TIME health

How the Gates Foundation Aims to Cut Childhood Mortality in Half

Filling bellies: Melinda Gates and the Gates Foundation are going after one of the leading killers of babies
J. Countess; Getty Images Filling bellies: Melinda Gates and the Gates Foundation are going after one of the leading killers of babies

Jeffrey Kluger is Editor at Large for TIME.

A new grant will go straight after a leading killer of kids under five: undernutrition

Correction appended, June 3

There are a lot of ways to think about child mortality—most of them not very pretty. You can think of the 6.3 million children every year who never live to see their fifth birthday. You can think of how that breaks down to the loss of 17,260 babies every day, day after day, for 365 days.

But you can also think that those terrible numbers are exactly half of what they were in 1990, meaning that last year, 6.3 million children who would not have seen age five did. Most of that extraordinary progress has been made by controlling, treating or vaccinating against preventable diseases like cholera, measles, pneumonia and malaria. Now, the Bill and Melinda Gates Foundation proposes to slash the child mortality rate in half once more, announcing a plan to invest $776 million over the next six years to advance one of the most primal and important health interventions of all: giving kids enough to eat.

Death by starvation or undernutrition can be hard to track, because while it’s not always the proximate killer, it’s often the accomplice. Expose a well-nourished child and an undernourished child to, say, the measles virus and it’s no mystery which one of them has a better prognosis.

“Estimates are that in about 50% of all of the remaining under-five deaths, nutrition played at least a significant role,” said Melinda Gates in a conversation with TIME.

The Foundation aims to change that in a lot of ways—little of which will involve the old bags-of-rice-offloaded-at-the-airport model. Emergency supplies can fill gaps in times of natural disasters, but they are, as Gates calls them, downstream strategies—sustainable only as long as the supplies keep flowing from generous benefactors. Upstream strategies involve putting systems in place so that generous benefactors are eventually not needed.

Part of the new strategy will involve providing seeds and the know-how for planting and harvesting such bulked-up crops as golden rice, the super banana and the fortified sweet potato. These and other GMO foods have caused all manner of controversy in the developed world, but people like the Gates focus on the increased vitamin A in such crops, which builds skin, teeth, bones and soft tissue and has anti-oxidant properties.

Instruction will also be given in no-till agriculture and drip-irrigation, which conserve both water and soil. Research stations will be opened in targeted areas to increase public awareness of both the existence of the crops and the best ways to raise them. And a special effort will be made to put this knowledge at the disposal of the family member who is likeliest to make the best use of it: the mother.

“Fifty percent of all farmers in Africa are women,” says Gates. “And research shows that every extra dollar a woman gets is 90% likelier to be put back into the family than a dollar a man gets. We want to put women at the center of this.” Expanding wireless access is another key part of the program, allowing farmers—men or women—to have ready access to commodity prices, so they can sell their crops at the top of the market.

Women are central in other ways too. Good nutrition starts before a baby is born, and most health experts believe it is the first 1,000 days—from conception through age two—that make the greatest difference in long-term physical and intellectual development. That means educating young women and adolescent girls about proper diet before they get pregnant, and encouraging breastfeeding after birth.

The Foundation will also be pressing to get government and religious leaders to climb on board—or at least get out of the way. “We need governments to impose the regulations needed to get the most out of nutrition programs,” says Gates. “We can do that by showing them the evidence. Brazil, for example, has gotten its malnutrition rate down by 80%. So we show that data and say, ‘Now it’s up to you to decide.'”

And while Taliban extremists have tried to block polio vaccination efforts in Pakistan, that kind of deadly obstructionism is hardly true of all parts of the Muslim world. “Nigeria has a high Muslim population and they have said ‘We will help you,'” Gates says,—and not just in matters directly related to food. “The Koran allows for family planning and we can get that message out.”

For now, the Foundation’s funds will be concentrated in five critical spots: India, Ethiopia, Nigeria, Bangladesh and Burkina Faso. That money will be supplemented by even more. The Gateses’ grant frees up $180 million in partial matching funds from the U.K.’s Department for International Development. The European Union, meanwhile, has pledged a whopping €3.5 billion by 2020 to battle child malnutrition.

That’s a big number—but it comes from a bloc of 28 nations. The Gates grant comes from a couple with a foundation and a mission. If that mission includes saving 17,260 babies every 24 hours, well, that’s a pretty fair day’s work.

