Two decades ago, we created a foundation focused on global health because we wanted to use the returns from Microsoft to improve as many lives as possible. Health is the bedrock of any thriving society. If your health is compromised—or if you’re worried about catching a deadly disease—it’s hard to concentrate on anything else. Staying alive and well becomes your priority to the necessary detriment of everything else.

Over the last year, many of us have experienced that reality ourselves for the first time. Almost every decision now comes with a new calculus: How do you minimize your risk of contracting or spreading COVID-19? There are probably some epidemiologists reading this letter, but for most people, we’re guessing that the past year has forced you to reorient your lives around an entirely new vocabulary—one that includes terms like “social distancing” and “flattening the curve” and the “R0” of a virus. (And for the epidemiologists reading this, we bet no one is more surprised than you that we now live in a world where your colleague Anthony Fauci has graced the cover of InStyle magazine.)

When we wrote our last Annual Letter, the world was just starting to understand how serious a novel coronavirus pandemic could get. Even though our foundation had been concerned about a pandemic scenario for a long time—especially after the Ebola epidemic in West Africa—we were shocked by how drastically COVID-19 has disrupted economies, jobs, education, and well-being around the world.

Only a few weeks after we first heard the word “COVID-19,” we were closing our foundation’s offices and joining billions of people worldwide in adjusting to radically different ways of living. For us, the days became a blur of video meetings, troubling news alerts, and microwaved meals.

But the adjustments the two of us have made are nothing compared to the impact the pandemic has had on others. COVID-19 has cost lives, sickened millions, and thrust the global economy into a devastating recession. One and a half billion children lost time in the classroom, and some may never return. Essential workers are doing impossible jobs at tremendous risk to themselves and their families. Stress and isolation have triggered far-reaching impacts on mental health. And families in every country have had to miss out on so many of life’s most important moments—graduations, weddings, even funerals. (When Bill Sr. died last September, it was made even more painful by the fact we couldn’t all come together to mourn.)

History will probably remember these last couple of months as the most painful point of the entire pandemic. But hope is on the horizon. Although we have a long recovery in front of us, the world has achieved some significant victories against the virus in the form of new tests, treatments, and vaccines. We believe these new tools will soon begin bending the curve in a big way.

The moment we now find ourselves in calls to mind a quote from Winston Churchill. In the fall of 1942, he gave a famous speech marking a military victory that he believed would be a turning point in the war against Nazi Germany. “This is not the end,” he warned. “It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”

When it comes to COVID-19, we are optimistic that the end of the beginning is near. We are also realistic about what it’s taken to get here: the largest public health effort in the history of the world—one involving policymakers, researchers, healthcare workers, business leaders, grassroots organizers, religious communities, and so many others working together in new ways.

That kind of shared effort is important, because in a global crisis like this one, you don’t want companies making decisions driven by a profit motive or governments acting with the narrow goal of protecting only their own citizens. You need a lot of different people and interests coming together in goodwill to benefit all of humanity.

Philanthropy can help facilitate that cooperation. Because our foundation has been working on infectious diseases for decades, we have strong, long-standing relationships with the World Health Organization, experts, governments, and the private sector. And because our foundation is specifically focused on the challenges facing the world’s poorest people, we also understand the importance of ensuring that the world is considering the unique needs of low-income countries, too.

To date, our foundation has invested $1.75 billion in the fight against COVID-19. Most of that funding has gone toward producing and procuring crucial medical supplies. For example, we backed researchers developing new COVID-19 treatments including monoclonal antibodies, and we worked with partners to ensure that these drugs are formulated in a way that’s easy to transport and use in the poorest parts of the world so they benefit people everywhere.

We’ve also supported efforts to find and distribute safe and effective vaccines against the virus. Over the last two decades, our resources backed the development of 11 vaccines that have been certified as safe and effective, and our partners have been applying the lessons we learned along the way to the development of vaccines against COVID-19.

It’s possible that by the time you read this, you or someone you know may have already received a COVID-19 vaccine. The fact that these vaccines are already becoming available is, we think, pretty remarkable—especially considering that COVID-19 was a virtually unknown pathogen at the beginning of 2020 and how rigorous the process is for proving a vaccine’s safety and efficacy. (It’s important that people understand that even though these vaccines were developed on an expedited timeline, they still had to meet strict guidelines before being approved.)

