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.”

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thank you.

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

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

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

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

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

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

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

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

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

Planning for the next 20 years

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

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

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

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

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

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

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

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

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

What the Gates Foundation hopes to accomplish

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The last chapter of my career

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

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

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

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

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

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

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

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

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

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.

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.

In a few days, I’ll be traveling to India—my third visit in three years. India is a place where big challenges meet even bigger ambitions, and where innovation is transforming lives at an incredible scale. Every time I’m there, I see firsthand how much progress is being made in public health, agriculture, and technology. And I come away with new ideas, because India is full of smart, ambitious people tackling some of the world’s hardest problems in creative ways.

This visit will also be significant because—as we mark our 25^th anniversary—the Gates Foundation’s Board of Trustees is meeting in the Global South for the first time. India is the right place for this milestone. The foundation has been working in the country for more than two decades, partnering with the government, researchers, and entrepreneurs to improve health and development. Today, India is home to some of the most impactful programs we’ve contributed to, from disease eradication and sanitation to women’s empowerment and digital financial services. This trip will give me a chance to see what’s working, what’s changing, and what’s next—for India and the foundation.

India’s track record in public health shows what’s possible. When I visited in 2011, it was one of the last places in the world still fighting polio. But that year, after relentless effort, India recorded its last case—and it’s remained polio-free ever since. Avahan, the HIV prevention program launched by the Gates Foundation two decades ago, is another success story. It pioneered a community-led approach to reduce infection rates that complemented the government’s efforts in high-prevalence states; eventually, management of the program transitioned to the Indian government, becoming part of the country’s broader health strategy.

That same model—leveraging local leadership, innovative solutions and data-driven insights—is now driving India’s fight against tuberculosis. The country has the world’s highest TB burden, but its investment in new diagnostics, AI-powered detection tools, and improved treatment strategies is accelerating progress toward elimination.

India’s success in childhood immunization is another reason I’m eager to return and learn more. Over the past several years, the country has scaled up routine vaccination programs, ensuring every major childhood vaccine is available. It has also used digital dashboards to track vaccine coverage, monitor cold storage, and improve maternal and child healthcare. These efforts have helped drive down mortality rates and create a stronger health system that can respond to new challenges.

India’s global health leadership is also transforming how the country approaches diagnostics and treatment for infectious diseases. As a result, it’s become a leader in low-cost vaccine manufacturing, ensuring that life-saving vaccines are available around the world. Indian companies are also tackling another critical challenge: making diagnostics more affordable. One effort I’m following closely is the push to make a saliva-based TB test for under $2, which could help millions of people in India and globally detect the disease earlier and get treatment faster.

Beyond health, India is also at the forefront of digital transformation. I’ve written before about how digital public infrastructure (DPI)—like Aadhaar and India’s digital payments system—has made it easier for millions of people to access banking, healthcare, and government services. Now, India is using AI-powered DPI tools to help rural health workers improve early disease detection, optimize pregnancy care, and manage patient data more effectively.

AI is also transforming agriculture across the country. When I was in Odisha last year, I saw farmers using AI-powered tools to predict weather patterns, choose crops, and reduce disease risks. I’m looking forward to seeing how much better those tools have gotten in the short time since.

What makes India’s progress so transformative, though, is that it doesn’t just benefit India. During India’s G20 Presidency in 2023, Prime Minister Modi declared his intent to make Indian innovations and know-how available to solve development problems globally. And that’s exactly what is happening. The solutions being developed there, from vaccine manufacturing to AI-powered diagnostics, are being shared with the world. Indian companies are making TB tests that could be game-changing across Africa. They’re developing AI models that could help farmers across Asia. And they’re proving that digital technology can make healthcare work better for everyone, especially the most vulnerable.

At the Gates Foundation, we tackle tough problems by working in close partnership with the people and governments most affected by them. India has been an incredible partner in this work because of the country’s deep expertise and willingness to develop and scale new ideas. The challenges remain: eliminating TB, improving nutrition, expanding access to AI-driven health and development services. But India has shown time and again that progress happens when innovation, local leadership, and investment come together.

That’s why I’m so excited for this trip. I’ll be meeting with government leaders, scientists, and philanthropists who are shaping the future of health and development in India. I’ll be visiting innovators who are working on solutions that could help people in India and around the world. And I’ll get to see how the foundation’s work fits into this bigger story—and how we can continue to support Indian-led efforts to improve lives.

I always leave India inspired. I know this trip will be no different.

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 grain did your family grow up eating? I’m from the United States, where wheat and corn are king. But if I had been born in East Asia, I probably would’ve eaten a lot more rice as a kid.

If you grew up in West Africa, you might have eaten an ancient grain called fonio. Fonio has been feeding families in West Africa for more than 5,000 years, longer than any other cultivated grain on the continent. That makes it older than toilets, the wheel, and even writing. It’s a super small grain with a texture that reminds me a bit of couscous when cooked in hot water. Its nutty taste is delicious on its own but is also good when ground into flour.

Fonio is just one part of a much bigger family of remarkable ancient grains: the millets. Perhaps you’ve heard of finger millet. It’s a staple in Uganda and parts of Kenya and Tanzania, and it’s beloved in India where it is called ragi. Or maybe you’ve heard of teff, a longtime favorite in Ethiopia where it’s used to make injera.

Millets have been around for centuries, but they’re currently experiencing a resurgence—both for consumers who enjoy their taste and for farmers who appreciate how reliable they are to grow.

Fonio, in particular, is like farming on easy mode. You wait until a good rain comes, lightly till the soil to loosen it up, and then scatter the seeds on the ground. Two months later, you harvest the grain.

I planted drought-tolerant seeds, fed and weighed chickens, and used a mobile phone to monitor weather forecasts and local crop prices.

These were a few of the chores I was given during my visit with Mary Mathuli, a smallholder farmer in rural Kenya.

I stopped at her home in Makueni County, south-east of Nairobi, during my recent trip to Kenya to better understand how farmers like Mary are faring in the face of climate change.

I arrived expecting to hear her talk about the record droughts and smaller harvests many farmers are experiencing throughout Africa.

Instead, to my surprise, she led me out to her fields to show off the innovations that are allowing her to continue to grow crops and earn an income to support her family, despite the drastic changes in rainfall and weather patterns.

A natural teacher, Mary encouraged me to learn by doing. She put me to work so I could understand how these new agricultural inputs and practices can make a big difference in their lives.

This experience taught me a couple important lessons.

First, my farming skills—like holding a chicken and swinging a hoe—need some work.

Second, and more importantly, I got a personal reminder of how resourceful and resilient African smallholder farmers like Mary are. Battered by years of drought and other extreme weather patterns, they are developing new skills and embracing new technologies to adapt to some of the toughest conditions for growing crops and raising livestock.

To be clear, African farmers face huge challenges due to climate change. Although sub-Saharan Africa accounts for only about four percent of the world’s carbon emissions, the continent is bearing the brunt of climate change impacts. Climate-related losses on many African farms are more than double those seen globally. In Makueni County, where Mary farms, yields of maize have been falling since 1994, largely due to changes in the weather.

While more innovation is needed to help Africa’s smallholder farmers keep pace with the threats posed by climate change, Mary and other farmers in Kenya are adopting some incredible new tools and practices that can limit crop losses and help their farms thrive even in extreme weather:

As farms go, Mary’s farm is quite small. Just about 4 acres, which is typical for farms in Africa. Still, she packs a lot of activities in this space, growing commercial and subsistence food crops and rearing poultry and livestock. In sub-Saharan Africa, more than half of the population works in agriculture. Together, they produce about 80 percent of the continent’s food supply. And most of the people doing the backbreaking farm work—like the chores I performed—are women.

I was impressed by Mary’s entrepreneurial spirit and her optimism. She appeared to seize every opportunity to try out new technologies and agricultural practices. It’s one of the reasons why she was trained as a model farmer and Village Based Advisor by the Cereal Growers Association, an organization that works with smallholder farmers to help improve their productivity. In this role, Mary provides guidance to several hundred farmers in her community, showing them how to use drought-tolerant seeds, raise chickens, and adopt other climate adaptation agricultural strategies.

She is clearly doing a good job in this role because more than 90 percent of farmers in her area have embraced one of the new adaptation practices.

I look forward to hearing how the seeds I planted with Mary are doing, despite the disappointing rains in recent months. I can’t imagine them in better hands than hers.

Thanks so much for the visit, Mary!

In the introduction to his latest book, How to Feed the World, Vaclav Smil writes that “numbers are the antidote to wishful thinking.” That one line captures why I’ve been such a devoted reader of this curmudgeonly Canada-based Czech academic for so many years. Across his decades of research and writing, Vaclav has tackled some of the biggest questions in energy, agriculture, and public health—not by making grand predictions, but by breaking down complex problems into measurable data.

Now, in How to Feed the World, Vaclav applies that same approach to one of the most pressing issues of our time: ensuring that everyone has enough nutritious food to eat. Many discussions about feeding the world focus on increasing agricultural productivity through improved seeds, healthier soils, better farming practices, and more productive livestock (all priorities for the Gates Foundation). Vaclav, however, insists we already produce more than enough food to feed the world. The real challenge, he says, is what happens after the food is grown.

This kind of argument is classic Vaclav—questioning assumptions, forcing us to rethink the way we frame problems, and turning conventional wisdom on its head. His analysis is never about the best- or worst-case scenarios; it’s about what the numbers actually tell us.

And the numbers tell a striking story: Some of the world’s biggest food producers have the highest rates of undernourishment. Globally, we produce around 3,000 calories per person per day—more than enough to feed everyone—but a staggering one-third of all food is wasted. (In some rich countries, that figure climbs to 45 percent.) Distribution systems fail, economic policies backfire, and food doesn’t always go where it’s needed.

I’ve seen this firsthand through the Gates Foundation’s work in sub-Saharan Africa, where food insecurity is driven by low agricultural productivity and weak infrastructure. Yields in the region remain far lower than in Asia or Latin America, in part because farmers rely on rain-fed agriculture rather than irrigation and have limited access to fertilizers, quality seeds, and digital farming tools. But even when food is grown, getting it to market is another challenge. Poor roads drive up transport costs, inadequate storage leads to food going bad, and weak trade networks make nutritious food unaffordable for many families.

And access is only part of the problem. Even when people get enough calories, they’re often missing the right nutrients. Malnutrition remains one of the most critical challenges the foundation works on—and it’s more complex than eating enough food. While severe hunger has declined globally, micronutrient deficiencies remain stubbornly common, even in wealthy countries. One of the most effective solutions has been around for nearly a century: food fortification. In the U.S., flour has been fortified with iron and vitamin B since the 1940s. This simple step has helped prevent conditions like anemia and neural tube defects and improve public health at scale—close to vaccines in terms of lives improved per dollar spent.

One of the most interesting parts of the book is Vaclav’s exploration of how human diets evolved. Across civilizations, people independently discovered that pairing grains with legumes created complete protein profiles—whether it was rice and soybeans in Asia, wheat and lentils in India, or corn and beans in the Americas. These solutions emerged from practical experience long before modern science could explain why they worked so well.

But just as past generations adapted their diets to available resources, we’re now facing new challenges that require us to adapt in different ways. Technology and innovation can help. They’ve already transformed the way we produce food, and they’ll continue to play a role. Take aquaculture: Once a tiny industry, it’s grown over the past 40 years to supply more seafood for the world than traditional fishing—a scalable way to meet global protein demands. The Green Revolution is another example. Beginning in the 1960s, innovations in higher-yielding crops, more effective fertilizers, and modern irrigation prevented widespread famine in India and Mexico. These changes were once seen as unlikely, too.

New breakthroughs could drive even more progress. CRISPR gene editing, for instance, could help develop crops that are more resilient to drought, disease, and pests—critical for farmers facing the pressures of climate change. Vaclav warns that we can’t count on technological miracles alone, and I agree. But I also believe that breakthroughs like CRISPR could be game-changing, just as the Green Revolution once was. The key is balancing long-term innovation with practical solutions we can implement immediately.

And some of these solutions aren’t about producing more food at all—they’re about wasting less of what we already have. Better storage and packaging, smarter supply chains, and flexible pricing models could significantly reduce spoilage and excess inventory. In a conversation we had about the book, Vaclav pointed out that Costco (which might seem like the pinnacle of U.S. consumption) stocks fewer than 4,000 items, compared to 40,000-plus in a typical North American supermarket.

That kind of efficiency—focusing on fewer, high-turnover products—reduces waste, lowers costs, and ultimately eases pressure on global food supply, helping make food more affordable where it is needed most.

How to Feed the World had a lot to teach me—and I’m sure it will teach you a lot, too. Like all of Vaclav’s best books, it challenges readers to think differently about a problem we thought we understood. Growing more and better food remains crucial—especially in places like sub-Saharan Africa, where there simply isn’t enough. But as the world’s population approaches 10 billion, increasing agricultural productivity alone won’t solve hunger and malnutrition. We also need to ensure that food is more accessible and affordable, less wasted, and just as nutritious as it is abundant.

After all, the goal isn’t to make more food for its own sake—it’s to feed more people.

What’s for dinner?

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

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

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

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

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

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

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

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

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

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

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

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

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

I’ve 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.

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. 

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

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

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

I've 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.

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

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

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

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

Can computers see? The answer is complicated. I've been following the field of computer vision for decades—ever since Paul Allen and I started dreaming about what you could do with a personal computer—and we're only now reaching the point where they can really understand visual inputs. We still have a long way to go, but the ability of computers to see things is already revolutionizing many parts of our lives. It makes autonomous vehicles possible. It’s used to read x-rays quickly and accurately, and it’s what allows a mobile phone to translate street signs from one language to another.

Lately I’ve been especially enthused about a different application (and one my teenage self never would’ve imagined caring about): scanning pictures of mosquitoes.

Mosquitoes are responsible for spreading malaria, which kills more than 600,000 people every year and is a major focus of the Gates Foundation’s health work. Although scientists have learned a lot about them in the past few decades, one challenge has been especially stubborn: telling one mosquito from another. There are around 3,500 different species of them, and many look alike. Even a highly trained entomologist has to examine one for several minutes under a microscope to identify it accurately.

Why do we care about mosquito species? Most importantly, because different species can carry different diseases, and some don’t carry any diseases at all. (The ones that carry malaria belong to the genus Anopheles.) There are other differences too: Some bite people indoors, while others feed outdoors. Some dine at dusk while others take their meals during the day. And only females bite—the blood gives them the energy needed to lay eggs.

All this variation means we need different tools for different mosquitoes. For example, indoor insecticides and bednets work well against species that primarily bite indoors. But for the ones that mainly live and feed outside, you’ll need to take other steps too, such as eliminating the outdoor spaces where they breed.

Fortunately, some novel uses of computer vision are supercharging the process of identification. They’re not only helping us know our opponent, they’re helping us target its weak spots, save more lives, and move even closer to eradicating malaria.

One of the most exciting innovations is called VectorCam—an app that lets someone with minimal training identify mosquito species in a matter of seconds.

VectorCam was developed by Dr. Soumya Acharya and his team of bioengineers at Johns Hopkins University, with support from Uganda’s malaria control program, Makerere University, and the Gates Foundation. Using a smartphone, the VectorCam app, and an inexpensive lens attached to the phone, you simply take a picture of a mosquito and get it identified right away. The app can distinguish among the different species that transmit malaria. It can also determine the sex of the mosquito and, if the insect is a female, whether it has recently fed on blood or developed eggs. And with further refinement, VectorCam could identify species that carry other diseases, like dengue and Zika.

Of all the things I thought would help fight malaria, 100-year-old mosquitoes would not have been high on the list. Then I learned about the work of Dr. Mara Lawniczak.

An evolutionary geneticist at the Wellcome Sanger Institute in the United Kingdom, Mara has spent much of her career trying to understand how the genomes of various mosquito species have changed in response to humans’ attempts to kill them. When, where, and how fast has it happened? What does that say about how they might evolve in the future?

