Q&A: Behind the Bill & Melinda Gates Foundation I

Shannon O’Leary talks with Tadataka “Tachi” Yamada, M.D., president of the Bill & Melinda Gates Foundation’s Global Health Program


So, what’s the state of global health as of 2008?
“The challenges are enormous and probably the statistic that best exemplifies the challenge is that each year 9.7 million babies die, mostly for unnecessary reasons because they have curable or treatable problems. That’s the best gauge of the challenge we have in front of us, globally. Most of those 9.7 million are in the poorest nations of the world. If you take the poorest third of nations in the world. So this is a big challenge for us and what drives me every day in thinking about what we have to do and it gives me a sense of urgency to do something.”

“Have you made progress?
Yes, we have. For example, our investments in the global alliance for vaccines and immunizations have resulted in an estimated 2.9 million lives saved since the year 2000. This is one of our largest investments and one of the earlier ones…we’ve made a total investment of $1.5 billion either spent or committed. $750 million for the first five years and $750 million for the next 10 years after that. So, that’s an investment that’s paying off and we’re delighted by it. It all goes to vaccine. The global alliance for vaccines and immunizations takes vaccines that are available for common diseases, hepatitis, yellow fever, new vaccines for thing like pneumonia, diarrhea, there’s a rotovirus vaccine for infant diarrhea. Infant diarrhea is a big problem, it kills some 20 percent of, it accounts for 2 million deaths roughly. So there are many, many causes of death, but one of the best interventions is a vaccine because it’s relatively low cost and it prevents death rather than treat patients once they get sick.”

“We made investments in different kinds of interventions. For example, we have large intervention programs to try to prevent the impact of HIV/Aids. One of our largest programs is a program calledThe Avahan Initiative, which is program that takes vulnerable populations, female sex workers, men who have sex with men and IV drug abusers and it’s a counseling community empowerment treatment campaign to help prevent the spread of HIV in one of the most populous countries in the world. In India for example many people in this population group were stigmatized so they couldn’t seek help, they weren’t empowered to practice safe sex, when they got into trouble they had nowhere to go and so I think the idea is if we can empower these people to do the right thing, they will do the right thing. If we also supply them with the tools they need to do the right thing. The jury’s out yet, we’ve been doing this for a few years. This is a program I think is in its fourth year now, it’s about to finish up next year. The first five years were to set up the program and the next five years that we’re now going forward with is one that’s meant to complete the program by handing it off to the Indian National Aids Coordinating Organization, which is going to assume all the functions we set up for this program. They like it and feel its effective and are going to take it on themselves.”

How do you decide what to fund?
“What we try to do is focus on problems that cause the greatest burden of illness in the poorest nations in the world and receive the least amount of attention. So that’s where we focus our investments. What we try to do is make sure that existing treatments that work are broadly available. The unique aspect of the Gates Foundation is that where there are no effective solutions, we can invest in the research to create new solutions. So, for example, we’re very heavily invested in HIV vaccines, in malaria vaccines, various diarrheal vaccines. These are all very important preventions and largely overlooked by the pharmaceutical industry. So we’ve made the investments to ensure that that kind of research goes on.”

“HIV/Aids is a huge problem causing a tremendous burden throughout the world and India was one of the places where the epidemic was one of the largest number of new cases. Between South Africa and India, these are the two countries that have the greatest burden from HIV, so this is where we focused on India. In South Africa it’s been a little more difficult because there are some political issues that prevented from doing a substantial program in South Africa.”

“India’s such a big country. There’s this tremendous disparity between the rich and the poor in India. If you just take roughly a quarter of all the children that die unnecessarily, die in India. Roughly a quarter of all the mothers that die in the world giving birth, die in India. 45 percent of all the unvaccinated children in the world are in India. So this is a big country, with big problems. It is like many countries in the world that have one part of the country that has a vibrant, aggressive and productive economy, but a large part of India still has issues.

“Similarly in China. There are a large number of people in China that are not well cared for from a health standpoint. We have a project right now that’s a joint project with the Chinese government on HIV/Aids prevention. The Chinese recognized that there was a problem and it was particularly important because there was an Aids outbreak because of some contaminated biological products that were being used and, as a result, people in a certain part of China had this big outbreak. There was a public outcry. The Chinese of course recognized how important this problem could be and started to take steps to address it, but recognized that they could very well use a partner like us because we had credibility in the field. It’s not really our money, so much as our expertise that they were looking to tapping into. They were seeking help from us that was technical in nature but also sort of strategic planning element, and I think we give some credibility to the Chinese government, in the terms of the seriousness with which they’re trying to address this HIV problem.”

