Aspen Institute Public Health Grand Rounds
December 4, 2015
Thank you for that generous introduction, Peggy – and good morning everyone.
Engaging with the Aspen Institute’s bright minds is always a great pleasure and I’m delighted to be here today on behalf of the Bill & Melinda Gates Foundation.
Now I have to be honest. After a career spanning the healthcare spectrum – clinician, cancer researcher, drug developer, chancellor of UCSF – I was drawn to the Gates Foundation because of the money.
No… I don’t mean my salary…I mean the incredible generosity of Bill and Melinda – and Warren Buffett too.
What excites me so much is that the financial resources they’re providing allow us to make a unique contribution to global health and development.
Most obviously, we can and do have grand ambitions; we can take risks others can’t or won’t as we work to reduce inequity and give everyone the opportunity to lead a healthy, productive life.
And the Foundation’s guiding belief - that all lives have equal value - is a simple but powerful conviction that resonates with all of us here as we meet at the end of what has been a momentous year.
2015, of course, saw the culmination of the Millennium Development Goals – which without a doubt can be considered a resounding success.
The MDGs focused the world’s collective attention on some of the most serious challenges we faced at the start of a new century.
And the concrete targets they set, enabling countries to track and measure progress, inspired extraordinary achievements at a pace unmatched in human history.
We all know the headlines by now – but they certainly bear repeating.
Maternal deaths cut nearly in half. Child mortality and malaria deaths cut by half. Extreme poverty cut by more than half.
Half, half, half… But that means that we are still only half way done.
That’s why 2015 was also significant for the adoption of the Sustainable Development Goals where the world came together to commit to finishing the work.
Here are a few of the objectives the world has set for ourselves between now and 2030:
- End poverty in all its forms everywhere.
- End hunger.
- Achieve gender equality.
- End the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases.
For me, this is one of the greatest legacies of the success of the MDGs: That it is now possible to set ambitious, challenging goals – and not be dismissed as a crank.
That’s because we know now what’s possible with public support and political will.
But that is the year behind us.
The question going forward is how we make good on the new promises to build a world where every person has the chance of a healthy, prosperous life.
The hard truth is that the current tools and technologies simply aren’t going to be enough to get us all the way there.
We’ll need greater investment and greater innovation. But we’ll need more than that.
If we are going to succeed on the SDGs, we’ll need to be far more specific about what needs to be done, who it needs to be done for, and where it needs to be done.
In short, we’re going to need more bespoke solutions as we focus ever harder on the areas of greatest need.
I’ve been doing a lot of thinking about this over the past few months.
And I am beginning to believe more and more in the need for a radically different approach to tackling global health problems.
One option has been at the forefront of my mind for some time and I’d like to discuss it with you this morning - and hope that we can perhaps open a wider conversation about its potential.
The idea is this: Can we apply the principles that underpin precision medicine to the global health agenda?
Precision. Now, that’s a word the scientist in me just loves.
Let me give a bit of context by touching briefly on the development of precision medicine, since I have been privileged to have had a front row seat as this field has developed - first as a clinician and researcher and then as a drug developer.
Precision medicine is the next level of what people have commonly referred to as “personalized medicine” – that is: having the right drug, for the right patient, at the right time.
Precision medicine is a bit different.
It’s about garnering all the data you can, and from there developing a very clear understanding of what will work best for a patient based upon the conclusions you draw from that data.
The data will allow you to understand the patient as a member of a sub-category of individuals who will respond particularly well - or particularly poorly - to a specific course of treatment.
That sub-category may be 10 million people, or it may be 100 people.
But the data will allow for a level of precision in treatment that can make an enormous difference for an individual patient, and for others with a similar make up, or similar diagnosis, or who are similarly afflicted.
Now, my affinity for precision medicine comes from a very special place of purpose.
When I did my medical training, I trained as a cancer doctor. And one of the things I was very unhappy about when I was in practice was how sick I made patients.
How the therapies I was using to try and make patients better made them lose their hair, or vomit, or – even more frightening – suffer from life-threatening infections, given that our aggressive assault on the cancer took a toll on their own normal cells and immune system.
I am a doctor. I didn’t like making people feel bad – even on the path to making them well.
So when I got to Genentech and worked on Herceptin, there was a beautiful thing about it, which was one of the first examples of precision medicine.
This breast cancer drug allowed us to precisely target HER2, which is the driver of breast cancer.
And when we targeted it with precision, we didn’t surprise the surrounding bone or the healthy cells – so we didn’t make people’s hair fall out or make them sick to their stomach.
