In Kim, an activist to lead the World Bank
This morning, with only a few hours to go before a deadline, President Obama nominated Jim Yong Kim, a Korean American physician, the co-founder of Partners in Health, and the president of Dartmouth College, to lead the World Bank.
It’s as important to note what Kim isn’t as what he is: Unlike three of the last four World Bank presidents, he’s not a banker. Unlike both of the Bush administration’s picks, he’s not a diplomat or an old foreign policy hand. Unlike every other named candidate for the position -- Jeffrey Sachs, Ngozi Okonjo-Iweala and Jose Antonio Ocampo -- he’s not an economist or economic policymaker. He is, in other words, a new direction for the World Bank.
Which fits, because the World Bank’s priorities are changing. As development expert Todd Moss explains, India, one of the bank’s largest fund recipients, is about to grow its way out of the International Development Association, the arm of the bank that primarily serves the world’s poorest countries. A host of others -- including Vietnam, Ghana, Nigeria and Mongolia -- are scheduled to follow soon after.
As incomes in these countries rise, they need less help from the bank. So resources will shift to those countries that haven’t been able to take advantage of rising global prosperity. Nearly all of those 30 or so extremely low-income nations are fragile, post-conflict zones in Sub-Saharan Africa. And their needs are substantially different from those of rapidly developing countries like India.
Kim is primarily known as a force with the global health community. Alongside Paul Farmer, he co-founded the famed “Partners in Health” organization, which pioneered the delivery of advanced health treatment to deeply rural, impoverished nations such as Haiti. In that world, he’s known as unusually able to bridge the divide between the activist and establishment communities. He moved from Partners in Health to the World Health organization and Dartmouth College, and he managed to keep both constituencies happy.
In “Mountains Beyond Mountains,” Tracy Kidder’s history of Partners in Health, the author recounts a late-night discussion between Farmer and Kim on how much time is wasted to ensure political correctness. “It’s a very well-crafted tool to distract us,” Kim griped. “A very self-centered activity. Clean up your own vocabulary so you can show everybody you have the social capital of having been in circles where these topics are talked about on a regular basis.”
Kidder asked for an example. Kim and Farmer replied with stories of the academics who would confront them by asking, “Why do you call your patients poor people?” Kim’s stock reply: “Okay, how about soon-dead people?”
Kim’s frustration with the medical establishment was equally severe. Partners in Health focused on the toughest diseases to treat -- AIDS, tuberculosis -- in the poorest, hardest-to-reach corners of the world. To do so, it had to battle the prevailing wisdom, which held sway even among many in the aid community, that it wasn’t worth expending scarce resources to treat those diseases in those areas because the efforts would not be successful.
Atul Gawande, the surgeon, writer and public health researcher, worked with Kim and Farmer at Harvard Medical School. He recalls that Congress “held hearings where they would bring out doctors saying these patients don’t have watches, you have drugs they need to take four times a day, you can’t have treatment in places where you don’t even have watches. What Kim and Farmer did was prove them wrong on a localized level. And then what Kim did was figure out how to scale that.”
Gawande describes Kim as the operational genius of Partners in Health. “He’s sort of a natural executive in a certain way that Paul Farmer is not. Farmer is a saint and a visionary. But Jim could see the vision and turn it into action.”
Perhaps Kim’s greatest coup was a bureaucratic one: Persuading the World Health Organization to reclassify “second-line” tuberculosis drugs as “essential medicines.”
Second-line drugs are used when drug-resistant disease foils basic treatments. But in the 1990s, they were incredibly expensive as the markets for them were desperate and, in the eyes of the drug companies, small. What Kim and Farmer realized was that it wasn’t so much that the markets for them were small as that the prices were high. If the prices came down, the markets would be huge.
So Kim gathered drug executives and made the case that the markets could be far larger, particularly if the World Health Organization would reclassify them as “essential drugs,” and thus put some muscle and funding behind their adoption. But there was an issue blocking that, too: Many in the medical community believed it would be dangerous to distribute these drugs widely.
As Kidder writes, the concern was valid. “In the real world, many places lacked even rudimentary health services, and others had clinics and hospitals staffed by the ignorant, the careless, the lazy. In the real world, some doctors and nurses peddled drugs on black markets, desperate patients sold their antibiotics to buy food, and stupid pharmacists mixed first-line TB drugs with cough medicine. Start distributing the second-line, the so-called reserve, antibiotics in settings like those, and you’d breed resistant strains that no drugs could cure.”
Kim solved it. Working off a model developed for the meningococcal vaccine, he founded “The Green Light Committee.” Here’s Kidder again: “The idea was simple. The committee would serve as the ultimate distributor for second-line drugs. Once prices fell, it would have real power. Any TB program that wanted low prices would have to prove to the committee that they had a good plan and a good underlying DOTs [directly observed treatment] program, one that wouldn’t breed further resistance.”
The WHO puts the drugs on an annex to their list. By 2000, the costs of the drugs required to treat a highly resistant strain in a poor country of TB had fallen by 90 percent. Kidder quotes Guido Bakker, who worked for a nonprofit that specialized in driving down the cost of essential drugs and who was involved in these conversations, saying, “I really see Jim as the one who really did this. He just pushed and pushed and pushed. Eighty-five percent of it was Jim.”
It was a massive achievement that required working both in and outside the system to persuade the drug companies and the World Health Organization to do something they didn’t want to do. It also made Kim’s reputation: In 2003, he won a MacArthur genius grant. In 2004, he was named director of the World Health Organization’s HIV/AIDS department, where he ran the “3x5” campaign, which sought to put three million new HIV/AIDS patients in developing countries on antiretroviral drugs by 2005 (it ended up taking till 2007). In 2006, he was on Time’s list of the 100 most influential people in the world. In 2009, he became president of Dartmouth College.
“At some point, you have to decide whether you’re going to keep throwing your body at a problem, which is what I’ve always done,” he told the New York Times. “You realize that one person can’t do that much. So what I want to do is train an army of leaders to engage with the problems of the world, who will believe the possibilities are limitless, that there’s nothing they can’t do.”
Some in the global development community, however, worry that Kim’s experience in world health isn’t necessarily the right experience for his new job. “The World Bank is staffed mainly by economists,” says Amanda Glassman, director of global heath at the Center for Global Development, “so they have a different view on these questions than a World Health Organization or a UNICEF. Having an economist’s perspective on those issues is important. I wouldn’t want to see the World Bank repeating things done better by other institutions. Their focus on economics and financing is a great one and should be nurtured rather than beaten down.”
William Easterly, a former World Bank economist who has been critical of the global aid community voiced a similar concern to my colleague Brad Plumer. “You have to have the mind-set to allocate scarce funds, rather than approaching the problem as if we have unlimited resources for suffering people. Frankly, I see some danger signs in this kind of pick.”
But Gawande isn’t concerned. “I don’t think this means that health will displace other things,” he says. “In Kim, you have someone coming to the table who has demonstrated through his career that he is fundamentally committed to the question, ‘Do the results change on the ground?’ And he’s not dogmatic about it. He’s the sort of person who will take the criticisms around aid and also take the way it can be empowering and figure out an empirical way forward.”