Bill Gates and his foundation have spent more than $1 billion to fight malaria, putting a little-known disease back in the public consciousness. Now the man who revolutionized computing hopes his next big launch will be the world’s first malaria vaccine.
Gates discussed his vision earlier this month with Times reporter Kristi Heim. This is an extended excerpt from their conversation.
Q: How was it that malaria first caught your attention?
A: Well, malaria’s one of the biggest killers in the world. It was in the United States in a very serious way, but not during my lifetime. The Center for Disease Control started out as the malaria war control board based in Atlanta. Partly because the head of Coke had some people out to his plantation and they got infected with malaria, and partly cause all the military recruits were coming down and having a higher fatality rate from malaria while training than in the field. We wiped out Anopheles with the help of DDT.
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Q: Was there something that convinced you to become fixated on solving the problem of malaria?
A: Well, malaria is a terrible disease and when you talk to people who’ve had malaria, you get a sense of how horrific that is. It’s terrible for everybody, but it’s most severe for infants who are very weak and often die of cerebral effects, and pregnant women.
So there’s a burden of malaria in terms of miscarriage and low birth weight that is actually hard to tally up. You might die of diarrhea or pneumonia, but it all goes back to that low birth weight that was [caused by] your mother’s malarial episode. It’s a horrific thing. And actually the disease burden even beyond the million a year killed, you’ve got all the people who have the disease.
My experience of malaria was just taking anti-malarials, which give you strange dreams because I don’t want to get malaria. And then just looking at the numbers and seeing how unbelievable it is that it’s gotten so little attention.
We announced a $50 million grant a long time ago. It would have been like 2001. And that doubled the private giving to malaria work, which seemed totally strange at a time when baldness or erectile dysfunction are getting huge $500 million budgets put into them.
This disease whose impact is easily a million times greater was getting almost nothing.
Actually malaria has killed more people… It’s setting a record every year. That is the number of people who died of malaria was higher last year than any year in history. Now it’s not as widespread in the world [as it once was]. But the population growth in the areas where it’s endemic, specifically Africa, has gone up enough, and you have difficulties in drug resistance and just lack of attention. That means it’s worse.
In world health, everything’s not worse. Measles certainly killed like 4.million a year and is now below a half-million a year. Polio was widespread. Now it’s completely gone; no, almost gone. Smallpox is gone.
Malaria, if you take the top diseases other than AIDS, which has grown quite dramatically and the TB piece that comes with that, malaria is one of the worst stories, and yet not that much has been put into it. AIDS you can say OK, because some small percentage of the infection was in the rich world there was a ton of money at least that went into drugs to treat it. In the case of malaria the lack of attention was completely across the board– vector control, drugs to treat and vaccines. All of those have a place to play. The vaccine is the high risk, high impact approach. If we had a perfect vaccine, many of the other efforts you wouldn’t need. A vaccine’s tough enough that we’re working on them all in parallel.
Q: At the launch of Windows Vista, you mentioned launching a malaria vaccine in the future. Americans are fairly self-absorbed. How can you get people excited about something that doesn’t affect them?
A: Well, I think when smallpox was eliminated, the whole world got pretty excited about that because it’s just such a dramatic success. And if we can finish polio, everybody will feel good about that, particularly organizations like Rotary or others who really played such a central role in it.
In the case of malaria, it does take place far away. Many speeches I’ve given, including the Harvard commencement speech, touch on the general theme of why don’t we give more, why doesn’t the richest country or the people in the richest country give more? The distance is a key thing. The fact that it’s not part of our life experience.
If we re-sorted the world and your neighbors were dying of malaria — that a kid you’d met and had a human connection with — the amount of urgency, resources going into this would be a hundred times what it is even now. I mean it would be viewed as a total crisis.
Q: You do have a lot of personal influence with world leaders. How can you use that to help your cause and get governments to contribute more?
