest per capita Covid-19 and excess mortality rates among the G7 for much of the pandemic, things could have been far worse without these social and economic supports. But we also know that our flimsy social protections made us vulnerable long before the pandemic. Yet we’re walking away from all of it, as well as walking away from the enhancements to the public health infrastructure built up during the pandemic as well.

As I happily watch PEPFAR being championed with genuine bipartisan support on Capitol Hill, I can’t help but wonder with trepidation if the contagion of the desire to “get back to normal” will spread far beyond Covid, as the Biden White House tries to mainstream and bury its global HIV work into day-to-day State Department activities. It’s as if these calamities—Covid, HIV—are too much to bear as the years wear on and they need to be hidden away somewhere, disappeared. Perhaps it’s because they point to our failure, our weakness, and our inability to make a commitment to basic human survival because it conflicts with the American way of life.

As Green says, this is all about whose way of life gets to survive. Rallying to address the health of all Americans, or those outside of our borders, means a sacrifice that most who lead us, those who have the power in our societies, are never willing to make. Farmer used to talk about a preferential option for the poor. Here in the land of plenty, we have a preferential option for the well-off and comfortable. Health for all by the year 3000? Not likely. With the existential threat of climate change and the risk of new pandemics, at this rate, from what I’ve seen, it’s more likely that no one will be around to make the waggish quip for that new millennium. And the joke will have been on us.