One year on: Q+A reflections from CEO Mark Suzman

February marks the one-year anniversary of Mark Suzman’s appointment as CEO of the Bill & Melinda Gates Foundation. To mark the anniversary and share his reflections, Mark joined a conference call on February 9 with subscribers of The Optimist to answer their questions. This conversation was moderated by the foundation’s chief communications officer, Susan Byrnes.

Well, thank you for the question, and welcome, everybody. And yes, it has been quite a year. This time last year, we had just made our very first grants, a couple of modest grants, around responding to COVID. COVID had not yet really moved out of China. And now, flash forward a year, we have allocated $1.75 billion to all aspects of the COVID response, which was not something that had remotely been on our radar screen. That’s on the direct COVID response, where we’ve been working on development of vaccines, therapeutics, diagnostics, support to developing countries around surveillance and treatments.

But other health crises have not stood still. In fact, as our Goalkeepers Report last year showed, there actually were massive setbacks, particularly in the first part of last year: Drops in vaccination rates, routine vaccination, polio campaigns, drops in availability of midwives available in South Asia and across sub-Saharan Africa.

And, of course, HIV, tuberculosis, and malaria continued to be deadly diseases. So in all health aspects, we’ve redoubled our focus on our core priorities, which are largely infectious diseases that affect the poorest, and then added and included the COVID response. Beyond that, there’s also been important work on, for example, our agricultural development program, looking at growing food security challenges, or our financial services program, looking at greater opportunities for financial inclusion, particularly for women. So it’s not changing our priorities, but in some ways it’s doubling down on our skill set and resources to try and both respond to previous threats and to tackle the new threats of COVID as well.

Let us start by looking at the biggest of big pictures, which is we are in amazing shape that we have as many vaccines that look as effective as they do so quickly after the disease was uncovered. That is truly unprecedented. It is an absolutely amazing scientific achievement by clinicians and pharmaceutical companies and scientists around the world.

That said, we know we are now in a challenging race with some of the new variants that have gone up because COVID, like all viruses, evolves and mutates. We had some news that one of the cheapest and easiest-to-use vaccines, AstraZeneca, may not be as effective against mild disease from a South Africa trial. And we don’t know yet about its effectiveness against serious disease. The South African government in this case has suspended a rollout of that vaccine, pending more information.

We do have good news across a range of different vaccines. There’s a Johnson & Johnson one, which recently produced results, which only requires a single shot, whereas most of the vaccines require two doses. And we’ve got both the mRNA vaccines, which are the Pfizer-BioNTech and Moderna ones.

So the good news is, we have effective tools. The bad news is, we are seeing very inequitable local distribution of those vaccines to date. While the COVAX Facility—which we helped set up, which is a multilateral facility designed to provide equitable access to vaccines, to pool resources, pool purchasing, and prioritize the 92 poorest countries in the world—it has funding, it’s raised over $2 billion, but it’s only part of what’s needed. And in the meantime, the so-called vaccine nationalism of many countries, particularly wealthy countries doing a range of bilateral deals, means that the vast majority of existing supply, because of manufacturing bottlenecks, is currently going to and reserved for rich countries.

That is a problem morally. It’s a problem in terms of public health, because we need to vaccinate more widely in order to tackle issues like the barriers. And it’s bad news in terms of the economic impact as well. And there’s been a variety of modeling—and we’ve supported some—that shows there’s going to be much longer, lingering economic damage if you prioritize the vaccinations exclusively in wealthy countries and don’t distribute them more evenly.

So that is a real global challenge. Earlier this morning, I joined the G20 group of nations, chaired by Italy at the moment, which is looking at new ways to finance pandemic preparedness in the future. And one of the things that is just so striking is the short-sightedness of the world, economically, on it. We’ve got between $28 trillion to $33 trillion of economic damage, whereas the cost of fully funding the current asks for the ACT Accelerator, which includes COVAX, is $27.1 billion. On its own, $27 billion is a huge amount of money, but it is so small compared to the economic damage and impact. And yet we’re struggling to raise those resources. So that’s going to be a real focus right now that we’re working hard on. Hopefully the Biden administration is going to be providing some resources, and other countries will really step up—because right now, we are falling short of equitable distribution. That’s a real problem.

Well, we’ve got to end the current one first, which we’re working on. But this time around—unlike after SARS, after Zika, after Ebola, where there was a lot of attention, a lot of energy, a blitz of financing, and then the world basically lapsed—this pandemic, as a reminder, was not just predictable, it was predicted by Bill Gates, among many others. We know there will be more. And so really, this is the time the world needs to step up and think about pandemic preparedness. These are the purest of global public goods because they help everybody.

We need strong global surveillance so you can track and follow diseases, including the genomic sequencing that we’re now seeing is so critical with the variants. We need the large mega-diagnostic platforms that can test up to 20 percent of the global population every week. We need to scale out new treatments, which are showing huge promise—monoclonal antibodies, for example, are a new type of treatment which we think can be very useful against future pandemics. The mRNA vaccines that we talked about—those are brand-new vaccines. There has never been a successful mRNA vaccine before, and now we have two—and this is a platform that can be used both against new pandemics and potentially against existing diseases like HIV and TB. And in fact, the Gates Foundation has already made a number of investments in that area over the last few years.

