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.  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thank you.

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

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

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

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

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

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

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

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

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

Planning for the next 20 years

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

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

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

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

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

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

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

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

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

What the Gates Foundation hopes to accomplish

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The last chapter of my career

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I was scrolling Reddit recently when I saw a video of a mosquito trying and failing to suck someone’s blood. Some of the replies were pretty funny, but I noticed that most of them were just some form of “How do I get this person’s superpower?” It was a great reminder of how universally hated these bloodsuckers are.

But I have good news—for Reddit users and everyone else: Real progress has been made in the fight against mosquitoes and specifically against malaria, the deadliest disease they carry. And I believe we’ll soon have the transformational tools needed to end malaria entirely.

Eradication is a goal Melinda and I set back in 2007, when we stood before a group of global health leaders and called for something many considered impossible: wiping malaria out completely from every country. And until that happened, our goal was—and is—to save as many lives as possible by maximizing the impact of the tools we already have. Eradicating the disease wasn't a new idea; the World Health Organization had made a similar declaration back in 1955. But that earlier campaign, while successful in many wealthier parts of the world, had fallen short across Africa, Asia, the Middle East, Eastern Europe, Central and South America, the Caribbean, and Oceania. Despite half a century of effort, malaria was still infecting up to half a billion people—and claiming a million lives—annually.

Today, the landscape has changed dramatically. In 2022—the last year we have data on—there were 249 million cases worldwide and 608,000 deaths. Those are staggering numbers, but they’re also improvements from where the world was back in 2007. Since then, 17 additional countries have been declared malaria-free by the World Health Organization. Outside of Africa, deaths from the disease have mostly been eliminated.

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.

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:

When Paul Allen and I started Microsoft, we had an ambitious goal: to put a computer on every desk and in every home. A lot of people thought we were out of our minds. But we believed in the power and potential of these machines to change the world. So every day, we came to work determined to make it happen. Now, it’s hard to imagine the world any other way. In a few short decades, that goal became reality for billions.

In 1990, the possibility that the world would be able to cut child mortality in half over the next thirty years would have seemed just as remote. But that’s exactly what happened. And I believe the world can do it again by 2040—we can cut child mortality in half once more—and get even closer to ending all preventable child deaths.

My introduction to this issue came 27 years ago, when I read a piece in The New York Times about deadly drinking water in the world’s poorest countries that contained the following statistic: “Diarrhea kills some 3.1 million people annually, almost all of them children.” Learning that shocked me to my core. There’s no greater pain than the death of a child. The death of millions of them—from something easily treatable in much of the world—is tragedy after tragedy on an almost unfathomable scale.

Before long, I was learning everything I could about global health generally and child mortality specifically. And shortly after, the Gates Foundation, which was just getting off the ground, made it our mission to fight preventable health disparities like this around the world—with an emphasis on children whose lives were being cut short before they ever had a chance.

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

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

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

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

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

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

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

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

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

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

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

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

Here is the chart as it looks today:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But several more-promising candidates are on the horizon. One involves drawing blood from patients who have recovered from COVID-19, making sure it is free of the coronavirus and other infections, and giving the plasma (and the antibodies it contains) to sick people. Several major companies are working together to see whether this succeeds.

Another type of drug candidate involves identifying the antibodies that are most effective against the novel coronavirus, and then manufacturing them in a lab. If this works, it is not yet clear how many doses could be produced; it depends on how much antibody material is needed per dose. In 2021, manufacturers may be able to make as few as 100,000 treatments or many millions.

If, a year from now, people are going to big public events—such as games or concerts in a stadium—it will be because researchers have discovered an extremely effective treatment that makes everyone feel safe to go out again. Unfortunately, based on the evidence I’ve seen, they’ll likely find a good treatment, but not one that virtually guarantees you’ll recover.

That’s why we need to invest in a fourth area of innovation: making a vaccine. Every additional month that it takes to produce a vaccine is a month in which the economy cannot completely return to normal.

The new approach I’m most excited about is known as an RNA vaccine. (The first COVID-19 vaccine to start human trials is an RNA vaccine.) Unlike a flu shot, which contains fragments of the influenza virus so your immune system can learn to attack them, an RNA vaccine gives your body the genetic code needed to produce viral fragments on its own. When the immune system sees these fragments, it learns how to attack them. An RNA vaccine essentially turns your body into its own vaccine manufacturing unit.

