Global Health Aims HIGH

After a year of consulting with fellow faculty members, the steering committee of the newly named Harvard Initiative for Global Health (HIGH; see www.globalhealth.harvard.edu/) has established its University-wide research agenda. Affiliated professors have begun to offer new undergraduate courses. And HIGH's staff have set about exploring ties to institutions around the world for scholarly and teaching collaborations.

Speaking to faculty members and students at HIGH's office-opening reception on October 4, Provost Steven E. Hyman described the initiative as "important for the world" and for Harvard. Given the health problems plaguing people who live in developing countries, he said, HIGH represents a potentially huge return on the funds (which will be substantial) and intellectual capital Harvard invests "across the disciplines"—from economics and anthropology to medicine, government, and gender studies.

Hyman shed his normal reserve in a subsequent conversation, speaking with passion about HIGH's potential. "There's a hunger on the part of students that we really have to meet," he said. Global-health field research provides one of the most compelling means for students to "engage in a serious and effective way with the world" while maintaining strong ties to classwork. For students to "profit maximally," he said, faculty members will have to create new kinds of courses extending across healthcare delivery, political and cultural concerns (why South Africa's government has resisted AIDS treatment, how the effort to eliminate polio has stumbled in northern India and Nigeria), economics, and more. For professors and students alike, Hyman said, these are "intellectually very challenging and important issues."

In an interview at the initiative's new headquarters, on two floors of an office building near Harvard Square, director Christopher Murray outlined six initial areas for inquiry: AIDS; cardiovascular diseases, diabetes, and related risk factors; infectious diseases other than HIV/AIDS; mental health; health systems and the quality of care (the delivery of health services); and population health metrics and analytical methods for setting priorities (tools for health assessment, cost analysis, and evaluation).

Murray, who is Saltonstall professor of population policy and professor of social medicine, said HIGH's faculty steering committee chose the topics based on Harvard's current strengths, prospects for making progress by attracting additional funding and people, educational opportunities, and the chance to "do something exciting" for health outcomes in the world. (See "Unfinished Business," below, for research subjects not now in HIGH's program.)

The course of action differs for each topic. Addressing the most developed of the six, Murray cited Harvard's "enormous contingent of AIDS researchers" in the schools of medicine (HMS) and public health (SPH), plus government (KSG) and the Faculty of Arts and Sciences (FAS).

Yet that strength—basic science and clinical research—pales before the policy challenges, according to Paul Farmer, Presley professor of social medicine and chair of a new University AIDS coordinating committee. At the October 4 event—just after Hurricane Jeanne killed more than 2,000 people in Haiti, where he runs a community health center—Farmer evoked a "planet riven by the most horrible inequality." Given Harvard's resources, he said, the new initiative raises the question, "What is the role of a global research university in a world like this one?" Confronting problems like AIDS, he said, "We need to develop novel ways of intervening in the world as a university. We don't have them yet."

Interviewed separately, professor of medicine Bruce D. Walker, who runs the large AIDS Research Center for the Harvard-affiliated Partners HealthCare hospital group, in Boston, said, "This program is what many of us have been waiting for years to see develop" at the University. Walker, like Farmer a member of HIGH's steering committee, said his own work on AIDS treatment programs in South Africa could be complemented by other experts in healthcare monitoring and evaluation, data analysis, and, eventually, outreach to individual practitioners who provide care to patients. Across the board, he envisioned education opportunities for Harvard students and staff, and joint applications for funding.

Although the AIDS effort is still nascent, Hyman said that enabling research ers to collaborate would be intellectually fruitful, making it easier for faculty experts from FAS, KSG, and elsewhere to find medical and other colleagues working on aspects of common problems. In addition, funding sources would rather encourage such synergies and the resulting larger-scale projects than evaluate competitive proposals from different parts of Harvard. Finally, he said of researchers' relationship to the clients and patients with whom they work in test sites around the world: "We owe the people whom we are studying, treating, and providing services to the very best that Harvard has to offer....I see that as a moral issue."

