EP. 114: A LIFE IN MEDICAL INNOVATION AND PHILANTHROPY

May 28

WITH SUE DESMOND-HELLMANN, MD, MPH

The former CEO of the Bill & Melinda Gates Foundation shares her journey from practicing oncology, to developing some of the most important chemotherapies in use today, to leading one of the most influential philanthropic organizations in the world.

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Episode Summary

The Bill & Melinda Gates Foundation, with an endowment of over $50 billion, is one of the largest and most influential philanthropic organizations in the world. With a focus on addressing global health, poverty, and education, its initiatives have led to the reduction of malaria mortality by 60% over the past two decades, the near eradication of polio, increased educational opportunities of millions of students, and improved sanitation conditions for millions of people in developing countries.

For six years, oncologist Sue Desmond-Hellmann, MD, MPH was the CEO of this organization. Prior to that, she served as Chancellor of the University of California at San Francisco, as well as President of Product Development at Genentech, where she oversaw the development of Herceptin, Avastin, Rituxan, and other blockbuster cancer drugs that are now staples in the arsenal of many medical oncologists.

The topics of our discussion in this episode are as varied as Dr. Desmond-Hellman's career. We discuss, among other things, how seeing the work of her pharmacist father encouraged her to pursue a career in medicine, how her early experiences treating HIV patients in Uganda spurred her to tackle global health challenges, how she discovered a passion for product development in the pharmaceutical industry, how she reconciles the ethical quandaries of developing medications that can cause serious adverse effects and that can sometimes cost hundreds of thousands of dollars per dose, what her mission while at the Gates Foundation was, and her perspectives on the role of artificial intelligence and human health and well-being, now that she has joined the board of directors of OpenAI, the company behind ChatGPT.

With a medical, scientific, and philanthropic career that spans more than 30 years, Sue Desmond-Hellmann, MD, MPH has devoted her life to improving the human condition through innovation. As CEO of the Gates Foundation for more than five years, Dr. Desmond-Hellmann led the organization’s 1,500 employees in its efforts to reduce inequity and combat infectious diseases around the world. Among many achievements, she oversaw the creation of the Gates Medical Research Institute — the world’s first nonprofit biotech organization — as well as the launch of the Economic Mobility and Opportunity investment strategy in the U.S.
Prior to joining the foundation, Dr. Desmond-Hellmann was the first female and ninth overall chancellor of the University of California at San Francisco (UCSF), overseeing all aspects of the university and medical center's strategy and operations. She had previously completed her oncologist clinical training at UCSF in the 1980’s, both in the Bay Area and in Uganda, to work on the emerging HIV/AIDS epidemic and cancer.
Before UCSF, Dr. Desmond-Hellmann spent 14 years at biotech firm Genentech, where she served as President of Product Development. She led the development of a number of breakthrough medicines, including two of the first gene-targeted therapies for cancer, Avastin and Herceptin. Her time at Genentech put her at the forefront of the precision medicine revolution, championing the public health approach to save lives by bringing the right interventions, to the right populations, at the right time.
She now serves on the board of directors at Pfizer and Open AI, is a member on the President's Council of Advisors on Science and Technology (PCAST), is an advisor at GV (formerly Google Ventures), and remains an adjunct professor at UCSF.
In this episode, you will hear about:
• 2:50 - How working in her father’s pharmacy led Dr. Desmond-Hellmann to a career in medicine
• 4:56 - A brief summary of Dr. Desmond-Hellmann’s multifaceted career trajectory
• 15:36 - What the day to day work of pharmaceutical drug development looks like
• 18:30 - The challenging ethical concerns that surround drug approvals especially as it pertains to safety concerns
• 23:44 - Dr. Desmond-Hellmann’s experiences in Uganda that forever transformed her views on poverty
• 27:55 - The aims of the Gates Foundation
• 30:47 - How Dr. Desmond-Hellmann views her work both in the non-profit and the for-profit sectors
• 37:15 - Dr. Desmond-Hellmann’s mission when she took on a leading role at The Gates Foundation
• 38:38 - How Dr. Desmond-Hellmann thinks about shaping the future of AI as she takes a seat on the board of OpenAI
• 45:14 - Dr. Desmond-Hellmann’s advice for medical trainees and clinicians on how to navigate the many opportunities available to them along their career path
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and healthcare executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine, we will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:02] The Bill and Melinda Gates Foundation, with an endowment of over $50 billion, is one of the largest and most influential philanthropic organizations in the world. With a focus on addressing global health, poverty, and education, its initiatives have led to the reduction of malaria mortality by 60% over the past two decades, the near eradication of polio, increased educational opportunities of millions of students, particularly in underserved communities, and improved sanitation conditions for millions of people in developing countries. For six years, oncologist doctor Sue Desmond-Hellmann was the CEO of this organization. Prior to that, she served as Chancellor of the University of California at San Francisco, as well as president of Product development at Genentech, where she oversaw the development of Herceptin, Avastin, Rituxan, and other blockbuster cancer drugs that are now staples in the arsenal of many medical oncologists. The topics of our discussion in this episode are as varied as Doctor Desmond-Hellman's career. We discuss, among other things, how seeing the work of her pharmacist father encouraged her to pursue a career in medicine, how her early experiences treating HIV patients in Uganda spurred her to tackle global health challenges, how she discovered a passion for product development in the pharmaceutical industry, how she reconciles the ethical quandaries of developing medications that can cause serious adverse effects, and that can sometimes cost hundreds of thousands of dollars per dose, what her mission while at the Gates Foundation was, and her perspectives on the role of artificial intelligence and human health and well-being, now that she has joined the board of directors of OpenAI, the company behind ChatGPT.
