Does saving kids’ lives lead to overpopulation?

Bill and Melinda Gates Foundation working with private sector to make existing drugs, vaccines available to people in poor countries
Chinese Academy of Agricultural Science to develop varieties of rice that tolerate drought, require less fertilizer, herbicide, pesticide

Developing countries have consistently accused the West of trying to depopulated Africa and Asia to their advantage. In fact philanthropists, donor agencies and foundations such as the Bill and Melinda Gates Foundation have been accused of pushing the agenda silently through promoting family planning, safe abortion and contraceptives. The Foundation has also been accused of promoting genetically modified organism (GMOs) in Africa and indeed Nigeria.

Every year, Bill and Melinda Gates publish a letter about their philanthropic work, lessons learned, and priorities ahead. Last year, Bill and Melinda Gates, during an online interview with The Guardian could not answer the question around the Foundation’s push for family planning.

However, this year, their 10th, the couple used their Gates Foundation letter to answer the “toughest” questions that they get asked, ranging from does saving kids’ lives lead to overpopulation, to why they give so much of their wealth away in the first place.

Does saving kids’ lives lead to overpopulation?
Melinda: We asked ourselves the same question at first. Hans Rosling, the brilliant and inspiring public health advocate who died last year, was great at answering it. I wrote about the issue at length in our 2014 letter. But it bears repeating, because it is so counterintuitive. When more children live past the age of five, and when mothers can decide if and when to have children, population sizes don’t go up. They go down. Parents have fewer children when they’re confident those children will survive into adulthood. Big families are in some ways an insurance policy against the tragic likelihood of losing a son or a daughter.

We see this pattern throughout history. All over the world, when death rates among children go down, so do birth rates. It happened in France in the late 1700s. It happened in Germany in the late 1800s. Argentina in the 1910s, Brazil in the 1960s, Bangladesh in the 1980s.
Bill: There’s another benefit to the pattern Melinda describes—first more children survive, then families decide to have fewer children—which is that it can lead to a burst of economic growth that economists call “the demographic dividend.” Here’s how it works.

When more children live, you get one generation that’s relatively big. Then, when families decide to have fewer children, the next generation is much smaller. Eventually, a country ends up with relatively more people in the labor force producing economically—and relatively fewer dependents (very old or very young people). That’s a recipe for rapid economic development, especially if countries take advantage of it by investing in health and education.

Fortunately, the number of child deaths is likely to keep going down. The rate of innovation in child health is extraordinary, and the world is starting to make progress on some of the most stubborn challenges in the field. For example, we now know that malnutrition is a contributing factor in half of all child deaths, but there are still many open questions about what causes malnutrition and how to prevent it.

One promising area is the study of the microbiome—all the bacteria in the human gut—and the role it plays in kids’ ability to absorb nutrients. We’re also working with a partner on a device that’s the thickness of a piece of string that can go down infants’ noses and take 360-degree microscopic pictures of the gut. Soon, we’ll be able to see how a child is developing, instead of having to guess.

Melinda: Saving the lives of children is its own justification. It also has the potential to improve life for everyone. But this demographic transition can happen in a reasonable period of time only if all women have access to contraceptives. Right now, more than 200 million don’t. For the sake of those women, their children, and their communities, we must meet their needs—and we must do it now. If we deny access, we are dooming them to a lifetime of poverty. But if we invest in providing access, families will use it to lift themselves out of poverty and build a better future for their children.

Why do you work with corporations?
Melinda: We work with companies like GSK and Johnson & Johnson because they can do things no one else can.

Take the example of developing new diagnostics, drugs, and vaccines for diseases of poverty. The basic science that underlies product development happens at research centers and universities. But when the goal is to build upon basic science, translate it into products that save lives, get those products tested and approved, and then manufacture those products, biotechnology and pharmaceutical companies have the vast majority of the necessary expertise. Every partner we work with is required to make products developed with foundation funding widely available at an affordable price.

Ideally, we’d like companies to seek out more opportunities to meet the needs of people in developing countries. If our limited partnerships encourage them to see potential in new markets, we’d consider it a big success.

Bill: We think poor people should benefit from the same kind of innovation in health and agriculture that has improved life in the richest parts of the world. Much of that innovation comes out of the private sector. But companies have to make a return on their investments, which means they have little incentive to work on problems that mainly affect the world’s poorest people. We’re trying to change that—to encourage companies to focus a bit of their expertise on the problems of the poor without asking them to lose money along the way.

The best examples so far are in global health. Some diseases of the poor require new vaccines and drugs, which as Melinda says is an area where biotech companies excel. So, for instance, we’re funding two early-stage companies that are working on ways to use messenger RNA to teach your body how to produce its own vaccines. It could lead to breakthroughs in HIV and malaria—as well as flu and even cancer.

We’re also working with the private sector to make existing drugs and vaccines available to people in poor countries. There is a group of more than a dozen awful diseases, known collectively as neglected tropical diseases, that affect more than 1.5 billion people. Most of these diseases can be treated, but the drugs are too expensive for the poorest countries to buy and deliver to their people. Several years ago, we learned that a few pharmaceutical companies were donating the necessary drugs. We loved the idea and helped bring together a larger group of companies to donate even more.

