Giving: A Conversation Between Clinton and Bill Gates

[START RECORDING]

BILL CLINTON: Just a few remarks. Last year, I believe it was, in commencement season he and I were speakers at the Harvard commencement. I spoke at Senior Day, which is a more informal thing, and he gave the formal commencement speech at his alma mater. It was one of the most astonishing statements of public commitment I have ever read, and it is probably on the internet somewhere and if you have not read it, you ought to do it. He basically said that he and his wife decided that all lives had equal value and no one behaved as if they do. And that he thought he should take his good fortune, not only his money, but what he had learned from life and spend the rest of his life trying to make his conviction a reality.

I have the great honor to work in many different ways with the Gates Foundation. It is not only the biggest foundation in America, it is almost certainly the best run and it is incredibly passionate and focused with all of its wide-ranging activities. I can’t tell you how much I respect him and Melinda and all the people with whom I have worked at the Gates Foundation.

He may have more money than you do, but if you had the commitment he did, and a million people did, we would change the world in ways that are immeasurable. So I would like to invite him out here and we will have a little talk. Bill Gates. [Laughter]

So how is your transition going?

BILL GATES: Well, it is fun to be able to focus full-time on the Foundation efforts. I am getting to learn new things. I spent all day Monday on malaria and I am thrilled that there are some breakthroughs, things that are starting to work. It is fun to get people who have been in the field, get scientists, get people who are a little cynical, get their point-of-view about how things have not worked in the past and figure out new paths forward. So it is a thrill. I decided to do it about three years ago and I can hardly believe the day actually came.

BILL CLINTON: One of the things that we were talking about backstage and, since we have some first timers here, I mentioned in the opening session that if you look at Africa, for example, typically Africa does not get in the general news unless something bad happens somewhere. People know about the continuing turmoil we had in Zimbabwe before the Power-Sharing Agreement was made. They know about Darfur.

But a lot of good things are happening. People know that there are problems with AIDS, TB and malaria, but a lot of progress has been made. And I would like for you to just give us a little rundown on what good things you think are happening and where and why; things you are involved in.

BILL GATES: Well, this is a great week to be taking stock of the progress that has been made because it is kind of this mid-point for the millennium development goals. That was a set of goals that were set in 2000 and there was a target for 2015. So we are kind of just past the halfway point and a lot of people are looking at that and saying okay, what are the success stories, what has gone well and what do we need to do more of.

And really, there is immensely good news here. Infant mortality continues to come down. A good statistic on that is in 1990 20 million children died; Died of things that they shouldn’t have. By the year 2005, that was down to 10 million. So in a 15-year period you had a factor two reduction even though there were more births taking place in the world.

Now a lot of that is vaccination. It is really a miracle thing. For example, measles was a huge part of that big death rate and it is a huge improvement because that is being used very broadly. So, for example, measles deaths in Africa have been cut by 80 percent. Just in the last five years there has been that progress. It is actually a case where Africa is ahead of Asia. Asia has got to do some work to catch up.

So as we look at these numbers, I think of it kind of like a report card. We can look at the malaria numbers; we can look at the infant mortality numbers. Overall in the world, we are doing quite well on those. Africa is the toughest place, but even there we see countries that are doing very well. And these numbers improve. Malaria is a great one because the bed net is an intervention that a lot of people are being asked to give money for and they can have a very clear means that if they donate for that bed net, it is being used—the adults, the kids are under that net. They are not being bitten and so malaria deaths are being cut dramatically. Zambia, which is one of the first to try and get broad coverage of this, just in the last few years has cut malaria deaths by over 40 percent. So we are going to scale-up those interventions and get more people involved, get more people giving. So, there is a lot of good news.

I think your point is a key one, which is that bad things kind of happen dramatically, all the sudden. The good thing is it is day by day improvement. And so stepping back and taking stock and saying “okay,” these vaccines are so great. What does it take to get more? What does it take to get 100-percent coverage? That is a very valuable thing to bring into the way we look at how we help the poorest.

BILL CLINTON: Malaria is a good example of the sort of thing that we just celebrated on the stage here. This is something that you can break down into discrete units so no matter how much or little money you have, you can give it to an NGO that will buy a high-quality bed net, put it up, do it in the right way. And so, if you had $5 a year to give, you could still make a big difference in a family’s life.

