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.

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 Horizon1000 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 Horizon1000.

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 Horizon1000 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.

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.

There’s a doomsday view of climate change that goes like this:

In a few decades, cataclysmic climate change will decimate civilization. The evidence is all around us—just look at all the heat waves and storms caused by rising global temperatures. Nothing matters more than limiting the rise in temperature.

Fortunately for all of us, this view is wrong. Although climate change will have serious consequences—particularly for people in the poorest countries—it will not lead to humanity’s demise. People will be able to live and thrive in most places on Earth for the foreseeable future. Emissions projections have gone down, and with the right policies and investments, innovation will allow us to drive emissions down much further.

Unfortunately, the doomsday outlook is causing much of the climate community to focus too much on near-term emissions goals, and it’s diverting resources from the most effective things we should be doing to improve life in a warming world.

It’s not too late to adopt a different view and adjust our strategies for dealing with climate change. Next month’s global climate summit in Brazil, known as COP30, is an excellent place to begin, especially because the summit’s Brazilian leadership is putting climate adaptation and human development high on the agenda.

This is a chance to refocus on the metric that should count even more than emissions and temperature change: improving lives. Our chief goal should be to prevent suffering, particularly for those in the toughest conditions who live in the world’s poorest countries.

Although climate change will hurt poor people more than anyone else, for the vast majority of them it will not be the only or even the biggest threat to their lives and welfare. The biggest problems are poverty and disease, just as they always have been. Understanding this will let us focus our limited resources on interventions that will have the greatest impact for the most vulnerable people.

I know that some climate advocates will disagree with me, call me a hypocrite because of my own carbon footprint (which I fully offset with legitimate carbon credits), or see this as a sneaky way of arguing that we shouldn’t take climate change seriously.

To be clear: Climate change is a very important problem. It needs to be solved, along with other problems like malaria and malnutrition. Every tenth of a degree of heating that we prevent is hugely beneficial because a stable climate makes it easier to improve people’s lives.

I’ve been learning about warming—and investing billions in innovations to reduce it—for over 20 years. I work with scientists and innovators who are committed to preventing a climate disaster and making cheap, reliable clean energy available to everyone. Ten years ago, some of them joined me in creating Breakthrough Energy, an investment platform whose sole purpose is to accelerate clean energy innovation and deployment. We’ve supported more than 150 companies so far, many of which have blossomed into major businesses. We’re helping build a growing ecosystem of thousands of innovators working on every aspect of the problem.

My views on climate change are also informed by my work at the Gates Foundation over the past 25 years. The foundation’s top priority is health and development in poor countries, and we approach climate largely through that lens. This has led us to fund a lot of climate-smart innovations, especially in agriculture, in places where extreme weather is taking the worst toll.

COP30 is taking place at a time when it’s especially important to get the most value out of every dollar spent on helping the poorest. The pool of money available to help them—which was already less than 1 percent of rich countries’ budgets at its highest level—is shrinking as rich countries cut their aid budgets and low-income countries are burdened by debt. Even proven efforts like providing lifesaving vaccines for all the world’s children are not being fully funded. Gavi (the vaccine-buying fund) will have 25 percent less money for the next five years compared to the past five years. We have to think rigorously and numerically about how to put the time and money we do have to the best use.

So I urge everyone at COP30 to ask: How do we make sure aid spending is delivering the greatest possible impact for the most vulnerable people? Is the money designated for climate being spent on the right things?

I believe the answer is no.

Sometimes the world acts as if any effort to fight climate change is as worthwhile as any other. As a result, less-effective projects are diverting money and attention from efforts that will have more impact on the human condition: namely, making it affordable to eliminate all greenhouse gas emissions and reducing extreme poverty with improvements in agriculture and health.

In short, climate change, disease, and poverty are all major problems. We should deal with them in proportion to the suffering they cause. And we should use data to maximize the impact of every action we take.

 I believe that embracing the following three truths will help us do that.

Even if the world takes only moderate action to curb climate change, the current consensus is that by 2100 the Earth’s average temperature will probably be between 2°C and 3°C higher than it was in 1850.

That’s well above the 1.5°C goal that countries committed to at the Paris COP in 2015. In fact, between now and 2040, we are going to fall far short of the world’s climate goals. One reason is that the world’s demand for energy is going up—more than doubling by 2050.

From the standpoint of improving lives, using more energy is a good thing, because it’s so closely correlated with economic growth. This chart shows countries’ energy use and their income. More energy use is a key part of prosperity.

Unfortunately, in this case, what’s good for prosperity is bad for the environment. Although wind and solar have gotten cheaper and better, we don’t yet have all the tools we need to meet the growing demand for energy without increasing carbon emissions.

But we will have the tools we need if we focus on innovation. With the right investments and policies in place, over the next ten years we will have new affordable zero-carbon technologies ready to roll out at scale. Add in the impact of the tools we already have, and by the middle of this century emissions will be lower and the gap between poor countries and rich countries will be greatly reduced.

I wasn’t sure this would be possible when Breakthrough Energy was started in 2015 after the Paris agreement. Since then, the progress of Breakthrough companies and others and the acceleration now being provided by the use of artificial intelligence have made me confident that these advances will be ready to scale.

All countries will be able to construct buildings with low-carbon cement and steel. Almost all new cars will be electric. Farms will be more productive and less destructive, using fertilizer created without generating any emissions. Power grids will deliver clean electricity reliably, and energy costs will go down.

Even with these innovations, though, the cumulative emissions will cause warming and many people will be affected. We’ll see what you might call latitude creep: In North America, for instance, Iowa will start to feel more like Texas. Texas will start to feel more like northern Mexico. Although there will be climate migration, most people in countries near the equator won’t be able to relocate—they will experience more heat waves, stronger storms, and bigger fires. Some outdoor work will need to pause during the hottest hours of the day, and governments will have to invest in cooling centers and better early warning systems for extreme heat and weather events.

Every time governments rebuild, whether it’s homes in Los Angeles or highways in Delhi, they’ll have to build smarter: fire-resistant materials, rooftop sprinklers, better land management to keep flames from spreading, and infrastructure designed to withstand harsh winds and heavy rainfall. It won’t be cheap, but it will be possible in most cases. Unfortunately, this capacity to adapt is not evenly distributed, a subject I will return to below.

So why am I optimistic that innovation will curb climate change? For one thing, because it already has.

You probably know about improvements like better electric vehicles, dramatically cheaper solar and wind power, and batteries to store electricity from renewables. What you may not be aware of is the large impact these advances are having on emissions.

Ten years ago, the International Energy Agency predicted that by 2040, the world would be emitting 50 billion tons of carbon dioxide every year. Now, just a decade later, the IEA’s forecast has dropped to 30 billion, and it’s projecting that 2050 emissions will be even lower.

Read that again: In the past 10 years, we’ve cut projected emissions by more than 40 percent.

This progress is not part of the prevailing view of climate change, but it should be. What made it possible is that the Green Premium—the cost difference between clean and dirty ways of doing something—reached zero or became negative for solar, wind, power storage, and electric vehicles. By and large, they are just as cheap as, or even cheaper than, their fossil fuel counterparts.

