By Justin Gillis
Washington Post Staff Writer
Wednesday, October 1, 2003
GABORONE, Botswana -- Bill and Melinda Gates smiled and nodded as the prostitutes stood up to dance.
Sha-boom! Sha-boom! Hips jiggling, arms swinging wide, the women moved in lock step, singing with no accompaniment. Their lilting voices filled a drab conference room at Gaborone's main hospital, and their modern African rap unfolded as the world's richest couple looked on.
"Save your life!"
Okay, so they were ex-prostitutes. Or, to use the politically correct new term, ex-commercial sex workers. They have been restored to respectability these days, thanks in part to a program the Gateses' money has helped to fund.
They sat back down, and soon the Gateses were firing off questions. Will men in Botswana use condoms during sex to protect themselves or their partners from the AIDS virus? (Sometimes.) Are condoms easy to get? (Yes.) Will men pay more for sex without a condom than with one? (Yes, a premium exceeding 50 percent.)
The scene in Botswana last week was a scripted moment, to be sure, with a handful of journalists in the room to record it. But it accurately reflected just how deeply Bill and Melinda Gates have become enmeshed in the health issues that shorten lives in poor countries.
The Gateses are pouring billions of dollars into world health initiatives, a cause they have backed since 1994 but have tackled with rising fervor in the past couple of years. The extent of their giving has grown so quickly that the world has barely begun to absorb the implications.
Their money is being used to dramatically expand and improve international vaccination efforts. They are bankrolling programs to find new ways to stop the world's greatest killers, including AIDS, tuberculosis and malaria.
The Gateses have created a foundation worth $25 billion, the largest in the world, and have pledged to give it most of the rest of their $46 billion fortune, derived largely from stock in Bill Gates's company, Microsoft Corp.
Their foundation far exceeds in assets some better-known names in American philanthropy. It is 10 times the size of the Rockefeller Foundation and three times the size of the Ford Foundation. It is only slightly larger than the Wellcome Trust, a London charity that was once the world's largest, but the Gates Foundation has adopted a more intensive focus on saving lives in poor countries.
The Gateses have said they expect to supervise the foundation for the rest of their lives, which could easily mean 30 or 40 more years. They seem virtually certain to surpass John D. Rockefeller and Henry Ford, the oil and automobile magnates, in the scope of their philanthropy.
In fact, the greatest difficulty with the Bill and Melinda Gates Foundation could be the sheer scale of their operation. The group is pumping money out the door so fast that spending it effectively could prove to be a huge challenge.
They have set up elaborate programs to track how their money is being used, but to date, the Gates Foundation can't point to a single big new drug or vaccine that it paid to develop. The foundation's biggest successes so far have been in helping poor countries adopt vaccines that were developed well before the Gateses got involved.
At the hospital in Botswana's capital, the four ex-prostitutes testified to the success of one Gates-backed program. They chose not to disclose their AIDS test results, but they did say many of their friends are infected.
In a jaunty brown cap, Khumo Tsope, 21, told of growing up desperately poor in her grandfather's household, of moving to the city in search of a better life but finding no work, of hanging out with men in the bars, doing what it took to survive. As a result of the Nkaikela Youth Project, she and the other women are learning better ways of supporting themselves -- making candles, growing vegetables, working as cashiers in kiosks.
"Now I am happy," Tsope said, and she smiled radiantly.
If a single one of the big bets pays off, the lives saved could cumulate rapidly into the millions. Already, the Gateses are as well known in African and Asian countries for their health programs as for Bill Gates's role in founding Microsoft.
So far, their efforts have yet to produce a breakthrough. But drug development takes years, and they haven't been at it very long. Richard Klausner, a former director of the National Cancer Institute in Bethesda, who now runs global health programs for the Gates Foundation, expressed optimism that it will score some home runs, and he hinted it may happen soon.
The Gateses consider their ability to take big risks, and survive failure, as one of the strengths of their foundation. But if five more years pass without large payoffs -- or if the new drugs aren't made affordable to poor countries once they are developed -- the Gates Foundation's biggest programs could well wind up disappointing the world's developing nations.
