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

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

One of them, Pakistan, is making major progress. Thanks to continued vaccination programs and strong leadership from the government, the number of children newly paralyzed by polio there dropped from 74 in 2024 to 31 in 2025 and just 6 so far this year. I think it is possible to get to zero if we keep up this momentum.

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

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

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

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

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

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

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

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

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

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

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

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

The world is so close to ending polio.

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

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

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

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

Her name is Shumaila Rehmani.

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

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

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

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

But Shumaila doesn’t give up.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This time really is different.

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

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

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

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

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

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

The transition to AI comes with three big risks.

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

Many jobs will disappear forever.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The world needs a plan.

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

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

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

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

Build a new system for managing the transition.

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

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

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

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

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

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

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

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

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

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

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

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

Set aside some jobs for humans.

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

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

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

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

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

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

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

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

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

Rebalance how we tax labor and capital.

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

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

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

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

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

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

What I’m doing.

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

My message to leaders is:

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

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

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

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

How should public institutions adapt?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I just got back from the most incredible week in Rwanda. My favorite trips are always the ones that leave me feeling inspired and energized. And if you’re looking for reasons for optimism, Rwanda is a good place to start.

What stood out to me was how Rwanda's long-term investments in people, strong institutions, and delivery have translated into real progress. Over the last 25 years, the country has delivered one of Africa’s most remarkable health transformations. Since the year 2000, the number of children who die before the age of five has dropped by 73 percent. Maternal deaths have fallen by over 80 percent, and nearly all pregnant women now give birth in a health facility with a skilled birth attendant present.

I was lucky to meet many of the local leaders and innovators driving that progress. Africa is entering a new era that is increasingly shaped by African leadership, and it’s amazing to see firsthand. At the Gates Foundation, our role is to listen to leaders like the ones I met, and to support them with resources, data, and technical expertise so they can get the greatest value from every dollar they invest in saving and improving lives.

These were some of the highlights from the week:

Rwanda’s frontline health heroes: My trip started in Mwulire, where Gaudence Ngendahayo, a community health worker, showed me what her work looks like as she made the rounds in her catchment. Rwanda’s community health worker program is the backbone of its health system, and when you watch Gaudence work, it’s easy to see why. She goes house to house checking in on how families are doing. If someone isn’t feeling well, she either treats them herself or refers them to the health center nearby. (Around 60 percent of all malaria cases in Rwanda are treated by community health workers.) Along the way, she collects invaluable information that helps connect communities to the broader health system.

Primary healthcare in the community: If Gaudence isn’t able to treat someone herself, their next stop is the Mwulire Health Center. I visited the facility, which is primarily staffed by nurses and offers all of the services you would expect from a primary care provider: outpatient consultations, prenatal and maternal care, normal deliveries, family planning, immunization, and HIV and TB services. (More complex cases are referred to district hospitals.) It was interesting to learn more about how the data collected here flows through the health system to Rwanda’s National Health Intelligence Center, or NHIC, connecting every level of care and helping health workers make quick and informed decisions.

Digging into the data: Next was seeing the NHIC firsthand, where real-time data from clinics, hospitals, and community health workers is used to generate insights that the Ministry of Health uses to make quick, evidence-based decisions. Rwanda has done an incredible job building digital public infrastructure, or DPI, and I got to learn more about how its investments have paid off over the last decade. Rwanda has created a culture where data and evidence matter. They track what they're doing, they see what needs to improve, and they take action. The NHIC is also where Horizon 1000, our partnership with OpenAI to improve quality care by accelerating the adoption of AI tools in primary health clinics, is housed. I wrote about the initiative earlier this year, and it was exciting to see it taking shape on the ground. Seeing real pilots underway rather than plans on paper was one of the best parts of the trip. I can’t wait until the day we can point to a patient who got better healthcare because of it.

Manufacturing key medical supplies: Most people don’t think about the supply chain when they picture healthcare systems, but it’s essential to ensuring health workers have the tools they need. The staff at Mwulire Health Center use auto-disable syringes—injectors that can only be used once, which prevents the spread of bloodborne pathogens like HIV—made nearby at the TKMD Rwanda Manufacturing Facility. Being able to make key supplies locally makes the system more resilient and reduces its dependence on imported products, while also benefiting neighboring countries that rely on these essential medical products.

Up close with Rwanda’s digital transformation: I’ve followed Rwanda’s work on DPI closely for many years, but there is nothing quite like seeing it in person at the Upanzi Digital Experience Center at Carnegie Mellon University Africa. The Upanzi Network was created to build Africa’s capacity to develop, test, adopt, and govern open-source digital technologies—like identity, payments and cybersecurity—in a way that is secure, inclusive, trustworthy, and locally relevant. I got to see their DPI stack up close, which is built on open-source platforms like MOSIP and Mojaloop and is now being adopted by a growing number of African governments to run their national critical infrastructure. It was super interesting to hear from the young researchers shaping it with their lived experiences across Africa. This is exactly the kind of African-owned, African-built infrastructure that will improve lives across the continent.

Young innovators leading the way with AI: I always love meeting with brilliant young innovators, so I knew visiting the Rwanda AI Scaling Hub in Kigali would be fascinating and inspiring. I met founders who are using technology and AI to tackle local development challenges, from expanding access to healthcare to helping communities access critical services. Dr. Loza Admassu, founder of Ambucycle, is using data-driven logistics to improve emergency medical transport and connect patients more quickly to life-saving care. Audace Niyonkuru, founder of Digital Umuganda, told me about the efforts she’s leading to collect and curate African local-language voice data to help train AI models that better understand and serve African communities. What stood out was not just the technology itself but the ambition, creativity, and determination of young Africans who are building solutions for their own communities and creating innovations with the potential to benefit people around the world.

The next generation of African health leadership: If I had to pick one highlight of my trip, it would be my day at the University of Global Health Equity in Butaro. My friend Paul Farmer was working at the university when he died, and it was moving to see how his vision of equity continues to shape the university, the hospital, and the community around it. Watching medical students train for the kinds of emergencies they will one day manage in their own communities was especially inspiring. I was honored to help launch the Butaro Dialogues and speak with students from across the continent, including members of the Consortium of Medical Students' Associations. Their questions reflected both a deep understanding of today's challenges and an ambitious vision for a more equitable future of global health. Africa’s greatest resource has always been its people. Sitting across from these young people as they talked about their big ideas for global health, it was crystal clear that they are the next generation of leaders who will shape the continent’s future.

Growing farms with data and AI: My last stop was the One Acre Fund, an African-focused organization that helps millions of smallholder farmers get more out of every harvest. I met farmers who work with the program and leverage on-time delivery of seeds and fertilizer, along with hands-on training, to help their families grow more food and earn more money. (Rwandan farmers in the program generated $118 million in new profits last year alone.) One Acre Fund connects farmers with technology by building on Rwanda’s digital farmer registry and subsidy system, connecting government data with on-the-ground support. They then pull in AI-powered tools like Virtual Agronomist, which can answer farmers’ questions over WhatsApp using real data on their soil and local weather. I’m super excited to see how innovations like this can arm more farmers across Africa with the information they need.

My time in Rwanda reminded me how much progress can be made when innovation reaches the people who need it most. Across the country, scientists, entrepreneurs, and governments are driving breakthroughs that are practical, affordable, and designed for local needs. Rwanda has already achieved major progress with even greater opportunities ahead, and its young people are poised to shape not only the African continent, but the world.

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’ve never been much of a soccer fan. (Tennis and pickleball are my favorite sports.) Still, seeing the athleticism and passion on display during the World Cup, I understand why soccer has earned the nickname “the beautiful game.” What makes soccer even more beautiful is the positive impact it can have off the field.

There may be no better example of this than the work of a unique non-profit organization called Grassroot Soccer, which was featured at a health innovation event where I spoke earlier this week.

For the last two decades, Grassroot Soccer has used the incredible popularity of the game to help young people across Africa navigate some of their toughest health challenges.

Despite significant progress in health and development in Africa, including a dramatic decline in child mortality, HIV/AIDS continues to be a leading cause of death among youth in Africa. Sexual violence threatens the health and safety of girls. A lack of access to contraceptives contributes to high rates of teen pregnancy. And mental health services are often unavailable.

Solving these challenges is difficult—and especially important given that 60 percent of Africans are under the age of 25. So, how can soccer make a difference?

Because it’s so popular, soccer offers a hook to capture the attention of young people. Grassroot Soccer uses the game to involve them in activities that encourage them to live healthier, more productive lives.

Here’s one simple example. In an activity called “Risk Field,” players are asked to dribble a soccer ball through cones labeled with some of the risky behaviors that young people often encounter, such as unprotected sex, HIV, multiple partners, and alcohol.

The local youth who serve as Grassroot Soccer coaches are a critical component of the program. Trained in basic counseling skills, the coaches play an important role as trusted mentors to the young participants.

The coaches also accompany adolescents to clinics where they can get HIV testing, contraceptives, and other services. (In some countries, young people might be turned away because of their age or criticized by health staff for seeking contraceptives and testing. The coaches serve as advocates to support their right to health services.) Coaches also conduct home visits to talk with parents and guardians about their programs and health services.

Founded in 2002 by Dr. Tommy Clark, a pediatrician and former professional soccer player, Grassroot Soccer initially focused on stopping the spread of HIV. (The Gates Foundation was an early funder of its work.) Today the organization works in more than 60 countries and has reached more than 18 million young people.

Studies have shown that its participants had better access to sexual and reproductive health services, were more likely to stick with their HIV treatment, and were less likely to experience depression.

That kind of impact gives everyone, even casual soccer fans like me, something to cheer about.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

On December 1^st, the global community will observe World AIDS Day. This year I would like to mark it by highlighting the work of two heroes who are making a difference in the fight against this deadly disease.

Chief Jonathan Eshiloni Mumena is chief of the Kaonde people, who live along Zambia’s border with the Democratic Republic of Congo. Risking his position as his people’s leader, Chief Mumena challenged long-held traditions to encourage Kaonde men to embrace voluntary medical male circumcision as a strategy to prevent HIV transmission. (Male circumcision can reduce a man’s risk of acquiring or transmitting HIV by up to 60 percent.) I had the privilege of meeting Chief Mumena in 2012. His story is an inspiring tale of courageous leadership and deep compassion for his people.

Guided by her belief that health care is a basic human right, Dr. Krisana Kraisintu, a pharmacist from Thailand, has worked tirelessly to make medicines affordable to even the poorest in the world. Her development of generic versions of the lifesaving HIV drugs dramatically reduced treatment costs, saving and improving countless lives. She has also dedicated her pharmaceutical skills to reduce treatment costs for malaria and other diseases.

Of course, Chief Mumena and Dr. Kraisintu are just two of the countless individuals—doctors, policymakers, researchers, activists, and political leaders—whose contributions have helped turn the tide against the disease. Today, 19.5 million people receive lifesaving antiretroviral therapy, giving them the opportunity to live full, productive lives. Improved access to treatment has also meant that millions of babies are now born HIV-free. 

Much of this progress has been made possible by the world’s enormous investments in efforts to defeat the epidemic, including the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the U.S. HIV/AIDS program known as PEPFAR, President’s Emergency Plan for AIDS Relief.

Still, many challenges lie ahead in the fight against the AIDS epidemic.

Funding for HIV control has been flat and there’s talk about cuts as the world turns to other priorities. Cuts in funding for HIV/AIDS would lead to sharp increases in deaths and new infections, reversing the gains that have been made the last decade. That’s why it’s more important than ever for the world to reaffirm its commitment to this fight. We need more AIDS heroes—from health care workers and advocates to global leaders. Together, we can bring an end to this public health threat.

If you want to be a hero this World AIDS Day, support the (RED) Shopathon. Our foundation is matching every dollar raised—up to $15 million—to fight HIV/AIDS in Africa.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In a rural health clinic, a baby tries to take her first breath.

But her lungs aren’t ready. Because she was born too early, they haven’t developed the slick, soap-like substance that keeps her air sacs from collapsing. Without that substance—called lung surfactant—breathing becomes a desperate, exhausting act.

She’s suffering from respiratory distress syndrome, or RDS, a life-threatening condition that appears within hours of birth in premature babies. Unless she gets treatment, her oxygen levels will plummet and her organs will begin to shut down. In one study from India, every baby born with RDS outside of a hospital setting died. In Ethiopia and Nigeria, RDS is responsible for almost half of all neonatal deaths.

At hospitals in higher-income countries, there’s a way to save her: a liquid form of organically-derived surfactant delivered directly into the lungs. But the procedure requires a highly-trained specialist to guide a breathing tube down the newborn’s windpipe—avoiding the stomach and placing it just right—at a cost of up to $20,000. In many parts of the world, that kind of care simply doesn’t exist.

But what if any healthcare worker anywhere in the world could simply hold a small nebulizer to the baby's face and deliver surfactant as an easy-to-administer inhalant?

This breakthrough—a synthetic surfactant that’s stable enough to be delivered through a nebulizer—is still in development, drive in part by Gates Foundation-supported research at Virginia Commonwealth University, Seattle Children’s Research Institute, and The Lundquist Institute. But its promise is extraordinary: an RDS treatment that costs less to make, doesn’t require a specialist to administer, and eliminates the need for intubation.

In other words, a therapy currently limited to the most advanced hospitals could become accessible in rural clinics and community settings around the world. Even in places with top-tier care, it could make treatment gentler, faster, and easier to deliver. In the United States—where RDS still affects 24,000 newborns a year—it could reduce the risks that come with intubating babies who might weigh only two or three pounds.

It’s the kind of innovation that could help solve one of the most persistent problems in global health: delivering intensive care without an intensive care unit, and helping millions more babies survive their first, most fragile moments.

Since 1990, the mortality rate for children under five has been cut by more than half—an amazing mark of global progress. But another statistic hasn’t fallen as fast: the number of babies who die in their first month of life.

Each year, 2.3 million newborns don’t survive past their first 28 days. And the day a baby is born is the most dangerous day of their life. The single biggest cause of these deaths is prematurity. Nearly 900,000 babies a year die from complications related to being born too soon, including infection, underdeveloped organs, and RDS.

Lower cost, easier-to-deliver surfactant is one way to give newborns a fighting chance, but it’s not the only way. Around the world, simple, affordable interventions already exist to identify at-risk pregnancies earlier, prevent more preterm births, and ensure a healthy birthing experience for mothers. Not only are these tools designed to work in the hardest-to-reach places—many of them start working even before a baby takes that first breath.

One of these innovations is a new type of ultrasound that’s changing who can catch the risks of preterm birth—and where.

Around the world, two thirds of women never get an ultrasound screening during pregnancy. Traditional machines are bulky and expensive, with specialized training required to operate them and interpret their results. In places where medical resources are already stretched thin, these types of ultrasounds are rarely an option.

But now, we have ultrasound devices about the size of a phone that can be operated by a nurse or midwife—no on-site specialist required. They weigh less than a pound. They process scans instantly. Their AI interface automatically detects high-risk conditions, like a shortened cervix or signs of early labor, so patients are referred for further care. And they have built-in telehealth functions to share images with remote specialists when needed.

By finding and flagging risks early, these AI-enabled ultrasounds are giving healthcare workers more time to act. In some cases, that means transferring the mother to a higher-level facility. In others, it means providing her with antenatal steroids—an inexpensive, underused treatment that speeds up fetal lung development—and, when needed, medications that delay labor just long enough for those steroids to take effect.

Early warning is essential, but we can save even more lives by going further upstream, starting with the health of pregnant women themselves.

In many low-income countries, undernutrition isn’t an exception. It’s the norm. And the intense demands of pregnancy make nutritional deficiencies even worse—putting mothers at increased risk of complications or death in childbirth, and raising the odds of early labor, low birth weight, and developmental delays for their babies.

But there’s a surprisingly simple fix: a daily supplement called MMS, or multiple-micronutrient supplementation, developed by the United Nations. It contains 15 essential vitamins and minerals for pregnancy—like zinc to reduce the risk of early labor, folic acid to help prevent birth defects, iron and vitamin D for healthy birth weight, and iodine for brain development. For an entire pregnancy, it costs just $2.60.

If MMS became the standard prenatal supplement in every low- and middle-income country, it could save nearly half a million newborn lives each year—and prevent serious complications in 25 million births by 2040.

The innovations above focus on treating, detecting, and preventing premature birth, a huge threat to newborn survival. But one of the most powerful ways to protect babies, preterm or full-term, is by ensuring their mothers stay healthy through pregnancy and childbirth.

When a woman dies during delivery, her baby is 46 times more likely to die in that first month of life. That’s why any serious effort to tackle infant mortality must also address postpartum hemorrhage—which tragically kills 70,000 women a year and is the leading cause of maternal mortality. Fortunately, two innovations are already helping healthcare workers catch and treat it before it becomes fatal.

The first is a calibrated drape—a simple plastic sheet placed under a woman during delivery that collects blood and shows, through printed measurement lines, exactly how much she’s losing. It gives healthcare workers a fast, accurate way to spot dangerous bleeding before it becomes life-threatening. The second is a one-time, 15-minute iron infusion during pregnancy that treats severe anemia—so if a woman does hemorrhage during childbirth, she’s less likely to experience catastrophic blood loss and more likely to survive.

Neither of these tools is complicated or expensive. But in combination, they can make a life-or-death difference for mothers and the babies who depend on them.

Taken together, these innovations form a chain of survival. They help mothers stay healthy through pregnancy. They detect problems before they become emergencies. They give fragile newborns a fighting chance. And they make it possible for families to celebrate a baby’s birth rather than mourning a loss.

Some of these tools are already saving lives. Others are on the verge of doing so. But their impact will be limited unless we prioritize and fund their delivery, not just their development. The world needs to make sure these innovations don’t get stuck in labs or warehouses—so they can reach the mothers and babies who need them most.

We started the Gates Foundation 25 years ago to save and improve children’s lives. But no one can solve a problem they don’t fully understand. And back in 2000, the world’s understanding of childhood mortality was occasionally inaccurate, often imprecise, and almost always incomplete.

That’s why I believe the breakthrough that transformed our foundation in the two-and-a-half decades since wasn’t a single vaccine or treatment—it was a revolution in the world’s understanding of childhood mortality. Through advances in how researchers collect and analyze global health data, we now know much more about what kills children, where these deaths occur, and why some kids are more vulnerable than others. By putting those insights to work, we’ve been able to save lives.

The first challenge was knowing exactly what was killing children.

Reading the 1993 World Development Report opened my eyes to the scale of the problem: Around 12 million children under the age of five were dying every year, with a staggering disparity between rich and poor countries. But the available data was fragmented and inconsistent. That made it difficult to understand trends or allocate resources effectively.

So the foundation helped create the Institute for Health Metrics and Evaluation at the University of Washington, to give a permanent home to the Global Burden of Disease study—originally developed in the 1990s by researchers at Harvard University and the World Health Organization. We wanted to expand it from a static snapshot of the problem into a regularly updated tool that tracked how diseases impact people around the world. That gave us something the world never had before: a comprehensive—and current—picture of child mortality across every country.

Measuring symptom-based causes of children’s deaths was an important step. But broad disease categories like “diarrhea” or “respiratory infection” didn’t give us enough information to act on. We needed to know which specific pathogens were responsible for the most common and fatal cases. So the Gates Foundation funded two landmark studies to find out.

In 2013, the Global Enteric Multicenter Study, or GEMS, found that rotavirus was causing 20 percent of lethal diarrhea cases in kids. At the time, diarrhea was the second-leading infectious killer of children. While oral rehydration therapy had already helped bring down deaths over previous decades, GEMS helped fast-track the rollout of a more targeted tool—a new rotavirus vaccine—in the hardest-hit countries, in close partnership with Gavi, the Vaccine Alliance.

A year later, the Pneumonia Etiology Research for Child Health study, or PERCH, revealed that respiratory syncytial virus, or RSV, was a much more common cause of severe pneumonia—the leading infectious killer of kids around the world—than previously understood. (And not just in low- and middle-income countries, where 97 percent of RSV deaths occur, but in higher-income ones too, where the virus still fills pediatric hospital wards each winter.) That prompted us to expand our investments in RSV prevention, which led to the approval of the first maternal vaccines for RSV in 2023.

But understanding what causes childhood mortality wasn’t enough on its own, because deaths aren’t distributed evenly across countries—or even within them. That’s why our second challenge was to figure out where exactly children were dying.

At the time, most health data was collected at national or regional levels. That masked major differences in disease burden from one community to the next—and made it harder to target interventions effectively.

To solve this second challenge, the foundation invested in new approaches to health mapping that combined satellite imagery, GIS technology, GPS data, and local health surveys. These maps gave Ministries of Health and implementing partners unprecedented, anonymized detail about disease patterns and population distribution, down to individual neighborhoods, that transformed how and where public health resources are deployed—while still preserving the privacy of the individual children and families in these places.

In Pakistan—one of just two countries where wild polio remains endemic—advanced mapping tools have helped vaccination teams reach and protect kids in settlements that weren’t on any official maps. Across sub-Saharan Africa, better geographic data has transformed the fight against malaria by revealing that transmission often clusters in small, hyper-local pockets. Through the Malaria Atlas Project, countries like Nigeria can now track those patterns more precisely—and then get bed nets, testing, and treatment where they’ll have the greatest impact.

With better knowledge of what was killing children, and where, one more fundamental question remained: Why might one child die from a disease while another—who lives in the same place, faces the same risks, and gets the same treatment—survives? This was our third big challenge.

In theory, traditional autopsies would provide the answer. But in the places where most childhood deaths still occur, these invasive procedures are often impossible to perform—too costly, and sometimes opposed for religious, cultural, or personal reasons.

