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Rx for Survival — A Global Health Challenge

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Global Health Champions

Jim Yong Kim

Jim Yong Kim

Co-Founder, Partners in Health
Director of HIV/AIDS, World Health Organization

From multidrug-resistant tuberculosis to the HIV/AIDS pandemic, Dr. Jim Yong Kim has taken on some of the most difficult challenges of global health and found innovative ways to make progress. "I like to change people's sense of what's possible," he told Newsweek in December 2003 after receiving a MacArthur Foundation genius grant. "Now I have a chance to do it on a global scale."

That same year, Kim went to work at the World Health Organization to help run an ambitious emergency effort to step up AIDS treatment, which set a goal of getting three million AIDS patients onto antiretroviral drugs by the end of 2005. The 3 by 5 program defines AIDS as an acute crisis and approaches its treatment as emergency disaster relief, dispatching technical teams to set up standardized training and treatment programs in communities with very little health infrastructure.

While the effort has not yet achieved its goal, the program has succeeded in dramatically raising awareness of the global AIDS epidemic and changing the life prospects of the 700,000 people now being treated. Unfortunately, millions are still going untreated, partly because persuading African countries that they could treat their HIV patients has presented a major obstacle. "It's just now that they're really believing it's possible," Kim says. Although it may take another 18 months to reach the program's goal, Kim remains optimistic: "We're going to reach the three [million]."

Trained as a physician and an anthropologist, Jim Kim has spent his career looking not only for the reasons why people are ill, but for the reason behind the reasons. Frequently the answer he comes up with is poverty. In Dying for Growth: Global Inequality and the Health of the Poor, published in 2000, Kim, along with co-editors Joyce V. Millen, Alec Irwin, and John Gershman, examines the socioeconomic forces that affect the health outcomes for poor people around the world.

While still a medical student at Harvard University, in 1987 Kim joined his colleague and friend Paul Farmer in the early days of Partners In Health (PIH), a Harvard-affiliated nonprofit organization that was working to provide health services in Haiti's Central Plateau. Today, Partners In Health's work has expanded to support health projects for poor communities in Peru, Mexico, Guatemala, Russia, Rwanda, and the United States. The organization's philosophy is rooted in the conviction that all people, regardless of how much money they have, should have access to health care and medicines when they are ill. Farmer has joked that, in Kim's new work at the World Health Organization, Kim is trying to "PIH-ify" the WHO. (Read more about the work of Partners In Health in the profile of Paul Farmer.)

In 1994, Partners In Health set up a program in Carabayllo, a town on the outskirts of Lima, Peru, at the persistent urging of a priest named Father Jack Roussin, whom Kim describes as "one of the most irreverent, brilliant, hardworking, creative humans I'd ever known." With Father Jack's help, Partners In Health was able to introduce many different programs, including creating a system of community health workers called Socios en Salud which gives jobs to local residents, building a pharmacy, and conducting a health census for the people of Carabayllo.

Despite the fact that Peru had one of the best tuberculosis programs in the world, Kim and his colleagues found myriad patients in the sprawling shantytowns surrounding Lima suffering from TB. The standard treatment for TB, DOTS (Directly Observed Treatment Short-course), did not seem to be working. At first Kim wondered if there was a problem with compliance: Perhaps patients were not completing the full course of medicines they had been prescribed, and the TB bacteria were learning how to resist the antibiotics.

But then Father Jack himself became ill, losing weight and coughing. Kim pleaded with him to go to Boston for treatment. He finally agreed to, checking into Brigham and Women's Hospital. There, X-rays revealed that his lungs were full of TB.

Father Jack was put on the four standard antibiotics used to treat advanced cases of the disease, what are called first-line drugs. Little did his doctors realize that just three miles away, sitting in an incubator at the Massachusetts State Lab, Father Jack's TB culture was beginning to show signs of drug resistance. By the time researchers discovered his TB was impervious to every first-line drug, the priest was dead.

Jim was stunned: Father Jack had never had TB or taken the drugs to treat it. He must have contracted a strain of drug-resistant TB that was stalking Lima's shantytowns. This shed some light on the clusters of patients the Partners In Health doctors were seeing who were taking their drugs but not getting better.

Treating patients with multidrug-resistant TB was not only expensive; it was dangerous. "Our own health workers," Kim recalls, "asked us questions like, 'You're asking us to take care of these patients, and we're scared. Aren't you scared?' And I'll never forget the answer that Paul [Farmer] gave was, 'Yeah, I'm scared. Everyone's scared. But look — it's here, it's in the community, and the only way to deal with this is to take it head-on and begin to treat the patients.' You've got to treat people with MDR-TB to prevent it from spreading to others."

Along with Farmer, Kim designed elaborate cocktails of rare drugs for their patients in Peru. Their means of getting the drugs to South America were unconventional, to say the least, bringing drugs in their personal luggage from Boston and into Peru. With these drugs come unpleasant side effects — nausea, fatigue, depression, joint pain — and patients were required to take them for two whole years. "We had to go and stand by them and convince them: 'Please, you need to continue taking your medicines, because if you don't, you're going to die,'" Kim remembers. Doubts lingered as to whether the treatment would work, but it was crucial that the effort be made to treat these patients, not only for their own sake, but to prevent the strain of tuberculosis from spreading more widely throughout the community and the world.

Partners In Health developed powerful alliances with the local community, training health workers to visit patients in their homes and encourage them to take their medicines. At first improvement was slow, but positive results gradually began pouring in: From a group of patients only recently considered incurable, soon 85 percent were disease-free. Partners In Health's enormous risk had paid off.

The impressive findings were presented to the World Health Organization. "The argument we were making wasn't simply a public health argument," says Kim. "It was also a moral argument. It was looking ahead. Look at the problem of drug-resistant TB in the world. Look at HIV in the world. What's going to be required for everybody in the long run is the ability to do complex health interventions in poor settings." The World Health Organization now recommends a treatment plan for multidrug-resistant TB based on Peru's example, but funding for such programs still falls short. And because only a fraction of the estimated 500,000 patients with multidrug-resistant TB are being treated correctly, the disease continues to spread.

Kim is particularly concerned about the convergence of HIV with TB — a devastating combination which has been called the "cursed duet." When HIV patients are exposed to TB, as many as 40 percent of them come down with the active disease. Warns Kim: "When drug-resistant TB and HIV collide, as it is right now in places like South Africa and the prisons of the former Soviet Union, it is going to be a disaster, the likes of which I think will surprise many of us. … There is no reason we shouldn't be able to get it under control now, with resources that are pitiful compared to what we spend on so many other silly things."

Despite the uphill struggles they are confronting, Kim takes pride in the fact that the Partners In Health technique of employing community-based people to ensure that TB and AIDS patients take their drugs has transformed ideas about whether complex drug regimens can be given effectively in poor communities. "These countries are full of resourceful people," says Kim. "They may lack employment, but look what happens when you give them a chance to make a difference."

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From the Series

An Incurable TB?

Jim Yong Kim and Paul Farmer are changing the way the world combats multi-drug resistant tuberculosis.

Part I: Poverty and the Rise of MDR TB in Peru (3:49)

Part II: Everyone Around Her is at Risk (8:20)

Part III: Facing TB Head-On (4:56)

Part IV: Reason to Endure (3:40)


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