Web Feature
September 29, 2009
MEETING THE CHALLENGES OF GLOBAL HEALTH: THE ROLE OF PUBLIC HEALTH
Julio Frenk, M.D., Ph.D.
Dean, Harvard School of Public Health
This talk was presented as a Dean's Colloquium and was consponsored by the Center for Global Public Health.
First of all I would like to thank our host, Dean Stephen Shortell, as well as the Center for Global Public Health, the Center for Emerging and Neglected Diseases, and the Berkeley Alliance for Global Health for the invitation to address this distinguished audience.
I was asked to speak about the challenges of global health. This is a topic of utmost importance: the ongoing influenza pandemic is reminding us that in terms of health our planet has become a global neighborhood and that the consequences of events that occur far away show-up, literally, at our doorsteps.
Global health is experiencing a moment of unprecedented attention and expansion. Yet, despite its increasing importance, global health has developed in the absence of a rigorous conceptual foundation that can guide its efforts to generate knowledge and lead its practical applications. I will first briefly propose a way of thinking about global health, one that has evolved during my 25 years of engagement both in the academic and the policy arenas. This framework will then provide the basis for analyzing the daunting challenges facing global health but also its enormous potential to address them in an enlightened manner.
Several definitions of global health have been proposed. Some of them emphasize certain types of health problems; others, a geographical focus; still others, a mission. However, as a field of public health, global health should be defined first and foremost by its population level of analysis. The distinctive feature of global health is that it involves the entire population of the world, along with the subjects of the international community, namely nations, with cultural and territorial identity; states, as the political organizations of these nations; various bodies comprising multiple nation-states, such as economic and political blocs or multilateral organizations; transnational corporations; global civil society movements; and, very importantly, academic institutions charged with the production of knowledge-related global public goods.
The contents of the concept of global health should be distinguished from those traditionally attributed to "international health." Coined around the creation of the International Health Commission in 1913 by the Rockefeller Foundation, the term 'international health' was identified with the control of epidemics across borders and in sea ports, and with the health needs of poor countries, mostly communicable diseases and maternal and child health.
Despite the appearance of originality, very often the term "global health" simply repackages the old meaning of international health, in a case of mere linguistic updating that is not accompanied by true conceptual renewal. Not only in popular media but also in scientific literature and in several major initiatives, global health is being again identified with problems that are supposed to be characteristic of the developing world.
Global health, however, is not "foreign health." Instead, it should be centrally concerned with the interactions among all countries, regardless of their geographical position or stage of development, including the distribution of health challenges around the world, which gives equity a key place in the global health agenda.
Neither should global health be identified exclusively with communicable diseases. The times of simple and clear-cut priorities are gone. Today, the rapid shift in the patterns of disease, disability, and death have added new layers of complexity. Problems only of the poor, like malaria or maternal mortality, are no longer the only problems of the poor. In fact, most developing countries are facing a triple burden of ill health: first, the unfinished agenda of common infections, malnutrition, and reproductive health problems; second, the emerging challenges represented by non-communicable diseases and injury; third, the health risks associated with globalization, including the threat of pandemics like AIDS and influenza, the trade in harmful products like tobacco and other drugs, the health consequences of climate change, and the dissemination of harmful lifestyles leading to the silent epidemic of obesity.
The concept that best fits this dynamic picture is the "global transfer of health risks." At its heart lies the interdependence of the health of populations, the fact that many health problems spread mostly through processes created to support production, trade, and travel worldwide, and are common to developed and developing nations, although with a very unequal distribution both of problems and of resources to deal with them.
As mentioned before, during most of the 20th century, traditional international health frequently viewed the needs of underdeveloped countries as threats. International health activities were also influenced by the idea that health needs in developing countries could be fully addressed through technological interventions. The common view was that risks flow from South to North, whereas solutions flow from North to South. Global health should go beyond this Manichaean view of the world and recognize that those flows also operate in the opposite direction.
Now, I do not mean to say that intense international contacts are new. From time immemorial the forces of trade, migration, war, and conquest have bound together persons from distant places. After all, the expression "citizen of the world" was coined by the Greek philosopher Diogenes in the fourth century B.C. What is new, though, is the pace, range, and depth of integration.
The most obvious case of the blurring of health frontiers is, of course, the transmission of communicable diseases. Again, this is not a new phenomenon per se. The first documented case of a transnational epidemic was the Athenian plague of 430 B.C. But with 2.6 billion air travelers every year, the world has reached an unprecedented scale of "microbial traffic," as evidenced by the unfolding pandemic of human influenza.
To make matters more complex, it is not only people and plagues that travel from one country to another; it is also ideas and lifestyles. Smoking and obesity are the exemplars of emerging health risks linked to globalization that are now placing additional burdens on the health systems of developing countries, further compounding health inequities. Tobacco-related deaths are increasingly concentrated in developing countries that lack the legal and regulatory muscle to counter the power of multinational corporations.
The only way to counter such power is to couple effective national policies with global instruments, like the Framework Convention on Tobacco Control, the first international public health treaty. I feel proud that, during my tenure as Minister of Health, Mexico was the first country to ratify this treaty in the region of the Americas.
