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

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

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

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

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

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

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

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

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

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

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

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

This time really is different.

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

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

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

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

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

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

The transition to AI comes with three big risks.

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

Many jobs will disappear forever.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The world needs a plan.

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

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

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

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

Build a new system for managing the transition.

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

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

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

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

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

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

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

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

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

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

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

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

Set aside some jobs for humans.

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

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

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

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

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

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

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

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

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

Rebalance how we tax labor and capital.

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

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

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

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

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

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

What I’m doing.

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

My message to leaders is:

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

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

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

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

How should public institutions adapt?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

m-mama is making sure those minutes count.

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

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

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

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

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

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

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

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

1.

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

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

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

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

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

2.

Will the world prioritize scaling innovations that improve equality?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We should be too.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I wish that were true. But it is not.

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

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

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

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

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

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

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

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

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

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

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

A Record of Progress—and What is at Risk

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 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 spent a lot of time over the last month talking about climate change. Whether it’s on my book tour, in media interviews, or just during conversations with colleagues, it’s been great to have so many thoughtful conversations with people about how we prevent the worst effects of climate change.

Most of the questions I’ve gotten are about how we get to zero greenhouse gas emissions. Mitigation is the biggest climate problem we need to solve, and it’s been great to see it get so much attention. But I’ve noticed there’s one key topic that people don’t ask about as much: how we can help the world adapt to climate change.

I understand why. I dedicated five chapters of the book to mitigation and only one to adaptation. (In retrospect, I wish I had written more about the subject.) But there’s a reason I named my book “How to Avoid a Climate Disaster” and not “How to Stop Climate Change:” Our climate is already changing.

You just need to look at last month’s freeze in Texas and last year’s wildfires in California to see that extreme weather events are becoming more common. The scary thing is that these events aren’t the only (or even the most devastating) way a warming world is making life more difficult for people. The biggest damage is happening too gradually to make headline news, mostly in places near the Equator—and no one is more at risk than the world’s poorest people. 

About two-thirds of those living in poverty work in agriculture, often relying on the food they grow to feed their families. A warmer world will be problematic for relatively well-off farmers in America and Europe, but potentially deadly for low-income farmers in Africa and Asia.

The closer you live to the Equator, the worse the effects of climate change will be. Droughts and floods will become more frequent, wiping out harvests more often. Livestock will eat less and produce less meat and milk. The air and soil start to lose moisture, leaving less water available for plants; in South Asia and sub-Saharan Africa, tens of millions of acres of farmland will become substantially drier.

When you’re already living on the edge, any one of these changes could be disastrous. We’re likely going to see a situation for these farmers where, instead of your crop getting wiped out every ten years, it gets wiped out every four years. If you don’t have money saved up to buy imported food—which is the case for most smallholder farmers—your children will likely become malnourished and more susceptible to disease.

The worst impact of climate change in poor countries will be to make health worse—which is yet another reason why we need to help the poorest improve their health. This starts with raising the odds that malnourished children will survive by improving primary healthcare systems, doubling down on malaria prevention, and continuing to provide vaccines for conditions like diarrhea and pneumonia. We also need to ensure that fewer children are malnourished in the first place by helping poor farmers grow more food.

This is a problem we can help solve with innovation. We need better methods and tools to grow food, just like we need to find zero-carbon ways to move around and generate electricity. No other organization is in a better position to create the innovations that will help poor farmers adapt to climate change in the years ahead than CGIAR, a global partnership that helps make plants and animals more resilient and productive. (I’ve written about how amazing CGIAR is before.)

Our foundation first got involved with CGIAR more than a decade ago, when we supported their work to develop drought- and flood-tolerant varieties of staple crops like maize. We’re already seeing big improvements in places like Zimbabwe. Farmers in drought-stricken areas there who used drought-tolerant maize were able to harvest up to 500 more pounds per acre than farmers who used conventional varieties—producing enough to feed a family of six for nine months.

CGIAR and other organizations are also creating tools to help farmers adapt to unpredictable weather, like sensors that tell you when to plant seeds and phone apps that help identify pests. Poor farmers need more advances like these, but to provide them, we need to invest more money in agricultural R&D. Doubling CGIAR’s funding so it can reach more farmers is one of the main recommendations by the Global Commission on Adaptation, which I led along with former UN secretary-general Ban Ki-moon and former World Bank CEO Kristalina Georgieva. (Other recommendations include shoring up water infrastructure and building a stronger safety net to help farmers recover faster.)

If we don’t take steps now to help farmers adapt, we’re setting ourselves up for a humanitarian and geopolitical disaster. The U.S. military predicts that climate change will become a huge driver of global instability. When people can’t grow enough food to feed themselves, they often leave those areas for places that can better support their families. We’re going to see more “climate refugees” move to cooler regions as the world gets warmer. The Department of Defense is already thinking about where a warmer climate could cause conflicts that they would be asked to intervene in.

