I’ve been following the fight against polio almost daily for more than two decades, ever since I got involved in the global coalition to eradicate it. But polio hardly ever makes headlines anymore, and most people are understandably not as focused on it as I am. So with World Polio Day coming up on Saturday, I want to give a quick update on how things are going.

Thanks to the world’s efforts—led by national governments with support from the Global Polio Eradication Initiative, which is a coalition of Rotary International, WHO, UNICEF, the United States CDC, the Gates Foundation, and the vaccine alliance known as Gavi—polio cases are down by 99 percent since 1988, and the virus is endemic in just two countries.

One of them, Pakistan, is making major progress. Thanks to continued vaccination programs and strong leadership from the government, the number of children newly paralyzed by polio there dropped from 74 in 2024 to 31 in 2025 and just 7 so far this year. I think it is possible to get to zero if we keep up this momentum.

In Afghanistan, unfortunately, polio cases have increased this year compared with last year. But the program is taking steps to do a better job getting the vaccine to all children, especially in the South region of the country. And it’s finding new ways to work with community leaders to hear from families who have doubts about vaccinations and to address their concerns.

Some encouraging news is coming out of Africa. Five variant polio outbreaks on the continent have been closed, interrupting transmission of the virus in those countries. It’s a testament to phenomenal work by governments at every level, local health workers, and the polio eradication initiative.

However, there continue to be outbreaks of variant polio in especially fragile settings. Humanitarian crises, weather-related disasters, and resource constraints are making it harder to vaccinate children. As global immunization rates remain low, the risk that the disease will spread internationally—even to places that have long been free of polio—is high. 

India and South Asia have now been free of wild poliovirus for 15 years. This region, which is home to a quarter of the world’s population, recorded its last case of wild poliovirus in 2011. Staying polio-free since then is a huge accomplishment in itself. But countries in the region are also building on infrastructure and lessons from the polio program to expand people’s access to other public health services.

An affordable six-in-one vaccine is making it easier to protect children in low-income countries. In most low- and middle-income countries, children get their polio vaccines in two ways: orally, via a few drops in their mouth, and by injection. The injectable vaccines require two shots, the second one weeks or months after infants have received all their other routine shots. Many families don’t come back for this second visit, which means those children aren’t fully protected.

The six-in-one vaccine incorporates polio protection into the vaccines that children already get routinely, reducing the need for another injection later. When a baby gets the shots that protect them from whooping cough, tetanus, and so on, they’re also getting protection against polio.

Six-in-one vaccines aren’t new; they have been used in wealthier countries for years. The breakthrough was to develop one that’s affordable for low-income countries. Thanks to support from Gavi, Senegal and Mauritania are already using it, and Pakistan just approved its use last month.

I wish there were better news to share about funding. Even some of the most generous partners have cut back on their giving. GPEI, the eradication initiative I mentioned earlier, had to cut its budget by 30 percent this year. I am grateful to the donors who have stayed committed and to new donors who have made significant contributions in recent years. These include the Kingdom of Saudi Arabia, the United Arab Emirates, the European Investment Bank, Qatar, Australia, Canada, Monaco, and the United States.

This has accelerated a process that was already under way: lower-income countries taking more ownership of the program. For example, in the past 18 months, three more labs in Africa have been certified to do genomic sequencing of poliovirus samples. If the virus is detected somewhere on the continent, a sample can be sent to one of these labs, where scientists study its genome to figure out where it came from. The plan is to keep expanding capacity in Africa, further reducing the need to send samples overseas.

Unfortunately, none of this makes up completely for the funding shortfall. Around the world, leaders of polio programs are making painful tradeoffs. If this shortfall continues, we could lose decades of progress and see polio return everywhere. I’ll continue to do my part, supporting the work through the Gates Foundation and using my voice to raise awareness.

This is a winnable fight. It is giving us a blueprint for eradicating other diseases, including malaria. It has also created a global network of labs and experts that has alerted public health officials to outbreaks of cholera, measles, Ebola, and COVID-19 at the height of that pandemic.

But for me, what it comes down to is that we should eradicate polio because it is entirely preventable. There is no reason any child should ever be paralyzed by it again. That’s why I’m proud to be part of the global partnership that is committed to getting rid of it forever.

When Ramesh Ferris speaks in public, which he does a lot, he has an unusual way of getting to the stage. He crawls across the floor.

Ramesh was paralyzed by polio when he was six months old. Today, at age 46, he can walk with crutches and leg braces, but as an advocate for polio eradication, sometimes he chooses not to. He wants his audience to see what the disease does to the human body.

“I’m the voice of the polio survivors that I’ve met crawling in the streets of their communities,” he says. “Showing my legs is the most powerful tool I can use to educate people about the reality of what happens when kids don’t receive the polio vaccine.”

Ramesh contracted polio in 1980, when he was six months old. The first polio vaccine had been invented 25 years earlier, and millions of children had received it, but it still hadn’t reached low-income communities like the one in the state of Tamil Nadu, India, where he was born.

His birth mother had never heard of the disease, much less a vaccine for it. She just knew that her boy kept getting sick, and she couldn’t afford medical care for him, so she made what must have been an agonizing decision. She put him in the care of an orphanage in her community.

A year later, Ramesh was adopted by a Canadian couple who raised him and five other adopted children in the Yukon. Life was hard at times—kids at school mocked and bullied him—but he got expert medical care. Through three surgeries, doctors straightened his legs, and after intensive physical therapy, he learned to walk with crutches and braces.

When Ramesh was 22, he took a trip that changed his life. He went to India to meet his birth mother for the first time, so he could tell her how grateful he was that she had sacrificed so much so he could get the care he needed.

On the same trip, he had another powerful emotional moment. “I saw a fellow human being that had polio because he didn’t receive the polio vaccine as a child,” Ramesh says. “He was crawling around the streets as a beggar.” The person he was traveling with told him: “You’re looking at your life if you weren’t adopted.”

Since that time, Ramesh has been traveling around the world as a volunteer with Rotary International to spread the word about how much progress the world has made and the work that still remains. He’s raised awareness and funds with eye-catching campaigns including a 7,140 km trip across Canada… by hand bike.

We’re close to eradicating the disease—there were 52 cases of wild poliovirus in 2025, down from 350,000 in 1988—but finishing the job is a tough challenge that takes continued funding and effort.

People like Ramesh remind us not only how we can do it, but why we should.

When most Americans think of polio, we probably picture President Franklin Delano Roosevelt. In 1921, at age 39, he was paralyzed by the virus and never regained the use of his legs. His story helped turn polio into a national cause. But in many ways, his experience was an anomaly.

After all, polio is overwhelmingly a childhood disease, with the vast majority of cases affecting those younger than five. That was true when FDR fell ill, and it’s true today. The typical patient isn’t an adult with an already established political career—it’s a little kid, often a little kid in a low-income country, who might never get the chance to take his first steps.

That injustice is one big reason I've spent the past two decades working to eradicate polio. The other reason is that eradication is actually possible, realistic, and well within reach. This is a disease we can get rid of—not just control, but eliminate everywhere. That is a rarity in global health.

The world has already made extraordinary progress. Back in 1988, when Rotary International and the World Health Assembly set the goal of eradication, the virus was paralyzing more than 350,000 children each year across 125 countries. Since then, cases have dropped by 99.9 percent. The strains known as Type 2 and Type 3 wild poliovirus have been eradicated. The entire African continent is certified wild-polio free. Only two countries—Afghanistan and Pakistan—still have persistent transmission of Type 1 wild poliovirus.

Now we're closer than ever to total polio eradication. But the last mile is proving the hardest because viruses find ways to exploit any immunity gaps or weaknesses. Wherever vaccination rates slip—even briefly—they can resurface.

One of the biggest challenges comes from what are called variant outbreaks. In communities where immunization is low, the weakened virus used in the oral polio vaccine can circulate asymptomatically and rarely, over time, mutate enough to regain the ability to cause paralysis in unvaccinated children.

While most variant outbreaks happen in places with extremely low vaccination coverage, poor sanitation, and weaker health systems, no place is risk-free until the world is polio-free. In 2022, the United States confirmed its first paralytic polio case in nearly a decade, and the virus was detected in New York wastewater samples. In the time since, variant polioviruses have also been found in the U.K., Ukraine, Indonesia, and other countries.

The good news is that today’s tools are better than anything we had even five years ago, and they make every dollar spent on the cause go further than ever before. We have a new oral vaccine, nOPV2, that’s far less likely to mutate and lead to new variant outbreaks; nearly two billion doses have already been given worldwide. New regional labs in Ghana, Nigeria, South Africa, and Uganda that test wastewater samples and sequence viruses have cut detection times by over 30 percent, which gives health workers a critical head start on outbreak response. And the surveillance network for polio is one of the most sophisticated ever built—also helping alert public health officials to outbreaks of cholera, measles, Ebola, and even COVID-19 at the height of that pandemic.

The Gates Foundation has been proud to support these advances as part of the Global Polio Eradication Initiative, a coalition of the WHO, UNICEF, the CDC, Gavi, Rotary International, and dozens of countries’ governments. It’s one of the most successful collaborations in the history of global health.

But right now, GPEI is facing a $1.7 billion funding gap, with various long-term donor governments cutting back their support. Without the right resources, vaccination campaigns may have to be scaled back, surveillance sites will likely close, and the virus could spread globally.

In the century since FDR was paralyzed by the virus, American leadership and generosity have helped turn polio into a fight the whole world could win. From the March of Dimes, which funded research, to the development of the first vaccines, to support for eradication campaigns, U.S. commitment has been decisive.

The world is at the brink of ending this terrible disease, and the stakes of this moment couldn’t be higher. If we finish the job, we free up billions of dollars for other health priorities and—most importantly—protect generations of children from a virus that has paralyzed millions. If we back down from the fight, up to 200,000 children could be paralyzed each year within a decade.

We have the scientific tools and infrastructure needed to cross the finish line. And we have hundreds of thousands of committed vaccinators who are determined to get us there—who go door to door across deserts, jungles, floodplains, and war zones to make sure no child is missed. I've met them, I've heard their stories, and I've seen how determined they are to finish the job.

We should be too.

Earlier this year, I made my first trip ever to Pakistan to learn more about the country’s incredible efforts to wipe out polio.

At the time of my visit in February, Pakistan had gone more than a year without a single child being paralyzed by the crippling disease. This was a huge achievement made possible by the skill and dedication of the polio program’s leadership and its more than 300,000 polio workers. Their energy and enthusiasm reminded me of what I saw in India and Nigeria when those countries were traveling the final mile to eliminate polio within their borders.

But the last mile is often the toughest. The gains made against this highly contagious disease are often fragile.

In recent weeks, the world received a sobering reminder of this fact when three new cases of wild poliovirus were detected in Pakistan: 12 and 15-month-old boys, and a two-year-old girl all living in the same district in Khyber Pukhtunkhwa Province, Pakistan, near the border with Afghanistan. (Pakistan and Afghanistan are the only two countries where the wild poliovirus has not been eliminated.) 

It is heartbreaking to see these three children paralyzed by a preventable virus that has been eliminated in nearly every part of the world. (The government of Pakistan is providing rehabilitation services and other support to help the children and their families.)

At the same time, the emergence of these new cases was not entirely unexpected given the challenges of wiping out the virus in one of the most challenging places on Earth. The border region between Pakistan and Afghanistan, where the cases were detected, struggles with insecurity and misinformation that can sometimes prevent vaccinators from reaching every child who needs the polio vaccine.

When I learned about the new cases, I was disappointed. But I was also heartened by the response of Pakistan’s polio program. Despite having every reason to be frustrated, Dr. Shahzad Baig, who runs Pakistan’s National Emergency Operations Center for polio, said his team was not deterred. “This strengthens our resolve to reach every child with the polio vaccine,” he said.

After what I saw during my visit to Pakistan, I shouldn’t have been surprised by the team’s unfailing confidence. The polio workers are driven and detail oriented. They understand that running effective polio vaccination drives is not about getting one thing right. It’s about getting everything right that’s necessary to ensure all children get vaccinated.

In Pakistan, that has meant training 300,000 frontline workers who walk from house to house to vaccinate over 43 million children under the age of five; creating detailed maps for those teams to use to ensure no child is missed; running public information campaigns to inform communities about the risks of polio and the benefits of vaccination; organizing security to protect vaccinators; and building strong supply chains so vaccines are available across the country.

In between vaccination drives, Pakistan’s polio surveillance workers are constantly hunting for signs of acute flaccid paralysis in children and testing the environment for the presence of the virus.  Pakistan currently has the largest environmental surveillance network in the world. From tiny villages to larger cities and urban areas, Pakistan’s system has the capacity to find the poliovirus wherever it exists.

The nerve center for all this work is the National Polio Emergency Operations Center, which was a highlight of my visit. A wall of screens in a control room displayed real-time information about vaccinations, security, and supplies, as well as detailed maps following the movements of polio workers. This data helps the team see where they need to make improvements to the vaccination programs to ensure they reach all the children. You probably know I have an insatiable appetite for data, especially health data. So, it should be no surprise I lingered here for longer than planned to look at all the information and learn from the polio experts who are as passionate about data as I am.

What was also remarkable to see is how Pakistan has continued to build community support for its polio activities by integrating them with other essential health programs, like routine immunization programs. During the pandemic, polio workers used their deep knowledge of local communities to reach out to families to raise awareness of COVID-19, teach them how to protect themselves with handwashing and mask wearing, and encourage people to get vaccinated.

Polio workers constantly battle rumors and misinformation about the polio vaccines. But by engaging openly with the public’s questions they’re making headway against this challenge.

I got a glimpse of part of this effort at a national immunization call center where doctors and other health workers respond to tens of thousands of queries every month from the public about immunization, including polio. If families hear a rumor about the polio vaccine, they can call for free and ask about it. Pakistan has reduced the number of vaccine refusals and I believe that the work of this call center is one of the key reasons why. The call center was set up to support polio inquiries, but due to the success of the program, the call center expanded its services to answer questions about COVID-19 vaccines and all other vaccines.

Pakistan’s polio effort also benefits from the strong support it receives from the very top of its government. I recently had an opportunity to speak with Pakistan’s new Prime Minister, Shehbaz Sharif, and it was clear that his administration is actively engaged in stopping transmission for good.

Even with the three new polio cases in Pakistan, the virus is still circulating at very low levels and the world has an historic opportunity to make sure this virus never paralyzes a child again. The fact is, we’ve never been closer to ending polio and it’s critical that the world doesn’t lose sight of this goal.

The last mile to end polio, of course, will be challenging. And that’s why it’s important that the world keep up its support for the polio programs in Pakistan and Afghanistan, so they don’t travel it alone.

I look forward to keeping you posted on their progress in the months ahead.

The world is so close to ending polio.

Since the start of the global eradication effort in 1988, the number of polio cases worldwide has fallen 99.9 percent.

19 million people who would have otherwise been paralyzed are now walking today because of vaccines. And 1.5 million people are alive who would have otherwise died from the disease.

Much of the credit for this progress goes to the thousands of polio workers who have gone door to door vaccinating more than 3 billion children over the last 33 years.

October 24 is World Polio Day and to mark the occasion I’d like to share the story of one of these dedicated polio fighters.

Her name is Shumaila Rehmani.

Shumaila is a polio vaccinator in Pakistan, which is one of the two countries in the world—the other is Afghanistan—where the wild poliovirus is still endemic.

Shumaila’s job is to deliver the polio vaccine to every child under age five in the community she serves. While that probably sounds like a straightforward job, what it takes to get it done is not. Reaching every child requires hard work, meticulous planning, and patience.

During polio immunization drives in Pakistan, Shumaila sets out on foot early in the morning with a cooler filled with vaccines and a detailed plan for all the homes she needs to visit. Then she begins knocking on doors to give the oral polio vaccine drops to every child.

The overwhelming majority of families she visits want their children to be vaccinated. Some parents, however, out of fear or a lack of information, refuse to have their children vaccinated.

But Shumaila doesn’t give up.

She talks with the mothers and fathers, answering all their questions about polio and reassuring them that the vaccine is safe and effective. She also works with community and religious leaders to speak with families about the importance of vaccination.

Progress can be slow. In the community she serves, Shumaila says this year she initially had more than 250 families refuse vaccinations. But today, because of her efforts to work closely with the families, all but four of them have had their children vaccinated. And she continues to talk with those families to encourage them to get vaccinated.

And thanks to the thousands of dedicated health workers like Shumaila and the leadership of Prime Minister of Pakistan Imran Khan, there’s been just one case of wild polio in Pakistan so far this year, compared with 84 in 2020.

While the incredible efforts of Shumaila and other polio fighters have brought us to the brink of a polio-free world, COVID-19 has created new challenges. The pandemic has disrupted polio campaigns and routine immunizations in many parts of the world, causing outbreaks of other forms of polio to crop up in Africa and Asia.

That’s why the global polio program adapted its approach to help contain the spread of COVID-19 while also working to end polio. The Global Polio Eradication Initiative used its workforce and laboratory and disease surveillance network to respond to the pandemic, investigating suspected COVID cases, coordinating response operations, and training health care workers. In Pakistan, the national polio team now operates a toll-free number for anyone who wants to speak with a doctor about COVID, polio, or get any questions answered about routine immunization. They have received more than 17 million calls during the pandemic.

Like other polio workers, Shumaila has used her community relationships to raise awareness of COVID, teach families how to stay safe, and provide handwashing and hygiene lessons. This has made for longer days, but Shumaila says it’s easy to stay motivated. As a mother of three children herself, she is driven by her dream of a day when polio will no longer be a threat to her children or any child in Pakistan.

It’s a day she knows will come soon, she says. Again and again since the start of the global polio eradication effort, one country after the next has eliminated this crippling disease from within their borders. Less than a decade ago, for example, Nigeria accounted for more than half of all wild polio cases worldwide. But last year, Nigeria, along with the 47 countries in the African region, were certified free of the wild poliovirus.

With Afghanistan recently announcing it would conduct a nationwide polio campaign in November—the first in over three years to reach all children in the country—and Pakistan’s continued commitment to eradication, the final two polio endemic countries will hopefully soon follow others on the path to ending wild polio.  

“If other countries can be polio free, why can’t Pakistan be?” Shumaila asks.

During my entire life I’ve only had two jobs. In the first one, I played a role in developing software to empower people through my work at Microsoft.

In my second one, which I started full time in 2008, I am giving back the wealth I made at Microsoft with the goal of making the world a healthier, better educated, and more equitable place. This is the job I will have for the rest of my life.

Both of these experiences inform my perspective on artificial intelligence. When I first learned about computers at age 13 I was fascinated by the idea of making them more intelligent and able to perform things that, at the time, only humans could do. Although the term “AI” was used from around the time I was born, the technology has only made significant progress in the last decade. It is now incredibly capable and it is continuing to improve at a mind-blowing rate. AI for the first time can replace and even exceed human cognition.

In terms of equity, AI will either be the greatest equalizer ever invented, or the worst source of injustice. The challenge is monumental. Even under the best circumstances, the transition to this new AI era will be one of the most turbulent times in human history. How will we use this technology to make the world a fairer place and keep it from widening the divide between rich and poor? How will we protect the people who are most vulnerable to the harms caused by artificial intelligence, including those who lose their livelihoods and the sense that they are in control of their future?

I believe that answering these questions and acting on the answers should be the world’s top priority. If the world takes the right steps AI will be a force for good and leave everyone better off.

Unfortunately, right now we are not preparing for it. I don’t see evidence that leaders, experts, and communities are confronting the challenges adequately. There is no plan to ease the entry into the AI era.

Part of the reason for this is that many commentators underestimate the extent of the impact AI will have. I think there are a few reasons why.

One is the fact that AI models still make mistakes. It is hard to envision any of them replacing human cognition when, not long ago, they couldn’t solve a simple Sudoku puzzle or figure out how many R’s are in the word strawberry.

But the reliability problem is being fixed quickly, as researchers create models that can check their own work and improve themselves. Soon they will be substantially better than humans at many tasks.

Another reason people underestimate AI is that analogies to the effects of past innovations are misleading. We have no experience with a technology that can be adopted quickly or that can think and move like a human. When the PC came along, it took twenty years to significantly change how we worked because the software had to be developed, the price had to come down, and people had to learn how to use the tools and incorporate them into their business processes. AI, on the other hand, runs on the devices we already have, and it uses natural language. We don’t have to adapt to it because it can adapt to us. It can watch the same training video that is used to train human workers and learn from existing data.

I want to acknowledge a potential bias. I have benefited enormously from the technology industry. Although I have diversified my portfolio quite a bit, I still have financial ties to it. I am working with Microsoft and other AI companies in my role as chairman of the Gates Foundation to try and ensure AI is deployed in ways that will truly benefit people around the world.

However, my views on AI are not motivated by the potential to make money for myself. Any profits generated by my investments, including those related to technology, will go to the Gates Foundation to tackle global inequity. Of course, readers will have to decide for themselves whether this clouds my view.

This time really is different.

For as long as I can remember, I’ve wished innovation could happen faster. With AI, my feelings are more complicated.

I wish the world could get the benefits rapidly and delay the problems it will cause as long as possible, but the benefits and problems are arriving at the same time. I believe we need time to prepare for the period of social, political, and economic upheaval we are about to enter. The people who need the most time are the ones who have the least—the accounting worker who’s replaced by a bot or the $20-an-hour worker who loses their job to a $10-an-hour robot.

Many observers say that this technology transition will be like previous ones. They give the example of how jobs in the United States shifted from agriculture to office work. However, that proceeded over several generations and created new jobs where human cognition was required. In this case, the technology can substitute for human cognition.

Because it can see, listen, speak, and reason and will eventually do physical work just as smoothly as any human, it will not just affect one sector. AI will take on work in law, customer service, medicine, software, and manufacturing. It will hit these industries rapidly, over the course of a decade rather than a few generations. There will be some new jobs, but without the right policies there will be far fewer than exist today.

If someone had a credible plan for slowing down AI advances globally, I would likely support it. However, I don’t think that’s going to happen. The geopolitical and economic incentives are pushing too hard to go full speed ahead.

To make sure we maximize the positive effects of this unprecedented technology and minimize the bad so we are better off overall, we need to understand both the benefits and the risks. I’ll start with the risks.

The transition to AI comes with three big risks.

I plan to write about each of these in more detail in the future, so I’ll touch briefly on them for now.

Many jobs will disappear forever.

In 1933, during the Great Depression, unemployment in the United States was roughly 25 percent. It remained in double digits for much of the following decade. It ultimately recovered as demand, investment, and growth returned.

AI may not reach this level, but its impact will not go away with an economic cycle. The jobs at most risk are entry- and mid-level, and the new jobs being created will mostly require skills that take many years to learn.

White-collar jobs are already being hit modestly. After the widespread adoption of generative AI, employment fell significantly among young workers in jobs that are especially vulnerable to replacement, but not among their older colleagues.

I think this trend will continue, but it will not be confined to a handful of industries or occupations. Jobs in sales and customer support (online and over the phone), software engineering, and paralegal work may be among the first affected, but the disruption will reach much further as AI takes on tasks that today still require trained workers: things like assessing loan applications, doing data analysis, and even triaging patients. A few areas like software engineering will generate new demand as the costs go down, so the net job loss in those areas will be less than in others as long as some tasks, such as design, are better done by humans.

Blue-collar jobs will be affected as well. Although robots are not as far along as AI, eventually their cost will be dramatically lower too. Many Americans I talk to don’t realize how fast dexterous robots are advancing because much of the advanced work is being done in other countries, primarily China. Or they may be confused by those videos of robots dancing badly that have been going viral lately. I think “smart” robots will begin to compete with people on some physical tasks—in the construction and hospitality industries, for example—by the end of the decade.

Robots and AI combined can create a vicious cycle. After one company adopts them and uses the savings to lower its prices, its competitors will feel immense pressure to do the same. If existing companies don’t adopt them, then start-ups will. Many people will shift to other jobs, but the turmoil of losing work, getting retrained, and finding other work will be significant. Market forces will make adoption go faster and faster and, unless we intervene, there will be fewer good jobs available and the benefits will accrue to a small group.

I’m especially worried about young people, who will enter a workforce with fewer entry-level openings. They understand the challenge because they are the most active users of AI and see both the capabilities and the rate of improvement. It’s no wonder that so many of them feel negatively about AI.

The biggest shift for workers will happen when AI provides nearly error-free work. At that point, it will be able to function on its own without a human checking in on it, and companies will have every economic incentive to let it.

This will lead to a fundamental change in how we think about work, income, and economic security. How will an economy that’s been built around employment operate if fewer people are working, or if many people are working fewer hours?

In a capitalist society, employment is the way most people get the money they need to pay for the basics of life as well as being a key source of dignity and social connection.

When a community has high unemployment, the ripple effects can be pervasive. Research suggests that in some parts of the United States, factory closures contribute to a rise in deaths from opioid overdoses. Now imagine similar pressures on both white-collar and blue-collar workers nationwide.

We have to think now about how to reduce job losses so that everyone can share in the prosperity that AI creates. Waiting until people are already displaced or underemployed will be too late. AI is a structural challenge to the way our economy is organized, and it requires thinking and action now.

AI will empower people (and perhaps AIs) to do more harm.

Long before AI entered the mainstream, there was information online about how to create weapons like bombs, bioweapons, even computer viruses. AI will make it much easier to not only get this information but act on it. Even criminals with very limited skills will be able to target victims at every scale: individuals, companies, and governments.

AI-enabled fraud, disinformation, deepfakes, and surveillance are the harms that many people will feel most keenly in their everyday lives.

AI capabilities are starting to be used for cyberattacks. The smartest cybersecurity experts I know are scared about the next few years, because the attackers are getting powerful new capabilities faster than the defenders can fix all the weaknesses. After all, the same AI model that can find a flaw in software so a company can fix it can also help a criminal exploit it. The resources needed to make an attack are going down significantly and we haven’t been able to separate those abilities from benign usage.

Think about the infrastructure that will be vulnerable: hospitals, financial institutions, water systems, power grids, systems for managing government benefits. When these institutions are attacked, it’s the patients, customers, and benefits recipients who stand to lose.

The same goes for bioterrorism. Although AI will lead to lifesaving advances in drugs and vaccines, it will also make it easier to design a deadly new disease. Again, the positive capabilities are hard to separate from the dangerous ones. This is a global problem.

The risks I’ve just mentioned are all about how AI will empower bad actors who have relatively little power now. The same tools will also concentrate power in places where it already exists. Autonomous weapons, for example, will make governments even more capable of using deadly force without a human being part of the decision. Monitoring and manipulating public opinion will be easier and cheaper, and more effective too.

Eventually, the power to use AI to harm people will not be limited to people or institutions. AI systems themselves already occasionally act in ways their designers didn’t intend. The technology is improving faster than anyone expected and in surprising ways, and as the models become more powerful, they could begin to act against our interests and we could lose control. I’ll have more to say about this in the future.

AI could stunt our kids’ development and replace human relationships.

When I was growing up in Seattle, I didn’t have that many friends aside from a few other boys who were like me. It took hard work and a lot of help from my mom to develop my social skills so I could relate to different kinds of people. I still draw on those lessons today at the age of 70.

I doubt I would have put in the same work if I had had an AI companion back then. They talk to you in ways you’re already comfortable with. They don’t push you outside your comfort zone. They are always available and never get mad at you. This gives them the potential to become highly addictive and to rob us of the lessons we learn from connecting with other people.

The body of evidence on this subject is still small and a bit mixed, but there are signs that we should be very concerned. For example, in one study of more than 1,100 people who use AI companions, researchers at Stanford and Carnegie Mellon found that those with smaller social networks were the most likely to turn to a chatbot for companionship. And the heavier and more emotionally personal that use became, the worse they felt.

Young people could be affected for their entire lives. In his book The Anxious Generation, Jonathan Haidt makes an observation about the effect of social media that is even more true for AI: “Like young trees exposed to wind, children who are routinely exposed to small risks grow up to become adults who can handle much larger risks without panicking. Conversely, children who are raised in a protected greenhouse sometimes become incapacitated by anxiety before they reach maturity.”

An AI companion designed to never upset you is a big, protected greenhouse.

We are only beginning to understand the dangers that the internet—especially social media—can pose to young people’s development. We’re seeing compulsive use, disrupted sleep, cyberbullying, and exposure to harmful content. AI could magnify many of these risks by making them more persuasive and difficult to escape, and we should not wait another generation to start taking them seriously. Countries including Australia, the United Kingdom, and Norway are adopting protections for children online. China has gone the furthest. Its rules restrict AI companion apps broadly, bar designs that foster emotional dependence, and ban virtual relatives and romantic partners for minors.

I’m also worried about AI’s impact on education. Ironically, the same tool that will allow people to learn more than ever could also lead to many people learning less. One preliminary survey suggested that heavier AI use was associated with less critical thinking. The effect was stronger for younger people.

This would be the worst possible time for humans to lose their critical thinking skills. In an era of deepfakes and misinformation that can be tailored to you individually, the ability to tell what is true from what is not becomes an essential life skill.

It’s unclear where to draw the line on these psychosocial problems. In some cases, AI may help people understand how to do better in their human relationships. It may be the only contact with the outside world for isolated elderly people and people with limited mobility, and it will be better than nothing. Wherever we end up drawing the line, it should be our decision, made intentionally.

The good things we do with AI could be very, very good.

It’s often said that we overestimate how much will change in the short term and underestimate how much will change in the long term.

With AI, I see something different going on. Some people see only the upside of AI and do not focus enough on the negatives. Others make the opposite mistake, which is to focus exclusively on the dangers—which are real—at the cost of missing the potential benefits.

We need both: deep concern about the AI harms we need to minimize, and grounded optimism about the positives if we maximize them for everyone.

Maximizing the benefits is just as important as minimizing the harms. If people see how AI makes their lives easier, it will help build the public trust that is necessary for managing the harder parts of the transition. If the first thing AI does in most people’s lives is take away their job, those who are already skeptical about it will outright reject it. This will make it harder to ever deliver on the benefits and it is another reason why governments, industries including the medical industry, and AI companies should be working together now.

With its ability to synthesize knowledge from every scientific field, AI can accelerate innovation in the world’s toughest technical challenges: providing reliable clean energy for everyone, combating climate change, growing enough food, eradicating diseases, and more. Researchers working on cancer treatments or nuclear energy can use AI to search through massive amounts of scientific literature. It can help them identify patterns that a human might miss and decide which experiments offer the most promise. When intelligence is no longer the limiting factor that it is today, smaller companies will be able to compete with organizations that have far larger research budgets. R&D and innovation will be supercharged.

Healthcare is one area where AI can help solve real-world problems. Many small American hospitals lack on-site specialists who can quickly diagnose a patient during a life-threatening emergency. In those places, AI could make sure a heart attack is caught in time and a family avoids the crushing expense of a medical emergency. Viz.ai is one example. It analyzes scans to detect strokes and other emergencies and helps medical teams coordinate their patients’ care. It is being used in nearly 2,000 U.S. hospitals.

AI will also help primary-care doctors make better diagnoses and keep in touch with their patients when they’re not in the clinic. It will help patients understand test results and complicated schedules for taking their medicine.

I surprise a lot of people when I tell them that a second area—agriculture—is where I see the fastest impact of AI in low-income countries. In most low-income countries, farmers don’t get reliable weather forecasts or advice on what seeds to plant, how to protect their crops and livestock from disease, or how to improve their soil. With population growth in these countries and the challenges of climate change, these farmers need more help than ever. Using AI, low-income farmers will soon be able to get better advice about all these things than even the richest farmers get today and increase their output substantially.

Government services are a third area where AI can make people’s lives easier. In the United States, I’ve met families who, understandably, were overwhelmed by the process of applying for health insurance, student aid, or food assistance. Faced with a huge stack of complicated bureaucratic forms, many felt like giving up. AI can streamline things dramatically so they get the help they need faster and the government can operate more efficiently. Governments can make the citizen’s experience far better, starting with those who need its safety net services the most.

Despite my concerns about its impact on our mental health, I think AI can also help a lot there. Most communities have too few counselors, psychiatrists, and addiction specialists. With the right privacy safeguards in place, AI tools could help people recognize warning signs. Then, if needed, they can offer evidence-based coping strategies and team up with a human to provide more responsive treatment.

AI can be a boon for education as well, despite the concerns I mentioned earlier. It can free teachers up to spend more time working with students one on one or in small groups and give them a clearer view of where the whole class is struggling. For students, an AI tool that preserves what researchers call “productive struggle”—the cognitive work that builds understanding—can strengthen learning. When a student first encounters a new idea, the AI gives substantive explanations and offers both questions and answers. Later, when it’s checking their comprehension, it holds the answer back and helps them arrive at it on their own.

Taken together, the advances in all these areas could make everyday life easier, more affordable, and less constrained by a person’s income or connections.

AI could give individuals and small businesses access to capabilities that today require expensive professional help or large staffs, while making products and services better and cheaper. It could help people with disabilities live more independently and enable workers and entrepreneurs with good ideas to accomplish far more than they can today.

Most importantly, it could give people back some of the time and attention now consumed by paperwork, bureaucracy, searching for reliable information, and tasks they cannot afford to pay someone else to handle. These benefits may seem modest, but multiplied across millions of lives, they would be profound: more people getting good advice when they need it and having greater freedom to focus on the lives they want to build.

In all these areas, the operative word is “can”—AI can improve life for people at every income level. But it won’t do that automatically. As with any new technology, we have to be deliberate about ensuring that it benefits everyone and not just a wealthy few. This will require governments and philanthropy to play a strong role so that less wealthy citizens and low-income countries are full beneficiaries.

The Gates Foundation has 19 years left of the 20 years in which it will spend its remaining $200 billion. AI will help it achieve its ambitious goals by both accelerating the discovery of vaccines and medicines for HIV, TB, malaria, and malnutrition and helping the healthcare workforce and patients know how to use those tools. The foundation’s goals include cutting the number of children who die every year in half again, as was done from 2000 to 2024. All of our work, not just health but also agriculture and education, will take full advantage of AI.

I will write much more about these efforts next month in the foundation’s annual Goalkeepers report—including our focus on making sure that AI models are available in the languages spoken by people in all the countries where we support work, and not just the ones that are common in rich and middle-income countries. Many of the leading AI companies, including OpenAI, Anthropic, Google, and Microsoft, are partnering with the foundation on all of these initiatives, which is making a big difference.

The world needs a plan.

It is great that some AI companies are proposing solutions to challenges raised by their own technology, but we should not expect them to lead the charge. Some of the issues are outside their area of expertise, and in a democratic society it’s not their role to decide these things.

Instead, solutions should be developed through a public democratic process that includes elected officials, policymakers, educators, health workers, local officials, and community leaders. Millions of people will have their lives disrupted, and we’ll need a stronger, more flexible social safety net to help them manage the transition. Local communities are already raising concerns about the energy and water needed for data centers. Without solutions, some groups will push for stopping AI development and deployment altogether.

The solutions should be shaped by our answers to the profound questions raised by AI, including how we preserve our humanity in a time when machines can out-think us. As people who spend their lives thinking about what it means to be human, religious leaders can play a key role in this. I was fascinated by Pope Leo XIV’s encyclical on AI, “On Safeguarding the Human Person in the Time of Artificial Intelligence.” It lays a strong foundation for the work that needs to be done.

In the coming months, I will share more ideas for making sure that AI’s benefits outweigh the harm it causes. Here are three to start, beginning with what I think is the most important one.

Build a new system for managing the transition.

The highest priority is a monumental task: creating a domestic and international framework for dealing with AI.

None of our current institutions were designed to handle a technology that spreads so fast and touches so many parts of our lives. So we’ll need to make new ones.

It’s hard to overstate what an enormous undertaking this will be. After the attacks of 9/11, the U.S. government went through its biggest reorganization since World War II for the purpose of improving just one function, national security.

AI will require much, much more. It will affect national security as well as employment, education, taxation, energy, elections, air and water, public health, the financial system, law enforcement, transportation, public lands, and IT systems.

These sectors overlap in ways our existing bureaucracy is not designed to manage. A labor department may understand workforce disruption but not security risk. A business regulator may understand market concentration but not AI’s effects on children and teenagers. Left to themselves, institutions will see only one part of the system, while the consequences of AI will ripple across the entire system.

At the national level, countries will need bodies that can set priorities across government agencies. The goal will be to make sure that every risk is accounted for. Otherwise, an AI-enabled attack might succeed because no one thought it was their job to stop it.

But even a country that gets its own house in order will still be exposed to risks that cross borders. This is why an international organization will need to be built in parallel.

It will be unlike any other institution we have ever created, though it can follow the model of some existing systems. There’s an inspections regime for nuclear weapons, regulations for international aviation, and agreements that protect the ozone layer. A new global organization for AI will need elements of all three and more.

It is fair to wonder whether the world’s institutions are up to the task of designing and implementing this new architecture. Government moves slowly when it moves at all, and polarization within and between countries makes it harder than ever to get things done. Some cooperation between the U.S. and China will be required.

We do not have the luxury of moving slowly. The place to start is with a process for building the right institutions before the disruption forces governments into crisis mode. National leaders should convene economists, technologists, labor experts, business leaders, and workers themselves regularly to identify where existing institutions are failing and what new authorities may be needed. Countries will need to learn from each other.

And the countries that host the leading AI developers and control critical parts of the supply chain should begin meeting now to set up shared norms, before competitive pressure makes it harder for them to cooperate.

Building the framework I’m talking about will take years, which is why we need to start now.

Set aside some jobs for humans.

My dad died of Alzheimer’s in 2020. In the later stages of his illness, he was cared for day and night by paid caregivers who understood him even when he struggled to express himself. He couldn’t always tell them when he was hungry, but they always knew.

My family and I will always be grateful to that amazing group of professionals. Something in the care they gave my dad was irreplaceably human. No robot could or should have done it.

I think about that team when the question of which jobs will disappear and which will remain comes up. I believe that as AI and robots improve, we’ll set aside certain things for only people to do. I’ve started calling this domain Human Reserved, and it’s an example of the kinds of ideas we’ll need to consider.

I like the phrase Human Reserved because it makes me think of nature reserves—places where we could put buildings and roads, but we choose not to because the loss would be too great.

We might set something aside as Human Reserved for economic reasons. For example, we may do it because allowing machines to take over a certain role will displace a large number of people who can’t easily change jobs. You can’t tell a 55-year-old who has worked in construction their whole career that they need to go work at an elder care facility and expect them to find it fulfilling.

Sometimes the decision to make something Human Reserved will be driven by other factors. In health, for example, imagine a robot giving you the awful news that you have an incurable disease. There’s no technical reason why it couldn’t. Yet it shouldn’t.

The Human Reserved domain will evolve over time—for example, we should consider setting aside some jobs now and phasing in AI slowly over years or decades with a commitment to preserve some jobs. Some areas, like education and mental health care, will be a mix, with a human in charge who’s using the technology to extend what they can do.

The lines will also vary from place to place. Some countries might insist on having humans take care of the elderly. But a country like Japan, which has a shrinking workforce and not enough young people to care for the old, may welcome a caregiving robot.

The idea of Human Reserved raises a host of questions I don’t have answers to. Who gets to decide what we reserve for humans? What criteria should we use? How do you keep companies from cheating and using robots anyway? What happens to international trade when one country lets robots make something and another country doesn’t? These will need to be worked out in public as part of the transition plan.

Rebalance how we tax labor and capital.

As workers are pushed into different jobs, they will need retraining and other support from the social safety net. But they will be working less, which means they will be paying less in income taxes, and government revenues will drop just when the demand for those services is greatest. The funds will have to come from somewhere at a time when budgets are stretched.

I believe we should tax AI tokens and robots. Right now, if you’re an employer and you hire someone, you pay payroll taxes on their earnings. But if you buy a robot, you can usually write it off right away as a business expense. The tax system nudges you toward replacing people with machines.

A tax would slow the rush away from human labor a little and raise money for retraining and a stronger safety net. It would need to be targeted so it does not slow down the purely beneficial uses of AI, like making medicine and education cheaper.

Critics of this idea point out that it’s not optimally efficient in an economic sense, but they’re not considering the broader value of work for individuals and society. And with all the accelerated innovation we will have, we’ll be able to afford a little inefficiency as the price for keeping people employed.

I proposed a robot tax years ago and most of the reaction was that it was a strange idea. I’m still a big proponent of it. Although it is not the whole solution to the threat of AI, it is part of a wise response.

However we raise money for more assistance, it needs to reach the people who need it most, including workers who lose their jobs to AI and robots, people whose hours or wages decline, and communities where the losses are concentrated. We need to start doing that work now so that the systems are ready when the need becomes acute.

What I’m doing.

