The Moment of Lift

by Melinda Gates

  Hans paused here in the story and told me, “I wasn’t the one who did that. It was Mama Rosa.”

  Mama Rosa was a Catholic nun who worked with Hans. She had told him, “Before you do a fetotomy, get permission from the family. Don’t cut a baby before you have their permission. Afterward, they will ask you only for one thing, to get the parts of the child. And you will say, ‘Yes, you will get the parts, and you will be given the cloth for the child.’ That’s the way. They don’t want anybody else to have parts of their baby. They want to see all the pieces.”

  So Hans explained, “When this woman died, I was sobbing, and Mama Rosa put her arm around me and said, ‘This woman was from a very remote village. We must take her home. Otherwise no one will come to the hospital from that village for the next decade.’

  “‘But how can we take her?’

  “‘Run out and stop the vaccine car,’ Mama Rosa told me. ‘Run out and stop the vaccine car.’”

  And Hans did it. “Mama Rosa knew what people’s realities were,” he said. “I never would have known to do that. Often in life, it’s the older males who get credit for the work that young people and women do. It isn’t right, but that’s how it works.”

  That was Hans’s deepest witness of extreme poverty. It wasn’t living on a dollar a day. It was taking days to get to the hospital when you’re dying. It was respecting a doctor not for saving a life but for returning a dead body to the village.

  If this mother had lived in a prosperous community and not on the margins among farmers in a remote forest in Mozambique, she never would have lost her baby. She never would have lost her life.

  This is the meaning of poverty I’ve come to see in my work, and I see it also in Hans’s story: Poverty is not being able to protect your family. Poverty is not being able to save your children when mothers with more money could. And because the strongest instinct of a mother is to protect her children, poverty is the most disempowering force on earth.

  It follows that if you want to attack poverty and if you want to empower women, you can do both with one approach: Help mothers protect their children. That is how Bill and I began our philanthropic work. We didn’t put it in those words at the time. It just struck us as the most unjust thing in the world for children to die because their parents are poor.

  In late 1999, in our first global initiative, we joined with countries and organizations to save the lives of children under 5. A huge part of the campaign was expanding worldwide coverage for a basic package of vaccines, which had helped cut the number of childhood deaths in half since 1990, from 12 million a year to 6 million.

  Unfortunately, the survival rate of newborns—babies in the first twenty-eight days of life—has not improved at the same pace. Of all the deaths of children under 5, nearly half come in the first month. And of all the deaths in the first month, the greatest number come on the first day. These babies are born to the poorest of the poor—many in places far beyond the reach of hospitals. How can you save millions of babies when their families are spread out in remote areas and follow centuries of tradition when it comes to childbirth?

  We didn’t know. But if we wanted to do the most good, we had to go where there’s the most harm—so we explored ways to save the lives of mothers and newborn babies. The most common factor in maternal and infant death is the lack of skilled providers. Forty million women a year give birth without assistance. We found that the best response—at least the best response we have the know-how to deliver now—is to train and deploy more skilled healthcare providers to be present for mothers at birth and in the hours and days after.

  In 2003, we funded the work of Vishwajeet Kumar, a medical doctor with advanced training from Johns Hopkins who was launching a life-saving program in a village called Shivgarh in Uttar Pradesh, one of India’s poorest states.

  In the midst of this project, Vishwajeet married a woman named Aarti Singh. Aarti was an expert in bioinformatics—and began applying her expertise to designing and evaluating programs for mothers and newborns. She became an indispensable member of the organization, which was named Saksham, or “empowerment,” by the people in the village.

  Vishwajeet and the Saksham team had studied births in poor rural parts of India and saw that there were many common practices that were high risk for the baby. They believed that many newborn deaths could be prevented with practices that cost little or nothing and could be done by the community: immediate breastfeeding, keeping the baby warm, cutting the cord with sterilized tools. It was just a matter of changing behavior. With grants from USAID and Save the Children and our foundation—and by teaching safe newborn practices to community health workers—Saksham cut newborn mortality in half in eighteen months.

  At the time of my 2010 visit to Shivgarh, there were still 3 million newborn deaths in the world every year. Nearly 10 percent of those deaths occurred in Uttar Pradesh, which has been called the global epicenter of newborn and maternal deaths. If you wanted to bring down the number of newborn deaths, Uttar Pradesh was an important place to work.

  On the first day of my trip, I met with about a hundred people from the village to talk about newborn care. It was a large crowd, with mothers seated at the front and men toward the back. But it felt intimate. We were sitting on rugs laid out under the shade of a large tree, packed in tightly to make sure no one was left out in the blistering sun. After the meeting, we were greeted by a family with a little boy about 6 years old. Seconds later, Gary Darmstadt, who was our foundation’s head of maternal and newborn health at the time, whispered to me, “That was him; that was the baby!” I looked back and saw the 6-year-old boy and said, “What baby? That’s not a baby.” “That’s the one Ruchi saved,” he said. “Oh my gosh!” I said. “That’s the baby you told me about!?”