In recent years, genetics has become an increasingly important tool for fighting malaria. Because mosquitoes breed so fast (a female can lay thousands of eggs in her lifespan of a couple of weeks), they evolve rapidly, at least compared to humans. By studying their genes, researchers are able to understand things like how they develop resistance to insecticides, crucial information that helps humans stay one step ahead.

After a few years of studying mosquitoes’ genomes, Mara had grown frustrated by the fact that the only insects available for study were ones that had been captured recently. Without DNA from their ancestors, there was no way to know how their genomes had responded to decades of human attacks. “We were often saying, ‘If only we could look into the past,’” Mara says. “And then it suddenly struck me: I'm sure there are historical collections of mosquitoes around.”

She was right. The Natural History Museum in London has a collection of 34 million insects from all over the world, carefully collected and preserved. Among the collection is a large sample of mosquitoes dating from 1936, when a British entomologist named H.S. Leeson spent a year in East Africa capturing and cataloguing the insects in the hope of learning more about malaria. Leeson didn’t know it at the time—DNA wouldn’t be discovered until the 1950s—but his collection of mosquitoes would become a vast source of genetic material that someone like Mara could study.

Mara reached out to the museum’s curators. They wanted to help, but there was a problem: Extracting DNA from the insects would require Mara to grind them up. Since the museum’s mission is to preserve its collection for future generations, they couldn’t let her do that.

So Mara and her colleagues invented a way around the problem. Working with the museum’s team, they developed a novel way to extract DNA from mosquitoes without damaging the specimen.

They affectionately call this work Project Neandersquito. It’s not because the mosquitoes date from the time of Neanderthals, some 40,000 years ago—this isn’t Jurassic Park, where they extract dinosaur DNA from a prehistoric mosquito trapped in amber. It’s because the mosquitoes they’re studying are 1,000 or 2,000 generations removed from modern ones, just as Neanderthals are more than 1,000 generations removed from modern humans.

Mara’s team has made some surprising finds. For example, because mosquitoes started developing resistance to the insecticide DDT in the 1950s, they expected to see genetic mutations for resistance appearing around the same time. But they didn’t. “We still don't see them even as late as the 1980s,” she says. “So the mosquitoes were somehow making themselves resistant to DDT in ways that we still don't really understand.”

They also hope to get insight into what's coming. “How fast can mosquitoes evolve? And as we throw new control initiatives at them, how quickly are they going to get around them?” Other labs are now using the process devised by the Lawniczak Group to do their own research.

Project Neandersquito is just one of the ways Mara and her team are using genomics to advance the fight against malaria. A different project, the Malaria Cell Atlas, is providing new genetic data that could inform the effort to make better malaria drugs and vaccines. Another project is designed to make it easier and cheaper to identify a mosquito’s species using its DNA—it’s surprisingly hard to do just by looking—as well as whether it’s carrying the parasite that causes malaria, and even which species of the parasite it has. Ultimately, the project’s goal is to help governments get data that will help them get the most out of their anti-malaria efforts.

Mara would be the first to say that these are just a few examples of the tools the world needs to eradicate malaria. It’s going to take global cooperation from governments, the private sector, and academia. And now we can add natural history museums to the list.

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.

About 10 years ago, the African country of Djibouti had nearly succeeded in wiping out malaria. The country’s leaders hoped that getting rid of the disease would help them attract new investment, development, and tourism.

Then suddenly the disease roared back. Cases surged from just 27 in 2012, to more than 73,000 in 2020—a huge number for this East African nation of just one million people.

The cause?

A highly invasive mosquito that had migrated from South Asia and the Arabian Peninsula into Africa.

This pest—the Anopheles stephensi mosquito—has now emerged as one of the biggest threats to malaria elimination in sub-Saharan Africa. Since establishing a beachhead in Djibouti, An. stephensi mosquitoes have been detected in Ethiopia, Sudan, Somalia, Kenya and as far away as Nigeria and Ghana, in West Africa. According to one study, if this mosquito is left unchecked an additional 126 million people on the continent will be at risk of malaria.

What makes An. stephensi particularly dangerous is where it has chosen to reside. Unlike other malaria-carrying mosquitoes in Africa that primarily breed in rural areas, An. stephensi thrives in urban environments. Cities are already home to 40 percent of the population in sub-Saharan Africa and continue to experience rapid growth, creating a fertile habitat for this mosquito. Making matters worse, An. stephensi has been found to be resistant to many of the insecticides used to control mosquito populations. And they bite in the evening before bedtime—not in the middle of the night like other mosquitoes—making bed nets less effective as protection.

But this story doesn’t end here.

In 2018, the government of Djibouti, in search for a new approach to combat these urban invaders, heard about a biotechnology company called Oxitec that has a potentially game-changing solution to mosquito control.

The fight against mosquitoes and the diseases they carry has always been a game of cat and mouse. Humans develop new interventions—like bed nets, insecticides, and treatments—to protect themselves from mosquitoes. Mosquitoes, meanwhile, have an incredible capacity to adapt, allowing them to eventually dodge or develop resistance to the latest control methods. Then humans respond with more innovations to outsmart the mosquitoes. And so on.

Oxitec, however, aims to change this game from cat versus mouse to mouse versus mouse. Or in this case, mosquito versus mosquito. Oxitec specializes in using mosquitoes to fight other mosquitoes. With its genetic technology, Oxitec has already developed mosquitoes to effectively combat the dengue fever–carrying mosquito, Aedes aegypti, in Brazil. Now Oxitec plans to use the same technology to help African governments control An. stephensi and reduce the spread of malaria.

Here’s how Oxitec’s technology would work against An. stephensi mosquitoes: Oxitec male mosquitoes carry a special gene to prevent their female offspring from surviving into adulthood. (Only female mosquitoes bite and spread malaria.)  Released into the wild, the male Oxitec mosquitoes mate with wild female mosquitoes. All the female offspring die. All the male progeny, which don’t bite, will survive and go on to mate with other wild females. With sustained releases of male Oxitec mosquitoes, more females die off, dramatically reducing the mosquito population and the spread of malaria. After the mosquito releases stop, however, because half of the gene’s carriers (the females) cannot survive, the gene steadily declines and disappears from the mosquito population within a few generations.

Genetic technology like Oxitec’s understandably raises many questions. Is it safe? What are the lasting environmental impacts? Here’s what’s important to know:

Because it’s passed through mating, the gene the Oxitec male mosquitoes carry only targets the An. stephensi mosquitoes. It doesn’t have any impact on other insects and cannot be established in the local ecosystem. After evaluating the potential risk of genetically modified mosquitoes, the U.S. Food and Drug Administration in 2016 and the EPA in 2022 have confirmed that the Oxitec mosquitoes do not pose a threat to humans or the environment. More than one billion Oxitec mosquitoes have been released worldwide, with no negative impacts. In Brazil, the Oxitec Aedes aegypti mosquitoes have been so successful in reducing the spread of dengue fever that they are in demand by communities, governments, and businesses in Brazil. Homeowners can even buy a kit to raise the mosquitoes in their own backyards. (If you want to learn more about this technology, I encourage you to visit the Oxitec website and the Centers for Disease Control and Prevention.)

Last year, the government of Djibouti formed a partnership with Oxitec, Association Mutualis (a non-profit public health organization in Djibouti), and the Djibouti National Malaria Control Programme to use this new technology to defeat An. stephensi.

No Oxitec mosquitoes have been released in Djibouti during the current pilot phase of the project. But the government of Djibouti expects to move forward with the first releases of Oxitec mosquitoes next year in Djibouti’s capital city, where 70 percent of the population live.

This solution is being pursued with the support of the people of Djibouti. The government of Djibouti, Oxitec, and its local partners have been working together to educate and engage the public about this technology, going door to door to listen to their concerns, and ensuring all the communities’ questions have been addressed before moving forward with the release of the mosquitoes. Local support has been outstanding to date.

To end malaria, we need many new tools and innovations to reduce the burden of this disease and move the world closer to eradication. I’m excited about the potential of Oxitec’s technology to help Djibouti and the rest of Africa achieve this goal.

Each year, I love sharing stories from around the world about the incredible work being done to fight malaria. Sometimes, though, those stories are best told firsthand. That’s why I invited Professor Charles Wondji—a malaria researcher, mosquito geneticist, and executive director of the Centre for Research in Infectious Diseases in Cameroon—to share his.

Dr. Magellan Tchouakui, Cameroon, Medical Entomology and Vector Control

Dr. Tchouakui is an expert in assessing the impacts of insecticides on major African malaria vectors’ abilities to survive and reproduce. He’s passionate about putting that research to use, and leads the testing of many companies’ novel insecticide formulations to improve bed nets and indoor-residual sprays.

Dr. Mersimine Kouamo, Cameroon, Functional Genomics

Dr. Kouamo employs tools such as transgenesis to “knock down” certain genes in mosquitoes, allowing her to study the genes’ functions and understand which ones enable the mosquitoes to withstand insecticide exposure. She is also a role model to younger female scientists.

Dr. Leon Mugenzi, Rwanda, Molecular Genetics of Vectors

Dr. Mugenzi’s interest is in providing and improving the tools used to control the spread of malaria. During his PhD work at CRID, he designed the first DNA-based diagnostic tool to detect metabolic resistance in mosquitoes to insecticides, which helps prolong the effectiveness of bed nets.

Are you a mosquito magnet? If you don’t seem to get your unfair share of mosquito bites every summer, chances are you know someone who does. Some people are just more attractive to the pests than others.

The reason why is probably how you smell. Mosquitoes rely on their sense of smell to find their targets, and they’re drawn to certain odors naturally produced by the human body. Although some people may be a little more attractive, the unfortunate truth is that we all smell like a delicious meal to mosquitoes. You can hide yourself for a while using a bug spray like DEET or treating your clothes with permethrin. But if you want sustained protection, you have to add another step to your routine, which not everyone has the time to do or can afford.

There’s good news on the horizon, though: A company called dsm-firmenich is working to make repelling mosquitoes as easy as washing up in the morning.

I actually visited dsm-firmenich’s lab in Geneva back in 2016, when I checked out their innovative work to improve sanitation for the world’s poorest by reducing toilet odors. The nutrition, beauty, and health company is one of the world’s largest manufacturers of flavors and fragrances. Most of their products are used to make our food taste better and our household products smell more appealing, but they also have a history of using their scent expertise to fight disease transmission. Their latest efforts are focused on stopping mosquitoes, because the diseases they carry kill hundreds of thousands of people each year, most of whom are children in low-income countries.

The team’s goal is simple: Incorporate scents that repel mosquitoes into everyday products. After doing extensive research into the household products used most frequently in places where mosquito-borne diseases are common, they decided to focus mostly on bar soap and powdered laundry detergent. (They’re also thinking about other things like body lotion and body cream.) These products are already scented with a fragrance—what if that fragrance also helped keep mosquitoes away?

The idea is that you gain an added halo of protection without having to add any new steps to your daily routine or buy any new products. No one at dsm-firmenich thinks this kind of protection will be a silver bullet, but their hope is that, when combined with other proven tools like bed nets, people can significantly and sustainably lower their risk of catching deadly diseases like malaria and dengue.

Making a bar soap that gives you all-day protection against mosquitoes is a lot more complex than just infusing it with citronella. The scientists in Geneva started by identifying a wide array of scent ingredients that keep the pests away and are commonly used to create perfumes. Some of these ingredients are true repellants, giving off a smell that causes mosquitoes to fly in the opposite direction. Others block receptors in the mosquito’s brain that usually perceive and draw them to humans.

As they were combining the ingredients to create new fragrances, the team knew they had to keep a human-centered design approach in mind. The best candidates wouldn’t necessarily be the most effective—they also had to smell clean and fresh. I love the smell of cheeseburgers, but I don’t think I’d want my laundry to smell like them every day even if they protected me from mosquitoes!

To test the most promising odors, researchers used a tool I know all too well: The arm-in-cage test, where a human puts their arm—which has been coated in the fragrance being studied—into an enclosed area filled with hundreds of mosquitoes. Sensors track how the mosquitoes respond and whether they’re biting the arm. The team considered any test with two mosquito bites a failure.

Behavioral tests like those being done in collaboration with the Swiss Tropical and Public Health Institute are still ongoing, but they’ve already revealed some surprising results. One of the most effective fragrances so far smells like lily-of-the-valley, a light floral scent that is commonly used in perfumery. It’s exactly the kind of fresh scent that people like in their soaps and laundry detergents. The team’s early results indicate that some lily-of-the-valley odors could be as effective as DEET when used at certain doses.

The next step is the most difficult, and it remains to be seen whether it will succeed. The mosquito experts at dsm-firmenich have handed off the best scent candidates to the company’s product formulation experts and perfumers, who are now looking for ways to make them last all day in consumer products.

It’s a tall order. Scent ingredients are fragile, and activities like scrubbing your hands or washing your clothes cause them to vanish quickly. (Think about how quickly that freshly laundered smell can fade from your clothes.) A perfume that protects you from mosquitoes all day will likely end up being the result of a whole lot of innovation and a complex combination of different scents, rather than one single ingredient. And, of course, the final result has to smell good enough that people are willing to use it every day.

Still, I’m optimistic the scent wizards in Geneva will find a way. The Gates Foundation is supporting their research with the hope that, one day, people in high-risk areas will gain more mosquito protection without having to do any extra work or spend any extra money. When the world gives children and families more tools to protect themselves, we save lives—and take the bite out of the world’s deadliest animal.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The world is so close to ending polio.

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

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

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

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

Her name is Shumaila Rehmani.

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

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

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

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

But Shumaila doesn’t give up.

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

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

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

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

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

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

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

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

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

Most people today probably don’t know what this is.

And that’s a good thing because it shows how much progress the world has made against polio, a terrible and now largely forgotten disease.

This metal tank is an iron lung, a mechanical respirator that saved the lives of thousands of polio victims.

Polio attacks the body’s nervous system, crippling patients. In the worst cases, the disease paralyzes their respiratory muscles and makes it difficult for them to breathe, sometimes resulting in death. 

Using changes in air pressure, the iron lung pulls air in and out of a patient’s lungs, allowing them to breathe and stay alive.

During the height of the polio epidemic in the U.S. in the 1940s and 1950s, rows of iron lungs filled hospital wards to treat thousands of polio patients, most of them children.

Whenever someone asks me why I believe it’s possible to eradicate polio, I tell them about my 2010 trip to India to visit one of the country’s lowest castes—the Musahar.

Today, India is polio free. But less than a decade ago, more than half the world’s cases of polio could be found in India. At the time, many health experts said that India would be the last place on Earth to stop polio because its high birth rate, poor sanitation, and population density allowed the disease to flourish.

So how did they wipe out the disease?

The answer can be found in the remote marshlands of the Kosi River in the Indian state of Bihar. The region is home to one of the poorest, most underserved castes in India, the Musahar. In 2010, vaccinating the Musahar and other people living in remote, high-risk areas was one of the biggest obstacles India faced in its long campaign to end the paralyzing disease. Thousands of children were being missed during the national immunization drives, allowing the disease to continue to spread.

In response, the Indian government launched an all-out effort to reach every child, employing a new communication campaign to mobilize support for polio immunization and better maps to ensure that no family was missed. They deployed more than 2 million vaccinators who covered every speck of the country, including the Musahar village I visited, which was often inaccessible because of flooding from the Kosi River. (One of the most inspiring photographs of that time was an image of polio workers wading waste deep in water to reach remote villages with the polio vaccine.)

By 2014, India achieved its goal of being polio free, proving that the paralyzing disease could be defeated in the most complicated circumstances. With new ties to even the remotest communities, health workers are providing children with much more than the polio vaccine. They continue to work with local communities to improve the delivery of other critical health services, including maternal and newborn care, as well as vaccinations for measles and other preventable diseases.

