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What was the goal of the ‘3 by 5’ campaign?The goal was to create a global target for HIV treatment. At that time, President Bush’s PEPFAR initiative [the President’s Emergency Plan for AIDS Relief] had already set the goal of treating 2 million people by 2008 in 15 countries. While that was a very important first step, we felt that the entire world needed a goal. Having worked with specialists in health care delivery and health care quality improvement, I understood that it was very difficult to accomplish something if you didn’t have a time-limited goal. The World Health Organization had not really taken a firm stand on what a treatment goal should be. The institution as a whole was sending out mixed messages; there were articles coming out of the WHO saying that prevention, as a whole, was more cost effective, so we should focus mostly on prevention. So, we launched the ‘3 by 5’ initiative in September 2003 to clarify our position and encourage countries to take action.

Has the goal been achieved?The goal was not achieved by the end of 2005. It was a great

disappointment that we hadn’t reached it; we had only gotten about halfway there. But, remarkably, it was achieved by the end of 2007. Many analysts have suggested that the momentum that was gained by ‘3 by 5’ really led to the achievement of ‘3 by 7’. Missing by two years is about as well as the WHO has ever done in reaching a global target. The investment in HIV treatment is the largest we’ve ever made for health care in Africa. And because HIV requires chronic management, we have an opportunity to build primary health care systems on the back of all this investment. That’s precisely what we have to do in order to make good on our promises for HIV treatment.

You went from being a champion of universal AIDS treatment at the WHO to being an advocate for health and human rights at Harvard. What led to the broadening of focus?I feel that I was advocating for health and human rights long before I went to the WHO through my work at Partners in Health. Our particular take on health and human rights has been more focused on

Straight talk with…Jim Yong KimFrom his early years as a medical student at Harvard University to his job as the director of the HIV/AIDS unit at the World Health

Organization (WHO), Jim Yong Kim has worked toward building health care systems to provide care for poor people on a global

scale. In the late 1980s, Kim worked with a team of doctors from the Cambridge, Massachusetts–based nonprofit Partners in

Health to upend conventional wisdom on treatment for drug-resistant tuberculosis in the shantytowns of Lima, Peru. The team’s

campaign brought the price of tuberculosis drugs down about 90%. Kim, a physician who also has a doctorate in medical

anthropology, says that the success helped overturn the notion that the disease could not be treated in such a poor setting.

While at the WHO, he turned his attention to AIDS. In 2003, amid much skepticism, his team launched the global ‘3 by

5’ campaign, an ambitious movement aimed at providing antiretroviral drugs to 3 million people worldwide by 2005. Today,

Kim leads the François-Xavier Bagnoud Center for Health and Human Rights at the Harvard School of Public Health, where

he oversees programs to address health issues plaguing poor childrenóespecially those afflicted with AIDS. Kim discussed the

current state of universal AIDS treatment and the role of biomedical research in promoting social justice with Prashant Nair.

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Q & a

nature medicine volume 14 | number 12 | december 2008 1299

ensuring social and economic rights, as opposed to civil and political rights. For a long time, the health and human rights community has been focused—rightly and effectively—on civil and political rights. But, if we really believe in health as a human right, what are we actually doing to realize that right? In other words, what are we doing to make sure that people have access to clean water, to housing, to employment and to health care?

Our group has been working on the day-to-day, nitty-gritty, practical requirements to ensure that people have access to those rights. We’ve done that in country after country. Many people misunderstand the commitment to HIV treatment as overly focused on medical treatment. The struggle for HIV treatment forced us to think about chronic care for chronic conditions in the poorest countries in the world. Thatís really the beauty of it. For me, getting the world to declare its commitment to HIV treatment is one of the greatest victories for health as a human right.

Before returning to your alma mater, Harvard, you worked as a physician and as an anthropologist. Has that research background shaped your role at the Center for Health and Human Rights?

Absolutely. I feel like a medical doctor most of the time, but I feel like an anthropologist all the time. Anthropology teaches you how to step back from your own way of seeing things. My training as an anthropologist was far more important to me than my training as a physician when I worked at the WHO, one of the most complicated bureaucracies in the world. The task of anthropology, which is to understand deeply and to find a path toward empathy for people who have very different perspectives from your own, is both difficult and critically important in organizations like the WHO.

What do you hope to accomplish in your present role?A very important issue for us is to ensure that children are not forgotten in the response to HIV. We’ve just completed a major effort with academics, community activists and people living with HIV from all over the world called the Joint Learning Initiative on Children and HIV/AIDS. We found that the money for HIV [treatment] is not reaching children and that the responsibility for caring for orphans and other children affected by AIDS has fallen almost completely on families and communities. Despite vast expenditures, the money has not been reaching the families and communities who are holding up the sky in terms of caring for these children. So, bringing children, their families and their communities back into focus is very important. We must find ways to move money directly to them instead of allowing it to be diverted into some of the large [nongovernmental organizations] that live on foreign aid.

What is the role of basic biomedical research in achieving your goals?I’m encouraged to see that basic science research on the problems in developing countries has grown. We have the [US National Institutes of Health] and the Bill and Melinda Gates Foundation to thank for that. If there’s one area that I would point to where we need much more investment, it would be in finding new drugs and diagnostics for tuberculosis and other so-called neglected tropical diseases.

But we’ve not taken seriously enough another area of research thatís not quite as sexy as basic biomedical research. Thatís operational researchóthe kind that engineers and management

scientists might do to improve our capacity to deliver health care effectively. For example, what are the most effective health system designs and implementation strategies to provide comprehensive HIV services in Africa? That’s a different kind of research. It involves fields like engineering, anthropology, management and strategy—fields that have not really had an impact on global health. Our community of scientists should now

embrace research around systems issues in developing countries. That’s the big hole we need to fill.

Won’t the current economic downturn put a damper on those efforts?There will be strong voices that say because of the current financial crisis we can no longer invest in health care for the poorest people, whether in our society or that of others. That’s a fundamental mistake. The economic downturn will force us to move even more quickly toward collaboration with experts in systems management and operational strategies. Whatever money is there—and I suspect there will be a significant amount—will have to be spent more effectively. We have to rethink how American aid is structured. We lose a lot of money in overhead and consulting costs. That money could be used in providing services.

The global community looks to the US for leadership in science, especially for funding of science. I’m encouraged that the next president of the United States has pledged to double government investment into scientific research. Basic scientists, applied researchers and operations researchers have a unique opportunity to work together to solve some of the most vexing problems of our time. If our voices are unified, I think the new administration is going to hear us.

One of the UN Millennium Development Goals is to raise $30 billion to save 10 million lives by 2015. Is that achievable in the present economic climate?I’ll make this argument as loudly as I can: the commitment to the millennium development goals has to be seen as one of our responses to the financial crisis as opposed to a luxury that has to be cut out because of it. This will be our most important investment to ensure productivity and political stability in the world.

Can medical research contribute to social change on a global scale?It already has. The combined response of the AIDS activists, the US

government, the US National Institutes of Health, the drug companies and the UN system to a particular virus is going to be remembered as one of the most extraordinary set of events in human history. We should work to repeat that story for other problems, like tuberculosis, maternal mortality and other problems of the poor. Harnessing science for the good of all humanity, including the poorest, is one of our most cherished values—and the

good news is that with HIV, we’ve shown that it is achievable.

The commitment to the millennium development goals has to be seen as one of our responses to the financial crisis as opposed to a luxury that has to be cut out because of it.

My training as an anthropologist was far more important to me than my training as a physician when I worked at the WHO, one of the most complicated bureaucracies in the world.

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