January
2001
A
Doctor of Social Justice: Globalization
and Health
The Satya Interview with Jim Yong Kim
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Jim Yong Kim
is a practicing physician and medical anthropologist. He is Executive
Director of Partners in Health (PIH), which works with sister organizations
in Haiti, Peru, Mexico, Cambodia and the U.S. to improve health care
for poor people. He also directs an HIV/AIDS treatment and prevention
program in Roxbury, MA. He is also Co-Director of the Program in Infectious
Disease and Social Change at the Harvard Medical School. On top of all
of this, Dr. Kim is co-editor of Dying
for Growth: Global Inequality and the Health of the Poor
(Common Courage Press, 2000), a new book that examines the complex relationships
between poverty, wealth and health. Dr. Kim recently took some timeout
to talk with Catherine Clyne
about some of the more pressing issues addressed in the book (and his
baby son Thomas gurgled along with his own commentary).
We live in a time when globalization is heralded by corporations
and governments as a good thing, that all of our problems will be solved
if everyone jumps on the bandwagon. What’s your response to this?
Globalization has many different faces. A scholar once said about
the term post-modernism: “it means everything and it means nothing.”
I think globalization has taken on the same sort of feel; no one actually
knows what it means but they use it all the time. It can mean increased
travel or the rise of the Internet or international finance—all
kinds of things. In anthropology and history, we’ve understood
for quite some time that global contact between peoples of different
cultures and socio-economic classes has been going on for a very, very
long time.
The speed with which financial transactions occur is clearly something
that’s new and can be attributed to the most recent forms of globalization.
But now, because of various political and ideological commitments and
convictions, globalization has had very different impacts on different
populations. We see accumulations of wealth that are absolutely unprecedented,
and at the same time we see increasing inequalities, so that the ratio
of income that is enjoyed by the top 20 percent versus the bottom 20
percent of the world’s population has actually gotten worse. In
1960 the ratio was around 30 to one, and now it’s closer to 70
even 80 to one. So we’re actually living in a time when inequality
has become even more severe.
From my perspective as a physician, the inequality of health outcomes
in some senses has gotten worse, particularly when looking at what is
available to wealthy people versus poor people. So many people in developing
countries are dying of treatable infectious diseases. I think we’ll
look back at this period of the last ten or 15 years as ‘primitive
times.’ Primitive in that we have the drugs that can cure people,
but because of notions of patent protection and ensuring company profits,
we’re letting people die. I hope that all the interested parties,
including the pharmaceutical industry, can eventually work together
to put this behind us.”
I’m not against pharmaceutical companies having a financial incentive
to make new drugs—that’s very important—but we have to
balance that with what I think is a deep fundamental moral problem for
us all, in that people with treatable diseases are dying. This has never
been more true than it is now, especially looking at HIV disease. Those
are the kinds of issues that we now have to take on. The path that globalization
has taken up to now is not necessarily the path that globalization has
to take.
If you look at what the World Bank is saying about HIV in Africa, they’re
admitting that they really missed the boat and that we should have been
thinking about much more aggressive prevention and treatment interventions
a long time ago. Back in the 80’s and 90’s there was a sense
that poor countries had to go through specific economic reforms in order
to grow, and with growth, all these problems—including HIV and
tuberculosis—would just dissolve away. So they applied a more or
less one size fits all formula of neo-liberal economic intervention:
open up your economies to multinational corporations and foreign investment,
float your currency, get rid of price supports, sell off all the publicly
held ventures and privatize them—including health services.
But the data shows that some of those interventions were absolutely
disastrous in many countries. That aspect of globalization, the broad
application of ideologically driven programs, has been really, really
damaging in many places. By “ideological” I am referring to
programs that were implemented without a firm base of evidence to support
them. For example, we have not found any evidence that shows that privatizing
health care systems in developing countries will improve overall health
outcomes. In fact, there’s evidence that just the opposite occurs,
that the poor are more excluded and their health care costs go up. Such
economic interventions may reduce costs for the government, but if that’s
our only goal, then we’re really going in the wrong direction.
For example, real debt relief for Africa, which has already been pledged
by the wealthy countries, could dramatically increase available funds
for health care. In that case, instead of simply looking for interventions
that reduce costs, we could take on the issue of providing decent, humane
and high quality care for all Africans.