I will use my voice and time to get AI and equity higher on the public agenda. I will raise the issue with lawmakers every time I visit Washington, D.C., and when I meet with leaders around the world. It will be front and center in my conversations with the people who are developing AI models. I will advocate for the national and international framework I described earlier. The Gates Foundation will help drive beneficial usage, including in Africa. Breakthrough Energy, a company I founded, will use AI to help companies develop cheap clean energy and help solve the climate problem. I will also be writing about AI on a regular basis.

My message to leaders is:

You have a chance to act now, before unemployment rises sharply, communities are hurting, and public trust has eroded. You can make sure that your government handles the problem holistically, rather than divvying it up into multiple bureaucratic fiefdoms. You can make sure AI benefits everyone. And you can work with other governments to meet this national and global challenge.

Finally, I will try to widen the circle of people shaping this debate. It should include workers, college students who are about to enter the workforce, community leaders, religious leaders and faith-based organizations, parents, educators, and others whose voices often aren’t heard but who have insight into how the transition will affect people’s lives.

How do we ensure that the benefits of AI reach people who do not already have wealth, influence, and access?

How do we strengthen the social safety net and help workers and communities thrive even when they’re displaced?

How should public institutions adapt?

And how do we preserve our humanity through all of this?

This unprecedented technology demands an unprecedented global response. If we get it right, the payoff for humanity will be phenomenal and the world will be a more equitable place.

I rarely stop thinking about AI—not because I have all the answers, but because the questions it raises are too consequential to leave to a small group of technologists. Leaders across academia, business, government, and civil society all have a role to play in shaping what comes next.

A core principle underlying the Gates Foundation’s work is closing the innovation gap between rich countries and everyone else. People in poorer parts of the world shouldn’t have to wait decades for new technologies to reach them. That’s why we've worked for 25 years to accelerate access to life-saving medicines and vaccines in low- and middle-income countries.

It's also why, today, the Gates Foundation and OpenAI are announcing an initiative called Horizon 1000 to support several countries in Africa, starting in Rwanda, as they apply AI technology to improve their health care systems.

Over the next few years, we will collaborate with leaders in African countries as they pioneer the deployment of AI in health. Together, the Gates Foundation and OpenAI are committing $50 million in funding, technology, and technical support to back their work. The goal is to reach 1,000 primary healthcare clinics and their surrounding communities by 2028.

Today’s AI can help save lives

A few years ago, I wrote that the rise of artificial intelligence would mark a technological revolution as far-reaching for humanity as microprocessors, PCs, mobile phones, and the Internet. Everything I’ve seen since then confirms my view that we are on the cusp of a breathtaking global transformation.

All over the world, AI, in the form of LLMs and machine learning models, are improving far more quickly than I first anticipated. From science to education to customer service and more, AI tools are reshaping every facet of our lives.

I spend a lot of time thinking about how AI can help us address fundamental challenges like poverty, hunger, and disease. One issue that I keep coming back to is making great health care accessible to all—and that’s why we’re partnering with OpenAI and African leaders and innovators on Horizon 1000.

Not enough doctors in the house

We have seen amazing successes in global health over the past 25 years: child mortality has been cut in half, and there are now real pathways to eliminating or controlling deadly diseases like polio, malaria, TB, and HIV. But one stubborn problem that keeps slowing progress is the desperate shortage of health care workers in poorer parts of the world.

In Sub-Saharan Africa, which suffers from the world’s highest child mortality rate, there is a shortfall of nearly 6 million health care workers, a gap so large that even the most aggressive hiring and training efforts can’t close it in the foreseeable future.

These huge shortages put health care workers in these countries in an impossible situation. They’re forced to triage too many patients with too little administrative support, modern technology, and up-to-date clinical guidance. Partly as a result, the WHO estimates that low-quality care is a contributing factor in 6 to 8 million deaths in low- and middle-income countries every year, and that’s not even counting the millions who die because they aren’t able to access health care at all.

Rwanda leads the way

Today’s AI can help save those lives by reaching many more people with much higher-quality care.

Rwanda currently has only one health care worker per 1,000 people, far below the WHO recommendation of about four per 1,000. It would take 180 years for that gap to close at the current pace of progress. So, as part of the 4x4 reform initiative, Minister of Health Dr. Sabin Nsanzimana recently announced the launch of an AI-powered Health Intelligence Center in Kigali to help ensure limited health care resources are being used as wisely as possible.

As part of the Horizon 1000 initiative, we aim to accelerate the adoption of AI tools across primary care clinics, within communities, and in people’s homes. These AI tools will support health workers, not replace them.

On the horizon

Minister Nsanzimana has called AI the third major discovery to transform medicine, after vaccines and antibiotics, and I agree with his point of view. 

If you live in a wealthier country and have seen a doctor recently, you may have already seen how AI is making life easier for health care workers. Instead of taking notes constantly, they can now spend more time talking directly to you about your health, while AI transcribes and summarizes the visit. Afterwards, AI can handle much of the onerous paperwork, so doctors and nurses can focus on the next patient.

In poorer countries with enormous health worker shortages and lack of health systems infrastructure, AI can be a gamechanger in expanding access to quality care. I believe this partnership with OpenAI, governments, innovators, and health workers in sub-Saharan Africa is a step towards the type of AI we need more of: systems that help people all over the world to solve generational challenges that they simply didn’t know how to address before. I invite others working on AI to think about how we can put these massively powerful tools to the best use.

This announcement is a great example of why I remain optimistic about the improvements we can make. I’m looking forward to seeing health workers using some of these AI solutions in action when I visit Africa, and I plan to continue focusing on ways AI technology can help billions of people in low- and middle-income countries meet their most important needs.

What do humans and cows have in common? Among other things, we’re both victims of tiny insects.

For cows, the latest culprit is the New World screwworm. Despite the name, the screwworm is actually a type of fly that likes to lay its eggs on animals like cows, which creates an often-fatal wound on the animal’s hide. Screwworms once killed up to one million cattle a year here in the United States, and sixty years after we eliminated them in our country, they’re back.

For humans, one of our greatest nemesis is the mosquito. There are plenty of reasons to hate mosquitoes, but malaria is easily at the top of the list. The disease kills more than 600,000 people every year, most of them children, and it’s transmitted when a mosquito infected with a parasite called Plasmodium bites you.

Protecting people (or cattle) from an insect poses an interesting challenge. How do you stop something so small from hurting anyone? There are lots of different ways to approach the problem.

One approach is to keep insects out of the places where people are. There are already lots of tools that do this with mosquitoes, with more in the pipeline. The most widely used is the bed net, a gauzy sheet of fabric treated with an insecticide that kills any mosquito that tries to reach the person sleeping under it.

Bed nets are magical. In some places where malaria is endemic in Africa, they’ve reduced the number of children who die before the age of 5 by 20 percent. But there’s a problem: Mosquitoes can develop resistance to the insecticide used in bed nets, just like bacteria can evolve resistance to antibiotics.

Enter the dual active ingredient bed net. (You’ll often see them referred to as dual AI nets, even though they have nothing to do with artificial intelligence.) By treating bed nets with two different insecticides, scientists have been able to figure out how to negate a mosquito’s resistance and keep people safe. The catch is that dual AI nets are more expensive than regular bed nets, which is why the Global Fund and the Gates Foundation stepped in to make them affordable for the countries that needed them most. The results so far have exceeded my expectations. Dual AI nets now make up more than half of the bed nets used, just two years after they became available.

Bed nets have another flaw: They only protect you while you’re under them, even though mosquitoes are also active in the hours before you go to sleep and after you wake up. A new tool called a spatial emanator aims to bridge that gap. It basically works like a plug-in air freshener—but instead of releasing a nice fragrance, it slowly releases an insecticide at a low-enough dose that doesn’t harm people but drives away any mosquito that might enter your home.

When spatial emanators received the green light for use a year ago, they became the first new malaria-prevention tool the WHO has recommended in over a decade. I’m super excited about their ability to protect people from mosquitoes for more hours of the day.

Another approach to stopping insects is to target them at the population level. That’s how the world stopped screwworm the first time. In 1954, scientists figured out a way to use radiation to make the males sterile. They released the neutered insects into the target area, and since they couldn’t reproduce, the population died off. This approach worked sixty years ago, and it still works today (and scientists are working on even more effective methods).

What if we could use a similar approach to stop mosquitoes? Last year, I wrote about an incredible project in Tanzania called Transmission Zero. The idea behind it is simple: a mosquito that can’t give you malaria.

Tanzanian scientists have found a way to make Anopheles gambiae mosquitoes—the species responsible for most of the malaria in Africa—produce two types of molecules, naturally found in frogs and bees, that block the parasite from developing inside the insect. The mosquitoes would continue flying around, doing their mosquito business, but they wouldn’t be able to make anyone sick with malaria. Each time they mated with another mosquito, they would pass on the gene that protected them from the parasite. (I just published a new profile of Dr. Lina Finda from the Ifakara Health Institute in Tanzania, who is helping lead this work.)

These malaria-free mosquitoes could potentially help save tens of thousands of lives every year. And Tanzania isn’t the only country on the cutting edge of advancing this work. The Ugandan Virus Research Institute and the University of Sciences, Techniques and Technologies of Bamako in Mali are also doing pioneering work to move the field forward. Scientists are learning more every day about the role mosquitoes play in ecosystems, and research is now underway on two other species beyond Anopheles gambiae.

Dual AI bed nets, spatial emanators, and malaria-free mosquitoes are just the latest breakthroughs to come out of the robust malaria innovation pipeline. Treatments continue to get better, and vaccines are already proving to save lives, with even more effective next-gen vaccines to come. A lot of interesting work is underway with endectocides, a type of drug that could potentially make your blood toxic to mosquitoes. There’s even a fascinating trial that looks at whether targeting mosquito larvae in rice paddies could make a difference. The goal of this trial is to stop malaria, but early results from Nigeria and Rwanda indicate that larval control could boost rice yields as much as 50 percent, which would be incredible for farmers.

Unfortunately, while the R&D progress we’re making is remarkable, the same can’t be said for the fight against malaria overall. Donor governments are cutting health aid—including money for the Global Fund, which has saved more than 70 million lives to date by helping deliver lifesaving tools like bed nets. Last year, our partners across Africa pulled off a miracle to minimize the impact of the cuts. With support from our foundation, they found creative ways to distribute supplies that were already in warehouses across the continent.

This year, the picture looks different. While some funding has since been restored, cuts from multiple donor governments mean it's not yet enough to guarantee bed nets and other tools reach every family who needs them. Our foundation is doing everything we can to help close that gap. I continue to advocate for increased funding, because it is ridiculous to put the health of the world’s children at risk when we know how to save them.

I believe we can end malaria forever. We have some of the tools we need already, and I think we’ll have the rest soon. We can defeat mosquitoes, just like we stopped screwworm more than half a century ago and just like we’ll stop it again. The question is whether the world will choose to make it happen.

The choice is obvious to me. We have an opportunity to ensure that no child dies from malaria ever again. Let’s take it.

Dr. Lina Finda’s work sounds simple. “My job is to listen,” she says. But the reality is much more complicated. On a typical day, she has to walk into a village in southern Tanzania or a meeting hall in Uganda and gauge reactions to the idea of ending malaria by an unusual method: releasing more mosquitoes.

It’s not as crazy as it seems.

That’s because the mosquitoes she’s talking about in this case carry a gene that blocks the malaria parasite from developing, so the mosquito can’t get you sick even if you get bitten. (I just wrote about the project researching these malaria-free mosquitoes, Transmission Zero, along with the other tools that are helping us fight this disease.) Release enough of them into the wild and, in theory, the trait spreads on its own until the local mosquitoes can no longer transmit the disease.

The science is advancing, and it’s exciting. But none of these malaria-free mosquitoes have been released in Africa yet. Whether that ever happens is a decision that will be made by African governments and the people who live where these mosquitoes would circulate. Finda co-founded the African Conversations Initiative to make sure those people have a say. Her team is now working in eight countries: Tanzania, Kenya, Uganda, Rwanda, Zambia, Ghana, Nigeria, and Senegal.

The question that started it

Finda first learned about the potential of malaria-free mosquitoes in 2017, at the beginning of her PhD in public health.

“My thought was, oh my God, we might eliminate this disease in my lifetime,” she says.

All the scientists in the room with Finda were equally impressed and excited. But she knew this kind of idea would never leave a lab if there wasn’t community trust and buy-in.

So she asked herself a question: “How might other people react to this?” She dedicated the rest of her career to understanding the answer.

Listening and learning

Her first attempts to explain malaria-free mosquitoes went poorly. The process that creates malaria-free mosquitoes is hard to describe, and Finda assumed that a farmer with no formal schooling would never get there. So she gave up on finding the right words and told the truth instead: She didn’t know how to talk about it. “I was honest with the community members and saying, I really don’t know what to call this or how to talk about it.”

The response surprised her.

One of those community members was Aloyce Kimario, a farmer who also teaches at a primary school outside Ifakara. He had never heard of malaria-free mosquitoes before Finda came to see him. He had, however, spent his whole life rearing animals.

The pigs he keeps are a local breed, hardy against the diseases that circulate around Ifakara. But they’re small. When he wants animals big enough to sell well, he crosses them with a heavier breed and hopes the piglets come out with the best traits of both sides. There’s a Swahili phrase for this, kubadilisha mbegu, which translates to “changing the seed.”

So, Finda started asking farmers to describe their ideal animal. One told her he wanted a pig that was 90 percent of the heavy breed and 10 percent of the local one.

“So what this technology does,” she told him, “is it makes sure that you get exactly what you want.”

Aloyce can now explain the science behind malaria-free mosquitoes, and the case for them, without any help from Finda, in terms other farmers immediately understand.

What she wishes scientists understood

Finda admits to underestimating what local farmers would be able to grasp, and she says she sees the science community making the same mistake. Worse, she says, “they assume that when someone opposes something it is because they don’t know it, and if they could know it, then they would definitely accept it.”

“From my years of listening to everyone, I have learned that these groups are quite knowledgeable,” she says. They may not use the scientific terminology, “but they understand it in their context.”

Finda’s team has now sat down with national malaria programs, regulators, scientists, civil society organizations, faith leaders, and youth groups from more than 25 African countries. Each group worries about something the others don’t, and all of the worries are valid.

“You don’t ever hear someone say, I want to develop a solution for this disease. Let me go talk to a priest,” Finda says.

But that’s exactly what Finda did. One of the leaders she convened was the presiding bishop of the Moravian Revival Church in Tanzania, who had learned about genetically modified organisms while studying theology in the UK but had never encountered the idea applied to mosquitoes. He prayed about it and came out in favor. According to Finda, many Muslim leaders she connected with reached a similar conclusion. They just had to be asked.

Making sense of the numbers

Still, Finda has encountered substantial opposition and even anger.

When she presented the latest national malaria mortality figures to a group of community leaders in Nigeria, they took the statistics as an accusation and nearly threw her out. “You are saying that many people have died of malaria in Nigeria. Show us where they are buried,” they demanded. “Why aren’t our hospitals flooded with malaria patients?”

Finda learned a lesson from this that I’ve had to learn and relearn myself: It’s not the scale of lives lost or saved that captures people’s attention. It’s the individual stories.

“The mothers want to talk about the children they lost,” Finda says. “Those numbers do not mean anything at all.”

So now, when she meets with people, she starts by asking about their own experiences. Aloyce, the teacher-farmer, told her he gets malaria roughly twice a year. So do his children, with some episodes landing them in the hospital. The bishop told her his firstborn child died of it.

Finda herself got malaria around the age of six. Her mother was traveling, so it fell to Finda to administer chloroquine, the recommended treatment at the time, to herself and her toddler brother twice a day for seven days, while both of them were vomiting. She shares this experience, too.

The preparation is worth it

Finda thinks we are still at least a decade away from any government decisions to release malaria-free mosquitoes. In the meantime, African-led research will continue to advance scientific understanding that can inform these decisions and those required to strengthen regulatory systems to govern them. Everything she does is working up to that moment, and aimed at making it as anticlimactic as possible.

“When it is released in the newspapers or the radio or TV,” she says, “that should not be the first time that people hear about this technology.”

For many people, because of Finda’s work, it won’t be.

A genetic cheat code

Moving ahead responsibly

 

I spend a lot of time thinking and worrying about malaria. After all, it’s one of the big focuses of my work at the Gates Foundation. But for most Americans, the disease is a distant concern—something that happens “there,” not here.

That’s true today. It wasn’t always.

It was especially rampant in the South, from the Carolinas and the Mississippi Delta down to Florida and all along the Gulf Coast.

Every summer, people braced for the start of “fever season.” In her Little House on the Prairie books, Laura Ingalls Wilder wrote about what she called “fever ‘n’ ague.” A laundry list of presidents—including George Washington, Andrew Jackson, Abraham Lincoln, and Ulysses S. Grant—battled the disease.

During the Civil War, Confederate General Robert E. Lee was even counting on malaria to weaken Union troops, confident that “the climate in June will force the enemy to retire.” (It ended up crippling his own army more.)

Without modern medicine, or any understanding of how the disease spread, people reached for whatever remedies they could find: drinking vinegar and whiskey, rubbing onions on their skin, and boiling bitter herbs into tea. Powdered quinine, a substance derived from cinchona bark, actually worked—but it was expensive and hard to obtain, so few people had access to it.

For most people, the fevers kept returning year 
after year and summer after summer.

The first breakthrough came at the turn of the 20th century. Scientists finally proved that malaria was transmitted by mosquitoes—not, as had been previously thought, by contaminated water or poor air quality. (Malaria means “bad air” in medieval Italian.) It was a crucial discovery. Finally, people knew what to target. Across the South, some communities began draining swamps to try to control their mosquito populations. But most of these efforts were basic and improvised. What was needed was the kind of massive, coordinated, well-funded approach that only the federal government could mount. Enter one of the most ambitious and impactful infrastructure projects in American history: the Tennessee Valley Authority.

Enter one of the most ambitious and impactful infrastructure projects in American history


the Tennessee Valley Authority.

The TVA wasn’t created to fight malaria. Launched in 1933 as part of the New Deal, its mission was mainly economic: to bring electricity and jobs to the rural South, where some of the country’s poorest people lived, during the Great Depression. But the region also had some of the nation’s highest malaria rates, with 30 percent of its population infected. TVA leaders quickly realized their work wouldn’t succeed unless public health improved too.

So they incorporated malaria prevention into their projects. As engineers built dams and power plants across the region, they also drained thousands of acres of swamps, reshaped rivers, regraded land, and upgraded housing—which all helped to destroy mosquito breeding grounds. At the same time, public health campaigns educated people on installing window screens and eliminating standing water around their homes after storms. Then came World War II.

Then Came


world war II

As military bases popped up across the South, malaria became a growing threat to soldiers and defense industry workers. So the U.S. responded by launching a new program in 1942: the Office of Malaria Control in War Areas, headquartered in Atlanta. It was the federal government’s first centralized program created explicitly to fight malaria—and it laid the groundwork for what would become the Centers for Disease Control and Prevention, or CDC, which officially took over the malaria effort in 1947.

The goal of the campaign, which began with wartime control before transitioning to peacetime eradication, was simple but ambitious: Stop mosquitoes from spreading malaria, and stop people from carrying it.

ON THE MOSQUITO FRONT

The campaign launched the largest insecticide operation in U.S. history and paired it with an aggressive effort to destroy mosquito breeding grounds. Teams of sprayers went door-to-door with tanks of DDT strapped to their backs, covering millions of homes in what was essentially a chemical shield against mosquitoes. In some areas, airplanes dusted entire counties with insecticide. Meanwhile, construction crews drained ditches by hand or with bulldozers. In Florida, they used dynamite to blast open drainage paths from mosquito-infested marshland.

ON THE HUMAN SIDE

Quinine and later chloroquine—its synthetic successor—were distributed widely, especially in rural areas with high infection rates. These drugs cleared the parasite from the bloodstream, which meant that even if someone was bitten by a mosquito, they wouldn’t pass the disease on. Mobile teams traveled from town to town, testing and treating entire communities. In the Mississippi Delta, they even set up roadside treatment stations where people could stop for a dose on the way to work or school.

Public health messaging played a huge role, too. One memorable cartoon featured a mosquito named Bloodthirsty Ann—yes, short for Anopheles—that taught troops how to reduce their risk of contracting malaria. Its creator was a young army captain named Theodor Geisel, who eventually became better known as Dr. Seuss.

Perhaps the most impressive part of the program was its scale and speed. In just a few years, tens of thousands of public health workers across fifteen states were hired and trained. Doctors, nurses, scientists, teachers, technicians, and trusted community figures knocked on doors, gathered data, treated patients, and made sure no outbreak went unchecked. In 1951, America declared victory over malaria.

In 1951


AMERICA DECLARED VICTORY OVER MALARIA

I think about this history a lot when I’m visiting Sub-Saharan Africa, where the parasite still kills 600,000 people a year. Because in many ways, the strategy hasn’t changed: Stop transmission, clear infections, and build public health systems that prevent malaria from roaring back.

Malarious area of the United States 

But the U.S. had some key advantages that made elimination much easier. Compared to the species responsible for most malaria today, our mosquitoes weren’t as efficient at transmitting the parasite. Our climate also limited transmission to the summer months; in tropical regions, people get infected year-round. And by the 1940s, our country had relatively strong infrastructure, even in rural areas, that many malaria-endemic countries today still lack.

ON THE TREATMENT SIDE

So the challenge today is much bigger. Fortunately, today’s malaria-fighting toolbox is much bigger—and better—too.

Instead of blanket spraying DDT, which has since been banned, modern prevention relies on safer insecticide-treated bed nets and indoor spraying techniques that use smaller doses of more targeted chemicals. Sugar baits, which lure mosquitoes to ingest a lethal dose of insecticide, are already helping reduce their numbers. And gene drive technology could soon block the parasite inside the mosquito itself—so even if someone gets bitten, they won’t get infected.

Chloroquine has been replaced by artemisinin-based combination therapies, or ACTs, which are more effective and less prone to resistance. New drugs like tafenoquine are helping eliminate recurring strains. Seasonal chemoprevention protects children during peak transmission months. And the first malaria vaccine has been approved, with more on the way.

Malaria elimination is never easy. But unlike a century ago, it’s no longer a mystery. The world knows how to stop this disease. We’ve done it before. And with the right investments and innovations, we can do it again—this time, for everyone.

I’ve been working in global health for two and a half decades now, and the transformation in how we fight HIV/AIDS is one of the most remarkable achievements I’ve witnessed. (It’s second only to how vaccines have saved millions of children's lives.)  

At the dawn of the AIDS epidemic, an HIV diagnosis was often a death sentence. But in the years since, so much has changed. Today, not only do we have anti-retroviral medications that allow people with HIV to live full, healthy lives with undetectable viral loads—meaning they can’t transmit the virus to others. We also have powerful preventative medications known as PrEP, or pre-exposure prophylaxis, that can reduce a person’s risk of contracting the virus by up to 99 percent when taken as prescribed. It’s an incredible feat of science: a pill that virtually prevents HIV contraction.

In theory, if we could get these tools to everyone who needs them and make sure they’re used correctly, we could stop HIV in its tracks. Because when people with the virus receive proper treatment, they can’t transmit it to others. And when people at risk take PrEP, they can’t contract it. In practice, however, getting these tools to people—and making sure they’re used correctly—is the hard part. Especially for PrEP.  

That’s because current preventatives require people to take medication every single day. Miss a dose, and protection drops. It’s like trying to remember to lock your front door 365 times a year—if you mess up once, you’re vulnerable. For many people, the barriers stack up quickly. Some have to walk hours to reach a clinic. Others struggle to store medication safely or discreetly at home. And many face judgment and stigma for taking PrEP, especially young women in conservative communities. The very act of protecting yourself can lead to being shamed or ostracized. 

That’s why I’m so excited about a new wave of innovations in HIV prevention. Scientists are in the process of developing several longer-lasting PrEP breakthroughs, each with distinct advantages that could help more people protect themselves on their own terms. 

Lenacapavir, which requires only two doses per year through injection, could open HIV prevention up to people who can’t make frequent clinic visits. Cabotegravir, another injectable option that works for two months at a time, offers a more flexible dosing schedule than daily PrEP pills, too. Meanwhile, a monthly oral medication called MK-8572, still in the trial stage, could provide an alternative for people who prefer pills to injections. The Gates Foundation is even exploring ways to maintain a person’s protection for six months or longer. And researchers are working on promising PrEP options that include contraception, which would be particularly valuable for women who need both types of protection. 

To understand how these options work in real life, and not just in labs, our foundation has supported implementation studies in South Africa, Malawi, and elsewhere. Unlike traditional clinical trials that test safety and efficacy in highly controlled settings, these studies examine how medications fit into people’s lives and work in everyday circumstances—looking at ease of use, cultural acceptance, and other practical challenges. This real-world understanding is crucial for successful adoption.  

Some people ask me if these new preventative tools mean the Gates Foundation has given up on finding an HIV vaccine. Not at all. In fact, these advances push us to aim even higher in our research for a vaccine that could prevent HIV for a lifetime—and not just a few months at a time. Our goal is to create multiple layers of protection, much like modern cars have seatbelts, airbags, and even collision-warning sensors. Different tools work better for different people in different ways, and we need every tool we can get. 

But even the most brilliant innovations make no difference unless they reach the people who need them most. This is where partnerships become crucial. Through grants to research institutions around the world, the foundation is working to lower manufacturing costs for HIV drugs so they’re accessible to everyone, everywhere. Then there are organizations like the Global Fund and PEPFAR, which have been instrumental in turning scientific advances into real-world impact.  

The Global Fund—which needs to raise significant new resources next year to continue its work—currently helps more than 24 million people access HIV prevention and treatment. And PEPFAR has saved 25 million lives since its inception in 2003—a powerful example of how American leadership can build tremendous goodwill while transforming the world. Motivated by the belief that no person should die of HIV/AIDS when lifesaving medications are available, President George W. Bush created PEPFAR with strong bipartisan backing and it continues to serve as a lifeline to millions of people.  

We're at a pivotal moment in this fight. Twenty years ago, many believed it would be impossible to deliver HIV treatment at scale in Africa’s poorest regions. Since then, we’ve made fantastic progress. Science has shown us promising paths forward—for better prevention options, easier treatment regimens, and, maybe one day, an effective vaccine. Our task now? Ensuring the life-saving innovations we already have reach the people whose lives they can save. 

Quarraisha and Salim Abdool Karim are two of the most respected HIV/AIDS researchers in the world. This year, the wife-and-husband team has also helped shape the world’s response to COVID-19. But it was a more humble setting that sparked their careers in epidemiology more than 30 years ago.

They had met in medical school in their native South Africa before moving to New York City for graduate school. In 1988, shortly after they were married, they took a trip to Mexico, where they met up in a tiny village in the Sierra Madre mountains with a friend, a physician who had written a seminal textbook on health care in remote rural settings.

Outside the village’s health clinic, they saw a man pedaling a bicycle that was mounted on a stand and connected to a power cable. It turned out that a local farmer also doubled as the village’s dentist—a pretty good one, apparently—and volunteers would pedal the bike to power his drill.

“We watched how this community took their destiny in their own hands,” says Salim, “and they had the most amazing dental care from this bicycle powering a drill. It imprinted on us how people can really change their own world.”

It was a powerful lesson about the need for scientists to understand and collaborate with the people they’re trying to help. The experience in that village would shape the rest of their careers, especially when they created a research center in South Africa designed to address two of the biggest problems in HIV/AIDS in Africa.

By the 1990s, the disease was devastating the Abdool Karims’ home country—and still is today. One out of every five people in the world with HIV lives in South Africa. The couple saw two issues that were rarely on the agenda of other HIV experts. One was that young women were bearing a disproportionate burden in the epidemic, and that there was no way to control the epidemic if their needs weren’t addressed. The other was that people living with HIV are at a high risk of contracting and dying from tuberculosis—a link that’s now known as HIV-TB coinfection. 

“These were very much our problems in Africa that few others were working on,” says Quarraisha, “and if we waited for solutions from elsewhere, it wasn’t going to come. We had to take the lead.”

In 2001, they brought together a group of researchers they felt could make a bigger impact on HIV and named the group CAPRISA (for the Center for the AIDS Program of Research in South Africa). Today CAPRISA runs three clinics where they provide antiretrovirals to people living with HIV and study new approaches to treating and preventing the disease. It is regarded as one of the world’s most influential AIDS research programs.

CAPRISA is probably best known for a landmark study published in 2010 proving for the first time that a microbicide—a gel that a woman could use before and after sex—can offer some protection from the virus. Scientists had been trying to make effective microbicides for nearly two decades, but the Abdool Karims’ formulation—one that used tenofovir, a drug normally given to people who already had HIV—was the first to offer any protection. Although the field has now moved on from microbicides and is focused on a more effective daily pill instead, the concept is still based on CAPRISA’s microbicide findings.

CAPRISA is as admired for the way it works as for its results. Inspired by the farmer-dentist they met in Mexico, Salim and Quarraisha make it a priority to empower the people they’re trying to help. They work closely with community leaders to make sure their research efforts are informed by realities on the ground and embraced by their neighbors. Here’s the story of one remarkable CAPRISA staff member, Gethwana Mahlase, and the way she represents the program in her community of Vulindlela.

Over the next few years, Quarraisha and Salim hope to build on their study of tenofovir as an HIV preventative. Right now, the best option is a pill you have to take every day, a regimen that can be hard to keep up. So CAPRISA is working on a form of the drug that could protect a woman for as long as a year at a time.

They’re also working on a fascinating approach called “broadly neutralizing antibodies,” which dates back several years. In 2012, they discovered that an HIV-positive woman in one of CAPRISA’s studies had a trait that was, as far as they knew, unique. The antibodies made by her immune system could attack not only the strain of HIV that she had, but also—this was the impressive part—80 percent of the other known strains of HIV from around the world. If they could isolate the cells that made these antibodies, reproduce them, and use them to create antibodies for other people, it would be a game changer.

After years of painstaking work with a number of partners, they were able to create the broadly neutralizing antibodies in a lab and test them in monkeys, with very positive results. Now the antibodies are being studied in humans for safety and, eventually, efficacy. If this approach works, you would need to get an injection just twice a year in order to get protection—a dosage that is far more practical than a daily pill. Success would also point the way toward the ultimate goal of an HIV vaccine.

Unfortunately, much of the Abdool Karims’ attention has been elsewhere this year. Drawing on their experiences from HIV and TB, they are helping guide the COVID-19 response in South Africa and around the world. It is a shame that they haven’t been able to focus on HIV/AIDS, but on the other hand, it is a reminder of how fighting old diseases like HIV helps the world prepare for new ones like COVID-19. Investing long-term in programs like CAPRISA—or work on polio or malaria—not only prevents deaths and disability from specific diseases, it also strengthens the overall field of global health. So when a pandemic comes along, we have a network of experts like Quarraisha and Salim ready to pitch in.

What strikes me about this couple is how upbeat they are, even in the face of devastating diseases like the coronavirus and HIV. Their motto at CAPRISA is, “Each day that you come to work, you should be looking for how today is going to be better than yesterday.” That is a lesson we can all take to heart.

Last year, at an event in New York, I learned about an impressive woman whose story I want to share with you. Her name is Cacilda Fumo, she lives in Mozambique, and every year she helps save hundreds of lives—by reminding them they are not alone.

Mozambique has one of the highest HIV infection rates in the world. More than 1.6 million people—10 percent of the adult population—are living with HIV.

Cacilda was diagnosed with HIV in 2002. “When I first learned about it, I thought I would die,” she recalls. “I used to wake up early morning and check if I am alive or not.”

But then she started meeting other people living with HIV, and as their numbers grew so did her strength and her belief she would live. Cacilda was one of the first in Maputo to be open about her status. She started wearing a t-shirt emblazoned with a logo that reads: “HIV POSITIVE.”

At times, people rejected her because of her status. Many more in her community, however, admired her for her courage, helping her create an even larger circle of friends and supporters. They met every week, praying together, cooking together, and sharing their stories. Eventually, the group had about one hundred people, many of them receiving life-saving anti-retroviral treatment. Cacilda emerged as their leader.

About the same time, Mozambique’s Ministry of Health was struggling to improve the delivery of anti-retroviral treatment. While the program was successful in putting thousands of patients on treatment for the first time, medical staff were overburdened with caseloads. People on HIV treatment often walked miles to reach their clinic and waited in long lines to get care. Every year, about 30 percent of HIV patients dropped off their life-saving treatment.

Working with Doctors Without Borders, the government of Mozambique decided to try a new approach to simplify care to help keep more people on treatment. They started organizing small peer support groups for people on HIV treatment. The idea was simple. Make treatment easier by putting more control into the hands of the patients. A representative from each patient group could pick up all the drugs for the group each month, saving the rest of the group the hassle of going to the clinic. Members of the groups, known as Community antiretroviral therapy (ART) Groups or CAGs, would also support one another to ensure they were all staying on their treatment.

When the program reached Maputo, Cacilda was ready to join. She helped organize dozens of support groups from her network. Then she went one step further. She kept track of the groups, checking whether members were attending their meetings and taking their treatment. If someone fell off treatment, she took upon herself to locate them and find out what was wrong.

“We help people feel strong knowing they are not alone,” she says.

Some patients who stop treatment are addicted to alcohol and forget to take their treatment, she says. Some don’t understand how the treatment works and the stop taking their medication as soon as they feel better. Others get busy with their jobs and drift away.

Whatever the reason, Cacilda warns them of the dangers of stopping treatment and encourages them to restart. Her efforts to bring back residents of Maputo to treatment has become nearly full-time work. Most days residents of Maputo see Cacilda traveling on foot—which is remarkable because due to a childhood injury she uses crutches—through the dirty alleyways and crowded markets in search of people who have stopped treatment. She doesn’t give up until she finds them.

Cacilda’s persistence pays off—in lives saved. Cacilda estimates that she tracks down about 500 people every year and encourages them to resume their treatment.

That’s a remarkable achievement—one that proves how much difference one life can make in the world. 

If you’re anything like me, you have a favorite chart. Mine has been the same for years. It plots under-five mortality year over year—a figure that has dropped by half since the turn of the century, from over 10 million deaths in 2000 to fewer than 5 million in 2023.

In my view, this data is the strongest evidence we have that progress is possible, even in tough times, and that the investments the world has made in vaccines, oral rehydration, bed nets, and better nutrition are working.

But there's a rule in global health statistics that complicates the story: To count as a death, someone must have first been born alive. It sounds simple and obvious. But in practice, it isn't. That's because every year, about 2 million pregnancies end in stillbirth, which is when a baby is lost at 28 weeks or later. That's late enough that the mother has been feeling the fetus move for months. Many parents have already picked out a name. Often, the loss occurs in the final stretch of a pregnancy, or during labor itself, when everyone was expecting a healthy birth.

These tragedies should be central to how we measure child survival. Instead, they've fallen through the cracks—not quite a maternal health issue, not quite a child mortality issue. The UN didn't publish its first full global estimate of stillbirths until 2020, and stillbirth research is still badly underfunded in both rich and poor countries.

What gets measured gets managed, as the saying goes—and what doesn't, well, doesn't.

The data reflects this disparity. Stillbirths have fallen just 34 percent since 2000, compared to 50 percent for under-five mortality over the same period. In 81 countries—mostly low- and middle-income—the stillbirth rate hasn't meaningfully improved at all in 25 years. For every one stillbirth in Europe, there are roughly 40 in sub-Saharan Africa.

What's frustrating is that we know what causes, and therefore how to prevent, most stillbirths. One of the biggest drivers is pre-eclampsia—a dangerous spike in blood pressure during pregnancy—which is responsible for half a million fetal deaths every year, along with 70,000 maternal deaths. Beyond that, the bulk of stillbirths stem from a cluster of conditions we understand well: maternal infections, obstetric complications during labor, and chronic conditions like untreated diabetes.

If we could catch these problems earlier, we'd have a much better chance of intervening before it's too late. But that's hard to do in the rural clinics where most pregnant women receive care, which often have unreliable electricity, no specialists, and little in the way of lab equipment. By the time pre-eclampsia is obvious, or gestational diabetes has gone unmanaged through the third trimester, the harm is often irreversible. Even emergency intervention may not help.

But a few months ago, I got to hold a device that has the potential to make a huge impact: the Remidio fundus camera. You hold it up to a patient's eye to get a high-resolution image of their retina in seconds, no dilation required. A community health worker with a few hours of training can use it. The device itself is about the size of a handheld video camera, battery-powered, and portable enough to carry from village to village.

Why the retina? It's the only place in the body where you can see blood vessels from the outside.

Remidio is a medtech startup out of India, and its camera was originally built to screen for diabetic eye disease. With an AI system running on a phone the camera plugs into, it can pick up early signs of the disease that would otherwise require blood draws and specialist follow-up to catch. It's already been used that way for more than 15 million patients in 40 countries.

But that same hardware, with different software, can also flag the conditions that drive so many dangerous pregnancies. Gestational diabetes sharply increases the risk of pre-eclampsia, preterm birth, and fetal death, and in most of rural sub-Saharan Africa or South Asia, it usually isn't screened for at all, because the standard test requires a lab. A retinal scan offers a different way in. Remidio’s device is currently being used in India to screen pregnant women for conditions that drive stillbirth. And researchers are now adapting the same hardware to screen for anemia and hypertension, too.

A tool like Remidio’s won’t solve the problem of stillbirths alone. We also need more skilled birth attendants, better emergency obstetric care, and stronger health systems. But small, portable, affordable diagnostics in the hands of community health workers are exactly the kind of lever that can start to move a number that hasn't moved in a long time. That's a big part of why the foundation committed $2.5 billion to women's health research and development last year, our largest investment in this area ever.

In 25 years, I hope my favorite chart in the world will have two lines on it: one tracking under-five mortality, and one tracking stillbirths. With the right commitment, I believe both will have fallen dramatically, and both could be approaching zero.

In the United States, when someone has a medical emergency, we take for granted that an ambulance will arrive. It will get to some places faster than others—a disparity driven by wealth and other factors. Still, by calling 911, we’re immediately connected to a vast fleet of emergency vehicles plugged into a system that’s designed to get people to hospitals in times of crisis.

But what about countries where ambulances aren’t readily accessible? What about places where even cars are scarce, where the nearest hospital with surgical capacity might be 100 miles away down an unpaved road, and where a family facing a medical crisis has no reliable way to get there or pay for the journey?

This is the reality for millions of pregnant women across sub-Saharan Africa.

Thanks to modern medicine, we now know how to prevent most maternal and newborn deaths. And maternal mortality has declined by 40 percent over the last two decades as a result. But hundreds of thousands of women and babies still die every year from complications during pregnancy and childbirth, because they can’t get to a place where someone can treat them in time.

In maternal health, this problem is called the “second delay.” It’s a terrible tragedy, one that the Gates Foundation has been trying to address for years.

Back in 2013, partners including Vodafone Foundation and local health organizations started tackling this problem by asking a simple question in rural Tanzania: What if you could create something like a 911 system that worked with whatever transportation was available in a community? They tested the idea in a few districts, and it worked well enough that they decided to scale it up. They called it m-mama.

m-mama works like this: When a community healthcare worker identifies an emergency—maybe it’s severe bleeding after delivery, or a premature baby who can’t breathe—they call a free hotline. A trained nurse dispatcher uses an app to figure out what kind of care is needed and where it’s available, then coordinates whatever transportation makes sense for that location (a community driver with a car where there are good roads, a motorcycle where there aren’t, a boat for island communities, even a horse for mountainous terrain.) The dispatcher stays on top of everything, tracking the journey, alerting the receiving facility, and handling payment at the end.

The numbers speak for themselves. Since 2013, m-mama has responded to more than 125,000 emergencies and saved an estimated 5,266 lives. And in regions where m-mama launched, maternal emergency transports more than doubled. That means there was a massive need that was going unmet for far too long. About 58% of the deliveries transported by m-mama end up requiring a C-section, compared to the 10-15% you would expect in the general population. These are genuinely high-risk cases that would have likely ended in tragedy without emergency transport.

What’s especially impressive about m-mama’s impact is that it hasn’t required building new hospitals or buying any expensive equipment. Instead, it makes existing health systems work better by coordinating resources that are already there—ambulances, facilities, healthcare workers—and filling gaps with options that cost a fraction of what traditional ambulances do.

And it is scaling. m-mama started as a pilot serving 750,000 people and now reaches 62 million in Tanzania. It’s gone nationwide in Lesotho. It just launched in Malawi and is scaling up in Kenya. There are plans for more countries across sub-Saharan Africa, supported in part by the Beginnings Fund—a partnership that includes our foundation, the Mohamed bin Zayed Foundation for Humanity, and other organizations working to improve maternal and newborn health across Africa.

