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 put the drugs on an annex to their list. By 2000, the cost 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 WHO 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 WHO’s HIV/AIDS department, where he ran the “3x5” campaign, which sought to put 3 million new HIV/AIDS patients in developing countries on antiretroviral drugs by 2005 (it ended up taking until 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 Eastman, 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.”