Now let’s talk about where we are with our shared passion on AIDS. The good news is that when we started a few years ago there were only 200,000 people in the non-rich countries getting medicine, two-thirds of them in Brazil where the government was doing it. And now there are 3 million and I am very grateful to the President and the Congress for the money they put into the Global Fund. Our Foundation, mostly because we got the price cut so much, has contracts that cover 69 countries. They buy medicine off our contracts and about half of the total increases come through these contracts because we have got the price down now to about $120 a person a year for adults and $60 for kids. And the global price has collapsed for generic medicines to within 20 to 25 percent of our price, which is good. I was trying to work myself out of a job. We all should be, by the way, because none of us are going to live forever. So it would be a good thing if we were not needed. We have to go.

But here is the problem I see. When you look at AIDS, and, to a lesser extent, some of these other serious diseases, the price of the medicine and the availability of the funds to buy them is no longer the primary barrier to dealing with the problem. It is, in my opinion—and I know you have spent a lot of money on this—it is the absence of functioning healthcare systems. I mean what you did in Botswana was truly stunning.

But we are now working in Ethiopia. We talk about this a little bit. Ethiopia only had 700 clinics when we started outside the urban areas in a country of about 80 million. They are trying to go to 3,500 clinics. Those things cost more money. Who should do what to build out the health systems in the world? And is there someway that people that are not as big as the Gates Foundation or do not have the access I have to big donors can make a contribution to that? What is your take on that?

BILL GATES: You are absolutely right that those clinics, sometimes called primary healthcare, are the key thing that you need to invest in. You need some drugs there, you need some training, not a full-blown doctor. And most of the difference in improving health conditions will take place if you have an appropriately functioning primary healthcare system.

What we need to do is make it so you can just go to the Internet, pick a country, pick a location and give modest amounts of money to say, get drugs stocked in one of those places or let them hire an additional person to come in and help out. So you can really associate yourself with a particular intervention. And no matter what scale you are working at, feel like you can track that what you are doing makes a very big difference.

The story with AIDS is there have been some setbacks in the last year. The treatment story is amazing and the Clinton Foundation not only has gotten the drug price down, they are also looking at what are the best practices in terms of how you train people, how you keep the costs of all the non-drug things very low so that we can continue this scale-up. The bad news is that we have not really lowered the rate of infection all that much. Over 2.5 million people a year are still acquiring the disease and there are some of the things where we were looking at microbosides or different vaccines, the scientific results have not panned out.

Now to me that means, all the more we need to invest and try different approaches. And there is one that I am hopeful for, which is, where you take a daily pill and that would hopefully reduce the chance of your getting the disease so dramatically that if that were used broadly, it would basically stop the epidemic. But we are at least five or six years away from having that, even if things go well. So we have got to keep investing in this treatment side, do it in a way that is not just about one disease. That is something that your Foundation and Paul Farmer, a lot of people have been very articulate that the vertical approach, although it was a good way to get started, it is a good way to look at the thing. As you get into the steady state, a lot of that delivery for tuberculosis, AIDS, vaccinations, the things that really have a huge impact, you need that well-operating year by year primary healthcare thing that is taking care of all the different diseases. And particularly pregnant mothers and young infants and making sure they get the kind of acute care that can make such a difference.

BILL CLINTON: I want to emphasize the point that Bill made that is most relevant to all the rest of you, as well as the people that will follow this over the Internet.

One of the most appealing of all the donor portals of the web is Kiva.org because you can get on there and you see people all over the world who need small amounts of microcredit. And so you do not have to set-up a big microcredit bank. Even if you can just afford $25 every three months, you can fund an entrepreneur and then when they pay the money back you keep it or turn around and give it away, give it to someone else. And it has been wildly popular. When I featured them in my book, within 48 hours after I was on television talking about them, all their businesses were funded. It is fascinating and they had to stop taking money until they went out and got some more targets.

But we do not have that so much in the health and education areas because no one has thought about how to deconstruct, if you will, what is in a clinic or what is in a school. This could also be very important in schools. All you hear is the numbers where there are 76 million or 100 million kids who do not go to school. The truth is that the number at risk is far higher than that because they go to school, but they have no access to trained teachers or learning materials or books or anything else.

