By JACKSON MUTINDA

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The CEO of the Bill and Melinda Gates Foundation, Mark Suzman, who will be in Nairobi in the coming week to meet with the Foundation's partners, spoke to Jackson Mutinda about their plan for East Africa

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What brings you to Nairobi?

Well, a lot of things but, first and foremost, you know, we've been long-time partners with Kenya and across East Africa, working on health and development issues and, as a commitment of our expansion in Africa, we are going to be opening our East Africa regional office in Kenya shortly and I'm hoping we will finalise the agreement with the government while I'm there — if not, soon after. So, part of it is to do that, part of it is to review the state of our work and partnerships, and I'll be joining a convening of all our partners across Kenya — which we've never had before — with well over 100 partners.

I'll also be participating in the Mo Ibrahim Governance events at the weekend, which he's hosting in Nairobi. He's a longstanding friend and partner of the Foundation and, obviously, a leading voice on African issues. So, I'm participating in a couple of panels and meetings there. It's a mixture of strong domestic issues and engagement with partners and, last but not least, I'm hopefully going to get out into the field outside of Nairobi to see some of our work, especially in agriculture.

This year, you announced the biggest budget ever. What informed that increase and what are your target areas of development?

Yeah, we did a record budget, the largest budget ever of any philanthropy in history — $8.3 billion. it was a reflection of our board and Bill and Melinda feeling that, for the issues we work on as a foundation — giving every person the opportunity to lead a healthy and productive life — this is the most challenging time in the Foundation's history. We were founded in 2000, we have been part of an unprecedented two decades of steady progress. Kenya is a good example of that. While there have been ups and downs, in aggregate for the first two decades of the 21st century, there were significant reductions in poverty, reductions in preventable child mortality, reductions in maternal mortality, reductions in HIV, TB and malaria deaths, and improvements in agricultural productivity. And what we've seen with the Covid crisis, not just in Kenya but across the continent and really across much of Asia and Latin America, is that progress is stalled and, in many areas, reversed. We haven't fully recovered from the Covid crisis.

And it's a time of fiscal challenges, a time when the Global North, while still a strong partner, is focused more on issues like the Ukraine war or inflation, which are important issues, but are coming to some degree at a cost of attention to bilateral aid. We got data last week that showed that bilateral aid to Africa declined by eight percent last year from traditional donors. If you combine refugee costs and direct aid to Ukraine, you get around $45 billion, which is more significant, I think about 50 percent more than the entire continent of Africa.

So, in that context, we feel it's much more important that we as an institution step up to support where we can because we believe strongly not just that there are opportunities to reverse some of the setbacks, but we can accelerate progress in the end. We are very keen to have big improvements in poverty reduction, agricultural productivity, financial inclusion and health indicators. But that needs resources, both in innovation and research and development.

So, our budget is a signal of that commitment, but it's really not just about money — it is about partnerships.

We have recently seen outbreaks of infectious diseases such as cholera, which now is spreading across Africa. We've seen Ebola in Uganda, Marburg in Tanzania and in West Africa, monkeypox… Are you thinking of tweaking your health programme to cover some of these emerging public health challenges for Africa?

Yes. Well, we focus our attention significantly on infectious diseases. That's one of our top priorities. But, even with those outbreaks that you talk about, by many orders of magnitude, the greatest impact is still the three big infectious diseases: tuberculosis, HIV/Aids and malaria.

Those are the three that have the biggest mortality burden. So that remains, and will remain, our primary focus until we can get those deaths reversed and, hopefully, down to zero.

The Covid-19 pandemic is a great case study. Clearly, the world needs, and Africa needs, a structure and a system to pivot and focus on disease outbreaks, both for potentially emerging new pathogens like Covid or existing ones like Ebola or monkeypox. Or understanding ones.

Cholera is hardly a new pathogen. We know how to control it and outbreaks like the ones we've seen that cause significant mortality need to be tackled. we've been working with the World Health Organisation, the Africa CDC and others.

This is the kind of thing that needs to be a global and continental set of priorities. We can provide some technical expertise and support in areas, but we would love to see a stronger global health emergency course setting at the World Health Organisation.