The program is financially sustainable too. Once the program is up and running, the governments cover operating costs. m-mama has proven it can be owned and run locally, which is the only way something like this works long-term.

m-mama is a reminder that not all breakthroughs in global health are new drugs or sophisticated technology. Sometimes they’re just smart ways of getting the right care to the right person at the right time. When a mother or baby is in crisis, minutes can make the difference between life and death.

m-mama is making sure those minutes count. 

I have always been an optimist. When I founded Microsoft, I believed a digital revolution powered by great software would make the world a better place. When I started the Gates Foundation, I saw an opportunity to save and improve millions of lives because critical areas like children’s health were getting so little money.

In both cases, the results exceeded my expectations. We are far better off than when I was born 70 years ago. I believe the world will keep improving—but it is harder to see that today than it has been in a long time.

Friends and colleagues often ask me how I stay optimistic in an era with so many challenges and so much polarization. My answer is this: I am still an optimist because I see what innovation accelerated by artificial intelligence will bring. But these days, my optimism comes with footnotes.

The thing I am most upset about is the fact that the world went backwards last year on a key metric of progress: the number of deaths of children under 5 years old. Over the last 25 years, those deaths went down faster than at any other point in history. But in 2025, they went up for the first time this century, from 4.6 million in 2024 to 4.8 million in 2025—an increase driven by less support from rich countries to poor countries. This trend will continue unless we make progress in restoring aid budgets.

The next five years will be difficult as we try to get back on track and work to scale up new lifesaving tools. Yet I remain optimistic about the long-term future. As hard as last year was, I don’t believe we will slide back into the Dark Ages. I believe that, within the next decade, we will not only get the world back on track but enter a new era of unprecedented progress.

The key will be, as always, innovation. Consider this: An HIV diagnosis used to be a death sentence. Today, thanks to revolutionary treatments, a person with HIV can expect to live almost as long as someone without the virus. By the 2040s, new innovations could virtually eliminate deaths from HIV/AIDS.

Budget cuts limit how many people benefit from lifesaving tools, as we saw to devastating effect last year. But nothing can erase the fact that for decades we didn’t know how to save people from HIV, and now we do. Breakthroughs are a bell that cannot be unrung. They ensure that we will never go back to the world in 2000 where over 10 million children died from preventable causes every year—and they form the core of my optimism about where the world is headed.

But as I mentioned, there are footnotes to my optimism. Although the innovation pipeline sets us up for long-term success, the trajectory of progress hinges on how the world addresses three key questions.

1.

Will a world that is getting richer increase its generosity toward those in need?

The “golden rule” precept is more important now than ever with the record disparities in wealth. This idea of treating others as you wish to be treated does not just apply to rich countries giving aid. It must also include philanthropy from the wealthy to help those in need—both domestically and globally—which should grow rapidly in a world with a record number of billionaires and even centibillionaires.

Through the Giving Pledge, I get to work with a number of incredible philanthropists who set a great example by giving away substantial portions of their wealth in smart ways. However, more needs to be done to encourage higher levels of generosity from the rich and to show how fulfilling and impactful it can be.

Turning to aid budgets for poor countries, I am worried about one number: If funding for health decreases by 20 percent, 12 million more children could die by 2045. I know cuts won’t be reversed overnight, even though aid represented less than 1 percent of GDP even in the most generous countries. But it is critical that we restore some of the funding. The foundation’s Goalkeepers report lays out what is at risk and how the world can best spend the aid it gives.

I will spend much of my year working with partners to advocate for increased funding for the health of the world’s children. I plan to engage with a number of communities, including health care workers, religious groups, and members of diaspora communities to help make this case.

2.

Will the world prioritize scaling innovations that improve equality?

Some problems require doing far more than just letting market incentives take their course.

The first critical area is climate change. Without a large global carbon tax (which is, unfortunately, politically unachievable), market forces do not properly incentivize the creation of technologies to reduce climate-related emissions.

Yet only by replacing all emitting activities with cheaper alternatives will we stop the temperature increase. This is why I started Breakthrough Energy 10 years ago and why I will continue to put billions into innovation.

The world has made meaningful progress in the last decade, cutting projected emissions by more than 40 percent. But we still have a lot of innovation and scaling up to do in tough areas like industrial emissions and aviation. Government policies in rich countries are still critical because unless innovations reach scale, the costs won’t come down and we won’t achieve the impact we need.

If we don’t limit climate change, it will join poverty and infectious disease in causing enormous suffering, especially for the world’s poorest people. Since even in the best case the temperature will continue to go up, we also need to innovate to minimize the negative impacts.

This is called climate adaptation, and a critical example is helping farmers in poor countries with better seeds and better advice so they can grow more even in the face of climate change. Using AI, we will soon be able to provide poor farmers with better advice about weather, prices, crop diseases, and soil than even the richest farmers get today. The foundation has committed $1.4 billion to supporting farmers on the frontlines of extreme weather.

I will be investing and giving more than ever to climate work in the years ahead while also continuing to give more to children’s health, the foundation’s top priority. The need to ensure money is spent on the most important priorities was the topic of a memo I wrote in the fall.

A second critical area where the world must focus on innovation-driven equality is health care. Concerns about healthcare costs and quality are higher than ever in all countries.

In theory, people should feel optimistic about the state of health care with the incredible pipeline of innovations. For example, a recent breakthrough in diagnosing Alzheimer’s will revolutionize how we test for—and ultimately prevent—this disease, saving billions of dollars in costs. (Funding Alzheimer’s research is a particular focus for me.) There’s similar progress on obesity and cancer, as well as on problems in developing countries like malaria, TB, and malnutrition.

Despite so much progress, however, the cost and complexity of the system means very few people are satisfied with their care. I believe we can improve health care dramatically in all countries by using AI not only to accelerate the development of innovations but directly in the delivery of health care.

Like many of you, I already use AI to better understand my own health. Just imagine what will be possible as it improves and becomes available for every patient and provider. Always-available, high-quality medical advice will improve medicine by every measure.

We aren’t quite there yet—developers still have work to do on reliability and how we connect the AI to doctors and nurses so they are empowered to check and override the system. But I’m optimistic we will soon begin to scale access globally. I am following this work so the Gates Foundation and partners can make sure this capability is available in the countries that need it most—where there aren’t enough medical personnel—at the same time it is available elsewhere. We are already working on pilots and making sure that even relatively uncommon African languages are fully supported.

Governments will have to play a central role in leading the implementation of AI into their health systems. This is another case where the market alone won’t and can’t provide the solution.

A third and final area I will mention briefly is education. AI gives us a chance for the kind of personalized learning to keep students motivated that we have dreamed of in the past. This is now a focus of the Gates Foundation’s spending on education, and I am hopeful it will be empowering to both teachers and students. I’ve seen this firsthand in New Jersey, and it will be game changing as we scale it for the world.

All three of these areas—climate, health, and education—can improve rapidly with the right government focus. This year I will spend a lot of time meeting with pioneers all over the world to see which countries are doing the best work so we can spread best practices.

3.

Will we minimize negative disruptions caused by AI as it accelerates?

Of all the things humans have ever created, AI will change society the most. It will help solve many of our current problems while also bringing new challenges very different from past innovations.

When people in the AI space predict that AGI or fully humanoid robots will come soon and then those deadlines are missed, it creates the impression that these things will never happen. However, there is no upper limit on how intelligent AIs will get or on how good robots will get, and I believe the advances will not plateau before exceeding human levels.

The two big challenges in the next decade are use of AI by bad actors and disruption to the job market. Both are real risks that we need to do a better job managing. We’ll need to be deliberate about how this technology is developed, governed, and deployed.

In 2015, I gave a TED talk warning that the world was not ready to handle a pandemic. If we had prepared properly for the Covid pandemic, the amount of human suffering would have been dramatically less. Today, an even greater risk than a naturally caused pandemic is that a non-government group will use open source AI tools to design a bioterrorism weapon.

The second challenge is job market disruption. AI capabilities will allow us to make far more goods and services with less labor. In a mathematical sense, we should be able to allocate these new capabilities in ways that benefit everyone. As AI delivers on its potential, we could reduce the work week or even decide there are some areas we don’t want to use AI in.

The effects of this disruption are hard to model. Sometimes, when a game-changing technology improves rapidly, it drives more demand at lower cost and, by making the world richer, increases demand in other areas. For example, AI makes software developers at least twice as efficient, which makes coding cheaper while also creating demand elasticity for code. (Computing is a good historical example where lower costs actually caused the overall market to grow.)

Even with this complexity, the rate of improvement is already starting to be enough to disrupt job demand in areas like software development. Other areas like warehouse work or phone support are not quite there yet, but once the AIs become more capable, the job disruption will be more immediate.

We’re already starting to see the impact of AI on the job market, and I think this impact will grow over the next five years. Even if the transition takes longer than I expect, we should use 2026 to prepare ourselves for these changes—including which policies will best help spread the wealth and deal with the important role jobs play in our society. Different political parties will likely suggest different approaches.

By including these footnotes, particularly the last one, some readers may find my continued optimism even more surprising. But as we start 2026, I remain optimistic about the days ahead because of two core human capabilities.

The first is our ability to anticipate problems and prepare for them, and therefore ensure that our new discoveries make all of us better off.  The second is our capacity to care about each other. Throughout history, you can always find stories of people tending not just to themselves or their clan or their country but to the greater good.

Those two qualities—foresight and care—are what give me hope as the year begins. As long as we keep exercising those abilities, I believe the years ahead can be ones of real progress.

I’ve been working in global health for 25 years—that’s as long as I was the CEO of Microsoft. At this point, I know as much about improving health in poor countries as I do about software. 

I’ve spent a quarter-century building teams of experts at the Gates Foundation and visiting low-income countries to see the work. I’ve funded studies about the effectiveness of health aid and pored over the results. I’ve met people who were on the brink of dying of AIDS until American-funded medicines brought them back. And I’ve met heroic health workers and government leaders who made the best possible use of this aid: They saved lives. 

The more I’ve learned, the more committed I’ve become. I believe so strongly in the value of global health that I’m dedicating the rest of my life to it, as well as most of the $200 billion the foundation will give away over the next 20 years.  

People in global health argue about a lot of things, but here’s one thing everyone agrees on: Health aid saves lives. It has helped cut the number of children who die each year by more than half since 2000. The number used to be more than 9 million a year; now it’s fewer than 5 million. That’s incontrovertible.  

So when the United States and other governments suddenly cut their aid budgets the way they've been doing, I know for a fact that more children will die. We’re already seeing the tragic impact of reductions in aid, and we know the number of deaths will continue to rise.

A study in the Lancet looked at the cumulative impact of reductions in American aid. It found that, by 2040, 8 million more children will die before their fifth birthday. To give some context for 8 million: That's how many children live in California, Texas, Florida, New York, Pennsylvania, and Ohio combined. 

I’ve submitted written testimony on this topic, which you can read below, for the Senate Appropriations Committee hearing occurring later today. In it, I discuss what’s already happened and what needs to happen next.

Testimony to the United States Senate Committee on Appropriations
June 25, 2025

Over the past 25 years—the same span of time I spent leading Microsoft—I have immersed myself in global health: building knowledge, deepening expertise, and working to save lives from deadly diseases and preventable causes. During that time, I have built teams of world-class scientists and public health experts at the Gates Foundation, studied health systems across continents, and worked in close partnership with national and local leaders to strengthen the delivery of lifesaving care. I have visited hundreds of clinics, listened to frontline health workers, and spoken with people who rely on these programs. Earlier this month, I traveled to Ethiopia and Nigeria, where I witnessed firsthand the impact that recent disruptions to U.S. global health funding are having on lives and communities.

Global health aid saves lives. And when that aid is withdrawn—abruptly and without a plan—lives are lost.

Yet, in recent months, some have questioned whether the foreign assistance pause has caused harm. Concerns about the human impact of these disruptions have been dismissed as overstated. Some people have even claimed that no one is dying as a result.

I wish that were true. But it is not.

It is important to note that while this hearing is about the Trump Administration’s $9 billion recission package, what is really at stake is tens of billions of dollars in critical aid and health research that has been frozen by DOGE with complete disregard for the Congress and its Constitutional power of the purse.

In the early weeks of implementing the foreign aid freeze, DOGE directives resulted in the dismissal of nearly all United States Agency for International Development (USAID) staff and many personnel at the Centers for Disease Control and Prevention (CDC). Some funding was later restored to allow for the continuation of what has been categorized as "lifesaving" programs. However, to date that designation has been applied narrowly and with limited transparency, in an inconsistent manner, often prioritizing emergency interventions when a patient is already in critical condition over essential preventative or supportive care.

For example, providing a child with a preventive antimalarial treatment, ensuring access to nutrition so that HIV/AIDS medications can be properly administered, testing pregnant women for HIV to see if they are eligible for treatment to prevent transmission to their children or identifying and treating tuberculosis cases early have not consistently qualified for exemption. As a result, many of the programs delivering these services have been suspended, delayed, or scaled back.

Recent reporting from the New York Times has shed light on the devastating human cost of the abrupt aid cuts. One especially tragic example is Peter Donde, a 10-year-old orphan in South Sudan, born with HIV, who died in February after losing his access to life-saving medication when USAID operations were suspended. His story is one of many.

During my recent visit to Nigeria, I met with leaders from local nonprofit organizations previously funded by the United States. One group shared the remarkable progress they had made in tuberculosis detection and treatment. In just a few years, case identification increased from 25 percent to 80 percent, a critical step toward breaking transmission and reducing the overall disease burden. That progress has now stalled. The grants that enabled this work were tied to USAID staff who have been dismissed, and with their departure, the funding ended, and the work stopped.

The broader effects of these sudden shifts are difficult to overstate. For example, funding for polio eradication has been preserved in the State Department budget but cut from the CDC—even though the two agencies collaborate closely on the program. This type of fragmented decision-making has left implementing organizations uncertain about staffing and operations. Many no longer feel confident that promised U.S. funds will materialize, even when awards have been announced. In some cases, staff continue to work without pay. Some organizations are approaching insolvency.

Meanwhile, in warehouses across the globe, food aid and medical supplies sourced from American producers are sitting idle—spoiling or approaching expiration—because the systems that once distributed them have been disrupted. Clinics are closing. Health workers are being laid off. HIV/AIDS patients are missing critical doses of medication. Malaria prevention campaigns, including bed net distributions and indoor spraying, have been delayed or canceled, leaving hundreds of millions of people unprotected at the peak of transmission season.

Efforts to track data that would illustrate the severity of this worsening crisis have also been severely compromised. Many of the people responsible for collecting and reporting health information—health workers, statisticians, and program managers—have been laid off or placed on leave. The systems that once monitored health outcomes are shutting down, and the offices where that data was once analyzed now sit empty. As a result, the true scope of the harm is becoming harder to measure, just as the need for information is most urgent.

The situation we face is not about political ideology, and it is not a debate over fiscal responsibility. U.S. government spending on global health accounts for just 0.2 percent of the federal budget. Shutting down USAID did nothing to reduce the deficit. In fact, the deficit has grown in the months since.

Furthermore, many of the allegations regarding waste, fraud, and abuse have proven to be unsubstantiated. For example, the widely circulated claim that USAID sent millions of dollars’ worth of condoms to the Gaza Strip is inaccurate. In fact, the Wall Street Journal reported that the program allocated approximately $27,000 for condoms as part of an HIV transmission prevention initiative—not in the Middle East, but in Gaza Province, Mozambique.

What we are witnessing because of the rapid dismantling of America’s global health infrastructure is a preventable, human-caused humanitarian crisis—one that is growing more severe by the day. DOGE made a deadly mistake by cutting health aid and laying off so many people. But it is not too late to undo some of the damage.

A Record of Progress—and What is at Risk

Since 2000, child mortality worldwide has been cut in half. Deaths from HIV/AIDS, tuberculosis, and malaria have declined significantly. And we are on the verge of eradicating only the second human disease in history: polio. These are not abstract statistics; they represent tens of millions of lives saved. None of this progress would have been possible without consistent, bipartisan U.S. leadership and investment.

Over the past several decades, the United States has built one of its most strategic global assets: a respected and robust public health presence. This leadership is not just a humanitarian achievement—it is a core pillar of American soft power and security. For example, a Stanford study analyzing 258 global surveys across 45 countries found that U.S. health aid is strongly linked to improved public opinion of the United States. In countries and years where U.S. health aid was highest, the probability of people having a very favorable view of the United States was 19 percentage points higher. Other forms of aid—like military or governance—did not have the same effect. Another example is the 2014 Ebola outbreak in West Africa. The rapid deployment of U.S. scientists, health workers, and CDC teams helped contain the virus before it could spread globally. Their presence allowed the U.S. to help shape the response strategy, speed up containment, and prevent a wider outbreak. Many African countries are facing the dual burden of rising debt and pressing health needs, forcing painful choices between repaying creditors, and protecting their citizens. Helping them navigate this challenge is not just the right thing to do—it is a strategic imperative. If the United States retreats, others will fill the gap, and not all of them will bring our values, our priorities, or our interests to the table. Preserving American global influence will require restoring the staff, systems, and resources that underpin it—before the damage becomes irreversible.

I understand the fiscal pressures facing Congress. I recognize the need to prioritize spending and to hold programs accountable for results. I also share the Trump Administration’s commitment to promoting efficiency and encouraging country-led solutions. But I believe those goals can—and must—be pursued while still protecting the programs that deliver the highest return on investment and the greatest impact on human lives.

The United States’ support for Gavi, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis, and Malaria; the President’s Emergency Plan for AIDS Relief (PEPFAR); and the Global Polio Eradication Initiative (GPEI) represent some of the smartest, most effective investments our country has ever made. These initiatives are proven, strategically aligned with American interests, and cost-effective on a scale few other government programs can match.

Together, Gavi and the Global Fund have helped save more than 82 million lives. Gavi has helped halve childhood deaths in the world’s poorest countries and returns an estimated $54 for every $1 invested. The Global Fund has contributed to a 61% reduction in deaths from HIV/AIDS, TB, and malaria. PEPFAR has saved over 26 million lives and helped millions of children be born HIV-free. GPEI has brought us closer than ever to the eradication of polio. Pulling back now would not only jeopardize these historic gains—it would invite a resurgence of preventable disease, deepen global instability, and undermine decades of bipartisan American leadership.

This is not a forever funding stream for the U.S. Government. These programs set out clear pathways for countries to “graduate” from aid, which many have already done. For example, nineteen countries, including Viet Nam and Indonesia, have successfully graduated from Gavi support and now fully finance their own immunization programs. Others—from Bangladesh to Cote d'Ivoire—are on track to do the same. This is how U.S. development policy should work: catalytic, cost effective, and designed to help countries become self-reliant and drive their own progress. I agree that aid funding should have an end date, but not overnight. The most effective path to that end date is innovation. By investing in the development and delivery of new medical tools and treatments, we can drive down the cost of care, and in some cases, make diseases that were once a death sentence treatable, or even curable. Advances in therapies for chronic conditions like sickle cell disease, HIV, or certain types of cancers could transform lives and health systems. American innovation offers a sustainable exit strategy—one that reduces long-term costs, allows the United States to responsibly step back, and builds lasting trust and good will that far exceed the original investment.

Over the past 25 years, the Gates Foundation has invested nearly $16 billion in global health partnerships like Gavi, the Global Fund, and GPEI. We will continue to invest, through innovation, research, and close coordination with partners. But no private institution—or coalition of them—can replace the scale, reach, or authority of the U.S. government in delivering lifesaving impact at the global level.

The decisions made in the coming weeks will shape not only the lives saved in the near term—but the legacy of American leadership for generations to come.

Download a PDF of the testimony with appendices that include reflections from Gates Foundation staff in Africa on the impact of the U.S. aid cuts; analytical projections from respected organizations; and a selection of first-hand reporting from reputable news organizations and journalists.

How do you get to work? Some people roll out of bed and move 10 feet to their desk. Others walk to the office or take public transit. I usually drive a car.

No matter how you get there, I guarantee that your commute isn’t as wild as Agnes Nambozo’s: She regularly climbs a rickety ladder that is nearly 1,000 feet tall—or 300 meters—before she can start work for the day.

Agnes is a nurse based in Buluganya, located in the shadow of Mount Elgon in eastern Uganda. Like many nurses in rural communities across sub-Saharan Africa, she wears a lot of different hats. She might spend one day delivering babies and treating wounds and the next as a health educator, promoting good nutrition and sanitation in her community. The days Agnes believes she makes the biggest difference, though, are the ones when she treks deep into the Ugandan countryside to vaccinate children.

Uganda has done an amazing job of reducing childhood mortality over the last 25 years. In 2000, about 145 children died per every thousand live births. By 2023, that figure had dropped to fewer than 40 deaths per 1,000 births. A lot of that progress can be attributed to vaccines and vaccinators like Agnes.

Eastern Uganda is a gorgeous place, but parts of it are incredibly difficult to cross. Many of the communities Agnes visits are high in the mountains. Some are only accessible by ladders, which act as links between communities. Older children can climb down them to go to school, but they are too steep for the little ones. Mothers can’t safely carry their babies down the ladders to the health clinic, so Agnes comes to them.

When Agnes was a little girl, she wanted to be a police officer—until her mom convinced her the job was too dangerous. Instead, she took a nursing course. She fell in love with the profession, even though it ended up being a much riskier job than her mom ever imagined. She travels to the villages to vaccinate kids in all kinds of weather. It’s often rainy in the mountains, and the ladders become slippery. “The ladders are risky because you might miss a step,” she says. “If you are lucky, you can get a fracture. If you’re not lucky, you can lose your life.”

On the days when she heads into the field to vaccinate children, Agnes leaves her house by 6:00 am. She takes a taxi from where she lives in Sironko to Buyaga, a town closer to where the health clinic is located. Cars can’t drive on the road to the clinic, so she takes a motorbike for the last stretch.

She arrives at the clinic around 8:00 am and starts packing for the day. Rural vaccinators like Agnes must carry their supplies on their backs, and there’s an art to making sure everything is loaded properly. The vaccines must be kept cold so she wears a heavy insulated backpack stuffed with ice packs.

Agnes then hops on another motorbike to a staging location before heading off on foot to the ladders. By the time she reaches the village and starts setting up to immunize the community, it’s usually around 10:30—more than four hours after she left her house for the day.

She comes in with a plan for how many people she’ll vaccinate, but Agnes always brings a couple extra doses just in case. A typical day usually means around 50 patients. Most are children under 5, who get vaccinated against deadly diseases like polio, measles, tetanus, and pneumonia. The latter is especially important in a region as rainy as this one, where the damp weather makes people more susceptible to respiratory diseases.

Agnes and her colleagues are often the only health workers who visit the most remote communities in the mountains, so they also provide general nursing care while they’re there. Agnes regularly gives kids deworming treatments and key supplements like vitamin A. She answers questions from the adults and offers them health guidance, including advice on planning a family.

After she wraps up for the day, Agnes makes the long trek back home. It’s exhausting, difficult work, but she is proud to help so many people. “Our motto for nurses in Uganda is ‘To love and serve,’” she says. “And to me, love is not just a word. It’s a verb.”

Unfortunately, Agnes’s job recently became a lot more difficult. Many of her colleagues at the health clinic in Buluganya were supported by USAID, and they lost their jobs when funding was cut. Some of the positions that were eliminated supported new and expectant mothers. Others worked on HIV and tuberculosis, distributing medication and testing high-risk individuals to prevent further spread.  

Agnes and the others who are left are doing their best to ensure communities still receive care, but they can only do so much. “Our community is suffering a lot,” she says. She is worried about burnout if funding isn’t restored.

Still, Agnes won’t rest until she has helped as many people as she can. Thanks to the support of the Rotary Club of Kampala, she recently went back to school and is working towards a degree in nursing. She hopes to learn new skills that will save even more lives.

“My dream is to make people feel good, to make them happy, and to give my service to the people,” says Agnes. “When you have positivity, nothing is impossible.”

I’ve been giving speeches about vaccines for 25 years. After so much time, it could have become routine for me. But it never has.

One reason is that the impact of vaccines—a single dose can protect a child from deadly diseases forever—is like a miracle to me, and who gets tired of talking about miracles?

The other reason is tied to this particular moment. There’s never been a point in the past 25 years when more lives hung in the balance. In all likelihood, 2025 will be the first year since the turn of the century when the number of children dying will go up instead of down. 

Why? Governments are cutting health aid—including funds for Gavi, the vaccine organization that the Gates Foundation helped start. As a result, Gavi will likely not have all the money it needs to fund its next five years of work. 

So when I spoke this week at a summit in Brussels where donors committed a new round of funding for Gavi, I focused on why it’s so important to keep the money flowing and maintain our momentum on vaccines. You can read my remarks below.

Remarks as delivered
June 25, 2025
Global Summit: Health & Prosperity through Immunisation
Brussels, Belgium

Good evening, and thank you to everyone joining us here tonight—and for all your support for one of the most transformative efforts in the world.

I want to particularly thank President von der Leyen and President Costa, and the European Union, for co-hosting this summit. President von der Leyen has long been an incredible champion for health and development, and the EU has been one of the Gavi's biggest supporters since the very beginning—support that's more crucial now than ever.

This chart is one that I think about a lot. It's really my most favorite chart. And I consider it almost kind of a report card for humanity. Because over the last 25 years, the reduction of under-five deaths has been far faster than any time in history. We've gone from over 9 million to now half as many deaths taking place by children. This is an unbelievable result.

And it doesn't fully state the benefit of these vaccines. The vaccines leave a lot of kids far more healthy, and so their ability to achieve their potential is increased.

Gavi prioritizes saving lives, and it's done with incredible scientific rigor. We're constantly improving vaccines. We're constantly looking at the safety, and I'm very proud of the work that's done to make sure that these vaccines are incredibly safe.

The founding of Gavi actually goes back to about the time the Gates Foundation was first started. And after 25 years, I can still say that it's at the top of the list of things that I'm very, very proud of. At that time, kids were not getting access to vaccines. They were too expensive. They hadn't been formulated properly. And I was stunned to learn that so many kids were dying from a disease like rotavirus because the vaccine wasn't getting out to all the children of the world.

So Gavi was created to not only help finance vaccines, but work with countries to adopt these new vaccines.

We've done an amazing job of getting these prices down. A good example is the pneumococcal vaccine, PCV. This vaccine became available in high-income countries the year that Gavi was founded. And it does a fantastic job of protecting kids against pneumonia, which was the single most deadly childhood infection. But it was very expensive.

And so Gavi and its partners incentivized vaccine manufacturers to develop a new, much cheaper PCV, which was introduced in 2017. Today, the manufacturers make PCV vaccines available to low-and middle-income countries for just $2 a dose.

And of course, we've seen similar reductions across all of the different vaccines, allowing us to add new vaccines to save even more children.

Since the founding of Gavi, the overall cost of fully vaccinating a child has been cut in more than half.

And we have a pipeline of new vaccines coming along, vaccines to address new diseases and that bring down costs even further.

A good example of this is the HPV vaccine. Cervical cancer, which HPV prevents, is the fourth most common cancer in women around the world. And this vaccine can prevent over 90% of these cases.

But countries were slow to adopt this vaccine, in part because it was hard to deliver: initially, it required three doses spread across six months.

Scientists believed that perhaps it could be done with fewer doses. And so the Gates Foundation funded a trial to see whether a single dose was essentially fully protective. And after seeing the incredible results, the WHO approved a single dose schedule in 2022.

Now, we have 75 countries around the world that have moved to this single dose approach.

And because the single dose is cheaper and easier to deliver, it's now getting to far more girls around the world. For example, after Nigeria introduced the single-dose vaccine, it was able to vaccinate more than 12 million girls in less than a year. That's really incredible.

Across Gavi countries, HPV vaccine coverage has increased dramatically. The year after this single-dose approval, we doubled the number of girls getting the vaccine. And [the next year] we doubled it again, and this year we'll double it again.

There's more than just making vaccines available. We have to work with our partner countries on helping improve their health systems. So the Gavi Alliance has spent a lot of its resources and a lot of its technical support in helping improve those primary health care systems, which are so vital. We've helped countries understand where they're missing kids and how to invest in raising those coverage levels.

As you've heard, over this 25-year period, that means over a billion children have been vaccinated—resulting in the saving of over 19 million lives.

Nineteen million is a big number. It's almost easier to understand if I just say: okay, here's a child whose life was saved. But you have to take your reaction to how valuable that is and multiply it by this absolutely gigantic number.

The total cost to save those lives was about $22 billion. And that means that Gavi saved children's lives for only about $1,000 per life saved.

And in addition, the kids who these vaccines have kept healthy not only go to school; they do well in school. They join the economy. They contribute to their country. And really, this is why improving health through vaccines is part of the formula for helping countries be self-sufficient.

Gavi's vaccination has generated $250 billion in economic benefits in the countries it supports. In fact, Gavi has had such an extraordinary economic benefit that over 19 countries that were Gavi recipients have now graduated, meaning they now fully fund their own immunization programs.

A great example is Indonesia. Since partnering with Gavi, it’s doubled the number of vaccines offered through its routine immunization program—and it’s seen childhood deaths fall to a quarter of what they were before. And now, Indonesia is not only transitioning to be fully self-supportive—it’s also become a Gavi donor.

Of course, this is a challenging time. All the progress we’ve made is at risk. Budgets are tight, and we all have to show our priorities when there’s tough trade-offs to be made.

There’s no denying: this is a global health crisis. Between the U.S. cuts and other funding cuts, in total, aid in total has gone down by 30 billion this year alone. It reinforces the incredible values being shown by the people who are showing up here today and being incredibly generous.

But with the cut in health resources, along with the financial situation a lot of these low-income countries are in, we are going to have a few years where things will go backwards.

As we think about this, think of a mother who will bring a baby wheezing for breath to a help center, and because the vaccines aren't available, that baby will not survive.

Think of a health worker trying to deal with a measles outbreak who, because there's less resources for that primary health care system or vaccines, that measles epidemic will continue.

This is agonizing. I mean, we have to put ourselves in the position of the parents who lose these children and how tough it must be for them to realize that the life could have been saved by a vaccine that costs just 30 cents.

So though our trend lines will briefly go into reverse, I believe that we can come back. I believe that we will resume that incredible progress that you saw.

I don't know if it'll be in two years or four years or six years, but I do know that as we bring these resources back, and we take advantage of an incredible pipeline of innovation, new drugs, new vaccines—lots of amazing things to help with these diseases—we will resume progress.

So everyone here, I'd say, is recommitting themselves, just like the Gates Foundation, to doubling down and staying committed.

You know, I'm not pessimistic. In fact, we have things like polio eradication that we are, as we say, this close to elimination. That'll be a mind-blowing thing. Likewise, malaria: we have tools, a variety of tools that brought together will give us a chance in the next 20 years to completely eradicate that as a disease, just like we're doing with polio.

This is all why the Gates Foundation is pledging $1. 6 billion to Gavi for this next five-year period. Thank you.

And it's why we'll invest billions in making sure that pipeline of new and lower-cost vaccines continues to make Gavi even more effective.

In closing, I think we can reflect on what Nelson Mandela once said: “There can be no keener revelation of a society's soul than the way it treats its children.”

In the last 25 years, Gavi has helped over a billion children live better, healthier lives—thanks to the extraordinary support of partners like you.

If we get this right, this trajectory of progress will continue for decades to come.

Thank you.

When I first began thinking about how to give away my wealth, I did what I always do when I start a new project: I read a lot of books. I read books about great philanthropists and their foundations to inform my decisions about how exactly to give back. And I read books about global health to help me better understand the problems I wanted to solve.

One of the best things I read was an 1889 essay by Andrew Carnegie called The Gospel of Wealth. It makes the case that the wealthy have a responsibility to return their resources to society, a radical idea at the time that laid the groundwork for philanthropy as we know it today.

In the essay’s most famous line, Carnegie argues that “the man who dies thus rich dies disgraced.” I have spent a lot of time thinking about that quote lately. People will say a lot of things about me when I die, but I am determined that "he died rich" will not be one of them. There are too many urgent problems to solve for me to hold onto resources that could be used to help people.

That is why I have decided to give my money back to society much faster than I had originally planned. I will give away virtually all my wealth through the Gates Foundation over the next 20 years to the cause of saving and improving lives around the world. And on December 31, 2045, the foundation will close its doors permanently.

This is a change from our original plans. When Melinda and I started the Gates Foundation in 2000, we included a clause in the foundation’s very first charter: The organization would sunset several decades after our deaths. A few years ago, I began to rethink that approach. More recently, with the input from our board, I now believe we can achieve the foundation’s goals on a shorter timeline, especially if we double down on key investments and provide more certainty to our partners.

During the first 25 years of the Gates Foundation—powered in part by the generosity of Warren Buffett—we gave away more than $100 billion. Over the next two decades, we will double our giving. The exact amount will depend on the markets and inflation, but I expect the foundation will spend more than $200 billion between now and 2045. This figure includes the balance of the endowment and my future contributions. 

This decision comes at a moment of reflection for me. In addition to celebrating the foundation’s 25^th anniversary, this year also marks several other milestones: It would have been the year my dad, who helped me start the foundation, turned 100; Microsoft is turning 50; and I turn 70 in October.

This means that I have officially reached an age when many people are retired. While I respect anyone’s decision to spend their days playing pickleball, that life isn’t quite for me—at least not full time. I’m lucky to wake up every day energized to go to work. And I look forward to filling my days with strategy reviews, meetings with partners, and learning trips for as long as I can.

The Gates Foundation’s mission remains rooted in the idea that where you are born should not determine your opportunities. I am excited to see how our next chapter continues to move the world closer to a future where everyone everywhere has the chance to live a healthy and productive life.

Planning for the next 20 years

I am deeply proud of what we have accomplished in our first 25 years.

We were central to the creation of Gavi and the Global Fund, both of which transformed the way the world procures and delivers lifesaving tools like vaccines and anti-retrovirals. Together, these two groups have saved more than 80 million lives so far. Along with Rotary International, we have been a key partner in reviving the effort to eradicate polio. We supported the creation of a new vaccine for rotavirus that has helped reduce the number of children who die from diarrhea each year by 75 percent. Every step of the way, we brought together other foundations, non-profits, governments, multilateral agencies, and the private sector as partners to solve big problems—as we will continue to do for the next twenty years.

Over the next twenty years, the Gates Foundation will aim to save and improve as many lives as possible. By accelerating our giving, my hope is we can put the world on a path to ending preventable deaths of moms and babies and lifting millions of people out of poverty. I believe we can leave the next generation better off and better prepared to fight the next set of challenges.

The work of making the world better is and always has been a group effort. I am proud of everything the foundation accomplished during its first 25 years, but I also know that none of it would have been possible without fantastic partners.

Progress depends on so many people around the globe: Brilliant scientists who discover new breakthroughs. Private companies that step up to develop life-saving tools and medicines. Other philanthropists whose generosity fuels progress. Healthcare workers who make sure innovations get to the people who need them. Governments, nonprofits, and multilateral organizations that build new systems to bring solutions to scale. Each part plays an essential role in driving the world forward, and it is an honor to support their efforts.

Of course, although the Gates Foundation is by far the most significant piece of my giving, it is not the only way I give back. I have invested considerable time and money into both energy innovation and Alzheimer’s R&D. Today’s announcement does not change my approach to those areas.

Expanding access to affordable energy is essential to building a future where every person can both survive and thrive. The bulk of my spending in this area is through Breakthrough Energy, which invests in companies with promising ideas to generate more energy while reducing emissions. I also started a company called TerraPower to bring safe, clean, next-generation nuclear technology to life. Both of these ventures will earn profits if successful, and I will reinvest any money I make through them back in the foundation, as I already do today.

I support a number of efforts to fight Alzheimer’s disease and other related dementias. Alzheimer’s is a growing crisis here in the United States, and as life expectancies go up, it threatens to become a massive burden to both families and healthcare systems around the world. Fortunately, scientists are currently making amazing progress to slow and even stop the progress of this disease. I expect to keep supporting their efforts as long as it’s necessary.

The success in both areas will determine exactly how much money is given to the foundation since any profits they earn will be part of my overall gift.

What the Gates Foundation hopes to accomplish

Over the next twenty years, the foundation will work together with our partners to make as much progress towards our vision of a more equitable world as possible.

The truth is, there have never been more opportunities to help people live healthier, more prosperous lives. Advances in technology are happening faster than ever, especially with artificial intelligence on the rise. Even with all the challenges that the world faces, I’m optimistic about our ability to make progress—because each breakthrough is yet another chance to make someone’s life better.

Over the next twenty years, the foundation’s funding will be guided by three key aspirations:

In 1990, 12 million children under the age of 5 died. By 2019, that number had fallen to 5 million. I believe the world possesses the knowledge to cut that figure in half again and get even closer to ending all preventable child deaths.

We now understand the essential role nutrition—and especially the gut microbiome—plays in not only helping kids survive but thrive. We’ve made huge advances in maternal health, making sure that new and expectant mothers have the support they need to deliver healthy babies. We have new, life-saving vaccines and medicines, and we know how to get them to the people who need them most thanks to organizations like Gavi and the Global Fund. The innovation is there, the ability to measure progress is stronger than ever, and the world has the tools it needs to put all children on a good path.

Today, the list of human diseases the world has eradicated has just one entry: smallpox. Within the next couple years, I expect to add polio and Guinea worm to the list. (When we eradicate the latter, it will be a testament to the late President Jimmy Carter’s leadership.) I’m optimistic that, by the time the foundation shuts down, we can also add malaria and measles. Malaria is particularly tricky, but we’ve got lots of new tools in the pipeline, including ways of reducing mosquito populations. That is probably the key tool that, as it gets perfected and approved and rolled out, gives us a chance to eradicate malaria.

In 2000, the year that we started the foundation, 1.8 million people died from HIV/AIDS. By 2023, advances in treatment and preventatives cut that number to 630,000. I believe that figure will be reduced dramatically in the decades ahead, thanks to incredible new innovations in the pipeline—including a single-shot gene therapy that could reduce the amount of virus in your body so much that it effectively cures you. This would be massively beneficial to anybody who has HIV, including in the rich world. The same technology is also being used to treat sickle cell disease, an excruciating and deadly illness.

We’re also making huge progress on tuberculosis, which still kills more people than malaria and HIV/AIDS combined. Last year, a historic phase 3 trial began that could be the first new TB vaccine in over 100 years.

The key to maximizing the impacts of these innovations will be lowering their costs to make them affordable everywhere, and I expect the Gates Foundation will play a big role in making that happen. Health inequities are the reason the Gates Foundation exists. And the true test of our success will be whether we can ensure these life-saving interventions reach the people who need them most—particularly in Africa, South Asia, and across the Global South.  

To reach their full potential, people need access to opportunity. That’s why our foundation focuses on more than just health.  

Education is key. Frustratingly, progress in education is less dramatic than in health—there is no vaccine to improve the school system—but improving education remains our foundation’s top priority in the United States. Our focus is on helping public schools ensure that all students can get ahead—especially those who typically face the greatest barriers, including Black and Latino students, and children from low-income backgrounds. At the K-12 level, that means boosting math instruction and ensuring teachers have the training and support they need—including access to new AI tools that allow them to focus on what matters most in the classroom. Given the importance of a post-secondary degree or credential for success nowadays, we’re funding initiatives to increase graduation rates, too. 

As I mentioned, having access to a high-quality nutrition source is key to keeping kids’ development on track. Smallholder farmers form the backbones of local economies and food supplies, and they play a key role in making that happen. One of the main ways the foundation helps farmers is through the development of new, more resilient seeds that yield more crops even under difficult conditions. This work is even more important in a warming world, since no one suffers more from climate change than farmers who live near the equator. Despite that, I’m hopeful that we can help make smallholder farmers more productive than ever over the next two decades. Some of the crops our partners are developing even contain more nutrients—a win-win for both climate adaptation and preventing malnutrition.

We’ll also continue supporting digital public infrastructure, so more people have access to the financial and social services that foster inclusive economies and open, competitive markets. And we’ll continue supporting new uses of artificial intelligence, which can accelerate the quality and reach of services from health to education to agriculture.

Underpinning all our work—on health, agriculture, education, and beyond—is a focus on gender equality. Half the world’s smallholder farmers are women, and women stand to gain the most when they have access to education, health care, and financial services. Left to their own devices, systems often leave women behind. But done right, they can help women lift up their families and their communities.   

The United States, United Kingdom, France, and other countries around the world are cutting their aid budgets by tens of billions of dollars. And no philanthropic organization—even one the size of the Gates Foundation—can make up the gulf in funding that’s emerging right now. The reality is, we will not eradicate polio without funding from the United States.

While it's been amazing to see African governments step up, it’s still not enough, especially at a moment when many African countries are spending so much money servicing their debts that they cannot invest in the health of their own people—a vicious cycle that makes economic growth impossible.