We also need to think about strengthening a kind of emergency response corps of professionals who can be ready to go on pandemic preparedness at a moment’s notice. They don’t need to sit idle like a fire brigade in the meantime, either; they can be working on other global health solutions in real time. They can be helping out with the polio battle or the malaria battle or other ongoing challenges. All of these steps are going to be needed and funded, and we’re going to have to think about it globally. It’s not something that a rich country can simply set up and keep its borders closed indefinitely, as we found out. So again, this will be a real test for the world this year.

Historically, governments are very bad at putting money into things that might happen rather than things that will happen—but now we’ve seen the level of consequences, the human consequences, the economic consequences. This time really has to be different.

Gender equality is a huge priority for the foundation, for both Bill and Melinda Gates, and Melinda has been a real global leader on it. That’s why, last year, the foundation elevated gender equality to its own division and appointed our first president of gender equality, because it is such a priority running through all of our work.

The COVID crisis really has thrown that into sharp relief in multiple ways—again, across rich and poor countries. In the United States last year, for example, over a million more jobs held by women were lost than jobs held by men. Meanwhile, women have faced much greater challenges in terms of child care and other home-based duties, with children out of school and other related issues—and the United States, again, is almost alone as a rich country that doesn’t have adequate child care and family leave policies.

In the developing world, we’ve seen something similar. One of our big problems is always gender data, but we’ve seen examples from India, from South Africa, from Ethiopia, where job losses seem to be impacting women more than men. We already know there are deeply entrenched problems—like India has very low female participation in the labor force that’s actually been shrinking in recent years and really needs to grow to unlock that economy.

We are both responding to the current crisis and trying to do particular interventions, including financial inclusion, earlier. One of the few silver linings has been a massive increase in digital social payments across the world, predominantly to poor women in developing countries. We’ve helped support efforts in places like Pakistan that have done this very successfully, and we hope those will be platforms that actually allow women to build digital wallets and digital payment systems, which we know from previous evidence helps build long-term financial resilience for women who are better able to invest in their families.

There have also been other challenges. Qualitative data shows increase in gender-based violence in many countries during some of the lockdown phases, and so this is a moment when we really have to tackle that.

The underlying issue of gender equality is one that has been talked about a lot, but action has been a little slower on the ground, unfortunately. There is a key moment coming up later this year, which is the Generation Equality Forum that was originally supposed to be scheduled last year to mark the 25th anniversary of the historic Beijing women’s conference. That got postponed because of COVID. It now will be held, probably virtually, and hosted by President Macron in Paris later this year.

That really needs to be a moment that sets out a clear set of follow-up agendas and measurable implementation. The rhetoric around gender equality has been very strong in recent years. What’s been less strong is the actual implementation. Whether it’s in the areas we work in—for example, how you support smallholder farmers, 50 percent of whom are women who tend to have access to smaller plots of land, have fewer extension services, have less time available to farm, and are less likely to get credit—all of those challenges are things that need to be tackled, and you can move that across sector by sector. So it’s a huge priority for us.

We’ll be putting a lot of effort into that Generation Equality Forum. I was actually speaking to the executive director of UN Women yesterday, which is the UN agency charged with holding this, and trying to see how we can really build some platforms across the private sector, across civil society, across governments, to move that agenda forward.

This is one of those deep, long-term crises where the true consequences won’t become clear for many years, but they are bad and damaging. Even before the pandemic, we know in the United States—which is where we focus primarily on education—there were deep challenges faced by Black, Latinx, and low-income students, which have been the primary focus of our education programs on K-12 and postsecondary success. While the data are imperfect, in postsecondary, for example, we have seen significant declines in college applications and financial aid applications by Black and Latinx and low-income students. That’s an early warning sign, because we know that college is the conveyor belt into better economic opportunity. That’s been something that’s been slowly and steadily rising, and now we’ve seen this huge setback.

We also know and have clear data that in the regular school systems, the families most likely not to have access to internet or be able to have access to online services are disproportionately Black and Latinx and Native American students. Between 20 to 30 percent of those students have not had proper access. Because testing has been postponed in many cases, we don’t have rigorous measures, but anecdotally the qualitative measures show massive challenges, particularly in math, which is a key indicator where there’s huge learning loss. So that’s the challenge.

The opportunity is—and the foundation had already been working extensively on this—trying to expand our digital education tools. That is where we’ve always been optimistic. We might be able to spread more effective teaching, syllabuses, and best practices more widely to some of those low-income groups and communities of color. And it has been difficult to get the attention of the educational establishment. People are very busy working. Suddenly that attention is there. Everybody—all school systems, school districts around the country, universities around the country—are looking at how to optimize our digital tools. And we’ve made a series of investments with our partners, both around curriculum and around educator training. We’re supporting a number of universities—for example, a group of HBCUs. They started black colleges and universities on a big digital learning initiative.

And so while there are challenges, our hope is that the infrastructure we’re building right now is infrastructure that really will help in the years ahead, not only to catch up students who are behind, but also really allowing a much more extensive and rigorous education that is accessible to all. But that’s clearly not the case right now. We are still in the middle of the crisis and really having to work very hard to come out of it.

