The Moral Choice of Optimism

When doctors Jim Yong Kim and Paul Farmer began treating patients with multidrug-resistant tuberculosis (MDRTB) in Peru in the mid-1990s, virtually no one wanted them to do it. The official guidance from the World Health Organization and other health agencies was that the drugs required to treat resistant forms of TB were too expensive and the treatment process too cumbersome to bother. 

But Kim and Farmer – who met as medical students at Harvard and together launched Partners in Health, a nonprofit dedicated to treating the world’s poorest citizens – wanted to know why. 

“I asked a very simple question of the people at the WHO who said the drugs are too expensive. I said, do you know if the drugs are off patent or on patent? And they didn’t know,” Kim recalled during an April 15 event hosted by the Duke Global Health Institute. “My jaw dropped. I said, you mean you just declared a death sentence for everyone in the poor world living with MDRTB, and you don’t even know if the drugs are generic?”

Kim, the former president of the World Bank Group, said the encounter was an example of Farmer’s willingness to buck conventional wisdom in his relentless efforts to advocate for the poor. By working to expand production of generic TB drugs, Farmer’s team helped reduce the costs of the medications by 90 percent, erasing any doubt that drug-resistant TB could be treated affordably in low-income countries. 

But Kim said it also illustrates the need for global health leaders to think more ambitiously about what they can do to improve the lives of vulnerable people around the world. 

“When you are faced with poverty and disease … optimism is not the result of didactic analysis,” Kim told an audience of more than 250 faculty, staff, students and alumni in Duke’s Karsh Alumni and Visitors Center. “Optimism is a moral choice.”

The event, the eighth annual Victor J. Dzau Distinguished Lecture in Global Health, highlighted the 40-year collaboration between Kim and Farmer, who graduated from Duke in 1982 with a degree in anthropology and went on to lead one of the most innovative and influential organizations in global health until his death in 2022. During the 75-minute conversation, moderated by DGHI deputy director Wendy Prudhomme O'Meara, Kim described Farmer as “one of the most fully formed human beings” he’d ever met and credited the interdisciplinary education Farmer received at Duke for inspiring Partners' life-saving work around the world. 

“So many of the roots of what we built at Partners in Health came from here,” Kim said. He quipped that Farmer came to Duke with hopes of being “a rich doctor,” but left with a moral calling. “So Duke did that to him, and did that for him,” he said.  

Farmer’s studies in philosophy and cultural traditions allowed him to think expansively about how to deploy his medical training in the world, said Kim, who like Farmer earned a Ph.D. in anthropology alongside his clinical training at Harvard. “Paul used to ask me, ‘With our ridiculously elaborate educations, what is the nature of our moral responsibility to the world?’”, Kim recalled. 

Such fundamental questions shaped Partners in Health’s mission as a voice for the forgotten, Kim said. From the organization’s launch in 1987, it was clear “we’re never going to be on the winning side,” he said. “We’re always going to stand with the losers. We’re always going to be trying to do things that most people think are impossible or shouldn’t be done.”

Farmer again chose optimism in the face of extraordinary odds when he became one of the first and loudest voices calling for wider HIV treatment in poor countries, Kim said. Along with Kim, who led the WHO’s HIV/AIDS program in the early 2000s, and others such as Anthony Fauci, Farmer helped make the case for President George W. Bush’s 2003 launch of the President’s Emergency Plan for AIDS Relief (PEPFAR), which is credited for saving the lives of more than 26 million people with HIV worldwide. 

“I’d say that Paul was the most important person in making that transition happen,” said Kim, relating how Farmer showed Bush pictures of people whose lives had been saved by HIV treatements in Haiti. “So Duke, through Paul Farmer, has really helped avert a disaster of historic proportions.”

Kim later became the first physician to lead the World Bank, where he oversaw unprecedented investment in global development projects aimed at reducing poverty. He now serves as chancellor of the University of Global Health Equity in Rwanda, an institution launched by Partners in Health in 2015 to provide medical education to underserved communities in sub-Saharan Africa. 

Throughout his career, Kim said his priorities have been shaped by reflecting on what problems and conditions future generations will find it hard to accept that societies allowed to persist. He described access to mental health services as one such area, noting that he is working to improve access to suicide prevention and treatment for mental illnesses. 

“I think it’s a good thing to ask yourself: Are you working on those things that in 15 years or 20 years, people are going to say, ‘Can you imagine that they allowed that situation to happen?’ I’m still trying to do that, to work on these seemingly intractable problems that require our attention,” he said.

Kim acknowledged that the massive reductions in U.S. funding for global health and foreign aid programs present significant obstacles to maintaining momentum on those goals. But he advised global health researchers and students to remember how Farmer was undeterred by scarce resources or opposition, believing progress was possible even in the worst of circumstances. 

“The only chance we have is to choose to be optimistic,” he said. “As bad as it gets sometimes, I always remember that.”

In addition to giving the Dzau lecture, Jim Yong Kim made several stops to meet Duke students, faculty and staff during his visit to campus. The day included a discussion with students in a class on health systems in low-income countries, part of DGHI's Master of Science in Global Health program, and meetings with DGHI and Duke leadership to discuss future collaborations with the University of Global Health Equity. Paul Farmer's wife, Didi Bertrand Farmer, and sister, Peggy Farmer, attended the event. See below for photos from the day.