The squabble between Johnson & Johnson and Medicines Patent Pool last week was another episode in a debate about when, where and how much for-profit pharmaceutical companies should contribute to non-profit causes related to human health.

J&J declined to make three HIV/AIDS drugs available to the patent pool, which would allow generic manufacturers to produce medicines in a less expensive fashion for patients in the developing world.

The Inquirer story is here and there was a bit more in Friday's PhillyPharma post. The full J&J statement from the company's Will Stephens is here. But, briefly, J&J said it has a batch of programs to deliver medicines and vaccines to troubled populations for less money and has agreements with generic manufacturers. It also says that without advanced health care facilities in many areas fighting the diseases, J&J couldn't be sure its drugs would be delivered properly.

Speaking of delivery, one of the very smart people with views on, and experience in, health care is Dartmouth president Jim Yong Kim, who is a medical doctor with a Ph. D. in medical anthropology. A former director of the department of HIV/AIDS with the World Health Organization, Kim spent years with various organizations and Harvard Medical School, helping fight infectious diseases such as HIV/AIDS, tuberculosis and malaria around the world. Through the non-profit Partners in Health, he also worked with programs in Boston neighborhoods.

While with the WHO, Kim worked with Eli Lilly and Co., Harvard/Brigham and Women's Hospital, Partners in Health, the Centers for Disease Control and Prevention and the International Red Cross, among other groups, on a partnership to fight drug resistant tuberculosis, which often infects some of same populations as HIV/AIDS.

Kim pulled together parts of Dartmouth to begin a program on improving how health care is delivered with hopes of improved outcomes at lower cost. In an interview with the Inquirer in July, Kim shared thoughts on Big Pharma's involvement in world programs, the U.S. health-care debate and how much Big Pharma must share in any sacrifice for a common solution.

"I worked very closely with the pharmaceutical industry in the past and I worked on specific issues," Kim said. "I worked with Eli Lilly and Co., which was an incredible champion. They invested $150 million to help tackle the problem of drug resistant TB and they had zero financial interest in it. They did it because they were good people. Seriously. The companies that make HIV drugs were a little resistant at first, but my goodness, they have come around and made enormous donations for causes in developing countries. I would argue that in terms of global citizens, there is not a single industry that has done more.

"I'm not an expert on the pharmaceutical industry, but they say that if they can't make the profit in the U.S. and Europe, then they are not going to be able to make new drugs. We should reform the health-care system [in the United States] so dramatically over time that we'll set the terms of the debate. If the health-care system is getting better, it doesn't necessarily mean the pharmaceutical industry is getting the better or worse of it. It could be that a lot more of the problems we see are dealt with on an out-patient basis with medicines.

"One quick example. We worked on a project in a Boston neighborhood where poor Haitian, Creole-speaking patients did much worse with HIV than white patients. We instituted a community health worker program. The community health worker visited them in the their homes every day to make sure they took their medicine. If they take their medicine, it often means they stay out of the emergency room and don't get all of the opportunistic infections that people can get in emergency rooms. What happened? Hospitalization costs dropped dramatically, by more than half, and the pharmaceutical costs went up. But that is a good thing. In health-care reform, I don't think it is a foregone conclusion that this industry has to be 'terrible' or that industry has to go down. We have to start the conversation.

"The pharmaceutical industry has to continue to make great drugs. We want to make the health care system work so well that the nature of the market will be clear. There will always be a market for Viagra. If they find a way to grow hair, there will always be a market for that and there will always be a market for cardiovascular drugs."

Kim said pharmaceutical companies do fine providing drugs when there is a rich-world market, but there has to be a solution for problems when there is little or no profit to be made.

"I don't agree with the idea that 'If Pharma just lowered their prices, everything would be fine.' I don't think that is true at all. It would be great if drugs were affordable for everyone. I believe that very much. But there is no one single answer to the problem of the health care system. How many times do you hear people say, 'It's simple," or "If you just did this, everything would be fine,' or 'If you just had ACOs or just changed the incentives.....' Come on. If it were that simple, at $2.7 trillion, we surely would have done something to make an impact. But every time we change the incentives, people change their strategy to make the most out of new conditions.

"If I was to make one point, it would be this: Policy is important, but not sufficient. Research is important, but not sufficient, policy research especially. What we need are new kinds of people who approach the problem in fundamentally different ways. Bring systems engineers into the mix, operations folks, anthropologists and sociologists, but it's not just one of those. It's all of those, working together to shift in a fundamental way the problems of delivery."