Crisis and Change: Conversations With Leaders— Navigating the Pandemic

0:00Never a waste of crisis. Crisis can be a chance to reinvigorate an institution and re-energize its staff and organization. Crisis can be a chance to build back the kind of world we want to see. Welcome back to Crisis and Change, Conversations with Leaders. I'm Eric Nee from Stanford Social Innovation Review. And you just heard the Rockefeller Foundation's president, Dr. Rajiv J. Shah, remind us that sometimes bad experiences, like a pandemic, can present opportunities for good innovation. And I'm Dan LeDuc from the Pew Charitable Trusts. Wow, Eric, I can't believe we're at the end of our series.

0:39Rajiv really put a fine point on the purpose of this series, to learn how leaders are tackling some of today's biggest challenges to make meaningful change during times of crisis. The COVID-19 pandemic has touched everyone's life in some way. Today, we'll hear a conversation with Rajiv and Mark Sussman, CEO of the Bill and Melinda Gates Foundation, about how COVID has affected them. Their foundations took on important roles to address the pandemic. And along the way, they changed the way their organizations work, helping to redefine the role that philanthropy and the social sector plays when society is confronted with a crisis.

1:14And that's where we begin the conversation. This podcast series is about crisis and change. And by any measure, the COVID-19 pandemic has been a period of crisis and of change. There's been a great deal of innovation over the course of this pandemic, from developing public-private partnerships to deploying vaccines and testing capabilities where they're needed. Can you each highlight an initiative that your foundation has been involved in that demonstrates your ability to create meaningful change in the midst of crisis? And let me start with you, Raj. Sure. Well, it is great to be with you. And it's great to be here with Mark, because the work that he has done and the Gates Foundation has done has been extraordinary at a moment in time when their expertise and their history has been needed by the entire planet.

2:06At the Rockefeller Foundation, we recognized, I think, early that this pandemic would both become something that exposes the deep, deep inequities in our society and significantly exacerbates those injustices. So we made a hard pivot in March of 2020. We restructured most of our major programs, and we launched efforts to move tens of millions of dollars and then hundreds of millions of dollars into direct pandemic and public health response here in the United States and around the world. We had a very strong focus on testing and building a testing infrastructure for the United States back before that was commonly discussed much in our politics or our news.

2:50We launched a global effort to make the testing access issue one that was pertinent to country after country. And we restructured our food and agriculture programs to help promote school feeding, for example, here in the United States, because as you'll remember, millions of children were potentially not going to get their school meals. In all those examples, we worked and needed to work very closely with policymakers at home and around the world to make sure our investments were reaching scale. But that big, hard pivot to pandemic response with the focus in the areas where we already had some expertise, health, food, economic equity and justice here in the United States, became emblematic of our efforts and I think delivered for us extraordinary results in terms of the impact on people's lives at home and around the world.

3:42Like Raj, I think this has been a very important moment for the philanthropic community generally in terms of how to engage and step up and see the needs. And with specific regards to COVID, let me use two examples which may be illustrative. One, building on Raj's point about testing. The very first COVID-related grant we made was in February of 2020 to help provide the African Centers for Disease Control the capacity to help African countries build the ability to test for COVID. That was before a single case had left China. And so our early resources were able to help the African CDC, and we've made many subsequent investments in partnerships with them, and they've become an institution that's been incredibly important in helping the continent address the COVID crisis.

4:33And similarly, a slightly more recent one, we've been engaged in a wider initiative, again, in Africa, the Africa Pathogenomics Initiative, which does the surveillance, the testing of different models and types of disease generally. And that's both a resource that can help with testing for any disease, but in COVID, we saw twice. South African researchers, Southern Africa, one was in Botswana, find both the beta and then the Omicron variant. We also, at an early stage, a bit like the Rockefeller Foundation, realized that while the COVID challenge was going to be huge, it didn't mean that any of our other problems that are our traditional focus areas were going to go away.

5:15In fact, all of them were likely to get worse as a result of COVID. And so we made a decision early on that all of our COVID funding would be additional. We did not want to eat into any of our existing programs, whether supporting health or agriculture abroad or education in the United States. And that was a big lift for us, but I think a very important one. You raise a good point that COVID didn't happen in isolation. In fact, it overlaid some problems which had been around, like wealth inequality and racism. But in some ways, it exacerbated those problems. So I'm curious to hear kind of your perception about how that happened and how that might have affected your work.