It’s deeply unfair that the people who contribute the least to climate change will suffer the worst from its effects. Extreme poverty has plummeted in the past quarter century, from 36 percent of the world’s population in 1990 to 10 percent in 2015 (although COVID-19 is a huge setback that is undoing a great deal of progress). Climate change could erase even more of these gains, increasing the number of people living in extreme poverty by 13 percent.

Rich and middle-income countries are causing the vast majority of climate change, and we need to be the ones to step up and invest more in adaptation. The world’s poorest deserve our help, and they need more of it than they’re getting.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Going Gaga

I couldn’t help but feel a little nervous.

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

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

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

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

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.

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.

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.

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.

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.

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.

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.

When’s the best time to kill mosquitoes?

While they’re making love—at sunset.

No kidding.

This is just one of many fascinating discoveries being made at a place called Mosquito City. Located in the swamplands of central Tanzania, the “city” is home to the world’s largest captive colony of mosquitoes used for researching ways to combat malaria and other mosquito-borne diseases. Day and night scientists work to better understand mosquito behavior (like when and where they enjoy having sex) as well as cutting-edge approaches to trap, repel, and most importantly, kill them.

I first learned about Mosquito City during a trip to Africa several years ago when I met scientists from Ifakara Health Institute, a Tanzanian health research organization which runs the site. While I haven’t had the opportunity to visit, Fredros Okumu, Ifakara’s chief scientist, offered a behind-the-scenes look at some of the research underway there in this video. If you’re wondering how they get enough blood to feed all the mosquitoes, watch for the moment when Fredros puts his arm in a cage containing more than 500 very hungry mosquitoes for a feed! (For larger mosquito colonies, too big for one human to feed, a cow is on the mosquitoes’ dinner menu.)

Mosquito City is located in a region of Tanzania that’s hot, humid, and swampy. In other words—perfect conditions for its primary residents. Malaria has been so widespread in this part of the country—once infecting 80 percent of the population—that one meaning of the name of the local town, Ifakara, is, “the place people go to die.”

Fortunately, malaria deaths are on the decline in recent years. One reason is the use of insecticide-treated bed nets, which remain one of the most effective means to control the disease. (New bed net distribution efforts like the one that just launched in Benin are helping to ensure every person at risk of malaria is protected by one.)

Still, much more needs to be done to fight the disease, especially as mosquitoes become resistant to some of the pesticides used to control them. That’s why scientists at Mosquito City are working to better understand mosquito behaviors and find ways to outsmart them.

“It's kind of a love- hate relationship. If you can't beat them, you join them for now, but then you can kill them from the inside. And that's what we try to do here at the Mosquito City,” Fredros says.

Fredros and his team are studying one of the deadliest mosquito species, Anopheles funestus. In southeastern Tanzania, it is responsible for nearly 9 out of every 10 cases of malaria even though other species of mosquito are far more common. And yet, it is one of the least understood species of mosquitoes because it is difficult to raise in a lab environment. Our foundation is supporting the Ifakara Health Institute’s research into its behavior so they can mount a targeted campaign against them.

One promising approach may be killing them while they are mating. Ifakara scientists learned that mosquitoes, including Anopheles funestus, have favorite locations—like rice fields, trash heaps, and banana trees—to mate. The male mosquitoes appear at their favorite mating spots at sunset to begin a ritualistic flight dance, drawing in the females. Because these mating events occur at predictable times and locations, researchers are experimenting with regularly targeting these swarms with pesticides, dramatically reducing the mosquito populations and malaria transmission.

As the researchers dig deeper into the unique characteristics of different mosquito species, it’s become more important to be able to quickly identify them. Once they understand which species is posing the greatest threat, they can choose the best methods to eliminate them. But identifying mosquito species and other indicators, like age, can be a laborious process. At Mosquito City, scientists are working on some alternative identification approaches that would accelerate their research. One is to use their buzzing sound to identify them. Another option uses infrared spectroscopy. Mosquitoes have a unique electromagnetic signal. By crushing the abdomens of mosquitoes and analyzing them under a spectrometer, researchers can identify the species and age of the mosquito.

Many of the innovations coming out of Mosquito City are designed to meet the immediate needs of the local community, who work in small farming villages and spend most of their day outdoors. Researchers have developed a variety of mosquito traps, some mimicking the odor of sweaty feet, a smell that mosquitoes find irresistible. They’ve created a range of mosquito repellents too, including furniture treated with repellent that allows people to sit outside in the evening and stay protected. They’ve even developed a line of sandals which will keep mosquitoes at bay from the sweatiest feet, protecting their owner from bites.

What will the team at Mosquito City think of next? I can’t wait to find out.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Unfortunately, it’s pure Hollywood fiction.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.

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.

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

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

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

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

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

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

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

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

Ten years ago, our foundation challenged the world to reinvent the toilet.

To raise awareness of this challenge, I shared a stage with a jar of human feces.

