Sue Desmond-Hellmann on health and healthcare – Full interview | VIEWPOINT

Michael: We’re here today with Sue Desmond-Hellmann,
CEO of the Bill & Melinda Gates Foundation. Thank you very much for being with us today
here at AEI. Sue: Sure. Glad to be here. Michael: You’ve done quite a bit. You had a public event this morning with Arthur
Brooks, and I think you just finished up our podcast, and you did Facebook Live as well
which I didn’t even know it was going on. So you’ve given me the… Sue: I’ve been everywhere at AEI. Michael: Thank you. Sue: Yeah. Nice new building. Michael: Yes, it is. It’s wonderful. Sue: It’s beautiful here. Yeah. Michael: It’s wonderful. I think this is my first interview in our
new TV studio. So I’m looking at the equipment and the camera
that’s skirting around on the floor, that’s you know, freaking me out a little bit, but
I’ll get used to it. So let’s just dive right in because we don’t
have a ton of time. My first question kind of relates to what’s
happening at AEI amongst some of our younger people. It’s graduate school application time. We are in the quarter-life crisis period right
now, and that’s starting to resolve itself a little bit, and people are getting ready
for their graduate school deadlines. You’ve had a really varied career, but it
started as a physician, and I was wondering if you could just let us know why you wanted
to become a physician. Sue: Oh, I wanted to become a physician because
I wanted to help patients. I was very motivated by my experience growing
up with my dad, who is a pharmacist, and our family doctor, Noah Smirnoff, who was just
a terrific guy. And seeing Dr. Smirnoff and my dad and their
interaction with people, and how much they helped people was a big motivator for me. And then as I got older, I knew that I loved
science and I loved math, and so going to medical school, I also got to take the classes
I liked the most. Michael: Well, that helps. Sue: Which was useful, yeah. Michael: You credit moving to Uganda in 1989
to work on HIV/AIDS and cancer, as a major turning point in your life. Why did you make that move in the first place? Sue: In 1982, I became an intern in San Francisco,
and in 1981, HIV/AIDS was first described. So like a lot of trainees in the ’80s, my
experience as a young doctor was incredibly impacted by the HIV epidemic. And my specialty as an oncologist was Kaposi
sarcoma, the cancer that affects HIV/AIDS infected patients. And so when the world started to get worried
about heterosexual transmission of HIV infection, the Rockefeller Foundation funded UCSF to
study heterosexual transmission in Sub-Saharan Africa, and UC San Francisco loaned my husband,
Nick Hellmann, an infectious disease doctor, and I, to Makerere University in Kampala,
Uganda, to start to understand what was going on, that was very different than the experience
in the U.S. had been so far with the main population affected being gay men. Michael: That’s fascinating. And so that’s how you got there. Sue: That’s how I got there. Michael: And it seems like there was a lot
of circumstance that kind of led you there. Once you were there, why did it become such
a turning point for you? Sue: In every way, it changed how I thought
about the world. It changed how I thought about poverty. It changed how I thought about myself. I was able to be a leader in Uganda in ways
that in a big university, just didn’t happen spontaneously. And I think the combination of those things,
getting to be a leader and seeing how much human potential was really not able to live
up to their capabilities because of that extreme poverty, that extreme disadvantage, I think
I just held myself accountable for making a difference in the world in ways that just
didn’t feel real for me before I had that experience. Michael: I see. The Gates Foundation strives to advance a
vision of the world in which every person has the opportunity to lead a healthy life. What do you mean by health? Sue: Ah. The most important thing that we mean by health
is not to be threatened, especially from an early age, by things that are so consequential. So it just doesn’t seem right to us that any
child should suffer or die from a vaccine-preventable disease. That shouldn’t happen in 2016, much less ever. So we’re obsessed with vaccines in a very
positive way. A vaccine-preventable disease might mean for
a few pennies, a child can go without measles, rubella, diarrheal disease, pneumonia. These are things that really have meaning
for us. We invest in nutrition because we know that
things, like stunting and wasting decrease human potential, not just for the obvious
things that you’re weaker and smaller than you would be, but your cognitive development,
is not as much as it should be. So what we mean by health is stacking the
