Mountains Beyond Mountains: Chapter 19 Summary & Analysis

By 1998, it’s become well known in the medical community that the usual TB treatments in the third world will fail, unless they’re accompanied by the MDR treatments pioneered by Farmer in Peru. Farmer’s research has begun to establish a new paradigm in the medical world. Previously, medical programs were measures for their cost-effectiveness: i.e., they were only adopted if the necessary financial resources saved a significant number of human lives. Farmer has used his influence to point out an uncomfortable truth, however: usually, the philosophy of “cost-effectiveness” is used to preserve the status quo. Thus, MDR treatment is said to be “cost-effective” in New York, but not in Haiti. Farmer wants to drive down the cost of MDR treatment to the point where it’s feasible to treat MDR patients throughout Peru.

Kidder stops to give some background information about Farmer’s partner, Jim Kim. Kim was born in South Korea and grew up in Iowa in the 70s. His father, who’d grown up in North Korea, was a talented periodontist (specialized dentist). His mother was a sharp-minded woman who taught Jim the importance of arguing and public speaking. Jim was popular and charismatic in high school, even though he was the only Asian in his school.

Jim Kim studied at Brown, where he deliberately spent most of his time with black and Hispanic students. Kim came to believe that race was “the central problem of his life.” He got a Ph.D. in anthropology, doing most of the research in pharmaceutical companies in South Korea. When he met Farmer, he was struck by Farmer’s devotion to helping the people of Haiti. Inspired by Farmer, Kim decided to devote his energy to fighting poverty in the Third World.

In the late 90s, Jim Kim and Farmer are researching drugs for treating MDR. They know from experience that the cost of a drug varies enormously from country to country. One TB drug costs 30 dollars in Boston, 9 dollars in Paris, and 20 dollars in Peru. Jim Kim knows that the best way to drive down the cost of a drug—as he and Farmer are trying to do in Peru—is to convince the World Health Organization (WHO) to encourage the production of cheaper alternatives to a drug. Kim tries to convince the WHO to do so, but his arguments fall on deaf ears.

Jim Kim makes contacts with a Dutch pharmaceutical company that specializes in making second-line (i.e., generic off-brand) drugs for a fraction of the normal price. Kim thinks that he can use companies of this kind to lower the cost of TB drugs. But this is a difficult process: in order to lower the cost of a drug, Jim has to convince pharmaceutical companies that there will be a large market of medical projects for the drug. But the only way to establish such a market is to lower the price. The only way to break through this circular chain is to lobby the WHO, which has already turned Kim down.

Kidder goes over the basics of the WHO. The World Health Organization is a coordinating site for the world’s government health departments. It’s always underfunded, and infamous for its bureaucracy. One major concern of the WHO with regard to Jim Kim’s project is that the MDR drugs could become too widely available—in other words, the drugs could become so cheap that they’ll be traded on the black market, resulting in new resistant strains of TB.

Jim Kim tries to strengthen his case by finding a precedent for promoting a second-line drug in the third world. He finds that an organization called the Green Light Committee promoted second-line meningococcal vaccines in the third world. Kim and Farmer plan to found a new committee for the circulation of second-line TB drugs. The committee will gradually reduce the price of these drugs.

By the year 2000, the new Green Light Committee, headed by Farmer and Jim Kim, has driven down the costs of MDR drugs by about 95 percent. Jim Kim’s strategy worked: it’s now “cost-effective” to treat MDR in Peru and other underdeveloped countries. Farmer acknowledges that Kim was the “mastermind” behind the success of Green Light.

Jim Kim and Farmer meet in Austria to attend a conference on TB. They discuss the “O for P,” an abbreviation for “a preferential option for the poor,” which they’re pursuing in Peru. At dinner, Kim tells Farmer that he has ambitions of getting into politics—helping alleviate suffering on a broader scale than medicine would allow. Farmer supports Kim’s ambition, as he knows that Jim would be an honest and trustworthy public servant.

Kidder considers what Jim Kim and Farmer have accomplished in Peru. The medical world thinks in terms of cost-effectiveness, arguing that it’s not efficient to fight disease in Haiti or Peru. For Farmer, this kind of thinking obscures the real issue: the reason that the costs of treating disease are high in certain parts of the world. By refusing to take cost-effectiveness arguments seriously, Farmer and Kim have dramatically reduced the price of a life-saving drug, helping entire communities.

In early 2000, Tom White’s money is running out. He’s spent millions of dollars on PIH and other similar ventures, and—just as he’d planned all along—he has little money left as he approaches the end of his life. Ophelia, who is now responsible for PIH’s budget, warns of a funding crisis: PIH needs to find new donors, quickly.

Jim Kim, Farmer, and Ophelia devise a bold new strategy. Using their success with treating MDR, PIH will raise money for wiping out TB and other dangerous diseases—perhaps even AIDS—in Peru and the rest of South America. Kim is making inroads with big donors like the Gates Foundation, which has an endowment of 22 billion dollars. Kim plans to ask the foundation for 45 million dollars—an incredibly bold request. Even Farmer is reluctant to ask for so much money.