In December 2000, Tom Paulson, the science and medical reporter for the Seattle Post-Intelligencer, visited Africa for a month to report on the impact of Bill Gates' philanthropic efforts to improve health care in the Third World. He was accompanied by photographer Mike Urban.
The Seattle-based Gates Foundation will provide at least $5 billion over the next 10 years for global health. The approach supported by Gates focuses on vaccines as perhaps the single most effective public health intervention for the Third World.
Seven of every 10 people infected with HIV worldwide live in Africa. In 1999, AIDS killed 2,154,000 Africans. As frightening as those numbers are, mortality from vaccine-preventable diseases is even worse. Respiratory infections, diarrheal diseases and measles together killed more Africans in 1999 than AIDS did. Malaria claimed nearly a million lives that year, while tuberculosis killed 357,000 Africans.
Paulson’s special report ran in the Post-Intelligencer in March 2001. The newspaper’s web site featured articles and color photographs, along with a reporter's journal, statistics on world health, and information on the organizations and personalities involved. To read the special report, see Dispensing Hope: Bill Gates' Global Health Gamble.
Martha Henry, program coordinator for the Knight Fellowships, asked Paulson about his experiences in Africa and the series that followed.
HENRY: Whose idea was the series?
PAULSON: It was my idea. But it might be worth mentioning that I didn’t really pay much attention to the Gates Foundation's global health effort until it gave $750 million to launch the Global Alliance for Vaccines and Immunization in January 2000. It seemed like a lot of money and I started asking around to see how big a deal it might be. I talked to experts independent of the Gates Foundation and they could hardly contain themselves, characterizing the effort as unprecedented, revolutionary, mind-boggling. When former CDC director and smallpox eradicator Bill Foege told me that this could be the biggest thing ever to happen in global health, I figured I needed to invest a lot more time and effort reporting on it.
HENRY: Was your newspaper eager or reluctant to send you to Africa for a month?
PAULSON: While "eager" is probably much too positive a word to use to describe the mindset of an editor, I have to say most of my alleged superiors were supportive of this story from the beginning. They needed convincing that it was worth the cost of sending a photographer and me to Africa for a month, but they were eventually convinced. We are a regional paper and typically don’t invest much in doing our own international coverage, but this was a potentially revolutionary global public health effort coming out of Seattle, so it was clearly a good story for us.
HENRY: Why did you take your trip before any of the Gates-funded vaccines had been delivered?
PAULSON: I recognized that judging the success or failure of the Gates Foundation’s global health efforts would not be possible for years, or decades, given the scope of it. This is a long-term project that aims to create broad, sustainable changes — not just the eradication of one or two targeted diseases. That’s what makes this effort so stunning, but also hard to assess or even describe. The purpose of this first series of stories was to describe how the effort came to be, its primary goals and the challenges ahead, along with a few hints that success is possible, even in the poorest parts of Africa.
HENRY: What kind of preparations did your make for your trip to Africa?
PAULSON: Mike and I had to get more than a dozen vaccinations for things like typhoid, yellow fever, hepatitis B, rabies and so on. We also needed malaria drug prophylaxis and were lucky that a new drug (Malarone) with fewer side effects than the standard drug (Larium) had just been approved in Canada. It wasn’t yet available in the U.S. (though it is now), so we drove up to Vancouver along with hordes of Medicare-aged drug runners looking to score cheap meds. We bought personal water filters as well, bug netting and all the other assorted gear necessary for sleeping in huts in regions where dusk brings bugs with malaria, river blindness, lymphatic filiariasis and all that. Most of the time, when the bugs were thick, we stayed indoors and didn’t need all the gear. But we did use it a few times. Mike got a bad case of diarrhea at one point, and ended up losing 20 pounds, but I never got sick.
HENRY: Where did you travel in Africa?
PAULSON: We spent about a week each in Nigeria, Gambia and Ivory Coast. In Nigeria, after a harrowing day passing through Lagos, we went north to Abuja and farther north to stay in Jos. We traveled throughout central and north Nigeria visiting villages and clinics to document the country’s desperate need for safe drinking water. Because of a long history of government corruption, Nigeria really has no public health system. We focused on water safety issues because safe water is perhaps an even more fundamental need than routine childhood vaccinations.
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| Photo by Mike Urban, Seattle Post-Intelligencer |
In Gambia, we wanted to visit the Medical Research Council Laboratories run by the British government. The MRC is one of the world’s leading tropical medicine labs and they were just starting a clinical trial of a new vaccine against pneumococcal pneumonia — one of Africa’s biggest killers. The Gates Foundation was helping fund the trial, so we went upcountry to look at how these guys do science in the bush.
