1. The Future of Global Health
Jim Yong Kim M.D., Ph.D.
François Xavier Bagnoud Center for Health and Human Rights
Brigham and Women’s Hospital
Harvard Medical School
Harvard School of Public Health
Partners In Health
Global Classroom
Columbia University 1

2. 2

3. The MDR-TB Death Sentence as Public Health Policy
“In developing countries, people with multidrug-resistant tuberculosis usually die, because effective treatment is often impossible in poor countries.”
- WHO 1996
“MDR TB is too expensive to treat in poor countries; it detracts attention and resources from treating drug-susceptible disease.” - WHO 1997 3

4. August 1996 MDR-TB treatment project initiated in Peru by Socios en Salud and Harvard/Partners in Health. 4

5. 5

6. Reduced prices of second-line TB drugs
Formulation
1997 price
1999 price
% Decline
Amikacin
1 gm vial
$9.00
$0.90
90%
Cycloserine
250 mg tab
$3.99
$0.50
87%
Ethionamide
$0.14
84%
Kanamycin
$2.50
$0.39
Capreomycin
$29.90
97%
Ofloxacin
200 mg tab
$2.00
$0.05
98% 6

7. Scaling up of DOTS-Plus
Feb – 35 projects 7

8. Changes in life expectancy in selected African countries with high HIV prevalence, 1950 to 200065 60
Botswana
Uganda 55
South-Africa
Life expectancy at birth, in years
Zambia 50
Zimbabwe 45 40 35
Source: United Nations Population Division, 1998 4 8

9. Act Up and Initial AIDS Protest Efforts
Paul Volberding and Margaret Fischl appear with fake blood spilt on them by activists at the Vancouver International AIDS Conference in 1996
Initial Act Up efforts in the US, including a die-in 9

10. Objections to Treatment
July 2000
There are many ways to communicate the vital information about HIV/AIDS. What works best in one country may not be appropriate in another. But to tackle the disease, everyone must first understand that HIV is the enemy. Research, not myths, will lead to the development of more effective and cheaper treatments, and hopefully a vaccine. But for now, emphasis must be placed on preventing sexual transmission.
- Durban Declaration signed by over 5000 attendees of the XIII International AIDS Conference in Durban, South Africa
“The Durban Declaration,” Nature, 406, (July 2000): 10

11. Global Protests Surrounding Access to ARV’s 11

12. “
No program to treat people in the poorest countries has more intrigued experts than the one started in Haiti by Partners In Health…” NEW YORK TIMES 11/30/2003
****Click for Joseph after treatment image 12

13. Launching PEPFAR
“AIDS can be prevented. Anti-retroviral drugs can extend life for many years. And the cost of those drugs has dropped from $12,000 a year to under $300 a year -- which places a tremendous possibility within our grasp. Ladies and gentlemen, seldom has history offered a greater opportunity to do so much for so many”
January 28, 2003
"The British government has learned that Saddam Hussein recently sought significant quantities of uranium from Africa." 13 13

14. 14 14

15. 3by5 is an attempt to use time in the most creative of ways
3by5 is an attempt to use time in the most creative of ways. Bureaucrats who were supposed to lead the battle against this epidemic were simply telling us that it was getting worse and that we should pay more attention. Body counts and meetings, more body counts and more meetings. When PLWHA demanded treatment for everyone, most of them just shrugged their shoulders and said it was too complex and not cost-effective. We knew as we were preparing to announce 3by5 that we needed to use time to light a fire under all of us who have the skills and the resources to do something about this epidemic. I wake up every morning in a cold sweat thinking about how little time left we have to reach our target of 3 million on treatment. But I take comfort in knowing that for even a brief moment, I might share a small fraction of the terror that people waiting for ARV treatment feel every moment of their lives.
Gustavo Gutierrez, during a public conversation with Noam Chomsky that was sponsored by Partners in Health, told us that there is a simplicity on this side of complexity and a simplicity on that side of complexity. He told us to try our best to never mistake the former for the latter and to do whatever we can to reach the latter in any great project we take on. 3by5 is often misunderstood as the simplicity on this side of complexity. Nothing could be further from the truth. 3by5 represents an understanding that the mighty battle we are now engaged in to struggle with and ultimately handle the complexities of HIV treatment, may be one of the few chances we have in this life for redemption. All of us, especially the health care workers among us, might be asked someday by our children, what did you do when you knew that AIDS was going to be such a huge problem. My own answer will be that I didn't do enough but we took a good shot at it with 3by5.
As you think about what you can do here in Seattle to participate in the great battles for health and social justice like the battle to bring treatment to poor people living with HIV, I would like to leave you with a quote from a particularly distinguished member of my tribe, the tribe of anthropologists. Margaret Mead once said, "never underestimate the ability of a small group of committed souls to change the world. Indeed, they are the only ones who ever have." It is my great, great privilege today to deliver a lecture named after a man who every day of his life, lives in solidarity with the suffering poor who are waiting for so many things, especially treatment for HIV. 15 15