One of the biggest projects the Gateses are backing, and possibly the most important, is an attempt to turn Botswana, a small, well-run African country of 1.7 million, into a model for delivering AIDS treatment to the huge populations of infected people in Africa. The project, started with $50 million from the Gates Foundation and $50 million from Merck & Co., is cranking up, but slowly. Despite three years of effort, only a few thousand Botswanan citizens are receiving treatment to date, out of the 110,000 who are estimated to need it immediately.
While some of the programs on the ground appear to be lagging, at least for now, the Gateses have reaped widespread publicity in the United States for their efforts.
They have said their interest in philanthropy grew as they got closer to middle age -- he is 47, she is 39 -- and began grappling with how to spend their wealth. Some people have noted, though, that the rising interest coincided with Microsoft's battle with the U.S. government over its Windows computer monopoly, during which Bill Gates took a drubbing in the court of public opinion.
That legal dispute is now resolved (others continue), but the Gateses haven't slowed down on public health. They are going at it more vigorously than ever. Gates handed the operational reins of his company to Steven A. Ballmer, remaining as chairman and chief software architect, and has thus had more time to pursue philanthropy.
They both came from close families -- his in Washington state, hers in Texas -- that took public service seriously, they said. They plan to give their children relatively small inheritances, to protect them from the potentially life-ruining effects of vast sums, so the only sensible thing to do with the money was to return it to public service.
"Who knows why we're in the situation we're in?" Melinda Gates said. "I don't think either of us can explain that. Yes, Bill worked really hard and he's been incredibly smart about some things, but also very, very lucky. Given that, we both feel a huge responsibility to do what we can with that resource."
If the only motive were publicity, the Gateses could perfectly well sit in their manse in Seattle and announce, say, huge new malaria grants. Instead, they travel to some of the bleakest places in the world to console the destitute and cheer doctors on the front lines.
They trekked the other day to a remote clinic in Mozambique to announce the biggest grants in history for malaria research, exploiting the accompanying media attention to highlight the toll of malaria -- more than 1 million dead children, mostly in Africa, every year -- and to call on the rest of the world to help them fight it.
Most people in the world with billions of dollars to give away, and there aren't many, would set broad guidelines, hire experts and trust them to use the money sensibly, while continuing to run whatever business enterprise produced the fortune.
The Gateses have hired experts, for sure, but they have also steeped themselves in the scientific details. They have read textbooks on immunology and infectious disease. They routinely interrogate doctors and staffers about the smallest points of controversy or uncertainty.
At various times on their African swing they reeled off the Latin names of various mosquitoes and parasites. They asked questions about "CD-4 counts" and "uptake rates" and the fine points of immunology.
On every major grant the foundation gives, staffers say, the Gateses themselves make the final call. When a big new round of grants is in the offing, Klausner said in an interview, the Gateses will deluge him with e-mail as they study each one. "There's pages and pages of questions," he said.
As their van rolled across the coastal plain of Mozambique the other day, toward the malaria clinic, the Gateses were questioning a doctor from there, Ricardo Thompson. Trained in Mozambique, he is one of a rising generation of African scientists who conduct world-class research and publish in top scientific journals.
Gates asked him how many doctors there were in Mozambique now.
"About 400," he said matter-of-factly.
A long pause in the van.
"Four hundred!" Gates fairly shouted.
Another pause ensued, and the conversation drifted elsewhere, but his mind kept churning.
Suddenly, he butted in to reel off the statistic for the number of doctors per thousand population in the United States, which he happened to know off the top of his head.
And then he did some quick math to demonstrate that the small urban elite of Mozambique would be enough by itself to soak up the efforts of half the country's doctors. That left about 200 doctors to take care of 18 million people, a ludicrous ratio by American standards. It means that, for all intents and purposes, there is no modern medical care for much of Mozambique.
Only in working over the number did Gates seem to get the full picture -- and to grasp what it meant for some sick person stuck out in a rural village.
"Four hundred!" he said, again and again.
Don't be surprised if there is soon a Gates Foundation grant in the tens of millions of dollars for training young doctors in poor countries.
Helene Gayle, a former top administrator at the Centers for Disease Control and Prevention who has held a lead role at the Gates Foundation for two years, has seen this phenomenon up close many times.
