Over the past 50 years childhood deaths have dropped dramatically. Take a look at Chart 1, which is one of my favorites. (I hope you didn’t think you were going to get through this letter without some figures being thrown at you.) What you see is that in 1960, when there were nearly 110 million children born, almost 20 million children under 5 died. In 2005, when more than 135 million children were born, fewer than 10 million children under 5 died. I think this is one of the most amazing statistics ever. The number of children born went up, while the number who died was cut in half. Two things caused this huge reduction in the death rate. First, incomes went up, and with that increase, nutrition, medical care, and living conditions improved. The second factor is that even where incomes did not go up, the availability of life-saving vaccines reduced the number of deaths. For example, measles accounted for 4 million children’s deaths in 1990, but fewer than 250,000 in 2006.
Despite this progress, 10 million children dying is still 10 million too many. Each death is a tragedy. In the United States we don’t think much about young people dying because it is so rare. It would be a huge breakthrough to cut that 10 million in half again, which I believe can be done in the next 20 years. Chart 2 shows a breakdown of what kills children under 5. As you can see, there are a few diseases, like diarrhea, malaria, and pneumonia, that cause over half of the deaths. The key to eliminating these conditions is the invention of a handful of new vaccines and getting them into widespread usage.
When Melinda and I first started our giving, in the late 1990s, our focus was on reproductive health rather than childhood deaths. We felt that giving mothers the tools to limit their family size to what they wanted would have a catalytic effect by reducing population growth and making it easier to feed, educate, and provide jobs for the children who were born.
We were surprised when we saw a newspaper article in 1998 showing that only a few diseases cause most childhood deaths and showing how little money was being invested in creating and providing vaccines for these diseases. A chart in the article showed that a particular type of diarrheal disease—rotavirus—was killing over 400,000 children per year. How could a disease we had never heard of get so little attention and kill this many children? We sent the article to my father and asked him to look into how we could help.
A surprising but critical fact we learned was that reducing the number of deaths actually reduces population growth. Chart 3 shows the strong connection between infant mortality rates and fertility rates. Contrary to the Malthusian view that population will grow to the limit of however many kids can be fed, in fact parents choose to have enough kids to give them a high chance that several will survive to support them as they grow old. As the number of kids who survive to adulthood goes up, parents can achieve this goal without having as many children.
This means that improved health is critical to getting a country into the positive cycle of increasing education, stability, and wealth. When health improves, people have smaller families and the government has more resources per person, so improving nutrition and education becomes much easier. These investments also improve health, and a virtuous cycle begins that takes a country out of poverty. This was a huge revelation for Melinda and me. It is why we expanded our focus from reproductive health to all of the major infectious diseases. Today the foundation’s Global Health Program, which accounts for about 50 percent of our total spending, focuses on 20 diseases. The top five are: diarrheal diseases (including rotavirus), pneumonia, and malaria—which mostly kill kids—and AIDS and TB, which mostly kill adults.
Ten years have passed since Melinda and I were shocked by the number of deaths and lack of focus on rotavirus. Unfortunately, the death toll has not yet been reduced. Two vaccines for rotavirus are now being used widely in rich countries. We need to get them into use in poor countries, but there are some significant challenges that have caused delays.
Each country wants to be sure that rotavirus is a big enough problem in their country to justify adding the rotavirus vaccine to the set of vaccines that their newborn children receive. They need additional funding, because a new vaccine costs over $20 per child—sometimes much more. (Usually this cost comes down to less than $1, but only after several decades.) A particular challenge for vaccines is that they need to be kept cold in refrigerators because they spoil if their temperature gets above 40 degrees Fahrenheit for very long. So adding a new vaccine, like one for rotavirus, that needs a lot of refrigerator space requires increasing the refrigeration capacity at every stage of the entire delivery chain, including very remote areas that don’t have electricity. The foundation is working with a grantee, the GAVI Alliance, and others to get a rotavirus vaccine into widespread use.
We know it can be done. In the past eight years, GAVI has added a vaccine to prevent liver cancer (Hepatitis B) and one to prevent respiratory disease (Haemophilus influenzae type b) to the standard group of six vaccines in a large number of countries. Nothing on the planet saves children’s lives more effectively and inexpensively than vaccines. I believe that within six years we will have enough distribution to have cut the number of rotavirus deaths in half. This is an ambitious goal, but it’s one of the key steps to cutting the overall number of childhood deaths from 10 million to 5 million.
At the foundation we are getting even more focused on our top health priority, which is helping to make sure that vaccines are developed and delivered to fight these diseases. With a handful of new vaccines, we should be able to save a year of a person’s life for well under $100. If we waste $500,000, we are wasting 5,000 years of life. This is the kind of trade-off I ask our employees to consider when they are deciding which areas to get involved in and which grants to make.