"The only option is to step up the fight"
After a successful career in banking, Peter Sands, former CEO of Standard Chartered, took over the helm of the Global Fund. Combatting HIV, malaria and tuberculosis is a role that he "could not refuse."
Interview Marisa Drew, CEO Impact Advisory and Finance, Credit Suisse
Peter Sands, you have been Executive Director of the Global Fund since 2018. It is the world's largest initiative to fight HIV, malaria and tuberculosis. Where do we stand today with regard to these three infectious diseases?
In 2017, these three diseases killed a total of nearly 3 million people, who are concentrated in the world's poorest communities. However, the figure was almost twice as high a decade ago. We have made huge progress but we still have a lot to do if we really want to end these epidemics.
Can we look specifically at each of the three diseases, starting with HIV?
One of humanity's greatest triumphs is that we have been able to transform this deadly disease into a chronic illness as a result of modern antiretroviral therapy. Reducing infection rates must be the next step – but this is where we have to battle against various prejudices and discrimination. Those affected are often sex workers, men who have sex with men, people who inject drugs, migrants, refugees and prisoners. These groups often have limited access to healthcare services or they are worried about using them. Another challenge is the lack of protection for girls and young women, especially in East and Southern Africa. In certain regions, an 18-year-old woman is five times more likely to become infected than an 18-year-old man.
What needs to be done?
We support initiatives that pay girls to stay in school, where they are proven to be less vulnerable. We finance programs to combat gender-based violence. And, of course, we also support classic prevention work and supply clinics with condoms. However, the root causes lie deeper than that: As already mentioned, HIV has a lot to do with equality and human rights – and the failure to respect them.
What can you tell us about malaria?
There are two different challenges when it comes to malaria. On the one hand, we have a set of countries that are well on their way to eliminating the disease. Argentina and Algeria have just become malaria-free, while others are close to achieving that goal. The challenge in these countries is to avoid a complete loss of political attention and funding. Once people take their eye off the ball, malaria surges back again. On the other hand, there is a second set of countries that still have a very high incidence of malaria. We have succeeded in reducing the number of deaths through more rapid and effective diagnosis and better treatment. However, we have unfortunately not been very successful in breaking the transmission dynamic between mosquitoes and humans. A mosquito lives for around two weeks, during which time it has to bite a person who is already infected with malaria in order to pick up the parasite and then bite another person without malaria in order for the disease to keep going. It is only by breaking that cycle that we can reduce the spread of malaria.
We have unfortunately not been very successful in breaking the transmission dynamic between mosquitoes and humans.
And finally, tuberculosis. What is happening with that disease, which may be as old as mankind itself according to the latest research?
I am glad that you mentioned how long tuberculosis (TB) has been around. TB was the infectious disease that claimed the greatest number of adult lives in Europe and the US in the '30s and '40s and in Japan in the '50s – and yet we have almost completely forgotten about it. Tuberculosis doesn't attract nearly the same level of attention nowadays as HIV or malaria. We need to change that – it is one of my stated aims.
Just how dangerous is TB for humanity today?
The biggest danger is that a lot of carriers are not diagnosed and therefore go untreated. Each year, around 10 million people fall ill with TB but around 3.6 million of them are unaware of it. You don't need to be an expert to understand that 3.6 million people unknowingly living with a highly infectious disease represent a major problem. We can't wait for patients to turn up at a clinic; we need to actively go out and find them. Another problem is the emergence of a new strain of tuberculosis, multidrug-resistant tuberculosis, which doesn't respond to the common antibiotic treatment and kills about half of all people infected. It poses an enormous threat to global health. We cannot afford to be complacent about tackling this disease and developing the next generation of antibiotics.
The third UN Sustainable Development Goal (SDG) is to end the three diseases by 2030. Is that realistic?
It is very difficult to completely eradicate the diseases themselves; that will probably take more time. But we should be in a position to stop these epidemics – in other words, to ensure that they are no longer a threat to public health.
You have spoken about your clear goals. Could you tell us about the Global Fund's successes to date and give us an insight into the related figures?
