Bill Gates, the co-founder of Microsoft and co-chair of the Bill & Melinda Gates Foundation, upset some health officials when he asked six or seven years ago about the possibility of performing autopsies on babies to figure out why they were dying.
The anecdote appears in the Gates Foundation’s 2017 annual letter, released on Wednesday, and it points to just how data driven the billionaire philanthropist is in his approach to fighting disease and reducing inequality.
“Here was this black hole of health understanding, and they acted as if it would be impolite to find out more,” Bill wrote.
In fact, the Gates Foundation went on to fund partners who developed a minimally invasive autopsy that uses advanced diagnostic tools to understand why children get sick and die. Last year, Gates was present at an autopsy of a baby boy who died three days after he was born outside of Johannesburg, South Africa.
This is one of the examples Bill and Melinda mention in their letter, which they addressed to Warren Buffett, the billionaire founder of Berkshire Hathaway, who doubled the resources of the Seattle-based Gates Foundation when he directed the bulk of his fortune toward supporting their work.
“The best investment any of us can ever make is in the lives of others,” they wrote. “The returns are tremendous.”
But they said they want to make sure his investment continues to pay higher returns, which means the foundation will have to save more lives in the future than it has in the past. The letter revealed the scope of the data-driven approach the foundation takes in its work on global health in order to try and fulfill that aim.
By the numbers
As uncertainty about the direction of U.S. policy persists, representatives meeting in Seattle discussed collaboration between organizations, disciplines and countries in a renewed effort to tackle global health challenges.
The letter kicks off with a big number, 122 million — the number of children’s lives saved since 1990.
“Warren, you’ve said ‘price is what you pay, value is what you get.’ There is no value greater than this,” Bill etched into the white space next to this big win for global health.
Last week, at an event at the University of Washington, Melinda mentioned this number along with several other facts and figures that made their way into the letter, which was at that point still a work in progress.
“Sometimes the news about global health that you hear — that hits your radar — are the negative things,” she said. “But the story of global health is an amazingly positive story.”
At the event, she mentioned the figure 86 percent — the percentage of children worldwide who receive basic vaccines — and the letter goes on to explain that for every dollar spent on childhood immunizations, there are $44 in economic benefits.
How has the Gates Foundation brought others on board with its goal to eradicate malaria? Devex reports from Seattle on how the focus on elimination has changed the way the foundation and the broader public health community are focusing their efforts.
Bill and Melinda end their letter with what they call the most magical number they know, zero. “Zero malaria. Zero TB. Zero HIV. Zero malnutrition. Zero preventable deaths. Zero difference between the health of a poor kid and every other kid,” Bill writes.
Polio could be history this year, the couple explains, and they are working toward ending malaria in their lifetimes, when they also expect that no one will die from AIDS.
Melinda hinted at the challenges U.S. government funding could pose for the Gates Foundation’s top priorities, which she called vaccines, HIV, malaria, contraceptives and polio.
“Ultimately every single thing we’re working on takes government money to scale it up,” she said.
By using the same numbers that guide their work and track their progress to tell what they see as a positive story of the ways that health is improving, it seems that Bill and Melinda are not only demonstrating a return on investment to Buffett, but making the case for governments to support these interventions.
The positive outliers
The annual letter features several graphs with steep downward trajectories: the number of deaths of children under 5, polio cases, people living in extreme poverty.
“Virtually all advances in society — nutrition, education, access to contraceptives, gender equity, economic growth — show up as gains in the childhood mortality chart, and every gain in this chart shows up in gains for society,” wrote Melinda Gates, referencing a chart from an Economist article on the decline of child deaths.
While the child mortality chart is a success story, it masks an area where more progress is needed, Bill and Melinda write. While the total number of childhood deaths is on the decline, 1 million babies died on the day they were born last year, with the percentage of newborn deaths representing childhood deaths on the rise, they said.
But data can also unveil what is working, as revealed by the work of Hans Rosling, the founder of Gapminder, whom Bill and Melinda paid tribute to in the Gates Notes post that preceded their annual letter.
“When a huge challenge comes up and you have no answer, it’s crucial to ask, ‘Is anyone doing this well?’” Melinda wrote in the letter.
Bill and Melinda reference the chart below from Gapminder.com and point to positive outliers in the data set that seem to do a better job than others. Rwanda, they explain, cut its newborn mortality by 30 percent from 2008 to 2015. The data is a certain point to answer the question of how this country is doing it better, in this case by encouraging mothers to breastfeed within the first hour of birth and exclusively for six months, cutting the umbilical cord hygienically, and recommending skin-to-skin contact between the mother and the baby.
“There’s a difference between asking who has always been better than expected and who has been making better progress than expected,” said Christopher Murray, director of the Institute of Health Metrics and Evaluation. “So you can have a snapshot view, or you can look at data over time, and that is more actionable in some ways.”
Last month, the Gates Foundation made a historic gift of $279 million to IHME, building on the $105 million grant that stood up the effort a decade ago.
“That investment is a global public good,” Melinda said at the University of Washington.
The money will fund ongoing work on the Global Burden of Disease, increased analysis of health financing, as well as forecasting of different scenarios, all in the service of informed policymaking. The amount of funding over this 10-year timeframe will allow IHME not only to improve the data available but also to improve local ownership and use, Murray told Devex.
“It also means we can serve the needs of the Gates Foundation, where they’re very data driven,” he said. “They’re an organization that’s really focused on using the evidence both to set their own internal priorities and to evaluate where they’re making progress.”
Progress in development will lead to improvements in the facts and figures on global health, Murray said. Forecasting allows the Gates Foundation to assess their contributions relative to what would have happened anyway. So these data and metrics can inform decisionmaking not only for policymakers but also for foundations.
“Are they bending the curve?” he said, using a term that often comes up in meetings about the way the foundation is trying to accelerate progress in their priority areas.
“Extreme poverty has been cut in half in the last 25 years,” Bill writes in the annual letter.
He referenced a survey in which 1 percent of respondents knew that, and 99 percent of respondents underestimated progress.
“That survey wasn’t just testing knowledge; it was testing optimism — and the world didn’t score so well,” he said.
Bill and Melinda often call themselves impatient optimists, hence the name of the Gates Foundation blog. And in conversation with heads of programs ranging from Water, Sanitation & Hygiene to HIV, one of the consistent themes is the importance of advocacy in global health and development work. At the Gates Foundation, data-driven advocacy is a key priority.
Emilio Emini spent 32 years in the pharmaceutical industry before taking on what he jokes is his retirement job. But amid growing concerns about the future of funding for HIV, he certainly has his work cut out for him.
“Data becomes important, otherwise you’re sort of flailing in the dark,” Emilio Emini, head of HIV at the Gates Foundation, said of the way data guides decisionmaking. “Acquisition of data for the sake of acquiring data doesn’t help anybody. The data has to be acquired and used in a way that one can actually then drive knowledge and decisions. That’s critical.”
Particularly when it comes to financing, demonstrating a return on investment and driving more dollars toward a particular area, arguments must be data driven in order to be convincing, he said.
Before Bill and Melinda begin their letter to Buffett, they include a brief note, remarking on new leadership in the U.S. and the U.K. and explaining that these numbers should point to how foreign aid should remain a priority and that improving global health is in the national interest.
When asked about her plans to work with the Trump administration, Melinda again emphasized the return on investment.
“I think what you will continue to hear Bill and I saying very vociferously, very publicly, is that that less than 1 percent portion of the budget is highly effective,” she said.
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