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Dzau Lecture on Global Health

Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, Mass.

What I thought I would do is put in a broad context why I think the kinds of efforts engaged in by the Division of Social Medicine are so central to what a great university like Harvard should be doing, and then offer some reflections on what seem to be some of the most important avenues for future research and practice.

When I became president of Harvard, the first thing I learned and was actually quite struck by was that I was only the seventh person to have become president of Harvard since the Civil War. And that said to me that whatever else I did, it was surely part of my job to take the long view, to think about what was going to make a difference in the very long run.

So I tried to ask myself what was going on in the first quarter of the 21st century that was likely to be in a history book 250 years from now and that Harvard could in some way touch.

I thought back, and I asked myself how well I had a distinguished picture in my own mind of the difference between the period between 1725 and 1750 and the period between 1750 and 1775. I realized that there was not actually going to be an enormous amount from when we were alive that will be in history books 250 years from now. But as I thought about it and talked to a lot of people, I came to the conclusion that there were two main things that were likely to be in those history books as best one could judge right now.

The first was the growing integration between what had been called the industrialized world and what had been called the developing world, with all that that would mean for the nature of the global system. And the second was the revolutions that were underway in the life sciences and what they contributed to our understanding of life itself and to the development of operational approaches to combating disease.

And if those conclusions were right, it was just a very small step to the recognition that really the only subject that brought those two concerns together was the set of questions around global health. So let me say a few words about how I see each of those two main themes and then move to the subject of global health.

The coming together of rich countries and poor countries is something that is being driven by what is happening in the developing world. It is something that is being driven remarkably by technology. I received an e-mail a couple of weeks ago, after a report of my comments appeared, offering an opinion on them from a Harvard scholar who was visiting East Timor.

As I thought about that e-mail, I reflected on the fact that it had only been 25 years ago that I had had what was a hugely influential life experience when I spent a summer in Jakarta working as an economic development advisor to the government of Indonesia.

At the time I was very eager to follow the Red Sox and to know what happened in their games, and there really was no way to know. If I was lucky, on Thursday I could get Tuesday’s International Herald Tribune, which would have the score and would have nothing else. And yet today we take it as an absolute matter of course that we are instantly in touch.

In 1988 I happen to remember being in a car in Chicago and the car had a telephone. Because the car had a telephone, I called everyone I knew because it was really quite remarkable to be in a car with a telephone.

Eight years later, I went on behalf of the U.S. Treasury and visited a village on the Ivory Coast and had the honor of turning the knob and inaugurating a well that was going to be the first source of fresh water for that village. We spent several hours in that village and then came back in a large kind of canoe across a lagoon. Right there somebody stuck a cell phone in my face and said “Bob Rubin has a question about the IRS appropriation.”

That was eight years after it had been a major novelty to be speaking in a car with a telephone in Chicago. So while it has always been true that there have been rich and poor, and there have been connections between the rich and poor that have worked for good and ill, it is one world today in a way that it has not been before.

There are many positive aspects of what is happening. A third of humanity live in India and China. That third of humanity over the last 15 years have seen their living standards increase at a rate where living standards double in less than 20 years and where they rise nearly eightfold in the course of an individual’s expected lifespan.

There has never been a moment in human history when any significant group of people could expect to see living standards grow anything like eightfold in a lifetime. During the Industrial Revolution at its height, Britain was growing at a rate where living standards could be expected to rise three, perhaps fourfold, over the course of a lifespan of today, and since an average lifespan then was only about 40 years, to only double within an individual lifespan.

If you look at the periods of the most rapid growth in the history of the American economy, they are periods when living standards did not as much as rise fourfold over the life of a single individual. So something truly remarkable is happening, and it is happening on a remarkable scale, most notably in India and China, but in much of Asia as well.

Indeed, I think it’s fair to say that if these trends continue for another couple of decades, one will have to say that as a transformation in how people live and how people think, what is going on in India and China and much of Asia is an event that will rank in the history of the last millennium only with the Industrial Revolution and the Renaissance.

At the same time, though, this process of globalization and process of global integration is anything but an unalloyed success. A billion people still live on less than a dollar a day. Africa as a continent today is poorer than it was 35 years ago. An individual’s life expectancy in more than 40 countries at birth is lower than it was 15 years ago. Words like nuclear proliferation and global warming remind us that for the first time in all of human history, man has the potential to fundamentally affect not just the conditions of other men’s life but also the conditions of all of life on this planet.

It seems to me that this question of how this process of global integration and societal transformation plays out, which will play out between the developing world and the industrialized world, is something that will surely be – for good or for ill, we do not yet know – the top story in the history books 250 years from now.

Indeed, one way to say it is, as important as it seems to us right now, my guess is that the fall of the Berlin Wall and the end of the 50-year struggle between the Soviet system and the American and European capitalist systems is likely to be the second story when that history book is written 250 or 300 years from now.

There’s a second observation, though, that also seems to me to define the times in which we’re living: the revolution that you all understand so much better than me that is underway in the life sciences where, if you measure compounds identified, theories generated, papers published, citations given, there has probably been more done in the last 25 or 30 years than in all of human history prior to that point and where the rate of expansion of knowledge is increasing even more rapidly.

Newton famously observed that if he saw a long way, it was because he stood on the shoulders of giants. And surely because of the progress of the last 50 years, we are in a position to ask and answer questions and to develop therapies in ways that we never have before.

I am struck also, as I think about the life sciences, that in a rather different way than we economists usually talk about, there are incredible inequalities that come to mind when one thinks about the life sciences.

In the nation’s great laboratories and universities, there is a more sophisticated understanding of biological processes than there has ever been before, and yet as The New York Times recently reported, but we all knew it before, in public schools not very far away from where those universities are located, there is more creationism being taught than there has been in a very long time and less willingness to endorse the theory of evolution than there has been in a long time.