There are at least five other efforts that look promising. But because no one knows which approach will work, a number of them need to be funded so they can all advance at full speed simultaneously.

Even before there’s a safe, effective vaccine, governments need to work out how to distribute it. The countries that provide the funding, the countries where the trials are run, and the ones that are hardest-hit will all have a good case that they should receive priority. Ideally, there would be global agreement about who should get the vaccine first, but given how many competing interests there are, this is unlikely to happen. Whoever solves this problem equitably will have made a major breakthrough.

World War II was the defining moment of my parents’ generation. Similarly, the coronavirus pandemic—the first in a century—will define this era. But there is one big difference between a world war and a pandemic: All of humanity can work together to learn about the disease and develop the capacity to fight it. With the right tools in hand, and smart implementation, we will eventually be able to declare an end to this pandemic—and turn our attention to how to prevent and contain the next one.

It’s Mosquito Week again on the Gates Notes. This year I’m exploring some of the science behind malaria and other mosquito-borne diseases. You can read below about how gene editing could play a key role in eradicating malaria. I’ve also written about amazing advances in tracking the disease and how the parasite is a deadly shapeshifter.

Humans have spent thousands of years inventing new ways to kill mosquitoes. The Romans did it by draining swamps. Today you might have a bug zapper in your back yard. In low- and middle-income countries, it’s common to see people spraying insecticides or setting up sticky traps baited with sugar.

But evolution is smart. It is one-upping us by creating mosquitoes that are harder to kill. In sub-Saharan Africa and parts of South America and southeast Asia, we are seeing an alarming number of mosquitoes that can withstand insecticides.

This is especially problematic for the fight against mosquito-borne diseases like malaria. To eradicate these diseases, we need new tools to complement the ones we already have.

Our foundation is backing a lot of different advances. One that I’m especially excited about is a set of techniques for genetically modifying mosquitoes that could dramatically reduce the number of disease-carrying insects in certain areas.

What is cool about these genetic techniques is how precise they can be. Precision matters because out of more than 3,000 species of mosquitoes, only five are responsible for causing most cases of malaria. Of those, only females spread the disease, because they’re the only ones that bite humans. (They do it when they need extra protein for reproduction. Experts call it “taking a blood meal.”) The males just drink nectar.

The promise of gene editing is that, instead of killing a bunch of mosquitoes indiscriminately, we could eliminate only the dangerous ones in a particular area. That would buy us time to cure all the people there of malaria. Then we could let the mosquito population return without the parasite.

One exciting gene-editing technique is called gene drive. The term covers several different approaches, but the basic idea is to use the CRISPR method to rewrite the usual rules of inheritance. Normally, for any given gene, there’s a 50 percent chance that a parent with that gene will pass it on to a child. (It is competing with one from the other parent, and only one of the two can win.) With gene drive, the odds go up to 100 percent. You give a few mosquitoes an edited gene that inserts—or drives—itself into all their offspring. When those mosquitoes mate with wild mosquitoes, all their children will have the edited gene, and over time it will make its way through the entire population.

Imagine if blue-eyed mosquitoes had only blue-eyed children, no matter what color their partners’ eyes were. Eventually, every mosquito in that population would have blue eyes.

This chart shows you how gene drive eventually spreads a gene throughout an entire population:

There’s no reason to think gene drive is even feasible in humans, let alone advisable. There are also serious questions surrounding the use of this technology on insects, which I will get to in a moment. But first I want to give you two examples of how it works.

One is the colorfully named X-shredder. As you might remember from biology class, the sex of a mosquito is determined partly by the sex chromosomes it inherits from its parents. Females got one X chromosome from each parent; males got an X from their mother and a Y from their father.

In 2014, scientists at Imperial College London and the Fred Hutchinson center here in Seattle were able to edit a protein in male mosquitoes so that it shreds the X chromosomes in their sperm. As a result, the males pass along mostly Y chromosomes, so most of their offspring will be males. Thanks to gene drive, those offspring will also have the edited protein, so most of their children will be males.

Within a few generations, the male/female ratio gets out of whack, and eventually the species dies off in that area.

