Doctor of Social Justice: Globalization
The Satya Interview with Jim Yong Kim
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. Whats 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 financeall
kinds of things. In anthropology and history, weve 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
The speed with which financial transactions occur is clearly something
thats 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 worlds population has actually gotten worse. In
1960 the ratio was around 30 to one, and now its closer to 70
even 80 to one. So were 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 well
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,
were letting people die. I hope that all the interested parties,
including the pharmaceutical industry, can eventually work together
to put this behind us.
Im not against pharmaceutical companies having a financial incentive
to make new drugsthats very importantbut 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
If you look at what the World Bank is saying about HIV in Africa, theyre
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 80s and 90s there was a sense
that poor countries had to go through specific economic reforms in order
to grow, and with growth, all these problemsincluding HIV and
tuberculosiswould 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 themincluding 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, theres 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 thats
our only goal, then were 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 didnt
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?
Theres really not much data that Ive seen that suggests
that competition and privatization improves health outcome in the U.S.
either. So, privatization is not about improving health outcomes; its
about decreasing expenditures for somebody, in this case its usually
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: whats the role of profitability in health care?
How does enormous private profit-taking in the health insurance industry
actually help things? I just dont understand. Do we need to create
better efficiency and more evidence-based practice of medicine here
in the U.S.? Sure, of course. But Im not convinced that profit-taking
by insurers is what will lead to those kinds of improvements.
Cant that question be applied to practically any transnational
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. Theres 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, lets look at another situation, like the privatization
of Perus 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 expendituresit made more than $45 millionin 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.
Im 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 isoverallfor
Peru, the selling of the gold mines may not have been such a great thing.
Im 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. Thats 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 forceelected
governments in most casesto oversee that peoples 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.
Im all for declaring health as a human right. But thats
actually been done with the international Declaration of Human Rights
and other declarations and proclamations.
But we never ratified that here.
Thats 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 dont
offer all those rights to their peopletheres no enforcement
mechanism. Its fine to talk about health as a human right, but
I dont know if standing on a soap box and saying its a human
right is going to improve the health of the 40-some million people who
dont 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 were onto
the next stage, and that is actually implementing programs that remove
these barriers to human rights. Thats 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, were working on utilizing anti-retroviral medications
for very, very poor people living in the central plateau, and were
showing that its much more feasible than anyone ever thought.
The only thing thats really preventing our ability to provide
the treatments much more widely is the cost. So were 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 nationsfor
one reason or othercant organize their lives or arent
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 cant
take anti-retroviral drugs because they have to be taken on a rigid
schedule and they dont have watches and cant tell time.
Plus, they dont have access to milk or distilled water, or whatever.
Thats really interesting that they did that. We would say,
if they dont have watches, you get em a damn watch! Give
me a break! We have sent so many watches to Haiti and people use them.
Its 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 theyll learn. These representations are a way of exoticizing
poor people to make it seem like well theyre kind of used
to this, they sort of like dying at 45. Ive 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 countriesall the
while complaining of being too fat.
Having worked in Haiti (which is about as close to sub-Saharan Africa
as youre 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. Weve
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, theres really not much we
can do because they dont have watches, so how are we going to
give them medications?, in five to ten years were probably
going to see up to 30 million people dead from HIV. So, if we dont
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. Were
talking about a genocide of incredible proportions, and were sitting
here, twiddling our thumbs. There has to be an all-out effort similar
tobut even larger thanthe eradication of smallpox, where
as a world we start deciding: whatever it takes to get medications to
these people, were 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 changesome
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 Im 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, hes going to turn to
me and say, Hey, you guys knew what was happening in Africa back
in 2000, why didnt you do more? Look at all the people you let
down, look at all the lame excuses you came up with. Its
going to be of a similar magnitude to what young German people said
to their parents after World War II. Were talking about pharmaceutical
manufacturers who can map the human genome, but they cant deliver
anti-retroviral therapies in Africa? It all depends on what sense of
urgency you have or dont have, and I think its the job of
all of us to increase that sense of urgency. We really need to wake
Instead of saying, They dont have infrastructure, lets
build it, lets do it now!, theyre just sitting back
and saying, Gee, they dont 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 weve 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 theyre going be seen as thatsimply excusesunacceptable
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 its because the rich people of the world didnt
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 peoples poverty will not stop
us from embracing their humanity. Some people would say embracing their
humanity means saying that their culture is cool. Thats
okay, anthropologists do that all the time. But truly appreciating their
humanity means saying, Theyre hungry, weve got to
do something about it; theyre going to die of TB, lets 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 Westespecially the
U.S.have no idea of how people in Africa and other impoverished
nations live. The reality is that they dont 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 weve 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 whats possible, and we have to stop short of nothing but global
health equity. Its 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? Shes not going to browse eBay. These
people need basic health care, food, moneyall 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 its 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. Whats your response to the theory that HIV doesnt
cause AIDS, that its 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 its the drugs for HIV that are the cause
of AIDS. I think hes wrong, and I think most people believe that
hes very wrong.
President Mbekis 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 shouldnt
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
I dont think that its possible to overplay the problem of
AIDS in Africa and its still being underplayedenormously.
We simply know that tens of millions of people will die in the next
few years unless we move really aggressively; thats the fundamental
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 its
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 theyre 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 its going through. I hope that it has an impact, but
its 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. Were 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 well 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.