India’s experience continues to be an inspiration for the world’s final push to wipe out polio in the three countries where it endures: Afghanistan, Pakistan, and Nigeria. Based on the latest figures, in 2017, there were just 21 identified cases of wild poliovirus in the world—the lowest number ever—down from 350,000 cases per year when the global polio eradication effort launched in 1988.

That’s an incredible achievement. But now is no time for complacency. If polio is a threat anywhere in the world, it is a threat to us all. That’s why it’s more important than ever for the world to continue to support the millions of vaccinators who are working tirelessly to finish the job. Their dream, as is mine, is to see the day that polio is defeated.

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

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

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

Have you ever heard a story that was so cool you couldn’t help telling everyone you met about it? Something you knew and wished that everyone else did too?

That’s how I feel about the people whose work I get to learn about through the Gates Foundation. Every day, around the world, they save lives and help people lift themselves out of poverty. Some are scientists. Others are educators, nurses, midwives, or advocates. Their work is so inspiring to me that I’ve committed virtually all of my wealth to supporting it.

When I see how much passion people like Josephine have for helping themselves and their neighbors, I’m inspired to help too. I hope these stories will be as inspiring for you as they are for me.

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

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

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

I’ve been visiting India since the 1990s, and I’m on my way to visit again this week. Over the years, I’ve learned about its rich history and visited some of its stunning monuments, including the Taj Mahal.

But when I think about India’s most important contributions to the world, these are not the first things that come to mind. India’s greatest gift is its ability to innovate.

This country has a long history of important breakthroughs. (Mathematicians in ancient India are widely credited with introducing the decimal system for numbers.) More recently, India has made advances that are saving and improving millions of lives in India and around the world. The Gates Foundation has been a partner in some of these efforts, and I’m visiting this week to learn about how we can continue working with India to help its ideas and inventions reach everyone who needs them, no matter where they live. This will be a main topic when I meet with Prime Minister Modi this week.

Health is one area where India is making a big difference. This country is the world's largest producer of vaccines—it supplies more than 60 percent of all vaccines distributed by Gavi, the organization that has helped vaccinate more than 1 billion children in lower-income countries. Indian companies pioneered the creation of high-quality, low-cost vaccines and drugs, leading the world in making affordable treatments for diseases like HIV/AIDS as well as vaccines for rotavirus, pneumococcal pneumonia, and COVID. The government has helped deliver huge supplies of vaccines to its own people and to other low- and middle-income countries, and now it’s looking to do the same for medical devices and diagnostics.

Thanks in large part to India, developing countries now get new medicines and vaccines much faster than they used to. I rank these efforts as one of the most important health achievements ever. (We’ve made progress, but we’re not done. The world should still do more to shrink the gap between when a drug or vaccine becomes available in rich countries and when it reaches lower-income ones.)

Another area where I admire India’s innovative spirit is what’s known as digital public infrastructure, or DPI. In short, DPI refers to the digital platforms and tools that help deliver various services. India’s biometric identity program, Aadhaar, covers more than 1.4 billion people, allowing them to take advantage of all kinds of government services without needing a photo ID. UPI, a digital payment system that ensures that the person you’re doing business with is who they say they are, processes more than 12 billion transactions a month.

During my trip I’ll get to see India’s DPI in action. I’ll visit an agricultural monitoring center in the state of Odisha where government officials use DPI to give farmers real-time guidance. Thanks to Aadhaar, this center is able to maintain a registry of 7.5 million farmers—even if they don’t own land—and their crops, so officials can keep track of who is growing what (and, therefore, what kind of farming advice they need). It has also developed a chatbot that makes it easy for farmers to get the latest information about their crops, using AI to tailor content to their particular needs and in their local language.

This service’s pest-management program now reaches more than 4 million farmers, and since it began in 2018, the volume of crops that participating farmers lose to pests every year has dropped by 90 percent. Now others—including other states in India as well as Ethiopia, Sri Lanka, and the World Bank—are looking to learn from Odisha’s experience with this service as well as its biometric ID and digital payments systems.

I'm also looking forward to learning more about how India is addressing urban poverty, especially among women. It has one of the fastest-growing urban populations in the world, and more than 100 million people there live in slums, where it’s hard and often impossible to get even basic services like health, education, and clean water. Women are particularly vulnerable because they face discrimination and violence.

This week, I’ll visit a low-income community in Odisha where a government program is helping women get the skills to fulfill government construction contracts. Since 2018, this program has helped 22,000 groups of women deliver on more than 52,000 projects including building roads, drains, and toilets.

This program could be a model for other countries that are facing similar challenges. The women who participate in it are partners in creating the projects: They get training in engineering, accounting, negotiating contracts, and other skills, and they’re involved in planning the project, making a budget, doing the construction, and doing maintenance on whatever they build. I'm looking forward to meeting a few women who are part of this program so I can hear about the challenges they face and the successes they’ve had.

India’s capacity to innovate will also become increasingly important to stopping climate change. Indians are already being affected by higher temperatures and less-predictable weather, and eliminating the greenhouse gases that are causing the problem is a huge scientific challenge. So it’s great that India is ramping up its ability to invent, manufacture, and deploy climate breakthroughs. The government is investing in research to raise the productivity of crops and livestock even in a warmer climate, and it’s expanding its plans for clean energy.

These are just a few of the ways in which India's innovations are changing the world. I could list many more, and I’m sure I’ll learn about a few new ones during my visit. I’m looking forward to speaking with government leaders, CEOs, and students who will drive innovation in India. This country has a lot to offer, and I'm optimistic that it will continue to lead the way in creating a more equitable world.

I’ve been a big fan of Brazil for a while. I first visited back in 1995 when Microsoft was building out our operations there, including working with one of the national banks to launch home banking. And some of my favorite family trips have been to the Amazon, whose river, basin, and rainforest come up often during conversations on climate change. But it wasn’t until I began working in public health that I started appreciating just how impressive the country’s track record in this area is—and how much the rest of the world could learn from it.

In roughly three decades, Brazil has cut maternal mortality by nearly 60 percent, slashed under-five child mortality by 75 percent—far outpacing global trends—and increased life expectancy by almost a decade. None of these achievements was accidental. Instead, they’re the result of long-term, laser-focused investments Brazil has made in its primary healthcare system that other countries can learn from and emulate.

The story starts in the late 1980s. Two decades under military dictatorship had turned Brazil into one of the least equitable countries in the world. In 1985, the country became a democracy; a few years later, it created a universal health system.

In the decade that followed, deaths from non-communicable diseases and maternal, neonatal, and nutritional causes all started to decline, and life expectancy rose. With an increase in primary healthcare services, even hospitalizations dropped.

But it’s one thing to guarantee healthcare. It’s another thing to fund it—and another thing entirely to make sure it reaches the people who need it most. While Brazil had been making progress, there was much more to do. So at the turn of the century, the government accelerated its efforts and took steps to close the gaps in its healthcare system, including a dramatic increase in healthcare spending. One of the most important steps was massively expanding the size and scope of its community health worker (CHW) program.

Community health workers are trained public health professionals who work within communities, especially in remote or underserved areas. While their roles vary around the world based on local needs, they generally include things like disease tracking, vaccine drives, and basic health screenings.

In Brazil, CHWs had already shown they could improve public health access and outcomes during a pilot program in the Ceara state. As federal funding for primary healthcare increased, almost fivefold in fifteen years, the ratio of CHWs tripled.

Today, Brazil has over 286,000 CHWs who serve almost two thirds of the population—almost 160 million people.  Each one visits about 100-150 households a month, offering guidance on health and hygiene, advocating for preventive care, following up after medical appointments, collecting socioeconomic data, and helping people navigate other government services.

In Brazil, CHWs act as the front door to the world’s largest universal free public healthcare system, and their impact has been transformative. They’re credited with further cutting child mortality and pushing immunization coverage to near-universal levels. (Unfortunately, the pandemic impacted vaccination rates, but there are efforts underway to bring them back up.)

The country’s Bolsa Familia program—which provides cash transfers to poor families if they meet certain conditions, including vaccination for children and prenatal care—deserves credit too. Expanded in tandem with primary healthcare, Bolsa Familia is just one of the many social programs Brazil has built out over the past few decades that have helped lift almost a fifth of the country’s population out of poverty. But it’s also helped broaden healthcare access and usage by giving people an incentive to enter the healthcare system—which is how Bolsa Familia has contributed to reductions in child mortality as well.

I’ve been able to learn about these initiatives through the Gates Foundation's partnership with Brazil's Ministry of Health—which has focused on combatting malaria, improving vaccine production, leveraging local brainpower to address global health issues, and documenting the impact of social and health programs through data sciences. And I’ve been really impressed.

Of course, despite all the progress that’s been made in recent decades, Brazil still faces challenges. Financial crises and austerity budgets have led to cuts in healthcare spending, for example, and there are still districts where poorer residents have no access to CHWs.

But Brazil’s healthcare system doesn’t have to be perfect to serve as proof of what happens when a country invests strategically in care for its most vulnerable: The returns are often far-reaching and life-changing. 

That is why Brazil is highlighted by the Exemplars in Global Health program, which I helped launch in 2020. The program's mission is to identify countries that have made remarkable progress on health problems, understand the keys to their success, and share those insights globally so others can make similar progress. By that standard, Brazil has a lot to teach.

That’s not to say any country can or should replicate Brazil’s approach exactly, since no two countries are alike. But with the right mix of investment and innovation, Brazil has made great strides in becoming a healthier place for its people. If the country continues on that path and keeps doing what it’s done well already, and if other countries follow—or simply forge their own paths with Brazil in mind—we’ll have a healthier world, too.

I had an amazing trip to Senegal last month. I always love getting the chance to travel and see the remarkable work the foundation’s partners are doing firsthand. These visits leave me more energized than ever to go to work every day—and my time in Senegal was no exception.

Senegal is a particularly interesting country to visit, because it has made exemplary progress improving the health of its people thanks to a focus on community-led care and many years of smart policymaking. Some of the statistics are mind-blowing: Since 1992, the country has cut its stunting rate in half. Since 2000, the number of Senegalese children who die before their 5^th birthday has dropped by 70 percent. And since 2005, the number of women giving birth in health facilities has increased from 62 percent to 80 percent. It’s the perfect place to talk about progress.

One of the highlights of my visit was a trip to the Institut Pasteur de Dakar, or IPD—a research center that has been pushing the frontiers of global health for nearly a century. The facility does it all: IPD plays a key role in monitoring for disease outbreaks in the region; produces millions of diagnostics every year; serves as an educational hub for the next generation of health workers and biomanufacturing workers; and will soon resume manufacturing vaccines.

It was inspiring to meet with brilliant Senegalese scientists who are doing remarkable work to keep their country healthy. Senegal’s health transformation is, in large part, a testament to their dedication and deep understanding of their communities, and I loved talking to them about how they’re constantly evolving to meet the needs of the moment. For example, when COVID hit in 2020, IPD quickly built up a test manufacturing facility. They’re now in the process of expanding that capacity so they can produce other essential tests, like one for measles and rubella.

I was also excited to attend the annual meeting of the Grand Challenges initiative in Dakar last month. The Gates Foundation launched Grand Challenges 20 years ago with a single goal in mind: to identify the biggest problems in health and give grants to the researchers who might solve them. Our hope was to inspire more brilliant scientists to think more ambitiously about transforming health in low-income countries. We hoped to create a scientific community that had support to sustain R&D for the benefit of billions of people whose health needs had been neglected.

In 2003, we put forth 14 Grand Challenges. The initial list included developing a vaccine that didn’t require refrigeration, creating a TB treatment for latent infection, and inventing a needle-free drug delivery system. In the years since, we’ve issued more than 200 challenges—and we even launched our first AI-specific call-to-action earlier this year.

I was lucky to spend a lot of time in Senegal with amazing scientists working on the next big breakthrough. Here are 5 of the coolest innovations I saw:

1. An AI trainer that teaches health workers in India how to treat high-risk pregnancies. Here’s a devastating statistic: One woman dies in childbirth every 2 minutes. Amrita Mahale and the team at ARMMAN are using artificial intelligence to improve the odds for new mothers in India. Their large language model will one day teach health workers how to treat high-risk pregnancies. The training chatbot can be used in both English and Telugu, and the coolest part is that it automatically adjusts to the experience level of the person using it. Whether you’re a brand-new nurse or a midwife with decades of experience, ARMMAN’s trainer can arm you with the knowledge needed to save lives.
2. A low-cost mRNA vaccine platform that puts manufacturing where it’s needed most. mRNA vaccines helped prevent millions of deaths during the height of the COVID pandemic. A company called Quantoom developed a new platform that will make it cheaper and easier to build and run factories that can be adapted to make different mRNA vaccines. I was proud to announce that the foundation is investing $40 million to scale up local mRNA vaccine manufacturing in low- and middle-income countries—which includes funding for IPD to use Quantoom’s platform. This will increase supply, lower costs, guard against the possibility of vaccine hoarding in emergencies, and provide a path for local scientists to discover and develop their own vaccines.
3. A new way of tracking mosquitoes on the molecular level to stop malaria. Cases of mosquito-borne diseases like malaria are increasing for the first time in decades. Although climate change is a big contributor, other reasons include conflicts and drug resistance. Fortunately, Isabella Oyier at the Kenya Medical Research Institute is fighting back against mosquito evolution. She uses molecular epidemiology to track mosquitoes who have the genes that cause drug resistance and integrate it into national malaria surveillance and monitoring efforts. This will give stakeholders more insight into where resistance is spreading—and how to stop it.
4. A novel approach to treating a common microbiome disorder. Our bodies are home to more microbial cells than human cells, and the good bacteria in our microbiome play an essential role keeping bad bacteria in check. When that balance is off, you get diseases like bacterial vaginosis—a common disorder that, among other problems, can make women more susceptible to HIV infection or more likely to give birth preterm. Today’s treatments are not very effective, so I was excited to talk to Meilin Zhu and her team about a new approach they’re exploring. It uses oleic acids to inhibit the growth of a “gateway” bacteria that can lead to more bad microbes, as well as promote the growth of the good bacteria. This research is still in its early stages, but it’s promising.
5. A new drug development platform that will make us better prepared for the next pandemic. Although the world made remarkable progress on vaccines when COVID struck, the same can’t be said for therapeutics. The team at Decoy Therapeutics is working to speed up the process of developing drugs with their promising new biologic platform. The idea is that lipopeptide molecules could be used to inhibit a virus’ fusion machinery and prevent it from infecting cells. If Decoy’s research pans out, scientists could one day use the platform to design therapies for novel viruses within days or even hours.

My time in Senegal reaffirmed my belief in the power of science and innovation. There is no question that our world faces some difficult problems. But when brilliant scientists dedicate their talents to taking on the world’s biggest challenges, progress becomes possible, and we move closer to a future when all people lead healthy lives.

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.

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

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

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

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

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

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

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

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

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

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

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

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.

When you see someone suffering from a terrible disease, it’s hard not to imagine a world where no one has to feel this way ever again. But the problem with eradication is that it’s really, really hard. The fewer cases remain, the more difficult it is to find them. That’s why, in all of human history, we’ve only eradicated two diseases: smallpox and the cattle disease rinderpest.

That might change soon.

The world is close to eradicating Guinea worm disease, a debilitating and painful condition that once devastated an estimated 3.5 million people in Africa and South Asia every year. Thanks to heroes like Makoy Samuel Yibi, that number dropped to 13 people in 2023.

As the national director of the South Sudan Ministry of Health’s Guinea Worm Eradication Program, Makoy helped reduce the number of cases in his country last year to just two. That’s a remarkable accomplishment by any standard, but it’s truly impressive when you consider the circumstances he and his team have faced: civil wars, the COVID-19 pandemic, the political changes brought by South Sudan’s decision to become an independent country in 2011, and the fact that the nation was once home to 90 percent of the world’s Guinea worm cases.

