Dr. Jim Yong Kim’s Candidacy: The Rationale for a BRIC Bank?
On March 23, President Obama nominated Dr. Kim to be the next president of the World Bank. President Obama mentioned that it was time to have a development expert in this post, and as one of his qualifications, it was mentioned that Dr. Kim had gotten antiretroviral medicines (ARVs) to 3 million AIDS patients in the developing world.
Since that time, several articles have appeared in the Financial Times, calling into question Dr. Kim’s “development experience”. For instance, one of the other candidates for this same position, the former minister of finance for Colombia, commented that Dr. Kim lacks “the appropriate credentials to do the job properly”. He went on to comment: “he is an excellent physician but we’re talking about a development institution”. Meanwhile, Brazil, Russian, India, and China have proposed a “BRIC” Bank to finance the much needed infrastructure capacity in other Member States. They strongly feel that such a macro-economic investment portfolio is desperately needed by emerging economies. How does Dr. Kim’s track record fit the bill?
It would be worthwhile, then, to briefly examine Dr. Kim’s development experience, and in particular to review his role as director of WHO’s ‘3 by 5’ program (aimed at providing ARVs to 3 million AIDS patients by 2005). There can be no question that Dr. Kim had an exemplary record in the formation and operation of the Green Light Committee, and in proving conclusively that MDR-TB interventions were possible in resource limited settings. In the first instance, the Committee addressed TB, and in the second, treating TB patients with multiple drug infections in Peru, and providing access to medicines for poor patients in Haiti and Rwanda. These can be considered micro-development experiences, largely within a single disease category.
However, his leadership of WHO’s ‘3 by 5’ program was a global undertaking, or better stated, an undertaking that qualifies it as a macro-enterprise effort in development aid.
WHO proposed ‘3 by 5’ in December 2003 and Dr. Kim was named as its Director. Many in the development community could not understand why the program was necessary. It duplicated several global AIDS programs then underway for a number of years, e.g., PEPFAR; the Global Fund to Fight HIV/AIDS, TB and Malaria; the UN/Accelerated Access Initiative—in which WHO was a founding member; the World Bank’s MAP Program; and public-private efforts in ten Southern African countries. WHO seemed to be reaching for global leadership in AIDS at a time when inter-agency collaboration and cooperation were so vitally absent.
When announcing the program, WHO proposed that the treatment “backbone” would be Cipla’s fixed dose combination ‘Triomune’, a drug composed of three different ARV products lamuvudine+stavudine+neveripine). It had been licensed by the Drugs Controller General (India) in June 2001. Of the twelve conditions placed on its use, one was: “no reference in the advertisements or medical literature is made that the Government has approved the drug”. Another: “to be sold by retail as the prescription of a R.M.P. only”. The license to produce ‘Triomune’ referred to it as a ‘formulation’, rather than a generic product.
During the period October – December 2003, WHO developed its Prequalification Program and placed ‘Triomune’ on its list of approved products, along with many other ARVs—all produced in India. Each of them had been reversed engineered from patented products. None of them had been approved by any stringent regulatory authority.
One of Dr. Kim’s innovative aspects in implementing ‘3 by 5’ was a method for urgently training tens of thousands of community health workers to support the delivery and monitoring of HIV/AIDS treatment. On paper, this seemed to make sense. Yet, it made no mention that the Organization had extraterritorial powers to subordinate the licensing authorities of one of its Member States: India. When WHO itself approved ‘Triomune’, as well as all other ARVs on its Prequalification Program, it issued this Disclaimer: “not warranted for safety and/or efficacy if used in the treatment of HIV/AIDS patients”.
By May 2004, five months into ‘3 by 5’, WHO had to de-list 18 of the ARVs on its Programme, and another 18 by September, all from Indian producers. In a press release, WHO explained the reason: lack of proof of bioequivalency”. However, WHO did not conduct any post-marketing surveys among those that had been using these ARVs to determine if any patients had experience adverse reactions—a standard requirement of stringent regulatory authorities.
There was an autocratic bent to ‘3 by 5’. South Africa was the epicenter of global AIDS. Dr. Kim and WHO assigned it a target of treating 375,000 AIDS patients by the end of 2005. In July 2005, they publicly took issue with progress in South Africa, complaining that a reason why ‘3 by 5’ would not meet its target was due to the failure of the government to follow WHO guidelines on numerical targets set from Geneva. This provoked an unusual public response from South Africa’s minister of health, who stated: “WHO had not consulted with South Africa on its plan and that her country was not chasing numbers but treating AIDS patients responsibly”.
In 2006, after ‘3 by 5’ had closed down, PEPFAR, the Global Fund, and the UN/AAI Program announced that they had been able to put 1.571 million AIDS patients under ARV treatment. In WHO’s final report on ‘3 by 5’, it was difficult to find any in this number which specifically could be attributed to the WHO program.
The entire failure of ‘3 by 5’ can’t be blamed on Dr. Kim. He isn’t the first senior executive of that Organization that couldn’t herd 189 Member States in the desired direction. Yet, as a clinician without peer when it comes to the provision of therapies in resource limited settings, it is rather inexplicable that he could occupy one of the most senior positions in ‘3 by 5’ and recommend the use of ARVs that had no known regulatory standards. His micro-experience with MDR-TB didn’t translate into a macro-application with global AIDS. If Dr. Kim is elected to be the World Bank’s next president, we may well see increased efforts for a “BRIC” Bank to handle the pressing finance and infrastructure needs of emerging economies.