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September 11, 2009

BILL MOYERS: If anyone understands the big challenges when it comes to healthcare systems, not just a domestic but a worldwide scale, it's the man you are about to meet.

Dr. Jim Yong Kim is a physician and anthropologist who has combined the skills of both to become one of the most acclaimed visionaries in the field of global health. "The world's troubles are your troubles," that's what he urged the recent graduating class of young doctors always to remember. That imperative has been the inspiration for his own work.

As co-founder of the humanitarian group, Partners in Health, and a senior official with the World Health Organization, Jim Yong Kim has been a crusader against infectious diseases and an advocate for the poor among the forsaken of the world in cities and villages in Haiti and Peru to Rwanda and Siberia. "U.S. News and World Report" said he is one of America's 25 best leaders. "Time Magazine" named him one of the 100 most influential people in the world. The Chair of three, that's right, three departments at Harvard University, Dr. Kim was a MacArthur Foundation genius whose efforts helped to treat 3 million new HIV/AIDS patients in developing countries.

By the way, he was also the quarterback for his high school football team in Muscatine, Iowa. So why at 50 years of age is this world renowned scholar and physician leaving all that behind for the hills of Western New Hampshire? Just a few days from now he will be formally inaugurated as the 17th President of Dartmouth College.

Welcome to the JOURNAL.

BILL MOYERS: Welcome to the Journal.

DR. JIM YONG KIM: Thank you very much Bill.

BILL MOYERS: I am indeed curious. You have spent the last 25 years of your life working with the sickest and the poorest people in the world. And here you are, now about to sit in the corner office of a wealthy, elite school with fewer than 6000 undergraduate students. What in the world did you tell the search committee?

DR. JIM YONG KIM: Well, it was entirely unexpected. I was minding my own business, working with colleagues who were interested in global health. But also colleagues in Harvard Business School and the engineering department at MIT, to try to figure out how to make health care programs in developing countries work more effectively. Dartmouth came out of the blue and said, "Would you look at this job?"

You know I work with Paul Farmer, who was chronicled in the book "Mountains Beyond Mountains," and he's one of my heroes and my closest friend in the world-

BILL MOYERS: Great public health--

DR. JIM YONG KIM: Great public health advocate, made a lot of personal sacrifices in his life. They call him the modern day Albert Schweitzer. But he is a person who works tirelessly for the health of poor people. And I have been very touched by the extent to which young people are motivated and moved by his life story. So I think that there's always a sense in young people that they want to do something great. I think there's a danger. A lot of young people don't think they can make a difference.

That's really what I am at Dartmouth to do. I'm there to tell the young people, "Look, a few committed souls can change the world." The famous Margaret Mead line, you know, that, never doubt the capacity of a small group of committed souls to change the world. In fact, that's the only thing that ever has. So I am there to give them that message. And you know I'm not sure. I'm not sure if that will work in my role as college president, but I'm going to give it a shot.

BILL MOYERS: But you know, you're coming with not the most popular message right now, because you know, when you told those young doctors graduating from medical school last May, "The world's troubles are your troubles." And that's the last thing many young people and old people in America want to hear right now, because we've got so many of our own troubles right here at home.

DR. JIM YONG KIM: Right. Well, I don't think that I would exclude our troubles. For example, one of the projects that I started just before leaving Harvard was a project looking at the health care of Native Americans in New Mexico. So there are a lot of problems right here. You know, in my own view, the life expectancy of Native Americans in the United States is one of the really great moral crises that we face.


DR. JIM YONG KIM: Well, the life expectancy is often very much lower than life expectancy in some of the developing countries that I work in, in the 40s and 50s in some communities. So the world's troubles are right here as well.

And I was just tantalized by the notion of reaching back into the undergraduate curriculum. And trying to think hard about what would it take to train a group of young people, who would leave the college energized, inspired, and really thinking that there's no problem that they couldn't tackle.

DR. JIM YONG KIM: And I think that this is a good time to get them thinking about, look, you know, there's global warming. There's the crisis in the health care system in the United States. There's global health problems. There's a lot of huge problems out there. What do you need to do to prepare yourself for a meaningful life, tackling those kinds of problems? That's the question I'm going to ask them every day, as college president.

BILL MOYERS: Why are we talking about the American health care system as a crisis? What's wrong with our health care system?

DR. JIM YONG KIM: My own particular take on it is that I think for many, many years, we've been working under the fantasy that if we come up with new drugs and new treatments, we're done.

