Everyone knows that the Bill & Melinda Gates Foundation likes technology, inventing new things and helping others find innovative ways to fight diseases of poverty and other scourges that afflict those living in the poorest parts of the world.
The world’s biggest philanthropy has reorganized to devote its global health program, run by former Novartis executive Trevor Mundel, almost entirely to supporting research aimed at finding new drugs or vaccines. The incoming CEO, Susan Desmond-Hellman, is a biotech leader and was head of product development at Genentech.
So it’s no wonder that some complain the Gates Foundation often sounds sometimes like just another drug company, is too focused on the ‘techno-fix,’ the silver bullet or some other kind of magical (Bill likes that word, ‘magical’) targeted intervention.
But that perspective may be missing a more fundamental transformation – the new, intentionally holistic Gates Foundation.
“We are more willing to fund the 10-year thing that other funders won’t fund,” said Bill Gates, speaking Wednesday to more than 500 participants at the philanthropy’s annual product development forum held through today at the Seattle Westin.
Gates announced the foundation’s support – and push for others to help fund – a late-stage trial of a new tuberculosis drug that the Microsoft co-founder enthused as a potential game-changer in the battle against this airborne killer.
“It’s going to take things like this to stem the tide,” he said. What he meant is that it’s going to take new drugs, new products, to curb the spread of increasingly drug-resistant TB.
We need a new TB vaccine, and vaccines against infectious diseases like malaria and HIV as well. The Gates Foundation loves the low-cost, simple power of vaccines and, arguably, has done more over the past few years to reinvigorate scientific interest (and crucially, funding) in the hunt for better vaccines, drugs and diagnostics against malaria, HIV and other big killers of the poor.
But what the philanthropy hasn’t done, say some of its critics, is invest much time, attention or money in dealing with some of the more fundamental – and complex – drivers of poverty, disease and inequity.
Diseases don’t disproportionately attack the poor because bugs are afraid of rich people; the poor suffer more from disease because they are poor and lack affordable, reliable access to basic health care, to clean water and good food or even just basic information.
The Gates Foundation has, for most of its history, tended to shy away from problems that lack clear (and measurable) solutions. Melinda’s push into family planning a few years ago was widely celebrated as a move into some of the more rights-based, highly politicized and socially complex drivers of inequity. But the reorganization of global health into what some see as a mini-drug company has revived concerns that the philanthropy is stubbornly techno-fix and loathe to deal with the ‘real world.’
That appears to be changing, in a big if not highly visible way.
“I can remember when Bill wouldn’t even say the words ‘primary care’ or ‘health systems’ when talking about global health,” said Dana Hovig, a new hire at the Gates Foundation who has been put in charge of’ a new program there called integrated delivery – the boring name given to this big internal transformation.
The main point of the Seattle meeting was to get together with the foundation’s grantees and partners in product development and talk about how they’re doing. A new malaria strategy was discussed aimed at getting the world closer to eradication. One panel looked at three new drugs for leishmaniasis, a neglected parasitic disease that afflicts millions of poor people.
But the Gateses also talked forthrightly about how they and the foundation have learned that narrowly focused approaches – or stratgeies that depend upon simply creating a new and better drug or vaccine – is not enough.
Bill talked at this product confab about the need to support health system strengthening in poor communities. Melinda described how some of the work they supported on developing a new injectable drug treatment for leishmaniasis was hampered by a failure to appreciate how it would work (not well, it turned out) in a poor community with few resources.
“I think we’re getting smarter about looking at the whole disease,” Melinda said. Beyond that, she said, the foundation recognizes that diseases exist within the broader social, political and economic contexts that determine success as much as a drug or vaccine’s efficacy. “We’re looking at things more holistically.”
The way they’re trying to do that is through Honig’s efforts dubbed integrated delivery. Aimed at cutting across all of the Gates Foundation’s programs first in health and then incorporating agriculture, it is being overseen by Chris Elias, head of the development program at the philanthropy.
Much of the Gates Foundation’s work in global health is done through Elias’ shop, which supports more of the ‘delivery’ side of the philanthropy’s work – fighting polio, expanding children’s vaccines and so on. According to a spokesman, the Gates Foundation spends about half of its global health war chest on product development and the other half on delivery or other non-R&D efforts.
“We have all these interventions for malaria, diarrhea, pneumonia or other health problems but mothers come into clinics with sick kids,” said Elias. “We don’t need separate delivery systems for dealing with specific problems; We need a health care system that can take care of sick kids, whatever they have.”
The Gates Foundation is going to stick with its strategy of investing in innovation, in ‘catalytic’ inventions that can stimulate big gains in health, he said.
But what’s new with the integrated delivery approach, Elias explained, is that the scientists or partner organizations who come to the philanthropy with a proposed research project are going to have to answer non-sciencey questions that address how their gizmos will work in the real world – the world of bad water, no money, poor governance and all sorts of other complexities.
“We’d been doing this already to some extent, but this just formalizes the integration of delivery with a starting focus on how these products will fare in the field,” Elias said.
“The foundation long ago recognized the value of routine immunizations,” added Honig. “But routine immunizations are dependent upon having a good primary health care system. We’ve learned the importance of systems and we’re looking at ways to improve these systems so they can absorb the innovations.”
A key question raised at the product confab is how the Gates Foundation intends to find the right balance between supporting research aimed at developing new products and funding initiatives aimed at getting the many existing drugs and vaccines out to the millions who are still dying from easily preventable diseases or disorders.
“That’s a big discussion for us all the time at the foundation,” said Melinda. She acknowledged that she and Bill often see things from a different perspective (she more ‘holistic’ and he a bit more techno, perhaps), but that they remain commited to focusing on the poor overseas, on supporting long-term change and using their money and clout to deal with the ‘market failure’ of the biomedical research industry when it comes to diseases of poverty.
The focus will continue to be on supporting innovative research and on infectious diseases, Bill said in answer to one question. But that focus will incorporate a much more deliberate early-stage discussion about how the innovation will be designed to ensure it is not just a cool new technology the poor never see.