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INTERNATIONAL HEALTH Community-based Program Targets AIDS, Drug-resistant TB in PeruHIV and tuberculosis are pandemic, and prevention alone will not stop them, says Jim Yong Kim, HMS assistant professor of medical anthropology in the Department of Social Medicine, chief of the Division of Social Medicine and Health Inequality at Brigham and Women's Hospital, and vocal advocate for universal access to AIDS and TB medications.
Jim Yong Kim beams with children from the shantytown of Carabayllo, on the outskirts of Lima, Peru, where Partners in Health began treating multidrug-resistant TB patients in 1994. (Photo courtesy of Partners in Health) Working in Haiti and in the shantytowns of Lima, Peru, he and Partners in Health cofounder Paul Farmer, also an HMS professor, take on daunting medical cases--patients infected with HIV or multidrug-resistant tuberculosis--and demonstrate that treatment can work even under impoverished, low-infrastructure conditions. It has been a watershed year for international public health. The new Global Fund to Fight AIDS, TB and Malaria has collected $2 billion. Drug prices are falling. Partners in Health has ambitious plans to extend its coverage in Haiti, helped by a Global Fund grant to the Haitian government of $66.9 million to treat HIV/AIDS, and it is integrating with the National TB Program in Peru to provide treatment of multidrug-resistant TB (MDR TB) throughout the country. But as money and medicines become available, the urgent question is how to ramp up delivery. Kim discussed the issue with Focus writer Anne Mahon. Focus: In Peru, Partners in Health developed a close-to-client, community-based treatment plan for patients with multidrug-resistant TB, called DOTS-Plus. This is a spin-off of the standard treatment strategy for nonresistant TB devised by the WHO, called DOTS (directly observed therapy, short course). Partners has been working with the National TB program to scale up DOTS-Plus for delivery throughout Peru. What is your long-term strategy? JK: We are investing in local infrastructure and training so that in addition to eventually overseeing its own MDR TB program, the Peruvian government will become a prominent leader in the fight against MDR TB in Latin America. For example, we are working closely with the Peruvian National Institute of Health to turn it into the first supranational reference laboratory for TB in the world located in a poor country. F: Not only do you wish to more fully integrate your initiative with the National TB Program, but the program must expand at an accelerated pace. How are you going to do this? JK: The next step, and the reason I'm optimistic that this can be done on a much larger scale, is that we are now working with Donald Berwick [an HMS and HSPH faculty member and president and CEO of the Institute for Healthcare Improvement]. What Don has done is borrow methods of quality improvement from W. Edwards Deming, a management guru. The model Deming used allows for rapid evolution of a production system to one that works economically and efficiently to yield a quality product. Don is helping us use a similar model in Peru. Soon, we will deploy these methods in Russia, Boston, and Haiti, as well. F: In the Deming model it is essential to secure a strong commitment from management. In your case this is the government of Peru. Do you have their support? JK: Yes. Obstacles are often systemic. That's why the political leadership from above is so important. The president of Peru has said he's enthusiastic. Without question, we will start this improvement cycle with the full involvement of the Ministry of Health. F: How do these improvement cycles work? JK: Don uses what he calls "breakthrough series collaboratives." Essentially, you define a specific aim for improvement then convene a group of experts and others familiar with the system. They work together to find innovative solutions. In our case, these insights might come from a community health care worker in Lima who has experience with all aspects of the problem or an international expert on MDR TB, or a local physician. It's a method for sharing innovation with a large group of people in a very intensive way to speed up the learning process. Through short cycles of incremental change we can rapidly improve infrastructure. F: Some health care professionals believe that the most efficient way to ramp up to AIDS treatment is by using the existing health care system. Are you going to use the MDR TB program in Peru to treat HIV also? JK: Yes. In Haiti we're essentially utilizing our TB program to treat AIDS patients. And I think there's no question that TB and HIV programs have to be extremely closely intertwined. Whether they can be the same program is a political issue and also a question of disease burden. Because the Peruvian Ministry of Health is trying to take apart all the vertical programs and make an integrated health system, my suspicion is HIV and TB will be very closely linked in Peru. We've been working closely with the ministry on both of these issues. F: To mount the effort necessary to fight global disease, you have said we need the kind of national mobilization of resources and intellect that made it possible to put a man on the moon. What will it take to generate the kind of enthusiasm for international health that Americans felt for the space program in the early 1960s? JK: The devastation--that and the innovative system we've adopted to rapidly integrate with the Peruvian TB program. We're going to have health care workers sitting inside a hovel with a blue plastic roof studying a flow chart that could have come out of ALCOA. It will be the heartbreak of AIDS orphans combined with the rationality and familiarity of state-of-the-art management science that will get the money flowing. This is my hope anyway. |
