Membership

Forum 2003: Address as Prepared by
Patty Stonesifer
Co-chair and President, Bill & Melinda Gates Foundation

Washington D.C.
May 20, 2002

Thank you, Rich, for that kind introduction. No foundation can make a difference in the developing world unless it has first-class partners on the ground, delivering services, getting results, and telling others about it. We count on the members of InterAction for your work and your advocacy. It's an honor to talk to you today.

As you might imagine, it is also an incredible honor for me to be leading our foundation in these early years - helping the Gates family try to reduce the worst inequities, that they see, by applying their wealth in a strategic way.

When you look strategically, you see that all the foundations and all the NGOs don't have enough money to make the lasting change we want to see in the world. We need the power of the public and private sectors working with us, and there is only one way to get it: bring 21st century advances in medicine, information, and education to people most in need. Bring hard evidence that these approaches are saving lives to the right audiences in business and government. Then prove to them that it will advance their financial and political interests to expand and sustain our work. That is advocacy, and that's what I want to talk about today.

Advocacy starts with love of neighbor. If we didn't have it, other people's suffering wouldn't be a problem for us; we wouldn't be here today. The theme is written into the scripture of every great religion; it's part of who we are: Love your neighbor as yourself. Today, as our world shrinks, our notion of neighbor needs to expand.

A few years ago I was in one of the worst slums in Delhi, participating in polio immunization day, when an old woman approached with a toddler perched on her hip. This toddler was the picture of health - but her grandmother's face was badly scarred. She was one of the very last Indian victims of smallpox, and she told me that she came that day to ensure her granddaughter would not suffer from disease as she had. She wanted to protect future generations. That old woman and her granddaughter are my neighbors.

They are also my teachers. They made me think - are we doing all we can to improve the future? None of us wants to spend our lives building sandcastles that wash away at high tide. We want to build something that lasts and changes the lives of future generations. We want to be good ancestors.

But will we? I think about the day a little girl will look up at me over the dinner table and ask: "Grandma, what did you do to stop AIDS? To stop hunger? To stop hatred? And how will I answer? Do you remember that book: "When Bad Things Happen to Good People?" There could be a companion volume, I'm afraid: "When Bad Things Happen in spite of Good People."

We know the list - the Nazi Holocaust, the Rwandan slaughter, America's centuries of slavery and segregation. They happened because bad people took action while good people stood by. Why did we stand by? I think it's because we too often think we are powerless, that we have no solutions to complex issues. Well guess what? We're not powerless - we have solutions. That's what you've devoted your lives to! But we need to make that case to others - to get them to believe that change is within reach, and to give us the support and the resources we need to move from love of neighbor to care for neighbor. That is advocacy.

We all have a special role to play. At the Gates Foundation, we believe our best role is in making the high-risk, front-end investments that can build and prove a solution. That's why we're investing a significant percentage of our resources in building low-cost, life-saving interventions, especially through vaccine research. It means a lot of trial and error - in fact sometimes a lot more error than business can afford and government can justify - but the more trial and error, the more knowledge gained, and the better the chance of a breakthrough. So that's where we're focusing most of our spending. But even if we fund historic breakthroughs, we do not have the resources to make our work reach all our neighbors in need and all our neighbors not yet born. For that, we absolutely need business and government to expand it and sustain it. And that, again, is why we need advocacy.

I'm going to tell you my worst nightmare - and it starts with a wonderful dream. My dream is that one day, in the not too distant future, there will be worldwide rejoicing over the discovery of an effective AIDS vaccine that will help us save six million lives a year. But then, the dream switches to a nightmare: We don't have a way to distribute it. We just stand by and continue to let millions die.

Unthinkable you say? I am afraid to tell you - it is totally thinkable - because that is exactly what we are doing today - in measles, in diphtheria, in tetanus, in hepatitis B. In the year 2000, more than three-quarters of a million children died from measles. Five hundred thousand people died from hepatitis B that same year because they didn't receive a vaccine that costs 3 or 4 pennies per dose. Every year in the past 5 years, 37 million children went unvaccinated with the basic EPI vaccines. That failure will cost the lives of nearly 20 million children. And why?

At the immunization day event I attended in India, we were immunizing for polio. Fifty years after we made the vaccine, young people are still getting polio, because we still haven't wiped it out. Who'd like to explain that to Franklin Roosevelt?