deck in favor of that child being able to thrive, being able to learn, to have a job,
to go to school, to have a life that we think anybody should have the possibility for. Michael: Listening to your answer, which is
very compelling, it reminds me of some conversations I’ve had recently with parents of newborns
about vaccinations here in the United States. And I’ve read some news reports that whooping
cough is breaking out in some parts of the country which is really troubling. Do you have any thoughts you’d like to share
on vaccinations here at home? Sue: Actually, vaccinations and health prevention
measures are something that as a public health person myself, I think it’s really, it’s so
important not to get complacent. And something that I think has happened in
the U.S. is a certain amount of complacency about vaccine-preventable illnesses. Things like measles, things like whooping
cough, we tend to take for granted that those aren’t problems anymore, and in most communities,
they aren’t problems because of vaccines. So it takes vaccination to prevent those diseases,
which feels obvious, but if too many people opt out of vaccines, then we actually have
a troubling fact, which is, what should be completely gone, like measles, like whooping
cough, from places like the United States, can come back, and come back fast and furious. Michael: That makes perfect sense. Let me talk a little about your career. You’ve had an extremely successful private
sector career. You helped develop two of the first gene-targeted
therapies for cancer, you were named by Forbes as one of the world’s seven most powerful
innovators in 2009, and for seven years, you were listed among Fortune’s top 50 most powerful
women in business. A lot of power there. So you were really at the pinnacle, and then
you left and became chancellor of a university. What made you want to leave the private sector,
and take a leadership role at a university? Sue: Well, I had been president at Genentech
for about five years, and in 2009, our majority shareholder, Hoffmann-La Roche, bought the
remainder of Genentech. And so the company was the focus of what people
call in the business world the squeeze-out. And when Roche bought the company, it would
have meant going from an 11,000-person biotech company in south San Francisco, to being part
of a 90,000-person international drug company. That wasn’t as compelling to me as what I
had been doing, and so the University of California, San Francisco, which is where I had done my
medical training and fellowship, had asked me to look at the job as chancellor. And given that transition time for myself
of going from Genentech to the Roche acquisition, I interviewed for the job, not thinking that
they would select someone from the private sector which was unusual. And so in 2009, I became their first female
chancellor which was a first. But I think a bigger first was the first private
sector chancellor because I’d been 16 years in the private sector, but had an adjunct
appointment and still taught at UCSF, at Stanford, and at UC Berkeley. I actually taught about portfolio management
in the business school. Michael: Oh, is that right? Sue: Which was kind of funny to do that. But I enjoy teaching, and I enjoyed scholarship. So it wasn’t too crazy. But it was definitely unusual. Michael: So it is very unusual. And do you think having a private sector background
helped you to succeed as a university chancellor? Sue: I think the private sector background
was helpful. And I think I had a lot to learn. I’ll give you one example that people who
know academia would chuckle about. The concept of shared governance, when I first
heard that… Michael: We have a lot of fun with that here
too. Sue: Yeah. When I first heard about shared governance
as being the faculty and the chancellor, I said, “Are you kidding me?” Like that makes no sense. Sharing is hard, you know. And so I learned a lot as chancellor, about
that. On the other hand, we had a major academic
medical center. UCSF Medical Center is a big, big medical
center, and it’s a big business. And so I definitely brought during that really
tough time, the big recession, a lot of business savvy to the university which I think was
very helpful. And I learned a lot about shared governance,
about student life, about really thinking about things that I was either not very knowledgeable
about, or had to catch up on, like what it’s like to work off of NIH grants, how to run
a lab in a world where the researchers feel small and the expenses seem big, and some… Michael: Yeah. And are growing. Sue: And are growing. So I learned a lot more than I had remembered
about academic life and what it’s really like to be a faculty member in these times. Michael: Yeah. It’s not a…gathering a group of 22-year-olds