Does the foundation’s credibility make your job easier?
“Absolutely. This foundation has broad credibility throughout the world in a way that I would not have guessed would happen. To begin with, it’s a foundation set up by a couple, one of the richest couples in the world, built on a sort of capitalist fortune. But I think the co-chairs, Bill and Melinda, have gained credibility throughout the world with the sincerity of their endeavor and the seriousness with which they were going to pursue some of the world’s toughest problems. I believe governments all over the world have recognized how important a model this is and how we are unfettered by many impediments that keep governments or multi-lateral agencies from doing what they’d like to do because we’re not tied to political issues. We’re more free and we can move quicker. We’re not tied to a past that we cannot escape from. And we don’t’ have any bureaucracy, well we have some bur., the decision tree for major investments and major programs here is a very short tree and it’s very easy to take a well thought out plan and get it approved and funded.”

Do you think your peers in [global heath] are jealous?
LAUGH “I can imagine there might be some jealously….People tell me I have the best job in the world and I have to agree with them.”

“There’s a lot less bureaucracy here than almost any other place that I’ve worked and what’s really wonderful about this place is the people we have here, and these are people from all over the world, most everybody is what I call quote ‘volunteer’ unquote. In other words they could be working elsewhere for more power, more money. But they’re here because they’re tied to a mission. What we’re trying to do as exemplified in these 9.7 million babies lives and that’s what drives us everyday. The rewards are unselfish rewards and that unselfishness comes out in almost every interaction I have during the day, and the willingness to be rationale about what we’re doing, to be questioned and accept the questioning because we’re all in this to try to improve people’s lives. The stock price is how many babies don’t die anymore.”

“These things take time. There was recently a report in the Lancet and also corroborated by some data from Unicef that this number of 9.7 million had come down from 16 million just a few years ago. So it is going down and I think we are making progress. Things like measles vaccination for example. In Africa, the overall vaccination rate is up to like 70 percent or so. I mean that’s pretty good when you consider how resource poor, how logistically difficult, these countries can be.”

“We don’t ever try to take the credit. I wish I could say, ‘we did that.’

“One of the things that I am trying to do within the foundation is to help our program officers, and other people who work in the foundation, link their daily activities to a certain subset of lives. So, let’s say I’m working on pneumonia and a one-third of pneumonia is caused by streppococcis pneumonia and I’m working on strep pneumonia vaccine, and I know that pneumonia kills about 2 million babies and one-third of those 700,000 babies die from strep pneu vaccine, that leaves about 2,000 a day. So if I can get that pneumonia vaccine out one day earlier, I’m saving 2,000 lives. One day later and I’m losing 2,000 lives. So it’s a way of linking what we do every day to a cost and a potential benefit. So when you start getting into political arguments, you say ‘well, what are we doing? We’re just wasting time because we’re losing lives while we’re wasting time arguing.’ ”

What role does research play in your work?
“The problem with most people is that they don’t fully appreciate the cycle from an idea to a product could be 15 years. So that’s why you get a lot of this excitement and then it fizzles out. It’s an unfortunate aspect, but making a new intervention, whether a medicine or vaccine is very hard. It’s one of the most difficult of all human endeavors. Most of the time, you fail. About 1 percent of all the ideas that are even taken up as worthwhile by a pharmaceutical company ends up as a product. Ninety percent of those ideas fail before they even get in demand, and of those products that get in demand, 90 percent of those products fail. So you have to be resilient, you have to be resolute and you have to be tough to do this sort of work.

You know, we’re going into it recognizing there’s a lot of challenges in front of us. We recognize how difficult it is, but we’re here to stay. We’re going to find an HIV vaccine, we’re going to find a malaria vaccine, we’re going to really make a big impact on TB through vaccines. We’re committed to new diarrheal or pneumonia vaccines. We may not be able to do it tomorrow, but we’re here for the long run.”

“There’s a malaria vaccine that we’ve had a big part of funding. This is with Glaxo Smith Kline...They’ve now done Phase II [company] trials of the vaccine that looks like it’s 65 percent effective in term of infants. It’s not perfect, but it’s not a bad start when you consider a million babies die…65 percent efficacy means you can save 65 percent of lives. That’s 650,000 lives. That’s a lot. That’s 2,000 lives a day and I’m OK with that.”

“We are jointly funding this, the company provides some money and we provide some money.”

“So many other [pharmaceutical] companies have now gotten it, if you will. Many other companies have understood what their responsibility in society is. We partner with these companies and Bill Gates calls this sort of thing ‘creative capitalism,’ this kind of commitment will help the world, but will also help the companies, whether it’s in reputation, whether it’s in inspiring their staff or motivating them, whether it’s real material gains potentially or whether through incentives that we can build in to reward the companies.”