So in 2015, the foundation launched the Child Health and Mortality Prevention Surveillance network, or CHAMPS, which now operates in nine countries across Africa and South Asia. Working with in-country partners, CHAMPS pioneered a new autopsy alternative—using minimally invasive tissue sampling—that can determine causes of death quickly and accurately while respecting local customs and beliefs.

Through CHAMPS, we discovered that childhood deaths rarely have a single cause. Instead, kids often have multiple conditions at the same time, with malnutrition frequently leaving them much more vulnerable to a whole host of infections. (While it rarely shows up on death certificates, it’s an underlying cause of death in nearly half of all child mortality cases.) That finding helped solidify nutrition as a core focus of the foundation’s global health work—and the research, innovation, and product development we invest in. On the ground, we’re supporting partners as they integrate nutrition screening into routine care and train healthcare workers to manage multiple risks at once.

CHAMPS also demonstrated that inadequate prenatal care is responsible for a majority of stillbirths, newborn deaths, and maternal deaths, prompting us to further expand access to maternal health services—like prenatal vitamins and AI-enabled ultrasounds—in the communities where we work.

But the biggest takeaway from CHAMPS is also the most hopeful—and a reminder of why we started the Gates Foundation in the first place: So many childhood deaths could be prevented with existing interventions. We just need to ensure they reach the right children at the right time.

Twenty-five years in, our work on child mortality is far from complete. Still, the impact of what we have learned has been enormous

The Global Burden of Disease, GEMS, and PERCH studies helped shift global priorities by showing the world what was really killing kids—and where new vaccines and treatments could make the biggest difference. Better geospatial tools have empowered countries to pinpoint disease hotspots, find previously unmapped settlements, and distribute life-saving resources where they’re needed most. And CHAMPS is giving governments better data on why children are dying—data that’s now shaping policies, improving reporting, and guiding more effective care.

Most importantly, even as the number of children born every year has gone up, the number of overall childhood deaths has fallen by more than half—from 11.3 million in 1990 to 4.5 million in 2022. Playing a part in making that happen is the best job I’ve ever had, and the most meaningful work I’ve ever done.

At the Gates Foundation, we used to say we could cut child mortality in half again by 2040. The truth, though, is that goal feels further out of reach now—not because the science has stalled, but because support for global health has. The progress we’ve been part of was only possible because governments around the world, including here in the U.S., made long-term commitments to saving lives and followed through. That kind of leadership gave millions of children who would have died a chance at life—and made life better for millions more. 

The last 25 years have shown us what’s possible. The next 25 will depend on whether the world keeps showing up for the children who need it most.

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

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

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

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

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

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

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

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

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

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

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

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

m-mama is making sure those minutes count. 

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

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

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

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

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

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

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

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

1.

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

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

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

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

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

2.

Will the world prioritize scaling innovations that improve equality?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The leading cause of death among children under age 5 often begins with little more than a cough.

Followed by chills, fever, and nausea.

And then as the child’s lungs get flooded with fluid, each breath becomes a desperate gasp for air.

What I’m describing is known as pneumonia, an acute respiratory condition that kills over 670,000 children every year.

And here’s a sentence I find difficult to write: Nearly all those deaths could have been prevented.

Access to vaccines, diagnostic tools, and treatments can protect children from deadly pneumonia. But these solutions are often not available or accessible in many low- and middle-income countries, where children are at greatest risk.

Even as child deaths have declined by nearly 50 percent over the past two decades, deaths from pneumonia have remained stubbornly high.

That’s why our foundation is focused on improving access to and development of vaccines that can prevent it.

One of the most exciting areas of progress is the development of a powerful new vaccine designed to protect children against pneumococcal bacteria, which is the leading cause of deadly pneumonia. Of the 670,000 children who die from pneumonia ever year, pneumococcal pneumonia is responsible for killing 400,000 of them.

What makes this new vaccine unique is that it is designed to protect against 25 different types of pneumococcal bacteria, more than any other available vaccine. Existing pneumococcal vaccines protect against about half as many types of pneumococcal pneumonia. To address the remaining deaths from pneumococcal pneumonia, vaccines that offer broader protection like this new vaccine will be needed.

The vaccine, called IVT-PCV25, is being developed by Inventprise, a small biotechnology company based outside Seattle. I recently took a tour of their new vaccine manufacturing plant and got an update on their progress.

It was amazing to see the innovations underway at Inventprise. Making a vaccine that is effectively 25 vaccines in one is an extremely complex challenge. Past efforts to add more strains of pneumococcal bacteria to vaccines using conventional technologies have resulted in vaccines that didn’t produce a strong enough immune response. Inventprise intends to overcome this obstacle with its proprietary vaccine technology that is designed to guard against many types of pneumococcal bacteria without any decline in protection.

Inventprise’s new factory, supported by a grant from our foundation, is a highly automated facility that marks an important step forward in Inventprise’s development of the vaccine. Clinical trials of the vaccine are expected to begin later this year.

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

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

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

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

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

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

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

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

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

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

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

I wish that were true. But it is not.

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

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

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

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

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

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

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

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

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

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

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

A Record of Progress—and What is at Risk

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We can’t afford to look away now

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Planning for the next 20 years

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

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

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

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

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

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

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

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

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

What the Gates Foundation hopes to accomplish

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The last chapter of my career

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

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

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

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

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

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

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

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

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

If you’re a big reader, you can probably point to a book or two that changed the course of your life. For me, it was a 1997 New York Times column by Nicholas Kristof about diarrhea, which was killing three million kids a year.

At the time, I had wealth—and knew I planned to give it away—but no clear mission. Nick’s article gave me one. I faxed it to my dad with a note: “Maybe we can do something about this.”

That ended up setting the direction for what became the Gates Foundation. It didn’t just give us a what—it gave us a how. Nick’s reporting showed us that the biggest challenge in global health isn’t always discovering new breakthroughs. Often, it’s making sure the tools we already have—vaccines, medicines, bed nets, or oral rehydration therapies for rotavirus—reach every child, no matter where they’re born.

Reading Nick’s new memoir, Chasing Hope, brought me back to that moment and showed me how it fit into the bigger story of his life. The book is a deeply personal account of a life spent documenting injustice and refusing to look away, whether it’s genocide in Darfur, refugee camps in Sudan, or the streets of his hometown in rural Oregon.

Nick’s impulse to go where the suffering is, and to make people care, has defined his career. He’s reported from more than 150 countries, covering war, poverty, health, and human rights. He and his longtime collaborator and wife, Sheryl WuDunn, won a Pulitzer Prize for their work. Together and individually, they’ve brought injustices around the world into view for millions of readers.

But Chasing Hope isn’t just a greatest-hits collection of his past reporting. It’s the story of how someone becomes Nick Kristof. He writes about growing up on a sheep and cherry farm in Oregon, driving tractors as a teenager, and nearly becoming a lawyer before deciding on journalism. He also reflects on the toll his career has taken on him, his family, and his capacity for hope.

I’ve known Nick for many years now, and I’ve admired his work since that 1997 rotavirus column. On paper, we don’t seem all that similar. He’s a journalist, I’m a technologist; he tells stories, I talk numbers. But reading Chasing Hope, I was struck by what we have in common: growing up in the Pacific Northwest, learning about the value of service from our parents, thinking globally.

We both attended Harvard and left early—me because I dropped out, him because he graduated in three years before heading to Oxford as a Rhodes Scholar. But neither of us ever stopped learning. I think we both believe the world’s pretty interesting if you remain a student.

Nick’s curiosity didn’t come out of nowhere, and neither did his sense of purpose. His mother was an art history professor and a civic leader who helped influence local politics. His father, a political science professor who fled both Nazism and communism, believed deeply in education and the responsibilities that come with freedom. That kind of upbringing left a mark on him and shaped the kind of journalist he became.

Over decades, he’s built a career reporting on crises that are often ignored because they happen in far-off places, far from centers of power. In Chasing Hope, he recounts his experiences chronicling river blindness in Ethiopia, maternal mortality in Cameroon, and malaria in Cambodia. Through the foundation, I mobilize science, data, and funding to address many of the same global challenges Nick reports on. Our approaches are different, but the underlying questions we ask (and try to answer) are the same: Why are some lives valued less than others? And how can we use the tools we have—information, resources, attention—to close that gap?

Nick has an admirable commitment to nuance, especially when it comes to hard subjects like China. Nick lived there for years, speaks Mandarin, and understands the country in a way most Western commentators don’t. I’ve always appreciated his ability to go beyond the headlines—and focus not just on what’s going wrong, but on what’s changing and why it matters.

Nick is also an optimist, which might sound strange given the kinds of suffering he writes about. But his work is grounded in a belief I share: The right data—or the right story—can move people to act. As Nick puts it, “A central job of a journalist is to get people to care about some problem that may seem remote.” People, when given the chance, want to make things better. Progress, while never guaranteed, is possible.

That optimism feels especially important, if increasingly difficult, right now. Isolationism is on the rise around the world, and governments are cutting back on foreign aid at the very moment when we should be doing more, not less. Millions of lives are at stake. Nick’s work reminds us what’s possible when we care about people beyond our own borders—and what happens when we don’t.

Chasing Hope made me think a lot about what kind of person chooses to run toward the hardest problems—and keep going back until they’re solved. It also made me think the world would be a much better place if there were more Nick Kristofs. In the meantime, we’re lucky to have this one.

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

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

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

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

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

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

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

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

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

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

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

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

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

What’s for dinner?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In the worst days of COVID-19, when people around the world were out of work and struggling to pay for food and housing, many national governments came to the same conclusion about the best way to offer immediate help: send people cash. More than 200 countries introduced emergency cash transfer programs or expanded existing ones; India, for example, transferred money to 300 million people, 200 million of whom were women, in the weeks after its first lockdown. Brazil reached 70 million people with emergency transfers.

Imagine the risk involved in making these payments with paper money during a pandemic. Government workers would have to physically deliver these payments, potentially exposing them and everyone they encountered to the virus. In addition, the whole process would be expensive and time-consuming at a time when people need help as quickly as possible.

Fortunately, most governments didn’t have to resort to in-person payment. They were able to deposit cash transfers directly into people’s accounts—allowing them to give crucial support without paper bills changing hands. And during the pandemic, even more users were brought into the digital fold. For example, after financial regulators in West Africa temporarily allowed people to open accounts by text or telephone, more than 8 million signed up for accounts while their countries were in lockdown.

Globally, transferring so much money without cash was possible thanks to more than a decade of painstaking work by governments, financial service providers, nonprofits, and other partners. Today, about three quarters of people worldwide have an account at a financial institution or through a mobile money provider. That’s a 50 percent increase in the past ten years, and the growth has not just been in higher-income countries. Developing countries have increased 71 percent in that time.

This growth is great news because it means that more low-income people—and especially low-income women—are being empowered to use products that let them make and receive payments, save and borrow money, and get insurance. Both research and experience show that this financial inclusion helps people exit and stay out of poverty. And using digital technology to do it is a low-cost way to build economic resilience and reduce extreme poverty, which is why it’s an essential part of the Gates Foundation’s strategy. We have granted several hundred million dollars to partners who are helping low- and middle-income countries build digital financial systems.

Whenever I talk to friends about this work, they’re surprised to learn that roughly 1.4 billion adults can’t or don’t use any type of formal financial account, and most of those unbanked people live in low- and middle-income countries. One reason is that analog banking requires buildings, piles of paperwork, security guards, and tellers, making the cost per transaction so high that it’s not economical for a company to serve people with low balances and small transactions. As a result, people create ingenious informal banking methods—doing things like pooling cash with family and neighbors or creating community savings groups. As creative as these solutions are, they don’t allow people to build assets or move money instantly. And they are often risky—cash stashed under a mattress can be stolen, for example.

Today, the proliferation of mobile phones means that you no longer need so much expensive infrastructure to provide modern financial services. With digital technology, costs are low enough that it makes economic sense for companies to serve more of the people whom the old system has ignored.

An early example was M-PESA in Kenya, which let people living in cities send money to their relatives in rural areas efficiently and inexpensively. As it caught on, it was eventually used to make payments in shops. Likewise, India’s Universal Payment Interface allows users to make instant digital payments to each other at extremely low cost; it now includes 323 financial service providers throughout the country and handles nearly 6 billion transactions each month. During the pandemic, more than 80 million adults in India made their first digital payment to a merchant.

Yet even the exemplar countries aren’t reaching everyone who needs digital banking. That’s why the World Bank (with support from the foundation) runs the Global Findex database, a comprehensive survey of how adults borrow, save, and send money and manage risks. The Findex has been updated periodically since 2011, and the latest version was just published earlier today. Using data gathered from 128,000 adults in 123 economies, it highlights steps that will expand formal banking to everyone in the world who wants it.

I eagerly read an early copy of the Findex report as soon as I had the chance, and I’m glad I did. I recommend the report to anyone, especially policymakers, who wants more people to benefit from financial inclusion. When the world knows more about where inclusion is growing and where it isn’t, we’re better equipped to make sure we’re reaching the people who are still left out.  

One Findex finding that jumped out to me is the gender gap. Although the world has made progress in empowering women to use formal financial services as much as men do, there’s still work to do. In developing countries, the gap was 9 percent in 2017 and 6 percent in 2021. The world can do better. Leaders should focus even more directly on expanding account ownership and use among women.

Another section of the report looks at a crucial question: What prevents the people who are still unbanked from joining the formal system? Knowing the answer will make it easier to create services that will work for them.

To find out, the researchers behind the Findex did extensive surveys of the unbanked. Their top explanations: The accounts are still too expensive, a family member already has one, banks are too far away, or they don’t have enough money to use an account. So making the accounts even more affordable, accessible, and appealing needs to be a priority. Introducing digital payments via mobile phones is a great way to start: Between 2014 and 2021, the percentage of people in Ghana using formal banking services went up 28 points, and virtually all of the increase was driven by people signing up for mobile-enabled digital payments.

I’ve heard people argue that there’s a simple way to automatically expand financial inclusion: introduce digital currencies, and specifically cryptocurrencies. But that idea isn’t rooted in an understanding of what poor people require—the kind of understanding that the Findex provides.

In many areas where the unbanked live, many transactions are still done in cash, so even people with digital accounts need the ability to convert digital money into paper money quickly, and vice versa. But today, that’s extremely difficult to do with cryptocurrencies, particularly in rural areas. In addition, cryptocurrencies don’t solve the problem of identification; buyers and sellers would still need to be able to prove they are who they say they are.

When it comes to financial inclusion, the most important thing is to consider what poor people require. That means creating secure financial systems that identify who is making transactions, and that are interoperable, so that a person using one system can make transactions with someone on another system. It also means updating regulations so they protect consumers while encouraging innovation.

I’m excited about the great progress that’s documented in this year’s Findex. More people around the world, including more women and low-income people, have and use bank accounts than ever before. A lot of people are still excluded, but we have a roadmap that is feasible without billions of dollars of extra money to build systems that empower them. By following the roadmap, we can help them lift themselves out of poverty and make the world a fairer place.

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

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

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

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

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

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

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

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

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

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

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

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

Going Gaga

I couldn’t help but feel a little nervous.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Here is the chart as it looks today:

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

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

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

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

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

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

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

It’s mind-blowing how much health has improved for the world’s poorest people over the past two decades. Malaria deaths, for example, have dropped by more than a third. Eradicating the disease has become a realistic goal.

Unfortunately, climate change threatens to slow or even reverse this progress. As temperatures go up and extreme weather events become more common, it will get harder to do things like provide bed nets, get rid of malaria-carrying mosquitoes, and offer basic health care in the world’s most vulnerable communities.

I’m optimistic that the world can avoid a climate disaster. But that effort can’t come at the expense of continuing progress on health care including malaria efforts.

If we fight only climate change and stop working on health, then we might reduce carbon emissions but allow malaria to make a comeback. Eradication would become even harder. No one will be better off in a world with fewer carbon emissions but more illness and death.

In this video, I talk more about the connection between climate change and malaria and explain why I’m optimistic that we can solve both problems.

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

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

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

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

I just returned from my visit to India, and I can’t wait to go back again.

I love visiting India because every trip is an incredible opportunity to learn.

During my travels last week in Mumbai, Delhi, and Bangalore, I met some amazing people, including political leaders, bureaucrats, philanthropists, and scientists, who taught me how they are using the power of innovation, science, and collaboration to find solutions to the world’s health, climate, and development challenges.

Along the way, I met a teen bridge champion, had fun conversations with two of India’s most popular YouTubers, and I even drove an electric rickshaw!

But instead of telling you about it, let me show you. Here are some photos from my trip and some of the stories behind them:

I’m headed back to India next week. Although I’ve spent a lot of time there over the years—doing everything from checking out toilets to visiting a village that’s home to the one poorest, most underserved castes in India—I haven’t been back since before the pandemic. I can’t wait to see how much progress has been made in that time.

This essay originally ran in the Times of India and Dainik Jagaran. You can read it here:

More than two decades ago, I set out to give the vast majority of my resources back to society. My goal from the beginning was to help reduce the awful inequities I saw around the world.

When I started this work, my biggest focus was global health, because it’s the worst inequity in the world and it’s a solvable problem. That’s still the case today. But as time went on—and as the disastrous consequences of a warming world became more evident—it became clear that you can’t improve life for the world’s poorest without also tackling climate change.

Climate change and global health are inextricably linked. Hotter temperatures will make poverty reduction harder by increasing food insecurity and the prevalence of infectious diseases and diverting resources away from those who need them the most. It’s a vicious cycle. The poorer a community is, the more vulnerable it is to climate change. And the more impacted a community is by extreme weather events, the more entrenched in poverty it becomes. To break the cycle, we need to make progress on both problems at the same time.

When I talk to people about this, I often hear the same response: “There isn’t enough time or money to solve both at the same time.” But this idea that we can only tackle one thing at a time is just wrong. I’m stubborn in my belief that with the right innovations and delivery channels to get them to the vulnerable, we’re capable of making progress on lots of big problems at once—even at a time when the world faces multiple crises. There is no better proof than the remarkable progress that India has accomplished.

Consider the field of next-generation chickpea plants currently growing at the Indian Agricultural Research Institute, or IARI, in Pusa. Chickpeas are a staple crop in India. They provide an important source of income for many smallholder farmers, and families across the country rely on them for nutrition. But the chickpea harvest is threatened by climate change. Higher temperatures could reduce yields by as much as 70 percent, putting lives and livelihoods at risk.

So, the Gates Foundation joined hands with India’s public sector and CGIAR institutions to support the work of researchers at IARI. They found a new solution: chickpea varieties that have more than 10% higher yields and are more drought-resistant. One variety is already available to farmers, and others are currently in development at the institute. As a result, India is better prepared to keep feeding its people and supporting its farmers even in a warming world. It’s no exaggeration to say that India’s agricultural future is growing right now in a field in Pusa.

One of the reasons why challenges like climate, hunger, and health seem insurmountable is that we don’t yet have all the tools to solve them. But I’m optimistic that one day soon we will, thanks in part to innovators like researchers at IARI.

India as a whole gives me hope for the future. It’s about to become the world’s most populous country—which means you can’t solve most problems there without solving them at scale. And yet, India has proven it can tackle big challenges. The country eradicated polio, lowered HIV transmission, reduced poverty, cut infant mortality, and increased access to sanitation and financial services.

How did they do it? India has developed a world-leading approach to innovation that ensures solutions reach those who need them. When the rotavirus vaccine—which prevents the virus that causes many fatal cases of diarrhea—was too expensive to reach every child, India decided to make the vaccine themselves. They worked with experts and funders (including the Gates Foundation) to build factories and create large-scale delivery channels to distribute the vaccines. By 2021, 83 percent of 1-year-olds had been inoculated against rotavirus—and these low-cost vaccines are now being used in other countries around the world.

There is no question today’s challenges will test the limits of that ingenuity and cooperation. India is on the frontlines of climate change. But the progress it has made on health will make its people more resilient and provide helpful insights for how to tackle other major challenges. And the pace of its development, its skill in rolling out large-scale programs, and its people’s innovative expertise mean that India can be a key part of making progress on today’s biggest challenges.

I’m going to India next week to see firsthand the work being done by innovators and entrepreneurs. Some are working on breakthroughs that will help us mitigate the effects of climate change, like the work being done by Breakthrough Energy Fellow Vidyut Mohan and his team to turn waste into biofuels and fertilizers in remote agricultural communities. Others are finding new ways to help people adapt to a warmer world, such as IARI’s efforts to create more drought-tolerant crops. I’m looking forward to seeing the progress that’s already underway by both the Gates Foundation’s and Breakthrough Energy’s amazing partners.

Like every other country on the planet, India has limited resources. But it has shown us how the world can still make progress in spite of that constraint. By collaborating and trying novel approaches, the public, private, and philanthropic sectors can turn limited resources into big pools of funding and knowledge that lead to progress. If we work together, I believe we can fight climate change and improve global health at the same time.

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.

In any crisis, leaders have two equally important responsibilities: solve the immediate problem and keep it from happening again. The COVID-19 pandemic is an excellent case in point. The world needs to save lives now while also improving the way we respond to outbreaks in general. The first point is more pressing, but the second has crucial long-term consequences.

The long-term challenge—improving our ability to respond to outbreaks—isn’t new. Global health experts have been saying for years that another pandemic rivalling the speed and severity of the 1918 influenza epidemic wasn’t a matter of if but when. The Bill & Melinda Gates Foundation has committed significant resources in recent years to helping the world prepare for such a scenario.

Now, in addition to the perennial challenge, we face an immediate crisis. In the past week, COVID-19 has started to behave a lot like the once-in-a-century pathogen we’ve been worried about. I hope it’s not that bad, but we should assume that it will be until we know otherwise.

