Event Introduction:

The transcript is from the inaugural session of ASM Microbe 2016, held in Boston. Dr. Lynn Enquist, ASM’s president, welcomes the attendees, both in-person and remote, and speaks about the convergence of ICAC general meeting and ASM’s general meeting. Over 11,000 participants are present.

Merging of Meetings:

Dr. Enquist explains that the two meetings have been merged to form this new, unified event. The merger had been in planning for two years and aims to create an “extraordinary meeting.”

Acknowledgment and Thanks:

Dr. Enquist thanks the community, including the program committee members and meetings board chair Dr. David Hooper, for their contributions to make this event happen.

Importance of Microbial Sciences:

She emphasizes that this is a significant moment for microbial sciences. The science holds the key to solving numerous global challenges, underlining the gravity of the meeting.

Bill Gates’ Role:

Bill Gates’ presence at the conference is highlighted as a major indicator of the importance of microbial sciences. Through his foundation, Gates collaborates globally to address significant health challenges.

Conversation Moderator:

Dr. Richard Besser, ABC News Chief Health and Medical Editor, will lead the conversation with Gates. Dr. Besser’s background in public health and journalism is expected to enrich the discussion.

The transcript ends with Dr. Enquist formally welcoming Bill Gates, who is slated to give opening remarks followed by a discussion with Dr. Besser. The anticipation is palpable, reflecting the significance of this event for the microbial sciences community.

Introduction and Background:

Bill Gates reflects on his journey from founding Microsoft to focusing on global health through his foundation. He acknowledges the role of microbiologists in understanding and combating diseases, expressing his excitement to be part of the discussion.

Child Mortality Rates:

Gates emphasizes the reduction in childhood death rates, dropping from 9% to 4.3% for children under five in the last 25 years. Despite this significant progress, nearly six million children still die each year, necessitating continued efforts.

Global Health Equity:

Gates aims for global health equity, where a child in a poorer country has the same chance of survival as one in a wealthier nation. Currently, children in poorer countries are 50 times more likely to die, highlighting the need for urgent action.

Causes of Childhood Death:

Gates presents a pie chart outlining the leading causes of childhood death, specifically targeting diarrhea, pneumonia, and malaria. He expresses confidence that, with continued focus and resource allocation, the death rates from these diseases can be halved within the next 15 years.

Neonatal Mortality:

The largest portion of childhood deaths occur in the first 30 days of life. Gates admits that there is insufficient data to understand these neonatal deaths completely, and this gap requires more research for prevention.

Vaccine Distribution:

Through a group called Gavi, the foundation aims to speed up the distribution of vaccines like rotavirus and pneumococcus to poorer countries. Gates notes that this initiative has helped to significantly reduce the time lag in vaccine availability between rich and poor countries.

Polio Eradication:

Gates discusses the foundation’s involvement in eradicating polio, pointing out that only two countries, Pakistan and Afghanistan, still have reported cases. He notes the challenges faced, including unrest and targeted attacks on healthcare workers but remains optimistic about eradicating the disease soon.

Disease Surveillance:

In light of the Ebola epidemic, Gates mentions the need for robust disease surveillance. His foundation is actively working to establish six surveillance sites in Africa to monitor existing and emerging diseases.

Concluding Remarks:

Gates concludes by reiterating the goal of global health equity and encourages the audience of microbiologists to continue their critical work, citing the phenomenal opportunity for progress in the field.

Catalytic Philanthropy:

Bill Gates discusses the concept of “catalytic philanthropy,” emphasizing that even a small amount of investment can generate a large impact. He identifies two primary avenues for this: invention of new tools like vaccines and improving existing delivery systems such as healthcare infrastructures in developing countries. In the latter case, optimizing training, supply chains, and performance measurement can substantially elevate the quality of healthcare services.

Criteria for Interventions:

When asked about the Gates Foundation’s approach to global health, Gates elaborates that they focus on high-impact interventions that save lives for around $1,000 or less. This amount is derived from the cost-effectiveness of certain interventions like measles campaigns and pneumococcus vaccines. Gates questions why more resources are not dedicated to these cost-effective life-saving measures, citing a lack of equity in global health investments.

Shift in Global Health Burden:

The host raises the point that global health priorities appear to be shifting from infectious diseases to chronic diseases like heart disease and mental health. In response, Gates acknowledges the transition but argues that infectious diseases are still a major contributor to “years of life lost.” He states that the Gates Foundation is geared towards tackling the issues with the highest impact, which currently remain largely within the infectious disease domain.

Evaluation and Future Goals:

Gates also notes that their success in reducing infectious diseases will naturally lead to a shift in focus. Diseases like pneumonia and diarrhea have seen reductions, and long-term goals even include eradicating diseases like malaria. He mentions that some of their work, like with the HPV vaccine, does have implications for chronic conditions.

