Welcome and Acknowledgements
Thank you, Director [of AIIMS] Venugopal for that introduction. Let me also thank Dr. Rangarajan, chairman of the Economic Advisory Council to the Prime Minister, for chairing today’s session.
I want to start by saying how grateful I am to have the opportunity to be here today. I want to thank the leadership of the All India Institute of Medical Sciences for inviting me to be part of its 50th anniversary celebration. I am particularly glad to be here with Dean Bloom and a contingent of his school’s strongest supporters. And I want to especially thank the Indian government for the welcome they have extended to me and to the many faculty and staff from Harvard that have traveled to India this week. Thank you.
It is an occupational hazard of being a president of a university that you are often asked to make some welcoming remarks or give a keynote speech, and the various situations have very little in common: sometimes the subject is public health and medicine, sometimes it is the research frontiers of theoretical physics, sometimes is constitutional law. The only thing these gatherings have in common is that whoever you are talking to inevitably knows far more about the subject than you do. And that is surely the case today.
So with that risk in mind, I want to make several observations about policymaking and research in medicine and public health – observations that I believe have a special relevance to India today and that are based on my current vantage point as president of Harvard University, and also on my experience in government and background as an economist.
The Century of Public Health
The first observation is that I believe the 21st century will be remembered as the century of global health. Think for a moment about the major events happening around the world today and ask yourself which of these events will be important enough to be memorialized in history books published three centuries from now. I suggest that more than any particular event, or terrorist attack, or war, there are two primary trends that will be remembered as definitive of our era:
- The first is the revolution underway in the life sciences. The revolution that is changing our conception of human nature – that is giving us the operational capacity to change what human life is and how humans live – the revolution that is offering us, for the first time in all of human history, an operational understanding of the human disease process and the capacity to interfere with that process. The revolution that, in the United States at least, enabled us to have, for the first time in history, fewer people die from cancer last year than in the previous year.
- The second trend is the economic and social revolution that is underway in the developing world and the rapid rate of convergence occurring between the developing world and the industrialized world. To put this in perspective, it is worth remembering that there was no period in the history of the United States when standards of living as much as tripled within a single generation. Yet today, in significant parts of the world, human standards of living are improving by ten or twenty or thirty-fold within a single human lifespan. In India, thanks to this trend, it is expected that average incomes will double over the next decade.
Global public health stands as the fulcrum linking these two trends. What happens for good or ill in the field of public health and biomedical science over the next 50 years will touch as many people in as large a way as anything else in human history.
India will be no exception. The convergence of these two trends is already having a profound effect here. One need only look to the rapid increase in the number of people infected with the HIV virus and the remarkable strides that are beginning to be made to combat this terrible disease.
By 2010, estimates suggest that more than 20 million Indians will be HIV positive, up from 5 million today. The rapid spread of this disease is being made possible by the same modern transportation technology that is helping to fuel India’s economic growth and convergence with the industrialized world. Indeed, it has been conservatively estimated that up to 11 percent of India’s truck drivers carry the virus.
The answer to HIV/AIDS in India will come from increased public awareness and education, yes – but I have no doubt that the ultimate solution will be a product of the revolution in the life sciences – from AIDS vaccine research like the promising research that is being conducted even now by AIIMS researchers and others at institutions around India.
HIV/AIDS is just one example – the most glaring one, perhaps – of how globalization and the revolution in the life sciences is having a profound effect on the lives of millions of ordinary Indians. Whether India can embrace these trends and use them to its advantage – or whether these trends overwhelm India – will have more to do with India’s success in the 21st century than any other single factor.
Social Development and Human Development
The second general observation I want to make is based far more on my experience in Washington than on the experience I have had the chance to have as president of Harvard.
The observation is that social development and economic development are inextricably intertwined and need to be thought of together. Investing in health is just as important economically as investing in schools, roads, and telecommunications.
The importance of this interrelationship is the reason why when I was at the World Bank we chose to devote the 1993 World Development Report to the question of investing in health. Bill Gates has said that it was this report that sparked his interest in issues of global health. When he read it, “Every page screamed out that human life was not being as valued in the world at large as it should be.” Among our conclusions was that 11 million children each year were dying from entirely preventable causes.