There are two reasons that COVID-19 is such a threat. First, it can kill healthy adults in addition to elderly people with existing health problems. The data so far suggests that the virus has a case fatality risk around 1%; this rate would make it several times more severe than typical seasonal influenza and would put it somewhere between the 1957 influenza pandemic (0.6%) and the 1918 influenza pandemic (2%).

Second, COVID-19 is transmitted quite efficiently. The average infected person spreads the disease to two or three others. That’s an exponential rate of increase. There is also strong evidence that it can be transmitted by people who are just mildly ill or not even showing symptoms yet. This means COVID-19 will be much harder to contain than Middle East Respiratory Syndrome or Severe Acute Respiratory Syndrome (SARS), which were only spread by those showing symptoms and were much less efficiently transmitted. In fact, COVID-19 has already caused 10 times as many cases as SARS in just a quarter of the time.

The good news is that national, state, and local governments and public health agencies can take steps over the next few weeks to slow the spread of COVID-19.

For example, in addition to helping their own citizens respond, donor governments should help low- and middle-income countries prepare for this pandemic. The health systems in many of these countries are already stretched thin, and a pathogen like coronavirus can quickly overwhelm them. And poorer countries have little political or economic leverage, given wealthier countries’ natural desire to put their own people first.

By helping countries in Africa and South Asia get ready now, we can save lives and also slow the global circulation of the virus. (A significant portion of the commitment Melinda and I recently made to help kickstart the global response to COVID-19—which could total up to $100 million—is focused particularly on developing countries.)

The world also needs to accelerate work on treatments and vaccines for COVID-19. Scientists were able to sequence the genome of the virus and develop several promising vaccine candidates in a matter of days, and the Coalition for Epidemic Preparedness Innovations is already preparing up to eight promising vaccine candidates for clinical trials. If one or more of these vaccines proves safe and effective in animal models, they could be ready for larger-scale trials as early as June. Drug discovery can also be accelerated by drawing on libraries of compounds that have already been tested for safety and by applying new screening techniques, including machine learning, to identify antivirals that could be ready for large-scale clinical trials within weeks.

All these steps would help address the current crisis. But we also need to make larger systemic changes so we can respond more efficiently and effectively when the next epidemic arrives.

It’s essential to help low- and middle-income countries strengthen their primary health care systems. When you build a health clinic, you’re also creating part of the infrastructure for fighting epidemics. Trained health care workers not only deliver vaccines; they can also monitor disease patterns, serving as part of the early warning systems that will alert the world to potential outbreaks.

The world also needs to invest in disease surveillance, including a case database that is instantly accessible to the relevant organizations and rules that require countries to share their information. Governments should have access to lists of trained personnel, from local leaders to global experts, who are prepared to deal with an epidemic immediately, as well as lists of supplies to be stockpiled or redirected in an emergency.

In addition, we need to build a system that can develop safe and effective vaccines and antivirals, get them approved, and deliver billions of doses within a few months of the discovery of a fast-moving pathogen. That’s a tough challenge that presents technical, diplomatic, and budgetary obstacles, as well as demanding partnership between the public and private sectors. But all these obstacles can be overcome.

One of the main technical challenges for vaccines is to improve on the old ways of manufacturing proteins, which are just too slow for responding to an epidemic. We need to develop platforms that are predictably safe, so regulatory reviews can happen quickly, and that make it easy for manufacturers to produce doses at a low cost and a massive scale. For antivirals, there will need to be an organized system to screen existing treatments and candidate molecules in a swift and standardized manner.

Another technical challenge involves constructs based on nucleic acids. These constructs can be produced within hours after a virus’s genome has been sequenced; now we need to find ways to produce them at scale.

In addition to these technical solutions, we’ll need diplomatic efforts to drive international collaboration and data sharing. Developing antivirals and vaccines involves massive clinical trials and licensing agreements that would cross national borders. We should make the most of global forums that can help achieve consensus on research priorities and trial protocols so that promising vaccine and antiviral candidates can move quickly through this process. These platforms include the World Health Organization R&D Blueprint, the International Severe Acute Respiratory and Emerging Infection Consortium trial network, and the Global Research Collaboration for Infectious Disease Preparedness. The goal of this work should be to get conclusive clinical trial results and regulatory approval in three months or less, without compromising patients’ safety.

Then there is the question of funding. Budgets for these efforts need to be expanded several times over. Billions more dollars are needed to complete Phase III trials and secure regulatory approval for coronavirus vaccines, and still more funding will be needed to improve disease surveillance and response.

Why does this require government funding—can’t the private sector solve this on its own? Pandemic products are extraordinarily high-risk investments, and pharmaceutical companies will need public funding to de-risk their work and get them to jump in with both feet. In addition, governments and other donors will need to fund—as a global public good—manufacturing facilities that can generate a vaccine supply in a matter of weeks. These facilities can make vaccines for routine immunization programs in normal times and be quickly refitted for production during a pandemic. Finally, governments will need to finance the procurement and distribution of vaccines to the populations that need them.

Obviously, billions of dollars for anti-pandemic efforts is a lot of money. But that’s the scale of investment required to solve the problem. And given the economic pain that an epidemic can impose—just look at the way COVID-19 is disrupting supply chains and stock markets, not to mention people’s lives—it will be a bargain.

Finally, governments and industry will need to come to an agreement: During a pandemic, vaccines and antivirals won’t simply be sold to the highest bidder. They’ll be available and affordable for people who are at the heart of the outbreak and in greatest need. Not only is this the right thing to do, it’s also the right strategy for short-circuiting transmission and preventing future pandemics.

These are the actions that leaders should be taking now. There is no time to waste.

This post originally appeared on the website of the New England Journal of Medicine. I wrote there about the need for a global pandemic response system in 2015, and about the threat posed by a novel respiratory virus in 2018.

These days I spend a lot of my time thinking about how technology can help the poorest people in the world improve their lives. It’s been a big focus for me since before Melinda and I launched our foundation. But looking back, I think I could have started down this path even sooner than I did.

People with a STEM background have a lot to offer the world of global health and development. That’s one of the reasons why I write about innovation so often here on TGN: I want to encourage software developers, inventors, and scientists to consider how they can use their skills to fight inequity. It’s deeply rewarding. You get the chance to learn from super-capable people—health care workers, farmers, political leaders—and work with them on tools that will empower them.

Last year I heard a talk from a young technologist who came to this realization sooner than I did. His name is William Wu, and he gave a fascinating demonstration at our foundation’s annual Goalkeepers meeting in New York City. Here are some highlights from his presentation:

After hearing William’s talk, I learned more about his story. He grew up in the Bay Area in the ’80s and ’90s. His parents helped him get excited about math and science from an early age. William studied engineering and computer science in college and grad school, ending up with a Ph.D. in electrical engineering from Stanford. While in grad school he met his future wife, Jiehua Chen (she goes by “JC”), who was getting a Ph.D. in statistics with a focus on global development.

After a short time writing code at various startups, William landed a job at NASA’s Jet Propulsion Laboratory, designing a telecommunications system for satellites including the International Space Station. It was fulfilling work—he had been obsessed with space since he was a kid—but eventually he realized he didn’t have to look to the stars for interesting problems to solve.

A turning point came when JC was working on soil analysis in Africa. The field team she was working with needed to convert thousands of data points on a spreadsheet into GPS coordinates, but they couldn’t figure out how to do it quickly. When JC mentioned the problem to William, he knew it could be solved with just a few lines of code. In minutes he had written a small program that did the job.

JC helped William see that someone with skills and interests like his could make a big difference in global development. In 2012, they founded their company, Quantitative Engineering Design, which develops software and hardware to improve farming and health care in developing countries. QED now employs about 20 engineers and scientists and works with national governments around the world as well as organizations like the Centers for Disease Control and Prevention.

The soil project that William describes in the video above is just one example of what QED is doing. They also built the data processing software used in Kenya by the CHAMPS project, an initiative that our foundation is funding to learn why so many young kids still die in some regions.

Another QED project involves digitizing medical forms. Throughout sub-Saharan Africa, health clinics use paper-based, handwritten medical registries. These registries contain a lot of (anonymous) data about how many patients come in and out of the clinic, the staff’s workload, the prevalence of different diseases, and so on. But because this is all done on paper, it’s hard to analyze the data for larger trends. QED is pilot-testing an app that would allow organizations to keep using paper-based books but quickly digitize the results. A health worker would use her mobile phone’s camera to scan the handwritten information, get it transcribed using optical character recognition, store it in the cloud, and export it for analysis, all in 60 seconds.

It’s too early to predict the impact of any of these projects. The point is that people with tech skills can find fascinating problems to work on and terrific partners to work with. It’s great if you decide to make a career of it, but you don’t necessarily have to. Sometimes all it takes to make a difference is the willingness to learn about a problem and use your talents to help solve it.

Our foundation maintains a list of sites that can point you to volunteer opportunities. It’s worth a look.

At some point in school, you probably learned about photosynthesis—how plants use energy from sunlight to convert carbon dioxide and water into food. This remarkable process is responsible for virtually all life on Earth, providing us with the energy we need and the oxygen we breathe.

But you might not have heard that photosynthesis has some flaws.

It turns out that plants are quite inefficient when it comes to using the sun’s energy. Just a fraction of the sunlight shining on a plant ends up fueling its growth, which means our crops are producing far less food than they could be.

An international group of researchers is aiming to fix that by giving photosynthesis a tune up. If successful, their research is expected to double the productivity of some of our most important crops—like rice, maize, cowpea, soybeans, and cassava.

That would be a much-needed breakthrough because the world is facing a crisis at the dinner table. With a growing population and changes in diets—like a greater demand for more meat as people earn higher incomes—we’ll need to produce 60 to 70 percent more food by 2050. At the same time, climate change is putting additional stresses on our food supply because of erratic rainfall, severe droughts, and the spread of pests and crop diseases.

Those who are at greatest risk of hunger in the years ahead are the world’s poorest people. They live in regions with high population growth and often rely on farming both to feed their families and to earn an income.

No single solution will solve this global food crisis. We’ll need to develop innovations in all areas of agriculture to increase productivity. Improved seed varieties for crops that are resistant to drought, flood, pests, and disease. Better data to help farmers manage their crops and livestock more efficiently. And some game-changing discoveries that will lead to bigger harvests.

That’s why our foundation along with the U.S. Foundation for Food and Agriculture Research and the U.K. Government's Department for International Development is investing in the global effort to make photosynthesis more efficient. This research program, known as Realizing Increased Photosynthetic Efficiency or RIPE, is being led by the University of Illinois.

RIPE scientists began their research by modeling the entire 170-step chemical process of turning sunlight into energy. Using computer simulations, they explored which changes might lead to the biggest increases in productivity—in the same way an efficiency expert might make improvements to a car production line to maximize output.

One promising area of research involves making plants absorb sunlight more effectively. While light is essential for a plant’s survival, too much high-intensity light can cause damage to the plant. To protect themselves, plants have developed mechanisms to siphon off some of the sun’s energy as heat when they are in direct sunlight. But this creates a problem when the sun goes behind a cloud and the plant is in the shade. The plant’s protective mechanism doesn’t adjust quickly to the reduced light, inhibiting the process of photosynthesis for minutes or sometimes hours. RIPE researchers discovered a way to speed up this transition, allowing the plant to continue with photosynthesis even with light fluctuations.

Another critical area of research involves an enzyme known as Rubisco, which captures carbon dioxide and turns it into sugars for the plant. Some researchers are working to speed up Rubisco activity in the plant, which would result in higher crop productivity.

Other researchers are trying to fix an inefficiency created by Rubisco: It has a hard time distinguishing carbon dioxide from oxygen. So, about 20 percent of the time Rubisco accidently grabs an oxygen molecule instead of a carbon dioxide molecule. This results in the creation of a compound that must be recycled by the plant through a process known as photorespiration. Photorespiration is long and complicated, costing a plant energy and resources that it could use for growth. To solve this, researchers have engineered an alternative pathway to drastically shorten the photorespiration process and save energy. When tested in the lab, this fix boosted plant growth by up to 40 percent.

Much of the field testing of these improvements to photosynthesis has been done using tobacco plants. While tobacco plants are not food crops, they are a convenient proof-of-concept crop because they are easy to transform genetically and they produce a large amount of seed, shortening testing cycles. In the next phase of research, scientists are working to transfer these new genetic traits to food crops, including cowpea, cassava, and soybeans.

Still, these high yielding crops are years away from being grown on farms around the world. And they would need to pass safety tests to gain consumer acceptance. I’m excited about the progress made by the RIPE team and I look forward to hearing more about their discoveries in the future.

Have you ever met someone new and immediately felt like you could talk to them for hours?

That happened the first time I met Aliko Dangote. A couple years ago, he and I ended up going to the same event in New York. A mutual friend suggested that I meet him because he knew we were both super interested in global health. So we made sure to sit next to each other at dinner.

As soon as we shook hands, it was clear we had a ton in common. We both started successful businesses in the late 1970s. For our second act in life, we both chose to start foundations aimed at improving health and education. (Today, the Dangote Foundation is the largest such organization in sub-Saharan Africa.)

More importantly, we both love to geek out over things that make some people’s eyes glaze over, like cement, fertilizer, and iodized salt. Check out this video of Aliko’s recent visit to our foundation’s office in Seattle for proof:

That first meeting sparked the beginning of a fruitful friendship. In 2016, our foundations announced a joint, five-year $100 million commitment to reducing malnutrition in Nigeria.

Malnutrition is the greatest health inequity in the world. It’s responsible for nearly half of all under 5 deaths in Nigeria (and around the world). Even if you survive to adulthood, your chances of dying are much higher, and your quality of life is greatly reduced.

One of the ways our foundations are working together to fight malnutrition is through food fortification. Kids often become malnourished when they don’t get enough micronutrients—vitamins and minerals—to digest their food properly. One way to correct this is by adding micronutrients to the food that families—especially those from low-income households—are purchasing every day.

When you go to a grocery store in the U.S., a lot of food already has this fortification. Think iodized salt, or milk that comes with extra vitamin D and calcium. By introducing additional micronutrients to the food people are already eating, you can improve health without changing any habits. Our foundations are now working together to find other staple foods and condiments that could be used to deliver more micronutrients to more people in Nigeria, like fortified bouillon cubes.

Improving health in Nigeria is critical to making progress in sub-Saharan Africa. The country is home to nearly a quarter of all people living in sub-Saharan Africa, and that population is only going to grow in the future. By solving problems in Nigeria, you can have a huge impact on all of Africa.

Aliko Dangote understands this, and that’s why he’s committed to making progress in his home country. Melinda and I are lucky to have him as a partner (and friend!) in improving health.

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.

I was 9 years old when Nelson Mandela was sent to prison on Robben Island. As a boy, I learned about him in school, and I remember seeing reports about the anti-Apartheid movement on the evening news. Decades later, I got to meet him and work with him. In person he was even more inspiring than I had imagined. His humility and courage left an impression that I will never forget.

So it was a special honor to be invited to give the Nelson Mandela Lecture in Pretoria, South Africa. I eagerly accepted the invitation and quickly began working on my remarks.

I decided to share my optimism about Africa’s future—to explain why I think the continent has the potential to change faster in the next generation than any continent ever has.

It’s because Africa is the world’s youngest continent, and youth can go hand in hand with a special dynamism. I was 20 years old when Paul Allen and I started Microsoft. The entrepreneurs driving startup booms in Johannesburg, Lagos, and Nairobi are just as young, and the thousands of businesses they’re creating are already changing lives across the continent. The potential will only grow as the digital revolution brings more advances in artificial intelligence and robotics.

But positive change across Africa won’t happen automatically. The real returns will come only if Africans can unleash this talent for innovation in all of the continent’s growing population. That depends on whether all of its young people are given the opportunity to thrive.

It is still an open question, and it is the crux of my speech, which I gave today at the University of Pretoria. It was an honor to give this lecture, and I’m grateful to the Nelson Mandela Foundation and the university for inviting me. You can read my full speech below the video.

Remarks as delivered
Nelson Mandela Annual Lecture
University of Pretoria, South Africa
July 17, 2016

BILL GATES:

Well, thank you. Good evening, ladies and gentlemen. Graça Machel, Professor Ndebele, Vice Chancellor de la Rey, members of the Mamelodi families, friends and dignitaries.

I can’t think of a greater honor than giving a lecture named after Nelson Mandela.

I’m also thrilled that the theme of this lecture this year is “living together.”

It’s truly fitting because in many ways, “living together” was also the theme of Nelson Mandela’s life.

The system he fought against was based on the opposite idea—that people should be kept apart, that our superficial differences are more important than our common humanity.

Today, South Africans are still striving to “live together” in the fullest sense. But you are so much closer to that ideal because Nelson Mandela and so many others believed in the promise of one South Africa.

I was only nine years old when Nelson Mandela was sent to Robben Island. As a boy, I learned about him in school. I remembered seeing reports about the anti-Apartheid movements regularly on the evening news.

The first time I got to speak to him was in 1994 when he called me to help fund South Africa’s election.

I was running Microsoft, and largely focused on software most of the time, but I admired him so much, and I knew the election was historic. So I did what I could to help.

My first trip to Africa had been just the year before that in 1993 when my wife Melinda and I had traveled to East Africa.

The landscape was beautiful, the people were friendly, but the poverty there, which we were seeing for the first time, disturbed us. It also energized us.

Obviously, we knew parts of Africa were poor, but being on the continent turned what had been an abstraction into an injustice we couldn’t ignore.

Melinda and I had always known that we’d give our wealth to philanthropy eventually. But when we were confronted with such glaring inequity, we started thinking about how to take action sooner.

This sense of urgency was further spurred on by another trip in 1997 when I came to Johannesburg for the first time as a representative of Microsoft.

I spent most of the time in the richer part of the city in business meetings, but I also went to the community center in Soweto where Microsoft was donating computers.

My visit to Soweto, which was quite different then than it is now, taught me how much I had to learn about the world outside the comfortable bubble I’d lived in all my life.

As I walked into the community center, I noticed there weren’t any electrical connections. To keep the computer on, the one I was donating, they had rigged up an extension cord connected to a diesel generator outside. I realized the minute I left, the generator would get moved to something more important.

So as I read my remarks about the importance of the technology gap, I knew that it was only a small part of the story. Computers could help people do very important things, and in fact, they are part of how life on the continent can be revolutionized. But computers alone can’t feed disease or cure children. And if they can’t be turned on, they can’t do much at all.

So after that, Melinda and I moved to start our foundation because the cost of waiting had become clear.

Our work is based on the simple idea that every person, no matter where they live, should have the opportunity to lead a healthy and productive life.

We’ve spent the past 15 years learning about the issues and looking for the leverage points where we can do the most to help people seize their opportunity.

It was when I started coming to Africa regularly for the foundation that I got to know Nelson Mandela personally. AIDS was one of the first issues our foundation worked on, and Nelson Mandela was both an advisor and an inspiration.

One thing we talked about was the stigma around AIDS. So I remember 2005 very clearly when his own son died of AIDS. Rather than stay silent about the cause of his son’s death, Nelson Mandela announced it publicly because he knew that stopping the disease required breaking down the walls of fear and shame that surrounded it.

It is important to recall Nelson Mandela’s legacy, and I’m grateful for the opportunity to do so.

But Nelson Mandela was concerned about the future. He believed people could make the future better than the past. And so that’s what I want to focus on for the remainder of my talk.

What can South Africa become? What can Africa become? What can the world become? And what must we do to make it that way?

The Millennium Development Goals adopted by the United Nations in 2000 laid a foundation that enabled the world, including Africa, to achieve extraordinary progress over the last 15 years.

And the Sustainable Development Goals that recently replaced them set even more ambitious targets for creating the better world we all want.

When I talk about progress, I always start with child survival because whether children are living or dying is such a basic indicator of a society’s values.

Since 1990, child mortality in sub-Saharan Africa has been reduced by 54 percent. That means one million fewer children dying each year compared to 25 years ago.

Ten African countries achieved the very ambitious MDG target of reducing child mortality by over two-thirds.

At the same time, the incidence of poverty and malnutrition is down. And though economic growth has slowed in the past few years, it’s been very robust in many African countries for more than a decade.

This is real progress, but the Africa Rising narrative doesn’t tell the whole story about the life on the continent.

First, the progress have been uneven. You know this very well here in South Africa.

In last year’s Nelson Mandela Annual Lecture, the French economist, Thomas Piketty, pointed out that income inequality in South Africa is, quote, “higher than pretty much anywhere else in the world.”

In general, African countries tend to have higher rates of inequality than countries on other continents.And despite healthy average GDP growth in the region, many countries have not yet shared in it.  Inequalities exist within countries and between countries.

So until progress belongs to all people everywhere, the real promise of living together will remain elusive.

Second, even with the great progress Africa has made, it still lags behind the rest of the world in most indicators. In sub-Saharan Africa, one in 12 children still die before they turn five. Now, that’s a vast improvement compared to 25 years ago, but African children are still 12 times more likely to die than the average child in the world.

And because rates of poverty and malnutrition aren’t shrinking as fast as the population is growing, the number of people who are poor or malnourished has actually gone up since 1990.

Finally, the progress is fragile. The continent’s two largest economies, here in South Africa and in Nigeria, are facing serious economic challenges. And new threats require attention. The Ebola crisis pointed out weaknesses in many national health systems. The effects of climate change are already being felt among farmers in many countries.

In short, to meet the ambitious goals of the Sustainable Development Goals, Africa needs to do more, do it faster, and make sure everybody benefits. It won’t be easy, but I believe it can be done.

