The Moment of Lift

by Melinda Gates

  Obviously, though, I understood the value of contraceptives for my own family. It’s no accident that I didn’t get pregnant until I had worked nearly a decade at Microsoft and Bill and I were ready to have children. It’s no accident that Rory was born three years after Jenn, and our daughter Phoebe was born three years after Rory. It was my decision and Bill’s to do it this way. Of course, there was luck involved, too. I was fortunate to be able to get pregnant when I wanted to. But I also had the ability to not get pregnant when I didn’t want to. And that allowed us to have the life and family we wanted.

  Searching for a Huge Missed Idea

  Bill and I formally set up the Bill & Melinda Gates Foundation in 2000. It was a merger of the Gates Learning Foundation and the William H. Gates Foundation. We named the foundation for both of us because I was going to have a big role in running it—more than Bill at the time, because he was still fully engaged at Microsoft and would be for the next eight years. At that point, we had two kids—Jenn was 4 and had started nursery school, and Rory was just 1—but I was excited to take on more work. I made it clear, however, that I wanted to work behind the scenes. I wanted to study the issues, take learning trips, and talk strategy—but for a long time I chose not to take a public role at the foundation. I saw what it was like for Bill to be out in the world and be well known, and that wasn’t appealing to me. More important, though, I didn’t want to spend more time away from the kids; I wanted to give them as normal an upbringing as possible. That was hugely important to me, and I knew that if I gave up my own privacy, it would be harder to protect the children’s privacy. (When the kids started in school, we enrolled them with my family name, French, so they would have some anonymity.) Finally, I wanted to stay out of the public work because I’m a perfectionist. I’ve always felt I need to have an answer for every question, and I didn’t feel I knew enough at that point to be a public voice for the foundation. So I made it clear I wouldn’t make speeches or give interviews. That was Bill’s job, at least at the start.

  From the beginning, we were looking for problems that governments and markets weren’t addressing or solutions they weren’t trying. We wanted to discover the huge missed ideas that would allow a small investment to spark massive improvement. Our education began during our trip to Africa in 1993, the year before we were married. We hadn’t established a foundation at that point, and we didn’t have any idea how to invest money to improve people’s lives.

  But we saw scenes that stayed with us. I remember driving outside one of the towns and seeing a mother who was carrying a baby in her belly, another baby on her back, and a pile of sticks on her head. She had clearly been walking a long distance with no shoes, while the men I saw were wearing flip-flops and smoking cigarettes with no sticks on their heads or kids at their sides. As we drove on, I saw more women carrying heavy burdens, and I wanted to understand more about their lives.

  After we returned from Africa, Bill and I hosted a small dinner at our home for Nan Keohane, then president of Duke University. I almost never hosted that kind of event back then, but I was glad I did. One researcher at the dinner told us about the huge number of children in poor countries who were dying from diarrhea and how oral rehydration salts could save their lives. Sometime after that, a colleague suggested we read World Development Report 1993. It showed that a huge number of deaths could be prevented with low-cost interventions, but the interventions weren’t getting to people. Nobody felt it was their assignment. Then Bill and I read a heartbreaking article by Nicholas Kristof in The New York Times about diarrhea causing millions of childhood deaths in developing countries. Everything we heard and read had the same theme: Children in poor countries were dying from conditions that no kids died from in the United States.

  Sometimes new facts and insights don’t register until you hear them from several sources, and then everything starts coming together. As we kept reading about children who were dying whose lives could be saved, Bill and I began to think, Maybe we can do something about this.

  The most bewildering thing to us was how little attention this got. In his speeches, Bill used the example of a plane crash. If a plane crashes, three hundred people die, and it’s tragic for the families, and there’s an article in every newspaper. But on the same day, thirty thousand children die, and that’s tragic for the families, and there’s no article in any newspaper. We didn’t know about these children’s deaths because they were happening in poor countries, and what’s happening in poor countries doesn’t get much attention in rich countries. That was the biggest shock to my conscience: Millions of children were dying because they were poor, and we weren’t hearing about it because they were poor. That’s when the work in global health started for us. We began to see how we could make an impact.

  Saving children’s lives was the goal that launched our global work, and our first big investment came in vaccines. We were horrified to learn that vaccines developed in the United States would take fifteen to twenty years to reach poor children in the developing world, and diseases that were killing kids in the developing world were not on the agenda of vaccine researchers back here. It was the first time we saw clearly what happens when there’s no market incentive to serve poor children. Millions of kids die.

  That was a crucial lesson for us, so we joined governments and other organizations to set up GAVI, the Vaccine Alliance, to use market mechanisms to help get vaccines to every child in the world. Another lesson we kept learning is that the problems of poverty and disease are always connected to each other. There are no isolated problems.

