Mark Suzman, Gates Foundation: Countries should be embarrassed

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1:42Mark Suzman:Hello, I'm BBC presenter Sam Fennec and this is the interview from the BBC World Service. The best conversations coming out of the BBC, people shaping our world from all over the world.

1:57Sam Fenwick:If you're not a little bit afraid, then you're not paying attention.

2:01Mark Suzman:We have never seen a people so united. Do not make that boat crossing. Do not make that journey. Being born in America, feeling American, having people treat me like I'm not. We're more popular than populism. In this interview, I met Mark Sussman, the CEO of the Gates Foundation, the world's largest philanthropic organisation and one of the most influential players in global health. Last year, the United States scaled back parts of its overseas aid budget. It wasn't the only country doing so, with many governments, including the UK, Germany, France and Japan, all spending less. You're going to hear why Mark Sosman thinks cuts are having a huge impact on the lives of the world's poorest.

2:47Sam Fenwick:In 2000, over 10 million children under the age of five died every year of preventable diseases. And in 2024, it reached 4.6 million. And yet last year, new projections show that that number went up for the first time this century.

3:04Mark Suzman:In its annual letter, the Gates Foundation said the decisions around aid spending are already costing lives.

3:14Mark Suzman:Welcome to the interview from the BBC World Service with Mark Sussman.

3:19Sam Fenwick:One of the great untold stories of the last 25 years has been the miracle in child survival. That, you know, in 2000, which is when the Gates Foundation was set up, over 10 million kids, children under the age of five, died every year of preventable diseases. That number has been steadily declining every single year since then. And in 2024, it reached 4.6 million. So more than halved. And yet last year, new projections show that that number went up for the first time this century to 4.8 million.

4:00Mark Suzman:So why the reversal?

4:02Sam Fenwick:Well, the primary reason is absolutely the cut in international development aid by first and foremost the United States, which did it very abruptly by closing USAID. But by many countries, including the United Kingdom, France, Germany, the Netherlands, all cutting back at a moment when we have proven successes in interventions which we know can save kids' lives.

4:28Mark Suzman:Why so quickly? We've had aid going into countries and helping children, as you've described, for 25 years. Why would suddenly the cut of this aid have such a dramatic impact?

4:42Sam Fenwick:Well, because it's set size and scale and scope. So the proportion of aid is being dropped by nearly 25 percent. When you put that into numbers, that's billions and billions of pounds that are cut. and those billions and billions of pounds, not all of them were used for what we would call the highest impact interventions. But if you're buying vaccines for kids, if you're buying antiretrovirals for patients with HIV, if you're buying bed nets for families to prevent them from getting malaria, if you reduce the amount of money that's supporting that, most of which has been funded by international aid, you reduce the number of people that you can help.

5:19Sam Fenwick:It's simple maths.

5:20Mark Suzman:So your projected figures for the end of 2025 was that there would be an increase in deaths of over 200 ,000. That is modelling. That is your sort of estimation. That is your forecast. How accurate is it?

5:37Sam Fenwick:Yeah, so that's modelling by the Institute for Health Metrics and Evaluation, which is a very credible, located at the University of Washington here in the US. and we suspect it may be an underestimate. It's very conservative estimates looking at all the different numbers and sort of inputs into what goes on in child mortality. And we think actually the number potentially would have been also much higher had there not been sort of drastic steps taken by some of the countries that are most affected to try and meet the shortfall. So with all of these, we're trying not to just cry, this is a sort of terrible number that we want people to pay attention to.

6:21Sam Fenwick:We're trying to be very realistic about what's happening on the ground, largely on the continent of Africa, but well beyond Africa too, and in Asia and other parts of the world.

6:31Mark Suzman:Your letter states very clearly that the reversal of child mortality wasn't inevitable, and that was actually the result of political choices and funding choices.

6:44Sam Fenwick:Absolutely. That is the bottom line, is if you take the two most successful multilateral investments of the 21st century, and I would argue potentially ever in terms of their impact per pound or dollar or euro spent, we have the Gavi Vaccine Alliance, which vaccinates millions of children around the world, and the Global Fund to Fight AIDS, TB, and Malaria. Both of those were set up in the early 2000s. The Gates Foundation was part of setting them up. The UK government has been a very prominent partner throughout the lifetime of those. And between them, they've saved conservatively over 80 million lives over that period.

7:28Sam Fenwick:Now, they both had replenishments last year, where they went around to government saying, we have a proven track record. We can show you how every dollar or pound or euro you spend on us saves lives. and they raised less money this time around than they had the previous time because donor governments said we need to prioritise our domestic spend.

7:49Mark Suzman:Well, that's it. And you've said it there, haven't you? There are different priorities now for governments and there are competing stresses for money.

