Peter Small wanted to get back on the front lines.
Small, who qualifies as one of the old-timers at the Gates Foundation having started there in 2002, has stepped down as head of the tuberculosis program at the philanthropy and moved — with his two young children and wife — to New Delhi to help fight one of the world’s biggest, and somewhat neglected, killers.
“I wanted to be there on the ground, engaging with the people who are doing the hard work,” said Small.
Tuberculosis kills nearly two million people every year. One of every three people on the planet are infected with the bacterium. And the potentially deadly bug is becoming increasingly resistant to drugs.
It’s a modern plague fought with an inaccurate diagnostic test developed before cars were invented, a frequently ineffective vaccine created during the (last) Great Depression and 50-year-old drugs.
And India is home to one-fifth of the world’s TB disease burden.
“They’ve actually done an incredible job at TB control,” Small said. “They’re a world leader in making the best of these bad tools.”
Getting better tools has been the primary mission of the TB program at the Bill & Melinda Gates Foundation. And while it is clear that better vaccines, tests and drugs are needed, Small said this focus just on technological innovation has made them the target of critics — legitimately, he added.
“Clearly, we need new technologies,” he said. “But the technologies need to have an impact. And the only way they can have an impact is if they work within systems.”
By “systems,” Small meant the public health system, the health care system, the pharmaceutical system, the government system and all the other cultural, social or economic factors that determine if a promising new technology is accepted and actually effective.
For example, he said, lack of accurate diagnosis of TB is a massive problem — perhaps the biggest reason for the spread of TB today, and for the spread of drug-resistant TB.
There is a new device, called the Xpert MTB/RIF (yes, they need better branding), that an untrained person can use which delivers highly accurate TB diagnoses in two hours. The World Health Organization, desperate to improve TB testing worldwide, has endorsed it.
It’s somewhat expensive for poor countries and reportedly also has problems working in very hot climates. Still, the cost savings from accurately diagnosing TB and preventing the spread of the disease, Small said, could justify its use even in poor communities.
But then again, he notes, India has something like 13,000 microscopy labs — businesses — that now do these tests. You can’t just introduce a job-threatening technology without considering its ripple effects.
It’s a systems problem, he notes, not a simple matter of introducing a better technology.
“Honestly, we really don’t understand the systems side to this or our role in it,” he said.
That’s why he’s relocating to India. To be there, inside the “system” and to figure out how new technologies can best have an impact.
In one sense, Small’s move — into the field, away from just writing checks — is emblematic of how the Gates Foundation has been changing over time. When he started there, he said they were often simply just responding to proposals as they came in.
“We’re changing from people sending us stuff and simply giving a thumbs up or thumbs down,” Small said. “We used to kind of just deal with whatever came over the gunwale. It was still transformational, but now I think we have come to realize that our core business is making strategy and investing against it.”
This transition, from passive donor to active collaborator, hasn’t always been smooth or easy, he added.
“There was some confusion,” he acknowledged.
But things are getting better, he said, clearer, in terms of how the Gates Foundation sees itself helping to conceive of new strategies and assisting with the implementation as partners — rather than simply writing checks.
Small, his kids and his wife, film-maker and fellow physician Delaney Ruston, plan to remain in India for two years.
“It’ll be great to be back on the front lines,” he said.