Sue Desmond-Hellmann of the Gates Foundation wants an A-plus

As a girl growing up in Reno, Nevada, Sue Desmond wasn't satisfied with an A. "I wanted an A-plus," she says. She also wanted to make a contribution. Watching her father, a drugstore owner, display kindness towards customers left a strong impression. As a young doctor, she and her husband, Nicholas Hellmann, moved to Uganda for two years to treat patients with HIV and cancer.Nearly 30 years later, not much has changed. As chief executive of the Bill and Melinda Gates Foundation, Desmond-Hellmann still strives to earn top grades and make an impact. Speaking of Bill Gates Sr., the lawyer-father of the Microsoft billionaire, Desmond-Hellmann says: "My favorite question of his? 'Have you helped someone today?'" If your reply is yes, be ready to prove it.I interviewed Desmond-Hellmann last week on stage at the Net Impact conference in Seattle. (Net Impact is an organization of students and young professionals who want to change the world for the better. I've just left the board after six years.) As you'd expect, Desmond-Hellmann came across as smart, confident and driven, aware of the power and responsibility that comes with sitting atop a $40 billion foundation. She also came across as down-to-earth and unpretentious, which you might not expect from someone who's enjoyed such a high-powered career.An oncologist, Desmond-Hellmann practiced medicine before becoming a researcher and then a senior executive at Genentech, where she helped bring path-breaking cancer drugs to market. In 2009, when Swiss pharma giant Roche bought the company (and made its well-paid top executives even wealthier), Desmond-Hellmann became chancellor of the University of California, San Francisco (UCSF), where she'd done her clinical training. In May, 2014, she became the first outsider to run the Gates Foundation, whose previous CEOs were ex-Microsoft execs and friends of Bill Gates. She also sits on the boards of Procter & Gamble and Facebook. If you want something done, as they say, ask a busy person to do it.Her background in so-called precision medicine, as well as in public health, academia and corporate America, makes her a good fit for the foundation, which is famously measurement-driven. "One of the reasons I joined the foundation is I like data," she said during our interview. "I was really pleased that Bill and Melinda and Warren and people who came before me set up the metrics and analysts and accountability.”This is mostly good in my view (as regular readers of this blog know) but it leaves the foundation open to the charge that it is overly technocratic and insufficiently attentive to the politics of poverty. You can measure interventions like bed nets to prevent malaria, or the number of polio vaccines administered or the productivity of a farmer who is given new seeds. You can't as easily track democracy, human rights, or the impact of government corruption on the poor. Some development economists, including Chris Blattman and William Easterly, who have been critical of the Gates Foundation, here and here, argue political stability, democracy and the rule of law are what really matter when it comes to ending extreme poverty.Desmond-Hellmann appears to get this. When I asked her to describe one of the foundation's successes, and what she learned from it, she talked about polio.

“In our history as a planet," she said, "we have been able to eradicate one disease—smallpox. Now we’re on the brink, literally on the brink, of wiping out another terrible scourge, polio.”

While a polio vaccine has been available since the 1960s, and a global campaign to wipe out the disease was launched in 1988, it was not until very recently that the disease was eliminated from all but three countries--Nigeria, Pakistan and Afghanistan. In September, Nigeria was removed from the polio-endemic list by the World Health Organization.

"For the first time ever, Africa’s been polio-free, for all of this last year,” Desmond-Hellmann said. “Now the final two countries on earth are in our sights—Pakistan and Afghanistan." These are, as she noted with some understatement, "areas of unrest."

“For people who are interested in making a difference, the polio journey has a couple of learnings," Desmond-Hellmann said. "One is that technical tools aren’t enough. We have the technical tools. We have the vaccine. On the other hand, getting that last kilometer, delivering the vaccine, getting it to people in difficult areas... is the journey.” Meaning that it's hard to carry out health interventions in war zones.