It's unclear whether the world’s richest countries will continue to stand up for its poorest people. But the one thing we can guarantee is that, in all of our work, the Gates Foundation will support efforts to help people and countries pull themselves out of poverty. There are just too many opportunities to lift people up for us not to take them.

The last chapter of my career

Next week, I will participate in the foundation’s annual employee meeting, which is always one of my favorite days of the year. Although it’s been many years since I left Microsoft, I am still a CEO at heart, and I don’t make any decisions about my money without considering the impact. 

I feel confident putting the remainder of my wealth into the Gates Foundation, because I know how brilliant and dedicated the people responsible for using that money are—and I can’t wait to celebrate them.

I'm inspired by my colleagues at the foundation, many of whom have foregone more lucrative careers in the private sector to use their talents for the greater good. They possess what Andrew Carnegie called “precious generosity,” and the world is better off for it.

I am lucky to have been surrounded by many generous people throughout my life. As I wrote in my memoir Source Code, my parents were my first and biggest influences. My mom introduced me to the idea of giving back. She was a big believer in the idea of “to whom much is given much is expected,” and she taught me that I was just a steward of any wealth I gained.

Dad was a giant in every sense of the word, and he, more than anyone else, shaped the values of the foundation as its first leader. He was collaborative, judicious, and serious about learning—three qualities that shape our approach to everything we do. Every year, the most important internal recognition we hand out is called the Bill Sr. Award, which goes to the staff member who most exemplifies the values that he stood for. Everything we have accomplished—and will accomplish—is a testament to his vision of a better world.

As an adult, one of my biggest influences has been Warren Buffett, who remains the ultimate model of generosity. He was the first one who introduced me to the idea of giving everything away, and he’s been incredibly generous to the foundation over the decades. Chuck Feeney remains a big hero of mine, and his philosophy of “giving while living” has shaped how I think about philanthropy.

I hope other wealthy people consider how much they can accelerate progress for the world’s poorest if they increased the pace and scale of their giving, because it is such a profoundly impactful way to give back to society. I feel fulfilled every day I go to work at the foundation. It forces me to learn new things, and I get to work with incredible people out in the field who really understand how to maximize the impact of new tools.

Today’s announcement almost certainly marks the beginning of the last chapter of my career, and I’m okay with that. I have come a long way since I was just a kid starting a software company with my friend from middle school. As Microsoft turns 50 years old, it feels right that I celebrate the milestone by committing to give away the resources I earned through the company.

A lot can happen over the course of twenty years. I want to make sure the world moves forward during that time. The clock starts now—and I can’t wait to make the most of it.

I was excited to get a drone for my birthday last year. I couldn’t wait to get it into the air and see what my backyard looked like from the sky. But, as anyone who has used one can tell you, I quickly learned a harsh truth: Flying a drone isn’t easy. It takes a lot of practice and skill.

Maybe it’s time to pull the drone back out, because I was lucky to get a lesson from the experts last month in India. During my visit to Delhi, I met with Sangita Devi, Sumintra Devi, and Kajol Kumari—three Drone Didis from Bihar who are taking India’s agricultural productivity to new heights.

The women I met are part of the Indian government’s Namo Drone Didi program. (Didi is the Hindi word for “sister.”) It was launched in 2023 to help rural women boost their income and boost India’s agricultural productivity—and although the program is still in its early days, I’m already impressed by its results.

Right now, the Drone Didis primarily use their flying skills to fertilize crops. Applying fertilizer via drone has a lot of benefits over doing it by hand. Since you can spray farther away from the plant, the liquid fertilizer becomes more atomized—which means that it turns into finer droplets that cover more area. This benefits both farmers and the environment, because you need significantly less fertilizer and less water to help distribute it. Plus, it’s faster. One Drone Didi can cover as much as five acres in the same time it would take five people to cover half an acre.

I cannot wait to see how the program expands in the years ahead. The Indian government has plans to equip the drones with advanced sensors and imaging technology. This will allow Drone Didis to use real-time data to deliver targeted interventions to improve the quality and quantity of farmers’ crops. They will be able to detect diseases and pests, assess soil moisture levels, monitor crop growth, and more.

I’m equally excited to track how the Drone Didi program continues to empower women across India. Every Didi is affiliated with a self-help group, or SHG. The plan is to provide nearly 15,000 drones to SHGs across India by the end of next year.

In the United States, where I live, self-help groups are usually associated with mental health. In India, they’re a form of mutual aid. Each SHG is small—most are around 12 people, although some are as big as 25—and brings together women to support each other socially and financially. They pool their savings, access microloans at lower interest rates, and solve problems in areas like health and education.

The Didis I met with were longtime members of SHGs organized by JEEViKA, an organization in Bihar that works to lift people from rural areas out of poverty. During our time together in Delhi, Kajol told me about how JEEViKA helped her open her own shop three years ago, where she sells seeds and fertilizers. She loves being an entrepreneur, and when she was approached about becoming a Drone Didi, she knew it would do wonders for her business.

Each Didi attends a training program in Hyderabad or Noida, where they are taught how to pilot the drone and apply fertilizer effectively. (I was surprised to hear that learning to fly is apparently easier and takes less time than learning to fertilize!) Other women in their SHGs are trained as drone technicians, ready to repair the machines if any problems arise.

In the less than two years, the Drone Didi program is already transforming the lives of its pilots. Kajol is using the extra income she’s earned to expand her shop offerings and build a warehouse to store her stock. She also plans to send her children to a better school. Sangita’s family couldn’t afford a bicycle before she became a Drone Didi—today, she is the proud owner of an auto rickshaw.

Sumintra hopes that, when people see someone like her flying a huge drone, it changes their perception of what women are capable of. Like many women in her area, she married very young and was expected to stay home with her children. Today, her kids call her “Pilot Mummy” and dream about her flying airplanes one day.

I hope you think of the Didis the next time you hear the buzz of a drone above you at a wedding or a park. It’s remarkable how one piece of technology can reshape what is possible in a community. Kajol told me that people sometimes look at her and say, “She’s flying too high! What will she do next?”

Her response? “This is just the beginning. Wait and see what’s coming.”

What’s for dinner?

It’s a question asked every day in homes around the world. No other organization has done as much to ensure families—especially the poorest—have an answer to that question as CGIAR, the world’s largest global agricultural research organization.

More than 50 years ago, CGIAR’s research into high-yielding, disease-resistant rice and wheat launched the Green Revolution, saving more than a billion people from starvation. In the years since then, their work on everything from livestock and potatoes to rice and maize has helped reduce poverty, increase food security, and improve nutrition.

Never heard of CGIAR? You’re not alone. It’s an organization that defies easy brand recognition. For starters, its name is often mistaken for “cigar,” suggesting a link to the tobacco industry. And it doesn’t help that CGIAR is not a single organization, but a network of 15 independent research centers, most referred to by their own confusing acronyms. The list includes CIFOR, ICARDA, CIAT, ICRISAT, IFPRI, IITA, ILRI, CIMMYT, CIP, IRRI, IWMI, and ICRAF, leaving the uninitiated feeling as if they’ve fallen into a bowl of alphabet soup.

It’s too bad that more people don’t know about CGIAR. Their work to feed our hungry planet is as important now as it’s ever been. By 2050, as the world’s population gets bigger and incomes increase (which causes dietary changes like eating more meat), global food demand is expected to increase by 60 percent. Meeting this challenge is made tougher by climate change, which is affecting food production in every corner of the globe. Farmers are under assault from shifting rainfall, more frequent and extreme droughts and floods, and severe pest and disease outbreaks among crops and livestock.

The people who are most affected by these changes today are the world’s smallholder farmers. About 500 million farming households, in South Asia and sub-Saharan Africa, earn their living by raising crops and livestock on small parcels of land. These families have the fewest resources to cope with the many impacts of a warming climate.

I’ve been writing a lot this year about why reducing emissions from all sectors of our economy, including agriculture and electricity generation, is critical in our fight against climate change. But it’s equally important for the world to stay focused on helping vulnerable populations, like smallholder farmers, prepare for the disruptive impacts of climate change. We owe it to them. The people who will suffer most from climate change, especially in sub-Saharan Africa, are the least responsible for emitting these greenhouse gases. According to an Africa Progress Panel report, an average Ethiopian would have to live for 240 years to equal the carbon footprint of the average American.

I’m now co-chairing the new Global Commission on Adaptation, which is playing a key role in building government and public support for efforts to reduce the impacts of climate change on communities most at risk. We will need CGIAR’s research to help supply farmers with a steady stream of climate-smart crop varieties.

A great example of a CGIAR innovation helping smallholder farmers adapt to climate change is its drought-tolerant maize program. More than 200 million households in sub-Saharan Africa depend on maize for their livelihoods. Maize productivity in Africa is already the lowest in the world. And as weather patterns have become more erratic, farmers are at greater risk of having smaller maize harvests, and sometimes no harvest at all.

In response to this challenge, CGIAR’s International Maize and Wheat Improvement Center or CIMMYT, with funding from our foundation, USAID and the Howard Buffett Foundation, developed more than 150 new maize varieties that could withstand drought conditions. Each variety is adapted to grow in specific regions of Africa. At first, many smallholder farmers were afraid of trying new crop varieties instead of more commonly planted ones. But as CIMMYT worked with local farmers and seed dealers to share the benefits of these new varieties, more and more farmers adopted drought tolerant maize. The results have been life changing for many farming families.

In Zimbabwe, for example, farmers in drought-stricken areas using drought-tolerant maize were able to harvest up to 600 kilograms more maize per hectare than farmers using conventional varieties. The additional harvest was enough to feed a family of six for 9 months. For farming families who chose to sell their harvests, it was worth $240 in extra income, giving them much-needed cash to send their children to school and meet other household needs.

CIMMYT, in partnership with another CGIAR center, the International Institute of Tropical Agriculture or IITA, has gone on to develop other maize varieties for farmers who are not only vulnerable to drought, but also poor soils, disease, pests, and weeds. These varieties are expected to give farmers up to 30 percent greater yields and help them fight malnutrition.

CGIAR’s team of more than 8,000 scientists and staff around the world are also developing other tools to help farmers adapt to unpredictable weather and diseases. They have created a smart phone app that allows farmers to use the camera on their phone to identify specific pests and disease attacking cassava, an important cash crop in Africa. There are also new programs to use drones and ground sensors to help wheat and sugarcane farmers determine how much water and fertilizer their crops need.

We will need many new ideas like these to help farmers be prepared to meet the challenges of our changing climate. If they are, we will all have an answer to the question “What’s for dinner?” for years to come.

Almost thirty years ago, I wrote a book called The Road Ahead, about the transformative potential of the internet and other new digital technologies. Back then, I envisioned a world where online payments and e-government would change how we interact with money, services, and each other. Today, much of that has become a reality, in part due to the development of digital public infrastructure. In my recent travels around the world, I’ve seen up close how DPI is revolutionizing the way entire nations serve their people, respond to crises, and grow their economies. And at the Gates Foundation, we see it as an important part of our efforts to help save lives and fight poverty in poor countries.  

There are a few core components that constitute DPI: digital ID systems that securely prove who you are, payment systems that move money instantly and cheaply, and data exchange platforms that allow different services to work together seamlessly. These systems and platforms are to the digital world what roads, bridges, and power lines are to the physical one—an underlying structure that connects people, data, and money online. Strong DPI can propel a country forward by making it easier for people to access essential services, participate in the formal economy, and improve their lives. On the flip side, DPI that is poorly implemented (or simply non-existent) can slow a country’s development and perpetuate inefficiencies and inequities.  

In the 21^st century, digital public infrastructure is proving to be as important for progress as its brick-and-mortar predecessors—and the effects have been impressive around the world, wherever it’s been embraced.

I’ve just wrapped up a busy five-day trip to Ethiopia and Nigeria. It’s the kind of trip that’s both tiring and energizing at the same time. Even though I stay in touch with a lot of partners in both countries—the Gates Foundation has been funding work in them for more than 15 years—there’s nothing quite like visiting to see the work in action.

Whenever I get home from a trip like this, friends are curious to hear how it went. Here’s what I’m telling them. From 2000 to 2019 or so, Ethiopia and Nigeria led the way on dramatic improvements in health and poverty that rippled across Sub-Saharan Africa. Since then, the pandemic, extreme weather, and political and economic instability have set both countries back, along with much of the rest of the continent. But as I saw on this trip, there’s great work going on in both places that makes me optimistic about their future, and Africa’s.

I want to share a few photos from the week. Thanks to everyone who shared their time and insights with me, including Prime Minister Ahmed of Ethiopia, Nigerian health minister Muhammad Ali Pate, and a special guest who came along for the trip: the amazing musician Jon Batiste. The foundation will be working with African partners even more in the future, and based on what I saw this week, my next visit will be just as inspiring.

Twenty-five years ago, I encountered a question that I have thought about literally every day since: Why do children die?

Before I tell you what drew me to this mystery, I want to acknowledge that child mortality is not an easy subject to talk about. As a parent, I can’t imagine what it would be like to lose a child. It is shocking even to see the words “children” and “die” used in the same sentence.

But I think “why do children die?” is one of the most important questions ever. It is hard to think of a measure of how a society is doing that reveals more than whether it is protecting its children, and especially its most vulnerable children. And the better we understand why children die, the more we can do to save them.

The very good news is that the world has made phenomenal progress in this area over the past several decades. Since 1990, the number of children who die every year has fallen by more than half! If progress on child mortality is a good measure of the state of the world, then—despite the huge global setbacks of the past few years, including COVID-19—the state of the world has improved dramatically. And based on what I know about innovations that are still to come, we can look forward to even more progress in the years ahead.

My introduction to the subject came 25 years ago, when I read a New York Times article about the health problems caused by unsafe drinking water in low- and middle-income countries. I was shocked to learn that every year, 3.1 million people—nearly all of them children—died of diarrhea, often because they had drunk contaminated water. Diarrhea kills 3.1 million children?, I thought. That can’t be true, can it? But it was.

I had to know more. What other major inequities did I not know about?

I read everything about global health that I could find, and I spoke to as many experts as I could. I learned that researchers define child mortality as the death of anyone under the age of 5. They use that age because the first five years are the riskiest time of childhood, when kids are the most vulnerable.

Learning about the history of child mortality helped me put the statistics in context. In 1950, some 20 million children died. In 1990, it was down to 12 million children, even though more babies were being born. By 2000, the number had dropped to fewer than 10 million. By 2019, it was below 5 million. Virtually all of these deaths occur in low- and middle-income countries.

So the next question was, why were so many children dying?

Around 18 percent of the deaths were caused by non-communicable conditions, such as cancer and cardiovascular problems. The large majority—82 percent—of the deaths were caused by communicable diseases, such as diarrhea and malaria, and health problems that their mothers experienced—and exacerbated by risk factors including malnutrition. (This 18:82 ratio still holds true today.)

On one hand, this was heartbreaking. The worst killers were all things that people in rich countries considered just an unpleasant episode (such as diarrhea) or never experienced at all anymore (such as malaria). In other words, although it was obviously true that children were dying because of deadly diseases, that was only part of the explanation. They were also dying because of where they were born.

On the other hand, it was encouraging to learn that such a large share of the deaths was preventable. When I saw the breakdown of diseases, I thought: Here is our road map. This is what the Gates Foundation should be working on. With the right team, partners, and funding, we could help the world move through the list, systematically going after the worst killers. The solutions that already existed could be made more affordable and delivered to people in low-income countries. The ones that didn’t exist could be invented.

Here is the chart as it looks today:

As you can see, pneumonia is the top preventable cause, but the story here is one of real progress. In 2000, it took the lives of more than 1.5 million children, but by 2019, the number was around 670,000—still an awful number, but a reduction of more than 55 percent. The innovation related to pneumonia that’s going on today is so exciting that I made a separate post and video about it.

Diarrhea is another example of progress. In two decades, its death toll has dropped 58 percent. A key reason is the use of low-tech interventions like oral rehydration solution (sugar water, essentially), which replaces lost electrolytes. Governments also ran large-scale sanitation programs to cut down on the spread of bacteria. And scientists developed an affordable rotavirus vaccine, and the world came together to deliver it. Between 2010 and 2020, this vaccine prevented more than 200,000 deaths. By 2030, it will have prevented more than half a million deaths.

Even though the overall number of deaths has gone down by half, the relative positions of the top three killers have not changed. They are the same today as in 1990: neonatal disorders, pneumonia, and diarrheal diseases. As you can see in this graphic, the fourth slot is where there has been a huge shift. In 1990, it was occupied by measles, responsible for half a million deaths. Today, it’s malaria that is in the fourth slot—not because malaria deaths went up (they actually went down), but because measles deaths fell by a whopping 87 percent.

Why? Vaccines. Since 2000, Gavi, the Vaccine Alliance has provided measles vaccines to more than 500 million children—half a billion!—through routine immunization and special vaccination campaigns. (This is just one example of the magic of vaccines—although unfortunately vaccination rates have dropped because of the pandemic and other factors.) And malaria may not be #4 on that list for long, thanks to innovations like malaria vaccines, improved insecticide-treated bed nets, and sugar baits.

Many groups deserve credit for the decades of progress I’ve described in this post. Countries with high disease burdens have launched massive vaccination campaigns, strengthened their health systems, and shared best practices with each other. Wealthy countries generously give aid that supports these efforts. Pharmaceutical companies have contributed technical expertise and made products affordable for low- and middle-income countries. Foundations including the Gates Foundation have stepped up with additional funding for innovative ideas. (At the foundation, we have staff and partners dedicated to each slice of the pie you see above.)

Although it’s still true that too many children do not live to see their fifth birthday, the world is moving in the right direction. If everyone keeps doing their part, we can move even faster and save even more lives. Because of COVID and other setbacks, the United Nations’ goal to cut childhood deaths in half again to below 3 million by 2030 will be missed, but it can still be achieved the following decade.

At a time when war and pandemic are in the news every day, it is important to look for reasons to be hopeful. The world’s opportunity—and ability—to save children’s lives is surely one of those reasons.

The most dangerous foe U.S. soldiers may have ever encountered is the mosquito, which has caused more casualties than bombs or bullets during the nation’s conflicts.

One of the first military expenditures by the Continental Congress was $300 for quinine to protect General George Washington’s troops from malaria. During the Civil War, there were over a million cases of malaria in Union troops alone. In World War II, there were nearly 700,000 cases of malaria. In Vietnam, 50,000 cases. And more recently, of all the American soldiers deployed in Afghanistan, one out of every 20 of them battled malaria.

Finding ways to protect soldiers from the mosquito—the world’s deadliest animal—is a top priority at the U.S. Department of Defense’s Walter Reed Army Institute of Research (WRAIR).

I expect most people have never heard about WRAIR—or, if they have, they may be confusing it with the more familiar but separate institution, the Walter Reed National Military Medical Center, where U.S. presidents visit wounded troops and go for medical treatment.

It’s too bad more people don’t know about the work being done at WRAIR. Since its founding in 1893, WRAIR has been a global research leader into new malaria drugs, mosquito control, and more recently, vaccines, to protect people from mosquito-borne diseases. This research benefits the lives of not only American soldiers, but also billions of people living in areas where mosquito-borne diseases are a threat. That’s why our foundation collaborates with WRAIR on a range of research projects in malaria and other diseases that endanger the lives of people living in some of the world’s poorest areas.

Here’s one of many incredible facts that speak to WRAIR prominence in malaria research: WRAIR has contributed to the discovery and development of all FDA-approved malaria drugs, including primaquine, mefloquine, atovaquone/proguanil (Malarone), tafenoquine, and doxycycline. If you’ve ever traveled to an area where malaria is prevalent you’ve probably been prescribed one of these drugs for protection. And because of the spread of malaria drug resistance, WRAIR continues to explore new drugs to stay one step ahead of this threat.

WRAIR, in partnership with the Smithsonian Institute, also manages the world’s largest mosquito collection, which currently has more than 1.7 million specimens. Some of the oldest were collected by Walter Reed, the Army major who helped discover that yellow fever is transmitted by mosquitoes. WRAIR is named in his honor.

This large mosquito collection allows WRAIR researchers to “know their enemy,” by giving them a deep understanding of the huge variety of mosquito species that populate the globe so they can mount the most effective defenses against them.

The first line of defense for soldiers is their clothing and WRAIR has developed uniforms treated with insecticides to protect them. Then, there are mosquito nets and various repellents, including ones that double as camouflage paint.

Highly effective vaccines against malaria and other mosquito-borne disease are also a priority at WRAIR. WRAIR developed the first-ever malaria vaccine in conjunction with GlaxoSmithKline. Researchers at WRAIR also led the development of a Zika vaccine.

One of the most surprising and important areas of research at WRAIR are the human malaria infection challenge trials. As part of this program, WRAIR recruits volunteers who agree to be bitten by malaria-infected mosquitoes, exposing themselves to a curable form of the disease to test the effectiveness of various interventions. This might sound scary, but the trials are extremely safe. The volunteers are carefully monitored and are quickly cured before they become too ill. In the last 30 years, WRAIR has performed over 100 trials on over 2,200 volunteers. Thanks to this research, WRAIR has greatly accelerated the development of experimental vaccines and malaria drugs.

What’s most exciting at WRAIR is the research that will help us all prepare for the threats of the future, including climate change, which will increase the spread of mosquito-borne diseases.

As Col. Brian Evans, WRAIR’s chief entomologist, says, “The challenge is always evolving and the role of WRAIR is to keep up with that, to stay ahead of the game.”

Thanks to their incredible work for more than 125 years, WRAIR has done just that.

Around this time last year, I wrote a Gates Notes post that began: “I just returned from my visit to India, and I can’t wait to go back again.”

Last week, I got my wish and returned to India—and now that I’m home, I can’t wait to go back for another visit.

My goal was to get an update on some of the world-changing ideas and inventions that are coming out of India, and that’s exactly what I got. I spent four days there, meeting with political leaders, government officials, scientists, philanthropists, women who are lifting their communities out of poverty, and many others. The Gates Foundation funds more work in India than in any other country (other than the United States), and it’s always uplifting and educational to be there in person and see the impact of the efforts we’re supporting. Here are a few photos from my visit.

Have you ever visited a place you haven’t been in a while, and it somehow manages to feel both new and familiar? That’s how I feel every time I go back to Nigeria.

It was amazing to return to Lagos and Abuja this week. I’ve been fortunate to spend a lot of time in Nigeria over the last two-plus decades, but it’s been nearly five years since my last visit due to the pandemic. Nigeria—and especially Lagos—is one of the most dynamic, vibrant places in the world, and I am always blown away by how much it's changed. At the same time, I loved getting to catch up with old friends and reconnect in person with longtime partners. (Remote meetings are great, but it’s nice to meet face-to-face on occasion.)

This week also marked my first-ever trip to Niger. Our foundation has been working with talented Nigeriens for years to help ensure children's health and prevent the spread of polio, and it was exciting to see the country for myself and talk about the future of that work.

It was a great week. These were some of my favorite moments:

I want to share a few impressions from my time in China. I just had a meeting with President Xi, in which we discussed the importance of addressing global health and development challenges, like health inequity and climate change, and how China can play a role in achieving progress for people everywhere.

As part of my work with the Gates Foundation, I’ve tried to visit China, India, countries in Africa and Europe, and Washington D.C. each year. On these trips, I’d talk to researchers, government leaders, advocates, and other experts who are working on inequities in health and development. I’d always learn a lot, returning inspired by what I saw and heard.

It’s great to be able to resume these regular visits. This was my first trip to China in four years, and immediately after this trip, I’m headed to West Africa for the first time in five years. And I went to India in March.

On each trip this year, I have a key message: Over the past two decades, the world made significant strides in reducing poverty and improving health outcomes, but COVID was a big setback and even reversed progress on some global goals like reducing poverty and fighting TB and malaria. Many African countries, for example, are particularly impacted by overlapping challenges, including the effects of climate change, high food prices, escalating poverty rates, surging infectious diseases, and significant debt pressures.

Even though the challenges facing many African countries are complex, I’m optimistic that innovation in health, agriculture, digital finance, and energy will help improve lives there. I’m looking forward to meeting leaders and young people helping to accelerate progress when I visit West Africa.

Solving these problems requires innovation—both new tools and new ways of doing things. China has eliminated diseases, including polio and malaria, within its borders, developed drugs like artemisinin that have saved millions of lives around the world from malaria, made great strides in poverty reduction, and has made significant investments in clean energy and climate adaptation. So I was looking forward to seeing what’s changed since my last visit four years ago.

One highlight was my visit to the Global Health Drug Discovery Institute, an organization our foundation helped establish six years ago in partnership with the Beijing Municipal Government and Tsinghua University. GHDDI represents a productive way for public and private partners to work together on discovering new medicines for diseases that disproportionately impact the world’s most vulnerable populations but have applications for the world. I spoke about the institute’s work on TB and malaria yesterday, and we also extended our partnership over the next five years.

I also got to visit the National Crop Genebank of China. This facility is a prominent crop research center and also serves as a long-term preservation storage space for seeds so that scientists around the world have access to important genetic data. During my visit, I met with agricultural scientists who are working with their counterparts worldwide, particularly in Africa, on new rice varieties that help farmers increase their productivity and minimize the need for fertilizers, pesticides, and irrigation.

The benefits of their work have reached millions of farming households across Asia and Africa. The continued investment in technology and innovation within the agricultural sector has played a significant role in the increase in agricultural productivity throughout China. What excites me even more is China’s commitment to share their expertise and innovative practices with low-income countries. By assisting farmers in adapting to climate change, increasing their income, and combating food crises, they are making a substantial contribution to global food security.

The genebank and GHDDI are just two examples of the promising work the foundation has seen in China in the more than 15 years we’ve been partnering here. And there will be more opportunities for China and others to step up later this year, including a summit on development financing in Paris, a meeting of the G20 in New Delhi, and the COP28 climate conference in Dubai.

I’m convinced that if the world works together to address climate change, health inequity, and food security we can make extraordinary progress. And I’m looking forward to exploring new opportunities for collaboration and innovation that will make a better future for everyone.

Page through the Guinness Book of World Records and you’ll learn that a lot can happen in 24 hours.

On February 14, 2004, Dan Meyer of Davis, California, set the record for the longest paperclip chain by an individual in 24 hours. Length: 5,340 feet. Total number of paper clips: 54,030.

On June 4, 2011, Nabi Salehi, a barber in London, set the record for giving the most consecutive haircuts in 24 hours. Total haircuts: 526.

And on January 30, 2017, another achievement—one that will improve millions of lives—was added to the Guinness World Record list. A group fighting neglected tropical diseases—including Guinea worm, river blindness, and elephantiasis—set the record for most drugs donated in a 24-hour period. Total number of drugs: 207,169,292!

This week in Geneva, I was excited to participate in the ceremony to celebrate the group that achieved this incredible feat, Uniting to Combat Neglected Tropical Diseases, a coalition of drug companies, governments, health organizations, charities, and other partners who work to reduce the burden of tropical diseases that impact the world’s poorest.

On January 30^th, they organized drug manufacturers, warehouse workers, delivery drivers, government officials, and health workers to deliver this historic number of donated drugs on four continents for distribution to people living in the remotest parts of the world.

What’s truly amazing is that the 207 million drugs donated on January 30^th represent just a small amount of this group’s generosity. Since 2012, when United to Combat Neglected Tropical Diseases signed a declaration to control or eliminate 10 of the worst neglected diseases, they have donated 7 billion treatments. I’m grateful to the pharmaceutical companies that have been making these donations year after year: Bayer, Eisai, Gilead, GSK, Johnson & Johnson, MSD, Merck KGaA, Novartis, Pfizer, and Sanofi.

Thanks to the efforts of these drug companies and their partners millions of people are receiving the medicines they need to cure and protect them from these diseases. These diseases are in retreat and the world is moving closer to the day when they will be eliminated altogether.

Of course, all world records get challenged. And I for one will be thrilled for the day when this record for drug donations gets broken. So will the millions of families around the world who need them. 

Every Christmas when I was a kid, my parents would send out a card with an update on what the family was up to. Dad’s law firm is growing, Mom’s volunteer work is going strong, the girls are doing well in school, Bill is a handful.

Some people think it is corny, but I like the tradition. These days, at the end of each year, I still enjoy taking stock of my work and personal life. What was I excited about? What could I have done better?

I thought I would share a few of these thoughts as 2018 concludes.

One thing that occurs to me is that the questions I am asking myself at age 63 are very different from the ones I would have asked when I was in my 20s.

Back then, an end-of-year assessment would amount to just one question: Is Microsoft software making the personal-computing dream come true?

Today of course I still assess the quality of my work. But I also ask myself a whole other set of questions about my life. Did I devote enough time to my family? Did I learn enough new things? Did I develop new friendships and deepen old ones? These would have been laughable to me when I was 25, but as I get older, they are much more meaningful.

Melinda has helped broaden my thinking on this point. So has Warren Buffett, who says his measure of success is, “Do the people you care about love you back?” I think that is about as good a metric as you will find.

It may sound grand, but I think the world is slowly going through a similar transition to a broader understanding of well-being. For most of human history, we have been focused on living longer by fighting disease and trying to grow enough food for everyone. As a result, life spans have gone up dramatically. Technology has played a key role in that through vaccines, medicines, and improved sanitation.

We still need a lot of innovation to solve problems like malaria or obesity, but we are also going to be focusing more on improving the quality of life. I think this will be the thrust of many big breakthroughs of the future. For example, software will be able to notice when you’re feeling down, connect you with your friends, give you personalized tips for sleeping and eating better, and help you use your time more efficiently.

There are not the same clear measures of these things as there are for diseases, and there may never be. But there is nascent work in this field and I think it is going to accelerate.

As I look back on the year, I am also thinking about the specific areas I work on. Some of this is done through our foundation but a lot of it (such as my work on energy and Alzheimer’s work) is not. What connects it all is my belief that innovation can save lives and improve everyone’s well-being. A lot of people underestimate just how much innovation will make life better.

Here are a few updates on what’s going well and what isn’t with innovation in some areas where I work.

Alzheimer’s disease

I saw two positive trends in Alzheimer’s research in 2018.

One is that researchers focused on a new set of ideas about how to stop Alzheimer’s.

The first generation of theories, which dominated the field for years, emphasized two proteins called amyloid and tau. These proteins cause plaques and tangles in the brain, clogging up and killing brain cells. The idea was to stop the plaques and tangles from forming. I hope these approaches pay off, but we have not seen much evidence that they will.

In the past year, researchers have doubled down on a second generation of hypotheses. One theory is that a patient’s brain cells break down because their energy producers (called mitochondria) wear out. Another is that brain cells break down because part of the immune system gets overactivated and attacks them.

This is a great example of how improving our understanding of biology will reduce both medical costs and human suffering.

The other trend this year is that the Alzheimer’s community focused on getting more and better access to data. We’re working with researchers to make it easier for them to share information from their studies broadly so that we can better understand questions like how the disease progresses.

Over the past few years, the U.S. government has dramatically stepped up funding for Alzheimer’s research, from $400 million a year to over $2 billion a year. There is also a big push to create better diagnostics.

The only problem where I don’t yet see a clear path forward yet is how to develop more efficient ways to recruit patients for clinical trials. Without a simple and reliable diagnostic for Alzheimer’s, it’s hard to find eligible people early enough in the disease’s progression who can participate in trials. It can take years to enroll enough patients. If we could find a way to pre-screen participants, we could start new trials more quickly.

But there is so much momentum in other areas—scientific tools, better diagnostics, improved access to data—that as long as we can solve the recruitment problem, I am confident that we will make substantial progress in the next decade or two.

Polio

I thought we would be closer to eradicating polio today than we are. Unfortunately, there were more cases in 2018 than in 2017 (29 versus 22).

I underestimated how hard it would be to vaccinate children in places where there’s political violence and war. Families move around to escape fighting, which makes it hard to keep track of children and make sure they get all the doses of the vaccine. Or sewage systems get destroyed, allowing the virus to spread as children come into contact with an infected person’s excrement.

This is a key reason why Afghanistan and Pakistan have never been free of polio—in fact they are the only two countries that have never been free of polio.

I spend a lot of time on polio, part of it talking to the funders to make sure they continue their commitment even though eradication is taking longer than any of us would like. I remind them of the huge benefits of success, and the risk that the disease will return in a big way if we don’t finish the job.

I also remind them what a difference innovation is making. We’re now able to test sewage samples to track the virus and find the source before an outbreak starts. And the global health community is finding creative ways to work in war zones, having stopped outbreaks in Syria and Somalia in recent years.

Finally, I am hopeful about a new oral vaccine being tested in Belgium and Panama. The results should be out in 2019, and if this one proves effective, it would overcome some of the problems with previous oral vaccines when they’re used in places where few children are immunized. The new vaccine could be in use as soon as 2020.

Despite all the challenges, I am still optimistic that we can eradicate polio soon.

Energy

Global emissions of greenhouse gases went up in 2018. For me, that just reinforces the fact that the only way to prevent the worst climate-change scenarios is to get some breakthroughs in clean energy.

Some people think we have all the tools we need, and that driving down the cost of renewables like solar and wind solves the problem. I am glad to see solar and wind getting cheaper and we should be deploying them wherever it makes sense.

But solar and wind are intermittent sources of energy, and we are unlikely to have super-cheap batteries anytime soon that would allow us to store sufficient energy for when the sun isn’t shining or the wind isn’t blowing. Besides, electricity accounts for only 25% of all emissions. We need to solve the other 75% too.

This year Breakthrough Energy Ventures, the clean-energy investment fund I’m involved with, announced the first companies we’re putting money into. You can see the list at http://www.b-t.energy/ventures/our-investment-portfolio/. We are looking at all the major drivers of climate change. The companies we chose are run by brilliant people and show a lot of promise for taking innovative clean-energy ideas out of the lab and getting them to market.

Next year I will speak out more about how the U.S. needs to regain its leading role in nuclear power research. (This is unrelated to my work with the foundation.)

Nuclear is ideal for dealing with climate change, because it is the only carbon-free, scalable energy source that’s available 24 hours a day. The problems with today’s reactors, such as the risk of accidents, can be solved through innovation.

The United States is uniquely suited to create these advances with its world-class scientists, entrepreneurs, and investment capital.

Unfortunately, America is no longer the global leader on nuclear energy that it was 50 years ago. To regain this position, it will need to commit new funding, update regulations, and show investors that it’s serious.

There are several promising ideas in advanced nuclear that should be explored if we get over these obstacles. TerraPower, the company I started 10 years ago, uses an approach called a traveling wave reactor that is safe, prevents proliferation, and produces very little waste. We had hoped to build a pilot project in China, but recent policy changes here in the U.S. have made that unlikely. We may be able to build it in the United States if the funding and regulatory changes that I mentioned earlier happen.

The world needs to be working on lots of solutions to stop climate change. Advanced nuclear is one, and I hope to persuade U.S. leaders to get into the game.

The next epidemic

In 1918, the Spanish flu killed 50 million people worldwide. It still ranks as one of the deadliest natural disasters ever.

I had hoped that hitting the 100^th anniversary of this epidemic would spark a lot of discussion about whether we’re ready for the next global epidemic. Unfortunately, it didn’t, and we still are not ready.

People rightly worry about dangers like terrorism and climate change (and, more remotely, an asteroid hitting the Earth). But if anything is going to kill tens of millions of people in a short time, it will probably be a global epidemic. And the disease would most likely be a form of the flu, because the flu virus spreads easily through the air. Today a flu as contagious and lethal as the 1918 one would kill nearly 33 million people in just six months.

I have been studying this for several years. To be prepared, we need a plan for national governments to work together. We need to think through how to handle quarantines, make sure supply chains will reach affected areas, decide how to involve the military, and so on. There was not much progress on these questions in 2018.

The good news is that there has been progress toward a vaccine that would protect you from every strain of the flu. This year I visited the U.S. National Institutes of Health in Maryland and got an update from some of the people leading this work.

The challenges of making a universal flu vaccine are fascinating. All strains of the virus have certain structures in common. If you’ve never been exposed to the flu, it’s possible to make a vaccine that teaches your immune system to look for those structures and attack them. But once you’ve had the flu, your body obsesses over the strain that got you sick. That makes it really hard to get your immune system to look for the common structures.

So it is clear how we could make a universal vaccine that would protect anyone (such as the very young) who has never been exposed to the flu before. But for anyone who has already had the virus, it is a lot harder. The problem is a long way from being solved, but new research money is coming in and more scientists are working on it.

To make the most of these scientific efforts (some of which our foundation is funding), the world needs to develop a global system for monitoring and responding to epidemics. That is a political matter that requires international cooperation among government leaders. This issue deserves a lot more focus.

Gene editing

Gene editing made the news in November when a Chinese scientist announced that he had altered the genes of two baby girls when they were embryos. What is unprecedented about his work is that he edited their germline cells, meaning the changes will be passed down to their children. (The other, less controversial type of gene editing involves somatic cells, which aren’t inherited by future generations.)

I agree with those who say this scientist went too far. But something good can come from his work if it encourages more people to learn and talk about gene editing. This might be the most important public debate we haven’t been having widely enough.

The ethical questions are enormous. Gene editing is generating a ton of optimism for treating and curing diseases, including some that our foundation works on (though we fund work on altering crops and insects, not humans). But the technology could make inequity worse, especially if it is available only for wealthy people.

I am surprised that these issues haven’t generated more attention from the general public. Today, artificial intelligence is the subject of vigorous debate. Gene editing deserves at least as much of the spotlight as AI.

I encourage you to read up on it whenever you have a chance. Keep an eye out for articles in your news feed. If you are willing to read a whole book, The Gene by Siddhartha Mukherjee is very well done. This story is one to follow, because big breakthroughs—some good, some worrisome—are coming.

Looking ahead

I am making a resolution for 2019.

Although I have never been one for New Year’s resolutions, I have always been committed to setting clear goals and making plans to achieve them. As I get older, these two things look more and more like the same exercise. So I am making a resolution for 2019. I am committing to learn and think about two key areas where technology has the potential to make an enormous impact on the quality of our lives, but also raises complex ethical and social considerations.

One is the balance between privacy and innovation. How can we use data to gain insights into education (like which schools do the best job of teaching low-income students) or health (like which doctors provide the best care for a reasonable price) while protecting people’s privacy?

The other is the use of technology in education. How much can software improve students’ learning? For years we have been hearing overheated claims about the huge impact that technology would have on education. People have been right to be skeptical. But I think things are finally coming together in a way that will deliver on the promises.

I will be posting updates on these and other issues on the Gates Notes.

In the meantime, Melinda and I are working on our next Annual Letter. The theme is a surprise, though it is safe to say we’ll be sharing some positive trends that make us optimistic about the future. We’ll send the letter out in February.

I hope you have a happy and healthy start to 2019.

The great epidemiologist Larry Brilliant once said that “outbreaks are inevitable, but pandemics are optional.” I thought about this quote and what it reveals about the COVID-19 pandemic often while I was working on my new book.

On the one hand, it’s disheartening to imagine how much loss and suffering could’ve been avoided if we’d only made better choices. We are now more than two years into the pandemic. The world did not prioritize global health until it was too late, and the result has been catastrophic. Countries failed to prepare for pandemics, rich countries reduced funding for R&D, and most governments failed to strengthen their health systems. Although we’re finally reaching the light at the end of the tunnel, COVID still kills several thousand people every day.

On the other hand, Dr. Brilliant’s quote makes me feel hopeful. No one wants to live through this again—and we don’t have to. Outbreaks are inevitable, but pandemics are optional. The world doesn’t need to live in fear of the next pandemic. If we make key investments that benefit everyone, COVID-19 could be the last pandemic ever.

This idea is what my book, How to Prevent the Next Pandemic , is all about. I’ve been part of the effort to stop COVID since the early days of the outbreak, working together with experts from inside and out of the Gates Foundation who have been fighting infectious diseases for decades. I’m excited to share what I've learned along the way, because our experience with COVID gives us a clear pathway for how to be ready next time.

So, how do we do it? In my book, I explain the steps we need to take to get ready. Together, they add up to a plan for eliminating the pandemic as a threat to humanity. These steps—alongside the remarkable progress we’ve already made over the last two years in creating new tools and understanding infectious diseases—will reduce the chance that anyone has to live through another COVID.

Imagine a scenario like this: A concerning outbreak is rapidly identified by local public health agencies, which function effectively in even the world’s poorest countries. Anything out of the ordinary is shared with scientists for study, and the information is uploaded to a global database monitored by a dedicated team.

If a threat is detected, governments sound the alarm and initiate public recommendations for travel, social distancing, and emergency planning. They start using the blunt tools that are already on hand, such as quarantines, antivirals that protect against almost any strain, and tests that can be performed anywhere.