6:01and the way you approach COVID. Let me just start with you, Mark. Yes, absolutely. Both in the United States and globally, I think what initially looked like it was going to be a great equalizing event that COVID was going to affect everybody equally actually ruthlessly exposed some of the deep inequities we have both in the United States and around the world where you soon had very differential access to testing, treatments, vaccines, equipment, PPE equipment before there were vaccines, and deep knock-on effects. Our largest area of investment in the United States is in the education sector, and the data is still limited because it's been so challenging to dig out, but there is no question that the impact and the learning loss in Black, Brown, and low-income communities that are the focus of our work has been immense and much higher than in wealthier areas and of the country.

7:03And so that's forced both a sort of hopefully broader discussion and a realization that that needs to be addressed, but it's also required us to think much more smartly about can we use some tools and innovations, perhaps the revolution that's underway in using digital tools for curricula in schooling or the revolution that's underway internationally with some of the investments like the mRNA vaccine technologies, which now have potential to be used for other diseases like malaria or HIV or TB. But yes, it's been a hugely damaging set of intersections. And it's certainly highlighted, particularly the racial inequities that continue to exist in the United States.

7:47I agree with everything Mark has said. And the only thing I would add is let's not think about it retrospectively, because while all of this happened, the truth is if you look forward, especially on global development related issues, it's very likely now that for the first time in seven or eight decades, we're going to experience a prolonged divergence where wealthier countries grow faster, recover faster, lift their economies up much faster and developing countries deal with the knock-on effects of the inequity in access to vaccines, the inequity in access to fiscal stimulus, and the inequities in the realities of monetary policy and how it affects their finances.

8:32The net effect of that is what Mark, I think, was getting at when he said that this really does unwind decades of progress against the sustainable development goals, the goals that basically say that every human being should experience the dignity of not being extremely poor and have access to basic health and food and other necessary items of modern living in a world that's safe and protected against the threat of climate change. And the reality is this divergence that we see coming in the next decade or two is likely to continue to unwind progress against those SDGs and make our collective work much harder unless we respond in kind.

9:17It's why at Rockefeller we mobilized a billion dollars for what we called a just recovery and called that our moonshot, our chances now to spend what for us is a tremendously outsized resource envelope in order to support partners across the world to help create a much more just recovery because we're very worried that the recovery will have the same inequities that Mark described around the core event. Raj, you started off by saying how the Rockefeller Foundation pivoted. It was pretty amazing to watch. Your organization, like many organizations, really had to adjust what they were doing, but also how you did it, right?

10:02How your organization worked, how you related to your staff. Could you talk a little bit about that? Sure. Well, you know, I'd say, and Mark can add to this, I think the Gates Foundation had existing programs focused on pandemics for quite some time, which is phenomenal. Rockefeller at the beginning of 2020 really did not. And so what we had to do was a full and thorough pivot. And that started by seeing the problem. I remember having coffee with Dr. Tedros in January and really understanding the gravity of what we were going to be experiencing, not just for the months ahead, but for years ahead.

10:42And that led to our hiring. We hired some folks who were world-respected pandemic experts. It led to dialogue with our health partners, big partners like UNICEF, WHO, and others, where we said, look, we have these big agreements, the Global Fund. Can we restructure our grants so that you have the flexibility to respond to this crisis however you believe you need to? It led to our team asking for and receiving more resources from our board in a March board meeting to make large emergency actions and do it in a way that didn't impinge upon other programs and activities. And it frankly led to a re-engagement with the United States Congress, congressional leaders and policymakers in an education and advocacy oriented way, but in a manner that said, how are we going to protect school kids who otherwise will go hungry and families who otherwise have had the floor taken out from under them because they never had$400 to respond to a crisis to begin with.

11:40And I think all of those efforts to kind of listen, learn, re-engage our staff and bring in some novel expertise enabled us to make that pivot in a way that I'm pretty proud of. I'm proud of it in part because our folks were exhausted and I'm proud that they persevered through change. Change is hard. And you remember back then we were also making the change from normal in-office work to virtual work. We were all so confused about are we going to travel to this meeting or that meeting. It was a big period of change. And sometimes philanthropic institutions are accused of not being nimble and agile.

12:17Our staff proved that they could be nimble and agile and focused on the problem at hand. And I think that's a great thing. So do you think those changes will be lasting? I do. I do in part because we did a bond issuance, our first one in 100 plus years, and we were able to raise enough money to make this billion dollar commitment to our moonshot, our effort to make the green recovery just for everybody. I think it's sustainable because it's engaged our staff and our board in a way that everyone is committed to the big picture. And it's sustainable because something I personally learned first at the Gates Foundation, but I think Bill Gates himself learned from the long history of the Rockefeller Foundation, which is sometimes what philanthropy can do that's special and unique is stay focused on the long term, take risks and remain persistent.

