A global attention on disease gives Bill Gates his moment

“Ebola has reminded people that it is not just poor people who can die of infectious disease,” Bill Gates tells me, in a characteristically matter-of-fact tone.

In a tragic, unsought sense, this is Gates’s moment. The focus of his life — preventable disease — is suddenly the obsession of the world. Gates, who has donated $50 million to the Ebola fight (through his foundation), will give a major address Sunday at the American Society of Tropical Medicine and Hygiene. According to a preview copy of the speech, he will cover the waterfront of vicious infections, from sleeping sickness to dengue to chikungunya (a decidedly unpleasant virus, which is spreading by mosquito in the Western Hemisphere, and which my brother recently contracted on a trip to Haiti).

Gates’s remarks on Ebola are the most likely to reach the media bloodstream. He will draw some lessons from the epidemic: on the interconnectedness of global health challenges; on the need to strengthen health-care systems in the developing world so they can identify and confront outbreaks earlier; and on the urgency of staying “fully invested in the R&D pipeline for new drugs, new vaccines, new diagnostics.”

Typically, Gates will set out a large goal. Instead of preventing the next Ebola epidemic, he will talk of making this “the last Ebola epidemic.” During our conversation, he said that, by the end of the current outbreak, we should have “vaccines and some drugs that, if stockpiled, should stop a major Ebola outbreak in the future.” Someone — perhaps Gavi, the Vaccine Alliance — will need to gather that stockpile. But it should be possible (as new technologies come online) to prevent Ebola from becoming a recurring epidemic.

The need for an unclogged research pipeline is a refrain from Gates, the humanitarian technologist. It is the task of innovation to stay ahead of evolutionary biology — the mutations that make diseases more deadly, easier to transmit, or more resistant to treatment. Gates acknowledged that the Ebola outbreak — given the virus’s history — would have been difficult to anticipate. But “for the big killers, society still underinvests on research.”

“Look at very fast-spreading epidemics we are not currently prepared for,” he said. “We see forms of flu that could kill large numbers of people. And forms that transmit easily between humans. Since 1918, we have not seen one that combines both features.” That prospective combination should frighten us into preparation.

The focus of Gates’s speech, however, is not flu or Ebola; it is malaria. This is an intentional revolt against the news cycle. It also illustrates Gates’s ambition. In 2007 — as malaria remained uncontrolled in many regions and was taking the lives of more than 1 million people each year — Gates declared the goal of malaria eradication. Some in the field regarded this as fanciful and naive. But programs such as the President’s Malaria Initiative and the Global Fund began making serious progress with existing technologies (bed nets, indoor spraying, artemisinin-based treatment). The Gates Foundation, meanwhile, has made serious investments in the development of products — drug treatments, insecticides and promising vaccines — to stay ahead of the evolution of the parasite that causes the disease. During his upcoming speech, Gates will announce a significant increase in his foundation’s malaria commitment.

In our discussion, Gates made clear that ambitious public health goals are not always wise — when premature, they can drive resources in unproductive directions. But the goal of eradicating smallpox, he said, “was a good choice. Polio is a hard but reasonable choice. Malaria is a very reasonable choice.” Gates projects that malaria can be eliminated over the next few years in 30 to 40 countries. And he says — at the age of 59 — that he will be “very disappointed” if malaria is not eradicated in his lifetime. The Plasmodium parasite has reason to be concerned.

Yet the Ebola outbreak, in addition to producing corpses and panic, is seriously complicating the work of malaria control and elimination. In affected countries, the breakdown of health systems has set back malaria control efforts by perhaps a decade. And in developed countries, there is a possibility that funds to fight Ebola may be reprogrammed from other diseases such as malaria — which Gates characterized to me as “a huge mistake.”

Following the Ebola crisis, infectious disease should remain a focus for good reasons: because dramatic gains are possible. And because losses can be sudden and deadly, affecting rich and poor alike.

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