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Good afternoon and welcome to the City Club of Cleveland.

We are devoted to conversations of consequence that help democracy thrive.

It's Friday, August 8th.

I am Stathis Antoniades president for University Hospitals Cleveland Medical Center.

I'm honored to introduce today's forum, which is presented in partnership with the Junaid Family Foundation.

Since its launch in 2020, the Gates Foundation has remained committed to fighting the greatest inequities in the world for 25 years.

The organization continues to be a significant leader, an influential force in addressing global development issues which include health, livelihood and education.

Today, it is a privilege to hear directly from Doctor Anita Zaidi, the president of the Gender Equality Division at the Gates Foundation, where she oversees the efforts to advance gender equality by including gender and all of the foundation's global work.

Now, doctors will likely be the first to tell you that there's no simple solution or singular approach to gender equality.

When communities prioritize women's and girls health and well-being and empower women to be leaders in their society, everyone benefits doctors, Aids.

Also pediatrician, infectious disease specialist.

Previously, she was the department chair of Pediatrics and child health at the Aga Khan University in Karachi, Pakistan, where she worked to reduce child mortality.

She joined the foundation in 2014 to lead a team focused on vaccine development for people in the poorest parts of the world.

In our conversation today, we will learn more about recent efforts by the Gates Foundation to improve gender equality and what it make what it takes to truly invest in women and children.

Moderating this conversation is my colleague Celina Cunanan, Chief Health Impact Officer at University Hospitals.

Celina is an experienced clinician leader and for 15 years served as the inaugural Division Director for Nurse Midwifery.

Under her leadership, midwifery grew to be the largest network of midwives in Ohio.

She also serves on the board First Year Cleveland Our Region Civic and Community Collaborative to address infant mortality and chairs the Ohio Commission on Minority Health.

A reminder for our live stream and radio audience.

If you have a question during the Q&A portion of the forum, you could text it to (330)541-5794, and the City Club staff will try to work it into the program now.

Members of friends of the City Club of Cleveland, please join me in welcoming Doctor Anita Zaidi and Celina Cunanan.

Thank you, Stathis, for that warm welcome.

And Anita is so such a pleasure to have you here in Cleveland to visit us.

And to talk more about the work of the Gates Foundation.

So, and the Gates Foundation has been in the headlines this week.

And I know many of us have a general sense of the work, but I wonder if you, for those of us who don't, might not know the full picture.

Could you walk us through what the Foundation does globally and more personally, what your team in the Gender Equality Division is doing to support women and girls around the world?

Sure, Celina.

So I have to start by thanking the, the City Club of Cleveland for the wonderful invitation and hospitality.

It's such an honor to speak here.

I mean, this club has a storied history, and I'm just grateful also for the book that, Dan gave me this morning.

And I'm going to treasure it.

So, so, incredible honor to be here.

And thank you also to the Junaid Family Foundation for sponsoring the event.

There's such a sense of community and, giving in Cleveland that I am just, overwhelmed by.

This is what I would say.

So the Gates Foundation is now 25 years old.

It was established by Bill and Melinda Gates in 2000.

And the foundation has a very simple but profound mission.

It's everyone deserves an equal chance, an equal opportunity to lead a healthy and productive life.

We've chosen to focus on three areas.

We focus on, closing the achievement gap in education, on economic mobility, and on health.

In the US, our work is mainly focused on, education and economic mobility.

And globally, we are most known for our work on health.

And within that, maternal and child health, reducing and, and preventing infectious diseases, such as, like killer killer infectious diseases like malaria, TB, HIV, polio, and then in lifting millions of people, out of poverty through our work in agricultural financial services or poverty alleviation in my division and which is now five years old, I am I have the incredible privilege of working for women and girls around the world.

And, what we focus on, again, it's very simple, but it's very powerful.

What we're trying to do is, improving women's health, incomes and, power to shape their own lives.

Okay.

And to many women and girls around the world, do not have them, they do not have a did not have the power or any income generating ability or even the choice of on their own, to shape their own destiny.

12 million, girls around the world get married before the age of 18.

Like what we call early and forced child marriage.

So how do we how do we, make the world better for women and girls?

And the fundamental belief there is that by making the world a better place for women and girls, we make the world a better place for everyone.

That's an important message.

You know, you were just in Boston, with Bill Gates, and have some big news to share.

For those that might not be familiar with it, tell us a little bit more about what is that big news and and why now and what and what does it really mean.

So, what Celina is referring to here is a very, big announcement, from the Gates Foundation and from my division on, increased focus on women's health R&D or women's health innovation.

And the reason for this is, that when we were establishing the gender equality division, one area that we saw where the foundation could play a, catalytic role wasn't really changing.

The paradigm for women's health.

And, I, I'm a pediatrician, scientist by background.

And, when I, when I, in Berkeley, I practiced, I practiced in Boston and North Carolina and in Pakistan.

So all across when I, when I, when I looked at what was happening to children, it was so intimately connected to what was happening with their mom and their family.

Right.

If the if the mom and the family were doing well, the children were doing well.