13:12And I think, you know, Mark and the Gates team started working on vaccines in, what, 1999. And all the expertise and impact and reach they've developed over two decades has enabled that institution and its partners to be of huge global consequence during a crisis that demanded universal global vaccination. So, yes, we intend to learn from those examples and stick with it for the long term. So, Mark, the Gates Foundation, as Raj said, was already doing a lot of work in this area, but no doubt you had to make some pivots yourself. I'm curious if you could talk a little bit about what those are. Yeah, absolutely.

13:54And, I mean, Raj is kind to say we were doing a lot of work already in pandemic preparedness. We had actually had some strong internal discussions. We made some key strategic investments, like the Coalition for Epidemic Preparedness Innovations, which we did with the Wellcome Trust and a number of governments, which we're very pleased we did because that's an organization that's played a big role in combating the pandemic. But we actually thought that because it's so clear, pandemic preparedness is a ultimate public good. And we're always looking at where philanthropic dollars can be the most valuable.

14:26We didn't put huge amounts of resources into it. we were advocating more with governments saying this is such a self-evident area for you to prioritize and allow us to use our resources to prioritize some of the more neglected areas like the continued work around malaria or neglected tropical diseases. And so when we were looking at what to do, we had to provide and put in additional resources. In fact, now two years on, the cumulative total of both combined grants and equity resources we put into the COVID response has been, you know,$2 billion now, which was not something we were planning on a couple of years ago.

15:04But we, again, as I said, didn't want to cut any of our existing programs, because we saw the needs and building on what Raj said about the big setbacks. We've seen after over 20 years of almost steady, continued, amazing progress across the developing world from child mortality to the fight against HIV, TB and malaria to reductions in absolute poverty, the last two years have seen a huge reversal. And the risk is that that reversal really lingers now because those developing countries don't have the resources. And so what we're now looking at is how can we do a lot of both and investments, investments that are supporting the COVID response in the short term, but are also laying the groundwork for longer term institutional response that can try and combat some of those setbacks.

15:51So examples would be diagnostic tools that can both do COVID, but can also pick up TB or HIV. And we've recently agreed that with our board, our co-chairs, that we will keep our spending at the higher level that we rose to during the pandemic. So we paid out, I think,$6.7 billion last year. And we're going to maintain that level because we see the needs being so great, both looking at the pandemic response and more broadly. And then last but not least, I do want to echo Raj's point that, like everybody else, our staff and our wider community were under all the strains we all share about how you pivot to work from home, the resilience, the extra challenges.

16:35And it was very difficult at times. I know we suffered from a lot of burnout, concerns around it, because when you're a mission-driven organization like ours, people feel compelled to step up and try and put in the extra work. And so trying to manage that and both think through the marathon as well as the sprint has been an ongoing challenge. But I'm really proud of how our organization and the philanthropic community more widely did rise to that challenge. So, Mark, you work with public with governments around the world, public health, the public health system, we might call it. How do you think it fared during the pandemic?

17:17Has it been innovating? and what are you helping to do to help make it more robust for the future? Well, the public health system has lots and lots of components. And Raj will talk some of the great work the Rockefeller Foundation has been doing here in the U.S. around some of that. But for us, the elements are both the ability to be able to provide the health system with the tools to see what the size of the challenge is, how to respond. But then it's actually the mechanics. In developing countries, again, one of the biggest challenges is having these already overstretched and under-resourced health systems suddenly dealing with an additional burden of COVID that has knock-on effects on, we saw setbacks and drops in childhood vaccination rates for the first time in decades.

18:02We saw resurgences in malaria and HIV cases. And so we've been working both with the global community organizations like the World Health Organization, Gavi, which has also been the host of the COVAX initiative, the Global Fund to Fight HIV, TB, and Malaria, about those kind of both end investments, how they can adapt, as Raj mentioned, and then also working with a number of individual countries from Bangladesh to Kenya. to Nigeria, to Ethiopia about their own national health systems and responses, because in the end, they have to lead. And we need to try and provide and see where we can be the most supportive.

18:43And so the hope is that we've been building some kind of infrastructure that's going to outlast this. I mentioned the Africa Centers for Disease Control Prevention, which interestingly was an institution that was only set up after the Ebola crisis, as a response to the Ebola crisis, where Raj played a leadership role back in his USAID days. And it really has done an amazing job. And now the African Union recently, just a couple of weeks ago, decided to institutionalize it and give it more independence and resources because it's proved its value to such a great degree. Raj, I'd like to hear your views on the public health system.