16. Number of people receiving ARV therapy in low- and middle-income countries, 2002—200616

17. Universal Access 2005 G8 Summit at Gleneagles, Final Communiqué:
“…working with WHO, UNAIDS and other international bodies to develop and implement a package of HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by 2010.” 17

18. ls

19. HIV Prevention and Treatment Integration into Primary Health Care
Boucan Carre June 03:
VCT with
Staff
Essential Meds
Community outreach
Boucan Carre March 03 19

20. The four pillars of primary health care
HIV prevention and care—integration
into primary health care services
Women’s Health, reproductive health,
family planning, PMTCT
The four pillars of primary health care 20

21. What does the ‘Rwinkwavu’ model cost?
Summary of detailed unit costing, extrapolated to a full district
100% = US$ 4.7 million in ‘steady state’ (2011)
Estimated ‘catchment’ area of unit
100% = 265,000
Rwinkwavu
Mulindi
Rukira
SOUTHERN KAYONZA
Murama
Methodology:
Theoretical catchment area
+ Patients coming from other areas (based on survey)
- Overlaps between centres
= Actual population served
New Sites/Capital investment (14%)
Administration
Building/ Infrastructure
Labour, excl. accompagnateurs (32%)
Referrals
Transport/ Communication
Labour, accompagnateurs only (5%)
Social (education, housing, mutuelles, micro-finance, etc.)
Outpatient Nutritional Support (5%)
Supplies (28%)
~25 US$/Capita
~6000 US$/Capita 21

22. Lesotho 22 22

23. KZN XDRTB Survey Patient Characteristics*
Characteristics No. (%)
No prior TB Treatment 26 (51)
Prior TB treatment
Cure or Completed treatment 14 (28)
Treatment Default or Failure (14)
HIV-infected (44 tested) 44 (100)
Dead (Includes 34% on ARV) 52 (98)
Identical M. tb spoligotype 26/30
* Moll A, Gandhi NR, Pawinski R, Lalloo U, Sturm AW, Zeller K, Andrews J, Friedland G.
HIV associated Extensively Drug-Resistant TB (XDR-TB) in Rural KwaZulu-Natal
(South Africa MRC Expert Consultation Sept 8, 2006) 23

24. Implementation bottleneck
Vaccines
Primary Health Care
Drug Therapies
Maternal and Child Health Care
Basic Surgery
Lighten up photo 24 24

25. Bill and Melinda Gates Foundation $6. 5 B The Global Fund $8
Bill and Melinda Gates Foundation $6.5 B The Global Fund $8.6 B President’s Emergency Plan for AIDS $15 B International Finance Facility $4 B Multi-Country HIV/AIDS Program $1.1 B Global Alliance $3 B Public-private partnerships $1.2 B Anti-Malaria Initiative in Africa (proposed) $1.2 B United Nations Fund $360 M TOTAL $40.7 B
-BMG data here represents how much money they have spent on global health thus far, to illustrate annual spending now a more accurate number would be between 2-3 billion
*Funds pledged, committed, or spent. Overlap exists between organizations (e.g., PEPFAR money supports the Global Fund).
Adapted from Jon Cohen, The new world of global health. Science 2006;311(5758): 25

26. Gates grants GATES GRANTS
$448M - new health technologies $413M - HIV/AIDS vaccine $258M - malaria vaccine $165M - new malaria drugs $124M - anti-HIV microbicides $115M - diarrhea/nutrition $106M - TB vaccines/diagnostics
BMG grants to Harvard
$44.7 million to develop the program model for the control of MDR-TB
$25 million to support AIDS Prevention in Nigeria (APIN)
$2.28 million to support the development human papilloma virus (HPV) vaccines
$7.57 million to develop a new paradigm for needle-free vaccination technology
$18.7 million to develop valid, reliable and comparable measurements of population health 26 26

27. Implementation bottleneck +
Vaccines
Primary Health Care
Drug therapies
Maternal Child Health Care
Basic Surgery
Gates Foundation develops:
Microbicides and other preventive tools
New malaria and TB drugs, diagnostics
New combination therapies
Drugs for neglected diseases
>10 new vaccines 27 27

28. Conventional wisdom explaining delivery failures
Markets not working; incentive misalignment
Slow diffusion of knowledge
Lack of management skills
Inadequate funding of infrastructure development
Health care delivery is a complex, multidimensional phenomenon that is difficult to understand and even more difficult to manage
All of these explanations are valid, but
Health care delivery is a complex, multidimensional phenomenon that is difficult to understand and even more difficult to manage 28

29. Harvard Business School Faculty: experts on delivery and operations research
Michael E. Porter, Bishop William Lawrence University Professor, Harvard University
Who is doing the research that we need? Faculty at the business school.
Michael Porter—most expensive consultant in the world ($125,000 for the day; $75,000 for an hour). Talked with Jim and expressed interest in GHD. 29