In the late 1970s and through the 1980s, a huge push was made for immunization by a charismatic leader you may know - Jim Grant - the head of UNICEF. Because of his focus, his personality and drive, immunization rates in the developing world went from an abysmal 15 percent up to 80 percent. An enormous amount of lives were saved. But when Jim was no longer leading this effort - immunization around the globe started sliding. Now, in sub-Saharan Africa 50 percent of children are not immunized against basics like measles and tetanus during their first year of life. We've made these vaccines; we've proved them in trials; we've delivered them around the world; and we've shown that they save lives. Still, they don't reach millions who need them. Again, we have to ask why?

The short answer is that ultimately, comprehensive, sustainable solutions must be driven in part by market and political forces; they cannot be sustained by charity alone. Unfortunately, as you well know, market forces and political forces don't work naturally to solve problems in the developing world. The private sector generally is not developing or delivering medicines for poor countries because poor people can't buy them, and rich governments are not fighting these diseases because the rich world doesn't have them.

Some say if the problem is systemic; you can never solve it. I say you can solve a systemic problem if you change the system. We have to build systems that reduce inequities in ways that give business the profits they need to stay in business and to build their enterprises, and give politicians the votes they need to stay in office and to lead the populace. Only then, will that put the power of government and business behind us.

A few years ago, with those same goals in mind, we helped launch the Global Alliance for Vaccines and Immunizations. GAVI is a collaboration of foundations, multilateral organizations, the vaccine industry and governments, all committed to vaccinating every child, everywhere.

At the beginning, we found that some vaccines were sitting on shelves for lack of purchasing, and other necessary vaccines were not even being manufactured. We're now setting up a system to make market and political forces work more favorably against the disease burden in the developing world. GAVI is putting up money to guarantee purchases so pharmaceutical companies can make a little bit of money, or at least not lose their shirts with unused supplies. They're bringing business practices into it by introducing supply/demand forecasting. They're determining commercial market mechanisms that can take some of the jaggedness out of the demand and guarantee a different kind of purchase cycle. And they're working with both donor governments and recipient governments to show the benefits of the effort and urging them to play a vital role in delivery and funding.

As a result, millions more people are being vaccinated, which translates into thousands of lives being saved every year. But no one's saying: "mission accomplished." Our goal is to build a system that is working now, and perhaps more importantly, still working a generation from now. No combination of foundations and NGOs can build that system or sustain it. It takes a system propelled by political and market forces. We can build that system only by proving to all of these partners that their participation will pay off in better lives, in political support, in financial return; in whatever drives the engines of their institutions.

Effective advocacy is about recruiting partners to turn a proven approach into a permanent solution. In my view, it has four steps: Situation. Action. Evidence. And Audience. You identify the situation that needs to be changed. Then you take action to help change it. You gather evidence that your action is working. And you present it to the right audience - the people who can expand it and sustain it. It may sound simple, but I believe most people who believe they're effective advocates for change - including many of the organizations who apply to us for funding - are missing at least one and often more of these key elements.

Nearly all advocates point to the urgency of the situation. Situations must be told in powerful stories that bring the suffering close to us and make us feel a love of neighbor. But as we paint the situation, we have to identify the action that can be taken. Talking only about the situation and not the solution makes potential partners turn away and makes potential advocates feel ineffective.

Yet even those who take great action often fail to produce great evidence - evidence that illustrates clearly - with math - what a dollar invested in your actions will return in reduced suffering or increased opportunity. I know it is hard to divert dollars badly needed for action into dollars needed to measure the impact of that action. But we need more evidence. The most common charge against our work is that the money is wasted. We all know it's often a false statement, but an effective one - even when it's offered without evidence. Without our own evidence, we have no way to prove the skeptics and the naysayers wrong. The burden of proof is on us.

Once we have the evidence, we've got to bring it to the right Audience. We have to decide what audience could block our efforts, if not neutralized by stronger voices - and what audiences could advance our efforts, if armed with the right evidence.

A few years ago, some advocates recognized that Senator Helms was a pivotal audience for AIDS funding. So people Senator Helms trusted and respected presented him with a situation he was moved by - in this case it was infants infected with HIV at birth. They told him of actions that would address that horrendous situation - again, in this case it's using nevirapine to prevent mother-to-child transmission. They then gave him evidence of how a very reasonable amount of U.S. funding could directly result in saving children's lives. They felt this would move him - emotionally, morally, intellectually, politically - and it DID! Love of neighbor became care for neighbor. Senator Helms described it in those terms, and what a key advocate he then became. He's been a bridge of credibility to new groups of supporters for addressing the horrific AIDS situation.

