'All Lives Have Equal Value': Reducing Inequality with Precision Public Health

Editor's Note: Susan Desmond-Hellmann's remarkable career includes leadership positions in the pharmaceutical industry, academia, and global public health. In this One-on-One interview with Medscape Editor-in-Chief Eric Topol, she talks about the many chapters of her career, focusing on the launch of a "precision public health" movement in her current role as CEO of the Bill & Melinda Gates Foundation.

This week, the University of California, San Francisco, in partnership with the White House and the Bill & Melinda Gates Foundation, is hosting a Precision Public Health Summit to discuss how precision medicine can be used to solve pressing global public health problems.

Roots in Napa, Home in Reno

Eric J. Topol, MD: Hello. I'm Eric Topol, editor-in-chief of Medscape. Today I have a legend in medicine, Sue Desmond-Hellmann, who has had a multidimensional career. She is currently the CEO of the Bill & Melinda Gates Foundation.

You grew up in Nevada, in a large family of seven kids, and your parents were a pharmacist and an English teacher. You went to the University of Nevada before you left, after medical school, for Berkeley?

Susan Desmond-Hellmann, MD, MPH: I grew up in Reno, Nevada, but my dad is a San Francisco native. I was born in Napa. That's very rare, because it was a tiny town back then.

When there were three kids in our family, my dad packed up and moved to open a family-owned pharmacy back in the boom days of Reno. When I came back to the University of California San Francisco (UCSF) where I did my residency, chief residency, and fellowship, I lived for a while down the street from my grandma. So I'm a California native, but I consider Reno my home.

In Uganda: The Early AIDS Epidemic

Dr Topol: Some amazing things happened early in your career. After training in public health at Berkeley, you went to Uganda for a couple of years, right?

Dr Desmond-Hellmann: I did. I think people forget about the early HIV epidemic. As a reminder, people talked about "3 H's"—homosexuals, hemophiliacs, and Haitians—back in those days, and they called HIV "gay-related immune deficiency" (GRID).

It just shows you how incorrect we were in our understanding of HIV. In the late 1980s there were rumblings that HIV was hitting sub-Saharan Africa and that it was being transmitted through heterosexual sex. Back then, people didn't believe that. They actually believed that it was so unacceptable to be gay in sub-Saharan Africa that people were fibbing. News of this came back to the Rockefeller Foundation. And the Rockefeller Foundation called up people, including Merle Sande and Dick Root, neither of whom are with us today. They were the principal investigators of a Rockefeller-funded grant to study heterosexual transmission of HIV in Uganda, and UCSF loaned two of its young faculty members to oversee this grant and work in Kampala, Uganda, before Global Health or any of that existed. My husband Nick Hellmann and I were those two young faculty members. I had trained in oncology and HIV. My specialty was Kaposi's sarcoma, and my husband was an infectious disease doctor.

Changing the Face of Cancer Medicine

Dr Topol: After that you were with Bristol-Myers Squibb.

Dr Desmond-Hellmann: I went to Bristol-Myers Squibb in their oncology division at the time, and they had a little drug that had just been approved, called Taxol. It had one indication, for use in advanced ovarian cancer, and the company was about to embark on two very critical approvals based on a big phase 3 trial. One was an approval for breast cancer in the United States, and the other was approval in Europe. They were very busy and needed an extra pair of hands. I became the drug safety person on Taxol. I think they thought that I couldn't do too much damage doing drug safety.

Dr Topol: Then you went on to a very remarkable phase in your career—14 years at Genentech, right? You were looking after Avastin and Herceptin, the first real personalized drugs in medicine.

Dr Desmond-Hellmann: Yes. Genentech had no cancer drugs, but Art Levinson, who was the head of research and development when I was recruited, outlined a dream for me that I was moved by. So even though I was by then the project leader for the Taxol team at Bristol-Myers Squibb, and it was the company's number-one seller and Bristol-Myers Squibb was doing great, Art's science vision, and his sense that all of the research at Genentech could translate into something powerful, captivated me. I probably took a one-level demotion, but I didn't pay any attention to that. I went to Genentech in 1995. Genentech did the deal with Biogen Idec on Rituxan soon thereafter. So I was able to participate in, and eventually lead the product development for, Rituxan, Herceptin, Tarceva, Avastin, and Lucentis in eye disease during the time I was at Genentech. It was an amazing, fantastic experience with all of my colleagues that I still look back on fondly.

First Female Chancellor at UCSF

Dr Topol: The most surprising thing for many was that they wouldn't take you back at UCSF, but then you were invited to be the chancellor of UCSF. What was that like?