7:57Sam Fenwick:Absolutely. But it shouldn't be done on the back of the poorest and most vulnerable. These are very small amounts of money. I think one of the concerns that we have is when you use a big phrase like foreign aid, it tends to get lumped. And then we know that the public in the UK also say, doesn't this all go to corrupt politicians? Why are we doing this here? And we go, no, if we reframe it and show and say, we can guarantee you. And if you walk up to, you know, a British taxpayer on the streets of Manchester today and we do this, very often and say, would you be comfortable if we could guarantee you that pound of your taxpayer, honey, is going to actually save a child's life?

8:38Sam Fenwick:And we can show you how that pound works through the system, goes to the Gabi Vaccine Alliance, purchases the vaccine, gets to that kid. Would you be comfortable doing it? The overwhelming majority say absolute. What they don't understand is that's what's being cut.

8:52Mark Suzman:But what about defence? Because you mentioned the UK a few times, and actually in the UK, a lot of the aid budget has gone towards defence. And a lot of other European nations will be looking towards that. And that does remain a priority for them.

9:10Sam Fenwick:Absolutely. But governments all have multiple priorities. The UK has been a historic leader in international aid and development and did put into law that they were going to admit 0.7 % of GDP to international aid. That's been cut by successive governments in recent years, and most recently by the current government last year announcing they would cut it again from 0.5 % to 0.3%. And exactly that 0.2 % that would be saved would go towards their NATO contributions. Now, that's a choice a government can make, absolutely. I would question certainly whether that is the right choice of where you would make the savings.

9:51Sam Fenwick:Clearly, Britain needs to invest in defense and our European countries and sovereign countries should make choices. but it's such a small relative amount of money going to the world's very poorest that does really save lives in a very concrete way and where the UK has been such a strong historic global leader that we think bluntly that was a mistake. Now having said that, it's clear that with the remaining resources the UK has they did make very generous contributions to both the Global Fund and Gavi last year but both of them were significant cuts still on what their previous contributions had been.

10:30Mark Suzman:How do you respond then to criticism that aid can leave countries exposed when it is pulled out quickly, that they have perhaps become too dependent on aid?

10:42Sam Fenwick:I think the long-term vision of all international aid, including ours at the Gates Foundation, is that it should not be in perpetuity. It's there to deliver services in the short term, but ultimately to build the capacity and the ability of those countries to deliver those services to their own citizens with their own resources.

11:04Mark Suzman:But up until recently, the Gates Foundation has just given it in perpetuity. It's only recently that you've decided that you're going to cut it off in 20 years' time.

11:14Sam Fenwick:Yeah, no, just to be clear, we never were a perpetuity foundation. What we were going to do was do ourselves out of business within 20 years of when Bill Gates died. But now what we did and we changed last year, we actually decided that the greatest impact will happen right now. And we announced that we will actually do ourselves out of business by 2045. Because we have a clear vision of the world that we think we can help leave behind, even with the challenges of 2025. which is a world that actually has halved maternal and child mortality again to below 2.5 million deaths a year, and broadly either eradicated or brought under control those big major infectious diseases that disproportionately affect the poorest.

12:06Sam Fenwick:So that's our goal and vision. And it is now a two-decade vision that we believe can be done in a way that builds strong self-reliance in the countries and communities where we work.

12:18Mark Suzman:What then are your priorities and what will guide how you spend that money over the next two decades? Yes.

12:27Sam Fenwick:So for context, we've spent$100 billion over our first 25 years, which is by far the largest payout by any philanthropic foundation in history. And we've now committed through the generosity of our chair, Bill Gates, who has committed the entirety of his remaining fortune over the next 20 years and our endowment, which will together will amount to$200 billion over that 20 years. And the reason we've done it is very much against this broad set of goals, as I talked about. We have three broad intentions as a foundation. One is to really bring child mortality and maternal mortality down as low as possible, certainly as close to high income levels as possible, meaning the child mortality rates that you have in the UK or in Europe.

13:15Sam Fenwick:and similarly on the infectious diseases. We think we can actually eradicate two critical diseases, polio, where we're very close to eradicating. It's only endemic in two countries, apparently Pakistan and Afghanistan, but has been a devastating disease over most of human history, and even malaria, which actually kills 600 ,000 people a year, the vast majority of them children, and has a much bigger effect, especially on Africans, such as illness and loss for activity. We think we can eradicate those two diseases and bring HIV and tuberculosis. Tuberculosis is the infectious disease that still kills more than any others.

13:54Sam Fenwick:1.6 million people a year, basically under control as manageable health conditions in the way that they currently are again in rich countries like the UK.

14:07Mark Suzman:You're listening to The Interview from the BBC World Service.

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15:18Mark Suzman:When I met Mark Sussman, there was none of the grandiosity that you might expect from someone running one of the most powerful foundations in the world. He's measured, thoughtful and careful with his words. What struck me, though, was the balancing act he was trying to maintain. On the one hand, he was very clear that philanthropy can't replace governments and that it shouldn't, And yet as aid budgets shrink and expectations grow, there's an increasing sense that organisations like the Gates Foundation are being pulled into a much bigger role. And throughout our conversation, you could hear that tension between influence and responsibility and how far that influence should really go.