A CONVERSATION WITH DR. JULIO FRENK

Interview by Julio Bracero, MD

Published on June 2009

RESIZE Decrease • Increase	SAVE PDF
PRINT	COMMENT

Global Pulse is extremely honored to present this interview with Dr. Julio Frenk, the dean of Harvard's School of Public Health (HSPH). He served as Minister of Health of Mexico from 2000-2006 and director of evidence and information for policy at the World Health Organization (WHO) from 1998-2000.

To say Dr. Frenk is one of the great visionaries of global and public health of our time is an understatement. In 1987, he was the founding director-general of Mexico's National Institute of Public Health, a leading research institution worldwide. As Minister of Health of Mexico, he was instrumental in implementing Seguro Popular, a national health insurance that has expanded access to health care for tens of millions of Mexicans. In 2006, he was one of the top candidates for the vacant position of Director General of the WHO, with the British medical journal The Lancet publishing an editorial endorsing him as the best candidate. In 2007, he worked as a senior fellow for the Bill & Melinda Gates Foundation, and as president of the Carso Health Institute in Mexico. In 2008, he received the prestigious Clinton Global Citizen Award for his work as minister of health of Mexico.

Despite his accomplishments and busy schedule - which includes dealing with the first influenza pandemic of the 21st century, with his home country as the epicenter - Dr. Frenk set aside some time to give us this exclusive interview.

Julio Frenk, MD, MPH, PhD, Dean of Harvard's School of Public Health

Global Pulse: Can you tell us about your experiences as Mexico's Minister of Health, specifically your work in reforming the nation's health system?

Dr. Julio Frenk: It [working as Mexico's Minister of Health] was a very rewarding experience. I had been studying health systems from all over the world for twenty years before becoming Minister of Health, and I had been developing a number of ideas and publishing in a number of academic journals, as well as popular magazines and newspapers, about better ways of reforming a health system in order to achieve goals in quality, efficiency, and financing. I was then given the opportunity to apply everything I had been thinking for two decades in a period of national reform. It was very rewarding because I was able to talk to the president and other members of the administration and congress about the need to introduce universal health insurance, and that actually happened! The reform was passed in 2003, and came into effect in 2004. It is providing insurance for 50 million previously uninsured persons in Mexico - that is half of the population, most of them poor, through the introduction of a new insurance scheme called Seguro Popular (Popular Health Insurance) that really has completely changed the face of health in Mexico. I found that using good evidence was a very persuasive tool. Engaging in ethical deliberations, and in particular espousing the value that health care cannot be seen as either a merchandise or a privilege but that it is a fundamental human right, was also very persuasive. Through the tools of good analysis, data, and evidence, with ethical deliberations around the fundamental values of the health system as a whole, it was possible to achieve the consensus needed to approve and then subsequently implement this large scale reform.

Global Pulse: Your research regarding health systems can be viewed as using science to promote social change, such as improving universal access to health care and medicines, and reducing the number of people living in poverty. Such a viewpoint often clashes with the traditional financial interests involved in health care management. How can we, as health professionals in training, work with policy makers and other players to include evidence, human rights, and financial feasibility on a health system?

Dr. Julio Frenk: Some of my colleagues at the Harvard School of Public Health, such as Michael Reich, have spoken of the three pillars of public policy: a technical pillar, a political pillar, and an ethical pillar. The three have to function in harmony to sustain the edifice of policy reform, and this is exactly what I think we can do in the health field.

The technical pillar is fundamentally about translating scientific knowledge into evidence that can be used to provide a firm foundation for policy design and implementation. So rather than having policies being designed by ideological preconceptions or by short term economic or political interests, evidence provides a scientific foundation for public policy and that is why the work of universities, think-tanks and other centers of research and analysis are so important in public policy.

The ethical pillar has to do with making explicit the values we want a health system to reflect. Do we want a health system that discriminates among people on the basis of their economic capacity? Well, if you ask that question most people in the world will say "no, we do not want that", but most people actually think that good health care, like education, is a condition for true equality of opportunity.

Good health care should not be part of the reward system of a society. It is instead a condition so that a reward can be considered fair because you do not have a fair society if every generation does not have the same opportunities to achieve, and health and education are the fundamental elements of equality of opportunity. So that defines the ethical pillar.

When you have those in place you can then engage in the political pillar - "politics" in the good sense of the word, for example, the patient construction of consensus around shared social goals.

But the only way you get that consensus, which can then be expressed in a piece of legislation, is if you have the other two pillars. If you have good analysis and data that show what is going on, what is real and what is not, we can take what has worked in one setting and carry it out in another country, and use it under local circumstances. Also, you need the ethical pillar to make explicit the values you want the health system to reflect.