Estimating that as many as 20 percent of the 7,000 or so faculty members at the medical school and affiliated hospitals work on cardiovascular and related diseases, Murray noted that Harvard's "extraordinary depth" is overwhelmingly focused on the United States. The science and pathophysiology must also be applied to health solutions for middle- and low-income countries, he said; redirecting a small fraction of the faculty's effort there would have a huge impact. He has detected wide interest in "turning the domestic community" toward global needs, but little knowledge of how to do so.

Similarly, in working on infectious diseases other than HIV/AIDS, Murray said, Harvard has substantial expertise among "wet-lab scientists," including those probing the genome and proteome, but the research is not tied to the problems of policy, finance, and healthcare delivery in less affluent countries that will need the emerging diagnostic tools and medicines.

Biomedical engineer and entrepreneur David A. Edwards

Photograph by Stu Rosner

McKay professor of the practice of biomedical engineering David A. Edwards brings some of that practical perspective from the Division of Engineering and Applied Sciences. The HIGH steering committee member—a chemist who studies medical aerosols and drug delivery—noted that when one of his techniques was commercialized through a company he founded, the market "carried it forward toward the disease indicators that are financially worthwhile." His interest in finding "healthcare solutions to problems unique to the [poorer] nations that have a high burden of illness"—for example, ways to deliver drugs to tuberculosis patients—requires channels separate from traditional pharmaceutical marketing.

In this context, Edwards said, HIGH is "tremendously exciting" because the initiative brings him into contact with medical and public-health specialists whose knowledge complements his focus on "translational research" and swift applications. Absent such connections, he said, "Scientists like me," with engineering expertise, "often can't figure out where to even begin."

The resources for pursuing global mental-health problems are nowhere near so substantial, Murray said, so HIGH's challenge will be to focus attention on the challenges and help support a larger research effort. Speaking at the October 4 gathering, Arthur Kleinman—Rabb professor of anthropology in FAS and professor of medical anthropology and of psychiatry at HMS—lamented that mental illnesses account for 12 to 13 percent of the global burden of disease, but garner less than 1 percent of health resources. The mismatch is even worse in developing nations, he said. He urged work on every aspect of theory and practice: documenting the extent and growth of depression, assessing psychiatric versus primary care, evaluating the findings from modern neuroscience and pushing them into healthcare regimes. "No group is more badly treated than the mentally ill," Kleinman said, citing a survivor of China's Cultural Revolution who said his sufferings then were far less severe than the stigma now borne by his schizophrenic son.

Turning from HIGH's medical and life-sciences priorities to subjects that cut across health fields, Murray described Harvard as a "powerhouse" in analyzing the quality of care and the organization of health systems. He saw an "immediate payoff" from applying that domestic expertise to other countries with different populations, economic resources, and delivery and financing systems.

Health metrics and analytical methods for setting priorities—HIGH's final focus, and the closest to Murray's own research—encompass measurement of health in populations; forecasting their future condition; characterizing the costs and efficacy of available interventions; and ethical questions in allocating health resources. Already under way is a large collaboration with Mexico, which is extending health insurance nationwide during the next seven years. Harvard researchers are helping to determine what technologies to cover, creating systems to measure if they are working, and evaluating the health reform itself.

Associate professor of health decision science Sue Goldie described the Mexico project as exactly the kind of task to attract her, as a junior faculty member looking for the most exciting challenges, to work on HIGH's agenda. In fact, she and her graduate students have relocated from the SPH to the initiative's Cambridge offices, so she and Murray can collaborate. Her ideal project, Goldie said, applies a team of epidemiologists, biostaticians, decision scientists, clinicians, field staff, and policymakers to create the best model of treatment for a disease in a specific venue. Compared to her earlier work on human papillomavirus (HPV) and cervical cancer, where she considered a few ways to combat a single threat (see "Medicine by Model," July-August 2002, page 44), Mexico's system involves 200 diseases and 600 possible interventions—requiring new kinds of analysis, on a new scale.