Took a giant whiff of pit latrine odor.

Drank water made from fecal sludge.

And convinced Jimmy Fallon to drink it too.

All these stunts got some laughs, but my goal was to draw attention to a serious problem: poor sanitation.

About 3.6 billion people—nearly half of the world’s population—lack toilets or use unsafe sanitation.

Living without a toilet is more than an inconvenience. It’s dangerous. Unsafe sanitation means contaminated water, soil, and food. It causes illness and death.

According to the latest estimates, diarrhea and other sanitation-related diseases kill nearly 500,000 children under the age of five every year.

As the world gets more crowded, the human toll of unsafe sanitation will only increase. The United Nations estimates that between now and 2050, the world’s population will grow by two billion people. More than 90 percent of that growth will be concentrated in cities and in developing countries—places that are least likely to have good sanitation.

The COVID pandemic has also served as a powerful reminder of the urgent work households and cities must do to contain and treat deadly pathogens.

But this sanitation crisis can be solved.

In 2011, our foundation’s Reinvent the Toilet Challenge asked researchers if they could develop safe sanitation solutions that work without relying on sewage systems or running water. (Sewers and treatment plants have historically been the best way to safely process waste, but they are extremely expensive to build, maintain, and operate. They also rely on large amounts of water when many countries are suffering from water shortages.)

In the decade since we launched this challenge, the world has responded with the power of innovation. Scientists and engineers from across the globe developed hundreds of exciting ideas for how to design toilets that safely process human waste with little or no need for water or electricity. They created toilets that convert feces into valuable resources, including fertilizer, clean water, and electricity.

Other researchers invented a new system to process fecal sludge from pit latrines, septic tanks and sewers that turns human waste from entire communities into drinkable water and electricity. These machines, called omni-processors, can be used to support a fecal sludge treatment plant or complement a waste-water treatment plant. And they require a fraction of the energy, space and cost that a traditional sewer and wastewater treatment plant require.

In the next phase of the Reinvent the Toilet work, a team of researchers led by Dr. Shannon Yee at Georgia Institute of Technology is taking the best of these ideas to develop a low-cost reinvented toilet. It’s called the Generation 2 Reinvented Toilet. You can read more about the progress Shannon and his team have made here.

To be sure, there are still challenges ahead to bring these innovations to market so that they can transform the lives of the billions of people who need them.

But I’m optimistic about what can be accomplished in the next 10 years and beyond.

Nearly three years ago, Indian Prime Minister Narendra Modi made one of the boldest comments on public health that I have ever heard from an elected official. It's still having a big impact today.

He made the comment during his first speech to the nation commemorating India's Independence Day. Modi said: “We are living in the 21st century. Has it ever pained us that our mothers and sisters have to defecate in the open?... The poor womenfolk of the village wait for the night; until darkness descends, they can`t go out to defecate. What bodily torture they must be feeling, how many diseases that act might engender. Can`t we make arrangements for toilets for the dignity of our mothers and sisters?”

I can’t think of another time when a national leader has broached such a sensitive topic so frankly and so publicly. Even better, Modi backed up his words with actions. Two months after that speech, he launched a campaign called Clean India (“Swachh Bharat” in Hindi), which now includes ending open defecation nationwide by 2019, installing 75 million toilets throughout the country—75 million!—and making sure that no untreated waste is dumped into the environment.

On my most recent visit to India, I made a video about this amazing undertaking:

If you’re wondering why the Prime Minister would put a spotlight on a subject that most of us would rather not even think about, take a look at the statistics. Of the 1.7 million people worldwide who die from unsafe water, sanitation, and hygiene each year, more than 600,000 are in India. A quarter of young girls there drop out of school because there’s no decent toilet available. When you factor in the deaths, sickness, and lost opportunity, poor sanitation costs India more than $106 billion a year.

In other words, solving this problem will save hundreds of thousands of lives every year, help girls stay in school, and boost the country’s economy. Improving sanitation is a big focus for our foundation, and we’re working closely with the Indian government in support of its goals.

There are two keys to achieving the targets of Clean India. One involves giving everyone access to a well-managed toilet, which means all the waste is treated (either on-site or in a treatment facility) to remove the pathogens that make people sick. It’s crucial to get the entire process right, from containing the waste in a toilet to collecting it, transporting it if necessary, and treating it. If one link in the chain fails, people still get sick.

Unfortunately, in many places, it’s not feasible to lay down sewer pipes or build treatment facilities. That’s why Indian researchers are testing a variety of new tools, including redesigned toilets that don’t require sewer systems and advanced ways to treat human waste.

So far, the progress is impressive. In 2014, when Clean India began, just 42 percent of Indians had access to proper sanitation. Today 63 percent do. And the government has a detailed plan to finish the job by October 2, 2019, the 150^th anniversary of Mahatma Gandhi’s birth. Officials know which states are on track and which are lagging behind, thanks to a robust reporting system that includes photographing and geotagging each newly installed toilet.