We think that there needs to be a much stronger laboratory and surveillance infrastructure across Africa. In fact, we have some strong partnerships in Kenya, which we deepened during the Covid-19 pandemic, around epidemiological surveillance and other issues, because that's the first critical step. You need to be able to identify outbreaks like Ebola as soon as they come. If the Ebola crisis in West Africa in 2015 had been a respiratory disease like Covid-19, when it circulated unrecognised for weeks, if not months, before it was tackled, the world would be a very different place.

One of the challenges of cholera is there has been a global shortage of cholera vaccines, so we've invested directly and this is a wide issue around supporting capacity in Africa, now in a South African company, Biovac, which is going to be the first on the continent to manufacture cholera vaccines for distribution on the continent. That's an area where the Gates Foundation can step in with specific knowledge and expertise for the specific partnerships and, hopefully, the purchase and take-up will be leveraged by WHO and African health departments.

Let's talk about malaria and I have two issues: One is that there was a promise of a more efficacious vaccine, and the other is about the declaration last year in Kigali at the Commonwealth Meeting about eradicating malaria and the neglected tropical diseases by 2030. Looking at the challenges that the continent has on public health programmes and the problems on the globe now — the war, the disruption of supply chains — do you think the 2030 target is reasonable?

Yes, for some neglected tropical diseases like sleeping sickness and Guinea worm. Guinea worm, I feel cautiously confident, will be eliminated by 2030. We're down to a handful of cases in a few countries like South Sudan and Chad, and actually challenges of animal reservoirs in dogs and baboons in Ethiopia. For malaria, no. Realistically, for elimination of malaria, 2030 is too ambitious. It's such a complex disease, has so many challenges, but we are committed. Melinda was the first person to challenge the world, saying we really can have a goal about eliminating this disease, not just controlling it. And we feel that, with some of the tools and innovations on the horizon, a deadline perhaps of 2040 is more feasible.

People learned a lot about vaccine efficacy during Covid-19. You know, the Covid vaccines have efficacy of 80 percent to 90 percent. That's very unusual of vaccines. The malaria vaccines tend to be closer to 35 percent, 40 percent, and they don't last. You need to reapply them.

But there's another new vaccine that's been developed at Oxford. We're still waiting for the large Phase 3 trials, but there certainly are lessons available on what could be better vaccines. There are also other tools available. One that we've been investing in is monoclonal antibodies. There were trials in West Africa in the past couple of years, which showed almost 100 percent efficacy. If you gave children monoclonal antibodies ahead of the malaria high season, they did not get malaria. Now, the problem with something like that at the moment is it’s too expensive. They're not ready for primetime for millions of people, but they show us the potential. Can we drive down the cost? Why were those so effective? Can we use some of the lessons from the effectiveness of the antibodies to actually inform the next generation of vaccines to make them much more effective?

And then there are other tools in the prevention space. We work on sugar bait, which you can hang on the rafters around roofs to attract mosquitoes before they get into houses. And there are also new treatments coming onboard.

We are the largest investor in the world on the research and development side malaria, because it's a classic public good failure. If it affected rich people in a consistent way, believe me, there would be billions of dollars going into malaria research and development. But because people in wealthy countries can largely use a prophylactic when they visit a malarial area, that's not seen as a market. And that's a key example of an area where we at the Gates Foundation feel we can use our resources -- act as the primary funder and work with partners -- governmental partners, the Global Fund in this case, to scale successful products.

Malaria is one of those glasses -- half full, half empty ones. In the past three years we've seen a slight increase in malaria after two decades of a decline, but we think we could have very rapid progress over the next, five to fifteen years, especially with some of these new tools.

There has been an argument that Africa needs to do more in the production of vaccines and medicines for its populations, but then the challenge is in the sharing of the intellectual property rights.

Africa seems to be more of a distributor than a manufacturer and that, according to Africans, will not help solve the problem.

I think it's important to separate the broader issue of vaccine manufacturing and markets. We think there's a need for greater expansion and capacity in Africa for vaccines and broader medical device manufacturing. But, as with all these things, you need to be very careful that you're actually building capacity that's going to have a market. The companies need to be viable; they need to know there are going to be purchases.

A good example is the Biovac one on the oral cholera vaccine, where we have some of the intellectual property knowledge passed over at no cost to Biovac. This will be manufactured, there will be a market, sadly, because, as you pointed out, there are lots of outbreaks and we're doing this very deliberately in a number of areas. So, we've been working with the Institut Pasteur de Dakar (IPD) in Senegal where, again, we've been working with a company on a proprietary new technology that does measles rubella vaccines. We can work in this case with IPD to develop capacity in Africa. We know there's going to be a market for measles rubella vaccines.

