Indeed, health issues have played an increasingly important role in the dialogue over international development of late--from South America, where frustrations over the scarcity of drinking water have contributed to political instability, to Africa, where the AIDS crisis continues to devastate an entire continent. At a global health conference in San Francisco recently, Frenk discussed the link between health matters and global security. Among other topics, he explained how developing nations often export health workers to developed nations, as well as the conditions of families in the Third World who pay high prices for their health care, noting that "health may become in itself an impoverishing factor."
MotherJones.com recently sat down with Frenk to discuss how health issues fit into the larger picture of globalization and development.
MotherJones.com: What would you say are some of the biggest issues in global health right now?
Julio Frenk: To me, the first issue has to be equity, because the gap between what could be done and what is actually being done is still too big. The variation between life expectancy of Japanese females and life expectancy of babies born in sub-Saharan Africa is just enormous. There are ten million preventable child deaths a year, deaths that could be prevented with existing technologies—we're not talking about problems that don't have a solution.
A large part of that challenge is due to three infectious diseases—AIDS, tuberculosis, and malaria. However, there's also been a profound shift going on in global health, where non-communicable diseases, as well as the spread of certain risk factors such as tobacco use and obesity, have taken on increasing importance. This puts a double burden on poor countries. They still haven't rid themselves of the more common infectious diseases, and yet now they also have to deal with the problems of industrialized societies—like obesity, diabetes, cancer, heart disease, and so forth.
A third big challenge is the weakness of health systems. Many times we do have solutions for certain problems, but don't have the financing and delivery mechanisms to make sure that everyone gets access. We are witnessing an emerging problem in developing countries, which is the financial burden on families. The World Health Organization (WHO) estimates there are 100,000,000 people that become impoverished every year because they have to pay for health care costs.
This is all in the context of growing interdependence among countries. You cannot afford, in an integrated world, to have huge regions of the world with billions of people just being left behind and not developing to their full potential, generating an enormous amount of resentment out of their impoverished situation, and generating migration because people just can't find opportunities in their own countries.
MJ.com: What role do you think international migration plays in spreading many of these diseases—both HIV and also problems like obesity?
JF: Mobility of people is a major factor in the spread of HIV. We know that the epidemic started in Mexico 22 years ago with workers returning from the United States. Nowadays there are studies showing that the migratory patterns from Central America through Mexico into the United States, and then back again, are a very important factor in the spread of HIV. Migrant workers are at a particular risk—the process of migration is itself highly stressful, migration is very often accompanied by family disruption, sexual patterns get disrupted. This is not, however, exclusive to migration into the United States. This is also a common pattern of dissemination in Africa: migrant workers working, for example, in the mines in South Africa without their families, having unprotected sex with commercial sex workers, come back to their families and then spread the infection.
As for obesity, it's important to note that globalization is not just about the movement of goods and people, it's also about the movement of lifestyles and ideas. What we're seeing are changes in lifestyles, in nutritional or dietary patterns. This is illustrative of the double burden I was mentioning: we still have malnutrition problems among the very poorest groups in Mexico—indigenous populations, rural inhabitants. But without having solved that proble, now we're also witnessing the rise of obesity and overweight.
MJ.com: From your work with the WHO and the G8 Global Health Security Group, can you give me an example of a global health dilemma which has been particularly difficult to address?
JF: Smoking, because there's a global industry. Over the years, developed countries have become stronger in their smoking regulations—by raising taxes, or by forbidding smoking in public places. That's great, but multinational companies then simply move to markets with less stringent regulations. That's why we need global instruments, like the WHO Framework Convention on Tobacco Control (the first public health treaty in history). Individual countries acting on their own cannot face the power of multinational tobacco companies. You have a policy decision made here in San Francisco to stop smoking in public places, which we must applaud, yet, if we don't then have the necessary instruments to protect countries where there's not that sort of political or economic power to oppose the interests of the tobacco industry, tobacco industries will just shift their attention to those other markets.
MJ.com: To go back to HIV and AIDS, would you say that the emphasis placed by HIV, in terms of recognition and funding worldwide, ends up coming at the detriment of other diseases and other health prevention programs?
JF: No, I don't think so. It could've been a risk, but I think the way it's been handled has prevented that. First of all, HIV in and of itself does deserve the attention it has received. It is now by far the largest pandemic in the history of humankind—forty million people currently infected. If we have an intelligent policy, we can then use this crisis to energize world attention around other health problems, and I think that has happened. I think that because of the size of the AIDS epidemic and the crisis it's created in sub-Saharan Africa—the fact that you have had reductions in life expectancy, the fact that GDP has shrunk, the fact that it's become not only a huge public health crisis, but a huge developmental crisis and security crisis—all of that has brought the limelight now not just on the public health community, but on the broader development community to focus more on health matters. For instance, the first session that the UN General Assembly ever devoted to a public health topic was the Special Session on AIDS in 2001. It's served, I think, to focus the attention of financial decision-makers and political leaders throughout the world on the centrality of health to larger development and the global security agendas.
