What if...

A letter from the CEO of the Bill & Melinda Gates Foundation
Sue Desmond
Sue Desmond-Hellmann CEO, BILL & MELINDA GATES FOUNDATION

One question unites those of us who work at the Gates Foundation: What if?

What if infectious diseases could no longer wreak havoc on poor communities? What if women and girls everywhere were empowered to transform their lives? What if all children – especially the poorest – had an equal opportunity to reach their full potential?

For more than 15 years, the Gates Foundation has been imagining what’s possible. Our belief that all lives have equal value guides everything we do to eradicate poverty and increase opportunity for the people we serve.

Visiting with Dhanmatia Devi and her children at her home in the Patna district of Bihar, India.
Visiting students at White Center Heights Elementary School in Seattle, WA.
As CEO of the Gates Foundation, I’ve had the privilege of traveling around the world and the country to meet our grantees and partners. Here I’m visiting Dhanmatia Devi and her children at her home in the Patna district of Bihar, India, and visiting students at White Center Heights Elementary School in Seattle, WA.

Throughout my career, including 14 years at Genentech, I’ve sought to bridge healthcare and innovation. Everything I do is driven by the fact that the lives of fellow human beings are at stake—and we can do something about it.

I joined the Gates Foundation as its chief executive two years ago. I’ve been here long enough to reflect, but I still think of myself as a relative newcomer.

There are aspects of who we are, what we do, and how we do it that aren’t as clear as they should be. I can’t cover every topic, but this letter is meant to undo some of that fuzziness by sharing examples of our work, including some you might not have known about.

Some initiatives are working better than we thought. Others show possibilities that you might find surprising. We’ve also had to course correct when we struggle to land on the best way to tackle complex challenges.

I want this letter to be the start of a new dialogue with our partners, followers, and fellow optimists about the inspiring and humbling challenge of navigating the path to possibility.

Our mission: Ensure more children and young people survive and thrive. We believe that the path out of poverty begins when the next generation can access quality healthcare and a great education.
Our mission: Empower the poorest, especially women and girls, to transform their lives. We believe that by giving people the tools to lead healthy, productive lives, we can help them lift themselves out of poverty.
Our mission: Combat infectious diseases that particularly affect the poorest. We believe we can save lives by delivering the latest in science and technology to those with the greatest needs.
Our mission: To inspire people to take action to change the world. We know our resources alone are not enough, so we work to change public policies, attitudes, and behaviors to improve lives.

Bill and Melinda guide our vision and bring crucial priorities to the global stage. I focus my expertise and passion on leading the foundation and boosting our ability to have impact in order to realize our vision.

As a foundation, we align ourselves and our strategies to shared global goals. Equally, we push ourselves to adapt to a changing world and confront emerging challenges. Pandemics like the Zika virus, for example, demand that we work quickly with partners in the face of urgency. We want to go faster and further than ever before.

That means we take risks others can’t or won’t. It also means building on what we know to approach problems in new ways. For example, I’ve begun exploring what can happen when the principles of precision medicine are applied to the field of public health.

Above all, everything we do depends on partnership—and we all need to play to our strengths. More and more, the Gates Foundation’s strength manifests as the ability to bring people together.

Our senior leadership dedicate a significant portion of their time building relationships with developing and donor country governments, international development agencies, private companies, and academic institutions, as well as other nonprofits and philanthropies. We want to be the best partner possible, so understanding each other’s priorities – and being clear about our own – is essential.

In order for programs to be delivered, tools to be honed and deployed, and behaviors to change we also have to understand local context. In-country partners are critical to creating and demonstrating innovative approaches that are grounded in local realities.

We want all perspectives (and all possible solutions) at the table. None of us wants to wall off any avenue to impact.

Taking on Tobacco

I am in awe of our partners. They show us what is possible and, at times, demonstrate that some things can work even better than we thought.

As someone who spent a significant portion of my career as a physician and cancer researcher, tobacco control really resonates with me.

More than a billion people use tobacco products worldwide. When used as directed, they are the only consumer products that will kill half of all users. Nearly 6 million people die of tobacco-related diseases each year, including more than 600,000 nonsmokers who are exposed to secondhand smoke. If current trends persist, the tobacco epidemic could kill more than 8 million people each year by 2030—80 percent of them in developing countries.

Since 2008, the Gates Foundation has committed over $225 million to partners who are working to address the tobacco epidemic in more than 30 countries in Africa and Asia. Our efforts began with an investment in the Bloomberg Initiative, which remains a key partner to this day.