The discussion provides valuable insights into the philosophy and strategy behind one of the world’s largest philanthropic organizations focused on global health.

Value of Disease Eradication:

Bill Gates argues that disease eradication yields extremely high returns on investment. By bringing a disease’s prevalence to zero, not only do you save on the cost of treating affected individuals but also eliminate all future intervention costs. He cites the example of smallpox eradication as having had “mind-blowing” returns.

Risk of Eradication Failure:

However, Gates also notes that the journey to eradication can be costly and risk-filled. At the final stages, a large sum of money may be spent to eliminate just a few remaining cases. Failing to eradicate a disease can hurt the credibility of global health initiatives and result in misallocated resources.

Polio Eradication Efforts:

Gates discusses the significant investment his foundation has made in eradicating polio, particularly in Pakistan and Afghanistan. He emphasizes that eradication efforts also strengthen overall health systems, making them more effective against other diseases.

Challenges in Trust and Funding:

Gates touches on the importance of trust in vaccination campaigns, highlighting the adverse impact of a CIA fake vaccination campaign on public trust. Moreover, he discusses the difficulty in sustaining financial support for polio eradication as the number of cases decreases, explaining that the global budget for polio had to be doubled to continue the effort.

Decision-Making for Future Initiatives:

Before embarking on new eradication campaigns like malaria, Gates urges careful consideration. He mentions that high-impact and cost-effective interventions in other areas, such as heart disease, could also become priorities for his foundation.

This segment of the talk encapsulates the complexity and high stakes involved in disease eradication, underscoring the need for a multi-faceted approach that includes effective interventions, financial planning, and public trust.

Importance of Innovation:

Bill Gates emphasizes the necessity of new technologies for malaria eradication. Two key technologies could be game-changing: an effective vaccine and gene editing tools like CRISPR to modify or reduce mosquito populations.

Vaccine Development:

Current vaccines have limited duration. Gates suggests that unless a new dosing strategy is found, a next-generation vaccine will be crucial for long-lasting immunity against malaria.

Gene Drives and CRISPR:

The use of CRISPR technology in combination with gene drives could either modify mosquitoes so they can’t carry the malaria parasite or reduce their population. These gene constructs can propagate efficiently within the mosquito population. However, the technology is not yet ready for mainstream use and faces unique regulatory challenges.

Regulatory Considerations:

There’s a question of who gets to decide when such a technology is safe for release. Typically, sovereign nations make these decisions, but often they look to regulatory structures in the United States or Europe for guidance.

Global Framework:

Technologies like these pose questions about international coordination, especially since mosquitoes do not respect borders. Similar to issues like climate change and epidemics, global problems require coordinated solutions, although achieving consensus can be challenging.

Application Beyond Malaria:

Gates mentions that genetically modified mosquitoes could also be instrumental in fighting other diseases, like Zika, as demonstrated in parts of Brazil where mosquito populations have been significantly reduced.

In summary, Bill Gates argues that new technologies are essential for eradicating malaria, particularly in high-prevalence areas. Regulatory and global coordination challenges do exist but are navigable. The potential for these technologies extends beyond malaria to other mosquito-borne diseases.

Community Response to Testing:

Bill Gates acknowledges the public’s hesitancy in Florida regarding the testing of genetically modified mosquitoes. He suggests that public opinion often changes when a community is directly at risk from vector-borne diseases like Zika.

Role of Scientific Literacy:

Although his foundation focuses on education and global health, Gates admits there’s no direct synergy in enlightening people about vaccines or scientific literacy as such. However, he emphasizes that public perception of such interventions often shifts once the threat becomes immediate.

Specific Interventions:

Gates is not involved with Oxitec’s sterile male mosquito technology, which faced initial pushback in Florida. His foundation is primarily involved in the Wolbachia infection of the Aedes mosquito, which dramatically reduces the number of mosquitoes carrying viruses like dengue and Zika.

Importance of Community Trials and Education:

Over the past 12 years, Gates and his partners have conducted community trials in Australia, Indonesia, and the Philippines, focusing on public education about the risks and rewards of these interventions. He notes that this approach has generally been met with a positive response.

Importance of Open Discussion:

Gates emphasizes that one can’t just introduce these technologies into a community without honest and thorough communication. He states that discussions about the rapid emergence of diseases like Zika are just beginning, underlining the importance of hearing both sides of the argument.

In summary, Bill Gates discusses the challenges and nuances of introducing new vector interventions, such as genetically modified mosquitoes, into communities. He emphasizes the role of public opinion, the lack of a direct focus on scientific literacy in his foundation’s work, and the importance of community education and open discussion.

