Interview: Gates Foundation CEO on global progress in 2018, and the biggest threat to the world’s future

As the CEO of the Bill & Melinda Gates Foundation, Sue Desmond-Hellman oversees the world’s largest philanthropy, on a mission to transform U.S. education and global health. But when asked to identify the biggest threat to the future of the world, she doesn’t point to a disease or a dictator.

“One of the biggest threats in my mind is a sense of despair and pessimism,” Desmond-Hellmann said in an interview with GeekWire. “The biggest threat to the future is, it’s youth who feel like they don’t have the opportunity to have a better life, to have a happy productive fulfilled life and to achieve something. That’s the biggest threat. Part of that threat is pessimism.”

Desmond-Hellmann cited investments in education as one key to overcoming that threat. And she said she remains optimistic overall about overcoming the challenges ahead, based in part on the progress of the past year. On Thursday, the Seattle-based Gates Foundation issued its annual “year in review” report for 2018, pointing to momentum in several key areas.
“I think the investments we make in everything ― from global health, family planning, nutrition, agriculture ― these are investments in human capital,” Desmond-Hellmann said. “Throughout history, when you invest in human capital, good things happen.”
In the U.S., the Foundation’s 2018 highlights included what could be called a reboot of Gates’ nearly two decade-old K-12 education strategy, now focusing on high school graduation leading to college or credential programs for black, Latino, and low-income students. The Foundation said it issued more than $90 million in grants as part of its Networks for School Improvement initiative. The grants went to 21 recipients in support of groups of schools working to solve common problems that can keep students from succeeding, such as middle school suspension.

Throughout history, when you invest in human capital, good things happen. I remain optimistic.
The Foundation said it grew its U.S. portfolio to invest $158 million over the next four years across the country to fund “research, data collection, and community initiatives” to combat poverty.

Globally, health remains the emphasis. The Foundation points to this year’s founding of the nonprofit Bill & Melinda Gates Medical Research Institute, a biotech organization which focuses on getting novel drug and vaccine candidates from the lab to human studies to combat malaria, tuberculosis, and diarrheal diseases. Those three, according to the Foundation, are major causes of death, poverty and inequality in developing countries.
As far as results, the Foundation says it and its partners have made what it calls “serious progress” on several fronts. For malaria, that includes Paraguay becoming the first country in the Americas in 45 years to eliminate the disease, and Swaziland nearly at that point in sub-Saharan Africa — which would be a first for a country in the region. It also cites the FDA approval of Tafenoquine, a new single-dose drug to cure relapsing malaria, which is prevalent in South America.
Bill and Melinda GatesBill and Melinda Gates visiting women in Jamsaut village in Bihar, India. (Gates Foundation Photo)
The Foundation says there were significant developments this year in new vaccines for typhoid and for rotavirus (a cause of diarrheal disease, which kills 150,000 children each year), as well as progress on major HIV vaccine trials in sub-Saharan Africa.

Unlike previous years, the 2018 year-in-review report doesn’t come in a formal letter or even a special website, but rather in a video the Foundation is distributing via social media with an emphasis on what was new during the year.
To get more insight into the Gates Foundation’s progress and plans, GeekWire’s Todd Bishop spoke with Desmond-Hellmann. Edited excerpts of the conversation are below, starting with a look at how Bill Gates’ “technocratic” approach to global health has been applied to malaria.

Todd Bishop, GeekWire: What happened in 2018 with malaria that surprised you, or continued momentum?

Sue Desmond-Hellmann, Gates Foundation: I think malaria is such a good example of this framing that Bill and Melinda use with Goalkeepers of “the promise and the peril.” The promise of malaria is just year-on-year continued advances. And in 2018, the big news was that Tafenoquine was approved.
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For me, the wonderful news in Tafenoquine is it’s the first new treatment for relapsing malaria in 60 years, and was such a milestone, and such a major accomplishment, that I actually went to Brazil for the first time ever, and traveled to Brazil to get up close and personal with the folks who’ve been working on Tafenoquine to learn why it’s so important for them.

When you think about relapsing malaria — which is the predominant malaria in the Americas — it’s the kind of malaria that hides out in your liver and can come back. The Tafenoquine medicine being approved means that there is a single-dose radical cure. That, instead of just controlling malaria, it gives the caregivers in Brazil some optimism that they can actually eradicate malaria in the Americas, which would be a very big deal.

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And so this new technical advance is the 2018 news. But the big picture news in malaria is just a combination of the history of malaria, and how it’s one of those things that people can start to think is always going to be with us.
Sue Desmond-Hellmann, CEO, Bill & Melinda Gates Foundation (left) visits the World Mosquito Program, Brazil, in Rio de Janeiro on June 19, 2018. Luciano Moreira, Project Director (right) of the program shows Sue around one of the research labs.Sue Desmond-Hellmann (left) visits the World Mosquito Program, Brazil, in Rio de Janeiro in June 2018. Luciano Moreira, project director (right) shows Sue around one of the research labs. (Gates Foundation Photo)
If you look at the history of malaria, it is one of the most interesting medical diseases ever. I don’t mean to exaggerate, but if you look at something as simple as World War II, General MacArthur was more worried about malaria than the Japanese in the South Pacific. There were battles where literally more Americans died of malaria than died at the hands of the Japanese in the South Pacific. If you look at Vietnam, China started a program during the Vietnam War that led to the Chinese scientists discovering Artemisinin as a therapy for malaria, and ended up with the Nobel being awarded to Tu Youyou, the first Chinese Nobel Prize winner in medicine and physiology in 2015.

