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‘All Lives Have Equal Value'

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Melinda Gates in a meeting of newborn care stakeholders in Rampur Bhuligadha village, Uttar Pradesh.
Melinda Gates in a meeting of newborn care stakeholders in Rampur Bhuligadha village, Uttar Pradesh.

Melinda Gates: ‘Bill and I care about keeping all kids alive and that really is our focus.'

Melinda French Gates is co-founder and co-chair — along with her husband, Microsoft founder Bill Gates, and his father William — of the Gates Foundation. It is one of the largest philanthropic trusts in the world, with an asset trust endowment of $33.5 billion, grant payments amounting to $3 billion in 2009, and grant commitments since inception totalling $22.61 billion. The Berkshire Gift, announced by Warren Buffett in June 2006, was a massive augmentation. The Foundation has been a major player in India, investing substantially in health-related fields, especially HIV-Aids prevention and maternal and newborn health.

Melinda Gates was in India in March 2010, visiting villages in Uttar Pradesh and talking about new investments and a Memorandum of Understanding with Chief Minister Mayawati and figuring out what needed to be done, including “cultural change,” to bring down the death rate among children under five in U.P. and Bihar.

She spoke to N. Ram about what she saw and learnt, the focus of the Foundation's investments in India, what Warren Buffett's Berkshire Gift has meant to the Foundation, and the Gates' philosophy of giving. Excerpts from the interview:

Melinda Gates: Hello. Bill enjoyed meeting you last time he was here.

N. Ram: We had a chat. Mainly on the Foundation, a bit about the media, and two per cent on Microsoft.

Melinda Gates: Really [laughs]? That was a switch from before.

If I may now ask you about the purpose of your current visit. I also read Bill Gates' Second Annual Letter at the Foundation website. What is really striking is this: “The health statistics from northern India are terrible – nearly 10 per cent of children there die before the age of 5.” Your Foundation, which believes “All Lives Are of Equal Value,” seems determined to do something about that. Can you give us your reading of the situation?

Bill and I both have been travelling to India. He was in Bihar last time he was here and I came to U.P. exactly for that reason — which was to look at the issues around maternal and child deaths. As a world, we have come down from 50 million childhood deaths under the age of 5 back in1960. Now we're down to nine million deaths of children under the age of 5 every single year. So a huge drop but nine million is still way too many.

So when you parse that and say, a portion of them die from one month to five years and another portion, a large portion, of them die in the first 28 days, in the first month of life. When you look at India as a percentage of that, it has basically a million kids who die between the age of one month and five years, predominantly in U.P. and Bihar. And 900,000 of the deaths in the first 28 days of life are in India. So for us, India is a really important place where we can invest.

India's commitment to the National Rural Health Mission is what gives us all a chance to even make progress against these deaths. The infrastructure that's being laid in that system is crucial. Because when Bill and I look at these huge issues, our money can only be catalytic. The issues that we're taking on are really governmental issues. But some of the things we can do — I'll give you two examples.

I was in Barabanki and Rae Bareli districts in U.P. In Barabanki, I wanted to see this ‘Sure Start' programme of PATH [an international non-profit organisation in which the Gates Foundation is a partner], where they really get together the young women who are in those child-bearing years and their mothers-in-law — to try and effect cultural change and to talk about this: ‘It's really important to breastfeed. Right away. Don't wait till Day 3.' They wait for the priest who comes and picks the auspicious day. ‘Start right away because that colostrum with all the antibodies is really, really important for the baby. Exclusive breastfeeding. Don't give water even in the summer months. You don't want to introduce dirty water and goat's milk.'

‘And keep your baby warm, even in the summer months, when it's delivered. Not to let it be set aside while the birth attendant goes to help the mother, but to really keep that baby warm. And not wash the baby and cause abrasions.'

Those are literally cultural change things that can bring down this death rate.

And in Rae Bareli, I went to see a project called Shivgarh. This is a research site that Johns Hopkins has, that we and USAID funded, to really get infant mortality down. That site has proven that if the women keep the baby warm, they can reduce infant mortality by 54 per cent. They proved that over 18 months. That's a practice that can spread. It's so simple for a woman: when you teach her to keep her baby warm and on her chest, she naturally starts to breastfeed, all the right things happen, the baby doesn't get chill. That's something we can spread all over India, where it needs to happen. But we can spread that practice around the world.

This is what Bill [Gates] calls innovative practices.