I recently caught up with Makoy at the COP climate conference in Dubai, where we both participated in an event focused on ending neglected tropical diseases, or NTDs, like Guinea worm. When you meet him in person, it’s hard to imagine a better person for the job. Makoy is passionate, brilliant, and laser-focused on making life better for the people of South Sudan. So I was surprised to learn that, as a young man, he never imagined a career in health.

Makoy was born in Terekeka County, a rural area located on the shores of the West Nile in southern Sudan. When he was a young man, Makoy had one primary focus: avoiding military service, which could be extremely dangerous. A chance meeting with a general from Terekeka resulted in a position with the national health department. A measles outbreak was ravaging parts of Sudan at the time, and Makoy’s first assignment was to travel from village to village providing care.

“What struck me,” he recalls, “was that, in every household we went to, we found at least half of the household was down with Guinea worm.”

The Guinea worm is a particularly nasty parasite. It’s unlikely to kill you, but the disease it causes—which is also called dracunculiasis, or “afflicted with little dragons”—can incapacitate you for months at a time and leave you permanently disabled. That can have devastating consequences if your family counts on you to grow the food you eat and sell it to make a living, as many people in South Sudan do.

The way the disease works is horrifying. If a person drinks water contaminated with Guinea worm larvae, the larvae enter the digestive system and mate. The impregnated female worm grows, undetected by the body’s immune system. Around a year later, the infected person will start to feel an itch somewhere on their body (usually the lower leg or foot). After a couple days, a painful blister appears and eventually bursts. The worm—which is now about one meter long—slowly starts to emerge from the wound.

This can take weeks or even months, and the pain it causes is excruciating. The wound can get infected, which could result in permanent disfigurement or even require amputation. And people often endure multiple worms emerging at the same time. Makoy has seen patients with as many as 40 worms.

And here’s the most insidious part: One of the few ways to relieve the pain of the blister is by soaking it in cold water, like a pond or a puddle. But that’s exactly what the worm wants. As soon as it touches water, it releases its larvae, starting the cycle anew. The Guinea worm is scarier and more efficient than any monster in a horror movie.

Makoy has seen countless times how devastating Guinea worm can be. “This is a situation where you see serious disruption of the livelihood of the community,” he says. “You see people going through a cycle of hunger because they don’t have enough. They have lost the window of cultivation. They’re not able to tend to their cattle, and there’s nothing they can do.”

There is no cure or treatment for Guinea worm, and yet, the world is on the doorstep of eradicating it. How? Through a series of highly effective interventions and a network of incredibly dedicated health workers.

Makoy’s team has built a network of volunteers in virtually every village in the country, who report rumors of Guinea worm cases. They spend every day searching for cases, getting the word out, and building trust in a country where more than 60 languages are spoken.

Makoy and his colleagues investigate every single rumor, no matter how remote. During the rainy season when the majority of cases happen, he often spends days hiking through the Sudd or up a mountain with all of his supplies on his back just to reach his destination. Last year, in a country the size of France with less than 100 miles of paved road, the team responded to nearly all of the 50,000 rumors they received within 24 hours.

Once the team finds a confirmed case, they make the patient as comfortable as possible and do what is called “controlled immersion.” This means soaking the affected area in a bucket of water and encouraging the worm to come out.

Makoy also spends a lot of time preventing people from getting Guinea worm in the first place. His team distributes free water filters and educates communities about safe water practices. The system they’ve built to support this work has strengthened health systems across the country, providing a platform for delivering other health services like childhood vaccination.

Makoy’s team has had a tremendous partner in all of this work: former U.S. President Jimmy Carter and the Carter Center. In 1995, when Makoy was first starting his public health journey, President Carter negotiated what remains the longest humanitarian ceasefire in history when he helped convince both sides of the Second Sudanese Civil War to lay down their arms and allow health workers access to treat Guinea worm and other diseases, like polio and river blindness. Today, the Carter Center continues to lead the global eradication campaign’s march to zero. The Gates Foundation is proud to support the Carter Center as part of our overall efforts to tackle NTDs. (You can learn more about Makoy’s partnership with the Carter Center in a new film called The President and the Dragon that is coming out later this year.)

Eradication is now within sight, although it won’t be easy to eliminate the last few cases. South Sudan previously reported no Guinea worm in 2018, but cases were subsequently discovered after a peace agreement was reached in the South Sudanese Civil War. And Guinea worm has recently been detected in dogs and other animals, mainly in Chad. Eradication will require stopping all transmission, both human and animal.

But Makoy Samuel Yibi is optimistic we can get there—and so am I. His determination to root out every last case makes me hopeful that we will someday soon celebrate the end of Guinea worm disease.

“In the places where Guinea worm has been eliminated,” he says, “you can actually see how communities have been energized. They are more active, and they are productive. The communities are now empowered to be more self-sufficient, because they don’t have to worry about Guinea worm.”

You may want to skip lunch—and probably avoid sushi for dinner—when visiting the world’s foremost museum of parasites in Tokyo.

At the quirky and endlessly fascinating Meguro Parasitological Museum, which I toured during my trip to Japan in August, you’ll find hundreds of stomach-turning displays featuring creepy parasite specimens.

Some of the strangest-looking ones have resided inside the bodies of fish, turtles, pigs, and other animals. But by far the most horrific specimens are the parasites that have chosen humans as their hosts.

What steals the show is the world’s longest tapeworm. In 1986, this garden-hose length parasite was discovered living in the small intestine of a Japanese man. He had dined on a piece of raw salmon that was infected with a tapeworm egg smaller than a grain of rice. Over the next three months it grew and grew until it reached 29 feet long! (If you’re a follower on my Instagram account, you may have gotten a glimpse of this impressive specimen.)

The man who recovered the tapeworm from this unfortunate patient was Dr. Satoru Kamegai, the founder of Meguro Parasitological Museum. A physician, Dr. Kamegai started practicing medicine after World War II. At the time the country’s water and sanitation systems were in ruins and many people throughout Japan suffered from parasitic diseases. Dr. Kamegai became fascinated by the strange world of parasites and started collecting them from his patients. In 1953, he opened a small museum to display his findings and raise awareness of these creatures. Dr. Kamegai passed away in 2002, but the museum has continued to operate as a private research and educational facility.

Today, the museum has a collection of 60,000 different parasites, about 300 of which are on display in the two-story collection. Entrance to the museum is free and it draws a steady stream of visitors. It even has a gift shop with parasite-themed t-shirts, pens, and jewelry. (I picked up a t-shirt with the famous tapeworm on it.)

While I had a busy trip to Japan, I took time to stop at this museum because of our foundation’s efforts to reduce the burden of so-called neglected tropical diseases, many of them caused by parasites. More than 1 billion people suffer from these overlooked diseases with often difficult to pronounce names, including dracunculiasis (Guinea worm disease), human African trypanosomiasis (sleeping sickness), visceral leishmaniasis (black fever), onchocerciasis (river blindness), and schistosomiasis (snail fever).

These diseases can cause anemia and blindness, stunt children’s growth, lead to cognitive impairments, complicate pregnancies, and result in thousands of deaths each year. And it’s not uncommon for people living in extreme poverty to suffer from more than one of these diseases at the same time, affecting their ability to go to school or make a living.

Our foundation works with partners on the treatment and control of these diseases. One of the most successful efforts has been mass drug administration, which seeks to treat everyone against a disease—even if they are not actually infected or show any symptoms. I observed this incredible work in Tanzania, where I joined a group of health workers going from house to house to distribute medicine to wipe out lymphatic filariasis, one of the world’s most painful and debilitating diseases. 

The good news is that there’s been a lot of progress in reducing parasitic diseases around the world. But there’s still more work to be done. That makes this museum a great place for people to learn about where these diseases still exist and the incredible work that’s going on to wipe them out.

If you happen to be in Tokyo, I encourage you to visit.

Health workers have an unusual tool for fighting disease that turns our old thinking about treatment on its head. I saw it at work recently in a remote hilltop village in Tanzania, where I joined a group of health workers going from house to house to distribute medicine to wipe out lymphatic filariasis, one of the world’s most painful and debilitating diseases. 

At each home, one health worker told the family about the swollen limbs, disfigurements, and other symptoms of the parasitic disease. Another carried a tall stick to measure the height of each family member to determine the correct dosage. Then, if they were willing to be treated, the parents and children took their pills and washed them down with a cup of water before our team moved on to the next house.

What was surprising about this effort is that none of the people who took the medicine were sick.

The village I visited was participating in what’s known as a mass drug administration campaign, which seeks to treat everyone against a disease—even if they are not actually infected or show any symptoms. Typically, of course, the sick are the ones who get treated, not the people who are healthy. But when it comes to combating some diseases, like lymphatic filariasis, it’s critical for health workers to try to treat the entire at-risk population to break the cycle of transmission. If not, the disease could continue to be spread by those who are not aware they are infected.

Ten countries have successfully eliminated lymphatic filariasis in this way, including Togo, which this year became the first country in sub-Saharan Africa to wipe out the disease. Still, more than 800 million people in 52 countries worldwide remain threatened by lymphatic filariasis.

Mass drug administration is not only effective against lymphatic filariasis, but also other neglected tropical diseases, including schistosomiasis, onchocerciasis, trachoma, and soil-transmitted helminths. These diseases go by names that are largely unknown and often difficult to pronounce. But it should be easy to understand why we should all care about them. They afflict people living in the poorest countries and cause untold suffering.

Lymphatic filariasis is one of the worst of these diseases. It’s caused by a parasite that’s spread by mosquitoes, and in the severest cases people may develop swollen limbs, a thickening of the skin known as elephantiasis, or other severe disfigurements. Beyond the pain and disabilities they experience, people affected by the disease are often ostracized by their communities and are unable to work, sinking them deeper into poverty.

To combat lymphatic filariasis, health officials could test everyone and then treat only those people who are infected. But testing the population for these diseases would be expensive and slow. The medicines used for treatment (ivermectin and albendazole), however, are inexpensive and have no side effects, making mass treatment a more effective approach to protect people from the disease. (And thanks to the generosity of the many pharmaceutical companies, billions of doses of these and other medicines combating neglected tropical diseases are being donated for free.)

Like many countries running mass drug administration programs, Tanzania’s biggest challenge is treating enough of its population at risk of the disease. To break the cycle of transmission, health workers must treat at least 65 percent of the population every year for 5 to 10 years. As you might imagine, meeting this target year after year is not easy.

Health officials must have strong public awareness campaigns, thousands of trained health workers, a well-organized supply chain to distribute medicines to the remotest corners of the country, and regular disease surveying to track their progress. At the same time, the program provides treatment and care for people who are suffering from the debilitating symptoms of the diseases.

Walking from door to door in the village with the health workers, I was struck that perhaps the most important element of the program is trust. Taking the medicine is strictly voluntary, making it important that the health workers distributing it earn the confidence of the community.  The health workers I met certainly had. They were knowledgeable, passionate about their work, and clearly cared about the community they were serving. At each home, they took the time to explain the goal of the program and address any of the villagers’ questions or concerns. Thanks to their hard work the latest survey of lymphatic filariasis in their district showed that the cycle of transmission had been broken. For the first time, the village was not at risk of the disease.  

By 2020, Tanzania hopes to eliminate lymphatic filariasis entirely within its borders. Based on what I saw in this village, I’m optimistic they will.

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

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

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

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

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

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

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

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

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

Warning: you may find what I’m about to write disturbing.

Imagine a fly infected with parasites bites you. First you get a fever, then headaches, joint pains, and itching. Eventually, when the parasites cross the blood-brain barrier, you lose your mind, you can’t control your muscles, and then you lose your life.

Now, imagine you drink a glass of water. The water contains tiny fleas containing even tinier larvae. The larvae mate and grow in your body. One year later, a painful blister forms on your foot. The head of a worm pokes out. It’s 3-feet-long and takes weeks to remove.

Finally, imagine a mosquito bites you. It’s infected with tiny larvae. They set up camp in one of your lymph nodes, where they mate and nest, causing your leg to eventually swell to 10 times its size.

Sound horrific? Well, I haven’t told you the most disturbing part. I’m not making up these diseases (Human African trypanosomiasis, Dracunculiasis, and Lymphatic filariasis). They are just three of more than a dozen tropical diseases that afflict some of the poorest people in the world. As I write this, more than a billion people suffer from at least one of them.

These diseases go by names that are largely unknown and often difficult to pronounce.

Still, it should be easy to understand why we should all care about them. Spread by worms and insects, they disfigure and disable people living in the remotest areas of the world, keeping children out of school and parents from being able to work. In the worst cases, they kill. And all of them can be prevented—if the world continues to work together to end them.

I am in Geneva, Switzerland this week for a meeting to raise awareness and continue support for the fight against these overlooked diseases.  Collectively, they’ve been dubbed “Neglected Tropical Diseases,” but lately they’ve been getting some of the attention they deserve.

Five years ago, Uniting to Combat Neglected Tropical Diseases, a group of pharmaceutical companies, governments, health organizations, charities, and other partners, came together to treat and prevent these diseases. They set a goal to control or eliminate at least 10 of them by 2020. Today, there’s a lot of progress to celebrate. Fewer people are suffering from them, and many countries are on their way to eliminating them altogether.

Here are some examples of the progress that’s been made.

Dracunculiasis (also known as Guinea worm), the parasitic disease I described above in which a large worm grows inside its victims, is nearing its end. In 1985, the disease afflicted an estimated 3.5 million people in 21 countries in Africa and Asia.  Last year, thanks to the work of Uniting to Combat NTDs, The Carter Center, and other partners the number of Guinea worm cases has been reduced by more than 99 percent to 25 cases.

Lymphatic filariasis, also known as elephantiasis, is thepainful, disfiguring disease spread by mosquitoes.  Five years ago, 1.5 billion people needed preventive drug treatment to protect them from the disease. Since then, it has been eliminated in six countries and reduced in 18 others.

Human African trypanosomiasis (HAT), commonly known as sleeping sickness, is also in retreat. Cases have declined by more than 90 percent, from 26,000 cases in 2000 to 2,733 in 2015.

What’s driving this progress? It’s been the result of drug donations by pharmaceutical companies and generous commitments by donors and governments. More than one billion people were reached with NTD treatments in 2015 alone—across nearly 150 countries.

New innovations for testing and treatment have also made a big difference. For example, the diagnostic test for sleeping sickness used to require electricity, bulky equipment, and refrigeration, making it difficult to deliver to remotest areas of the world. Now, a simple finger-prick blood test allows health workers to test for the diseases. And new smartphone-based mapping tools could make it easier to map these diseases so health workers can target their treatment efforts in real time down to the household level.

Still, there’s a lot of work to be done. We need continued support from donor governments to finish the job. We need more research on improved drugs and tests to help make it easier to treat people quickly. And we must support the frontline health workers who have the tough job of delivering the drugs in the hardest to reach regions of the world.

If the world keeps up the fight against these diseases, we can improve the lives of millions of the poorest families. They won’t be neglected anymore.

Take Action
Help us eliminate these debilitating diseases that afflict the world’s poorest by supporting The END Fund. The END Fund is a GiveWell Top Charity.

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

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

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

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

Officially, Uganda’s maternal mortality rate is double the global average. But because that number doesn’t count those who give birth at home—in a country where poverty, distance, stigma, and distrust are all barriers to medical care—Eva Nangalo believes the real one may be much higher.

That’s why, as a midwife determined to eliminate these deaths altogether, she’s spent the past 23 years working to make hospital deliveries both more safe and more common.

For Nangalo, this is more than a job. It’s her life’s work, and something she’s felt called to do for as long as she can remember. “I was created to be a midwife, born to be a midwife, trained to be a midwife,” she said. “It’s what is in my DNA. That’s what I am.”

Working the night shift at Nakaseke General Hospital in rural central Uganda and tending to her family’s farm while off the clock, Nangalo is known for sleeping maybe one or two hours, if that, a day. When the power goes out in the middle of a delivery—which happens often—she uses the flashlight on her cellphone to get the job done. She even keeps her hair short rather than style it the way she’d prefer.