If this isn’t sufficient, then the world’s innovators immediately get to work developing new tests, treatments, and vaccines. Diagnostics in particular ramp up extremely fast so that large numbers of people can be tested in a short time. New drugs and vaccines are approved quickly, because we’ve agreed ahead of time on how to run trials safely and share the results. Once they’re ready to go into production, manufacturing gears up right away because factories are already in place and approved.

No one gets left behind, because we’ve already worked out how to rapidly make enough vaccines for everyone. Everything gets where it’s supposed to, when it’s supposed to, because we’ve set up systems to get products delivered all the way to the patient. Communications about the situation are clear and avoid panic.

And this all happens quickly. The goal is to contain outbreaks within the first 100 days before they ever have the chance to spread around the world. If we had stopped the COVID pandemic before 100 days, we could’ve saved over 98 percent of the lives lost.

I hope people who read the book come away with a sense that ending the threat of pandemics forever is a realistic, achievable, and essential goal. I believe this is something that everyone—whether you’re an epidemiologist, a policymaker, or just someone who’s exhausted from the last two years–should care about.

The best part is we have an opportunity to not just stop things from getting worse but to make them better. Even when we’re not facing an active outbreak, the steps we can take to prevent the next pandemic will also make people healthier, save lives, and shrink the health gap between the rich and the poor. The tools that stop an outbreak can also help us find and treat more HIV cases. They can protect more children from deadly diseases like malaria, and they can give more people around the world access to high quality care.

Shrinking the health gap was the life’s work of my friend Paul Farmer, who tragically died in his sleep in February. That’s why I’m dedicating my proceeds from this book to his organization Partners in Health, which provides amazing health care to people in some of the poorest countries in the world. I will miss Paul deeply, but I am comforted by the knowledge that his influence will be felt for decades to come.

If there’s one thing the world has learned over the last two years, it’s that we can’t keep living with the threat of another variant—or another pathogen—hanging over our heads. This is a pivotal moment. There is more momentum than ever before to stop pandemics forever. No one who lived through COVID will ever forget it. Just like a war can change the way a generation looks at the world, COVID has changed the way we see the world.

Although it may not always feel like it, we have made tremendous progress over the last two years. New tools will let us respond faster next time, and new capabilities have made us better prepared to fight deadly pathogens. The world wasn’t ready for COVID, but we can choose to be ready next time.

At the beginning of the movie Outbreak, there’s a scene where three government virologists arrive by helicopter at a remote village. Most of the village has recently died from Ebola-like symptoms. Wearing protective moon suits while triumphant music plays in the background, our heroes immediately get to work trying to contain the threat before it hurts anyone else. It’s an inspiring scene.

Unfortunately, it’s pure Hollywood fiction.

A full-time team like this doesn’t exist in real life—yet. I’m hoping this changes soon, because it is one of the most important things we can do to prevent the next pandemic.

Today, there are many organizations that work hard to respond to a major epidemic, but their efforts are largely dependent on volunteers. The best known is the Global Outbreak Alert and Response Network, or GOARN, which does heroic work but doesn’t have the staffing, funding, or global mandate to tackle every threat.

We need a permanent organization of experts who are fully paid and prepared to mount a coordinated response to a dangerous outbreak at any time. In my book, I propose that we call this group the GERM—Global Epidemic Response and Mobilization—team.

The GERM team would be made up of people from all over the world who have a wide range of expertise: epidemiology, genetics, data systems, diplomacy, rapid response, logistics, computer modeling, communications, and more. When they aren’t actively working in the field, most of them would call individual countries’ public health agencies home base, though some would sit in the WHO’s regional offices and at its headquarters in Geneva. (I talked about GERM at length in my TED talk last month.)

It's important that GERM have a diverse workforce. The team is going to serve the entire world—it only makes sense that its members reflect the experiences and backgrounds of the people they’re going to work with. Ideally, GERM would have a high number of local experts from countries at a higher risk of outbreak, and outsiders would only show up when necessary and when the in-country team requests help.

Here’s how a GERM response would work: The team’s disease monitoring experts would look for potential outbreaks. Once it spots one, GERM should have the ability to declare an outbreak and work with national governments and the World Bank to raise money for the response very quickly. Product-development experts would advise governments and companies on the highest-priority drugs and vaccines. People who understand computer modeling would coordinate the work of modelers around the world. And the team would help create and coordinate responses, such as how and when to implement border closures and recommend mask use.

But GERM’s response to an active outbreak is only one part of their work.

The team’s most important job is helping to run outbreak response exercises that test whether the world is ready for the next major outbreak. Militaries regularly run war games to evaluate their readiness—we should do the same with disease threats. In most countries, these exercises can be run by local public health and military leaders, with GERM acting as an advisor and reviewer. For some low-income countries, the world should invest in building this capacity and lend resources as needed.

You can learn more about what these germ games would look like by reading chapter 7 of How to Prevent the Next Pandemic, which is available as a free download for all Gates Notes Insiders.

The GERM team would also be responsible for developing a checklist for pandemic preparedness, similar to the ones that airplane pilots follow before every takeoff and many surgeons now use during an operation. A checklist sounds like such an obvious tool, but very few places had a plan like this in place when COVID hit. A GERM-developed checklist could be used anywhere and help make sure that governments are ready with an efficient and effective response.

But GERM’s impact won’t be limited to stopping pandemics. The group will improve overall health around the world, especially in the poorest countries.

Emerging diseases will always be their top priority, but when there isn’t an active pandemic threat, the team will keep their skills sharp by helping out with deadly diseases like polio and malaria. For example, they could work alongside public health workers in Nigeria to help distribute millions of doses of the oral polio vaccine every year to keep the country polio-free. This would both save a lot of kids from needless suffering and help the GERM team build relationships with communities they will need if an outbreak strikes. Now that’s what I call getting your money’s worth!

Running GERM will cost the world around $1 billion a year to cover salaries for the force of 3,000 people we’d need, plus equipment, travel, and other expenses—money that would come from governments. The work would be coordinated by the WHO, the only group that can give it global credibility, and it needs to be accountable to the public.

When Hollywood gets something wrong, the result is usually pretty silly and unrealistic. But movies like Outbreak nailed it when they imagined a global disease-fighting team who is ready to respond to a crisis on a moment’s notice. If we’re going to make sure that COVID-19 is the last pandemic, we need the GERM team.

As the COVID-19 pandemic spreads across Africa, hospitals across the continent face shortages of essential medical supplies needed to treat the respiratory disease and keep patients alive.

Not just masks and ventilators, but oxygen.

For people living in wealthy countries, medical oxygen is often taken for granted. In many low-income countries, however, oxygen is often in short supply or not available at all. And globally, a lack of oxygen –needed to treat pneumonia, malaria, and other diseases—leads to hundreds of thousands of deaths each year.

Addressing this often overlooked challenge is the life’s work of Bernard Olayo, a Kenyan doctor who founded Hewatele, an innovative organization working to ensure all patients—even in remote areas of the country—have access to oxygen.

Now, he is playing a critical role in Kenya’s preparations to tackle COVID-19 by scaling up oxygen supplies that will be needed to keep the most critically ill patients alive. 

While the number of COVID-19 cases in Africa remains low compared to other parts of the world, the continent is bracing for a surge of infections. According to the World Health Organization, up to 190,000 people could die of COVID-19 in Africa if the disease is not controlled.  A widespread outbreak would flood many of Africa’s fragile health systems.

A lot of attention has been focused on the lack of ventilators in Africa. Ventilators are the mechanical devices that help patients breathe, pushing air in and out of their lungs, when they can’t on their own. And the shortage of them is a real problem. But the lack of oxygen itself is equally worrying. The coronavirus attacks the respiratory tract, inflaming the lungs and making it difficult for patients to breathe. Oxygen, delivered through a mask or nasal tube, is an essential and effective first line of treatment that’s less invasive than being on a ventilator. Oxygen is also needed to run a ventilator. If COVID-19 patients have access to oxygen as an initial treatment, however, it may prevent many of them from becoming so critically ill that they would require one of the limited number of ventilators to breathe.

What Bernard is hoping to avoid during this pandemic are the painful choices he faced as a young doctor because of a lack of oxygen. After medical school he was posted to a rural hospital, where many of the patients were children battling pneumonia who needed oxygen for treatment. But Bernard soon learned that there was never enough oxygen available. He and the other hospital staff often had to share a single cylinder of oxygen between patients. When there were too many patients and not enough oxygen, he and other doctors would be forced to decide which children would receive oxygen and live, and which would go without it and sometimes die—a choice that broke his heart, he says.

That experience inspired Bernard to investigate the source of Kenya’s oxygen supply shortages.  He discovered that one of the biggest challenges is that oxygen is expensive in Africa. In Kenya, oxygen costs about 13 times more than what it does in the United States. The high cost was driven, in part, by a lack of competition. In many countries, including Kenya, there was just a single oxygen supplier for the entire country. And with many health facilities located hundreds of miles away from the oxygen plants, transportation costs drove up prices even higher. The long distances and poor roads also meant that deliveries were unreliable. Hospitals and clinics would regularly run out of oxygen supplies.

In 2014, Bernard founded a public-private partnership to try a new approach that would make access to medical oxygen more affordable and reliable. He named the organization Hewatele (Swahili for “abundant air”). Given the delivery challenges in Kenya, Bernard decided to build oxygen plants at several of the busiest hospitals in the country, where demand is highest and reliable electricity for production is available. The oxygen is then sent out for delivery using a milkman model, with oxygen cylinders regularly dropped off at remote hospitals and clinics and the empty cylinders returned to be refilled. This system ensures that there is always more than enough oxygen available at each facility. Using this new approach, Hewatele has cut the market price for oxygen in Kenya by 50 percent. Now, Bernard is working to expand the number of oxygen plants in Kenya and bring Hewatele’s business model to other parts of Africa.

While the COVID-19 pandemic has brought much needed attention to the oxygen gap in Africa, more needs to be done to ensure that everyone has access to this simple medical intervention. Thanks to Bernard’s efforts, progress is being made. His work has already helped save the lives of thousands of children and adults and will save many more in the future—one breath at a time.

This week global leaders are coming together at the UN General Assembly, which presents an opportunity to refocus energy and commitment on ending the crisis phase of this pandemic and to make sure we’re better prepared for the next one. In this piece I talk about how we can apply what we have learned since early 2020 and embrace a set of global actions that chart an equitable course out of the pandemic—vaccinate now, contain the disease, and coordinate the global response.

We’ve reached the 18^th month of the COVID-19 pandemic, a somber milestone marked by yet another surge of cases and deaths fueled by the Delta variant. This global crisis has been a health, economic and moral disaster playing out in waves in every geography, sparing none. While the pandemic has been a shared experience, the experience has not been the same everywhere.

In the past year-and-a-half, we have witnessed scientific breakthroughs with multiple safe and effective vaccines developed in record time, incredible multilateral cooperation resulting in billions of dollars raised for the response, and heroic efforts by healthcare and frontline workers in communities worldwide. But at the same time, we have also seen widening gaps in equity that go against everything our foundation and its partners have worked for over the past 20 years. The advent of vaccines was an opportunity to bend the curve in the direction of a global recovery. It turned out that unequal distribution and a lack of funding and supply meant the recovery has been precarious and halting.

In last year’s Goalkeepers report, Melinda and I shared modeling that warned that globally deaths would be higher if doses went predominantly to high income countries. To date, less than 2% of people in low-income countries have received a dose of a COVID-19 vaccine, compared to more than 60% of people in the U.S. The pull of the inequity we’re seeing isn’t only on the here and now—the economic recovery of low-income countries that are slow to be vaccinated is stuck in the starting blocks. These countries can expect to experience between 2-4% GDP losses through 2025 (averaging 3% per year in sub-Saharan Africa).

After 18 months of surprises around every corner with variants fueling new waves of disease there’s a tendency to say one cannot predict what will happen next. To some extent that’s true—nature is wily, and the virus will continue to mutate if it can transmit unchecked. But it’s also defeatist and incorrect to suggest that the acute phase of the pandemic will spiral on from one variant to the next. Just as the virus can change, so can the world’s response to it. Whether the world can finally turn the corner, however, will be determined by what we do next and how it’s done.

Our path out of the pandemic has always required one thing—a commitment to equity. A willingness to see that what happens in lower-income countries affects high-income countries. There is no nationalistic solution to this global problem. We’ve seen countries try and fail in that pursuit as variants emerge and threaten progression from the acute phase of the pandemic. There are three things that can be done in the coming months that can bring about the end of the acute phase of the pandemic and set the world on a different timeline in preparation for the next. I hope that leaders meeting virtually this week at the COVID Summit commit to actions that meet these needs:

1. Vaccinate Now

Governments and the private sector must work together to build a more transparent system to accelerate the global supply of vaccines. While a shortage of supply was a major issue in the first half of the year, recently 41 million doses per day have been distributed globally. It’s progress, but there’s a long way to go. The WHO/Gavi-led COVAX AMC, Africa CDC-led African Vaccine Acquisition Task Team (AVATT) and other channels can move vaccines, but they need more doses, visibility to supply, and sufficient money to acquire and deliver them. This is quickly turning into a logistics and financing challenge, and we know how to solve those types of problems. A consolidated global dashboard that provides real-time vaccine production and availability data will enable countries and global institutions to collaborate on filling access gaps. While donations to COVAX were slow to arrive, current funding can support delivery to about 30% of the population in lower- and middle-income countries. It’s a good start, and funding for 70% coverage in the lowest income countries needs to be made available by mid-2022 along with enhanced delivery capacity at the country level.

2. Contain the Disease

In addition to getting vaccines out to close the global equity gap we also must contain outbreaks as they happen. This can help keep countries out of the cycle of lockdowns that has left schools and businesses in constant flux. To reduce the risk of variants jumping from border to border, the world must invest in readily available rapid testing, a system for sharing genetic sequences, and a mechanism to deliver expertise and commodities (like oxygen, PPE, and life-saving drugs) quickly where they are needed. We’ve seen this done successfully with diseases like polio and malaria—using data to inform actions that bring outbreaks under control. We need to have expert support and response materials like oxygen, PPE, and life-saving drugs ready to deploy in the event of major outbreaks. The private sector has a role to play, using its expertise in logistics to reduce lead times and fill supply gaps.

3. Coordinate the Global Response

The establishment of the Access to COVID-19 Tools Accelerator (ACT-A) in early 2020 was a milestone: governments, international organizations and the private sector came together in response to the crisis. We now need all governments to appoint a COVID-19 global lead, reporting to the head of state, and for these leads to regularly convene through 2022. With the support of independent monitoring this globally coordinated, time-limited task force can complement ACT-A and take us from aspiration to ending the pandemic through collective action and provide a model for the long-term coordination needed to prevent future pandemics.

For people involved in global health, what happened during the pandemic is disappointing, but not a surprise. The system whereby lower-income countries rely on the generosity of high-income country donors broke down when those donor countries were experiencing the same struggles. The next 18 months do not have to look like the past 18 months. But we cannot turn the page on this pandemic until we’ve addressed the fundamental inequity that stands in our way.

I’m optimistic about the potential of this moment. Health is not a zero-sum game—we can meet everyone’s needs through planning, investment, collaboration, and applying lessons learned. The cost of this pandemic has already been unacceptably high. Ending it cannot come at the cost of progress on other global health and development priorities. Reducing poverty, advancing gender equality, and finishing the job of eradicating polio are all possible through the same collective action that is needed to end this pandemic.

For those that want to go deeper, Gargee Ghosh who heads up the policy and advocacy division at the Gates Foundation has shared a white paper with more details on actions the world could take to end the COVID crisis.

I’ve spent a lot of time over the last year meeting with colleagues at our foundation and around the world about ways to test for, treat, and prevent COVID-19. In recent months, the experts in those meetings are increasingly asking the same question: How will new variants impact our efforts to end the pandemic?

The world has come a long way in the fight against COVID-19, but new variants of the virus could threaten progress we’ve made over the past year. Here are five things you should know if you want to understand how variants are (and aren’t) complicating the pandemic.

1. If you’ve ever gotten a flu shot, you’ve already dealt with a virus variant.

Viruses evolve all the time. Unless you work on infectious diseases, the idea of a “variant” might seem new and scary—but there’s nothing particularly unusual about them. Influenza’s ability to mutate quickly (I’ll talk more about this in the next section) is why we get a new flu shot every year. We need to update the vaccine annually to keep up with constantly shifting flu virus strains.

To understand why the virus that causes COVID-19 is changing, you need to understand how it works (or spreads) in your body. The coronavirus—like all viruses—has only one goal: to replicate itself. Every time the virus invades your cells, it tricks the cell into following the instructions encoded in its RNA to make more copies of the virus.

When the cell is making a new virus, it has to copy those instructions. If you’ve ever had to take a typing class in school, you know how hard it is to retype something without making a mistake. The code for the virus that causes COVID-19 is around 30,000 letters long. That’s a lot of opportunities to mess up—which the coronavirus often does.

Most mistakes lead to a virus that either is functionally identical or can’t replicate. But every once in a while, there’s a change that makes it easier for the virus to infect people or evade the immune system. When that change starts to spread through a population, a new variant emerges.

2. We’re seeing the same mutations pop up again and again. That may be good news.

All viruses evolve, but not all viruses evolve at the same rate and in the same way. Some, like the flu, change rapidly. Others mutate slowly. Fortunately for us, SARS-CoV-2 is in the latter camp. It mutates about half as fast as the influenza virus.

I know it feels like new variants are popping up all the time right now. That’s because there is so much virus circulating around the world, giving it more opportunities to change. Once case numbers go down, I suspect we’ll see new variants emerge much less often.

Compared to influenza viruses—which are made up of eight genetic segments that can be rearranged in lots of different ways—the coronavirus is a much simpler virus. The most notable mutations we’ve seen so far have happened in the same spot: the spike protein that sticks out of the surface of the virus.

That spike protein is the key to COVID’s spread. Its shape is what enables the virus to grab onto human cells. If the spike protein changes just a little, it might bind with cells more effectively (which makes the virus more transmissible) or become harder for the immune system to target (which makes people more susceptible to it). But if it changes too much, the virus can no longer gain the entry that’s key to its lifecycle.

That limited capacity for change may explain why we keep seeing the same mutations appear in different places rather than lots of distinct variations. Both B.1.1.7 (which was originally detected in the UK) and B.1.351 (which was first found in South Africa) evolved independently, yet they share a number of the same mutations. There’s clearly something about these specific mutations that makes them more likely to succeed than other changes.

Some experts think we may have already seen the most concerning mutations that this virus is capable of. But COVID-19 has surprised us before, of course, and it could surprise us again.

3. The virus is changing, but the path to ending the pandemic remains the same.

For the last year, public health experts have been repeating some form of the same message: we need to contain COVID-19 as best we can until the vaccine is ready and available for everyone.

The good news is that many of the vaccines being used today appear to prevent severe disease, even from the new variants. This is a tribute to how effective the vaccines are in general. We still need a lot more data about how effective every vaccine is against the different variants, but many of the early numbers are reassuring (especially out of Israel, where many people are already vaccinated and the B.1.1.7 strain is dominant).

The big question now is whether we need to update the vaccines to target the variants. Regulators and drug companies are working on a modified vaccine that could be out in a couple months if it’s deemed necessary. Here in the United States—where the majority of people will likely be vaccinated by the end of the summer—some people may end up getting a booster shot that protects against additional strains.

For now, the key is to keep following best practices. The best way to prevent new variants from emerging is by stopping transmission of the virus altogether. If we remain vigilant about social distancing, wearing a mask, and getting vaccinated, we will bring the pandemic to an end much sooner.

4. Variants make it even more important that vaccines are made available everywhere.

COVID-19 anywhere is a threat to health everywhere. That’s true with the original virus, and it’s true when it comes to variants.

The more the virus that causes COVID-19 is out there in the world, the more opportunities it has to evolve—and to develop new ways of fighting our defenses against it. If we don’t get the vaccine out to every corner of the planet, we’ll have to live with the possibility that a much worse strain of the virus will emerge. We could even see a new variant emerge that evades existing vaccines altogether.

No one wants that to happen. The best way to make sure it doesn’t is by getting the vaccine out to everyone who needs it, no matter where they live. That’s why our foundation is working with governments, vaccine manufacturers, organizations like CEPI and Gavi, the Vaccine Alliance, and others to deliver COVID-19 vaccines to low-income countries through an initiative called COVAX.

COVAX recently announced that it’ll be able to deliver 300 million doses by mid-2021. That’s great news, but the world is going to need a lot more if we’re going to truly stamp out the threat of COVID-19.  I hope rich world countries continue to support COVAX’s work, even as life starts to get back to normal in some parts of the world over the summer.

5. We can do better next time.

Virus variants are inevitable. If we ever find ourselves in a pandemic scenario again where a pathogen is spreading around the globe, we should expect to see it adapt to survive our attempts to stop it—just as we saw with COVID-19. I hope the difference next time is that we’re better prepared to spot these variants earlier.

The key will be genetic sequencing in combination with better disease surveillance. Right now, if you test positive for COVID-19, there’s a possibility that your test sample gets selected to be sequenced. This lets researchers see the exact 30,000 letter code that makes up the virus’ RNA instructions. That code gets uploaded to a database, where a computer compares the virus in your sample to all the other strains in circulation. . If you have a new strain that’s starting to pop up over and over in your area, scientists can compare the sequence data to transmission, death, and hospitalization rates to see if there’s need for concern.

Researchers need to take a systematic approach to catch variants early. Some experts think we need to sequence at least 5 percent of all test samples to get an accurate picture of how a pathogen is mutating—although sequencing a large number of samples alone isn’t enough. The UK has analyzed nearly 8 percent of its tests and linked that data with their surveillance capabilities, which helped them see that B.1.1.7 was spreading much faster and was more lethal. South Africa was able to quickly see how vaccines worked on B.1.351 by comparing results from clinical trials there to sequenced data.

The tools we’re putting in place to monitor variants in this pandemic will prove invaluable long after the worst of COVID-19 is behind us. Widespread sequencing should be part of any plan to prepare for the next pandemic. If you’re doing enough sequencing and comparing that data with other measures, you can see concerning variants when they first emerge. The earlier you identify a change, the more time you have to study it and, if needed, to tune vaccines and therapeutics to address any changes that have taken place.

There’s no doubt that variants complicate our efforts to bring an end to this pandemic. Even once the worst is behind us, we’ll need to remain vigilant. Fortunately, we know what we need to do to stop them from emerging. For now, the best thing you can do to protect yourself is to follow public health guidelines and get vaccinated as soon as you’re eligible.  

At the start of the pandemic, many people feared that not only would COVID-19 itself be a disaster, but the lockdowns and other prevention methods would have an awful ripple effect: disrupting the fight against malaria in a catastrophic way.

A modeling analysis from the World Health Organization, which I shared here last year, found that annual malaria deaths in sub-Saharan Africa could double, returning to death rates not seen in over 20 years.

A year later, I’m happy to be able to report that this worst-case scenario, at least for now, has been avoided. This is thanks to the leadership of African countries, which quickly adapted their malaria programs to meet the challenges of the pandemic. Practicing social distancing and other safety measures, malaria workers were able to carry out their duties, delivering long-lasting insecticide-treated bed nets, controlling mosquito populations with indoor spraying, and providing preventive treatment for pregnant women and children. In Nigeria, which still suffers from 60 million cases of malaria each year, health workers managed to even increase their delivery of malaria control, protecting millions of children in one of their largest campaigns to date.

At the same time, malaria resources have served double duty, tackling the mosquito-borne disease and helping to control the spread of COVID-19.

In Zambia, the scientists and equipment in the National Malaria Elimination Program’s genomic surveillance laboratory used to monitor malaria drug resistance quickly pivoted to find COVID-19 variants in the country. In Mozambique, an app created for health workers to provide real-time reporting of malaria cases and fevers has supplied critical data to the national COVID response.

Despite this progress, our work is not over. Malaria still kills more than 400,000 people each year. And pandemic lockdowns and movement restrictions have hampered some critical malaria activities, including access to diagnosis and treatment efforts in Africa.

Still, I’m optimistic that a world without malaria is within reach. And the COVID-19 pandemic reminds us why eradicating malaria is essential. Many of the building blocks we need to fight malaria and prevent the next pandemic are the same: accurate, real-time data; reliable supply chains to bring medicines and resources where they are needed most; and cross-country collaboration.

Investments in malaria programs help build stronger health systems that will not only save lives and bring an end to malaria, but also protect us from the next pandemic. And that creates a healthier, safer world for all.

Earlier this year, I shared a video where I drank water made from feces. (My review: It was delicious.) Today the machine that produced the water, the Janicki Omni Processor—or JOP—is in Dakar, Senegal, as part of a pilot project that could ultimately save lives and reduce disease in poor countries. Here’s an update on where things stand:

You may recall that the JOP takes human waste and turns it into drinking water, electricity, and ash. (It is actually one of several Omni Processors being developed that treat human waste and produce something of value.) It’s tempting to focus on the drinking water, for obvious reasons. But the goal is not to provide water. The goal is to dramatically improve sanitation for all the cities in poor countries.

Today at least 2 billion people use latrines that aren’t properly drained, and diseases caused by poor sanitation kill some 700,000 children every year. Unfortunately, rich-world solutions aren’t feasible in poor countries—they require too much expensive infrastructure. (We put together this slideshow so you can see how the system works in Dakar today and how the JOP fits in.) The idea behind every Omni Processor design is to solve this problem by making sanitation affordable for the poor.

We think we have solved the big engineering challenges, thanks to ingenious design work by our partners Janicki Bioenergy. The technology just keeps getting better: The next version of the machine will burn most types of garbage in addition to human waste, and it will be easier to maintain. We also think we have a good business plan. Janicki is discussing the sale of the first JOP to a Senegalese company, and they’re talking to potential buyers in wealthier countries too.

But business plans and brilliant engineering are not enough. The machine has to be tested—and unlike a computer program, sanitation machines can’t be tested from a desk in Seattle. The real world introduces lots of variables. For example, you have to find the right personnel to run the machine. You have to work with local and national governments and gauge the public’s reaction.

So it is great that we are now on the learning curve with a unit in the field. So far, the results on all fronts have been promising. The JOP is working as predicted. The partners in Dakar, especially the national sanitation utility, have been fantastic—you can see in the video how energetic and optimistic they are. At every step, we’re learning and will incorporate what we find in future designs and operating plans. For example, the team is still looking at ways to make the JOP cheaper and smaller.

Much of the technology involved in the JOP has been around for years. So why hasn’t anyone built one before now? Because the people who understood the technology weren’t getting sick or dying from contaminated water, and they didn’t know anyone who was. Nor was it clear how they could make a profit by working on the problem. It was a classic market failure.

Now we have a business plan, an impassioned team of engineers, great in-country partners, and a pilot project in motion. I think we have a real shot at solving the sanitation problem. This is a great example of what can happen when we get bright people focused on the world’s biggest problems.

The next time you flush a toilet, consider this: 1 billion people defecate in the open. Another 4 billion use rudimentary toilets and their waste is never treated.

I have visited communities where this is a sobering fact of life. The smell can be overwhelming, but even worse, the sewage seeps into the water supply, spreading disease. Poor sanitation is linked to the deaths of some 700,000 children every year.

Our foundation is funding the Omni Processor, a machine that we hope will make sanitation affordable.

Dr. Mbaye Mbeguere is one of the Senegalese officials leading this pilot project. You can see the Janicki OP behind him. Dr. Mbeguere and his colleagues hope Omni Processors will change the face of sanitation in cities around the world. I am optimistic that they are right.

I watched the piles of feces go up the conveyer belt and drop into a large bin. They made their way through the machine, getting boiled and treated. A few minutes later I took a long taste of the end result: a glass of delicious drinking water.

The occasion was a tour of a facility that burns human waste and produces water and electricity (plus a little ash). I have visited lots of similar sites, like power plants and paper mills, so when I heard about this one—it’s part of the Gates Foundation’s effort to improve sanitation in poor countries—I was eager to check it out.

The water tasted as good as any I’ve had out of a bottle. And having studied the engineering behind it, I would happily drink it every day. It’s that safe.

Here’s a short video from my visit in November, which explains how it all works:

Why would anyone want to turn waste into drinking water and electricity?

Because a shocking number of people, at least 2 billion, use latrines that aren’t properly drained. Others simply defecate out in the open. The waste contaminates drinking water for millions of people, with horrific consequences: Diseases caused by poor sanitation kill some 700,000 children every year, and they prevent many more from fully developing mentally and physically.

If we can develop safe, affordable ways to get rid of human waste, we can prevent many of those deaths and help more children grow up healthy.

Western toilets aren’t the answer, because they require a massive infrastructure of sewer lines and treatment plants that just isn’t feasible in many poor countries. So a few years ago our foundation put out a call for new solution.

One idea is to reinvent the toilet, which I’ve written about before.

Another idea—and the goal of the project I toured—is to reinvent the sewage treatment plant. The project is called the Omniprocessor, and it was designed and built by Janicki Bioenergy, an engineering firm based north of Seattle. I recently went to Janicki’s headquarters to check out an Omniprocessor before the start of a pilot project in Senegal.

The Omniprocessor is a safe repository for human waste. Today, in many places without modern sewage systems, truckers take the waste from latrines and dump it into the nearest river or the ocean—or at a treatment facility that doesn’t actually treat the sewage. Either way, it often ends up in the water supply. If they took it to the Omniprocessor instead, it would be burned safely. The machine runs at such a high temperature (1000 degrees Celsius) that there’s no nasty smell; in fact it meets all the emissions standards set by the U.S. government.

Before we even started the tour, I had a question: Don’t modern sewage plants already incinerate waste? I learned that some just turn the waste into solids that are stored in the desert. Others burn it using diesel or some other fuel that they buy. That means they use a lot of energy, which makes them impractical in most poor countries.

The Omniprocessor solves that problem. Through the ingenious use of a steam engine, it produces more than enough energy to burn the next batch of waste. In other words, it powers itself, with electricity to spare. The next-generation processor, more advanced than the one I saw, will handle waste from 100,000 people, producing up to 86,000 liters of potable water a day and a net 250 kw of electricity.

If we get it right, it will be a good example of how philanthropy can provide seed money that draws bright people to work on big problems, eventually creating a self-supporting industry. Our foundation is funding Janicki to do the development. It’s really amazing to see how they’ve embraced the work; founder Peter Janicki and his family have traveled to Africa and India multiple times so they can see the scope of the problem. Our goal is to make the processors cheap enough that entrepreneurs in low- and middle-income countries will want to invest in them and then start profitable waste-treatment businesses.

We still have a lot to learn before we get to that point. The next step is the pilot project; later this year, Janicki will set up an Omniprocessor in Dakar, Senegal, where they’ll study everything from how you connect with the local community (the team is already working with leaders there) to how you pick the most convenient location. They will also test one of the coolest things I saw on my tour: a system of sensors and webcams that will let Janicki’s engineers control the processor remotely and communicate with the team in Dakar so they can diagnose any problems that come up.

The history of philanthropy is littered with well-intentioned inventions that never deliver on their promise. Hopefully, these early steps will help us make sure the Omniprocessor doesn’t join the list. If things go well in Senegal, we’ll start looking for partners in the developing world. For example I think it could be a great fit in India, where there are lots of entrepreneurs who could own and operate the processors, as well as companies with the skill to manufacture many of the parts.

It might be many years before the processor is being used widely. But I was really impressed with Janicki’s engineering. And I’m excited about the business model. The processor wouldn’t just keep human waste out of the drinking water; it would turn waste into a commodity with real value in the marketplace. It’s the ultimate example of that old expression: one man’s trash is another man’s treasure.

Ever since I was a teenager, I’ve tackled every big new problem the same way: by starting off with two questions. I used this technique at Microsoft, and I still use it today. I ask these questions literally every week about COVID-19.

Here they are: Who has dealt with this problem well? And what can we learn from them?

They seem like obvious questions, but sometimes it's surprisingly hard to find the answers—especially when it comes to global health. There are low- and middle-income countries that have made huge leaps in, for example, delivering vaccines or ending malnutrition. But anyone who wants to identify those countries, find out how they did it, and apply the lessons in their own country would have their work cut out for them.

In sports, every coach is able to study the most successful teams and figure out what they’re doing well. There’s no reason that things should be any different when the goal is preventing childhood deaths instead of scoring touchdowns.

That’s why I was eager to be part of a global effort to fill the gap. Over the past three years, health experts and organizations from countries at every income level (including the Gates Foundation) have come together to find out who has made the most progress on certain health problems, identify what made them so successful, and help others put these lessons into action.

The result of all this effort—the Exemplars in Global Health program—launched earlier this year. If you want to know which countries have made the most progress with limited resources, Exemplars is a great place to start.

For now, Exemplars focuses on five areas: under-five mortality; vaccine delivery; the role of community health workers; epidemic preparedness and response; and childhood stunting (the reduction in physical and mental development caused by poor nutrition). The team will be adding other areas, including newborn and maternal mortality, family planning, maternal anemia, and primary health care systems.

The Exemplars team has scoured the world for the best performers and worked with experts in those countries to find out what worked so well. For example, they identified seven countries that have excelled at reducing the number of children who die before their fifth birthday: Bangladesh, Cambodia, Ethiopia, Nepal, Peru, Rwanda, and Senegal. The Exemplars website has a profile of each country, detailing insights from its work that other countries could learn from.

Bangladesh—whose childhood mortality rate dropped 56 percent between 2000 and 2015—used data, research, and testing especially well, and empowered women to make decisions about their children’s health. Peru, which achieved roughly the same decline as Bangladesh, conducted local studies to identify interventions that might suit specific communities. All seven countries built up strong community health systems and made specific efforts to close the equity gap by reaching the poorest people.

Of course, not all lessons can be applied in the same way everywhere. What works in one country may not work exactly the same way in another. And it is not always obvious how to implement big changes in national health systems, which are very complex and require a lot of coordination among the government, the private sector, and non-profits.

Recognizing these challenges, the Exemplars program is much more than a website. There is also a community of global and in-country experts ready to help countries make the case for investing in the most effective programs and figure out how to adapt the lessons to their particular needs. We’re not interested in simply getting the information out there—we want to help drive change.

Our hope is to connect with decisionmakers: people who work in the governments of low- and middle-income countries, at development agencies like America’s USAID and the World Bank, and at organizations that implement health programs. Exemplars is all about figuring out how to improve health care based on evidence of what works. It will help governments use time and money more efficiently—and with the COVID-19 pandemic, there has never been a greater need to get the most impact out of every dollar spent.

I’m grateful to all the people in governments, academia, and non-profits who made the Exemplars program possible. We all started out with one goal in mind: to accelerate the progress in improving health, so that the poorest countries don't have 20 times the childhood death rate of the richest ones. I think Exemplars is a great resource that will spread success stories so even countries with very little money can benefit. And that will, ultimately, save lives.

Vaccines have been saving lives for centuries. But from the time Edward Jenner created the first vaccine in the late 1700s, not everyone has had equal access to them. As a result, children in some parts of the world continued to die from diseases that were preventable in other parts.

When Melinda and I learned about this inequity over twenty years ago, we thought it was infuriating—and deeply unfair. So, in 2000, our foundation teamed up with countries whose children were impacted the most, the World Health Organization, the World Bank, UNICEF, vaccine manufactures, and donors to do something about it. Together, we created an organization called Gavi, the Vaccine Alliance.

Gavi works with governments to make sure that every child has access to the lifesaving vaccines they need. The organization makes this happen by negotiating vaccines at prices that are affordable for the poorest countries. Since Gavi guarantees high volumes, manufacturers are able to lower the cost of vaccines quite dramatically. Gavi also helps low-income countries strengthen systems to deliver vaccines to all communities.

Over the last two decades, Gavi has helped vaccinate more than 760 million children and prevented more than 13 million deaths. That’s a truly amazing result.

Governments and partners from around the world are meeting virtually today to raise funds for Gavi’s next five years of work. This investment is more important than ever before, because Gavi is going to play a key role in making sure that, when we have COVID-19 vaccines, they reach the most vulnerable people. Their expertise and experience in distributing vaccines will be invaluable as we work to end this outbreak once and for all.

This post originally appeared as an opinion piece in the Washington Post. It’s adapted from a longer article, which you can read here.

It’s entirely understandable that the national conversation has turned to a single question: “When can we get back to normal?” The shutdown has caused immeasurable pain in jobs lost, people isolated, and worsening inequity. People are ready to get going again.

Unfortunately, although we have the will, we don’t have the way—not yet. Before the United States and other countries can return to business and life as usual, we will need some innovative new tools that help us detect, treat, and prevent COVID-19.

It begins with testing. We can’t defeat an enemy if we don’t know where it is. To reopen the economy, we need to be testing enough people that we can quickly detect emerging hotspots and intervene early. We don’t want to wait until the hospitals start to fill up and more people die.

Innovation can help us get the numbers up. The current coronavirus tests require that health-care workers perform nasal swabs, which means they have to change their protective gear before every test. But our foundation supported research showing that having patients do the swab themselves produces results that are just as accurate. This self-swab approach is faster and safer, since regulators should be able to approve swabbing at home or in other locations rather than having people risk additional contact.

Another diagnostic test under development would work much like an at-home pregnancy test. You would swab your nose, but instead of sending it into a processing center, you’d put it in a liquid and then pour that liquid onto a strip of paper, which would change color if the virus was present. This test may be available in a few months.

We need one other advance in testing, but it’s social, not technical: consistent standards about who can get tested. If the country doesn’t test the right people—essential workers, people who are symptomatic, and those who have been in contact with someone who tested positive—then we’re wasting a precious resource and potentially missing big reserves of the virus. Asymptomatic people who aren’t in one of those three groups should not be tested until there are enough tests for everyone else.

The second area where we need innovation is contact tracing. Once someone tests positive, public-health officials need to know who else that person might have infected.

For now, the United States can follow Germany’s example: interview everyone who tests positive and use a database to make sure someone follows up with all their contacts. This approach is far from perfect, because it relies on the infected person to report their contacts accurately and requires a lot of staff to follow up with everyone in person. But it would be an improvement over the sporadic way that contact tracing is being done across the United States now.

An even better solution would be the broad, voluntary adoption of digital tools. For example, there are apps that will help you remember where you have been; if you ever test positive, you can review the history or choose to share it with whoever comes to interview you about your contacts. And some people have proposed allowing phones to detect other phones that are near them by using Bluetooth and emitting sounds that humans can’t hear. If someone tested positive, their phone would send a message to the other phones, and their owners could get tested. If most people chose to install this kind of application, it would probably help some.

Naturally, anyone who tests positive will immediately want to know about treatment options. Yet, right now, there is no treatment for COVID-19. Hydroxychloroquine, which works by changing the way the human body reacts to a virus, has received a lot of attention. Our foundation is funding a clinical trial that will give an indication whether it works on COVID-19 by the end of May, and it appears the benefits will be modest at best.

But several more-promising candidates are on the horizon. One involves drawing blood from patients who have recovered from COVID-19, making sure it is free of the coronavirus and other infections, and giving the plasma (and the antibodies it contains) to sick people. Several major companies are working together to see whether this succeeds.

Another type of drug candidate involves identifying the antibodies that are most effective against the novel coronavirus, and then manufacturing them in a lab. If this works, it is not yet clear how many doses could be produced; it depends on how much antibody material is needed per dose. In 2021, manufacturers may be able to make as few as 100,000 treatments or many millions.

If, a year from now, people are going to big public events—such as games or concerts in a stadium—it will be because researchers have discovered an extremely effective treatment that makes everyone feel safe to go out again. Unfortunately, based on the evidence I’ve seen, they’ll likely find a good treatment, but not one that virtually guarantees you’ll recover.

That’s why we need to invest in a fourth area of innovation: making a vaccine. Every additional month that it takes to produce a vaccine is a month in which the economy cannot completely return to normal.

The new approach I’m most excited about is known as an RNA vaccine. (The first COVID-19 vaccine to start human trials is an RNA vaccine.) Unlike a flu shot, which contains fragments of the influenza virus so your immune system can learn to attack them, an RNA vaccine gives your body the genetic code needed to produce viral fragments on its own. When the immune system sees these fragments, it learns how to attack them. An RNA vaccine essentially turns your body into its own vaccine manufacturing unit.

There are at least five other efforts that look promising. But because no one knows which approach will work, a number of them need to be funded so they can all advance at full speed simultaneously.

Even before there’s a safe, effective vaccine, governments need to work out how to distribute it. The countries that provide the funding, the countries where the trials are run, and the ones that are hardest-hit will all have a good case that they should receive priority. Ideally, there would be global agreement about who should get the vaccine first, but given how many competing interests there are, this is unlikely to happen. Whoever solves this problem equitably will have made a major breakthrough.

World War II was the defining moment of my parents’ generation. Similarly, the coronavirus pandemic—the first in a century—will define this era. But there is one big difference between a world war and a pandemic: All of humanity can work together to learn about the disease and develop the capacity to fight it. With the right tools in hand, and smart implementation, we will eventually be able to declare an end to this pandemic—and turn our attention to how to prevent and contain the next one.