at your feet and talking about Aristotle anymore. Sue: No. It’s definitely not that. And student life has changed a lot. Student life has changed, and students’ aspirations
and their expectations are different than mine were when I went to medical school, now
a long time ago. Michael: In what way? Sue: I would say that students’ expectations
for how they have a well-rounded life or how they have a life outside of medicine in a
positive way is different than what I expected. I expected that I would be immersed in medical
school and in my internship and residency. In fact, now there’s laws that govern the
hours of residents. Those laws didn’t exist when I was in training. Michael: Do you think those are good laws? Sue: I think that those laws are generally
good. I think it’s really important for the health
and safety of the patients you’re caring for and for the residents themselves. There are some down sides to the laws. You have to do a lot of hand offs when you
have duty hours laws, and the hand offs aren’t good for patients, and aren’t actually good
for learning. And so now there’s a very healthy inquiry
about how do you protect those trainees and the patients they care for while giving the
patients that continuity that they got when I was in the hospital for 36 hours straight. So trying to make sure you get continuity
and great training at the same time as you don’t do things that…I mean, if you just
say out loud 36 hours straight at a job, you know that makes no sense, right? Michael: The thought of being treated by somebody
on their 35th consecutive hour always gave you the willies a little bit. Sue: Yeah. No, I think those are things that you have
to balance in how you learn with supervision, so that… I always used to say that one of the things
that I learned in medical training is the difference between the hairs being up on the
back of your neck, and the hairs being up on the back of my neck. Like that sense that I’m on the spot and this
patient’s dependent on me, you need that in your training, but you don’t wanna put that
patient at risk. Those are some of the nuances of medical training
that are really tough. But the great news is, and I’d learned this
as chancellor, there are experts in clinical education, be it medical, nursing, pharmacy,
dentistry, which is the areas that are clinically trained at UCSF. There’s actually a lot of scholarship on that
now. Best ways of learning, best ways of experiencing,
so you can maximize technical proficiency and empathy. So we all want… Michael: Yeah. You gotta balance. Sue: We want a good doctor who has a good
bedside manner as well. Michael: That’s right. One of your many contributions as a public
intellectual is this concept of precision public health. What is that, and why is it important? Sue: So precision public health for me is
important because it takes the incredibly powerful concept of precision medicine: right
drug, right patient, right time, and applies it to public health and global health. So you think about the right set of interventions
for the right population, in the right geography. If you’re a minister of health in Ethiopia,
you’ve got frontline healthcare workers who might have a 10th-grade education, who might
have limitations in budget. And you’ve gotta pick 10 things that she has
in her bag that she goes out and carries to somebody in her village. What should be in that set of 10 interventions? What belongs there? What should she be trained to do? That’s a tall order. That is a tall order. So precision public health, for me, is the
concept of using data and monitoring and feedback to give those caregivers and the decision-makers
in the Ministry of Health, no matter where you are in the world, or the Department of
Public Health, if you’re here in Washington, D.C., the right information to maximize the
value of every penny spent on health in service of that community. It really is a transition from a highly individualistic
precise way of thinking to a more prevention-oriented, more community-oriented way of thinking about
being productive with the resources including the human resources you have to keep a community
healthy. Michael: Do you have an example of where that’s
being done particularly well? Sue: Well, actually I think we all are seeing
an example of how that can be done well with the Zika virus epidemic. If you look at how we know where Anopheles
mosquitoes are, that’s the malaria mosquito, we’ve used that for malaria control. The Aedes aegypti mosquito, which is the source
of Zika and dengue fever and chikungunya, some of the things people have been reading
about, we know where the Aedes aegypti mosquito is, we know where Zika has traveled, we know
community by community. Yesterday we knew that there was a case of