In her own words: “I’ve wanted my hair to be like other women. But then I think of the one dollar saving a mother’s life.”

That isn’t theoretical. Nangalo regularly reaches into her own pockets to ensure that expecting mothers have the transportation they need to get to the hospital in the first place—and the food, milk, and medicine they and their babies need to survive not only childbirth but also what comes next. She once tore a piece of her own bedsheet to give to a mother who didn’t have one at home.

It’s no wonder she’s made a name for herself—literally—among the women she’s served, with many choosing to name their daughters after her.

Her advocacy efforts—and their effects—are broad and far-reaching. Understanding the fears and misconceptions that exist in Uganda around healthcare facilities, she uses the radio to reach skeptics and explain the merits of hospital deliveries and the higher risks of fatal infection and bleeding inherent to home births. She helped establish a newborn clinic in Nakaseke, improving the safety of childbirth at the hospital and increasing the number of families served. She even pushed the government to make good on its own policies and open a health facility in every sub-county.

It’s no exaggeration to say that Eva Nangalo is making childbirth in Uganda safer for everyone involved.

“The future looks bright,” one colleague said, “if we have more and more people like Eva.” Fortunately, she’s working to ensure that’s exactly what happens.

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.

Inside a two-story brick building in Medellín, Colombia, scientists work long hours in muggy labs breeding millions and millions of mosquitoes. They tend to the insects’ every need as they grow from larvae to pupae to adults, keeping the temperature just right and feeding them generous helpings of fishmeal, sugar, and, of course, blood.

Then, they release them across the country to breed with wild mosquitoes that can carry dengue and other viruses threatening to sicken and kill the population of Colombia.

This might sound the beginnings of a Hollywood writer’s horror film plot.

But it’s not.

This factory is real.

And the mosquitoes being released don’t terrorize the local population. Far from it. They’re actually helping to save and improve millions of lives.

Here’s how they do it: The mosquitoes being produced in this factory carry bacteria called Wolbachia that block them from transmitting dengue and other viruses, such as Zika, chikungunya and yellow fever, to humans. By releasing them to reproduce with wild mosquitoes, they spread the bacteria, reducing virus transmission and protecting millions of people from illnesses.

I’ve written before about these amazing Wolbachia mosquitoes, including last year when a new study showed how effective they could be in preventing diseases. The randomized controlled trial conducted in Yogyakarta, Indonesia, found that Wolbachia-carrying mosquitoes reduced the number of dengue cases in the city by 77 percent and dengue hospitalizations by 86 percent. In a new study in Medellín, dengue cases have declined by 89 percent since Wolbachia mosquitoes started being released in 2015.

These results are a huge breakthrough, offering proof that this new technology will protect entire cities and countries against the threat of mosquito-borne diseases. The World Mosquito Program, which is leading the Wolbachia effort, is now releasing these mosquitoes in 11 countries: Brazil, Colombia, Mexico, Indonesia, Sri Lanka, Vietnam, Australia, Fiji, Kiribati, New Caledonia, and Vanuatu.

And what’s remarkable about the Wolbachia mosquitoes is that once enough of them are released to offer disease protection, it’s a solution that’s self-sustaining. Over time, families will be spared the heartbreak of losing loved ones and communities won’t need to spend money on prevention and treatment for these mosquito-borne diseases, freeing up funds for other health priorities.

The World Mosquito Program aims to spread Wolbachia among Aedes aegypti mosquitoes, a tropical mosquito that is a host for dengue, yellow fever, and other viruses. (Malaria is spread through a parasite carried by the Anopheles mosquito and is not a focus of the Wolbachia effort.) With climate change, there is an urgency to the World Mosquito Program’s work. As global temperatures rise, Aedes aegypti mosquitoes, are finding more regions of the world habitable, increasing the spread of these diseases. The biggest risk is posed by dengue, which infects more than 400 million people each year and kills 20,000.

The demand for these lifesaving mosquitoes continues to grow and that means the World Mosquito Program needs to produce hundreds of millions of Wolbachia mosquitoes. That brings us back to the factory in Medellín, which is currently the world’s largest mosquito breeding facility in the world, producing more than 30 million mosquitoes per week. Other World Mosquito Program sites around the world are also breeding Wolbachia mosquitoes, but Colombia’s is currently the largest.

Until now, killing or repelling mosquitoes with insecticides, bed nets, and traps has been the priority, not mass producing them. As difficult as it is to kill mosquitoes, raising them by the millions may be even harder. Mosquitoes must be bred, fed, and housed under ideal conditions for them to grow and reproduce. The factory in Medellín has been perfecting the process and improving its efficiency so they can breed and release Wolbachia mosquitoes on a large scale.

The centerpiece of the mosquito factory is a colony of Wolbachia mosquitoes, called the brood stock, from which all future populations of Wolbachia mosquito offspring are bred. The brood stock offspring are then raised to create millions of eggs, which hatch when put in water and become larvae. Fed with fish meal, the larvae grow to become pupae, which then become adults. To thrive, adults need sugar (check out this story about how researchers in Zambia are exploiting mosquito’s craving for sugar to create a new bait that will control the spread of malaria) and blood, which the team sources from expired stocks at blood banks. 

Once the factory has bred millions of eggs and adult mosquitoes, they are ready to be released. The eggs are packaged in small gelatin capsules, each containing 300 eggs, which are given to residents to drop in water to hatch. The advantage of egg releases like this is that the eggs can easily be transported long distances and they can be hatched as needed.  The factory also releases adult mosquitoes by the thousands from the back of motorcycles roving the city. The World Mosquito team is also experimenting with releases from drones. The adult releases allow the Wolbachia mosquitoes to immediately begin mating with the wild mosquito population and spreading the virus-blocking bacteria.

It’s exciting to see how far the World Mosquito Program has come. Years ago, the idea of releasing mosquitoes as an ally in the fight against diseases struck many people as crazy. But support for this innovative solution has caught on in communities around the world. These amazing mosquitoes are taking flight and saving lives.

Everyone knows mosquitoes have a taste for blood, but did you know they have an even bigger sweet tooth?

Mosquitoes love sugar.

Just as humans are drawn to the sweet smell of a chocolate shop or bakery, mosquitoes find the smell of sugar irresistible.

All mosquitoes need sugar to survive. Female mosquitoes consume blood to lay eggs, but both male and female mosquitoes require sugar for energy. In fact, even though mosquitoes buzzing in your ears may appear single-minded about biting you, they need sugar more often than they need blood.

Exploiting this craving, researchers have developed a lethal new tool to kill mosquitoes and protect people living in areas at high risk for malaria and other mosquito-borne diseases.

Here’s how it works: In nature, mosquitoes get sugar from flower nectar and plants. But scientists have developed a tempting bait that lures mosquitoes with a highly attractive fruit scent. When they land on it to get their sugar fix, the mosquitoes begin feasting on a sweet meal laced with insecticide. Not long after, they drop dead, reducing mosquito populations and, researchers hope, the spread of malaria in the communities where the traps are used.

While other insects, like bees and butterflies, may also be drawn to the bait’s sweet scent, the bait is just lethal for mosquitoes. A protective membrane, only accessible to mosquitoes, covers the bait and prevents other insects from feasting on the deadly meal inside.

This new mosquito control tool, called Attractive Targeted Sugar Baits or ATSBs, developed by Westham Co., is simple to use, affordable, and has the potential to be a game changer in the effort to eradicate malaria.

And it couldn’t arrive soon enough.

Over the past two decades, the world has dramatically reduced the global burden of malaria, preventing 1.7 billion cases and saving 10.6 million lives. This progress has been attributed, in large part, to the widescale use of long-lasting insecticide-treated bed nets, which protect people from bites while they sleep, and indoor residual spraying, which kills mosquitoes that land on insecticide-treated walls and ceilings in homes.

As effective as these tools have been, both mosquitoes and the malaria parasite are constantly evolving, sometimes making these interventions less effective. We’ve seen this again and again with resistance to insecticides and malaria drugs. And that’s why it’s critical that the world continues to innovate with new ways to prevent the spread of malaria.

In response to the widespread use of bed nets and indoor insecticide spraying, mosquitoes have changed their behaviors, according to some researchers. In some areas, instead of seeking their blood meals only inside homes after bedtime, malaria-carrying mosquitoes are now biting outside homes, and earlier in the evening, when people will often cook and socialize.

And this is how the sugar baits fit in.

By attracting mosquitoes outside, sugar baits offer a highly effective mosquito control tool for households. About the size of a sheet of notebook paper, sugar baits can be easily installed with a hammer and a nail. Two baits hung on the adjacent outside walls of a home are enough to offer months of protection.

In studies conducted in Mali in 2016 and 2017 researchers found that the sugar baits dramatically reduced mosquito populations and malaria cases in the communities where they were used.

A more recent modeling analysis predicted that sugar baits, when used to complement long-lasting insecticide-treated bed nets and indoor spraying, could reduce malaria cases by 30 percent in areas with high malaria burdens.

In 2020, there were an estimated 241 million malaria cases. A 30 percent reduction in malaria cases would be a huge breakthrough and save many lives.

That’s why our foundation has been supporting the development of sugar baits, including sponsoring a large-scale field trial currently underway in Kenya, Mali, and Zambia. So far, the results have confirmed the effectiveness of the bait stations.

If all goes well with the trials, sugar baits could be available for widespread use as soon as next year.

No need to sugarcoat it. For the millions of people at risk of malaria around the world, that would be welcome news.

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.

The greatest medical breakthrough of this pandemic—and surely one of the most important in decades—is the creation of COVID-19 vaccines. One study found that in their first year, they saved more than 1 million lives and prevented 10 million hospitalizations in the U.S. alone. The number of deaths averted around the world is of course far higher. It’s horrifying to think what COVID-19 would be doing to humanity if it weren’t for vaccines.

The world has a lot to be proud of in the creation and delivery of these vaccines. Scientists have never developed one nearly as quickly as they did in 2020, and the governments of the world have never run immunization campaigns that were as fast and as far-reaching as the ones that took place in 2021.

But there are also serious problems that we need to solve before the next potential pandemic comes along. One is the huge inequity in who has been vaccinated and who has not. It is both unjust and unwise to give a third shot to a healthy 25-year-old in a rich country before a 75-year-old cancer survivor in a poor country gets her first shot.

Another concern is that the speed with which vaccines were created was only partly a matter of skill and diligence. It was also a matter of luck.

Because coronaviruses had already caused two previous outbreaks (SARS and MERS), scientists had learned quite a lot about the structure of the virus. In particular, they had identified its charac­teristic spike protein—the tips on the crownlike virus you’ve seen a dozen pictures of—as a potential target for vaccines. When it came time to create new vaccines, they had a sense of what part of the virus was most vulnerable to attack.

In the next outbreak, we may not be so lucky. It could be caused by a virus that scientists haven’t studied as closely, or by one they’ve never seen at all.

This is why the world needs to adopt a serious plan for developing, manufacturing, and distributing new vaccines to prevent another pandemic. The manufacturing alone is a huge challenge: To prevent the inequities we’ve seen in COVID-19, the world needs to be ready to produce enough vaccines for everyone on the planet within six months of discovering a new pathogen. That’s 8 billion doses for a single-dose vaccine, and 16 billion for a two-dose version. In a typical year, around 5 billion or 6 billion doses are produced—that’s all vaccines combined.

The plan needs to cover four steps, starting with accelerating the invention of new vaccines.

During the pandemic, the process of creating a new vaccine got a huge boost (no pun intended). Typically, the process involves a lot of trial and error: Scientists spend years identifying weak spots in the virus and trying to identify vaccine candidates that would teach the immune system to attack them.

The creation of the first mRNA vaccines during the COVID-19 pandemic was a big step forward. They work by delivering genetic code to your body that instructs it to make shapes that look like the weak part of the virus. Your immune system notices that those shapes are foreign and sets out to attack them. Once it does, it remembers what the shapes looked like and will attack them the next time they show up. That’s what makes you immune.

One reason mRNA vaccines were so revolutionary is that they’re easily adapted for different pathogens. Once the weak spot of a virus has been identified—a process made much easier by recent advances in mapping viral genomes—it’s simply a matter of changing the genetic code in the vaccine so that it tells your body to make a new shape. This can be done in a matter of days.

As a result, the development of new vaccines will be exponentially faster—as long as researchers have the same deep understanding of future pathogens as they did of coronaviruses. So it is imperative to invest in basic research on a wider array of known viruses and other pathogens, so we understand as much as possible before the next outbreak.

Once a vaccine has been invented, the second step is to test it and get it approved for use in humans. Typically, it takes years to run all the trials necessary to prove that a vaccine is safe and effective—including time spent recruiting tens of thousands of volunteers. Assuming the vaccine proves out, it can take another year to get it authorized by the WHO and the relevant government agencies.

But when an outbreak is threatening to go global, we won’t have years. So we need ways to speed up the process without sacrificing the safety and effectiveness that people have come to expect from vaccines.

The world should build on models like the RECOVERY trial in the U.K. It set up protocols for running drug trials in advance and built infrastructure that made it much easier to get started once COVID hit. In addition, the agencies that regulate vaccines need to agree ahead of time on how volunteers will be enrolled in trials and on the software tools that will enable people around the world to sign up as soon as the disease strikes. And by connecting diagnostic tests to the trial system, we can automatically suggest to doctors that their patients should join a trial if they’re eligible.

The third step, once a vaccine has been approved for use in humans, is to make enough of it fast enough to stop the outbreak. Ending a relatively small outbreak might require hundreds of thousands of doses of a new vaccine, which is not hard to make. (The world already produces more than 5 billion doses of vaccines every year.) But countries need to be prepared for the worst—another big outbreak in which everyone needs to be vaccinated—so we must be ready to produce as many as 8 billion or even 16 billion, roughly triple the amount manufactured in a typical year.

During COVID-19, the closest thing to a breakthrough in manufacturing vaccines was the proliferation of second-source deals. These are agreements in which a company that invented a vaccine agrees to let other companies use their factories to make it. (Picture Honda Accords rolling off the line of a Ford facility.)

It’s hard to overstate the impact of second-source deals during COVID-19. In less than two years, a single manufacturer, AstraZeneca, signed second-source deals involving 25 factories in 15 coun­tries. (AZ also agreed to forgo its profits on the COVID vaccine.) Novavax also signed one with Serum Institute of India—leading to a COVID-19 vaccine now being used in many countries—and Johnson & Johnson signed one with the Indian company Biological E. Limited and the South African firm Aspen Pharmacare. All told, second-source deals led to the production of billions of additional COVID vaccine doses.

In the future, such deals could be done even faster if companies that have them now can maintain their relationships with one another so they can hit the ground running during the next outbreak.

mRNA vaccines could also help speed up manufacturing. Many of the conventional ways to make vac­cines are quite complex, so it can take a lot of time to transfer the technology and know-how from one company to another. But because the basic approach to mRNA is pretty much the same—you just swap out your old mRNA for the new one and make sure the lipid is made the right way—it should be easier to transfer between companies. There are also some new modular technologies in the pipeline that, if they prove out, will make it cheaper and easier to build and run factories that can be adapted to make different vaccines.

Finally, the fourth step in the world’s plan should be to make sure that new vaccines reach everyone who needs them—including people who live in low-income countries. In 2021, only 8 percent of people in those countries received at least one dose of a COVID-19 vaccine, while more than half of the world’s population did.

So how can the world make sure that doesn’t happen in future outbreaks?

One key is to take on the problem of vaccine hesitancy. Check out this video about how, by dealing with rumors and myths, one community in India increased its COVID-19 vaccination rate by a factor of five and created a model that other communities are now taking up:

Another key is to make sure it’s possible to manufacture enough vaccines that supply is not a limiting factor, as it was during much of 2021. Another is to make sure that vaccines are affordable for every country. Organizations like COVAX have helped with that during COVID-19. It also helps to work with manufacturers in developing countries to design new vaccines that are much cheaper to produce than existing ones. This is how the price of the pentavalent vaccine, which protects against five debilitating and deadly diseases, dropped from $3.50 per dose to less than $1 a dose—which in turn allowed the number of children who get it every year to increase by more than 16 times since 2005.