We have a small team at the foundation who work on tobacco control. As CEO, I’m excited that we have a nimble team making and managing a portfolio of grants. But I’m even more excited by the fact that this means we’re truly leveraging the knowledge and expertise of our partners and the countries we support.

Our role is to listen to what countries need and provide resources to the right mix of partners that can support implementation of the top evidence-based tobacco control measures.

One incredible example of country-led tobacco control is happening in the Philippines. In 2013, the Philippine Government stood strong in the face of intense tobacco industry opposition and implemented the landmark Sin Tax Law, which increased taxes on tobacco by up to 820 percent.

After just one year, the government earned $980 million in new tobacco tax revenue – far exceeding projections. Cigarette prices also increased, leading to an overall decline in smoking in the Philippines, with the largest reductions among young adults (18-24 year olds) and the very poor. Money saved from not buying tobacco products due to increased prices can be spent on essential household items.

It gets even better.

Revenue from the Sin Tax nearly doubled the Philippine Department of Health budget, and financed the extension of fully subsidized health insurance for more than 43 million poor Filipinos – nearly tripling the amount of poor families enrolled in the National Health Insurance Program.

This is the kind of health intervention that gets me really excited. It’s curbing the tobacco epidemic—and it’s doing it with a revenue-generating solution, the proceeds of which are reinforcing the larger health system.

The Surprising Story of a Nasty Parasite 

One of our core missions is to combat infectious diseases, particularly those that affect the poorest. We focus a large part of our health work on diseases such as polio, malaria, HIV/AIDS, diarrheal diseases, pneumonia, and tuberculosis—diseases that take a huge toll on people living in poverty.

We also prioritize what are called neglected tropical diseases (NTDs), which, historically, have attracted little donor funding or attention. Yet, more than a billion people in developing countries suffer from one or more NTDs, making joint efforts to combat NTDs the largest medical intervention in history—and at the same time the most unknown.

These are diseases of neglected people, those living in the hardest-to-reach places, with the fewest resources, and very limited access to healthcare—if any.

But progress against one tropical disease caught me by surprise: Human African trypanosomiasis or HAT—also known as sleeping sickness.

HAT is a parasitic infection spread through tsetse flies. It endangers millions in sub-Saharan Africa, and is nearly 100 percent fatal if left untreated.

“We have what it takes to eliminate sleeping sickness – a disease the world doesn’t pay attention to.”

   
Here’s the surprising part: We have what it takes to eliminate sleeping sickness – a disease the world doesn’t pay attention to – and it can happen sooner than you might think.

Progress in Uganda already shows what’s possible. In 2006, there were nearly 300 cases. By 2013, that number had dropped to 10. This year, we’ve seen only four.

This is exactly why the Gates Foundation invests in innovation. There are now new diagnostic technologies, new drugs in clinical trials, new products to reduce insect populations, and – borrowing a chapter from the polio eradication playbook – state-of-the-art mapping and micro-planning can guide our efforts with greater precision.

But innovations only matter when they reach the people who need them. This is especially true in the Democratic Republic of the Congo, where cases are highest, but inadequate funding, inaccessibility, and de-prioritization have left efforts stagnant.

We need people to believe – as we do – that a world without sleeping sickness is possible. This means asking: Can we set our goals higher?

The answer to that is a resounding yes.

One reason we’re optimistic is because we increasingly see private sector partners stepping up with resources and expertise outside the norm for global health and development.

Each prong of HAT elimination – insect control, diagnostics, and treatment – has a commercial partner involved.

In order to make markets work for the poor, the Gates Foundation takes on financial risk that the private sector can’t or won’t. But in the case of sleeping sickness, companies are combatting a disease where there isn’t a market incentive or chance to make substantial profit, but there is an opportunity to impact public health.

In other words, private sector partners are involved in sleeping sickness programs for a simple reason: it’s the right thing to do.

I spent a significant portion of my career in the biotechnology industry, and am excited by what can happen when the capabilities of private companies are unleashed on the problems of the poor. Corporate social responsibility is one path to impact. We also want to address market failures through mutually beneficial partnerships with the private sector. When we all play to our strengths none of us should be surprised by the possibilities.

Lessons in U.S. Education

From the beginning, Bill and Melinda wanted their foundation to be a learning organization; one that evolves and course corrects based on evidence. We want to get continually smarter. One of our greatest areas of learning has been our work in K-12 U.S. education.

We are firm believers that education is a bridge to opportunity in America. My colleague, Allan Golston, spoke passionately about this at a gathering of education experts last year.

However, we’re facing the fact that it is a real struggle to make system-wide change.

