The Gates Foundation’s Grand Challenges in Global Health programme is a decade old. How has it done, and what should it do in the future?

TEN years ago the Bill & Melinda Gates Foundation began divvying up the money for what it hoped would be a novel approach to the task of solving the world’s health problems. The new programme’s organisers, led by Mr and Mrs Gates themselves, had identified 14 “grand challenges” in the field—from “preparing vaccines that do not require refrigeration” to “developing a genetic strategy to deplete or incapacitate a disease-transmitting insect population”—and had invited suggestions from the world’s scientists for specific projects of a sort that might not otherwise get funded, which might meet these goals. Not surprisingly, since the foundation had announced a year earlier that it was making $200m available to pay for all this, hundreds of research groups lined up to dip their bread in the gravy.

A bold idea then, perhaps bordering on the naive. And that word was used more than once by Mr Gates, in a tenth-anniversary review meeting of the Grand Challenges in Global Health programme, as it is known, which was held this week in Seattle. He and his fellow board members had hoped their philanthropic version of venture capitalism would lead to breakthroughs in the search for vaccines and other treatments for widespread and destructive diseases such as malaria. A decade—and $1 billion—later, neither the original project nor its offspring, Grand Challenges Explorations (which gives seed money to young researchers rather than relying, as the original did, on established names) has thrown up any of the blockbusters that real venture capitalism requires to counterbalance the numerous, inevitable failures. Undaunted, though, Mr and Mrs Gates used this week’s meeting to announce a new set of challenges, this time spreading the net wider than the strictly science-based suggestions the programme has encouraged until now.

The story so far

Though not as spectacular as its organisers had hoped at the outset, Grand Challenges in Global Health has enjoyed at least modest success. Of the 44 original projects, a fifth are moving towards fruition and another fifth have worked in part. Scott O’Neill of Monash University, in Melbourne, for example, was one of the original challengers. He plans to attack dengue fever not by killing the mosquitoes which transmit it, but by making those insects immune to the virus that causes it. Conveniently, such immunity is conferred by a bacterium called Wolbachia. More conveniently still, this bacterium is sexually transmitted in a way that encourages it to become ubiquitous (it passes from mother to egg, and if an uninfected female mates with an infected male, her eggs will not develop—so the number of infected mosquitoes increases with each generation).

That might wipe dengue out, at least locally. Grand Challenges has therefore invested $44m in Dr O’Neill’s project, and the Wellcome Trust, the Tahija Foundation and the Gillespie Family Foundation, three other charities, have added more. Dr O’Neill and his team have begun field trials in Australia, Brazil, Indonesia and Vietnam, releasing Wolbachia-infected mosquitoes to see if these can establish themselves as theory predicts they should.

Another promising project, led by James Collins of Boston University, is attempting to create a drink laced with bacteria that kill other, cholera-causing bacteria after they have become established in someone’s intestines. Dr Collins’s genetically engineered bugs will produce anti-cholera drugs, and then disintegrate when their work is done. He has started a company, called Synlogic, to develop this idea and to investigate whether it can be extended to other diseases.

Tinkering with gut microbes to treat disease is all the rage now, so Dr Collins could be on to a good thing. But other grand-challenge ideas are more speculative. The “explorations” part of the project is, for instance, backing an astrophysicist who proposes to use lasers to herd malarial mosquitoes away from people, and a car mechanic who is trying to help the health of newborns by adapting a common car-repair tool to assist with difficult births.

One grand-challenges investment in neonatal health that is already paying off is a machine designed to stop the lungs of premature babies collapsing. Such machines have been around in rich countries for a long time but, at $6,000 a pop, the poor cannot afford them. Rebecca Richards-Kortum, a bioengineer at Rice University, in Houston, Texas, has developed a version that costs $400. These have been installed in 17 hospitals in Malawi, the country that has the world’s highest rate of pre-term births. The survival rate for premature infants born in these hospitals has, as a consequence, risen from 24% to 65%.

All of this is good, of course, and may end up justifying the original investment. But it is not quite the stuff of grands projets. The Gateses had been hoping for something more spectacular when the programme started. Hence, perhaps, this week’s change of course.

The new grand challenges are rather different from the existing ones. “All children thriving”, “putting women and girls at the centre of development” and “creating new interventions for global health” sound more like aspirations than proposals for action. Indeed, the third of them embraces 11 of the original grand challenges under a single heading. And this time the foundation is not going it alone. All sorts of partners, from America’s foreign-aid agency to the governments of Brazil, Canada, India and South Africa, are being recruited.

The new challenges are, in part, a response to criticism that the original ones were too technocratic. The Victorians, for example, got rid of cholera not by treating people who developed it, but by developing the political will to build sewers. More generally, public health depends on educating people and persuading them to change their behaviour, as well as on having the right medicines, as the example of HIV and AIDS eloquently shows. That sort of approach requires social change as well as appropriate technology.

Hot fuzz?

Ideas like “all children thriving” and “putting women and girls at the centre of development” do indeed ooze of social sensibility. Children will not thrive by the invention of a new vaccine if mothers are not convinced of that vaccine’s value—and those mothers are less likely to be convinced if they are poorly educated, which is why they need to be at the centre of development. The grand challenges’ change of direction thus makes sense.

And yet, what made the Gates’s original challenges such a refreshing approach was precisely their specificity. The whole bureaucratic apparatus of global health and development, from foreign-aid agencies to charities to the World Health Organisation is signed up to the idea of children thriving and of women and girls being at the centre of development. No right-thinking person believes these to be bad ideas. But they are often fuzzy ideas. If the Gates Foundation can bring to them specific proposals to improve matters, as it has tried to do with disease, then its change of tack may blossom. But if the Grand Challenges programme loses that specificity, and gets buried in the groupthink which pervades the field of international do-goodery, then a valuable alternative approach will, from a scientific viewpoint, have been lost.