30. HOW DO WE STUDY COMPLEX STRATEGY PROBLEMS?
Careful study of numerous case studies spanning multiple settings and encompassing both success and failure
Conduct in-depth field research focused on the role of organizational leaders and their choices, studied in context
Employ a mix of quantitative and qualitative analysis
Develop analytic frameworks that can be applied prospectively to guide practice
Develop theoretical principles about the underlying phenomenon based on experience from other industries
Encompass the complexity of the whole problem
Intensive interaction with practitioners to disseminate concepts and refine implementation in specific country settings
-Strategy is based on underlying economic theory, but there is an economic theory of strategy
-Studying strategy requires careful analysis of case studies spanning multiple settings.
-The goal in studying cases is to incorporate complexity.
-So much of the work being done in global health seeks to control for variables and assume away complexity.
-This misses the point; so much of what is important in global health care delivery are those complex variables for which we can’t control.
-Understanding strategy in global health will require the careful study of rich case studies.
-Cases are no good without frameworks
Michael E. Porter, Harvard Business School 30

31. Mismatch in Skills Taught and Skills Needed
Bachelor’s
MPH
MBA/MPA MD
No defined degree program in global health
Broad liberal arts courses on on social or basic science
Field-work on an ad-hoc basis
Focus on quantitative methodology and research
Population-level interventions
Field-work on an ad-hoc basis
Private/public management emphasis
Little discussion of work in resource-poor settings
No education of health science
Focus on clinical and basic science
Little education on health care delivery or public health issues
Focus on single-patient interventions
No or extremely limited focus on health care delivery 31

32. Is there a place for a new discipline in health education?
Basic
Science
Clinical
Science
Evaluation Sciences
What is the pathophysiology?
What is the appropriate intervention?
Does the intervention work? 32

33. Is there a place for a new discipline in health education?
Basic
Science
Clinical
Science
Healthcare
Delivery
Science
Evaluation Science
How do we best deliver the intervention to everyone?
What is the pathophysiology?
What is the diagnosis and appropriate intervention?
Does the intervention and delivery model work? 33

34. Global Health in 2007: Increasing Access
“The importance of the worldwide Internet population continues to grow.  Internet users outside the U.S. now account for 80% of the world’s online population, with rapidly developing countries experiencing double-digit [internet] growth rates year-over-year.” 34

35. Building the Field of Global Health Delivery
Our Response:
Building the Field of Global Health Delivery
Better Health
Care
Outcomes
Advance Evidence Based Strategies
Developing Leaders
Build the Field and
Disseminate
Lessons Learned
Improving Service Delivery
Training
Programs
Field Test Best Practices
with Global Health
Practitioners
Community of Practice
EMR Systems
Case Production
Create Innovation
Network
Phase II
Phase I 35

36. Objections to HIV Treatment
April 2006
The standard policy prescription is that in order that to maximize health, with a limited budget, funds should first be allocated to more cost- effective interventions, and only then to interventions with lesser cost effectiveness. With limited resources, should the focus of efforts to combat HIV/AIDS be on prevention or treatment?...if the goal is to maximize the health benefits produced, developing country governments and international institutions should focus their health spending first on the prevention of HIV transmission, before moving on to treatment. The opportunity cost of emphasizing HIV/AIDS treatment over prevention in a resource-constrained environment is measured in millions of lives needlessly lost.
David Canning, Professor of Economics and International Health at the Harvard School of Public Health 36

37. The Fruits of Advocacy
“Bridge to Nowhere”- $ 398 Million

38. Before
After

39. The Fruits of Advocacy “Bridge to Nowhere”- $ 398 Million
National Security: FY2008 war supplemental- $196.4 Billion

40. Before
After

41. The Fruits of Advocacy
National Security: FY2008 war supplemental- $196.4 Billion
“Bridge to Nowhere”- $ 398 Million
Corn- $5.1 Billion/yr

42. Before
After

43. The Fruits of Advocacy “Bridge to Nowhere”- $ 398 Million
National Security: FY2008 war supplemental- $196.4 Billion
Corn- $5.1 Billion/yr
Sugar- up to $1.9 Billion/yr

44. G7 Military Spending and Foreign Aid, 2006
Center for Arms Control and Non-Proliferation and OECD 44

45. American Perceptions on Foreign Aid and Defense Budget
Recent 2005 survey showed Americans typically believed that economic and humanitarian aid = 10% of total federal budget
Only 18% guessed less than 3%
Actual = 1.6%
When asked what % should be allocated to foreign aid, median response = 15%
PIPA Federal Budget Poll 45

46. “ To create and nurture a community of the best people committed
to leadership in alleviating human suffering caused by disease.”
HARVARD MEDICAL SCHOOL MISSION STATEMENT 46 46