No one country or company could have achieved this alone. Funders around the world pooled resources, competitors shared research findings, and everyone involved had a head start thanks to many years of global investment in technologies that have helped unlock a new era in vaccine development. If the novel coronavirus had emerged in 2009 instead of 2019, the road to a vaccine would have been much longer.

Of course, creating safe and effective vaccines in a laboratory is only the beginning of the story. Because the world needs billions of doses in order to protect everyone threatened by this disease, we helped partners figure out how to manufacture vaccines at the same time as they were being developed (a process that usually happens sequentially).

Now, the world has to get those doses out to everyone who needs them—starting with frontline health workers and other high-risk groups. Our foundation has worked with manufacturers and partners to deliver other vaccines cheaply and on a very large scale in the past (including to 822 million kids in low-income countries through Gavi, the Vaccine Alliance), and we’re doing the same with COVID-19.

Our foundation and its partners have pivoted to meet the challenges of COVID-19 in other ways as well. When our friend Warren Buffett donated the bulk of his fortune to double our foundation’s resources in 2006, he urged us to stay focused on the issues that have always been central to our mission. Tackling COVID-19 was an essential part of any global health work in 2020, but it hasn’t been our sole focus over the last year. Our colleagues continue to make progress across all of our program areas.

The malaria team has had to rethink how to distribute bed nets in a time when it’s no longer safe to hold an event to give them to a lot of people at once. We’re helping partners understand COVID-19’s impact on pregnant women and babies and making sure that they continue to receive essential health services. Our education partners are helping teachers adjust to a world where their laptop is their classroom. In other words, we remain trained on the same goal we’ve had since our foundation opened its doors: making sure every single person on the planet has the chance to live a healthy and productive life.

If there’s a reason we’re optimistic about life on the other side of the pandemic, it’s this: While the pandemic has forced many people to learn a new vocabulary, it’s also brought new meaning to old terms like “global health.”

In the past, “global health” was rarely used to mean the health of everyone, everywhere. In practice, people in rich countries used this term to refer to the health of people in non-rich countries. A more accurate term probably would have been “developing country health.”

This past year, though, that changed. In 2020, global health went local. The artificial distinctions between rich countries and poor countries collapsed in the face of a virus that had no regard for borders or geography.

We all saw firsthand how quickly a disease you’ve never heard of in a place you may have never been can become a public health emergency right in your own backyard. Viruses like COVID-19 remind us that, for all our differences, everyone in this world is connected biologically by a microscopic network of germs and particles—and that, like it or not, we’re all in this together.

We hope the experience we’ve all lived through over the last year will lead to a long-term change in the way people think about global health—and help people in rich countries see that investments in global health benefit not only low-income countries but everyone. We were thrilled to see the United States include $4 billion for Gavi in its latest COVID-19 relief package. Investments like these will put all of us in a better position to defeat the next set of global challenges.

Just as World War II was the defining event for our parents’ generation, the coronavirus pandemic we are living through right now will define ours. And just as World War II led to greater cooperation between countries to protect the peace and prioritize the common good, we think that the world has an important opportunity to turn the hard-won lessons of this pandemic into a healthier, more equal future for all.

In the rest of this letter, we write about two areas we see as essential to building that better future: prioritizing equity and getting ready for the next pandemic.

Can we emerge from this pandemic more equal than we entered it?

Melinda: One of the things I’ve missed most over the last year is traveling to see our foundation’s work in action. I have photos all over our house of the women I’ve met on these trips. Now that I’m working from home, I see their faces all the time.

I often wonder what the pandemic looks like through their eyes and how they’re coping. When I’m on videocalls with experts and world leaders, I try to imagine how the decisions being made in these conversations will affect these women and their families. They’re a daily reminder of the importance of ensuring that the world’s COVID-19 response leaves no one behind.

From AIDS to Zika to Ebola, disease outbreaks tend to follow a grim pattern. They hurt some people more than others—and who they hurt most is not random. As they infect societies, they exploit pre-existing inequalities.

The same is true of COVID-19. People with less are faring worse than those with more. Essential workers are facing greater risks than those who can work from home. Students without internet access are falling behind students who are learning remotely. In the United States, communities of color are more likely to get sick and die than other Americans. And all around the world, women who have been fighting for power and influence over their lives are seeing decades of fragile progress shattered in a matter of months.

