A Conversation with Bill and Melinda Gates at the Forum on Leadership (Highlights)

Yeah. So we were thrilled when President Bush and Laura invited us to come here tonight. Really, the leadership they've shown on global health made such a difference. It created the framework that we've been able to step into. There are actually three amazing programs that were created by President Bush. The biggest, and still phenomenal today, that's saved tens of millions of lives, is PEPFAR, that's been mentioned. Also, the President's Malaria Initiative was created and that continues to this day. It's a phenomenal piece of work that in decades to come will eventually let us do malaria eradication. And then finally, the Millennium Challenge Corporation (MCC), which was very cleverly designed. Unfortunately, that one wasn't maintained by the successors quite as well, unlike the other two, but it was a very thoughtful approach to having countries commit to what they needed to do. So as we got started giving money away, the idea of what did children die of, how many children were dying, we were quite naive about that. It was in the late 90s when we started to learn that vaccines were magical. Still at that time, about 10% of all children under the age of five did not survive to the age of five, and there were lots of vaccines that weren't being given to these children. In fact, some of the vaccines were being given to the middle-income and rich country children who had very little risk of dying of diarrhea, and yet that same vaccine, rotavirus vaccine, wasn't getting to the poor children. So we found a huge opportunity to build on the science that many people have done and to invest in that, to build on PEPFAR in terms of HIV work. Today, the number of children who died before the age of five has been cut in half, so it's gone from 10% to 5%. That means it's gone from over 10 million a year to less than 5 million, and there's lots of opportunity to take that number and cut it even more. So the spirit of reaching out to the poorest, particularly with the HIV emergency, that's something that spoke to our hearts just like it did the President. So it's great to be here and talk about how that work continues to be one of the greatest acts of generosity ever.

Thanks, Holly. Well, it's funny because the numbers that you cite are very large about the amount we've given away, but I think the most important thing for us and other philanthropists to constantly reflect on is what is the role of philanthropy. I think one of the things that Bill and I have been really cognizant of, or tried to be since the very beginning, is that philanthropy is the catalytic wedge. It's the piece that philanthropy can take a risk where a government can't really take a risk with taxpayer money. So what the philanthropy's job is is to figure out, to experiment, and as we see it, we're big believers—we both come out of the tech center in innovation—to innovate, try things, prove them out, actually measure their results, and figure out if you're really getting results. And then ultimately, philanthropy is just the catalytic wedge; it takes government to scale things up. So we think of things at scale. PEPFAR, along with the Global Fund, is an at-scale program. If we had taken every single ounce of resources we have and put it just against HIV/AIDS, we would have gone by now. Our job is to take and figure out what are the new HIV treatments that make a difference, how do we help bring down the cost, how do we bring down the cost of vaccines so that this large-scale government funding that is working can spread even more of the latest medicines and technologies and vaccines to people all over the world that saves lives. So we've always tried to be cognizant of what our role is. And ultimately, we also now advocate to governments. What are the things that we spend—Bill and I spend a lot of time doing, which we would not have ever guessed I think when we started—is advocating on the Hill and advocating to the EU and to governments all over the world to keep up the funding for things like PEPFAR or vaccines, because we know that those tools make an enormous difference in people's lives.

There are really two big goals. One is to get the death number down dramatically, even from the five million that it's at today. And the other is that even the kids who survive have a bad health experience. That diet, so malnutrition and sickness, means that they're not fully developed. You can measure that through height with stunting or wasting in terms of their body weight. The great advance in science is letting us understand malnutrition: what's missing from those diets, how does their gut get into a situation where even with the given food they're not able to absorb it. So our belief is that by having kids grow healthily from literally day one, if you get off that growth path, that's where you're most vulnerable to these diseases. So the big upside is the innovation. We can have very ambitious goals. Polio is a disease that's almost eradicated. A few more years, if people stay committed, we ought to be able to achieve that. And eventually, all these diseases we ought to be able to bring down the levels so that kids in poor countries have no more chance of dying or being malnourished than in rich countries. The only thing that I would say is negative, because time is on our side with innovation and these countries over time get so they can fund these things themselves, the world is turning inward somewhat. So as we go out to raise money for a Global Fund, which is the multilateral, multi-country version of PEPFAR that the U.S. is by far the biggest donor to, giving a third of it right now, we're a bit worried that that commitment, with the focus on Brexit or our national issues, won't be there. So we have to remind people about the great success and make sure that the U.S. and Europe stay committed. In fact, we were talking to the President tonight about who still energetic, who remembers how great this program is, how do we make sure that people keep the faith of what he got started. I think one of the other things to understand a little bit about our foundation is that the gut microbiome is a really interesting scientific area right now, and lots of companies are going after it and looking at it, but they're looking at it for good reason at obesity in the United States or in other places in the world. But what we do is go and send those companies to look at the gut microbiome and to study it for undernutrition, which most low-income people around the world are facing: poor microbiome for nutrients. So any of the things that we work on, whether it's vaccines, we go for instance to the pharma companies, and where they're working on vaccines maybe for the rich world because that's where they make their money, we incentivize them to work on vaccines for the poor world too, because that is where society and capitalism leaves behind a lot of low-income people.