Dr Desmond-Hellmann: Coming into the university, it was 2009—right on the heels of a terrible recession. UCSF is a public university, so when I started I was under water. I didn't know as much about academia as I wished I knew—for example, how things really work—so I had a steep learning curve. We lacked money and resources. I needed to focus right away and was scrambling to make sure that we were going to be okay financially. I was working with the academic medical center and all of its programs to make sure that we weren't losing faculty or losing our excellence as a result of these fiscal constraints. I wanted to be able to say in leaving the university in 2014 that I Ieft it a better place, and I feel very confident that it's a better place.

Returning to Global Public Health

Dr Topol: Then you got a call from Bill and Melinda Gates, and they say, "We want you to run the Gates Foundation." Was that something that you were thinking of going back to—a kind of global health mission?

Dr Desmond-Hellmann: That was not the plan in any way. It was not on the life plan or the career plan. But a couple of things made a big difference. There's something deeply profound about what Bill and Melinda are trying to accomplish with their foundation and Warren Buffett's support. That's why I made the decision to leave UCSF, which was excruciating. It was gut-wrenching. I was driving both Bill and Melinda (and myself) crazy over this decision. It was a hard decision, because I love UCSF and am passionate about the work, but the Gates Foundation is deeply serious about inequity. They have a way of taking this vision, which is that all lives have equal value, and profoundly trying to make that real. No matter where you're born, who your mom and dad are, or what your conditions of coming into the world are, you should have a chance to have a healthy and productive life.

What does that mean? In the United States, that means supporting education. For a long time in the United States, education has been the great equalizer. Regardless of how you were born, you would have every opportunity in the world. So education is our focus as a foundation in the United States. Outside of the United States, it's health. Global health is extremely important to the foundation, and that's some of what I wrote about in [my recent CEO] letter. Increasingly, however, it goes beyond health. We support agriculture outside the United States because we would like to help smallholder farmers be more productive, so that the farmer can feed his or her family and maybe make some money.

We also invest in mobile money, water sanitation, and hygiene. We're known for our toilet fairs and innovation on toilets. What all of these have in common is that everyone has a chance at a healthy and productive life.

Dr Topol: You have made pretty remarkable headway in a short period of time. There is no polio in Africa; polio is found only in Pakistan and Afghanistan now.

Dr Desmond-Hellmann: Progress is being made. The global health community has really changed since my days in Uganda, and I think this is worth celebrating. Fewer people in the world are poor. In 2015, Bill and Melinda put out a series of big bets. They sent out a letter in early 2015, and their biggest bet was that progress in the next 15 years (by 2030) would lift more people out of poverty than at any other time in human history. That's pretty profound. They are optimistic about that, because we're making so much progress.

Polio is a good example. When I joined the foundation, Nigeria, Pakistan, and Afghanistan were the three difficult countries in the world where wild polio still existed. With our partners, we committed to having a vaccination health surge in Nigeria. If the African continent becomes wild polio–free, then the world could turn its attention to Pakistan and Afghanistan. Africa and Nigeria now have been polio-free for 21 months. But no one is celebrating. We're still deeply concerned about coverage and vaccination in the continent of Africa, and nobody's taking their eye off of that. The way polio works is that you get certified as polio-free after 3 years by the World Health Organization. But that success in Nigeria allowed us to focus on Pakistan and Afghanistan. As of about 2 weeks ago, there had been 14 cases in the world this year. So we are literally end-game on polio. The only human disease that has ever been eradicated in the world is smallpox, and that was in 1979.

Dr Topol: What I love is that you are thinking about planetary health. Most of us are happy to just make a little bit of a difference. You are doing some really big stuff.

Dr Desmond-Hellmann: It's good to be ambitious.

Network Effect and Behavior Change... on Facebook

Dr Topol: Besides what you are doing on a global scale, you have other interesting connections and no shortage of stimulation. You have worked with Mark Zuckerberg and Sheryl Sandberg on the Facebook board. What is it like to be in the midst of one of the largest communities of people by far in the world, with 1.65 billion active users? What is it like to be part of that network?

Dr Desmond-Hellmann: As chancellor, I started learning much more about obstacles to great health. As an oncologist, I always knew that controlling tobacco was one of the single most powerful things anyone could do. It's the only thing on earth that kills half of its users when used as directed. That's pretty profound. But if you start to look at diabetes, heart disease, and cancer, one of the keys to success is behavior change. And we're not very good at behavior change. I read a paper about the network effect and behavior change. The paper said that if your friends smoke you smoke.

Dr Topol: Is that the Nicholas Christakis and James Fowler work?

