Society is his patient

Spring 2009 ]

Julio Frenk’s arrival in January as the seventh Dean of the Harvard School of Public Health (HSPH) was, in a sense, a homecoming. It was in 1953 that his father, a research fellow at Boston’s Children’s Hospital, was doing experiments in a basement laboratory at HSPH. With his mother at home close by, he says, “my twin sister and I were enjoying the comfort of embryonic life.”           

Frenk muses that perhaps this early “imprinting” led him to employ Harvard as a touchpoint throughout his life. His academic collaborators have included three former HSPH deans and at least one Harvard graduate, his wife, Felicia Knaul. He has been a visiting professor at Harvard twice in his professional life, and twice delivered HSPH’s commencement address. Now he returns for the next phase of his career, one dedicated to ensuring that, through research and education, HSPH will continue to generate highest quality, highly relevant knowledge, which he believes is the best hope for solving problems ranging from the worldwide obesity epidemic to inequitable, inefficient health systems, to HIV/AIDS, malaria, and other scourges that disproportionately afflict the poor.

Recently Dean Frenk sat down with the Harvard Public Health Review to answer questions about his career, his vision for HSPH, and the future of public and global health.

A quest for equity: Julio Frenk career highlights

1987: Launches Mexico’s National Institute of Public Health, grounding in hard evidence fresh strategies to improve health systems

1998: At the World Health Organization, where HSPH alumna Dr. Gro Brundtland is director-general, creates the first unit explicitly charged with using scientific knowledge to drive policy change

2000: Named Minister of Health in Mexico under President Vicente Fox

2001–2006: Spearheads Seguro Popular, a program to provide health insurance to 50 percent of Mexicans—mostly poor—who have none

2007: Serves as senior fellow in global health at the Bill & Melinda Gates Foundation and as president of the Carso Health Institute, in Mexico City, a foundation that spurs health systems innovation

2008: Receives Clinton Global Citizen Award in recognition of Mexico’s landmark universal insurance progra

2008: Named Dean of the Harvard School of Public Health, effective January of 2009

Q: What led you to public health?

A: I am a physician, born into a family of physicians and musicians. From the very beginning of my medical education I wanted to reach beyond the care of individual patients, important though that is, and try to understand the reasons why people get sick in the first place. I wanted to make the whole of society my patient.

As a graduate student at the University of Michigan, I worked with HSPH alumnus Avedis Donabedian to understand the functioning of health systems and the social and economic environment that determines why some people get sick. How do we organize a system that is responsive to people’s needs in an efficient but also equitable manner?
Early on my focus was the academic enterprise, because creating new knowledge-through research, and by training the next generation of leaders-is the most potent instrument we have for making the world a better place.

What is the line connecting the apparently disparate dots of my career, you might ask? That line is the belief that good evidence can be translated into policy and practice. Evidence is the light that must illuminate our path. The unique contribution of this public health school is the creation, translation, and utilization of knowledge-in the form of research, of higher education, of outreach activities.

Q: Public health defies easy definitions. What is yours?

A: Public health is a field of inquiry and an arena for action that is driven by a fundamental mission: to improve the health of entire populations. We make society our patient. We value prevention above anything else; we are proactive in anticipating risks. When diseases happen, we try to provide our “patient” with the best evidence on how to organize and finance our health system, so that everyone will have access to high-quality care.

Q: What about “global” health? How is that different?

A: When we take the entire globe as our population, that is global health.

Let us be clear: Global is not the opposite of domestic. Global health is not foreign health. A global outlook means we recognize that the local and the global are united, increasingly interdependent and interconnected. We recognize that what happens outside of the U.S. affects us, and whatever happens in the U.S. impacts the rest of the world.

For evidence of this we have only to look at our global economic crisis. Look too at pandemics: If there is an outbreak in another part of the world, it will eventually affect us. We cannot ignore problems related to HIV/AIDS in Africa, tuberculosis, and malaria in South Asia without understanding that they will eventually have an impact on well-being in the United States. Moreover, when we see 10 million children die of unnecessary causes in poor countries, it presents an ethical dilemma for all of us who are privileged to live in the United States. These children are not dying from rare diseases; we have the tools to prevent the death of a child.