We went to Ivory Coast to visit Robert DeWolfe, point man for the Gates’ effort in West Africa. DeWolfe was trying to launch the Children’s Vaccine Program there first because Ivory Coast had always been the most stable country in West Africa. Unfortunately, when we got there, it was during a military coup and the country had become increasingly unstable. We traveled around Ivory Coast, talking to nervous officials about their needs and talking to Bob about his inability to get anything going thanks to the military’s clamp-down on the government. Weeks after we left, Ivory Coast exploded with riots and killings that eventually pushed a new president into office. Bob has since moved the vaccine program’s offices to Dakar, Senegal.
HENRY: What kind of assistance did you have? Driver? Guide? Interpreter? Translator?
PAULSON: In Nigeria and Gambia, we usually didn’t need a translator because these are English-speaking countries. But we did have guides and sometimes needed help with people who only spoke tribal languages. In Nigeria, we had a driver (the roads are horrific) and guides. In Gambia, we were accompanied upcountry by MRC folks. In Ivory Coast, which is Francophone, we rented our own car and hired a translator/guide. He was a physician who kept trying to show us all of the good things the government was doing for its people. He became irritated with our desire to visit poor people in the urban slums, saying he considered them too dangerous. He became quite an obstacle at times.
HENRY: In the journal section of your report, you mention that you got better and cheaper about bribing officials. Under what circumstances did you have to bribe? What were the amounts of the bribes? How did you file for bribes on your expense account?
PAULSON: It would take too much space to describe all of the circumstances under which we were required to "offer a dash," as many folks there put it. In Lagos, for example, a person who appeared to be an official (he had a badge) introduced us to a baggage handler who suggested we needed to pay them both something to make sure our luggage got on the airplane with us. I haggled uncertainly and ended up giving them about 20 pounds sterling (we had arrived from London). I learned later from our Nigerian hosts that I could have given them much less or, better yet, called the police over. I did try to interest the police after I had paid these two fellows, but they didn’t seem to care. Later, we found involving the police in these things sometimes just meant having to pay an additional bribe. Most of the time, we had to pay these "dashes" to officials or soldiers at airports to get through customs, immigration and so forth. Sometimes, it was required as a "fee." Usually, it wasn’t much money, $5 or $10. But it added up. We had to file it as a miscellaneous expense.
HENRY: Are bribes a necessary part of doing business in Africa? Will health organizations have to spend significant money on bribes to accomplish anything?
PAULSON: I don’t want to over-emphasize this problem. Many Africans, including police and government officials, are scrupulously honest and generous. Bribery is mostly a problem in those few instances where you need to get through some bureaucratic or regulatory checkpoint. I think our inexperience in Africa played the biggest part in how often we had to bribe. Once you’re an old hand in Africa, I doubt bribery is as necessary. And I don’t think most health organizations will have to bribe anyone to pursue their goals in Africa. The bigger problem will be in assuring that the funds given for public health projects actually go where they’re supposed to go (a problem we also have in this country, by the way, with our government agencies).
HENRY: Were you in danger of catching any of the diseases you were reporting on?
PAULSON: We kept lathered up with bug spray and observed all the precautions. I don’t think we were in danger of much beyond the gastrointestinal variety of bug Mike got. We knew what not to eat or drink.
HENRY: Why the lag time between your return and the publication?
PAULSON: We had a newspaper strike that disrupted things. As it turned out, the delay helped. We ended up publishing the series just a week before the new Global Alliance delivered its first batch of vaccines to Mozambique.
HENRY: Bill Gates set up the Global Alliance for Vaccines and Immunization (GAVI), which brings together huge organizations, such as the World Bank, UNICEF, the World Health Organization (WHO) and drug companies. A similar initiative, the Children's Vaccine Initiative, launched in 1990, collapsed because of power struggles between UNICEF and WHO. Your story is mostly about, as you put it, "establishing bureaucratic structures." As a journalist, what kind of access did you have to GAVI’s internal workings?
PAULSON: Well, this is an interesting question to try to answer. Because of the collapse of similar previous attempts, GAVI was created as an alliance of several organizations rather than as a new, separate organization. It has a small secretariat office, based in Geneva, but it’s perhaps better thought of as a global council with independent members who meet every once in a while to decide policy, etc. As such, there is no single set of "internal workings" to try to access. Instead, I need to approach each agency or organization (WHO, UNICEF, Gates Foundation, Rockefeller Foundation, etc.) to figure out what’s going on. It’s tough to report on because it’s such a unique, amorphous structure. I think this is part of the reason it still has gotten so little media attention.
HENRY: Most of your readers in the Seattle area have never heard of and are in little danger of contracting many of the afflictions you write about, such as guinea worm, snail fever, elephantiasis, and river blindness. Were your editors afraid that what you were writing wasn’t relevant to your readers?
