by Tracy Kidder
He had left Iowa prepared, naturally enough, to think that ethnicity was the central problem of his life. By the time he came back from Korea to Harvard, to continue medical school and write his thesis, he had grown bored and a little disgusted with what was known in academic circles as the politics of racial identity. It seemed like an exercise in selfishness. “I discovered South Korea was doing just fine, and that what Koreans wanted was for me to write grant proposals so they could come to the States and get degrees. I had looked at student movements. They were all about Korean nationalism, just sort of troublemaking.” When he met Farmer, he was ready to change directions. At one point during their talks in the old, one-room PIH office, Farmer told him, “If you come to Haiti, I’ll show you you’re blan, as white as any white man.” Jim thought of his black, Hispanic, and Asian friends at Brown, and how angry that remark would have made them.
He told Farmer that he felt liberated from “the self-hatred and evasion of ethnicity” he’d felt in Muscatine.
“It’s good to have to come to understandings of that, but you’ve got to put that behind you now,” said Farmer. “So what are you going to do? Be the first Asian to do some stupid thing like walk on the moon?”
They hadn’t talked long before Jim declared that he wanted to make Farmer’s preferential option for the poor his own life’s work.
All his life, it seemed, Jim had been jumping at the next new thing, the bigger and better thing. Perhaps this was the residue of growing up in Muscatine with a cosmopolitan mother. “You’re not Korean, you’re careen,” Ophelia told him once. Jim himself said, “I tend to feel a problem’s solved once I’ve thought it through.” Then again, he was fond of overstatement, even when talking about himself. After all, he’d stuck with PIH for a decade by now, and done a lot of its most menial chores along the way. What Jim had, above all, was enthusiasm. He’d weigh facts against possibilities as if the two were equivalent. A lot of students had joined PIH after hearing him talk. Change the world? Of course they could. He really believed this, and he really believed that “a small group of committed individuals” could do it. He liked to say of PIH, “People think we’re unrealistic. They don’t know we’re crazy.”
From his research in Korea, Jim already knew that the price of a drug may have little to do with its usefulness or the costs of manufacturing and distributing it. Often, the price is high because only one company makes it. A firm can secure this monopoly power through patents, but that wasn’t the case with the second-line TB drugs. In the world, perhaps as many as 750,000 people suffered from MDR. Treating all of them would require a large quantity of drugs, because treatment lasted so long. So the potential market was big, but most people with the disease were poor, so actual demand was small. Not many companies made the drugs. Those that did could pretty much name their price.
Eli Lilly and the second-line drug capreomycin, for instance. After long badgering from Farmer, that company was finally selling PIH capreo in Peru—for $21.00 a vial. Farmer and Kim had bought the same drug, made by Lilly, for $29.90 a vial at the Brigham in Boston. Then they had discovered that it cost only $8.80 in Paris. So they’d tried to buy capreo in Paris but were told they couldn’t. “There’s a global shortage of capreo,” the drug agent in Paris had told Farmer over the phone.
“Why?” Farmer asked.
“There seems to be an emergency.”
“Where?”
“In Peru.”
Jim went to Howard Hiatt and told him the story. “Looks like price gouging to me,” Hiatt said. In fact, so-called differential pricing was standard in the world of large drug companies; Americans paid far more for their products than any other nationality. But Hiatt thought Lilly might want to pick up some good publicity by donating drugs to the project in Peru. He knew a member of Lilly’s board. He and Jim went to work on the company, and meanwhile Jim began pursuing other angles.
Jim got WHO to agree to hold a meeting to encourage drug companies to produce more second-line antibiotics—he hoped to create competition, which would drive down prices. Then WHO backed out, and Jim convened the meeting himself in Boston. He wasn’t above hyperbole or dramatics. At one moment he put a list of numbers up on the slide projector, describing very large potential demand for the second-line antibiotics, in order to impress the drug companies. The numbers themselves were accurate, but the demand they described wasn’t real, because no one contemplating MDR treatment programs had the cash to buy the drugs. The tactic didn’t work quite as Jim planned. Out in the audience there was a Dutchman in his twenties named Guido Bakker. He worked for a nonprofit company, the International Dispensary Association—IDA. It specialized in driving down the prices of essential drugs, the kinds of drugs that poor countries need most urgently. Bakker saw right through Jim’s ploy. But he felt angry at the representatives from the for-profit drug companies. They started arguing that the prices for second-line TB drugs ought to remain high. Finally, Bakker announced from his seat, “IDA is going to do everything we can to lower prices, by exploring generic manufacturers.”