Of course, to get to net zero, we need more breakthroughs. This will become even more important if new evidence shows that climate change will be much worse than what the current generation of climate models predicts, because we will need to lower the Green Premium faster and accelerate the transition to a zero-emission economy.

Luckily, humans’ ability to invent is better than it has ever been.

Breakthrough Energy focuses its new investment on the areas of innovation that still have large positive Green Premiums. Below I write about the state of play in the five sectors of the economy that are responsible for all carbon emissions. I’ll cover highlights and challenges—one common theme will be the difficulty of scaling rapidly—and I’ll include some of the companies Breakthrough Energy works with so you can see how much activity there is in each sector.

Electricity (28 percent of global emissions)

Making electricity is the second biggest source of emissions, but it’s arguably the most important: To decarbonize the other sectors, we’ll have to electrify a lot of things that currently use fossil fuels. We need more innovation in renewables, transmission, and other ways to generate and store electricity.

• New approaches to wind power can generate more energy using less land, and advances in geothermal mean it’s being tapped in more places around the world. (Examples: Fervo, Baseload Capital, Airloom)
• Companies are pilot-testing highly efficient power lines that can transmit much more electricity than the previous generation of cables.  (TS Conductor, VEIR)
• We need to keep reducing the cost of clean energy that’s available around the clock, including new nuclear fission and fusion facilities. More than half of today’s emissions from electricity could only be eliminated using these so-called “firm” sources, but they have a Green Premium of well over 50 percent. I’m hopeful that we can get rid of the Green Premium with fission; a next-generation nuclear power plant is under construction in Wyoming. And fusion, which promises to give us an inexhaustible supply of cheap clean electricity, has moved from science fiction to near-commercial. (TerraPower, Commonwealth Fusion Systems, Type One Energy)

Manufacturing (30 percent of global emissions)

When someone tells you they know how to curb emissions, the first question you should ask is: What’s your plan for cement and steel? They’re key to modern life, and they’re hard to decarbonize on a global scale because it’s so cheap to make them with fossil fuels.

• Zero-emissions steel exists today. It’s made using electricity, so if you can get clean electricity that’s cheap enough, you end up with clean steel that’s cheaper than the conventional type. The technology still needs to get into more markets, and companies that make clean steel need to expand their capacity. (Boston Metal, Electra)
• Clean cement faces similar hurdles. Several companies have found ways to make it with no Green Premium, but it takes years to get a foothold in the global market and ramp up manufacturing capacity. (Brimstone, Ecocem, CarbonCure, Terra CO2, Fortera)
• One of the biggest energy surprises of the past decade is the discovery of geologic hydrogen. Eventually, hydrogen will be widely used to make clean fuels and will help with clean steel and cement. Today we make it from fossil fuels or by running electricity through water, but geologic hydrogen is generated by the Earth itself. Companies have already proven that they can find it underground; now the challenge is to extract it efficiently. There’s also been a lot of progress on making hydrogen with electricity much more cheaply than current technology does it. (Koloma, Mantle8, Electric Hydrogen)
• Companies are beginning to roll out ways to either capture carbon from facilities that currently emit it, such as cement and steel plants, or to remove it directly from the air and store it permanently. If captured carbon becomes cheap enough, we could even use it to make things like sustainable aviation fuel. (Heirloom, Graphyte, MissionZero, Deep Sky)

Agriculture (19 percent of global emissions)

Much of the emissions from agriculture comes from just two sources: the production and use of fertilizer, and grazing livestock that release methane.

• Farmers can already buy one replacement for synthetic fertilizer that’s made without any emissions, and another that turns the methane in manure into organic fertilizer. Both are selling at a negative Green Premium. Now the challenge is to produce them in large quantities and persuade farmers to use them. (Pivot Bio, Windfall Bio)
• Additives to cattle feed that keep livestock from producing methane are nearly cheap enough to be economical for farmers, and a vaccine that does the same thing has been shown to work. It’s now moving into the next stage of development. (Rumin8, ArkeaBio)
• Another source of methane is the cultivation of rice, one of the world’s most important staple foods. Companies are helping rice farmers around the world adopt new methods that both reduce methane emissions and increase crop yields. (Rize)
• One stubborn problem is that some of the nitrogen in fertilizer seeps into the atmosphere as nitrous oxide, a potent greenhouse gas. It’s very dilute, which makes it hard to capture.

Transportation (16 percent of global emissions)

Nearly one in four cars sold in 2024 was an EV, and more than 10 percent of all vehicles in the world are electric. In some countries including the U.S., they still have disadvantages, such as long charging times and too few public charging stations, that keep them from being as practical as gas-powered cars. In addition, cars and trucks are just one part of this sector, which also includes tough-to-decarbonize activities like shipping and aviation.

• Airplane emissions are projected to double by 2050, and clean jet fuel still comes with a Green Premium of over 100 percent. Today we know of only two cost-effective ways to make it: produce it with algae, or make synthetic fuel using very cheap hydrogen. Companies are in the early stages of work on both approaches.
• As more transportation goes electric, the demand for batteries is going to increase, which is why companies have developed ways to make them cheaper and more efficient. (KoBold Metals, GeologicAI, Redwood, Stratus Materials)

Buildings (7 percent of global emissions)

Heating and cooling buildings is the smallest slice of global emissions today, but it’s going to skyrocket with urbanization and the growing need for air conditioning.

• Electric heat pumps are widely available, up to five times more efficient than boilers and furnaces, and often the cheaper option. But there aren’t enough skilled workers around the world to install them. Next-generation, extra-efficient heat pumps are already on the market, and ones that are easier to install are in the works. (Dandelion, Blue Frontier, Conduit Tech)
• Other zero Green Premium products are available, including building sealants and super-efficient windows. But as with so many clean technologies, reaching scale takes time. (Aeroseal, Luxwall)

The global temperature doesn’t tell us anything about the quality of people’s lives. If droughts kill your crops, can you still afford food? When there’s an extreme heat wave, can you go somewhere with air conditioning? When a flood causes a disease outbreak, can the local health clinic treat everyone who’s sick?

Quality of life may seem like a vague concept, but it’s not. One useful tool for measuring it is the United Nations’ Human Development Index, which provides a snapshot of how people in a country are faring—from 0 to 1, with higher numbers meaning better outcomes.

If you look through a list of the HDI scores of the world’s countries, the disparities leap out at you. Switzerland has the highest HDI, at 0.96. South Sudan, the lowest, is at 0.33. The 30 countries with the lowest HDI scores are home to one out of every eight people on the planet, but they produce only about one third of 1 percent of global GDP. They have the highest poverty rates and, tragically, the worst health outcomes. A child born in South Sudan is 39 times more likely to die before her fifth birthday than one born in Sweden.

This inequity is the reason our climate strategies need to prioritize human welfare. This may seem obvious—who could be against improving people’s lives?—but sometimes human welfare takes a backseat to lowering emissions, with bad consequences.

For example, a few years ago, the government of one low-income country set out to cut emissions by banning synthetic fertilizers. Farmers’ yields plummeted, there was much less food available, and prices skyrocketed. The country was hit by a crisis because the government valued reducing emissions above other important things.