Henry Bair: [00:02:44] Sue, it's an honor to speak with you. Thank you so much for taking the time to join us, and welcome to the show.
Sue Desmond-Hellmann: [00:02:49] Thank you.
Henry Bair: [00:02:50] So as we discussed in the opening, your career has spanned clinical medicine, academia, industry, public health, philanthropy, and in both the nonprofit and for-profit sectors. That's a lot we can dive into. But to kick us off, can you tell us what first drew you to medicine?
Sue Desmond-Hellmann: [00:03:06] That's an easy one. I was the daughter of a pharmacist. My dad really enjoyed the practice of pharmacy. He read about it, talked about it, hired part time most of his kids to help in the drugstore. So, um, that was a big part of my childhood. And experiencing what it was like for my dad to help people by giving them medicine and to collaborate with our family doctor made a huge impact on me. We have a funny picture, when I was probably 8 or 9 years old, in one of my dad's white shirts and a plastic stethoscope, so I know it was pretty early that I decided that a life in medicine was the good life for me.
Tyler Johnson: [00:03:55] That forges an immediate connection between us, because I had a grandfather who was an entrepreneur, who was a proprietor of his own, as they called them, then drugstore. And I remember going to his house when I was little, and he would have these enormous, like five inch black, three ring binders that were his pharmacopeia, where he would look up all of, you know, his drugs and whatever as, as he was filling prescriptions. And then I didn't learn until later, much later, after I had gotten into medical school, that he had actually wanted to become a doctor when he was young, but his family circumstances were not such that he could, you know, put aside sort of family and financial responsibilities long enough to go through the arduous training process. And so he became a pharmacist, sort of, as he viewed it, as sort of the next best thing anyway, which is just to say that I, I think that connection through family pharmacy is lovely.
Sue Desmond-Hellmann: [00:04:48] My brother and my sister in law are also pharmacists. I think it's a wonderful profession I still love whenever I get to collaborate with my wonderful pharmacists.
Tyler Johnson: [00:04:56] One of the things that I think will be helpful to serve as a framework for our discussion. You're relatively unusual in that your career has taken a number of sort of twists and turns, right? You've done a lot of disparate things. Can you just briefly walk us through what your path has been? Like, what have been the major way stations along the way? I know there have been a lot of them, but just because then we can sort of hang the rest of the conversation on talking about some of those way stations.
Sue Desmond-Hellmann: [00:05:25] Well, I will try and be brief, but the first thing that made a big impact on my career was training in San Francisco during the AIDS epidemic. So I'm a medical doctor and an oncologist. My primary area of expertise at UCSF was Kaposi sarcoma. One of the cancers experienced by patients with HIV Aids. And so the first big curveball in my career was the Rockefeller Foundation funding. My husband, who's an infectious disease doc, and I to be loaned to Makerere University in Kampala, Uganda. So after oncology fellowship, we moved to East Africa. I had never even been east of Chicago, so let me tell you, that was pretty crazy. And I worked and collaborated with Ugandan colleagues for more than two years in Uganda studying Kaposi sarcoma, studying heterosexual transmission of HIV, which was really quite novel in concept at the time, and did so in a way that was life changing. I mean, the experience experiencing what the kind of poverty I had never imagined that humans could experience experiencing a terrible epidemic up close and personal in Uganda, um, really changed how I thought about myself in medicine forever. And the other big change was on returning to the US, realizing that UCSF had no global health program and there was no logical academic home for us when we came back. So I practiced oncology for a couple of years.
Sue Desmond-Hellmann: [00:07:09] The next big shift in career was when Bristol-Myers Squibb recruited my husband to work on one of the new Aids drugs, and I was the trailing spouse. So if your listeners want any pearls about career development, you know, if life gives you an opportunity, you take it. So the opportunity was to work for the first time ever in industry on a new drug that Bristol-Myers Squibb had called Taxol, that became the number one cancer drug in the world, very important drug for ovarian cancer, breast cancer and other tumor types. And I found out something that was a big surprise to me, which is I loved doing drug development, I loved it, I loved the statistics, the inference, the trials, the innovation. It was fantastic. It was the kind of job that in many ways, I had been preparing for, because I went back and got a master's in epi and biostat at UC Berkeley in public health. And so the statistical part of it was just for me, really, really interesting and important. And things went so well that Genentech recruited me to come out because they wanted to be a cancer company. And so we came back to San Francisco, and this time my husband was the trailing spouse in a good reversal. But I spent 14 years at Genentech in the kind of experience that I've described to people as magical, like just an amazing thing. If you love product development and I do, being associated with Herceptin, Rituxan, Avastin, Lucentis, the kinds of innovation actually Zoller, which was recently approved for food allergy after a long time. It was tremendous.
