Dean’s message: H1N1 and comprehensive health security

photograph REUTERS/Sergio Moraes

[Winter 2010]

Health Reform in an Era of Pandemics

The H1N1 pandemic has had a profound impact on global security. This pandemic clearly shows us that, in health matters, the world has become a single neighborhood—and that the consequences of actions taking place far away show up, literally, at our doorstep.

Since at least 2005, the world has been aware of the danger of an influenza pandemic. But we didn’t know where and when it would start, nor which type of virus would trigger the outbreak. We were dealing with an expected but unknown event.

We also understood that there was a limited number of things that health authorities could do to prevent such an event, and that we had only a handful of measures at our disposal to control the immediate consequences of an outbreak. The population was worried but tolerant.

As I argued in a New York Times op-ed published shortly after the pandemic began in the spring of 2009, considering the complexities of dealing with the first occurrence of a novel threat, the initial response was quite competent, though certainly not perfect. Since then, the burgeoning knowledge about the H1N1 virus that has emerged, its mechanisms of spread, and the way to confront it, has changed our perception of the influenza pandemic. Now in the midst of the winter season, we believe we will be facing an expected and known event. This transformation changes public expectations.

People know that health authorities can limit the spread of H1N1 through the new vaccine and other public health measures, and that health services have at their disposal a reasonable arsenal of clinical devices to treat cases. But with the vaccine slow in arriving in October and November, the population was anxious and demanding.

So in a matter of months, according to the School’s Marc Lipsitch, we moved from an environment of high public attention, low scientific certainty, and low social anxiety to an environment of still high public attention, but now with high scientific certainty and, consequently, high social anxiety. This anxiety rose as the number of cases and deaths continued to spike up in the Northern Hemisphere throughout the beginning of the 2009-2010 flu season.


SARS, bioterrorism, and influenza are largely responsible for the growing attention and resources being directed toward global health. Indeed, during the past few years, health has been increasingly recognized as a key element of global security, sustainable economic growth, and democratic governance. Indiana University law professor David Fidler notes that in foreign policy terms, health has moved from the realm of “low politics” to that of “high politics.” Its relevance to security concerns has become so obvious that the term “health security” has recently gained currency.

There is no doubt that investments in epidemiological surveillance and response contribute to the control of threats facing nation-states, such as pandemics and biological warfare. But investments in the protection of individuals from threats that endanger their health would also make our world a safer place. This idea, in fact, lies at the core of the concept of “human security,” which, according to the United Nations Development Programme, embraces not only health security but also economic, food,  environmental, personal, community, and political security.

Coined by the Palme Commission in 1982, the concept of human security has evolved over the years. It culminated in the work of the Commission on Human Security, established in 2001, which was co-chaired by Madame Sadako Ogata and Nobel laureate and Harvard economist Amartya Sen. According to the report of this commission, human security “means protecting people from critical and pervasive threats and situations, building on their strengths and aspirations. It also means creating systems that give people the building blocks of survival, dignity, and livelihood.”

Until recently, the term “health security” had meant protection against external threats. I believe that we should move beyond this limited usage and adopt a comprehensive definition, which may anchor our efforts to improve global public health. Consider three main dimensions of health security.

The first could be called “epidemiological security,” referring to protection against specific risks of disease or injury through biological and chemical agents.

The second dimension deals with personal services, and has been called “health care security.” This was the usage introduced by President Bill Clinton in his reform initiative of 1993, which was in fact named the Health Security Act. Addressing Congress, President Clinton defined this dimension as follows: “Security means that those who do not now have health care will have it; and for those who have it, it will never be taken away.” While security of access is key, we should also include safety from harm by medical treatment itself, effectiveness, and, very important, responsiveness that safeguards the dignity of patients.

The third and final dimension is financial security, which refers to protection against the economic consequences of disease, especially against the risk of catastrophic expenditures as a result of paying for care. Patients should not have to run the risk of going broke from getting sick.

These three dimensions of health security are consistent with the guiding principles of the health care reform initiative hotly debated in the United States over the past several months. The principles include: protecting families from bankruptcy or debt because of health care costs; improving patient safety and quality of care; and investing in prevention and wellness, which directly ties into the public health measures that protect our population from epidemics.

The topic of health security became particularly relevant this fall at a unique intersection of events: the debate over U.S. health reform;  the worst economic crisis since the Great Depression; and the appearance of a pandemic that conjures images of the Great Influenza of 1918.


History teaches us that many of the most enlightened social protections have been crafted precisely at times of economic or political crises. In fact, guaranteeing health security becomes even more urgent in times of economic upheaval. Economic shocks are often short-term, but health shocks leave enduring scars. The current recession has left many individuals and families either uninsured or underinsured, forcing many to delay or skip needed medical care because of prohibitive costs. Without health care reform, more will fall through the cracks.

Our concern for global security must therefore be grounded on a renewed ethic, the ethic of human rights, so that every human being may have the same opportunity to achieve his or her full potential, as stated by the Commission on Human Security.

Consider the remarks of Amartya Sen at the International Symposium on Human Security, held in Tokyo in the year 2000:

“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.”

In the words of President Barack Obama, this is a future we should not fear, but, with the help of scientific knowledge, work together to shape. Our generation has no task more urgent or important than to achieve comprehensive health security for all.

Julio Frenk is Dean, Harvard School of Public Health and T & G Angelopoulos Professor of Public Health and International Development