For five years, I took care of children with HIV.

Right.

And this was at a time when there was no, highly active antiretroviral therapy.

So this is 1995, heart came, and late 1995.

So when you were taking care of a child, you were really taking care of the whole family because their mom also had HIV.

Typically the dad wasn't there.

And social, social workers and all of the support was so important.

And if the mother was alive and the grandmother was alive, the child did okay.

But there was one child died.

And so it just it really, crystallized for me that this is all connected up.

Yeah.

So then the opportunity, to start the division, was there I made a very big case for.

We really need to do more for women's health broadly.

And, and, and we also wanted to make this not about the Gates Foundation and what we thought.

Okay?

We wanted this to be, community led effort.

So we actually set up structures that, talked to a lot of women from around the world about what was important to them.

A lot of researchers, ethicists, regulators, biotech academic, people who have spent their life working on women's health, midwives, the like what is it that's important that is lacking right now in women's health?

And what should we focus on?

And the result of that was actually, we had a very big forum, a forum like this called Innovation Equity Forum, which resulted in an opportunity map for what are the areas in which much more research is needed.

And women's health.

And so this announcement in Boston was about a $2.5 billion commitment over the next five years to work in very neglected areas of women's health around the world.

The work is mainly focused on low and middle income countries, but actually is going to lift up women's health all over the world.

And that's our hope, is that it's it's, it's a spark to the field to bring in much more new thinking and new money into neglected areas right now.

I mean, thank you.

I want to give you two stark statistics.

Okay?

Only one if you take out if you leave out cancer, only 1% of the current R&D funding is that is, dedicated to conditions that are only suffered by women.

Okay.

And women are half the population.

I don't know who.

That.

The second one is.

90% of the drugs that are in use today have never been tested in pregnant women.

And so if you develop a problem during pregnancy, whether that's connected to your pregnancy or not, there is no, we have no idea of what will work or not work.

Okay.

So that that's where we are today.

And we think that we need to cha Only some good news that's coming out of women's health.

Right.

So that's the thank you.

Thank you for asking me that because it's getting sound like a doom and gloom, but like what I can tell you is this when people put their minds to something amazing, progress is possible.

Junaid and Sophia talked about one thing, which is the, what we call in, in medical terms, multiple micronutrients.

But what you might hear, more commonly is prenatal vitamins.

So if I prenatal vitamins and actually prenatal vitamins for a whole course in developing countries cost only $2.50 less than the, the price of a cup of coffee, the whole for the whole pregnancy at $2.50 for the whole pregnancy.

Less than a cup of coffee.

And what does it do?

It has an incredible impact on reducing stillbirths, on reducing low birth weight babies.

On reducing premature births, because, poor people do not have access to a nutritious diet.

Okay.

This is also true in the in the United States where people do not have access to a nutritious diet.

So just the simple, humble prenatal vitamin can solve many of these micronutrient deficiencies.

And now, through work of Foundation, Unicef, many other, philanthropists and governments, every woman, in developing countries will have access to prenatal vitamins.

Okay.

That's amazing.

Another one, which I think fewer people would know about is the progress in, HPV vaccines or human papillomavirus vaccines.

So human papillomavirus is the, only cause of cervical cancer.

Okay.

And, we've had a vaccine for a while, but that vaccine had very low uptake because it's either 2 or 3 doses.

The Gates Foundation, funded research because we were seeing a lot of data from around the world of girls.

Girls get this vaccine between the ages of 9 to 11 who never came back for their second or third shots.

And those girls were followed for many years, and none of them developed high risk HPV disease.

So the idea was, maybe you don't need 2 or 3 doses, maybe you only need one dose.

So we funded a lot of the work around the world too.

So is one dose enough?

And the results were incredible.

Like no breakthrough disease with one dose of HPV vaccine.

So when these data came out, many countries around the world changed their guidance.

And Gavi is an organization that funds vaccines for poor countries.

It's supported by the Gates Foundation.

It was also previously for many, many years, supported by the U.S government and many other sovereign and other donors around the world.

So Gavi made it possible for girls in developing countries to get HPV vaccine.

And this is a rocket that I like.

Okay, because the HPV vaccine uptake went from like this over ten years to.

So this year already 60 million girls have gotten HPV vaccine.

Okay.

Yeah.

And our target for the whole year was 80 million.

So we're already two thirds of three fourths of the way there.

Wow.

And what this means is no more cervical cancer.

Right.

Which is the biggest killer after breast cancer for women.

Can in oncology.

So I think that for the young people in this room, and there are some young people who in your lifetime you will see cervical cancer disappear like it will be eliminated.

Yeah.

Amazing stories.

That would be amazing.

So you've worked with women around the world from all walks of life?

For me, I've spent my entire career here at University hospitals and.

And delivering care to women here in this community.

I've probably over a thousand babies in my career, which has been a privilege.

It's been the privilege of a lifetime.

You know, I know at our organization, we're taking steps to improve maternal health and dignity through initiatives like our centering pregnancy program.