Sue Desmond-Hellmann: [00:09:00] But the next big change in my career came when Roche bought the rest of Genentech. So Roche was the majority owner of Genentech, and when Roche bought the rest of Genentech, that was a big shift from a small to medium sized biotech company to being part of a big Pharma, which wasn't appealing to me. And so UCSF asked me to look at the job as chancellor, and I moved from Genentech back to academia to be chancellor of UCSF, where I probably still would be had not Bill and Melinda Gates called and said, look, we know about your experience in Uganda. We know your history. You need to come up here to Seattle and help us out at the Gates Foundation. And so it's very hard to say no to Bill and Melinda Gates and that mission. And so I went up for just a little short of six years to Seattle and led the Bill Melinda Gates Foundation, which, again, was just tremendous. I mean, the kind of mission and capital and opportunity that anyone who cares about getting rid of poverty, helping people who who really can help themselves if just given a chance. It was a really amazing experience to be at Gates Foundation as well. So I've been really fortunate. I've been able to do many, many things. At one point, my parents came to Genentech to visit. Mean. And they looked around and they said, Sue, where are the beds? Where's your stethoscope? And they were just sad that I wasn't a real doctor. And I understood that I complete. But you can't do everything.
Tyler Johnson: [00:10:38] Many of our listeners are early trainees or not even in medicine. So just to demystify a couple of the terms that you use. So Kaposi sarcoma, as you mentioned, is a is a malignancy that often appears as these kind of purplish blotches on the skin. That happens mostly in people with HIV Aids. You can see it sometimes otherwise, but that's certainly the most common manifestation. And sometimes the presenting manifestation of that disease, especially in under-resourced countries. And then Taxol is a what we now refer to as a quote unquote, old fashioned chemotherapy medication. Although, as you say, when it came out, it was certainly important and still functions as one of sort of the bedrock. You know, anybody who's an oncologist knows that that's one of the things you sort of fall back on. If you don't know if there's anything else that you can use. That's one of the most commonly used chemotherapy medications in the world. And then Herceptin and Avastin are two medications that are not old fashioned chemotherapy medications. So one of them, Avastin, works by trying to limit the ability of tumors to recruit and create new blood vessels, because if they can't make new blood vessels, then you can't expand the scope of the tumor because it doesn't have a blood supply. And then Herceptin is a medication was the first medication initially used in breast cancer, but now proliferating into many other tumor types. That works by helping the body to attack the Her2 protein, which is a protein that's expressed on the surface of many kinds of cancer cells, most commonly breast cancer, but now also used in colon cancer, rectal cancer, stomach cancer, lung cancer, and a whole host of other ones. Which is just to say that Sue, over the course of time and in various different posts, has helped to produce sort of multiple iterations of oncologic therapeutic revolutions at various stages along her career. Okay.
Sue Desmond-Hellmann: [00:12:28] I'm really glad you did that. Let me just add to what you said. When I say I love product development, I think that sort of quest for innovation, making things better, the statistics of does it work? All that I find technically really interesting. The best day ever is when someone says to me, you know, my mom got Herceptin and it really helped her, or my wife is on Herceptin, and she's so grateful that there's something for her kind of breast cancer. And I think it's something that I, I have never gotten tired of somebody saying, you helped me or as an oncologist saying, you know, we have something for you now. We have a medicine for that, or we're trying to get a better medicine for that. Doing better is the part of innovation, I think that is. So, um, it's not always perfect. There's side effects. You have to be really measured, especially in talking to patients about the pros and the cons. But having an option, having hope is what it's all about. Yeah.
Tyler Johnson: [00:13:28] And to that point it's interesting. So we're not going to get into the weeds of the oncology treatment. But I just want to mention very briefly that breast cancer can be broken down in different ways. But one of the ways that it is most commonly broken down is people who have either hormone receptor, that is either estrogen or progesterone receptor positive breast cancer. That's one subtype. Her2 positive breast cancer is a second subtype. And then so-called triple negative breast cancer is a third subtype. The reason I'm making that distinction is because previously it was the case that if you had Her2 positive breast cancer, we knew about it purely because it was a negative prognostic marker. And people who had overexpression of the Her2 protein on the surface of their cancer cells did generally worse than those who didn't. But there was nothing that we could do about it. But then the advent of Herceptin led to opening, eventually opening the floodgates. This was over decades, but still to a whole host of anti-her2 oncology medications, so that now I don't even know the number. And whatever the number is that it's FDA approved, it's probably 6 or 7.