Sometimes the pressure comes from outsiders. For example, multilateral lenders have been pushed by wealthy shareholders to stop financing fossil fuel projects, with the hope of limiting emissions by leaving oil, gas, and coal in the ground. This pressure has had almost no impact on global emissions, but it has made it harder for low-income countries to get low-interest loans for power plants that would bring reliable electricity to their homes, schools, and health clinics.

Granted, situations like these are complicated, since burning fossil fuels helps people now at the cost of making the climate worse for people in the future. But remember that climate change is not the biggest threat to the lives and livelihoods of people in poor countries, and it won’t be in the future. In the next section, I’ll explain why and what it means for our climate strategies.

A few years ago, researchers at the University of Chicago’s Climate Impact Lab ran a thought experiment: What happens to the number of projected deaths from climate change when you account for the expected economic growth of low-income countries over the rest of this century? The answer: It falls by more than 50 percent.

This finding is exciting because it suggests a way forward. Since the economic growth that’s projected for poor countries will reduce climate deaths by half, it follows that faster and more expansive growth will reduce deaths by even more. And economic growth is closely tied to public health. So the faster people become prosperous and healthy, the more lives we can save.

When you look at the problem this way, it becomes easier to find the best buys in climate adaptation—they’re the areas where finance can do the most to fight poverty and boost health.

At the top of that list is improvements in agriculture.

Most poor countries are still largely agrarian economies. The average smallholder farmer in these countries has between two and four acres and makes about $2 a day. And she gets relatively little from her fields, about 80 percent less per acre than an American farmer. A single drought or flood can wipe her out for an entire season.

Lower emissions will eventually lead to fewer devastating losses, but today’s farmers don’t have time to wait for the climate to stabilize. They need to raise their incomes and feed their families now.

Mobile phones are already making a dramatic difference. Farmers use their phones to get advice on what to plant, when to plant, and when to fertilize that’s tailored by artificial intelligence to account for their soil, weather, and other local conditions. In India, during the most recent summer monsoon, around 40 million farmers in 13 states received an advance warning by SMS that the rains would arrive early and then pause. That single message saved millions of acres of crops.

And the technology is improving rapidly: In the next five years, a low-income farmer will be able to get better advice than anything that’s available to the richest farmers today.

Advances in crop breeding are another great buy, and Kenya has set an excellent example. Nearly 20 years ago, a group of African agricultural scientists saw that hotter, drier seasons were putting staple crops like maize under stress. So with support from the Gates Foundation and others, they developed a variety that could thrive in a changing climate. It worked: The new seeds gave a group of Kenyan farmers 66 percent more maize, enough to feed a family of six for a year and still have $880 worth of crops left over to sell. That’s equivalent to five months of income for them.

The list of innovations goes on. For example, researchers have helped farmers identify breeds of cattle that are naturally more resilient in tough conditions. And the new class of natural zero-emissions fertilizers I mentioned earlier is being tailored to the conditions in low-income countries. Scientists at the Tamil Nadu Agricultural University in India found that when smallholder farmers added these biofertilizers to their fields, their yields went up as much as 20 percent.   

Improvements like these need to go hand in hand with improvements in health. I think if you ask most people how they think climate will affect health, they’ll talk about heat waves and natural disasters. So let’s start there and look at the facts.

Excessively hot weather now causes around 500,000 deaths every year. Despite the impression you’d get from the news, though, the number has been decreasing for some time, chiefly because more people can afford air conditioners. And, surprisingly, excessive cold is far deadlier, killing nearly ten times more people every year than heat does. As for what will happen in the future, heat deaths will go up and cold deaths will go down. The best current estimates suggest that the net effect will be a global rise in temperature-related mortality, and that most of the increase will be in developing countries.  

The story so far with natural disasters is similar. In the past century, direct deaths from natural disasters, such as drowning during a flood, have fallen 90 percent to between 40,000 and 50,000 people a year, thanks mostly to better warning systems and more-resilient buildings.

But indirect deaths from natural disasters have not followed the same pattern of decline. In most cases today, people caught in storms and floods are more likely to die from a waterborne disease than from drowning. When floodwaters contaminate drinking water, they create ideal breeding grounds for cholera and rotavirus, which cause diarrhea and are especially deadly for children. More floods equals more diarrheal deaths.

But pathogens don’t wait around for storms or floods to infect people. Diarrheal diseases kill more than a million people a year, and the vast majority of infections don’t happen in a sudden tragic flash. They’re part of life in a low-income country. And, sadly, they’re not the only ongoing health threat.

If you include the other major causes of death in poor countries—malaria, TB, HIV/AIDS, respiratory infections, and complications from childbirth—poverty-related health problems kill about 8 million people a year.

And the burden is even worse when you factor in the health problems that don’t kill people but make them too sick to work, go to school, or take care of their kids. If a pregnant woman is already malnourished and then has her food supply cut off because of a flood, she’s even more likely to give birth prematurely, and her baby is more likely to start life underweight. But if she’s well-nourished to begin with, she and her baby have a much better chance to stay healthy.

I’m not saying we should ignore temperature-related deaths because diseases are a bigger problem. In fact, temperature-related deaths are one of the reasons why cheap clean energy is so important—it will make heating and air conditioning more affordable everywhere.

What I am saying is that we should deal with disease and extreme weather in proportion to the suffering they cause, and that we should go after the underlying conditions that leave people vulnerable to them. While we need to limit the number of extremely hot and cold days, we also need to make sure that fewer people live in poverty and poor health so that extreme weather isn’t such a threat to them.

Artificial intelligence has already begun to help do that. Today, for example, AI-powered devices make it possible for health workers to provide ultrasound exams for pregnant women in low-income settings—a breakthrough that means many more women will get the treatment they need to survive childbirth and deliver a healthy baby. AI is also helping researchers develop new vaccines and treatments faster, adding to the long list of affordable lifesaving tools that are already available, including vaccines, biofortified foods, bed nets, and treatments for diseases like AIDS, malaria, and tuberculosis.

The benefits of improving health and agriculture go beyond climate resilience. For example, as child survival rates go up, something unexpected takes place: People choose to have smaller families. When this happens, governments of poor countries can invest more in schools and health clinics, roads and ports, and sanitation systems and power grids. These things in turn make it easier to improve health and raise incomes. It is a remarkable virtuous cycle and it is set in motion by better health and agriculture.

In this memo, I’ve argued that we should measure success by our impact on human welfare more than our impact on the global temperature, and that our success relies on putting energy, health, and agriculture at the center of our strategies. 

Development doesn’t depend on helping people adapt to a warmer climate—development is adaptation.

Under Brazil’s leadership, adaptation and human development will get more attention at COP30 than at any other COP. That’s a promising first step.

For COP30 and beyond, I see two priorities that I hope the climate community will embrace.

1.

Drive the Green Premium to zero.

At each COP, governments take turns announcing commitments to lower their emissions. Unfortunately, this process doesn’t tell us which technologies are needed to meet those commitments, whether we have them yet, or what it will take to get them.