Teen birth initiatives, our Who's the center for Women and Children, when we cut the ribbon on that facility, had one of the highest mortality rates in the nation.

So we're really proud of the work that we're trying to do here in the community.

But what really strikes me is how universal the experience is for women all over the world, whether it's here in Cleveland, across the country or around the world.

The fear, the hope, the need to be treated with dignity, autonomy.

Why is that still not the norm for so many people in 2025?

So this is a subject I'm really passionate about.

And I've thought a lot about why, this is such a problem.

Because if you talk to women everywhere, they will say that they don't get respectful care.

They don't get care with dignity, whether you're, And then you'll be setting or you're bringing your children for vaccination or, your menopause or whatever your stage of life, it's a common, thing that you hear.

I think it's because of two reasons.

One is that we have not, listened to women in the R&D, ecosystem.

And so there those issues are have not been solved.

And the second is that the health systems are not designed with women's needs in mind.

So, if you're bringing a child, your child for, immunization, you could be walking.

And I have seen this like, you could be, and I'll give you a story from Ethiopia where I saw a woman would walk 20km to bring her child for vaccination and get a contraceptive for herself.

And neither things were stocked.

Right.

And and and what did the the staff tell them?

Just come back tomorrow.

Right.

That is not thinking about what women are going through.

So this is this is, And why how do we fix this?

Right?

And I think we fix it by, And you are a midwife.

And I was very happy when I saw that.

I'm in my 20s.

And you're a midwife in leadership.

Yeah.

You know, which I really have to commend.

University hospital for.

Thank you.

We need more women, in decision making roles in research.

And we need more women in decision making roles and health systems.

Yeah, okay.

And that's the only way change.

That's.

What do you, you're known for?

Combining kind of cutting edge research, with the real lives of women.

Is there a breakthrough, that makes you pause and think, gosh, this could change everything?

Yeah.

So that's a great question, because this whole $2.5 billion over the next five years, what's underneath that announcement is actually 40 innovations that we think can be game changing.

And many of these can be they're available for women in the next five years.

Okay.

Some will take a little bit longer, but I'll talk about the two that I think are out next five years.

Okay.

Or maybe three.

I'll talk about three.

The.

So I think that women everywhere, in the world, who are, pregnant, and are seeking care will be able to get an AI guided ultrasound.

Okay.

And what does that mean?

What that means is that you no longer need a skilled provider for doing the ultrasound or interpreting the ultrasound.

That this will be just blind sweeps, very small probe connected to a, tablet.

And I love kids.

Thank you for bringing that.

The, it'll be a, small probe connected to either a tablet or a phone that can, do three sweeps this way and three sweeps this this way.

And you would know, the state of the baby and the fetus.

And what does that do?

And prenatal care is, in especially in low resource settings, but also in settings in the United States, which are now becoming maternity deserts.

Right.

Is this a normal pregnancy or a high risk pregnancy.

So if it's a high risk pregnancy, the family would know that they should seek care, proactively at a more, higher level center.

Yeah.

So we think that this is game changing technology and it's coming like, it's it's it's, we've we've, we are deep into the, paradigm, shifting technology right now with what you can do with AI here.

The other place where I will make a huge difference is in making sure that women get cesarean sections if they're really necessary.

Okay.

Because now you would have.

Yeah.

Because now you can have wireless fetal monitoring, which is AI enabled, which will, tell you if a baby is doing well or not well during labor.

Okay.

So, it can be a very good, tool for midwives, for example, to, to know.

And it can be a very good, tool in very busy maternity centers where I can basically be monitoring a pregnancy.

And I would tell you that this is going this is going okay.

And this is not going okay.

And, in, in place.

So we have two problems with cesarean sections, right?

Either you get to few in places where there are not skilled providers and there are delays in care seeking, which is most of Africa.

Or you get so many, for example, in Brazil, where 70% of births are now are by cesarean section.

And this is a whole sort of incentive structure about why this is happening.

But this, this can be fixed by, sensors that are I in labor.

The second area that's really exciting is all of the research that's happening on the microbiome that will be very helpful to women and also to men.

Okay.

What's what's happening there?

Is, you know, all of all many, so many of our body parts are colonized by bugs.

Now, these bugs can be healthy or they can be, not, not healthy.

So we are understanding what leads to a healthy microbiome and what leads to a, poor microbiome.

In the context of the gut, where a lot of the diseases that we think we see, in high income countries are related, are related to an abnormal microbiome, but in poor countries are related to too much exposure.

So the causes are different, but the end result is the same.

It's inflammation of the gut.

Okay.

Inflammation of the gut in the US shows up as immune diseases like, like ulcerative colitis or Crohn's disease.

And in poor countries it shows up as malnutrition.

They just cannot absorb food.

And we now know that, for example, where gut microbiome during pregnancy results in a baby that is, what we call intrauterine growth retarded or smart, small born, low birth weight.

And now we are figuring out what collections of probiotics you can give to actually really get rid of that inflammation.

Okay.

So it's huge.

And it's it looks real like I'm seeing the data.

Okay.

Now the other place that this will be very, helpful is in, vaginal health.