As it happens,  Desmond-Hellmann and I have been reading the same book, Nobel Prize-winner Angus Deaton's The Great Escape. Like Blattman and Easterly, Deaton argues that "poverty and underdevelopment are primarily consequences of poor institutions." Aid, he argues, can actually undermine democracy.

When I asked about that, Desmond-Hellmann said it's a mistake to lump all kinds of aid together (which is the argument Bill Gates makes in his review of the book). “Sometimes I think it’s almost a definitional thing about foreign aid," she said. "The Green revolution has famously allowed places like China and India to come out of poverty.” Some credit for economic growth in poor countries belongs to foreign aid and philanthropy, she said, but local institutions are obviously important. "I also agree that governments are in charge and they always will be in charge," she said. 

Some other topics we discussed:

Direct cash transfers: If foundations are data-driven, I wondered, why aren't more funding direct cash transfers to extremely poor people, an intervention that has been shown to be effective. "Maybe they (the poor) know what’s best for them, as opposed to us saying that we’re going to give you seeds or a cow or a cookstove," I observed.

Desmond-Hellmann responded that direct cash transfers could make sense for philanthropists who don't have the time or the desire to investigate other interventions. “On the other hand," she said, "I think there’s really something really quite profound that we find about innovation and technology. Cash in my hand, if my kids are dying of a vaccine-preventable disease, isn’t enough.”

She said the choice between cash transfers and foundation-funded work aimed at disease eradication or better agricultural inputs is a false tradeoff: “I think it’s an ‘and.’ Get cash in the hands of people who need it most and never forget how much innovation can help.”

Power and accountability: The Gates Foundation has just three trustees--Bill and Melinda Gates and Warren Buffett. Its $40bn endowment is nearly as big as the next four biggest foundations (Ford Foundation, J. Paul Getty Trust, Robert Wood Johnson Foundation, William and Flora Hewlett Foundation) combined. Who holds the Gates Foundation accountable?

“Everyone’s watching us," Desmond-Hellmann said. "If people could be on be on the inside of the foundation, looking in at how how we hold ourselves accountable—it starts with that.” She went on to say that everything the foundation does is done in partnerships, with partners ranging from national governments to local school boards who hold the foundation accountable. Well, maybe, but partners who are beholden to the foundation aren't likely to push back. I wouldn't give this answer an A-plus

Certainly the foundation gets critical press attention, including a new book. Desmond-Hellmann said she welcomes debate. "The healthy public dialogue requires a thick skin," she said, "but it is healthy."

Transparency: If the primary goal of evaluations is to learn, I asked, why don't foundations as a matter of practice make their evaluations of projects, programs and nonprofits public? Why not share insight?

That "does resonate for me," Desmond-Hellmann replied. "We should share our lessons...We want to be a learning organization, to help colleagues learn and then learn from others.” This was a gutsy answer about an important topic. More to come, soon, as The Center for Effective Philanthropy prepares a report on foundations and transparency

Effective altruism: "I'm very positive about the Effective Altruism movement, for a few reasons," Desmond-Hellmann said. It encourages generosity and recommends that people be more "intentional and purposeful" about how they donate.

Women: “We have continued to invest globally in something that women have been asking for—that is, ready access to modern contraception. Women deserve access.” This is a particular interest of Melinda Gates.

Leadership: Desmond-Hellmann said she measures herself and others by two standards. "What are your contributions? And did people prosper when they worked with you or for you?" Nice.

Our interview lasted 35 minutes, and the time flew by. I would have liked to talk with Desmond-Hellmann about the foundation's investment and divestment policy, and to dig more deeply into its programs.

In her prepared remarks, Desmond-Hellmann said something that resonated with me: “Learning something new every chance I get isn’t just a goal. It’s a way of life.” For me, too. That's one reason why I write this blog.

Learning, of course, requires listening. It requires admitting how much we don't know. It can be humbling.

It also strikes me as just the right mindset for the top executive of a big foundation like Gates.