This is why, in addition to country-by-country commitments, every COP should have high-level discussions and commitments based on the five sectors. Policies and innovations in each sector need to get more visibility. Representatives from each of the five sectors should report on progress toward affordable and practical zero-carbon innovations, using the Green Premium as their yardstick.

Government leaders would get a view into whether they can meet their commitments with existing tools. They would see, sector by sector, which technologies they can start adopting now, which ones they should plan to roll out soon, and which ones still need government action to reduce the Green Premium. They would talk to their peers from other countries about working together on promising breakthroughs that will help everyone meet their commitments.

If you’re a policymaker, you can bring this sector-by-sector focus on the Green Premium to your government’s work. You can also protect funding for clean technologies and the policies that promote them. This is not just a public good: The countries that win the race to develop these breakthroughs will create jobs, hold enormous economic power for decades to come, and become more energy independent.

If you’re an activist, you can call for steps that make clean alternatives in every sector as cheap and practical as their fossil fuel counterparts. The public is more likely to switch to clean technology when it’s cheaper and better than fossil fuels.

If you’re a young scientist or entrepreneur, this is a moment to rethink what it means to change the world. The people working on clean materials today will have an enormous impact on human welfare. If you need pointers, the Climate Tech Map published last month by Breakthrough Energy and other partners is an excellent guide to the technologies that are essential for decarbonizing the economy. 

If you’re an investor, I encourage you to invest in companies working on high-impact clean technologies that will eventually have no Green Premium. I’m putting more of my own money into these efforts because reducing the Green Premium to zero demands more for-profit capital. It’s also a fantastic investment in what will be the biggest growth industry of the 21^st century. (I will give any profits I make from my investments to the Gates Foundation.)

2.

Be rigorous about measuring impact.

I wish there were enough money to fund every good climate change idea. Unfortunately, there isn’t, and we have to make tradeoffs so we can deliver the most benefit with limited resources. In these circumstances, our choices should be guided by data-based analysis that identifies ways to deliver the highest return for human welfare.

Vaccines are the undisputed champion of lives saved per dollar spent. Since 2000, Gavi has spent $22 billion to immunize children in poor countries, preventing 19 million deaths. That means Gavi can save a life for a little more than $1,000. Other estimates find that vaccines cost less than $5,000 per life saved. And vaccines become even more important in a warming world because children who aren’t dying of measles or whooping cough will be more likely to survive when a heat wave hits or a drought threatens the local food supply.

Every effort in the world’s climate agenda should undergo a similar analysis and be prioritized by its ability to save and improve lives cost-effectively. Malaria prevention, for example, is nearly as good as vaccines on the basis of cost per life saved. Energy innovation is a good buy not because it saves lives now, but because it will provide cheap clean energy and eventually lower emissions, which will have large benefits for human welfare in the future. Many of the best buys in agricultural innovation will be on display at COP30 in a showcase hosted by the Gates Foundation, the Brazilian government, and other partners.

This moment reminds me of another time when I called for a new direction. 

Thirty years ago, when I was running Microsoft, I wrote a long memo to employees about a major strategic pivot we had to make: embracing the internet in every product we made. 

It seems like an obvious move now, given that online activity is such an integral part of everyone’s life, but at the time, the internet was just entering the mainstream. If we hadn’t adjusted our strategy, our success would have been at risk.

For a company, it's relatively easy to make a shift like that because there’s only one person in charge. By contrast, there is no CEO who sets the world’s climate priorities or strategies, which is exactly as it should be. These are rightly determined by the global climate community.

So I urge that community, at COP30 and beyond, to make a strategic pivot: prioritize the things that have the greatest impact on human welfare. It’s the best way to ensure that everyone gets a chance to live a healthy and productive life no matter where they’re born, and no matter what kind of climate they’re born into. 

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.

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 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.

In 1997, I came across a New York Times column by Nick Kristof that stopped me in my tracks. The headline was “For Third World, Water Is Still a Deadly Drink,” and it included a statistic I almost didn’t believe: Diarrhea was killing 3.1 million people every year—most of them kids under the age of five.

I didn’t know much about the problem back then, except that it seemed so solvable. After all, in rich countries it felt like it already had been. My oldest daughter was a toddler at the time, and we never worried that an upset stomach would kill her. None of the other parents I knew worried about that either.

But in much of the world, kids without clean drinking water or basic sanitation were constantly being exposed to rotavirus, cholera, shigella, typhoid, and more—dangerous pathogens that spread easily when toilets are scarce and water is contaminated.

Nick’s column ended up changing my life. I sent it to my dad with a note: “Maybe we can do something about this.” He agreed. And after he traveled to Bangladesh to see the problem firsthand, we made a $40 million investment in vaccine research for diarrheal diseases. That grant helped shape what would become the Gates Foundation—and kickstarted decades of progress that’s now saved millions of lives.

Within a few years, I stepped away from Microsoft to focus on this work full-time. Once you’ve seen what’s possible in global health, it’s hard to do anything else.

When we first got involved, diarrhea was one of the biggest killers of kids worldwide. But over the past two and a half decades, these deaths have dropped by more than 70 percent.

The biggest breakthrough came from making vaccines for rotavirus, the leading cause of severe diarrhea and death in kids, affordable and accessible. When the vaccines first debuted in the early 2000s, they were priced at around $200 per dose—which meant they were completely out of reach for most families in most of the world. So the foundation partnered with vaccine manufacturers in India like Bharat Biotech and Serum Institute to develop high-quality, low-cost alternatives. Today, rotavirus protection costs about a dollar.

But getting the vaccines developed was only half the challenge. The other half was getting them to the kids who needed them most.

That’s where Gavi came in. The organization was set up a few years earlier to help low-income countries pay for lifesaving vaccines that had existed for decades but weren’t reaching the world’s poorest. But they were well-positioned to do the same with a new vaccine, and they did—purchasing the rotavirus vaccine for millions of children and supporting countries as they added it to their routine immunization programs. USAID played a huge role in this work, too, by helping local governments train community health workers and strengthen their vaccine delivery systems. Meanwhile, public health campaigns promoted treatments like oral rehydration salts and zinc supplements that can save a sick child's life for pennies. (Think of it as the medical-grade equivalent of Pedialyte.)

As all this was happening, countries quietly made enormous progress on clean water and sanitation too. Since 1990, 2.6 billion people around the world have gained access to safe drinking water—and the number of people who now have basic sanitation similarly has skyrocketed. These improvements help break a cycle where kids get sick, recover, and then get reinfected a few weeks later.

Despite the incredible progress, around 340,000 kids under five are still dying from diarrhea each year.

Part of the problem is that many kids still don't get vaccinated. Some live in places where health systems are weak or vaccines are hard to transport and store. Others are caught in conflict zones that make it dangerous for health workers to reach them.

And new challenges make the fight against diarrheal diseases even harder than it was 25 years ago. Shigella—one of the nastiest bacterial causes of diarrhea—is becoming more and more resistant to antibiotics, and we still don't have a vaccine. Climate change is making cholera and typhoid outbreaks more frequent, as floods contaminate water supplies and droughts force people to drink from unclean, unsafe sources.