There’s no question the United States missed the opportunity to get ahead of the novel coronavirus. But the window for making important decisions hasn’t closed. The choices we and our leaders make now will have an enormous impact on how soon case numbers start to go down, how long the economy remains shut down and how many Americans will have to bury a loved one because of COVID-19.

Our foundation has been working to slow the outbreak for several months. To date, we’ve invested $105 million in efforts to create new therapeutics, expand access to testing, and limit the virus’s impact here in Seattle.

As a result of this work, I’ve spoken with experts and leaders in Washington and across the country. It’s become clear to me that we must take three steps.

First, we need a consistent nationwide approach to shutting down. Despite urging from public health experts, some states and counties haven’t shut down completely. In some states, beaches are still open; in others, restaurants still serve sit-down meals.

This is a recipe for disaster. Because people can travel freely across state lines, so can the virus. The country’s leaders need to be clear: Shutdown anywhere means shutdown everywhere. Until the case numbers start to go down across America—which could take 10 weeks or more—no one can continue business as usual or relax the shutdown. Any confusion about this point will only extend the economic pain, raise the odds that the virus will return, and cause more deaths.

Second, the federal government needs to step up on testing. Far more tests should be made available. We should also aggregate the results so we can quickly identify potential volunteers for clinical trials and know with confidence when it’s time to return to normal. There are good examples to follow: New York state recently expanded its capacity to more than 25,000 tests per day.

There’s also been some progress on more efficient testing methods, such as the self-swab developed by the Seattle Coronavirus Assessment Network, which allows patients to take a sample themselves without possibly exposing a health worker. I hope this and other innovations in testing are scaled up across the country soon.

Even so, demand for tests will probably exceed the supply for some time, and right now, there’s little rhyme or reason to who gets the few that are available. As a result, we don’t have a good handle on how many cases there are or where the virus is likely headed next, and it will be hard to know if it rebounds later. And because of the backlog of samples, it can take seven days for results to arrive when we need them within 24 hours.

This is why the country needs clear priorities for who is tested. First on the list should be people in essential roles such as health-care workers and first responders followed by highly symptomatic people who are most at risk of becoming seriously ill and those who are likely to have been exposed.

The same goes for masks and ventilators. Forcing 50 governors to compete for lifesaving equipment—and hospitals to pay exorbitant prices for it—only makes matters worse.

Finally, we need a data-based approach to developing treatments and a vaccine. Scientists are working full speed on both; in the meantime, leaders can help by not stoking rumors or panic buying. Long before the drug hydroxychloroquine was approved as an emergency treatment for COVID-19, people started hoarding it, making it hard to find for lupus patients who needed it to survive.

We should stick with the process that works: Run rapid trials involving various candidates and inform the public when the results are in. Once we have a safe and effective treatment, we’ll need to ensure that the first doses go to the people who need them most.

To bring the disease to an end, we’ll need a safe and effective vaccine. If we do everything right, we could have one in less than 18 months—the fastest a vaccine has ever been developed. But creating a vaccine is only half the battle. To protect Americans and people around the world, we’ll need to manufacture billions of doses.

Without a vaccine, developing countries are at even greater risk than wealthy ones, because it’s even harder for them to do physical distancing and shutdowns. The further down the income ladder people live, the more important it is that they go to work every day just to feed their family.

If they live in the poorest parts of sub-Saharan Africa or India, staying home simply isn’t an option. Even if they do stay home, they can’t just wall themselves off from their neighbors; in slums, the houses are packed together so closely that there’s no way to keep your distance. All the work that rich countries are doing now to develop vaccines will save lives in those places, too.

We can get a head start on manufacturing all of the doses we’ll need now by building the facilities where these vaccines will be made. Because many of the top candidates are made using unique equipment, we’ll have to build facilities for each of them, knowing that some won’t get used. Private companies can’t take that kind of risk, but the federal government can. It’s a great sign that the administration made deals this week with at least two companies to prepare for vaccine manufacturing. I hope more deals will follow.

In 2015, I urged world leaders in a TED talk to prepare for a pandemic the same way they prepare for war—by running simulations to find the cracks in the system. As we’ve seen this year, we have a long way to go. But I still believe that if we make the right decisions now, informed by science, data, and experience of medical professionals, we can save lives and get the country back to work.

A version of this post originally appeared on the website of the Washington Post.

In any crisis, leaders have two equally important responsibilities: solve the immediate problem and keep it from happening again. The COVID-19 pandemic is an excellent case in point. The world needs to save lives now while also improving the way we respond to outbreaks in general. The first point is more pressing, but the second has crucial long-term consequences.

The long-term challenge—improving our ability to respond to outbreaks—isn’t new. Global health experts have been saying for years that another pandemic rivalling the speed and severity of the 1918 influenza epidemic wasn’t a matter of if but when. The Bill & Melinda Gates Foundation has committed significant resources in recent years to helping the world prepare for such a scenario.

Now, in addition to the perennial challenge, we face an immediate crisis. In the past week, COVID-19 has started to behave a lot like the once-in-a-century pathogen we’ve been worried about. I hope it’s not that bad, but we should assume that it will be until we know otherwise.

There are two reasons that COVID-19 is such a threat. First, it can kill healthy adults in addition to elderly people with existing health problems. The data so far suggests that the virus has a case fatality risk around 1%; this rate would make it several times more severe than typical seasonal influenza and would put it somewhere between the 1957 influenza pandemic (0.6%) and the 1918 influenza pandemic (2%).

Second, COVID-19 is transmitted quite efficiently. The average infected person spreads the disease to two or three others. That’s an exponential rate of increase. There is also strong evidence that it can be transmitted by people who are just mildly ill or not even showing symptoms yet. This means COVID-19 will be much harder to contain than Middle East Respiratory Syndrome or Severe Acute Respiratory Syndrome (SARS), which were only spread by those showing symptoms and were much less efficiently transmitted. In fact, COVID-19 has already caused 10 times as many cases as SARS in just a quarter of the time.

The good news is that national, state, and local governments and public health agencies can take steps over the next few weeks to slow the spread of COVID-19.

For example, in addition to helping their own citizens respond, donor governments should help low- and middle-income countries prepare for this pandemic. The health systems in many of these countries are already stretched thin, and a pathogen like coronavirus can quickly overwhelm them. And poorer countries have little political or economic leverage, given wealthier countries’ natural desire to put their own people first.

By helping countries in Africa and South Asia get ready now, we can save lives and also slow the global circulation of the virus. (A significant portion of the commitment Melinda and I recently made to help kickstart the global response to COVID-19—which could total up to $100 million—is focused particularly on developing countries.)

The world also needs to accelerate work on treatments and vaccines for COVID-19. Scientists were able to sequence the genome of the virus and develop several promising vaccine candidates in a matter of days, and the Coalition for Epidemic Preparedness Innovations is already preparing up to eight promising vaccine candidates for clinical trials. If one or more of these vaccines proves safe and effective in animal models, they could be ready for larger-scale trials as early as June. Drug discovery can also be accelerated by drawing on libraries of compounds that have already been tested for safety and by applying new screening techniques, including machine learning, to identify antivirals that could be ready for large-scale clinical trials within weeks.

All these steps would help address the current crisis. But we also need to make larger systemic changes so we can respond more efficiently and effectively when the next epidemic arrives.

It’s essential to help low- and middle-income countries strengthen their primary health care systems. When you build a health clinic, you’re also creating part of the infrastructure for fighting epidemics. Trained health care workers not only deliver vaccines; they can also monitor disease patterns, serving as part of the early warning systems that will alert the world to potential outbreaks.

The world also needs to invest in disease surveillance, including a case database that is instantly accessible to the relevant organizations and rules that require countries to share their information. Governments should have access to lists of trained personnel, from local leaders to global experts, who are prepared to deal with an epidemic immediately, as well as lists of supplies to be stockpiled or redirected in an emergency.

In addition, we need to build a system that can develop safe and effective vaccines and antivirals, get them approved, and deliver billions of doses within a few months of the discovery of a fast-moving pathogen. That’s a tough challenge that presents technical, diplomatic, and budgetary obstacles, as well as demanding partnership between the public and private sectors. But all these obstacles can be overcome.

One of the main technical challenges for vaccines is to improve on the old ways of manufacturing proteins, which are just too slow for responding to an epidemic. We need to develop platforms that are predictably safe, so regulatory reviews can happen quickly, and that make it easy for manufacturers to produce doses at a low cost and a massive scale. For antivirals, there will need to be an organized system to screen existing treatments and candidate molecules in a swift and standardized manner.

Another technical challenge involves constructs based on nucleic acids. These constructs can be produced within hours after a virus’s genome has been sequenced; now we need to find ways to produce them at scale.

In addition to these technical solutions, we’ll need diplomatic efforts to drive international collaboration and data sharing. Developing antivirals and vaccines involves massive clinical trials and licensing agreements that would cross national borders. We should make the most of global forums that can help achieve consensus on research priorities and trial protocols so that promising vaccine and antiviral candidates can move quickly through this process. These platforms include the World Health Organization R&D Blueprint, the International Severe Acute Respiratory and Emerging Infection Consortium trial network, and the Global Research Collaboration for Infectious Disease Preparedness. The goal of this work should be to get conclusive clinical trial results and regulatory approval in three months or less, without compromising patients’ safety.

Then there is the question of funding. Budgets for these efforts need to be expanded several times over. Billions more dollars are needed to complete Phase III trials and secure regulatory approval for coronavirus vaccines, and still more funding will be needed to improve disease surveillance and response.

Why does this require government funding—can’t the private sector solve this on its own? Pandemic products are extraordinarily high-risk investments, and pharmaceutical companies will need public funding to de-risk their work and get them to jump in with both feet. In addition, governments and other donors will need to fund—as a global public good—manufacturing facilities that can generate a vaccine supply in a matter of weeks. These facilities can make vaccines for routine immunization programs in normal times and be quickly refitted for production during a pandemic. Finally, governments will need to finance the procurement and distribution of vaccines to the populations that need them.

Obviously, billions of dollars for anti-pandemic efforts is a lot of money. But that’s the scale of investment required to solve the problem. And given the economic pain that an epidemic can impose—just look at the way COVID-19 is disrupting supply chains and stock markets, not to mention people’s lives—it will be a bargain.

Finally, governments and industry will need to come to an agreement: During a pandemic, vaccines and antivirals won’t simply be sold to the highest bidder. They’ll be available and affordable for people who are at the heart of the outbreak and in greatest need. Not only is this the right thing to do, it’s also the right strategy for short-circuiting transmission and preventing future pandemics.

These are the actions that leaders should be taking now. There is no time to waste.

This post originally appeared on the website of the New England Journal of Medicine. I wrote there about the need for a global pandemic response system in 2015, and about the threat posed by a novel respiratory virus in 2018.

People often ask me which technologies have the most potential to change our lives in the decades ahead.

AI is always near the top of the list. It can help us make sense of complex biological systems—like the microbiome in the human gut—and give us new insight into tough problems in global health, such as premature birth.

Gene-based tools are another technology that I always mention. For example, advances in that field are giving researchers powerful new tools to investigate potential cures for AIDS, sickle-cell disease, and other conditions.

These tools can also give us key insights into new diseases, such as the novel coronavirus that recently emerged, so that we can develop diagnostic tests, treatments, and vaccines faster.

Thanks to these and other breakthroughs, science is giving us the opportunity to improve lives more rapidly than ever. But we’ll only make the most of that potential if we ensure that these tools reach everyone who needs them, including the poorest people in the world.

That’s the focus of much of our work at the Gates Foundation. Today I’m honored to be giving a speech on this subject at the annual meeting of the American Association for the Advancement of Science. Here’s what I plan to say:

Remarks as prepared
Seattle, WA
February 14, 2020
American Association for the Advancement of Science

Thank you. It’s great to be here today.

The Coronavirus

I want to take a few minutes to talk about the novel coronavirus, which I know is on everyone’s mind.

Our foundation has committed up to $100 million to address this new coronavirus because we believe it poses a serious threat to global health. This money will support efforts to detect, isolate, and treat confirmed cases, help countries in sub-Saharan Africa and South Asia take steps to prepare for the epidemic and protect their most vulnerable citizens, and accelerate the development of vaccines, treatments, and diagnostics.

We believe that multilateral organizations and national governments must make every effort to stop this outbreak, but we also want to help the world be better prepared if it becomes a global pandemic. Above all, we believe that the world will need to be guided by science, not fear, in the weeks ahead.

The Diseases of Poverty

A few blocks from here is the foundation that Melinda and I started in 2000. When we decided to focus on philanthropy, we knew that the core of our work would be eliminating the gross inequities in health that we had seen a few years earlier on our first trip to Africa.

One area where we believed we could make a difference was investing in R&D to address diseases of poverty. Today, I want to talk about several exciting and important tools of modern science that have the potential to help us solve some of the biggest health problems—not only in low- and middle-income countries, but everywhere.

To be sure, health in lower-income countries has improved. Over the last 25 years, we’ve nearly eradicated polio. Child mortality has been cut in half. And we’ve significantly reduced deaths from HIV, TB, and malaria.

But there is still room for a lot more improvement.

This year, more than 5 million children under the age of five will die. HIV, TB, malaria, and other diseases still kill millions of people every year. And nearly a quarter of a billion children are malnourished. Almost all of this disease burden is carried by people in the poorest countries on the planet.

Innovation with Equity in Mind

To make further inroads against the diseases of poverty, we need every sector to engage. Governments need to continue funding of basic research; partners like our foundation need to nurture the best ideas through discovery and translation; and the private sector needs to develop solutions that are commercially viable, affordable, and scalable in countries with limited resources and fragile health care systems.

The private sector has much to gain from pursuing breakthroughs that benefit people in lower-income countries. Over the next few decades, developing economies will continue to expand. By 2050, the population of sub-Saharan Africa will more than double to almost 2.5 billion. That’s more than twice the forecasted population of the Europe and North America combined.

Yet, today, the overwhelming percentage of investments in health R&D reflect market opportunities in rich countries. If we stick to this model, market forces will continue to prioritize development of costly products designed to meet the needs of the few and unaffordable to most. Imagine if we turned this traditional market model on its head and committed to designing new vaccines, therapeutics, and diagnostics with equity in mind.

Today, we have an opportunity with the evolution of tools like AI and gene-based technologies to develop a new generation of health solutions that can benefit everyone, everywhere. This is what really excites me about the future.

The Potential of AI and Gene Therapy

As a 7^th grader at the Lakeside School here in Seattle, I became fascinated not only with computers, but also with Shakey, the Mobile Robot. Life Magazine called Shakey the “first electronic person.” That might have been overstating it a bit, but Shakey was an early example of how artificial intelligence could be applied. It had a limited ability to perceive objects in its environment and adapt its movement. It could plan simple travel routes, and it had the ability to rearrange simple objects. For its time, Shakey was really cool.

Since Alan Turing laid the groundwork for artificial intelligence in 1950, AI has gone through a kind of boom-and-bust cycle—enthusiasm would grow and then expectations weren’t met.

But we are finally beginning to realize the potential of AI. The computational power available for AI applications is doubling every three and half months—far surpassing the historical metric of Moore’s Law. This processing capability is being coupled with troves of new data, and we are learning to annotate this data in smarter ways. That’s enabling us to realize some of the promises of AI: the ability to synthesize, analyze, see patterns, gain insights, and make predictions across many, many more dimensions than a human can comprehend.

This data revolution will apply to virtually all of the disciplines represented here today. What I’m most excited about is how it can help us make sense of complex biological systems and accelerate the discovery of therapeutics to improve health in the poorest countries.

And, with recent breakthroughs in gene-editing technologies like CRISPR, we are on the verge of a new era of precision diagnostics, therapeutics, and vaccines that has the potential to improve health—not only for rare genetic disorders, but also for diseases that predominately afflict people in poor countries.

It’s amazing to think how far we’ve come since Crick, Watson, and Franklin laid the foundation for modern genetics. It was only 15 years ago that the Human Genome Project gave us the ability to read our DNA and identify specific sequences that cause or contribute to disease. It was only 8 years ago that CRISPR gave us the ability to edit DNA precisely.

Now, with the latest CRISPR gene-editing approaches, it’s believed that up to 89% of genetic variants known to be associated with human disease can be corrected.

Last year, researchers began using the molecular scissors of CRISPR in clinical trials to remove, edit, and inject people’s cells back into their bodies.

In short, artificial intelligence and CRISPR have emerged as powerful tools with the potential to revolutionize healthcare and many other fields.

The Product Pipeline for Global Health

I’d like to share a few examples of innovations in the pipeline that make me optimistic about the future.

Our foundation is working with the National Institutes of Health to develop affordable, gene-based cures for sickle cell disease and HIV. The goal is to move these solutions into clinical trials in the next 7-10 years. This would be a huge breakthrough.

Of the 38 million people worldwide living with HIV, 95 percent live in lower-income countries and one-third aren’t receiving treatment. Imagine if we could cure every one of them.

Sickle Cell Disease is also a major health burden in lower-income countries. Fifteen million babies will be born with sickle cell disease in the next 30 years, the vast majority in Africa. Although exact numbers are hard to come by, at least half and maybe as many as 90% of these children will die before their fifth birthday.

In recent years, we’ve seen gene-based therapies introduced for some rare genetic diseases as well as for sickle cell disease. Ongoing trials are promising, with early results showing clinical benefit to more than a dozen people with sickle cell disease. But the treatments are prohibitively expensive—likely to cost $1 million or more per person.

And they require highly trained doctors and state-of-the-art hospitals to administer the cures—which involve in vitro editing of bone marrow stem cells for reinfusion, and toxic bone marrow conditioning regimens.

The focus of our work with the NIH on sickle cell disease is to develop effective, durable, safe, and affordable gene-based cures that don’t require costly hospital stays.

We hope to create in vivo gene editing techniques that can be delivered with a single injection using vectors that target and edit blood-forming cells in the bone marrow—with high efficiency. This approach could reach millions of patients in primary care facilities at a fraction of the cost.

Similarly, with HIV, the purpose of our collaboration with the NIH is to investigate the use of in vivo gene editing and other technologies that could drive a functional cure for those infected with HIV in an affordable, scalable way. A high bar, for sure, but it’s the kind of bold approach to designing therapeutic innovation with equity in mind that excites me.

Gene editing shows great promise for our work in malaria, too. The world has made huge progress against malaria in the past two decades. Since 2000, deaths have dropped from about 1 million per year to 400,000 per year. But further progress requires new tools and strategies.

Researchers are exploring the use of CRISPR to create “gene drives” that suppress the handful of mosquito species most responsible for malaria transmission. They are also working on introducing genes that could eliminate the parasites as they pass through a mosquito’s gut on their way to its salivary glands.

Newborn Health

One area where I see great potential for progress is newborn health. As you’ll see on this chart, nearly half of the 5.3 million children under age 5 who die this year will die in the first 28 days of life.

Deaths from complications associated with premature births account for the single largest percentage of neonatal mortality. The reason the number of deaths is so high is that there is still so much we don’t know about the root causes of prematurity and neonatal mortality. We are funding several studies to help solve this mystery.

First, by applying artificial intelligence to a range of complex data sets, we are learning about the biological pathways leading to prematurity and low birth weight.

Second, we’re combining clinical data with information from low-cost devices like a hand-held ultrasound and wearable sensors—and using AI to identify indicators that a pregnant woman may be at risk of giving birth before full term. We can do something similar to look for signs that newborns may be in trouble.

Third, researchers are exploring the associations between maternal undernutrition, the maternal microbiome, and premature birth. By distinguishing abnormal changes in the microbiome during pregnancy, we may be able to give pregnant women microbial therapeutics—as well as nutritional interventions—to improve fetal growth and reduce the risk of pre-term birth.

The Microbiome

It is increasingly clear that the gut microbiome and nutrition—and the interplay between the two—are also big factors in child health and development.

An estimated 225 million children worldwide are severely malnourished—and malnutrition is an underlying cause of more than 40 percent of under-five child mortality. Children who are malnourished often have underdeveloped microbiomes that make them more vulnerable to disease and to cognitive impairments that last a lifetime.

There is also evidence that children in wealthy countries who grow up in super-hygienic environments – with an abundance of processed foods and antibiotics—have poor gut health that may make them more susceptible to obesity, diabetes, allergies, and maybe even auto-immune disease.

But there’s still a lot we don’t know about the microbiome—including which bacterial species are most critical for health and whether augmenting these species can reduce malnutrition. Deciphering the human microbiome is not an easy task. It contains more than 100 trillion organisms and 200 times more genetic material than the human genome.

Using artificial intelligence, scientists hope to analyze the composition of the trillions of microbes in our body and identify the patterns, interactions, and changes we can't see that indicate a higher risk of disease—or, conversely—a protective shield against disease.

One tool that’s helping us understand how to optimize the gut microbiome is technology called “organs-on-a-chip.” In simple terms, this technology allows in vitro modeling of human organs in ways that mimic how organs perform normally . . . and when they are diseased.

Linking different organ chips together—for example, intestine, liver, and kidney chips—can enable researchers to model human drug kinetics.

Culturing a human intestinal microbiome-on-a-chip can enable researchers to probe the complex interactions between microbiome, host, nutrients, and pathogens in a systematic way.

Researchers are using this technology to study the vaginal microbiome and therapeutics that could reduce the incidence of pre-term birth and risk of HIV infection. We’re also supporting other “organ-on-a-chip” studies, including one that’s using lymphoid organoids to understand vaccine responses.

This technology has the potential to shave years off the time it takes to evaluate the safety and efficacy of new drugs, vaccines, and other therapeutics—and save hundreds of millions of dollars associated with research and clinical trials.

Climate Change and Agricultural Adaptation

I’ve been talking about the innovation we need to build on recent progress in global health. Many people are surprised when I say that progress in global health also depends on the fight against climate change.

There are two parts to addressing climate change. Mitigation and adaptation. Mitigation is about what we need to do to get to zero on greenhouse gases that are warming the climate.

Adaptation is about helping people cope with the changing climate. It’s unfortunate, but true, that the people who are most affected by climate change today account for a tiny amount of the world’s greenhouse gasses. Specifically, the 2 billion smallholder farmers and their families who rely on the food they grow to survive.

Increasingly, climate change is putting their livelihoods—and their lives—at risk. More extreme weather conditions mean more floods, more droughts, and more plant pests and diseases that can wipe out a crop.

When smallholder farmers lose their harvest, their kids may not have enough to eat and that makes them susceptible to the effects of malnutrition.

To adapt, farming families need seeds and livestock that have been bred to thrive in the more extreme conditions caused by climate change.

The world’s largest agriculture research group, CGIAR, has developed dozens of new varieties of maize and rice that can withstand drought—including one called “scuba” rice that can survive for two weeks under floodwaters.

A team of scientists led from the University of Cambridge is using evolutionary genomics to help maize and other cereals partner more effectively with microorganisms in the soil to capture nutrients and water.

For farmers with poor soils and no access to fertilizer, this process could supply the nitrogen needed to increase production. That’s good for food security, farmers’ livelihoods, and the environment.

Conclusion

Earlier this week, Melinda and I released our 2020 annual letter. It’s something we’ve done every year for the last 10 years. This year, we reflected on the progress in global health since we started our foundation 20 years ago and the challenges that remain. And we talk about where things stand with the primary focus of our work in the US—improving K-12 and postsecondary education.

These issues share one very important feature in common. They are both key to a healthier, better, and more equal world. Disease is both a symptom and a cause of inequality, while public education is a driver of equality.

When we first started our foundation, we were optimistic about the power of innovation to drive progress. Looking at progress in global health over the last two decades and the amazing advances I talked about today, I’m more optimistic than ever that we are closer to the goal of giving every person the opportunity to live a healthy, productive life. Thank you.

It’s Mosquito Week again on the Gates Notes. This year I’m exploring some of the science behind malaria and other mosquito-borne diseases. You can read below about how gene editing could play a key role in eradicating malaria. I’ve also written about amazing advances in tracking the disease and how the parasite is a deadly shapeshifter.

Humans have spent thousands of years inventing new ways to kill mosquitoes. The Romans did it by draining swamps. Today you might have a bug zapper in your back yard. In low- and middle-income countries, it’s common to see people spraying insecticides or setting up sticky traps baited with sugar.

But evolution is smart. It is one-upping us by creating mosquitoes that are harder to kill. In sub-Saharan Africa and parts of South America and southeast Asia, we are seeing an alarming number of mosquitoes that can withstand insecticides.

This is especially problematic for the fight against mosquito-borne diseases like malaria. To eradicate these diseases, we need new tools to complement the ones we already have.

Our foundation is backing a lot of different advances. One that I’m especially excited about is a set of techniques for genetically modifying mosquitoes that could dramatically reduce the number of disease-carrying insects in certain areas.

What is cool about these genetic techniques is how precise they can be. Precision matters because out of more than 3,000 species of mosquitoes, only five are responsible for causing most cases of malaria. Of those, only females spread the disease, because they’re the only ones that bite humans. (They do it when they need extra protein for reproduction. Experts call it “taking a blood meal.”) The males just drink nectar.

The promise of gene editing is that, instead of killing a bunch of mosquitoes indiscriminately, we could eliminate only the dangerous ones in a particular area. That would buy us time to cure all the people there of malaria. Then we could let the mosquito population return without the parasite.

One exciting gene-editing technique is called gene drive. The term covers several different approaches, but the basic idea is to use the CRISPR method to rewrite the usual rules of inheritance. Normally, for any given gene, there’s a 50 percent chance that a parent with that gene will pass it on to a child. (It is competing with one from the other parent, and only one of the two can win.) With gene drive, the odds go up to 100 percent. You give a few mosquitoes an edited gene that inserts—or drives—itself into all their offspring. When those mosquitoes mate with wild mosquitoes, all their children will have the edited gene, and over time it will make its way through the entire population.

Imagine if blue-eyed mosquitoes had only blue-eyed children, no matter what color their partners’ eyes were. Eventually, every mosquito in that population would have blue eyes.

This chart shows you how gene drive eventually spreads a gene throughout an entire population:

There’s no reason to think gene drive is even feasible in humans, let alone advisable. There are also serious questions surrounding the use of this technology on insects, which I will get to in a moment. But first I want to give you two examples of how it works.

One is the colorfully named X-shredder. As you might remember from biology class, the sex of a mosquito is determined partly by the sex chromosomes it inherits from its parents. Females got one X chromosome from each parent; males got an X from their mother and a Y from their father.

In 2014, scientists at Imperial College London and the Fred Hutchinson center here in Seattle were able to edit a protein in male mosquitoes so that it shreds the X chromosomes in their sperm. As a result, the males pass along mostly Y chromosomes, so most of their offspring will be males. Thanks to gene drive, those offspring will also have the edited protein, so most of their children will be males.

Within a few generations, the male/female ratio gets out of whack, and eventually the species dies off in that area.

Another example involves the doublesex gene, which in mosquitoes works along with the sex chromosome to determine whether an insect turns out male or female. Last year, researchers at Imperial College London found that females with edited doublesex genes develop a mix of male and female organs, including male genitalia and a proboscis that is too flimsy to break human skin. They can’t reproduce, so the population shrinks; and they can’t take a blood meal, so they won’t spread the parasite.

The doublesex edit doesn’t affect males, although thanks to gene drive, they will pass it to their offspring, which is how it keeps spreading through the population.

We know gene-drive technology works in the lab. When the Imperial College researchers put 150 males carrying a copy of the doublesex edit in a small cage with 450 wild-type mosquitoes, the population died off within a few months (about 10 generations). The sex bias edit produced similar results.

The next step is to run tests in larger cages and, eventually, get permission from governments to do them outdoors. We need to understand things like: What’s the impact on the food chain if a certain species of mosquito starts dying off? How many altered insects would we need to introduce? How long do we need the mosquitoes to be gone? Last year, the government of Burkina-Faso agreed to allow the release of sterile, non-gene-drive mosquitoes in the wild so researchers could begin to study some of these questions.

As I mentioned, social and regulatory issues also come into play. For example, because mosquitoes don’t exactly respect national boundaries, neighboring countries will probably need to agree on the rules surrounding the use of gene-editing technology. Policymakers and scientists have been debating these questions in forums like the World Health Organization and the African Union’s development agency, and they are moving toward a consensus.

I think we can have the regulatory approvals in place by 2024 and the first gene-drive mosquitoes ready for use by 2026. Although this technique will never replace the other tools we have for fighting malaria, I’m optimistic that it could become one more important weapon in eradicating the disease.

It’s Mosquito Week again on the Gates Notes. In this post I write about how the malaria parasite changes shape to foil your immune system. I’ve also written about ingenious new genetic techniques for fighting mosquitoes and maps that could help us defeat malaria.

I remember an old episode of the original Star Trek where the bad guy is a shapeshifter who turns himself into a second Captain Kirk. There’s a great scene at the end where Spock has to figure out which one is the impostor.

Shapeshifters are not just the stuff of science fiction, though. We have them right here on earth. Some are innocuous, like a caterpillar turning into a butterfly. But there’s another shapeshifter that’s responsible for more than 400,000 deaths every year. I’m talking about the group of microscopic parasites that cause malaria.

Malaria is one of the most fascinating and frustrating diseases our foundation works on, and its ability to change shape is one of the main reasons why. These parasites have figured out ingenious ways to fool your immune system. They have also (mostly) evaded our best efforts to make a malaria vaccine.

To understand how, it helps to know a bit about how your immune system works.

Your system is very good at detecting unusual objects in your body. It looks at the proteins on the surface of an invader and says, “I’ve never seen the funny shape on the outside of this thing. I’m going to attack it.” After the invader is defeated, your body remembers what it looked like and will go after it if it ever shows up again. Vaccines work by taking advantage of this process. When you get a measles shot, it contains a little bit of the virus; it won’t make you sick, but your body learns how to defend itself against future infections.

Unfortunately, malaria is a lot more complex than viruses or bacteria. For one thing, it is caused by parasites. Parasites don’t look as weird to your body as viruses or bacteria do. In fact, they more closely resemble your own cells, so your immune system has a harder time fighting them off.

Another problem is that the malaria parasite goes through three different stages in your body. It looks radically different in each stage, and as the infection goes on, you have all three going on at once.

Stage 1 begins when an infected mosquito bites you and injects a little saliva under your skin. This dose of saliva might contain only 100 parasites (called sporozoites in this stage). They are small and don’t cause any inflammation in your body, so your immune system doesn’t bother to look for them. You’re not feeling any symptoms yet.

Within an hour or two, the sporozoites make their way to your liver for stage 2. Coming out of your liver, they take a new form (called merozoites) and start invading your red blood cells. This invasion causes the symptoms—fever, chills, and so on—that make malaria such a miserable and deadly disease.

Now your body knows it’s sick and your immune system kicks in. But this is where the parasite’s shapeshifting comes into play.

Remember how the measles vaccine helps your immune system learn to identify the virus by looking for certain proteins on its surface? That works because those proteins look the same on each clone of the measles virus in your body. With malaria, each one can present up to 60 different proteins—and thanks to a mechanism that tells the parasite to alter its surface periodically, they shuffle these proteins around in different combinations every few days.

As a result, by the time your immune system has figured out how to attack one shape, the parasite has transformed, and your body’s defenses are useless. Your immune system adjusts, but not before the parasite has shifted again. It’s as if there’s a door on the surface of the parasite, but it keeps changing the locks so your body never has the right key.

Finally, in stage 3, a few of the merozoites develop into male and female cells. These hang out in your bloodstream, waiting for the next mosquito to come bite you. Once they’re in the mosquito’s stomach, they form new sporozoites, which make their way to the bug’s saliva glands and get injected into the next human, where the cycle starts all over again.

So that is the life cycle of malaria. What does all this mean for the effort to control and eventually eradicate this disease?

You might think we could create a vaccine that simply recognizes all the different shapes of the parasite. Unfortunately, that’s not practical. The only vaccine we have ever done that with is for a type of pneumonia. It is very expensive to manufacture and covers only a dozen shapes or so, versus the 60 shapes in one malaria infection and the many hundreds across all malaria parasites worldwide.

The malaria community (including our foundation) has been working for years on a vaccine to protect you in stage 1, before the infection takes hold. This vaccine, called RTS,S, teaches your immune system to hunt for a bit of protein that is always on the surface of the parasite. Unfortunately, the protection provided by RTS,S is not strong enough for long enough to help us make real headway toward eradication. And there are other forms of protection (such as bednets and insecticides) that are more cost-effective for saving lives.

People often ask me if it’s frustrating to fund work that takes so long to come to fruition. My answer is: not at all. Of course, I’m disappointed that we don’t have a long-lasting vaccine yet. But this is hard work. Parasites are such complex organisms that there are no effective vaccines for any of the human diseases that they cause. Besides, the research on RTS,S has given scientists a lot of insight into how malaria works and new clues about how to stop it. In fact, much of what we know about how your body responds (or fails to respond) to this type of parasite came from research on RTS,S.

The malaria community is now building on this knowledge. For example, scientists are working on new approaches that we hope will trigger the immune system to create long-lived, antibody-generating cells. Another promising idea is to create synthetic antibodies rather than trying to get your immune system to make natural ones. These monoclonal antibodies have revolutionized the treatment of cancer and inflammatory disease, and they could do the same for infectious diseases like malaria.

Knowing how complex malaria is helps me appreciate how much progress the world has made in fighting it. Deaths from malaria have dropped 42 percent since 2000, thanks to investments in bednets that prevent it and medicines that cure it. When I see how far we have come and how much we have learned, I am as optimistic as ever that we can beat this clever shapeshifter.

I was 9 years old when Nelson Mandela was sent to prison on Robben Island. As a boy, I learned about him in school, and I remember seeing reports about the anti-Apartheid movement on the evening news. Decades later, I got to meet him and work with him. In person he was even more inspiring than I had imagined. His humility and courage left an impression that I will never forget.

So it was a special honor to be invited to give the Nelson Mandela Lecture in Pretoria, South Africa. I eagerly accepted the invitation and quickly began working on my remarks.

I decided to share my optimism about Africa’s future—to explain why I think the continent has the potential to change faster in the next generation than any continent ever has.

It’s because Africa is the world’s youngest continent, and youth can go hand in hand with a special dynamism. I was 20 years old when Paul Allen and I started Microsoft. The entrepreneurs driving startup booms in Johannesburg, Lagos, and Nairobi are just as young, and the thousands of businesses they’re creating are already changing lives across the continent. The potential will only grow as the digital revolution brings more advances in artificial intelligence and robotics.

But positive change across Africa won’t happen automatically. The real returns will come only if Africans can unleash this talent for innovation in all of the continent’s growing population. That depends on whether all of its young people are given the opportunity to thrive.

It is still an open question, and it is the crux of my speech, which I gave today at the University of Pretoria. It was an honor to give this lecture, and I’m grateful to the Nelson Mandela Foundation and the university for inviting me. You can read my full speech below the video.

Remarks as delivered
Nelson Mandela Annual Lecture
University of Pretoria, South Africa
July 17, 2016

BILL GATES:

Well, thank you. Good evening, ladies and gentlemen. Graça Machel, Professor Ndebele, Vice Chancellor de la Rey, members of the Mamelodi families, friends and dignitaries.

I can’t think of a greater honor than giving a lecture named after Nelson Mandela.

I’m also thrilled that the theme of this lecture this year is “living together.”

It’s truly fitting because in many ways, “living together” was also the theme of Nelson Mandela’s life.

The system he fought against was based on the opposite idea—that people should be kept apart, that our superficial differences are more important than our common humanity.

Today, South Africans are still striving to “live together” in the fullest sense. But you are so much closer to that ideal because Nelson Mandela and so many others believed in the promise of one South Africa.

I was only nine years old when Nelson Mandela was sent to Robben Island. As a boy, I learned about him in school. I remembered seeing reports about the anti-Apartheid movements regularly on the evening news.

The first time I got to speak to him was in 1994 when he called me to help fund South Africa’s election.

I was running Microsoft, and largely focused on software most of the time, but I admired him so much, and I knew the election was historic. So I did what I could to help.

My first trip to Africa had been just the year before that in 1993 when my wife Melinda and I had traveled to East Africa.

The landscape was beautiful, the people were friendly, but the poverty there, which we were seeing for the first time, disturbed us. It also energized us.

Obviously, we knew parts of Africa were poor, but being on the continent turned what had been an abstraction into an injustice we couldn’t ignore.

Melinda and I had always known that we’d give our wealth to philanthropy eventually. But when we were confronted with such glaring inequity, we started thinking about how to take action sooner.

This sense of urgency was further spurred on by another trip in 1997 when I came to Johannesburg for the first time as a representative of Microsoft.

I spent most of the time in the richer part of the city in business meetings, but I also went to the community center in Soweto where Microsoft was donating computers.

My visit to Soweto, which was quite different then than it is now, taught me how much I had to learn about the world outside the comfortable bubble I’d lived in all my life.

As I walked into the community center, I noticed there weren’t any electrical connections. To keep the computer on, the one I was donating, they had rigged up an extension cord connected to a diesel generator outside. I realized the minute I left, the generator would get moved to something more important.

So as I read my remarks about the importance of the technology gap, I knew that it was only a small part of the story. Computers could help people do very important things, and in fact, they are part of how life on the continent can be revolutionized. But computers alone can’t feed disease or cure children. And if they can’t be turned on, they can’t do much at all.

So after that, Melinda and I moved to start our foundation because the cost of waiting had become clear.

Our work is based on the simple idea that every person, no matter where they live, should have the opportunity to lead a healthy and productive life.

We’ve spent the past 15 years learning about the issues and looking for the leverage points where we can do the most to help people seize their opportunity.

It was when I started coming to Africa regularly for the foundation that I got to know Nelson Mandela personally. AIDS was one of the first issues our foundation worked on, and Nelson Mandela was both an advisor and an inspiration.

One thing we talked about was the stigma around AIDS. So I remember 2005 very clearly when his own son died of AIDS. Rather than stay silent about the cause of his son’s death, Nelson Mandela announced it publicly because he knew that stopping the disease required breaking down the walls of fear and shame that surrounded it.

It is important to recall Nelson Mandela’s legacy, and I’m grateful for the opportunity to do so.

But Nelson Mandela was concerned about the future. He believed people could make the future better than the past. And so that’s what I want to focus on for the remainder of my talk.

What can South Africa become? What can Africa become? What can the world become? And what must we do to make it that way?

The Millennium Development Goals adopted by the United Nations in 2000 laid a foundation that enabled the world, including Africa, to achieve extraordinary progress over the last 15 years.

And the Sustainable Development Goals that recently replaced them set even more ambitious targets for creating the better world we all want.

When I talk about progress, I always start with child survival because whether children are living or dying is such a basic indicator of a society’s values.

Since 1990, child mortality in sub-Saharan Africa has been reduced by 54 percent. That means one million fewer children dying each year compared to 25 years ago.

Ten African countries achieved the very ambitious MDG target of reducing child mortality by over two-thirds.

At the same time, the incidence of poverty and malnutrition is down. And though economic growth has slowed in the past few years, it’s been very robust in many African countries for more than a decade.

This is real progress, but the Africa Rising narrative doesn’t tell the whole story about the life on the continent.

First, the progress have been uneven. You know this very well here in South Africa.

In last year’s Nelson Mandela Annual Lecture, the French economist, Thomas Piketty, pointed out that income inequality in South Africa is, quote, “higher than pretty much anywhere else in the world.”

In general, African countries tend to have higher rates of inequality than countries on other continents.And despite healthy average GDP growth in the region, many countries have not yet shared in it.  Inequalities exist within countries and between countries.

So until progress belongs to all people everywhere, the real promise of living together will remain elusive.

Second, even with the great progress Africa has made, it still lags behind the rest of the world in most indicators. In sub-Saharan Africa, one in 12 children still die before they turn five. Now, that’s a vast improvement compared to 25 years ago, but African children are still 12 times more likely to die than the average child in the world.

And because rates of poverty and malnutrition aren’t shrinking as fast as the population is growing, the number of people who are poor or malnourished has actually gone up since 1990.

Finally, the progress is fragile. The continent’s two largest economies, here in South Africa and in Nigeria, are facing serious economic challenges. And new threats require attention. The Ebola crisis pointed out weaknesses in many national health systems. The effects of climate change are already being felt among farmers in many countries.

In short, to meet the ambitious goals of the Sustainable Development Goals, Africa needs to do more, do it faster, and make sure everybody benefits. It won’t be easy, but I believe it can be done.

The successes and failures of the past 15 years have generated examples and lessons we can follow. Phenomenal advances in science and technology are expanding the range of solutions available to solve development challenges. And then there is the ingenuity of the African people.