The rest of the system will take care of itself. In my view, the rocket science in health and health care is how we deliver it. And unfortunately, there's not a single medical school that I know of that actually teaches the delivery of health care as one of the essential sciences

In other words, what we've learned about organizations is that it is very difficult to get a complex organization, a group of people, to work consistently toward a goal. In the business world, if you don't do it well, the market gets rid of you. You go out of business. But many hospitals executing very poorly persist for a very, very long time. So my own view of it is that we have to rethink fundamentally the kind of research we do and the kind of people we educate, so that they'll think about the complexity of delivery as a topic that we can take on and study and learn about as a science.

BILL MOYERS: What do you mean, complexity of delivery?

DR. JIM YONG KIM: Well, just think about a single patient. So a patient comes into the hospital. There's a judgment made the minute that patient walks into the emergency room about how sick that person is. And then there are relays of information from the triage nurse to the physician, from the physician to the other physician, who comes on the shift.

From them to the ward team, that takes over that patient. There's so many just transfers of information. You know, we haven't looked at that transfer of information the way that, for example, Southwest Airlines has. Apparently they do it better than any other company in the world.

BILL MOYERS: Computers?

DR. JIM YONG KIM: No, they have taken seriously the human science of how you transfer simple information from one person to the next. And in medical school, and in the hospitals that I've worked in, we've done it ad hoc. Sometimes we do it well. Sometimes we don't do it well. But what we know is that transfer of information is critical. Now to me, again, that's the rocket science. That's the human rocket science of how you make health care systems work well

What we need now is a whole new cadre of people who understand the science, who really are committed to patient care. But then also think about how to make those human systems work effectively. We've been calling it, aspirationally, the science of health care delivery. And we do it at Dartmouth.

30 years ago, one of our great faculty members, Jack Wennberg, started asking a pretty simple question. Why is there variation, for example, in the number of children who get their tonsils taken out, between one county in Vermont versus another? 'Cause one of his children was in school at one place. Another of his children were in the school in another place.

And in one place, almost everyone had their tonsils out. And in another place, almost no one did. And of course, he found that there happened to be a doctor there who liked to take tonsils out and benefited from it. And he kept asking this question, you know, outcome variation. He called it the evaluative clinical sciences. And I think that's really the forerunner to what we're talking about in terms of the science of--


DR. JIM YONG KIM: --health care delivery.

BILL MOYERS: That's a fancy name. What does it mean to the layman?

DR. JIM YONG KIM: It means how do you evaluate clinical outcomes? How do you understand variation in doctors' practices, for example? And ultimately, how do you fix the problems? So the group at Dartmouth Institute does all of that. We look at variation. You know, why is a Medicare reimbursement rate, you know, almost a third in the Mayo Clinic area, as opposed to Miami?

It's around 6,000 and around 15,000, huge differentials. And they simply ask that question. That's the Dartmouth Atlas, that looks at variation in health care expenditures from one place to the other. And we keep asking the question. "Why does this happen? Why does this happen?"

And we continue to do that research. And then we find places that are spending a lot of money and not getting the outcomes that they want. Folks in the Dartmouth Institute have developed techniques that borrow from industry, that borrow from, for example, the Toyota production system models, Six Sigma, these great management tools, and try to bring them to the hospital.

So not only do we study the problem and try to understand why there's variation and why there's poor outcomes in one place, but we also work very hard in the kinds of interventions that will change the tide. I think that's the science of health care delivery. And that's what we're going to really grow at Dartmouth College.

BILL MOYERS: Why have we been so resistant to doing this? It sounds so sensible.

DR. JIM YONG KIM: Well, I've noticed over the years that when it comes to our most cherished social goals, not only do we tolerate poor execution, sometimes we celebrate poor execution. Sometimes it's part of the culture. You know, these folks are trying to solve this terrible problem. They can't keep their books straight.

They really don't know what they're getting. They don't measure anything. But they're on the right side, so that's okay. I think we're in a different time.

BILL MOYERS: So what can we learn, for our own health care purposes, from the partnerships you've spent the last 25 years creating around the world?

DR. JIM YONG KIM: One of the things that we've learned is that community health workers, which are really members of the community who help people go through very difficult treatment regimens, this can work anywhere. We've done it first in Haiti. Then we did it in Peru. And then in Africa. But most remarkably, we've also implemented that program in Boston, and are now thinking of implementing it on the Navajo reservation in New Mexico.