For too many students today, the bridge to a prosperous and fulfilling life is obstructed and uncertain. In 2015, the ACT Condition of Career and College Readiness study revealed that only 40 percent of students met three of the four college-readiness standards across English, reading, math, and science. And performance was much lower for students of color.

That statistic reads like part of a bad word problem, but it is real. It is really tough to create more great public schools.

However, I’m optimistic that all students can thrive when they are held to high standards. And when educators have clear and consistent expectations of what students should be able to do at the end of each year, the bridge to opportunity opens. The Common Core State Standards help set those expectations.

“We are firm believers that education is a bridge to opportunity in America.”

We’ve begun to see signs of improvement in student performance in some of the states that have embraced the Common Core. Kentucky, the first state to adopt the standards, is a prime example.

To implement the Common Core, Kentucky engaged the community and worked with parents, teachers and school leaders to build an interconnected system of standards, teacher feedback and support, and measurement over time. As a result, Kentucky has increased from 27 percent to 33 percent students meeting three out of four ACT benchmarks for college readiness since 2011. The same metric nationally has remained flat since 2011, so a 6 percentage point increase is a sign of real progress.

Deep and deliberate engagement is essential to success. Rigorous standards and high expectations are meaningless if teachers aren’t equipped to help students meet them.

Unfortunately, our foundation underestimated the level of resources and support required for our public education systems to be well-equipped to implement the standards. We missed an early opportunity to sufficiently engage educators – particularly teachers – but also parents and communities so that the benefits of the standards could take flight from the beginning.

 
Bill and Melinda Gates visit with students at Betsy Layne High School in Eastern Kentucky.

This has been a challenging lesson for us to absorb, but we take it to heart. The mission of improving education in America is both vast and complicated, and the Gates Foundation doesn’t have all the answers.

But every tough lesson only reinforces our commitment to teachers and student success.

All teachers and students should have access to learning materials of the highest quality. But far too many districts report that identifying or developing Common Core-aligned materials is a challenge, meaning that teachers spend their time adapting or creating curriculum, developing lessons, and searching for supplemental materials.

One of the best parts of my job is getting to hear from educators. And no one knows teaching like teachers. So, we’re doubling down on our efforts to make sure teachers have what they need to make the most of their unique capabilities.

Digital content and tools that provide support for lesson planning – including LearnZillion, Better Lesson, and EngageNY – are providing millions of teachers with an increasingly attractive alternative to traditional textbooks.

We’re supporting a partnership with EdReports.org, the Consumer Reports of K-12 curriculum, to provide free and open-access teacher-led reviews and evidence on instructional materials. This will increase the capacity of educators across the country to seek, develop, and demand high-quality, aligned instructional materials.

Our learning journey in U.S. education is far from over, but we are in it for the long haul. I’m optimistic that the lessons we learn from our partners – and, crucially, from educators – will help the American school system once again become the powerful engine of equity we all believe it should be.

Imagine What's Possible

Finally, let me tell you about Haliru Usman.

Mr. Usman is an environmental health officer in Nigeria who collects sewage samples so that they can be tested for the polio virus. I met him while visiting Kaduna state to learn about disease surveillance, one of the critical innovations necessary for the global goal of eradicating polio.

Mr. Usman took pride in doing his work because he knew it would help save lives and prevent suffering.

Environmental health officer Haliru Usman testing sewage for the polio virus in Nigeria.

He was right. Nigeria reached the milestone of a year without polio one month after my visit. For the first time in recorded history, the entire African continent went a full year without a child paralyzed by wild poliovirus.

This progress is the result of decades of hard work by the Global Polio Eradication Initiative (GPEI). Well before the Gates Foundation got involved, GPEI’s members were at the vanguard, working to bring a halt to the disease. Today, progress against polio is simply a thing of beauty.

As the world focuses on the last frontiers of polio eradication, Pakistan and Afghanistan, we again find ourselves asking: What if?

What if we channel the best science and technology, leverage global partnerships, and mobilize heroes and health workers like Mr. Usman to realize a vision decades in the making?

It is a real honor to work with so many others dedicated to writing history’s answer to that question.

Eradicating polio will mean that we have wiped out one of humanity’s oldest scourges. But it will also mean that the world has built upon the groundwork of possibility to end other diseases that disproportionately affect the poor.

We believe that realizing that vision – a vision started with the audacious goal of a world without polio – is utterly possible. Look how far that has taken us.

And as we rise together to face new global goals, imagine how much further we can go.

Please share your thoughts on the letter.

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