So a lot of gynecological disorders right now have no treatment like, bacterial vaginosis.

Bacterial vaginosis has no treatment.

You keep getting women keep getting recurrent infection, and they keep having to take antibiotics.

And it comes back.

And now we know that actually a cocktail of a few probiotics, can take care of it.

And if you have this bacterial vaginosis, you're also much more likely to get HIV.

Because you're, you're inflamed.

So you just other bugs can get in.

So HIV, other STIs and things.

So if you think that by, being able to give a probiotic that creates a healthy, healthy microbiome and different parts of the body, you actually get rid of a lot of other diseases.

So I think these are two very real, innovations that are going to be helping women everywhere.

That's like the, you know, you mentioned about the prenatal vitamins.

It's $2.50 can give prenatal vitamins throughout the entire pregnancy.

What about the cost structure or.

Something like that?

So that's a great question, Celina.

So one of the things that the gates found at the Gates Foundation, that is our job is to see, like, how can you make low cost innovation possible?

So in fact, one of the people who's, working on this, got, health issue, I was just I just met them in Boston, earlier this week, and we were I was saying the most important thing to us, apart from getting this done quickly, is to bring the cost down, right?

To bring the cost down.

So it is a $2 thing.

Yeah.

So the whole course should be $2.

Because otherwise it's not accessible.

Right.

It's not accessible around the world.

So my favorite thing is it should be less than $1, right.

Not everything can be less than $1.

The dollar store.

Right.

Dollar store for health care.

Yes, exactly.

Yes.

Right.

Yeah.

You know, we've we midwives and frontline workers are, you know, the backbone of women's health and especially worldwide.

But they remain some of the most under supported and one of the hopes of, this Boston moment, I think, was to mobilize new funding and energy around that.

What will it truly take?

Not just in dollars, but in mindset and will in models to finally value, invest in and scale the kind of community based care women everywhere deserve?

Yeah.

So I think that, I could, I come back to the, our women in the right roles, to be leading this change.

And, when I talk to midwives, in, let's say, Nigeria, they talk about safety, they talk about, inadequate pay.

So, they talk about lack of equipment.

So one of the programs that we've been proud to, fund from the Foundation is called, Women Lift Health Care.

And what this program does is, it takes mid-career women from different sectors of the health care system and tries to see how do we equip these women, to be better advocates for their own area of work.

So the idea is that people will solve their own problems if they have the right skills.

Right.

And so, so, so, so the idea is to have like 5 or 6000, women around the world who are in these sort of leadership roles, who can advocate for better health systems.

So this program is also in the, in North America.

I mean, I, as the women left health also, helps women in North America who want to get leadership training for a year, mentored, mentored, mentored training, to equip them to be better advocates for their areas of work.

That's amazing.

We know that, you know, obviously, midwives are, you know, providing primary prenatal care for women around the world and, you know, still in this country as well.

You know, midwives still do a fraction of the births that happen here in the United States, and that that number needs to change as well.

I completely agree.

So, you know, so the best outcomes for moms are if midwives are leading maternal care okay.

It's as simple as that.

If and there are countries that get that right their Scandinavian countries.

The Scandinavian countries.

Yes.

I mean if you look at Scandinavia, they have the best maternal outcomes.

And because they have midwifery led models of care.

So I believe in midwives.

Right.

Thank you.

Thank you.

You know, we are you know, sometimes when we're, you know, you've told we've talked a lot of stories and we talked we got the opportunity to talk yesterday a little bit about, some of the work, incredible work that you've done, around the world.

And, and sometimes it just takes kind of that one moment to remind us of why this work matters.

I have those stories in my head of things that I've done over my career, and, like, this is why I get out of bed every day.

This is why I show up to work every day.

Is there a story in your vast experience that's really stayed with you that and and is it one that shows, you know, kind of how far we've come and how far we still need to go?

Yeah.

So there are so many.

Okay.

So, maybe I can do two.

The, I recently had a colleague at the Gates Foundation, who developed, after many years of trying, she became pregnant, and, and she had about a pre-eclampsia and her in her pregnancy, pre-eclampsia.

Its, hypertension during pregnancy.

And it currently has no treatment.

So the only treatment, preeclampsia, only treatment that exist is you have to deliver them.

Yeah.

So otherwise the baby's life is at risk and the mom's life is also at risk.

So she was really struggling.

And, eventually, I mean, we all try to help you get the best care possible.

She had to deliver, two and a half months before, premature baby.

The baby got excellent care, and both mom and baby are doing fine.

I have her permission to talk about her baby.

Her name is Mika Dewdrop.

It made me think of all of those women that I have in my career, and, and practice in Pakistan as a pediatrician, that I haven't been able to help because there has been no treatment, there has been no support for premature baby.

So if you deliver the baby, deliver the mom, the baby dies.

Right.

And, and you see and sort of the look on the family's face and the mom's face like, you can't do anything for me.

There's not there's nothing that you can do to treat this.

That happens in the U.S as well.

Yes.

Right.