A: Well, we’d say the whole global health agenda today versus 10 years ago is in a big up tick. We’ve done our part to help that be the case, in terms of credibility of saying hey these are super high impact things, these things can work. This is not your typical AIDS story where when it’s all done you don’t know if you made a difference. Here you’re really saving lives. That’s a huge thing. The lives you save reduce population growth, that’s a huge thing. Then you can educate. All the virtuous cycle things that have kicked in in many parts of the world like China or Brazil you would have thought as developing countries. Now there’s a rich classification you have to do because health was improved enough that they got into the virtuous cycle. The countries that are left that need our help to get that going include most of Africa. Basically malaria is in poor countries. There isn’t much malaria in rich countries; that’s a sad thing to say.
Q:You’ve spent more than $1 billion to fight malaria for about five years. How much more do you really think it will take to get where you want to get?
A: It’s very hard to put a number on that. We picked the big diseases as our priority. Whatever it takes we’re just going to stay at it. This is what we’re about. The big five are AIDS, tuberculosis, malaria, respiratory and diarrhea.
Depending on different criteria, [malaria] would bounce around between number one and number three. In terms of human misery, there’s a pretty strong case it’s number one. We’re going to work on all of them. Fortunately we have enough resources in all five of those we’ll be able to pursue broad strategies that include some redundancy because of the risk involved
The best case is during the next five years, we get a great vaccine. In the five years after that, we get it into widespread use. I’m enough of an optimist to say that’s a real possibility. There’s no scientific guarantee of that. Certainly the world has taken on the goal of eliminating malaria a number of times and fallen flat on its face.
Q: As the head of Microsoft you’ve had some formidable adversaries over the years. Now you’re up against a mosquito.
A:That’s right. The vaccine approach, though, isn’t the same as vector elimination; that is you’re not trying to find every little place mosquitoes might grow and make sure you’re getting insecticide there. In case of vaccine, you’re using the same approach that successfully eliminated small pox and is close to eliminating polio. We don’t have the vaccine yet. In fact were backing many different efforts, including the big pharmaceutical company GlaxoSmithKline, which is in some ways the furthest along. This SBRI approach, a kind of unusual approach that has to do with pulling sporocytes out of living mosquitoes and irradiating those, so even in the vaccine area we’re trying a number of things. The final solution might even be a combination of various elements of those.
Q: The technical side of developing a vaccine is so complicated, but then so are the logistics of getting it out to people. What have you learned about that side of the equation?
A: A vaccine with a modest number of doses, often three, you can get lifelong immunity. The logistics of getting a malaria vaccine out … it’s hard. But malaria is a very recognized disease. People are in deep fear of their child. When they start to get fever, they almost hope it’s some respiratory thing because malaria can so quickly create the fever that disables or kills the child. Unless you can get in and get an IV with the right stuff there’s a good chance your child may die. The demand side on this one, if we have the full impact, the demand will be very high. Amazingly vaccination can work even in places where there’s not a lot of infrastructure. It’s a lot easier to get vaccines out than it is to put someone on lifelong treatment for a disease like AIDS, so called antiretroviral treatment, where you’re looking for side effects and they’ve got to take their pills every day. Here we’re talking about if we have a vaccine just getting them in childhood or maybe a booster as you get older. But that’s way, way easier. Unlike some diseases like AIDS where the connection between what caused it, what made you sick. Here with malaria the understanding of the disease is very high amongst people who live in Africa, and there’s no kind of denial or shame associated with this disease. It’s all out in the open.
Now there are people who aren’t as optimistic as me about the vaccine who say OK we need to take our current interventions and go after those. The foundation is part of that as well. The Presidents Malaria Initiative, the Global Fund money, some World Bank money, Nothing But Nets. If you compare that to even five years ago, there’s a ton going on to take known interventions, including the nets and using the insecticides the right way. There’s a thing the foundation was involved in inventing called intermittent treatment, where you don’t actually prevent the episodes but because you have partial immunity you reduce the chance of them being fatal quite dramatically. Those are two new tools that I think are fantastic. The Zambia thing that we’re one of the big movers in involves taking all these things and applying them. Melinda actually was in Zambia and saw those activities. I have not been there. Until after July 1, I don’t get to visit any malaria sites, but I will after that.
Q:You’re making some very big bets. Do you ever worry that your motives will be misinterpreted or that you will be viewed as an outsider trying to impose your solutions onto others? Why should the world trust you?