Tyler Johnson: [00:14:31] There are a whole host of other ones that are in the pipeline, which is just to say that I recently I'm not a breast oncologist, but I asked a breast oncologist and this was a few years ago. I said, well, there are so many medications now that if you know, as one of my mentors used to say, if you were going to the cancer store and you had to choose a Her2 positive or Her2 negative breast cancer, you would still rather have ERP or positive breast cancer. But there are so many, so many therapies now for Her2 positive breast cancer that I think it's getting to the point and may eventually reach a tipping point where it's arguably better to have Her2 positive breast cancer because of all of the therapeutic options that are available, whereas it used to be that it was purely a negative prognostic indicator. And so I think taking something that was previously viewed generally universally with dread and taking it into something that at the very least is an opportunity and maybe will eventually actually get to become a positive thing is, is a relatively remarkable pharmacological achievement.
Sue Desmond-Hellmann: [00:15:30] It's cancer. Jujitsu.
Speaker4: [00:15:32] Yes.
Sue Desmond-Hellmann: [00:15:33] You want to do it every day.
Tyler Johnson: [00:15:34] Precisely.
Henry Bair: [00:15:36] Yeah. You highlighted for us earlier, this big shift from the clinical world of seeing patients to the pharmaceutical industry. It's a pretty big shift and the work involved is so different. Can you tell us what your day to day responsibilities and product development looked like?
Sue Desmond-Hellmann: [00:15:53] The work of product development varies a lot. There's a few things that every day has. One of the things that's true every day is that you're collaborating, starting with colleagues in basic research. So there's a lot of work that has to be done on. Are there new targets? Are there new ways of treating people and what is missing to turn that new idea into a medicine. So lots and lots of collaboration at Genentech once a week I attended for four hours the research review committee hearing about science, thinking about what we could do next. So a lot of collaboration with research, a lot of collaboration with thought leaders. So going to Stanford or UCSF or other academic centers and making sure that that you're aware of what are the unmet needs, what's missing are there her two positive patients are patients who are estrogen or hormone receptor positive with breast cancer. Are they running out of steam on the medicines that we have for them now when we need a new one? So really being clear on the unmet need and then very importantly, overseeing clinical trials and working with colleagues and with the Food and Drug Administration on testing in a very rigorous way. The new ideas that is the most important job of a product developer is to prove that the medicine is what an FDA language is called safe and effective.
Sue Desmond-Hellmann: [00:17:22] Safety and efficacy are the goal posts of product development, and that means it's effective enough to be a new drug, and it's safe enough to be a new drug. And anything that's an adverse event, if it causes your blood count to go down, causes a rash, whatever it causes is included in the package insert. There's a very formal process all product developers go in, starting with asking FDA, can we start treating patients with this? And as an experiment and and not ending, but going to a product label and an approval and then post-approval monitoring for safety. The first job I had in industry was overseeing drug safety. And some people might think that's mundane or boring. It was a fantastic way to learn because it's what you say as a physician, first, do no harm. If your drug causes safety problems, they better be minimal and you better understand them. And so being very, very good at drug safety means being a good doctor, paying attention, and working to make sure that prescribers and patients understand what they're signed up for.
Tyler Johnson: [00:18:30] So let me ask, though I agree with you that those problems are very interesting. And at the same time, I feel like they are pretty thorny, especially in the world of cancer drug development. Right. So just to give one example, one of the drugs that has come on the tail of Herceptin is a drug called enhertu, which is also a drug that utilizes the abundance of Her2 protein on the cell surface of some cancer cells, but then attacks the cancer cells in a different way. So the reason I bring up Enhertu is because, on the one hand, multiple clinical trials and multiple different types of cancer have demonstrated unequivocally that Enhertu is not only effective, but most remarkably, is effective even in patients who have already had Herceptin and in whom Herceptin is no longer effective. So we're leveraging the same drug target, but with a drug that works after the first drug is no longer working. So that's quite remarkable. But then the thing that has also been demonstrated in multiple different cancer types is that enhertu can cause what amounts to a sort of like an allergic reaction or a type of inflammation in the lungs that is not uncommonly serious and in a reasonable number of cases has been fatal.
Tyler Johnson: [00:19:42] That is to say that people who have taken the drug have developed this sort of a inflammatory reaction in their lungs that eventually renders them unable to breathe, and they have died. And in spite of that, the drug has been approved and is and I mean, I use it somewhat frequently. And, you know, it's used widely in places where it's available. So I guess all of that is to say I have a two part question here. But the first part is just sort of, broadly speaking, philosophically, if you're sort of the, I don't know, the real term in corporate pharmacology, but if you're sort of the chief safety officer, so to speak, for drug development at a place, and you have a drug that is going to help x percent of people, but is going to be dangerous or even fatal to a much smaller number, but still a significant and reproducible number of people. How do you think about the ethics of looking to have that drug approved?
