From the Gene to the Globe
Julio Frenk, who became dean of the Harvard School of Public Health (HSPH) in January, has more hands-on experience in the field than most scholars. Frenk served as Minister of Health in Mexico from 2000 to 2006. In that role, he was distinctive for the opposite reason: he was the first minister with formal training in public health. Harvard Center for the Environment Director Dan Schrag talked with Frenk on May 4. Edited excerpts of their conversation follow:
Emissions from coal-fired power plants illustrate the intersection of health and environmental concerns: fine particles--such as the coal fly ash seen in the electron micro-graph image below--harm human health, while carbon dioxide emissions contribute to global warming. Copyright Photo Researchers, Inc.
Schrag: What were your primary goals as minister of health?
Frenk: If I analyze the six years I was Minister, there were two fundamental agendas. One was to introduce universal health insurance. That’s the part of my legacy that’s best known because it was a highly successful program and it’s right on track. There are thirty-five million people now covered out of the fifty million that have to be covered by 2010.
The second priority was the creation of a whole new public health agency that did not exist before. We called it the Federal Commission for Protection Against Health Risks. It’s an elaborate name, but every word was carefully chosen. It was a commission rather than an individual...and that’s based on the premise that collective decision-making tends to be better and much less susceptible to discretion, and therefore corruption.
This agency, in a sense, was a little bit like the FDA, but with a substantial number of functions that, in the United States, would be carried out by either the Occupational Safety and Health Administration or by the Environmental Protection Agency, because it was explicitly mandated to determine standards for occupational and environmental exposures. And the structure was very carefully designed to be science-driven, with a topnotch scientific advisory committee chaired by none other than Mario Molina, the Nobel Prize Winner born in Mexico [who helped uncover the damaging effects of chlorofluorocarbons in the atmosphere]. Mario chaired our scientific advisory committee. That made the environmental variable central to the whole work of the agency.
Schrag: Beyond traditional environmental health, what about this whole new class of environmental hazards coming from issues like climate change, that are potentially also going to threaten health, such as water resource availability; nutrition issues; and, especially for Mexico, the energy issue associated with declining oil production? That’s going to affect the Mexican economy, but also health in Mexico, since there will be more pressure to use food crops for fuel.
Frenk: These environmental questions, to my mind, illustrate better than almost anything else the fact that we have moved into whole new domains that are much more complex than anything we faced in the past. We are in the midst of one of the most intense health transitions in the history of humankind.
The way to understand it is that developing countries are faced with a triple challenge. The first part is the backlog of the unfinished agenda. The second is a set of emerging issues. And the third challenge involves health threats emerging from globalization. Let me show how this relates to the environment.
In the first challenge—the backlog of problems—you still have the basic agenda represented by biological contamination of food and water. In large parts of the developing world, that is a major cause of diarrheal disease, common respiratory illnesses, and all manner of infectious diseases.
Without having completely solved the problems stemming from contamination of food and water, developing countries are now facing the new challenges posed by chemical pollution and air pollution. In addition, all of these countries are now exposed to threats that affect everyone in the world, most notably the health consequences of global change, and phenomena such as the spread of global pandemics. Never before have health systems been subjected to such strain.
We used to live in a world that was generally dichotomous, accepting that, when it came to environmental risk factors, the poor countries would be subject to infections, malnutrition, and reproductive health problems caused primarily by biological contamination. In rich, industrialized countries, the problems centered mostly on non-communicable diseases and chemical pollutants.
Today, I would say practically every developing country has a mix of these two problems; and in addition, everyone in the world is exposed to this third burden: the health challenge emerging from the forces of globalization. Environmental questions are at the very heart of that and it makes the agenda very complicated.
For example, we have in a country like Mexico the longstanding problem of indoor air pollution because of the use of biomass for fuels ??
Schrag: People burning charcoal in their homes?
Frenk: Right. The exposures are many times higher than the pollution from [power generating plants and transportation sources]. In rural areas of Mexico you still have the immediate problem of acute respiratory illness, not just in children, but also in women, who do most of the cooking. At the same time you are coping with the same pressures of climate change as everybody else.
