Harvard Public Health Review
Summer Fall 2006
Passages to China and India
In the transitions of these countries toward greater wealth and health, the School is playing a valuable role
China and India have burst onto the global scene as among the most intellectually vibrant and dynamic of all developing countries, with news outlets reporting briskly on their rapidly expanding economies. Both countries' rising prosperity reveals remarkable advantages that participation in the global economy offers for improving the standard of living in developing nations.
Thanks in part to improvements in public health, each country has made heroic advances in economic development, with GDP real growth rates in 2004-05 of about 9 percent for China and 7 percent for India, according to World Bank figures. In 1900, average life expectancy at birth for both countries was estimated to be about 25 years. In the last few years, life expectancy has climbed to 72 years in China and 64 years in India. Yet each also faces huge problems of social development, particularly with respect to disparities in health, wealth, and education among their widely diverse populations.
In China, a health system forged under Mao's regime and staffed by "barefoot doctors" with little training provided technically poor but widely accessible minimal health care to hundreds of millions of people. That system was dismantled in the 1980s, however, and nothing has yet replaced it in the rural areas, now home to 60 percent of China's population. An estimated 300 to 600 million people will be moving in the next 15 years from the agricultural sector to work in newly expanded cities in the industrial sector. For health, this transition will create enormous challenges--including providing basic services to migrants, protecting air and water quality, and preventing occupational injuries that are already out of control.
The modernization of India's economy began later and somewhat differently than China's, with a focus on creating a knowledge-based economy. Two decades ago, computers would have been seen as an inappropriate technology for India; now, a third of all software in the world is written there. India too is industrializing, with an emphasis on high technology, including biotechnology and pharmaceuticals. Nevertheless, 600 million people living in over half a million rural villages are still earning less than U.S. $2 per day, with little or no access to health facilities.
Both China and India have made enormous strides in reducing malnutrition and curbing the spread of infectious diseases. Each has made spectacular gains in immunizing their children. But in both, the majority of health care financing is private, with little insurance coverage; thus households must make large out-of-pocket payments for health services, and catastrophic illness is the major cause of bankruptcy. As these countries have modernized and children under five have ceased to die in great numbers, each has to face the inevitable problems of chronic diseases, from cardiovascular disease to obesity, diabetes, and cancer. In the wake of emerging infectious diseases ranging from SARS to avian flu, both countries recognize the need to improve their public health systems and provide access to basic preventive as well as curative health services.
FOR HSPH--AND A PERSONAL JOURNEY
The Harvard School of Public Health has long been deeply involved in initiatives in both China and India. For example, members of our faculty contributed, beginning in the late 1960s, to the development and dissemination of oral rehydration therapy, a mix of salts, glucose, and water that, for pennies, has prevented the deaths of millions of children from diarrhea caused by cholera, rotavirus, and other pathogens. In China, for example, our researchers have led or are leading studies of the effects of cotton dust in the workplace on lung function; the relationship between particulate air pollution and increased cardiopulmonary mortality and morbidity; strategies for controlling schistosomiasis and HIV/AIDS; and a scheme for providing health insurance to rural families. Our wide-ranging work in India involving students and faculty includes efforts to improve the efficiency of public sector health services and studies of the relationship of health to well-being and economic development. (For details on the School's research in Asia, visit https://webapps.sph.harvard.edu/cfdocs/worldmap/map.cfm.)
For me personally, both China and India hold very special meaning. China, with its rich history and culture, first became part of my life as my wife, Irene, a scholar of Chinese philosophy, moved from the role of graduate student at Columbia University to that of chair of the Department of Asian Studies at Barnard College. Then, in 1984, it was my privilege to be invited to China to help negotiate the entry of the Chinese Immunology Society into the International Union for Scientific Societies. There I was befriended by Ma Haide (George Hatem), one of two Western physicians who accompanied Mao on the great Long March. Dr. Ma is credited with helping create a public health system that virtually eliminated sexually transmitted diseases in China. As chair of the Immunology of Leprosy Committee at the World Health Organization (WHO), I helped to engage him in the cause of initiating treatment for leprosy patients.
In 2003 came SARS--a viral disease that rose to crisis levels before China's leaders recognized the importance of the problem. At HSPH, transmission modeling was being done for the first time in real time during the course of an epidemic by a doctoral student, Christina Mills, and two junior epidemiology faculty at HSPH, Megan Murray and Marc Lipsitch. This outstanding team did the work--and as dean I was invited to meet with the Minister of Health and his senior officials to consider how HSPH might help them improve their response to emerging public health challenges. In the fall of 2005, we at HSPH were honored with a visit of Minister of Health Gao Qiang, who delivered a thoughtful assessment of China's efforts to improve health and public health. One of several ways in which HSPH could help, we agreed, was by providing advanced training for mid-level officials in China's central and provincial ministries of health. In August of 2006, the first group of 28 outstanding future leaders completed HSPH's inaugural three-week China Senior Health Executive Training Program, led by Yuanli Liu, an assistant professor of international health in the Department of Population and International Health.