From the beginning of the pandemic, our foundation has worked with partners in the United States and around the world to address the uneven social and economic impacts of COVID-19 and keep those pre-existing inequalities from growing deeper.

In the United States, many of our anti-COVID efforts overlap with our work on racial equity. For example, the data tell us that Black Americans are three times as likely as white Americans to get COVID-19, and they are also more likely to live in an area with limited access to COVID-19 testing. To help meet the demand for local community testing, our foundation partnered with historically Black colleges and universities to expand diagnostic testing capacity on their campuses.

We’re also addressing the pandemic’s disproportionate impact on people of color in other ways, including through our foundation’s U.S. education work. We’re concerned about students falling behind at all levels (when schools closed last spring, the average student lost months of learning), but we’re especially troubled that COVID-19 could exacerbate long-standing barriers to higher education, particularly for students who are Black, Latino, or from low-income households. Median lifetime earnings of college graduates are twice those of high school graduates, so the stakes for these young people are high. To help students navigate COVID-19 roadblocks, our foundation expanded our partnerships with three organizations that have a proven track record of using digital tools to help students stay on the path to a college degree. We think the models and approaches these organizations are honing now will continue to expand opportunities for students post-pandemic, too.

When it comes to our work outside the United States, my major focus has been calling on world leaders to put women at the center of their COVID-19 response. If governments ignore the fact that the pandemic and resulting recession are affecting women differently, it will prolong the crisis and slow economic recovery for everyone.

For example, because of the economic shutdowns over the last year, hundreds of millions of people in low-income countries have needed help from their government to meet basic needs. But the cruel irony is that the women who most need these economic lifelines tend to be invisible to their governments. It’s hard to send cash safely and swiftly to a woman who doesn’t appear in the tax rolls, have a formal identification, or own a mobile phone. Unless financial systems are specifically designed to include these women, these systems are likely to exclude them, pushing them even further to the economic margins. Our foundation has worked with the World Bank to help countries overcome these hurdles and create digital cash transfer programs with women’s needs in mind.

More broadly, we’re supporting efforts to design economic response plans targeted at women and low-wage workers. In low- and middle-income countries, the poorest people tend to be self-employed in the informal sector—as farmers or street vendors, for example. Policymakers often overlook these workers, and traditional stimulus measures don’t meet their needs. (Tax rebates don’t really help people who don’t pay taxes—and who pays for your paid leave if you work for yourself?) Our foundation helped fund research into how governments can repair these holes in the safety net by prioritizing measures like cash grants, food relief, and moratoriums on rent and utilities.

This past year has also shined a spotlight on women’s unpaid labor, an issue I’ve written about in this letter before. With billions of people now staying home, the demand for unpaid care work—cooking, cleaning, and childcare—has surged. Women already did about three-quarters of that work. Now, in the pandemic, they’ve taken on even more of it. This work may be unpaid, but it comes at an enormous cost: Globally, a two-hour increase in women’s unpaid care work is correlated with a 10 percentage point decrease in women’s labor force participation. As governments rebuild their economies, it’s time to start treating child care as essential infrastructure—just as worthy of funding as roads and fiber optic cables. In the long term, this will help create more productive and inclusive post-pandemic economies.

Bill and I are deeply concerned, though, that in addition to shining a light on so many old injustices, the pandemic will unleash a new one: immunity inequality, a future where the wealthiest people have access to a COVID-19 vaccine, while the rest of the world doesn’t.

Already, wealthy nations have spent months prepurchasing doses of vaccine to start immunizing their people the moment those vaccines are approved. But as things stand now, low- and middle-income countries will only be able to cover about one out of five people who live there over the next year. In a world where global health is local, that should concern all of us.

From the beginning of the pandemic, we have urged wealthy nations to remember that COVID-19 anywhere is a threat everywhere. Until vaccines reach everyone, new clusters of disease will keep popping up. Those clusters will grow and spread. Schools and offices will shut down again. The cycle of inequality will continue. Everything depends on whether the world comes together to ensure that the lifesaving science developed in 2020 saves as many lives as possible in 2021.

Existential crises such as these leave no facet of life untouched. But solutions that are worthy of these historic moments also have ripples. Demanding an inclusive response will save lives and livelihoods now—and create a foundation for a post-pandemic world that is stronger, more equal, and more resilient.