  That 6-year-old boy had become lore. He was born in the first month of the Saksham program when the community health workers had just been trained, community skepticism was high, and everyone was watching. The baby, whom I had just seen as a healthy 6-year-old, was born in the middle of the night. The mother, in her first pregnancy, was exhausted and fainted during childbirth.

  As soon as the sun came up, the recently trained community health worker was notified of the birth and came immediately. Her name was Ruchi. She was about 20 years old and came from a high-caste Indian family. When she arrived, she found the mother still unconscious and the baby cold. Ruchi asked what was going on, and none of the family members in the room said a thing. They were all terrified.

  Ruchi stoked the fire to warm the room, then got blankets and wrapped the baby. She took the baby’s temperature—because she was trained to know that hypothermia can kill babies or be a sign of infection. The infant was extremely cold, about 94 degrees. So Ruchi tried the conventional things she’d done in the past, and nothing worked. The baby was turning blue. He was listless, and Ruchi realized that he would die unless she did something right away.

  One of the life-saving practices Ruchi had learned was skin-to-skin care: holding a baby against the mother’s skin to transfer warmth from the mom to the newborn. The technique prevents hypothermia. It promotes breastfeeding. It protects from infection. It is one of the most powerful interventions we know of for saving babies.

  Ruchi asked the baby’s aunt to give the infant skin-to-skin care, but the aunt refused. She was afraid that the evil spirit she thought was gripping the baby would take her over as well.

  Ruchi then faced a choice: Would she give the baby skin-to-skin care herself? The decision wasn’t easy; doing something so intimate with a low-caste infant could bring ridicule from her own relatives. And this was a foreign practice in the community. If it didn’t go well, the family could blame her for the death of the baby.

  But when she saw the baby getting colder, she opened up her sari and placed the newborn against her bare skin, with the baby’s head nestled between her breasts and a cloth covering both her head and the baby’s for modesty and warmth. Ruchi held the baby that way for a coup
le of minutes. His skin color appeared to be changing back to pink. She took out her thermometer and tested the baby’s temperature. A little better. She held the baby a few minutes more and took his temperature again. A little bit higher. Every woman there leaned in and watched as the baby’s temperature rose. A few minutes later, the baby started to move; then he came alive; then he started to cry. The baby was fine. He wasn’t infected. He was just a healthy baby who needed to be warmed and hugged.

  When the mother regained consciousness, Ruchi told her what had happened and guided her in skin-to-skin care, then helped her initiate breastfeeding. Ruchi stayed another hour or so, watching the mother and baby in skin-to-skin position, and then she left the home.

  This story spread like lightning through the nearby villages. Overnight, women went from saying “We’re not sure about this practice” to “I want to do this for my baby.” It was a turning point in the project. You don’t get behavior change unless a new practice is transparent, works well, and gets people talking—and Ruchi’s revival of this one-day-old baby had everybody talking. This was a practice all women could do. Mothers became seen as life-savers. It was immensely empowering and transformative.

  Their Cup Is Not Empty

  I learned a lot from my trip to Shivgarh, and the most striking lesson for me—and what made it a departure from a lot of our prior work—is that it wasn’t about technological advances. Our emphasis at the foundation has always been on scientific research to develop life-saving breakthroughs like vaccines. We call this product development, and it continues to be our main contribution. But Vishwajeet and Aarti’s program for mothers and newborns showed me how much can be achieved by sharing simple practices that are widely known throughout the world. This taught me in a profound way that you have to understand human needs in order to effectively deliver services and solutions to people. Delivery systems matter.

  What do I mean by a “delivery system”? Getting tools to people who need them in ways that encourage people to use them—that is a delivery system. It is crucial, and it is often complex. It can require getting around barriers of poverty, distance, ignorance, doubt, stigma, and religious and gender bias. It means listening to people, learning what they want, what they’re doing, what they believe, and what barriers they face. It means paying attention to how people live their lives. That’s what you need to do if you have a life-saving tool or technique you want to deliver to people.

  Before launching the program, Saksham hired a local team of top students who spent six months working with the community to understand their existing practices and beliefs around childbirth. Vishwajeet told me, “Their cup is not empty; you can’t just pour your ideas into it. Their cup is already full, so you have to understand what is in their cup.” If you don’t understand the meaning and beliefs behind a community’s practices, you won’t present your idea in the context of their values and concerns, and people won’t hear you.

  Historically, the mothers in the community would go to the Brahmin, a member of the priestly caste, and ask when to start breastfeeding, and he would say, “You can’t let down milk for three days, so you should start after three days.” False information is disempowering. Mothers would heed the advice of the Brahmin, and for the first three days of the newborn’s life, they would give the baby water—which was often polluted. Vishwajeet and Aarti’s team had prepared for this moment. They gently questioned traditional practices by pointing to patterns in nature that were part of the villagers’ way of life. They cited the example of a calf and its mother. “When we try to milk a cow and it doesn’t express milk, we make the calf suckle her to get the milk to let down, so why don’t you try the same and keep the baby against your breast to express milk.”