There is incredible and sophisticated medical progress being made that is offering the prospect of finding cures for debilitating and fatal conditions that are quite rare.

At the same time, opportunities to spend 25 dollars and save a life through oral rehydration therapy are being missed and not happening in large parts of the world. We economists have an idea, and it’s an idea that’s kind of second nature to us and depending on which way it’s going at a particular moment, other people either find it natural and intuitive or highly offensive.

The basic idea is that if you’re investing in a bunch of different areas, you should invest money to the point where the last dollar you spend has an equal impact in each area, because if you spend a dollar in area A and it’s got twice as large a benefit as spending a dollar in area B, then it really makes sense to transfer some resources from area B to area A until those margins are equalized.

If we look at what’s happening in the health care system, there is probably no area where the disparity in the returns on different investments around the world is greater. We have missed investments of very low cost that will prolong lives for many years. We actually probably have investments that have literally zero benefit or negative benefit that are taking place on a fairly substantial scale.

I don’t know how else to interpret the statistics on the incidence of certain kinds of surgery in many different cities in this country or many different cities in this world. And so it seems to me that for a university that has as its basic premise that the best lever to move the world is to train students and to develop and bring to fruition new ideas, that if what is happening in the life sciences and what is happening as nations integrate are the most important trends that are going to be in the history books 250 years from now, that we think in a very serious and comprehensive way about issues of global health and that we seek to bring as many people as we possibly can to bear on those issues where the social rate of return is surely incredibly high.

When I was at the World Bank, we looked at these issues in the World Development Report that was published in 1993 and tried to make estimates of the return that was generated from a variety of kinds of health interventions in the developing world, and what was staggering was how high those returns were.

If one took no account of grief of those who lost a loved one, if one took no account of pain and suffering, if one took no account of freedom from worry, and if one simply looked at the benefits in terms of the increased productivity of the workforce, in terms of the increased contribution to economic wellbeing, there were few investments as productive as investments in improving healthcare in the developing world.

What are some of the key priorities for us as a university? This is not a subject that we can address in a single top-down plan, nor should we, because if we tried, we’d probably get it wrong, and it is much better to be diversified.

But there are some things I see that are very positive:

  • substantially increased emphasis in drawing young people into this field whether it takes place in the form of a residency program in the Division of Social Medicine,

  • whether it takes place in the substantial infusion of financial aid funds in the Public Health School for those who are working on questions of global health,

  • the most surprising thing I learned when I visited a set of Medical School classes a couple of years ago – that nearly half of Harvard medical students at some point in their four years here take time off and spend time in the developing world,

  • whether it is the new undergraduate programs and course offerings we are developing in global health with six or seven freshman seminars offered this year under Chris Murray’s leadership.

    Drawing in the future, we need to think more about bringing all the different kinds of expertise that a university has: the kind of expertise in management that the Business School has, in thinking about policy that the Kennedy School has, to bring to bear alongside the traditional medical specialties we are to be maximally effective in this area.

    The second way in which the university leads is through its research. And here there are surely great opportunities to understand diseases that are not important in the United States but are important in the less developed world. Perhaps I should have emphasized it earlier – it’s a point that I remember Victor Dzau once made to me – that one of the consequences of modernity and prosperity spreading in the world is that a set of conditions like the heart attack when you’re 62 because you have too much cholesterol that have traditionally been industrialized country issues are becoming issues at an epidemic level in many countries that had larger problems and didn’t focus on those problems before.

    And surely it is a welcome thing that if one looks at what is happening at our great teaching hospitals, if one looks at the Medical School, if one looks at the strength of the programs in the Public Health School, we are, as a university, doing much more on each of these diseases than we were a decade ago.

    But I am convinced that we have to find the energy and to find the funds to do much more because as a university, we are in a special and a different position than many others who do research.

    It has been asserted, and I don’t know whether it’s literally the case or not, that the pharmaceutical industry over the last several years has spent more money on pet disease than it has on diseases that are unique to the tropics. It may be true. It may not be true, but if it is remotely plausible that it could be true, it suggests that there is a very large gap for those of us in academic life to fill, and we need to do much more.

    The third area – which is in many ways the one that is most complex for someone in my position looking out at the university and it’s the one that in many ways is most important to Paul Farmer – involves looking beyond teaching and doing research to actually doing and making a difference through direct action.

    Universities, it seems to me, need to proceed with considerable caution. Our great strength is our intellectual base in teaching and in research. The history of organizations and institutions of every kind teaches that if the mission is too diffuse, the mission is not advanced in any particular direction.

    Yet, as I’ve been here longer and as I’ve spoken with more people in the medical community, I’ve come also to understand that there are types of knowledge that are not achievable except through direct involvement with patients and direct involvement with settings.

    An experiment in a new way of delivering care is, yes, the delivery of care, but it is also a piece of research from which the world learns if it succeeds or if it fails. And that’s why it seems to me that as a university, we need to be very disciplined, very careful, but also very creative in thinking about how we can give our students and our faculty the opportunity to engage with these issues, to engage in environments that are much less regulated and regular than the environment than this hospital or Harvard Yard represents, but environments in which they can really make an enormous difference and in which their example can have enormous effect.

    And so what I would like to leave you with, and I assume by your presence here that you are very committed to the agenda that Victor and Paul, Joe Martin, and many others have set in social medicine: to say that this is an area that I believe is as important as any other for Harvard in the decades ahead, to give you a sense of the reasons why I feel that way, and to assure you that the center of the university wants in every way it can to be very supportive of your efforts.

    Thank you very much.