Social scientist Gary King

Photograph by Stu Rosner

That kind of research involves the deliberate application of social science to health, as enthusiastically promoted by Florence professor of government Gary King, director of the Center for Basic Research in the Social Sciences (CBRSS). Comparing a political scientist and a public-health researcher—one seeking to determine a voter's behavior, the other an individual's life prospects given her economic circumstances and health risk factors—he said, "What the scholars do is almost the same thing."

Global health, King said, is an "intellectual crossroads" that encompasses projects to devise better survey instruments for determining how people assess their own health status, to apply medical "case-controlled" study rules to tough problems in social science (why certain countries go to war), and more. "The scientists are becoming social scientists," King said, "and the social scientists are going to use their results"—for instance, to interpret how individuals respond to medical knowledge about obesity.

As HIGH's research agenda evolves, its affiliated faculty members are expanding the curriculum. In the College, six new freshman seminars on topics related to global health were introduced this year. Goldie co-taught one (with a researcher from CBRSS), on decisionmaking for childhood vaccination, maternal mortality, and reproductive health. She was delighted that 70 percent of the applicants were male, and found those who enrolled "untainted" by the kind of biases and training that sometimes afflicts graduate and professional students—an encouraging first step toward her goal of "creating a generation that is interested [in global health problems] a full decade earlier" than survivors of medical, postdoctoral, or resident/intern training who then settle into careers.

Murray's survey Core course, Social Analysis 76, "Global Health Challenges," drew 152 students this fall (see the syllabus at http://my.harvard.edu/icb/icb.do?course=fas-sa76). "It's forcing me to catch up on everything," he said, from vaccines to malaria. "It brings back vividly the enormous scope of the scientific and practical questions that need to be answered to make progress in global health."

The final piece of that puzzle is perhaps the most vexing: how to make Harvard itself actually global. Harvard AIDS researchers, for example, work at sites in Haiti, South Africa, Botswana, Nigeria, Vietnam, Cambodia, and other countries. HIGH's ambitions to send scholars and students out into the world, and to bring people from around the globe to Harvard for training, are forcing wider thinking about how, practically, to maintain appropriate venues and relationships, and to make the most of such opportunities.

In fact, Provost Hyman has charged a faculty committee with making such an assessment. Its chair, Dillon professor of international affairs Jorge I. Domínguez, director of the Weatherhead Center for International Affairs, said the study ranges from physical extensions of Harvard—business-school research offices, the Rockefeller Center for Latin American Studies' office in Chile—to multiyear, continuing affiliations with other universities, medical schools, or governments. He characterized Harvard's existing policy, promulgated in 1997, as "restraining, conservative, prudential." Now, in light of the University's expanding research and teaching presence internationally, the faculty members and provost are grappling to understand "What's the shape of the beast?"

Deploying professors and students at field sites in the developing world may ultimately be HIGH's most transforming effect on the University. Such exchanges, said Shawn J. Bohen, HIGH's executive director, have to benefit not only visiting Harvardians but also their local hosts, collaborators, and institutions. "That makes 'take' into 'give and take,'" she said. Echoing Paul Farmer's challenge and Hyman's view of researchers' obligations, she said, "We don't want to create opportunities for Harvard students to be tourists to poverty." The goal is both education and impact.

Perhaps the most moving articulation of that hope came from public-health dean Barry R. Bloom. Summing up the presentations at HIGH's office-opening reception, he recalled his 38-year career in global health (he is an expert on the immune response to tuberculosis), and noted the challenges involved in engaging Harvard deeply in troubled parts of the world. Given students' "passion to do something in the world and the idealism to make a difference" where human needs are great, he expressed real hope for HIGH's activities. He closed by quoting Oscar Wilde: "A map of the world that does not include Utopia is not worth even glancing at." "This initiative," Bloom said, "is intended to change the map of the world."