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he world has changed dramatically since the start of this century, when the Millennium Development Goals were put forward as the overarching framework for development cooperation. World leaders at the Millennium Summit sought to create what they called ‘a more peaceful, prosperous, and just world’. That did not happen as planned. To understand the newer challenges now embodied in the 2030 Agenda for Sustainable Development, we need to look at the larger sea in which these trends were set afloat.Since 2001, terrorist attacks that deliberately target civilians have become more deadly, daring, and common. Armed conflicts are now the largest and longest experienced since the end of World War II. The refugee crisis in Europe taught the world that wars in faraway places will not stay remote. International humanitarian law is now largely ignored, with the deliberate bombing of healthcare facilities and the use of siege and starvation as weapons of war. Warnings about the consequences of climate change are increasingly shrill. Records for extreme weather events are being broken a record number of times. The past three years have been the hottest ever. The phrase “mega-disaster” entered the humanitarian vocabulary following devastating earthquakes, tsunamis, tropical cyclones, droughts, and floods.The world population is now bigger, more urban, and a lot older, adding dementia to the list of top health priorities. Everywhere in the world, people are living longer sicker lives, increasing the burden on health services, budgets, and the workforce.Hunger has persisted, but most of the world got fat. The world has 800 million chronically hungry people, but it also has countries where more than 70 per cent of the adult population is obese or overweight. The globalized marketing of unhealthy products opened wide the entry point for the rise of lifestyle-related chronic conditions. Noncommunicable diseases have overtaken infectious diseases as the biggest killers worldwide. This is a unique time in history, where economic progress, improved living conditions, and greater purchasing power are actually increasing diseases instead of reducing them.Social media have become a new voice with considerable force, yet few safeguards governing the accuracy of its content. The proliferation of front groups and lobbies, protecting commodities that harm health, has created arguments that further muddle public thinking and challenge the authority of evidence.What does this mean for public trust in the evidence produced by science, medicine, and public health?The 21st century has been rocked by the emergence of four new human pathogens: SARS, the H5N1 and H7N9 influenza viruses, and the MERS coronavirus. Other older diseases have remerged in ominous ways, including Ebola, yellow fever, and Zika virus disease. As the century progressed, more and more first- and second-line antimicrobials failed. The pipeline of replacement products has nearly run dry, raising the spectre of a post-antibiotic era in which common infections will once again kill.The world is also much richer than at the start of this century. Countries like China and India lifted millions DR MARGARET CHAN, DIRECTOR-GENERAL, WORLD HEALTH ORGANIZATION (WHO)GRAND CHALLENGES FOR THE NEXT DECADE IN GLOBAL HEALTH POLICY AND PROGRAMMES“THIS IS A UNIQUE TIME IN HISTORY, WHERE ECONOMIC PROGRESS, IMPROVED LIVING CONDITIONS, AND GREATER PURCHASING POWER ARE ACTUALLY INCREASING DISEASES INSTEAD OF REDUCINGTHEM”T070 HEALTH