bill gates_ ‘death is something we really understand extremely well’

7/30/2019 Bill Gates_ Death is something we really understand extremely well

1/5

5/19/13 Bill Gates: Death is something we really understand extremely well | Wonkblog

www.washingtonpost.com/blogs/wonkblog/wp/2013/05/17/bill-gates-death-is-something-we-really-understand-extremely-well/?print=1 1/5

Bill Gates: Death is something we

really understand extremely wellBy Ezra Klein, Updated: May 17, 2013

I always use this chart of childhood death, Bill Gates says. In 1960, 25% of kidsdied before the age of 5. And now were down below 6% of kids dying before the ageof 5.

Were sitting in a bare conference room at his foundations D.C. headquarters. Gates who Bloomberg News calculates is once again the worlds richest man is in town

to talk to members of Congress about his top priority this year: Global health and,in particular, the total eradication of polio. He wants to drive that 6 percent evenlower, and he believes he can. Wiping out a disease like polio sounds impossible. But its actually, Gates tells me, completely achievable. Perhaps even by the end of 2013.This is a transcript of our conversation, edited for length and clarity.

Ezra Klein: Your Foundation is known for taking a particularly data-drivenapproach to its work. So how do you know whats actually working when youre infailed states with very little data-collection capacity?

Bill Gates: Of all the statistics in health, death is the easiest, because you can go out and ask people, Hey, have you had any children who died, did your siblings have any children whodied? People dont for get that. I f you say to them, Did your kids get vaccines or not,they might have done it and not remember, or they might think, Oh, this person wants meto say yes, maybe I look bad if I dont say yes. Death is something we really understandextremely well.

But you can save a lot of lives. One thing about the childhood death rate is you really cansplit it into the first 30 days of life versus 30 days to 5 years. Thirty days to 5 years is all

vaccine preventable stuff its diarrhea, respiratory and malaria. The first 30 days, the primary healthcare system really has to engage with the mother pre-birth, and then get themother to do things like keeping the baby warm, making sure to avoid doing things that

break the babys skin, breast-feeding, and thats been harder. Weve had sites in Indiawhere we can cut those deaths down by over 50 percent just by training the mother. But theworker has to engage with the patient, hopefully speak the same language or be of the samecaste so that theyre willing to trust the advice that theyre getting.

EK: Whats been the biggest surprise? What has the data shown works, or doesntwork, that you simply didnt expect?

BG: I was completely surprised that nobody was funding some of these vaccines. When Ifirst looked at this I thought, well, all the good stuff will have been done. It was mind-

blowing me to find things like Rotavirus vaccine were going unfunded. One hundred percentof rich kids were getting it and no poor kids were. So over a quarter million kids a year

Print
https://twitter.com/BloombergNews/status/335122632527712256http://window.print%28%29/https://twitter.com/BloombergNews/status/335122632527712256


2/5



were dying of Rotavirus-caused diarrhea. You could save those lives for $800 per life.Thats like $20 or $30 per year of life. Its just ridiculous that an intervention like that isntfunded.

And Im really surprised at the variance. Some very poor countries run great vaccinationsystems and some richer ones run terrible programs. The north of Nigeria has about 30

percent vaccination coverage, and theyre above average in terms of wealth within Africa.

You compare that to, say, Somalia, which has absolutely no government at all, and they getabout 60 percent vaccine coverage of children. So you have a place literally with nogovernment getting a better vaccine coverage than a place thats above average wealth.

EK: Why?

BG : Well, in Somalia theyve given up using the government. The money goes through the NGOs. Whereas in Nigeria theyve designed a system where the federal government buysthe vaccines, the state government provides the electricity, and the one level down belowthat provides the salaries. Its just a bad design. You know, the north of India has very poor

vaccination rates, so we picked a state up there with 80 million people and we drove it from30 percent to 80 percent. But they had a really good chief health minister and the federalgovernment was providing lots of money and lots of good technocrats, so the skills werethere, as long as you employed them in the right kind of system.

EK: This gets into an interesting question about public health, which is that whenwe think about health-care challenges, we think primarily about technologicalchallenges. We think about cures for cancer and vaccines for AIDs. But in publichealth, much of the challenge is logistical and organizational how you deliver,how you organize, who you actually partner with. And that seems much harder toreplicate. If you can invent the pill, then you can probably keep reproducing the pill,but even if you get a good system in the north of India with their good healthminister, it isnt necessarily the case that you can move that over to the south of Nigeria.