For me, having a powerful, effective cancer drug that didn’t have those side effects – well, it was like a miracle.
I just couldn’t imagine why I wouldn’t try hard - literally for the rest of my life - to see if I could make that possible for other patients, even outside of cancer.
So when I went to UCSF, I started leading on this concept of precision medicine and we had a good deal of success.
When I arrived at the Gates Foundation 18 months ago, though, I honestly thought I’d left it all behind.
Because like most people, for me precision medicine seemed most consistent with sequencing, genetics, high cost medicine for cancer, and other diseases that most often afflict people in rich countries.
Then a kind of light went on.
As I said at the outset, our guiding belief at the Foundation is that all lives have equal value. And I still care passionately about helping people avoid suffering - that’s a big life-long motivator for me.
So I thought: It isn’t fair, or right, or really all that pragmatic, that poor countries historically haven’t benefited from the same innovations as all of us, is it?
That’s why I am increasingly both intrigued and interested in whether or not a precision approach can be brought to bear on the issues that we’re trying to solve at the Foundation.
What if you were to take great science, great technology, big data, and all the smarts in the world, to try to reduce inequity and human suffering?
Surely, you can use the lessons from precision medicine to map a future for detecting, controlling, and combating infectious diseases everywhere, especially those that affect the poor.
Or to ensure more children and young people survive and thrive.
Or to empower the poorest – especially women and girls – to transform their lives.
It’s an approach I am starting to call “precision public health” – and we’re increasingly beginning to develop the concept at the Foundation.
So how could precision public health be effective?
Take the pretty compelling example of the lymphatic filariasis triple drug.
It’s a huge opportunity, a real potential advance in the treatment – or even elimination - of certain neglected tropical diseases that place a big burden on a small number of communities.
But if you apply it in mass drug administrations, in certain vulnerable areas, you’ll blind people.
So if you want to take advantage of this opportunity you have to know who you can actually treat - and then do it in a very precise way.
Let me explain a little further why I think this tailored approach has the potential to make such a difference.
I think there’s a belief out there – a myth, really - that we have the solutions for most public health concerns, it’s simply a delivery problem, just a question of getting drugs where they need to be.
Yet the reality is that not only do we not have the solutions, in many cases we don’t even know what we’re trying to solve.
At the start of this talk, I mentioned the incredible progress we’ve seen against child mortality.
We have big aspirations for even greater progress over the next decade and a half.
Yet whenever you look at a pie chart on the causes of death for children under five, there’s a big slice - about 40 percent - that says simply, “neonatal.”
Neonatal! That’s not a cause of death, that’s a timeframe, nothing more than an adjective to describe babies in their first month of life.
What “neonatal” ultimately means is: “We have no idea.”
If we’re ever going to achieve our ambition to make sure more children survive and thrive, we don’t just need to know that babies are dying in the first 30 days of life – we need to know why they’re dying.
Say for example you have a condition such as strep B.
Many of the babies who perish from strep B in low-income countries would all be counted under that dreadful “neonatal” category – or, maybe, as “perinatal deaths” or “stillbirths”.
The point is that no one – and the parents especially – would have known the death was due to group B strepsis.
So the next pregnancy would go on with a seven-fold increase risk in strep B.
Everything could change by simply giving the mother penicillin during pregnancy.
It’s hard to think of a cheaper or safer prevention than that. But no one’s going to suggest it if we don’t have the knowledge that it is strep B in the first place.
Just imagine the progress we could make on newborn health if we truly had the power of data at our disposal in dealing with this absolutely fundamental global health challenge.
As a partial response, our Foundation is supporting the development of the Child Health and Mortality Prevention Surveillance - or CHAMPS - network.
This program will establish six sites in Africa and South Asia over its first three years.
Those sites will collect comprehensive, standardized primary data addressing all causes of death in children under the age of five - including through the use of minimally invasive tissue sampling. The ambition is that the CHAMPS network will grow to more than 20 sites over the next two decades.
Our Foundation is prepared to commit at least $73 million over the next three years.
But we estimate that full funding of this network will cost more than twice that much, about $150 million.
We’re looking to partners to join us in supporting this initiative, which is an extraordinarily practical and effective investment.
As the CHAMPS network gains clearer data on the causes of child mortality, we will be able to direct our spending on this paramount global health issue with ever-greater precision.
Similarly, we recently launched a new Grand Challenge around putting women and girls at the center of the development agenda – which is critical to human progress.
There are myriad programs that seek to improve gender equality and empowerment.
What we need to better understand is how to do this most efficiently and under what conditions the various approaches will be most effective.