The Dutch group’s strategy was to ignore the giant multinational drug companies, the ones that mainly rely on research and brand names and patent protection, and to deal instead with the myriad smaller companies that make and sell, at greatly reduced prices, already invented generic drugs under different names (as acetaminophen instead of Tylenol in the United States, for instance). This seemed to Jim like a better idea than his own. His fondness for the new and better idea might be his salient weakness, but it sometimes served him well. He didn’t care where an idea came from. He was forever reading books about corporate management, looking for tips from capitalists. He embraced Guido Bakker’s plan. Ultimately, IDA and the renowned organization Doctors Without Borders took on the job of finding generic manufacturers of second-line drugs. IDA even talked some companies into making the drugs, and they assumed responsibility for quality control and distribution. And Doctors Without Borders put up the cash to buy the first shipments.
But other steps came first. Jim’s task was like a logician’s conundrum. To lower the prices of the drugs, he had to show that a lot of TB projects would use them. For a lot of projects to use them, the prices had to be lower. For the prices to be lower, the generic manufacturers would have to get involved. They’d be more inclined to get involved if WHO would put the second-line antibiotics on its official list of essential drugs. But rarely used drugs are by definition not essential. To break through this circular chain, Jim began to lobby WHO for the drugs’ inclusion on the list.
The World Health Organization serves as the coordinating body for virtually all the world’s ministries of health. It sets guidelines and standards, publishes recommended approaches, acts as an advisory group. It’s where all the information about health and a lot of the complaints go, and it performs some crucial functions well, such as the collection and dissemination of worldwide epidemiological data. But it is perennially short of money, and like most parts of the United Nations it is infamously, inevitably, tangled in bureaucracy. It has a tendency to freeze in the face of controversy. The organization’s critics said it had two mottoes: “Slow down” and “It’s not our fault.” Even Jim’s strongest ally there got frightened when various eminent TB experts wrote to Geneva saying they couldn’t countenance the elevation of second-line antibiotics to the essential drugs list. Some wrote that the plan wouldn’t work. Others believed that if it did and prices fell, the drugs would become too widely available.
This worry had substance. 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 cur
e.
But all this was already happening, Jim said again and again. He talked about those patients in Peru who had come to Socios already resistant to second-line antibiotics, a couple of them with TB effectively resistant to every known anti-TB drug. The only way to prevent more of this was sound, well-financed MDR treatment, added on to DOTS. But while Jim believed in that argument, he knew he had to find a mechanism to ensure real control over cheaper drugs. He and Paul had just sent a young man to work at WHO in Geneva. Jim called him and explained the need for a control mechanism. “See if you can find a precedent,” he said. A few days later the young man called to say he’d found one, an international entity called the Green Light Committee, established to control the distribution of meningococcal vaccine. “That’s great!” said Jim. “Let’s do the same thing. We’ll create a committee to control second-line drugs.”
“What do we call it?” asked the young PIH-er.
“Red Light Committee would be bad,” said Jim. “How about Green Light Committee? That’ll make it seem like we’re just following precedent. ”
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 program, one that wouldn’t breed further resistance. Most of “TB” endorsed the idea, and in a final compromise, WHO placed the second-line antibiotics in an annex to its essential drugs list.
The price reductions came in stages. By the year 2000, projects buying through the Green Light Committee paid about 95 percent less for four of the second-line drugs than they would have in 1996, and 84 percent less for two others. Howard Hiatt and Jim had persuaded Eli Lilly to donate large amounts of two antibiotics to PIH, and Lilly had promised to grant other MDR treatment projects vastly lowered prices. Capreomycin now cost ninety-eight cents a vial, 97 percent less than when Jim and Paul had first borrowed it from the pharmacy at the Brigham on their way to Peru. The drugs to treat a four-drug-resistant case of MDR now cost PIH about $1,500, instead of $15,000, and prices were still falling, substantially and rapidly. Arguments were far from over, but no one could say anymore that cost alone ruled out treating the disease in poor countries.
One member of WHO’s TB division who had initially opposed the Green Light Committee took to describing himself as “the architect.” Others had better claims to credit for the falling prices, including some members of Doctors Without Borders, to whom Jim and Paul had gone for help. But Guido Bakker, who was involved in most of the proceedings, told me, “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.”
Since the start of the project in Lima, Jim and Paul had seen each other less and less frequently. They’d kept in touch mostly through e-mail. But they met up at a TB meeting in Salzburg, Austria. Jim found it riveting, Paul nearly fell asleep. Afterward, they went out to dinner alone. Jim and Paul had always shared certain appetites. For telegraphic expression—“O for the P” instead of “a preferential option for the poor”—and action adventure movies and People magazine, which they called the Journal of Popular Studies, the JPS. They had similar diets, too. Dr. Farmer doused everything he ate with salt. Dr. Kim liked to say, “There are only two kinds of plants, stir-fryable and non.” Not having had a chance to talk face-to-face in a while, they celebrated the occasion by ordering pizza.
Jim had a lot on his mind that evening. A few years back Paul had talked him into training as an infectious disease specialist. After a few months Jim had quit. He liked doctoring well enough, but Peru had introduced him to medicine on a different scale. It was the big issues surrounding health that excited him, he’d realized. He actually liked sitting for hours in conference rooms talking about operational research in international TB control. But he felt vaguely ashamed to admit that he wanted to have a hand in creating international health policy. As sometimes happened, Paul seemed to know what Jim was thinking.