Apart from these humanitarian considerations, our world neighbors need to have healthy children and healthy adults to be able to grow economically. All of this in turn benefits the U.S. economy.

Finally, in those countries where children die early and mothers die in the act of giving life, injustice breeds. This injustice can lead to unrest and, eventually, to the terrorist mindset that seeks to redress injustices through completely unacceptable means. We must all recognize that we cannot aspire to have a secure world if we do not combat the root causes of insecurity, the most dramatic of which are unnecessary illness, suffering, and death.

Q: What lured you to HSPH?

A: HSPH is a school that balances two fundamental values: the value of excellence and the value of relevance-relevance to our own society and to the world.

Our outlook and our efforts must be global-we do not look inward, but rather outward, and to the future. Our global outlook is reflected in the composition of our faculty and students, who come from all regions of the world. We also value and promote diversity. You will find here a great diversity of outlooks and of ideas.

Finally, we are all motivated by our belief that health is a universal value.

Inscribed on this School’s main building is a phrase from the preamble to the WHO constitution: “The highest attainable level of health is a fundamental human right.” We see health as neither merchandise nor a privilege, but part of a set of common rights that unites us all as members of the same human family. This ethical orientation is recognized in the founding instruments of international law and national legislation. It is the reason universal health insurance is so important: It is a way of turning this abstract declaration into concrete benefits for all.

Q: What are our biggest challenges in public health right now?

A: The public health agenda of our time includes three major sets of challenges:
First, we have the “unfinished agenda” of disease represented by common infections, reproductive health problems, and under-nutrition. These problems are unfinished in that they have solutions, but solutions that are not reaching everyone.

Second are the emerging challenges represented by non- communicable problems, such as cardiovascular diseases, diabetes, and mental disorders, as well as injuries.

Third are health challenges linked to the forces of globalization. These include climate change and other environmental health threats; the spread of harmful lifestyles across continents; commerce in harmful products like tobacco and illegal drugs; and emerging infectious disease pandemics.

Q: What good can one graduate school do in the face of such an onslaught?

A: Good leadership is the main factor when it comes to improving the health of populations. The Harvard School of Public Health has for many decades made fundamental contributions to improving the health and security of the world, both through research and also by training generations of leaders. These leaders occupy central positions in governments, in international agencies, and in other research institutions. Our efforts get multiplied through our students, who go out to lead others. We need to keep our educational mission vibrant.

By making our university available to students from around the world, we can help the development of countries that are struggling. To attract good leadership from around the globe is also our way of investing in our own security, and in our own capacity to lead the world.

Harvard is unique in that it is both a great university and home to a great school of public health. That is rare. The experience of students here will shape their lives, because they have access to a wealth of resources.

I have seen in my own home country of Mexico the enormous impact Harvard University has had. Three presidents have studied at Harvard. The number of senior leaders at the ministry of health, at universities, and at NGOs who are Harvard graduates, is a testimony to the School’s global influence.

Q: Why it is so important now for the United States to invest in health?

A: I am very pleased to see the enlightened way that the Obama administration is addressing health reform. Looking at health as part of the stimulus package is exactly the right approach. A common response by many governments to an economic crisis has been to cut health budgets. We now have sufficient evidence that this makes the crisis worse.
You don’t get out of an economic crisis without healthy people. Healthy adults drive the economy; healthy children represent the human capital of a nation. In the U.S., the health sector is the largest sector of the economy. So spending in health is a great way to create high-value-added jobs.

The global knowledge economy is exactly that part of the global economy where the United States still has an undisputed edge—an edge now being challenged by other countries. Investing in health and education is a way to secure continued leadership in this arena.

That said, there are better and worse ways of spending. For the amount of resources that it absorbs, the U.S. system generates not-so-good results compared to its peer industrialized countries. It is important to achieve not only more money for health, but also more health for the money.