Global Pulse: As of today (May 22, 2009), there are over 11,000 cases of influenza A (H1N1), and while the U.S. has the highest number of cases, it is Mexico, the outbreak’s epicenter, that has the highest number of deaths. Can you share your thoughts as to why the mortality in Mexico is higher than in other countries? It seems most health professionals expected the next outbreak in Asia, not Mexico.

Dr. Julio Frenk: Three weeks ago, the WHO declared an emergency in the face of an outbreak of human influenza virus. That event had been widely expected. In fact, we had been preparing for such an event since the SARS outbreak in 2000. It is true that no one knew exactly when and where it would occur, and it is true that the expectation was that it would happen in Asia, because we have had outbreaks of avian flu, such as the H5 subtype in December 2003. What did not conform to what was expected was for the initial outbreak to happen in the Americas- in the United States and Mexico. But the event itself was widely expected. Of course, we all knew that it could happen anywhere in the world and it could be other strains [than avian influenza], which is exactly what happened.

Fortunately for the world, the response has been very good, because we had been preparing. It shows the enormous value of public health preparedness. Since it was an expected event, plans had been drawn; stockpiles of antivirals and other drugs had been built up. The laboratory capabilities of many countries had been strengthened, surveillance networks were developed, and new international health regulations were passed by the WHO in 2005. The world was much better prepared to deal with this outbreak, and the response has been quite swift. At least, the initial outbreak has been largely brought under control.

Now, why is it that the largest number of deaths are concentrated in Mexico is a very important question, and many researchers are right now working on trying to answer this very question. I think there are many factors that can explain that. One factor is that when you are the very first country affected, how can the patients or the health providers know this is a new virus? It is likely that in the very early cases, people did not seek care in a timely fashion, because they just did not know that this was a new virus. As you know, this virus, the H1N1, is quite susceptible to antiviral medication, but it is only effective if administered within 48 hours after symptoms. Not knowing what it was, many people may not have started treatment in time, and that is why you see most of the deaths happening in the first days of the epidemic.

This is probably not the only cause, only a contributing factor. It may also be that there are many, many more cases than what we are seeing, because only the most serious cases go to a health facility. I think it is going to be very important over the next weeks to carry out serological surveys to find out how many people already have antibodies, meaning they were exposed to the virus. That way we can get a true estimate of the real magnitude of the disease. Lastly, we cannot discard that there may be some specific environmental or genetic factors that made the Mexican population more susceptible, and that is now the subject of investigation. As I said, it could simply be the price of Mexico being the first country affected, and they were not aware that this was a new disease.

Thanks to the very timely reporting by the Mexican government, the rest of the countries of the world had the advanced warning that allowed them to prevent a lot of the deaths that might have happened if Mexico and the U.S. had not reported this was a new virus. So one important lesson is that, in contrast to SARS, where some governments withheld information from the international community, this outbreak of influenza has demonstrated that some countries can be transparent- as the U.S. and Mexico have been- and immediately report cases. In that way we give the rest of the world an advance warning that allows other countries to better prepare and avoid deaths.

Global Pulse: You advocate for the use of a "diagonal" strategy instead of solely focusing on vertical or horizontal approaches towards health programs and funding, the former referring to specific interventions for specific diseases, the latter referring to modifications in the general structure of a health system. Can you expand on the merits of the diagonal approach with some examples for global health programs?

Dr. Julio Frenk: That nomenclature was actually invented by my friend and colleague, Dr. Jaime Sepulveda who is also from Mexico and currently working at the Gates Foundation. The public health community has been divided by this long standing debate between the vertical and the horizontal approach. The vertical approach has the advantage that it allows us to focus on priorities like immunization, AIDS, tuberculosis, or malaria. It has the disadvantage that it can fragment the health system, because you create parallel structures for each of those categories, where you create [specific] vaccines or vector control, for example for the control of malaria.

You see many health systems that have been fragmented with parallel structures of personnel, facilities, and information systems for each of those diseases. Now the opposite view is the horizontal approach - let's build the general infrastructure first. Let's build clinics, train doctors, and build information systems, and then deal with whatever diseases appear. This has the advantage of creating a single health system, but the disadvantage is that when priorities are not explicit, most health systems have a tendency to cater to the needs of the richest and most powerful members of society, neglecting the health of the poorest and most vulnerable. The solution is to actually extend the geometric metaphor, and instead of speaking of vertical versus horizontal, really design a system based on a diagonal approach: a system based on the two approaches, so that you can use explicit priorities to drive general improvements in the health system.