In fairness to the World Bank, however, I have to say that the changes
that have taken place since the presidency of James Wolfensohn are remarkable
and very important. For example, their admission that they didn’t
move quickly enough on AIDS in Africa is among the most honest and transparent
acts I have witnessed coming from a large bureaucracy. There is no question
that the AIDS crisis will not be solved without the active participation
of the World Bank and I for one am very encouraged by their evolution
as an institution.
Do you think the failure of privatization is evident in the American
health care system?
There’s really not much data that I’ve seen that suggests
that competition and privatization improves health outcome in the U.S.
either. So, privatization is not about improving health outcomes; it’s
about decreasing expenditures for somebody, in this case it’s usually
the government.
Some of these health care institutions are making money hand over fist.
There are compensation packages for heads of health insurance companies
that run into the tens of millions of dollars. The question that one
has to ask is: what’s the role of profitability in health care?
How does enormous private profit-taking in the health insurance industry
actually help things? I just don’t understand. Do we need to create
better efficiency and more evidence-based practice of medicine here
in the U.S.? Sure, of course. But I’m not convinced that profit-taking
by insurers is what will lead to those kinds of improvements.
Can’t that question be applied to practically any transnational
corporation?
You have to look at each situation differently. For example, in
Peru, the privatization of the phone system worked extraordinarily well
so far: service is much better, prices have gone down and there is much
more competition in the market. There’s little question that the
rapid improvement of the phone and communications systems has and will
continue to have a role in accelerating Peruvian economic growth.
But then, let’s look at another situation, like the privatization
of Peru’s gold mines. For example, the Yanacocha mine was bought
by a consortium of buyers including a U.S. mining company for about
$45 million. Well, we have heard that this consortium recouped all its
initial expenditures—it made more than $45 million—in its
first few years of operation. In the meantime, one of the attractive
things about the Peruvian gold mine was that the environmental restrictions
(or at least the Peruvian authorities’ ability to enforce their
own laws) were relatively limited compared to other developed countries.
I’m not an expert on this, but a recent National Public Radio piece
made it clear that quite a bit of mercury is being released, and that
environmental damage is being caused by these mining operations. Peruvian
companies might have done the same, but the point is—overall—for
Peru, the selling of the gold mines may not have been such a great thing.
I’m not saying that privatization and competition are never good;
just that in the case of health care and in specific industrial cases,
it has not been. Kenneth Arrow, a Nobel Prize-winning economist from
Stanford University, said many years ago that health care is absolutely
the worst place to apply market principles. That’s because the
market will fail frequently when it comes to solving health care problems,
especially those that affect the poor. You need some sort of other force—elected
governments in most cases—to oversee that people’s health
is being protected outside of market forces.
Tuberculosis is a perfect example of how markets fail. While it remains
one of the leading infectious killers of adults in the world, no new
drugs have appeared on the market for over 20 years. TB patients are
almost universally poor and thus do not represent a real “market.”
Drug-resistant strains are now a huge problem and we are scrambling
to find ways to develop new drugs. The research-based pharmaceutical
industry, under pressure from their stakeholders to make profits, has
been completely uninterested in taking this on, despite the fact that
drug-resistant tuberculosis represents a major public health threat
for the world.
In the U.S., one way to approach this might be to consider health care
as a “human right” to which people are entitled.
I’m all for declaring health as a human right. But that’s
actually been done with the international Declaration of Human Rights
and other declarations and proclamations.
But we never ratified that here.
That’s true. But even if we did ratify it, the question is:
how could one act on that? There are countries that have ratified the
international Declaration of Human Rights that certainly don’t
offer all those rights to their people—there’s no enforcement
mechanism. It’s fine to talk about health as a human right, but
I don’t know if standing on a soap box and saying it’s a human
right is going to improve the health of the 40-some million people who
don’t have health insurance.
In terms of strategy, those who put these various human rights declarations
together have played a very important role, but I think we’re onto
the next stage, and that is actually implementing programs that remove
these barriers to human rights. That’s what we do at the organization
Partners in Health. We actually work in poor communities solving health
care problems on the ground. We try to provide the kind of direct services
that will teach us how to break through these human rights violations,
as it were, and actually provide people with health care.
Can you give an example?
In Haiti, we’re working on utilizing anti-retroviral medications
for very, very poor people living in the central plateau, and we’re
showing that it’s much more feasible than anyone ever thought.
The only thing that’s really preventing our ability to provide
the treatments much more widely is the cost. So we’re trying to
negotiate to find lower cost medications.
What are anti-retroviral medications?
