By all accounts, the medical response to January’s devastating earthquake in Haiti has been overwhelming. But what about the situation in Haiti before the earthquake? At the beginning of the year, the small nation boasted the 2nd-highest number of non-governmental organizations, NGOs, per capita, trailing only India. And yet when the 7.0 earthquake struck just 15 miles southwest of Port-au-Prince, not only did buildings crumble, but so too did the infrastructure of the country. The strong NGO presence had done little to help Haiti construct more earthquake-resistant buildings, and most of the medical aid for the hundreds of thousands of injured came from outside Haiti’s borders.
“They were not serious about building a lasting infrastructure,” said Jim Yong Kim, president of Dartmouth College, in a lecture at the University of Chicago on Wednesday. “8,000 NGOs, but I have to say that the execution of those NGOs in this unbelievably beleaguered country was about as poor as I have ever seen.”
Harsh words from Dr. Kim, but as his talk emphasized repeatedly, the time for niceties is over when it comes to delivering health care to the world’s poor. Titled “Why We Can’t Wait: Building a Science of Health Care Delivery,” Kim’s lecture argued that the lack of evidence-based research about how the medical woes of underserved communities can best be addressed squanders billions of dollars and unmeasurable amounts of good intentions each year on unsuccessful efforts.
“What I see a lot of are do-gooders who are very very committed to the notion of themselves going out into the world and doing good, but unfortunately I don’t see very many of those do-gooders committing to truly executing so that their outcomes match their desire to do good,” Kim said. “So much of what we see – and this has never been more true than in Haiti recently – is people who are saying ‘I’m committed to the act of giving, and that’s enough.'”
Kim speaks from experience as the co-founder of Partners in Health, a Boston-based non-profit organization with the mission of bringing health care to poor communities around the world. Through his talk, Kim drew upon case studies of successful projects he oversaw with PIH and the World Health Organization as examples of how an NGO can be effective against a medical problem in a developing country. In one case, Kim and colleagues worked to reduce the price of expensive drugs for multiple drug-resistant tuberculosis – in the face of a WHO stance that the problem was too complicated to address. Later, working with the WHO as the director of their department of HIV/AIDS, Kim launched The 3×5 Initiative, an effort to provide 3 million people in developing countries with anti-retroviral therapy by 2005. Again, Kim said, he met with resistance from organizations that did not want to be pinned down to such a specific goal – and in the end, the 2005 timetable was not met. But so what, Kim seemed to say – they met their goal in 2007, and 3 million people with HIV experienced the “Lazarus Effect” of anti-retroviral treatment.
“It’s the first time in history where rich countries have committed to chronic care for a chronic condition in poor people,” Kim said. “That’s why it’s so important.”
The common thread through these examples was that effective therapies were available, but were not reaching the populations that most needed them. That disconnect continues today, Kim said, even in the work of organizations such as the Bill and Melinda Gates Foundation, which has dedicated billions to achieving world health equity. With the foundation’s focus on basic science solutions creating new treatments for diseases such as malaria, tuberculosis and HIV/AIDS, Kim said that they risk committing the same fallacy as preceding organizations.
“If they make all these new tools and we’re no better at delivering them, then they are going to actually create greater inequity, because the people who are going to get those tools are the travelers and the wealthy people in those countries,” Kim said.
The only solution, Kim argued, was to create an entirely new research field, one focused on how best to deliver treatment and health care to countries with little or no medical infrastructure. Before accepting the presidency at Dartmouth, Kim created a course at Harvard to do just that, modeling the framework on the business school exercise of analyzing case studies of programs that worked. The idea was to arm students with models of strategies with proven effectiveness, not so they could be merely copied and applied to situations they might not fit, but so new approaches could be reassembled from pieces of strategies previously found to be successful.
But one course does not create an entire field, and Kim appealed to University of Chicago physicians and researchers in attendance to join Dartmouth in creating an entirely new area of research, dedicated to studying how to best deliver new interventions to all people who need it. Like the creation of relatively new fields such as clinical science and comparative effectiveness research, scientists will have to come up with new rules to define the field, such as how to effectively measure the outcomes of health care delivery efforts. And perhaps most challenging, researchers will have to convince those who dole out funding to support this new field – no easy task, Kim admitted.
“If Bill Gates thinks that delivery is just something that happens magically, and he’s the smartest person I’ve ever met, how are members of Congress going to get it?,” Kim said.