BILL MOYERS: And in essence, it means what? Describe it to me briefly.

DR. JIM YONG KIM: It means that for people who are, say, taking HIV medications that are very difficult, that they have to take every day, that they have to really be careful about, with nutrition, et cetera, that having someone who just visits every day, just to make sure that you're taking your medicines and you're doing okay, that has a huge payoff down the line in terms of overall outcomes, overall health outcomes.

You know, we found a group of patients living with HIV in Boston, who are really falling through the cracks. And we implemented almost an identical program in Roxbury. And we've had really astounding results. The cost of their care has gone down. And of course, they're back and they're working, and they're productive members of society. And they're not landing in the emergency room, when their disease gets out of control. So we think that that's one of the lessons. But there are many more that I think can be directly applied to health care in the United States.

BILL MOYERS: Does President Obama get it? Did you watch his speech?


BILL MOYERS: What do you think about it?

DR. JIM YONG KIM: Well I thought as a speech, it was really stunning and masterful. He's a wonderful speaker. But what was most interesting to me was the Republican response afterwards. And how many things that they seem to agree on. What do they agree on? One, everyone should have health insurance.

Two we need to lower cost. Three, we need to maintain quality, that the expenditures that right now, in health care, especially public expenditures are unsustainable.

But my view of this goes back to what I said earlier. There's no simple solution to this problem. I think we have to take very seriously that health care delivery is rocket science. And we've got to bring the best and the brightest to work on this problem.

And the only way to do that is to get more people thinking every day about it. Right now, the physicians who are running these hospitals have never been trained. Most of them have never been trained in system thinking, in strategy, in management.

And the places where there are leaders. Intermountain Healthcare, which President Obama mentioned, is run by a visionary leader named Brent James, who was a biostatistician and has been an expert on studying outcomes for a very long time. So when you bring that kind of expertise to the running of a hospital system, it gets better.

BILL MOYERS: One of the big disappointments to a lot of people is that the White House seems to have made a deal, reportedly has made a deal with the drug industry, not to use the power of the government to negotiate lower drug prices, or through Medicare and Medicaid. Now I know you know something about negotiating for lower drug prices, when you were at the World Health Organization, right?


BILL MOYERS: Tell me about that.

DR. JIM YONG KIM: It's a very complicated business. If you look at three diseases, the three major killers, HIV, tuberculosis and malaria, the only disease for which we have really good drugs is HIV. And it's very simple, because there's a market in the United States and Europe.

So what we know is that market incentives to drive drug delivery are critical. We have to maintain them somehow, because if you don't have market incentives, there are almost no malaria or tuberculosis patients, we have almost no new drugs. So somehow, we have to maintain the market incentives, for the pharmaceutical industry to keep working.

Now having said that, I've worked a lot with the drug companies to say, "Okay, so make as much money as you can on the HIV drugs in the first world. We will work with you to protect those markets and protect your intellectual property. On the other hand, in those areas where you make no money anyway, work with us to make those drugs available." And they've done that for HIV drugs, in a way that's really quite astounding.

So somehow-- you know, this is a complicated issue. We've got to make sure that the incentive for the drug companies to make new drugs is still there. But at the same time, be reasonable about making sure that people have access to them.

BILL MOYERS: Yeah, there was a strain of TB, if I--


BILL MOYERS: --understand the story, that could be cured by a drug, but the drug was so expensive that poor people couldn't afford it in the developing world. And what did you do about that?

DR. JIM YONG KIM: What happened was, we looked at the cost of these drugs and the drugs for a complete cure for a patient living in a developing world. When we started, was about $25,000. But what we later learned was that the only reason they were so expensive is because they were only sold in first-world countries.

So what we did was we got everyone who was interested in purchasing these drugs. We went to Doctors without Borders. We went to other health organizations and said, "Can you help us get the Indian and Chinese drug industry to start making these drugs?" And they did it. Now, the real key was at Eli Lilly and Company, that was making two of the drugs, they came on board and said, "You know what? We're going to help you with this program. We don't make any money off these drugs, they're off patent a long time ago. We're going to actually help you find manufacturers in those countries that can make these drugs at a lower cost."