Anti-retroviral medications are highly active medications for HIV
disease. The utilization of anti-retrovirals has dramatically decreased
mortality and morbidity; the number of deaths per year from HIV, for
instance, has gone down over 70 percent in the U.S. For many people
for whom the anti-retrovirals work, it turns HIV disease into essentially
a chronic disease, so we have people surviving ten, 15, 20 years or
more on anti-retroviral medications.
There is a common perception that people in poor nations—for
one reason or other—can’t organize their lives or aren’t
responsible enough to take such medications. This was reflected in a
recent episode of the TV show “The West Wing” where the president
of a fictional African nation urgently approached the U.S. government
to help bring low-cost or generic drugs to his country, which was plagued
with HIV/AIDS. During a round-table discussion, representatives of the
pharmaceutical industry said that basically African people can’t
take anti-retroviral drugs because they have to be taken on a rigid
schedule and they don’t have watches and can’t tell time.
Plus, they don’t have access to milk or distilled water, or whatever.
That’s really interesting that they did that. We would say,
if they don’t have watches, you get ‘em a damn watch! Give
me a break! We have sent so many watches to Haiti and people use them.
It’s not as if these people are of a different species. These are
fellow human beings who, if you give them a watch, they learn how to
use it in about two seconds. You commit yourself to teaching them to
read and they’ll learn. These representations are a way of exoticizing
poor people to make it seem like “well they’re kind of used
to this, they sort of like dying at 45.” I’ve never seen people
who are not aware of the tragedy and irony of their living to 45 while
everyone else lives to 70 or 80 in developed countries—all the
while complaining of being too fat.
Having worked in Haiti (which is about as close to sub-Saharan Africa
as you’re going to find in the Western Hemisphere), my sense is
that once you provide high quality, compassionate care for people suffering
from HIV disease, and they start seeing these incredible results, they
will do very, very well. For those who have to follow a difficult regimen
for a long period of time and need support, you do directly-observed
therapy: give them the medicines and watch them take it. We’ve
done this with TB for years and it is not only feasible, we have observed
that community health worker programs that provide directly observed
therapy yield benefits to the community above and beyond the treatment
of the patients.
If we sit back and say, “well, there’s really not much we
can do because they don’t have watches, so how are we going to
give them medications?,” in five to ten years we’re probably
going to see up to 30 million people dead from HIV. So, if we don’t
do something, in the next ten years more people will die of HIV in Africa
than died in all the wars of the twentieth century combined. We’re
talking about a genocide of incredible proportions, and we’re sitting
here, twiddling our thumbs. There has to be an all-out effort similar
to—but even larger than—the eradication of smallpox, where
as a world we start deciding: whatever it takes to get medications to
these people, we’re going to do it.
During the process, we can rebuild the health infrastructures of poor
countries and that would have positive effects on public health for
a long time to come. You can do this for really chump change—some
estimate that $5 to 10 billion a year could do it. What is $5 to 10
billion? Just to give a sense of scale: the world spends about $60 billion
a year playing golf; the U.S. spends $4 billion a year to keep 100,000
troops in Germany (for what I’m not sure). If everyone in the U.S.
skipped one movie and popcorn a year (about $10 per person), that would
be $2.7 billion per year. We, the rich countries, absolutely can afford
to do this. The challenge is to get everyone to care.
In 20 years, when my son is 20 years old, he’s going to turn to
me and say, “Hey, you guys knew what was happening in Africa back
in 2000, why didn’t you do more? Look at all the people you let
down, look at all the lame excuses you came up with.” It’s
going to be of a similar magnitude to what young German people said
to their parents after World War II. We’re talking about pharmaceutical
manufacturers who can map the human genome, but they can’t deliver
anti-retroviral therapies in Africa? It all depends on what sense of
urgency you have or don’t have, and I think it’s the job of
all of us to increase that sense of urgency. We really need to wake
up.
Instead of saying, “They don’t have infrastructure, let’s
build it, let’s do it now!,” they’re just sitting back
and saying, “Gee, they don’t have infrastructure, what are
you going to do? I guess 30 to 40 million people are going to have to
die.” If we ignore this, I think our children are going to see
what we’ve done in its appropriate context, that we let a genocide
take place, because we had all these excuses for why it was impossible
to intervene. And they’re going be seen as that—simply excuses—unacceptable
to our children and grandchildren.
Why are people defending the status quo and not working to implement
health care structures and demanding low-cost medicines?