And because there is no treatment and there are low income women in the US who don't get I mean, these are some of the reasons why, mortality in African-American populations is so much higher because it is not diagnosed, pre-eclampsia is not diagnosed.

And, and both mom and baby suffer.

The other one I would mention is because you need this here, and Sophia's here, which is the, the, the story about supply chain.

Right.

So you, you don't think of supply chain as a medical issue, right?

But it is a huge medical issue for the last mile.

It is.

What result?

Not getting your supply chain right is what results in the kind of story that I was telling you earlier, that a mom could walk for 20km and not have the drug or the, the, the equipment that she needs for her care, because somebody messed up the supply chain.

I would use another word, messed up the supply chain.

Okay.

Right.

So, how do we bring the best minds to think about supply chain?

For, for for countries, is something that I'm really going to pick Janine's brain on.

And we've connected him up with, you know, many companies who have to figure this out, figure this out, like Unicef.

He was talking about, how do we get how do we do better for people around the world?

Yeah.

And I think that brings us to a point of, you know, where we talk about health outcomes or let's talk specifically about, you know, maternal health outcomes or, you know, maternal mortality, infant mortality.

I think so often people think, well, this is health care's problems to solve.

Right?

And it's not, you know, we do our part, right.

But I always like to, you know, we have, an incredible group of leaders throughout the region here from all different industries and walks of life.

And, you know, I think it's an important discussion to say, what can you do in your space?

Right.

What is it that you can do in your space if you're an employer?

What's your paid leave policy right for your how do you provide opportunities for economic growth, and advancement for your workers, your lowest paid workers in there?

You know, those are things that I think we need to think about or encourage other, you know, industries to think about when you say.

100%.

Yep.

In fact, Cleveland has such a rich tradition of people stepping up and helping.

And, I asked, in my, when Diane was giving me this book, I said, well, who are you?

You know, who would you say are top of mind for you, for moms and babies?

And he gave me a list.

So I to read that out.

It's not exhaustive.

I'm sure there are many other people.

So Cleveland Foundation, Gund Foundation, Mount Sinai Foundation, Saint Luke's Foundation, JFF, Junaid Family Foundation, doing incredible work.

And then the the people who are the recipients are just making incredible difference in their communities.

A few of them, here for, relevant for moms and babies, birthing beautiful communities.

Jasmine Long.

Yeah.

First year Cleveland, which is a coalition.

That focuses on the baby's first year of life.

Infant mortality.

And then the Greater Cleveland food bank that I got a wonderful run with for for doing incredible work.

And I got to see some of the I mean, I didn't get to visit.

I would have love to visit.

But I got to see, hear from junior about the, you know, what they're doing with you and so incredible work that just looking at it just connects up.

You know how we are thinking about nutrition and pregnancy for vulnerable populations globally and locally here in Cleveland.

Right.

And I'm I'm super looking forward to looking at the results of that, study that you're doing.

So yeah.

And I, you know, in we talk about, of course, my love for midwives as midwives and your love for midwives, you know, really proud to say that there's so many midwives here in Cleveland, right?

All three major health care systems, Cleveland Clinic, university hospitals.

Metro health is the newest one to have opened a midwifery service with midwives in private practice throughout the region.

FQHCs.

So, you know, anyone who wants a midwife should have access to a midwife.

And so, you know, really grateful for the partnership of other health care organizations here in town who are lifting up that narrative and making that available for women here in this community.

Wonderful, great.

So, anything else you want us to know about the wonderful work of the Gates Foundation and some of the initiatives that your folks and we've talked a lot about maternal health.

Yeah.

I'm wondering if there's other things in terms of, you know, gynecologic care or other areas of interest or focus that you're looking at.

So I would spend a couple of minutes talking about contraception.

Okay.

So.

So, there are 200 million women around the world who want contraception and don't have access to it.

Okay, then there are a lot of women who want contraception, but there is no option that works for them.

Because, because of their needs and preferences.

So it's actually a global problem.

And so one of the things that's in this $2.5 billion announcement is looking at newer options for contraception.

And I'll, maybe I'll mention a few of them.

So just to understand the, the breadth of the, possibilities, one is, how about if there was a patch that you could just put on for two minutes and take it off, and it lasts for six months?

You only put it on for two minutes.

The drug gets in, but it's in a pill form that can last for six months.

Okay, so totally system independent.

It could be over-the-counter.

What if we had that.

So we're trying that okay.

What if, we had non-hormonal contraceptive options that you could take by mouth okay.

Because currently all of the stuff that you take by mouth is all hormonal.

And it works wonderfully for many, many women.

And they have been able to plan their lives.

I love the slogan, made possible by family planning.

All of us are sitting here today and having a good life because it was made possible by family planning.

Okay.

So so we are doing that.

That work is actually, I have learned so much from sort of funding that work because I had no idea how much, knowledge about women's biology is just lacking.

So some of the like the questions, for example, if you if you take a drug by mouth, how much of it actually gets into the uterus?

We don't know the answer to this.

We don't know.

Right.

So so we are actually having to start there.

Right.

And understanding, the, the blood urine barrier.