Zika in Texas. That’s precision public health. Knowing precisely what community, where the
patient was, what the transmission route was. And that allows caregivers and decision makers
not to just say, “Okay, everybody in America should be worried about Zika.” That makes no sense, and it’s cost-prohibitive. But if you know the very communities, you
can target vector control, getting rid of the mosquitoes, you can target messages for
women who are pregnant or who might become pregnant, you can target messages for males
who can transmit Zika to their partners. And both the public health messages on the
communication front and the interventions on vectors and virus can be much more precisely
delivered. That’s a good example of where, with the right
resources and the right data, we can make a huge difference. Michael: So would it be fair to summarize
this as getting the right information out, and acting on it appropriately? Sue: Absolutely. And it starts with getting the right information. It’s amazing how often we’re nearly flying
blind. And one of the aspects that we’ve been investing
in at the foundation, is the causes of neo-natal mortality. So there’s a period of life, actually, your
most scary day is your birthday. The first day of life. Michael: Is that right? Sue: Under-five mortality is the highest in
the first day of life. And in too many of those cases, we don’t actually
know why those children are dying. If we had that knowledge, if we had the information,
much better information on all causes of death in the first 30 days, only then can we more
precisely give a remedy. I’ll give you a really easy example. So Group B Strep is a bacterial infection
that causes fatalities very early in life. If a woman’s baby dies of Group B Strep, she
has seven times the chance that her next baby will also die of Group B Strep, this bacterial
infection. And it can be prevented with penicillin, pennies
a dose, right? So that’s a good example of where that data,
that information getting back to those communities if you’re seeing Group B Strep as a cause
of mortality, that community needs penicillin for those women. So a really simple remedy. I’m not talking rocket science. I’m talking penicillin for heaven’s sakes. You would only do that if you were able to
diagnose the Group B Strep. Michael: Yeah, yeah. That makes sense. You mentioned Zika. Are you worried about pandemics in general? Do you think that the world is ready for a
full-scale pandemic? Sue: I’m very worried about pandemics. Since I’ve been at the foundation, we’ve actually…the
world has seen both Ebola and Zika, and the foundation didn’t intend to invest or specialize
in pandemics, but we’ve gotten very involved because it’s clear to us and the global health
community that the world isn’t ready for the biggest threat of all which almost surely
is influenza. We have been lucky as a globe that Ebola is
actually not as contagious as influenza. That Zika, while horrible for the families
involved because it causes a terrible birth defect, is very limited, and in most people,
doesn’t cause a difficult disease. It’s much more like a flu. If the world saw pandemic flu, we are not
ready. And so our foundation with the global community
has gotten involved in governance issues, surveillance issues, and in getting better
tools. We need better tools, be they diagnostics,
therapeutics, vaccines. The world needs to have things in our tool
kit so that we can respond more rapidly. What we found with Ebola, in particular, is
that the vaccinations were ready when the epidemic was finished. Michael: Yeah. That sounds worrying. So if this flu season turned out to be a really
bad one, do you think we’d be able to step in and take the kind of measures that we needed
to? Sue: So the seasonal flu, we’re on it. Seasonal flu, the Centers for Disease Control
in the United States monitors the most common causes of seasonal flu, and the flu vaccination
campaigns are appropriate in the U.S. There’s always ways to improve that, and always
innovations that can make seasonal flu vaccination coverage better. A pandemic flu like the H1N1 and things that
we’ve seen, that’s a different nature. That would be a global flu, and it would be
something that most worrisome would be it springs up in an area of the world that is
an area of unrest, or an area that doesn’t have good standards of health. So one of the best ways to be ready for that
is something that is in the sustainable development goals that the world has put in front of us
for 2030 in that every place in the world has a health system that works. So actually it sounds like mom and apple pie. Doesn’t it? Michael: Sure. Sue: It turns out that if you wanna be ready
for an epidemic, having working health systems everywhere is extremely important. The health system in Liberia, in Guinea, in
