Summary

This chapter explores the optimism of Jim Kim. His meeting had produced a committee to study the feasibility of DOTS-Plus programs, but the arguments about MDR are far from over. Jim is fighting with his 21st century optimism the basically 19th century utilitarian philosophy of the greatest good for the greatest number. He knows that any proposals he makes must pass the cost-effectiveness analysis. This philosophy, however, is flawed when Jim and Farmer think about how international health care councils often use it to rationalize an irrational status quo: MDR treatment is cost-effective in a place like New York, but not in a place like Peru.

What the two men, especially Jim, come to realize is that what makes MDR treatment inordinately expensive is the high-priced drugs used to treat it. They need to drive down prices and that's where Jim finds his calling. He doesn't exactly know how to do it, but he's willing to make the assertion and then figure out the means.

Jim is a South-Korean who grew up in Muscatine, Iowa where his father was a periodontist. His father was very proud of his practice, and his mother was a small elegant woman who spent her years as a wife and mother teaching her children about exploring their world.

Jim was the quarterback on the Muscatine High School football team, a starting guard in basketball, and the valedictorian of his class. They were the only Asian family in town and Jim spent much of his youth embarrassed by his parents' Koreanness. He went to the University of Iowa and then transferred to Brown where he discovered an organization called the Third World Center. He became its director and would only associate with African-Americans, Hispanics, and Asians. He eventually went to Korea to live and learn his native language. However, he became bored with the politics of racial identity and was ready to change direction when he met Farmer. It wasn't long before he wanted to make Farmer's preferential option of the poor part of his own life's work. Like many students who had joined PIH after hearing Farmer speak, he believed he could change the world. He said of PIH, People think we're unrealistic. They don't know we're crazy.

Through his research in Korea, Jim learned that the price of a drug is often based on how many companies make it. Usually, only one company makes it, and they don't want to deal with second line drugs, because even if the market is large, it is usually poor, so the demand is small. When he and Farmer try to buy capreomycin from Eli Lilly, they are quoted $21.00 a vial. They find out they can buy it in Paris for $8.80, but the French won't sell it, because there is a global shortage created by the need in Peru! When Howard Hiatt hears this news, he comments that it sounds like price gouging. This is standard practice among drug companies and is the reason why Americans pay so much more for their drugs than other countries. Hiatt then proposes that he will put pressure on a friend, who is on Lilly's Board of Directors, to donate the drugs as a means of good publicity.

Jim then calls a meeting to encourage drug companies to produce more second line drugs but WHO backs out. Jim holds it anyway, using slides to show the drug company representatives the numbers indicating the demand for these medicines. The drug company reps just argue that second line drugs ought to stay high. That's when a Dutchman named Guido Bakker, who works for the International Dispensary Association (a company that specializes in driving down prices of essential drugs needed in poor countries), rises to announce that his company is going to doe everything it can to lower prices by exploring generic manufacturers. This strategy is intended to ignore the giant multinational drug companies and rely on the smaller companies that make and sell at greatly reduced prices already invented drugs under different names. Jim loves the idea and like many other inspirations he has, he borrows from someone else and adapts it to what he is working on.

Now the biggest problem is going to be to get WHO to add the second line drugs to its list of essential medicines. WHO becomes reluctant to do so when physicians from all over world begin to write and insist that these drugs should not be included, because if prices fall, they will become too widely available. This means that black market salesmen and unscrupulous pharmacists will flood the market with them and breed resistant strains that no drugs can cure. That's when Jim knows he has to find a mechanism to ensure control of the cheaper drugs. He gets another idea, this time from the Green Light Committee, an international entity established to control the distribution of the meningococcal vaccine. He believes PIH can do the same thing and suggests they use the same name - Green Light Committee - to show they are following precedent. Simply put, the committee will serve as the ultimate distributor for second line TB drugs. Once prices fall, they will have real power. Then, if a TB program proves that they have a good plan and a good underlying DOTS program, they will receive the drugs. WHO capitulates and places all the TB antibiotics in an annex to the essential drugs list. The prices fall in stages, but eventually, capremycin costs 98 cents per vial. Now no one can say anymore that cost alone rules out treating MDR in poor countries. Guido Bakker claims that 85% of the work that made this happen can be attributed to Jim Kim who pushed and pushed and pushed until it all came true.

Soon, Jim tells Farmer that the political side of public health interests him much more than patient care and Farmer encourages him this endeavor, saying, We trust you with power. We know you won't betray the poor. Jim has finally come of age with Paul's blessing. He is no longer second fiddle, but a doer and a shaker of his own.

One of the biggest problems for PIH, unfortunately, comes to a head. They desperately need cash, and Tom White is now in his 80's with much of his fortune already given to them. Farmer believes, as a result, that within a year or two, they'll have to go back to supporting their one little corner of Haiti, but Jim believes otherwise. He thinks they should propose a project to wipe out TB all over Peru and then go international and show the world it is possible to beat back the dread disease. If they can win out over it, why not AIDS? For over a year, he has been courting big shot donors, including the Gates Foundation. It has an endowment of 22 million dollars and wants to work on projects to improve world health. Jim and Paul meet the foundation's senior science advisor, Bill Foege, who likes programs that favor unconventional methods to solve supposedly impossible problems. He encourages them to write a grant for money to help PIH. Jim and Paul discuss how much to ask for and Paul suggests two or maybe four million dollars. However, Jim reaches for the sky and insists they ask for 45 million dollars. Paul says they'll never get that much. To which, Jim replies, On exactly what data do you base that statement?

Notes

This chapter is a wonderful showcase for the talents of Jim Kim. He is an enthusiastic member of PIH and always seeks to go high and higher. With his know-how and determination, Partners In Health are poised to go international.