Those are absolutely innovative practices. A lot of times people think the Foundation is absolutely about innovations in science, in technology and biotechnology. We believe in that innovation but another piece of big innovation is social, cultural change. How do you talk to the women in a way to understand why they've been doing what they've been doing? They have good reasons for why they believe what they have been doing is the right thing. But how do you talk to them in a way that appreciates their culture but helps them understand what will keep their children alive? There are innovations to be done there. That's what we're learning out of Shivgarh and Sure Start, which we'll spread in other places.

When you first encountered these realities, were you shocked, morally and culturally shocked? Or were you prepared for it?

No, I don't think you're ever prepared for it. And I am still shocked when I travel. I travel to a lot of places: Bangladesh, Malawi, I was there eight weeks ago, I was in Ethiopia twice last year. I've been to India now several times. It's always shocking, even on this trip. To be in these villages and see what these mothers and these dads are up against and to try and understand.

The thing that you constantly come back to when you talk to the women is they want to do the right thing. They are always saying to themselves, ‘How do I keep my children alive and what lengths would I go to!' And when they understand that immunisation works, they'll come. When they understand that these cultural practices will start to work, they'll come. Literally when you survey these communities by a raise of hands — we have the whole community gathered in Shivgarh and you just say, ‘How many of you lost a baby before?' And they would raise their hands. ‘How many of you lost a baby these last two years?' The numbers go down. So they're seeing the change. So for me when I see the pieces that are very heart-breaking and then see the things that are actually working and know that change is possible, that's what gives me optimism. That's what I carry back to the Foundation: how do we spread these things?

The third round of India's National Family Health Survey (2005-2006) reported some good news and some serious bad news, namely that ‘good health States,' States that were relatively advanced and were industrialised, high-growth States, slipped when it came to full immunisation coverage. NFHS 2005-2006 shows this for Andhra Pradesh, Gujarat, Maharashtra, and Punjab. Those figures go back five years. But you seem to be hopeful in the midst of what the statistics reveal, a mixed picture.

It is a mixed picture. But I think there's so much to build on in India. You have to understand that in the other places I travel to there isn't this infrastructure. The Indian government has put in place this commitment to the National Rural Health Mission, the discussion that they'll do eventually for the National Urban Health Mission, the fact that they're starting to say, ‘Let's get the real data about vaccinations, let's not kid ourselves and say that the vaccination rates are higher,' the fact that they are willing to say, ‘Let's look at this and see where the gaps are,' then it gives you a chance to improve upon it. The fact that they've got a system and we can build on what's there, that's what gives me the hope. So we'll put in a number of grants in both Bihar and U.P. to try and raise that immunisation rate. It's got to get raised.

We've seen this even in other developed nations where they'll keep moving along, these immunisation rates, it'll start to dip, and then you've got to re-commit to it. That's where India is, in some States that have come further along. They need basically to recommit, saying ‘This is important to do.' The fact that that gets publicised is fantastic. And the fact that you've also got competition amongst the States, even for the ones that have come the farthest along to say, ‘I want to do better than that State,' that's a very positive thing.

The South seems to be somewhat better off, particularly the State where I come from, Tamil Nadu. There have been good reports about what primary health centres have done, particularly in the area you're looking at now — maternal and child health and mortality rates, bringing them down. Obviously, that's not your priority — where they're doing well?

Right. Our priority is to try and go where the deaths still occur and say, ‘What is it about those States? What is it about the way the infrastructure is set up? What is it about the cultural practice?' My understanding, after talking to a lot of people, is that it's somewhat different for a woman living in the South versus the North. In terms of how she can negotiate: if she even knows that the right thing to do is to get to a clinic, can she convince her mother-in-law? Can she convince her husband to do that? They're the ones who are going to transport her there. You know, taking some of those practices from the South and trying to learn what's worked well there and get those to the North is important. But also I think this piece of cultural change is going to be really, really key.

Bill and I believe in equality. The whole Foundation premise is ‘All Lives Have Equal Value.' No matter where they live on the planet. No matter what State, city, country you're born in, whether you are male, female. We care about keeping all kids alive and that really is our focus.

‘All Lives Have Equal Value' — how did you come to that mission? Who thought of that phrase?

It's a coming to it, I would say, over time. One of the things you have to understand is that both Bill and I grew up in families that really believed in giving back. So we came to the marriage knowing that the money that had been amassed from Microsoft would be given back to society.