But giving people access to toilets isn’t enough. You also have to persuade them to use the toilets. That’s the second key to Clean India, and in some ways it is even harder than the first. People can be reluctant to change old habits.

Clean India has ingenious ways of tackling that problem. In some communities, groups of children band together to call out people who are defecating in the open and encourage them to use public toilets instead. In a pilot project that will be expanded next year, the government worked with Google so users in 11 cities could search online for the nearest public toilets, get directions, and read reviews by other users. On streets throughout the country, billboards remind passers-by of the mission. Stars from Bollywood films and cricket teams speak out on TV and radio. Even India’s currency features the Swachh Bharat logo.

The hard work is paying off. Today more than 30 percent of Indian villages have been declared free of open defecation, up from 8 percent in 2015. (You can track the progress on this handy dashboard.)

What I love most about Clean India is that it identified a big problem, got everyone working on it, and is using measurement to show where things need to be done differently. As the old saying goes, What gets measured gets done. If you don’t set ambitious targets and chart your progress, you end up settling for business as usual—and in this case, business as usual would mean poor sanitation keeps killing more than half a million Indians every year.

By aiming high, the people of India are demanding change, and they are taking action to make it happen. It is a great example for other countries and an inspiration for all of us who believe everyone deserves a chance at a healthy, productive life.

I just traveled halfway around the world to look at a toilet.

If you’re a long-time reader of TGN, this shouldn’t come as a surprise. There are few things I love talking about more. Sanitation is one of the most important issues we work on. I even drank water made from human feces a couple years ago.

That’s why I’m so excited to visit Beijing, China this week for the Reinvented Toilet Expo, where some of the most high-tech toilets in the world will be on display.

The toilets at the expo aren’t just fascinating gadgets—they have the potential to save millions of lives. More than half of the world’s population uses unsafe sanitation facilities. Even in places where people have access to toilets or pit latrines, their waste isn’t disposed of safely. The pathogens from the waste find their way into the local water supply and makes people sick.

The diseases caused by contaminated water kill more than 500,000 children under five every year. Those who survive are often too sick to go to school. It’s no exaggeration to say that poor sanitation holds back whole communities and entire nations.

If you live in a level 3 or 4 country, you can thank your sewer system for keeping you safe. Sewers have historically been the best way to make sure waste isn’t releasing harmful pathogens into the environment.

But what if you didn’t need a sewer to keep people safe? What if your toilet could dispose of waste all on its own?

Here in China, I get to see this and several other amazing new inventions that could deliver on the promise of sewer-less toilets.

Our foundation has invested a lot of money to develop a pipeline of next-generation sanitation solutions. In 2011, we launched the Reinvent the Toilet challenge. Many of the solutions created for that challenge are now ready to license. A remarkable cohort of engineers, scientists, companies, and universities around the world has done the hard work of getting a safe, off-grid sanitation market ready for take-off. My hope is that this week’s showcase moves their hard work one step closer to being used by real people around the world.

Each of these toilets seeks to solve the same problem, but they’ve all taken a different approach to get there. (The video above explains what specifically makes each toilet special.) Several run on solar power, so they can operate off-grid.

Others generate their own power, like the Cranfield nanomembrane toilet. Opening or closing its lid moves a screw that separates liquids from solids. A gasifier converts the solids into ash and heat that is used to operate the toilet.

A big theme for next-gen toilets is the ability to turn waste into something useful. The Ecosan extracts clean water, which is safe to use for hand-washing. The water created by Duke University’s neighborhood treatment system can be used to flush toilets or supplement fertilizer. The University of South Florida’s New Generator even collects methane gas for cooking or heating.

Another common feature involves burning waste to get rid of it (I apologize if you’re eating right now, but there’s no delicate way to describe this). The Janicki Firelight dries out urine and feces, turning them into sterile ash and water.

As you might have guessed, these toilets are a lot more complicated than your average toilet. Just look at the maintenance panel used to operate a public restroom:

The user experience for each is more or less the same as any other toilet, though. Most of the magic happens behind the scenes.

I know most people wouldn’t describe what toilets do as magical, but I think it’s true in this case. Think about it: the toilet hasn’t really changed in more than a century. If you could go back in time to the mid-1800s, you’d find flush toilets that work basically the same as the toilet in your home. And if you live somewhere with pit latrines, toilet design has stayed the same for even longer.

The toilets on display here in Beijing might one day replace a piece of technology that’s been with us for ages—and they could save millions of lives in the process.

I recently traveled to Switzerland to take a giant whiff of pit latrine odor. What I inhaled was a strong kick to the nostrils, a potent combination of sewage stink, barnyard sweat, and bitter ammonia topped off with vomit (or was it parmesan cheese?). The stench was foul and made me wince.

Fortunately, I also got to smell something much fresher and more pleasing during my trip. I took the first sniffs of a future of odor-free toilets and better sanitation for all.