Sue Desmond-Hellmann: [00:20:34] Yeah, so I am very strongly influenced by experiences I had both in HIV and in cancer. In interacting with patients, I was surprised by patients negative feedback about, you know, you're over protecting me. Don't forget, I'm on my deathbed or I'm on my way to a death faster than I want. So make sure you don't overdo when you're being careful or being safe. And yet, you know, the thought that a drug that I developed hurts somebody. You know, that's a terrible, terrible thing. So you're balancing. I mean, the first tool you have is you have a tool that is a black box if you're an oncologist or if you're a prescribing physician and there's a black box on that label. The black box sounds kind of scary. And it is. It says, look, we're going to take and frame a very serious, scary warning. Be careful out there. Here's a very scary lung side effect that you need to think about. And you may not even want to use this drug knowing about this. So working with the FDA to make darn sure and sending out a letter to people who are prescribers and doing everything you can to make sure people are aware. The other thing that I think is increasingly available, and I think is a good thing, because you hate to take a drug like Enhertu off the mark. I mean, that's a really powerful, important drug, the same precision medicine that allows us to select patients who are appropriate for her to targeted therapy should help us to pick out the patients who are at greatest risk for safety issues. So the question is, could you say I'm going to do this test? And if you get X outcome on this test, I won't.
Sue Desmond-Hellmann: [00:22:21] Treat you with this drug because I don't want to hurt you. Very, very important. And then informed consent patients need to understand risks and benefits. And I always tell patients, look, I mean, from the earliest days when I was treating lung cancer patients with cisplatinum, now that's a lousy drug. That is a tough drug to take. And I would say, look, I'm planning six courses every course. We're going to have a dialog. If at the end of the second course you feel too lousy, we'll stop. If at the end of the third one, we'll stop. Patients are in the driver's seat. Now, it's easy for me to say patients are in the driver's seat. We all know it's not that easy when you're sick and when you're not a physician to understand everything. And it's not uncommon. Patients will say, well, what would you do? You know, so sort of going through here's how I'd think about it. If I feel a little bit more like, I don't feel good, I might, I might wait or I might stop. How are you feeling? So make sure people know what they're up against. Make sure patients know what they're up against to the extent you can. And the last thing I'll say on this, and I had the experience at Genentech, at some point, if the safety starts to outweigh efficacy and there's other drugs that patients can have you withdraw from the market, you can take a drug off the market if you're starting to see. And in fact, it's done and it should be done if there's other alternatives for patients.
Tyler Johnson: [00:23:44] So I want to turn now to your time at the Gates Foundation. Not that I, you know, have the ability to draw a straight through line, but you kind of mentioned that there's at least some connection between the work that you had done early on in Uganda and on Kaposi sarcoma and other things, and then being called to lead the Gates Foundation thereafter. So before we get to the Gates Foundation, per se, could you talk about you mentioned that your time in Uganda was a formative experience, particularly in the sense that it gave you an understanding of what true poverty looked like in a way that you couldn't have had before. But could you articulate for us one specific experience in Uganda that really left an impression and explain what happened and how it changed you?
Sue Desmond-Hellmann: [00:24:32] Maybe I'll tell you two short stories that really changed how I thought about thing. The first one was going to Uganda and driving from Entebbe, where the airport is, to Kampala, where the Uganda Cancer Institute is and where our office was. And there's a long road as a dirt road back then. Now it's nicer and there's these little shops that are along the road that people talk about. You could go and buy a samosa or get a soda or something like that on your road trip. And most of those shops were deserted, and the shops that were not deserted had coffins standing up. And it was extremely clear that the best business in town was coffin making. And realizing that that was a direct result of HIV Aids. Remember, there was no antiretroviral therapy. I was just shocked at how pervasive HIV was. And how rapidly it was killing people in the prime of their lives. If a 16 year old girl went to the sexually transmitted disease clinic to be treated. She had a 50% five zero. Half of those 16 year old girls had HIV. And most of them with their first and only ever sexual partner. That was what it was like in 1989. To say it was shocking. It was overwhelming. It, you know, where do you start? How do you think about something so, so difficult and with very limited resources, very limited medical staff, and the only thing to do is roll up your sleeves, take care of as many patients as you can.
Sue Desmond-Hellmann: [00:26:27] Decrease suffering. I often wouldn't have all the chemotherapy drugs I wanted or needed. So you thought about quality of life, always thought about quality of life, treating STDs aggressively to decrease transmission because it's all we could do. So the sense of, you know, people talked about in New York City about Covid, how it felt to some people like HIV. Again, that kind of dread that you had of something really shocking and scary happening was just right in your face. Even having been in San Francisco for HIV in the earlier 80s. The second thing is just sort of a funny story that we were in a duplex. We were in this compound that a tiny little duplex that we shared, and we had a plastic white bucket that we would put our trash in, and we would set it outside the back door. And we had a couple of people who helped us with our house and cleaning up. And so we would put this white bucket out. And I realized a couple of months into living there, nobody came and picked up the trash. There was nothing that we threw away that somebody didn't want. Like including a piece of paper. So the concept, when I say I didn't understand poverty, I didn't understand not having anything, not having a piece of paper, not having a can that you could use to carry water in, just not having anything. And so the needs and the poverty and the, the struggling really made a huge impact on me.