We’ve also done some with the Institute for Disease Modeling, which is working here in Washington state and elsewhere to help inform the governor around school opening policies. There are education groups across the country with similar tools in the short term. But really the big issue is about how we actually get access to learning in real time to these communities, which are being left behind right now. The consequences could be devastating—because we know each lost year of education actually is a massive loss of future income for students. So that’s a very big priority for us.

Thank you for the question. We’ve always had a fairly significant focus on this issue because, for example, as I mentioned about U.S. education, we know the data has always been clear that communities of color have less access to good education opportunities than white or other students. And so that’s been a real focus for us from the Gates Millennium Scholars program—over 20 years, I think, we spent over $2 billion to support education for over 20,000 students of color.

Definitely in the last year, we redoubled that focus. We made an extra $100 million set of investments and commitments. For example, when we talk about math curriculum, can we target and frame the curricula in ways that are going to be more successful for students of color, that are more sensitive to the environments within which they’re having to learn—the classroom environments, the tools which they have, the examples that are used in schoolbooks? I recently sat through a very interesting set of demonstrations which showed very simple openings by teachers and others about how they treated and set expectations for students of color around those issues, that could vastly transform performance. So there are both soft interventions and hard interventions. And that is a very big focus for us.

More broadly, both in the United States and globally as part of our internal diversity, equity, and inclusion agenda, it’s something I’ve made a priority since becoming CEO. Internally, we’ve implemented an extensive examination of our own staffing and recruitments and other related issues. And externally, we’re really trying to redouble our efforts to build out and support partners in the communities where we work. So that means having more extensive building of institutional capacity by local partners in sub-Saharan Africa and South Asia, because those are the partners who are key to the long-term sustainability of any of our interventions. Your money can always buy short-term results, but for longer-term results we really need to have strong, local, indigenous partners. That’s a major focus for us going forward.

That’s a great question. Let me build on my previous answer about what we’re trying to do in terms of building local capacity. So the very first grant we made around COVID, which we made in January of last year, was to the Africa Centers for Disease Control and Prevention. That’s a new body. That body was only set up after the Ebola crisis by the African Union. It’s nascent; it has a strong leader who actually won our Goalkeepers Award last year. But it’s been building infrastructure and building credibility in the continent. And at that time, only two countries in Africa even had the capacity to test for COVID. Our resources were helping provide the Africa CDC with the resources to build and train, which they then did for dozens of countries in Africa.

Since then, the Africa CDC has worked with other initiatives like the Africa Medical Supplies Platform, which we’ve helped support to help bring in things like dexamethasone, which is the main therapeutic treatment that we know is successful against COVID. It’s working on some of the vaccine acquisition. The Africa CDC really has come through in this crisis, and it’s playing, in real time, a critical role. And we’ve been able to partner with them, provide critical bridge financing and technical support. Our hope is, when we talk again about the long term, the Africa CDC is now going to be an institution that can work across the continent to build much stronger platforms for pandemic preparedness and oversee a network of laboratories; that offers stronger, better surveillance across the continent; that can provide and link in technical expertise to each of the countries. And there are equivalents all over the world. Sub-Saharan Africa is the place where that’s been most lacking and most needed. And so it’s been great to see the Africa CDC step up at this moment, and we’ve been very proud to be able to support it.

Well, maybe two related things. One thing is when I do a call like this, I spend a lot of time talking about what we’re doing externally, and we’ve been doing a lot of great work that I’m very proud of, and I know Bill and Melinda are as well. But we, like everybody, have been operating under strain. This has been a very challenging moment. We’ve all been working from home. I have not had a full meeting with all of my staff in person since becoming CEO. And who knows when I’m going to be doing that. Everyone’s been struggling with child care duties, responsibilities, and worries about older relatives. I’ve just been really proud about how the foundation has managed to not only meet the challenge but rise beyond it.

In a note I wrote to the foundation employees on February 1st—so, earlier this month—I said that one of the things we’ve historically struggled a little to do is to be more than the sum of our parts. We have great teams, and we aim to work across our boundaries, but people tend to get very focused on their own work. Suddenly, it’s more challenging for the infectious disease people in tuberculosis and malaria to think about how they’re engaging with the Africa team or the India team, or how they’re working with our integrated health delivery. And COVID really has been a stimulus that pulled us together and showed how, as a foundation, we can draw on our technical expertise, our advocacy expertise, our financial and internal operational expertise—whether it’s around the vaccine struggle or whether it’s about the support to developing countries, or whether it’s about those big efforts in digital education I talked about. It’s just been really, really gratifying to see, not just within the foundation but the network of partners we’re able to bring across.

That’s something I really hope will outlast the pandemic. We’ve shown we can do it as an institution. We’ve shown it makes us much more impactful. We know that the challenges we face have not only not gone away, but unfortunately COVID has made everything we work on more difficult, and it has had an impact in the communities where we seek to help build a healthy and productive life, in the United States and around the world. And so that really is our agenda for 2021. And I’m hoping we can build on that conditional success of 2020.