What did you make of the whole health care rollout debacle?
They should have done better. But that's a minor issue compared to the notion of "Will they get enough people in the risk pool so that the pricing is OK?" And some of the price-rigging they've done, where the young overpay relative to the old, is a problem. You know, it's all intended for a good thing, which is access. But it's layered on top of a system that has huge pricing-capacity problems. Which it basically did not address.
You'd normally want to be able to tune something of this complexity. But because you have a political deadlock, you can't. Even the tuning that's being done – like delaying some of the mandates – is claimed to be against the law. So we're doing something novel and complex in a very rancorous environment, in an area where our achievements in the past have been pretty weak.
Health care reform is one of the areas where there is a lot of discussion about the corrupting role of money in politics. And as Washington becomes increasingly unable to address big problems, you hear more and more about the corrosive role of special interests. Do you agree?
Money has always been in politics. And I'm not sure you'd want money to be completely out of politics. You know, I don't give a lot of political contributions, and I'm glad there are limits on political contributions. I wish there were more limits. But our government wasn't designed to be efficient. We've got a system with a lot of checks and balances. When you get into a period of crisis where the overwhelming majority agrees on something, government can work amazingly well, like during World War II.
But now you have people who are shrill about the size of government or how we're not doing enough about climate change. But they don't have enough of a consensus, and they're looking at a government system whose default answer is the status quo. Look at people who say, "I'm going to shrink the government!" Well, show me when they actually did shrink the government. They caused it not to grow as much, but shrink? When? You know, good luck on that. The principle of shrinkage may be agreed on, but when they get into the particulars, it's not as easy as you might think. Farm subsidies, yes or no? Research for medicine, yes or no? Loans for students, yes or no? So you have this frustration. But to label that as coming from an increasing amount of money in politics, that's only one of many things going on.
Well, there certainly is plenty of frustration with our political system.
But I do think, in most cases, when you get this negative view of the situation, you're forgetting about the innovation that goes on outside of government. Thank God they actually do fund basic research. That's part of the reason the U.S. is so good [at things like health care]. But innovation can actually be your enemy in health care if you are not careful.
If you accelerate certain things but aren't careful about whether you want to make those innovations available to everyone, then you're intensifying the cost in such a way that you'll overwhelm all the resources.
Like million-dollar chemotherapy treatments.
Yeah, or organ transplants for people in their seventies from new artificial organs being grown. There is a lot of medical technology for which, unless you can make judgments about who should buy it, you will have to invade other government functions to find the money. Joint replacement is another example. There are four or five of these innovations down the pipe that are huge, huge things.
Yeah, but when people start talking about these issues, we start hearing loaded phrases like "death panels" and suggestions that government bureaucrats are going to decide when it's time to pull the plug on Grandma.
The idea that there aren't trade-offs is an outrageous thing. Most countries know that there are trade-offs, but here, we manage to have the notion that there aren't any. So that's unfortunate, to not have people think, "Hey, there are finite resources here."
Let's change the subject and talk about your foundation. How do you make the moral judgment between, say, spending your time and energy on polio eradication versus, say, climate change?
I want to focus on things where I think my experience working with innovation gives me an opportunity to do something unique. The majority of the foundation's money goes to a finite number of things that focus on health inequity – why a person from a poor country is so much worse off than somebody from a country that's well-off. It's mostly infectious diseases. There's about 15 of those we're focusing on – polio is the single thing I work on the most. And then, because of the importance of nutrition and because most poor people are farmers, we're in agriculture as well.
Agriculture is hugely important, especially in a rapidly warming world, and especially with the Earth's population projected to reach 9.6 billion by 2050. How are we going to feed them all?
In the 1960s, there was this thing called the Green Revolution, where new seeds and other improvements drove up agricultural productivity in Asia and Latin America. It saved millions of lives and lifted many people out of poverty. But it basically bypassed sub-Saharan Africa. Today, the average farmer there is only about a third as productive as an American farmer. If we can get that number up, and I think we can, it will help a lot.
There is also this problem where as people get richer and join the global middle class, they want to eat more protein. It's a nice problem to have that people are getting richer. But eating meat is hard on the environment – it demands a lot of land and water. And yet we can't go around telling everyone they have to be vegetarians. So coming up with affordable plant-based proteins, basically meat substitutes, that really taste like meat is another area that can make a big difference. I've tasted a few of them, and I really couldn't tell the difference between them and the real thing.
In your annual letter from the foundation, you argued that there will essentially be no poor countries in the world by 2035. Why do you believe that?
We made really unbelievable progress in international development. Countries like Brazil, Mexico, Thailand, Indonesia – there's an unbelievable number of success stories. The places that haven't done well are clustered in Africa, and we still have Haiti, where I was last week, as well as Yemen, Afghanistan and North Korea, which is kind of a special case. But assuming there's no war or anything, we ought to be able to take even the coastal African countries and get them up to a reasonable situation over the next 20 years. You get more leverage because the number of countries that need aid is going down, and countries like China and India will still have problems, but they're self-sufficient. And over the next 20 years, you get better tools, new vaccines, a better understanding of diseases and, hopefully, cheaper ways of making energy. So time is very much on your side in terms of raising the human condition. Even things like decent toilets, which is a particular project of the foundation, can make a big difference.
Progress depends on such simple things – like functioning toilets.
We take things like TV or Internet or a microwave or a refrigerator for granted, but moving people from basic lives to decent lives requires a lot less than that. You know, development sometimes is viewed as a project in which you give people things and nothing much happens, which is perfectly valid, but if you just focus on that, then you'd also have to say that venture capital is pretty stupid, too. Its hit rate is pathetic. But occasionally, you get successes, you fund a Google or something, and suddenly venture capital is vaunted as the most amazing field of all time. Our hit rate in development is better than theirs, but we should strive to make it better.
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