One topic that Nelson Mandela came back to over and over again was the power of youth. He knew what he was talking about because he started his career as a member of the African National Congress Youth League when he was still in his 20s.

Later on, he understood that highlighting the oppression of young people was a powerful way to explain why things must change. There is a universal appeal to the conviction that youth deserve a chance.

I agree with Mandela about young people, and that is one reason I am optimistic about the future of this continent. Demographically, Africa is the world’s youngest continent. And its youth can be the source of a special dynamism.

In the next 35 years, two billion babies will be born in Africa. By 2050, 40 percent of the entire world’s children will live on this continent.

Economists talk about a demographic dividend. When you have more people of working age and fewer dependents for them to take care of, you can generate phenomenal economic growth. Rapid economic growth in East Asia in the 1970s and 1980s was partly driven by the large number of young people moving into their workforce.

But, for me, the most important thing about young people is the way their minds work. Young people are better than old people at driving innovation because they’re not locked in by the limits of the past.

When I started Microsoft at the age of 19, computer science was a young field. We didn’t feel beholden to old notions about what computers could or should do. We dreamed about the next big thing and we scoured the world around us for the ideas and tools that would help us create it.

But it wasn’t just Microsoft. Steve Jobs was 21 when he started Apple. Mark Zuckerberg was only 19 when he started Facebook.

The African entrepreneurs driving startup booms in the Silicon Savannahs from Johannesburg and Cape Town to Lagos and Nairobi are just as young in chronological age, but also in their outlook. The thousands of businesses they’re creating are already changing daily life across the continent.

In a few days, I’ll be meeting with some of these young innovators. People like the 21-year-old who founded Kenya’s first software coding school to provide other young people with computer programming skills. And like the 23-year-old social entrepreneur here in South Africa who manufactures school bags from recycled plastic shopping bags. Besides being highly visible to protect children as they’re walking to school, these school bags sport a small solar panel that charges a lantern during the journey to and from school, providing illumination so students can study at home.

The full returns will come if we can multiply this talent for innovation by the whole of Africa’s growing youth population. That depends on whether Africa’s young people—all of Africa’s young people—are given the opportunity to thrive.

Nelson Mandela said, “Poverty is not natural, it is man made and it can be overcome and eradicated by the actions of human beings.”

We are the human beings that must take action. And we have to decide now because this unique moment won’t last. We must clear away the obstacles that are standing in young people’s way so that they can seize all of their potential.

If young people are sick and malnourished, their bodies and brains will never fully develop. If they are not educated well, their minds will lie dormant. If they do not have access to economic opportunities, they will not be able to achieve their goals.

But if we invest in the right things, if we make sure the basic needs of Africa’s young people are taken care of, then they will have the physical, cognitive, and emotional resources they need to change the future. Life on this continent will improve faster than it ever has. And the inequities that have kept people apart will be erased by broad-based progress that is the very meaning of the words “living together.”

When Melinda and I started our foundation 15 years ago, we asked ourselves: What are the areas of greatest impact? It was clear to us that investing in health was high on the list. When people aren’t healthy, they can’t turn their attention to other priorities. But when health improves, life improves by every measure.

Over the last 15 years, our foundation has invested more than $9 billion in Africa. And we are committed to keep on investing to help Africa.

In the next five years, we will invest another $5 billion.

Some of this money has gone into discovering and developing new and better vaccines and drugs to help prevent infectious disease. We’ve also invested in global partnerships that work closely with countries across the continent to get these solutions to the people who need them most.

We’ve been fortunate to work with amazing partners, and together we’ve seen incredible progress.

For example, the entire continent of Africa has been polio free for two years, which puts us within reach of wiping polio out from the face of the earth forever.

The newest vaccines that protect children from two of the most devastating diseases—pneumonia and diarrhea—are reaching children across Africa at the same time they’re available for children in wealthier countries.

Countries that invest in strong, community-based primary healthcare systems—including Malawi, Ethiopia, and Rwanda—are making great progress reducing child mortality.

Malaria infections and deaths are down significantly thanks to better treatment and prevention tools.

And efforts like the Ouagadougou Partnership in West Africa are helping millions of women get access to contraceptives, which make it easier for them to care for their families.

HIV/AIDS is another area where there’s been good progress. Though it’s a complicated story, and there are still big challenges ahead.

In a few days, I’ll be speaking at the International AIDS Conference in Durban. When the global AIDS community last met there in 2000, only a few thousand Africans were receiving antiretroviral drugs. Today, more than 12 million Africans are on treatment, more than a quarter of them living here in South Africa.

So this is a huge achievement, and millions of lives have been saved. But the rate of new infections remains high. In sub-Saharan Africa, more than 2,000 young people under the age of 24 are infected every single day. The number of young people dying from HIV has increased fourfold since 1990.

We need to get people to get diagnosed, we need people to seek treatment, and people who are on treatment need to be fully adherent.

Along with HIV, we have high rates of tuberculosis, including here in South Africa where TB/HIV co-infection continues to wage a devastating toll.

So we need more creative ways to make testing and treatment accessible and easier to use.

We need to get much more out of existing prevention methods like condoms, voluntary medical male circumcision, and oral anti-HIV medicine.

And we’re going to have to invent new and better preventative solutions like medicines you only have to take once a month or an effective vaccine.

If we don’t act both on today’s treatment and create these tools, the hard-earned gains made against HIV in sub-Saharan Africa over the last 15 years could actually be reversed. Because of the population growth, just doing what we are today is not enough. We need to do more.

Nutrition is another critical area of focus for Africa. Nearly one-third of the continent’s children suffer from malnutrition that stunts their growth and robs them of their physical and cognitive potential. Millions more suffer from micronutrient deficiencies. These are impacts that last a lifetime and impact whole generations of African youth.

African Development Bank President Akin Adesina put it best when he said recently that the greatest contributor to Africa’s economic growth is not physical infrastructure, but gray matter infrastructure, people’s brainpower. The best way to build that infrastructure includes proper nutrition.

Without eliminating malnutrition, we won’t get the great potential that’s there.

We know that when mothers and infants get good nutrition, that breast feeding is a key part of that. We know that certain vitamins and minerals are essential for children.

We have a number of ways to intervene to help nutrition, things like fortified cooking oil, sugar fortified with vitamin A, and sugar and flour enriched with iron, zinc, and vitamin B.

One of the most exciting advances is the breeding of crops so they are naturally more nutritious. For example, when adolescents eat high-iron pearl millet, their likelihood of iron deficiency is reduced six-fold.  And just half a cup of biofortified orange sweet potato is all it takes to meet a child’s daily vitamin A needs.

The toll of micronutrient deficiency is huge, but the costs of fighting it are not.

Recent estimates done in Nigeria and Uganda indicate that every dollar invested to reduce stunting returns $17 in greater earning capacity in the workplace.

When children’s bodies and brains are healthy, the next step is an education that helps them develop the knowledge and skills to become productive contributors to society.

Improving education is hard work. I’ve learned this first hand through our foundation’s efforts to create better learning outcomes for primary, secondary, and university students in the United States.

But this hard work is incredibly important. A good education is the best lever we have for giving every young person a chance to make the most of their lives.

In Africa, as in the United States, we need new thinking and new educational tools to make sure that a high-quality education is available to every child.

In Uganda, young innovators at the NGO called Educate! are helping high schools prepare young people for the workplace by teaching students how to start their own business.

And with the high level of mobile phone penetration in Africa, technology using mobile phones to connect to the Internet have the potential to help students build foundational skills while giving teachers better feedback and support.

Globally, the educational technology sector is innovating and growing rapidly and it’s exciting to see new models and tools emerging to meet the needs of educators and students who are not connected to current systems.

At the university level, we need not only to broaden access, we have to also ensure that we have high-quality public universities that will launch the next generation of scientists, entrepreneurs, educators, and government leaders.

South Africa is blessed with some of the best universities in Africa, like the one we’re at today.

For our foundation, we partner with these universities to do our work in health and agricultural research. Maintaining the quality of this country’s higher-education system, while expanding access to more students will not be easy, but it is critical to South Africa’s future.

Other countries in the region will do well to follow South Africa’s example and provide the highest-level university education to the largest number of qualified students.

Healthy, educated young people are eager to make their way in the world. But Africa’s youth must have economic opportunity to channel their energy into progress.

Some of those youths will work in agriculture, where still over half of the workforce toils today.

We need advances to make agriculture far more productive. Today, the seeds that are used are unproductive, the soils are not very good, and so many farmers grow just enough to feed their family.

With climate change leading to more severe weather, doing more of the same will not be good enough.

The key to this is a series of innovation at every step along the way from farm to market.

First, farmers need better tools to avoid disasters and grow surplus. Things like seeds that can tolerate drought, floods, pests, and disease; affordable fertilizers that have the right mix of nutrients to replenish the soil; and easy-to-administer livestock vaccines that can help prevent flocks and herds from being wiped out.

Next, farmers need to be connected to a market where they can buy these inputs at a good price, and sell their surplus, and earn a profit that they can invest not only in their family’s basic needs, but also back into the farm.

This, in turn, will provide employment opportunities both on and off the farm as more prosperous farmers begin to support a range of agribusinesses like seed dealers, trucking companies, and processing plants.

I recently met with a group of young crop breeders, one from Ethiopia, one from Kenya, one from Nigeria, one from Uganda. I really love talking about the science of plant productivity. And in this case, I was amazed at the expertise all of these scientists brought to their work on cassava, a staple crop that provides more than one-third of the calories in many African diets.

Some had ways of improving the nutritional content of cassava. Others were breeding a variety that can resist both of the devastating diseases that are threatening to wipe out the cassava crop.

Our foundation is also working with a young computer scientist from Makerere University who designed a mobile phone app that lets farmers upload a picture of their cassava plants to find out whether it’s infected or not.

These are examples of the kind of innovators who can drive an agricultural transformation across the continent if they have the support they need. For many decades, agriculture has suffered from dramatic underinvestment. Many governments didn’t see the link between their farmers and economic growth.

Now, however, this misconception is gone. And through the Comprehensive African Agricultural Development Program, countries have a framework for transforming agriculture. The investment needs to follow so that young Africans have the means to create the thriving agriculture they envision.

With Africa’s farms as a base, the next step in economic growth is to promote job creation in other sectors. Doing this will require investment in infrastructure including energy.

Seven in 10 Africans lack access to power, which makes it harder to do everything. Harder to get healthcare in a dark clinic. Harder to learn in school when it’s boiling hot. Harder to be productive when you can’t use labor-saving machinery.

Ultimately, a shortage of power, like many African countries—including South Africa—have experienced, is also a drag on economic growth.

Businesses will not invest fully in places where they can’t operate efficiently.

A recent report projected that 500 million Africans won’t have electricity even in 2040. We need to change that.

What Africa needs is what the whole world needs: An energy advance that provides cheap, clean energy for everyone.

I’ve spent a lot of my time in the last two years working on this issue because it’s such an important advance.  I’m involved with a group of business people who are collaborating with governments to not only increase energy R&D, but also to vastly increase the private investment in this area.

I get angry when I see that Africa is suffering the worst effects of climate change, although Africans had almost nothing to do with causing this.

The rich countries need to follow through on their commitment to double their energy R&D budgets so that we get the breakthroughs that are applicable globally, and we need to do that urgently.

Africa needs power now. And so there are many pragmatic steps we need to take even in advance of these new inventions.

In parts of Africa, there’s hydro and geothermal sources which are both reliable and renewable that can be exploited. There’s been a lot of work on small-scale grids and the use if micro solar. This approach can provide individuals with electricity for basic purposes, but we also need large-scale power including well-managed electrical grids.

It means organizing the power system so that it’s economic, so that the electronic bills are paid for, and so that the network is reliable 100 percent of the time.

Once we get economic viability for these utilities, then it bootstraps the economy. It allows investments that are job creating.

So there are many challenges that I’ve laid out here: Challenges in health, education, agricultural productivity, energy, and creating enough job opportunities.

These advances only happen in the context of governments that function well enough to enable them. I applaud initiatives like Mo Ibrahim’s Annual Index of African Governments, which looks objectively at multiple measures of government performance in each country on the continent.

Citizens in other regions would be well served by this kind of comprehensive effort to spotlight and spread effective governance.

A lot can be accomplished by focusing on fiscal governance and accountability. Here in South Africa, the government gets strong marks for the budget information it provides to the public.

The International Budget Partnership, an independent monitoring organization, also ranks South Africa highly for its oversight of government spending.

In some countries, individual citizens are leading the way. In Nigeria, 30-year-old Oluseun Onigbinde gave up a career in banking years ago to devote himself full time to pulling back the curtain on the Nigerian federal expenditure.

With savvy use of data and social media, he founded BudgetIT Nigeria, which provides facts and figures the average Nigerian can understand. No doubt, he’s a thorn in the side of some of Nigeria’s elite, but to me he’s an example of what one person can do to make a difference.

Governments have an opportunity not only to learn from what’s been done in the past, but to do things in new ways. One of the exciting prospects is the role they can play in accelerating use of digital technology to leapfrog traditional models and costly infrastructure associated with banking and delivery of government services.

By using mobile phones, tens of millions of people are already storing money digitally and using their phones to make purchases as if they were debit cards.

A good example of this is M-PESA in Kenya. These services don’t just give people a better way to move money around, they give people a place to save cash to fund a startup of a micro enterprise or pay a child’s school fee. They create informal insurance networks of friends and families who can help with unexpected shocks. And they increase the profitability of small businesses by lowering transaction costs, making it easy to order products and supplies, and having greater security of financial assets.

A digital financial connection can also help governments deliver services more efficiently. Studies from India show the government able to save tens of billions a year by connecting households to a digital payment system and automating all government payments.

The early evidence suggests that similar programs in Africa can also yield substantial benefits. For example, recent research in Uganda showed that providing people with digital cash transfers rather than direct food subsidies not only saved the cost of delivery, it also improved nutrition because recipients used the money to purchase a greater diversity of foods and to space out meals as needed.

Governments can accelerate this digital transformation by implementing policies that encourage commercial investment, innovation, and healthy competition.

Countries like Kenya, Tanzania, and Nigeria are already investing in the building blocks of this new digital financial platform. And I believe they’ll see substantial positive returns.

If there’s one thing I’m sure of, it’s this: Africa can achieve the future it aspires to.

That future depends on the people of Africa working together across economic and social strata and across national borders to lay a foundation so that Africa’s young people have the opportunities they deserve.

Recently, I had a meeting with students at Addis Ababa University. I started asking them the kinds of questions you would ask college students in the United States like, “What do you want to do after you graduate? What fields are you thinking of going into?”

They looked at me like I was kind of crazy for asking those questions. Each of them had a plan for their future. They felt their parents had sacrificed for decades so they could go to this university. They weren’t weighing their options, they had come to the university to get specific training, and they were eager to take that training and use it to make their country more prosperous.

They saw themselves as part of a large community with great needs.And they were going to dedicate themselves to serving that community by meeting those needs.

I see that sense of purpose when I come to Africa, and especially when I talk to young Africans. I think it’s a unique asset that people see the need to change and that they want to give back.

The students here believe not only in themselves, they also believe in their countries and the future of the continent. Our priority is to make sure they have the opportunity to turn those beliefs into action because young people with this sense of purpose can make the difference between stagnation and faster progress.

Nelson Mandela said, “Young people are capable, when aroused, of bringing down the towers of oppression and raising the banners of freedom.” But our duty is not merely to arouse, our duty is to invest in these young people, to put in place the basic building blocks so they can build the future.

And our duty is to do it now because the innovations of tomorrow depend on the opportunities available to children today.

I’m sure it’s clear to everyone that these are big and complicated challenges. But it’s just as clear that people with bravery, energy, intellect, passion, and stamina can face big, complicated challenges and overcome them.

There is so much more work to be done to create a future in which we can all live together, but there are also so many people who are eager to get to work.

Let’s do everything within our power right now to help build the future that Nelson Mandela dreamed of and the future that we will achieve together.

Thank you.

If you were living on $2 a day, what would you do to improve your life?

That’s a real question for the nearly 1 billion people living in extreme poverty today. There’s no single right answer, of course, and poverty looks different in different places. But through my work with the foundation, I’ve met many people in poor countries who raise chickens, and I have learned a lot about the ins and outs of owning these birds. (As a city boy from Seattle, I had a lot to learn!) It’s pretty clear to me that just about anyone who’s living in extreme poverty is better off if they have chickens.

In fact, if I were in their shoes, that’s what I would do—I would raise chickens.

Here’s why:

• They are easy and inexpensive to take care of. Many breeds can eat whatever they find on the ground (although it’s better if you can feed them, because they’ll grow faster). Hens need some kind of shelter where they can nest, and as your flock grows, you might want some wood and wire to make a coop. Finally, chickens need a few vaccines. The one that prevents the deadly Newcastle disease costs less than 20 cents.
• They’re a good investment. Suppose a new farmer starts with five hens. One of her neighbors owns a rooster to fertilize the hens’ eggs. After three months, she can have a flock of 40 chicks. Eventually, with a sale price of $5 per chicken—which is typical in West Africa—she can earn more than $1,000 a year, versus the extreme-poverty line of about $700 a year.
• They help keep children healthy. Malnutrition kills more than 3.1 million children a year. Although eating more eggs—which are rich in protein and other nutrients—can help fight malnutrition, many farmers with small flocks find that it’s more economical to let the eggs hatch, sell the chicks, and use the money to buy nutritious food. But if a farmer’s flock is big enough to give her extra eggs, or if she ends up with a few broken ones, she may decide to cook them for her family.
• They empower women. Because chickens are small and typically stay close to home, many cultures regard them as a woman’s animal, in contrast to larger livestock like goats or cows. Women who sell chickens are likely to reinvest the profits in their families. Read more about women and chickens in Melinda’s blog post.

Dr. Batamaka Somé, an anthropologist from Burkina Faso who has worked with our foundation, has spent much of his career studying the economic impact of raising chickens in his home country. In this video he explains why he is so passionate about poultry.

A big bet on chickens

Our foundation is betting on chickens. Alongside partners throughout sub-Saharan Africa, we are working to create sustainable market systems for poultry. It’s especially important for these systems to make sure farmers can buy birds that have been properly vaccinated and are well suited to the local growing conditions. Our goal: to eventually help 30 percent of the rural families in sub-Saharan Africa raise improved breeds of vaccinated chickens, up from just 5 percent now.

When I was growing up, chickens weren’t something you studied, they were something you made silly jokes about. It has been eye-opening for me to learn what a difference they can make in the fight against poverty. It sounds funny, but I mean it when I say that I am excited about chickens.

Beyond breeding, Wylarah Station uses technology to ensure that their herds receive proper nutrition. I was surprised to see their ranch hands use smart watches to track how much the cows are drinking.

In the past someone had to manually inspect all of the water troughs scattered across the ranch, driving hundreds of kilometers every day. Now they receive a notification on their watch when a sensor detects that a tank needs attention. The whole operation was a far cry from the John Wayne cowboy movies I used to watch as a kid.

Not all of AACo’s innovative approaches could work in the poor world. It’s unlikely that every farmer in Africa will be wearing a smart watch anytime soon (if ever). But as smartphone usage continues to grow across the continent, it’s easy to imagine a future where Africans might use an app to order the perfect bull DNA or make sure their cattle are eating enough—something that an African ICT company called iCow is promoting in Kenya, Ethiopia, and Tanzania with help from our foundation.

Farmers across sub-Saharan Africa are already raising cattle—beef and dairy—in massive numbers. Ethiopia, Sudan, and Tanzania are among the world’s top 15 cattle producing countries. While there are legitimate questions about whether the world can meet its appetite for animal products without destroying the environment, it’s a fact that many poor people rely on cattle for both nutrition and income. I believe they should be able to raise cattle as efficiently as farmers in rich countries do.

I’m optimistic that technology can improve the quality of African cattle. A typical dairy cow in the United States produces nearly 30 liters of milk every day. Compare that to your average cow in Ethiopia, which produces just 1.69 liters of milk a day. If you want to increase milk yield, you can’t just take a high-producing Holstein cow from Wisconsin and drop it into the tropical savannah. Unlike indigenous breeds, temperate cattle have no natural resistance to tropical diseases—like trypanosomiasis, or sleeping sickness—and they struggle to get enough nutrition from local food sources.

Instead, you could breed cattle that will flourish in the local climate. That means using artificial insemination—like the process they use at Wylarah Station—to crossbreed a native female cow (with her built-in resilience to tropical heat and diseases) with a bull from a genetic line that produces lots of milk.

Our foundation is already tackling this, but AACo’s technology could make the process much more precise than it is today. One of the things that amazed me most during my visit was how much they know about the ancestry of their cattle. The animals on their ranch have a more detailed family history than most people do. If farmers in Africa were equipped with the same level of knowledge, they could handpick the best possible cow parents and breed a better calf. But that leads us to another problem.

Because they lack adequate storage, most African farmers rely on artificial insemination stations (yes, that’s what they’re really called) to provide sperm samples. Depending on how far a farmer lives from a station, the sample can sometimes heat up too much and effectively die before it is delivered. Many farmers decide not to take the risk. Instead they get their cows pregnant the old-fashioned way, which makes it harder to control genetic integrity and can lead to calves that are less resilient or produce less milk.  

AACo is looking into methods that extend the viability of sperm samples. Similar technology is currently used in Europe to improve the success rate of fertilization, but it hasn’t been tried yet with tropical cattle. If successful, it could double the amount of time a sample can survive outside of storage and make it easier for more farmers across Africa to use artificial insemination.  

Beyond breeding, Wylarah Station uses technology to ensure that their herds receive proper nutrition. I was surprised to see their ranch hands use smart watches to track how much the cows are drinking.

In the past someone had to manually inspect all of the water troughs scattered across the ranch, driving hundreds of kilometers every day. Now they receive a notification on their watch when a sensor detects that a tank needs attention. The whole operation was a far cry from the John Wayne cowboy movies I used to watch as a kid.

Not all of AACo’s innovative approaches could work in the poor world. It’s unlikely that every farmer in Africa will be wearing a smart watch anytime soon (if ever). But as smartphone usage continues to grow across the continent, it’s easy to imagine a future where Africans might use an app to order the perfect bull DNA or make sure their cattle are eating enough—something that an African ICT company called iCow is promoting in Kenya, Ethiopia, and Tanzania with help from our foundation.

There’s a lot we can learn from Wylarah Ranch about how to more efficiently raise cattle, but I can’t ignore the big question: should we rely on animals for food at all? Eating too much meat contributes to higher levels of obesity and heart disease, and raising animals contributes to climate change. That’s why I’ve invested in companies working on meat substitutes, which could one day eliminate the need to raise and slaughters animals entirely.

Although it might be possible to get people in richer countries to eat less, we can’t expect people in low income countries to follow suit. When I went vegetarian for a year in my late 20s, all I had to do to get my daily serving of protein was buy a can of beans or a container of tofu at the grocery store. It’s not so easy for families in poor communities to get the nutrition they need.

For them, meat and dairy are a great source of high-quality proteins that help children fully develop mentally and physically. Just 20 grams of animal protein a day can combat malnutrition, which is why our foundation’s nutrition strategy wants to get more meat, dairy, and eggs into the diets of children in Africa. Cattle are also a huge economic driver in some parts of Africa. In Ethiopia alone, cattle account for 45 percent of their agricultural GDP. In addition, livestock can actually contribute to ecosystems by stimulating pasture growth, enhancing biodiversity, and recycling energy and nutrients.

As more people in poor countries move into the middle class, they will likely eat more beef and drink more milk. But we can mitigate the impact of that growth on the environment by increasing production from the cows they already have. The cowboys of Wylarah Ranch have mastered the art of raising tropical cattle. I don’t know yet how African farmers can benefit from their expertise—our foundation is just starting to dig into this—but I’m excited about the possibilities.  

You may have seen in the news that elected officials in Washington, D.C., are working on next year’s federal budget. One of the ideas that has been floated is to make deep cuts in foreign aid—the investments that America makes to help other countries fight poverty and disease.

That would be a big mistake.

For one thing, these programs amount to less than 1 percent of the federal budget. For anyone worried about the budget deficit, cutting 1 percent will not make a dent.

More importantly, these programs give American taxpayers a phenomenal return on investment, one of the best anywhere in government. They do this in three ways:

• Making Americans safer and the world more stable
• Creating jobs at home and promote trading partners that will buy American goods
• Saving lives and building up health systems so other countries can take better care of their people

Together these three points make what you might call the strategic case for aid—the argument that aid helps the countries that give it as well as those that receive it.

To be honest, the strategic case is not what prompted Melinda and me to get involved in this work more than 17 years ago. We were moved by what you could call the moral case: the idea that it is terribly unjust that people in poor countries—especially children—die of diseases that can be prevented. That is still the main thing that drives us today. But over the years we have come to see the compelling strategic case too. And we have found that people often support aid who aren’t convinced by the moral argument but are by the strategic one.

In this post I want to focus on point #1 above. I’ll come back to #2 and #3 in subsequent posts.

Let’s look at how promoting health and development keeps Americans safe.

Preparing for the next epidemicYou may remember the Ebola epidemic of 2014–16. It killed more than 11,000 people in three West African countries. Each of those deaths was a tragedy, but the epidemic could have been far worse. If it had spread to neighboring Nigeria, home to more than 180 million people and a busy international travel hub with daily flights to the world’s capitals, it would have been very hard to contain. It could have easily jumped the Atlantic and infected Americans, and spread throughout Europe or Asia.

Why didn’t that happen? One key reason is that a number of health workers were stationed in Nigeria as part of the global campaign to stamp out polio. As the Ebola epidemic took hold, they were quickly reassigned from polio to Ebola. They already had a system in place for identifying possible cases, tracking them, and reporting the data to people organizing the response. They helped contain the disease and keep it from spreading farther than it did.

The polio eradication program helped stop Ebola and saved countless people, including Americans. Its biggest public funder? The United States government.

In addition, Ebola may have been only a preview of what is to come. The next epidemic—say, a virulent flu as bad as the Spanish Flu of 1918—could be far worse. Epidemiologists estimate it could kill 30 million people, more than three times the population of New York City.

Funding from the U.S. government helps keep that from happening. It helps other countries strengthen their health systems so they can identify dangerous diseases and contain them before they get out of control.

It is no accident that the Ebola epidemic hit hardest in three countries—Guinea, Sierra Leone, and Liberia—with especially weak health systems. Helping them improve makes it more likely that we can prevent a worldwide epidemic that destabilizes entire regions of the world and kills tens of millions of people.

Stabilizing vulnerable countriesPreventing pandemics is one specific way that U.S. funding makes Americans safer. There is also a broader point here: by fighting poverty and disease, we make the world a more stable place.

For example, both evidence and common sense tell us that when people don’t have reliable food supplies, they will pick up and move someplace else—becoming migrants or refugees—and that leads to more instability. Look at the countries with the least reliable food supplies in the world: Sudan, South Sudan, Eritrea, Burundi. Each of them is either at war or recently emerged from conflict.

Syria is another tragic example. In 2007, the country suffered the worst drought in its history. More than 1 million people fled rural areas for the cities, where they hoped to find food. This migration stoked political tensions and created the foundation for the horrific civil war that continues today. Of course that war has many causes, and not every drought-stricken country will become another Syria. But it is clear that the world is not a safer place when more people are going hungry—and that when we strengthen food and farming systems, we tackle some of the root causes of migration and instability.

Improving health is another way to make countries more secure. One of my favorite all-time examples is PEPFAR, the program America launched in 2003 to stop the spread of AIDS. Today it provides life-saving medicine for more than 11 million people living with HIV in some of the world’s poorest countries. Those 11 million people are teachers, health-care workers, and police officers—people who build strong, self-sufficient societies. So it should not be surprising that in countries where PEPFAR has a presence, political instability fell by 40 percent between 2004 and 2013. In non-PEPFAR countries, it dropped only 3 percent. And the PEPFAR countries grew three times faster.

Shoring up national securityAmerican military leaders understand that fighting poverty and disease is part of a smart national-security strategy. It was true after World War II, when the United States invented modern development assistance to combat instability in Europe and prevent a third World War, and it’s true today. The more stable poor countries are, the lower the odds that America will need to intervene in them.

More than 120 retired generals and admirals recently wrote a letter to Congress arguing that U.S. aid programs “are critical to preventing conflict and reducing the need to put our men and women in uniform in harm’s way.” While he was the head of U.S. Central Command, overseeing American operations in Syria, Pakistan, Afghanistan, and elsewhere, Secretary of Defense James Mattis said: “If you don’t fully fund the State Department”—which houses many aid programs—“then I need to buy more ammunition.”

Aid is an important part of our broad diplomatic and security relationships. Out of 135 countries that receive some health or development aid from the United States, we have bilateral defense agreements with 131 of them.

These are some of the arguments I have been making in Washington on behalf of American aid. In future posts I will explain how aid not only keeps Americans safe, but also creates jobs in the United States and helps other countries become more self-sufficient. All reasons why I believe this money is well-spent and ought to be maintained.

At a time when world leaders are understandably focused on terrorism and other security threats, another enemy is being largely overlooked—the next epidemic.

We don’t know when the next pathogen will emerge, what it will be, how it will spread, or who will be affected, but we do know that the world is not prepared to deal with it. That was the tough lesson that Ebola (and the Zika outbreak since) taught us. Ebola claimed thousands of lives, caused billions of dollars in economic losses, and showed how vulnerable our society is to epidemics of infectious diseases. As I’ve written about before, the world lacks an effective system to detect, respond to, or prevent the next outbreak.

That’s why I’m excited this week, at the World Economic Forum in Davos, to participate in the launch of a new organization that will help the world get ready for future epidemics. Backed by the governments of Norway, India, Japan, and Germany, along with the Wellcome Trust and our foundation, the Coalition for Epidemic Preparedness Innovations (CEPI) will invest in innovations to accelerate the development of vaccines we’ll need to contain outbreaks.

CEPI’s focus on vaccine development is a critical part of getting prepared for whatever pathogens threaten us next. We know from the world’s defeat of smallpox and its successful fights against polio, measles, and other diseases that vaccines are incredibly effective tools for preventing disease and saving lives. Now, this alliance of governments, philanthropies, vaccine manufacturers, academia, NGOs, and other partners needs to work together to develop new vaccines to make the world safe from future epidemics. 

Traditional approaches to making new vaccines are too slow to respond to a sudden disease outbreak. Currently, the development of a new vaccine, including testing and deployment, is a process that can typically take more than 10 years. Fast-moving epidemics don’t allow us to be that patient. In 1918, an extremely infectious and deadly strain of the flu infected about one-fifth of the world’s population and killed at least 30 million people in less than two years. Ebola and Zika were also both frightening viruses, but the way they are transmitted—through bodily fluids and mosquitoes—helped limit their spread globally. A highly-contagious airborne disease would pose a far greater threat. It would thrive in densely populated urban areas and could easily cross national borders and oceans by air travel.

My great hope for CEPI is that it will help enable the world to produce safe, effective vaccines as quickly as a new threat like this emerges. With $460 million in initial funding, CEPI will work to bring together the most advanced vaccine technologies and resources from the private and public sector that can help lead to new breakthroughs in vaccine development. CEPI’s vaccine development strategy includes two areas of focus: “just in time” vaccines for those currently unknown pathogens that will emerge, and “just in case” vaccines for pathogens that we know are at high risk of causing another outbreak, like Ebola and Middle East respiratory syndrome or MERS.

One promising area of vaccine development research is using advances in genomics to map the DNA and RNA of pathogens and make vaccines. The vaccines can be decoded by human cells to make their own vaccines and antibodies inside the body. If successful, this technology could dramatically reduce the development timeline from years to possibly months or weeks.

What’s exciting about these new technologies is that they wouldn’t just protect us from future epidemics. They also would help us to develop vaccines for existing health threats to hundreds of millions of people around the world, including HIV, malaria, and TB.

At the same time, CEPI will work to minimize regulatory hurdles that further delay the deployment of vaccines. CEPI will fund studies to evaluate these newly-developed vaccines and build vaccine stockpiles before epidemics begin, so countries can move swiftly to full vaccine efficacy trials and emergency deployment during an outbreak.

As pleased as I am to see CEPI’s work get underway, it’s important for everyone to understand that this effort is just the first step toward getting us prepared for the next epidemic. It’s an important step, but CEPI alone won’t be enough to protect us. We have a lot more work to do.

We need a global warning and response system for outbreaks. It begins with strengthening local health systems in poor countries, which have gotten hit the hardest during recent epidemics. The thousands of remote health clinics around the world will be the backbone of our global effort to defeat future epidemics. They must have trained health workers who can provide primary health care, deliver vaccines, and monitor the health of their communities.

We must have a better disease surveillance system, which includes a global database so countries can share information on cases. We also need trained medical personnel ready to mount a rapid response to an outbreak.

Last, we need to continue to invest in health research to develop not just vaccines, but also new drugs and diagnostic tests that will strengthen our ability to respond quickly and effectively to the next epidemic.

Still, we’ll never know exactly when a new disease outbreak will emerge. It could arrive tomorrow, next month, next decade, or next century. But that uncertainty shouldn’t be an excuse for inaction. I hope that today’s announcement marks the first of many steps the world will take to get prepared for the next epidemic. All of our futures depend on it.

If you could shuffle all of the homes in the world like a deck of cards so that people in wealthy countries lived side by side with people from poor countries, it would transform the world’s fight against poverty, hunger, and disease. It would be impossible for people to look away, impossible for them not to help.

I was naïve about the deep poverty in the world until I took my first trip to Africa with Melinda in 1993. Seeing the disparities with our own eyes made all the difference and inspired us to start our foundation.

Since then, I’ve continued to travel regularly to Africa, India, and other parts of the developing world. I always return from my trips humbled and inspired. My one disappointment is that I wish everyone could have seen what I did. I have no doubt it would help more people become aware of the challenges the world’s poorest people face. It would also leave them as optimistic as I am about the incredible progress the world is making in health and development.

During my trip to South Africa in July, I tried something new that I hope will allow people to experience what I have. I had highlights of my visit recorded in virtual reality. It’s still an emerging technology but what excites me about it is that it allows viewers to immerse themselves in another world. You can look up and down. Turn right or left. Listen to sounds all around you. I used to think there was no substitute to being there and seeing things for yourself. But virtual reality is a close second. It fulfills my dream of allowing people to see what I’m seeing and, perhaps, feel what I’m feeling, too.

In this video, you will hear the stories of young women living with HIV. Sit beside me as I drive from the leafy suburbs of Johannesburg to the dusty township of Soweto. Feel what it’s like to be in the center of a stomping gumboot dancing troupe. And be inspired by the power of South Africa’s youth, who will drive the next generation of innovations to create a future free of AIDS.

If you want to know more about my trip to South Africa, you can read about my visit here and here. I also encourage you to learn more about The Global Fund, which has helped provide lifesaving treatment to millions of people living with HIV.

Thanks for watching and look out for more virtual reality videos in the months ahead.

Let me cut to the chase. There’s a program that has helped save the lives of 17 million people in poor countries since 2002. It’s called the Global Fund to Fight AIDS, TB, and Malaria. It’s poised to do even more good in the years ahead, but to continue its work, it needs donors to make new funding pledges.

I just got back from Europe, which is starting to think through many tough decisions surrounding Brexit. Despite that challenge, the governments of France and Italy became the latest to make commitments to the Global Fund, building on recent pledges from Japan, Canada, the United States, and the European Commission. When I was in London, a senior member of the British government confirmed to Parliament that they remain committed to the Global Fund’s success. Although I’m confident the Global Fund will raise the money it needs—donors have consistently recognized that it’s an effective and low-cost way to save lives—we are not there yet.

Since the Global Fund started, Melinda and I have committed $1.6 billion to it. Here are four reasons why we are such big believers:

• Saving lives. In countries where the Global Fund operates, deaths from HIV, TB, and malaria have dropped by a third since 2002. Certainly the Fund doesn’t deserve sole credit for that phenomenal progress, but it has played an irreplaceable role. And its work is far from finished: Three million people still die every year from these diseases.
• Getting rid of diseases so we never have to fight them again. In my lifetime I expect to see the end of malaria, which kills nearly half a million children every year. When you eradicate a disease, you not only save lives, you free up billions of dollars and many hours of effort. One reason I’m so optimistic about ending malaria is the work of the Global Fund, which has slowed the spread of the disease and saved lives by distributing hundreds of millions of bed nets.
• Helping poor countries become more self-sufficient. If you ever hear people say “poor countries just keep getting foreign aid forever,” tell them about the Global Fund. It helps the countries it works with improve their health systems so they can take better care of their people. They also devote an increasing share of their own budgets to health (they have promised to spend 50 percent more between 2015 and 2017 than they did in the previous three years). That translates into less spending by rich governments.
• Using aid efficiently. The Fund has a done a great job keeping costs low and streamlining its work. Its operating costs are just over 2 percent of all the grants it gives out. That means the vast majority of the money that flows through the Global Fund is reaching the people who need it most.

The Global Fund raises money in three-year batches; the current batch will cover the years 2017-19. They’re asking for $13 billion, which will go toward delivering lifesaving drugs and bed nets as well as developing new tools like better diagnostics and next-generation prevention techniques. To put that number in context, it’s about 3 percent of the total foreign aid that rich countries give over three years. And consider the payoff: By one estimate, the $13 billion raised by the Global Fund will generate about $300 billion in economic benefits.

It is never easy to raise large sums of money like this, and it certainly isn’t easy now, with the refugee crisis in Europe compounding an already difficult global economy. Although I don’t think anyone would argue that fighting disease will directly end wars or stop the flow of refugees, improving health certainly makes countries more stable and more prosperous—and less likely to spread disease and instability to their neighbors.

If you want to save and improve lives, health is one of the most effective investments you can make. And if you want to improve health, the Global Fund is one of the most effective investments you can make. It is one of the kindest things people have ever done for one another, and I am inspired by the countries and leaders who are stepping up to support it.

This presidential election has the country captivated. As many commentators have pointed out, the primaries are more focused on personalities than policy. While the parties focus on who is going to represent them in the fall, I want to make the case for something that I hope every candidate will agree on in November: America’s unparalleled capacity for innovation. When the United States invests in innovation, it creates companies and jobs at home, makes Americans healthier and safer, and saves lives and fights poverty in the world’s poorest countries. It offers the next president a tremendous opportunity to help people in America and around the world.

Of course, America’s capacity for innovation is nothing new. We have been inventing for more than two centuries: think of Benjamin Franklin, Margaret Knight, Thomas Edison. By the end of World War II, the United States led the world in automobiles, aerospace, electronics, medicine, and other areas. Nor is the formula for success complicated: Government funding for our world-class research institutions produces the new technologies that American entrepreneurs take to market. 

What is new is that more countries than ever are competing for global leadership, and they know the value of innovation. Since 2000, South Korea’s R&D spending (measured as a percentage of GDP) has gone up 90 percent. China’s has doubled. The United States’ has essentially flatlined. It’s great that the rest of the world is committing more, but if the U.S. is going to maintain its leading role, it needs to up its game.

I have seen first-hand the impact that this type of research can have. I was lucky enough to be a student when computers came along in the 1960s. At first they were very expensive, so it was hard to get access to them. But the microchip revolution, made possible by U.S. government research, completely changed that. Among other things it enabled Microsoft, the company I co-founded, to write software that made computers an invaluable tool for productivity. Later, the Internet—another product of federal research—changed the game again. It is no accident that today most of the top tech companies are still based in the United States, and their advances will have a massive impact in every area of human activity.

My favorite example is health. America’s investment in this area creates high-paying jobs at universities, biotech companies, and government labs. It leads to new treatments for disease, such as cancer therapies. It helps contain deadly epidemics like Ebola and Zika. And it saves lives in poor countries. Since 1990, the fraction of children who die before age 5 has fallen by more than half. I think that’s the greatest statistic of all time, and the United States deserves a lot of credit for making it happen.

The next few years could bring even more progress. With a little luck we could eradicate polio, a goal that is within reach because of vaccines developed by U.S. scientists. (Polio would be the second disease ever eradicated, after smallpox in 1979—in which the U.S. also played an irreplaceable role.) There is also exciting progress on malaria: The number of deaths dropped more than 40 percent from 2000 to 2012, thanks in part to America’s support for breakthrough tools like drugs and bed nets. But to make the most of these opportunities, we need to invest more in basic health research and specific areas like vaccines.

Energy is another great example. American-funded research defines the state of the art in energy production. Early advances in wind and solar technology were developed with federal money. And this research offers a strong return on investment. Between 1978 and 2000, the Department of Energy spent $17.5 billion (in today’s dollars) on research on efficiency and fossil fuels, yielding $41 billion in economic benefits. Yet until this year, the DOE’s research budget hadn’t seen a real increase since the Reagan administration.

