Learning from H1N1: Dean Frenk offers expanded concept of global health security

With the unfolding example of the world's public health response to the novel H1N1 virus, HSPH Dean Julio Frenk asked an audience of public health students, faculty and practitioners last month to consider an expanded concept of what is meant by "global  health security."

"This pandemic is clearly showing us that in health matters the world has become a single neighborhood," said Frenk, "and that the consequences of actions that are taking place far away show up, literally, at our doorsteps."

Frenk spoke September 16 about "The H1N1 Pandemic and Global Health Security" to a capacity crowd in Kresge Auditorium -- and to several hundred more viewers watching the live webcast in other rooms at the School. His lecture kicked off the 2009-10 HSPH Center for Public Health Preparedness Speakers Series.

Frenk, who is the T & G Angelopoulos Professor of Public Health and International Development, began by offering an overview as the new flu season starts in the Northern Hemisphere with the added component of H1N1, now the world's dominant flu type.

The encouraging news: With information learned last spring by public health practitioners around the world, the initial wave of the pandemic was basically kept under control, and now there is confidence in confronting the second wave this fall. So far most H1N1 cases have been moderate, there is no evidence that H1N1 has mutated to a more lethal form, the antivirus drug oseltamivir is still effective against it, and H1N1 vaccine should be available in October.

The bad news: Some people, including pregnant women and obese individuals and the immuno-suppressed, are especially vulnerable; respiratory failure cases could overwhelm hospitals in developing nations where health systems are already under stress; and there is still great opportunity for H1N1 to mutate to something nastier given the many millions of people not yet infected.

Frenk described a paradox in the evolving public attitudes toward pandemic response. Because researchers around the world, including HSPH modeler Prof. Marc Lipsitch, have done such a good job of describing H1N1 so quickly, Frenk said, public expectations of health authorities have changed. The public last spring was "worried but tolerant" because people understood there were a limited number of methods and tools to confront an "expected but unknown" new virus. Now the virus has become "expected but known" and this has changed the public mood to "anxious and demanding" of its public health authorities. "There will not be much room for justifying failures in this next response," said Frenk.

In his talk, Frenk chose to emphasize the need for developing better models for understanding how health authorities should respond to global health threats. The international community has learned a lot since the discovery of severe acute respiratory syndrome, or SARS, in 2003. Then, travel advisories were issued and nations blamed each other. SARS, new flu types (avian and H1N1) and the threat of bioterrorism are responsible for the increased attention and resources devoted to global health in the past decade, Frenk said, including new multinational efforts at cooperation -- "investments that have paid off in the current wave."

Mexico had begun to strengthen its response system in the 1980s in cooperation with the U.S. Centers for Disease Control and Prevention. Additionally, Frenk pointed out, many of the top persons dealing with the epidemic wave last May in Mexico were graduates of HSPH: "Hundreds of lives were saved because of the response in that first country ...that response allowing the rest of the world to respond."

The idea of "health security" was an obvious outgrowth of these transnational emergencies. Frenk traced its evolution through two particular strands of thought: 1) that epidemiological surveillance and response do help to control threats in nation-states, and 2) that "investments in the protection of individuals from threats that endanger their health would also make our world a safer place." The health of individuals, Frenk noted, is a central part of a model for human security -- as opposed to national security -- put forth by a landmark commission created by the United Nations in 2001 on Human Security and co-chaired by Amartya Sen, Harvard's Thomas W. Lamont University Professor and Nobel laureate in economics.

Rather than continuing to accept the limited definition of health security as simply protecting against external threats, Frenk proposed a new three-part and comprehensive definition.

The first part he called "epidemiological security," encompassing the traditional approach to preventing the spread of disease-causing agents or harmful chemical agents.

The second part is "health-care security," a term first introduced by President Bill Clinton in proposing the Health Security Act. Frenk said the term should include not only access to personal health care, but also an assurance of quality so that individuals are offered effective treatments and are not harmed by their health care, and that their dignity is safeguarded.

The third part Frenk called "financial security", "especially against the risk of catastrophic or impoverishing expenditures that result from paying for care; protection against the risk of going broke from getting sick. This is a key dimension of living in a secure world."

These three principles, Frenk noted, are "consistent with the guiding principles of the health care reform initiative that, as I speak, is being debated in the United States and the American Congress." And he found it remarkable that the health care reform debate coincides with the worst economic crisis since the Great Depression and the worst influenza outbreak since 1968.

Frenk ended by quoting Sen: "We live in a world that is not only full of dangers and threats, but also one where the nature of the adversities is better understood, the scientific advances are more firm, and economic and social assets that can counter these menaces are more extensive. Not only do we have more problems to face, we also have more opportunities to deal with them."

-- John Lenger. Photo by Suzanne Camarata.