Right.

For drugs.

Because sometimes you might want a drug to pass through another times you might not want a drug to pass through.

But depending on what your clinical indication is.

So, so we are so a lot of this work would be very basic science, reproductive biology, trying to understand, you know, how drugs work in women's bodies.

So that's two and then the third, third, contraceptive option, which is, primarily focused on developing countries, many women will know this option.

Maryna, under the hormonal IUD not available in developing countries.

Right.

And it's it's, really the best treatment also for heavy menstrual bleeding.

So, we don't have that in developing countries.

It's too expensive.

And so we're trying hard to make a lower cost option for, hormone or diet for women in developing countries.

That's amazing.

So this all this contraception problem, but also, heavy menstrual bleeding problem.

Yeah.

We don't even know how many women have heavy menstrual leading because we don't have a definition for it.

Okay.

So those two those basic things and we.

Don't talk about it.

Right.

Because we think of things, it's like we need to start talking about these things, more about the things that women have to deal with.

And, and how do we and how how what is the innovation that could be placed in this space to make lives their lives better?

Right.

I couldn't agree more.

So if we're about to begin the audience Q&A for those just joining in via our live stream or audio radio audience, I'm Celina Cunanan and chief health impact officer at University Hospitals and moderator for today's conversation.

Joining me on stage is Doctor Anita Zaidi, president of the Gender Equality division at the Gates Foundation.

We are discussing the foundation's efforts to improve outcomes for women and children across the globe.

We welcome questions from everyone's city club members, guests and those joining via our live stream at City Club Borg, our live radio broadcast at 89.7 KSU Ideas Stream Public Media.

If you'd like to text a question for Doctor Zaidi, please text it to (330) 541-5794.

That's (330)541-5794, and city club staff will try to work it into the program.

A reminder to keep your questions short, to the point and actually questions so we can get to as many questions as possible and we'll have the first question please.

First of all, congratulations to the city of Cleveland and in particular, City Club.

We're honored to have the Gates Foundation here.

The good that you do is immeasurable.

Thank you.

And I had a question as a fellow pediatrician, I know as a fellow pediatrician, we've all been in situations.

Well, this really goes to Paul Starr's work on the power equation.

And things don't happen unless the power equation goes your way.

So what advice can you deliver to Cleveland that would be relevant from your world experience?

When doctors, other health care professionals, midwives and others find themselves in confrontation with other powers that stand in the way of advancing health, whether that be government or corporations or even medical centers.

Yeah.

So, it's very relevant, to the conversation around vaccines as well.

Right now.

And, vaccines are the most cost effective.

Intervention in public health that exists today.

And, I am very worried that in the United States, you will see a lot of regression.

And you will have many big measles outbreaks.

You will have pertussis outbreaks.

Lots of children will die, not as many as in developing countries, because it's a global world right now.

And a lot of what happens in the US then starts happening in the rest of the world.

The US has historically been a leader, in fighting diseases, poverty and malnutrition around the world.

I think that's a really, really important role.

And we have to fight to preserve that role.

Okay.

Good afternoon.

This is such an important program, and I'm so glad this is happening.

It's pretty common knowledge where a lot of people know that there is a serious lack of trust between the African-American community and doctors, and I'm generally speaking generally, of course, but.

So, because of the Tuskegee experiment, and I've been told by doctors that doctors are taught that African-Americans can experience more pain than other races.

So my question is, how do you deal with that lack of trust?

What is done to try to encourage, African-American women to to feel comfortable in the work that you're doing?

Thank you.

That's a great question.

I will answer it from a developing country perspective.

And then, Celina, I will because I it's, I see these issues all over the all over the world.

But the solution is the same.

Okay.

And then I then you should talk about the, the U.S. and the Cleveland experience.

So what happens?

Is why does distrust develop?

It's historical.

Based on inequities and what was done to marginalized populations and the, so in our work, what we have found is when you have, so, for example, in these, very, vulnerable communities that I've done a lot of my research in, I, often we would refer a woman to a hospital if she we thought that really, this was a hospital delivery.

We should not be delivering at home with a birth attendant or whatever.

And they wouldn't listen, okay?

They said, because they didn't trust the hospital system.

We realized that if we paired her with the woman from the community who could go with her.

So the doula concept.

Right.

That if so.

So that there was somebody to advocate for her, who knew the hospital, who knew how things work.

It just tremendously increased community trust, to have that her person there with her.

Right.

Her person who knew her community, who knew her and who knew the hospital.

I think this is a universal principle.

When there is lack of trust, how do you bring how do you bring a bridge that trust in the U.S, this worked very well in Covid, right?

Because we learned that there was a lot of distrust among African-American communities for getting Covid vaccine.

It was solved by engaging community, right, and community leaders from the Cleveland side.

Yeah, I think it's you know, it's still the same, right.

How do we listen to women?

How do we center their voices, how do we uplift what their needs are?

And I think, you know, we're in partnership, right.

Health care organizations.

Yes.

In general.

Right.

Not lack of trust for communities of color.