A: Well, I don’t think those issues really come up here. The strategy we’re pursuing on malaria involves bringing together the top malaria people in the world. I wish there were more of them. Then they might even disagree more. But there’s not that many malaria experts in the world. And so when Regina goes to Johns Hopkins and London School and maybe about 20 other places and gathers 4 or 5 people from each place… you’re talking about a very high percentage of people whose lives are devoted to malaria drug intervention, both vaccine and drugs and you could even throw even the insecticide group, which is a tiny little group. Have you ever heard of a new insecticide invented since DDT? No. Zero money went into that.
If we only had the money to fund drugs or vaccines, or if only to fund one drug or one vaccine, then we’d be making hard choices. Not me so much but Regina Rabinovich and people on her team… they’re the experts on these things. We’re backing all the things we can see that have a chance of success. It’s lucky we have the resources to do be able to do that If we hear of some new great thing we’ll go and back that as well. It’s not a field where there’s a bunch of companies trying to do malaria that nobody knows about. This is a pretty small field.
Q: In the world of technology you’ve been aggressive and driven, sometimes bending the rules to change the way things worked. What about in the world of philanthropy and global health?
A: I wouldn’t characterize my technology career quite that way. Personal computers are about empowerment, letting people be empowered by software. Global health in my view is not a very controversial thing: the idea of saving these lives and creating the environment where the virtuous cycle of education, wealth and stability can kick in.
This is the greatest inequity in the world. Anybody who goes and sees this stuff feels the need to get involved in some way . .. It’s just the greatest tragedy in the world that science is as advanced as it is, and the world is as rich as it is, and yet we haven’t gone and solved the top five or even the top 20 infectious diseases.
And that should be done. That’s what we’ve assembled world-class people to go off and do.
Q: But since the world health community hasn’t solved these problems you’ve been talking about, does it need a fresh approach? Are there some changes to the system that are needed?
A:Well the allocation of resources to go after infectious diseases — that needs to change. Remember we benefit from biological understanding, particularly of the immune system. The NIH spends $30 billion a year… That’s the platform we live on. That gives us tools like sequencers and expression differentials so the world just understands biology. We sequence plasmodium. Go meet those SBRI guys and ask them is there anything you’re doing that could be done five years ago. No way. It’s a rational design. What we’re doing with GSK is a more classic way vaccines have been done in the past. That actually could have been pursued more energetically before. So every year the increased understanding helps us, helps our grantees.
It’s great the health community does research. The only thing that’s strange is that when it goes beyond basic research to applied research, there’s a huge tilt of the money going into things where there’s rich world markets. That’s to be expected, and you have to offset that by some degree of government grants and philanthropy to make sure that the diseases of the poorest don’t get completely ignored. And they have been largely ignored. Ninety percent of the world’s spending on infections disease goes on 10 percent of the problems, and 10 percent of the money goes on 90 percent of the problems.
Look at the number of articles that were about SARS than about malaria, and then compare the disease burden. Well SARS, hey, there were some rich people. Some got sick and some almost got sick. That was different, new, scary, unbounded; whereas malaria, it’s hey a million a year this year. 1.1 million next year. 1.2 million the next year. It just goes on and on.
Q: In terms of raising awareness, you must have been pleased to see a malaria fundraising drive on “American Idol.”
A: Yeah that show was quite phenomenal. And they raised a lot of money. Fox had talked to us beforehand. We were super glad they were doing it. I think they viewed it as such a success they may do it again. It was great to see the response. Global health aid is one of these paradoxical things. If you survey people, citizens think the government’s spending ten times as much as they’re actually spending on it. Global health aid ..gets a very positive response. If you ask about aid in general then you get a more ambivalent, skeptical response. If you get focused in on the things we do, it’s not the top of the list politically, but there is actually despite the lack of these diseases being here, there is an awareness.
Enlightened politicians have been a big help to us. It’s partly because they do feel that people care about these issues. The more visibility there, the more people care. The more they care, the more visibility we get. Some people like Bono have been great in getting these issues out there.
Q: How has he influenced you?
