By 1998, it’s become well known in the medical community that the usual TB treatments in the third world will fail, unless they’re accompanied by the MDR treatments pioneered by Farmer in Peru. Farmer’s research has begun to establish a new paradigm in the medical world. Previously, medical programs were measures for their cost-effectiveness: i.e., they were only adopted if the necessary financial resources saved a significant number of human lives. Farmer has used his influence to point out an uncomfortable truth, however: usually, the philosophy of “cost-effectiveness” is used to preserve the status quo. Thus, MDR treatment is said to be “cost-effective” in New York, but not in Haiti. Farmer wants to drive down the cost of MDR treatment to the point where it’s feasible to treat MDR patients throughout Peru.
Farmer uses his experience with anthropology and his knowledge of American foreign policy to argue for the futility of cost-effectiveness arguments. As Farmer pointed out before, nobody talks about the “cost-effectiveness” of treating TB in America: it’s understood that the lives of Americans are worth preserving at any cost. It’s only when Americans begin to talk about treating TB in faraway, third-world countries that the arguments for cost arise. In this way, the very notion of cost-effectiveness always implies a second-handedness to the value of the human lives in question; e.g., Americans’ lives are more valuable than Haitians’.
Kidder stops to give some background information about Farmer’s partner, Jim Kim. Kim was born in South Korea and grew up in Iowa in the 70s. His father, who’d grown up in North Korea, was a talented periodontist (specialized dentist). His mother was a sharp-minded woman who taught Jim the importance of arguing and public speaking. Jim was popular and charismatic in high school, even though he was the only Asian in his school.
Kidder has spent so much time talking about Farmer that we’ve forgotten who Farmer’s colleagues are—he can’t do all this work alone. Jim Kim is another very impressive doctor and humanitarian, and in some ways is more impressive than Farmer himself. It’s worth knowing a little more about him.
Jim Kim studied at Brown, where he deliberately spent most of his time with black and Hispanic students. Kim came to believe that race was “the central problem of his life.” He got a Ph.D. in anthropology, doing most of the research in pharmaceutical companies in South Korea. When he met Farmer, he was struck by Farmer’s devotion to helping the people of Haiti. Inspired by Farmer, Kim decided to devote his energy to fighting poverty in the Third World.
Jim Kim has always experienced life as a racial minority in the U.S., and as a result he approaches his work in Haiti in slightly different terms than Farmer. For Farmer, working in Haiti is a matter of right and wrong—a reflection of his universal moral principles. For Kim, however, working in Haiti is a form of racial solidarity (and correcting international racism) as well as moral idealism. He feels a strong connection to Haitians, in part because of his own feelings of racial otherness in the U.S.
In the late 90s, Jim Kim and Farmer are researching drugs for treating MDR. They know from experience that the cost of a drug varies enormously from country to country. One TB drug costs 30 dollars in Boston, 9 dollars in Paris, and 20 dollars in Peru. Jim Kim knows that the best way to drive down the cost of a drug—as he and Farmer are trying to do in Peru—is to convince the World Health Organization (WHO) to encourage the production of cheaper alternatives to a drug. Kim tries to convince the WHO to do so, but his arguments fall on deaf ears.
Kim’s strategies for lowering the cost of TB drugs suggest another different between Farmer and Kim. Farmer, at the end of the day, is a medical doctor, focused on spending time with his patients. Kim, by contrast, feels more comfortable thinking in statistical and economic terms: he wants to fight disease indirectly by negotiating with pharmaceutical companies and the WHO. This is why they make such a good team—one is more politically minded, and the other focuses more on individual cases.
Jim Kim makes contacts with a Dutch pharmaceutical company that specializes in making second-line (i.e., generic off-brand) drugs for a fraction of the normal price. Kim thinks that he can use companies of this kind to lower the cost of TB drugs. But this is a difficult process: in order to lower the cost of a drug, Jim has to convince pharmaceutical companies that there will be a large market of medical projects for the drug. But the only way to establish such a market is to lower the price. The only way to break through this circular chain is to lobby the WHO, which has already turned Kim down.
In facing the bureaucracy and greed of big business, Kim faces a challenge every bit as difficult as the challenges Farmer has faced while treating disease in Haiti. With corporations Kim can’t rely on his power to persuade or lead by example: he must instead try to help TB victims by following a set of strict procedural rules, and by framing things in terms of economic risks and profits.