19:20You have a lot of experience in that area. How do you think it responded? And what is Rockefeller Foundation doing to help make it more robust going forward? Well, I think in the United States, it responded poorly. I think we have to just admit that in America. You know, we were rated by all pre-pandemic indices very highly on the list in terms of preparedness and capacity to deal with the pandemic. And for a variety of reasons, America did not respond effectively. We didn't get testing to be robust and prevalent quickly. We didn't have guidance for schools and critical institutions. So we turned almost every school district into America into a mini CDC and asked them to figure it out on their own.

20:07We didn't really have the kind of data transparency we needed to drive a world-class response, the kind you saw in South Korea, for example, or some of the Asian countries that had recent experiences with pandemics and therefore were set up better to deal with it. So I think hopefully it's better for the next go around. I mean, Rockefeller helped build infrastructure in the United States that connected mayors, both parties, to the federal government, to the CDC, to experts to optimize the response in its first year. We expanded that to build state infrastructure to allow state governments to pool their resources and buy test kits and other things together as opposed to separately.

20:51That actually was something we learned from the immunization space many, many decades ago, but that allowed us to use credit guarantees from our endowment in a manner that unlocked the testing market and access to testing here in America. I think there's a lot of space for a very careful review of what happened in the United States, and there should be a political willingness on both sides to say, how can we approach the next one with more of a purple political strategy and more of a commitment to transparency and efficiency and response. On a global basis, that despite the important capacity investments in areas like surveillance, we have not mounted a response that is equivalent to the task.

21:33And whether that task is sort of reaching the 70 % vaccine target everywhere, or more likely something that's more nuanced given the Omicron variants broad spread and what it now looks like. Clearly, countries don't have effective access to vaccines. They don't have the low-cost, high-prevalence rapid testing they need, and too many countries haven't had access to simple, proven treatments like oxygen and need some of the new treatments like Plaxivir in order to actually kind of live with COVID at a certain level in terms of an endemic disease that is expected to have future variants. So I think there's a lot of learning in the global space too.

22:18And just to put a fine point on it, we spent in the rich world, in OECD countries, something like 20 to 25 % of GDP in fiscal stimulus and in priced monetary actions. And that's a massive, massive amount of money. And Mark and I worked together for a long time, and we used to always say it's not about money alone, but you do need money in order to build a strong global and protective health system. That's enough money to build health systems for decades to come. And it's just important that we use this moment of a recovery to make the investments in what caused this problem to begin with. And that was inadequate investments in public health and public health science and public health capacity, particularly in vulnerable communities here in the United States and around the world.

23:08And I fear too many people will forget that that's what got us here and move on to the next thing. And so I'm glad that Rockefeller Gates and so many other health-oriented foundations can keep the focus on that purpose. What's an important lesson that you've each learned over the last couple of years during this COVID crisis, Mark? For me, the biggest lesson is around the huge inequities that continue to divide the world and the country and that have worsened during the crisis and that need the political attention more than ever. Raj mentioned that the world is not rising to the challenge of preparing for the next pandemic yet, let alone the wider knock-on effects that have happened, social, economic, education, other areas.

23:56And that's the lesson. It's the need more than ever for a true joined up global response, because that's the only way we're going to make sure that next time around we don't suffer the same kind of challenges and setbacks. Raj, what's the lesson you've learned? Never a waste of crisis. At the end of the day, crisis can be an opportunity to stand up and respond on behalf of those who don't have voice and who are vulnerable and who are suffering, but often suffering quietly. crisis can be a chance to reinvigorate an institution and re-energize its staff and organization. A crisis can be a chance to build back the kind of world we want to see, the one that's characterized by more resilience and more justice for everybody.

24:43Thank you, Raj. And thank you, Mark, both of you for taking time to talk with us. It's been a great conversation.

24:53Thanks for listening, and thanks to the special guests who joined us in these conversations about crisis and change. As we conclude this special series, it's clear that despite the overwhelming challenges facing our world, such as climate change, wealth inequality, and political polarization, We are learning important lessons in moving forward remarkable innovations to create lasting and positive change. You can find more resources and listen to additional episodes featuring leaders from the social sector at SSIR.org or pewtrust.org slash after the fact. Make sure to also search on your preferred streaming platforms under the Inside Social Innovation or After the Fact podcast and click subscribe.

25:41Thanks for joining us.