The same principle could be done anywhere. So some enterprising person here in this audience or out there in cyberspace who is following this, that is an opportunity that ought to be seized.

There is a man that I invited here today because former President Bush and I made this announcement about the Gulf coast. I read about him in the August 11 edition of Forbes, and he sat up a website called Modest Needs. And he just basically catalogs people who are mostly lower-income working people that get caught in a flood or have the kid that has an accident but they are between jobs and they do not have health insurance and it is only for America. But basically the average grant is $500. If you did that in other countries for working people, you could do the same sort of thing.

The only point that I am making is that Mr. Gates’ former life as a techno wizard has great application here that we have not even begun to fully realize in the NGO field. So he has given me a good idea about this healthcare thing.

Let me ask you one other question. There is a lot of background murmuring here, even though all these folks are committed. We are sort of preaching to the saved about whether the turmoil in our financial markets and other economic challenges will necessarily lead to a reduction in the level of commitment, not just of money, but of time and skills and sometimes physical objects to the non-governmental work. What is your take on that? What would you say to somebody that says “look, you know I would like to keep doing this. But my stock is only worth 60-percent of what it was last week. I need to go back to work. I can’t think about this anymore.”

BILL GATES: Well, I think for companies, the great companies take a long-term view and they take a global view. And as they think about either having their products be relevant to people further down on the income rungs, or they think about hiring the brightest people and competing with other companies for that. This idea of taking some of their innovation power, whether it is what they do with cell phones if they are a cell phone company, or drug invention if they are a pharmaceutical company, or loans at small levels if they are a bank. That type of activity will give them an edge. And I can’t claim it will give them an edge in the short-term, but great business success is not based on just thinking about the short-term. It is based on hiring those great people and developing the reputation over a period of decades.

And I do think that there are a lot of rich people. The percentage that is being given to these great causes and inequity relative that wealth is very small. And so a fairly modest increase in the amount going can certainly offset the gyrations in terms of stock market valuation. We do have to get their attention. We have to show them that it is fun, that it has impact, that there are great success stories, even though it will be done at a distance.

As you said, the Internet is our friend in that and we have to be more creative about it. No matter what the scale of giving is, we can be more connected to the problems and to the positive impact that we are having.

So definitely, the reception I get on this creative capitalism is I talk with companies about: here is how you have employees in developing countries here. Here is how you could do medical trials or here is how you can take your scientists and think about these things. I think it is overwhelmingly positive.

There is so much innovation power and the corporate sector can do things that government can’t do and that NGOs can’t do. They really know they should. You have got to be reasonable. You can’t say to a drug company, take all of your work, take huge amounts of it and divert it to this. You can say hey, let’s get 4 or 5 percent of these programs aimed at these special needs. And if it is super expensive, maybe we can get things like the Orphan Drug Act or the U.S. government thing where you can get a fast track approval on another drug if you come out with a drug for a neglected disease. Or you can get donations to cover some part of what you have to do. Our relationship with GlaxoSmithKline where they are working on the malaria vaccine, they put their best scientists on to it, but a lot of the risk of the cost of these trials is born by our Foundation.

And I am sure it is similar, I mean you had a lot of experience talking to these pharm executives. How did you feel about the reception you got as you went through that process?

BILL CLINTON: Well, you know they were basically horrified in the beginning that I wanted to use these generic drugs. And I remember, I had one great conversation with a man who is no longer now running one of the big pharmaceutical companies, but he said “you know, this is terrible.” These things are not any good and they are only 60 percent as effective as our drugs. And I said, “first, I do not think that is factually verifiable. But secondly, if I were you, I would not make that argument because our prices are less than a tenth what yours are. So that means I’m still saving m ore lives than you are for the same amount of money even if I miss four out of ten times but we had come a long way.” A lot of these big companies were absolutely essential in what we did with the testing equipment and the processes and how we, because you can’t get this medicine out if you can’t test.

First you’ve got to know if you’re HIV positive. Then you’ve got to know if it’s working. Then you have to know when it’s time to change. There are no generic producers of any of that stuff. So we had to be in the mainstream economic business and we just worked it through. Now we’re doing more and more partnerships in cooperation with big pharma.

I think it’s just something you just have to decide what you’re going to do and then you just keep chipping away and most people do not want to fail and most people think they’re good people. Once you start with that, you just keep chipping away and try to work through it.