Correction: The original version of this story misstated the amount of money the Bill and Melinda Gates Foundation is investing. It is $776 million.

Read next: Here’s What’s on Bill Gates’ Summer Reading List

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TIME health

How to Save More Than 14 Million Newborns By 2030

YEMEN-HEALTH-CHILDREN
MOHAMMED HUWAIS—AFP/Getty Images A Yemeni mother holds her malnourished infant at a therapeutic feeding centre in the capital Sanaa on December 9, 2014. Over one million Yemeni girls and boys under 5 suffer from acute malnutrition, including 279,000 who suffer from severe acute malnutrition (SAM), in a situation exacerbated by political instability, multiple localized conflicts and chronic underdevelopment, according to UNICEF.

Bjorn Lomborg is president of the Copenhagen Consensus Center, a think tank ranking the smartest solutions to the world's biggest problems by cost-benefit.

We would be wise to target neonatal deaths and cervical cancer

In a world where there are so many worthwhile targets demanding our attention, we need to focus on those for which we have the best chance of doing the most good. How about saving more than 14 million newborns by 2030? That’s a pretty eye-catching figure, but one which the author of a new analysis for the Copenhagen Consensus believes is not only achievable, but also highly cost-effective.

Günther Fink, from the Harvard School of Public Health, is a one of more than 60 expert economists my think tank has asked to make the case for a wide range of key targets that the world’s governments and the UN are currently debating, the so-called Sustainable Development Goals. These will shape global progress over the next 15 years, so it’s important to get them right.

Is it really possible to make such a dramatic difference in the survival of newborn babies? Past experience would suggest that it is. UN figures show that nearly 18 million children round the world died before reaching the age of 5 in 1970, while in 2013 that figure had come down to just above 6 million. This is still way too high, of course, but it’s nevertheless a very impressive figure when we realize that the number of children born annually has increased during those 40 years. The headline is that the number of under-5s dying per 1,000 live births fell from 142 to 44, a 70% drop.

The problem is that the more progress you make, the harder the remaining targets are to reach. Much of the progress in controlling infant mortality since 1970 has been in areas such as controlling infectious diseases and improving nutrition. Progress in this should and will continue, but this won’t be as rapid as before. It’s a sobering thought that, with the current birth rate, under-5 mortality would still exceed 4 million each year even if all infectious diseases were eradicated. One of the biggest challenges going forward will be providing high quality care to newborns, particularly to those born too early and with low birth weight. Deaths in the first seven days after birth are virtually one-third of all under-5 deaths, and premature birth is the biggest single cause, accounting for half of these.

As well as the perils of prematurity, birth complications and sepsis are significant causes of deaths of young babies. Proper care can have a really big impact, but it costs money to build more clinics and train and pay more doctors and nurses: about $17.3 billion a year to hit the target of a 70% reduction in neonatal deaths, according to estimates. That sounds like a lot, but the benefits are much bigger at more than $120 billion annually. Using standard health economics methodology, every dollar invested yields $9 in benefits.

Reducing infant mortality is not the only good target, of course. One that gets a lot of attention is access to contraception, which enables women to have children when the time is right for them, gives them better employment prospects and enables them to invest more in their children’s future. A dollar spent on this could pay back perhaps 120-fold.

But while family planning is high profile, there are other good ways for the international community to invest in women’s health. This was analyzed in another paper from Dara Lee Luca and colleagues from Harvard University. The fourth most common cancer among women globally is cervical cancer, with half a million cases diagnosed annually and more than 200,000 deaths each year. Eighty-five percent of cases occur in the developing world, where it is the second deadliest cancer among women, after breast cancer. Its impact is particularly great because it also affects younger women who are raising and supporting families.

Fortunately, many of these cases are preventable, because nearly all are associated with a viral infection, and a vaccination is available. The vaccine is more expensive than most and three doses are needed, but in total, a course of treatment in developing countries would cost $25 per girl. Vaccinating 70% of girls in one cohort throughout most of the developing world would cost about $400 million and would save 274,000 women from dying, often in the prime of their lives, from cervical cancer. For each dollar spent, we would do more than $3 worth of good.

Health is obviously high on everyone’s agenda, but the escalating costs in rich countries shows there are no easy answers. Choosing the best targets for the international community to support between now and 2030 is going to be important if we are to do the most good with the resources available. Dealing with neonatal deaths and cervical cancer could be two of the smart targets we should choose.

