Novo Nordisk Global Science Summit

Bill Gates
May 6, 2024
Helsingør, Denmark
AS DELIVERED

Well good afternoon and I want to thank everybody at Novo Nordisk for putting this event together for the strong partnership we're building together. It's pretty amazing that Novo's been helping patients for over a hundred years.

It's helped millions and millions and I think we can work together and raise our sights to do even more including our tripartite partnership that includes the Wellcome Trust.

Building on your legacy of impact not only here in Denmark but all over the world will allow us to achieve more. I am confident we can make a big difference.

The needs right now do feel really great but I am optimistic that we can meet these challenges.

We've shown that human ingenuity really makes a big difference. The chart I'm bringing up now is my favorite example.

I would say that if humanity has a report card this would be at the top of the list of incredible achievements.

What it shows is that since the turn of the century we have cut in half the number of children who die before their fifth birthday. It was over 10 million and now it's under 5 million. That's a generation of lives saved and that was done with new diagnostics, drugs, and vaccines. It was a triumph of science and a triumph of delivery through new partnerships.

I'm optimistic that building on success we can do it again. We can cut this number in half again. That's a goal that the United Nations stated in their so-called Sustainable Development Goals and it's worthy of getting the great science and the funding to make it happen.

This is at the center of the purpose of the Gates Foundation. In the late 1990s, when I was thinking about how the wealth I was lucky enough to have from the success of Microsoft would go back to society, I was looking into what goes on, what things did the market not address?

What I saw was that things like diarrhea, pneumonia, malaria, that each were killing over a million children were getting almost no attention because the poorest in the world who were suffering from these things didn't have a voice in the marketplace. It seemed like these poverty-related diseases deserved philanthropic attention.

We've seen an increase in the funding for things like malaria, TB, and other diseases of poverty, but we still need to see more. Those diseases still kill millions of people, and yet the R&D going against those has actually been going down somewhat. In 2022, it was down 20% from four years earlier.

That's why it's so important that we build these partnerships like the one being announced today. To get the very best scientists working on these problems.

Partly because of the tools that are driven by for-profit work, we can make more progress than ever before. We'll have to take risks as we do this R&D. Some things will bear fruit and some will not, but that's the nature of R&D. And there are so many great opportunities, many of which will have incredible impact.

So many areas that we could focus on, but let me give some of my favorite examples.

Last year, we partnered with Novo Nordisk Foundation to develop new ways to convert carbon dioxide, pull it out of the atmosphere, and use it to make acetate. And have that as a replacement for sugar as a key ingredient for fermentation. This could have profound effects on the economics of the products made that way, as well as giving us a way of using CO2, and therefore reducing climate change. These acetate-based approaches can drive the food system into a much better regime.

Another area of R&D is pandemic preparedness. The Danish government has been a leading supporter of wastewater surveillance, and that can help us see outbreaks far earlier, which is what we need in order to stop them from going global and turning once again into what we saw with the COVID pandemic.

We should look not only in urban sewage, but look at the wastewater coming from major travel hubs, and that will give us a real-time map of how pathogens are moving around the world and how we can intervene. So we'll see the threats, and we'll be able to target our responses.

A final area to mention is artificial intelligence using machine learning. The promise here is to accelerate progress in every area of science, and no area more than in biology.

Biology is very complex, and yet we have gathered lots and lots of data about genetics, patient outcomes, protein shapes, and these models allow us to have very deep insights into drug design, into organ pathologies. It's amazing that these tools are now being deployed. In some cases, we've seen preclinical development cut the time involved, cut by a third, because of this target selection. And early on, we can see things like drug side effects and understand the best formulation.

Also, AI will help us in the delivery. We can give people essentially a medical advisor on their cell phone that will help them seek the treatment they need and understand what's going on in their health.

In Africa, we say there's 4 million missing health workers. Part of the way to remedy that is to supplement them by taking AI and not just using it in the rich world, but as fast as we can, reducing inequity by getting it into the developing countries. From climate to pandemics to AI, there are many innovations that should get us excited about what science can bring.

I want to focus on one particular R&D priority that alone would cause a massive revolution in health. And that's a deep understanding of nutrition and the microbiome.

