John Harvard's Journal
A Global Health View
Julio Frenk’s appointment as dean of the Harvard School of Public Health (HSPH) took effect on January 1, but his relationship with the school began long before. More than 20 years ago, he became founding director of Mexico’s National Institute of Public Health (still, he notes proudly, the only non-American school of public health approved by the U.S. accrediting body)—and one of that school’s original advisory board members was then-HSPH dean Harvey V. Fineberg.
In the early 1990s, Frenk spent a year at HSPH as a visiting professor—and his project set the course for the next decade-plus of his life. He completed a report that detailed the burden of disease in Mexico. The report led to an invitation to become Mexico’s minister of health (a post he held from 2000 to 2006) and laid the foundation for a landmark achievement: Seguro Popular, Mexico’s universal health-insurance program, begun in 2003 and still being implemented. When the need arose for an external evaluation of the program, the Harvard Initiative for Global Health (HIGH; www.globalhealth.harvard.edu) carried it out.
In his new role, Frenk names global health as a top priority—but, he cautions, “global is not the opposite of domestic… Global refers to processes that affect the entire globe”—including First World countries. He uses the example of disease surveillance: The frequency of international travel today means events in a single country reverberate around the world; thus, whether motivated by philanthropic instinct or self-interest, it behooves the United States and other wealthy countries to foster development of an infrastructure that can pinpoint disease outbreaks before they become epidemics.
The new dean believes in using evidence to persuade. This was how he rallied political will behind Seguro Popular, which enrolled 30 million uninsured Mexicans in its first five years and is on track to reduce the uninsured rate nearly to zero in two more. “People were not aware that four million families a year were becoming completely impoverished” because of high medical costs, Frenk says. His report also revealed that the Mexican government was spending three times as much on health services for people who had insurance as it was on care for the uninsured. “Nobody was measuring it,” he recalls. “You bring these things to light by doing research about them.”
This is an example of what he calls moving from declaration to implementation: “It’s one thing to declare a right. It’s another thing to create the mechanism to actually exercise the right.” Mexico had amended its constitution in 1983 to guarantee its citizens a right to the highest attainable standard of health, mirroring the constitution of the World Health Organization (WHO). Yet in 2003, its health-insurance system was still so rigidly linked to formal employment that 50 million Mexicans—half the population—were uninsured and at risk of being bankrupted by a health emergency. In a just and compassionate society, Frenk said in a 2006 address at HSPH, “access to healthcare cannot be part of the reward system.”
The common thread linking his government service to his Harvard post, he says, is the power of knowledge—it can break down bureaucratic barriers, as with Seguro Popular, but can also work in a more populist fashion, as he noted in the 2006 address: “Individuals use knowledge to structure their everyday experience and generate health-promoting behaviors. People wash their hands because of knowledge about microbial transmission of disease. People change the most intimate parts of their sexual behavior because of knowledge about the way AIDS and other STDs are transmitted. People quit smoking because of the knowledge that smoking actually kills you.”
Frenk’s father and grandfather—a Jew who fled Nazi Germany—were both physicians. In fact, Frenk represents the fourth generation of physicians in his family. He saw patients briefly after completing medical school at the National Autonomous University of Mexico, but quickly realized that he was more interested in considering society as a patient. He arrives at Harvard with experience not only in Mexico, but at WHO, where he was executive director of evidence and information for policy. He is also a member of the Institute of Medicine and has served as a senior fellow in global health at the Bill & Melinda Gates Foundation. Besides his medical degree, he holds three degrees from the University of Michigan: master’s degrees in public health and in sociology, and a Ph.D. in medical-care organization and sociology.
An opera fan, Frenk is the third of seven children whose careers divided roughly evenly between music (their mother is a concert pianist) and science and medicine (their father’s domain). The Mexico City native was almost born in Boston: his father had a fellowship at Children’s Hospital, but his mother returned to Mexico for the delivery, and then rejoined her husband. Frenk and his twin sister spent most of their first year in Boston—and coincidentally, the lab where their father worked was in an HSPH building. Now he is himself the father of four, and the author of two children’s books explaining the functions of the human body. His wife, economist Felicia Marie Knaul, Ph.D. ’95, has held senior government posts in Mexico and Colombia; most recently, she worked for the Mexican Health Foundation.
Frenk voices excitement at taking the helm of HSPH at a time when public health is coming into its own, with disciplines from economics to security studies recognizing its importance. “We know today that investing in health is the best way to create prosperity and security for everyone,” he said in a December panel discussion at the Harvard Kennedy School. He adds: “Living in a world where children die unnecessarily, or women die while giving birth—this is what sows the seeds of resentment.”
Health’s relevance across disciplines makes HSPH a perfect candidate, he says, for a move to Allston, where it would be closer to the schools of business and government, and possibly a relocated school of education. But with Allston plans under review given the steep decline in the Harvard endowment (see pages 42-43), such a move is uncertain. In the near term, Frenk says, the school is going ahead with some long-postponed renovations and trying to consolidate (its offices and labs currently span 27 separate buildings). But he is hopeful that the school will make the move eventually, while keeping a foothold in Longwood for proximity to Harvard Medical School.
Compared to other Harvard faculties, HSPH has been somewhat insulated from the financial crisis: a decline in the endowment distribution pinches less, because HSPH gets the lowest percentage of its operating budget from that source—13 percent in fiscal 2008 (see “Harder Times,” January-February, page 47). And, Frenk notes, the school is in a good position when it comes to federal funding (its principal source of revenue), with no large grants coming to an end soon.
He vows that the school will not pull back on financial aid for its thoroughly international student body (one-third of the students are foreign citizens, representing 50 countries in all). He aims to create more financial support for junior faculty, including funds to incubate research ideas that don’t fall within the guidelines for federal grants. And, Frenk says resolutely, “We have no plans of laying off personnel. We are not contemplating any drastic measures.”
Another endeavor that is proceeding: hiring a new director for HIGH. Given the obvious relevance of this interfaculty initiative to HSPH concerns, and the fact that the new leader will have a faculty appointment through HSPH, the search had been suspended; in January, it was well under way—a good thing, Frenk says, considering health’s increasingly central role on the global stage, and increasing appeal to undergraduates.
He believes the twenty-first century will witness a “human-rights revolution” that has already begun. It is “critical for the future of democracy,” he says, that democratic societies demonstrate concrete benefits for their citizens: the right to vote is not enough if it is not accompanied by other fundamental rights—such as access to healthcare. “Even if you’re not sick,” Frenk says, “knowing that you have a place you can go if you need it creates a feeling of security.”