Bjorn Lomborg is president of the Copenhagen Consensus Center, a think tank ranking the smartest solutions to the world’s biggest problems by cost-benefit.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME infant mortality

Saving 3 Million Babies Is Easier Than You Think

Melinda Gates: it's time to save the rest of the babies
Thomas Imo; Photothek via Getty Images Melinda Gates: it's time to save the rest of the babies

The news on the childhood mortality front is both very good and very bad. Millions have been saved, but millions are still dying. Melinda Gates, in an address to the World Health Assembly, offers some smart solutions.

No one will ever know the names of the 17 million babies who didn’t die last year. Nearly all of them live in the developing world and nearly all of them would have been lost to preventable conditions like measles, cholera or malaria. But that didn’t happen. Instead, they were born healthy and most of them stayed healthy and will be celebrating their first birthdays sometime this year.

That’s part of the very, very good news about childhood mortality, defined as the death of children before their fifth birthday. Since 1990, when the United Nations drafted its Millennium Development Goals—eight broad targets for human health and equality—childhood mortality rates have fallen 47%, which, when corrected for population growth, yields those 17 million lives saved last year. But that means that 6.6 million babies and small children still died. That’s the equivalent of 18,000 every day, day after day, until the year ended. Unless things change, that pattern will repeat itself in 2014, 2015 and beyond.

The answer, however, isn’t simply doubling down on the strategies that have worked so far, like getting vaccines, antimalarial bed nets, cholera rehydration fluids and more to the people who need them. Those interventions must continue, but as Melinda Gates, co-chair of the Bill and Melinda Gates Foundation, made clear in an address to the World Health Assembly in Geneva today, they’ve worked so well that the overwhelming share of the remaining deaths are caused by other problems entirely—ones that occur far earlier in the babies’ very short lives.

Each year, Gates said—citing, in part, exhaustive new studies by The Lancet—2.9 million children die in the first month of life and 1 million of those die almost immediately after birth. Worse, an additional 2.6 million babies each year are stillborn at some point in their third trimester—a death toll that is not even counted in the 6.6 million figure.

But, Gates stressed, the majority of newborn deaths are preventable. “I want to be very clear about what I mean when I say preventable,” she added. “I don’t mean theoretically preventable under ideal but unrealistic circumstances. I mean preventable with relatively simple, relatively inexpensive interventions.”

In most cases, actually, those interventions are entirely free. There are five protocols neonatal health experts recommend to cut newborn mortality dramatically and three of them are simply drying the baby completely after birth to prevent hypothermia, breastfeeding within the first hour of life and breastfeeding exclusively for the first six months if possible, and practicing what’s known as kangaroo care—or skin-to-skin contact between a baby and its mother or at least another adult caregiver as much as possible. Even in the developed world, kangaroo care is only now being broadly appreciated and adopted, particularly in neonatal intensive care units, where studies show that respiration, heart rate, blood pressure and a whole range of other vitals strengthen and stabilize when babies are held. Kangaroo care also increases the flow of breast milk in the mother, thanks mostly to elevated levels of the hormone oxytocin—colloquially known as the cuddle chemical.

Also important is the availability of resuscitation masks for babies who stop breathing at birth or shortly after. A mask and basic training in its use cost only about $5—nothing at all compared to the cost of caring for a sick or dying baby over the longer term. Finally, health specialists call for universal availability of the antiseptic chlorhexidine—at a cost of just a fews cents per application—to clean the end of the umbilical cord after it’s been cut and prevent what can be fatal infections.

“These are the best practices that work everywhere,” Gates said, “but that aren’t being used optimally anywhere.”

Inevitably, questions of cost are raised, but as with nearly all preventive measures, intervening early is almost always cheaper than dealing with problems later. In the U.S., an estimated $10 billion is spent each year to help babies deal with the health effects of not being sufficiently breast-fed. In the developing world, studies show that every $1 of neonatal intervention pays back $9 down the line, as families grow healthier, countries grow more stable, and economies are allowed to flourish.

Money, of course, is only one of many considerations—and a lesser one at that. It’s the moral component, the human component that we’d like to think will govern our choices. Even if saving the lives of babies were more expensive than it is, can you name a way that that money could be better, more humanely spent? The policymaker who can answer that question ‘yes’ is perhaps a policymaker who needs another job.

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