For malnourished kids, everything is harder: They're more vulnerable to diarrheal diseases in the first place, and their damaged digestive tracts don't respond as well to oral vaccines or treatments. For families barely scraping by, diarrhea is both a medical crisis and an economic disaster. Parents miss work to care for sick kids. Kids miss school. Expenses pile up. It's one of the ways that disease keeps families trapped in poverty—and one of the reasons that a country’s public health is key to its development.

The encouraging news is that there’s a promising pipeline of innovations that builds on what we already know and could save even more lives.

At the foundation, we’re supporting scientists who are working on a vaccine for Shigella, which has become the leading bacterial cause of childhood diarrhea. We’re also funding efforts to combine different vaccines into a single shot, which would lower costs and make things easier for health workers and kids alike.

New delivery methods could make a big difference too. One example: vaccine patches for measles that don’t require needles, refrigeration, or trained staff to administer them. Just peel, stick, and protect. 

We've already learned a lot about how chronic infections damage kids’ guts and make it harder for them to absorb nutrients or respond to vaccines. Now, scientists are researching how to repair that damage, which could help the sickest kids recover faster.

And outside the lab, environmental monitoring tools are being developed to detect early signs of outbreaks—by regularly testing sewage for typhoid, for instance. It’s like having an early warning system for epidemics.

We can’t afford to look away now

I’ve been talking about diarrhea for 25 years, even though it makes some people squeamish, because it’s a microcosm of global health. It’s proof that the world can come together to solve big problems. When we refuse to accept that some children won’t make it to their fifth birthday, we can save millions of lives.

But it’s also a warning of what can happen when we look away.

Right now, global health funding is being slashed around the world. According to one estimate, cuts to aid from the U.S. have already led to almost 60,000 additional childhood deaths from diarrhea. If nothing changes, by next January that number could rise to 126,000. These are projections, not final counts, but the reality is undeniable: When lifesaving programs are eliminated, kids pay the price.

Diarrhea is one of the most solvable problems in global health. We’ve come a long way, but we’re not done yet.  

What do Adirondack chairs, Stetson hats, the city of Pasadena, and World War I have in common? According to John Green, all of their origin stories include tuberculosis.

In his new book, John argues that it’s impossible to separate the deadliest disease in history from, well, the rest of history. Adirondack chairs were designed by a man who vacationed in the New York mountains—a popular spot for TB patients seeking fresh air—and soon became staples of sanatorium porches across the country. John B. Stetson, who had TB himself, traveled west for dry mountain air and invented the cowboy hat to protect from sun, wind, and rain. Pasadena became a hub for TB treatment in the late 1800s, and TB “tourism” was a major driver of the city’s early economy, real estate, and identity. And the teenage assassins who killed Archduke Franz Ferdinand, which kicked off World War I? They were more willing to die for their cause since they were already dying of TB. 

No wonder John calls this book Everything Is Tuberculosis. In so many ways, TB shaped the world we live in. Even though the disease is now both rare and treatable in rich countries, in poorer places it’s on the rise and still a death sentence for so many.  

John is best known as the author of some of the best young adult novels of all time (at least according to my daughter Phoebe, whose encouragement led me to read The Fault in Our Stars and Turtles All the Way Down). So a lot of people were surprised when he announced that his next book would be about global health—about a disease most people in the western world think of in the past tense.

I wasn’t. After all, I first met John over a decade ago, when he joined me on a Gates Foundation trip to Ethiopia. While traveling, we talked about a lot of the big questions John wrestles with in Everything Is Tuberculosis—like why the place a person is born influences their odds of surviving childhood (or childbirth), and what people like us can do to increase those odds.

Since then, John has been an invaluable partner to the foundation, bringing his curiosity and clarity to our events and helping raise awareness of our work. But he’s also become a powerful advocate for global health in his own right. I don’t know anyone else who could turn a book about tuberculosis into a number one New York Times bestseller.

Everything Is Tuberculosis is poignant, smart, and at times infuriating. At its heart is the story of a boy named Henry, whom John met at a TB clinic in Sierra Leone. Henry was just six when he started showing classic signs of the disease: fatigue, weight loss, night sweats. But the first tests he got came back negative, so he was sent home from the hospital. By the time he was eventually diagnosed, Henry was already very sick.

He began treatment with the standard cocktail of decades-old antibiotics. It’s a brutal regimen that involves months of pills, painful injections, constant side effects—and, once the infection starts to subside, aching hunger from having an appetite again. The drugs only work if they’re taken consistently and on schedule, but that’s often unrealistic for patients. In much of the world, TB treatment means walking miles to a clinic, missing work or school, going into debt, and facing social stigma and isolation. Even though Henry’s mom did everything she could to support him, there were interruptions to his treatment, and eventually the TB became drug-resistant.

In the end, Henry got lucky. Even as he got sicker and ran out of options, his doctors wouldn’t give up on him. They fought to get him access to a personalized drug regimen—something that’s rarely available to kids in poor countries. That care ended up saving his life, and today Henry is thriving. After years stuck in the hospital, he’s caught up academically and now in university (and even has a YouTube channel where he shares his journey and advocates for other TB patients). John doesn’t romanticize Henry’s story as some kind of miracle. Instead, he uses it as proof: that TB is curable, that good care works, and that the real question isn’t whether we can save lives—but whether we’re willing to make that care available to everyone.

Even though John finished writing the book last year, he nails the urgency of this moment. He shows how a disease that most people in rich countries have forgotten is still killing over a million people a year, and how easily that number could keep climbing. That’s especially true now, as foreign aid cuts disrupt TB care across the globe. Henry might not be alive today if it weren’t for organizations like Partners In Health—funded in part by U.S. health aid—which fought to get him the treatment he needed. These aid cuts will be devastating for kids like him, who may lose access to treatment altogether. They’ll also lead to more interrupted care, more cases, more drug resistance, and more strains of an infectious disease that will be harder and more expensive for the entire world to contain.

This is a book about the central challenge of global health today: the reality that, in John’s words, “the cure is where the disease is not, and the disease is where the cure is not.”

A book about tuberculosis could be pretty boring, but John makes it super compelling by weaving in TB’s long and strange history, from the myth that it only afflicted white people, to the theory that it inspired creative genius, to its influence on Victorian beauty standards. (I didn’t know about those last two… or the Stetson hats.) If you’re familiar with John’s work, this approach won’t surprise you. He has a gift for getting people to care about things they might not think are “for me,” whether that’s poetry, astrophysics, or infectious disease.

John ends Everything Is Tuberculosis with a stirring call to action. He makes the case that saving lives from TB isn’t really a scientific challenge anymore; it’s a moral one. I largely agree. But I also think there are more reasons for hope than the book lets on.

While John is clear-eyed about the failures of the past and present—the slow pace of progress, the sky-high prices of new TB drugs, the inequality that determines who gets treated and who doesn’t—he doesn’t spend much time on what comes next. Having spent the last two-and-a-half decades investing in the science behind TB care through the Gates Foundation, I’ve seen a different side of the story. I know what’s in the pipeline, and I know what’s possible.

