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Bill Gates and the science of global health

Bill Gates’s Global Fund has 6.1 million people on antiretroviral therapy for AIDS and has treated 11.2 million people for TB.

Frederic Courbet

Bill Gates makes big – $1.4-billion to date – donations to the Global Fund, the worldwide effort to combat and eradicate the triple scourge of HIV-AIDS, malaria and tuberculosis. Results have been remarkable. The Global Fund, operating in more than 140 countries, has 6.1 million people on antiretroviraltherapy for AIDS, has treated 11.2 million people for TB, and distributed 360 million insecticide-treated nets to protect families against malaria. But it's about far more than money and numbers.

Mr. Gates spoke recently of his deep commitment to primary health care and how to leverage science and technology in pursuit of his foundation's goal that "every person deserves the chance to live a healthy, productive life." Here is what he had to say about his work, its impact on his own life, and his ambition to do more work in the field and meet "the heroes on the front line." This interview has been edited and condensed.

Global health is the vast majority of what we do and will be for the rest of my life. You know, about six and a half million kids under five died last year yet that is an amazing reduction from the 20 million who died annually back in 1960. So vaccines and other heath interventions are really uplifting people's lives. We've gone from about 25 per cent of kids under five dying to now, where we are at about five per cent.

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I come from the world of science and innovation and I think: "Wow, we're doing all these great things for rich world health but are we doing enough for poor world health where we can often come up with – especially if we are smart about it – very inexpensive vaccines whose impact in terms of dollar per life saved, or dollar per disability eased is quite phenomenal.

Where does science improve the human condition the most? I would say in global health. Now that doesn't take away from the fact that eventually we want connectivity and cell phone and all those things for these people as well but the primary thing that if it's executed well is not that expensive. It's basic health.

With the three-year fundraising cycle, in which Canada promised $650-million, just completed, Mr. Gates looked ahead to what might be achieved by the next round.

People can expect pretty significant progress on all three of the diseases. In the case of TB … we have some new drugs in the pipeline that will be out in the next couple of years. With TB, the sooner you diagnose somebody, the better. The longer they are coughing the more people they infect. The name of the game is to get so that one person infects less than one other person so your total number goes down.

With malaria, we should have the death rate down quite a bit and we should have a few countries where we will have cleared large areas.

HIV is our toughest because we still have a lot of people who got HIV in the past who will progress to needing treatment. In the case of HIV a lot of the money goes to increase the number of people on treatment which avoids deaths. A fair bit of the money goes to HIV prevention, like scaling up circumcision and that will bring the numbers down. You know, we do have behavioural change … where we need to convince people not to do risky things, convince them to use condoms.

There are two miracle things we want in [dealing with] HIV. One is a vaccine, so that eventually you can stop people from getting the disease, and the other is a cure, so that even people who have it don't have to keep taking these drugs for the rest of their lives. It's hard to get people to comply, it costs money and there are side effects to the drugs. So lifelong treatment is massively good compared to the death sentence but it is not as good as a cure. I doubt we will have [a cure] three years from now; six years from now, I would hope so and the vaccine – six years from now – there's a chance we will have one.

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So on all three diseases we have made good progress. We've got the death rate down on all three. I think we can get it down more in the next three than the last three because we are smarter than we were before.

He spoke about his desire to get out into the field.

I was just in Nigeria a few weeks ago and they are starting to do some things right but their primary health care system is very weak and need a lot of focus, whether it's on polio or just getting vaccines out or bed nets or nutrition. I want to actually go to primary health care centres and meet the guys [running the clinic]. And I go and see the nurses who are giving out vaccines and find out whether they have stock-outs and how long people have to wait in line. If you decide that something is very important, like primary health care, you need to get out to the very point of delivery to meet people and see the heroes on the front line. You want to see where the systems just don't work or the paperwork is too complicated. It's always eye-opening to see things in the field. You know the health statistics overall are pretty bad so you want to get a sense of why don't they have refrigerators for the vaccines. Why haven't they trained the workers; what is it that's breaking down.

And he reflected on the underlying commitment.

It raises the question: Do we view these lives as having equal value? Because for less than one per cent of what we spend on saving lives in our own country, these lives can be saved. So the equity is kind of staring us in the face.

It's tragic that AIDS existed in the rich world but you do have to wonder that if people hadn't seen it at all in the world they live in, if they hadn't seen AIDS at all, would there be this same very generous response of the richer countries to the world at large.? You know when the Global Fund was created, we definitely thought we were piggybacking malaria and TB on to the disease [AIDS] where there was still a strong rich-world awareness.

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And why it matters.

We say society is "richer" and "more inventive" but to what end.? Bringing that innovation to bear on the reality that a parent doesn't want their child to die. And then there is this deep irony that in societies that have terrible health, parents choose to have a lot of kids so that a few will survive, so bad health and population growth are [closely linked]. Everywhere in the world there is either good health, low population growth or bad health, high population growth. So whether you believe in the environment or stability or feeding people or educating people, health is the primary lever.

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