BG : It can be replicated, though. Ethiopia is a good example of a country that decided toget serious, train 35,000 health workers and actually put them in the right places. So theydid the map, looked at it, got the donor money, its a work in progress. Its doing quite well

but there are still a few of the supply chain things that need to be fixed. So, it can be

replicated. We do report cards for each country, saying OK, did you have a plan, do youhave the money, did you do the personnel right, did you do the supply chain right?

EK: Whats the difference between trying to work in high-income, middle-income,and low-income countries?

BG : The low-income, middle-income and high-income health systems have extremelydifferent problems. You know, in low-income countries, getting to a health post is hard. Itsvery expensive. Whereas in rich countries, yes, you can get to your doctor. In low-incomecountries, the main problems you have is infectious diseases. Were dealing with countries

that in the worst case where kids have death rates of 20 percent and thats all infectiousdisease. And nothing else. In the U.S., in terms of kids under 5, other than premature birth,you really dont have big problems. Kids just dont die of infectious disease.

Then as you get into the adult phase, in the U.S., what do people die of? From age 5 till age


3/5



50, youve got suicide, youve got traffic accidents. Theres very little cancer and heartdisease before age 50. Then once you get past your 50s, the poor countries basically say,Hey, I hope you dont get cancer, because if you do get cancer, we just dont have enoughmoney per person, were just not gonna buy chemotherapy drugs. Were just not going toget engaged in that.

EK: How do you make these decisions about what is and isnt worth paying for?

BG: The way that this is talked about is, whats a year of life worth? They call it a disability-adjusted life year (DALY). When youre running a poor country health-care system, youcant treat a year of life as being worth more than, say, $200, $300 or else youll bankruptyour health system immediately. So, with very few exceptions, you do nothing for cancer. If you get cancer, youre going to die. And so none of the stuff thats going on in the U.S.about $300,000 a year chemotherapy drugs is relevant.

Even simple things dont pass the test. Were on the verge of saying that Africa should do blood pressure medicine because its become generic and so cheap and thats such a

common issue in terms of heart attack death, the so-called polypill is so cheap that its oneof the few non-infectious disease things that meets the dollars per DALY threshold toactually go into a poor healthcare system and say this is worth it given the extremely finitenot only financial resources, but personnel resources, that you have.

But heres the good news for these countries. If you spend the less than 2 percent of whatthe rich countries spend, but you spend it on vaccinations and antibiotics, you get over half of all that healthcare does to extend life. So you spend 2 percent and you get 50 percent. If you spend another 80 percent youre at over 90 percent.

EK: Your top priority, Im told, for the next year is the literal eradication of polio.Whats between here and there?

BG : Whenever you can eradicate one of these infectious disease, you get these exponential benefits. Polios the extreme example where were near the magic number of zero, so the$2 billion that the year spends protecting kids against getting polio, the day you know youreat zero you have to really know youre there then you save the $2 billion. And, youknow, that happened for smallpox. Nobody spends any money on smallpox unless theyworry about a bio-terrorist recreating it. Its financially the best thing that ever happened

because were saving all that money forever after.So in 1988, the World Health Organization, through the World Health Assembly, declarestheyre going to eradicate polio. Its already been eradicated in North America and SouthAmerica and most of Europe. Polio is paralyzing 360,000 kids a year when they start. Theyget it down below 10,000 by the year 2000. Then from 2000-2010 it stays flat. And theylose credibility because theyre always saying Oh, just give us two more years, andtheyre just doing the same thing and its not working. And so in 2010, the polio communitygot together and said, Look, are we going to succeed or not? And so there were a lot of improvements made, those led to finally getting done in India in 2011. And India was

expected to be the hardest and the last.

EK: Just a point of clarification, the functional mechanism here is a high enoughlevel of vaccine coverage, right? When we say eradicate, we mean got it to a highenough level of vaccine coverage that the disease died out?


4/5



BG : Yeah, eradicate means theres no poliovirus around. The method of doing that is youget to extremely high levels of vaccination that is, over 90 percent of the kids have thedrops three times, and that protects them and the disease dies out. The number is actuallywell below 90 percent if youre in a community that either has good sanitation or where thekids dont move around much.

EK: So what did we learn that made eradication possible in India?