"Bill is very numerical," she said in an interview in Botswana. "When you present him with the right information, a moment will come when he goes, 'Aha! You mean there's a vaccine that costs pennies a dose and millions of children are dying because we're not getting it to them? That does not compute.' "
Voices bounced off the walls as a group of young community activists, gathered for lunch with Melinda Gates, described the waning hopes of a youthful generation.
Nearly half the South African population is too young to remember the apartheid era of racial segregation and oppression. Social progress seemed imminent when a black-majority government finally took over from the white-minority regime in 1994, but it has stalled. The young generation has been dealt a grave blow by the twin ills of unemployment and AIDS. South Africa has the largest infected population in the world, nearly 5 million, and life expectancy in the country is falling sharply, as in many parts of Africa.
Melinda Gates propped her elbows on the table, held her face in her hands and stared into their faces as the young people in the room described various programs they have created to try to combat these problems.
These involve schemes to encourage people to start their own businesses, to prepare them for jobs in a growing tourism industry, to give the youth firsthand exposure to the ravages of AIDS by partnering them with sick people.
But the youth leaders admitted it's all tough, with loans to start new businesses scarce, educational standards lagging, and a dire case of "information fatigue" in a country weary of hearing about the ever-worsening AIDS crisis.
No one said it, but everyone at the table knew they were talking to the richest woman in the world, and everyone knew a little money could go a long way in one of these programs.
Riding in a van to her next appointment, Melinda Gates was philosophical about the problems. Then she expressed a thought that she and her husband have brought up several times on their trip to Africa:
They don't, in the end, have all that much money to give, compared with the scale of the problem they're tackling.
The $25 billion in assets for their foundation and their own private fortune of $46 billion add up to something like two weeks' worth of revenue for the government of the United States. The total is about as much as the major drug companies spend every two years researching new treatments (most of which is spent on diseases of rich countries, where people can pay for drugs).
The Gateses said they can't try to solve every social ill -- they have to target their philanthropy in ways that are likely to unlock additional money from governments, or in ways that could have long-run strategic benefits. That's one reason they have invested so heavily in vaccine development, despite the high risk of failure.
As central Johannesburg passed by in the windows, Melinda Gates wondered aloud why South Africans have been so patient with their government, which has been exceedingly slow to develop a treatment plan to combat AIDS deaths.
The obvious answer -- that it is their government, one that black South Africans fought for most of a century to put into power -- feels inadequate, at least to outsiders, in a situation where half a generation is about to be lost to a wretched pandemic, and in which the science to stop that tide of death is at hand but isn't being applied.
"I don't understand why people are not rioting to demand . . . treatment," Melinda Gates said.
Here is another hallmark of the Gates philanthropic program: a sense of urgency.
"I think they look at their three beautiful children, and they know how much the children mean to them, and they are able to make the leap to say that other people's children must mean just as much to them," Gayle said.
At the same time, their computer science brains are able to look at very large numbers and somehow calculate the human toll behind them.
The other day, they awarded a $28 million grant for a huge series of tests on a technique that could theoretically, in a few years, cut malaria deaths in Africa in half. Malaria is, in several countries, the leading cause of death in young children.
The usefulness, or lack thereof, of that technique would have been proved eventually without their involvement, but the Gateses' largess essentially means the answer will be obtained as quickly as it humanly can be obtained. If their grants speed up the research by just three years, and if the technique does work, the extra lives saved by speed alone could well exceed 1 million.
The Gateses don't understand why other people, and their governments, don't share their sense of urgency.
On their African trip, they expressed gratitude for President Bush's plan to spend billions helping the continent fight AIDS, but the Gateses have said several times that they thought more governments and philanthropists would have adopted their cause by now.
Bill Gates, in an interview as he was leaving Botswana, recalled a famous episode when his interest in public health soared after he read a 1993 World Bank development report, and he wondered aloud why others don't share his fascination with such health statistics.
"I think they're the unusual case, and I'm the normal case," Gates said at the tiny airport in Gaborone as his jet waited on the tarmac to whisk him away. "This is about life and death. This is about the degree to which we've improved human existence, and how much more we have to go. Years from now people will look back at this era and ask: Was humanity improving?"