If we step up these investments, we can create new jobs in the energy sector and develop the technologies that will power the world—while also fighting climate change, promoting energy independence, and providing affordable energy for the 1.3 billion poor people who don’t have it today. Some of the more promising areas include making fuel from solar energy, much the way plants do; making nuclear energy safer and more affordable; capturing and storing carbon; and creating new ways to store energy that let us make the most of renewables.

There’s a lot of momentum right now on clean energy research. Last year the leaders of 20 countries, including the United States, committed to double federal investments in this area. Complementing that crucial effort, I helped launch the Breakthrough Energy Coalition, a group of private investors who will back promising clean-energy companies. The next president will have a chance to accelerate this momentum.

Investing in R&D isn’t about the government picking winners and losers. The markets will do that. It’s about doing what we know works: making limited and targeted investments to lay a foundation for America’s entrepreneurs. This approach has been fundamental to U.S. leadership for decades, and it will become only more important in the years ahead.

By the end of this summer, the political parties will have chosen their leaders and will start looking ahead to the November election. The nominees will lay out their vision for America and their agenda for achieving it. These visions will probably have more differences than similarities. But I hope we can all agree that, no matter how you see America’s future, there will always be an essential role for innovation. 

This article was originally published by Reuters News Agency.

I am in Vancouver this week attending the TED conference. I just gave a brief talk on a subject that I’ve been learning a lot about lately—epidemics.

The Ebola outbreak in West Africa is a tragedy—as I write this, more than 10,000 people have died. I’ve been getting regular updates on the case counts through the same system we use to track new cases of polio. Also, last month I was lucky enough to have an in-depth discussion with Tom Frieden and his team at the Centers for Disease Control and Prevention in Atlanta.

What I’ve learned is very sobering. As awful as this epidemic has been, the next one could be much worse. The world is simply not prepared to deal with a disease—an especially virulent flu, for example—that infects large numbers of people very quickly. Of all the things that could kill 10 million people or more, by far the most likely is an epidemic.

But I believe we can prevent such a catastrophe by building a global warning and response system for epidemics. It would apply the kind of planning that goes into national defense—systems for recruiting, training, and equipping health workers; investments in new tools; etc.—to the effort to prevent and contain outbreaks.

This is what my TED talk was about. You can watch it here:

The more I learn about what it takes to respond to an epidemic, the more impressed I am by the health workers who have been risking their lives to care for the sick. Just putting on a protective suit is huge undertaking. Once it’s on, it’s hard to hear what anyone else is saying, and you start to sweat after just a few minutes.

Here’s a short photo essay about one attempt to solve this problem that I was involved with. 

At TED we also put together an exhibit where attendees could try on a suit for themselves:

Finally, if you’re interested in learning more, you might want to check out this op-ed I wrote for the New York Times. And if you are willing to read a little more (okay, a lot more), here is a longer paper I wrote for the New England Journal of Medicine.

Melinda and I remain committed to improving the health of the poorest 2 billion. The good news is, many of the steps required to save lives in poor countries—such as strengthening health systems—also improve the world’s ability to deal with epidemics. So I’m optimistic that we can solve this problem. Making the right investments now could save millions of lives.

Getting new tools into the hands of the people fighting Ebola is much harder than it needs to be. I have experience with one alarming example.

Health workers in protective suits get so hot that they have a hard time caring for their patients. (For example your goggles fog up and you sweat profusely.) I asked a team of experts who work on technology for keeping vaccines cold to refocus on keeping the medical workers cool.

Within days, the team had found an existing solution: a vest with pockets where you could insert cooling packs.

Doctors who had treated Ebola patients in West Africa helped test and improve these cooling vests. Here you see Dr. Colin Bucks of Stanford University testing a vest and suit at home while under quarantine after working in Liberia. He rode a stationary bike to simulate the heat of West Africa.

Unfortunately, there was no coordinated system for getting the vests to West Africa. The team had to create new distribution channels by working directly with treatment centers in the region. They eventually got the suits to over a thousand health workers.

Although this wasn’t a critical issue, it is just one example of the challenge of preparing for a highly infectious disease. We see similar breakdowns in detecting outbreaks early, training and deploying volunteers, coordinating with the military, and more. But I’m optimistic that if we start now and stay focused, we can get ready for the next epidemic.

Kids love dinosaurs. When you’re three feet tall and can’t have dinner unless somebody brings you food, the idea of enormous, powerful creatures that have fangs to defend themselves and claws to capture their own meals seems pretty great.

I loved dinosaurs as much as anyone, but eventually I grew tall enough to get my own dinner, and my interest in dinosaurs waned.

My friend Nathan Myhrvold, though, never stopped loving dinosaurs. Actually, there are a lot of things Nathan never stopped loving—he’s published best-selling cookbooks and essays on bioterrorism, among other things—but if you ask him about his longest-running obsession, he’ll tell you it’s dinosaurs. His office is full of dinosaur bones, some of which he dug up himself, along with a model of a dinosaur whose tail moved so fast it broke the sound barrier.

Because he’s so curious, Nathan can take what he knows about these great reptiles and apply it to fields that seem completely unrelated—fields like childhood nutrition, one of the most important and misunderstood areas in all of development.

Here’s a short video in which he explains the connection:

Dinosaur growth rates, it turns out, are hard to study. There may be only thirty fossils of a particular dinosaur species in the world, and none of them may be complete. So how do you know whether a bone is shaped a certain way because that’s how triceratops grew or whether your particular specimen just had a funny-looking head?

In poor countries, children’s physical development is also hard to study, though for different reasons. For one thing, measurements are notoriously inaccurate. If you’re measuring a crying, squirming baby who doesn’t want a cold tape measure pressed up against his body, you might not get the numbers exactly right. There’s also a host of reasons a child could be short. Is this girl short because she’s malnourished? Is she from a short family? Or has she just not hit her growth spurt yet?

What that means is that in both areas, dinosaur growth and childhood growth, you end up with problematic data; with children, it’s messy, and with dinosaurs, it’s sparse. In both cases, though, the problem is the same: looking at the data from the wrong angle gives you the wrong answers.

Nathan thinks he’s figured out a systematic way to look at the growth records from the right angle. Since we started working with him he’s shared some promising ideas about how to measure children’s growth accurately, analyze the trends, and take action on the analysis. For example, some researchers recently looked at the relationship between gross domestic product and childhood stunting and, to everyone’s surprise, they found no correlation—until Nathan pointed out that they were using the wrong statistical methods to analyze the information. The methods he suggested instead—based on his work on dinosaurs—showed that the relationship was actually even stronger than many people in the field had thought. And that could have a big impact on how policymakers and health-care workers approach the problem of childhood nutrition.

This is a great example of a trend I hope we’ll see a lot more of: taking scientific advances from lots of different fields and using them to solve problems in global health.

Ever since dinosaurs were discovered, kids have showered them with love. Thanks to this work, we may have found a way for dinosaurs to pay them back.

Imagine there’s an infectious disease spreading through your community. It leaves some people crippled; others die from it. Then someone comes along and says: “Here’s something that will protect you from this disease for the rest of your life. You and your family can have it, for free.” You would be very relieved, right?

This scenario may seem hypothetical (though perhaps less so given how much the Ebola virus has been in the news). But it is very real for millions of people in the world’s poorest countries. Vaccines that were once out of reach for them are being delivered in greater numbers every year. That means more parents are feeling the relief of knowing their families are protected.

I’ve been looking at some of the data on vaccines and thought I would share what I’m seeing. At a time when so many news headlines are grim, it is inspiring stuff.

I’ll start with polio. Cases are down more than 99 percent since 1988. Earlier this year, we celebrated a fantastic achievement: India was declared polio-free. And in Nigeria, the number of polio cases is at an all-time low, just 6 so far this year versus more than 50 by this time last year. It’s one of only three countries that have never been polio free (the others are Pakistan and Afghanistan).

Wherever we make progress on polio, it’s a testament to the amazing work of many people: political leaders who prioritize stopping the disease, donors who help fund the effort, and—most importantly—the health workers who doggedly go from house to house to deliver vaccines. Thanks to all this work (and with a little luck), 2015 could be the first time Nigeria goes a year without a case of wild poliovirus, and the first time all of Africa is polio-free. If we maintain this commitment, I’m quite optimistic that by 2018 we will get rid of this crippling disease, everywhere, forever.

There’s also fantastic progress in delivering basic immunizations for diseases like measles and pneumonia. The impact is phenomenal: By next year, the public-health group known as Gavi, the Vaccine Alliance will have helped prevent 3.9 million deaths. And expanding vaccine coverage over the next five years can save as many as 6 million lives and unlock more than $100 billion in economic benefit.

Along those lines, we hit a big milestone in September. With the addition of South Sudan, pentavalent vaccine—which protects against five debilitating diseases—has now been introduced in all 73 countries that get financial support from Gavi. Pentavalent replaced a vaccine that protected against only three diseases, which means kids are protected from more diseases without getting any extra shots. This would never have happened without Gavi: By negotiating with manufacturers and bringing in new suppliers, it drove down the cost of pentavalent vaccine from $30 per dose in rich countries to just $1.19 for poor countries.

Another big step has been the rollout of a vaccine for rotavirus, which causes severe diarrhea. Rotavirus is one of the reasons Melinda and I first got involved in global health; in the late 1990s, we were shocked by a newspaper article that said it killed 800,000 children a year—nearly all of them in poor countries—more than almost any other disease. After more research, we decided rotavirus should be a focus of our giving. We’re gratified to see that 65 countries are now rolling out rotavirus vaccines, and more are signing up. Manufacturers in India are working on a new vaccine and talking about exporting it to other countries, which would help save even more children.

We’re also getting closer to solving some big delivery problems, like the fact that many vaccines spoil if they get too warm. Researchers are field-testing a specially designed container that keeps vaccines cold for a month or more, using just a single batch of ice and no electricity. These trials are helping thousands of African children get immunized. I’m very hopeful that containers like this one will eventually help health workers reach far more people.

A Ripple Effect
Vaccines save lives, which is reason enough to make sure they get out there. But that’s not their only benefit. Healthy children spend more time in school, and they learn better while they’re there. When health improves, poor countries can spend more on schools, roads, and other investments that drive growth, which makes them less dependent on aid.

Vaccines deliver all this for, in some cases, just pennies per shot. That’s why I say that if you want to save and improve lives around the world, vaccines are a fantastic investment. 

How You Can Help
One way you can help is to ask your political leaders to support Gavi next year, when donor governments need to renew their commitments. In the United States you can do that through Shot@Life, whose website makes it easy to send a message to your representatives.

You can also help by donating to Shot@Life. For $20, you can help protect a child from pneumonia, diarrhea, polio, and measles. And Shot@Life has teamed up with Walgreens for a “Get a shot. Give a shot” program: Get a vaccine at Walgreens and they will provide one for a child in a poor country.

This is flu season in the United States, so you may already be planning to get immunized. Why not help out someone else while you’re at it?

Once in a while, you read something that’s so compelling, you want to share it with everyone you can. Dr. Ada Igonoh’s story had that effect on me.

Dr. Igonoh is a physician in Lagos, Nigeria, where she helped care for Patrick Sawyer, the patient who introduced Ebola into Nigeria in July. After coming down with the deadly virus herself, she spent two harrowing weeks getting treatment in isolation wards.

When I met her at a conference in New Orleans last week, Dr. Igonoh handed me a written account of her experience. Even knowing she was going to be okay, I couldn’t stop reading—I had to know what happened next. Her optimism was inspiring. Her story also gave me a deeper appreciation for all the health workers who are heroically caring for patients and trying to stop this epidemic. And it is a good reminder of the way uncertainty reigns in the early days of an epidemic. The world’s response since then has been remarkable, and Nigeria has now been certified free of Ebola.

I want to thank Dr. Igonoh for her courage, and for agreeing to let me share her story here. It is well worth your time to read it. — Bill Gates

On the night of Sunday July 20^th, 2014, Patrick Sawyer was wheeled into the emergency room of the First Consultants Medical Centre, Obalende, Lagos, with complaints of fever and body weakness. The male doctor on call admitted him as a case of malaria, and took a full history.

Knowing that Mr. Sawyer had recently arrived from Liberia, the doctor asked if he had been in contact with an Ebola patient in the last couple of weeks, and Mr. Sawyer denied any such contact. He also denied attending any funeral ceremony recently. Blood samples were taken for full blood count, malaria parasites, liver function test, and other baseline investigations. He was admitted into a private room and started on antimalarial drugs and analgesics. That night, the blood count result came back as normal and not indicative of infection.

The following day, however, his condition worsened. He barely ate any of his meals. His liver function test result showed his liver enzymes were markedly elevated. We then took samples for HIV and hepatitis screening.

At about 5:00 p.m. he requested to see a doctor. I was the doctor on call that night, so I went in to see him. He was lying in bed with his intravenous (IV) fluid bag removed from its metal stand and placed beside him. He complained that he had stooled about five times that evening and that he wanted to use the bathroom again.

I picked up the IV bag from his bed and hung it back on the stand. I told him I would inform a nurse to come and disconnect the IV so he could conveniently go to the bathroom. I walked out of his room and went straight to the nurses' station where I told the nurse on duty to disconnect his IV. I then informed my consultant, Dr. Ameyo Adadevoh, about the patient's condition, and she asked that he be placed on some medications.

The following day, the results for HIV and hepatitis screening came out negative. As we were preparing for the early morning ward rounds, I was approached by an ECOWAS [Economic Community of West African States] official who informed me that Patrick Sawyer had to catch an 11 o'clock flight to Calabar for a retreat that morning. He wanted to know if it would be possible. I told him it wasn't, as he was acutely ill. Dr. Adadevoh also told him the patient could certainly not leave the hospital in his condition. She then instructed me to write very boldly on his chart that on no account should Patrick Sawyer be allowed out of the hospital premises without the permission of Dr. Ohiaeri, our Chief Medical Consultant. All nurses and doctors were duly informed.

During our early morning ward round with Dr. Adadevoh, we concluded that this was not malaria, and that the patient needed to be screened for Ebola Viral Disease. She immediately started calling laboratories to find out where the test could be carried out. She was eventually referred to Professor Omilabu of the LUTH Virology Reference Lab in Idi-Araba, whom she called immediately.

Prof. Omilabu told her to send blood and urine samples to LUTH straightaway. She tried to reach the Lagos State Commissioner for Health but was unable to contact him at the time. She also put calls across to officials of the Federal Ministry of Health and National Centre for Disease Control.

Dr. Adadevoh at this time was in a pensive mood. Patrick Sawyer was now a suspected case of Ebola, perhaps the first in the country. He was quarantined, and strict barrier nursing was applied with all the precautionary measures we could muster. Dr. Adadevoh went online, downloaded information on Ebola, and printed copies which were distributed to the nurses, doctors and ward maids. Blood and urine samples were sent to LUTH that morning. Protective gear, gloves, shoe covers and facemasks were provided for the staff. A wooden barricade was placed at the entrance of the door to keep visitors and unauthorized personnel away from the patient. Despite the medications prescribed earlier, the vomiting and diarrhea persisted. The fever escalated from 38°C to 40°C.

On the morning of Wednesday, 23^rd July, the tests carried out in LUTH showed a signal for Ebola. Samples were then sent to Dakar, Senegal for a confirmatory test. Dr. Adadevoh went for several meetings with the Lagos State Ministry of Health. Thereafter, officials from the Lagos State came to inspect the hospital and the protective measures we had put in place.

The following day, Thursday 24^th July, I was again on call. At about 10:00 p.m. Mr. Sawyer requested to see me. I went into the newly created dressing room, donned my protective gear and went in to see him. He had not been cooperating with the nurses and had refused any additional treatment. He sounded confused and said he received a call from Liberia asking for a detailed medical report to be sent to them. He also said he had to travel back to Liberia on a 5:00 a.m. flight the following morning and that he didn't want to miss his flight. I told him that I would inform Dr. Adadevoh. As I was leaving the room, I met Dr. Adadevoh dressed in her protective gear, along with a nurse and another doctor. They went into his room to have a discussion with him, and as I heard later to reset his IV line which he had deliberately removed after my visit to his room.

At 6:30 a.m., Friday 25^th July, I got a call from the nurse that Patrick Sawyer was completely unresponsive. Again I put on the protective gear and headed to his room. I found him slumped in the bathroom. I examined him and observed that there was no respiratory movement. I felt for his pulse; it was absent. We had lost him.

It was I who certified Patrick Sawyer dead. I informed Dr. Adadevoh immediately and she instructed that no one was to be allowed to go into his room for any reason at all. Later that day, officials from WHO came and took his body away. The test in Dakar later came out positive for Zaire strain of the Ebola virus. We now had the first official case of Ebola virus disease in Nigeria.

It was a sobering day. We all began to go over all that happened in the last few days, wondering just how much physical contact we had individually made with Patrick Sawyer. Every patient on admission was discharged that day and decontamination began in the hospital. We were now managing a crisis situation.

The next day, Saturday 26^th July, all staff of First Consultants attended a meeting with Prof. Nasidi of the National Centre for Disease Control, Prof. Omilabu of LUTH Virology Reference Lab, and some officials of WHO. They congratulated us on the actions we had taken and enlightened us further about the Ebola Virus Disease. They said we were going to be grouped into high risk and low risk categories based on our individual level of exposure to Patrick Sawyer, the "index" case. Each person would receive a temperature chart and a thermometer to record temperatures in the morning and night for the next 21 days. We were all officially under surveillance. We were asked to report to them at the first sign of a fever for further blood tests to be done. We were reassured that we would all be given adequate care. The anxiety in the air was palpable.

The frenetic pace of life in Lagos, coupled with the demanding nature of my job as a doctor, means that I occasionally need a change of environment. As such, one week before Patrick Sawyer died, I had gone to my parents' home for a retreat. I was still staying with them when I received my temperature chart and thermometer on Tuesday, 29^th of July. I could not contain my anxiety. People were talking about Ebola everywhere—on television, online, everywhere.

I soon started experiencing joint and muscle aches and a sore throat, which I quickly attributed to stress and anxiety. I decided to take malaria tablets. I also started taking antibiotics for the sore throat. The first couple of temperature readings were normal. Every day I would attempt to recall the period Patrick Sawyer was on admission—just how much direct and indirect contact did I have with him? I reassured myself that the contact with him was quite minimal. I completed the anti-malarials but the aches and pains persisted. I had loss of appetite and felt very tired.

On Friday, 1^st of August, my temperature read a high 38.7°C. As I type this, I recall the anxiety I felt that morning. I could not believe what I saw on the thermometer. I ran to my mother's room and told her. I did not go to work that day. I cautiously started using a separate set of utensils and cups from the ones my family member were using.

On Saturday, 2^nd of August, the fever worsened. It was now at 39°C and would not be reduced by taking paracetamol. This was now my second day of fever. I couldn't eat. The sore throat was getting worse. That was when I called the helpline and an ambulance was sent with WHO doctors, who came and took a sample of my blood. Later that day, I started stooling and vomiting. I stayed away from my family. I started washing my plates and spoons myself. My parents, meanwhile, were convinced that I could not have Ebola.

The following day, Sunday, 3^rd of August, I got a call from one of the doctors who came to take my sample the day before. He told me that the sample which they had taken was not confirmatory, and that they needed another sample. He did not sound very coherent and I became worried. They came with the ambulance that afternoon and told me that I had to go with them to Yaba. I was confused. Couldn't the second sample be taken in the ambulance like the previous one? He said a better-qualified person at the Yaba Centre would take the sample. I asked if they would bring me back. He said "yes." Even with my symptoms, I did not believe I had Ebola. After all, my contact with Sawyer was minimal. I only touched his IV fluid bag just that once without gloves. The only time I actually touched him was when I checked his pulse and confirmed him dead, and I wore double gloves and I felt adequately protected.

I told my parents I had to go with the officials to Yaba and that I would be back that evening. I wore a white top and a pair of jeans, and I put my iPad and phones in my bag.

A man opened the ambulance door for me and moved away from me rather swiftly. Strange behavior, I thought. They were friendly with me the day before, but that day, not so. No pleasantries, no smiles. I looked up and saw my mother watching through her bedroom window.

We soon got to Yaba. I really had no clue where I was. I knew it was a hospital. I was left alone in the back of the ambulance for over four hours. My mind was in a whirl. I didn't know what to think. I was offered food to eat but I could barely eat the rice.

The ambulance door opened and a Caucasian gentleman approached me but kept a little distance. He said to me, "I have to inform you that your blood tested positive for Ebola. I am sorry."

I had no reaction. I think I must have been in shock. He then told me to open my mouth and he looked at my tongue. He said it was typical Ebola tongue. I took out my mirror from my bag and took a look and was shocked at what I saw. My whole tongue had a white coating, looked furry, and had a long, deep ridge right in the middle. I then started to look at my whole body, searching for Ebola rashes and other signs, as we had been recently instructed. I called my mother immediately and said, "Mummy, they said I have Ebola, but don't worry, I will survive it. Please go and lock my room now; don't let anyone inside and don't touch anything." She was silent. I cut the line.

I was taken to the female ward. I was shocked at the environment. It looked like an abandoned building. I suspected it had not been in use for quite a while. As I walked in, I immediately recognized one of the ward maids from our hospital. She always had a smile for me but not this time. She was ill and looked it. She had been stooling a lot, too. I soon settled into the corner and looked around the room. It smelled of feces and vomit. It also had a characteristic Ebola smell to which I became accustomed. Dinner was served—rice and stew. The pepper stung my mouth and tongue. I dropped the spoon. No dinner that night.

Dr. David, the Caucasian man who had met me at the ambulance on my arrival, came in wearing his full protective hazmat suit and goggles. It was fascinating seeing one live. I had only seen them online. He brought bottles of water and ORS, the oral fluid therapy, which he dropped by my bedside. He told me that 90 percent of the treatment depended on me. He said I had to drink at least 4.5 litres of ORS daily to replace fluids lost in stooling and vomiting. I told him I had stooled three times earlier and taken Imodium tablets to stop the stooling. He said it was not advisable, as the virus would replicate the more inside of me. It was better, he said, to let it out. He said good night and left.

My parents called. My uncle called. My husband called crying. He could not believe the news. My parents had informed him, as I didn't even know how to break the news to him.

As I lay on my bed in that isolation ward, strangely, I did not fear for my life. I was confident that I would leave that ward some day. There was an inner sense of calm. I did not for a second think that I would be consumed by the disease.

That evening, the symptoms fully kicked in. I was stooling almost every two hours. The toilets did not flush, so I had to fetch water in a bucket from the bathroom each time I used the toilet. I then placed another bucket beneath my bed for the vomiting. On occasion, I would run to the toilet with a bottle of ORS, so that as I was stooling, I was drinking.

The next day, Monday, 4^th of August, I began to notice red rashes on my skin, particularly on my arms. I had developed sores all over my mouth. My head was pounding so badly. The sore throat was so severe I could not eat. I could only drink ORS. I took paracetamol for the pain. The ward maid across from me wasn't doing so well. She had stopped speaking. I couldn't even brush my teeth; the sores in my mouth were so bad. This was a battle for my life but I was determined I would not die.

Every morning, I began the day with reading and meditating on Psalm 91. The sanitary condition in the ward left much to be desired. The whole Ebola thing had caught everyone by surprise. Lagos State Ministry of Health was doing its best to contain the situation but competent hands were few. The sheets were not changed for days. The floor was stained with greenish vomitus and excrement. Dr. David would come in once or twice a day and help clean up the ward after chatting with us. He was the only doctor who attended to us. There was no one else at that time. The matrons would leave our food outside the door. They hardly entered in the initial days. Everyone was being careful. This was all so new. I could understand, was this not how we ourselves had contracted the disease? Mosquitoes were in our room until they brought us mosquito nets.

Later that evening, Dr. David brought another lady into the ward. I recognized her immediately as Justina Ejelonu, a nurse who had started working at First Consultants on the 21^st of July, a day after Patrick Sawyer was admitted. She was on duty on the day Patrick reported that he was stooling. While she was attending to him that night, he had yanked off his drip, letting his blood flow almost like a tap onto her hands. Justina was pregnant and was brought into our ward bleeding from a suspected miscarriage. She had been told she was there only on observation. The news that she had contacted Ebola was broken to her the following day after results of her blood test came out positive. Justina was devastated and wept profusely—she had contracted Ebola on her first day at work.

My husband started visiting but was not allowed to come close to me. He could only see me from a window at a distance. He visited so many times. It was he who brought me a change of clothes and toiletries and other things I needed because I had not even packed a bag. I was grateful I was not with him at home when I fell ill or he would most certainly have contracted the disease. My retreat at my parents' home turned out to be the instrumentality God used to shield and save him.

I drank the ORS fluid like my life depended on it. Then I got a call from my pastor. He had been informed about my predicament. He called me every single day, morning and night, and he would pray with me over the phone. He later sent me a CD player, CDs of messages on faith and healing, and Holy Communion packs through my husband. My pastor, who also happens to be a medical doctor, encouraged me to monitor how many times I had stooled and vomited each day and how many bottles of ORS I had consumed. We would then discuss the disease and pray together. He asked me to do my research on Ebola since I had my iPad with me, and told me that he was also doing his study. He wanted us to use all relevant information on Ebola to our advantage. So I researched and found out all I could about the strange disease that had been in existence for 38 years. My research, my faith, and my positive view of life, the extended times of prayer, study and listening to encouraging messages boosted my belief that I would survive the Ebola scourge.

There are five strains of the virus, and the deadliest of them is the Zaire strain, which was what I had. But that did not matter. I believed I would overcome even the deadliest of strains. Infected patients who succumb to the disease usually die between 6 to 16 days after the onset of the disease from multiple organ failure and shock caused by dehydration. I was counting the days and keeping myself well-hydrated. I didn't intend to die in that ward.

My research gave me ammunition. I read that as soon as the virus gets into the body, it begins to replicate really fast. It enters the blood cells, destroys them and uses those same blood cells to aggressively invade other organs where they further multiply. Ideally, the body's immune system should immediately mount up a response by producing antibodies to fight the virus. If the person is strong enough, and that strength is sustained long enough for the immune system to kill off the viruses, the patient is likely to survive. If the virus replicates faster than the antibodies can handle, however, further damage is done to the organs. Ebola can be likened to multi-level, multi-organ attack, but I had no intention of letting the deadly virus destroy my system. I drank more ORS. I remember saying to myself repeatedly, "I am a survivor, I am a survivor."

I also found out that a patient with Ebola cannot be re-infected and they cannot relapse back into the disease as there is some immunity conferred on survivors. My pastor and I would discuss these findings, interpret them as it related to my situation and pray together. I looked forward to his calls. They were times of encouragement and strengthening. I continued to meditate on the Word of God. It was my daily bread.

Shortly after Justina came into the ward, the ward maid, Mrs. Ukoh, passed on. The disease had gotten into her central nervous system. We stared at her lifeless body in shock. It was a whole 12 hours before officials of WHO came and took her body away. The ward had become the house of death. The whole area surrounding her bed was disinfected with bleach. Her mattress was taken and burned.

To contain the frequent diarrhea, I had started wearing adult diapers, as running to the toilet was no longer convenient for me. The indignity was quite overwhelming, but I did not have a choice. My faith was being severely tested. The situation was desperate enough to break anyone psychologically. Dr. Ohiaeri also called us day and night, enquiring about our health and the progress we were making. He sent provisions, extra drugs, vitamins, Lucozade, towels, tissue paper; everything we needed to be more comfortable in that dark hole we found ourselves. Some of my male colleagues also had been admitted to the male ward two rooms away, but there was no interaction with them. We were saddened by the news that Jato, the ECOWAS protocol officer to Patrick Sawyer, who had also tested positive, had passed on days after he was admitted.

Two more females joined us in the ward; a nurse from our hospital and a patient from another hospital. The mood in the ward was solemn. There were times we would be awakened by the sudden, loud cry from one of the women. It was either from fear, pain mixed with the distress, or just the sheer oppression of the isolation.

I kept encouraging myself. This could not be the end for me. Five days after I was admitted, the vomiting stopped. A day after that, the diarrhea ceased. I was overwhelmed with joy. It happened at a time I thought I could no longer stand the ORS. Drinking that fluid had stretched my endurance greatly.

I knew countless numbers of people were praying for me. Prayer meetings were being held on my behalf. My family was praying day and night. Text messages of prayers flooded my phone from family members and friends. I was encouraged to press on. With the encouragement I was receiving, I began to encourage the others in the ward. We decided to speak life and focus on the positive.

I then graduated from drinking only the ORS fluid to eating only bananas, to drinking pap and then bland foods. Just when I thought I had the victory, I suddenly developed a severe fever. The initial fever had subsided four days after I was admitted, and then suddenly it showed up again. I thought it was the Ebola. I enquired from Dr. David, who said fever was sometimes the last thing to go, but he expressed surprise that it had stopped only to come back on again. I was perplexed.

I discussed it with my pastor, who said it could be a separate pathology and possibly a symptom of malaria. He promised he would research if indeed this was Ebola or something else. That night as I stared at the dirty ceiling, I felt a strong impression that the new fever I had developed was not as a result of Ebola but malaria. I was relieved. The following morning, Dr. Ohiaeri sent me an antimalarial medication, which I took for three days. Before the end of the treatment, the fever had disappeared.

I began to think about my mother. She was under surveillance along with my other family members. I was worried. She had touched my sweat. I couldn't get the thought off my mind. I came across a tweet by WHO saying that the sweat of an Ebola patient cannot transmit the virus at the early stage of the infection. The sweat could only transmit it at the late stage.

That settled it for me. It calmed the storms that were raging with me concerning my parents. I knew right away it was divine guidance that caused me to see that tweet. I could cope with having Ebola, but I was not prepared to deal with a member of my family contracting it from me.

Soon, volunteer doctors started coming to help Dr. David take care of us. They had learned how to protect themselves. Among the volunteer doctors was Dr. Badmus, my consultant in LUTH during my housemanship days. It was good to see a familiar face among the care-givers. I soon understood the important role these brave volunteers were playing. As they increased in number, so did the number of shifts increase and subsequently the number of times the patients could access a doctor in one day. That allowed for more frequent patient monitoring and treatment. It also reduced care-giver fatigue. It was clear that Lagos State was working hard to contain the crisis.

Sadly, Justina succumbed to the disease on the 12^th of August. It was a great blow and my faith was greatly shaken as a result. I commenced daily Bible study with the other two female patients and we would encourage one another to stay positive in our outlook, though in the natural it was grim and very depressing. My communion sessions with the other women were very special moments for us all.

On the 10^th day in the ward, the doctors having noted that I had stopped vomiting and stooling and was no longer running a fever, decided it was time to take my blood sample to test if the virus had cleared from my system. They took the sample and told me that I shouldn't be worried if it comes out positive as the virus takes a while before it is cleared completely. I prayed that I didn't want any more samples collected from me. I wanted that to be the first and last sample to be tested for the absence of the virus in my system. I called my pastor. He encouraged me and we prayed again about the test.

On the evening of the day Justina passed on, we were moved to the new isolation centre. We felt like we were leaving hell and going to heaven. We were conveyed to the new place in an ambulance. It was just behind the old building. Time would not permit me to recount the drama involved with the dynamics of our relocation. It was like a script from a science fiction movie. The new building was cleaner and much better than the old building. Towels and nightwear were provided on each bed. The environment was serene.

The following night, Dr. Adadevoh was moved to our isolation ward from her private room where she had previously been receiving treatment. She had also tested positive for Ebola and was now in a coma. She was receiving IV fluids and oxygen support and was being monitored closely by the WHO doctors. We all hoped and prayed that she would come out of it. It was so difficult seeing her in that state. I could not bear it. She was my consultant and my mentor. She was the imperial lady of First Consultants, full of passion, energy and competence. I imagined she would wake up soon and see that she was surrounded by her First Consultants family but sadly it was not to be.

I continued listening to my healing messages. They gave me life. I literally played them hours on end. Two days later, on Saturday the 16^th of August, the WHO doctors came with some papers. I was informed that the result of my blood test was negative for the Ebola virus. If I could somersault, I would have, but my joints were still slightly painful. I was free to go home after being in isolation for exactly 14 days. I was so full of thanks and praise to God. I called my mother to get fresh clothes and slippers and come pick me up. My husband couldn't stop shouting when I called him. He was completely overwhelmed with joy.

I was told however that I could not leave the ward with anything I came in with. I glanced one last time at my CD player, my valuable messages, my research assistant, a.k.a my iPad, my phones and other items. I remember saying to myself, "I have life; I can always replace these items."

I went for a chlorine bath, which was necessary to disinfect my skin from my head to my toes. It felt like I was being baptized into a new life as Dr. Carolina, a WHO doctor from Argentina poured the bucket of chlorinated water all over me. I wore a new set of clothes, following the strict instructions that no part of the clothes must touch the floor and the walls. Dr. Carolina looked on, making sure I did as instructed.

I was led out of the bathroom and straight to the lawn to be united with my family, but first I had to cut the red ribbon that served as a barrier. It was a symbolic expression of my freedom. Everyone cheered and clapped. It was a little but very important ceremony for me. I was free from Ebola! I hugged my family as one who had been liberated after many years of incarceration. I was like someone who had fought death face to face and come back to the land of the living.

We had to pass through several stations of disinfection before we reached the car. Bleach and chlorinated water were sprayed on everyone's legs at each station. As we made our way to the car, we walked past the old isolation building. I could hardly recognize it. I could not believe I slept in that building for 10 days. I was free! Free of Ebola. Free to live again. Free to interact with humanity again. Free from the sentence of death.

My parents and two brothers were under surveillance for 21 days and they completed the surveillance successfully. None of them came down with a fever. The house had been disinfected by Lagos State Ministry of Health soon after I was taken to the isolation centre. I thank God for shielding them from the plague.

My recovery after discharge has been gradual but progressive. I thank God for the support of family and friends. I remember my colleagues who we lost in this battle. Dr. Adadevoh my boss, Nurse Justina Ejelonu, and the ward maid, Mrs. Ukoh were heroines who lost their lives in the cause to protect Nigeria. They will never be forgotten.

I commend the dedication of the WHO doctors, Dr. David from Virginia, USA, who tried several times to convince me to specialize in infectious diseases, Dr. Carolina from Argentina who spoke so calmly and encouragingly, Mr. Mauricio from Italy who always offered me apples and gave us novels to read. I especially thank the volunteer Nigerian doctors, matrons and cleaners who risked their lives to take care of us. I must also commend the Lagos State government, and the state and federal ministries of health for their swift efforts to contain the virus.

To all those who prayed for me, I cannot thank you enough. And to my First Consultants family, I say a heartfelt thank you for your dedication and for your support throughout this very difficult period.

I still believe in miracles. None of us in the isolation ward was given any experimental drugs or so-called immune boosters. I was full of faith, yet pragmatic enough to consume as much ORS as I could, even when I wanted to give up and throw the bottles away. I researched on the disease extensively and read accounts of the survivors. I believed that even if the mortality rate was 99 percent, I would be part of the 1 percent who would survive.

Early detection and reporting to hospital is key to patient survival. Please do not hide yourself if you have been in contact with an Ebola patient and have developed the symptoms. Regardless of any grim stories one may have heard about the treatment of patients in the isolation centre, it is still better to be in the isolation ward with specialist care, than at home where you and others will be at risk.

I read that Dr. Kent Brantly, the American doctor who contracted Ebola in Liberia and was flown out to the United States for treatment was being criticized for attributing his healing to God when he was given the experimental drug, Zmapp. I don't claim to have all the answers to the nagging questions of life. Why do some die and some survive? Why do bad things happen to good people? Where is God in the midst of pain and suffering? Where does science end and God begin? These are issues we may never fully comprehend on this side of eternity. All I know is that I walked through the valley of the shadow of death and came out unscathed.

I’m in New Orleans, where I just had the honor of speaking at the annual meeting of the American Society of Tropical Medicine and Hygiene (ASTMH). As you can imagine, given that this is a gathering of experts on infectious diseases in poor countries, Ebola is on everyone’s mind.  

Even though I am confident that the U.S. and other countries with strong public health systems will contain the cases that are popping up within their borders, it’s devastating to see what this virus is doing to entire families in West Africa. At times like this, it’s easy for organizations like ASTMH to make the public case that global health matters to all of us in our increasingly interconnected world. I hope that will help strengthen the public will to do more to help poor countries lift the burden of disease—not just from emerging killers like Ebola but also from pathogens that have held back human potential for thousands of years.

That’s why, in my remarks at the conference, I addressed the Ebola crisis but devoted the bulk of my time to another killer disease: malaria. Based on the progress I’m seeing in the lab and on the ground, I believe we’re now in a position to eradicate malaria—that is, wipe it out completely in every country—within a generation. This is one of the greatest opportunities the global health world has ever had. Melinda and I are so optimistic about it that we recently decided to increase our foundation’s malaria budget by 30 percent.

Melinda and I first called for eradication back in 2007 along with Margaret Chan, who runs the World Health Organization. Melinda was eloquent and passionate in her call to action: “Any goal short of eradicating malaria is accepting malaria; it’s making peace with malaria; it’s rich countries saying: ‘We don’t need to eradicate malaria around the world as long as we’ve eliminated malaria in our own countries.’ That’s just unacceptable.”

Some people said then (and still say today) that we’re overly optimistic to be talking about eradication. After all, malaria is an enormously complex target and has defeated efforts to stamp it out in the past. They’re right that we shouldn’t promise the moon—you don’t get rid of a disease this complex overnight—but I am confident that the future will be different from the past.

Why? Because we’ve seen a huge scale-up in the resources and brainpower focused on this disease. Four countries have eliminated malaria since 2000, and two dozen more could do it in the next decade. Mortality rates worldwide have gone down by a remarkable 42 percent in that time—a good-news story that ought to make critics wary of trumpeting claims that foreign aid doesn’t work. More than 3.3 million people who would have died of malaria are alive today.

And we have tools today we’ve never had before—not everything we will need to achieve eradication, but more than we’ve ever had. Here are two of the recent innovations that fuel my optimism:

• Diagnostics: Malaria is not only treatable but also curable, thanks to a class of drugs derived from a flowering plant called Artemesia annua, or sweet wormwood. But until recently, there was no good way for most people who came down with a fever to find out whether they had malaria. In 2010, we got a great new tool, called the RDT (rapid diagnostic test). Armed with this 50-cent test, community health workers with little training can determine in minutes with 99 percent accuracy whether someone has malaria or not. Last year, we deployed 200 million of them in Africa alone.
• Modeling Systems: The digital revolution has produced fantastic new tools for tracking the disease. Public health experts are combining anonymous data from mobile phone records with data on malaria incidence to identify the key migration hotspots—allowing countries to target their resources in the most cost-effective and strategic ways. In Kenya, for example, these maps helped experts target large-scale tea plantations in the country’s Lake Zone. Comprehensive efforts at the plantations could make it possible to eliminate malaria from large swaths of the country’s highlands without even having to run elimination efforts there.

Just as important as any specific innovation, our team has converged on an eradication strategy that will make the whole greater than the sum of the parts. That strategy has three components: Complete Detection, Complete Cure, and Complete Prevention.

Complete Detection is a departure from current approaches, which focus on finding and treating only those people who have active malaria cases. To achieve eradication, health workers need to find all people who have the parasite in their blood, regardless of whether they’re showing symptoms. (I wrote about this work earlier this year, after Melinda and I saw it in action in Cambodia.) We’re supporting many efforts to develop and bring to market a new generation of diagnostic tools that are even more sensitive than the RDTs now in use and can identify the presence of malaria parasites in all infected individuals.

Complete Cure means using treatments that clear all malaria parasites from the body. Our best anti-malaria treatment today, known as ACT, generally cures the patient clinically but does not eliminate all forms of the parasites that are responsible for continued transmission. So we are trying to supercharge efforts to develop long-lasting, single-dose treatments for malaria that can completely clear malaria parasites from the body and provide a period of protection following the treatment. We believe that our largest partner in this effort, the Medicines for Malaria Venture, could bring these complete-cure drugs to market within five years.

Complete Prevention means reducing opportunities for mosquitoes to pass the parasite on to humans, and preventing the emergence of strains that resist drugs and insecticides. We’ll need next-generation vaccines that block transmission for six months to a year, so that once an area is cleared of the parasite, it stays clear. We’ll also need new insecticides to offset the widespread emergence of mosquito resistance to the chemical compounds we use most frequently today. We may even need cutting-edge approaches, like introducing special fungi into mosquito populations to kill them off or introducing modified genes that can stop mosquitoes from reproducing.

I believe it’s not only possible to eradicate malaria; I believe it’s necessary. Ultimately, the cost of controlling it endlessly is not sustainable. The only way to stop this disease is to end it forever.

If you want to join the fight, please consider donating to our partner Malaria No More.