Bill & Melinda Gates Foundation CEO Sue Desmond-Hellmann talks about the just-issued Goalkeepers Report, tracking progress against poverty and disease even as the population keeps rising.
Steve Mirsky: Welcome to Scientific American’s Science Talk, posted on September 25th, 2018. I’m Steve Mirsky. On this episode:
Sue Desmond-Hellmann: If you would go to a health clinic in an area where things like diarrheal disease, pneumonia are still massive threats to child survival, women will walk for many kilometers with a baby on their back to have that baby vaccinated.
Mirsky: That’s Sue Desmond-Hellmann. She’s a physician. She was chancellor of the University of California, San Francisco. And she’s now the CEO of the Bill & Melinda Gates Foundation, which just published its second annual Goalkeepers Data Report. So what’s that? Well, in 2015 the U.N. set what it calls its Sustainable Development Goals. These are 17 broad goals for the world to try to achieve by 2030, in health, poverty eradication, infrastructure and more. The Gates Foundation Goalkeepers report looks at ways to achieve the U.N. goals and tracks the progress in meeting them. I spoke with Desmond-Hellmann by phone.
Mirsky: Let’s talk a little bit about the success stories of China and India and the challenges that we’re facing in Africa.
Desmond-Hellmann: Absolutely. I think that that is one of the things that if you reflect on the progress the world has made over the last couple of decades, more than a billion people have lifted themselves out of poverty and more than 750 million of those were in China and India and so one of the ways to frame progress on poverty reduction is to think about potential waves. So in the 1990s there was a first wave of China coming out of poverty and then in the 2000s the second wave was driven in no small part by India and so many of the Indian population coming out of poverty and one of the questions that…and challenges for the world is how do we help governments in sub-Saharan Africa create the conditions for the opportunity for a third wave in sub-Saharan Africa? And I think that is in the absence of that by 2050, 87 percent of the world’s extreme poor will be in sub-Saharan Africa. That’s sort of the peril but the promise is a potential third wave of poverty reduction.
Mirsky: And for a long time at conferences I’ve been hearing about demographic time bombs, which is really kind of an inflammatory way to talk about how many young people there in various parts of the world. The number of people who are below—let’s say 24 (I think that’s the number in the report) is really pretty astounding though.
Desmond-Hellmann: It is.
Desmond-Hellmann: The estimates are that 60 percent of Africans are under 24 but if you go to Europe, 27 percent of Europeans are under 24 so that’s a pretty remarkable difference and I will say, Steve, it’s interesting the way you characterize the population. I’ve talked to so many Ministers of Finance about the demographic dividend. The demographic dividend is you have a lot of youth. Those youth have access to things that are positive in health and education and that drives your future economy and so the bottom line is the opportunity if you have a lot of youth is that those youth have access to a healthy and productive life and really that’s at the heart and soul of what Gates Foundation believes in.
Mirsky: So let’s talk about nuts and bolts. What do we do to try to improve conditions so that either the projections don’t happen the way they look like they’re gonna happen or if they do happen, the availability of people for a better life is there?
Desmond-Hellmann: Well, we think that if your goal is to reduce poverty and drive human capital that health and education are two central tenants and so as we’ve approached this work in the most difficult areas of the world you really start with the basics: Vaccines, access to maternal neonatal and child health so that you look at really key indicators like under-five mortality and maternal death rates so the basics are those kinds of things that people have access to (vaccines, healthy childbirth). When you move from there you start to talk about nutrition so that children can have access to what they need to grow and to thrive. We wanna reduce stunting and help children to grow and develop both their bodies and their brains well, that moms have access to family planning so women can have their children when they want, at the age that they’d like them, to have as many children as they desire. And so if you put those things together on the health front, things like vaccines, healthy childbirth, access to good nutrition for moms and babies so that she could also breastfeed and access to family planning and you combine with that access to education so that these kids who do have access to nutrition and are healthy have access to education, both boys and girls, that starts to drive your human capital. And in the report we give real examples, like in Vietnam, that that actually (improving their education) translates into an improvement in their economy.
