September 27, 2007
A conversation with Christopher Murray
Dr. Christopher Murray is a world-renowned health economist who left Harvard University to become director of the new Institute for Health Metrics and Evaluation at the UW and a professor in the new Department of Global Health. Murray was previously director of the Harvard University Initiative for Global Health, and is a former senior official at the World Health Organization (WHO).
Q. Describe the UW Institute of Health Metrics and Evaluation and what prompted you to bring your work to Seattle.
A. The story behind the institute goes back to 1998, when I was at the World Health Organization and so was Julio Frenk [Gate’s Foundation senior fellow and Mexico’s former minister of health]. Gro Harlem Brundtland, the director general of WHO, had recruited us to WHO to strengthen their work in the area of monitoring and evaluation and policy analysis. Over the next five to six years, it became clear that it’s hard to do that within the U.N. system because of the nature of the governance of those organizations. It’s one country, one vote. And when you’re reporting objectively about what happens, sometimes that’s not popular with some countries.
That created a natural tension that was tricky to manage. So that didn’t come to pass. Julio and I had been trying to make the case to others that this missing piece of the global health landscape — independent monitoring using the most rigorous scientific methods possible, and evaluation of programs, of what works and what doesn’t — was really needed.
Then the Bill & Melinda Gates Foundation, and Bill and Melinda Gates themselves, as well as the president of global health at the Gates Foundation, Tachi Yamada, bought the argument that this was an important thing to do. The first serious discussion of this was in December 2006, when I came from Boston and Julio Frenk came from Mexico to meet Bill Gates and the people at the foundation. In a very short period of time, from December until June when the grant was awarded, all this came to pass.
The idea has been around for a very long time, and there was a happy constellation of factors that made this possible to do here in Seattle. The attraction of Seattle is that, increasingly, it has become an alternative hub for global health — an alternative to Geneva. Five or six years ago, anybody wanting to start anything in global health wanted to be based in Geneva because that’s where the WHO is located. But I think with the growth of activity in Seattle, research at the University of Washington, and the affiliated research institutions like Seattle Biomedical Research Institute, PATH (Program for Appropriate Technology in Health), the Infectious Disease Research Institute, the Hutch, and of course, most importantly, the Bill and Melinda Gates Foundation, Seattle has really become this alternative location for global health. It was an ideal fit to establish the institute as part of the University of Washington.
Q. How many people did you bring with you to the UW?
A. We have brought quite a few people from Harvard University, and we’re trying to bring more. We’ll have about 30 people by the end of September. The trajectory is to be about 70 in a year and, in faculty and researchers, to be about 100 in two years. We expect to stabilize at 130 people in three years. The nature of global health is you need people from all over with skills in all disciplines. It’s very important to have people not just from the U.S. working on the subject.
Q. How did you become interested in global health?
A. My parents did medical work in Africa. They took us as a family to Niger, Kenya, Ethiopia, the Comoros Islands. In some ways, I didn’t really make a career choice, I just sort of assumed I would do something on health in developing countries. It wasn’t called global health back then. My decision was more about what, exactly, to do.
I spent a lot of time wondering how one could make a bigger difference than simply providing care in a particular community, in a particular place.
The questions for which I’m still searching for answers are: How do you make a big difference? How do you get beyond just direct provision of services? How do you strengthen the capacity of developing countries to train their own physicians and nurses and health-care providers and, therefore, provide more services? How do you have a bigger impact on people’s health?
That’s how I became very focused on measurement because we don’t know a lot about the effectiveness of health systems and patient care. What works in different settings? Why do some health systems work better than others? When I did my doctoral work in England, the question I was interested in is that, with the same level of income, some countries do well in terms of improving health. And there are countries that do not do very well at all. It’s not related to how much money you have. What is the success story? And how could you transfer those successes to places where things aren’t going so well?
Interestingly, to answer that question, I got stuck very quickly because there were no meaningful comparable measurements of: Where was money going in health care? Who was getting services? And what was the impact?
You keep running up against the impossibility of making even basic comparisons and learning from these success stories. That’s where I have ended up spending a lot of time on finding ways to measure these things better and determining how we should learn what works and what doesn’t. How do we know what is a good health system in a particular context? How do you deal with the fact that different countries — and communities — have different health problems and varying amounts of money?
There is a role for this super-generalist looking broadly. It’s not a substitute for this incredible volume of research that goes on finding specific solutions. But there’s a place for this role of stepping back and saying what’s actually happening in the world? Where are we making progress? What are we missing in understanding that? And are there any lessons we can learn from that?
In terms of tackling the problem that every place is so different and the problems are so different, the more you step back, it’s almost the opposite. You find out that, yes, there are incredible differences in some parts of the world. But there’s probably greater similarity across broad regional groupings than you tend to recognize. Obesity and diabetes are huge problems in the U.S.; they’re also the No. 1 problem in Mexico, and seemingly the No. 1 problem in a number of Latin American countries.
Q. What do you think of the work of Paul Farmer, physician and subject of the Pulitzer Prize-winning book “Mountains Beyond Mountains,” by Tracy Kidder?
A. Paul Farmer, Jim Kim [co-founders of Partners in Health] and I went to med school and did residency together. In fact, we shared an infectious disease fellowship. Because all of us had outside research ongoing, we split the fellowship so we each did four months of the year for three years. We had one slot together.
I have had the opportunity to work with Paul and Jim for years. I would say that Paul exemplifies the best of a commitment to doing something at the individual level and taking insights learned from that individual caregiving in places like Haiti and Rwanda and drawing lessons for others. Paul’s coming at the problems in global health from the frontline and increasingly thinking of the broader implication.
I’m coming at it from the policy end. I used to teach a general global health class at Harvard and had one guest lecturer every year — and that was Paul. He would give the students his perspective from the direct provision of care. I would say Jim Kim, who obviously worked with Paul a lot, is somewhere in the middle since he is always interested in the broader dimensions. Jim’s time at the World Health Organization gave him practical experience in the challenges of trying to scale up antiretrovirals for the treatment of HIV in a whole series of countries.
I think those perspectives are very important. But I think, and I’m sure Paul and Jim would agree, the only way you can actually figure out what are effective strategies to delivering primary health care in remote areas is by careful evaluation of all the different ways people have tried to do this. We all hope there are better ways that can be identified. Of course, the concern is that every place is so different, and how do you compare them.
The three of us approach global health from different angles. I think the philosophy is we have a moral responsibility to help improve health around the world, particularly for people with bad health. For me, and I know it’s true for Paul and Jim, that extends to the U.S. I’ve always had part of my research focused on looking at disparities in the United States. I think Americans face the same issues, same levels of health as do poor people, disadvantaged people in poor countries. We should be able to do a better job in the U.S. because of the money we have available, but the reality is a small fraction of the U.S. population has levels of health that really look like sub-Saharan Africa.
Q. What do you do to unwind?
A. We (Murray and his wife, Emmanuela Gakidou, who also joined the UW as an associate professor of global health) are avid mountain bikers and skiers. In fact, when we lived in Geneva, our favorite place to ski was – and still is – Whistler.
Q. How do like life in Seattle? Are you ready for the rain?
A. We’re outdoors people, which is why Seattle is a great place for us. I thought it was like this all year [looking out the window on a sunny day]. Three hundred days of sunshine a year!