How do we how do we make sure that there's leaders within the organization that are listening, that are forming, partnerships with outside organizations, community based organizations?

You know, my hat's off to my friend Jasmine Long in the back and birthing beautiful communities for their incredible partnership and how they partner with all health care systems across this region and folks, to make sure they're building strong, healthy relationships with health care partners and community members, to ensure that the voices of women are heard.

To your earlier point about women in leadership, right?

Are there women of color in leadership, in organizations?

That how do we elevate their voices in that manner?

That's where we have a lot of work to do, even just in terms of getting more professional, that represent the people of the community in the United States, you know, maybe 15,000 midwives across the country, less than 10% of those are black.

Less than 2% of those are Asian.

You know, same thing in health care in general, too.

Purposeful investments in, encouraging people of communities to get them into health care careers.

It's a lot of the work that I do at university hospitals as well, with our youth pipeline programs and exposing kids from communities that might not otherwise have those opportunities be exposed to health care opportunities in in the system, I think is really, really important.

It's a long game, to get those things done.

But there's always things that we can do and every organization needs to be doing.

So next question.

Good afternoon.

Tony Richardson, President George Gund Foundation here in Cleveland.

I think this past May, Mark, bill, your board of trustees announced that you were all going to sunset in, 20 years.

So in 2045, the plan is to accelerate or deploy $200 million across your portfolio and grantmaking globally.

And I'm just curious to get a sense, how are you thinking about your your, particular portfolio in a way that allows you to deploy those resources and, strategically, responsibly, with care and in a way that protects your existing, investments so that when you all leave in 2045, there's some self-determination, some infrastructure for the various communities and peoples that you've supported over the last.

It's a fantastic question.

Yeah.

So let me repeat it for the for, for people who might not know what what you just said.

So, Bill gates announced earlier this year, in May that the foundation will sunset in 2045.

He will give his entire wealth, 99% of his wealth, to $100 billion, to, to the foundation, to be spent over the next 20 years.

And then we will close our doors in 2045.

His motivations, are that, he he he feels that he has, he wants to solve the problems of today, right?

He's not interested in sending people to Mars.

And, and so thank you.

And, Yeah, it's, and so solving the problems today means that you spend the money today.

Okay.

This puts a certain, extra responsibility on us to bring a sense of urgency, to our work.

And that was part of what motivated me to work on this five year thing.

Like, what can we do in five years for women's health R&D to really sort of accelerate the pipeline, to get these 40 things out that I think could be real?

It also, whole behooves us to think about the, who carries the work forward when we are not there.

Right.

And, that thinking is very active right now, actively happening at the foundation right now.

How do we how do we leave a world that is, much better than it is today?

And who takes the work forward?

Right.

And and, the hope is also that many other people will will join in the effort.

We are in a crisis situation right now in the world, in global health, in many other areas.

And and, so, so we are hoping that many other people step up, many other, you know, philanthropists step up and say, you know, we we want to solve the problems of today, right?

And also give their wealth, that is, some of you may know about this giving pledge, which is, which is, effort that, Bill, Melinda, and Warren Buffett started to get, very high net worth individuals to commit that they will give 50% of their wealth away during their lifetime or soon, or upon their death.

And so getting those giving Pledge members, to act on that, as well as getting new people to sign up, is very important right now.

Good afternoon.

Jasmine long, great media for communities.

And a study by the Commonwealth Fund.

It show that the U.S, amongst most developed countries, we were 11 with respect to paid leave time off with families.

And, you know, my question is, as you all look to diversify and think about economic mobility, how is or has or will the Foundation seek to exploit economic mobility through things such as pay leave?

That's a great question to so I'll, say two things.

In response to that.

So we, we know when we look at, okay, what, what affects women's careers and income generating ability in every conversation we have anywhere in the world?

Having access to affordable childcare, comes up very, very flexible work schedule, affordable childcare, from the foundation, what we, we have done, so the foundation doesn't work on these issues, directly on care issues in the United States.

I will come back to how the foundation works in the United States on these issues, but, but globally, we have supported, through the world Bank, a trust fund for countries that are interested in improving affordable childcare in the, in their, in their countries.

And when we set up the trust fund, it's about $100 million.

It has been so oversubscribed that the money and how much quicker than we thought, because so many countries are interested in figuring this out, because affordable childcare is actually essential.

Infrastructure is as important as telecoms and roads and things.

And it's also, employment, an income generator.

The particular issue of the US, which does not is one of the few, industrialized countries without, federally mandated, paid leave during pregnancy.

This is a topic that is very dear to Melinda, French Gates.

And now she's no longer, part of the foundation.

She, she co-founded Pivotal Ventures.

And she that's a very big issue that she's, she's focused on from Pivotal Ventures.

And so within the gates, ecosystem, it's an important topic, that is being, advocated for and funded.

What about paid leave here in the United States?

What do you think needs to happen here?

I think policy needs to change.

Yeah, yeah.

I mean, it's over without without that.

I mean, people are talking about declining populations, but there's a very big reason for it.

It's very hard to it's childcare is very hard.

