Faces of Public Health: Julio Frenk, Harvard School of Public Health
Several weeks ago, the Harvard School of Public Health celebrated its Centennial with fanfare, fundraising and a panel discussion featuring world health leaders who are graduates of the school. Following the centennial, NewPublicHealth spoke with the School’s Dean, Julio Frenk, MD, MPH, PHD, who has a joint appointment at the Harvard Kennedy School of Government. He is also a former health minister of Mexico and a former senior fellow in the global health program of the Bill and Melinda Gates Foundation.
NewPublicHealth: What do you think have been the key changes in public health efforts since the Harvard School of Public Health was founded 100 years ago?
Julio Frenk: The 100 years that have passed since the School of Public Health was founded are not just any 100 years—they’re the 100 years with the most intense transformations in health in human history. We have seen a more than doubling of life expectancy since the school was founded. Around 1900, the global average for life expectancy was 30 years. At the end of the century, the global average was about 65 years. It more than doubled in the 20th century, and that increase has continued with some setbacks, most notably the AIDS epidemic in Saharan Africa. And we have had a qualitative shift not just in the level of mortality, but in the causes of death. So we went from a preponderance of acute infections to now a predominance of mostly chronic non-communicable diseases, and that’s an incredible transition.
A critical change is that the experience of illness became very different starting from the beginning of the 20th century. Before then, illness was mostly a succession of acute episodes, from which one either recovered or died. If you recovered, you went on to get your next acute illness. Now, illness is more a condition of living. People live with cancer. People live with AIDS. So that’s a big transformation of the patterns of health, disease and death.
Another big change is the emergence of complex health systems, and that’s—again—a process that started at the beginning of the 20th century. Before the 20th century, the social function of the sick was mostly trusted to undifferentiated institutions, such as the family or religious institutions, and it’s not until the 20th century when you see this incredible explosion of specialized institutions and specialized human resources, doctors, nurses and other health professionals. In the 20th century, healthcare is 10 percent of the global economy and employs millions of people, including eight million doctors. These are all profound transformations.
NPH: How has the training of students of public health changed in the last 100 years?
Frenk: There has been profound change. What happened at the beginning of the 20th century was the emergence of public health as a field of action. The practices of engineering emerged in Europe, especially with the rapid urbanization there starting around the 17th century, but then greatly expanded in the 18th century. Engineering allowed for access to clean water and taking care of waste, which resulted in some diseases coming under control. In the 19th century the discovery of microbiology gave rise to the abolishment of the germs as causes of illness. That is the junction that gives birth to public health, along with the idea of social policy, of social activism that actually changed social conditions. It’s in that mix that public health gets shaped.
When the school was founded it offered the opportunity for a choice of two careers: people who would work in laboratories, since this was the beginning of laboratory science to support public health; and health officers who would control social conditions to improve health, such as inspections of food and water.
Today, we see a much more diversified set of career paths. About 35-40 percent of our students will pursue careers in research, but that research is not only an arena for action policy, but also an interdisciplinary field of inquiry which brings together scientists from basic laboratory research to social policy scientists and behavioral scientists.
The majority of our students pursue careers in the areas of policy and practice. That area has also become much more diverse, including immunologic surveillance in specific programs such as environmental health. And increasingly, as the health system has become larger and more diversified, many people go into health management and health policy positions. We train many of the managers and leaders of health care institutions and that is a key point where public health and healthcare come together. Many schools of public health now have departments of Health Management and Policy whose graduates will be running hospitals, complex health systems and insurance companies, or will be in government shaping health policy.
Another good example of that is that we have a program at the school for clinicians who are appointed, for example, as chiefs of a service president of a hospital, which means they add to their clinical role a management role, and there’s nothing in their training as physicians in medical school that prepares them for that.
We actually compete with business schools because many now offer Masters of Business Administration with a special track on health care institutions, bearing in mind that this is the largest sector of the U.S. economy. But I do think that schools of public health provide a superior understanding, as you place the individual hospital or insurance plan or complex healthcare system in the context of a population and you understand the population perspective of those patients.
