Grand Challenges Annual Meeting 2023

Bill Gates
October 9, 2023
Dakar, Senegal
AS PREPARED

Thank you, Oumar. And thank you President Sall, not just for welcoming us to your country, but also for your leadership in global health.

Finally, thank you to the Grand Challenges community. It has been a pleasure working with you and learning from you for the past 20 years. 

When I look back over the history of Grand Challenges, I see a lot to celebrate.

The state of global health in 2003 was, frankly, awful. Two million people died of AIDS that year. Two and a half million more died of malaria and TB. Even so, the R&D pipelines for most infectious diseases were nearly empty.

Huge numbers of deaths—but tiny amounts of money spent on science to save lives. That lopsided equation is what inspired the partners who created Grand Challenges. It was shocking and unjust, and we believed we could do something about it.

We started Grand Challenges with two goals.

In a narrow sense, we wanted to spur specific advances we thought could lead to breakthroughs. In 2003, we listed 14 Grand Challenges—priorities like creating therapies that could cure latent TB infection—and supported researchers who had exciting ideas in those areas.

In a broader sense, we hoped to inspire more brilliant scientists to share big ideas about transforming health in low-income countries. We hoped to create a scientific community that was supported to sustain R&D for the benefit of billions of people who had been neglected.

Grand Challenges started as a single program funded by our foundation and a few other partners in wealthy nations.

There are now about a dozen Grand Challenges initiatives on four continents.

Together, the partners have supported approximately 4,000 projects in almost 120 countries.

We always expected that most Grand Challenges projects would fail. If they all succeeded, we’d know we weren’t taking enough risks.

But we also believed that if we did take risks, some projects would lead to real breakthroughs.

And they did. Consider the Grand Challenges grant that went to an international team, led by Douglas Young of Imperial College London, to develop drugs for latent TB.

The consortium that Young’s team organized laid the groundwork for the TB Drug Accelerator, a public-private partnership with 25 members that’s largely responsible for the amazingly robust TB drug pipeline we have today.

I am optimistic the world will soon have the new TB drugs it desperately needs.

Today, treatment consists of a six-month course of four antibiotics with significant side effects. It’s hard for patients to keep up with, and drug resistance is getting worse.

But with next-generation drugs, treatment can be shorter, safer, and more effective.

Another early Grand Challenge grant supported work to reduce the mosquito population and stop disease transmission.

The original idea of the project, now called Target Malaria, was to use homing endonuclease genes to drive a bias for male offspring so that it was inherited preferentially from generation to generation, gradually preventing mosquitoes from reproducing themselves.

This is as relevant today as it was then.

Even though malaria deaths are down by almost 40 percent since 2000, the disease has still killed more than 15 million people since then.

The gene drive work went slowly—until CRISPR Cas-9 gene-editing technology became available about 10 years ago. Since then, researchers have successfully tested gene drives on caged mosquito populations in the UK and Italy.

Now the work is shifting to several malaria-endemic countries where gene drives would actually be tested if and when they receive regulatory approvals and local support.

People have concerns about gene drives, which is not surprising. It’s never been tried in the field.

A few months ago, I spoke with Abdoulaye Diabaté, who leads Target Malaria in Burkina Faso, about the careful work his team is doing to prove that genetically modified mosquitoes and gene drives are safe.

They are giving people the time and information they need to answer their questions. In the meantime, they’re convening regulators across Africa. Because mosquitoes move, a gene drive in one country will affect mosquitoes in others, and it’s critical to foster a regional dialogue.

Our foundation is committed to supporting this process so that leaders of malaria-endemic countries can make evidence-based decisions.

The nutrition-related Grand Challenge we issued in 2003 was focused on biofortified crops—and grantees developed a Vitamin A-enriched “golden rice.”

But if we were issuing the Grand Challenges today, we would probably focus on the gut microbiome: the millions of microorganisms that live in our intestines.

We know now that a healthy microbiome is one of the keys to addressing chronic malnutrition, which affects about one in four children in the world.

One of the great aspects of Grand Challenges is that we can issue new requests for proposals based on new insights, and we’ve launched several Grand Challenges about gut health in recent years.

Around the world, there are 150 million young children whose growth is stunted.

What we’ve learned from these projects and other research we’ve funded could result in innovations that greatly cut that number and help children start life on the right track.

We know, for example, that a bacterium called B. infantis is the first building block of a healthy microbiome in babies, because it helps them digest complex sugars in breastmilk.

But many babies, especially those born pre-term or underweight, lack B infantis.

This year, the WHO recommended the use of probiotics to restore B. infantis for vulnerable babies and jumpstart their development. 

We have also learned about interventions during pregnancy that improve mothers’ nutrition.

MMS, multiple micronutrient supplements containing 15 essential vitamins and minerals, are now displacing the iron-folic acid tablets mothers have been taking for years.

But we’re also working with partners on what we call MMS Plus.

It’s Plus because it includes a number of bioactive ingredients to reduce inflammation and improve nutrient absorption.

I am hopeful that this work will unlock dramatic progress in nutrition.

As important as it is to celebrate the past, it’s even more important to plan for the future, and there is still urgent work to be done.

AIDS, TB, and malaria still kill about two and a half million people a year. Five million children still die before their fifth birthday, and most of those deaths are preventable. To save more lives, we need to keep challenging ourselves to innovate.

I talk every year at this conference about the miracle of vaccines. I may be the world’s number one fan of vaccines. But there are still big mysteries to solve if we’re going to make them even better.

For example, some vaccines, like the one for HPV, protect against disease for 10 years or more. Others, like the COVID vaccine, start to lose effectiveness after just a few months.