That this tragic loss of life and lack of basic services has an enormous economic impact is suggested by common sense. But it can also be powerfully demonstrated by careful empirical research. For example, the World Bank has shown that higher HIV infection rates not only involve the potential for significant loss of life, but that high infection rates can also be a significant drag on economic growth – even more so than conventionally supposed. This is because the typical individual likely to be infected is a young adult in his or her prime working years. Death from the diseases destroys the “mechanisms that generate human capital formation.” In addition, HIV/AIDS leaves large numbers of orphans whose own social development is set back. The result is a vicious cycle that if unchecked can destroy a society’s potential.
Another example can be found in the work of Professor Bill Nordhaus of Yale University. Professor Nordhaus put together a survey where he asked people in the United States this question: Which would you prefer: To have the health care and the health system and the medical capacity of 1900 and the economic standard of living of 2000, or to have the economic standard of living of 1900 and the health care capacity of 2000. The answer that came out of that survey was that people were about equally divided between the two options.
That’s a remarkable thing. What those results say is that in the United States over the past century the product of a relatively small part of the economy and the research of an even smaller part of the economy produced as much good for human well-being as all the economic growth during those 100 years.
The survey results speak to the importance of social and economic development occurring together. And it points out something that is profoundly important for India as it continues on its aggressive development path and considers the various types of societal investments that are to be made. And that is regardless of what might appear to be the large absolute size of investments that India will need to make in health care, if the experience of the United States is any guide, those investments will produce benefits in terms of human well-being that will far exceeds their monetary costs.
Medical Metrics and the Importance of Evaluation
The third observation I want to make is that there is a truism in business that also applies in government and I believe applies with a special importance in health care. And that is that what you count, counts.
Let me give you an example from my own field of economics. I would argue that the creation of the poverty line and the annual measure of the number of people who are in poverty in the United States was as important an innovation as any other in promoting the reduction in poverty in the United States over the last 40 years. The fact that we as a society are measuring the number of people in poverty, reporting the number of people in poverty each year and comparing the number of people who are in poverty in different states at different times and with different countries has motivated significantly more aggressive efforts to eradicate poverty than there otherwise would be.
We need far, far more of that in health care. We need more measures of success. I believe that in the next few decades, the creation of systematic public health metrics that will enable people to see how well they are doing, and how well others are doing, will be as important as any particular new medical innovation or treatment to improving health care outcomes here in India and around the world. The creation of such metrics will in ways that no one will notice and no one can predict drive staggering amounts of improvement in the United States, in India, and around the world.
Harvard University is beginning to take some steps in this direction through the establishment of a new institute at Harvard under the leadership of Professor Chris Murray. The Institute’s mission is to improve resource allocation in global public health by establishing key metrics that will allow governments, non-profits, and the private sector to evaluate and improve their performance.
Some of this type of activity is also beginning to occur here in India. Jishnu Das and Jeffrey Hammer of the World Bank have undertaken rigorous studies of the quality of care provided by Indian doctors in the Delhi area. They have found that despite the extraordinarily high standard of care in private hospitals, the vast majority of India’s urban citizens do not have access to this quality of care. Indeed the typical patient visiting the typical physician after being sick for three days could expect to see their doctor for around three minutes, be asked only three questions, and have less than a 50 percent chance of receiving instructions on follow-up care. While these statistics are disappointing, they provide a benchmark for assessing improvement and will hopefully provide an impetus for undertaking specific reforms that will benefit poor consumers of health services. India needs much, much more of this type of measurement in the public health sector.
At the same time, counting and measuring must be but a part of a larger attitude that embraces careful thought and analysis about difficult problems.
Let me give you an example of what I mean: In the United States, if you compare the rates certain medical procedures are performed in different cities, you will find some of these procedures are performed three times as often in some cities as they are in other cities, with no dramatic difference in health care outcomes but with dramatic difference in cost. We need to take the results of that analysis and do more of what works and less of what doesn’t. That is as true here in India as it is in the United States.
I can tell you based on my experience in government that this is much easier said than done. Because often a smart government official will have some new policy that she is excited about and that policy is put into place. But then someone comes along with the bright idea that you should do a careful evaluation to see if the policy is actually working. There are two possibilities: one is the evaluation shows that the policy was a good idea, in which case everybody will discount the evaluation because it came from the people who wanted to institute the policy in the first place. The other possibility is that the analysis shows the policy was a bad idea, in which case the person who was the proponent of the policy looks like a failure.
