HT interview | India continues improving mortality rates, says Bill Gates

Every September, the Bill & Melinda Gates Foundation releases its Goalkeepers report tracking progress on the Sustainable Development Goals. In the 2024 report, the focus turns to malnutrition. “Every now and then, somebody will ask me what I would do if I had a magic wand. For years, I’ve given the same answer: I would solve malnutrition,” co-chair of the foundation, Bill Gates, says in his introduction to the report. In a Zoom interview, Gates discussed the key challenge, and the looming climate crisis which adds a layer of complexity to just about every problem. Edited excerpts.
The report speaks of the huge progress in global health between 2000 and 2020, and how it came to an abrupt halt, primarily because of the pandemic. What can we do to revive it? Or are the returns going to be incremental from now on?
It’s super important that people see the incredible progress that was made from 2000 until the start of the pandemic and really understand, why did things go so well during that time? And think about the aid, generosity or funding for innovation that allowed that to be an amazing period where the death of children under 5 years of age was cut in half.
A big part of that was that we introduced new vaccines. Some of those were vaccines, like rotavirus for diarrhea and pneumococcus for pneumonia, that actually were being given to kids in rich countries but not all the world’s kids. And so by creating Gavi, by partnering with companies like Serum, Bio-E and Bharat, getting countries to adopt these new vaccines, that was a major factor… Those vaccines had a huge impact in India, a huge impact in Africa, and led to that incredible success.
Once we hit the pandemic, some countries went backwards, although India continues to make progress on improving mortality rates. Africa is now facing a particular challenge with the aid generosity down. India, although it gets some aid, it’s not a high percentage of the economy and so it’s less affected . But it’s a significant factor in Africa, including the interest costs for the debts that they’ve incurred over the last 20 years.
We need to drive the innovation pipeline with great, new approaches and we need to get the financing for primary health care to be a priority at a time where many governments are having to make very tough budget tradeoffs, where they’re paying these very high interest rates. It’s the idea that we can that we got from 10 million deaths a year to 5 million, and now we can get down to 2.5 million, I hope that is a priority and excites the world.
But we’re having to do a better job to get attention when you have all the challenges of the war in Ukraine, the challenges of the Middle East. It’s more difficult to get the visibility of this work and therefore the resources that we need.
The report focuses on malnutrition. Do you think malnutrition suffers from being a problem that’s not so glamorous? It’s a very huge problem, but it’s not something that makes the headlines on a regular basis.
Certainly, malnutrition has been vastly underfunded and ignored, even just the research. It’s only in the last decade that a very basic understanding of why kids are malnourished has been developed. Mostly when you say the word, “malnourishment”, people think of famines where there’s just not enough food and the kids are suffering from that. That’s tragic when it happens, usually when you have wars or big natural disasters.
But that’s not the primary cause of malnutrition. Malnutrition mostly is that you have these very limited diets and eventually your gut microbiome gets inflamed, and so you’re not able to absorb nutrition. If you have a limited diet, it generates that problem, and then once you get that problem, you’re not able to absorb the nutrients.
The foundation funded a lot of studies, even where we would take twins and see what was going on in the gut of the one whose growth didn’t progress and what intervention we could use to prevent that. So, now we understand that there’s a lot of these vitamins, micronutrients are missing, and that’s super important. And by fortifying food and by giving pregnant women more vitamins, we’re making progress on that.
We also learned that protein deficiency is a major part of malnutrition. The mother has to have lots of protein, and the child in the first couple of years has to have lots of protein. And so, figuring out how to make milk cheaper, or eggs cheaper, or other foods that have the protein and then educating families on how they diversify their diet is very, very important.
When we look at these deficits in India, we do still see stunting, which says we haven’t solved the problem. It’s not as widespread as in Africa, and there’s a commitment by the government who we partner with through ICMR to really research these interventions and come up with better measurement. We’ve had to invent new tools, even things like looking at brain development. How do you tell that malnourishment prevented the full mental development?
There hasn’t been good metrics of that, and we continue to work on that so we can quickly try out new interventions and see how does that improve brain development. We partner with a lot of Indian researchers on this, not only to help India, but also to give us the insights that will apply globally, including in Africa.
