To understand how the Gateses lead, it helps to think of toilets.
This is just a guess, mind you, but it’s likely that there are few people on the planet who get more excited talking about commodes than Bill Gates does. In a world where as many as 4.5 billion don’t have “safely managed sanitation,” according to the World Health Organization—and of whom nearly 900 million (mostly rural) people still defecate in the open—a safe, affordable, self-contained waste treatment apparatus that requires neither running water nor sewers is the sine qua non of public health interventions.
To make the point, Bill again took to the podium, flying to Beijing this past November for the Reinvented Toilet Expo. Next to him, for their shared keynote—and resting on its own, shorter podium—was a jar of human excrement. “This small amount of feces,” said Gates, “could contain as many as 200 trillion rotavirus cells, 20 billion shigella bacteria, and 100,000 parasitic worm eggs.”
Despite the laughter in the audience, the container was filled with deadly stuff: In much of the developing world, in fact, it is a weapon of mass destruction, as proven by history’s seemingly unbroken epidemics of cholera, typhoid, dysentery, hepatitis, and diarrheal disease.
The toilet expo showcased a number of ingenious prototypes—the “most significant advances in sanitation in nearly 200 years,” Bill called them—and the Gates Foundation has put some $200 million into the effort so far.
But as Bill and Melinda explained in a joint interview in Seattle in late March, the reinvented commodes represented something potentially more liberating still. The toilets were a direct link to girls’ and women’s health and, ultimately, their economic empowerment. In sub-Saharan Africa, one in 10 school-age girls don’t go to school during their menstrual period, according to UNICEF, and many drop out after menstruation begins. “Think about what it’s like for a child to miss five or six days and how far behind they get,” says Melinda. Sometimes it is the threat of violence that keeps a woman or a girl from a public latrine—and because it’s usually women who take their children to the bathroom, that has a cascading effect.
“We have to draw the line” between all of these connecting data points, she says. “Because if people don’t draw the lines—if we just talk about the importance of sanitation in terms of people’s health,” we fail to fully comprehend the missed opportunities and challenges. “What we’ve learned in our work is that you have to talk about the gender pieces, too, because they are specific.”
Indeed, as Melinda discovered in her two-decade journey through the developing world, for virtually everything that tends to limit human capital, there is a line connecting it to gender in some way. The boldest of these lines, certainly, concern the rights of women to decide if and when they get married, and if and when they have children. Both of these choices, in much of the world, have been taken away from women, with devastating and transgenerational consequence.
Melinda, a practicing Catholic who attended an all-girls Catholic high school in Dallas (where she graduated as valedictorian), has met resistance from some quarters on some of her family planning efforts, which involve offering women access to contraception. But as Geeta Rao Gupta, a senior fellow at the UN Foundation in Washington, D.C., explains, the Gates Foundation stance on family planning has been, as with everything else it does, about “meeting unmet need.”
The effort isn’t about telling women in the developing world to have fewer kids, says Rao Gupta: “It’s that women want to control their fertility. They’re asking for contraception. They don’t want this many children or too many children, and they don’t have the ability, the tools that are available to the world, to be able to make that choice.”
Filling that gap is not just about understanding social, cultural, or religious barriers, as important as they are. “What Melinda found was that there were supply barriers and logistical barriers in getting contraceptives into the hands of women. So then even when societies were open to that idea, there were challenges,” says Rao Gupta, who also founded the 3D Program for Girls and Women, which focuses on economic empowerment.
There were other gender lines, too—like those connecting birth choices to education, and then to child mortality. When it comes to the survival of kids under 5 years old, says Gates Foundation CEO Sue Desmond-¬Hellmann, who is both a physician scientist and former chancellor of the University of California, San Francisco, “one of the best determinants of a child’s health is the educational status of the mom.”
“And so when you invest in education for both boys and girls, which most of the world happily does now, you’re investing in the future of those women as mothers—and in the health of their children.”
Melinda, who earned a bachelor’s degree in computer science from Duke University and an MBA from Duke’s Fuqua School—and who spent the next nine years at Microsoft—has carefully studied the data on gender-based barriers. And the data that wasn’t already available, she has commissioned through her foundation. But mostly she has learned through in-person absorption—through a kind of human osmosis: from listening to women in self-help groups in India; from talking to girls and mothers everywhere from Bangladesh to Indonesia. The insights came when she and her then 17-year-old daughter Jenn spent the night in the “goat hut” of a Maasai couple in the Tanzanian village of Mbuyuni, as they did in her homestay with son Rory in Malawi.
“It’s not at all where we started as a foundation,” Melinda says. “But I would say in the last six, seven years, we’ve really started to talk about this gender piece and have put specific investments down to make sure we address it.”