Henry Bair: [00:27:55] So that's a that's a great segue to discussing your work at the Gates Foundation. Can you share with us? For those who may not be aware, what does the Gates Foundation do?
Sue Desmond-Hellmann: [00:28:05] Well, the Gates Foundation deploys capital from belonged to Gates and Warren Buffett. And it is a foundation that the only work they do in the US. So the only work people might see in the US is in education. Very important work, especially in K through 12, but also higher ed globally. The Gates Foundation started in global health and has expanded to agriculture, women's empowerment, financial services for the poor like mobile money, making it easier for people to have money. Family planning. It's a massive foundation. It has billions of dollars of capital that it can put to work and always works through others. It's not an operating foundation, it's a grant making foundation. So I think for your listeners, one of the things that I found really great about the Foundation is they're very disciplined in how they use the money, because you can imagine you get a lot of cards and letters, and you have the Bill and Melinda Gates on your logo. In Global health, they're very focused on children. The idea is that everyone deserves the chance to have a healthy and productive life. That's a great. By the way, you can't do a better slogan than that. Having a chance to have a healthy, productive life means you're healthy.
Sue Desmond-Hellmann: [00:29:24] So they focus on malaria. Tuberculosis. They focus on neglected tropical diseases because they're neglected, right? They focus on polio because there's a dream that polio could be the second ever disease that's eradicated, the first disease being smallpox that was eradicated more than 20 years ago. And so let me tell you about one program I think is in many ways the best program so far at the Gates Foundation, and that is Gavi, the global Aids Vaccine Alliance. What Gavi does is it is a program with many partners Gates Foundation, Who, Unicef. It goes to companies and says, okay, we will commit to you. We'll buy 2 million doses of your vaccine. If you give us your vaccine at this price. And then they pool all those vaccine doses and work with countries, one country at a time, to supply doses for countries with low income, millions and millions of children have been vaccinated who would not have been vaccinated otherwise. So millions of lives have been saved by having affordable vaccines that are distributed appropriately. It's a fantastic program that has scale and reach because of the resources and the voice of the Gates Foundation.
Tyler Johnson: [00:30:47] Let me ask a question that I recognize maybe uncomfortably, potentially juxtaposes two different parts of your life, but in a way that I think is really important. Dave Chokshi, the former commissioner of health in New York during the pandemic and who is a friend and a medical school classmate of mine during medical school, brought this sort of moral dilemma to my attention, and it has never really left me. Which is to say that on the one hand, you have worked for the Gates Foundation or led the Gates Foundation, which is. So, for instance, you mentioned neglected tropical diseases. One of the things that is so powerful about an organization like the Gates Foundation is that it can identify what are in a sort of the universal scheme of things, relatively lower hanging fruit. Right? In other words, if you're looking at the number of dollars spent to achieve improvement, whether that's in quality of life or number of years lived or whatever metric you want to use, there are things that can be done that are not that they are simple and not that they are cheap, but that, relatively speaking, you can do more for less if you know how to deploy the capital in the appropriate places, with the appropriate people in the appropriate way. On the other hand, you have also worked for and helped to lead US based or so-called developed world based pharmaceutical companies that spend billions of dollars to develop drugs that in some cases lead to.
Tyler Johnson: [00:32:19] I don't want to dismiss the impact that any given drug can have for any individual patient. But if you look at them sort of writ large. So in the oncology world, in the United States, you can get FDA approval for a drug if the drug improves the median overall survival of a patient with a given disease by two months, even though the drug costs billions of dollars to develop and then may cost tens or hundreds of thousands of dollars to administer to any given patient to lead to what is, on average, an increased overall survival of a couple of months now. There may be, you know, remarkable responders and all that, which is a separate conversation. But but nonetheless, the average impact is relatively small. And so I guess I just wonder, like the part of you that was devoted to the Gates Foundation and the part of you that was devoted to very wealthy US pharmaceutical companies, what do those two parts of you say to each other if they converse? Right, like like how do you think about putting those two parts of your life together?
Sue Desmond-Hellmann: [00:33:23] So I don't find it a dilemma. Those two parts, it is inarguably good for the world to make new medicines. In my opinion, it is. Also important for those companies to look at how they help not just the rich people, but more broadly, and how their medicines impact society, both financially and in other ways. So there's two things that I think are interesting about your question. One is you're suggesting that we could direct product development with a more public health lens rather than a commercial lens. That's not the way that we've set up the pharma industry in the US. It's a for profit commercial enterprise. One of the things I established at Gates Foundation with colleagues is a Gates Medical Research Institute. The Gates Medical Research Institute is a not for profit biotech. Basically, they are doing trials in malaria and TB of new medicines because it's very hard for companies that are for profit to do those kinds of studies. And so I think that that is a good thing. And I think they and I know they work with other companies to get the chemistry and to get some of the things, the assets they need to get it done. So I think that's a like a test model.