BILL GATES: In one aspect of our mutual work on AIDS is that with the price of these tests having come down so much and you were very critical on that. The idea is that you would get a high percentage of people to test their status and then if they test positive not only seek treatment, but also to change their behavior.

It has taken a while for that to get started but in the last few years in Africa where you have the high prevalence, there’s a number of countries including Botswana, Rwanda, a couple of others where the amount of testing has gone up very dramatically and so we’ll get to see over the next couple of years if that leads to the kind of behavior change that we’re hopeful for.

We’ve also seen that circumcision is a great intervention; that is that men who are circumcised are far less transmissive of the disease than men who are not. When I first heard that, I thought “well that’s fine. People willing to get circumcised in some cultures when they’re young but adults just aren’t willing,” but in fact at least the initial data suggests there is willingness.

So, if we can get providers out there who do it in a sterile way and make sure that’s not leading to infections or bad things, it looks like that intervention is one that, at least in some countries, can come along. And again we need to get the equipment and training but it can have a serious impact.

BILL CLINTON: To those of you who don’t know what the data is, basically the studies show that you reduce your likelihood of transmitting the virus by 60 percent through circumcision. That’s a huge number.

Now obviously in the beginning, it only helps men stay alive but it also will help women stay alive. I was afraid when this data came out, I saw everybody walking around on tippy toes and they thought, “well, the culture will resist it or whatever,” but it turns out people really prefer being alive if at all possible [laughter].

So, I mean I was surprised—weren’t you?—as to how much willingness there was. If you just lay the facts out to people and intelligence being equally distributed, this can happen as long as it’s done in a safe and sound way. I’ve been impressed.

Let me ask you another thing, because I know you have to go, but you have to make decisions running this vast foundation that others may have to make even more frequently because they don’t have as much, but you have to do it too. How do you decide what to do and how do you decide what not to do?

Are there people who have particular responsibility for that in your foundation across various lines? When Bill started, he basically was doing all this health care work in the beginning in Botswana. Then you did a lot in India and amazing education work in this country including promoting smaller high schools and he did a lot of work here in New York, which was very helpful.

Now he didn’t say, he was too modest, that the Gates Foundation funds the work that my foundation does to evaluate what the most cost-effective way to do all these health interventions are and whether it’s working or not. We discovered, we didn’t really want to do it but nobody was doing it, there was no ongoing research about how you told whether the money was going as far as possible and you were saving a maximum number of lives given the fixed investment.

So every day he’s got 100 people coming up to him or 1,000 saying, “this is like a slot machine that always pays off and they can be interested in one other good cause.” I think it’s worth saying because if you do something with real commitment, it’s not just the bad projects; you have to say no too, sometimes you have to say no to something good too, maybe more often something good and something not good, to pursue your mission.

So and I deal with it too. Anything that saves so many lives, all I can do to say “how are we going to say no?” That’s one reason we’re always over budget every year in the AIDS program because once you open one of these clinics, who the heck are you supposed to turn away, right? It’s almost impossible to budget for. So how do you say no and how do you decide what to say yes to? What system do you have?

BILL GATES: Well I think every foundation would probably be better off if they took on a narrower set of things and they took them on in a deeper way in a longer term way because [applause] what you’re providing is not just money. You’re providing a voice. You’re providing expertise. You’re creating jobs and when you first get into an area, you’re kind of naïve. You make mistakes and so, in the case of our foundation, we picked the Global Health as the big thing and just infectious diseases.

So people come to us and say what about cancer, heart disease, those things. Well we’ve decided to be experts on the infectious diseases and to go deep on those. I hope that the rich world market is funding the kind of research and invention and if it ever gets to the point where we make progress on the infectious things then maybe delivering some of those interventions to poor countries, we might have the ability to do that—but that’s more than a decade away.

We need to stay focused on the infectious diseases. That was an easy choice because the impact per dollar was very high. The degree to which it wasn’t being done was very high. We did our first $50 million grant for malaria; we became the biggest private funder on malaria. I thought, “well that’s insane,” but it was the case. It was just not visible because the disease had been so long since it had been experienced in the rich world that it hadn’t been thought about and there had been a lot of failures.