Similarly, as disruptive changes in feeding patterns and physical activity spread throughout the world, we are witnessing the rise of a silent pandemic of obesity, which someone has called "globesity," precisely to underscore its link with globalization, and which paradoxically coexists with undernutrition, in a further dramatic example of the multiple burdens befalling poor populations throughout the world.
The globalization of health is rendered even more complex by the fact that it goes beyond diseases and risk factors to include also health products. To mention but one example, careful regulations on access to prescription drugs in one country may be subverted when its neighbor allows the unrestricted purchase of antibiotics, thereby stimulating the appearance of resistant microbes that show up in the first country. This is a particularly relevant issue for the U.S.-Mexico border. It is estimated that 5 per cent of the roughly 350 million annual crossings there may be health-related.8 This represents more than 17 million annual instances of the binational search for health care. Contrary to common perception, seventy-five per cent of these crossings are from the U.S. into Mexico, most often to purchase pharmaceuticals without prescription, including antibiotics.
Such practices are at least in part responsible for the emergence of new forms of microbial adaptation and mutation, which have in turn produced resistance to many antibiotics. This has become one of the major hurdles in the fight against TB. The most recent WHO global survey indicates that 5 percent of new TB cases, almost half a million per year, are resistant to first-line antibiotics.
Another recent development with potential implications for irrational prescription practices and the ensuing spread of antibiotic resistance is the growing commerce of services and drugs through the Internet. That this is no longer a marginal phenomenon is reflected in recent efforts by WHO to curb it.
The growing commerce of health care services also illustrates the blurring of political frontiers. Mexican nationals, for instance, are regular users of health care in the border states of the United States. But health care consumers are also moving in the opposite direction, as I mentioned before. Residents in border regions of the United States go to Mexico on a regular basis in search of less expensive medical and dental services. Insurance plans have also been developed since the early 1980s to provide health care in Mexico to migrant farm workers and there is a growing number of innovative binational health solutions.
The movement of providers across borders is also increasing. The most dramatic example is the migration of nurses. Intermittent nurse shortages are a common phenomenon in rich countries, but are particularly acute in the United States. In the last 15 years the shortages in the United States have been met through the importation of nurses mostly from the Philippines but also from Jamaica, Nigeria and India, sometimes leaving a weakened health care system in source countries. This trend is increasing given the enormous predicted shortfall in the United States for the following decade.
The risks and opportunities involved in this process are considerable and require careful examination. The international debate around the responsibilities of all actors has produced an interesting range of proposals, which include ethical recruitment guidelines and increased educational investments both in exporting and in importing countries. As in all issues related to migration, cooperation should always be the motto of interdependence.
In the field of health, in fact, interdependence has opened novel avenues for international collective action. Thus, initial efforts in the 1990s to secure cheaper drugs for AIDS victims in poor countries yielded only modest results. A few years ago, however, strong international mobilization persuaded several major multinational drug companies to establish agreements with developing countries to sell AIDS drugs at heavily discounted prices. Mexico benefited from these agreements and thanks to them universal access to anti-retrovirals has become a reality since 2003.
Forces related to globalization also prompted the organization in 2001 of the historical U.N. General Assembly Special Session on HIV/AIDS. This was the first time that a session of the General Assembly was devoted to a health topic, thus underscoring the growing link between pandemics such as AIDS, economic development, and global security.
Social mobilization has also played a key role along the U.S.-Mexico border in strengthening cooperative public health interventions. A great example is the "Binational Health Week," organized for the first time in 2001 thanks to the energetic efforts of the University of California, notably my good friend Xochitl Castañeda. This innovative program includes health education and awareness activities, as well as specific prevention campaigns, such as immunization of migrant children.
As we can see, national, regional, and global forces have contributed to the growing complexity of health systems. Such complexity, in turn, has made international comparisons more valuable than ever. Given the enormous economic and social impact of policy decisions, countries can benefit from a process of shared learning. This was the significance of the effort carried out in the year 2000 by WHO to assess the performance of all health systems of the world.13 Comparative analysis is likely to promote the international dissemination of good practice.
This type of knowledge-related global public goods will be key to achieve further improvements in health.14 In fact, we now know that most of the health gains during the 20th century can be attributed to the advancement of knowledge, through three main mechanisms. First, knowledge gets translated into new technologies, such as vaccines and drugs. This is the best known mechanism through which it improves health. But knowledge is also internalized by individuals, who use it to structure their everyday behavior in key domains like personal hygiene, feeding habits, sexuality, and child-rearing practices. Finally, knowledge becomes translated into evidence that provides a scientific foundation both for health care and for policy formulation.
This last point is nicely illustrated by the health reform efforts that I was privileged to lead in Mexico just a few years ago. This is probably a textbook case of evidence-based policy. Indeed, sound analysis made decision makers and the public aware of critical realities that required solution. Thus, the careful calculation of national health accounts revealed that more than half of total expenditure in Mexico was out-of-pocket. This proved to be a direct result of the fact that approximately half of the population lacked health insurance.