Dr Desmond-Hellmann: Exactly. I became fascinated by the network. My husband is a big cyclist and he eats a healthy diet. I'm a big cyclist and I eat a healthy diet. Our friends do that. The network effect resonated with me; it was really powerful. We used to call it peer pressure, but I wondered whether that could scale from a medical and health perspective. So, ironically, my public health way of thinking led me to be interested in learning about the social network and Facebook.

Mark invited me to be on the board. I signed up 3 years ago now and I am profoundly interested in how people connect—how people share and connect, and how that could contribute in a positive way to the human condition.

Dr Topol: In meeting with both Mark and Sheryl, I have begged them to harness this power. When they did that for transplants, for people to donate their organs, it had a profound impact. If they started to do that more, of the tech titans—Google, Apple, IBM, Microsoft—they are the ones who haven't taken their power forward enough for health.

Dr Desmond-Hellmann: Here's a great story. You know Kathy Giusti, who runs the Multiple Myeloma Research Foundation. Kathy talked to me a few years back, but it's a story that I've never forgotten. There had been a lot of advances in myeloma. Things in multiple myeloma are better than they were. But there was a genetic variant that affected about 15% of all myeloma patients. There was no remedy for them, and that's a small market. So this group of patients learned about each other by connecting through the Multiple Myeloma Research Foundation Facebook site. They were connected and talking. That group of patients went to Genentech and other biotech companies and made a value proposition: that if a company would make a targeted therapy for this variant of multiple myeloma, they would have a clinical trial that they could enroll in in 1 hour. Even though they might not make as much money as if they were to develop a lung cancer drug or a big-market drug, they would have a targeted, ready clinical trial population.

When I heard that story, I thought, "Think of the power of being able to do precision medicine in such a profound way." This ability to connect people, the impact it could have on behavior and that network effect in a positive way—we are at the tip of the iceberg right now.

Dr Topol: I couldn't agree more. We have seen so many rare but novel diseases where we have been able to go from one case to finding 10-20 through Facebook.

Dr Desmond-Hellmann: Another example is chronic myelogenous leukemia and Gleevec. It started small. And we thought that GIST, a stomach cancer, was rare. But come to find out, if you start to look, you will find—we did this with Rituxan—many more lymphoma patients being treated with watch-and-wait. This thinking about moving from a disease by body part to moving to disease by target is transformational.

A Transformational Career

Dr Topol: Speaking of transformational, you fit into that category. I don't know anyone else who has done so many different things in a career and is still going. You have plenty more. What further chapters do you envision in your career?

Dr Desmond-Hellmann: Here's the thing I'm passionate about now. I'm all in at the Bill & Melinda Gates Foundation. I am learning so much. I am moved by the work. I'm so passionate that we make a difference in the world.

One thing that I'm mad about is that problems that affect the world's poorest are underserved. That is what led Bill and Melinda down this path. They couldn't imagine that for preventable diseases like measles and mumps, kids would go without a vaccine anywhere in the world. These are cheap vaccines that prevent diseases. That same sense of fairness and equity has me thinking about something that I've spent more time on, particularly in the past 6-12 months. The world that you and I were trained in has changed dramatically. People who care about innovation in medicine have ubiquitous smartphones. They have self-monitoring. They have low-cost sequencing. They have electronic health records and they have big data. All rich people have tons of folks working on how to improve health using all of those tools. And then I see people who are public health and global health experts in Ethiopia, northern Nigeria, or India. And the Minister of Health is thinking, "Here is my tiny number of resources, here are my frontline healthcare workers. How am I going to deliver something to moms and babies to decrease suffering and prevent preventable deaths? How can I innovate? What's there for me?"

So I started pushing myself to answer the question, "How can we bring these two worlds together—this world of wonderful need and spirit in public and global health, and this world of technocrats who are innovating. How do I merge those two worlds?" So I started talking about precision public health.

The way that I think about precision public health is going from N equals 1—right therapy for the right patient at the right time—to 1 of N, the way a population-health person would think of it. This community, this population, this subpopulation needs a package of interventions, and the public health department, the Ministry of Health, is thinking about interventions at a community and population level, so you have the right set of interventions for the right population in the right geography. It's a pretty big move from one to the other. But for me, right now, it's about as inspiring as anything I've spent time on.

Dr Topol: That cuts across population health to a highly intelligent solution. I look forward to seeing your TED talk on this topic. You have given some deep thought to this and have some great ideas. I use the term "legendary" because I don't know anyone who has done so many different things and who's still rocking it. I congratulate you on your career. And what you are doing with the Gates Foundation is so much bigger than what we were just talking about in this country. If anybody fulfills the description of being one of the most interesting people in medicine and healthcare, it's got to be you, Sue. Thanks for joining us on Medscape.

Thanks to all of you for joining us for this conversation with Sue Desmond-Hellmann. We'll be back with some other really fascinating people in medicine.