So we’ve kind of picked, right or wrong, we’ve picked the broad areas. Now when it comes to the actual tactics of who’s vaccine approach do you fund, that’s where we’re lucky that we’ve been able to attract very smart people and we can have boards of experts get together and help us do reviews.

One of the most fun things we did recently is what we call The Grand Challenge Explorations, which is where people send in to our foundation, at most, a two-page application for —it’s just $100,000—for an idea that you want to get funded. What we did is we picked about 80 people to review these things and all it took was one person to say this is a good one and it was funded.

There were no interviews, nothing they had to fill out. Just send your two-page things in and if one of the 80 reviewers picked it as their favorite then immediately that was funded. That was to get this early stage kind of start-up part of the science going better because that’s a very tough thing and it was amazing. A lot of these were people earlier in their career. About a third of it was from very poor countries where there’s a lot of good science being done and they don’t have an NIH to fund it.

So coming up with new mechanisms like that to unleash the creativity, we rely on the staff very much to do those things but we have basically picked, at this point. And I do think for any of you, it can be daunting to say, “Do I pick this or I pick that or I pick the other thing?” At some point you really do just have to pick and get into it and get down that learning curve and get the people who are deeply dedicated to that thing, and start to partner with anybody who’s in a connected area.

I’m amazed at how fun the foundation work is. I mean I’d say of anything, I enjoy the foundation work even more than I enjoyed my Microsoft work. That’s saying a lot. I had immense fun being part of the Microsoft stuff and now this has the same level of complexity but there’s actually a lot of low-hanging fruit, things that aren’t being done.

So you can feel good about the impact, and the people are so smart and they’re so interesting. I mean just come into a group like this and there’s so many people here doing fantastic work.

BILL CLINTON: Nine years ago, Hillary and I had an event at the White House that you attended, on philanthropy, and what the role of government would be in solving social problems, what the role of foundations would be. You made a remarkable talk there in which you said, among other things, I remember as if it were yesterday, “It may be harder to give this money away than it was to make it.”

Given how much you had made, no one in the audience believed you. I would like to ask you in a serious way, do you still feel that way? If so, why? If not, why?

BILL GATES: Well, we’ll make a lot of mistakes giving this money away and the nice thing is it’s kind of like venture capital where over half that money is completely wasted. The reason it makes so much sense is that some of the things they fund do so extremely well. The impact is unbelievable. In fact, we could almost guarantee a lot is wasted because we’re backing many approaches. Take the malaria vaccine. We’re backing six different approaches. Well the world doesn’t need six malaria vaccines. It needs one but to have the probability that we’re going to get one requires knowing that five out of six are going to be a dead end. That’s probably why governments haven’t been that effective at funding drug discovery—because you’ve got to stick with it. You have more failures than you have successes. It just hasn’t been the kind of thing they’ve gone after.

We did have ea challenge and a fun challenge that when Warren made his gift, we went through a three-year period where we had to double the amount of giving that we’re doing and we’re basically through that now. We’ve grown the organization and now the big scramble is okay, which good idea do we fund? We’re not short of things where there’s the capacity and the belief that those things are out there but I certainly find things where we’ve maybe made a mistake or backed the wrong thing.

My reaction is a lot like it was at Microsoft, “hey did we learn from it?” Are we being smart about this and every day has some good news and bad news. So it’s no different than the business world. You’re going to make mistakes. The one thing that’s probably the most frustrating to me is if you give in a country and then the governance in that country goes backwards, there’re very few things that can continue to be effective. Vaccinations may be one of the few, you can still do high vaccination rates in Zimbabwe or Ethiopia but many of the other interventions we do, for example better seeds, well these better seeds require that you be able to sell your output. They require that you be able to get the seeds. They require that you, in many cases, use a little bit of fertilizer, which is an investment in advance.

So that’s one that I’m thinking a lot about is how do we—and this is one I’m sure you and I will work together on —how do you help governments in these countries perform more effectively? How do you make sure that misgovernance doesn’t hold these things back?

BILL CLINTON: Well I think, I’ll answer that and then I’m going to comment about that. I think there are two things. First, you have to have a strict no corruption policy. We can all screw up but [applause] if I give you my money, I’m trying to save your peoples’ lives so what you do in the rest of your business is not my business and this business, it’s got to be straight.