The successes and failures of the past 15 years have generated examples and lessons we can follow. Phenomenal advances in science and technology are expanding the range of solutions available to solve development challenges. And then there is the ingenuity of the African people.

One topic that Nelson Mandela came back to over and over again was the power of youth. He knew what he was talking about because he started his career as a member of the African National Congress Youth League when he was still in his 20s.

Later on, he understood that highlighting the oppression of young people was a powerful way to explain why things must change. There is a universal appeal to the conviction that youth deserve a chance.

I agree with Mandela about young people, and that is one reason I am optimistic about the future of this continent. Demographically, Africa is the world’s youngest continent. And its youth can be the source of a special dynamism.

In the next 35 years, two billion babies will be born in Africa. By 2050, 40 percent of the entire world’s children will live on this continent.

Economists talk about a demographic dividend. When you have more people of working age and fewer dependents for them to take care of, you can generate phenomenal economic growth. Rapid economic growth in East Asia in the 1970s and 1980s was partly driven by the large number of young people moving into their workforce.

But, for me, the most important thing about young people is the way their minds work. Young people are better than old people at driving innovation because they’re not locked in by the limits of the past.

When I started Microsoft at the age of 19, computer science was a young field. We didn’t feel beholden to old notions about what computers could or should do. We dreamed about the next big thing and we scoured the world around us for the ideas and tools that would help us create it.

But it wasn’t just Microsoft. Steve Jobs was 21 when he started Apple. Mark Zuckerberg was only 19 when he started Facebook.

The African entrepreneurs driving startup booms in the Silicon Savannahs from Johannesburg and Cape Town to Lagos and Nairobi are just as young in chronological age, but also in their outlook. The thousands of businesses they’re creating are already changing daily life across the continent.

In a few days, I’ll be meeting with some of these young innovators. People like the 21-year-old who founded Kenya’s first software coding school to provide other young people with computer programming skills. And like the 23-year-old social entrepreneur here in South Africa who manufactures school bags from recycled plastic shopping bags. Besides being highly visible to protect children as they’re walking to school, these school bags sport a small solar panel that charges a lantern during the journey to and from school, providing illumination so students can study at home.

The full returns will come if we can multiply this talent for innovation by the whole of Africa’s growing youth population. That depends on whether Africa’s young people—all of Africa’s young people—are given the opportunity to thrive.

Nelson Mandela said, “Poverty is not natural, it is man made and it can be overcome and eradicated by the actions of human beings.”

We are the human beings that must take action. And we have to decide now because this unique moment won’t last. We must clear away the obstacles that are standing in young people’s way so that they can seize all of their potential.

If young people are sick and malnourished, their bodies and brains will never fully develop. If they are not educated well, their minds will lie dormant. If they do not have access to economic opportunities, they will not be able to achieve their goals.

But if we invest in the right things, if we make sure the basic needs of Africa’s young people are taken care of, then they will have the physical, cognitive, and emotional resources they need to change the future. Life on this continent will improve faster than it ever has. And the inequities that have kept people apart will be erased by broad-based progress that is the very meaning of the words “living together.”

When Melinda and I started our foundation 15 years ago, we asked ourselves: What are the areas of greatest impact? It was clear to us that investing in health was high on the list. When people aren’t healthy, they can’t turn their attention to other priorities. But when health improves, life improves by every measure.

Over the last 15 years, our foundation has invested more than $9 billion in Africa. And we are committed to keep on investing to help Africa.

In the next five years, we will invest another $5 billion.

Some of this money has gone into discovering and developing new and better vaccines and drugs to help prevent infectious disease. We’ve also invested in global partnerships that work closely with countries across the continent to get these solutions to the people who need them most.

We’ve been fortunate to work with amazing partners, and together we’ve seen incredible progress.

For example, the entire continent of Africa has been polio free for two years, which puts us within reach of wiping polio out from the face of the earth forever.

The newest vaccines that protect children from two of the most devastating diseases—pneumonia and diarrhea—are reaching children across Africa at the same time they’re available for children in wealthier countries.

Countries that invest in strong, community-based primary healthcare systems—including Malawi, Ethiopia, and Rwanda—are making great progress reducing child mortality.

Malaria infections and deaths are down significantly thanks to better treatment and prevention tools.

And efforts like the Ouagadougou Partnership in West Africa are helping millions of women get access to contraceptives, which make it easier for them to care for their families.

HIV/AIDS is another area where there’s been good progress. Though it’s a complicated story, and there are still big challenges ahead.

In a few days, I’ll be speaking at the International AIDS Conference in Durban. When the global AIDS community last met there in 2000, only a few thousand Africans were receiving antiretroviral drugs. Today, more than 12 million Africans are on treatment, more than a quarter of them living here in South Africa.

So this is a huge achievement, and millions of lives have been saved. But the rate of new infections remains high. In sub-Saharan Africa, more than 2,000 young people under the age of 24 are infected every single day. The number of young people dying from HIV has increased fourfold since 1990.

We need to get people to get diagnosed, we need people to seek treatment, and people who are on treatment need to be fully adherent.

Along with HIV, we have high rates of tuberculosis, including here in South Africa where TB/HIV co-infection continues to wage a devastating toll.

So we need more creative ways to make testing and treatment accessible and easier to use.

We need to get much more out of existing prevention methods like condoms, voluntary medical male circumcision, and oral anti-HIV medicine.

And we’re going to have to invent new and better preventative solutions like medicines you only have to take once a month or an effective vaccine.

If we don’t act both on today’s treatment and create these tools, the hard-earned gains made against HIV in sub-Saharan Africa over the last 15 years could actually be reversed. Because of the population growth, just doing what we are today is not enough. We need to do more.

Nutrition is another critical area of focus for Africa. Nearly one-third of the continent’s children suffer from malnutrition that stunts their growth and robs them of their physical and cognitive potential. Millions more suffer from micronutrient deficiencies. These are impacts that last a lifetime and impact whole generations of African youth.

African Development Bank President Akin Adesina put it best when he said recently that the greatest contributor to Africa’s economic growth is not physical infrastructure, but gray matter infrastructure, people’s brainpower. The best way to build that infrastructure includes proper nutrition.

Without eliminating malnutrition, we won’t get the great potential that’s there.

We know that when mothers and infants get good nutrition, that breast feeding is a key part of that. We know that certain vitamins and minerals are essential for children.

We have a number of ways to intervene to help nutrition, things like fortified cooking oil, sugar fortified with vitamin A, and sugar and flour enriched with iron, zinc, and vitamin B.

One of the most exciting advances is the breeding of crops so they are naturally more nutritious. For example, when adolescents eat high-iron pearl millet, their likelihood of iron deficiency is reduced six-fold.  And just half a cup of biofortified orange sweet potato is all it takes to meet a child’s daily vitamin A needs.

The toll of micronutrient deficiency is huge, but the costs of fighting it are not.

Recent estimates done in Nigeria and Uganda indicate that every dollar invested to reduce stunting returns $17 in greater earning capacity in the workplace.

When children’s bodies and brains are healthy, the next step is an education that helps them develop the knowledge and skills to become productive contributors to society.

Improving education is hard work. I’ve learned this first hand through our foundation’s efforts to create better learning outcomes for primary, secondary, and university students in the United States.

But this hard work is incredibly important. A good education is the best lever we have for giving every young person a chance to make the most of their lives.

In Africa, as in the United States, we need new thinking and new educational tools to make sure that a high-quality education is available to every child.

In Uganda, young innovators at the NGO called Educate! are helping high schools prepare young people for the workplace by teaching students how to start their own business.

And with the high level of mobile phone penetration in Africa, technology using mobile phones to connect to the Internet have the potential to help students build foundational skills while giving teachers better feedback and support.

Globally, the educational technology sector is innovating and growing rapidly and it’s exciting to see new models and tools emerging to meet the needs of educators and students who are not connected to current systems.

At the university level, we need not only to broaden access, we have to also ensure that we have high-quality public universities that will launch the next generation of scientists, entrepreneurs, educators, and government leaders.

South Africa is blessed with some of the best universities in Africa, like the one we’re at today.

For our foundation, we partner with these universities to do our work in health and agricultural research. Maintaining the quality of this country’s higher-education system, while expanding access to more students will not be easy, but it is critical to South Africa’s future.

Other countries in the region will do well to follow South Africa’s example and provide the highest-level university education to the largest number of qualified students.

Healthy, educated young people are eager to make their way in the world. But Africa’s youth must have economic opportunity to channel their energy into progress.

Some of those youths will work in agriculture, where still over half of the workforce toils today.

We need advances to make agriculture far more productive. Today, the seeds that are used are unproductive, the soils are not very good, and so many farmers grow just enough to feed their family.

With climate change leading to more severe weather, doing more of the same will not be good enough.

The key to this is a series of innovation at every step along the way from farm to market.

First, farmers need better tools to avoid disasters and grow surplus. Things like seeds that can tolerate drought, floods, pests, and disease; affordable fertilizers that have the right mix of nutrients to replenish the soil; and easy-to-administer livestock vaccines that can help prevent flocks and herds from being wiped out.

Next, farmers need to be connected to a market where they can buy these inputs at a good price, and sell their surplus, and earn a profit that they can invest not only in their family’s basic needs, but also back into the farm.

This, in turn, will provide employment opportunities both on and off the farm as more prosperous farmers begin to support a range of agribusinesses like seed dealers, trucking companies, and processing plants.

I recently met with a group of young crop breeders, one from Ethiopia, one from Kenya, one from Nigeria, one from Uganda. I really love talking about the science of plant productivity. And in this case, I was amazed at the expertise all of these scientists brought to their work on cassava, a staple crop that provides more than one-third of the calories in many African diets.

Some had ways of improving the nutritional content of cassava. Others were breeding a variety that can resist both of the devastating diseases that are threatening to wipe out the cassava crop.

Our foundation is also working with a young computer scientist from Makerere University who designed a mobile phone app that lets farmers upload a picture of their cassava plants to find out whether it’s infected or not.

These are examples of the kind of innovators who can drive an agricultural transformation across the continent if they have the support they need. For many decades, agriculture has suffered from dramatic underinvestment. Many governments didn’t see the link between their farmers and economic growth.

Now, however, this misconception is gone. And through the Comprehensive African Agricultural Development Program, countries have a framework for transforming agriculture. The investment needs to follow so that young Africans have the means to create the thriving agriculture they envision.

With Africa’s farms as a base, the next step in economic growth is to promote job creation in other sectors. Doing this will require investment in infrastructure including energy.

Seven in 10 Africans lack access to power, which makes it harder to do everything. Harder to get healthcare in a dark clinic. Harder to learn in school when it’s boiling hot. Harder to be productive when you can’t use labor-saving machinery.

Ultimately, a shortage of power, like many African countries—including South Africa—have experienced, is also a drag on economic growth.

Businesses will not invest fully in places where they can’t operate efficiently.

A recent report projected that 500 million Africans won’t have electricity even in 2040. We need to change that.

What Africa needs is what the whole world needs: An energy advance that provides cheap, clean energy for everyone.

I’ve spent a lot of my time in the last two years working on this issue because it’s such an important advance.  I’m involved with a group of business people who are collaborating with governments to not only increase energy R&D, but also to vastly increase the private investment in this area.

I get angry when I see that Africa is suffering the worst effects of climate change, although Africans had almost nothing to do with causing this.

The rich countries need to follow through on their commitment to double their energy R&D budgets so that we get the breakthroughs that are applicable globally, and we need to do that urgently.

Africa needs power now. And so there are many pragmatic steps we need to take even in advance of these new inventions.

In parts of Africa, there’s hydro and geothermal sources which are both reliable and renewable that can be exploited. There’s been a lot of work on small-scale grids and the use if micro solar. This approach can provide individuals with electricity for basic purposes, but we also need large-scale power including well-managed electrical grids.

It means organizing the power system so that it’s economic, so that the electronic bills are paid for, and so that the network is reliable 100 percent of the time.

Once we get economic viability for these utilities, then it bootstraps the economy. It allows investments that are job creating.

So there are many challenges that I’ve laid out here: Challenges in health, education, agricultural productivity, energy, and creating enough job opportunities.

These advances only happen in the context of governments that function well enough to enable them. I applaud initiatives like Mo Ibrahim’s Annual Index of African Governments, which looks objectively at multiple measures of government performance in each country on the continent.

Citizens in other regions would be well served by this kind of comprehensive effort to spotlight and spread effective governance.

A lot can be accomplished by focusing on fiscal governance and accountability. Here in South Africa, the government gets strong marks for the budget information it provides to the public.

The International Budget Partnership, an independent monitoring organization, also ranks South Africa highly for its oversight of government spending.

In some countries, individual citizens are leading the way. In Nigeria, 30-year-old Oluseun Onigbinde gave up a career in banking years ago to devote himself full time to pulling back the curtain on the Nigerian federal expenditure.

With savvy use of data and social media, he founded BudgetIT Nigeria, which provides facts and figures the average Nigerian can understand. No doubt, he’s a thorn in the side of some of Nigeria’s elite, but to me he’s an example of what one person can do to make a difference.

Governments have an opportunity not only to learn from what’s been done in the past, but to do things in new ways. One of the exciting prospects is the role they can play in accelerating use of digital technology to leapfrog traditional models and costly infrastructure associated with banking and delivery of government services.

By using mobile phones, tens of millions of people are already storing money digitally and using their phones to make purchases as if they were debit cards.

A good example of this is M-PESA in Kenya. These services don’t just give people a better way to move money around, they give people a place to save cash to fund a startup of a micro enterprise or pay a child’s school fee. They create informal insurance networks of friends and families who can help with unexpected shocks. And they increase the profitability of small businesses by lowering transaction costs, making it easy to order products and supplies, and having greater security of financial assets.

A digital financial connection can also help governments deliver services more efficiently. Studies from India show the government able to save tens of billions a year by connecting households to a digital payment system and automating all government payments.

The early evidence suggests that similar programs in Africa can also yield substantial benefits. For example, recent research in Uganda showed that providing people with digital cash transfers rather than direct food subsidies not only saved the cost of delivery, it also improved nutrition because recipients used the money to purchase a greater diversity of foods and to space out meals as needed.

Governments can accelerate this digital transformation by implementing policies that encourage commercial investment, innovation, and healthy competition.

Countries like Kenya, Tanzania, and Nigeria are already investing in the building blocks of this new digital financial platform. And I believe they’ll see substantial positive returns.

If there’s one thing I’m sure of, it’s this: Africa can achieve the future it aspires to.

That future depends on the people of Africa working together across economic and social strata and across national borders to lay a foundation so that Africa’s young people have the opportunities they deserve.

Recently, I had a meeting with students at Addis Ababa University. I started asking them the kinds of questions you would ask college students in the United States like, “What do you want to do after you graduate? What fields are you thinking of going into?”

They looked at me like I was kind of crazy for asking those questions. Each of them had a plan for their future. They felt their parents had sacrificed for decades so they could go to this university. They weren’t weighing their options, they had come to the university to get specific training, and they were eager to take that training and use it to make their country more prosperous.

They saw themselves as part of a large community with great needs.And they were going to dedicate themselves to serving that community by meeting those needs.

I see that sense of purpose when I come to Africa, and especially when I talk to young Africans. I think it’s a unique asset that people see the need to change and that they want to give back.

The students here believe not only in themselves, they also believe in their countries and the future of the continent. Our priority is to make sure they have the opportunity to turn those beliefs into action because young people with this sense of purpose can make the difference between stagnation and faster progress.

Nelson Mandela said, “Young people are capable, when aroused, of bringing down the towers of oppression and raising the banners of freedom.” But our duty is not merely to arouse, our duty is to invest in these young people, to put in place the basic building blocks so they can build the future.

And our duty is to do it now because the innovations of tomorrow depend on the opportunities available to children today.

I’m sure it’s clear to everyone that these are big and complicated challenges. But it’s just as clear that people with bravery, energy, intellect, passion, and stamina can face big, complicated challenges and overcome them.

There is so much more work to be done to create a future in which we can all live together, but there are also so many people who are eager to get to work.

Let’s do everything within our power right now to help build the future that Nelson Mandela dreamed of and the future that we will achieve together.

Thank you.

If you were living on $2 a day, what would you do to improve your life?

That’s a real question for the nearly 1 billion people living in extreme poverty today. There’s no single right answer, of course, and poverty looks different in different places. But through my work with the foundation, I’ve met many people in poor countries who raise chickens, and I have learned a lot about the ins and outs of owning these birds. (As a city boy from Seattle, I had a lot to learn!) It’s pretty clear to me that just about anyone who’s living in extreme poverty is better off if they have chickens.

In fact, if I were in their shoes, that’s what I would do—I would raise chickens.

Here’s why:

• They are easy and inexpensive to take care of. Many breeds can eat whatever they find on the ground (although it’s better if you can feed them, because they’ll grow faster). Hens need some kind of shelter where they can nest, and as your flock grows, you might want some wood and wire to make a coop. Finally, chickens need a few vaccines. The one that prevents the deadly Newcastle disease costs less than 20 cents.
• They’re a good investment. Suppose a new farmer starts with five hens. One of her neighbors owns a rooster to fertilize the hens’ eggs. After three months, she can have a flock of 40 chicks. Eventually, with a sale price of $5 per chicken—which is typical in West Africa—she can earn more than $1,000 a year, versus the extreme-poverty line of about $700 a year.
• They help keep children healthy. Malnutrition kills more than 3.1 million children a year. Although eating more eggs—which are rich in protein and other nutrients—can help fight malnutrition, many farmers with small flocks find that it’s more economical to let the eggs hatch, sell the chicks, and use the money to buy nutritious food. But if a farmer’s flock is big enough to give her extra eggs, or if she ends up with a few broken ones, she may decide to cook them for her family.
• They empower women. Because chickens are small and typically stay close to home, many cultures regard them as a woman’s animal, in contrast to larger livestock like goats or cows. Women who sell chickens are likely to reinvest the profits in their families. Read more about women and chickens in Melinda’s blog post.

Dr. Batamaka Somé, an anthropologist from Burkina Faso who has worked with our foundation, has spent much of his career studying the economic impact of raising chickens in his home country. In this video he explains why he is so passionate about poultry.

A big bet on chickens

Our foundation is betting on chickens. Alongside partners throughout sub-Saharan Africa, we are working to create sustainable market systems for poultry. It’s especially important for these systems to make sure farmers can buy birds that have been properly vaccinated and are well suited to the local growing conditions. Our goal: to eventually help 30 percent of the rural families in sub-Saharan Africa raise improved breeds of vaccinated chickens, up from just 5 percent now.

When I was growing up, chickens weren’t something you studied, they were something you made silly jokes about. It has been eye-opening for me to learn what a difference they can make in the fight against poverty. It sounds funny, but I mean it when I say that I am excited about chickens.

In the tiny African kingdom of Swaziland*, one of the most effective tools in the fight against malaria is a telephone number: 977.

When someone tests positive for the mosquito-borne disease at a Swazi clinic, a nurse immediately dials those three digits to report the case to the country’s national emergency response center. The call triggers a text message to the national malaria program team, which dispatches investigators—armed with computer tablets that have built-in satellite maps and GPS software—to interview the patient and test all people living within a one-kilometer radius of their home. A separate team is called in to reapply insecticide to the walls of homes in the community to help protect other families from infection.

Such vigilance is one of the reasons why Swaziland may become the first malaria-free country in sub-Saharan Africa, where most malaria deaths occur.

Swaziland’s well-coordinated malaria program—including a robust surveillance and control system—has helped reduce the number of cases in the country by more than 90 percent since 2002. Now, Swaziland aims to eliminate malaria entirely within its borders by 2020.

Swaziland’s bold goal is evidence of the incredible progress the world has made against malaria. Between 2000 and 2015, the combination of increased donor investment, strengthened political commitment, and new tools (including artemisinin combination therapies, rapid diagnostic tests, indoor residual spraying, and insecticide-treated bed nets), led to a 60 percent decline in malaria deaths.

At the same time, the difficulties Swaziland has experienced trying to become malaria free are a sobering reminder of the challenges the world faces to reach its goal of eradicating the disease.  While the number of malaria cases in Swaziland has fallen to just a few hundred cases each year, tackling those final cases is more difficult than anyone imagined. Swaziland thought it would eliminate the disease by the end of 2015, and again by the end of 2017, but each time fell short of its goal. Last year, Swaziland saw its number of malaria cases rise sharply. 

Globally, progress in the malaria fight has stalled. Further progress is in peril given the plateauing funding levels which make it impossible to fill remaining gaps in prevention and treatment of malaria and address the challenges of drug and insecticide resistance. After years of dramatic declines in malaria cases and deaths, the world is starting to lose ground. In 2017, the World Malaria Report showed that for the first time in years the number of malaria cases went up.

These setbacks should not lead to despair. They should serve as a wake-up call. As I told health officials at the Malaria Summit in London last week, the world needs a new strategy to meet the challenges ahead. That means developing innovations that will keep driving down malaria cases and malaria deaths, while tailoring interventions to address the specific needs of a country or region.

Swaziland is a good example of how countries can adapt their malaria control strategies to meet their unique circumstances. One of Swaziland’s biggest challenges is the cross-border movement of people infected with the disease from outside the country. Mozambique, Swaziland’s next-door neighbor, has one of the highest malaria burdens in the world. Workers from Mozambique may come into Swaziland with malaria. And when Swazis go to Mozambique, they sometimes return with the disease, which can then be passed on to their neighbors. Unpredictable weather also poses a challenge. The sudden spike of new cases last year was driven by heavier rainfall in the region, resulting in more mosquito breeding.