This same approach has helped us in our efforts to vaccinate every child. We saw a situation where children were dying from preventable causes. We believed the most effective action was to build a system to manufacture and deliver vaccines and are committing more every year. We've taken those actions, built our evidence, and brought it to the right audiences. Today our government and seven others have now given $400 million to manufacture and deliver vaccines, and are committing more every year. As evidence of our success grows, we hope to increase funding by an additional $1 billion over the next five years. We hope to reach more children and provide these children with access to more life-saving vaccines.

We need to make the most of these lessons. Let me ask you for a moment to do an exercise with me. Think for a moment about the situation that has captured your heart and forced you to take action - maybe it's poverty or hunger or disease; and think about the different actions you're taking to address it: whether it's educating girls, fighting infant mortality, offering micro-enterprise loans. Now - here's where it gets harder: What evidence do you really have that your action is working? What piece of evidence could really prove the value of your work - fewer infant deaths, more young women equipped to enter the professional workforce, more entrepreneurs supporting their families? What are you doing to gather that evidence? Finally: Who is your key audience? A news organization? A political leader? The head of a religious group? Who could really advance your cause; what are you doing with your evidence to win them over?

The world is riding on your answers. Your piece of the challenge may seem small to you - but when the President of the United States proposed $15 billion to fight AIDS, it was the culmination of thousands of tiny efforts at advocacy that started years ago and miles away in places like Thailand and Uganda, when people first began to take action, began to save lives, and began to build evidence. Now their evidence has reached the right audience. Thailand and Uganda's approach is now held up as model for how the U.S. will consider its next steps in the battle against the global spread of HIV. There are signs that this country is opening its heart to your work and is willing to turn Love of Neighbor into Care for Neighbor. This is a precious opening for us. Let's claim our moment.

Keep pressing on. Keep gathering evidence that what you do works. Keep on talking to people who can expand it and sustain it. As you make your case, never forget that part of your evidence is your own credibility. Poll after poll shows that people have more support for foreign assistance if the money flows through you and not through governments. People trust you. Make the most of it.

Also, many of you here are from faith-based groups. That gives you added credibility in the eyes of many. Debt relief would not have happened without the passionate backing and the moral message of religious organizations. If you make your case well enough and often enough -- to donors, to your own congregations, to politicians -- you can help make the morally right thing to do become the politically smart thing to do. Senator Helms and President Bush both explained their AIDS initiatives by referring to the wounded traveler on the road to Jericho. They know their audiences. We should know ours.

The worst thing that could happen is for us to think that the little evidence each of us has - or the little audience each of us knows - isn't enough to make a difference.

Let me tell you what keeps me striving - what keeps me convinced of the need to make a difference. In 1999, President Mandela came to Seattle to meet with us at the Gates Foundation. On the second day of his visit, when he was speaking at a breakfast in Seattle - in a room like this one, to a group like this one, full of civic leaders committed to change, he said quietly and simply and elegantly:

"Would all those of you who took personal action, any action big or small, to end the terrible injustice of apartheid, please stand up." And then he said… "And will those of you who took personal action, something - anything - big or small, to help me walk free from Robben Island please stand up."

The next 60 seconds made up the longest, most painful minute of that decade for me and many others in that room. The power of the moment was magnified by the bearing of President Mandela - there was no anger in his question, there was no recrimination, he was not judging us, he was simply asking us to judge ourselves.

And to a person, we found we all came up short. Those of us who had done nothing wished we had done something, and those of use who had done something wished we had done far, far more.

I asked myself that day and almost every day since - why didn't we act? Why didn't we do more? We all believed his cause mattered. Perhaps we believed our efforts didn't matter. We knew there was a problem; we didn't believe we could have a part in the solution.

That gives us our mission right now. There are millions - millions - of well-meaning people who are sick at heart over the suffering of our neighbors. But they are like the people left sitting in front of President Mandela - they don't know how they can change the world.

So we must show them. We must turn our stories into evidence and bring our evidence to the right audience, and say: "See this suffering? Here's the solution. You're part of it. Here's the proof. So let's get moving."

If together we can prove there are solutions to the problems that paralyze us, then the next time a leader like President Mandela stands in front of a room like this one and says "What about you?" Have you taken action against inequity and injustice?" then I will stand and you will stand and people around the globe will stand and say, "Yes. Yes, we have." And we will show him the evidence of the great change we've made. Thank you.