  * * *

  On one of my early trips for the foundation, I went to Malawi and was deeply moved to see so many mothers standing in long lines in the heat to get shots for their kids. When I talked to the women, they’d tell me the long distances they’d walked. Many had come ten or fifteen miles. They’d brought their food for the day. They’d had to bring not only the child who was getting vaccinated but their other children as well. It was a hard day for women whose whole lives were already hard. But it was a trip we were trying to make easier and shorter, and a trip we were urging more mothers to take.

  I remember seeing a young mother with small kids and asking her, “Are you taking these beautiful children to get their shots?”

  She answered, “What about my shot? Why do I have to walk twenty kilometers in this heat to get my shot?” She wasn’t talking about a vaccination. She was talking about Depo-Provera, a long-acting birth control injection that could keep her from getting pregnant.

  She already had more children than she could feed. She was afraid of having even more. But the prospect of spending a day walking with her children to a far-off clinic where her shot might not be in stock was deeply frustrating to her. She was just one of the many mothers I met during my early trips who switched the topic of our conversation from children’s vaccines to family planning.

  I remember traveling to a village in Niger and visiting a mother named Sadi Seyni whose six children were competing for her attention as we talked. She said the same thing I heard from so many mothers: “It wouldn’t be fair for me to have another child. I can’t afford to feed the ones I have now!”

  In a large and very poor neighborhood of Nairobi named Korogocho I met Mary, a young mother who sold backpacks made from scraps of blue jean fabric. She invited me into her home, where she was sewing and watching her two small children. She used contraceptives because, she said, “Life is tough.” I asked if her husband supported her decision. She said, “He knows life is tough, too.”

  Increasingly on my trips, no matter what their purpose, I began to hear and see the need for contraceptives. I visited communities where every mother had lost a child and everyone knew a mother who had died in childbirth. I met more mothers who were desperate not to get pregnant because they couldn’t take care of the kids they already had. I began to understand why, even though I wasn’t there to talk about contraceptives, women kept bringing them up anyway.

&n
bsp; The women were experiencing in their lives what I was reading in the data.

  In 2012, in the world’s sixty-nine poorest countries, 260 million women were using contraceptives. Over 200 million more women in these nations wanted to use contraceptives—and couldn’t get them. That meant millions of women in the developing world were getting pregnant too early, too late, and too often for their bodies to handle. When women in developing countries space their births by at least three years, each baby is almost twice as likely to survive their first year—and 35 percent more likely to see their fifth birthday. That’s justification enough to expand access to contraceptives, but child survival is just one reason.

  One of the longest-running public health studies dates from the 1970s, when half of the families in a number of villages in Bangladesh were given contraceptives and the other half were not. Twenty years later, the mothers who took contraceptives were healthier. Their children were better nourished. Their families had more wealth. The women had higher wages. Their sons and daughters had more schooling.

  The reasons are simple: When the women were able to time and space their pregnancies, they were more likely to advance their education, earn an income, raise healthy children, and have the time and money to give each child the food, care, and education needed to thrive. When children reach their potential, they don’t end up poor. This is how families and countries get out of poverty. In fact, no country in the last fifty years has emerged from poverty without expanding access to contraceptives.

  We made contraception part of the early giving of our foundation, but our investment was not proportional to the benefits. It took us years to learn that contraceptives are the greatest life-saving, poverty-ending, women-empowering innovation ever created. When we saw the full power of family planning, we knew that contraceptives had to be a higher priority for us.

  It wasn’t just a matter of writing bigger checks, either. We needed to fund new contraceptives that would have fewer side effects, last longer, and cost less, and that a woman could get in her own village or take by herself in her home. We needed a worldwide effort that included governments, global agencies, and drug companies working with local partners to deliver family planning to women where they lived. We needed a lot more voices speaking up for women who weren’t being heard. By that time I had met many impressive people who had been working in the family planning movement for decades. I talked to as many as I could and asked them how our foundation could help, what I could do to amplify their voices.

  Everyone I approached seemed to become awkwardly silent, as if the answer was obvious and I didn’t see it. Finally, a few people told me, “The best way for you to support the public advocates is to become one. You need to join us.”

  That wasn’t the answer I was looking for.

  I am a private person—in certain ways, a bit shy. I was the girl in school who raised her hand to speak in class while other kids bellowed their answers from the back row. I like to work offstage. I want to study the data, go see the work, meet people, develop a strategy, and solve problems. By then, I was accustomed to making speeches and giving interviews. But suddenly friends, colleagues, and activists were pressing me to become a public advocate for family planning, and that alarmed me.

  I thought, Wow, am I going to step publicly into something as political as family planning, with my church and many conservatives so opposed to it? When Patty Stonesifer was our foundation’s CEO, she warned me, “Melinda, if the foundation ever steps into this space in a big way, you’re going to be at the center of the controversy because you’re Catholic. The questions will all be coming to you.”