So I think it's one of the greatest acts of corporate philanthropy I've ever seen, Eli Lilly and Company stepping in on two drugs that they don't make any money off anymore, helping us to craft the overall response to drug-resistant tuberculosis. We're not there yet. If there were a market for tuberculosis drugs, then I think we'd have lots of new drugs. But because there's not one in the developed world, we're still struggling.

So those of us who have been really working, you know, on a day-to-day level to try to provide those drugs, we've learned a couple of things. One, intellectual property is important-- but the drug companies, if you keep working with them, they'll see that there is a great philanthropic and humanitarian achievements that they can claim for themselves, by helping to make them accessible. Now we're not there yet. But you know, the Gates Foundation, for example, is working very hard to fill the holes that the market is not filling. You know, we're all-- got our fingers crossed, hoping that Bill and Melinda Gates will be successful in getting us these new drugs and vaccines.

BILL MOYERS: But when you see health fairs where people so poor in this country go because they can't afford to have a toxic tooth pulled, how do you justify spending that much effort and that much money in Africa and Haiti and South America and other places, when we have such desperate need in this country? And that's a question--


BILL MOYERS: --I get a lot.

DR. JIM YONG KIM: If you look at what we're doing in those developing countries-- so for example, all of the efforts that we're making in some of the poorest countries, what we're doing is we're taking annual expenditures on health care from two or three dollars up to maybe 15, 20, or 30 dollars.

Where as in the United States, it's well over $7000 per person per year. So they're two very different problems. Both of them break my heart. So in a country where we're spending, on average, $7000 per person per year, we should be able to find a way to provide health care for everyone. And I think, we can do that. And I think we can do that fairly quickly, if we put our minds to it. The problems with health in the developing world, for example, drug-resistant tuberculosis. The majority of the cases of drug-resistant tuberculosis are among the foreign-born. So it is not a smart idea to think that those kind of diseases are over there, and we're immune from them. We're not, in fact. And you know, with H1N1 and the other pandemic flues, we are-- that has shown us more than anything else-- I was at the World Health Organization and involved in the very later stages of the response to the SARS epidemic. Boy, you know, there's no question that in terms of infectious diseases and other health problems, we are one planet.

BILL MOYERS: You are trained as an anthropologist too, as well as in medicine. What do you think the eye of an anthropologist sees, that a physician on his or her own might not see?

DR. JIM YONG KIM: Well, I think that in medicine, what we're trained to do is to look for patterns, to build order out of great complexity, out of very subtle signs and symptoms, and then have a plan where you can act. Anthropologists are a little bit different, we don't often act on what we do. So I'm sort of in the middle now. I do the ethnography, to try to get a sense of what the culture is.

You know, if you want to know what anthropologists do, one of my great professors, Sally Falk Moore once said, it's very simple. You walk into a room and you say, "Who are these people and what do they want?" So if you're constantly asking that question, over time, you build up a sense of how a particular social system works. That's always what we've done. Paul Farmer's also an anthropologist, we've done this together for many, many years.

What is it that we need to do to actually change policy around HIV treatment or drug resistant TB treatment? And that anthropological piece of it, linked to a physician's approach to solving a problem and putting a solution on the table, taking people through difficult times-- That's been a very good combination for me.

BILL MOYERS: Friends of mine and viewers who are anonymous will write me or say to me, you know, "Moyers, don't bring us any more bad news. We don't want to see any more starving children in Rwanda, sick children in the Congo or dying children in Haiti. If Bill Gates can't save them, there's nothing we can do." What keeps you from getting depressed?

DR. JIM YONG KIM: Well, again, I-- for 25 years, in working with Partners in Health, we've really seen some tremendous changes. I mean, in the central plateau of Haiti, Haiti suffers from so many problems, including deforestation, poor health care, poverty, all these different kinds of problems, but in our one little area, not only have we built a health care system that now sees almost two million patients a year, but the trees have come back.

We just sort of did this almost quixotic little project where we kept planting trees. And the area around our clinic looks almost like the rainforest that it once was. So, in going to those really difficult situations, first of all, it does something to me, make-- you know, it brings out a kind of humility that I don't feel unless I go and see the most excruciating thing in the face of the earth, which to me is a mother who can't feed her child.

So having the experience of seeing those things, I think it does something to me as a person, to my soul. But then in seeing the possibilities, the programs that can turn things around, that's the most inspiring thing that I've ever seen.

BILL MOYERS: Where does this passion come from in you? I mean, if an anthropologist walked in here and said, "Who is that person, where he's from?" What's the answer?