One of the things that we’ve noticed is that the solutions typically need to be customised. Not just in terms of local food habits and availability of plentiful, local sources of grain but also in terms of the specific deficiencies that people in a certain region have. For instance in India, there are certain micronutrients which many people are lacking in. How does one drill down and focus on these specific inadequacies?
Because the nutrition area was kind of ignored, the ability to take food in a shop and test, does it have the micronutrients in it? That was too hard, too expensive, and the ability to survey people where you take blood samples and you look at those, and you say, okay, what micronutrient is missing? That basic ability to diagnose the food supply and diagnose where those deficits were, I was stunned how tough it was.
And so now, we’re coming up with very low-cost tests to test anaemia for women. We now have the new formulation which we’re working with our Indian partners to make cheaper, where you can get one infusion during pregnancy and it solves the severe anaemia issue. That’s a very new thing, but extremely beneficial.
And so, the whole feedback loop of “look at what’s missing” which is mostly blood analytics that we’ve made a lot cheaper and a lot more accurate, and then consider how you’re going to get those micronutrients out. Which food vehicles — you can use wheat or rice, or salt or sugar, and understand for different parts of the country what coverage you’re getting. And so, the sophistication of gathering the data and understanding the diets is far, far better today than it was even five years ago.
Like many other things, the whole malnutrition challenge is made a lot more difficult by the climate crisis. At one level, there are just so many other things that countries and health providers are having to focus on, new challenges that are posed by the climate crisis, even in terms of infectious diseases and other things. For instance, we’ve had a very wet monsoon in Delhi this year and the dengue numbers are off charts, the number of people and so that’s at one side.
You’re tackling those things; meanwhile, your food sources, what you grow, when you grow, all those things are typically changing because of the climate crisis.
Mostly when people meet to discuss climate, they’re discussing climate mitigation — that is reducing the emissions, and that’s very important. But the need to adapt to climate because of the challenges you mentioned doesn’t get nearly as much attention. And so, the biggest effect of climate change, the biggest damage it causes is its effect on the food system.
When climate causes natural disasters, that’s very visible because it’s all in one place. But most of the negative effects of climate operate because it makes growing food harder, and it increases the number of years where the harvest is very, very low. And so, to build up resilience, India has the various ways the government makes sure food is available but you’re going to have to change the seeds that are grown. Change the varieties, adopt more productive varieties.
We work a lot in this agricultural field. Other than our health work, it’s our second-biggest area…, coming up with crops that are adapted to climate change is a great partnership between the foundation and the India agricultural research institutions.
The other area you mentioned is that higher temperatures mean the mosquitoes are thriving in new locations, particularly in wet years. That’s just terrible because some of these mosquitoes are carrying dengue, or yellow fever, or malaria and those are terrible diseases. The Gates Foundation is the biggest funder of what type of nets or insecticides, we could use to reduce mosquito populations.
Do you think a return to traditional crops… In India, for instance, we’ve had this resurgence of interest in millets. Do you think this is something that can help us, one, in terms of growing crops that are suitable to the climate, and also in terms of addressing whatever malnourishment gaps exist?
As part of my last trip [to India], I got to see the work being done on millets and how that plays a role in an overall balanced, nutritious diet. Some traditional crops have very low productivity per hectare, and so unfortunately, that doesn’t work well. The good news on millets is that there has been work to raise the productivity quite a bit, and it doesn’t require as much water and it can deal with the higher temperature and it’s a valuable piece of the diet.
You have to look crop by crop and say, okay, are we missing some of these crops that could contribute vitamins or protein, and maintain high productivity even in the face of the climate weather changes? I also saw that the digital systems were being used (in India) to communicate with farmers, to give them advice, to tell them about pest control, to help them to know which variety, using better AI for weather forecasting so farmers know when to plant.
In the fight to grow more food, more nutritious food, even in the face of the climate thing, I think all these techniques, better seeds, informing the farmer, better forecasting — those all play a role. I think the millet story is a very good story, and there’s probably others like that, but we’d have to look crop by crop because you do need high productivity for the farmers to thrive.