Yeah, what's behind it? Thanks. So I have a book coming out on April 23rd. Please go online and order it, or go to Barnes & Noble. It's called "The Moment of Lift." And what inspired me to write this book is over 20 years of travel for the foundation. I've been lucky enough to travel to many, many places in the world, in many countries in Africa and communities. And when I would be there—Bill and I go often, we travel off into different countries, we often are meeting with government leaders, we're meeting with scientists, we're meeting with advocates—but it's so important to meet with people who are in slums and in villages. And if I've gone in, I usually go in as a Western woman in a pair of khaki pants and a t-shirt. They don't know where I'm from in the United States, and just that I'm there to listen and to see if there's any way we might help. And I learned so much from the women I've talked to, who invite you into their homes or on a mat in the village. And they've inspired me. They've called my life to action, and by telling their stories, I hope to call others to action. So that's the purpose of writing the book.

Yeah. The word nationalism, of course, has many ways people interpret it, but there certainly is somewhat of a term of saying, "Are the dollars that we spend outside the country, do they accrue to the benefit of US citizens?" And sort of a default view by some that no, that isn't being well thought through. And in fact, even the very best government programs like PEPFAR, there's a question: who's supposed to go witness what's being done and come back and tell people? Well, the US government isn't supposed to have a lot of money to market its own programs, and those aren't really the skills those people are picked for. So strangely, in some ways, our foundation and people we work with are really saying, "Okay, let's articulate what it means." When people hear "millions of lives saved," they want—it's much better to not only get that figure but also to give examples of people that Melinda and I have met. So the fact that these programs create stability in these countries and they create health systems in these countries, which over time means that the chance of diseases like Ebola or Zika spreading from these countries to the US has greatly reduced, the chance of having to deploy the military—whether it's an Iraq-type situation or when the Ebola outbreak took place, eventually the US did, which was great, have to invest a lot because the world looked to our leadership to step in there. So there are benefits that are coming from these programs that a lot of people aren't going to articulate. And they really are, if you look at how people admire the US and how much domestic money is now being put into these same things, the success is pretty unbelievable. So people ought to be proud of that. Every citizen of the country should be proud of what the country stepped up and did under President Bush's leadership.

Well, ultimately, the foundation is a reflection of our values as a couple. And by starting with that mission that all lives have equal value, we are constantly trying to live that out through the foundation. So certainly we show up—I think it's like good parenting: you show up with a common point of view inside the doors, and anything that you don't agree on specifically, on the specifics, it's never that one of us wants to do malaria and one of us wants to do tuberculosis. It's not that those decisions have come easily, but you have all these decisions to make about how you spend the money: how much of it you spend on upstream science versus how much do you spend on the pain and suffering of today, and how does that balance work? So if we ever have small disagreements about those issues, we always work it out at home because you want to show up with a very unified front. I think over the years, Bill's now been retired from Microsoft, you're coming up on 11 years this summer. Over the years, we both have had more time to spend on the foundation. We have three children: our oldest daughter's now off to college on her way to med school, we have a son who's a freshman in college, and we have a daughter who's 16 in high school. So as they've gotten older, we both had more time. Bill's had more time with his retirement from Microsoft. So what it's allowed us to do is we always want to be learning the same things so that we can share topics. If I go out in the field, the first person I want to come home or call on the phone and talk to is Bill, and likewise. If he's learned a new science topic or I've learned a new science topic, the person I want to come home and talk to is Bill. So we come with these shared visions and points of view. And then I think over time, we've learned this dance a little bit more about who's going to lead on which things. So Bill is absolutely the leader on polio. I completely agree with trying to eradicate polio from the planet, but he's the lead on it. And he absolutely believes in the thing that I lead on, which is family planning. I think I have a bit of a different voice in it because I am a woman. So we support each other in some of those roles, but it's just kind of like a good dance: you just learn how to do it, and you enjoy it. And even certain meetings we do, even certain leadership meetings like a leader, a president or a prime minister of a country, these days one of us might go in and meet with that leader, and then six months later it's the other one. So we are constantly handing to one another the baton, and even who can show up on which particular trip. In fact, this is kind of rare, to be honest, for us to both be on stage together, and it's nice. And I think as the kids get older, we'll get to go to more places together, but just with raising three kids, we often one of us would have to be on the road and one would be home.

