Richard Klausner Spends to Save Lives

One of the shifts within the global-health program is a focus on being less reactive and more proactive. That is, actively seeking new ideas for grants rather than relying on the proposals that come in. Klausner aims to do this through working groups -- not a new idea at the foundation but one that he hopes to formalize as part of the grant-making process. Because of the enormous funding potential that the foundation represents, the Gates Foundation has the ability to convene top-notch leaders, innovators, and broad thinkers (read: nonexperts) around the world's most challenging health problems. The strategy gets results. One gathering that focused on malnutrition in the developing world led to the formation of the Global Alliance for Improved Nutrition, a partnership between the public and private sectors -- thanks to the Gates Foundation's $50 million commitment.

"We're convening terrific people and asking them to become think tanks for us, to try to get their heads around what it's going to take to make a tuberculosis vaccine, for example," Klausner says. "We're asking them about developing diagnostics that are appropriate for the developing world. We're reaching out to the community and saying, 'What do you think the big problems are?' "

Klausner holds the same seemingly contradictory attitude toward the pursuit of global-health solutions that he had toward curing cancer at his last job. He's both optimistic and realistic, impatient and patient. In that way, he fits right in at the Gateses' creation.

"I really like the paradox that this foundation represents of taking on overwhelming problems and not being overwhelmed," Klausner says. "Of being audacious and remaining humble about how hard this is."

He prods the staff not to lose sight of the big picture when focusing on a particular project. "You don't think big by asking, 'What do you want to do next?' or 'What's the next trial? The next intervention? The next drug?' " he says. "A lot of thinking big is about imagination. It's about imagining the system that you wish already existed. It's about asking, 'What if there were no restrictions? Where do we want to be 10 years from now?' "

What's Going to Make a Difference?
At a recent staff meeting, Klausner sits at the head of a long conference table. He's compact, with salt-and-pepper hair and mustache and an open-collar gray shirt. Although he just moved to Seattle a few weeks ago (he spent the summer working out of the foundation's East Coast office, in Washington, DC), he kids with the staff -- and they kid back -- as though he's been here since the beginning.

Today's topic is HIV/AIDS in India. Although the incidence rate is around 1%, India has the second-highest number of HIV/AIDS cases, because it has a population of more than 1 billion, second only to South Africa's. The foundation didn't wait for a grant proposal to attack the problem. Instead, Sharon Stash, a program officer in HIV/AIDS and tuberculosis, has spent months researching possible solutions. She recently returned from India, where she met with government officials, health agencies, NGOs, and various companies.

The HIV/AIDS situation is precarious, she tells the staff, because about one-tenth of the population, mainly men, migrate for months at a time to work in the country's centrally located industrial cities, where HIV/AIDS happens to be more prevalent. When they return home, many of the men, now infected, take the disease with them, facilitating the spread of HIV/AIDS into the areas of the country with the fewest infections.

The lively discussion that follows addresses a number of key questions: What's the most effective way to focus on the greatest number of migrational workers? What's working on a small scale that could be carried out on a larger scale? Who are the potential partners? And, of course, how much should be invested?

Klausner is keen for more evidence and ideas for the next round of discussions on the project: An investment of this magnitude demands it. "He challenges us to think about what it's going to take to make a difference in that disease or condition," says Dr. Helene Gayle, director of the foundation's HIV/AIDS and tuberculosis program.

The Gates Foundation's overarching strategy is not to come up with temporary solutions. The goal, says Klausner, is to have a lasting effect. Of course, in the face of so much human suffering, the immediate debate over treatment versus prevention isn't an easy one; it never has been. Imagine that it's 50 years ago, he says, and the foe is polio.

"You could invest in thousands and thousands of iron lungs, which in many ways would be the right thing to do as a doctor," he says. "You must react to individual suffering. But the reality is that the investment you would want to make in the 1950s would be to develop a vaccine. The iron lungs wouldn't be the answer."