These olfactory revelations occurred during my tour of Firmenich, a family-owned fragrance and flavor company based in Geneva. The 120-year-old firm is known for crafting some of the world’s best-known fragrances and enhancing the flavors of beverages and foods. But it is also one of our foundation’s newest partners in the effort to improve sanitation in the world’s poorest countries.

I’ve written before about the world’s sanitation challenge. The numbers are staggering. One billion people have no access to toilets so they defecate out in the open. Three billion more have toilets, but their waste is dumped untreated, seeping into water and food supplies. About 800,000 children under age 5 die each year from diarrhea, pneumonia, and other common infections caused by unsafe water and sanitation. Beyond the tremendous human suffering, it’s a problem that slows economic development. In India alone, poor sanitation costs nearly $55 billion each year—more than 6 percent of GDP.

So how could a perfume company help?

Because smell matters.

Millions of new toilets are being built around the world to help end open defecation, including in India where a massive new toilet construction program is currently underway. This is great news. Unfortunately, many of these new toilets, especially the pit latrines, don’t get used because they smell bad and people continue to relieve themselves in the open where the air is fresher. This is a worrying trend that threatens to undermine the progress that’s been achieved in global sanitation.

A few years ago our foundation organized a “smell summit” to discuss ways to address this problem. Representatives from Firmenich were among the attendees and they thought they might be able to help.

With more than a century of experience creating perfumes and flavors, Firmenich has developed sophisticated approaches to analyzing odors and breaking them down to their chemical components. They started their work with the foundation’s sanitation team by asking a basic question: why do toilets smell so bad?

The answer may seem obvious. But toilet odors are actually quite complex. They consist of more than 200 different chemical compounds arising from feces and urine that change over time and vary depending on the health and diet. Firmenich researchers wanted to know which ones were responsible for the terrible smell.

They isolated four chemical culprits: indole, p-cresol, dimethyl trisulfide, and butyric acid. Then, they asked their scientists to try to recreate the odor using synthetic compounds. In other words, they made a fragrance that smelled like fecal matter and stale urine. A poop perfume!

To make sure they got the offensive odor just right, Firmenich asked people in Switzerland, India, and Africa which fragrances most closely mimicked a stinky toilet. The result of their efforts? The fragrance I breathed in during my visit. I put my nose up to a glass sniffing tube in Firmenich’s research facility and I was hit by a blast of foul-smelling odors. As I described (perhaps too vividly) above, it smelled as bad as the worst toilets I’ve ever visited.

With the poop perfume in hand, Firmenich’s researchers could use it to experiment with various other fragrances, exploring how to effectively mask the offensive odors.

In the long history of battling disagreeable odors, from sweaty armpits to wet dogs, the world has largely relied on one solution to the problem. We use pleasant fragrances to cover over the malodors we want to hide—the olfactory equivalent of sweeping dirt under a rug.

Firmenich wanted to try a different, more innovative approach to this age-old challenge. They wanted to attack the problem on a molecular level at the connection between our noses and our brains.

Our noses have 350 olfactory receptors, each one awakening us to new sensations from the smell of a rose to stinky feet. Just a handful of them allow us to smell repulsive odors. Firmenich researchers used this knowledge to develop fragrances that block certain receptors in our noses, making us unable to register certain malodors.

The approach is similar to noise-canceling headphones which many people use to block out jet engine noise on flights. Electronics in the headsets create a sound wave that is 180 degrees out of phase with the ambient noise that needs to be blocked. This wave cancels unpleasant sounds and allows you to enjoy peace and quiet. Likewise, the ingredients in the fragrances developed by Firmenich inhibit the activation of the olfactory receptors sensitive to malodors. By blocking the receptors, our brains do not perceive the bad smells.

I had an opportunity to experience the odor-blocking fragrances in action. I was invited to push my nose into a glass sniffing tube and breathe in a mixture of the poop perfume I had just experienced and one of the new odor-blocking fragrances. It smelled pretty good. There was no evidence of repulsive odor I had experienced earlier. Instead of stinky sewage, sweat, and ripe cheese, I sniffed a pleasant floral scent.

The question now is whether this technology is good enough to make a difference in communities with poor sanitation. That’s why Firmenich is launching pilot projects in communities across India and Africa to understand whether the fragrances will make toilets and pit latrines more inviting for users. They also need to determine if it’s better to distribute the fragrance as a spray, a powder, or something else. The ultimate goal is to make the product affordable and easy-to-use.

I continue to be amazed by the innovation that’s underway in the field of sanitation. Until recently, sanitation was a taboo subject. It didn’t attract many resources or interest from researchers. Now, dozens of researchers, technologists, and decision-makers from both the private and public sectors are partners in the effort. Together, we are working to identify and develop solutions that people value and that will improve the health and dignity of urban slums and other densely populated communities where the need for better sanitation is greatest.