So that illustrates this triple burden in a very clear way. Public health cannot focus only on one or the other of these three challenges. It has to address all three.
A couple making coal bricks for cooking in a northern province of Vietnam. Indoor pollution from charcoal stoves, which are heavily used in most developing countries, is responsible for serious respiratory illnesses. Hoang Dinh Nam/AFP/Getty Images
Schrag: How do you allocate finite resources among these different classes of problems?
Frenk: In what mixture, in what measure, that’s the central policy question. But we’re way past the simple old ways of a bipolar world when it comes to global health challenges.
Schrag: So now you’ve come to Harvard, to the ivory tower, although to a part of Harvard that is perhaps more involved in the real world than any other school. You have expertise at your fingertips: brilliant scholars who work on nutrition, on the environmental health risks associated with air pollution indoors and out, and who study epidemiology and infectious disease. Yet the tradition hasn’t been of bringing these disciplines together.
Now that you are here, how do you actually craft new paradigms and new ways of thinking about health, global health, and environment? How do you actually implement strategies here at Harvard? In fairness, you and I have both been struggling with this.
Frenk: These are tough questions. I’ve been dean now for four months. I will say that, already, I can articulate not so much a vision as an ambition for this school.
My ambition is to make this the first school of public health of the twenty-first century. I use “first” in a double meaning: first in time, and first in quality. Obviously, the question is, What is different about public health in the twenty-first century from, say, public health in the twentieth century? I think there are a number of issues, but I think one is especially relevant to this conversation.
Public health in the twenty-first century is fundamentally global. Global is not the opposite of domestic. The first big conceptual shift is to move away from the traditional divide between global, on the one hand, and domestic on the other. We’ve tended to use the phrase global health to signify foreign health; and we have a simple view, where basically problems and risks flow from the south to the north, and solutions flow from the north to the south. I think that is wrong.
Global is about the connections among every country and every population in the world, and risks flow not only from south to north—we tend to see infectious diseases traveling with people—risk factors also flow from north to south.
One example is differential standards for environmental safety and health. These allow the transfer of risks that are unacceptable in industrialized, developed, democratic societies to countries that have much weaker regulatory frameworks that will allow the import of toxic waste: the use of southern countries as dumpsites for the industrial wastes of the north.
Another example is tobacco. The two giants of tobacco production in the world are located in the United States and in the UK. So as their domestic anti-smoking policies become successful—tobacco control in the United States is one of the big success stories of public health and societal engagement—that, itself, creates an incentive for some of those companies to look for markets in countries where the regulatory focus is absent.
That’s why I made it a priority, when I was Minister of Public Health in Mexico, to strengthen [the anti-smoking] program, because it’s a very neglected side of the public health agenda. Because if you have an asymmetric world in terms of protection against risks, then you are creating incentives for this flow from north to south.
Conversely, policy solutions sometimes move from developing to developed countries, particularly through experiments in applications. In both cases, the big difference is that public health in the twenty-first century is global.
Another major difference in twenty-first century public health is that it ought to be mostly about integration: reaching across disciplines, which we’ve been doing for many years, and reaching across levels of analysis. One of the great strengths of the Harvard School of Public Health is that it has the capability to take a problem and analyze it all the way from the gene to the globe. We have fantastic laboratory capacity and we have social scientists, policy scientists, and epidemiologists. If you look at an area like environmental health, we have people who are experts in doing very basic things—whether it be measurements of risks, or understanding the biological response to some exposures—all the way to epidemiologists who look at the distribution of those exposures in populations, and on to policy scientists who are trying to understand the policy process for setting exposure standards.
This is the strength of the School of Public Health. It’s a problem-oriented school where you can take any health challenge and analyze it on all levels.
There is another kind of integration, which is what I call the integration between excellence and relevance: moving away from dichotomous thinking, in which it is one thing to do research and another separate process to translate that research into policy and practice. I think that what unites everyone at the School of Public Health is the fact that we all have a common product. The product is knowledge. This is what we produce and this is why we exist.