Swaziland and Mozambique are part of the Elimination 8 regional malaria elimination effort, which aims to wipe out malaria from eight countries in southern Africa. Last year, as part of that effort, Swaziland and Mozambique set up malaria posts along their border. As people go back and forth between the two countries, they are offered malaria tests and treatment to help prevent the importation of new cases. Since the posts were set up last year, thousands of people have been tested and treated and the national malaria program is optimistic that the number of cases will fall this year as a result.

At the same time, Swaziland remains committed to the painstaking work of investigating every new malaria case and responding swiftly to reduce the chance the disease will spread. The country also organized intensive media campaigns to warn residents and travelers of the danger of malaria and teach them how to protect themselves. Malaria diagnosis and treatment are free to everyone in private and public clinics.

I look forward to hearing more about Swaziland’s progress in the months ahead. If successful eliminating malaria within its borders, Swaziland can achieve a major milestone toward a goal once thought impossible—making Africa malaria free. I hope to see many more countries follow its lead.

* Just before I posted this, King Mswati III of Swaziland announced that the name of the country was changing to the Kingdom of eSwatini. In order to avoid confusion, I’ve used Swaziland in this post.

Mosquitoes keep me up at night.

If you ask someone about what things scare people the most, there’s a list of usual suspects: shark attacks, heights, enclosed spaces, etc. Mosquitoes usually don’t make the cut—but they frighten me more than almost anything else.

This fear might be a bit irrational in Seattle, where I live. Our climate is too mild for the types of mosquitoes that harbor serious diseases. In other parts of the world, however, families have good reason to be afraid. Mosquitoes and the diseases they carry kill more than half a million people every year. Consider this mind-blowing statistic:

Of all the illnesses mosquitoes spread, malaria is the worst by far. More than 200 million people suffer from it every year, and a child dies from malaria every other minute of every day. If you survive, it can leave you vulnerable to other debilitating diseases and chronic anemia. It’s an awful, painful disease (I wrote about what it feels like to have malaria a couple years ago).

Melinda and I encounter a lot of suffering through our work, but one of the worst things I’ve ever seen is a child having seizures from cerebral malaria in Tanzania. I will never forget watching his small body twist in agony, as his parents waited to find out if he would survive. I wouldn’t wish that experience on anyone.

So why exactly are people more afraid of sharks than mosquitoes? The late Hans Rosling would argue that humans are hardwired to fear things that cause us physical harm. This instinct is practical if you live in poverty (on level 1 or 2), where an animal attack is more likely to kill you. But if you can afford life-saving healthcare, it can distort your perception of how significant a threat really is.

Even if you know that you’re 50,000 times more likely to get killed by a mosquito than a shark, human instinct wins out. A photo of a shark attack victim on the evening news evokes a visceral reaction, because the threat is obvious. A picture of a malaria victim in a hospital ward doesn’t trigger our fear instinct in the same way.

Despite this, I’m determined to spread the word about mosquitoes—which is why I’m bringing back Mosquito Week here on Gates Notes.

Everything I’m posting this week is dedicated to my least favorite pest. You can read some good news about a country that hopes to eliminate malaria by 2020. You can see how the bed nets the Mozambique Ministry of Health and World Vision distributed last year on behalf of the Gates Notes Insider community are making a difference. I’m going to be talking about mosquitoes on my social channels all week, and I hope you’ll join the conversation.

As long as Hollywood keeps making blockbusters about sharks, I’ll keep talking about why everyone should be more scared of a tiny bug than a 3,000-pound carnivore. Jaws is nothing compared with the flying terror that is a mosquito.

The world is making incredible progress against malaria. New innovations—including more effective drugs for treatment, rapid diagnostic tests, and better insecticides—have helped prevent more than 600 million cases of malaria and saved 6.8 million lives between 2000 and 2015. One new tool that helps protect families in Africa is a long-lasting type of bed net. Learn more about the impact these bed nets are having in the southern African country of Mozambique.

Fourteen-month-old Judite Luis battles malaria (and complications from malnutrition) at Chicuque Rural Hospital in Inhambane, Mozambique with her mother, Adozinda Augusta, at her side. Malaria is the leading cause of death among children under 5 in Mozambique. Judite died the day after this photo was taken.

A boy points out the holes in an old mosquito net used in his home. While the older generation of bed nets helped protect families from malaria in Mozambique, they had some downsides. They needed to be soaked in insecticide every six months and didn’t stand up to repeated washings when they got dirty, leading to tears that mosquitoes could fly through.

In November, thousands of families in Inhambane, Mozambique lined up to receive long-lasting insecticidal mosquito nets from the Mozambique Ministry of Health’s National Malaria Control Program and World Vision partnership. The nets protect people from mosquitoes for three years and can even be washed when they get dirty. (The bed net donation was made possible, in part, by the participation of Gates Notes readers in a bed net giveaway campaign last year. Thanks for your help!)

Clayton Pedro Albert, age 6, and his 11-month-old sister, Sharmila, go to bed under one of the long-lasting insecticidal nets. “There is no malaria in this house this year. Last year, it was so many times,” said Carolina Alberto, their mother. Across Mozambique, World Vision, in partnership with the Ministry of Health, has distributed more than 21 million bed nets. Ensuring families use their new bed nets is critical for controlling malaria. World Vision follows up with households to show families how to hang and care for their nets and remind them of the importance of sleeping under them every night.

Silvina Jorge Mahoche and her daughter, Celineza Mahoche, share their new insecticidal net. The Mahoche family has had malaria more times than they can remember. What they don’t forget are the painful symptoms: “A fever, chills, joint pain, headaches, and vomiting,” Silvina said. Since receiving the net last year, no one in the family has been sick from malaria.

Villagers return home after receiving new mosquito nets. Ensuring communities have universal coverage of nets and follow up to ensure appropriate use is critical to achieving malaria control and elimination. Some mosquitoes are now developing resistance to the pyrethroid insecticides used in bed nets—so researchers are working on next generation nets that use combinations of insecticides and appear effective against all mosquitoes, including insecticide-resistant ones. Much more work needs to be done to eliminate malaria in Africa, but continued innovation in bed nets and other tools will ensure that the world will continue to make progress against this deadly disease.

We’ve come a long way since the days of blaming the stars.

Malaria has terrorized humankind for thousands of years, but for most of that time, we had no idea what caused it. The ancient Greeks thought Sirius the dog star might be responsible. A Chinese medical text from 270 BCE speculated that three demons spread the disease. As recently as the mid-1800s, doctors believed malaria was caused by the stinky fumes that wafted into cities from nearby swamps (the word malaria means “bad air” in Italian).

Today, we know exactly who our enemy is: the mosquito. Doctors no longer subject malaria sufferers to unpleasant (and pointless) treatments like blood-letting and chewing tree bark. Most importantly, we’ve made massive progress in fighting a disease that as recently as 2000 killed nearly 870,000 people in a single year.

This progress is one of the most remarkable global health stories in recent years. Malaria claimed more than 429,000 lives last year, mostly in Africa and Southeast Asia. While that figure is still way too high, it represents a 50 percent reduction overall from the disease’s peak in the early 2000s. I don’t throw the word “miracle” around lightly, but that number is nothing short of miraculous.

How did we get here? I give credit to an unprecedented scale-up in global commitment and cooperation—malaria funding rose by 1,000 percent from 2000 to 2015. This money fueled a number of amazing scientific breakthroughs, enabled us to deliver them at scale, and focused more brainpower on improving both control and treatment efforts.

This October marks a decade since Melinda and I first called for eradicating malaria. It was a controversial move at the time, but the progress made since then has convinced many that this is a realistic goal (although some are still skeptical).

If I had known back in 2007 how much progress we would make in ten years, I would’ve been thrilled by how much we’ve cut the death rate. I’d also be impressed by how many insecticidal bed nets are now in use, how new treatments are helping people with the most severe cases of malaria, and how rapid diagnostic tests have made it easier to find and treat people. But it wouldn’t all be good news.

In 2007, I thought we’d have a long-lasting malaria vaccine by now. The WHO plans to begin pilot demonstration projects of a first-generation malaria vaccine in sub-Saharan Africa next year, although without a booster dose it only protects a child for less than six months. I’m hopeful that researchers will develop a next generation vaccine that offers much longer protection within the next 10 years, but a decade ago I was overly optimistic about where we’d be today.

There are still plenty of reasons to believe we can eradicate malaria, though. In the war against malaria and the mosquitoes who carry it, we’re already fighting on every front. Consider the wide array of innovations in development right now:

• New Insecticide-Treated Bed Nets: The older generation of bed nets needed to be soaked in a special insecticide solution every six months. The long-lasting nets we will distribute in Mozambique through our giveaway protect people from mosquitoes for three years and can even be washed when they get dirty. Unfortunately, some mosquitoes are now developing resistance to the pyrethroid insecticides used in these nets—so researchers are working on next generation bed nets that use combinations of insecticides and appear effective against all mosquitoes, including insecticide-resistant ones.
• Tackling Drug Resistance: In Southeast Asia, we’ve seen some types of the malaria parasite develop resistance to the drug combinations we use to cure and prevent the disease. If this drug resistance spread to Africa, it’d be a disaster. Fortunately, we have partners on the front lines finding ways to fight back. Watch this video about the amazing work one team of researchers is doing to combat drug resistance in Thailand:

• Disease Mapping: We know more today about where malaria is occurring than we have at any other point in history. Public health experts are combining anonymous data from mobile phone records with data on malaria incidence to track the movements of infected mosquitoes. That's super valuable, because it helps countries use their limited resources in places that have the highest disease burden.
• Eave Tubes: Many houses in hot climates have a gap between the roof and the walls to keep the inside cool. By sealing these gaps and inserting special tubes just below the roofline, air still flows into the house but keeps mosquitoes out with a mesh filter. Since the tubes are too high for children to reach them, the mesh can be coated with a high enough dose of insecticide to kill even insecticide-resistant mosquitoes.
• Genome Editing: Our foundation has invested a lot of money into editing the genetic code of mosquitoes. We’re still in the very early stages of development, but scientists are exploring whether this technique could one day render a small number of key mosquito species infertile or unable to carry the malaria parasite.
• Attractive Targeted Sugar Baits: Only female mosquitoes bite people, and they only do it when they’re breeding. The rest of the time, they rely on sugar for energy. These calendar-sized traps hang on the outside of homes and contain a minimum risk toxin that kills more than 95 percent of the mosquitoes that flock to their sweet scent without affecting pollinators. Trials are underway in Mali.

I think we will see an end to malaria in my lifetime. It’s a preventable and curable disease, and the public health community has already demonstrated that it’s possible to shrink the map and save lives. These new tools in the development pipeline will play a huge role in reaching our goal.  While we’re still decades away from wiping malaria off the map for good, one thing is clear: the mosquito has met its match.

You may have seen in the news that elected officials in Washington, D.C., are working on next year’s federal budget. One of the ideas that has been floated is to make deep cuts in foreign aid—the investments that America makes to help other countries fight poverty and disease.

That would be a big mistake.

For one thing, these programs amount to less than 1 percent of the federal budget. For anyone worried about the budget deficit, cutting 1 percent will not make a dent.

More importantly, these programs give American taxpayers a phenomenal return on investment, one of the best anywhere in government. They do this in three ways:

• Making Americans safer and the world more stable
• Creating jobs at home and promote trading partners that will buy American goods
• Saving lives and building up health systems so other countries can take better care of their people

Together these three points make what you might call the strategic case for aid—the argument that aid helps the countries that give it as well as those that receive it.

To be honest, the strategic case is not what prompted Melinda and me to get involved in this work more than 17 years ago. We were moved by what you could call the moral case: the idea that it is terribly unjust that people in poor countries—especially children—die of diseases that can be prevented. That is still the main thing that drives us today. But over the years we have come to see the compelling strategic case too. And we have found that people often support aid who aren’t convinced by the moral argument but are by the strategic one.

In this post I want to focus on point #1 above. I’ll come back to #2 and #3 in subsequent posts.

Let’s look at how promoting health and development keeps Americans safe.

Preparing for the next epidemicYou may remember the Ebola epidemic of 2014–16. It killed more than 11,000 people in three West African countries. Each of those deaths was a tragedy, but the epidemic could have been far worse. If it had spread to neighboring Nigeria, home to more than 180 million people and a busy international travel hub with daily flights to the world’s capitals, it would have been very hard to contain. It could have easily jumped the Atlantic and infected Americans, and spread throughout Europe or Asia.

Why didn’t that happen? One key reason is that a number of health workers were stationed in Nigeria as part of the global campaign to stamp out polio. As the Ebola epidemic took hold, they were quickly reassigned from polio to Ebola. They already had a system in place for identifying possible cases, tracking them, and reporting the data to people organizing the response. They helped contain the disease and keep it from spreading farther than it did.

The polio eradication program helped stop Ebola and saved countless people, including Americans. Its biggest public funder? The United States government.

In addition, Ebola may have been only a preview of what is to come. The next epidemic—say, a virulent flu as bad as the Spanish Flu of 1918—could be far worse. Epidemiologists estimate it could kill 30 million people, more than three times the population of New York City.

Funding from the U.S. government helps keep that from happening. It helps other countries strengthen their health systems so they can identify dangerous diseases and contain them before they get out of control.

It is no accident that the Ebola epidemic hit hardest in three countries—Guinea, Sierra Leone, and Liberia—with especially weak health systems. Helping them improve makes it more likely that we can prevent a worldwide epidemic that destabilizes entire regions of the world and kills tens of millions of people.

Stabilizing vulnerable countriesPreventing pandemics is one specific way that U.S. funding makes Americans safer. There is also a broader point here: by fighting poverty and disease, we make the world a more stable place.

For example, both evidence and common sense tell us that when people don’t have reliable food supplies, they will pick up and move someplace else—becoming migrants or refugees—and that leads to more instability. Look at the countries with the least reliable food supplies in the world: Sudan, South Sudan, Eritrea, Burundi. Each of them is either at war or recently emerged from conflict.

Syria is another tragic example. In 2007, the country suffered the worst drought in its history. More than 1 million people fled rural areas for the cities, where they hoped to find food. This migration stoked political tensions and created the foundation for the horrific civil war that continues today. Of course that war has many causes, and not every drought-stricken country will become another Syria. But it is clear that the world is not a safer place when more people are going hungry—and that when we strengthen food and farming systems, we tackle some of the root causes of migration and instability.

Improving health is another way to make countries more secure. One of my favorite all-time examples is PEPFAR, the program America launched in 2003 to stop the spread of AIDS. Today it provides life-saving medicine for more than 11 million people living with HIV in some of the world’s poorest countries. Those 11 million people are teachers, health-care workers, and police officers—people who build strong, self-sufficient societies. So it should not be surprising that in countries where PEPFAR has a presence, political instability fell by 40 percent between 2004 and 2013. In non-PEPFAR countries, it dropped only 3 percent. And the PEPFAR countries grew three times faster.

Shoring up national securityAmerican military leaders understand that fighting poverty and disease is part of a smart national-security strategy. It was true after World War II, when the United States invented modern development assistance to combat instability in Europe and prevent a third World War, and it’s true today. The more stable poor countries are, the lower the odds that America will need to intervene in them.

More than 120 retired generals and admirals recently wrote a letter to Congress arguing that U.S. aid programs “are critical to preventing conflict and reducing the need to put our men and women in uniform in harm’s way.” While he was the head of U.S. Central Command, overseeing American operations in Syria, Pakistan, Afghanistan, and elsewhere, Secretary of Defense James Mattis said: “If you don’t fully fund the State Department”—which houses many aid programs—“then I need to buy more ammunition.”

Aid is an important part of our broad diplomatic and security relationships. Out of 135 countries that receive some health or development aid from the United States, we have bilateral defense agreements with 131 of them.

These are some of the arguments I have been making in Washington on behalf of American aid. In future posts I will explain how aid not only keeps Americans safe, but also creates jobs in the United States and helps other countries become more self-sufficient. All reasons why I believe this money is well-spent and ought to be maintained.

Of all the charts I’ve seen, this one is the most beautiful:

Why?

First, that descending red line captures one of the most amazing stories of human progress: It shows how the number of deaths of children under 5 per year has been cut in half since 1990.

Second, hidden along that line are millions of stories of the incredible work being done by health officials, governments, donors, and parents around the world to help save all those lives.

Here’s one of those stories. It begins with some remarkable women I met in Ethiopia. They are part of an innovative program that’s improved the health of millions of children in their country.

You can meet them yourself (and join us for a cup of coffee) in this video.

Back in 1990, Ethiopia had one of the highest rates of child mortality in the world. One in five children were dying before their 5^th birthdays. With few doctors and most of its population living in rural areas, Ethiopia struggled to provide basic health services to the country. Most women in rural areas gave birth at home.

Then in 2000, the Ethiopian government made a commitment to improve its healthcare system. Ethiopia signed on to the United Nations’ Millennium Development Goals, which focused the world’s attention on fighting disease and ending poverty by using data to measure progress on health and development progress. As part of the goals, Ethiopia pledged to reduce under-five death rates by at least two-thirds by 2015.

To achieve it, Ethiopia needed to find an effective way to deliver healthcare to the remotest corners of the country. But training thousands of new doctors to staff them would take years and would be extremely costly. Instead, Ethiopia created a community health worker program. They selected thousands of people, primarily young women with at least a 10^th grade education, and trained them in a set of basic health skills—including how to deliver babies, administer immunizations, and provide family planning support—that are proven to save lives. Most of the health workers were recruited from the communities they served, helping to quickly build public trust in the new effort.

In 2012, I made my first trip to Ethiopia to see the program in action for myself. I was amazed. I visited a remote health post south of Addis Ababa run by two health workers, Yetagesu Alemu and Betula Shemesie. They spent many of their days walking from door to door in their village caring for pregnant women and families with newborns. Their health post didn’t have electricity or any high tech medical equipment. Still, their efforts had made an impact on the health of the families in their community.

What was exciting to see was how this success was being repeated in villages across the country. Despite being one of the poorest countries in the world, Ethiopia managed to dramatically reduce the rate of child mortality.  By 2012, Ethiopia had met the target for the Millennium Development Goal on child survival, with under-five death rates dropping by 66 percent since 1990.

One of the key reasons the program has been so effective is that the health workers are dedicated to measuring their progress. Covering nearly every square inch of the walls of the health post I visited were large charts, where the health workers would track births, immunizations, malaria cases, and other indicators. Each indicator helped them understand how well they were performing and which areas demanded more attention.

Today, Ethiopia has more than 15,000 health posts delivering primary health care to the farthest reaches of this rural country of 100 million people. The health posts are staffed by 38,000 health workers like Betula and Yetagesu.

Last summer, I had a chance to visit Ethiopia again. I caught up with Yetagesu and Betula over coffee and to learn more about how the health worker program was going. They told me how women who once delivered their babies at home were now choosing to give birth at health centers. Their communities also had access to ambulances that would pick up any woman who is ready to give birth. Yetagesu and Betula were also proud to report that they had received additional medical training to sharpen their health skills.

To be sure, there’s a lot more work to be done to improve health services in rural Ethiopia. Their communities need more ambulances. Just one vehicle serves 17 health posts, Yetagesu said. They also hoped the country would hire more health workers so they would have the time to provide families with more comprehensive services. And as Melinda and I discussed in this year’s annual letter, one of the biggest challenge in child survival is newborn deaths. In Ethiopia, about 44 percent of all childhood deaths occur within the first 28 days of life. We need to find innovative ways to solve this challenge.

Still, I’m confident that Ethiopia will continue to make progress in child survival. And what’s most exciting is that Ethiopia’s health program has been so successful that it now serves as a model for other countries to follow. Sharing lifesaving innovations like Ethiopia’s ensures that in the years ahead the most beautiful chart in the world will become even more beautiful. 

Foreign aid is often in the hot seat, but today the heat is cranked up especially high. The United States government, one of the world’s most influential donors, is considering dramatic cuts to health and development programs around the world. I understand why some Americans watch their tax dollars going overseas and wonder why we’re not spending them at home. Here’s my answer: These projects keep Americans safe. And by promoting health, security, and economic opportunity, they stabilize vulnerable parts of the world.

This is a lesson I’ve learned myself. When I first got involved in health and development more than 15 years ago, the main motivation was to save and improve people’s lives around the world. That’s still true today, but over the years I have come to see the tangible ways in which American aid benefits Americans too.

For one thing, it helps prevent epidemics. The most recent Ebola outbreak in West Africa killed more than 11,000 people, but the death toll would have been much worse if the disease had spread widely in neighboring Nigeria, an international travel hub that’s home to 180 million people. What contained it? Among other things, a group of health workers who were stationed there for an anti-polio campaign. They were quickly reassigned to the Ebola fight, and their efforts helped stop the disease—and keep it from crossing the Atlantic to the United States.

The biggest public funder of anti-polio work has been the U.S. government, and for good reason. It is protecting Americans and helping us get ready for the next epidemic, which could be orders of magnitude deadlier than Ebola. To stop emerging diseases, we need the infrastructure built by consistent funding of well-run health programs.

Another example is America’s global HIV/AIDS effort, known as PEPFAR, which began under President George W. Bush and works with some of the world’s poorest countries. PEPFAR is an undeniable success. There are 11 million people with HIV who are alive today because of the medicines that it provides. Many more never got the virus in the first place because of prevention efforts supported by PEPFAR.

This is not simply a humanitarian accomplishment. For those countries it means more teachers, entrepreneurs, police officers, and health-care workers contributing to strong, stable societies. According to one bipartisan study, political instability and violent activity in African countries with PEPFAR programs dropped 40 percent between 2004 and 2015. Where there was no PEPFAR program, the decline was just 3 percent.

Better health puts nations on the path to self-sufficiency. How? When health improves, people decide to have fewer children, because they’re confident that the children they do have will survive into adulthood. As family size drops, it gets easier for countries to feed, educate, and provide opportunity for their people—and that is one of the best ways to stabilize any vulnerable region.