MJ.com: Is this view of global health as an economic issue new, and what forces have contributed to looking at health and epidemics in this way?
JF: I don't think it's that new. If you look at the understanding of the importance of a healthy workforce in very utilitarian terms, with the emergence of mass salaried work in the 19th century in Europe, it was very clear that you needed a healthy workforce to sustain the Industrial Revolution. That's why social security emerged in Europe in the late 19th century, because it was part of the industrialization, and already there was this view that a healthy workforce was fundamental to economic growth.
That's a very narrow view, and it's questionable on ethical grounds—that you would just value life because it's productive. I think what's emerged in the last five years is a much broader understanding, a paradigm shift. Before, development economists and macroeconomists had a linear view: you first achieve economic growth, and once you get those economic growth goals, then you spend on social expenditures like health. I think the shift now is that, if you want to achieve growth, you need to invest, not spend, on health so that health is seen not just as a product or consequence of economic growth, but as an essential precondition. That's partly because of better labor productivity, but it's also because healthier children learn better and so the efficiency of the social investment in education is much higher if you have healthier and well-nourished children.
Health has also become a growing sector of the economy in and of itself—it employs huge amounts of people. In the United States it's the largest sector of the American economy, with 15 percent of the GDP. Globally it represents about 10 percent of the global product, so it's become a motor of economic growth. This is now a broader view, and the important thing here is that health is an intrinsic value. Health is what gives meaning to life and allows people to enjoy life fully. In addition to that, and without any contradiction, you can also say that it is a fundamental investment of society that allows societies to achieve economic goals, like better growth and better distribution of that growth.
MJ.com: What are your opinions on the newly released UN Millennium Project report, and do you think that the approaches and recommendations outlined will be effective?
JF: I think the Millennium Goals are precisely illustrative of this new understanding that development entails a much broader view that also includes health issues. I think the project makes all the actors—governments, multilateral institutions, and global civil society—more focused on results by specific dates. That, I think, is very helpful—most of the goals must be met by 2015. Secondly, it was arrived at through a process of consensus. I think they have been a very powerful advocacy and fundraising tool. Out of the eight development goals, four are directly linked to health and the other four are indirectly linked, so it's placed health very prominently at the center of the development agenda. This year there's a review to see how we're moving towards those goals, and many countries are off-track. That is again galvanizing global energy and attention to the fact that we need to invest substantially larger amounts of money, and invest more efficiently if we want to achieve the goals.
MJ.com: Are you aware of any active international dialogues on the health effects of violence?
JF: Very much. There was recently the release of a world report on violence and health by the WHO. Violence is certainly a major emerging problem in the world, and it has at least three variants: widespread violence due to civil conflict, the violence associated with crime, and then domestic violence, which is, in many countries, the largest source of injury. For health systems it is a growing burden. Health systems usually deal with the consequences of violence. We normally, in the health system, don't have the tools to prevent it, because these require policy interventions in every arena.
But the health system is always at the receiving end. For example, in Mexico we have a large initiative—for us, the main source of violence is domestic violence directed particularly against women and children—and for us it's a public health emergency because it's growing. If you look more broadly at injury, so it includes also accidents, it's the largest cause of death in children of school age in Mexico. It's an enormous problem.
Nowadays, a minister of health cannot consider his or her job done simply by looking at the health care system. It's not enough to have a health policy, you need healthy policies elsewhere. We need to redefine health not as a specialized sector with doctors and nurses, but as a social objective. You need very strong policies for empowering women, for promoting a fair justice system that brings perpetrators of violence to justice, and—in the case of accidental injury—for safe roads. All of those are instruments of policy that are not within that ministry of health, but the ministry of health has to make sure that they are in place to prevent those sorts of causes of ill health, of disability, and death which are related to violence.
MJ.com: This is tied in with violence: I wanted to ask you about the drug-prevention challenges faced by countries, such as Mexico, which are both producers and consumers of narcotics.
JF: In the case of drug abuse, it is a highly complex problem because the demand side and supply side are so interrelated, so you need policies on both sides. In the case of Mexico, we have a comprehensive policy, a single policy-making body which looks at tobacco, alcohol, and illegal drugs. We have a unified strategy on the supply side that combats criminal networks. That, obviously, has to be an international endeavor, because it's an international business.
We used to think that countries that were just producers, or transit countries, were just sending the problem elsewhere—mostly to the United States. We now understand that a country like Mexico is more at risk of higher consumption because the availability of drugs in our territory also stimulates the demand. It is a very complex matter, and we need policies combating the production and trafficking of drugs, preventing use through education, and legislation that encourages people to want to stop. Then we need good treatment and rehabilitation facilities, and the research agenda to look for the neurobiological basis of drug addiction to devise new tools. These emerging issues are what have made the health field so challenging in the 21st century.