At this school, we do three things with such knowledge. We’re engaged in its production, its reproduction, and its translation: the production of knowledge through research; the reproduction through higher education, where knowledge is reproduced in the minds of the next generation of leaders and scholars; and the translation into policy and practice, as well as translation to the general public through communication.
When you [recognize] that the unifying element is knowledge, it no longer looks like separate activities. You may have specialized functions, but whether in the laboratory doing research; in the classroom teaching; writing a policy brief to influence the new Administration policies; or writing a press release to shape the public’s perception, we’re all handling the same product: knowledge. That’s what binds us together.
I think that’s the way to achieve the integration between excellence and relevance. Our knowledge has to be of the highest quality—that is, achieved through academic excellence—and it has to be extremely relevant to solving the problems of the world today. These are not separate objectives; they actually reinforce each other.
Schrag: I certainly agree with you. In other areas that’s absolutely true. As you know, the Center for the Environment works hard to connect scholars across disciplines all over the University and encourage the best scholarship on environment. You’re involved heavily in setting up a similar effort in the global health domain. What can the rest of the University offer you: the Harvard Kennedy School, the Business School, the School of Engineering, the Medical School and the Faculty of Arts and Sciences’s economics and basic science departments?
Frenk: I always say that this is a great school and a great University. That’s the rare combination. There are other good schools of public health in the United States, but they’re not part of a great university. Conversely, there are great universities that do not have great schools of public health, or any school of public health. The particular mix that Harvard has is not common: a great school of public health at a great university. The corollary is that we have to mobilize all the intellectual capital of the University to take advantage of this privileged position.
Public health is not a discipline. It’s a set of problems. When you mobilize talent across disciplines, that is when you achieve real progress. Global health issues are particularly amenable to this kind of University-wide participation. My aspiration is to make global health everybody’s business at the University. In that way, we can bring the whole of Harvard’s intellectual resources to bear on what is one of the most important topics of our time.
Schrag: Two of President Faust’s principal priorities in science are, on the one hand, the environment and, on the other hand, global health. These are clearly two of the largest issues of our time. How do you think they could help bring the University together?
Frenk: I’ve watched with great admiration what is being done in the Harvard University Center for the Environment. I think in terms of a structural model—a governance model—that it offers very strong lessons for what the University could do in global health. I would hope to establish a similar initiative—one as successful as the one you’ve built centered on the environment—so that our two groups will continue the very deep communication they are already having as part of the terrific group on global health and environmental issues.
I think it’s a very exciting conception. And I think President Faust was right. These are probably the two best topics in science today for uniting multiple groups from across the University. I would like to see people within disciplinary approaches adopt global health as an arena for advancing [their own work]. People who are interested in development studies could see health as a way of testing their theories; people who are interested in the role of diplomacy, at the Kennedy School, for example, could see global health as an arena in which to advance the study of international relations; people who are interested in global trade could explore health as a focal point for questions around trade; and scientists who are interested in the spread of risks across borders [could study this through the lens of global health]. Public health offers a whole collection of problems around which these disciplines can advance their own fields of interest.
Certainly, we are seeing that undergraduate students, particularly, are enormously interested in global health. I have the impression there is a new idealism among young people in American universities. They see that global health [and energy and the environment] are offering new challenges.
How we offer those opportunities not just to graduate students, which we already do at the School of Public Health, but now increasingly to the undergraduates, is a very exciting question.
Schrag: One of the opportunities on which the Center for the Environment is hoping to work with you, is finding ways of creating financial incentives that will encourage faculty in public health to teach undergraduates, so that they can learn the problem-solving skills your school requires, developing expertise that is often quite different from that learned in the arts and sciences.
Frenk: I think that’s the intersection. We must take these topics that are inherently integrative, like energy and environment, and global health, and mobilize the wealth of interest. I would love to see a handshake between those communities that are discipline-oriented and those that are problem-oriented. That’s the handshake that a place like Harvard can stimulate.