BG : The two things that were done super well were social mobilization and mapping wherethe houses were. When somebody would refuse to take the vaccine, they would mark itdown and they would have either a political leader or religious leader come in and convincethem. Dealing with refusals is a huge part of this. If your team goes in, maybe they dontspeak the dialect, theyre not the same caste, the family has heard a rumor that the vaccineis bad, theres many reasons you get refusals, and so you need follow-up for refusals.Usually youll get 10 to 20 percent refusals. But if theres been a rumor, you get muchhigher refusals.

EK: A rumor that, say, the vaccine is bad, or it makes you sick?

BG : Yeah or that the U.S. government uses vaccination campaigns to sterilize Muslimwomen. Vaccination always has problems with rumors. The U.S. doesnt achieve nearly ashigh a vaccination rate as many countries. Vietnam is 99 percent vaccination, the U.S. isabout 95 percent. Because people just hear Oh, what about autism or something. But its

particularly bad in poor countries.

EK: The logistics of the operation seem basically impossible. How do you ensure

you hit every tiny village in a mountainous, rural, poor country?

BG : We began using satellite maps and were finding particularly in Nigeria we were missinga lot of settlements, a lot of nomadic people. The thing we were missing the most was avillage would be on a border, and one government would say, Oh, thats on their side,and the other guy would say, No, thats on their side. So your chance of getting polio wassuper elevated if you happened to live on the border between these local governmentadministrative boundaries.

Then in terms of the teams doing their job, we now put a phone with a GPS sensor in it,every three minutes it says where this team is. Its in the box with the vaccine so when theycome in at the end of the day we plug that in and see if they really went where they weresupposed to go.

Our biggest problems now are violence, which causes campaigns to be canceled, or people just not to be willing to go into various neighborhoods, and refusals having to do with badrumors about the vaccine campaign. And these are both serious issues in both Pakistan and

Nigeria. Afghanistan is just part of the Pakistan thing, and its not the big deal. The number of cases there is pretty small and its just in the areas where theres fighting.

EK: I almost feel bad asking it after this particular discussion, but what has thiswork made you think about our health-care systems problems, recognizingeverything you said about how incredibly, incredibly different they are from, trulypoor countries?


5/5



BG: Its an important topic and I do care about it. My deep interest in this came somewhat because its fascinating but also because our big cause in the U.S. is education, and if youlook at state budgets, they are moving money from education to health. They have to

because the health costs are just exploding. So very quickly say to yourself, gosh, if theresgoing to be any money left for university education and adequate money for K-12, even tostay flat, you have to figure out health-care costs.

Unfortunately, in rich-world health, innovation is both your friend and your enemy.Innovation is inventing organ replacement, joint replacement. Were inventing ways of doingnew things that cost $300,000 and take people in their 70s and, on average, give them anextra, say, two or three years of life. And then you have to say, given finite resources,should we fire two or three teachers to do this operation? And with chemotherapies, wevegot things where well spend our dollars on treatments where youre valuing a life here atover $10 to $20 million. Really big, big numbers, which if you were infinitely rich, of coursethat would be fine.

So most innovations, unfortunately, actually increase the net costs of the healthcare system.Theres a few, particularly having to do with chronic diseases, that are an exception. If youcould cure Alzheimers, if you could avoid diabetes those are gigantic in terms of savingmoney. But the incentive regime doesnt favor them.

EK: Youve talked a lot so far about this question of DALYs. Were ve ryuncomfortable putting a value on human life. The way I see our health system isweve chosen to pay a huge premium in order to avoid these questions. Aprerequisite for the kind of cost-cutting innovations youre talking about it is beingwilling to make judgments about what a human life is worth, or even what a few

months of a human life are worth. Because if you cant decide that, then of courseyou just pay for everything. But if you start trying to make those choices, or evenget people to think about those choices, people cry death panels!

BG . Yes, someone in the society has to deal with the reality that there are finite resourcesand were making trade-offs, and be explicit about that. When the car companies werefound to have a memo that actually said, This safety feature costs X and saved Y lives, thevery existence of that memo was considered damning. It was Oh, you think human life isonly a bank account. Or when you made it reimbursable for a doctor to ask, Do you wantheroic care at the end-of-life, that was a death panel. No, it wasnt a death panel! It wasasking somebody to make a decision.

The Washington Post Company

bill gates_ ‘death is something we really understand extremely well’

Documents