In fact, when we were engaged, we took our first trip together to Africa — neither of us had been to Africa before — and we went on a safari to see the animals. But we came back very touched by the people. You know, you can't go to Africa and not ask yourselves: ‘What's going on here? Why are these people walking in droves? Why do the women not have shoes on their feet but a lot of the men do? Why do you see so many women who are pregnant with a child on their back and some bunch of sticks on their head?' So it was that trip to Africa that really, I think, stimulated us to start getting us asking the questions, ‘What's going on? What's going on in health? Where're the gaps? Who's not filling the gaps?' And from that is when we came to this belief — that this is where we want to work.

And we started first in childhood vaccinations and population stabilisation and branched out from there.

Your or Bill's copyright, this phrase [‘All Lives Have Equal Value']?

Neither of us owns the copyright! I don't even know. It's funny because if we both go back and ask, ‘When did we come to that specific naming of it?' it would be hard to say. It was in the first two to three years of the Foundation.

You had a meeting with an interesting political leader, Chief Minister Mayawati, who is a very distinctive and powerful politician in India. What did you really talk about? Did you find her receptive?

She wanted to talk all about development issues. So she really came in talking about them. She knows what's going on in her State. She knows we're committed to working there. She wanted to talk about what our focus is, so we talked about that; and what our investments would be. We talked about polio with her because it's still in 66 blocks in U.P. The two places where polio still exists in India are U.P. and Bihar. If we can get it done there and show the momentum from India that this can be eradicated, it's really, really key for the world. We talked about what I was seeing in immunisation. And then we talked about these maternal and child issues, and just development overall in her State.

And you're going to put in a lot of resources from the Foundation into this?

We are committing $55 million in the State of U.P. [over the next three to five years]. And we're going to work on a Memorandum of Understanding with the government. It was one of the things that came out of that meeting.

I asked Bill Gates about some questions that came up from the Lancet articles. You must have read that research reported in Lancet, which while praising the work of the Foundation said that the money could have been used better, that there were certain imbalances in its flow or in its distribution. There was criticism of what they called disproportionate allocations, to GAVI perhaps. Would you like to tell us what you think of this?

Yes. We are very interested in GAVI as an institution, the Global Alliance for Vaccine Immunisation. So we put our original investment in: it was $750 million over five years. And we felt so good about that investment that we came back and put another $750 million investment over ten years.

You know the great thing about GAVI is that it has this focus on two things. One is raising the immunisation rate around the world. And with that it means a decrease in the lead-time when we get a new vaccine in the U.K. or the U.S. or Japan, getting that out to the developing world. The other focus is that we work with pharma and biotech to come up with new vaccines specifically focussed on the developing world.

There's a new one out around rotavirus, which is a diarrhoeal disease, one of the biggest killers of children. There's another new vaccine coming out for pneumococcus, which is pneumonia disease; it kills thousands of children in India. Those are two new vaccines GAVI will help get out in the countries. That's the big mechanism we use, GAVI, so we really believe in it.

The last question really is on the future of your Foundation. It's astonishing, the scale of your gifting and your actual work. As though this were not enough, Warren Buffett has augmented it. Could you tell us what this means, what the terms mean?

Bill and I were thrilled when Warren made that gift to the Foundation. What it allowed us to do is: we already were deep into this Global Health work. We'd already started doing things in Global Development, which were things like agriculture. Once people are living a healthy life, helping them have some means of lifting themselves out of poverty. So the agricultural work and the financial services for the poor work and some of the work in clean, modern sanitation, we'd started to do some pilots and experiments. When Warren's money came along, it really allowed us to start to scale that up. Because we'd always wanted to take our health work and do development around that as well. It's not really enough to help somebody live a healthy life. You want to help them lift themselves out of poverty. Warren's money allowed us to accelerate this group we call Global Development. It's absolutely fantastic.

We, like Warren, completely want to take the resources that we have from Microsoft and his Berkshire Gift and spend that basically on the problems of our lifetime. None of the three of us thinks there's a crystal ball that says 500 years from now…

You are not looking to immortality?

We are not looking to immortality, none of the three of us! So Bill and I have made a commitment that 50 years after the last of the two of us has died — I'm pointing to myself because I'm younger but you never know — all our money would have been given away.

Having that premise, knowing that about Warren's gift, gets us to accelerate the work and makes us measure very, very carefully: ‘Is this another place we want to invest?' If you think there's some pressure in giving your own money away, believe me, giving out somebody else's money makes you really want to focus on ‘Are we getting the results?' And it's helped us think through the measurement and the evaluation as we go along.


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