The number of people dying from AIDS has come down by more than 55 percent. In the case of malaria, the death rate has been reduced by 60 percent. We have been somewhat less successful with tuberculosis, where the death rate is down by around 40 percent. It is important to note here that there has been a subtle shift of strategy at the Global Fund and an adjustment of its objectives. The Global Fund was established during a period of crisis and had to respond to an emergency situation. The imperative was to save the lives of people who were in acute danger. We have expanded on this objective and are now focusing on ending epidemics in order to save future lives. This is why we are also turning our attention to infection rates which, incidentally, have not come down quite as fast as the death rates I just mentioned. We need to change that.
You were CEO of Standard Chartered, one of the UK's biggest banks, for many years. Was it very different to the Global Fund?
Not really. The Global Fund invests around 4 billion US dollars each year and my job is to maximize its returns. However, my return metrics are not of a monetary nature; they relate to the number of lives we save and how many infections we prevent. The Global Fund is also data obsessed and we constantly ask ourselves whether we are focusing our investments in the right way. We have a complex supply chain: We have drugs, bed nets and diagnostic kits for TB – we are the world's largest purchaser of these items – but the question is how can we help our partners get them to people who don't live in the most accessible places in the world? Risk management is another area that we put a lot of focus on at the Global Fund, just as I did previously at the bank.
We can't wait for patients to turn up at a clinic. We are spending enough to keep the disease at bay but not enough to really beat it.
The Global Fund is a public-private partnership involving a wide range of stakeholders. How do you find the interaction between the two sides?
We work with governments, private philanthropic institutions, companies, suppliers, technical partners and representatives of civil society, as well as large, international NGOs and small local NGOs. All the different stakeholders bring their own perspectives, which can lead to tensions and challenges. However, I see that in itself as very constructive. The Global Fund has developed a proper culture to reconcile these different viewpoints.
Could you describe what happens at a board meeting?
At the bank, these meetings were quite small, whereas as at the Global Fund there are 300 people in the room. I had never seen anything like it before. But I have since concluded that having all stakeholders present is a major strength. It means that everyone is involved in reaching sometimes difficult trade-offs.
The Global Fund has a three-year funding cycle. The next cycle will run from the start of 2020 to the end of 2022. What are your expectations?
We want to raise at least 14 billion dollars, which is an increase of 15 percent compared to the current cycle. That is not a randomly defined figure. We have conducted very detailed epidemiological modeling along with external partners and, in fact, 14 billion dollars is the minimum amount of funding needed for this cycle.
What is your response if someone says that he or she would rather support a cause that is less well funded?
Malaria is a disease that kills around half a million people annually – primarily small children and pregnant women. Around 250 million people are newly infected each year. Large swathes of the world's poorest regions are affected, especially in Africa. Total global spending on malaria amounts to around 3.5 billion dollars annually. That is equivalent to the budget of a large hospital in New York – but we are talking about 250 million patients. And malaria is a good example of how we could manage to end an epidemic – but we need to invest more money to achieve this. From an economic standpoint, what we are doing is in fact irrational.
Irrational in what respect?
We are spending enough to keep the disease at bay but not enough to really beat it. Another perspective is to then ask whether the investments are really worthwhile. In the case of malaria, there is a return of 19 dollars on every dollar invested. And, lastly, it is important to emphasize that there is no middle ground. We either win or we lose in the battle against these illnesses. We have seen cases where governments limited the action being taken and the number of infections immediately rose again. As soon as we pause our efforts, there is a resurgence in the number of cases. The only option is to step up the fight in order to end these epidemics once and for all.
Are there other factors in addition to funding that are needed to eliminate these diseases?
We need more innovation in terms of drugs and, in particular, diagnostics. We need to help patients to adhere to drug regimens – this is where a lot of impact is lost today. The relevant stakeholders need to work together more closely and effectively. In the end, what we need is better data so that we can scale up the measures that work and scale back other interventions.
You spent 12 years at Standard Chartered, including almost nine years as CEO. It would have been possible to step back and take on well-paid board positions. What motivated you to accept this role at the Global Fund?
You don't often get the opportunity in life to take on a job where the difference between doing it well and doing it badly can literally be measured in terms of hundreds of thousands, if not millions, of lives. Turning it down was not an option.