These findings were unexpected as it was generally believed that the Mexican health system was based on public funding. The realization that millions of households had been paying impoverishing out-of-pocket sums generated a different perspective on the operation of the health system. For the first time, it became clear that Mexico was facing an unacceptable paradox: whereas health is a key factor in the fight against poverty, a large number of families became impoverished by expenditures in health care and drugs.
The careful interplay between national and international analyses generated the advocacy tools to promote a major legislative reform establishing a system of social protection in health, which was approved in 2003 by a large majority of the Congress. This system is reorganizing and increasing public funding over seven years in order to provide universal health insurance. To this effect, a new program, called Seguro Popular, is gradually enrolling the 50 million Mexicans—most of them poor—who until then had been excluded from social insurance schemes for salaried workers.
In addition to its technical aspects, the ongoing Mexican reform has been designed, promoted, implemented, and evaluated using an explicit ethical framework, which is predicated on the fundamental principle that health care is not a commodity or a privilege, but a social right. The important point in this regard is that social rights belong to the category of second-generation human rights, which are, by definition, rights that everybody posses as a member of the human race. This means that the demand for healthcare can come from anybody, and not only from citizens of a particular country. This issue is particularly relevant given the level of migration that the world is witnessing. The implications of a rights-based approach are clear: it is unethical to limit access to health services on the basis of the migratory or legal status of any person.
We do not have time to go into all the details of the Mexican reform, which have been explained in a series of seven articles published by the prestigious journal The Lancet in 2006. What I would like to stress today is that the Mexican experience offers a clear example of how globalization can turn knowledge into an international public good that can then be brought to the center of the domestic policy agenda in order to address a local problem. Such application, in turn, feeds back into the global pool of experience, thus generating a process of shared learning among countries. Everyone stands to benefit if we have the wisdom to move beyond the false dilemmas between research and action, and between the global and the national levels.
The performance of local health systems can also be enhanced by one of the most potent motors of globalization: the telecommunications revolution. In particular, M-Health—the health applications of mobile phones—is opening vast perspectives for improving the access of underserved populations to the benefits of innovation, since it points the way to a future when physical distance may no longer be a significant barrier to health care.
The challenge, of course, will be to make sure that the distance divide is not merely replaced by the digital divide, and that the new technologies do not generate new forms of social exclusion. The magnitude of this challenge becomes clear when we realize that the 80 per cent of the human population living in developing countries represents less than 10 percent of internet users.
The new forms of social exclusion feed on the old scourges of poverty and inequality. The 1.3 billion people who survive on one dollar per day are a reminder to all of the enormous gaps that must still be overcome within and between countries. These gaps have major consequences for health as expressed by the existing and, in some regions, increasing inequalities in health conditions and access to health care.
Exclusion and inequality are one dark side of globalization. Insensitivity to local cultures is another. Together they may explain a painful paradox of our days: Precisely when technology has brought human beings closer to each other than ever before, we are witnessing the reappearance of xenophobia, tribalism, and other extreme expressions of intolerance.
In the long run, the challenge we have before us is to build a world order characterized by peace in the midst of diversity. Instead of asserting one's identity by rejecting or destroying what is different, we must try to soften collisions, balance claims, and reach compromises. In this way, we may try living according to what Vaclav Havel, former President of the Czech Republic, has called a basic code of mutual coexistence.
Health may contribute to this pursuit because it involves those domains that unite all human beings. It is there, in birth, in sickness, in recovery, and ultimately in death that we can all find our common humanity. In our turbulent world, health remains one of the few truly universal aspirations. We can make health a powerful force for diplomacy, because it offers a concrete opportunity to reconcile national self-interest with international mutual interest. More today than ever, health is a bridge to peace, a common ground, a source of shared security, a way to give globalization a human face.
But for this to happen, we must renew global cooperation for health. In closing, let me suggest three key elements for such renewal, three "e's": exchange, evidence, and empathy.
Health systems around the world are facing similar challenges; many of them, as we have just discussed, are related to globalization. The communications revolution provides the opportunity to exchange information about the challenges facing national health systems and about the initiatives to deal with them.
To be informative, such exchange should be based on sound evidence about alternatives, so that we may build a solid knowledge base of what really works, which may be transferred across countries when its culturally, politically, and financially reasonable.
But there is another value. The British philosopher Isaiah Berlin has proposed the comparative study of other cultures as an antidote against intolerance, stereotypes, and the dangerous delusion by individuals, tribes, states, ideologies or religions of being the sole possessors of truth. And this leads us to the third element, empathy, that human characteristic which allows us to emotionally participate in a foreign reality, understand it, relate to it and, in the end, value the core elements that make us all members of the human race.
As we engage in the process of renewal, we would do well to remember the words of a great American and a universal person, Dr. Martin Luther King Jr., who wrote forty years ago:
"It really boils down to this: that all life is interrelated. We are all caught in an inescapable network of mutuality, tied into a single garment of destiny. Whatever affects one directly, affects all indirectly."Let us continue to weave together the destiny of better health for all the citizens of our interrelated world.