Sierra Leone, those health systems didn’t work. So Ebola quickly got out of control in no
small measure because there was no working health system. To be ready for a pandemic, specifically,
a flu, having working health systems and surveillance that works globally is step one. Michael: How far are we from being able to
effectively deal with a pandemic flu? Sue: I would say that in terms of the global
governance, there’s already been an enormous amount of work since the globe came together
on Ebola. And so there are, now we’re at the kind of
report stage, and at the building global capacity stage. One of the efforts that we’ve been a part
of is something called CEPI, which is the Collaboration for Epidemic Preparedness and
Innovation. And CEPI is a way for people from pharma,
from the not-for-profit sector, from academics, to come together and say, “What are the tools
that the world needs to be ready for an epidemic?” CEPI didn’t exist before we had Ebola, before
we had this knowledge that the world needs to get ready. There’s also efforts at reform going on in
WHO, to make sure that WHO or others are ready for the governance. Who’s in charge? Who’s in charge when there’s an epidemic? There’s clearly a role for sovereign nations,
but there’s a need for global governance systems. What Ebola served as for the globe is a wake-up
call, and I would say we’re not quite where I’d like us to be, but the good news is, even
though we don’t have an epidemic, the global community has continued to push for us to
get ready. And always, like everything else in life,
you get very focused, and then you go onto the next problem. This has been, now Ebola a couple of years
ago, a continuous stretch, driven by really terrific people globally, but particularly
great leadership coming from the UK, from the U.S., from Germany, and organizations
like the G7 and the G20, have been part of driving that global agenda, to make sure that
the world is ready next time. Michael: So we’re not ready yet, but we’re
making progress. Sue: I think we’re getting better. Yeah. Michael: Let’s turn to the United States. You’re a physician, you’re a scientist, you’ve
been a university chancellor, a business executive, and now you’re the CEO of the Gates Foundation. Taking the broad view, what are your thoughts
about healthcare in the United States? Sue: Oh, gosh. For me, healthcare in the United States has
been a big challenge. Since I went to medical school, people have
been talking about healthcare in the United States. And there are many, many challenges, many
of which I’m not an expert on. We don’t do health in the U.S. Here’s what
I’m sure of: what I’m sure of is that working on prevention, working on the more public
health aspects of health, are a net positive, globally and in the United States. And yet, one of the biggest challenges with
our health system is that we try and fix things after they exist. You know, I’m an oncologist, and so often,
I would be working to try and fix problems that were preventable. We don’t know how to prevent all cancers,
but we know how to prevent one of the most important ones which is lung cancer, for example. So I think that in the United States, any
future health systems discussion, should come with a vigorous discussion of how do we enhance
healthy behaviors? How do we enhance vaccinations, healthy diet,
exercise, all the things we’ve known for a long time are good for human beings. How do we treat hypertension, rather than
deal with a lot of strokes or heart failure? These are things that public health knows,
and yet one of the sad things for me is that public health has been underresourced in the
United States. That’s a great investment. That’s a great investment. Michael: So you think with more resources,
we could get people to live healthier lives? Sue: I actually think that we have lots of
resources going to health in the United States. We spend a larger proportion of our GDP on
health than any country on earth. It is how those resources are used, and what
they’re spent on. So I hope this dialogue that I know will be
up coming on the future health system for the United States, I hope that those decision
makers keep in mind the importance of public health and what a great investment it is,
particularly for young people, to have public health that drives healthy behaviors and wellness. Michael: Thank you very much for meeting with
us. Thanks for all you’ve done at AEI today, and
congratulations on all the success that you’re having and the success of the Gates Foundation,
and we look forward to watching the great work Gates is doing, going forward. Sue: Thanks a lot. Nice talking to you. Michael: Thank you.

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