Another example involves the doublesex gene, which in mosquitoes works along with the sex chromosome to determine whether an insect turns out male or female. Last year, researchers at Imperial College London found that females with edited doublesex genes develop a mix of male and female organs, including male genitalia and a proboscis that is too flimsy to break human skin. They can’t reproduce, so the population shrinks; and they can’t take a blood meal, so they won’t spread the parasite.

The doublesex edit doesn’t affect males, although thanks to gene drive, they will pass it to their offspring, which is how it keeps spreading through the population.

We know gene-drive technology works in the lab. When the Imperial College researchers put 150 males carrying a copy of the doublesex edit in a small cage with 450 wild-type mosquitoes, the population died off within a few months (about 10 generations). The sex bias edit produced similar results.

The next step is to run tests in larger cages and, eventually, get permission from governments to do them outdoors. We need to understand things like: What’s the impact on the food chain if a certain species of mosquito starts dying off? How many altered insects would we need to introduce? How long do we need the mosquitoes to be gone? Last year, the government of Burkina-Faso agreed to allow the release of sterile, non-gene-drive mosquitoes in the wild so researchers could begin to study some of these questions.

As I mentioned, social and regulatory issues also come into play. For example, because mosquitoes don’t exactly respect national boundaries, neighboring countries will probably need to agree on the rules surrounding the use of gene-editing technology. Policymakers and scientists have been debating these questions in forums like the World Health Organization and the African Union’s development agency, and they are moving toward a consensus.

I think we can have the regulatory approvals in place by 2024 and the first gene-drive mosquitoes ready for use by 2026. Although this technique will never replace the other tools we have for fighting malaria, I’m optimistic that it could become one more important weapon in eradicating the disease.

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.

Of all the things I did when I visited Cornell University recently, I probably had the most fun brushing up on how plants have sex.

Cornell is one of the world’s top universities for research on improving crops. Their work involves a lot of plant breeding. During one meeting, I got to try my hand at cross-pollinating wheat, which is a surprisingly delicate procedure. It gave me even more respect for the people who do it every day.

Cornell’s work on crop improvement also involves a lot of cutting-edge genetics. You might see the words “crop improvement” and “genetics” in the same sentence and think I’m talking about GMOs. Although Melinda and I do support research in that area—we don’t think poor farmers should be denied the choice to use any tools that might benefit them—the work I saw at Cornell is different. It’s focused on how the science of genetics can improve agriculture in other ways. And the advances are really exciting.

I got interested in crop breeding through my work with the Gates Foundation. Because most of the world’s poor people are farmers, helping farmers grow more food is one of the most powerful levers we have for fighting poverty. The faster we can improve crops—making them more nutritious or drought-tolerant, for instance—the faster we can help farmers become more productive.

My main guide was Dr. Ed Buckler, a scientist in his mid 40s who works at Cornell for the U.S. Department of Agriculture (USDA). Over the four hours we spent together I asked Ed dozens of questions (I’ve learned a lot about agriculture, but I’m still a city boy at heart), and he was always quick with an answer. Yet Ed and his colleagues aren’t just experts in their field—they’re also deeply passionate about their work. I can see why: The advances they’re working on will change people’s lives by dramatically accelerating a process that is now slow and laborious.

Here’s how it works today. Suppose you want a variety of corn with a natural resistance to a certain pest. You start by planting as much corn as you can. You wait 8 to 12 weeks for it to grow, and then you take pollen from some of the plants that aren’t infested and use it to pollinate others. If the offspring of those plants is pest-resistant, you’re in luck—your plant won the genetic lottery. If not, you have to start over. Because you’re limited by the growing season, the process can take seven to ten years.

Genetics research will cut that time in half.

Getting there takes three steps. One is to understand the crop’s genetic makeup. Ed took me on a short tour of a lab where machines called sequencers were analyzing DNA from thousands of plants. They were mapping the genes that give each plant its physical traits: its height, color, etc.

The second step is to go into the field and record those physical traits for each individual plant whose genes you’re studying. Cornell researchers are growing hundreds of acres of corn and other crops not far from campus, and they make regular treks out there to collect data. Unfortunately, I didn’t have time for a field trip on this visit.

Finally, you build a computer model that puts the two together—the genetic maps of individual plants, along with the data about their physical traits. Once you have that model, you no longer need to cross two plants and just hope for the best. You can ask the computer, “Out of all the plants I have in my field, which two should I breed in order to produce one that is pest-resistant?” Think of it as a highly sophisticated Match.com for plants.