There are also a lot of innovations that make it easier to deliver vaccines. For example, auto-disable syringes have a built-in safety mechanism so health workers can’t accidentally poke themselves or use them more than once. New coolers can keep vaccines at the right temperature for longer. Advanced methods for delivering vaccines, such as replacing the needle and syringe with a small patch containing micro-needles—picture something that looks superficially like the nicotine patches that people use to stop smoking—will also help.

With these advances, it will be possible to achieve something amazing beyond preventing pandemics: eradicating entire families of pathogens. The world could rid itself of all coronaviruses, for example, or even all influenza viruses. A future without pandemics—and without the flu—is worth investing in.

When I sat down to write my new book, my goal was to create a concrete list of steps the world could take to prevent the next pandemic. There’s a lot we can and should learn from COVID-19. But I knew that I wanted to focus more on the future instead of the past.

For decades, people told the world to get ready for a pandemic, but hardly anyone made it a priority. Then COVID struck, and stopping it became the most important thing on the global agenda. Governments need to take action now to get ready for the next pathogen, while all of us still remember how awful COVID was (and still is) and feel the urgency of never allowing another one to happen.

If we’re going to make COVID-19 the last pandemic, the world needs to get to work right away on three key areas:

1.

Make and deliver better tools.

The story of Katalin Kariko and mRNA vaccines proves that ideas for new tools must often be nurtured and researched, sometimes for decades, before they produce anything of practical value. That’s why step one in any pandemic-prevention plan should be to keep investing in better vaccines, therapeutics, and diagnostics.

You can read more about how new vaccines can be developed and delivered faster here. This includes improving our ability to test and approve new products, as well as scaling up manufacturing capacity and creating better way of delivering vaccines (like microneedle patches) so we can get out lots of doses fast.

On the therapeutics front, it took nearly two years to find effective treatments for COVID. The trajectory of the pandemic would’ve looked a lot different if we had found them sooner. We need to build out the systems that will allow us to make new treatments much faster in the future.

One key step is to create a library of antiviral compounds that are designed to attack common respiratory viruses, so that we can more easily find out if an existing drug will work in the event of an outbreak. We can also take advantage of advances in artificial intelligence and other computational methods. A computer could quickly scan a 3D model of a pathogen to figure out which drugs might be effective against it. It would be able to tell you which drugs look promising, figure out how to improve them, and, if necessary, even design new ones from scratch.

We should also expand incentives for generics manufacturers to create low-cost versions of new drugs. This can be achieved through advance orders on behalf of low- and middle-income countries, which get generic drugmakers to start manufacturing a new drug through advance orders and agreements that allow one company to manufacture a drug invented by another company even while it’s still going through regulatory approvals.

Another area where we need to spark more innovation is in diagnostics. Researchers should keep working on—and funders should keep supporting—high-throughput PCR tests, which have all the benefits of a PCR but are significantly faster at returning results, much cheaper to run, and easier to adapt to a new pathogen. We also need to support work on new types of tests that make it easier to collect samples and turn around results quickly, like better versions of the rapid antigen tests that many of us now take at home for COVID or even handheld devices that health workers can use to easily test people in their community. And testing should be tied to treatment, so if you test positive, you get the medication you need right away.

2.

Improve disease monitoring.

Creating the GERM—Global Epidemic Response and Mobilization—team is one of the most important steps we can take to stop the next pandemic. GERM will play a crucial role in virtually every aspect of pandemic prevention, but improving monitoring will be the most significant part of their mandate.

GERM is only one piece of the puzzle, though. Another crucial step is to improve civil registration and vital statistics in the developing world. At a minimum, many low- and middle-income countries need stronger registries of births and deaths, so that GERM can work with local organizations to more easily spot if there’s an unusual pattern worth investigating. Then, building on that foundation, countries should expand into autopsies that use minimally invasive tissue samplings, wastewater surveillance, and other practices.

The world’s disparate disease monitoring systems also need to be integrated so that public health officials can rapidly detect pathogens. Data must be made available in real time, with test results integrated into the public health system so that officials can watch for outbreaks. And in countries like the United States, where testing can be extremely expensive, governments need to make diagnostics cheaper and more accessible to everyone.

Finally, we need to expand our capacity to sequence the genomes of pathogens in order to track new variants. We should double down on investments in projects like the Africa Pathogen Genomics Initiative, a network of labs across the continent that share genomic data with each other, and in new tools that will let us sequence more genomes in more places.

3.

Strengthen health systems.

Good health care starts with good health systems. That’s true for basic care, and it’s especially true for pandemic prevention. When a new or deadly pathogen emerges, you need somewhere for sick people to reliably seek treatment. You need health workers who can identify potential threats and the infrastructure to report anything out of the ordinary. And, once a pathogen starts to spread, you need trained professionals who can administer higher level tests, treatments, vaccines, and more.

The pandemic devastated health systems around the world, but the need in low-income countries is especially acute. The fundamental challenge is that they don’t have the funding, expert capacity, or institutions they need to offer basic health services to all their people, let alone manage a major outbreak. And during the pandemic, the problem got worse, as many rich governments cut foreign aid or took money from work on other diseases and redirected it to COVID.

We need to reverse this trend. A major part of the Gates Foundation’s work has been to help improve health systems—investments that both save lives, end preventable infectious diseases, and pave the way for economic growth. But philanthropy alone cannot close the gap between rich and poor countries. The models for wealthy countries are still Sweden and Norway, who each give at least 0.7 of their GDP in aid. If we’re going to be serious about preventing the next pandemic, we need to not just go back to pre-COVID aid levels but increase investments in strengthening health systems (which will also help shrink the overall health gap between the rich and the poor).

For their part, low- and middle-income countries should focus on health spending that achieves many things at once. For example, hiring more health workers gives you more people who can manage malaria cases, offer HIV testing and treatment, and give public officials unprecedented insight into what’s causing illness and death in their country.

But as COVID made clear, low- and middle-income countries aren’t the only ones that need to strengthen their health systems. There are steps that countries at every income level should consider, like improving primary health care and deciding in advance of a crisis who will oversee what. Governments and donors also need a global forum where they can coordinate action with poor countries.

All of these efforts—new tools, better disease surveillance, and improved health systems—won’t be cheap, but they will save lives and money in the long run. I estimate that, over the next decade, governments combined need to spend $15 to $20 billion per year to develop the tools we need. Strengthening health system will cost the world an extra $30 billion a year, on top of the money we should already be spending to improve health in low income countries.

That sounds like a lot of money until you learn that the International Monetary Fund estimates this pandemic will cost $12.5 trillion over just five years. Think of it like insurance. This is the billions we need to spend in order to save millions of lives and trillions of dollars.

And here’s the best news: Even when we’re not facing an active outbreak, these investments will make people healthier, save lives, and shrink the health gap between the rich and the poor. This is an opportunity to not just stop things from getting worse but to make them better.

We don’t need to surrender to living in perpetual fear of another global catastrophe. But we do need to remain aware of the possibility and be willing to do something about it. I hope the world seizes this moment and invests in the steps needed to make COVID-19 the last pandemic.

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

Unfortunately, it’s pure Hollywood fiction.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Last week, I went to the TED conference in Vancouver. It was my first time back at TED since 2015, when I gave a speech about how the world wasn’t ready for the next epidemic.

A lot of people watched that talk, but almost all of the views came after the start of the COVID-19 pandemic. This time, I spoke about the same subject, but a lot had changed. No one in the audience needed to be convinced that a deadly virus could kill millions of people around the world and upend our lives.

My talk was all about how we can make COVID-19 the last pandemic. I believe we can eliminate the threat of pandemics completely if we approach infectious diseases like we approach fires. We need a well-oiled system in place, complete with full-time professional personnel and innovative tools ready to be deployed at a moment’s notice.

You can watch my full talk here:

Giving a TED talk is always a memorable (and nerve-wracking!) experience. I started thinking about what I wanted to say a couple months ago. I decided to focus on what I call the GERM—Global Epidemic Response and Mobilization—team, a new full-time, paid group whose entire job is to prepare for the next outbreak. I talk a lot about GERM in my upcoming book, but this was the first time I was going to speak about GERM publicly at length.

One of the coolest things about TED is how visual all the talks are. I had the opportunity to make sure the graphics for mine looked okay during a rehearsal. I also got to practice bringing the Roman fire brigade bucket I was using as a prop onto the stage. (It’s a lot heavier than it looks!)

Last week, I traveled to Germany to attend the 58^th Munich Security Conference, a gathering of leading experts on global security, health, development, and international relations. After learning from and working with so many of them virtually for two years, I was eager to hear from heads of state and global health leaders—in person at last!—about the ongoing impact of COVID-19 on their countries, the infectious disease and inequity challenges they’re still contending with, and what we need to be doing now to prevent future pandemics.

Health security was already a big priority at the MSC in pre-COVID times, but this year’s conference underlined how much global health is now rightfully seen as a serious national and global security issue. It’s clearer than ever that investing in health R&D, disease surveillance, and strong health systems is critical to keeping people safe, wherever they live in the world.

In Munich, I took part in a panel discussion that included the foreign ministers of Canada and Sweden, the CEO of the Crisis Group, and remarks from Tedros Adhanom Ghebreyesus, the director-general of World Health Organization. These leaders hit on the same themes I heard from many others I talked with on this trip—themes I’ve given a lot of thought to while writing a book about how to prevent the next pandemic. For one, when it comes to COVID, we’re not out of the woods yet, because the virus is still mutating. At the same time, the pandemic is evolving, with vaccines plus the rapid spread of Omicron appearing to offer many more people some protection against severe disease. Meanwhile, COVID continues to exacerbate existing inequities—something we’ll feel the effects of for years to come.

In all countries, especially the poorest, the pandemic is still hindering the prevention and treatment of other diseases. The world’s response must continue prioritizing equity and protecting the most vulnerable. We need an integrated approach that manages COVID for the long haul alongside other infectious diseases such as HIV, TB, and malaria, which continue to kill millions. This will enable countries to take limited resources and apply them where they are needed most, whether by mitigating COVID risks, supplying insecticide-treated nets against rising malaria cases, or making up for lost ground with other life-saving vaccinations.

Another theme that came up in Munich is the need for stronger health systems and tools to prevent, detect, and respond quickly to emerging and existing infectious diseases. We discussed how this can prevent future pandemics and what role multilateral cooperation must play. For example, the effects of COVID would have been much worse without investments made to fight other infectious diseases like HIV, TB, malaria, and polio. For decades, countries like Pakistan, Kenya, and South Africa have strengthened their health systems by training community health workers, building surveillance and lab capacity, creating efficient supply chains, and accelerating innovation.

The world’s response to COVID was far from perfect, but these advances helped put some countries in a better position to pivot and defend against the virus. And they helped mitigate the pandemic’s impact on these countries’ ability to fight other diseases.

Take the Global Polio Eradication Initiative. Thanks to investments made by governments, the private sector, and philanthropy, wild polio cases are at a historic low, and the disease is endemic in just two countries: Pakistan and Afghanistan. Last week I also went to Pakistan, where I visited two of the country’s innovative command centers for fighting diseases, the National Emergency Operations Center for polio eradication and the National Command and Operation Centre for COVID. The NEOC uses state-of-the-art informational tools developed by GPEI to track polio so that no child is ever paralyzed by it again. The NCOC has applied resources and lessons learned from the polio program—including data analysis, vaccine campaign planning, and community engagement—to coordinate Pakistan’s response to COVID. Both centers blew me away.

At the NEOC, we pored over a wall of screens that displayed an up-to-the-minute summary of immunization rates and areas where children have not been reached with the vaccine. The health officials I talked to in Pakistan told me that the polio program’s infrastructure was invaluable once COVID hit. By setting its priorities based on the needs at the time, Pakistan was able to expand and redirect health infrastructure that had been supported by the global community—the national help line call center, communication systems, and networks of religious leaders and community influencers—to help protect people during the pandemic.

It’s easier to ramp up testing and deliver vaccines and protective gear during a pandemic when you already have a community health workforce, labs, surveillance capacity, and supply chains in place. Another organization that has proven invaluable over the last two years is the Global Fund, which funds more than half of all global programs working to end AIDS, tuberculosis, and malaria. The Global Fund’s partnerships with countries enabled community health workers who go door to door to detect, diagnose, and report fevers as malaria or COVID. Along the same lines, organizations like the Coalition for Epidemic Preparedness Innovations, which accelerates work on vaccines for infectious diseases, and Gavi, which has immunized nearly 1 billion children since 2000, have been key partners in developing and distributing COVID vaccines. 

Unfortunately, this isn’t a simple success story. We’ve also seen increases in cases and deaths from malaria, HIV, and tuberculosis for the first time in 20 years because of COVID. But the backsliding was not nearly as bad as it could have been.

I’m optimistic about the future. We have learned so much from COVID, and the innovations have been tremendous. Talking to public health leaders in Munich and Islamabad, it’s clear that long-term funding for global health—including investments in proven initiatives like GPEI, Global Fund, and CEPI —helped save millions of lives during this pandemic. Just think: It took less than a year after the virus emerged to develop a vaccine against it. I believe we’ll do even better next time and can deliver them to everyone within six months of an outbreak if we build enough global capacity.

As the pandemic continues to evolve and the world adapts strategies and investments to match, we can apply these lessons and make choices that help prevent future pandemics. We need a full-time global team dedicated to responding to new disease outbreaks and working to end other infectious diseases. We should, above all, approach this work with a greater focus on improving inequities by understanding that investments in global health and pandemic prevention are critical security issues. And they’re mutually reinforcing.

Now is the time to build on these lessons, increase our funding for the basic building blocks of public health, and support countries in meeting their needs. If we make the right choices and investments now, we can end other devastating diseases and make COVID-19 the last pandemic.

While promoting my new pandemic book the last month, I’ve been telling audiences and interviewers that if we want to make COVID-19 the last pandemic, we need to combat infectious diseases the same way we fight fires.

Just like we have a robust system of fire alarms, firefighters, and fire hydrants to help detect and extinguish fires, we need to create an equally effective system to identify and respond to new disease outbreaks.

This firefighting comparison is also a useful way to understand the amazing work of Sofonias Tessema.

Officially, Sofonias is the program lead for the Africa Pathogen Genomics Initiative at the Africa Centers for Disease Control and Prevention or Africa CDC. But in firefighting terms you might think of him as a fire safety officer who is building a network of fire watchtowers and smoke detectors across Africa.

Instead of looking out for the first signs of a fire before it can spread, however, Sofonias is focused on quickly detecting deadly pathogens before they can grow into a global threat. And instead of using watchtowers and smoke detectors, he relies on powerful genomic sequencing technologies to spot disease outbreaks.

Genomic sequencing allows scientists to read the DNA and RNA of pathogens and understand what they are, how they spread from one person to another, and develop counter measures like vaccines. During COVID-19, this technology has been an invaluable tool for identifying new variants, tracking the evolution and spread of the virus, and guiding public health responses.

Advances in this technology have made it easier, faster, and cheaper to do genomic surveillance. Over the last two decades, the price of sequencing a full human genome has fallen dramatically. And one company, Oxford-Nanopore, has even developed a portable gene sequencer that can be operated with a laptop and no need for a lab, allowing health officials to conduct genetic testing in remote areas where outbreaks may occur.

As powerful as genomic sequencing technologies have become, many countries have not taken full advantage of them. Building genomic disease surveillance capacity presents challenges because it requires investments in labs, expensive equipment, and specially trained personnel. While the COVID-19 pandemic has sparked new interest in using genomic sequencing to improve disease surveillance, many parts of the world are still working to strengthen their capacity to use this critical technology.

In 2019, Sofonias joined the Africa CDC to establish a continent-wide genomic disease surveillance network. One of Sofonias’s first projects was to conduct an assessment to understand how many African nations were prepared to use this technology.