Governments don’t tend to over-emphasize evaluation for that very reason. And yet, if we are going to make progress, we must do on a global scale what businesses do all time – and that is to learn from success, but also to recognize failure and change strategies when what we are doing isn’t working.
And while this simple idea about the importance of analysis and evaluation can be difficult to put into practice, it is profoundly and urgently important that we do so in global public health policy. The sheer scale of human activity we are talking about – there are more than 50 million nurses and 30 million doctors and over 9 percent of global GDP is spent on health care – strongly suggests that we should be devoting at least a 10th of a percent of that expenditure and that time to evaluating whether we are getting value for our money and how to deploy scarce resources most efficiently.
The Power of Education
This brings me to my final point, which is the critical role of education and of the importance of institutions such as the All India Institute and Harvard University in developing that new knowledge and passing it along to their students, the rest of the world, and future generations.
Albert Einstein reportedly once said that the most powerful force in the universe is compound interest. In many ways, research and education is a form of compound interest – as knowledge is discovered and transmitted it builds upon itself. Knowledge is viral.
Twenty-five years ago, the present dean of the Harvard School of Public Health, Barry Bloom, was sent by the World Health Organization to this institution to teach the very first course in immunology ever offered in India. The class had 28 students. By the time he returned in 1996 to receive an award at the first international congress in immunology ever held in India, there were more than 3,000 registered Indian immunologists. That is the compounding power of education.
That is why the creation of new institutions such as The Public Health Foundation of India – a unique public-private partnership with a mandate to create schools of public health and to address the crying health needs of the people of India and the developing world – are so vital to India’s future. The Institute has the support of the Indian government, the Gates Foundation and was developed with the involvement of the Harvard School of Public Health. Harvard University through the School of Public Health stands ready to continue to assist in this important endeavor. I look forward to a mutually valuable partnership with a substantial two-way flow of students, faculty, and ideas. The Harvard School of Public Health cannot have the leverage it wishes without strengthening its Indian ties. And I am hopeful that the Indian institutions will gain from the world-class resources at our public health school and those of other leading American universities.
I want to make a related point about the power of education. The point is that there is probably no more important social and economic commitment a nation can make than the commitment to improving the educational opportunities of young girls.
This point grows out of research that I also had a chance to lead when I was at the World Bank. We looked at government spending on measures to support the education of girls – particularly in primary and secondary schools – throughout the developing world. We tried to determine through careful analysis all of the benefits girls received from that education.
We looked at how much healthier the children of more educated mothers were. And we thought about how much it would cost to achieve those same outcomes through pure investments in health care. Then we looked at the impact on maternal mortality and to the impact additional spending on education had in supporting family planning policies and smaller families and asked how much would it cost to achieve these impacts through direct spending programs.
When we added it all together we concluded that of all the investments that could be made in the developing world, it was quite likely that spending more money on educating girls would have as high or higher a return than any other type of investments that could be made in health care, in family planning, or in any other kind of direct subsidy that the government could engage in.
According to the United Nations, only 2 out of every 5 Indian women can read or write and up to 40 percent of girls under the age of 14 do not go to school. All of us can agree that this is a situation that needs to be remedied. But in addition to the moral imperative of providing equal opportunity for young girls, the returns in terms of economic development, in terms of social development, will be significantly in excess of the direct costs of providing that opportunity.
I want to conclude by sharing a personal story. Some 20 years ago I spent no small amount of time in one of Harvard’s great teaching hospitals, being treated with the ultimate outcome in some doubt for a time. My treatment worked out very well. And when that course of treatment ended, I asked a question.
I asked: At what point in the development of science had the discoveries been made that had made possible my treatment? The answer was about 10 or 15 years before I was treated. And I thought to myself, wasn’t I fortunate that that research program had been pursued as aggressively and as quickly as it had? And weren’t the countless others who were reaping the benefits of modern medical science fortunate that places like Harvard and the All India Institute existed and were as committed to the development of knowledge as they are?
There is no other area of human endeavor in which the application of thought and resources can make so profound a difference in as many peoples’ lives as in the world of public health and biomedical research. I commend you and your great institution for what you have accomplished in the past half century. If history is any guide, the next half-century will be truly remarkable – for this Institute, but also for the nation and people of India.