I was excited to see Firmenich contributing its expertise and creativity to solving this challenge and look forward to updates on the progress they’re making.

It had been a busy day in Geneva for my nose and my 350 olfactory receptors. But one scent continues to linger. It’s the smell of success—the kind that happens when people put their talents together to make the world a better place.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

Mosquitoes don’t practice social distancing. They don’t wear masks, either.

As COVID-19 spreads across the globe, it’s important to remember that the world’s deadliest animal hasn’t taken a break during this pandemic.

Mosquitoes are out biting every night, infecting millions of people with malaria—a disease that kills a child every other minute of every day.

Most of these deaths occur in the poorest countries with the weakest health systems. Now, they face the added burden of halting the coronavirus. And in many of these countries, COVID-19 cases are likely to peak at the worst possible time: the height of their malaria transmission seasons.

During the 2014 Ebola outbreak in West Africa, endemic diseases like malaria, tuberculosis and HIV/AIDS contributed to many more deaths than Ebola because the epidemic disrupted local health care systems. Health officials fear the same could happen with COVID-19.

Lockdowns and social distancing regulations have already made it difficult for health workers to provide malaria prevention and treatment in many parts of Africa. There have also been interruptions to supplies of essential malaria tools—like bed nets, anti-malaria medicines, and rapid diagnostic tests—that have been instrumental in cutting malaria deaths by more than half since 2000.

Now that incredible progress may be in jeopardy. A recent modeling analysis from the World Health Organization found that if essential malaria prevention and treatment services are severely disrupted by the pandemic, malaria deaths in sub-Saharan Africa would reach mortality levels not seen since 2000. That year, an estimated 764,000 people died from malaria in Africa, most of them children.

There is not a choice between saving lives from COVID-19 versus saving lives from malaria. The world must enable these countries to do both. Health officials urgently need to step up to the challenge of controlling the pandemic while also making sure that malaria, as well as other diseases like HIV and tuberculosis, are not neglected.

For malaria, that means continuing with campaigns to deliver long-lasting insecticide-treated bed nets, control mosquito populations with indoor spraying, and provide preventive treatment for pregnant women and children in high-risk communities. At the same time, health workers must deliver these services while not putting their communities at risk of the coronavirus.

The good news is that many countries are finding ways to maintain key malaria programs even in the face of the pandemic. In Benin, a country in West Africa with one of the highest burdens of malaria in the world, the government teamed up with Catholic Relief Services and our foundation this year to develop a new, innovative way to distribute bed nets across the country. Using smartphones, real time data collection, and satellite mapping, Benin has helped ensure that all families, no matter where they live, will be protected by a bed net at night. And scientists haven’t paused research efforts to find new ways to prevent malaria and control mosquito populations, like those underway at “Mosquito City” in Tanzania.

What’s exciting to see is how some existing malaria programs are also helping to control COVID-19. For example, emergency operations centers that track outbreaks of malaria in Africa are now being used to monitor the spread of COVID-19. By tracking the shape and movement of the pandemic across countries and regions, health officials are also able to deepen their understanding of health conditions in communities that will, in turn, help improve their responses to malaria in those areas.

The progress the world has made against malaria is one of the greatest global health success stories. The COVID-19 pandemic only reinforces why eradicating malaria is so essential. So long as malaria exists, it will continue to flare up and burden the most vulnerable communities. Ridding the world of preventable, treatable diseases like malaria will save millions of lives and lead to healthier, more prosperous communities. And that will make them better prepared to confront any new health challenges like COVID-19 in the future.

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

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

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

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

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

In any fight, it’s important to know your enemy. Unfortunately, in our battle against COVID-19, there’s a lot that we still don’t know.

How many people are infected with the virus, including those without symptoms?

Is it seasonal or weather dependent?

And how will we know when it might be safe to get back to work and send kids back to school?

These are important questions. More testing, of course, will help us answer them. But with tests in short supply in many parts of the world, including the U.S., it is impossible to test everyone—at least for now.

That’s why I’m excited about a new disease surveillance program in the Seattle area to detect cases of COVID-19 and help guide public health responses. Not only will it help improve our understanding of the outbreak in Seattle, it will also provide valuable information about the virus for other communities around the world.

The greater Seattle Coronavirus Assessment Network—or SCAN—is a first-of-its-kind disease surveillance platform for COVID-19 that allows participants to use a self-swab test to collect their own nasal samples and send them to a lab without leaving home. As a surveillance program, SCAN’s goal isn’t to test every person or serve as a replacement for medical care. Instead, SCAN is testing a sample of people in the Seattle region, including those who are healthy as well as those who are feeling sick. The test results and other data (like a person’s age, gender, race, zip code, and any underlying health conditions) are used by researchers, data modelers, and public health officials to paint a clearer picture of how COVID-19 is moving through the community, who is at greatest risk, and whether physical distancing measures are working.

