The body of a 1-year-old boy lay on a bare examination table in Soweto, South Africa—looking precious and small, heartbreakingly beyond help. In the dimly lit room, two researchers did their work methodically and in silence, taking samples from the child’s brain, lungs, and liver with a needle and swab, and then carefully packaging them to be sent for testing. Then the child’s body was gently lifted into a postmortem pouch, to be sent for a proper burial.
The autopsy of a baby is horrible to behold, but it’s a practice that serves an essential purpose at the Wits Vaccines & Infectious Diseases Analytics (Wits-VIDA) Research Unit. In a region where more than one in 20 children die before they reach the age of 5, this basic act of investigation is an affirmation of the child’s humanity.
That’s why the boy’s grieving mother consented to the examination by the Child Health and Mortality Prevention Surveillance, or CHAMPS, global surveillance program funded by the Gates Foundation to gather data about child deaths in poor countries. She sat mutely outside the autopsy room, waiting to learn why her child was taken from her so young.
It’s an answer that millions of parents never get. While any parent in a wealthy country who loses a child can expect to know the cause, the deaths of poor children around the world have remained largely an unsolved—and uninvestigated—mystery. For the researchers at CHAMPS, which operates in Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Nigeria, Pakistan, Sierra Leone, and South Africa, the mission is to treat every death of a child as a tragedy worth investigating—and not a faceless statistic.
The approach is core to the Gates Foundation’s ethos, Bill Gates explained in an interview with Fortune in which he laid out his commitment to spend $200 billion over the next 20 years to hopefully eradicate or dramatically reduce a slew of deadly infectious diseases and reduce childhood and maternal mortality.
“When I was asking in the late ’90s, ‘What do children die of?,’ there were only sketchy answers,” Gates recalled. Since then, he said, “global health has gone from being very naive to being a very data-driven, deeply understood thing.” CHAMPS has conducted tissue sampling and lab work on over 9,000 cases to date, according to the organization’s tracker. The CHAMPS testers go beyond labeling the deaths “preventable”; the investigations show how they could be prevented.
What emerged from CHAMPS’ investigations challenged assumptions about what kills children and often revealed a combination of factors: The most common causes of death among children under 5 in the nine countries CHAMPS operates in are preterm birth complications, sepsis, pneumonia, burns, malnutrition, and respiratory infections, according to the researchers. “Until CHAMPS started, the WHO was fairly adamant that any child can only die from a single cause,” said Dr. Shabir Madhi, the Soweto site’s codirector and director of Wits-VIDA. “But there are a number of other contributing factors.”
Around the launch of CHAMPS in 2015, senior leaders at the Gates Foundation examined the results of the pilot study of 250 cases. “The buzz in the room was unbelievable,” said Madhi, because the investigations yielded some unexpected results. “We were now seeing causes of death which simply didn’t even feature in the estimates that were being done.”
For example, in neonatal deaths, hospital-borne infections were found to be a much more common cause than previously understood, and the CHAMPS testing found out that some of the pathogens killing children were resistant to available antibiotics. Results underlined the need for new antibiotics and infection control protocols in hospitals.
The information has led to a slew of possible reforms and protocols to prevent and treat these conditions: For stillbirth and preterm delivery, the CHAMPS team has worked to improve ultrasound access and preeclampsia prevention. For older children, the team is working on burn prevention and improving toxicology testing to identify poisons that have led to deaths.
“If we had intervention to prevent the prematurity, or if we had intervention to prevent the chronic lung disease, that child wouldn’t have ended up in that situation,” Madhi said.
A $1 invention that can save millions of lives
Data, and a kind of tech startup mindset that’s always seeking efficiencies, has informed much of what the Gates Foundation has done, said Anita Zaidi, the foundation’s Gender Equality Division president. In the 11 years that she has worked with Bill Gates, she says, she has learned that he’s always drawn to the most effective, low-cost innovations: “If you could say, ‘I could get it to $1,’ that’s the best thing, because that’s his frame.”
It was just such an innovation that Zaidi and then cochair Melinda French Gates championed following a Gates Foundation–funded trial to find solutions to treat postpartum hemorrhage, excessive bleeding after giving birth, which the WHO estimates kills 70,000 women a year globally. To determine when a hemorrhage was underway, instead of “eyeballing the blood on the floor,” the trial found that a calibrated drape—essentially a plastic funnel—could be used to measure the blood loss more quickly and accurately. The simple, cheap device aided a drastic reduction in maternal deaths from severe bleeding and is now written into the WHO’s guidelines. “Those drapes are less than $1,” Zaidi said, “and you’ll save hundreds of thousands of lives around the world.”
Hands-on cost-cutting is in the foundation’s DNA. “We are very oriented toward understanding how to make very cheap things—very cheap vaccines, cheap drugs,” Gates says. “It’s a novel set of skills.”
French Gates, who cofounded the foundation with her then husband Bill Gates, recalls how, on some of her first travels with the foundation, it became clear how little data there was on women’s health and contraception. “I had to learn to say, ‘No, no, we need to go build the data system to understand what contraceptives women have access to. What do they want?’” she said. “And we learn from country after country that you have to have a range of options.” Based on what she learned from that data, French Gates has championed access to family planning as the number one poverty reducer.
The approach isn’t just about creating the most effective, cheap treatment—governments and public health providers must be convinced to use it, and persuading them can be complex in a fractured and politicized global health landscape. Case in point: the Gates Foundation’s campaign to change the way the HPV cervical cancer vaccine is administered. Initially, the vaccine called for two or three doses. It was highly effective, but expensive and complicated to roll out. The foundation wondered if one dose would work just as well, so the Gates Foundation funded the trial.
It showed that a single dose is just as effective as two or three. The first country to switch to the protocol tested by the foundation wasn’t one of the poor nations for which the trial was conducted, but rather the U.K.
“That gave a degree of comfort to countries all across the world,” says Gates Foundation CEO Mark Suzman. “You obviously reach twice as many kids if you only have to vaccinate them once.”
In 2022, less than a quarter of girls worldwide were receiving even one dose of the HPV vaccine. This innovation, which will lower cost and supply burdens, could prevent over 110 million cervical cancer cases in 100 years if adherence rises, according to estimates from a preliminary study.
It’s a victory that offers reason for optimism. “In our lifetime, we’re going to see cervical cancer disappear,” Zaidi said. “The magnitude of impact is so huge, and I just feel lucky that I was a part of that story and did my little part to make this a reality.”
As well as these cost-effective solutions, the Gates Foundation is known for investing in moonshot innovations: 6-in-1 combined vaccines, genetically modified mosquitoes to tame malaria, and AI ultrasounds to reduce maternal mortality. “Data is at the heart of everything we do,” Suzman says. “To help guide, to help course-correct.”
The foundation’s AI task force put out a call for innovations in May 2023 and received more than 1,300 responses within two weeks, with 80% coming from low- and middle-income countries. The project is in early stages, but the foundation is actively brainstorming how AI could help save lives.
The goal is always to do more with less, explained Ankur Vora, the Gates Foundation’s chief strategy officer: “We’re constantly looking for the Archimedean lever.” That’s not just to maximize the impact of the Gates Foundation’s money; it’s also to leave the world—after the foundation shuts down—with solutions that can be scaled up easily.
“The resources in the world are shrinking,” Vora said, “and so we need to work harder to find things that are easier to deliver and cheaper to deliver.”
Geoff Colvin contributed to this story.