  I knew this would be a huge shift for me. But it was clear the world had to do more on family planning. Despite decades of efforts by passionate advocates, progress had largely stalled. Family planning had fallen off as a global health priority. This was partly because it had become so politicized in the United States, and also because the AIDS epidemic and vaccine campaigns had drawn funding and attention away from contraceptives globally. (It is true that the AIDS epidemic did lead to widespread efforts to distribute condoms, but for reasons I’ll explain later, condoms were not a helpful contraceptive tool for many women.)

  I knew that my becoming an advocate for family planning would expose me to criticism I wasn’t used to and would take time and energy from other foundation activities. But I began to feel that if anything was worth those costs, it was this. I felt it in a visceral, personal way. Family planning was indispensable to our ability to have a family. It allowed me to work and have the time to take care of each child. It was simple, cheap, safe, and powerful—no woman I knew went without it, but hundreds of millions of women around the world wanted it and couldn’t get it. This unequal access was simply unjust. I couldn’t look the other way as women and children were dying for want of a widely available tool that could save their lives.

  I also considered my duty to my children. I had a chance to stand up for women who didn’t have a voice. If I turned it down, what values was I role modeling for my kids? Would I want them to turn down difficult tasks in the future and then tell me that they were following my example?

  And my own mother had a powerful influence on my choice, though she might not have known it. She always said to me as I was growing up, “If you don’t set your own agenda, somebody else will.” If I didn’t fill my schedule with things I felt were important, other people would fill my schedule with things they felt were important.

  Finally, I have always carried in my head images of the women I’ve met, and I keep photographs of the ones who have moved me the most. What was the point of their opening their hearts and telling me about their lives if I wasn’t going to help them when I had the chance?

  That clinched it for me. I decided to face my fears and speak out publicly for family planning.

  I accepted an invitation from the UK government to cosponsor a family planning summit in London with as many heads of state, experts, and activists as we could attract. We decided we would double our foundation’s commitment to family planning and make it a priority. We wanted to revive the global commitment that all women worldwide must have access to contraceptives, so that we can decide for ourselves whether and when to have a child.

  But I still had to figure out what my role would be and what the foundation needed to do. It wouldn’t be enough just to convene a global summit, talk about contraceptives, sign a declaration, and go home. We had to set goals and form a strategy.

  We joined the UK government in a sprint to hold the summit in London in July of 2012, two weeks before everyone’s attention turned to the opening of the London Olympics at the end of the month.

  The approach of the summit triggered a wave of media stories that highlighted the life-saving value of family planning. The British medical journal The Lancet published a study funded by the UK government and our foundation showing that access to contraception would cut the number of mothers who die in childbirth by a third. A report by Save the Children said a million teenage girls die or are injured in childbirth every year, which makes pregnancy the number one cause of death for teen girls. These findings and others helped set a tone of urgency for the conference.

  There was a big crowd at the summit, including many heads of state. The speeches went well, and I was pleased with that. But I knew the test of success would be who stepped up and how much money we raised. What if national leaders didn’t support the initiative? What if governments didn’t increase their funding? Those worries had been giving me a sick feeling for months—not very different from the fear of throwing a party where no one shows up, but in this case, the media would show up to report on the failure.

  I won’t say that I shouldn’t have worried. My worries make me work harder. But the funding and support were greater than my highest hopes. The United Kingdom doubled its commitment to family planning. The presidents of Tanzania, Rwanda, Uganda, and Burkina Faso and the vice president of Malawi were present at the conference and
played a key role in raising the $2 billion committed by developing countries. That included Senegal, which doubled its commitment, and Kenya, which increased its national budget for family planning by a third. Together we pledged to make contraceptives available to 120 million more women by the end of the decade in a movement we called FP 2020. It was by far the largest sum of money ever pledged to support access to contraceptives.

  Just the Beginning

  After the conference, my best friend from high school, Mary Lehman, who had traveled with me to London, joined me for dinner with some influential women who also attended the conference. We were all having a glass of wine and enjoying a sense of satisfaction, and I was personally relieved to be done. After many months of planning and worrying, I felt I could finally relax.

  That’s when these women all said to me, “Melinda, don’t you see? Family planning is just the first step for women! We have to move on to a much bigger agenda!!”

  I was the only one at the table naïve enough to be surprised—and I was overwhelmed. I didn’t want to hear it. Talking to Mary in the car after dinner, I said over and over, “Mary, they’ve got to be kidding.” I was near tears and kept thinking, No way. I’m already doing my part and it’s more than I can handle, and there is already a ton of work ahead on family planning alone to meet the goals we just declared—never mind a wider women’s agenda.

  The call for “more” was especially hard to hear after an emotional visit I’d had a few days earlier in Senegal. I was sitting in a small hut with a group of women talking about female genital cutting. They had all been cut themselves. Many had held their daughters down to be cut. As they were telling me about it, my colleague Molly Melching, who’s worked in Senegal for decades and was acting as my translator that day, said, “Melinda, some of this I’m not going to translate for you because I don’t think you could take it.” (At some point I have to summon the guts to ask her what she was holding back.)