We've recently worked with and do partner with Aspen Pharmacare in South Africa, which has been partnering with the Serum Institute of India -- which is the world's largest vaccine manufacturer --to make four different vaccines.

I know Moderna is looking at developing a factory in Kenya. We work in close partnership with BioNTech, which did the other vaccine. So, yes, I think there is scope and growth in vaccines. But you need to look at which product for which markets, when and then find the right partners.

Beyond vaccines, there is the wider issue of medical devices. One of the investments we made during Covid was actually in Kenya, and one in Rwanda to help support syringe manufacturing on the continent, because there was a shortage. Now, that's a less complex manufacturing technique, but it's a great need. There's a steady market. So, we should be looking across the full range of medical products and devices, diagnostics tools like syringes, treatments and then vaccines are small subset; they’ve become much more visible post-Covid.

Very reasonably, the issue of vaccine nationalism was raised and is very troubling for us. But, remember, vaccines are actually a small part of a much bigger set of healthcare products and needs.

What do you think is the place of genetic modification technology in solving the food challenges in Africa?

It's important take a step back and ask, what is the most important issue that needs to be tackled, not just Africa but globally, to increase productivity of core crops and livestock? And that is more important than ever because of climate change. Climate change is making the demand for more drought- and flood-resilient, disease-resistant crops more than ever. So, our view at the Foundation is we make a very wide range of investments across conventional and GM and other related things. About saying what's going to work best in which area, we are neutral. We just want what's going to increase productivity, nutrition, disease resistance. And what you need is a strong, robust, informed scientific and regulatory framework both globally and nationally. And it does need to be national because unlike, say, medicines, crops can grow and outbreak differently in different regions. Ultimately, all countries, like Kenya, need to make choices based on science and the best regulatory evidence of what's most needed in the country. But, certainly, we feel that in that context there is a place for GM crops that have proven safety and health records.

Take cassava. It's a staple across Africa. Cassava across Kenya is at risk of brown streak virus, which really devastates the crop.

Conventional tools have proved challenging to deal with that, so there is some potential for GM technology that could tackle the virus.

We have huge investments in regular, conventional breeding and support, and lots of tools like that. But you need the robust, regular, scientific infrastructure and ultimately the choice needs to be national, based on the best needs and science in the country.

What are your focus areas in Kenya specifically and Africa generally?

In Africa, which is a major growing folks here, we've committed over $13 billion directly to Africa over the lifetime of the Foundation and actually when Bill Gates visited Kenya at the end of last year, he made the commitment of an additional $7 billion over the next four years. And it's really not just about money. We actually, in practice, give more money than that, because we provide resources to UN and global agencies like the Gavi Vaccine Fund or the Global Fund to fight TB and Malaria. And they spend money in Kenya.

But it's as much about the actual partnerships, especially with the government, but at both national and county level, and there we work across a range of areas. Our biggest area of priority has traditionally been health. That's where our deepest expertise lies, particularly in combating infectious diseases and providing vaccines, maternal and child healthcare-related issues. So, we are very focused on primary healthcare, particularly at the county level and then some specific areas like family planning.

And then agriculture. Agriculture has been a huge priority. In recent years it's shifted much more heavily but I think it's become more of a focus because of the critical need for climate adaptation. And I think Kenya, you're now in Year 4, heading into Year 5 of unprecedented drought. And that really highlights the challenges, particularly for the smallholder farmers who are dependent; they're still the poorest people in the country by and large and most victimised by climate change and needing some of the resources and support -- financial, extension services, access to better seeds or technology, digital soil health mapping -- which we do.

And then we also work in areas like financial inclusion, where Kenya has been a strong leader, but clearly there's a lot more that can be done. And I know that the President (William Ruto) has made this a particular priority with the Hustler Fund. So it really is across the full range of the Gates Foundation’s priorities that we work in Kenya, because Kenya has a dynamic mixture of private sector and entrepreneurial partners as well as governmental partnerships and multilateral partnerships. So it's a very strong set of interventions and our opening the office is a sign of our long-term commitment. we are going to be here for the long haul as partners with Kenya as long as the Foundation is in existence.