Sue Desmond-Hellmann: [00:34:48] And we need other test models of how we get new medicines for neglected diseases. I'd like to call them no longer neglected diseases. I think that would be good. And you all know the stories of like river blindness and ivermectin or trachoma and Pfizer's donations. These companies are making big donations for tropical diseases, which I think is important. But let me turn to the other question you asked, which I think is this is a dilemma. So a cancer drug that adds two months of life, let's just have that as the headline. So when Taxol, the old fashioned chemotherapy was approved, it was approved in breast cancer. That's already spread. When Herceptin was approved, it was approved in breast cancer that's already spread. So somebody is in a really tough position and they've got very difficult to treat breast cancer. When those two drugs were moved earlier in the course of treatment, they made a bigger difference. I know the the adjuvant therapy with Herceptin can cure someone. We weren't talking about cures when we got Herceptin first approved. So my worry if you say it has to hit a bar that's really, really good is that you'd have to go to early stage and spend many, many years and a lot more money to hit that hurdle rate.
Sue Desmond-Hellmann: [00:36:07] Now, that might be true with some of the new targeted therapies, but I think it's too arbitrary to say if your first trial isn't a home run, you don't get approved. So I would push back on that. I am definitely worried about the cost of drugs. I so understand the issues about the cost of drugs. I also understand the issues of the US paying the way for the rest of the world. I think those are valid arguments and improvements are needed, and I have some ideas about how we could make it better. But there are ill formed ideas. But I can tell you that I used to say this and I will. I will say what I used to tell people who asked me about career choices in pharma or academia or philanthropy. I've seen people whose morals and values I feel really good about in academia, industry and philanthropy. And I've seen people who I don't have a lot of respect for their morals or their values in academia, philanthropy and industry. So I don't think you should bend people by where they work.
Henry Bair: [00:37:15] You know, so you've shared with us what the Gates Foundation does as you stepped into the leadership role of this massive enterprise endeavor. What was your mission going into it like? What were you hoping to accomplish?
Sue Desmond-Hellmann: [00:37:30] In that role. I wanted to make sure that to the extent I could make a contribution, it would be that everybody who worked at the Gates Foundation felt like the organization brought out the best in them. When you're at a place with a mission as compelling as Gates Foundation and with inspiring leaders as inspiring as Bill and Melinda, you tend to overwork and burn out and like, really, really burn the midnight oil. So I wanted people to be able to contribute and thrive. That was really important to me. I also wanted for us to show up in ways that were humble. To be a learning organization and to be as collaborative as possible. Because there was a power asymmetry at Gates Foundation that I felt like we were always dealing with. We had money and the people who we were interacting with needed money, you know? So you really had to have a humility and an understanding that you didn't have all the answers. You just had a checkbook.
Tyler Johnson: [00:38:38] So I hate to turn to yet another subject, but I know that we're drawing short on time. And I do want to discuss this because I think it's really important. Just to give a little bit of background, though, many of our listeners, I'm sure, will be aware, but so the arguably the most exciting frontier in medicine and in society right now is with generative AI. And famously, a few months ago, Sam Altman, who was then the CEO of arguably the most powerful company in AI, which is called OpenAI, was ousted very briefly. And then it came into sort of screaming public view, this dispute that had been sort of boiling beneath the surface, which was that OpenAI has this very strange sort of self-made directive about being a for profit company that's supposed to have not for profit motives is sort of what it boils down to. As I understand it. And there were members of the board who thought that that sort of dual purpose was not being appropriately served, and some of them thought that Sam Altman was the cause of that disservice. And so he was ousted. He was only ousted for like 48 hours or something. It was like a weekend. And then he was brought right back on.
Tyler Johnson: [00:39:47] But one of the preconditions for his rehiring after 48 hours or whatever of firing was that they would constitute a new OpenAI board. And you were announced as one of the members of this newly constructed board at the company. So Henry and I have had a growing number of conversations on the program with people who are either involved in AI from the medical side, or even who are leaders of AI on the corporate side. And we think that this is a really important thing to talk about, because it is so likely to have such a determinative impact on the practice of medicine as we move into the 2030s and 2040s and beyond. And so one of the things that I wanted to ask you, as someone who's just going to assume a place on what someone could argue is one of the most important boards of directors in the world in terms of shaping the world's future. So let me back up and say one more thing, and then I'll ask my question. We recently had a conversation with Eric Horvitz, who's the chief scientific officer at Microsoft. And and his main focus is on AI. And one of the things that really struck me, both in our conversation with him and also in reading about Sam Altman and in multiple other places that these conversations are going on, is that the people who are the scientific experts in AI, including in designing it and whatever, openly admit that they a don't really understand a lot about how it works, and b are incapable of predicting what it's going to do in the future.