Today, we’re closer than ever to breakthroughs that could change everything about how we treat and even prevent TB: shorter drug regimens, better diagnostics, and even vaccines. These tools will only make a difference if they’re affordable enough to reach kids like Henry. But I think it’s important to recognize that the companies often criticized for pricing are also, ironically, the only ones that have been willing to invest in TB at all. We need to keep working with them as partners, keep the innovation coming, and keep bringing costs down.

If we do, we can make Henry’s story of survival the norm, not the exception—and make tuberculosis a disease of the past, not the future.

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.”

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.

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.

I've always thought of myself as a student trying to get to the bottom of things. A good day for me is one where I go to sleep with just a little bit more knowledge than I had when I woke up in the morning. So, when I am deciding how to spend my time these days, I usually ask myself three questions: Will I have fun? Will I make a difference? And will I learn something?

My new Netflix Series, What’s Next? The Future with Bill Gates, is out today. And when I think back on the process of working on it over the last two years, the answer to all three questions is a resounding “yes.”

I had an amazing time working with the super talented director, Morgan Neville. Morgan directed one my favorite documentaries, Best of Enemies, which is about Gore Vidal’s and William Buckley’s debates during the 1968 U.S. presidential election. Morgan also won an Oscar for his terrific film 20 Feet from Stardom.

As you might guess from the title, What’s Next? is a show about the future. I’m very fortunate to get to work on a number of interesting problems. Between fighting to reduce inequities through the Gates Foundation, leading Breakthrough Energy’s work on the climate crisis, and my continued engagement with Microsoft, I have a front seat to some of the biggest challenges facing us today.

I feel extremely grateful to have had the opportunity to work with and learn from some truly incredible people during the making of this show. (I’m hesitant to even use the word “work” because the process was so much fun!) My hope is that people watch What’s Next? and feel like they’re joining me on my learning journey.

Each episode focuses on a different challenge: artificial intelligence, climate change, misinformation, disease eradication, and income inequality. I sat down with some of the big thinkers and innovators who are pushing for progress. Some of them have different ideas than I do about how to tackle these challenges, and I loved getting to hear their perspectives. It was an eye-opening experience.

I got to have conversations on camera with familiar faces like Dr. Anthony Fauci, Open A.I. co-founder Greg Brockman, and the groundbreaking director James Cameron. And I made a lot of new friends as well—including an ingenious malaria researcher from Burkina Faso named Abdoulaye Diabaté, young climate activists who impressed me with their intelligence and passion, and an amazing group of people from across the Bay Area who overcame tremendous adversity in their path from poverty to stability.

There also were dozens of people who participated in the series with standalone interviews, like my friend Bono and the brilliant Mark Cuban—each of whom brings an inspiring and grounded view of the challenges we’re facing. My hope is that, together, we can combat the doomsday narratives that so often surround these issues.

It’s hard to pick which discussion I learned the most from. But three conversations will always stand out in my memory: the ones with Lady Gaga, Senator Bernie Sanders, and my younger daughter, Phoebe.

Going Gaga

I couldn’t help but feel a little nervous.

I was in Palm Desert, CA, preparing to have a filmed conversation with Lady Gaga for our episode about misinformation. Being around famous people doesn’t normally affect me. But I’m a big fan of A Star is Born—especially its music—and I was aware of her reputation as an outsized personality. I couldn’t wait to hear what she had to say.

Luckily, I had nothing to worry about. I was blown away by how thoughtful Gaga was. She made me laugh with the outrageous stories of how she’s been the subject of misinformation in the past—and inspired me with some of the ways she thinks about the topic.

In the early years of her career, one of the most persistent internet rumors about Gaga was that she was actually a man. It became so mainstream that reporters would ask about it during interviews. She refused to confirm or deny it. Instead, Gaga turned it back on the interviewer and asked, “Would it matter if I was?”

On the day of our Netflix conversation, I had been filming earlier with my two sisters, Kristi and Libby. So I asked them to come and watch the conversation between Lady Gaga and me.

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.

If you’ve ever traveled to a part of the world where there’s a risk of malaria or other mosquito-borne disease, you probably slept under a mosquito net.

The gauzy fabric creates a physical barrier that protects you from mosquitoes. At the same time, you serve as bait in a deadly trap. Treated with potent insecticides, the net kills mosquitoes that land on it during their futile efforts to bite you.

It’s a remarkably simple tool, but it’s proven to be one of the most effective weapons we have against malaria. Increased bed net use is largely responsible for the more than 50 percent drop in malaria deaths worldwide since 2000.

Still, more needs to be done to ensure that communities at highest risk of malaria have access to them.

That’s why I’m excited that the government of Benin this year launched a new, innovative approach to distributing bed nets to their population.

Using smartphones, real time data collection, satellite mapping and other surveillance techniques, Benin’s distribution program will give health officials the data they need to provide full bed net coverage to the country.

Benin is faced with one of the highest burdens of malaria in the world. The West African country of nearly 12 million people has about 2 million cases each year. If successful, this new bed net distribution effort will save thousands of lives and serve as a blueprint for other high burden malaria countries to follow.

As you might imagine, distributing bed nets to every household is a massive logistical effort involving thousands of people—from truck drivers to health workers. And the job is made even harder in Benin where exact population numbers are uncertain.

For many years, Benin’s distribution campaigns were run with pencil and paper systems. Health officials used thick ledgers to keep track of the names and addresses of residents and how many beds nets they needed. It was time-consuming and often inaccurate. No one knew exactly how many nets would be needed or if they reached their intended destinations. As a result, many families were missed during the distribution, putting them at higher risk of malaria because they lacked the protection of a bed net.

But this year’s distribution is different. In partnership with Catholic Relief Services and our foundation, Benin’s national malaria program created a new, digitized distribution system that is more accurate and efficient in getting bed nets into the homes of all households in the country.

In many ways, this effort is based on the lessons the global health community has learned in the fight against polio. As vaccinators sought to immunize every child against polio in India and Nigeria, they would sometimes miss households, especially in remote areas. But with satellite mapping and better data collection, health workers were able to quickly identify gaps in vaccination coverage and reach every home.

Benin’s new bed net distribution operates in much the same way. Walking door to door, health workers make home visits throughout the country and perform a brief census: the number of people living there, including number of children and pregnant women, number of bed nets needed, etc. Using cell phones, they enter this information into a database. They also give each household a uniquely coded voucher to redeem at a nearby distribution center where they can collect their bed nets.

On the distribution day, people come to collect their nets and get lessons on the proper way to set up and care for them. As people arrive to redeem their vouchers for the nets, the malaria team has real time data on which households have received their nets and which ones have not. This data—which can be reviewed on a digital map—allows the malaria team to quickly identify any problems with their delivery system. It also gives health workers detailed information about which households need to be targeted for follow up to ensure they all have nets.

I admit none of what I’ve just described may sound that revolutionary. But in global health, I’ve learned again and again that saving lives is the result of getting the smallest details—from the temperature of a vaccine to the address of a beneficiary—right. And Benin’s new digitized bed net distribution program does just that by giving the government a powerful tool to manage a complex job.

And with this new digital distribution system in place, Benin can use it as a platform to manage other big health campaigns—like vaccinating against meningitis and door-to-door efforts to eliminate neglected tropical diseases.

