Our Approach to Health Care Must Be Global, President Frenk Advises in Gross Lecture
University of Miami President Julio Frenk drew a dramatic, urgent picture of the United States’ deep connection to global health and the dangerous consequences of any possible retrenchment from the global arena as he delivered the 14th Ralph H. and Ruth F. Gross Endowed Lecture on Nov. 16.
“Really huge changes have been going on,” Frenk said in his lecture, titled “Global Health in an Era of Retrenchment” and sponsored by the Department of Health Informatics and the Louis Calder Memorial Library at the Miller School of Medicine. “I want to offer you a very different way of thinking about global health, very different from the standard way we talk about it.”
There is truly a “new world health order” with a number of dimensions, Frenk said. Especially since the beginning of the 21st century, health has become a major part of economic growth and development and questions of national and global security, which are highlighted every time we have a pandemic. No other area in the world has grown as fast as health expenditures: development assistance for health grew from $5.6 billion in 1990 to $37.6 billion in 2016. In developing countries, government health expenditures have grown from $128.2 billion in 1995 to $521 billion in 2010.
At the same time, there has been an “explosion” of new organizations in the global health arena — from an era with only the World Health Organization and other United Nations agencies, to today’s long list including the Gates Foundation, Partners in Health, professional associations, transnational corporations, research funders, and academic institutions including UM. “We are part of the global health ecosystem,” Frenk said.
“All of this happened while the world was undergoing an unprecedented health transition, a huge shift in the health conditions around the world,” he said. It started with dramatic growth in life expectancy. “For most of human history life expectancy was very low” — only to age 30 all the way up to the beginning of the 20th century. The climb to a life expectancy of 65 by the year 2000 is often called “the health revolution of the 20th century.”
The experience of disease changed, from acute episodes to the current reality, in which most of us spend a substantial part of our lives in some level of disease or disability, such as cancer or AIDS or mental illness.
“When you look at the world today, you see enormous change, and a triple burden of disease,” Frenk said. There is the “unfinished agenda” of infections, malnutrition and reproductive health problems; the emerging challenges of non-communicable diseases, mental health and injury; and the health risks associated with globalization, including pandemics and climate change, which we are feeling in South Florida with the resurgence of vector-borne diseases including Zika and Chikungunya.
Another health revolution resulted in “specialized and differentiated entities called health systems, which have grown now to be the largest sector of the U.S. and the global economy” — about $7.5 trillion invested worldwide. As hospitals became places where people went to get cured and not just to die, they turned into “a ubiquitous presence in our lives — most people are born in a hospital, will die in a hospital, and spend a substantial amount of time in a hospital,” Frenk said. Which means there are now about 8.5 million doctors, and 18 million nurses.
Edward Abraham, M.D., acting executive vice president for health affairs, CEO of UHealth, and dean and chief academic officer of the Miller School, introduced President Frenk and expressed gratitude to the Gross family for making the lecture series possible.
It all began when Ralph and Ruth Gross moved to South Florida before World War II and started a poultry farm in Broward County. Only eight of the first 100 chicks survived, but instead of focusing on the chicks that died, Ralph Gross concentrated on why the survivors lived. He spent hours in the Calder Library researching nutrition and health, requesting material from other libraries, and consulting with faculty. The feed supplements he later invented saved his business, earning him a patent.
In the mid-1980s, his wife, Ruth, honored her husband’s memory by seeding a $1 million library endowment. To recognize the generous gift, the library established the Gross Lecture series. Ruth and Ralph Gross’s daughters, Patricia Gross Bergman and Carol Gross Clarkson, and Carol’s daughter, Joanna Clarkson, attended this year’s lecture by President Frenk, who brings a wealth of global health leadership experience to Miami as Mexico’s former minister of health and former dean of the faculty at the Harvard T.H. Chan School of Public Health.
“We have had what I call a 21st century roller coaster in global health,” Frenk said. Along with the September 11 attacks, an unprecedented increase in development assistance for health, and increased concern for health security related to the H1N1 influenza pandemic, Ebola crisis and Zika epidemic, the Brexit vote — Britain’s withdrawal from the European Union — sent a clear signal of the rise of nationalism, populism and “a discourse about retrenchment from the global sphere,” he said.
“I want to argue that that is not a good idea,” the President said. “A key message is that we need to pay attention to global health.” He was on the commission that drafted the Institute of Medicine’s 1997 report on America’s interest in global health, saying the U.S. needed to stay involved because it protects the people of the U.S., it enhances the U.S. economy as health care is a huge sector of that economy, it advances the country’s international interests and leads to what has been called smart diplomacy.
“I propose a new way of thinking about global health,” Frenk said. “We tend to think of global health as foreign health — it’s not.” A traditional view held that risks flow from south to north, and solutions flow from north to south. The current view emphasizes interdependence, because “no country can by itself control all the threats to global health. A lot of what happens in any country in the world is determined by events that are happening somewhere else.” And that means the organized social response must come from both national and global health systems.
The global health system ensures that research is conducted across boundaries and affects everyone, standards and guidelines classify disease in the same way in every country, and through surveillance and information sharing a global network of laboratories determines the mix for vaccines. “Without this cooperation and coordination we would not have influenza vaccines that were effective in any country in the world,” Frenk said.
Coordination for preparedness and response is essential for crises such as Ebola or SARS. Mobilization of global solidarity brings development financing, technical cooperation and humanitarian assistance. “Consensus around the main functions of global health institutions will determine their future architecture: form should follow function,” Frenk said.
In a phenomenon he called “patients without borders,” 14 million people a year cross borders for health care. It is a $45.5 to $72 billion market, and includes 1.4 million Americans who travel outside the country for medical care because some procedures are significantly less expensive.
The importance of a global approach to health has been central to Frenk’s mission at many stages of his career.
“As minister of health of Mexico, it was clear to me that if I was to protect the health of the people of Mexico, I couldn’t do it without engaging globally,” he said.
“Let me leave you with one of my favorite quotes, which I think captures the essence of what I’ve been trying to tell you,” Frenk said in closing. It is from The Trumpet of Conscience, a collection of lectures by Martin Luther King, Jr.:
“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.”
Concluded Frenk: “This is why we cannot afford retrenchment.”