How can we make vaccines that protect for a lifetime?

With the microbiome, each new answer we get leads to more questions. What is the precise order in which a healthy microbiome develops in infants? By what mechanism does an unhealthy microbiome affect infection, immune function, and brain development?

How does a mother’s gut health impact an infant's microbiome?

We’ll have to solve these big mysteries if we are to fully realize the potential of the microbiome and optimize the development of every child.

I mentioned the impact of the microbiome on brain development—that’s another area ripe for breakthroughs. Our knowledge of what hurts brain development, what helps it, and when or how to intervene, is extremely limited.

For years, we used stunted growth as a proxy for cognitive underdevelopment. Now, we are moving to neuroimaging, so at least we are actually looking at the brain, but we have a long way to go to connect brain structures to brain functions.

Solving the mysteries of cognitive development would open up whole new pathways to health and well-being for hundreds of millions of children.

In short, there are plenty of big scientific challenges to solve. I’d like to conclude by talking not about what needs to happen but about how it will happen.

It is true that we’ve made a lot of progress in global health R&D in the past 20 years. It is also true that we need much bigger improvements in the next 20 years to approach health equity.

What needs to change?

I hope you will carry on this discussion over the next several days, but I will share a few ideas to get us started.

First, artificial intelligence.

AI has the potential to revolutionize R&D by linking data and people in new ways.

We need to make sure—right now, while the technology is still in its formative stages—that all countries get to participate and all countries benefit, not just wealthy ones.

We recently gave Grand Challenges grants to 50 innovators in low- and middle-income countries to pilot different AI approaches. Many of you are here today.

I am optimistic that you will generate knowledge and develop technologies that help fulfill the potential of AI in global health. We’ll talk more about this in a session tomorrow.

A second way to accelerate impact is to rethink how to use regulatory processes.

During COVID-19, the U.S. Food and Drug Administration issued Emergency Use Authorizations and the WHO issued Emergency Use Listings, so drugs and vaccines could be used before going through the usual, complete development process.

And in their first year, COVID vaccines saved 20 million lives.

But what about epidemics that aren’t big threats in wealthy countries—like AIDS, TB, and malaria? People are waiting for years for development and approval processes to unfold, even when we already have certain data about safety and efficacy.

Consider malaria. We have next-generation drug candidates in late-stage development, and time is of the essence because drug resistance is spreading rapidly.

But since 250 million cases of malaria have not been declared a public health emergency of international concern, children will wait longer and keep dying.

We need strong regulatory systems that rigorously protect people’s health. Regulators cannot cut corners.

However, as they have done with COVID, polio, and—early on—HIV, regulators can use their emergency authority to consider the full context when they make decisions.

And part of that context should be that saving lives in poor countries is just as urgent as saving lives in rich ones.

So I call upon the WHO and other public health officials to make the emergency declarations needed to unlock additional regulatory pathways for the some of the deadliest infectious diseases.

And I call upon regulatory authorities to use them.

A third way to accelerate our work is to invest in the right infrastructure in the right places. Not every institution needs every capability, but where we see gaps that slow or stop progress, we need to fill them.

To that end, today our foundation is announcing $40 million to scale up local mRNA vaccine manufacturing.

We are supporting the company Quantoom, to help it finish developing its breakthrough, low-cost mRNA platform. And we are supporting Biovac in South Africa and IPD here in Senegal to acquire the technology and start making mRNA vaccines.

The idea behind Quantoom and its parent company, Univercells, is to supplement expensive, centralized vaccine manufacturing infrastructure with small-footprint facilities spread around the world.

This is especially important for local diseases—like Lassa fever here in West Africa—that will always be overlooked by big companies.

Having the ability to manufacture vaccines should incentivize scientists to discover and develop vaccines for locally relevant diseases.

There is one final priority that is more important than all the rest combined if our goal is to accelerate progress. Here, I am speaking not to the scientists in the room, but to philanthropists, policymakers, and politicians.

We need more funding for global health R&D. Period.

In 2021, only $4 billion was spent on diseases that mostly affect the poor—like malaria and TB. That’s a tiny fraction of health R&D spending on diseases that kill millions, and it brings me back to what I said at the beginning:

Huge numbers of deaths—but a relatively tiny amount of the spending.

Our foundation’s partner Policy Cures Research has been tracking global health R&D funding since 2007. It’s incredibly frustrating to see how little it’s increased over those 15 years. The amount of money available is so much less than the amount of money we need.

The R&D portfolios in many disease areas are robust, but most candidates are in the early stages of development. The later stages are much more expensive.

The world should be spending at least $3 billion more every year on diseases that primarily affect low-income countries—so that when we generate promising candidates, we don’t then waste all that potential because we don’t have the funding to follow through.

In addition, there are some areas of research we just haven’t pursued because we don’t have the resources. For example, we know that the antibiotic azithromycin reduces child mortality, which is great news.

Unfortunately, we really don’t understand why, which means we can’t build on this finding to develop new lifesaving interventions.

Our foundation has funded some research on this. There needs to be more.

You deserve more support for your fascinating, important work.

Even more important, billions of people deserve more investment in their health and their lives. So, I will never stop calling on governments, philanthropists, and private industry to do more.    

I think the best way to celebrate the 20^th anniversary of Grand Challenges is to embrace the spirit of its founding and keep on focusing on the hardest problems and the most innovative solutions.

Our goal is a world in which all people lead healthy lives. That is the biggest Grand Challenge of all, and I am honored to back you as you work to meet it.