I’m looking forward to hearing more about Benin’s progress in the fight against malaria and other diseases because of this new system—and I hope other countries will learn from their success.

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:

Two of the things I love most about my job are getting to see amazing innovations and talk to remarkable people. During a recent trip to New York, I got to check both boxes. I met a woman named Papa Blandine Mbwey who is using a revolutionary new invention to help more kids get vaccinated.

Blandine has worked as a vaccinator in a remote part of the Democratic Republic of the Congo for over a decade. Most days, she travels on foot to villages all over her region so she can vaccinate kids who live too far from a health clinic to make the trip themselves.

Blandine’s job is complicated by a simple fact: vaccines must be kept between 2 and 8° C. If they get too warm, they spoil. If they get too cold, the water in them freezes, and they can stop working. Vaccines must stay within this temperature range through each step of what’s called the “cold chain.”

By the time Blandine reaches the children, the vaccines she’s carrying have traveled nearly 5,100 miles. They could have spoiled at any point during that journey, but vaccines are particularly at risk during the last two stops.

First there’s the health clinics where vaccinators like Blandine usually pick up their supply of vaccines. Many of these clinics are in areas with frequent power outages or no electrical grid at all, which means the refrigerators can’t always keep the vaccines cold.

But even if the vaccines survive the clinic, they still need to make it to the children. Most vaccinators carry them in ice-lined coolers. If you’ve used a cooler to keep your drinks cold at a picnic, you know the big problem with ice: it starts melting as soon as you take it out of the freezer. This means that some of the kids never get vaccinated, because coolers can’t keep vaccines cold long enough to reach them.

Several years ago, I asked a group of inventors called Global Good that I support to take on the cold chain problem. They came up with two remarkable innovations that are changing the game for vaccinators like Blandine.

The first is the MetaFridge. Although it looks like a regular refrigerator, MetaFridge has a hidden superpower: it keeps vaccines cold without power for at least five days. The electrical components are designed to keep working through power surges and brown-outs. During extended outages, an easy-to-read screen tells you how much longer it can stay cool without power so health workers know when to run a generator or move vaccines elsewhere. And if the fridge stops working properly, it transmits data remotely to a service team so they can fix it before vaccines are at risk of spoiling.

The other innovation Global Good invented is the Indigo cooler, which is the device you see Blandine using in the video above. It keeps vaccines at the right temperature for at least five days with no ice, no batteries, and no power required during cooling.

It sounds counterintuitive, but the Indigo needs heat before you can use it. When exposed to a heat source, water inside its walls evaporates and moves into a separate compartment. It can then sit on a shelf for months after heating, ready for use.

When it’s finally time to head out to the children, you open a valve, and the water starts moving back where it started. Because the pressure inside the Indigo has been lowered to the point where water evaporates at 5° C, the water particles take heat with them (the way sweating lowers your body temperature) and cool the storage area down to the perfect temperature for vaccine storage.

Both inventions are already making an impact in the field. A Chinese manufacturer started selling the MetaFridge last year, and a new solar-powered version will hit the market soon. One of the biggest surprises so far is just how much we’ve learned from its remote data monitoring capabilities. We knew the electrical grids in sub-Saharan Africa were unreliable, but we now know exactly how much the power fluctuates. This information will be helpful moving forward for health providers and anyone designing a product meant to work in these areas.

The Indigo is in the field trial phase. It’s still early, but the data suggests that the Indigo is allowing vaccinators to reach four times as many places as they could with the old ice-based coolers. That’s a big deal, and I’m excited to learn more.

Keeping vaccines cold when you’re delivering them to the most remote places on earth is a tough problem—and these devices show how innovation can help solve tough problems. I hope MetaFridge and Indigo inspire other inventors to find creative solutions.

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.

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.

When I first started traveling to Africa, I would often meet children in the villages I was visiting and try to guess their ages. I was shocked to find out how often I guessed wrong. Kids I thought were 7 or 8 years old based on how tall they were—would tell me that they were actually 12 or 13 years old.

What I was witnessing was the terrible impact of malnutrition in Africa. These children were suffering from a condition known as stunting. They were not starving, but they were not getting enough to eat, leaving them years behind in their development—and it was hard to see how they could ever catch up.

Stunting not only affects a child’s height. It also has an impact on brain development. Stunted children are more likely to fall behind at school, miss key milestones in reading and math, and go on to live in poverty. When stunted children don’t reach their potential, neither do their countries. Malnutrition saps a country’s strength, lowering productivity and keeping the entire nation trapped in poverty.

Worldwide, one in four children is stunted. Three-quarters of them live in South Asia and sub-Saharan Africa. However, while stunting has declined by more than a third in South Asia since 1990, in sub-Saharan Africa, the number of stunted children is still on the rise, up 12 million since 1990 to 56 million. Forty percent of all children in sub-Saharan Africa are stunted.

I run into a lot of people from rich countries who still think of Africa as a continent of starvation. The fact is, that’s an outdated picture (to the extent that it was ever accurate at all). Thanks to economic growth and smart policies, the extreme hunger and starvation that once defined the continent are now rare. As I saw when I was back in Africa last month with best-selling author John Green, today the issue isn’t quantity of food as much as it is quality—whether kids are getting enough protein and other nutrients to fully develop.

As Melinda and I have grown aware of the scale of this challenge, we’ve made improving nutrition a bigger priority for our foundation. One thing we’ve quickly come to appreciate is the problem’s complexity.  There’s no vaccine to prevent stunting. Proper nutrition involves eating enough food, and the right kinds, every day of your life. While the global health community is still working to understand all of the causes and solutions to malnutrition, we do know a lot about how to ensure children get the nutrition they need for a healthy start to life.

We know that getting children the right nutrition in the first 1000 days—from the start of a woman’s pregnancy until her child’s 2nd birthday – is the best down payment on their future, giving them the opportunity to grow and develop physically and mentally. We also know that exclusive breastfeeding in the first six months of a child’s life is the single most effective intervention to help the brain develop and protect against life-threatening diseases. That’s why we continue to research the best ways to address cultural beliefs and other barriers that have kept almost half of all women from using optimal breastfeeding practices.

We know kids have a hard time getting the nutrients they need when fruits, meats, and vegetables are in short supply—so fortifying staple foods like cooking oil, flour, and salt with essential vitamins and minerals can fill the gap. We’re also beginning to develop new crops that are more-nutritious--including a sweet potato that’s enriched with vitamin A—and also produce a higher yield. Not only does this help smallholder farmers earn more income that can be used to diversify their family’s diet, it also puts more nutritious food directly on their table.

Providing better health care can make a difference too. Children who receive the rotavirus vaccine, for example, have fewer bouts of diarrhea, which can drain kids of vital nutrients and make them more susceptible to infection. Likewise, clean water and sanitation play a role in improving nutrition by reducing illness and disease.

We have many great interventions on our side, but with so many factors at play it can be difficult to measure which interventions have the most impact on improving nutrition and why. If I could have one wish, I would want the world to have a better understanding of malnutrition and how to solve it.

We have much more research to do in this area and we will continue to make progress. But what’s not in doubt is the importance of giving all children the nutrition they need for a healthy start to life. Their future depends on it. So does Africa’s.