Every once in a while, I've been asked if I had one wish, if I could get rid of one disease or one condition, what would it be? And of course, there are many worthy candidates, getting rid of HIV, getting rid of TB. So many millions of lives would be saved by either of those things. But those aren't at the top of the list. For me, the thing at the very top is the need to solve undernutrition.

Undernutrition is very much at the root of everything the Gates Foundation is trying to do. We want people not only to survive, but also to thrive, to have their physical and mental potential fully achieved. The key thing that stands in the way of that is malnutrition.

Even if we take the more narrow view and just focus on childhood deaths, if every child was properly nourished, that alone would cut the deaths in half. In other words, a child that's on their growth path has a certain resilience.

Not only are they going to go on if they survive to live a very productive life, but they can survive the various challenges they face - bouts of diarrhea, bouts of pneumonia, bouts of malaria, and go on to thrive. So just this one thing alone, if we achieved 100% effect, would be at the center of this ambitious goal to cut deaths in half again.

Kids who are malnourished have very weak immune systems. So the infections thrive, they’re longer lasting, and they're more severe. But if you have the right nutrients, the human immune system is an incredible miracle, and you can fight off these episodes.

But also with malnourishment, we see incredible effects on cognition. Kids that are well nourished have the opportunity to learn and to give back and create amazing productivity.

The biggest asset in most countries, but particularly for Africa, is their young, and the great potential if the health of that generation is far better than it has been in the past.

Now, when we used to think about undernutrition, we'd think about famine. There are cases where just the amount of food is not enough, and so it's just getting those calories in there and it's all about quantity, not about a deep understanding.

But more and more, we understand that is not at the heart of this problem. In fact, in Africa, you can look at twins, and often one of them will be on their growth path, and the other one will have growth faltering. So there's clearly something that goes on that's not simply the diet that you're eating.

Over years, we have understood there are key vitamins. There are micronutrients, and we've come up with ways to do supplementation and diet recommendations that help. For example, we put iodine into salt, and that has had an incredible effect on getting rid of the awful effects of iodine shortage.

But the great thing that we needed to learn about to figure out what's going on is to understand the microbiome - to understand the bacteria that live in the gut. It's a very complex system, but only by understanding that will we really be able to solve the question of what are the low-cost nutritional interventions that can get rid of malnutrition.

We see in the guts of these children in poor countries that the various insults lead to inflammation. Their intestinal villi become blunted, and they can't absorb even the nutrients they're able to eat. There it's clearly not about food availability. That syndrome is called EED, environmental enteric dysfunction.

Another way that we see this is that when we look at our oral vaccines, for example, the vaccine for polio or the vaccine for rotavirus, we can see that in places where kids are well nourished, over 90% of kids develop protective response when they're given that vaccine.

But in the poor countries, which is exactly where we need the effectiveness, because rotavirus is still killing hundreds of thousands of children, only 60% of the kids develop that full protection. That's because when they take that vaccine, if their gut is inflamed, it doesn't get the right exposure to the immune system. And so, that alone says that we've really got to get to the bottom of what's going on and get rid of those inflammatory episodes.

The work, of course, will include working on the food systems and the crops that are grown and making sure those crops are very nutritious. But that's not the end point. We will have some level of supplementation so that the immune system comes out of a healthy gut as they're protecting all of these children.

Now, it's interesting that if you had to say, you know, what's the biggest problem in poor countries, it's undernutrition. If you had to say what's the biggest problem in rich countries, I would probably say that it's overnutrition. And these two things have very common biology.

Understanding the microbiome and how you intervene is very important to solve all the different metabolic conditions that are driven by food consumption. So the fact that the microbiome plays that key role gives incredible opportunity to take the deep insights that the people who work in both fields can absolutely bring together.

As you can see in this chart, no matter what level of income you're at, you have both problems. In fact, you can see here what's called lower middle income, which would be countries like India. Sadly, they still have huge challenges with undernutrition, even as they're developing significant challenges with overnutrition. Both of these are huge imperatives.