It is unacceptable ethically and politically that the richest country in the world has 40 to 50 million inhabitants without insurance. As we have seen elsewhere, inclusiveness builds a sense of community and of national identity and pride. I also think that the reform efforts will become a fundamental piece of American leadership throughout the world. If you can show that you can make a health system that actually works, this will have a multiplying effect.

Q: You received a Clinton Global Citizen Award, in part for your work in Mexico. What have you learned from this effort to bring health insurance to 50 million people?

A: My main accomplishment as minister of health in Mexico was to institute universal health insurance through a program called Seguro Popular. An enormous effort was made to achieve consensus, across political parties and different groups, that a society where half the people were excluded from access to care was unacceptable. There are 35 million people now involved in that insurance scheme, which was started in 2004 and will be fully rolled out in 2010.

The distinguishing characteristic of my time as minister of health was that I made an enormous effort to enact evidence-based policy. Because I believe in evidence, we started a process of systematic evaluation of this reform from the beginning. It was built into the reform and not as an afterthought.

Mexico has huge social inequities. I believe that the way to deal with such inequities is to give everyone the same opportunity. Opportunity has two pillars: education and health. The only basis for a fair society is if every new generation enters the race for life on the same starting line. For children who begin far back of that line because their mothers were malnourished during pregnancy or because they didn’t have access to care or didn’t go to school, education and health can level the playing field.

While Mexico is not one of the world’s poorest countries, it has some of the poorest people on earth. Mexico is therefore a microcosm, because there we are not only providing insurance, we are also setting the foundation for reducing the gaps. In addition to solving the immediate problem of access to care, we are laying the foundations for a fair society.

Q: Many organizations-the Gates Foundation, the WHO, the International Monetary Fund, UNAIDS-play a part in the global health mission. What is the School’s distinct role within this alphabet soup?

A: Harvard School of Public Health has a unique function in the global architecture for improving health: First, the production of knowledge through research.

Second, the reproduction of knowledge through higher education.

Third, translating it into hard evidence that the WHO, the Gates Foundation, or national ministries of health can use to guide their programs. Then we close that circle by evaluating, in a scientific way, what’s happening out there. Now we know what works and doesn’t work. And we nurture the values of transparency and accountability, both central to the scientific enterprise.

Q: How might HSPH involve and reap talent from the rest of Harvard?

A: I’m very excited about the growing interest in health in other parts of the university. Part of our job is to create that interest. Public health is a set of problems that can only be solved if we bring the insights from many disciplines. One of our strengths is to reach out and mobilize the talent of other parts of the university, its faculty and its students.

People are now realizing that global health is one of the defining topics of our era. It is fundamental for economic development, for global security, and for the spread of democratic governance. In this time of global crisis, HSPH and Harvard have critical contributions to make to public service and public solutions. Together we must help students serve the common good, ensuring that the power of ideas has its fullest impact on the ideas of power.

Q: Some shake their heads, insisting that the problems public health addresses are overwhelming and unsolvable. What would you say to them?

A: I am an optimist. I have seen what public health has done for humanity in the 20th century. We doubled life expectancy. We saw the threat of diseases like smallpox completely wiped out. We are close to eradicating polio as well. In HIV/AIDS we faced the largest public health challenge in the history of humankind, and there was a worldwide response, thanks to which three million people are on treatment today. This is something nearly everyone thought was impossible, not decades ago, but five years ago.

The challenges are huge, but we have never before had the set of resources—intellectual, technological, societal—that we do now. We have never before had the level of public awareness about the central importance of public health. Its high visibility has been translated into enormous growth in financial assistance to health and international cooperation of an unprecedented magnitude.

Why is it that the wealthiest people in the world, when they set up their philanthropic enterprises, see public health as a top priority? It is because money spent on health is money well spent. We are hard-pressed to find any area of activity that has yielded more benefits to humankind than public health.

Photograph: Kent Dayton/HSPH