Cornell and the USDA have already built such a model for some traits in corn; because people in rich countries eat corn, there’s a big market for better varieties. Meanwhile, crops that are eaten mostly by the poor have largely been ignored by scientists. But that’s starting to change.

With support from the British government, our foundation, and others, researchers at Cornell and the USDA are now working on a model for cassava, a root vegetable that’s a staple crop in many tropical regions. Partners in Uganda and Nigeria are growing lots of plants, recording their traits, and sending genetic samples to Cornell for sequencing. When the cassava model is finished, it will help breeders develop new varieties faster than ever. (Incidentally, I’m fascinated by cassava—and you may not know that it is responsible for the fun factor in bubble tea.)

During my visit, I learned about one trait that I had never thought about before: poundability. Over lunch with several graduate students, a Ugandan researcher named Paula Iragaba told me that women in her country do most of the work to turn cassava into flour, and they wish it were easier to process. “Women’s preferences have to be taken into account,” she said. I couldn’t agree more.

Keep in mind, none of the genetics research I saw changes the basics of plant sex. Breeders in the field still have to move pollen from one plant to another, as they have for ages. We’re just getting a lot smarter about helping them pick the best partners. And the result will be phenomenal—a much faster path to more-productive crops so that millions of people can eat better food, earn more money, and improve their 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.

Search the Web for “what it feels like to have malaria” and you will find a lot of harrowing descriptions.

Here’s an especially gripping one:

I awoke to what felt like lightning going through my legs, and then spreading through my body and in my head. Probably the worst headache, body aches, and chills you could possibly imagine. It felt like I was being stung repeatedly by an electric shock gun and could barely control my movements. The pain was so intense; I actually believed I was dying, literally crying out in pain so bad that I was taken to a 24 hour clinic that night at 3am.

Imagine feeling like that and trying to go to school, work, or take care of your family. It would be impossible.

It’s no surprise that economic growth in countries with severe malaria is significantly lower than in countries without it, even after accounting for other factors. As the economists Jeffrey Sachs and John Luke Gallup have written, “The only parts of Africa free of malaria are the northern and southern extremes, which have the richest countries on the continent.” Malaria is far from the only cause of poverty—but it is a significant one.

Whenever someone asks me why we should fight malaria, I have a simple answer: Because it kills so many people (more than 600,000 every year), and it leaves so many more people too sick to function, which holds back the world’s poorest from making the most of their lives. Malaria is gone from the United States and Europe. But where it is still a problem, few diseases do more to limit human potential.

This may all sound hopeless, but I’m actually optimistic that we can eventually eradicate malaria. I wrote about why here. I hope you’ll take a look.

You’re probably seeing a lot of people’s year-end lists right now, going through the best movies, books, YouTube clips, grumpy cat memes, etc.

I thought I would share a different kind of list: some of the good news you might have missed. I’ve limited my list to global health and development, where Melinda and I spend a lot of time, but even so, there’s a lot to report. If you measure progress by the number of children who die of preventable causes, or by the number of people who escape extreme poverty—as I do—then 2013 was definitely a good year.

For example:

We got smarter and faster at fighting polio. You may have heard about recent polio outbreaks in Syria, Kenya, and Somalia. What you may not know is just how rapid and effective the response has been. It looks like the outbreak in the Horn of Africa was controlled in 4 months, less than half the time it took to control an outbreak there in 2005. That speed is due in part to the work done at the Global Vaccine Summit held inAbu Dhabi this year. In the past, the world has had to make tough trade-offs between responding to outbreaks, improving routine immunization, and fighting the disease in the last three countries where polio is still circulating (Afghanistan, Pakistan, and Nigeria). There was no coordinated plan or long-term funding for doing all three at once. At the summit the world got both. We adopted a comprehensive plan for pursuing all three goals, including making the world polio-free by 2018. And more than 30 donors—including a number of very generous private individuals—backed the plan with a total of $4 billion in long-term funding. That means we won’t have to make those trade-offs anymore. It’s a huge step forward.

There’s also great news from India. In early 2014, India will have gone three years without a single polio case (assuming no new ones are reported between now and then). That’s a testament to the fantastic job they’ve done immunizing every child, even in the most remote parts of the country. Now they’re focused on keeping the disease from coming back.

