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we’d achieved for our patients. This effort to link praxis and policy
started on the local level. For example, our work with Haiti’s national tuberculosis and AIDS programs in the late eighties began in a handful of towns and districts. A few years later, thanks in large part to Dr. Jim Kim, another founder of Partners In Health and then also a Harvard faculty member, and to Dr. Jaime Bayona, a Peruvian colleague, we became more engaged in international health policy debates about tuberculosis, including the more difficult-to-treat forms of drug-resistant tuberculosis. “Difficult-to-treat” did not mean “untreatable,” we argued, again and again, in meetings and in obscure medical journals. 2 Unlike many in the international agencies we sought to persuade, we had direct clinical experience treating patients with drug-resistant tuberculosis, and we could claim some degree of authority thanks to high cure rates in Haiti and Peru.
    These debates led us to Russia, which was facing epidemics of drug-resistant tuberculosis, as the United States had faced a few years prior. In Russia and elsewhere in the former Soviet Union, these epidemics were large and were proving especially deadly inside prisons. 3 The financier-philanthropist George Soros had donated more than twelve million dollars to provide tuberculosis care in Russian prisons. He’d asked our team to help because conventional treatment approaches were failing to cure patients with drug-resistant strains. But the program as conceived still did not have enough financing for second-line medications (needed to treat drug-resistant tuberculosis) or enhanced lab capacity, which would permit clinicians to discern which patients needed such drugs. When we asked Soros for more money, instead of saying yes, as we expected, he said no. It would be a mistake, he explained, to let governments off the hook.
    It was this work (and Soros himself) that led me in the 1990s to visit the White House, where Hillary Clinton became a patron of our efforts to raise the standard of tuberculosis care in Russian prisons and elsewhere. (TB was not a regional epidemic, but a global threat.) She soon also became a friend and mentor. Over the next decade I saw firsthand how high-level policy interventions could open up new—and sometimes vast—possibilities for improved delivery of services to the poor and marginalized. In one prison in western
Siberia, we worked with the Russian Ministry of Justice, to bring case-fatality rates from 26 percent (more than a quarter of those on treatment died) to close to zero within two years. 4 The drugs were expensive, but they worked, and better planning and pooled procurement would drive costs down further. In its first year of operation, the Gates Foundation supported an ambitious program to scale up these complex interventions in Peru while also augmenting efforts in Russia.
    The tuberculosis pandemic was one complex health problem among many, and neither Russia’s prisons nor Lima’s slums were the world’s poorest settings. Other epidemics were spreading in Africa, even as science gave us new tools to fight them. By the close of the millennium, it was obvious that we needed a radically different approach to the health problems of the poor. Existing models were premised on the idea that public health and medicine should be cheap. But these anemic approaches wouldn’t do much to lessen the burden of disease on the poor. Those on the front lines encountered millions with AIDS and tuberculosis and malaria, and also every imaginable cancer and noncommunicable disease. Because these patients were poor before they became sick, we needed something other than fee-for-service models. We also needed heavy investments in infrastructure, training, and direct services, especially for the bottom billion—the poorest and most marginalized. Implementation was the biggest challenge—and figuring out how to finance