One of the biggest questions puzzling public health officials is exactly how many people are infected with the virus. Think about the pandemic like an iceberg, says Dr. Jay Shendure, scientific director of the Brotman Baty Institute, one of SCAN’s lead partners. With ongoing COVID-19 medical testing, which has been largely focused on people with symptoms, we have been able to see the tip of the iceberg. Just below the surface, however, there is the part of the iceberg we don’t see—the unknown number of people who are infected but experience mild symptoms or no symptoms at all. Dr. Shendure compares SCAN to “a set of sonar pings where we’re skimming over the water and pinging to see what lurks beneath.”

I want to be clear that SCAN does not replace the widespread testing that is still needed in communities. But it has the potential to become an important tool for health officials seeking insights about the spread and behavior of the virus. Early results from SCAN found many cases of COVID-19 in Seattle that might otherwise have gone undetected among individuals who had experienced some symptoms (fever, cough, or shortness of breath) but had not yet sought medical care. As SCAN gathers more test results in the weeks ahead, researchers expect the new data to provide a better sense of the number of infections and serve as one source to help answer other questions, like when physical distancing measures can be relaxed.

SCAN is a partnership between Public Health—Seattle & King County, the Brotman Baty Institute, University of Washington Medicine, Fred Hutchinson Cancer Research Center, and Seattle Children’s Hospital. It relies on data modeling support from the Institute for Disease Modeling (IDM) and receives support from my private office, Gates Ventures, and our foundation.

SCAN is an outgrowth of a research study started before COVID-19. It’s been clear for years that there was a lot the scientific community didn’t understand about respiratory viruses, such as how they spread through a community, and the best ways to stop them. So, in 2018, my office teamed up with the Brotman Baty Institute and other partners to launch a study of respiratory illnesses, including the seasonal flu. That effort, the Seattle Flu Study, aimed to recruit 10,000 volunteers in Seattle who showed cold symptoms to provide a simple nasal swab at kiosks set up in health centers and through at-home tests.

One of the early discoveries of the study was the impact of high-intensity physical distancing measures on reducing the flu. In the winter of 2019, a major snowstorm in Washington state led to week-long school and workplace closures. Analyzing the data from that flu season, researchers found that the snowstorm’s dramatic disruption of social contact led to a drop in the transmission of the flu and other respiratory illnesses.

The Flu Study team hoped that these and other findings would help researchers develop tools to curb and even prevent the spread of the flu—and maybe one day help public health officials prepare for a future pandemic.

That day arrived sooner than anyone ever imagined with COVID-19.

In late January 2020, the first confirmed case of the novel coronavirus appeared in the U.S., just outside Seattle. The patient had visited Wuhan, China, the origin of the outbreak. 

Several weeks later, the Seattle Flu Study team started picking up signs of the coronavirus’s genetic signature in their flu study survey samples. In February, they identified the first known case of transmission in the U.S.—a teenager living outside Seattle who had not traveled to China and had no link to anyone with the virus. The Flu Study team sequenced its genome, and quickly realized that the virus had been spreading undetected for weeks.

This finding and the discovery of dozens more coronavirus cases suddenly put the Seattle Flu Study at the center of the area’s response to the coronavirus. We were fortunate to have this existing surveillance platform and an experienced team to quickly shift their focus to the outbreak. In March, we formed the new SCAN partnership with King County’s public health agency to track the spread of COVID-19.

One of the innovations of SCAN is an easy-to-use, at-home, self-swab test kit. The key advantage of this at-home testing approach is that people don’t need to go to a clinic, where they risk exposing themselves or others to infection. People interested in participating in SCAN can enroll online, and, once approved, they get a test delivered directly to their home. After individuals complete the nasal swab test, a courier service picks it up from their home and returns it to SCAN for processing. Anyone who has a positive result gets contacted by a public health worker who provides guidance on how to care for themselves and their families. And all participants can check their results online.

SCAN is currently testing 300 people per day, but actively working to test more. Those test results are then analyzed by disease modelers to map virus transmission chains. By examining the genetic signature of an infection, they can determine whether it represents a new introduction to the region or is part of a local transmission. They can also use the data to estimate disease prevalence and build models to look at how the virus is responding to certain measures—like school closures and physical distancing. You can learn more about their work on Nextstrain and the Institute for Disease Modeling’s research site.

As the SCAN team collects more data, I’m looking forward to learning more about their insights into many of the questions we have about this pandemic and how we can prevent the next one.

One of the questions I get asked the most these days is when the world will be able to go back to the way things were in December before the coronavirus pandemic. My answer is always the same: when we have an almost perfect drug to treat COVID-19, or when almost every person on the planet has been vaccinated against coronavirus.

The former is unlikely to happen anytime soon. We’d need a miracle treatment that was at least 95 percent effective to stop the outbreak. Most of the drug candidates right now are nowhere near that powerful. They could save a lot of lives, but they aren’t enough to get us back to normal.