India too has shaped my life, and my scientific career as an immunologist. When in 1966 my laboratory and another, at HSPH, simultaneously discovered a new class of molecules that regulate how T-cells, macrophages, and other cells communicate with each other, WHO invited me to participate in a small meeting in New Delhi to try to apply this new insight to what was perhaps the most neglected of all infectious diseases: leprosy.
The meeting was an awakening--to the infectious disease problems of a poor developing country, to the fear and stigma associated with a disfiguring disease, and to the enormous opportunity for basic science to shed light on disease processes--and possibly contribute to new interventions to prevent and cure those diseases. At that time, reductionist model systems were in vogue among lab scientists, few of whom were working on actual infectious diseases of the poorest countries. The impact of this first visit to India was also transformative, in that it shifted my research agenda from basic studies of immune mechanisms of model molecules to exploring mechanisms of pathogenesis and immunity in diseases afflicting the world's poor, particularly leprosy, Chagas' disease, and tuberculosis.
A few years later, WHO again sent me to India to teach the first course in the country in my field, immunology. This class, taught over a summer at the All India Institute for Medical Sciences, had 28 students. Together we worked day and night, improvising in ways I had never before imagined. Because cows are sacred in India, the students had to adapt all of our cell cultures to grow in the serum of water buffalo rather than fetal calf serum--and adapt they did. Their energy, enthusiasm, and thirst for knowledge were truly an inspiration.
Albert Einstein, when asked to identify the most important discovery in mathematics, answered: "compound interest." Einstein was right, but there is no compound interest with returns greater than those reaped by educating young people. When in 1997 I returned once again to India for the first International Congress of Immunology to receive the Novartis Award, the impact of this compounding power was abundantly clear: In attendance were 3,000 registered Indian immunologists.
THE PUBLIC HEALTH FOUNDATION OF INDIA:
A PUBLIC-PRIVATE PARTNERSHIP
When I became dean, in 1999, I sought a way to give something back to India. While modern India excels in many sciences, it is equally clear that, for a country of a billion people, it has few schools of public health and a tragically underdeveloped public health system. In September of 2000 I was privileged to meet Rajat Gupta, a distinguished Indian expatriate who had accomplished a great deal for India by organizing humanitarian activities within the Indian community in the United States. Gupta, an alumnus of Harvard Business School, was managing director for McKinsey & Company, and a global expert in management. Over breakfast, I made the case that investments in public health would be a great thing for India, particularly for the 600 million in rural areas who had so little access to health care. I would like to believe that that breakfast was transformative for Gupta. He has since become a great global advocate for public health, serving on the boards of the Global Fund for AIDS, Tuberculosis, and Malaria and the Bill & Melinda Gates Foundation.
With Gupta's support, I joined Peter Berman--then director of HSPH's International Health Systems Program, now an adjunct faculty member who heads the World Bank's Health Nutrition and Population team in India--and met with India's health secretary and health minister to advocate for a major investment in public health training. Our concept was a novel one: to create a public-private partnership which, with a business plan developed by Gupta and McKinsey, became a reality this past spring in the form of the Public Health Foundation of India (PHFI). The vision is to create initially two, and ultimately five or six, schools of public health, and a "think tank" that will provide evidence-based information for major health policy decision-making.
Enthusiasm for the concept has been overwhelming. The launch of PHFI two days after the Harvard Alumni Association meeting in New Delhi, included Prime Minister Manmohan Singh and other secretaries and ministers. In signing a memorandum of understanding, Harvard University's then-president, Larry Summers, HSPH, and PHFI pledged to collaborate in the development of training and research programs for India. PHFI has received the enthusiastic support of all the deans of the U.S. Association of Schools of Public Health, who have offered their help in training India's future teachers and trainers. Our challenge now is to raise financial support for the training at Harvard and other schools of public health of India's brightest and most dedicated students, and to foster an environment so challenging and intellectually appealing that they will be motivated to serve their home countries as India's new public health leaders. This is the kind of "compound interest" through which HSPH can truly make a difference.
This issue of the Harvard Public Health Review describes the journeys of many of our faculty and students as they strive to make lasting contributions to public health in Asia. Suffice it to say that it remains a great privilege for many of us at our School to travel along with the leaders and students of China and India, both as passengers and as guides.
Barry R. Bloom, Dean
Joan L. and Julius H. Jacobson II Professor of Public Health
Harvard School of Public Health
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