If you look at malaria, it had a massive geopolitical impact forever, and had always been slowly going down. In 2017, there was a slight reversal in malaria progress.
And this is where the sort of technocratic piece comes in that I think is really interesting. There’s two aspects of malaria that gets us all revved up ― it’s really fun to work with Bill on the global malaria program ― one is surveillance, and also data are critical in malaria.
So just as it’s true in tech in general that you can’t rest on your laurels, you’ve got to stay ahead. We need to keep innovating to stay ahead of malaria. So we have programs in vector control, we have programs in antimalarials and we have a massive effort underway to get better surveillance and data on both malaria occurrence and resistance that are gonna help drive the promise of malaria, which is that regional elimination could take place.

What do you think could happen in 2019 based on the trends that you’re seeing there?

Desmond-Hellmann: The promise in 2019 is that with the preventive programs that are already in place and better health systems around the world, that there could be continued progress on malaria. Most of the deaths from malaria occur in sub-Saharan Africa, and most of the deaths are in kids under five years old. One of the areas of focus that we’ve been working with governments all over sub-Saharan Africa on is better methods of testing and treating kids with fevers. Some of this is primary health care. The other thing that we’re hoping is continued progress in vector control.

It seems like you’re getting more into the direct development of solutions with the Medical Research Institute. Can you talk about the decision to do that Institute and how it fits into the larger Gates Foundation strategy?

Desmond-Hellmann: We’ve been investing heavily out of research labs to do much more basic research and applied research in areas of global health. If you compare the research we fund at Gates Foundation to what a company would fund, we tend to fund things that are market failures. So malaria is such a good example of a market failure. And a market failure just simply means that if you look at all of your investments in R&D and you look at potential future markets, malaria occurs much more in poor countries than in countries who have a lot of wealth.
One of the things that we’ve observed over the years is that those discoveries moving from the bench science and the lab work into clinical trials is what pharma and biotech call ― and venture capital uses this term ― “the valley of death.” The valley of death in the private sector means that you have something that’s a “eureka” in a test tube or an animal model, and that moving from that phase of testing into humans is expensive, complicated and often a huge challenge for academic researchers.

When we looked at that valley of death for the things that we’re trying to accelerate, specifically things like malaria, we felt that the Gates Medical Research Institute could allow us to more effectively cross the valley of death to do translational work specifically in three areas where they are originally focused on: TB [tuberculosis] vaccine, malaria vaccine and diarrheal disease remedies.
One of the areas that we would love to see accelerated is an effective vaccine for malaria. The Gates Medical Research Institute can set up the assay work, the pharmacology, the toxicology. Some of what takes a lot of technical expertise not readily found in academia and work with our academic colleagues to move their discoveries more quickly towards the clinic.

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You talked about the trends in malaria, and the fact that this is really a sign that the technocrat approach championed by Bill Gates works. I know this is a divisive issue in the global health world. Is it too much to say that 2018 was the triumph of the technocrats?

Desmond-Hellmann: [laughter] I wouldn’t argue with that. There was a thing that back in the days when I was a young new manager and read some business books. One person who I read about was Jack Welch. I was never really a giant fan of his kind of aggressive leadership qualities, but the one thing that really resonated for me was that leaders really need to burrow deeply into things to understand when you’re starting to struggle with something.
One of the reasons we’re struggling in malaria is that our old tools no longer work. So that a safe insecticide that we put in bed nets, the mosquitoes are resistant to those. We need innovation to come up with safe and effective pesticides. And you can imagine something that you’re going to put in the bed nets and cover a baby’s bed has to be incredibly safe and well-tested. Innovation, in the kind of pesticide that you can put in a bed net, needs a technocratic approach.

An effective malaria vaccine, again, that’s a tool that the world would benefit from.
India Minister of Health and Family Welfare Dr. JP Nadda administers the new rotavirus vaccine Rotavac to an infant. (Research Council of Norway Photo)
The other area of great advances in 2018, it was a great year for vaccines. We saw two HIV vaccines enter clinical trials in sub-Saharan Africa. That’s a huge accomplishment in the area of vaccines. We also saw the first new polio vaccine in more than 50 years start to undergo testing, and new typhoid vaccines, and two new rotavirus vaccines. If you say the world has all the tools they need now, all these pests are going to outsmart the tools we have now and we need to keep innovating ahead of emerging resistance.
I mentioned Artemisinin. Sadly in areas in particular in Asia, there is emerging resistance to Artemisinin in malaria. We need new malaria tools. A vaccine is one way to stay ahead of resistance.
The efforts in poverty in the U.S. really stood out.