Working to support the effort to rid the world of polio has taken me to some exotic places. But earlier this month, it took me to Washington, DC (I suppose you could argue this is also quite an unusual spot) to talk with policy makers about the historic opportunity we have to end polio forever. 

My conversations with lawmakers gave me a chance to discuss some of the doubts people have expressed about whether we can really do this. But it also provided the opportunity to bring lawmakers up-to-speed on the results of important changes in the Global Polio Eradication Initiative’s (GPEI) approach—including cool new technology being used and the increased engagement on the part of governments in the countries where polio transmission continues.

In my opinion, the changes and progress in 2012 have made for the most convincing case yet that ending polio is possible—and is one of the most concrete accomplishments possible for global health.

For more than 10 years, we have been 99 percent of the way toward ridding the world of polio. Since then, every few years the global community would vow that year would be the year when polio transmission would stop.

However, 2012 is notably different from the earlier stagnation in progress. And while the global program hasn’t stopped transmission of the wild polio virus everywhere as some had predicted, it did close a big gap in that last one percent when India became polio-free early in the year after a long and hard battle to protect more than 172 million children under the age of five from polio. This was incredible tough terrain in which to run thousands, if not tens of thousands of vaccination campaigns. So, the lessons learned from India’s success are serving as a great guide for what’s needed in the remaining three countries where polio transmission persists—Nigeria, Pakistan and Afghanistan.

There’s no doubt that these countries aren’t easy places to get rid of the disease. There are a number of factors that need to be in place including improved campaign quality, meeting the program’s global funding needs, and anticipating political challenges. 

I heard from U.S. lawmakers that the news regularly coming out of Afghanistan and Pakistan has led to reasonable concerns about the role insecurity plays in being able to reach children with vaccines. But in the last 11 months, incredible efforts are being made in these two countries by government officials, religious and community leaders and non-government organizations to negotiate access to children in hard-to-reach places. 

And those efforts are paying off. 

The polio program has been partnering with a number of NGOs to conduct negotiations to secure access to children, leading to breakthroughs in the past few months. In Afghanistan, the average number of inaccessible children in thirteen of the highest risk districts of the country has been reduced by more than half, from nine percent in June 2012 to 3.4 percent this November. And in the Terah Valley in Pakistan, where children hadn’t received vaccines in three years, approximately 30,000 children were reached with the polio and other critical vaccines during a vaccination campaign earlier this fall.

On the other front, in Nigeria, while cases have actually gone up this year, there is a full-scale effort to revamp the program, with many changes based on what vaccinators in India implemented to great success. Included in these changes are decreases in the size of vaccination teams and the addition of female vaccinators, tracking of nomadic populations, rigorous microplanning and scaling up of additional staff to help with all of these activities. 

Another major innovation that is leading to early reports of impressive progress is the work on GIS mapping and GPS tracking to improve polio campaign planning and performance.  (It’s a really ingenious use of the technology that you can learn more about here.) GPEI’s focus on using the polio program to increase routine immunization is ensuring that the polio program has an even broader long-term impact on the population.

The Independent Monitoring Board of the GPEI also notes the positive changes in a report released last week and their conclusion that the GPEI “has never been in a stronger position” reflects what I’m seeing too.  Their assessment about what comes next for the history books is telling: “The time is momentous for public health history. A final concerted effort could indeed mean writing the story of polio’s last stand.” 

I couldn’t agree more.

In 2009, during a foundation trip to South Africa, I met with Neal Macleod, head of Durban Water and Sanitation. Neal is a health expert working to improve sanitation so people no longer have to use pit toilets such as the one in the photo.

The typical developing world toilet is just a pit. You dig a hole in the ground, you put up a shack around it, and in some cases you put some kind of seat in there. There may or may not be water or toilet paper. It’s pretty unattractive, particularly the smell.

Neal showed me an improved toilet model called a Ventilated Improved Pit latrine or V.I.P. The Ventilated Improved Pit latrine is set up so that air flows down through the toilet, down into the pit and up through a pipe which dramatically reduces the smell problem. And by putting the right mesh wiring on the top of the pipe, flies can’t get in.

One challenge is that you’ve got to empty the pit. In preparation for emptying a pit latrine, large plastic containers are lined up behind the toilet.

The workers have to wear gloves and protective masks to empty the latrines.

Workers pump out waste from a pit latrine. They would remove the liquid waste by using a hand pump.

Workers empty the waste from a pit latrine into large plastic containers. Each pit would yield 25-60 of these huge buckets full of waste.

I started my last day in India at a Bangalore community center called Swathi’s House—a drop-in center for sex workers that’s part of a foundation-supported HIV prevention project called Avahan. The community members gave me a traditional Indian welcome, called an aarti. It was a day to celebrate, because the program is being handed off to the government for long-term support. But the real driver of success are the members themselves.

The center is run by a remarkable community-based organization called Swathi Mahila Sangha, which has approximately 8,500 members out of a population of about 19,000 sex workers in Bangalore. They provide counseling, medical help, HIV prevention training and a micro-finance bank. All of this is done with a cadre of peer educators and outreach workers. It’s a great model for self-help and empowerment.

I was touched by the community’s honesty and resolve—and their entrepreneurial spirit. Roughly half of the members now have savings accounts and their micro-finance bank has $800,000 USD in assets, with a recovery rate of nearly 100%. (I think most U.S. banks would be envious.) Thanks, in part, to their efforts, rates of HIV and sexually-transmitted diseases are down and the woman I talked with spoke of no longer feeling alone and helpless. They were proud of being able to keep their money, instead of remaining victims to “the thugs and the goons.”

Even though they are still a marginalized group, the sex workers are succeeding in advocating for their own rights and are enthusiastic about getting even more sex workers signed up and involved. There’s also been tremendous progress at the government level tackling the problem of HIV infection head-on, and Avahan and community centers like Swathi House are great examples.

I spent the last part of my trip at a gathering of a number of business leaders and philanthropists. I was the guest of two remarkable individuals. Azim Premji is the founder of Wipro and one of Asia’s biggest philanthropists. Ratan Tata is one of the country’s foremost business leaders and a member of the Tata  family well known throughout Indian industry and philanthropy. They were nice enough to invite me to make a few remarks at the beginning, but mostly it was an opportunity to listen and learn about their perspectives on philanthropy in India.

While the circumstances for giving are unique in India, it was amazing just how much their discussion sounded like the conversations I’ve had with wealthy business people and philanthropists in the U.S. and elsewhere. A few common themes emerged. People agreed it was often easier to make the money than to give it away in a thoughtful way. There was a huge feeling of personal satisfaction in their philanthropic work, and a deep sense of societal obligation to give back. With so many problems to address, deciding where to engage and how to do it weighs heavily on their minds.

The group decided they wanted to get together again to learn from one another and talk through issues of common interest. That was fantastic. India is in a new phase of its long history of charitable giving, and I am certain many of these families are going to lead the way by doing remarkable things.

It’s been a very productive and moving three days. I’m grateful I had the chance to meet with so many amazing people in a short time. I’ll post some thoughts on the trip as a whole as well as some video the week of June 11. There’s a lot to reflect on.