Next door, in Pakistan, the political leaders are clearly resolved to get polio out of the country once and for all. When I met Prime Minister Nawaz Sharif this fall, he made it clear that he sees vaccinating children as a matter of justice. Despite the ongoing violence there and in Afghanistan—including horrifying reprisals against vaccine workers—the next couple of years are a good opportunity for us to make progress on this goal.

Child mortality went down—again. One of the yearly reports I keep an eye out for is “Levels and Trends in Child Mortality.” The title doesn’t sound especially uplifting, but the 2013 report shows amazing progress—for example, half as many children died in 2012 as in 1990. That’s the biggest decline ever recorded. And hardly anyone knows about it! If you want to learn more—and I’d urge you to—the report has a good at-a-glance summary on page 3.

The poverty rate went down—again. If you want to read just one article that explains the state of the world’s poor and the future of the fight against poverty, check out “Not Always With Us,” which the EconomistEconomist ran in June. It gives a short but thorough overview of the progress so far—the poverty rate has dropped by half since 1990—and the prospects for keeping it going. As the article says, the biggest factor in reducing poverty over the past few decades has been economic growth—growth that touches not just those who are already rich, but a broad range of people. We’ll need to maintain this growth in the coming decades to keep the poverty numbers coming down. That’s one reason I argue for stepping up our investments on health: Health may not cause growth directly, but it does help lay the foundation for it. I never miss an issue of the , and this might be the best piece they ran this year.

Rich countries re-committed to saving lives. Just this month, donors met in Washington, D.C., to renew their funding commitments to the Global Fund to Fight AIDS, TB, and Malaria. I was there and I got to meet Connie Mudenda, a Zambian woman living with HIV who started getting treatment in 2004 thanks to the Global Fund. The medicine she takes costs just 40 cents a day, and it helped her get healthy, go back to work, and support her family. Connie says that a decade ago, she’d often see people who were so sick with AIDS that they couldn’t even walk. A family member would push them down the street in a wheelbarrow. Today, though, 80 percent of Zambians with HIV have access to treatment, the country’s economy is growing, and Connie says the wheelbarrows have vanished.

There’s a terrible Catch-22 in global health: You need new tools to fight diseases, but if you can’t pay to deliver them, they don’t get made; and if they don’t get made, then no one gives money to deliver them. So it’s fantastic that donors are stepping up to avoid this problem by making big commitments to the Global Fund.

A fantastic Web site got launched. If you love data, and if you’re curious about what causes the most suffering around the world, you should check out the Global Burden of Disease Web site, which was launched early this year. (The foundation helped pay for it.) Personally I am a yes on both categories, which is why I have spent a lot of time on there. It lets you make beautiful charts that help you understand the impact of disease in different countries and even see how things change over time.

On a personal note, I should say how grateful I am to everyone who made time to meet with me, from world leaders to health workers in India, Nigeria, Pakistan, and around the globe. Some of these workers take great risks to help people, facing attacks from extremists in order to vaccinate children. They are true global-health heroes.

What’s Ahead in 2014

Next year I’m excited about the continued rollout of a vaccine called pentavalent (because it prevents five diseases). Next year it will be available in South Sudan, the last of the 73 poorest countries to introduce it. India just announced that they’ll start giving it to every child in the nation in 2014. If other countries follow India’s example, pentavalent could prevent 7 million deaths by 2020. Next up are new vaccines to prevent pneumonia and rotavirus (which causes diarrhea). And we’re seeing more middle-income countries like China and India develop the ability to manufacture vaccines, which drives the cost down.

Crucial to delivering all these vaccines is GAVI, an alliance that has helped 440 million children get immunized since 2000. (Go back and read that again: 440 million.) Next year GAVI will be asking donors to renew their commitments, just as the Global Fund did this year. It will be a challenge to raise more money, but I know from experience that people want to help kids get vaccinated when they see what a phenomenal impact it has. It’s hard to resist the thrill of helping to save the life of a single child, let alone millions.

One last note about 2014: I’ll be publishing my sixth annual letter in January. This time I’m planning to take a slightly different tack from years past—Melinda and I will be tackling some of the biggest myths we encounter in our work on health and poverty. It should be a fun one to write. If you’d like to get an e-mail notice when the letter is out, you can sign up here.