Is there going to reach a point where symbolically the Gates Foundation will say that, that is now a third pillar, alongside global health and U.S. education, in terms of your overall investments?

Desmond-Hellmann: I don’t see it as a third pillar. Here’s how I see the investment in economic opportunity and mobility. If you were talking to the folks at Robert Wood Johnson [Foundation], they would tell you that they’ve been focused on U.S. healthcare for a long, long time. They started talking about the social determinants of health a few years ago. You can’t talk about diabetes without talking about food deserts, and the ability to get exercise, and “is there a park” and “is there fresh fruit access.” I see in a similar way, our economic mobility work in some ways as the social determinants of education.
Access to a great education is the path to the American dream, of doing better than your parents did. But there is a lot of inequity in education and there are other determinants of economic mobility above and beyond education.
When we look at the differences in economic mobility by ZIP code or by census tract …

we ask ourselves, “are we getting the kind of oomph that the education work is meant to offer for economic mobility?”

We continue to believe strongly that education is the single-most important attribute. Access to a great education is the path to the American dream, of doing better than your parents did. But there is a lot of inequity in education and there are other determinants of economic mobility above and beyond education.

I see the economic opportunity work and the data that we’re trying to make available to people … as being very much complementary and extending the dream of our education work in the United States. That education work has always had the dream that no matter your race, your background, your ZIP code, your community, the education of your parents or their wealth, that you have the opportunity to have a happy and fulfilling life as an American.
What numbers do you look at to measure that? In other words, you could look at things like the median income by race, and I know especially for African American families in the U.S. the median household income has only just now recovered from the 2008 downturn.

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What are the numbers that you look at to measure that overall progress in education and the related progress in poverty?

Desmond-Hellmann: We look at a number of different measures. One of the things we look at is high school duration rates; an extremely important number is high school graduation rates. We also look at college completion rates. So, not only “are students completing college,” but the timing of their completion. We’re increasingly looking at both access and affordability, so student debt [as well] ….

I think that means and medians are really important. So I don’t disagree with the data you just cited. But there’s something about place that brings these numbers to life. When you see in King County that two census tracts right next to each other have differential rates of economic mobility, it makes one ask the question, “what’s different about those neighborhoods? What’s different about those communities?”
When we talked a year ago, you were an anomaly for your optimism, especially at that moment when I think the world was still grappling with election.

How do you feel now at the end of 2018?

Desmond-Hellmann: I remain an optimist. We just had this Goalkeepers event. The Goalkeepers event I thought was such a wonderful opportunity to take a step back and look at the big picture.
The reason I remain an optimist is, I love history. I look at things like malaria through the lens of history. I look at things like the Gates Foundation by looking at Carnegie Foundation, the Ford Foundation and the history of foundations. When I look at poverty eradication, if I look at the ’90s and what happened in China, and the ’00s in India and those who took themselves out of poverty. About 750 million people did that in China and in India.
I’m optimistic because I really believe that in sub-Saharan Africa there will be that next, third wave of people lifting themselves out of poverty. There is so much pent-up talent and passion and opportunity in the youth in Africa.
I’m optimistic because I really believe that in sub-Saharan Africa there will be that next, third wave of people lifting themselves out of poverty. There is so much pent-up talent and passion and opportunity in the youth in Africa. When I get up close and personal with people, that’s the great thing about traveling. The people I meet, the students I meet when I travel, whether it’s in Ethiopia or Brazil or in Pune, India, that’s all about human capital and human potential. I remain really positive.
I think the investments we make in everything ― from global health, family planning, nutrition, agriculture ― these are investments in human capital. Throughout history when you invest in human capital, good things happen. I remain optimistic.
There are reasons for us to be clear-eyed and have our eyes wide open on the threats to that human capital development, but I remain an optimist.

If you could identify one threat that is on your mind, what would it be?

Desmond-Hellmann: One of the biggest threats in my mind is a sense of despair and pessimism. And I mention youth. It is amazing when you sit across [from] national leaders, especially in places in sub-Saharan Africa, they are concerned about unemployed youth. They are concerned about youth who don’t have a sense of their future.
Will they be able to have a happy productive life? Will their lives be better than their parents? And I think that’s a global threat. The biggest threat to the future is, it’s youth who feel like they don’t have the opportunity to have a better life, to have a happy productive fulfilled life and to achieve something. That’s the biggest threat. Part of that threat is pessimism.

How do you address that?

Desmond-Hellman: For me, that’s why we invest in education. If you look at opportunities for youth right now, they are opportunities for educated youth. You can’t educate youth who don’t get a healthy diet, who aren’t vaccinated, who don’t have access to surviving beyond the age of five. In areas of low resource, it starts with health. But it includes good nutrition and access to education. That is why we started talking about human capital because you can’t be optimistic about youth, about your own children or your grandchildren if they don’t have access to health and education.

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