  The villagers still said, “No, this isn’t going to work.” So the local team went to a few people in the community who had courage and influence and tried to persuade them. Team members knew that if they could create a culture of support around a young mother, the mother would be much more likely to try the new practice. When a few mothers tried it and were able to breastfeed right away, they said, “Wait a minute; we didn’t realize we could do this!” Then things took off; the community began to try the other health practices as well.

  It’s a delicate thing to initiate change in a traditional culture. It has to be done with the utmost care and respect. Transparency is crucial. Grievances must be heard. Failures must be acknowledged. Local people have to lead. Shared goals have to be emphasized. Messages have to appeal to people’s experience. The practice has to work clearly and quickly, and it’s important to emphasize the science. If love were enough to save a life, no mother would ever bury her baby—we need the science as well. But the way you deliver the science is just as important as the science itself.

  Midwife in Every Village

  When I returned to the foundation after my trip to Shivgarh, I talked to our staff about delivery and cultural awareness and how crucial they are to saving lives. I said we have to keep working on innovation in products, in science and technology, but we have to work with the same passion on innovation in delivery systems as well. Both are indispensable.

  Let me illustrate with an example that is personal to me, and one I haven’t shared before. It’s about my mom’s older sister Myra.

  My aunt Myra is very dear to me. I called her “my other mother” when I was growing up. When she used to visit us, she would spend time coloring and playing board games with my sister, Susan, and me. We also went shopping a lot. She was so energetic and upbeat that it didn’t ever figure in my image of Aunt Myra that she didn’t have the use of her legs.

  When my mom and Myra were young girls in the 1940s, they were playing at their great-uncle’s house, and afterward he told my grandmother, “Myra was sure being lazy today. She wanted me to carry her home.”

  That night Myra woke up screaming in pain. My grandparents took her to the hospital, and a team of doctors figured out she had polio. They wrapped her legs up with gauze, boiled water, and put on hot packs. Doctors thought the heat would help, but it didn’t make any difference. Three or four days later, her legs were paralyzed. She was in the hospital for sixteen months, and my grandparents were allowed to visit her only on Sundays. Meanwhile, none of the kids in the neighborhood would play with my mom anymore. Everyone was terrified of the polio virus.

  In the 1940s, the great polio challenge was product development, namely, finding a vaccine. Delivery didn’t matter. There was nothing to deliver. It wasn’t a question of privilege or poverty. The scientific innovation hadn’t happened yet. There was no protection for anyone against polio.

  As soon as Jonas Salk developed his polio vaccine in 1953, the passionate effort to protect people from polio shifted from product development to delivery, and in this case, poverty did matter. People in wealthy countries were vaccinated quickly. By the late 1970s, polio had been eliminated in the US, but it continued to plague much of the world, including India, where the vast landscapes and large population made polio especially hard to fight. In 2011, defying most expert predictions, India became polio free. It was one of the greatest accomplishments in global health, and India did it with an army of more than 2 million vaccinators who traversed the entire country to find and vaccinate every child.

  In March of 2011, Bill and I met a young mother and her family in a small village in Bihar, one of the most rural states in India. They were migrant workers, desperately poor, and working at a brick kiln. We asked her if her children had been vaccinated for polio, and she went into her hut and returned with an immunization card with the names of her children and the dates they received the vaccine. The vaccinators had not just found her children once. They had done so several times. We were awestruck. That is how India became polio free—through massive, heroic, original, and ingenious delivery.

  Meeting people who deliver life-saving support to others is one of the highlights of my work. A few years ago on a trip to Indonesia, I met a woman named Ati Pujiastuti
. As a young woman, Ati had enrolled in a government program called Midwife in Every Village that trained 60,000 midwives. She completed the program when she was just 19 years old and was assigned to work in a rural mountain village.

  When she arrived in the village, she wasn’t welcome. People were hostile and distrustful of outsiders, especially young women with ideas for how to make things better. Somehow, this young woman had the wisdom of a village elder. She went door-to-door to introduce herself to everyone. She showed up at every community event. She bought the local newspaper and read it aloud to anyone who couldn’t read. When the village got electricity, she scraped up the money to buy a tiny TV and invited everyone to come watch with her.

  Still, nobody wanted her services until, by pure accident, a pregnant woman who was visiting the village from Jakarta went into labor and asked Ati to deliver her baby. The birth went well, the villagers began to trust Ati, and soon every family wanted her present when mothers gave birth. She made sure that she was there, every time, even at the risk of her own life. Once she lost her footing while crossing a river and had to cling to a rock until help came. Another time she slipped on a muddy mountain path next to the edge of a cliff. Several times, she was thrown off her motorbike while riding on unpaved roads. Still, she stayed on and kept delivering babies. She knew she was saving lives.