NPH: In some professional schools—graduate schools of business, for example—connections in school that are then used to great advantage in professional relationships are a key benefit of that education experience. With so many graduates of schools of public health taking up key management and government roles, should relationship building among students of public health be an important part of the experience?
Frenk: It has happened organically, but part of the educational reform that we have undertaken to mark the centennial is to try to be much more proactive. We do exit surveys of our students and asked students what was the best part of their experience here; they say that it was the interaction with other students. That happens right now not just because they’re part of a community, but it happens outside of the formal instructional experience. It happens without supervision or mentoring from faculty members. One thing we’re doing as part of our educational reform is what’s been calling the flipped classroom—shifting the part of education that requires lecturing to transmit concrete information to online platforms for our residential students. We created those jointly with MIT and they allow students to participate in a lecture in the privacy of their dormitory or their home, at their own pace. That allows you to free up the time in the classroom or in a series of educational experience where it’s the face-to-face interaction that really matters, such as team problem solving and case-based learning. These are interactions that right now happen outside the classroom and are unsupervised and are mentored. But, if you flip the classroom and bring the interaction among students into a pedagogical context with a faculty member who is facilitating and supervising and mentoring those interactions, I think that’s a very powerful idea and it’s a centerpiece of our new educational strategy.
Last month, we hosted the Second Century Symposium about chartering the second century of public health education. We invited all the deans of all the schools of public health, many of whom were attending the annual meeting of the American Public Health Association, and we had more than 450 participants including a large portion of the deans of other schools, and I presented our new education strategy on which we have been working to strengthen the efforts.
NPH: As part of the centennial celebration, the Harvard School of Public Health announced a capital campaign of $450 million. What will you do with those funds?
Frank: Capital campaigns are part of the way we finance the school because the United States is the only industrialized country where private universities do not receive an unrestricted subsidy from the federal government. For private universities such as Harvard, every cent we get from the federal government is competitive through grants that are for specific research projects, or fellowships and scholarships which are also competitive. The capital campaigns become a crucial part of appealing to society for support, and to me it’s also about explaining why we are worthy of the support of members of society. It makes us more accountable to the public, and for me this has been an opportunity to articulate our value added, which is carrying out the research, education and the policy translation to develop and find the solutions to four threats:
- Old and new pandemics
- Harmful physical and social environments
- Poverty and humanitarian crises
- Failing health systems
To achieve our goals, we have three big priorities for which we are raising the funds: people, ideas and infrastructure. By people we mean financial aid for our students. People going into a career in public health are more often than not choosing a career path in public service, so to graduate with a heavy burden of debt is difficult indeed. The second rung of people is aimed at funding professorships so that our faculty can have the freedom and the expansive creativity of their minds applied to doing the research and teaching, and not always with the anxiety of securing their own funding.
Under ideas, our goal is support for specific research projects and educational innovations. Then lastly for infrastructure, we’re singling out two big priorities: first the infrastructure that we need to collect, curate and analyze big data sets; and second our campus. We need to reform the way we think about classrooms to accommodate the new educational strategy.
NPH: Going forward, will it be necessary to differentiate the training tracks for students who plan careers in foreign countries and students who plan to work in the United States?
Frenk: I think the big shift with the expansion of globalization is that there is no longer a relevant distinction between local and global. You may be a local health officer, but if you’re not fully connected to global networks of information and action you won’t be ready if, for example, an outbreak of polio in Syria shows up at your doorstep. So we have been globalizing our curriculum. Global health is not a subfield of public health—it is a perspective that permeates everything we do. And that cuts both ways. Most of the graduates of our Department of Health Policy and Management will indeed work in the United States’ leading healthcare organizations, but think about the Affordable Care Act, which has huge global implications. If you’re going to expand access to health care, you are going to affect global labor markets for nurses and other health professionals. And more importantly, the lessons from the implementation of the Affordable Care Act will be incredibly valuable for other countries that are struggling to make similar changes. Even though the circumstances are very different, the policy concerns are remarkably uniform across the world. Every country is searching for better ways of providing access to high-quality health care with financial protection so that people don’t get bankrupt, and to provide it in a way that’s affordable by society as a whole.
Everything that’s global affects the United States, and anything that happens in the United States has global implications. That has been our philosophy and our approach.