A more stable world is good for everyone. But there are other ways that aid benefits Americans in particular. It strengthens markets for U.S. goods: of our top 15 trade partners, 11 are former aid recipients. It is also visible proof of America’s global leadership. Popular support for the U.S. is high in Africa, where aid has such a dramatic impact. When you help a mother save her child’s life, she never forgets. Withdrawing now would not only cost lives, it would create a leadership vacuum that others would happily fill.

Syria is a tragic example of what can happen when the key ingredients of stability don’t come together. Beginning in 2007, the country experienced the worst drought in its history, driving more than a million people from rural areas into the cities, stoking political tension, and laying the foundation for the horrific civil war that continues today. Of course there were many causes of that war, and not every country that has a severe drought collapses as badly as Syria did. But the world will not be a safer place if the U.S. stops helping other countries meet their people’s needs.

None of this is lost on our military leaders. More than 120 retired generals and admirals recently wrote a letter to Congress arguing that U.S. programs “are critical to preventing conflict and reducing the need to put our men and women in uniform in harm’s way.” Secretary of Defense James Mattis famously said, back when he was commander of U.S. forces in Afghanistan, Pakistan, and other hotspots: “If you don’t fully fund the State Department”—which runs many of America’s key programs—“then I need to buy more ammunition.”

Protecting Americans, preventing epidemics, strengthening markets, saving lives: aid delivers phenomenal benefits, and for a bargain. It represents less than 1 percent of the federal budget, not even a penny out of every dollar. It is some of the best return on investment anywhere in government. This money is well spent, it has an enormous impact, and it ought to be maintained. 

This post originally appeared on time.com.

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 visited South Africa earlier this year to learn more about the progress the country is making in the fight against HIV. I toured health clinics, met with doctors and researchers, and listened to the stories of people living with HIV. Again and again, our conversations turned to an often forgotten disease which is HIV’s lethal partner: tuberculosis.

Tuberculosis, or TB, is an infection of the lungs that kills about 1.8 million every year, including 400,000 people with HIV and TB. Historically, TB was dubbed “consumption” because it caused such severe weight loss that the disease appeared to “consume” its patients.

Together, HIV and TB form a deadly duo. HIV weakens the immune system, which makes it susceptible to TB infection and much harder for the body to fight the disease. Last year, about one-third of people living with HIV were also infected with TB bacteria, and about 35 percent of deaths among HIV-positive people were due to TB. Worldwide, South Africa has the largest number of people infected with TB and HIV.

Since 2000, better testing and treatment programs have helped drive down TB deaths by more than 20 percent, saving tens of millions of lives. But a new World Health Organization report found that the TB epidemic is larger than previously estimated. New surveillance and survey data revealed hundreds of thousands of new cases, the bulk of them in India. In 2015, there were an estimated 10.4 million new TB cases worldwide, up from 9.6 million cases in 2014. The WHO report also found that of the 10.4 million people with TB, 4.3 million of them did not receive quality care because of significant gaps in testing, treatment, and reporting of TB by health providers. TB deaths climbed to 1.8 million, up from 1.6 million in 2014.

One of the key concerns among health officials fighting TB is the rising threat of drug resistance, something I learned about during a previous visit to South Africa. New strains of the disease have emerged that do not respond to the most commonly used drug treatments available. Treating people with drug-resistant TB is complicated and costly. It also places incredible hardships on the patients who must undergo months of treatment using drugs which are toxic and have serious side-effects.

Last year, Simbongile, a young mother living outside of Cape Town, learned she was infected with drug-resistant TB and started the difficult road to recovery. Her story is heartbreaking, but she is among the lucky ones. In 2015, nearly 600,00 people fell ill from drug resistant TB treatment worldwide. Just 1 in 5 received treatment.

While the impact of drug-resistant TB is a serious problem, the vast majority of TB cases are drug sensitive, meaning they can be cured effectively with medicines so long as they are taken properly. Drug resistance emerges because of incorrect prescriptions by health providers, low-quality drugs, and patients stopping treatment prematurely. That’s why the best way to prevent drug resistance is to improve TB testing and treatment programs for drug-sensitive cases.

TB, like so many other diseases, primarily impacts the world’s poorest people. If you live in a wealthy country, it might be easy to think, as many people do, that TB is a disease of the past. That fact is reflected in the lack of funding for TB programs around the world. In 2016, global support for TB care and prevention fell $2 billion short of the $8.3 billion needed.

Stories like Simbongile’s, however, are a powerful reminder that TB is still an active threat and the world is in dire need for new innovations to prevent and treat it. By investing more in research and development, I know it will be possible to create a new generation of TB drugs and develop a new and effective TB vaccine.

TB is not a disease of the past, but if the world works together to fight it, I have no doubt it can be.

A few years ago, I pulled off a purposeful prank. While I was giving a TED Talk on malaria to a room full of influential people, I opened a canister and let loose a small swarm of mosquitoes. “There’s no reason that only poor people should have the experience,” I said. I let the audience squirm in their seats for about half a minute before I let on that the mosquitoes were not infected with malaria. My gimmick worked. A distant problem suddenly got very close to home.

Today, gimmicks are no longer necessary for convincing Americans of the danger of mosquito-borne diseases. The spread of Zika virus in south Florida, Puerto Rico, and other parts of the U.S. has given millions of Americans a direct understanding what it’s like to live with the fear of mosquitoes and the harm they can do, especially to pregnant women and children.

The world must focus serious attention and resources on ending the Zika epidemic. At the same time, we should keep in mind that the overwhelming toll of mosquito-related illness and death comes from malaria. Malaria is the key reason mosquitoes are the deadliest animal in the world.

Over the years, I have been in hospitals in several African countries when malaria is at its peak. I’ve seen beds out in the corridors and two children to a bed. There’s nothing more painful to see than a child experiencing cerebral malaria, when the parasite is attacking the brain and causing horrible seizures. As a parent, these memories will stay with me for life.

That’s why it gives me great joy to share a new report published todayin The New England Journal of Medicine. Rigorous new data show that the malaria death rate in sub-Saharan Africa has declined by a stunning 57% since 2000. With almost 500,000 children still dying of malaria every year, we obviously have a long way to go. But cutting the death rate by more than half is a miracle. It’s one of the greatest success stories in the history of global health.

We’ve known for some time that malaria deaths have been declining steeply. The significance of this new study, which was produced by the Institute for Health Metrics and Evaluation, is that we now have the strongest evidence ever of just how steep the decline has been.

This progress on malaria is no accident. It’s the result of an unprecedented increase in focus and commitment by rich and poor countries alike. The amount of money available to pay for bed nets, effective medications, and malaria research rose by 1,000 percent from 2000 to 2015, fueling massive new prevention and control efforts in countries hit hard by malaria.

In Tanzania, a country that has led the way with a major scale-up, the mortality rate fell more than 80 percent from 2000 to 2015. I remember visiting Tanzania years ago during the rainy season and seeing overflowing hospitals. When I went back years later, there were almost no children in the wards.

Tanzanian health authorities have launched major campaigns to distribute insecticide-treated bed nets and encourage people—especially children—to sleep under them every night. They’ve done widespread spraying of insecticides inside homes and in urban ponds, puddles, and marshes where mosquitoes breed. And they’ve used great medications that contain a drug called artemisinin, which earned its discoverer, Youyou Tu, the 2015 Nobel Prize in Medicine. If you take three days’ worth of these pills, you can get rid of the malaria parasites in your bloodstream, which helps you and also stops you from being the source of malaria spreading back to other people.

And now we have an awesome new tool in our arsenal: precision malaria maps. In the same New England Journal article I mentioned above, the authors report on cutting-edge mapping efforts that have given us an ability to see at a very high degree of granularity (5 km by 5 km) the burden of malaria in sub-Saharan Africa. That’s super valuable for short-term interventions, like helping a country determine where to deploy health staff. It’s just as valuable for long-term efforts to reduce the rate of transmission and shrink the malaria map.

When you zoom in with these high-definition maps, you can quickly home in on the hot spots where malaria is hitting hard and yet existing tools like bed nets are not being used widely enough. These maps show that in most countries it’s actually a very small percentage of the country where the disease burden is high and you need to focus your interventions.

And here’s more good news: After years of investment, we now have better diagnostics for detecting infections in people who show no physical symptoms (because people who are infected with malaria parasites but don’t show signs of illness are a big part of the chain of transmission). We have helped private-sector companies develop new, safe insecticides that will allow us to preserve the gains we have made against malaria. We have also helped bring to market simple technologies to protect families from mosquitoes, such as “eave tubes” that kill mosquitoes trying to enter homes and new traps which exploit mosquitoes’ attraction to sugar to kill them outdoors.

As a result of all this progress, I am confident that we can pursue the end goal of not just shrinking the malaria map but wiping malaria off the map altogether. Last year, Ray Chambers, the UN Secretary General’s special envoy for malaria, and I put forward a concrete plan for eradicating the disease by 2040. The potential upside is enormous: 11 million lives and $2 trillion dollars of economic impact. And the alternative to eradication—controlling the disease forever without eliminating it—is biologically and politically untenable. It would require endless investment in the development of new drugs and insecticides just to stay one step ahead of disease resistance. I also believe it would be impossible to maintain strong political commitment to fighting malaria unless we can define a clear end point. History has shown that unless countries rid themselves of malaria altogether, they eventually see the disease come roaring back on a massive scale.

To achieve eradication by 2040, we’ll need several other key innovations under development to come to fruition.

First, we’ll need new classes of drugs that completely clear malaria parasites from the body with just one dose. We should have these new cures in about a decade.

Second, we need new tools that can prevent malaria transmission. This can either be done with an effective malaria vaccine or by reducing mosquito populations. We will soon have a first-generation vaccine, but it protects a child for less than six months without a booster dose. I’m betting that within the next 10 years, researchers can produce a vaccine that provides much longer protection.

We have another potential game-changer in the works. Our foundation is supporting scientists who are using a powerful new tool called “genome editing” to introduce genetic changes in the Anopheles gambiae species of mosquito, one of the most effective transmitters of malaria in Africa. These genetic edits cause females to produce mostly male, sterile offspring. In theory, scientists could drive this trait throughout entire populations of mosquitoes in much of Africa, dramatically reducing malaria transmission in a very short time. While I’m excited about the potential of this technology, I know that changing the mosquito genome in a permanent way is something that should be done only with incredible caution and care. My hope is that it will be possible to deploy some version of this technique in a safe manner within 10-12 years.

In 1999, Melinda and I made our first major investment in malaria—a grant to establish the Malaria Vaccine Initiative. Funding for malaria research was so diminished at the time that we nearly doubled the resources with that one single grant. That blew my mind.

Today, this is no longer a lonely fight. More than 50 countries have joined together to mobilize billions of dollars through The Global Fund. And these resources are coming not just from wealthy countries. African countries such as Benin, Côte d’Ivoire, Kenya, Namibia, Nigeria, Senegal, South Africa, Togo, and Zimbabwe are contributing as well. In fact, African countries are now, for the first time ever, mobilizing more of their own resources for malaria than they’re receiving from donors.

So the next time you hear skeptics charging that foreign aid doesn’t work, point to malaria. Foreign assistance has not chased away local resources. On the contrary, it’s encouraged African nations to step up their own health efforts. And the results have been nothing short of remarkable.

Next week I’ll be traveling to Durban, South Africa, to attend the International AIDS Conference. It’s an important opportunity for members of the AIDS community to discuss our ongoing efforts to fight the disease. I’ll be there to listen and learn. But I’ll also be delivering my own message.

The good news is that the fight against AIDS has seen many successes. The infection rate declined for several years and millions of people have been put on treatment, allowing them to live full, productive lives.

But we have not turned the corner. The infection rate has essentially stopped declining. That’s a particular problem in sub-Saharan Africa, which has a growing population of young people, who are most susceptible to the disease. If the infection rate stays the same while the at-risk population rises, then the number of people in sub-Saharan Africa who contract HIV each year could start going up instead of down.

One reason the infection rate has stagnated is that AIDS funding has stagnated. Another reason is that the current prevention tools have not had as much impact as any of us had hoped. Voluntary medical male circumcision is a very effective prevention approach, but the programs offering the procedure have not been scaled up sufficiently to reach all those who would benefit. The newest tool, using AIDS treatment as a way to prevent HIV infection among healthy people, has not been rolled out fast enough, and asking people to take a pill every day for prevention presents its own challenges.

There is the idea of “treatment as prevention”: Treating people who have HIV not only saves their life, it also makes them much less likely to pass the virus along to others. This is a promising approach and certainly we should treat as many people as possible so we can save their lives. But it is not yet clear to me that it is financially feasible to treat enough people to get a large prevention effect. I hope to learn more about this question at the conference next week.

For all these reasons, we need to invest more in both delivering the best prevention tools we have and developing new ones that are even more effective. For example, researchers are working on prevention and treatment tools that last for several months after a single dose, which would make it easier for people to stick to the regimes. I am also optimistic that within a decade we will have an AIDS vaccine that provides an acceptable level of protection.

In this video, I explain what it will take to make the most of these opportunities and ensure that AIDS cases keep going down:

Let me cut to the chase. There’s a program that has helped save the lives of 17 million people in poor countries since 2002. It’s called the Global Fund to Fight AIDS, TB, and Malaria. It’s poised to do even more good in the years ahead, but to continue its work, it needs donors to make new funding pledges.

I just got back from Europe, which is starting to think through many tough decisions surrounding Brexit. Despite that challenge, the governments of France and Italy became the latest to make commitments to the Global Fund, building on recent pledges from Japan, Canada, the United States, and the European Commission. When I was in London, a senior member of the British government confirmed to Parliament that they remain committed to the Global Fund’s success. Although I’m confident the Global Fund will raise the money it needs—donors have consistently recognized that it’s an effective and low-cost way to save lives—we are not there yet.

Since the Global Fund started, Melinda and I have committed $1.6 billion to it. Here are four reasons why we are such big believers:

• Saving lives. In countries where the Global Fund operates, deaths from HIV, TB, and malaria have dropped by a third since 2002. Certainly the Fund doesn’t deserve sole credit for that phenomenal progress, but it has played an irreplaceable role. And its work is far from finished: Three million people still die every year from these diseases.
• Getting rid of diseases so we never have to fight them again. In my lifetime I expect to see the end of malaria, which kills nearly half a million children every year. When you eradicate a disease, you not only save lives, you free up billions of dollars and many hours of effort. One reason I’m so optimistic about ending malaria is the work of the Global Fund, which has slowed the spread of the disease and saved lives by distributing hundreds of millions of bed nets.
• Helping poor countries become more self-sufficient. If you ever hear people say “poor countries just keep getting foreign aid forever,” tell them about the Global Fund. It helps the countries it works with improve their health systems so they can take better care of their people. They also devote an increasing share of their own budgets to health (they have promised to spend 50 percent more between 2015 and 2017 than they did in the previous three years). That translates into less spending by rich governments.
• Using aid efficiently. The Fund has a done a great job keeping costs low and streamlining its work. Its operating costs are just over 2 percent of all the grants it gives out. That means the vast majority of the money that flows through the Global Fund is reaching the people who need it most.

The Global Fund raises money in three-year batches; the current batch will cover the years 2017-19. They’re asking for $13 billion, which will go toward delivering lifesaving drugs and bed nets as well as developing new tools like better diagnostics and next-generation prevention techniques. To put that number in context, it’s about 3 percent of the total foreign aid that rich countries give over three years. And consider the payoff: By one estimate, the $13 billion raised by the Global Fund will generate about $300 billion in economic benefits.

It is never easy to raise large sums of money like this, and it certainly isn’t easy now, with the refugee crisis in Europe compounding an already difficult global economy. Although I don’t think anyone would argue that fighting disease will directly end wars or stop the flow of refugees, improving health certainly makes countries more stable and more prosperous—and less likely to spread disease and instability to their neighbors.

If you want to save and improve lives, health is one of the most effective investments you can make. And if you want to improve health, the Global Fund is one of the most effective investments you can make. It is one of the kindest things people have ever done for one another, and I am inspired by the countries and leaders who are stepping up to support it.

This presidential election has the country captivated. As many commentators have pointed out, the primaries are more focused on personalities than policy. While the parties focus on who is going to represent them in the fall, I want to make the case for something that I hope every candidate will agree on in November: America’s unparalleled capacity for innovation. When the United States invests in innovation, it creates companies and jobs at home, makes Americans healthier and safer, and saves lives and fights poverty in the world’s poorest countries. It offers the next president a tremendous opportunity to help people in America and around the world.

Of course, America’s capacity for innovation is nothing new. We have been inventing for more than two centuries: think of Benjamin Franklin, Margaret Knight, Thomas Edison. By the end of World War II, the United States led the world in automobiles, aerospace, electronics, medicine, and other areas. Nor is the formula for success complicated: Government funding for our world-class research institutions produces the new technologies that American entrepreneurs take to market. 

What is new is that more countries than ever are competing for global leadership, and they know the value of innovation. Since 2000, South Korea’s R&D spending (measured as a percentage of GDP) has gone up 90 percent. China’s has doubled. The United States’ has essentially flatlined. It’s great that the rest of the world is committing more, but if the U.S. is going to maintain its leading role, it needs to up its game.

I have seen first-hand the impact that this type of research can have. I was lucky enough to be a student when computers came along in the 1960s. At first they were very expensive, so it was hard to get access to them. But the microchip revolution, made possible by U.S. government research, completely changed that. Among other things it enabled Microsoft, the company I co-founded, to write software that made computers an invaluable tool for productivity. Later, the Internet—another product of federal research—changed the game again. It is no accident that today most of the top tech companies are still based in the United States, and their advances will have a massive impact in every area of human activity.

My favorite example is health. America’s investment in this area creates high-paying jobs at universities, biotech companies, and government labs. It leads to new treatments for disease, such as cancer therapies. It helps contain deadly epidemics like Ebola and Zika. And it saves lives in poor countries. Since 1990, the fraction of children who die before age 5 has fallen by more than half. I think that’s the greatest statistic of all time, and the United States deserves a lot of credit for making it happen.

The next few years could bring even more progress. With a little luck we could eradicate polio, a goal that is within reach because of vaccines developed by U.S. scientists. (Polio would be the second disease ever eradicated, after smallpox in 1979—in which the U.S. also played an irreplaceable role.) There is also exciting progress on malaria: The number of deaths dropped more than 40 percent from 2000 to 2012, thanks in part to America’s support for breakthrough tools like drugs and bed nets. But to make the most of these opportunities, we need to invest more in basic health research and specific areas like vaccines.

Energy is another great example. American-funded research defines the state of the art in energy production. Early advances in wind and solar technology were developed with federal money. And this research offers a strong return on investment. Between 1978 and 2000, the Department of Energy spent $17.5 billion (in today’s dollars) on research on efficiency and fossil fuels, yielding $41 billion in economic benefits. Yet until this year, the DOE’s research budget hadn’t seen a real increase since the Reagan administration.

If we step up these investments, we can create new jobs in the energy sector and develop the technologies that will power the world—while also fighting climate change, promoting energy independence, and providing affordable energy for the 1.3 billion poor people who don’t have it today. Some of the more promising areas include making fuel from solar energy, much the way plants do; making nuclear energy safer and more affordable; capturing and storing carbon; and creating new ways to store energy that let us make the most of renewables.

There’s a lot of momentum right now on clean energy research. Last year the leaders of 20 countries, including the United States, committed to double federal investments in this area. Complementing that crucial effort, I helped launch the Breakthrough Energy Coalition, a group of private investors who will back promising clean-energy companies. The next president will have a chance to accelerate this momentum.

Investing in R&D isn’t about the government picking winners and losers. The markets will do that. It’s about doing what we know works: making limited and targeted investments to lay a foundation for America’s entrepreneurs. This approach has been fundamental to U.S. leadership for decades, and it will become only more important in the years ahead.

By the end of this summer, the political parties will have chosen their leaders and will start looking ahead to the November election. The nominees will lay out their vision for America and their agenda for achieving it. These visions will probably have more differences than similarities. But I hope we can all agree that, no matter how you see America’s future, there will always be an essential role for innovation. 

This article was originally published by Reuters News Agency.

I am in Vancouver this week attending the TED conference. I just gave a brief talk on a subject that I’ve been learning a lot about lately—epidemics.

The Ebola outbreak in West Africa is a tragedy—as I write this, more than 10,000 people have died. I’ve been getting regular updates on the case counts through the same system we use to track new cases of polio. Also, last month I was lucky enough to have an in-depth discussion with Tom Frieden and his team at the Centers for Disease Control and Prevention in Atlanta.

What I’ve learned is very sobering. As awful as this epidemic has been, the next one could be much worse. The world is simply not prepared to deal with a disease—an especially virulent flu, for example—that infects large numbers of people very quickly. Of all the things that could kill 10 million people or more, by far the most likely is an epidemic.

But I believe we can prevent such a catastrophe by building a global warning and response system for epidemics. It would apply the kind of planning that goes into national defense—systems for recruiting, training, and equipping health workers; investments in new tools; etc.—to the effort to prevent and contain outbreaks.

This is what my TED talk was about. You can watch it here:

The more I learn about what it takes to respond to an epidemic, the more impressed I am by the health workers who have been risking their lives to care for the sick. Just putting on a protective suit is huge undertaking. Once it’s on, it’s hard to hear what anyone else is saying, and you start to sweat after just a few minutes.

Here’s a short photo essay about one attempt to solve this problem that I was involved with. 