Well, I was very lucky that the foundation got substantial funding in the year 2000. And so there were eight years there where a person who'd been at Microsoft, Patty Stonesifer, that Melinda and I knew and trusted, and my dad basically ran the foundation, and we were part-time, partly because the kids were younger and I was still at Microsoft. So that we got a sense of it. We were still improving all the big projects. I was able to get some time to learn the science. So by the time I switched to be full-time, fortunately we had enough projects, the scale was such that it really could grab full-time attention. And we had the experience of those previous eight years. We had some really good people who gave us the understanding of how to work with governments in Africa. We're still learning about that, and 54 countries, each one is a bit different, and it's tricky. In the long run, the government really has to take charge of these issues. Even in time funding all the HIV and malaria and other health needs, in some cases that's clearly going to be many decades, even if you help them along that path. So the sophistication on the science and the delivery things, that's just been a huge journey. And the difficulty of delivery, I think getting their full time helped us see more about why some countries were doing really well and some countries were not really doing well. And one of the things that we talked about with the foundation is that we are on a learning journey as a couple and as a foundation, and we should never stop learning. So in fact, one of our heroes in global health, a guy named Bill Foege who's at Emory, says that certainty is the death of a foundation. And I think he's absolutely right. You have to constantly be learning and thinking and measuring and innovating. Like one of the things we got started in philanthropy—I mean, think about it, I'm guessing everybody in this room probably has a cell phone on them tonight, and most of you probably have a smartphone. That tool didn't exist when we got in the field of philanthropy. And now we can be out in some very remote part of Bangladesh or in remote Senegal, and there is no running water, there is no electricity, and somebody's cell phone rings. And the power that tool gives us and the access it gives us for making sure that people have information, if you make sure that it's equally done so that women and men have access, and even a digital bank account—a digital bank account which is spreading all over the world now—for a woman to be able to save a dollar a day, two dollars a day, when she can't go to town, she's not welcomed in town at the bank, the money gets stolen from her, her husband dies and her brother-in-law steals it, so she can save and start to plan for the future, or her husband goes and gets a job and sends money home. There are all these new tools and science that has come along, like the gut microbiome, and so we are constantly trying to learn and stay ahead of those fields and then push those fields so that they benefit everybody, and particularly low-income people.

Yeah, it's a huge challenge that the place where babies will be born are increasingly the toughest places in the world. The number of babies being born has peaked and is going down slightly, but the portion that are born in Africa will go over the course of the century from about 22% today to about 50% by the end of the century. And Africa today is only a billion of 7.3 billion people, so the fact that that's where half the children will be born by the end of the century speaks to this issue. And even within Africa, it's places like the north of Nigeria where you'll still have a lot of kids being born. So we have to help those governments get their primary education right, get all the things that we take for granted. Fortunately, some countries are graduating. China, Brazil, Indonesia, even India, things are going well enough that they'll be able to support almost all of their own needs. So Africa, with a few additional countries, is where all the foreign aid and philanthropy can focus in, because of the success in most of Asia and Latin America with these very tough issues. One of the things that surprised us when we got into this work, and I think is worth mentioning tonight, is that as you save these children's lives—that is, as Bill said, death rates of children under the age of five have been cut in half—there used to be this fear around the world that if you cut childhood death rate, then you would have massive overpopulation. But luckily, the converse is true. Parents in these low-income settings are making basically an insurance bet. They want to know that several of their children will survive to adulthood. So as they can see that their children survive, they actually will bring down the number of kids they have. But today, there are still many places like northern Nigeria or Niger where you go, and if you sit in a village—and I've done this—and you sit and there's maybe 150 women, the men have gone back to the fields to work, and you stay and talk to the women, and you say, "How many of you know a woman who's lost a child in childbirth?" Literally every single hand will go out. And then if you say, "How many of you have lost a child in childbirth?" you'll still see about 40% of the hands go up. So they've seen so much death with children, they're having a lot to make sure they survive. And yet women will say to you over and over again, "I want to have fewer children, but what happened to that clinic that used to have contraceptives for me? What happened to the fact that the clinic's still there but there's no supply of what I want to use?" So one of the things that we have gotten deeply involved in is access to contraceptives. 220 million women are telling us they want access. And so if families can—we know from great research and data in Bangladesh that if parents can bring down the number of children they have, their children are healthier, their children are better educated, and the family is wealthier. It is the greatest anti-poverty tool. So if you think about why women in the United States have the opportunity to work, it was the advent of the pill. So we are quite determined to help women have access to the tools that they want around the world, and that will help with some of the population numbers in Africa, but that is not the reason to do it.

Yeah, there's a lot that I could name. In just the vaccine field alone, there's great hope that in the next 10 or 15 years we'd have a vaccine for tuberculosis and HIV and malaria, so the big, big killers. And that's why it's worth holding HIV in check until we get that tool that we can stop people from getting infected. In terms of the thing I'm most excited about, I'd go back to nutrition. The fact that 40% of the kids never have their body or brain fully developed, and that by solving that growth problem, having them have full growth, they will also survive even tough episodes of these diseases. That is so exciting. And it requires genetic sequencing, it requires big data, it requires all these tools that ten years ago—the microbiome, which I wasn't the first to mention that, I always try not to use too many scientific words, but she said at first that microbiome was opaque because the amount of sequencing data processing you have to even understand what's going on. These are the bacteria growing in your gut. That's the single thing that I'm most excited about. We will very likely in this decade dramatically reduce malnutrition.

Well, the thing that I think is imperative for the world, in addition absolutely to the science which moves us forward, is we have to empower women and girls. And if you want to lift up societies, you empower and educate girls. And it starts in most of these countries with good health, because if you don't have decent health, you can't go on to get a great education. But the more and more I've seen, and the longer we've been in this work, is you lift up women and they're going to lift up everybody else. And you see that time and time again. So we're quite dedicated to doing that as well.