The results, Sofonias said, were shocking.

Of the African Union’s 55 member states, just seven had public health institutions with trained personnel and equipment to do genetic sequencing.

Given the scale of the job before them, Sofonias and his team had planned for a phased approach to help African nations build genomic surveillance capabilities. They had to acquire the technology, hire and train the technicians to operate them, and create the data systems so governments can analyze and share the genetic information and use it to inform public health decisions. Building this system would take time.

But the Africa CDC soon learned that time was a luxury they didn’t have. Within weeks of Sofonias joining the Africa CDC, the first cases of COVID-19 were detected in China. And two months later, the first cases were identified in African countries.

It’s hard to overstate the challenge before Sofonias and the Africa CDC. While genomic surveillance had been used during Ebola, Lassa fever, and cholera outbreaks, bringing this technology to scale posed many challenges in Africa, where many countries did not have the infrastructure or trained personnel to run these labs.

But this was just the kind of challenge Sofonias had always been eager to take on.

Born in Ethiopia, Sofonias grew up in a rural town where malaria was always a major threat. Seeing people die and suffer from the mosquito-borne disease got him interested in a career in public health. He earned a PhD in malaria genomics, an emerging field of research that uses genetic data of the malaria parasite to advance malaria eradication efforts. After graduate school, he was working as postdoctoral fellow at the University of California in San Francisco, where he was focused on how genomic data combined with mobile phone data could help researchers understand how malaria spreads from one country to another.

In 2019, when a call came from the Africa CDC asking if he would use his knowledge of genomic surveillance technologies to help Africa, he jumped at the opportunity. Sofonias saw the untapped potential of this new technology to make more informed public health decisions in Africa. And after years living abroad, he was also excited to return home to Ethiopia, where the Africa CDC is based.

Sofonias and his team scrambled to quickly build up Africa’s capacity to do genomic disease surveillance. The Africa CDC focused first on scaling up COVID-19 testing capabilities. At the beginning of the pandemic, only two African nations had the ability to perform PCR COVID tests, highly accurate tests that detect genetic material from the virus.

At the same time, his team worked to acquire next-generation sequencing technologies (NGS) for Africa. NGS technologies offer a more efficient, accurate, and cheaper way for researchers to track the slightest genetic changes in pathogens which may cause disease outbreaks. This effort received support from a group of public, private, and non-profit partners including the African Union, Illumina and Oxford Nanopore, which produce next-generation sequencing machines, the US Centers for Disease Control and our foundation.

Thanks to Sofonias and the rest of the Africa Pathogen Genomics Initiative team, 31 African nations now have the capability to do genetic sequencing for surveillance of COVID, malaria, cholera, Ebola, and other diseases.

Despite this progress, much remains to be done. Sofonias’s team faces challenges in bringing this technology to all African nations. Access to the equipment needed in the labs has been delayed because of global supply chain disruptions. Training enough lab technicians and data scientists to process and analyze the samples has been difficult. Finally, more coordination is needed between countries to share their genetic data and use it to inform collective health responses.

But every month, Sofonias’s team continues to strengthen and expand the system across the continent. The goal is to create a seamless, integrated network that includes laboratories at the community level, which can spot the first signs of an outbreak, perform genomic testing of pathogens, and analyze the results to guide a public health response.

“Our vision is bold. Our vision is optimistic. We always push forward and continue to work with the countries to show that this is actually feasible,” he said. “It really makes me hopeful that this technology can improve outbreak detection and response in Africa.”

Sofonias shared the progress and challenges of building a genomic disease surveillance network with a group of graduate students who participated in a recent Gates Notes Deep Dive on pandemic prevention.

For most people, the highly effective mRNA COVID vaccines made by Moderna and Pfizer-BioNTech seemed to come out of the blue. But these new vaccines, which were essential to end this pandemic and will likely play a critical role in preventing future pandemics, are the product of decades of painstaking work by researchers.

One of those researchers is Dr. Katalin Karikó, a Hungarian biochemist who long ago saw the potential of mRNA to save lives when few others did.

The daughter of a small-town butcher in Hungary, Karikó knew from a young age that she wanted to become a scientist. She was drawn to biochemistry and developed a particular fascination with messenger RNA, or mRNA, molecules that (among other things) direct the creation of proteins in your body.

Messenger RNA functions as a kind of middleman—it carries the directions for making proteins from your DNA to the factories in your cells where the proteins will be assembled. It’s a bit like the waiter in a restaurant who writes down your order and takes it to the kitchen, where the cooks will make your meal.

In the 1980s, while working on her PhD in her native Hungary, Karikó became convinced that tiny strands of mRNA could be injected into cells to send instructions to the body to make its own medicines. She was interested in developing mRNA treatments for stroke, cancer, and other diseases.

Although vaccines were not the focus of Karikó’s work, other researchers saw that it would be possible to use mRNA to make those as well—for flu, coronaviruses, and maybe even various forms of cancer.

Using mRNA to make vaccines would be a major departure from the way most vaccines work. Many conventional vaccines operate by injecting a weakened or dead form of the virus you’re trying to stop. Your immune system sees the new shapes on the virus, kicks into gear, and builds up immunity. While conventional vaccines have been very effective, it takes years of lab work and clinical studies to make sure that they are safe and will produce a good immune response.

The idea behind mRNA vaccines was quite clever. Since mRNA takes the orders for proteins from the DNA and delivers them to the cooks in your cells’ kitchen, what if we could change those orders in a very targeted way? By teaching your cells to make shapes that match shapes on the actual virus, the vaccine would trigger your immune system without having to introduce the virus itself.

If they could be made, mRNA vaccines would be a huge advance over conventional vaccines. Once you had mapped out all the proteins that make up the virus you wanted to target, you’d identify the one that you want antibodies to grab. Then you’d study the virus’s genetic code to find the instructions for making that protein, and you’d put that code into the vaccine using mRNA. If, later, you wanted to attack a different protein, you’d just change the mRNA. This design process would take at most a few weeks. You would ask the waiter for fries instead of a side salad, and your immune system would do the rest.

There was just one problem: It was only a theory. No one had ever actually made an mRNA vaccine. What’s more, most people in the field thought it was crazy to even try, not least because mRNA is inherently unstable and prone to degrading quickly. Also, cells have evolved to avoid being hijacked by foreign mRNA, and there would need to be a way of getting around this defense system.

Karikó’s interest in mRNA eventually brought her to the U.S. And in 1993, while doing research at the University of Pennsylvania, Karikó and her boss managed a feat that told them they were on to something: They got a human cell to produce a tiny amount of new proteins using a modified version of mRNA that had been altered so it could get past the cell’s defense system. This was a breakthrough, because it meant that if they could expand the production dramatically, they would be able to make a cancer treatment using mRNA.

Stories of medical discoveries often don’t travel in straight line from breakthrough to lifesaving impact. And Karikó’s story is no different. Karikó’s work lost momentum when her boss left academia for a biotech firm. She no longer had a lab or financial support for her work; although she applied for grant after grant, every application was rejected. In 1995, she had a cancer scare, she was taken off the tenure track at work, and her husband was stuck in Hungary because of a problem with his visa. But Karikó was undeterred.

Then in 1997, she began working with Drew Weissman, a new colleague who came to the University of Pennsylvania with a promising background: He had done a fellowship at NIH under the supervision of Tony Fauci, and he was interested in using Karikó’s work on mRNA to develop vaccines.

Together Karikó and Weissman kept pursuing the idea of working with mRNA that had been engineered in a lab. But they still had to get more mRNA past the cell’s defense systems, a problem that other scientists helped solve. In 1999, a cancer researcher named Pieter Cullis and his colleagues proposed that lipids—basically, tiny bits of fat—could be used to encase and protect a more delicate molecule, such as mRNA. Six years later, working with Cullis, biochemist Ian MacLachlan did it for the first time. The lipid nanoparticles he developed paved the way for the first mRNA vaccines.

As late as 2010, hardly anyone in the federal government or private industry was interested in trying to make vaccines using mRNA. Major pharmaceutical companies had tried and failed, and some scientists felt that mRNA would never trigger enough of a response in the body. But an official at DARPA, the little-known research program for the U.S. military, saw enough promise in the technology that he started funding mRNA vaccines for infectious diseases.

As pioneering as this work was, it didn’t lead immediately to new vaccines. Accomplishing that would be the task of companies dedicated to translating the breakthrough into a product that could be approved and sold; the U.S.-based Moderna and Germany-based CureVac and BioNTech were founded to do just that.

In 2014, Karikó joined BioNTech, which was working on an mRNA vaccine for cancer. Early efforts didn’t work, although a test of a rabies vaccine showed promise. Still, Karikó and her BioNTech colleagues persevered, as did scientists at Moderna. When COVID hit, they immediately set out to make a vaccine for the new virus. It was a good bet.

The notion that mapping a virus’s genome would allow you to create an mRNA vaccine in a matter of weeks proved to be exactly right. In March 2020, just six weeks after scientists sequenced the COVID virus’s genome, Moderna announced that it had identified an mRNA-based candidate and begun making it for clinical trials. On December 31, the mRNA vaccine made by BioNTech in partnership with Pfizer was approved for emergency use by the World Health Organization. When Karikó received the first dose of the vaccine she had done so much to create—a few days before it was officially approved—she wept.

For all her amazing foresight, I doubt even Dr. Karikó imagined that mRNA vaccines would one day play an essential role in ending a pandemic – and giving us a tool to prevent the next one. And to me, that’s the important lesson of her story: It’s impossible to predict exactly how breakthroughs will shape the future. That’s why it’s critical, if the science makes sense, that we should be willing to bet on crazy sounding ideas and the researchers like Dr. Kariko willing to fight tooth and nail to pursue them. They just might change the world.

In Africa, the latest statistics on COVID-19 are discouraging. Just 6 percent—about 78 millionof the continent’s 1.3 billion people have been fully vaccinated. Worldwide, by comparison, 43 percent are fully vaccinated, and boosters are now widely available in many countries.

Without enough vaccines available in Africa, COVID-19 marches on infecting millions of people. Even assessing the true scale of the pandemic on the continent is difficult. A recent World Health Organization assessment estimated that only one in seven cases of COVID in Africa are being detected because of a limited amount of testing.

And while many Western and Asian countries are recovering economically from the pandemic and returning to some version of normalcy, most countries in Africa continue to struggle. Disruptions to schooling, health care, and livelihoods have sunk many families deeper into poverty, leaving them without enough food and basic services.

We should all be upset about this inequity. (I’ve written recently about this divide and the steps the world needs to take to get the virus under control.) It’s critical that more be done to get vaccines into the arms of the people at high risk for COVID, including the elderly and immunocompromised, who are living in low-income countries. And the recent detection of the Omicron variant serves as a reminder of how important increasing vaccination rates is to deter new mutations of the virus from emerging.

But even during this difficult time, I think it’s important to highlight the many Africans who are fighting back against this pandemic. They are stepping up to alleviate suffering, to combat misinformation, and to develop the tools needed to prevent future pandemics.

There are thousands of examples of heroic work being done in Africa during this pandemic. Here are three stories of organizations and individuals who are working to save lives and bring hope to their communities.

1. South Africa: The Truck

As COVID-19 swept across South Africa, one of the most pressing needs was access to public health information. People needed to know about the virus and how to stay safe. And as South Africa started rolling out COVID vaccines this year, health officials were also tasked with counteracting the spread of misinformation about the virus and vaccines. This was especially challenging in hard-to-reach communities in South Africa, where people don’t have access to television and other media. But UNICEF, in partnership with the national government, had an answer to this challenge: A truck. Not just any truck but a multi-media messenger on wheels. The truck has LED screens, which allows the truck’s organizer to broadcast videos telling local stories about COVID-19. They also organize presentations in communities to raise awareness of the virus, teach people how to prevent its spread, and promote COVID testing and vaccinations. The truck has logged more than 40,000 miles and delivered messages to hundreds of thousands of people.

2. Lesotho: Mamello Makhele

Mamello Makhele is a nurse-midwife working to improve health care for women in rural Lesotho, where there are high rates of maternal mortality. During the pandemic lockdowns many health facilities closed, leaving women living in these remote communities without access to family planning services. On foot and by donkey, Mamello travels high into the mountain to offer health care, deliver babies, and distribute contraceptives. Mamello has also worked nationwide to empower young women, encouraging them to take control of their health and prevent unwanted pregnancies. Thanks to her incredible work, many women are healthier today in Lesotho.

3. Tanzania: Afyadata

Even as the world seeks to end the current COVID-19 pandemic, we need to also be thinking about how to prevent future pandemics. That’s just what a mobile app called Afyadata is helping health officials do in Tanzania. Designed by the Southern African Center for Infectious Disease Surveillance (SACIDS), Afyadata is a digital surveillance tool that allows health workers and even ordinary people to serve as disease detectives. Users can report unusual health occurrences not only in humans, but also animals. Monitoring animals is critical because most new pathogens start in animals before they spread and sicken humans. With the app, farmers can easily report any suspicious illness among their livestock to health officials, who can then quickly follow up with further investigation, if necessary. While this app is still being piloted in several districts of Tanzania and other parts of Africa, it has already been effective in the detection and identification of several small disease outbreaks. I look forward to learning more about Afyadata’s progress.

When I was a kid, my image of a hero was largely inspired by my dad’s collection of early Superman comics. I read them all. A “hero” was somebody who had supernatural powers like flying, laser vision, or the strength to bend steel.

As humans, of course, we’re all pretty limited in our physical powers. We don’t fly. We can’t see through walls. But what’s unbounded in us is our ability to see injustices and to take them on—often at great risk to ourselves.

My work in global health and development has introduced me to many extraordinary heroes with this kind of superpower. And I’ve had the honor of highlighting many of them on this blog: An epidemiologist who helped eradicate smallpox. A doctor working to end sexual violence in Africa. A researcher working to end hunger with improved crops. Just to name a few.

Why do we need heroes?

Because they represent the best of who we can be. Their efforts to solve the world’s challenges demonstrate our values as a society and they serve as powerful examples of how to make a positive difference in the world. And if enough people hear about their actions, they can inspire others to do something heroic too.

If there’s ever been a time that we need heroes, it’s now. The COVID-19 pandemic has created unprecedented health and economic challenges, especially for the most vulnerable among us. The good news is that many people from all walks of life are doing their part to help them. Health care workers. Scientists. Firefighters. Grocery store workers. Aid workers. Vaccine trial participants. And ordinary citizens caring for their neighbors.

Here are portraits of a few individuals from around the world working to alleviate suffering during this pandemic. I hope their stories inspire you just as much as they have me.

To these heroes and heroes everywhere, thank you for the work you do!

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

Not just masks and ventilators, but oxygen.

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

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

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

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

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

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

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

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

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

Here’s a fact that’s hard to believe: At this time two months ago, the world did not yet know about the omicron variant.

It’s both remarkable and horrifying how quickly omicron has become the dominant cause of COVID-19 in many countries. In just seven weeks, it has led to record-high case numbers and hospitalizations around the world. I’m still optimistic that the pandemic can come to an end sometime in 2022, but first we have to contend with a virus that’s spreading faster than any other in history. (I recently had a good discussion about this with global health Professor Devi Sridhar.)

The omicron surge has been an unfortunate reminder that the only way to eliminate the threat of COVID-19 somewhere is to eliminate it everywhere. As long as the virus continues to circulate at a high level in some parts of the world, we’ll always be at risk for another devastating variant. Game-changing innovations—including vaccines and new antivirals—will save lives but won’t truly accelerate the end of the pandemic until they’re accessible to everyone.

That’s why the Gates Foundation is renewing its investment in the Coalition for Epidemic Preparedness Innovations, or CEPI. I’m excited to announce a new $150 million commitment to its future work on COVID and beyond.