“What do you want to do now?” he asked.
There was warmth in the question, Jim felt, a real invitation for him to come clean. “Political work is interesting to me, and it has to be done,” he said. “I prefer it to taking care of patients. It’s O for the P on an international scale.”
“Well then, do it,” Paul said.
“But didn’t we always say that people who go into policy make a preferential option for their own ideas? For their own sorry asses?”
“Yeah, but, Jim, we trust you with power. We know you won’t betray the poor.”
Paul’s self-assurance had sometimes seemed to fill all the space around him and Jim. In the old days, when Paul blew in from Haiti and wanted to talk to Jim but had to get to an appointment, he’d say, “Walk with me,” as if everything on his agenda mattered more than anything Jim might have to do himself. For years Jim used to pick him up at the airport, but Paul never did that for him, not once. When they argued, which happened fairly often, Paul usually came out on top—or if he didn’t, Jim often felt compelled to make him think he had. If Jim praised him, Paul was apt to say something like, “Thanks, Jimbo. I need to hear that.” One time, when Jim replied, “Yeah, but why don’t you ever say it to me?” Paul seemed surprised. “I do, don’t I?”
Jim liked to say that he and Paul were “twin sons of different mothers.” If so, Jim had been born second, and now, over pizza in Salzburg, he’d come of age, with Paul’s blessing.
A lot of Farmer had rubbed off on Jim. Over the years their philosophical views had become virtually indistinguishable, especially on that set of notions which, it seemed to them, international health had adopted as scripture. Jim told me once, “There have been fundamental frame shifts in what human beings feel is morally defensible, what not. The world doesn’t bind women’s feet anymore, no one believes in slavery. Paul and I are anthropologists. We know that things change all the time. Culture changes all the time. Advertising people force changes in culture all the time. Why can’t we do that? People in international health sit back and say, ‘Will things change for the better? Who knows? But these Paul Farmers, they’ll drop out, and when they do, we stalwarts will still be here figuring out the best way to spend two dollars and twenty-seven cents per capita for health care.’ ”
“Resources are always limited.” In international health, this saying had great force. It lay behind most cost-effectiveness analyses. It often meant, “Be realistic.” But it was usually uttered, Kim and Farmer felt, without any recognition of how, in a given place, resources had come to be limited, as if God had imposed poverty on places like Haiti. Strictly speaking, all resources everywhere were limited, Farmer would say in speeches. Then he’d add, “But they’re less limited now than ever before in human history.” That is, medicine now had the tools for stopping many plagues, and no one could say there wasn’t enough money in the world to pay for them.
At PIH, though, the saying was true enough. They had spent several million of Tom White’s dollars to buy the drugs for Peru. Ophelia had been hoarding up portions of the contributions PIH received, trying to create an endowment for the organization. She’d managed to put aside about a million dollars. Now it was gone, spent on Peru. And White was in his eighties and, as he’d planned, not very far from the end of his fortune. In early 2000 Ophelia, who was still in charge of the budget, wrote to Paul and Jim:
Boys,
We desperately need a big lump of cash. Basically, with 40k per month in salaries, 60k to Haiti, and 35k to Peru we can’t make it on Tom’s money. That is to say nothing of other expenses such as mortgage, health insurance, utilities blah blah blah. … Any ideas?
The three devised what they called “a disassembly strategy”—or, out of Tom White’s earshot, “the post-Tom plan.” Because of the falling prices of the second-line drugs, they could go on for a while treating patients in Lima, but in a year or two they’d have to stop. They’d also have t
o stop financing the research branch of PIH that Paul had founded years ago with his MacArthur money, and essentially remain a tiny private charity, struggling to support a health system in one corner of Haiti. “Screaming into the wilderness,” as Jim put it.
Jim had an alternate vision, of course. In it, PIH would become an instrument for expanding the resources to treat TB, and in the process save itself. They had halted the spread of MDR in the shantytowns of northern Lima. Now they’d propose a project to wipe it out all over Peru. Then they’d go international. They’d show the world that it was possible to beat back that dread disease, and they’d show the world how to do it. And if MDR, then why not AIDS?
For over a year, Jim had been courting what he called “big-shot donors.” None was bigger than the Gates Foundation. It had an endowment of roughly $22 billion, and it planned to spend about half the income, about $550 million a year, on projects to improve global health. Howard Hiatt had introduced Jim and Paul to the foundation’s senior science adviser, a man named Bill Foege, one of the people responsible for the eradication of smallpox, known to favor unconventional approaches to supposedly impossible problems. Foege had encouraged them. So Jim started putting a grant proposal together. He met up with Paul again, this time in Moscow. They sat on the edges of their beds in a room at the Holiday Inn and talked about how much money to ask for. They argued a little. Paul thought two million dollars, maybe four.