Mirsky: And the girls and women have to be included.
Desmond-Hellmann: It is inarguable that if you wanna drive human capital development, women and girls are an essential part of that and that is…that’s not actually being nice or having a philosophy, that’s just a fact that a healthy, thriving community requires women to be healthy and have access to family planning and healthy children requires that both boys and girls have access to vaccines, clean water, a healthy diet and education.
Mirsky: You wanna talk about HIV a little bit because in the developed world, HIV has transformed in the last 30 years to almost what seems to be a manageable condition in a lot of cases but that’s not true everywhere?
Desmond-Hellmann: No and HIV I think in some ways is such a good example of the promise. As you mentioned in the richer countries what we’ve seen is the transformation of this deadly disease into really a chronic disease. Still a big challenge and something that you’d like to avoid but with modern therapy you can control HIV and live with HIV whereas these same demographics that we’ve just been talking about, we talk about Zimbabwe in the Goalkeepers Report. Sixty-one percent of Zimbabweans are 24 years of age or younger.so these, these citizens of Zimbabwe, most of their citizens are entering the period of their lives where they’re at greatest risk of HIV and we know that at the height of the HIV epidemic, in 1997, a quarter of Zimbabwean adults were infected with HIV but through really good work that’s happened in Zimbabwe since 2010 the new infection rate has gone down by 49 percent and deaths from HIV have gone down by 45 percent. So I know up close and personal because I actually lived in Uganda when we saw those kinds of HIV infection rates like they saw in Zimbabwe how much can be done if you combine with today’s world treatment and prevention strategies? And so the same kinds of things that we’ve seen in richer countries when you use education, when you decrease stigma so people know their HIV status and when you give people in communities access to HIV therapy and today’s prevention strategies, you can make a massive difference.
And these are the most vulnerable. These are young people who are at the time in their lives when they begin to have sex and so we know from lots of work done on therapy and prevention and I know firsthand from living in Uganda what can happen with HIV. And in the report we also talk about innovation, which as you know investing in global health R&D is an important thing for us at the Gates Foundation and there’s two things we’re most excited about in the medium and long-term in HIV. One is having long, active prevention strategies so what’s called PrEP, this Pre-exposure Prophylaxis, if you had long-acting PrEP and you could increase compliance, we think that can drive the medium and long-term prevention strategies and then an effective vaccine against HIV could also be a major contribution to preventing cases of HIV. So we use Zimbabwe as an example because I think the promise of treating and controlling HIV is there but the peril is that HIV is still an absolute threat in some of the most difficult situations where the young population is growing the most.
Mirsky: You know this is not directly related to the report but what we saw with the last big Ebola outbreak was the people who were treated in the West survived and the people, many of the people who were treated on-site did not survive and we learned that the big problem with Ebola may be the availability of high-level medical treatment because that makes a difference in the mortality rate, a huge difference.
Desmond-Hellmann: Well, you’re pointing out something that I think is the heart and soul of both our philosophy and the Goalkeepers Report and that is equity. Inequity drives a number of different bad outcomes and you’re talking about inequity in terms of access to basics of, like, rehydration and care for somebody as sick as people are if they get Ebola. Inequity drives access to vaccines. Inequity drive access to the things that most of us take for granted and you know some people might ask, “Why are you putting out a report that talks about Nigeria and Democratic Republic of Congo?’ Well, Ebola is a good reminder that, you know, and we’ve said this since the Ebola epidemic, a health crisis anywhere is a health crisis everywhere and so the fact that countries in Europe, here in the United States, we actually pretty scared about Ebola when there were outbreaks in West Africa and we’re now aware of just within days of the most recent outbreak a second outbreak of Ebola in Democratic Republic of Congo in an area of great unrest where it’s gonna be despite these wonderful innovations with a new vaccine it’s gonna be even trickier to control Ebola and so investments in equity, investments in health, investments in education and having a thriving population no matter what geography you live is a net positive for the world.