Then I think beyond that, everything to the maximum extent possible, we should be trying to build government capacity while we do whatever good it’s doing. I’ll give you an example. When we went into Haiti I was only too happy to do anything with Paul Farmer because I knew what Partners in Health had done in Haiti and in other countries; but I told him—and we talked—we said, ”normally we, first we won’t go into a country unless we’re asked by the government and normally we like to work with the government.”

And he said “look, I and another man, independent of me, we have great hospitals and networks. You should work with us but you should also do these two big government hospitals because if you do it even if they’re not, in the beginning they’re not quite as effective as we are, you will be building the capacity. You have to build the capacity and you have to endure the frustrations and you have to take the failures because,” he says, “what happens if my foundation is not here ten years or 20 years or 30 years from now?”

They will be and our obligation, he looked at me and he said, “your obligation and mine is to build their capacity to serve the public on a permanent basis irrespective of the personalities.” I think we have to see ourselves, at least those of us who have any reach at all, as part of our responsibility is to increase capacity. As long as they’ll do whatever we’re doing without corruption then we should focus on capacity.

The other thing I would say is because all these biochemical issues really are endlessly fascinating, and I think the fact that you knew that you had enough funds in this foundation to fund repeated failures in the biochemical area, in the recent medical research area, is in the end, maybe one of your most lasting legacies because you don’t tolerate failure in the projects you do. Like if the stuff we do together, your people review it and if I screw it up, you don’t keep funding it; but if when you’re trying to push back the frontiers of science and particularly with the HIV virus, it’s genetically, it’s one of the most maddening things I have ever even tried to get my mind around. You have to be willing to fund failure. That’s what medical science is all about. That’s what every, pushing back all frontiers.

When it’s all said and done, you may look back on that and say you know, I never got the AIDS vaccine or I never got a microbial gel that really worked. I never got this and then two years later somebody else will get it and it never would have happened but for all the accumulated scientific findings of all the failures you piled one on top of another until finally one day people could live who would have certainly died. I think that the rest of us who will never be able to do that are profoundly in your debt for that. I think it’s an amazing, amazing gift [applause].

BILL GATES: Well thank you.

BILL CLINTON: So I know you got to go, I’ll give you a chance to make a closing remark but you said three times and I want you to say whatever you want in closing but the thing that I noticed about Bill is that he‘s like me. I’m having as much fun as I ever had in my life doing this work. This is really fun. I think if you’ve been given a good life, being able to give something back is a lot more fun than just sort of pursuing some essentially irrelevant obsession when you realize how fleeting life is. So what else do you want to tell them before you leave [laughter]?

BILL GATES: Well I’m very pleased that, over the last five years, the visibility of these global health and issues of the poorest have really gone up dramatically. I think Jeffrey Sach’s work on the Millennium Development Goals that we helped support, that’s been great. I think CGI brings together a community and people renew their energy. New people are drawn in.

I think the telling of the success stories, getting the word out about the malaria, we’ve got people like Peter Churnin and Ray Chambers, who have been drawn into this thing because they see the opportunity and they’re doing great work. Other people see that.

So telling a balanced story, sharing the successes and yet also talking about the failures, it’s always been tough for this field. There’s a tendency to be on the two extremes of sort of overtelling what’s worked or just looking at what didn’t happen. When it came to PEPFAR, which is the government funding for AIDS, I just crossed my fingers that the first story wouldn’t be about one percent of the money that hadn’t been spent so well that that would hurt the whole program, but instead, the story would be about how quickly they got out there and the treatment got scaled up, which really did happen.

That execution on that was fantastic. The Congress just a few months ago, made a commitment to keep increasing those funds. Now whether that happens with the budget crunch that is coming here will be hard to say, but I hope so. I think so. So as a field, getting more visibility, letting people get involved at all levels, having the success stories come through, not letting the cynics own the day, while admitting that the things that were not doing very well, it’s very tricky but I think the trajectory is good. Certainly I think you’re having lent your voice to these issues makes a huge difference and I look forward to doing more together [applause].

BILL CLINTON: Give him a hand, Bill Gates. Thank you [applause].

MALE SPEAKER: Ladies and gentlemen, the plenary session is now concluded. Doors will open for this evening’s reception at the Museum of Modern art promptly at 8 P.M. tonight. Thank you.

[END RECORDING]

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