A: We work together. He’s incredibly articulate. He’s reached out to way more politicians than I have. He can speak about things in a different way. We have the same goals in mind, which is to raise visibility. He was very involved in the big U.S. generosity around AIDS, the PEPFAR program. We were more directly involved in the malaria initiative. We’ve worked together enough I’ve learned a lot about how to talk about the cause in a way that draws people in from him because he’s so eloquent, but in this totally genuine way.
Q: Many U.S. charities are motivated to help others by religion. But can secular people be just as driven to do good in the world? Tell me about your underlying motivation.
A: Well, the United States as a country believes in equity and that’s a very tough thing to deliver, whether it’s gender equity or racial equity.
But the biggest inequity is if you look globally and see the conditions that the poorest are condemned to, the way that, despite any motivation or ability on their part they can’t put themselves into a reasonable situation. They can’t get away from the disease and the lack of resources. Anyone who gets awareness of that, just on pure humanistic grounds or religious grounds, will really want to say, “Wow, why haven’t we done better?”
Are we really going to look back and say that the world set its priorities properly?
We were involved in the commission that set up these Millennium Development Goals. That’s been a great thing that articulates companies have a report card, students have a report card. Here’s a world helping the people in need report card. Even if the world falls short, which on some of the goals it will, particularly related to Africa the fact that it got the attention and drew people in to think about it, and think about innovative ideas for achieving those goals, it’s been a fantastic thing overall.
The foundation is measuring itself by saving lives and improving these conditions. We think that’s a very exciting thing to work on. Every philanthropy gets to pick their own things to work on the ability to bring organizational approaches in, the ability to bring the latest science in, to draw on the smartest people. I saw that it was a pretty unique time for those pieces to come together, and then I saw the shocking vacuum that was there in terms of how little activity, either philanthropic or governmental, for the infectious diseases of the developing countries. I said OK, that’s what we should go and do and just stay at it as long as it takes.
Q: I’ve been reading your speech about “creative capitalism.” It was capitalism that helped you become the richest man in the world and now I hear you want to change it.
A: No Nobody believes in completely unadulterated capitalism. Go back to Adam Smith and the book he wrote before “The Wealth of Nations” or even parts of “The Wealth of Nations.” Motivational systems are very powerful things. It turns out that in terms of product innovation and doing great things for people, socialistic, communistic systems weren’t that good at motivating. Things that are at least somewhat capitalistic have done well.
Take all the new drugs created in the world. What systems did they come out of?
You can bemoan the fact that more didn’t come out of them. People like GlaxoSmithKline understand how to do drug trials and organic chemistry extremely well. So you want to create a framework where they can take some of their best people, not all of them, and work on drugs that won’t have a huge profit return but do it in a way where they’re not losing a ton of money.
So they’re giving up a lot of opportunity costs but not behaving in a way that’s totally contrary to what their financial dictates push them to do.
If they do it, (the) employee morale or reputation benefit they get somewhat pays off the big opportunity cost of having taken these great scientists and put some of them onto diseases where the financial opportunity is quite modest. That’s striking the balance.
It comes down to very specific things. We highlight our relationship with people like GlaxoSmithKline as a good exhibit. If you are creative you can bring together the incredible skill sets that you only see in a capitalist environment… but take some portion of those and go after something where the market signals aren’t there to prioritize those things… People have this term public private partnerships. There’s creativity going into that to get the best of private sector actors, and yet going after goals that normally wouldn’t rise to the top.
Q: What is it that you want to contribute most to conquering malaria in the end?
A: Well, to get the disease burden to be extremely low. If you can reduce the 200 million malaria episodes a year — a million deaths a year — the impact that has just in and of itself is mind blowing. .. If you saved someone’s life, you say, “Wow, that’s big.” If you saved 10, 100, 1,000, 10,000, if you go into those communities and see what it means to those mothers and fathers and how they spent their savings to go to the hospital to try to save the kid I’m just hopeful we can have a huge impact on this disease, by bringing the right people in, by using the latest biology, by getting a lot more money into it and tapping into some private-sector actors.
This is the time period where malaria can largely be conquered. And we’ll just keep trying. We’re five years into it and things, I’d say, have gone very well.