Around the world, one in four children are chronically undernourished, and two in five people are overweight. As we see this explosion of cases, it's an imperative to act on this, making research into nutrition and the microbiome a very, very clear shared global priority.

With more collaborations and commitment from institutions around the world, I believe in the next decade we will start a golden age of nutrition. After all, we have such amazing tools to understand the complex interplay between nutrition, the gut microbiome, metabolites, the immune system, and the other systems in our body, including connecting up to what's going on in the brain.

When this term microbiome came around just less than 25 years ago, our understanding was very, very weak. We could see some of the populations, and so we looked at correlations of various signatures there, but we didn't know enough to understand, okay, what is the causation? Are there interventions into the microbiome that can improve these health conditions? Now, though, we have far, far better tools.

We can do mass sequencing, we can look at the RNA, the metabolites, and figure out the entire system, exactly what's going on. It opens the door to new interventions to address these problems. With GLP-1, a miracle that Novo Nordisk helped drive, the world is getting a glimpse of what even one tool can do to help with overnutrition and how over time that will be complemented with many more tools.

Let me give some examples of not quite the equivalent, but some promising directions over on the undernutrition side.

The first is that we have therapeutic foods that are not only nutritious in the sense of the food getting directly to the human, but also be nutritious to the microbes in the gut that are the beneficial ones.

We're not just targeting the protein needs of the individual, we're also targeting the beneficial bacteria in the gut. Green bananas given to children in Bangladesh was something that we tried on this and we saw very significant positive results.

The second intervention is the idea of a probiotic that is seeding bacteria into the gut microbiome that restores a key species. And the first intervention of this type is called B. infantis.

That's a type of bacteria that's associated with a healthy microbiome. We now understand how the infant microbiome develops, and it starts in your very early time period during these first six months, going from being very simple to very complex. We realized that if we get B. infantis in, in significant numbers early on, the eventual state of that microbiome is far, far healthier than if we don't do that.

Now, this is a very complex system. For an adult, you've got over 100 trillion cells, more cells in your gut than in your body itself. So understanding how we drive this sequence is something we already have some insights, but we need to study even more.

The reason B. infantis looks so beneficial is that it's very good at digesting the complex sugars that you get from breast milk. We've done a lot of work to understand the components of breast milk, and understand this interaction.

B. infantis plays a role in the sequencing of other microbes coming in and getting developed. Just recently, the WHO recommended probiotics for premature babies. Now we're studying if we shouldn't use it even more broadly. We feel that if we can get the the cost down, get broad acceptance of this, that it'll actually be used for millions and millions of children.

We even see in the rich world that decades of unhealthy diets have led to B. infantis dropping in infant guts. There may be an intervention there because that is closely related to this increase in metabolic disease.

Understanding the science, understanding how we can actually manufacture these things, they're both huge opportunities. One of our partners in this, helping with that manufacturing, is a group inside Novo Nordisk called Novonesis. And it looks like we can get the cost down and make it affordable for all these children.

The last area I want to talk about is a different microbiome. Usually when we say microbiome, we mean the gut. But, of course, you've got bacteria on your skin. And women have a vaginal microbiome which is very different. It's much simpler. But again, here, the wrong microbiome can lead to inflammation.

There's the equivalent to B. infantis in this case it is called L. crispatus. And those women who have that are at far lower risk of many things, including getting infected with HIV and giving birth preterm. So it looks like we may be able to apply that, make that inexpensive, easy to do, and also improve that microbiome.

Let's go back to my favorite chart of all time and think about this goal of cutting that number in half again.

Nutrition can play a huge role in that.

We also will need new vaccines. We don't have a good vaccine for TB. We have one that's under trial. We don't have one for HIV. The ones we have for malaria don't have the duration of impact that we'd like to see.

So there are many other new tools that we need to build to drive this overall health. If we have good nutrition and additional tools, it's kind of the one-two punch against infectious disease.

There's a lot of work to do at the science level. There's a lot of work to do at making these interventions low cost and figuring out how to use the primary healthcare system to get them out to all the world's children.

But I firmly believe that despite all that complexity, if we devote ourselves to this cause, we can develop the highest impact interventions ever in the history of healthcare and provide justice in health.

Thank you.