Gates Foundation CEO on the importance of innovation, but also prioritization

SAN FRANCISCO — Sue Desmond-Hellmann, CEO of the Bill & Melinda Gates Foundation, said she is committed to saying no more often.

“The thing that keeps me awake is that our ambitions are too large and so we don't execute as efficiently or quickly or expertly as we could if we decreased the number of things on our plate,” she said during a conference call with stakeholders this week. “Being overly ambitious about the number of things we take on would probably be top of my list for things I worry about.”

Following a busy year where it launched a number of new programs, the Gates Foundation plans to spend 2019 refining its strategies, rather than taking on new challenges. On Thursday, the Gates Foundation released its annual year in review, capturing what happened in 2018, including the launch of three new strategies: $170 million for gender equity, $68 million for global education, and $158 million for mobility from poverty in the United States.

Desmond-Hellmann says that while “innovation is helping more people than ever” lead healthy and productive lives, the Gates Foundation strategy moving forward must involve innovation, as well as prioritization.

She says the foundation thinks about innovation in two ways: both the technological innovation it is known for and innovations in the face of market failures. The two areas that excite her most from the past year were advancements in malaria and vaccines, two major areas of focus for the foundation.

“I like the saying I heard this year, ‘Vaccines cause adults,’” she said on the call, adding, “we could use a little more edge in how we talk about vaccines.”

She noted that by the end of 2018, 700 million children will have been immunized and 10 million deaths will have been averted in developing countries due to work supported by Gavi, the Vaccine Alliance, which the Gates Foundation provided the seed money to launch.

“Vaccines are truly the greatest health innovation that we’ve seen in history,” she said.

R&D for vaccines remains critical, Desmond-Hellmann said, explaining how the Gates Foundation has invested in antigens, which induce an immune response in the body, in order to improve vaccine effectiveness.

Beyond investing directly in R&D, she explained that the foundation is also leveraging a suite of financial tools, such as price and volume guarantees, to engage the private sector in global health.

“When we think a company can hit a target product profile for a certain price and a certain safety and efficacy profile for a new product, we will use our capital to backstop that company, so they can put their capital at risk and feel like they're not taking a big financial risk,” she said, speaking in large part to the work of the Gates Foundation’s Strategic Investment Fund.

Desmond-Hellmann mentioned an example of volume guarantees for long-acting contraception that was so successful that Merck and Bayer ultimately trusted the market.

“There's a terminology we use in the biotech and pharma space called the ‘valley of death,’” Desmond-Hellmann said in an interview with Devex after the call. “The valley of death is that place between a research lab and getting to the clinical trial.”

While the foundation funds academic labs all over the world to pursue global health R&D, the hard work of conducting a toxicology study, working with the Food and Drug Administration to file an Investigational New Drug Application, or planning clinical trials in developing country contexts often leaves these efforts in the valley of death, she said.

One way the foundation is seeking to innovate is through the launch earlier this year of the Bill & Melinda Gates Foundation Medical Research Institute, a nonprofit biotech organization in Boston. Its focus is on translational medicine, advancing drug and vaccine candidates to human studies.

The group is now fully staffed and working to take innovations for malaria, tuberculosis, and diarrheal diseases from laboratory settings to human studies, Desmond-Hellmann told Devex. The goal is “translating the scientist in a white coat saying ‘Eureka,’ and making that a drug,” she said.

At one point in the call, a question came up on low-tech innovation.

“I will tell you that we are technophiles,” said Desmond-Hellmann, laughing. “We do love our technology and our innovation.”

But she noted that this is beginning to change, mentioning the foundation’s growing interest in human centered design, which has been driven in part by Melinda Gates.

“Increasingly as a foundation we know that innovation comes in all different forms,” she said.

The Gates Foundation is working in collaboration with governments, including in Ethiopia, India, and certain states in Nigeria, on primary health care delivery, which will extend its impact to noncommunicable diseases. But infectious diseases, and especially those that affect the poor, and specifically polio, HIV, TB, malaria, pneumonia, and diarrheal diseases, remain the top global health priorities of the Gates Foundation.

While the foundation is interested in taking advancements in immunology for oncology and applying them to infectious diseases, the plan is not to focus on cancer, cardiovascular disease, or diabetes, aside from involvement in certain vaccine preventable cancers such as cervical cancer.

“Pretty much once a year we get the question about noncommunicable diseases and it is compelling,” she told Devex. “There are really good reasons for us to say no and we have said no.”

Pharma and biotech companies are well rewarded in rich countries working in cancer, diabetes, and heart disease, so there is not a market failure.

“In the absence of a market failure, we don’t feel like there’s a giant call to action for the Gates Foundation,” she said.

As the largest private foundation in the world, the Gates Foundation faces a high level of scrutiny, and that can get in the way of risk taking.

“We don't like to be criticized. We're human, you know, we are sensitive to criticism, and so I sometimes worry that we're so careful,” Desmond-Hellmann said on the call. “Risk means you don't make everyone happy.”

Taking risks means making decisions about what to do and what not to do, she continued, explaining this is part of why she plans to say no more often.