Focus on Primary Healthcare:

Bill Gates emphasizes that the Gates Foundation is the biggest external funder for primary healthcare systems, which are the backbone of quality healthcare delivery. He cites examples like Rwanda, Ethiopia, Sri Lanka, and Senegal, where even with limited resources, effective primary healthcare systems exist. This primary focus is because most people in these countries will never meet a doctor and rely on rural clinics for healthcare.

Role in Epidemic Preparedness:

When questioned on the disease-specific approach of the Gates Foundation, Gates explains that their fastest-growing program is ‘integrated delivery’, which aims to implement best practices from countries with effective healthcare systems. While they focus less on public health systems, they are working to train healthcare workers in malaria eradication efforts to be able to respond to outbreaks of other diseases, leveraging their existing expertise.

Public and Global Funding:

Bill Gates points out that although the U.S. has not been as generous in funding epidemic preparedness as he would prefer, it has been the most generous among all nations. He expresses concern about the diversion of funds meant for building systems in Africa to other concerns, like Zika. He advocates for the need to build both global and local capacity for epidemic response.

Role of Governments:

Gates believes that the Gates Foundation’s work is not letting governments off the hook. By foundation standards, they contribute a large sum, but compared to total overseas aid and government programs, their contribution is not overwhelmingly large. He argues that they serve as a catalytic factor for attracting more resources into global health.

Status of Global Institutions:

Regarding the World Health Organization (WHO), Gates says there’s a gap between what people think WHO is funded to do and what they are actually funded for. While he acknowledges that the WHO could have performed better during the Ebola crisis, he emphasizes the need for proper funding for the WHO and domestic governments to handle similar situations.

Unfunded Responsibilities:

Gates concludes by pointing out that there is a significant gap in funding for what global and domestic governments are expected to do. He cites the absence of organizations equivalent to the U.S.’s BARDA (Biomedical Advanced Research and Development Authority) in other countries as an example of this shortfall.

Free Market vs Philanthropy in Global Health:

Bill Gates explains that free-market solutions are not always the answer to global health problems, particularly in regions where markets fail. He notes that pharmaceutical companies focused solely on profit margins will not develop drugs for such areas.

HIV and Tiered Pricing:

Gates praises the pharmaceutical industry’s role in combating HIV through strong medicine discovery rates. A tiered pricing approach allows these companies to fund their R&D through sales in wealthier countries, while making drugs affordable in poorer countries. The greater cost now lies in personnel, not the drugs themselves.

Neglected Diseases and Malaria:

The philanthropist highlights that diseases like malaria and other neglected ones do not receive the same level of attention because they can be managed with prophylactic drugs. Wealthy countries, therefore, are less concerned, making philanthropy and government aid the primary solutions for R&D in these areas.

Case Study: Meningitis in Africa:

Gates discusses a successful project in Africa’s meningitis belt. The Gates Foundation collaborated with Serum in India and the Canadian regulator to produce a 35-cent meningitis vaccine. This vaccine was significantly cheaper than previous options, enabling widespread immunization. The cases of meningitis have dropped to near zero in areas where it was once rampant.

Role of GAVI:

Funding mechanisms like GAVI play a crucial role in countries that cannot afford even the low-cost vaccines. They provide financial backing to ensure that vaccines reach the populations in need.

The Gates Foundation’s approach combines market mechanisms where possible and philanthropic efforts where markets fail, offering a nuanced strategy to tackle global health issues.

Combating Superbugs:

Bill Gates underscores the challenge of combating antibiotic-resistant bacteria or superbugs. He notes that the problem is more severe in poorer countries, but the United States, being wealthy, has for-profit incentives to develop new antibiotics. The latest scientific methodologies can help us understand bacteria at the DNA level, providing leads for potential antibiotics. However, Gates also acknowledges the issue of market failure in antibiotic development, as the ideal antibiotic would be used sparingly to avoid building resistance, making the R&D investment less appealing for pharmaceutical companies.

Orphan Drug Legislation:

Gates suggests that orphan drug legislation could serve as a model for incentivizing antibiotic development. The legislation has spurred progress in treatments for rare diseases, and a similar approach could be used to create special incentives for new antibiotics. He remains optimistic that scientific opportunities to develop new antibiotics are plentiful, given the vast range of chemicals created by evolution that have yet to be discovered.

Supporting Young Scientists:

On the question of nurturing the next generation of scientists, particularly in Africa, Gates says that most funding goes towards trials in affected countries. Encouraging young scientists, especially in agriculture and family health, is part of the mission. Capacity building in South Africa has been especially successful, but a “huge vacuum” remains in the rest of the continent, which can only be filled by providing young scientists with opportunities.