Mirsky: And now more with Sue Desmond-Hellman. When Gates Foundation gets involved in developing countries, how do you get local people to trust you?
Desmond-Hellmann: Ah so that’s such a great question and so the Gates Foundation in no small part is a foundation that invests in others. We make investments in organizations that have a presence on the ground and in the communities that we wanna work with. So Step 1 is we work with local governments. We work with Ministries of Health, we work with U.N. agencies who have a footprint already on the ground be it UNICEF or WHO but just like is true in your neighborhood and my neighborhood, communities drive their future and we found out over and over again one of the first things to know is and this particularly true in pandemics but it’s also true with polio irradiation and any vaccination strategy, who do people trust? If they trust their mayor, if they trust the iman, if they trust their local pastor, that’s who you need to go to, to drive particularly things that are essential in whether it’s HIV prevention or preventing the spread of Ebola, behavior change so if you want a community or a front-line community health workers to drive behavior change, it’s essential to know where the power comes from in that community and so everyone who’s an expert on delivery knows this and at Gates Foundation a lot of our work, whether it be in health, in education, in agriculture, is driven by the local conditions and people who are experts on where local people get their information from, who they trust.
Mirsky: Right so you’re not sweeping in a buncha westerners and tell everybody how it’s done?
Desmond-Hellmann: That would be the opposite of [laughs] what we should do. That would … in fact we’re constantly learning and we’re constantly hopefully asking the most important questions, which is what is this country driving? I’ll give you a real example. Our work in Ethiopia in the last couple of years as Ethiopia put in place their own country’s Health Systems Transformation Plan and the government of Ethiopia is driving that and we are collaborating with them in a responsive what to what their needs are. And then that translates into what communities need and them driving their … what they need for their own conditions.
Mirsky: Yeah I’m sure you wind up learning a lot because people on the ground with limited resources can be incredibly innovative.
Desmond-Hellmann: It’s astounding. Last month I was in Brazil. I was in Rio de Janeiro and going to a health clinic and recognizing what it really takes for a neighborhood clinic to serve people who often live in really tough conditions it starts with listening and learning what their needs are. In our Goalkeepers Report we talk about family planning. I think that’s one of the most profound lessons that anyone like me who’s new to this kind of work has discovered.
It turns out that if you’ll listen or if you ask questions women in areas all over the world, no matter what her income is, want access to family planning. They’re asking us for what you might call in the West women’s empowerment and I would call it women’s right to choose. She wants to have as many children as she wants, when she wants and with whom she wants. If that’s not a story of a woman driving her fate I don’t know what is. So at Gates Foundation we want her to have access to something that is available and is a modern contraceptive method that’s safe and effective and meets her needs.
Mirsky: You reminded me I just heard this [laughs] yesterday, you know, because vaccines are more controversial here where we’ve seen the benefits of them and people forget what it’s like not to have them than in other parts of the world but somebody very succinctly yesterday said, “Vaccines cause adults.”
Desmond-Hellmann: [laughs] I think that’s so beautifully said. In health we often worry about getting complacent. If you would go to a health clinic in an area where things like diarrheal disease, pneumonia are still massive threats to child survival, women will walk for many kilometers with a baby on their back to have that baby vaccinated. At Gates Foundation we think of vaccines as near-miracles and I don’t think that’s an exaggeration. For pennies-a-dose they prevent some of the world’s scariest diseases that before we had vaccines we had to worry about everything from, you know, here in America, smallpox to polio to measles, mumps. And so being able to prevent those childhood illnesses that we forget that they are both deadly and cause enormous suffering, it’s a good reminder. Vaccines do cause adults. I’m happy to be an adult [laughs] as a direct result of vaccines.
Mirsky: Absolutely yeah I think we’ve got about two generations now that have never seen somebody who survived polio or smallpox and you know if those things were around everybody would be clamoring for vaccines.