PAULSON: Yes, and I shared that fear. I worried readers wouldn’t connect and that any hint of moral obligation would turn them off. I knew that, in fact, most readers would consider these stories irrelevant if I couldn’t convince them otherwise. Since people like reading about Bill Gates, I thought there would be interest in how his global health efforts were causing a shake-up of the status quo. I thought compelling stories about scourges like the guinea worm would keep people reading. I don’t know if we succeeded in making these stories relevant to most readers or not. But, as a journalist, I think I have a responsibility to report on important stories even if readers don’t yet regard them as important. These kinds of stories are always hard to sell and I’m gratified that my editors supported the project.
HENRY: Much of the Gates initiative is based on making fundamental improvements in public health systems. Yet as you point out in your stories, political instability can quickly undermine gains in public health. Is GAVI’s collective clout and money expected to have an impact on politics in Africa? Did you talk to any political analysts for your story?
PAULSON: I talked to some folks with expertise on African politics, and I read up on it. While in Nigeria, I talked to former Nigerian head of state Yakubu Gowon about this as well. I didn’t expend a lot of ink on analysts’ opinions because the problem is obvious — look at Nigeria’s plight and at what happened to public health when Ivory Coast exploded. But the approach taken by GAVI is to provide a "carrot" — funds for improving public health and more funds if the countries can show gains in health. If political problems or corruption end up undermining public health, the country just won’t win the next award of funding. It’s an unusual approach in the global health arena, which until now has tended to award funding based upon the compassionate hope of improvement and with admonitions for political integrity. The Gates/GAVI approach isn’t betting on just good will and hope. It demands results.
HENRY: Bill Gates comes out of your stories looking like a pragmatic visionary. Were you able to find critics of his approach to health in the Third World?
PAULSON: Because the Gates Foundation, the world’s largest philanthropy, is now funding projects in almost every arena of global health, it’s hard to find anyone in global health willing to publicly criticize the Foundation. There are critics, of course, but most of the criticism I’ve heard so far has been minor, focusing on procedural or bureaucratic issues, or some vague mistrust of Gates’ motivation. Since most of this has been said to me off-record, I can’t go into specifics. But in general, the critics think that too many of the big decisions in global health these days are being made by just a handful of people at the Gates Foundation. Some of the established players in global health resent the fact that folks in Seattle are creating new projects and dictating policy on their turf. But it’s pretty clear the global health establishment failed to follow through on its own mandates when it comes to childhood vaccines. In much of Africa, things are worse now than they were 10 years ago because people lost interest in immunization. Bill and Melinda Gates, guided by some key visionaries, were convinced it was time to try a different approach.
HENRY: What kind of follow-up have you done since the initial series?
PAULSON: I’ve done a few articles since then: on the delivery of the first GAVI vaccine in Mozambique; on the Gates-funded effort to come up with an effective vaccine against malaria: on the Foundation honoring Bangladeshi scientists who developed oral rehydration therapy; and on a prevention-treatment debate over how best to deal with AIDS in Africa.
HENRY: Have you received much response to your story?
PAULSON: My series came out the same day Boeing announced it was leaving Seattle for Chicago, which may have diverted public attention. I didn’t get a lot of local response, but over time, I have received responses and inquiries from all over the world.
HENRY: Was the Post-Intelligencer pleased with the series?
PAULSON: They haven’t fired me yet.
HENRY: Do you plan to return to Africa to see what practical effects GAVI is having?
PAULSON: Yes, I would like to go back in a few years to see what has been accomplished. I would also like to visit other parts of the world where the Gates Foundation’s efforts are underway.
HENRY: Did your experience as a Knight Fellows change the way you view your work?
PAULSON: The Fellowship gave me a much-needed opportunity to think broadly about what I should do with my life, both personally and professionally. It was an incredibly productive time, emotionally and intellectually, but difficult to describe briefly. To put it simply, I learned how to focus on what’s important to me and ignore the rest.
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| Paulson and Cog at MIT's Artificial Intelligence Lab |
I wanted to write about something that’s invisible to most Americans — basic public health. When it works well, it’s taken for granted. Since Americans have the luxury to take it for granted, how excited can they get when reading about countries lacking it? All of these factors made the story harder to tell. Despite the revolutionary nature of what Gates is doing, it still gets little media attention.
Before the Knight Fellowship, I judged my success or failure as a journalist based on the typical measures — immediate impact or reaction involving the appropriate officials or agencies, copycat stories in other media or maybe winning awards. The problem with these criteria is only certain kinds of stories tend to work this way. The Knight Fellowship somehow helped me focus on the stories I wanted to tell rather than simply chasing "impact" stories or the news du jour. I’d like to have impact, of course, but I’m more interested in learning new things and writing about what excites me — whatever the impact.
Tom Paulson has been the science and medical reporter for the Seattle Post-Intelligencer since 1987. He was a 1997-98 Knight Science Journalism Fellow. To read his special report, see Dispensing Hope: Bill Gates' Global Health Gamble. He can be reached at tompaulson@seattlepi.com
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