That is why we have focused the Grand Challenge on developing and testing solutions and generating evidence for approaches – particularly on how to promote equitable decision-making – that are sustainable, cost-effective, and with potential for scale.
Precision public health, then, is all about looking at that child mortality chart, and recognizing that categorizing deaths as “neonatal”, is simply unacceptable.
Or that “empowering women and girls” is futile if you don’t know what empowerment really is to individuals in their unique circumstances - or how you achieve it on the ground.
Only once we chip away at our own ignorance, will we be able to build real, lasting solutions.
If we’re serious about achieving the SDGs, then we are going to have to devote the best minds, the latest technology, and the most robust science to solving the big global health problems.
And I believe passionately that the same tools that help create targeted therapies for an individual’s genetic make-up, can be harnessed for this endeavor – to ultimately help entire populations.
In this way, precision public health adds a layer of equity to precision medicine, taking what we can do for an individual patient and applying it to a population or a community.
Because what really irritates me is when people – even people who care about public health – wall off large avenues of innovation from being utilized.
That’s when I get impatient, and a little fired up, and say, “What? Poor people don’t get that good stuff?”
So for me, when I try to spend any time on this, I kind of come back to what gets me fired up.
Basically, if you’re poor or you’re suffering from anything from HIV to diarrheal disease, all the tools should be there for you.
And precision public health would bring every scientific tool to bear – sequencing, molecular biology, data-based disease surveillance – to create better remedies, diagnostics, and therapeutics.
In other words, it takes the gifts of technology and applies them to the problems of the poor.
But it’s more than that. It’s also about using those technologies in ways that take account of local contexts and the needs of specific, mainly impoverished, populations.
And for that you have to rely primarily on data. Lots of data. Fast, real-time data. The kind of data that requires serious up-front investment and a sustained commitment over time.
And if we want to move faster and better, we’ll also need to actually share the data faster and better.
We could create an entire community that has open access to this data as a shared global good.
That could bring more opportunities for people who aren’t part of the traditional scientific community to help find solutions to the challenges we face.
I think this would be something radically different and an interesting way to think about innovation beyond, “It’s mine and I’m patenting it and I’m publishing it – and until then, nobody touches it.”
Which – frankly - would be a seismic shift. But imagine the progress we could make. There’s something of a template for it too.
In 2011, I co-chaired a National Academy of Sciences committee that recommended creating a data network aimed at developing more diagnostics and treatments tailored to individual patients.
This network of knowledge proposed integrating the wealth of data emerging on the molecular basis of disease with information on environmental factors and patients’ electronic medical records.
The vision was to enable basic scientists to mine and manipulate patient data in order to explore common molecular mechanisms across illnesses, and to test their hypotheses about the causes of diseases.
Clinicians could tap into the network to learn about the latest findings, informing their diagnoses, and enriching their treatment approaches.
What’s to say we couldn’t adopt a similar data pool for treating diseases of the poor? And why wouldn’t we want to?
In our ever more inter-connected world, a health crisis anywhere can become a health crisis everywhere.
We saw this most obviously, of course, with the Ebola epidemic. But we are also seeing it in the refugee crisis that has torn millions of people from their homes and compelled them to gather in camps and makeshift towns.
The public health consequences of this became apparent with the appearance of wild-type polio cases among Syrian refugees in late 2013.
With populations in flux and national borders in many places more porous, infectious diseases of the poor represent a practical health interest for everyone - as well as an abiding moral interest.
As Bill Gates wrote in his New England Journal of Medicine article in April, the Ebola outbreak needs to serve as a warning of the potential destructiveness of future epidemics that could spread far more rapidly and far more widely.
Now, I’m not trying to suggest to you this morning that the concept of precision public health is fully formed, which is why I’m eager to draw you into the conversation.
I’m mindful that this approach is not without risks.
I do think for instance that the more you use big data, or tracking, or monitoring – I try not to use the word surveillance – that it raises for people a creepy factor and a privacy issue.
I wonder how much it raises red flags for you all here.
I’m not sure there is an answer just yet beyond the obvious: that it’s a legitimate concern and you need to ensure you have the right levels of protection.
But taking risks others can’t or won’t, as I said at the outset, is one way the Gates Foundation tries to move the needle, which is why I’m putting this idea out there.
I am convinced there’s a case to be made for adopting a precision approach to global public health.
That it really could have the same potential for populations as precision medicine has had for individuals.
That it can be game-changer.
And I find that prospect incredibly exciting. I suppose it’s what makes me an impatient optimist.
I’m fascinated to know what you think.