I mean, in fact, I even give this example.

It's very personal.

I have two children.

One both of them were born in the in the, us.

But I waited seven years to have my second child because there was just no way I could take care.

I couldn't afford childcare for two kids, right?

Yeah.

So, and my second job was one three months before I left for Pakistan.

I timed it perfectly so that I could get a job again in Pakistan.

And it's much harder.

It's much harder to bring up kids in the US because of the childcare issue than it is in so many other countries in the world.

Okay.

Thank you, Doctor Zadeh, for that wonderful overview of Gates Foundation work for maternal fetal health.

And you, my name is Marina Margaret.

I work at University Hospitals.

You alluded to this, that gender sensitive research is something that's lacking.

And lately, a lot of funding for gender sensitive research has been cut back.

Like me give you an example, like, you know, the best example that women have high pain tolerance is that they give birth to babies, which is what.

Can you do with their past?

I'm sorry.

Yeah.

You know, the women having the high pain tolerance and giving birth to babies, that's the best example of that.

But a lot of research shows that they have less pain thresholds, and a lot of gender sensitive research is lacking.

What's gates Foundation?

What other, you know, areas are they focusing on for gender sensitive research.

Yeah.

So that's a that's a very big part of what we are looking at is how do you bring how do you center.

Women's biology, into research which has been neglected so far, including pain, pain during IUD insertion, for example.

We we can actually we think that there are innovative tools that can be much less painful, but they just have not been, researched.

So, so that's what I meant by when I said, you know, just like the basic research and products that are keeping women's needs in mind and talk to women.

So a lot of the contraceptive research, for example, we're doing a lot of user insight work, which is like, what is it that you want?

What is it that will work for you?

What is it that you need right to inform product design?

And now, because of AI, you can actually do it very quickly.

So like, you can just get because they can chat with the bot, right?

And say, I mean, you can ask this question, you get the response.

We have a project that actually is in is in Pakistan as well.

But it's also in many different countries around the world, which is called A day in the life of.

So it follows women for like a week and gets responses from them about their life, whether it's about their menstrual products or their contraceptive needs or their pregnancy or their diet, and gets like tons of information that can be very quickly synthesized into like, okay, what is what is, what is lacking that needs to be addressed.

So we are funding a lot of work like that.

Hi.

My name is, Ken Smith.

I'm a state senator for Ohio.

In January 2023, University Hospital hosted an issue briefing for the Cuyahoga County delegation.

They talked about, among other things, the research on the destructive nature of utility shutoffs in the first year of life.

That led us to introduce legislation to try to have the most comprehensive utility disconnection policy in the country.

Now, that didn't become law.

And but I wanted to thank University Hospital for providing that forum.

I do believe the relationship with the Chi County delegation has been harmed by the firing of Doctor Fouts, Fowler and Doctor Bean, but what I'd like to ask you, Doctor Zaidi is I've heard you talk about prenatal vitamins.

I've heard you just talk about child care.

But can you think of other solutions from a state policy perspective that could be used to advance maternal and child health, care, or would those be two things that you think we could take back to the capital?

Thank you.

Oh, that's a great, question.

And I'm also going to ask you to comment, comment on that as well, because your, perspective for Ohio would be very important.

I think listening to women, that's the simplest thing, listening listening to women, what is it that they want and need?

What works for that?

What works for them?

And then introduce that into into policy.

So without, without consultation, with, with the, women from communities, from different communities, from underrepresented communities.

You're not going to have great policy for moms and babies.

Now, Ohio is one of the states that has a higher maternal and and child mortality rate than many other states.

Often this is because, there aren't, avenues for women to seek or get appropriate care, right?

There are states that have had a very when they recognized this, for example, that there are gender, there are, racial disparities, racial inequities in access to care.

And they addressed it.

They made huge progress.

And so that would be my sort of where I would start looking, and seeing like, how can we do better?

I think the program that we just heard about from the, the or I was alluding to from the greater, Cleveland Food Bank, where they're trying to say, how do how do we improve the diets of low income women?

Right.

So, of low income pregnant women, provide results that are directly relevant to state policy.

I think just, you know, looking at the minimum wage, what are we paying our workers?

How are we providing them again?

Upward mobility.

So that they can afford the things that the everyday things that they need paid leave is huge.

You know, I think those are the things that we think we'd like to see in the state that can make things better for all women here in the state of Ohio.

Thank you, Doctor Anita Zaidi and Celina Cunanan for joining us at the City Club today.

Forums like this one are made possible thanks to generous support from individuals like all of you and including many of you.

You can learn more about how to become a Guardian of free Speech at City club.org.

Our forum today was presented in partnership with the Junaid family Foundation.

We thank you so much for your engagement.

We would also like to welcome guests at tables hosted by the center for Community Solutions.

Collaborate.

Cleveland first year Cleveland G2G consulting, the Junaid Family Foundation, Newbridge and University Hospitals.

Thank you so much for being a part of this today.

Once again, doctors aid.

Celina, thank you so much.

Our farm is adjourned.

Have a great weekend.

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Right.

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