Our foundation helped create CEPI in 2017 to accelerate work on vaccines against new infectious diseases and make sure those vaccines reach people in the poorest countries. The organization has played an invaluable role in the COVID-19 pandemic as one of the leaders of COVAX, the global effort to get vaccines out to low- and middle-income countries.

As with malaria, polio, and many other diseases that our foundation works on, the key to pandemic prevention and preparedness is to keep on innovating. This pandemic’s most significant innovation is mRNA vaccines, which were available less than a year after the virus that causes COVID was identified. CEPI began funding efforts to develop mRNA vaccines for COVID just days after the virus was detected outside of mainland China. (One of the candidates CEPI backed in January 2020 was Moderna.)

But CEPI’s support for research on mRNA vaccines predates COVID-19—which is one of the reasons the approach was successful. The groundwork had been laid years before by investments from governments, pharmaceutical companies, and (more recently) CEPI. And the progress they’ve supported will continue to pay dividends long after the COVID pandemic ends. The mRNA platform is already being used to test new vaccines for TB and malaria diseases. Scientists are hard at work formulating next-generation vaccines that don’t require as many doses and don’t need to be kept frozen.

Altogether, CEPI has invested in 14 COVID vaccine candidates and it continues to work on variants of concern and develop next-generation vaccines that could protect against all coronaviruses. It is also focusing on six other diseases of epidemic potential.

But creating new vaccines isn’t enough. We also have to make sure that everyone who can benefit from vaccines has access to them, and that’s where the world has collectively failed in its response to COVID. While at least 9 billion doses were distributed in the past year, less than one percent went to people in low-income countries. It doesn’t make sense that so many people at lower risk of infection in wealthier countries got vaccinated before we reached the most vulnerable people, including the elderly, those with underlying medical conditions, and healthcare workers.

We need to do better the next time the world faces a pathogen that has the potential to spark a pandemic. (I’m currently writing a book about what the world needs to do to prevent the next pandemic, which will come out later this year.) I believe that the world can and should be ready to develop a new vaccine and make enough for everyone in the world within six months of detecting a potential pandemic—and CEPI will play a crucial role in achieving that. It is one example of how we need to be making investments now to support innovations that will prevent disasters in the future. For example, the organization is supporting efforts to increase manufacturing capacity and recently released a study that provides valuable insights into how we can improve the world’s production capabilities. This is the type of investment we need to make now to prevent disasters in the future.

And because CEPI is a global institution rather than a national one, it can focus on providing access for everyone, alongside other effective global institutions that have saved millions of lives like WHO, Gavi, and the Global Fund to Fight AIDS, TB and Malaria. These groups will help make sure that vaccines don’t just go to the highest bidders.

Imagine how different the last two years would’ve been if everyone in the world had had access to safe, effective COVID vaccines within six months. I know it’s hard to think about the next pandemic as the omicron variant surges around the world, but we have an opportunity to make sure the world never experiences this hardship again. Investing in organizations like CEPI is an important step that moves us closer to a world without pandemics.

Today, 46 percent of the world’s population has received at least one dose of a COVID-19 vaccine. It’s hard to overstate what a remarkable achievement this is. Humanity has never made and distributed a vaccine for a disease faster than it did for COVID-19. It accomplished in 18 months something that used to take a decade or more.

But within this amazing success there is a startling disparity: Just over 2 percent of people in low-income countries have received any COVID-19 vaccines. And the gap will be harder to close as rich-world governments buy up extra doses to serve as booster shots.

People are right to be upset about the inequity here. Vaccines make COVID-19 a largely preventable disease—and a survivable one in all but the rarest cases—and it is heartbreaking to know that people are dying of a disease not because it can’t be stopped but because they live in a low-income country.

Sadly, this inequity is not new. It is not even the worst gap in global health. There were shocking disparities in health long before any of us had heard of COVID-19.

Every year, more than 5 million children die before their fifth birthday, mostly from infectious diseases, and almost entirely in low- and middle-income countries. A child in northern Nigeria is 20 times more likely to die before the age of 5 than a child in a rich country. That is simply unjust, and reducing this inequity has been the Gates Foundation’s top priority for more than 20 years.

If you step back and look at the trends, though, there is good news. Since 1960 the childhood death rate has been cut by more than 80 percent, thanks in large part to the invention and distribution of vaccines for children around the world.

The fact that routine childhood vaccines are reaching so many people is reason to believe COVID-19 vaccines can too. Providing them to everyone who needs them is one of three crucial steps in controlling this pandemic, along with containing the virus so it doesn’t come roaring back and coordinating the global response. At the same time, we can learn from the inequities that were so clear during this pandemic so we can do a better job of closing the gap during the next one. (Assuming there is a next pandemic. I think it is possible to prevent them altogether. But that’s a subject for another time.)

How could we achieve vaccine equity in a future pandemic? I see two ways.

1. Change how the world allocates doses.

What would the optimal allocation look like? It’s not simply a matter of proportional representation, where if your county has X percent of the world’s population, you get X percent of the vaccines. There are two different benefits to consider, and both are important.

One benefit is to the individual who’s immunized; they get protection from the virus. The more likely you are to get infected—and the more likely you are to become seriously ill or die if you do get infected—the more benefit you get from a vaccine. A COVID-19 patient in their seventies is 90 times more likely to die of the disease than a patient in their twenties. From a global perspective, it is neither fair nor wise to protect that young person before the old one.

Second, when an individual is vaccinated, society gets the benefit of lowering the risk that the person will spread the disease to others. This is the core of the argument in favor of vaccinating health workers and people who work in elderly care facilities, since even when a lockdown is in place, they can transmit the virus to people at high risk.

When a virus is spreading, we should maximize both benefits—saving lives and stopping transmission. This means that, when supplies are short, we should prioritize vaccinating people who both have a high risk of death and live in the places where the virus is spreading fastest.

Those will not necessarily be low-income countries. When COVID-19 vaccines first became available, many of the most severe epidemics were in rich- and middle-income countries.

The gravest inequity, even more than vaccinating rich people before poor ones, is vaccinating young people in rich countries before older people in middle-income countries with bad epidemics, such as South Africa and most of South America.

To their credit, rich countries have pledged to share more than a billion doses with poorer countries during COVID-19. But they haven’t yet delivered fully on those pledges, and even if they had, the gap would still be enormous.

Although sharing doses needs to be part of the solution, it will never be sufficient to solve the problem. For one thing, the number of doses won’t be high enough. And will future politicians always be willing to tell young voters they can’t be vaccinated because the doses are going to another country, at a time when schools are still closed and people—including a few young people—are still dying?

That’s why it’s so important to find ways to produce more doses in less time. The world should have the goal of being able to make and deliver enough vaccines for everyone on the planet within six months of detecting a potential pandemic. If we could do that, then the supply of doses would not be a limiting factor, and the way they were allocated would no longer be a matter of life and death.

2. Make more doses.

As limited as the supply of COVID-19 vaccines has been, the situation could have been even worse.

We are fortunate that mRNA vaccines work so well, since this is the first disease for which the mRNA technology has been used. If they hadn’t, we would have been far worse off.

It is also great that some vaccine companies entered into second-source deals, which allowed huge volumes of their vaccines to be manufactured by other firms. This was a crucial and remarkable step. (It’s as if Ford let Honda use its factories to build Accords.) Just one example: In less than two years, a single manufacturer, AstraZeneca, signed second source deals involving 25 factories in 15 countries.

You may have heard the argument that waiving intellectual property (or IP) restrictions would have made a difference. Unfortunately, that’s not true in this case. IP waivers and licensing are a complicated issue, so I want to take some time to untangle it.

There are cases in which IP licensing is a great way to make something cheaper and better. For example, in 2017, the Gates Foundation and a number of partners were involved in an agreement to make a new, more effective version of an HIV drug cocktail that would be more affordable for the world’s poorest countries.

In the deal, a pharmaceutical company gave the recipe for the key ingredient in this cocktail to firms that specialize in producing generic drugs. These firms were able to reduce the cost so much that today nearly 80 percent of people who get HIV treatment in low- or middle-income countries are receiving the improved cocktail.

Unfortunately, IP licensing doesn’t work as well with vaccines. Here’s why.

Many drugs are made using chemical processes that are well defined and measurable. If you mix the same ingredients in the right proportion and so on, you’ll get the same product every time, and you can check your work by looking at the chemical structure after the drug is made. Company A can give a recipe to company B, and company B will be able to make precisely the same drug consistently.

But many vaccines don’t work that way. Manufacturing them often involves living organisms—anything from bacteria to chicken eggs. Living things don’t necessarily act exactly the same way every time, which means that even if you follow the same process twice, you might not get the same product both times. Even an experienced vaccine maker might not be able to simply take another’s recipe and replicate it reliably.

This is why broadly waiving IP protections would not meaningfully increase the supply of vaccines. (In the case of COVID-19, though, a narrow waiver that applied to specific easily transferred technologies during the pandemic made sense.) Supply has been limited not because of IP rules, but because there aren’t enough factories capable of handling the more complicated process of making vaccines.

Licensing IP—or having the rights to it waived—only guarantees that company A can’t sue company B. Second-source deals are far superior because they involve sharing not only the recipe but also knowledge about how to use it, as well as personnel, data, and biological samples. It was a second-source deal with AstraZeneca—not an IP waiver—that allowed Serum Institute of India to produce 100 million doses at a very low cost and in record time.

So how can the world make more doses faster next time?

First, decision makers should get serious about expanding the world’s vaccine-making capacity. In particular, governments and industry should make sure there’s enough capacity to quickly make huge volumes of mRNA vaccines; now that we know the mRNA platform works, it will allow new vaccines to be developed faster than any other approach. And if companies that have second-source deals now maintain their relationships with each other, they won’t have to start from square one in the next outbreak.

Another step is to develop prototype vaccines against the diseases that are most likely to cause future outbreaks, and to develop universal vaccines for flu and coronaviruses, which would protect people against any form of the two pathogens. The NIH and Coalition for Epidemic Preparedness Innovations are doing excellent work on both, but even more research is needed.

One longer-term step is for more countries to build the capacity to develop, manufacture, and approve vaccines themselves.

Historically, the companies that invent new vaccines have been based in higher-income countries. Because it costs so much to develop a new product, they try to recoup their costs as quickly as possible by selling doses at the higher prices that rich countries can afford. They have no financial incentive to try to lower their costs (by optimizing the production process, for example) so that the price can be cheap enough for lower-income countries.

The pentavalent vaccine—which protects against five diseases—is a great example. It was invented in the early 2000s, but there was only one manufacturer, and at more than $3.50 per dose, it was far too expensive for low- or middle-income countries. Our foundation and other partners worked with two vaccine companies in India—Biological E Limited and Serum Institute of India—to develop a pentavalent vaccine that would be affordable everywhere. Today that vaccine costs about $1, and it is given to 80 million children a year. That’s a 16-fold increase since 2005.

We need more examples like this. Pentavalent took years to pull off. If there were more high-volume vaccine manufacturers whose primary goal was to produce low-cost vaccines, then affordable doses would be available much faster. Middle-income countries are a natural home for these companies, and some have set ambitious goals for themselves. For example, a group of African leaders has set a target of manufacturing 60 percent of the continent’s vaccines by 2040.

Helping middle-income countries build their vaccine-making capacity is something the Gates Foundation has been working on for two decades. We’ve helped bring 17 vaccines to market, and we’re supporting the African efforts to build theirs out by 2040.

What we’ve learned is that creating an entire vaccine-making ecosystem is a tough challenge. But the obstacles can be overcome.

One issue is the need for regulatory approvals. Vaccine factories are required to be approved by what’s known as a “gold-standard” regulator. India is the only developing country with a gold-standard regulator; factories in any other developing country have to be approved by their own government first, and then by the WHO. It’s time-consuming.

Regional agencies in Africa are working with the WHO and the European Union to create gold-standard regulation on the continent. Governments are also collaborating on regional standards for vaccines, so manufacturers don’t have to meet different safety and efficacy requirements in each country.

Another challenge: If vaccine manufacturers don’t have other products to make between outbreaks, they’ll go out of business. Unfortunately, making existing vaccines isn’t a viable option, at least right now, because the market is already saturated with existing vaccines, and it would be hard for new entrants to compete on price with established low-cost / high-volume companies.

But new products are coming that would be ideal products for them. As vaccines become available for diseases like malaria, tuberculosis, and HIV, they’ll create opportunities for producers in middle-income countries. In the meantime, countries can take on the fill and finish process—putting vaccines made elsewhere into vials and distributing them.

To anyone who has lost a loved one to COVID-19, or had to choose between paying the rent or buying food, it is no comfort to suggest that anything has gone well in this pandemic. But as my friend the late Hans Rosling used to say, “The world can be both bad and better.” The situation today is bad, and also better than it would have been if COVID-19 had come along ten years ago. If the world makes the right investments and decisions now, we can make things better next time. And maybe even make sure there is no next time at all.

This post originally appeared on CNN.com.

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

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

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

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

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

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

1. Vaccinate Now

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

2. Contain the Disease

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

3. Coordinate the Global Response

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

5. We can do better next time.

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

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

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

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

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

When it comes to killing humans, no other animal—not sharks, snakes, or crocodiles—is as deadly as the mosquito.

But in the fight against dengue fever, one kind of mosquito has been transformed into a surprisingly powerful ally to save and improve lives.

Dengue fever is a virus spread through bites by the Aedes aegypti mosquito. Nicknamed “breakbone fever” because of the severe pain it causes, dengue infects about 400 million people every year and kills more than 20,000. Warming temperatures due to climate change have expanded the geographic range of the mosquitoes, driving up the number of dengue cases in recent years.

Researchers with the World Mosquito Program, however, have been working on a breakthrough that just might defeat dengue for good.

This breakthrough relies on a tiny bacterium called Wolbachia and the Aedes aegypti mosquito.

Wolbachia is a common and harmless bacterium found in 60 percent of all insects, including fruit flies, bees, moths, and butterflies. But it’s not found in Aedes aegyptiWolbachia mosquitoes. More than a decade ago, researchers made a surprising discovery about . If Wolbachia Aedes aegyptiWolbachiais given to  mosquitoes, it blocks them from transmitting the dengue virus. Researchers learned that spreads rapidly among mosquitoes when they mate, blocking the spread of dengue from one generation of mosquitoes to the next.

All this initial research was done in a lab setting. The next step was to test whether this approach would work in the real world. If Wolbachia mosquitoes were released into a community, would it lead to a reduction in dengue cases?

That’s the experiment the World Mosquito Program, a non-profit working to stop the spread of dengue and other mosquito-borne diseases, has been conducting in Yogyakarta, Indonesia. (Our foundation has been a proud funder of this research. In 2014, I visited Yogyakarta to see this work just as it was getting started. I even helped feed some of the Wolbachia-carrying mosquitoes!)

As part of a randomized controlled trial, researchers released Wolbachia mosquitoes in parts of Yogyakarta, which has some of the highest rates of dengue fever in the country.

Setting mosquitoes free in people’s neighborhoods is, of course, an unconventional solution to fight dengue. To earn public trust, researchers collaborated closely with the local community. They met with thousands of people in the city and addressed their questions and concerns about the program.

This public outreach effort took years. But it was worth it.

In June, the New England Journal of Medicine published the results of the trial, which show that the Wolbachia-carrying mosquitoes reduced the number of dengue cases by 77 percent and dengue hospitalizations by 86 percent.

Now, the World Mosquito Program is working to expand this effort in other parts of the world where dengue is a threat, including cities in Sri Lanka, Vietnam, Brazil, Colombia, Mexico, Australia, and Fiji.

This effort can be effective in preventing not only dengue, but also Zika, yellow fever, and other diseases transmitted by Aedes aegypti mosquitoes.

It’s hard to overstate the impact the World Mosquito Program may have on communities at risk of these diseases. Every dollar spent on this effort is expected to deliver $4 in economic benefits by saving billions of dollars in health care costs and preventing billions of hours of lost productivity due to illness.

I look forward to sharing more news about this incredible project in the years ahead.