I think it’s because the rich people of the world didn’t
really embrace the poor people of the world as being truly human, and
this is a part of our primitive past. We hope that now, and in the year
2020, things are changing and that people’s poverty will not stop
us from embracing their humanity. Some people would say embracing their
humanity means saying that their culture is “cool.” That’s
okay, anthropologists do that all the time. But truly appreciating their
humanity means saying, “They’re hungry, we’ve got to
do something about it; they’re going to die of TB, let’s make
it possible for them to be cured.” For all of us physicians and
those who care about the rest of the world, fully embracing the humanity
of others and letting their suffering fracture our own existence is
the most difficult and most important thing we have to do.
Bill Gates has observed that people in the West—especially the
U.S.—have no idea of how people in Africa and other impoverished
nations live. The reality is that they don’t need computers, the
Internet and cell phones, they need clean water, food, etc. What do
you think about the millions of dollars that the Gates Foundation has
committed to Africa?
We received a large grant from the Gates Foundation for treatment
of drug-resistant TB, and I have to say that the Gates Foundation has
done more to transform what we think is possible in public health than
any other group we’ve seen in history. Talk about impossible: if
we look back at smallpox, it cost $313 million to eradicate it from
the planet. Today, $313 million looks like a bargain. Bill Foege, who
is now the Senior Health Advisor, is trying to bring that same vision
to the Gates foundation, saying, “we have to expand our notion
of what’s possible, and we have to stop short of nothing but global
health equity.” It’s gotten people to dream of eradicating
this and eliminating that, as opposed to just doing little projects
where we put Band-Aids on people.
Bill Gates said the right thing about the idea of computers being the
answer. What is a woman in an African village whose children are starving
going to do with a computer? She’s not going to browse eBay. These
people need basic health care, food, money—all kinds of things.
What Bill Gates has given is relatively small compared to the overall
need in global health, $500 or 600 million a year. Yet that amount has
catalyzed all kinds of other great investments and it’s also invigorated
the public health community immeasurably.
South African President Thabo Mbeki ruffled lots of feathers when
he questioned the conventional virology at the AIDS conference last
summer in Durban. What’s your response to the theory that HIV doesn’t
cause AIDS, that it’s the toxic medications combined with compromised
immune systems, malnutrition and other diseases that is causing death?
There are several ways of looking at this. One is looking at what
Peter Duesberg and his colleagues have been saying, that HIV is not
the cause of AIDS, that it’s the drugs for HIV that are the cause
of AIDS. I think he’s wrong, and I think most people believe that
he’s very wrong.
President Mbeki’s position is more complicated. I think at first
he made some very incorrect, exaggerated statements that were in accord
with some of the things Duesberg said. But at the Durban meetings, what
he was talking about was rather different. He was saying that we shouldn’t
look at AIDS in Africa as a little boil or cancer that you have to carve
out of the body of Africa, but that it is part of a much larger set
of problems that African people face, and the notion that caring about
Africa only for its AIDS problem is not such a great thing if you really
take into account the overall problems of socioeconomic inequality and
health.
I don’t think that it’s possible to overplay the problem of
AIDS in Africa and it’s still being underplayed—enormously.
We simply know that tens of millions of people will die in the next
few years unless we move really aggressively; that’s the fundamental
reality.
Can you tell us about TB in Russian prisons?
Russia has the highest prisoner to population ratio in the world
except for the U.S. Of the roughly one million Russian prisoners, the
numbers suggest that around ten percent have active TB, and out of those,
at least 20 percent have multi-drug resistant TB (MDR-TB). With MDR-TB,
you go from a six month treatment to a two year treatment with second-line
drugs that have more side-effects and are more expensive, so it’s
more difficult to treat. I think the Russian prison problem is the worst
disaster we have ever seen in terms of a TB epidemic. The Russians went
from a system of the greatest level of economic equality in all of Europe
in 1987, to the greatest level of inequality in all of Europe by 1995.
The government does not have a lot of money to take on this TB problem,
so they’re faced with having to take loans. I think the World Bank
has been heroic in taking on the Russian TB problem. They have gone
forward in dealing with an incredibly difficult problem and have made
sure that it’s going through. I hope that it has an impact, but
it’s a problem that will take at least ten years to even begin
to get a handle on. In the meantime, prisoners are released with MDR-TB
and they travel. We’re going to start seeing Russians with TB and
MDR-TB in parts of Eastern and Western Europe and also the U.S., and
at that point I think we’ll get more serious about treating it
in the prisons. But for now we are trying desperately to work with our
Russian colleagues to implement treatment programs that are effective.
To learn more about Partners in Health and the Institute for Health
and Social Justice call 617-441-6288 or visit www.pih.org.