Let me give you an example from Mexico. When we introduced the Seguro Popular insurance program, it was clear that there were many needs that had to be resolved and addressed. We created a special fund for catastrophic health expenditures, that is to say, expenditures from very serious and costly illness. We began by covering treatment for AIDS, so the priority was very clear. By starting with AIDS we were able to build the entire insurance system that was then in place to start covering other diseases. By having a very explicit initial priority the public was able to understand what the insurance was all about. Sometimes the word "insurance" can sound abstract. But when you say, "insurance means that everyone who needs treatment for AIDS will get it" then the public can understand exactly what you are talking about, relate to the concrete benefits of the insurance program, and then support it.

As we were enrolling people and creating all the management and financial instruments for the insurance plan, we had a very clear initial priority and the system was already in place so that we were able to start covering many other disease and eventually have a comprehensive package of benefits. Another example is using vaccination strategies to build up better information systems, and train community health workers that initially are there to immunize kids. As we expand these workers' mandate, we end up creating whole networks of community health workers that can then deal with many other health problems. You can develop laboratories with the aim of being able to test for AIDS, but then leave the infrastructure that would then be able to run any other laboratory test. This is an example of the diagonal approach, where we make the priorities explicit. You begin by assigning clear priorities, which means you start with problems that disproportionately affect the poor, and problems for which we have very good cost effective interventions. You then use those initial priorities to build up the health system.

Global Pulse: Immigration of Latin Americans into the United States is an issue often discussed in global health. We tend to focus more on the economical and health aspects of immigrants in the United States, but seldom ask the cost of immigration to Latin American countries. From a health and human rights perspective, what are your thoughts on how to address the myriad of problems that immigration brings?

Dr. Julio Frenk: As an immigrant myself, since I am now living in the United States, I believe that immigration is a reality of our times and a part of the globalized world we live in. Historically, it has been a positive force. Some of the anti-immigration groups have to understand that immigration has been an integral part of civilization from the very earliest human beings, and it has actually been a force for progress because it has allowed the cross fertilization of ideas and cultures that drive the advancement of society. In our modern times, because of the huge inequalities of income distribution, it has become a huge political topic. In my mind, what is needed is a very exclusive framework that allows immigration to be an orderly process, and that creates rules. We have many examples around the world where this has happened. I think that a human rights perspective on health has a very clear implication. It is unethical to deny access to health care to a person based on his or her legal or migratory status. If health is a human right, then everyone has to have access to it. I think what we need is to understand the potential mutual benefit of an enlightened immigration policy and then reach agreement. Simply banning or restricting immigration through coercive means, or through the denial of the human rights of immigrants, is not the right way to proceed. We need to have a clear respect for the human rights of immigrants and to develop ethically grounded immigration policies that can be mutually beneficial for all those involved, for the sending countries, the receiving countries, and most of all, for the migrants themselves.

Global Pulse: What is the biggest challenge for you as a health professional working in the field of global health?

Dr. Julio Frenk: The biggest challenge is [achieving] global health equity. There is still a huge gap between what is achievable with our existing knowledge and technology, and what we are actually achieving with our current practices and health systems. That gap needs to be closed. Every year, over 10 million children die from diseases that can be easily prevented with current technologies, and this is unacceptable. There are half a million deaths of women during pregnancy or delivery and 90% of those deaths occur in poor countries. Again, these deaths are completely unnecessary given our current state of knowledge, and these casualties are all concentrated in very poor countries. So, closing the gap between what is achievable and what is achieved with our current system, I think, is the biggest challenge. If we do that we will close the huge inequity, or the huge differentials, that make the world very inequitable in terms of health.

Global Pulse: What advice would you give to health profession students looking to get involved in global health issues?

Dr. Julio Frenk: My first piece of advice would be to embrace global health - it is a growing field. My second piece of advice would be to understand that global health does not mean "foreign health". Global health refers to all of the health issues that involve the world as a whole, and this includes domestic problems. Taking the current influenza pandemic, this is an example of something that may appear in one country but very quickly involves the world as a whole. Now it is a global problem. Also, take a broad view of global health, encompassing all matters related to health, such as issues that local communities may face. Lastly, embrace global health as career, as it has become one of the central topics of our time. Health is now widly understood to be crucial for economic development, global security, and indeed for our sense of what makes a decent world. So if people want to go into global health and use the tools of knowledge to carry out the necessary improvements in national and global institutions, we will definitely improve the health of everyone in the world.

Article downloaded from http://www.globalpulsejournal.com/2009_frenk_julio_interview.html