What are some of the other problems you’re tackling?
“Nutrition, for example, is a very big area. In many countries of the world, there are tremendous malnutrition as measured by stunting in children, they’re short, smaller. And these children have a life-long problem, if they’re not addressed in the first 2 years of life. They are more likely to die obviously, they don’t respond as well to vaccines because they’re immuno-comprised, they go on to develop bigger problems. Paradoxically, they’re more prone to being obese in the future. They get diabetes, obesity and heart disease and people have done these studies and they’re income is two-third of somebody who isn’t stunted. Here we’re really focusing on what we call micro-nutrients, getting not just calories, but the right kind of calories. We’re focusing especially on the first two years of life where everything makes a difference. If you can get them in the first 2 years of life, you’re going to do better. But if you have malnutrition in the first 2 years of life then that’s when you have the problems that last for a long, long time: reduction in IQ, reduction in income, reduction in a healthy life, essentially.”

“We have a partnership, an organization we created called the Global Alliance for Improved Nutrition and what they really are focused on is food fortification. So they try to increase the span of the number of people that have access to fortified food, whether it’s iodine, which all of us have iodized salt (so we don’t have goiter, cretinism or the kind of problems you used to see in this country), vitamin E, vitamin A, for example, or iron or zinc. So what this organization tries to do is to ensure that this supplementation is made broadly available in countries. Take Ghana, for example. In Ghana there are three companies that make wheat flour and we negotiated with them and now all three companies now fortify their wheat. The big problem we have is that they buy their wheat from the US and Canada and the cost of the wheat has skyrocketed because of the cost of fuel and also because of bio-diesel taking it. So the cost is going up, which means fewer people are buying the wheat fortified. They’re buying their own local grains which aren’t fortified. We’re just really trying to address this problem.

Where else are some of the biggest health crises?
“Countries in sub-Saharan African are big problems. India is another big country with lots of people and lots of difficult problems of malnutrition and infectious diseases and high maternal and child death and so on.

India’s a big country. I’ve been there several times and it’s a big challenge that we’re looking at. South Africa: big country, lots of problems. It’s more frustrating there because we don’t have an active collaboration by the government. Up until now the government has been very reluctant to appreciate that there’s a big HIV problem and we know it’s a big problem. The total number of HIV patients in South Africa is as large as the total in India. They’re both right up there: number 1 and number 2.”

“There are other countries where we’ve gone in, and Zambia is a country with a big problem with malaria and we’ve gone in. We’ve had a big malaria prevention program and it looks like it’s actually having a significant effect and we’re really pleased about that. We set up this program called Mosefa (SP?), which is a comprehensive malaria prevention and treatment program and we’ve worked very closely with the government. Provided technical assistance and eradication and control strategy and it looks like it’s paying dividends. And now we’re looking at how to spread that knowledge to other countries that are equally afflicted with the problem.”

“We look at where the biggest problems are and often what we’ll do is we’ll try to create a solution one place and if it works, we’ll spread it out elsewhere. So we did this malaria control program with the [Zambian] government and it looks like it’s been very successful. Now we’re planning to go to 3 or 4 other countries with a similar program in Sub-Saharan Africa.

“I think we bring large resources to the table where there were very few before. We really believe in an active partnership model in the way we do things. We work often with other players like the WHO and Unicef, along with bi-lateral donors, like the UK, France or Canada or Spain and these countries that are all trying to increase the amount of development assistance that they provide. So, A, we bring a lot of resources and, B, we catalyze other resources and work closely in partnership and, C, we have just great people working in the foundation who have a lot of experience and a true commitment to what they’re doing and I think a disciplined, business model for how we do our jobs. I think inspired very much by the co-chairs Bill and Melinda.”

What’s the day-to-day of your job?
“Many of my days are focused on group meetings to discuss strategy. So, I had a group meeting today on infections, diarrhea. I just had a group meeting today, an hour and a half, on pandemic flu. I had a group meeting on India strategy and what we’re going to do in India. I’ve had a number of different one on one conversations. I’m involved with advocacy…I will spend a good deal of time traveling and when I’m traveling I meet with grantees, I meet with partners and I meet with our advocacy partners, whether it’s the media or political figures or the like.”

“For example, recently I was in Gautemala and I met with top government officials about some of their biggest problems occurring in their indigenous populations. I will go to India and meet with their top officials their. The health minister of India came here. So we meet with government officials from recipient countries as well as from donor countries.

What’s your relationship with PATH and other Seattle organizations?
“PATH is one of our largest single partners in terms of grant funding. They do many different things for us. From running very important product partnerships, like the malaria vaccine, for example, and the diarrhea vaccine, to doing real trials of integrated health solutions and interventions. PATH is a partner with us also on the malaria control initiative in Zambia.”

“We at the Gates Foundation don’t do anything ourselves, we usually work with intermediaries. We give them grants and ask them to do it.”

“We have large grants with the SBRI. A very important group we give to is the University of Washington Health Metrics and Evaluation, which is a University of Washington group that we set up to measure our performance, as much as anything else.”