Regulatory Systems and New Methods:

Lastly, Gates speaks on the efficacy of current regulatory systems in adopting new transformative methods like microbiome research. He generally finds the system good but acknowledges that exceptions have been made in crises, like the HIV epidemic. Some intriguing research includes engineered E. coli as a probiotic for treating undernutrition. Gates anticipates that the regulatory approach will be reasonable and allow for the introduction of these tools in the next four or five years.

Political Season & Global Health:

Bill Gates observes that global health has been largely overlooked in the current political discourse, despite the approaching general elections. He finds it noteworthy that no candidates have mentioned this issue during the primary season, considering that the United States has ongoing health concerns of its own.

Historical Commitment to Global Health:

Gates notes that both the Bush and Obama administrations made significant contributions to global health. He cites the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative during the Bush era. Despite a negative response he received at an HIV conference when praising President Bush, Gates emphasizes that the effort has been bipartisan.

U.S. Leadership in Funding and Expertise:

Under the Obama administration, more funds were allocated for combating diseases like polio. Though not a considerable amount, Gates says it helped make the case to other donors that the U.S. was contributing its part. He also praises the Centers for Disease Control and Prevention (CDC) for its unparalleled expertise and willingness to deploy to areas affected by diseases like Ebola.

The Importance of Continuity:

Gates expresses hope that the U.S. will continue its positive record in global health initiatives. He indicates that some current candidates lack a full understanding of the importance of vaccines and the benefits of embracing the global community.

Summing Up:

The talk emphasizes the crucial role the U.S. has historically played in global health, urging that it should remain a priority even amidst domestic health issues and current political debates. Bill Gates advocates for bipartisan support in maintaining America’s leadership role in global health.

Similarities in Organizational Culture:

Bill Gates identifies some cultural elements that remain consistent between his experience at Microsoft and the Gates Foundation. Both environments value analytical thinking, open-mindedness, and a long-term commitment to scientific endeavor. Employees are encouraged to be engaged and open to learning.

Divergent Bottom Lines:

Gates explains the primary distinction is in their respective “bottom lines.” At Microsoft, the focus was on software sales volume and profitability. In contrast, the foundation is geared towards human-centered metrics such as reducing under-five mortality rates, improving nutrition, and eradicating diseases.

Adaptation to Diverse Environments:

Gates describes how the foundation requires skill sets tailored to working in poor countries, often where governments have limited capacity. The need for effective collaboration with governments worldwide is more pronounced in the foundation’s operations. The goal is to ensure complementary efforts and that funds are used effectively.

Engagement with Governments:

In his role with the foundation, Gates has found himself more engaged with governments than he was at Microsoft. He expresses satisfaction with the willingness of governments to collaborate with the foundation, describing it as “quite incredible.”

Multidisciplinary Skill Sets:

Gates emphasizes that the foundation needs a diverse set of skills for maximum impact. These range from scientific expertise to hands-on fieldwork experience. The complex challenges the foundation tackles require a blend of six or seven deep types of skills.

In summary, Gates outlines the cultural and operational nuances between Microsoft and the Gates Foundation, highlighting that although both require similar core competencies, they also demand unique sets of skills and focus to achieve their different objectives.

Career Phase and Organizational Fit:

Bill Gates reflects on the difference between running Microsoft in his 20s and 30s and running the Gates Foundation later in life. He notes that the quick, hands-on engineering cycles at Microsoft were better suited for his younger self. Gates implies that his current role requires a different type of patience, benefiting from his mature perspective.

Project Management and Patience:

Gates compares how he oversaw projects at Microsoft to his current approach at the Gates Foundation. In his younger days, he was more hands-on and quick to check progress. Now, he adopts a more patient approach, checking in with various teams like those working on HIV vaccines, less frequently but expecting meaningful progress.

Upcoming Global Health Challenges:

Looking forward, Gates identifies the most pressing health challenges as potential epidemics, nutrition, HIV, malaria, and TB. He underscores the significance of nutrition, particularly in Africa, which affects children’s physical and mental development.

Optimism for the Future:

Gates is hopeful that the next 20 years will bring solutions to these challenges. He anticipates the development of tools and vaccines that will address these issues, contributing to the betterment of global health.

Scientific Imperatives:

In his closing remarks, Gates emphasizes the need for continued scientific investigation into nutrition and diagnostics. He calls for a deeper understanding of the microbiome and better point-of-care diagnostic tools. He asserts that the skills and innovations from the scientific community will be crucial in achieving these goals.

In summary, Bill Gates discusses the differing but equally rewarding challenges he’s faced at different phases of his life—first at Microsoft and now at the Gates Foundation. He outlines major global health challenges and expresses optimism about future solutions, underlining the essential role of scientific research and innovation.