In 2016 they provided treatment for at least one of these diseases to 1 billion people in 130 countries. I’m optimistic that we can eliminate a number of neglected tropical diseases in the next decade, and this work is one reason why.

Sometimes we use more complex financial deals to bring in the private sector. For example, donors can remove some of the risk for companies by guaranteeing them that they will either get a certain price for their product or sell a certain volume of it. We are one of several donors that created a price guarantee to scale up the delivery of a vaccine for pneumococcal disease, an infection that kills nearly half a million children every year. Poor children in 57 countries now get this vaccine, and it could save 1.5 million lives by 2020.

We’re also working with the private sector in other areas, but those efforts aren’t as far along. Agriculture companies like Monsanto are making seeds that could help farmers in poor countries grow more food, earn more money, and (as Melinda mentioned earlier) adapt to climate change. And we’re working with mobile-phone providers like Vodafone so that more poor people can save money, make payments, and borrow through their phone. This work took off initially in Kenya and is now expanding to other countries, including India.

Why don’t you give money to fight climate change?
Bill: We do! Some of it involves our foundation, and some of it involves our own personal investments.

Personally, we’re investing in innovations that will cut back on greenhouse gases (what’s called climate-change mitigation). The world needs new sources of reliable, affordable clean energy, but it has been dramatically underfunding the research that would produce these breakthroughs.

This funding gap is different from the problems we work on at the foundation. In philanthropy, you look for problems that can’t be fixed by the market or governments. The clean-energy problem can be fixed by both—as long as governments fund basic research and create incentives to reduce greenhouse gas emissions and investors are patient while companies turn that research into marketable products. That’s why I’m working on it personally rather than through our foundation.

In the past two years, there’s been a lot of progress. Twenty-three countries have committed to doubling their investments in clean-energy research by 2020. Breakthrough Energy Ventures, a private investment fund I am involved with, now has more than $1 billion from a variety of investors and will fund companies in several areas (such as grid-scale storage and geothermal power) that are ripe for innovation. BEV will also be working with a coalition of other clean- energy investors to connect them with governments. Right now, public and private spending on clean energy isn’t coordinated, which is one reason some promising technologies don’t make it to market. We want to bridge that gap.

Melinda: Even breakthrough technology can’t stop the weather from changing. So the world needs to adapt to what’s happening now and what we know is coming. That’s why our foundation’s work, especially in global agriculture, is increasingly focused on climate issues.

Hundreds of millions of people in developing countries depend on farming for their livelihoods. They had almost nothing to do with causing climate change, but they will suffer the most from it. When extreme weather ruins their harvest, they won’t have food to eat that year. They won’t have income to spend on basic necessities like health care and school fees. For smallholder farmers, climate change is not just an ominous global trend. It is a daily emergency.

But just as innovation can limit climate change, it can also help people cope with it. We invest to help farmers be more productive, so that they’ll have more buffer to withstand lean years when they come. We also invest in climate-smart crops that are less susceptible to extreme heat and cold, drought and flooding, and diseases and pests. For example, we’re working with partners including the Chinese Academy of Agricultural Science to develop varieties of rice that tolerate drought and require less fertilizer, herbicide, and pesticide. Innovations like this “Green Super Rice” could be key to fighting poverty and feeding the world in the decades to come.

Are you imposing your values on other cultures?
Bill: On one level, I think the answer is obviously no. The idea that children shouldn’t die of malaria or be malnourished is not just our value. It’s a human value. Parents in every culture want their children to survive and thrive.
Sometimes, though, the person asking this question is raising a deeper issue. It’s not so much a question about what we do, but how we do it. Do we really understand people’s needs? Are we working with people on the ground?
Melinda: We’re acutely aware that some development programs in the past were led by people who assumed they knew better than the people they were trying to help. We’ve learned over the years that listening and understanding people’s needs from their perspective is not only more respectful—it’s also more effective.

Our foundation is designed with this principle in mind. When we say “we” work on a certain issue, we don’t mean that Bill or I or the foundation’s employees are installing sewage systems in rapidly growing cities, delivering treatments for river blindness, or training farmers to rotate their crops. What we mean is that we fund organizations with years and sometimes decades of local experience that do those things. These organizations, our thousands of partners, keep us connected to the people we’re trying to help.

We have about 1,500 employees in offices on four continents who look at the data, survey the universe of possible approaches, study what’s worked and what hasn’t, and develop strategies that we believe will maximize our impact. But one of the most important parts of their job is to listen to partners, adjust the strategies based on what they hear, and give implementers the leeway to use their expertise and their local knowledge. That’s not to say we always get it right. We don’t. But we try to approach our work with humility about what we don’t know and the determination to learn from our mistakes.

On top of relying on local partners, we also have a strong conviction about the importance of empowerment. We aren’t interested in making choices for anyone. We invest in family planning, for example, not because we have a vision of what other people’s families should look like but because parents around the world have told us they want the tools to make their vision of their own family come to fruition. In all our work, we are interested in making sure people have the knowledge and power to make the best choices for themselves.