Desmond-Hellmann: Well I think if you look at our reaction to Ebola it’s a good reminder that we actually do care about our health and we are frightened of scary, infectious diseases. I think it’s up to all of us who care deeply about public health to keep redoubling our efforts about what it takes for people to have trust and confidence that those vaccines prevent things that we haven’t heard about, we haven’t seen because of those vaccines.
Mirsky: We’ve got about five minutes. What do you wanna talk about that I haven’t brought up yet?
Desmond-Hellmann: Well, I think that one of the trends that’s the most exciting that we talk about in this report is moving from something that in the Millennium Development Goals or MDGs that were timed for 2015 to now the Sustainable Development Goals by 2030, we’re not just talking about survival, we’re talking about thriving and it’s estimated now that about one third of children in Africa have stunting, which is being too small for your age. We’ve seen firsthand and in the last Goalkeepers Report, we talked about Peru where the government reduced stunting by more the half in just eight years because of nutrition interventions so I think that’s the exciting thing about knowing about the importance of heath is moving from let’s just make sure that children survive to their fifth birthday much less, you know, their first birthday, to what does it take to have healthy, thriving children who can learn, who can prosper in school and drive the future for their communities and their countries? We increasingly are moving from that surviving to thriving and I think that’s exciting. I think that’s where the youth becomes your potential future for your country, the people who will come up with the next innovations, the next internet, the next space travel. I don’t know what it’ll look like but I know that investing in children thriving in their health and education is a huge positive for the world.
Mirsky: And if their body is stunted their brains are stunted and they’re not going to be as smart and as creative as maybe they would’ve been.
Desmond-Hellmann: You know everybody deserves to have a chance to learn and to be healthy and so if their body is stunted that says something about not just the development of their muscles and their bones and their legs but their brain and so that, it is investing in nutrition and investing in children thriving is, frankly, a direct investment in human capital, in knowledge development and to their opportunity to learn.
Mirsky: Let’s real briefly talk about some of the agriculture work.
Desmond-Hellmann: You know the work we do in agriculture I think is part of these countries’ transformation where it starts with understanding about soil health, understanding about climate change, understanding about how farmers thrive and gets to develop from low-income to middle-income and there you go.
Mirsky: With our remaining 90 seconds or whatever would you like to briefly talk about Hans Rosling?
Desmond-Hellmann: Oh that would be a pleasure so one of the really, really sad events for the world in this last year was wen Hans Rosling passed away and you know I love public health and I love numbers and statistics and data and yet I am fully aware of how dull that can [laughs] be for students and for learners and if people read just one book this year, they should read Factfulness because it’s a beautiful description of why Hans Rosling made such a difference in the world. He literally brought to life what could be cramming numbers in your head and made all of us feel a lot smarter and a lot more aware of how much it matters for the world that we get those numbers right.
Mirsky: And I was fortunate enough to attend a lecture he gave where he displayed some of his animated charts and they’re just … they bring so much information, like, directly into your spinal cord past your frontal cortex, it’s just great stuff.
Desmond-Hellmann: Well, it’s not just the charts. As you know having seen him in action, I mean, I would call him, I don’t think it’s an exaggeration, the P.T. Barnum of Statistics. He [crosstalk] --
Desmond-Hellmann: Just … his enthusiasm for what was under the charts and the numbers and his belief that if we understood the world better, we would be smarter and better able to enable everybody to care about the right things. It literally was contagious.
Mirsky: And his book, again, is called Factfulness.
Desmond-Hellmann: Factfulness, yes.
Mirsky: Great. Thanks so much, great to talk to you.
Desmond-Hellmann: Great talking to you, too, Steve.
Mirsky: That’s it for this episode. Get your science news at our Web site, www.scientificamerican.com. Where you can also check out the article on how the seven billion people on the planet actually contribute to the way Earth wobbles on its axis.
And follow us on Twitter, where you’ll get a tweet whenever a new item hits the Web site. Our Twitter name is @sciam. For Scientific American’s Science Talk, I’m Steve Mirsky, thanks for clicking on us.