Johns Hopkins University
December 3, 2015
Thank you, Dr. Flexner, for that kind introduction.
I am delighted to be here, especially with the honor of being the Center for AIDS Research visiting professor.
So let me start by adding a personal thank you to you, Dr. Flexner, for the critical work you’re doing on HIV/AIDS.
We really have come a long way since I was starting out on my career in the 1980s.
Back then I was working in the Bay Area during my clinical training at UCSF, when this terrifying and, then, unknown condition began taking the lives of gay men in our community.
As this week’s World AIDS Day highlighted, there’s still a long way to go.
But I’m optimistic we’ll get there because of the persistence of individuals like you, Dr. Flexner, who have already helped us make great progress.
It’s also great to be here as CEO 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, of course.
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.
That being said, we don’t do it alone. We believe in the power of partnerships.
And there is, as you may know, a great history of partnership between Johns Hopkins and the Gates Foundation.
In fact, Hopkins was one of our earliest partners.
In the late 1990s – even before the actual formation of the Gates Foundation – when Bill, Melinda, and Bill’s dad were getting started in philanthropy, they were certain of just two things.
The first was that they had a passion for learning – and they wanted to know about the biggest inequities in the world, and what was being done to address them.
The second was that they wanted to allocate money in a meaningful way, to make sure their resources had as much impact as possible.
It’s no surprise then that they sought advice from experts at Johns Hopkins - a university with a reputation for rigor and excellence and a long-standing commitment to improving lives on a grand scale.
Laurie Zabin - and the other folks the Gateses met with - made a powerful case that if the smartest people in the world were working on family planning, it would lead to transformative progress.
From those very conversations came the Bill & Melinda Gates Institute for Population and Reproductive Health at the JHU Bloomberg School of Public Health.
And I am happy to say that Laurie was proven right.
Since its founding the Gates Institute has utterly changed the conversation about family planning, population dynamics, and reproductive health.
More than that, we’re today better equipped with better data to make better decisions.
Not to mention a growing cadre of experts and fellows who are improving the health of women and girls more than ever before.
Isn’t that awesome?
Brilliant minds using the best data available to give more people the opportunity of a healthy, prosperous life.
That dynamic really speaks to me. I’m what you might call a “data geek.”
While it isn’t on my LinkedIn profile, it’s undoubtedly one of the reasons Bill and Melinda recruited me as CEO.
And that geekiness goes back a long way. I have long believed that the insights we gather from data can help those of us in the health field make more precise decisions to improve patient outcomes.
My affinity for this approach 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 in hopes of making them ultimately feel better.
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 what I called “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 to benefit from, even outside of cancer.
So when I went to UCSF, I started leading on this concept of precision medicine: therapy that would help people more dramatically and cause fewer damaging side effects.
And to be honest, when I arrived at the Gates Foundation 18 months ago I thought I’d left all that 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.
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 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.
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.
For example, 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 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 Sustainable Development Goals – or SDGs, 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 suggesting my idea of precision public health is a fully-formed concept yet.
But I am convinced that we need a radically different approach to make more progress on global health and development.
We have set ourselves some big challenges in the Sustainable Development Goals.
To eradicate poverty, hunger, AIDS, tuberculosis, and malaria by 2030.
And if we’re serious about that – and I am - then we are going to have to dedicate ourselves to identifying areas where we are failing to address the health challenges of the poorest.
And once we’ve done that we’ll have to devote the best minds, the latest technology, and the most robust science to solving them.
Adopting a precision approach to public health could, I believe, be game-changer.
It really could have the same impact for populations as precision medicine has had for individuals.
I am incredibly optimistic about its potential.
There’s also another reason I’m optimistic – actually, it’s a few hundred reasons – and that’s all of you here today.
Students and faculty who have devoted a lot of laborious nights and dedicated your future to improving health.
To achieve the SDGs, we’re going to need the energy, creativity, and compassion of the next generation of immunologists, physicians, health policy gurus, epidemiologists—you name it.
In other words, we’re going to need you.
And it’s up to you to demand the most of yourselves in order to make the greatest difference.
If you’re like me that means owning the fact that you’re a data geek and staying excited about its capacity to overcome the world’s biggest problems.
You know, it’s great to live in a time when an entire auditorium at a world-class university gets to have a discussion about problems like improving the health of the poor.
What’s even better is that we live in a time when we don’t just get to talk about those problems, we actually get a chance to try to solve them.
I look forward to watching you – and working with you – to help make that happen.
And thank you.