Kidder goes over the basics of the WHO. The World Health Organization is a coordinating site for the world’s government health departments. It’s always underfunded, and infamous for its bureaucracy. One major concern of the WHO with regard to Jim Kim’s project is that the MDR drugs could become too widely available—in other words, the drugs could become so cheap that they’ll be traded on the black market, resulting in new resistant strains of TB.
The World Health Organization seems to specialize in the kind of practical, utilitarian thinking that Farmer despises. And yet it’s hard to dismiss the WHO.’s argument that too many cheap drugs could lead to a boom in black market trading. This kind of calculation may seem cold-blooded, but in the grand scheme of things it saves lives.
Jim Kim tries to strengthen his case by finding a precedent for promoting a second-line drug in the third world. He finds that an organization called the Green Light Committee promoted second-line meningococcal vaccines in the third world. Kim and Farmer plan to found a new committee for the circulation of second-line TB drugs. The committee will gradually reduce the price of these drugs.
In order to bring down the cost of drugs, Jim Kim is forced to enter the world of pharmaceuticals. He’s trying to fight the problem from the inside, and so must “dirty his hands” with big business and placing economic value on human lives. All this further challenges traditional ideas of charity “saintliness.”
By the year 2000, the new Green Light Committee, headed by Farmer and Jim Kim, has driven down the costs of MDR drugs by about 95 percent. Jim Kim’s strategy worked: it’s now “cost-effective” to treat MDR in Peru and other underdeveloped countries. Farmer acknowledges that Kim was the “mastermind” behind the success of Green Light.
It takes years, but Kim succeeds in driving down the cost of TB drugs. More than anything, Kim’s success proves that arguments for cost-effectiveness are almost always shortsighted. It’s always possible to drive down the costs of a drug—it’s just that most people don’t feel any need to do so.
Jim Kim and Farmer meet in Austria to attend a conference on TB. They discuss the “O for P,” an abbreviation for “a preferential option for the poor,” which they’re pursuing in Peru. At dinner, Kim tells Farmer that he has ambitions of getting into politics—helping alleviate suffering on a broader scale than medicine would allow. Farmer supports Kim’s ambition, as he knows that Jim would be an honest and trustworthy public servant.
It’s hard for Farmer to disagree with Kim, especially after Kim’s success with TB. Kim has demonstrated that it’s possible to enact enormous, positive changes by working within bureaucratic political world. While it’s true that bureaucracy can be slow and corrupt, it’s also true that bureaucrats are capable of accomplishing a lot when they actually take action. Farmer himself would never become a bureaucrat, but he respects Kim’s thinking (and also needs Kim’s political genius in order to do more good).
Kidder considers what Jim Kim and Farmer have accomplished in Peru. The medical world thinks in terms of cost-effectiveness, arguing that it’s not efficient to fight disease in Haiti or Peru. For Farmer, this kind of thinking obscures the real issue: the reason that the costs of treating disease are high in certain parts of the world. By refusing to take cost-effectiveness arguments seriously, Farmer and Kim have dramatically reduced the price of a life-saving drug, helping entire communities.
Farmer and Jim Kim have accomplished a great deal in Peru—they’ve done what the cynics said was impossible, and lowered the cost of a drug by 95%, saving many lives in the process. But of course, Farmer and Kim aren’t the kinds of people who rest on their laurels: they’re already thinking ahead to their next projects.
In early 2000, Tom White’s money is running out. He’s spent millions of dollars on PIH and other similar ventures, and—just as he’d planned all along—he has little money left as he approaches the end of his life. Ophelia, who is now responsible for PIH’s budget, warns of a funding crisis: PIH needs to find new donors, quickly.
Here we can see the limitations of personal donations—it’s been crucial that Tom White gives so much of his money to PIH, but his supply of money isn’t endless. Ophelia returns as a character in the book, but now she’s an important member of PIH, and no longer romantically connected to Farmer. Their friendship and charitable work has proved stronger than a break-up.
Jim Kim, Farmer, and Ophelia devise a bold new strategy. Using their success with treating MDR, PIH will raise money for wiping out TB and other dangerous diseases—perhaps even AIDS—in Peru and the rest of South America. Kim is making inroads with big donors like the Gates Foundation, which has an endowment of 22 billion dollars. Kim plans to ask the foundation for 45 million dollars—an incredibly bold request. Even Farmer is reluctant to ask for so much money.
Kim’s request for 45 million dollars is incredibly bold, but on the other hand, Kim has already accomplished a great deal in South America. If anyone deserves 45 million to fight disease in the Third World, it’s Partners in Health.