Gro Harlem Brundtland

WHO’s Director-General and HSPH Alumna Brundtland Speaks

A recent symposium to honor two venerated former HSPH deans drew the Director-General of the World Health Organization (WHO), the Minister of Health for Mexico, Harvard’s Provost, and more than 300 audience members to the school. "A Global Dilemma: Health Disparities" on Friday, September 27 resulted from what HSPH Dean Barry Bloom described as a felt need by members around the school to express their appreciation to former Deans Harvey Fineberg and Howard Hiatt.

Fineberg and Hiatt chose health disparities as the day’s topic. Bloom introduced both former deans, stressing their efforts to address health disparities throughout their careers.

Providing opening remarks, Harvard University Provost Steven Hyman expressed the pleasure of knowing Hiatt and Fineberg, who was Hyman’s predecessor as Harvard Provost. Hyman described health disparities as a critically important topic that requires all of the efforts of the university to help solve.

Christopher Jencks, Malcolm Wiener Professor of Social Policy at the John F. Kennedy School of Government, talked about the relationship between income and health. He said that while both national and individual income are powerful predictors of health, the relationship between them and health needs further study.

Jencks said that raising per capita GNP income in a poor country boosts life expectancy in that country. (When per capita GNP income doubles, life expectancy rises by about five years.) However, the same principle does not apply to richer nations where life expectancy is already reasonably high.

Redistributing wealth among nations to lessen disparities would therefore help poor countries significantly while having little effect on life expectancy rates in richer nations. However, there is no mechanism for such distribution and little support for the idea among rich nations, including the US, the world’s wealthiest country.

Jencks was pessimistic about making much progress against health disparities in the US. Surveys have shown that Americans are more likely than citizens of other rich nations to blame poverty and unemployment on the flaws of the poor rather than on problems within the society. They are more likely to believe that there is equal opportunity in the US, and they are less likely to want the government to play a big role in the economic affairs of the country.

Those attitudes result from more than historical tradition, he said. One source is America’s dismal racial history and slavery legacy. He said that it was very clear that the US states that have the greatest level of health inequalities also have the largest numbers of African Americans. He said that race is a factor that cannot be ignored in health disparities discussions.

The idealized notion that immigrant ancestors pulled themselves up by their own bootstraps–and therefore others should do the same–detracts from the possibility of more egalitarian health policies in the US, he said. He added that the government has a lot of veto power to skewer health care measures, and politicians are increasingly coming under the influence of wealthy people who have agendas not necessarily focused on health disparities.

Lisa Berkman, Thomas D. Cabot Professor of Public Policy in the Department of Health and Social Behavior, next described the importance of the population health perspective in understanding health and cited the growing trend of obesity among American kids as a good example. In 1963, five percent of US kids were overweight. That number has grown to between 14 and 15 percent. Genetic differences do not explain the tremendous shift, she said.

The population perspective reveals interesting facets of the health disparities issue. Overall, Americans are living longer than ever before, yet dramatic differences between groups remain. In 1996, white men in the US had a life expectancy of 73.9 years. Black men however had a life expectancy of 66.1 years–nearly the same age that white men averaged in 1950.

Berkman is looking into the social determinants of health, such as social isolation. She is also investigating the importance of neighborhood settings in affecting health. For example, she commented, if people do not feel safe walking around their neighborhoods, they are less likely to exercise outdoors.

Public health’s role is to partner with members of other sectors, such as education, transportation, and the environment, to inform and evaluate the field, she concluded.

Julio Frenk, the Minister of Health of Mexico and a former visiting professor at HSPH, talked about the importance of evaluating health systems and of setting precise health agendas. He said that inequalities can be reduced through sound policies, even in the face of persistent income inequities.

Before becoming health minister of Mexico, Frenk worked at WHO. One of the projects he served on was creating a framework to assess health systems. The project concluded that any health system should have three main goals: improving health, responding to the legitimate expectation of people that their human rights will be respected, and distributing the burden of health care financing fairly. Frenk has applied that framework to Mexico and has now set distinct goals for the health care system there to achieve.

Frenk emphasized the importance of leveling the burden of paying for health care among groups. He reported data showing that two to three million Mexicans face catastrophic health care costs every year. More than 80 percent of those people do not have health insurance.

The final speaker, Gro Harlem Brundtland, Director-General of WHO and alumna of HSPH, said that inequalities in health are largely the result of economic and social inequalities in society. Yet, echoing Frenk, Brundtland said that sound policies can reduce health disparities.

She described some goals that WHO has set: the reduction of the burden of excess mortality and morbidity on the poor; the countering of potential threats to health due to economic crises, unhealthy environments, and risky behaviors; the development of more effective health care systems; and an increased investment in expanding knowledge bases that will aid health care gains in the future.

Progress has been made over the last decade while, at the same time, opportunities have been missed. Using a joint Harvard-WHO study from 1990 as a baseline, Brundtland said that measles has now dropped off the top 10 list of causes of disease, and cases of diarrheal diseases have decreased. However, HIV infection has become a much bigger part of the global disease burden picture, while progress on acute respiratory infections and malaria has been slow.

Tobacco-related illnesses are taking a toll on populations. Even as smoking rates are decreasing in the US and in other nations, they are expected to climb in developing countries, which have become attractive markets for tobacco companies.

Brundtland called upon wealthier nations, particularly the US, to spend more money on programs to help poorer countries. The amounts that would be needed to save eight million lives each year are small compared to the size of the global economy, she said.

Bloom concluded the symposium by reflecting that there are big problems in the world that can be perceived as lost causes, but, he said: "We fight for lost causes not in the expectation that anything will triumph but rather to keep something alive. In our business, keeping alive means keeping millions and millions of people alive, and keeping alive means keeping the spirit and commitment to the humane values of Harvey (Fineberg) and Howard (Hiatt) alive in this place."

A webcast of the symposium is at www.hsph.harvard.edu/live/Global_Dilemma.html.