DR. JIM YONG KIM: Well, I've been very fortunate. You know, my father came by himself, across the North Korean border when he was seventeen. And hasn't seen his brothers or sisters or parents since then. And he died some time ago, but never saw any of his relatives. My mother was a refugee, in war-torn Korea. And was plucked, because she was a good student, to come to Scarritt College in Tennessee. So there have been so many accidents of luck that have gotten me to this position.

BILL MOYERS: Where did you all come to from--

DR. JIM YONG KIM: So we first came to Dallas, Texas, where my father-- my father had been a well-established dentist in Korea, but then had to do dental school all over again, because they didn't recognize Korean degrees. So Dallas, Texas, Southern Methodist University-- excuse me, Baylor University -- he did his dental degree--

BILL MOYERS: --There's a big difference, one's Methodist, one's Baptist.

DR. JIM YONG KIM: I know. I know. (LAUGHTER) That's right. I couldn't get that wrong. So he got his dental degree from Baylor dental school, and then we moved to a small town in Iowa, and grew up in Iowa. And even though, you know, we lived a very-- a sheltered kind of existence, I always kind of knew from my mother, who, again, lived through war and then did her master's with Reinhold Niebuhr and Paul Tillich and these folks at Union Theological Seminary.

BILL MOYERS: Two great theologians of the twentieth century.

DR. JIM YONG KIM: Absolutely. It was one of the most exciting intellectual environments in the country at that time, in the 1950s. So we always had the sense from my mother that we should do something great, that there are great things to be done in the world.

BILL MOYERS: What does she say to you? What does she do with you?

DR. JIM YONG KIM: Well, she would read to us the speeches of Martin Luther King in 1968. She would-- she even gave me, at one point, I remember reading Booker T. Washington when I was in grade school. So I had the exposure to a lot of great thinkers.

So she kept trying to convince us that, you know, we had a responsibility in the world. Now my father was a dentist, one of the most practical people on the face of the earth. When I came back from my first semester at Brown University, he picked me up at the airport and we were driving home. And I said to him, I said, "Dad, I think I'm going to study philosophy." So he slowly pulls his car over to the side of the road, looked back at me and says, "Look. When you finish your residency, you can do anything you want."

It was clear. If I was going to make it in this country as an Asian-American, he said, "You're going to need a skill. You can do anything with that. You know, whatever you do after you have that skill is okay. But I can't go to my grave," he basically said, "without knowing that you have some way of supporting yourself, if everything else falls through."

BILL MOYERS: Were you the only Asian family in that little town?

DR. JIM YONG KIM: We were.

BILL MOYERS: What was that experience like?

DR. JIM YONG KIM: Well, we were comfortable, economically. But if you go to a mall, just up the road, where they don't know who you are, of course, back in those days Kung Fu was the big exposure to Asian culture. So you know, everyone would come up to us and either be fearful or mocking. So racism was there. But you know, I've come to understand that the racism that we felt was more like sort of indignant, it was it was embarrassing. It wasn't the kind of racism that, in fact, that impacted, for example, African-Americans in the south in the '30s and '40s. It was different. I think I developed a sensitivity for people who are marginalized and outcast. But I don't have any illusions about me being an oppressed person. I-- you know, my father was a dentist. My mother was a philosopher. We loved Iowa Hawkeye football, so we had a great time there.

BILL MOYERS: I gave the commencement at Dartmouth a few years ago, and I discovered that roughly 80 percent of the students there participate in varsity, club or interactive-- intramural sports. So my only advice I would give you is: don't go without a Frisbee.

DR. JIM YONG KIM: Well, I have to tell you, Bill, I've already played with the women's volleyball team-- I played volleyball in college-- I've already been out throwing the football around with the football team, and that's one of the really great perks of this job, these fantastic young people who are both athletes and students. I happen to believe that athletics is a really important part of one's educational experience. So that's really the fun part of a job.

BILL MOYERS: Doctor Jim Yong Kim, thank you for being with me on the Journal, and good luck at Dartmouth.

DR. JIM YONG KIM: Thank you, Bill.

BILL MOYERS: That's it for the Journal. Don't forget to log onto our Web site at Click on "Bill Moyers Journal" and you can learn more about Dr. Jim Yong Kim and his pioneering work in education and global health. You'll also be able to observe the human cost of war as seen through the eyes of some of the world's finest photojournalists. That's all at I'm Bill Moyers. See you next time.

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