At TED we also put together an exhibit where attendees could try on a suit for themselves:

Finally, if you’re interested in learning more, you might want to check out this op-ed I wrote for the New York Times. And if you are willing to read a little more (okay, a lot more), here is a longer paper I wrote for the New England Journal of Medicine.

Melinda and I remain committed to improving the health of the poorest 2 billion. The good news is, many of the steps required to save lives in poor countries—such as strengthening health systems—also improve the world’s ability to deal with epidemics. So I’m optimistic that we can solve this problem. Making the right investments now could save millions of lives.

Normally when I post here on TGN, give a speech, or write an op-ed, I’m out to share good news about how the world is getting better. But last month I made an exception. In a TED talk, an op-ed in the New York Times, and a longer paper in the New England Journal of Medicine, I wanted to highlight a sobering fact: The world is not prepared to handle a major epidemic. I shared a few thoughts about what it might take to get ready, based on lessons from the Ebola epidemic in West Africa.

I was curious to hear people’s feedback on my suggestions, so it was great to meet in Berlin with a group of health experts from governments, non-profits, and pharmaceutical companies, and then with U.S. senators in Washington, D.C. In this post, I want to share a few of the things I heard.

There is general agreement that this is a big challenge. Everyone I talked to, politicians and technical experts alike, felt strongly that the world isn’t doing enough to prepare. There is also broad agreement about what to do: we need to create a global alert and response system for epidemics.

As we got into the details, though, we ran into some tough issues.

For example, I argued that in a severe epidemic, the military has to play a role. It’s the only group that can quickly move large numbers of people and equipment in and out of an affected area. But in my conversations in D.C., it became clear that the U.S. military is not chartered for this work and doesn’t prepare for it, which meant that in West Africa they were learning on the fly.

In addition, what happens when there’s an outbreak in a region where people see the army—whether it’s domestic or foreign—as the bad guy? Some NGO leaders and health workers worry that being associated with armed forces could put them in harm’s way by making them a target.

This is one of the toughest issues that came up and it deserves more discussion. At a minimum I think we need a diverse set of military groups from different countries ready to help. And we can take steps to make it clear that troops are on a humanitarian mission, for example by running simulations in different countries so citizens can see what they’re up to.

Another big topic was drug trials. In an epidemic you want to develop and test new treatments very quickly. But how do you make that happen when the usual drug-approval process takes years? Should there be an emergency regulator who decides which drugs to test, how to test them quickly, and whether to deploy one? Should (and can) they indemnify whoever is producing the drug to protect them from lawsuits?

All these conversations raised a larger issue that is fascinating to me: How should the world get ready for rare, potentially cataclysmic events? When an epidemic strikes, we will want the best health and logistics experts ready to spring into action. But which group has the budget to maintain that kind of spare capacity? Even more importantly, how do we get brilliant people to sit around waiting for an event that has a small chance of occurring in any given year?

The closest analogy I can think of is the military, where troops might go years at a time without seeing combat. They use training exercises and war games to stay sharp. I think we should be doing something similar—germ games—for epidemics.

What happens next? Even though the experts mostly agree on the broad strokes of what should be done, I don’t know whether the world will choose to put meaningful resources into this effort. But I am hopeful that it will happen. The group I joined in Berlin is providing input to German Chancellor Angela Merkel and the G7 group of wealthy countries as they think about how they can help solve this problem. Creating a global plan would help more nations see how they can contribute and hopefully draw them in. The United Nations and WHO are also looking at various steps that could improve their ability to respond. And at the Gates Foundation we’re talking about how we might be able to assist.

It is great to see this issue rising up the global agenda. The world isn’t ready yet for a serious epidemic, but I think we have a good chance to make real progress in the next few months.

Getting new tools into the hands of the people fighting Ebola is much harder than it needs to be. I have experience with one alarming example.

Health workers in protective suits get so hot that they have a hard time caring for their patients. (For example your goggles fog up and you sweat profusely.) I asked a team of experts who work on technology for keeping vaccines cold to refocus on keeping the medical workers cool.

Within days, the team had found an existing solution: a vest with pockets where you could insert cooling packs.

Doctors who had treated Ebola patients in West Africa helped test and improve these cooling vests. Here you see Dr. Colin Bucks of Stanford University testing a vest and suit at home while under quarantine after working in Liberia. He rode a stationary bike to simulate the heat of West Africa.

Unfortunately, there was no coordinated system for getting the vests to West Africa. The team had to create new distribution channels by working directly with treatment centers in the region. They eventually got the suits to over a thousand health workers.

Although this wasn’t a critical issue, it is just one example of the challenge of preparing for a highly infectious disease. We see similar breakdowns in detecting outbreaks early, training and deploying volunteers, coordinating with the military, and more. But I’m optimistic that if we start now and stay focused, we can get ready for the next epidemic.

Kids love dinosaurs. When you’re three feet tall and can’t have dinner unless somebody brings you food, the idea of enormous, powerful creatures that have fangs to defend themselves and claws to capture their own meals seems pretty great.

I loved dinosaurs as much as anyone, but eventually I grew tall enough to get my own dinner, and my interest in dinosaurs waned.

My friend Nathan Myhrvold, though, never stopped loving dinosaurs. Actually, there are a lot of things Nathan never stopped loving—he’s published best-selling cookbooks and essays on bioterrorism, among other things—but if you ask him about his longest-running obsession, he’ll tell you it’s dinosaurs. His office is full of dinosaur bones, some of which he dug up himself, along with a model of a dinosaur whose tail moved so fast it broke the sound barrier.

Because he’s so curious, Nathan can take what he knows about these great reptiles and apply it to fields that seem completely unrelated—fields like childhood nutrition, one of the most important and misunderstood areas in all of development.

Here’s a short video in which he explains the connection:

Dinosaur growth rates, it turns out, are hard to study. There may be only thirty fossils of a particular dinosaur species in the world, and none of them may be complete. So how do you know whether a bone is shaped a certain way because that’s how triceratops grew or whether your particular specimen just had a funny-looking head?

In poor countries, children’s physical development is also hard to study, though for different reasons. For one thing, measurements are notoriously inaccurate. If you’re measuring a crying, squirming baby who doesn’t want a cold tape measure pressed up against his body, you might not get the numbers exactly right. There’s also a host of reasons a child could be short. Is this girl short because she’s malnourished? Is she from a short family? Or has she just not hit her growth spurt yet?

What that means is that in both areas, dinosaur growth and childhood growth, you end up with problematic data; with children, it’s messy, and with dinosaurs, it’s sparse. In both cases, though, the problem is the same: looking at the data from the wrong angle gives you the wrong answers.

Nathan thinks he’s figured out a systematic way to look at the growth records from the right angle. Since we started working with him he’s shared some promising ideas about how to measure children’s growth accurately, analyze the trends, and take action on the analysis. For example, some researchers recently looked at the relationship between gross domestic product and childhood stunting and, to everyone’s surprise, they found no correlation—until Nathan pointed out that they were using the wrong statistical methods to analyze the information. The methods he suggested instead—based on his work on dinosaurs—showed that the relationship was actually even stronger than many people in the field had thought. And that could have a big impact on how policymakers and health-care workers approach the problem of childhood nutrition.

This is a great example of a trend I hope we’ll see a lot more of: taking scientific advances from lots of different fields and using them to solve problems in global health.

Ever since dinosaurs were discovered, kids have showered them with love. Thanks to this work, we may have found a way for dinosaurs to pay them back.

Imagine there’s an infectious disease spreading through your community. It leaves some people crippled; others die from it. Then someone comes along and says: “Here’s something that will protect you from this disease for the rest of your life. You and your family can have it, for free.” You would be very relieved, right?

This scenario may seem hypothetical (though perhaps less so given how much the Ebola virus has been in the news). But it is very real for millions of people in the world’s poorest countries. Vaccines that were once out of reach for them are being delivered in greater numbers every year. That means more parents are feeling the relief of knowing their families are protected.

I’ve been looking at some of the data on vaccines and thought I would share what I’m seeing. At a time when so many news headlines are grim, it is inspiring stuff.

I’ll start with polio. Cases are down more than 99 percent since 1988. Earlier this year, we celebrated a fantastic achievement: India was declared polio-free. And in Nigeria, the number of polio cases is at an all-time low, just 6 so far this year versus more than 50 by this time last year. It’s one of only three countries that have never been polio free (the others are Pakistan and Afghanistan).

Wherever we make progress on polio, it’s a testament to the amazing work of many people: political leaders who prioritize stopping the disease, donors who help fund the effort, and—most importantly—the health workers who doggedly go from house to house to deliver vaccines. Thanks to all this work (and with a little luck), 2015 could be the first time Nigeria goes a year without a case of wild poliovirus, and the first time all of Africa is polio-free. If we maintain this commitment, I’m quite optimistic that by 2018 we will get rid of this crippling disease, everywhere, forever.

There’s also fantastic progress in delivering basic immunizations for diseases like measles and pneumonia. The impact is phenomenal: By next year, the public-health group known as Gavi, the Vaccine Alliance will have helped prevent 3.9 million deaths. And expanding vaccine coverage over the next five years can save as many as 6 million lives and unlock more than $100 billion in economic benefit.

Along those lines, we hit a big milestone in September. With the addition of South Sudan, pentavalent vaccine—which protects against five debilitating diseases—has now been introduced in all 73 countries that get financial support from Gavi. Pentavalent replaced a vaccine that protected against only three diseases, which means kids are protected from more diseases without getting any extra shots. This would never have happened without Gavi: By negotiating with manufacturers and bringing in new suppliers, it drove down the cost of pentavalent vaccine from $30 per dose in rich countries to just $1.19 for poor countries.

Another big step has been the rollout of a vaccine for rotavirus, which causes severe diarrhea. Rotavirus is one of the reasons Melinda and I first got involved in global health; in the late 1990s, we were shocked by a newspaper article that said it killed 800,000 children a year—nearly all of them in poor countries—more than almost any other disease. After more research, we decided rotavirus should be a focus of our giving. We’re gratified to see that 65 countries are now rolling out rotavirus vaccines, and more are signing up. Manufacturers in India are working on a new vaccine and talking about exporting it to other countries, which would help save even more children.

We’re also getting closer to solving some big delivery problems, like the fact that many vaccines spoil if they get too warm. Researchers are field-testing a specially designed container that keeps vaccines cold for a month or more, using just a single batch of ice and no electricity. These trials are helping thousands of African children get immunized. I’m very hopeful that containers like this one will eventually help health workers reach far more people.

A Ripple Effect
Vaccines save lives, which is reason enough to make sure they get out there. But that’s not their only benefit. Healthy children spend more time in school, and they learn better while they’re there. When health improves, poor countries can spend more on schools, roads, and other investments that drive growth, which makes them less dependent on aid.

Vaccines deliver all this for, in some cases, just pennies per shot. That’s why I say that if you want to save and improve lives around the world, vaccines are a fantastic investment. 

How You Can Help
One way you can help is to ask your political leaders to support Gavi next year, when donor governments need to renew their commitments. In the United States you can do that through Shot@Life, whose website makes it easy to send a message to your representatives.

You can also help by donating to Shot@Life. For $20, you can help protect a child from pneumonia, diarrhea, polio, and measles. And Shot@Life has teamed up with Walgreens for a “Get a shot. Give a shot” program: Get a vaccine at Walgreens and they will provide one for a child in a poor country.

This is flu season in the United States, so you may already be planning to get immunized. Why not help out someone else while you’re at it?

Once in a while, you read something that’s so compelling, you want to share it with everyone you can. Dr. Ada Igonoh’s story had that effect on me.

Dr. Igonoh is a physician in Lagos, Nigeria, where she helped care for Patrick Sawyer, the patient who introduced Ebola into Nigeria in July. After coming down with the deadly virus herself, she spent two harrowing weeks getting treatment in isolation wards.

When I met her at a conference in New Orleans last week, Dr. Igonoh handed me a written account of her experience. Even knowing she was going to be okay, I couldn’t stop reading—I had to know what happened next. Her optimism was inspiring. Her story also gave me a deeper appreciation for all the health workers who are heroically caring for patients and trying to stop this epidemic. And it is a good reminder of the way uncertainty reigns in the early days of an epidemic. The world’s response since then has been remarkable, and Nigeria has now been certified free of Ebola.

I want to thank Dr. Igonoh for her courage, and for agreeing to let me share her story here. It is well worth your time to read it. — Bill Gates

On the night of Sunday July 20^th, 2014, Patrick Sawyer was wheeled into the emergency room of the First Consultants Medical Centre, Obalende, Lagos, with complaints of fever and body weakness. The male doctor on call admitted him as a case of malaria, and took a full history.

Knowing that Mr. Sawyer had recently arrived from Liberia, the doctor asked if he had been in contact with an Ebola patient in the last couple of weeks, and Mr. Sawyer denied any such contact. He also denied attending any funeral ceremony recently. Blood samples were taken for full blood count, malaria parasites, liver function test, and other baseline investigations. He was admitted into a private room and started on antimalarial drugs and analgesics. That night, the blood count result came back as normal and not indicative of infection.

The following day, however, his condition worsened. He barely ate any of his meals. His liver function test result showed his liver enzymes were markedly elevated. We then took samples for HIV and hepatitis screening.

At about 5:00 p.m. he requested to see a doctor. I was the doctor on call that night, so I went in to see him. He was lying in bed with his intravenous (IV) fluid bag removed from its metal stand and placed beside him. He complained that he had stooled about five times that evening and that he wanted to use the bathroom again.

I picked up the IV bag from his bed and hung it back on the stand. I told him I would inform a nurse to come and disconnect the IV so he could conveniently go to the bathroom. I walked out of his room and went straight to the nurses' station where I told the nurse on duty to disconnect his IV. I then informed my consultant, Dr. Ameyo Adadevoh, about the patient's condition, and she asked that he be placed on some medications.

The following day, the results for HIV and hepatitis screening came out negative. As we were preparing for the early morning ward rounds, I was approached by an ECOWAS [Economic Community of West African States] official who informed me that Patrick Sawyer had to catch an 11 o'clock flight to Calabar for a retreat that morning. He wanted to know if it would be possible. I told him it wasn't, as he was acutely ill. Dr. Adadevoh also told him the patient could certainly not leave the hospital in his condition. She then instructed me to write very boldly on his chart that on no account should Patrick Sawyer be allowed out of the hospital premises without the permission of Dr. Ohiaeri, our Chief Medical Consultant. All nurses and doctors were duly informed.

During our early morning ward round with Dr. Adadevoh, we concluded that this was not malaria, and that the patient needed to be screened for Ebola Viral Disease. She immediately started calling laboratories to find out where the test could be carried out. She was eventually referred to Professor Omilabu of the LUTH Virology Reference Lab in Idi-Araba, whom she called immediately.

Prof. Omilabu told her to send blood and urine samples to LUTH straightaway. She tried to reach the Lagos State Commissioner for Health but was unable to contact him at the time. She also put calls across to officials of the Federal Ministry of Health and National Centre for Disease Control.

Dr. Adadevoh at this time was in a pensive mood. Patrick Sawyer was now a suspected case of Ebola, perhaps the first in the country. He was quarantined, and strict barrier nursing was applied with all the precautionary measures we could muster. Dr. Adadevoh went online, downloaded information on Ebola, and printed copies which were distributed to the nurses, doctors and ward maids. Blood and urine samples were sent to LUTH that morning. Protective gear, gloves, shoe covers and facemasks were provided for the staff. A wooden barricade was placed at the entrance of the door to keep visitors and unauthorized personnel away from the patient. Despite the medications prescribed earlier, the vomiting and diarrhea persisted. The fever escalated from 38°C to 40°C.

On the morning of Wednesday, 23^rd July, the tests carried out in LUTH showed a signal for Ebola. Samples were then sent to Dakar, Senegal for a confirmatory test. Dr. Adadevoh went for several meetings with the Lagos State Ministry of Health. Thereafter, officials from the Lagos State came to inspect the hospital and the protective measures we had put in place.

The following day, Thursday 24^th July, I was again on call. At about 10:00 p.m. Mr. Sawyer requested to see me. I went into the newly created dressing room, donned my protective gear and went in to see him. He had not been cooperating with the nurses and had refused any additional treatment. He sounded confused and said he received a call from Liberia asking for a detailed medical report to be sent to them. He also said he had to travel back to Liberia on a 5:00 a.m. flight the following morning and that he didn't want to miss his flight. I told him that I would inform Dr. Adadevoh. As I was leaving the room, I met Dr. Adadevoh dressed in her protective gear, along with a nurse and another doctor. They went into his room to have a discussion with him, and as I heard later to reset his IV line which he had deliberately removed after my visit to his room.

At 6:30 a.m., Friday 25^th July, I got a call from the nurse that Patrick Sawyer was completely unresponsive. Again I put on the protective gear and headed to his room. I found him slumped in the bathroom. I examined him and observed that there was no respiratory movement. I felt for his pulse; it was absent. We had lost him.

It was I who certified Patrick Sawyer dead. I informed Dr. Adadevoh immediately and she instructed that no one was to be allowed to go into his room for any reason at all. Later that day, officials from WHO came and took his body away. The test in Dakar later came out positive for Zaire strain of the Ebola virus. We now had the first official case of Ebola virus disease in Nigeria.

It was a sobering day. We all began to go over all that happened in the last few days, wondering just how much physical contact we had individually made with Patrick Sawyer. Every patient on admission was discharged that day and decontamination began in the hospital. We were now managing a crisis situation.

The next day, Saturday 26^th July, all staff of First Consultants attended a meeting with Prof. Nasidi of the National Centre for Disease Control, Prof. Omilabu of LUTH Virology Reference Lab, and some officials of WHO. They congratulated us on the actions we had taken and enlightened us further about the Ebola Virus Disease. They said we were going to be grouped into high risk and low risk categories based on our individual level of exposure to Patrick Sawyer, the "index" case. Each person would receive a temperature chart and a thermometer to record temperatures in the morning and night for the next 21 days. We were all officially under surveillance. We were asked to report to them at the first sign of a fever for further blood tests to be done. We were reassured that we would all be given adequate care. The anxiety in the air was palpable.

The frenetic pace of life in Lagos, coupled with the demanding nature of my job as a doctor, means that I occasionally need a change of environment. As such, one week before Patrick Sawyer died, I had gone to my parents' home for a retreat. I was still staying with them when I received my temperature chart and thermometer on Tuesday, 29^th of July. I could not contain my anxiety. People were talking about Ebola everywhere—on television, online, everywhere.

I soon started experiencing joint and muscle aches and a sore throat, which I quickly attributed to stress and anxiety. I decided to take malaria tablets. I also started taking antibiotics for the sore throat. The first couple of temperature readings were normal. Every day I would attempt to recall the period Patrick Sawyer was on admission—just how much direct and indirect contact did I have with him? I reassured myself that the contact with him was quite minimal. I completed the anti-malarials but the aches and pains persisted. I had loss of appetite and felt very tired.

On Friday, 1^st of August, my temperature read a high 38.7°C. As I type this, I recall the anxiety I felt that morning. I could not believe what I saw on the thermometer. I ran to my mother's room and told her. I did not go to work that day. I cautiously started using a separate set of utensils and cups from the ones my family member were using.

On Saturday, 2^nd of August, the fever worsened. It was now at 39°C and would not be reduced by taking paracetamol. This was now my second day of fever. I couldn't eat. The sore throat was getting worse. That was when I called the helpline and an ambulance was sent with WHO doctors, who came and took a sample of my blood. Later that day, I started stooling and vomiting. I stayed away from my family. I started washing my plates and spoons myself. My parents, meanwhile, were convinced that I could not have Ebola.

The following day, Sunday, 3^rd of August, I got a call from one of the doctors who came to take my sample the day before. He told me that the sample which they had taken was not confirmatory, and that they needed another sample. He did not sound very coherent and I became worried. They came with the ambulance that afternoon and told me that I had to go with them to Yaba. I was confused. Couldn't the second sample be taken in the ambulance like the previous one? He said a better-qualified person at the Yaba Centre would take the sample. I asked if they would bring me back. He said "yes." Even with my symptoms, I did not believe I had Ebola. After all, my contact with Sawyer was minimal. I only touched his IV fluid bag just that once without gloves. The only time I actually touched him was when I checked his pulse and confirmed him dead, and I wore double gloves and I felt adequately protected.

I told my parents I had to go with the officials to Yaba and that I would be back that evening. I wore a white top and a pair of jeans, and I put my iPad and phones in my bag.

A man opened the ambulance door for me and moved away from me rather swiftly. Strange behavior, I thought. They were friendly with me the day before, but that day, not so. No pleasantries, no smiles. I looked up and saw my mother watching through her bedroom window.

We soon got to Yaba. I really had no clue where I was. I knew it was a hospital. I was left alone in the back of the ambulance for over four hours. My mind was in a whirl. I didn't know what to think. I was offered food to eat but I could barely eat the rice.

The ambulance door opened and a Caucasian gentleman approached me but kept a little distance. He said to me, "I have to inform you that your blood tested positive for Ebola. I am sorry."

I had no reaction. I think I must have been in shock. He then told me to open my mouth and he looked at my tongue. He said it was typical Ebola tongue. I took out my mirror from my bag and took a look and was shocked at what I saw. My whole tongue had a white coating, looked furry, and had a long, deep ridge right in the middle. I then started to look at my whole body, searching for Ebola rashes and other signs, as we had been recently instructed. I called my mother immediately and said, "Mummy, they said I have Ebola, but don't worry, I will survive it. Please go and lock my room now; don't let anyone inside and don't touch anything." She was silent. I cut the line.