Tyler Johnson: [00:41:23] It's as if they are rubbing the proverbial lamp and waiting to see what the genie looks like when it comes out, acknowledging that they don't really know what it looks like or is going to look like, or what it's what it is capable of. But what everyone agrees on is that even though they don't understand what it's going to do, they are confident that it has the potential to be genuinely transformative. Like, I think Eric Horvitz said, that we'll look back 500 years from now on this the next 20 or 30 years as the beginning of a new age, which will be the age of AI. So all of that is to say that with all of that as background, how do you think about shaping such a potentially powerful and transformative technology when we don't even understand how it works and we don't know what it's going to do?
Sue Desmond-Hellmann: [00:42:09] That's a big question, by the way. Eric Horvitz is not only chief scientific officer at Microsoft, he is one of the members of the President's Council of Advisors on Science and Technology with me. So we're both members of that group. And one of the experiences we've had is having a great dialog with President Biden and our colleagues to really try and contribute to the kind of federal response to AI and the need to make sure that we take this quite seriously. I want to just second something that Eric said, which is this feels to me super important. And on any given day, if you care about science and if you care about health care, you think, oh my gosh, think of what we could do. Think of what we could achieve, think of what is possible. And I think that's tremendously exciting with all of the caveats, all of the watch outs, what I think is implicit in what you're saying is should you slow down or stop? I turn to governance and regulation and guardrails. You may not understand everything, but understanding enough so that you set some limits. If you are a biotechnology person, you know that in 1970s I think it was 73 or something like that. They had a famous conference at Asilomar because people were really nervous about gene splicing. Do you remember that, uh, Herb Boyer always tells stories about it, which I enjoy immensely because he's a good storyteller. So this is not the first or the last time we have a technological advance that makes us all scared.
Sue Desmond-Hellmann: [00:43:52] What was interesting about Asilomar, and I don't think will happen with AI, is that it was an American event to talk about gene splicing and maybe a little bit of collaboration with the Brits, but this is a global issue. I and so we also need to think about the regulation and the governance with the understanding that the world is going to act on AI with or without us. So I take on this role on the board with a wish to understand how governance, which is the role of a board, can help with two things. One, you mentioned a structure that's got not for profit and for profit, which I think is a really interesting and challenging structure to make work. And so making sure that that is done with rigor and oversight and then most importantly, making sure that that we're safe, especially given all the uncertainty that you outlined. There is a lot of uncertainty. There's been a lot of uncertainty before, though. It's not the first time. This seems so fast and so powerful, though. Again, for your listeners, I would really recommend Peter Lee and Zach Cohen's book on AI in medicine. It's very small, easy to read, and they they have use cases which, you know, they use a lot of examples, which is really helpful. And just understanding what the heck are we talking about?
Henry Bair: [00:45:14] Well, thank you very much for shedding some light on your perspective there. I'd love to close with a question that we typically like to ask our guests towards the end, which is bringing it back down to some personal advice you might have. For our listeners, let's say we have some trainees or early career clinicians who are wondering what they should do with their lives, whether it's academia or just becoming a clinician or industry or something else, or government. And since you have done so many of those things over the course of your career, I think you're in a unique position to shed light on. What are the things that we should keep in mind as we make those decisions for ourselves? What advice do you have for people? For someone who comes to you with what that question?
Sue Desmond-Hellmann: [00:46:01] So a couple things. The first is from a work perspective I ask about is the work you're committing to do important? Are the people you're going to work around bright and do they share enough so you'll learn from them? Because it should be fun. I mean, we get to work on such interesting things that are for society. It should be fun and it should be. I always think the beginning of the year versus the end of the year. What am I going to know at the end of the year? I didn't know at the beginning how am I going to be better? How am I going to contribute? So being in a role where you get to contribute and learn and grow matters a lot, it really matters a lot. And the second thing is, and in so many ways, for me, it's the first thing. What's the impact of that role on your family? The best thing that's happened to me in my career wasn't being the CEO of the Gates Foundation. It was a good job. It was, you know, I always say it's a fancy job. The best thing is that when I was an intern, I met my husband, who was also an intern at UCSF, and we've been together ever since. And any time something comes up that I might do first person I talk to, first person I think about what will be the impact on him because you can get a different job, but having to fix things at home is way worse. You know, it's way worse than fixing the wrong job. So I think people who are smart and talented and well trained are at risk of forgetting that home trumps everything else. Yeah. So don't let that happen.
Henry Bair: [00:47:37] That's a really heartwarming answer, and not one that we it's true. We don't often think about it in certainly not in medical education. So we are with that. We want to thank you so much again, Sue, for taking the time to join us, for walking us through your life journey and for all the insights that you've accumulated along the way. Thanks again for your incredible work, both in industry and in philanthropy. And now, I suppose, in artificial intelligence as well. So you're really, uh. You're really playing a big part in the future that is to come. So thank you very much for all of that.
Sue Desmond-Hellmann: [00:48:10] Thanks for the conversation. I appreciated talking to both of you.
Tyler Johnson: [00:48:13] Thanks so much, Sue.
Henry Bair: [00:48:40] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctor's Art.com. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:48:59] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:49:13] I'm Henry Bair
Tyler Johnson: [00:49:14] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.