I was taken to the female ward. I was shocked at the environment. It looked like an abandoned building. I suspected it had not been in use for quite a while. As I walked in, I immediately recognized one of the ward maids from our hospital. She always had a smile for me but not this time. She was ill and looked it. She had been stooling a lot, too. I soon settled into the corner and looked around the room. It smelled of feces and vomit. It also had a characteristic Ebola smell to which I became accustomed. Dinner was served—rice and stew. The pepper stung my mouth and tongue. I dropped the spoon. No dinner that night.

Dr. David, the Caucasian man who had met me at the ambulance on my arrival, came in wearing his full protective hazmat suit and goggles. It was fascinating seeing one live. I had only seen them online. He brought bottles of water and ORS, the oral fluid therapy, which he dropped by my bedside. He told me that 90 percent of the treatment depended on me. He said I had to drink at least 4.5 litres of ORS daily to replace fluids lost in stooling and vomiting. I told him I had stooled three times earlier and taken Imodium tablets to stop the stooling. He said it was not advisable, as the virus would replicate the more inside of me. It was better, he said, to let it out. He said good night and left.

My parents called. My uncle called. My husband called crying. He could not believe the news. My parents had informed him, as I didn't even know how to break the news to him.

As I lay on my bed in that isolation ward, strangely, I did not fear for my life. I was confident that I would leave that ward some day. There was an inner sense of calm. I did not for a second think that I would be consumed by the disease.

That evening, the symptoms fully kicked in. I was stooling almost every two hours. The toilets did not flush, so I had to fetch water in a bucket from the bathroom each time I used the toilet. I then placed another bucket beneath my bed for the vomiting. On occasion, I would run to the toilet with a bottle of ORS, so that as I was stooling, I was drinking.

The next day, Monday, 4^th of August, I began to notice red rashes on my skin, particularly on my arms. I had developed sores all over my mouth. My head was pounding so badly. The sore throat was so severe I could not eat. I could only drink ORS. I took paracetamol for the pain. The ward maid across from me wasn't doing so well. She had stopped speaking. I couldn't even brush my teeth; the sores in my mouth were so bad. This was a battle for my life but I was determined I would not die.

Every morning, I began the day with reading and meditating on Psalm 91. The sanitary condition in the ward left much to be desired. The whole Ebola thing had caught everyone by surprise. Lagos State Ministry of Health was doing its best to contain the situation but competent hands were few. The sheets were not changed for days. The floor was stained with greenish vomitus and excrement. Dr. David would come in once or twice a day and help clean up the ward after chatting with us. He was the only doctor who attended to us. There was no one else at that time. The matrons would leave our food outside the door. They hardly entered in the initial days. Everyone was being careful. This was all so new. I could understand, was this not how we ourselves had contracted the disease? Mosquitoes were in our room until they brought us mosquito nets.

Later that evening, Dr. David brought another lady into the ward. I recognized her immediately as Justina Ejelonu, a nurse who had started working at First Consultants on the 21^st of July, a day after Patrick Sawyer was admitted. She was on duty on the day Patrick reported that he was stooling. While she was attending to him that night, he had yanked off his drip, letting his blood flow almost like a tap onto her hands. Justina was pregnant and was brought into our ward bleeding from a suspected miscarriage. She had been told she was there only on observation. The news that she had contacted Ebola was broken to her the following day after results of her blood test came out positive. Justina was devastated and wept profusely—she had contracted Ebola on her first day at work.

My husband started visiting but was not allowed to come close to me. He could only see me from a window at a distance. He visited so many times. It was he who brought me a change of clothes and toiletries and other things I needed because I had not even packed a bag. I was grateful I was not with him at home when I fell ill or he would most certainly have contracted the disease. My retreat at my parents' home turned out to be the instrumentality God used to shield and save him.

I drank the ORS fluid like my life depended on it. Then I got a call from my pastor. He had been informed about my predicament. He called me every single day, morning and night, and he would pray with me over the phone. He later sent me a CD player, CDs of messages on faith and healing, and Holy Communion packs through my husband. My pastor, who also happens to be a medical doctor, encouraged me to monitor how many times I had stooled and vomited each day and how many bottles of ORS I had consumed. We would then discuss the disease and pray together. He asked me to do my research on Ebola since I had my iPad with me, and told me that he was also doing his study. He wanted us to use all relevant information on Ebola to our advantage. So I researched and found out all I could about the strange disease that had been in existence for 38 years. My research, my faith, and my positive view of life, the extended times of prayer, study and listening to encouraging messages boosted my belief that I would survive the Ebola scourge.

There are five strains of the virus, and the deadliest of them is the Zaire strain, which was what I had. But that did not matter. I believed I would overcome even the deadliest of strains. Infected patients who succumb to the disease usually die between 6 to 16 days after the onset of the disease from multiple organ failure and shock caused by dehydration. I was counting the days and keeping myself well-hydrated. I didn't intend to die in that ward.

My research gave me ammunition. I read that as soon as the virus gets into the body, it begins to replicate really fast. It enters the blood cells, destroys them and uses those same blood cells to aggressively invade other organs where they further multiply. Ideally, the body's immune system should immediately mount up a response by producing antibodies to fight the virus. If the person is strong enough, and that strength is sustained long enough for the immune system to kill off the viruses, the patient is likely to survive. If the virus replicates faster than the antibodies can handle, however, further damage is done to the organs. Ebola can be likened to multi-level, multi-organ attack, but I had no intention of letting the deadly virus destroy my system. I drank more ORS. I remember saying to myself repeatedly, "I am a survivor, I am a survivor."

I also found out that a patient with Ebola cannot be re-infected and they cannot relapse back into the disease as there is some immunity conferred on survivors. My pastor and I would discuss these findings, interpret them as it related to my situation and pray together. I looked forward to his calls. They were times of encouragement and strengthening. I continued to meditate on the Word of God. It was my daily bread.

Shortly after Justina came into the ward, the ward maid, Mrs. Ukoh, passed on. The disease had gotten into her central nervous system. We stared at her lifeless body in shock. It was a whole 12 hours before officials of WHO came and took her body away. The ward had become the house of death. The whole area surrounding her bed was disinfected with bleach. Her mattress was taken and burned.

To contain the frequent diarrhea, I had started wearing adult diapers, as running to the toilet was no longer convenient for me. The indignity was quite overwhelming, but I did not have a choice. My faith was being severely tested. The situation was desperate enough to break anyone psychologically. Dr. Ohiaeri also called us day and night, enquiring about our health and the progress we were making. He sent provisions, extra drugs, vitamins, Lucozade, towels, tissue paper; everything we needed to be more comfortable in that dark hole we found ourselves. Some of my male colleagues also had been admitted to the male ward two rooms away, but there was no interaction with them. We were saddened by the news that Jato, the ECOWAS protocol officer to Patrick Sawyer, who had also tested positive, had passed on days after he was admitted.

Two more females joined us in the ward; a nurse from our hospital and a patient from another hospital. The mood in the ward was solemn. There were times we would be awakened by the sudden, loud cry from one of the women. It was either from fear, pain mixed with the distress, or just the sheer oppression of the isolation.

I kept encouraging myself. This could not be the end for me. Five days after I was admitted, the vomiting stopped. A day after that, the diarrhea ceased. I was overwhelmed with joy. It happened at a time I thought I could no longer stand the ORS. Drinking that fluid had stretched my endurance greatly.

I knew countless numbers of people were praying for me. Prayer meetings were being held on my behalf. My family was praying day and night. Text messages of prayers flooded my phone from family members and friends. I was encouraged to press on. With the encouragement I was receiving, I began to encourage the others in the ward. We decided to speak life and focus on the positive.

I then graduated from drinking only the ORS fluid to eating only bananas, to drinking pap and then bland foods. Just when I thought I had the victory, I suddenly developed a severe fever. The initial fever had subsided four days after I was admitted, and then suddenly it showed up again. I thought it was the Ebola. I enquired from Dr. David, who said fever was sometimes the last thing to go, but he expressed surprise that it had stopped only to come back on again. I was perplexed.

I discussed it with my pastor, who said it could be a separate pathology and possibly a symptom of malaria. He promised he would research if indeed this was Ebola or something else. That night as I stared at the dirty ceiling, I felt a strong impression that the new fever I had developed was not as a result of Ebola but malaria. I was relieved. The following morning, Dr. Ohiaeri sent me an antimalarial medication, which I took for three days. Before the end of the treatment, the fever had disappeared.

I began to think about my mother. She was under surveillance along with my other family members. I was worried. She had touched my sweat. I couldn't get the thought off my mind. I came across a tweet by WHO saying that the sweat of an Ebola patient cannot transmit the virus at the early stage of the infection. The sweat could only transmit it at the late stage.

That settled it for me. It calmed the storms that were raging with me concerning my parents. I knew right away it was divine guidance that caused me to see that tweet. I could cope with having Ebola, but I was not prepared to deal with a member of my family contracting it from me.

Soon, volunteer doctors started coming to help Dr. David take care of us. They had learned how to protect themselves. Among the volunteer doctors was Dr. Badmus, my consultant in LUTH during my housemanship days. It was good to see a familiar face among the care-givers. I soon understood the important role these brave volunteers were playing. As they increased in number, so did the number of shifts increase and subsequently the number of times the patients could access a doctor in one day. That allowed for more frequent patient monitoring and treatment. It also reduced care-giver fatigue. It was clear that Lagos State was working hard to contain the crisis.

Sadly, Justina succumbed to the disease on the 12^th of August. It was a great blow and my faith was greatly shaken as a result. I commenced daily Bible study with the other two female patients and we would encourage one another to stay positive in our outlook, though in the natural it was grim and very depressing. My communion sessions with the other women were very special moments for us all.

On the 10^th day in the ward, the doctors having noted that I had stopped vomiting and stooling and was no longer running a fever, decided it was time to take my blood sample to test if the virus had cleared from my system. They took the sample and told me that I shouldn't be worried if it comes out positive as the virus takes a while before it is cleared completely. I prayed that I didn't want any more samples collected from me. I wanted that to be the first and last sample to be tested for the absence of the virus in my system. I called my pastor. He encouraged me and we prayed again about the test.

On the evening of the day Justina passed on, we were moved to the new isolation centre. We felt like we were leaving hell and going to heaven. We were conveyed to the new place in an ambulance. It was just behind the old building. Time would not permit me to recount the drama involved with the dynamics of our relocation. It was like a script from a science fiction movie. The new building was cleaner and much better than the old building. Towels and nightwear were provided on each bed. The environment was serene.

The following night, Dr. Adadevoh was moved to our isolation ward from her private room where she had previously been receiving treatment. She had also tested positive for Ebola and was now in a coma. She was receiving IV fluids and oxygen support and was being monitored closely by the WHO doctors. We all hoped and prayed that she would come out of it. It was so difficult seeing her in that state. I could not bear it. She was my consultant and my mentor. She was the imperial lady of First Consultants, full of passion, energy and competence. I imagined she would wake up soon and see that she was surrounded by her First Consultants family but sadly it was not to be.

I continued listening to my healing messages. They gave me life. I literally played them hours on end. Two days later, on Saturday the 16^th of August, the WHO doctors came with some papers. I was informed that the result of my blood test was negative for the Ebola virus. If I could somersault, I would have, but my joints were still slightly painful. I was free to go home after being in isolation for exactly 14 days. I was so full of thanks and praise to God. I called my mother to get fresh clothes and slippers and come pick me up. My husband couldn't stop shouting when I called him. He was completely overwhelmed with joy.

I was told however that I could not leave the ward with anything I came in with. I glanced one last time at my CD player, my valuable messages, my research assistant, a.k.a my iPad, my phones and other items. I remember saying to myself, "I have life; I can always replace these items."

I went for a chlorine bath, which was necessary to disinfect my skin from my head to my toes. It felt like I was being baptized into a new life as Dr. Carolina, a WHO doctor from Argentina poured the bucket of chlorinated water all over me. I wore a new set of clothes, following the strict instructions that no part of the clothes must touch the floor and the walls. Dr. Carolina looked on, making sure I did as instructed.

I was led out of the bathroom and straight to the lawn to be united with my family, but first I had to cut the red ribbon that served as a barrier. It was a symbolic expression of my freedom. Everyone cheered and clapped. It was a little but very important ceremony for me. I was free from Ebola! I hugged my family as one who had been liberated after many years of incarceration. I was like someone who had fought death face to face and come back to the land of the living.

We had to pass through several stations of disinfection before we reached the car. Bleach and chlorinated water were sprayed on everyone's legs at each station. As we made our way to the car, we walked past the old isolation building. I could hardly recognize it. I could not believe I slept in that building for 10 days. I was free! Free of Ebola. Free to live again. Free to interact with humanity again. Free from the sentence of death.

My parents and two brothers were under surveillance for 21 days and they completed the surveillance successfully. None of them came down with a fever. The house had been disinfected by Lagos State Ministry of Health soon after I was taken to the isolation centre. I thank God for shielding them from the plague.

My recovery after discharge has been gradual but progressive. I thank God for the support of family and friends. I remember my colleagues who we lost in this battle. Dr. Adadevoh my boss, Nurse Justina Ejelonu, and the ward maid, Mrs. Ukoh were heroines who lost their lives in the cause to protect Nigeria. They will never be forgotten.

I commend the dedication of the WHO doctors, Dr. David from Virginia, USA, who tried several times to convince me to specialize in infectious diseases, Dr. Carolina from Argentina who spoke so calmly and encouragingly, Mr. Mauricio from Italy who always offered me apples and gave us novels to read. I especially thank the volunteer Nigerian doctors, matrons and cleaners who risked their lives to take care of us. I must also commend the Lagos State government, and the state and federal ministries of health for their swift efforts to contain the virus.

To all those who prayed for me, I cannot thank you enough. And to my First Consultants family, I say a heartfelt thank you for your dedication and for your support throughout this very difficult period.

I still believe in miracles. None of us in the isolation ward was given any experimental drugs or so-called immune boosters. I was full of faith, yet pragmatic enough to consume as much ORS as I could, even when I wanted to give up and throw the bottles away. I researched on the disease extensively and read accounts of the survivors. I believed that even if the mortality rate was 99 percent, I would be part of the 1 percent who would survive.

Early detection and reporting to hospital is key to patient survival. Please do not hide yourself if you have been in contact with an Ebola patient and have developed the symptoms. Regardless of any grim stories one may have heard about the treatment of patients in the isolation centre, it is still better to be in the isolation ward with specialist care, than at home where you and others will be at risk.

I read that Dr. Kent Brantly, the American doctor who contracted Ebola in Liberia and was flown out to the United States for treatment was being criticized for attributing his healing to God when he was given the experimental drug, Zmapp. I don't claim to have all the answers to the nagging questions of life. Why do some die and some survive? Why do bad things happen to good people? Where is God in the midst of pain and suffering? Where does science end and God begin? These are issues we may never fully comprehend on this side of eternity. All I know is that I walked through the valley of the shadow of death and came out unscathed.

I’m in New Orleans, where I just had the honor of speaking at the annual meeting of the American Society of Tropical Medicine and Hygiene (ASTMH). As you can imagine, given that this is a gathering of experts on infectious diseases in poor countries, Ebola is on everyone’s mind.  

Even though I am confident that the U.S. and other countries with strong public health systems will contain the cases that are popping up within their borders, it’s devastating to see what this virus is doing to entire families in West Africa. At times like this, it’s easy for organizations like ASTMH to make the public case that global health matters to all of us in our increasingly interconnected world. I hope that will help strengthen the public will to do more to help poor countries lift the burden of disease—not just from emerging killers like Ebola but also from pathogens that have held back human potential for thousands of years.

That’s why, in my remarks at the conference, I addressed the Ebola crisis but devoted the bulk of my time to another killer disease: malaria. Based on the progress I’m seeing in the lab and on the ground, I believe we’re now in a position to eradicate malaria—that is, wipe it out completely in every country—within a generation. This is one of the greatest opportunities the global health world has ever had. Melinda and I are so optimistic about it that we recently decided to increase our foundation’s malaria budget by 30 percent.

Melinda and I first called for eradication back in 2007 along with Margaret Chan, who runs the World Health Organization. Melinda was eloquent and passionate in her call to action: “Any goal short of eradicating malaria is accepting malaria; it’s making peace with malaria; it’s rich countries saying: ‘We don’t need to eradicate malaria around the world as long as we’ve eliminated malaria in our own countries.’ That’s just unacceptable.”

Some people said then (and still say today) that we’re overly optimistic to be talking about eradication. After all, malaria is an enormously complex target and has defeated efforts to stamp it out in the past. They’re right that we shouldn’t promise the moon—you don’t get rid of a disease this complex overnight—but I am confident that the future will be different from the past.

Why? Because we’ve seen a huge scale-up in the resources and brainpower focused on this disease. Four countries have eliminated malaria since 2000, and two dozen more could do it in the next decade. Mortality rates worldwide have gone down by a remarkable 42 percent in that time—a good-news story that ought to make critics wary of trumpeting claims that foreign aid doesn’t work. More than 3.3 million people who would have died of malaria are alive today.

And we have tools today we’ve never had before—not everything we will need to achieve eradication, but more than we’ve ever had. Here are two of the recent innovations that fuel my optimism:

• Diagnostics: Malaria is not only treatable but also curable, thanks to a class of drugs derived from a flowering plant called Artemesia annua, or sweet wormwood. But until recently, there was no good way for most people who came down with a fever to find out whether they had malaria. In 2010, we got a great new tool, called the RDT (rapid diagnostic test). Armed with this 50-cent test, community health workers with little training can determine in minutes with 99 percent accuracy whether someone has malaria or not. Last year, we deployed 200 million of them in Africa alone.
• Modeling Systems: The digital revolution has produced fantastic new tools for tracking the disease. Public health experts are combining anonymous data from mobile phone records with data on malaria incidence to identify the key migration hotspots—allowing countries to target their resources in the most cost-effective and strategic ways. In Kenya, for example, these maps helped experts target large-scale tea plantations in the country’s Lake Zone. Comprehensive efforts at the plantations could make it possible to eliminate malaria from large swaths of the country’s highlands without even having to run elimination efforts there.

Just as important as any specific innovation, our team has converged on an eradication strategy that will make the whole greater than the sum of the parts. That strategy has three components: Complete Detection, Complete Cure, and Complete Prevention.

Complete Detection is a departure from current approaches, which focus on finding and treating only those people who have active malaria cases. To achieve eradication, health workers need to find all people who have the parasite in their blood, regardless of whether they’re showing symptoms. (I wrote about this work earlier this year, after Melinda and I saw it in action in Cambodia.) We’re supporting many efforts to develop and bring to market a new generation of diagnostic tools that are even more sensitive than the RDTs now in use and can identify the presence of malaria parasites in all infected individuals.

Complete Cure means using treatments that clear all malaria parasites from the body. Our best anti-malaria treatment today, known as ACT, generally cures the patient clinically but does not eliminate all forms of the parasites that are responsible for continued transmission. So we are trying to supercharge efforts to develop long-lasting, single-dose treatments for malaria that can completely clear malaria parasites from the body and provide a period of protection following the treatment. We believe that our largest partner in this effort, the Medicines for Malaria Venture, could bring these complete-cure drugs to market within five years.

Complete Prevention means reducing opportunities for mosquitoes to pass the parasite on to humans, and preventing the emergence of strains that resist drugs and insecticides. We’ll need next-generation vaccines that block transmission for six months to a year, so that once an area is cleared of the parasite, it stays clear. We’ll also need new insecticides to offset the widespread emergence of mosquito resistance to the chemical compounds we use most frequently today. We may even need cutting-edge approaches, like introducing special fungi into mosquito populations to kill them off or introducing modified genes that can stop mosquitoes from reproducing.

I believe it’s not only possible to eradicate malaria; I believe it’s necessary. Ultimately, the cost of controlling it endlessly is not sustainable. The only way to stop this disease is to end it forever.

If you want to join the fight, please consider donating to our partner Malaria No More.

Whenever I visit small farmers in a poor country, I’m struck by how many are laboring with hoes, plows, and other implements that haven’t changed in generations. Yet farmers in wealthier countries have benefited from wave after wave of technological improvements. This gap is one big reason why some farmers produce much more food than others.

Thankfully, some of the brightest minds in Africa, India, and elsewhere are creating new tools to close the gap.

Here are four especially promising innovations…

For many years, so little agriculture research was being done in Africa that we knew less about the soil there than we did about the surface of Mars. Now that’s changing, thanks to an initiative to map the continent’s soil. The Africa Soil Information Service is creating digital maps that help farmers make informed decisions about which seeds to plant, which fertilizers to use, and how to raise their crop yields. They’re available free to anyone with a cell phone or Internet connection.

In Africa, half a billion people depend on cassava as a staple crop. But breeding more-nutritious, disease-resistant varieties of the root takes a long time—a decade or more. Now scientists with the Next Generation Cassava Breeding (NEXTGEN) project have cut that time in half, using computer modeling techniques and a treasure trove of new information on the plant’s genome. They have also improved the breeding cycle, so they can zero in on the most desirable traits earlier in the process.

How do you cheaply spread good information about farming? The Indian nonprofit Digital Green is having success with simple YouTube videos. They’ve shot thousands of videos featuring farmers sharing best practices. (See for yourself.) Farmers, they’ve found, are much more likely to listen to peers who look and sound like them. The idea isn’t limited to farming either: The UK’s development agency is now helping Digital Green use its platform to spread health messages.

Being a dairy farmer has risks. As I learned on a trip to Kenya, milk can spill or spoil on its way from the cow to the chilling station. So I asked the team at Global Good to study the problem. Working with Heifer International, they made a jug that’s easy to clean and won’t spill. Partners in Kenya and Ethiopia will make and sell them for about $5 each, versus up to $30 for other jugs. This modest step could help dairy farmers earn more money—and create new manufacturing and sales jobs too.