Which leaves us with a vaccine.

Humankind has never had a more urgent task than creating broad immunity for coronavirus. Realistically, if we’re going to return to normal, we need to develop a safe, effective vaccine. We need to make billions of doses, we need to get them out to every part of the world, and we need all of this to happen as quickly as possible.

That sounds daunting, because it is. Our foundation is the biggest funder of vaccines in the world, and this effort dwarfs anything we’ve ever worked on before. It’s going to require a global cooperative effort like the world has never seen. But I know it’ll get done. There’s simply no alternative.

Here’s what you need to know about the race to create a COVID-19 vaccine.

The world is creating this vaccine on a historically fast timeline.

Dr. Anthony Fauci has said he thinks it’ll take around eighteen months to develop a coronavirus vaccine. I agree with him, though it could be as little as 9 months or as long as two years.

Although eighteen months might sound like a long time, this would be the fastest scientists have created a new vaccine. Development usually takes around five years. Once you pick a disease to target, you have to create the vaccine and test it on animals. Then you begin testing for safety and efficacy in humans.

Safety and efficacy are the two most important goals for every vaccine. Safety is exactly what it sounds like: is the vaccine safe to give to people? Some minor side effects (like a mild fever or injection site pain) can be acceptable, but you don’t want to inoculate people with something that makes them sick.

Efficacy measures how well the vaccine protects you from getting sick. Although you’d ideally want a vaccine to have 100 percent efficacy, many don’t. For example, this year’s flu vaccine is around 45 percent effective.

To test for safety and efficacy, every vaccine goes through three phases of trials:

• Phase one is the safety trial. A small group of healthy volunteers gets the vaccine candidate. You try out different dosages to create the strongest immune response at the lowest effective dose without serious side effects.
• Once you’ve settled on a formula, you move onto phase two, which tells you how well the vaccine works in the people who are intended to get it. This time, hundreds of people get the vaccine. This cohort should include people of different ages and health statuses.
• Then, in phase three, you give it to thousands of people. This is usually the longest phase, because it occurs in what’s called “natural disease conditions.” You introduce it to a large group of people who are likely already at the risk of infection by the target pathogen, and then wait and see if the vaccine reduces how many people get sick.

After the vaccine passes all three trial phases, you start building the factories to manufacture it, and it gets submitted to the WHO and various government agencies for approval.

This process works well for most vaccines, but the normal development timeline isn’t good enough right now. Every day we can cut from this process will make a huge difference to the world in terms of saving lives and reducing trillions of dollars in economic damage.

So, to speed up the process, vaccine developers are compressing the timeline. This graphic shows how:

In the traditional process, the steps are sequential to address key questions and unknowns. This can help mitigate financial risk, since creating a new vaccine is expensive. Many candidates fail, which is why companies wait to invest in the next step until they know the previous step was successful.

For COVID-19, financing development is not an issue. Governments and other organizations (including our foundation and an amazing alliance called the Coalition for Epidemic Preparedness Innovations) have made it clear they will support whatever it takes to find a vaccine. So, scientists are able to save time by doing several of the development steps at once. For example, the private sector, governments, and our foundation are going to start identifying facilities to manufacture different potential vaccines. If some of those facilities end up going unused, that’s okay. It’s a small price to pay for getting ahead on production.

Fortunately, compressing the trial timeline isn’t the only way to take a process that usually takes five years and get it done in 18 months. Another way we’re going to do that is by testing lots of different approaches at the same time.

There are dozens of candidates in the pipeline.

As of April 9, there are 115 different COVID-19 vaccine candidates in the development pipeline. I think that eight to ten of those look particularly promising. (Our foundation is going to keep an eye on all the others to see if we missed any that have some positive characteristics, though.)

The most promising candidates take a variety of approaches to protecting the body against COVID-19. To understand what exactly that means, it’s helpful to remember how the human immune system works.

When a disease pathogen gets into your system, your immune system responds by producing antibodies. These antibodies attach themselves to substances called antigens on the surface of the microbe, which sends a signal to your body to attack. Your immune system keeps a record of every microbe it has ever defeated, so that it can quickly recognize and destroy invaders before they make you ill.

Vaccines circumvent this whole process by teaching your body how to defeat a pathogen without ever getting sick. The two most common types—and the ones you’re probably most familiar with—are inactivated and livevaccines. Inactivated vaccines contain pathogens that have been killed. Live vaccines, on the other hand, are made of living pathogens that have been weakened (or “attenuated”). They’re highly effective but more prone to side effects than their inactivated counterparts.

Inactivated and live vaccines are what we consider “traditional” approaches. There are a number of COVID-19 vaccine candidates of both types, and for good reason: they’re well-established. We know how to test and manufacture them.

The downside is that they’re time-consuming to make. There’s a ton of material in each dose of a vaccine. Most of that material is biological, which means you have to grow it. That takes time, unfortunately.

That’s why I’m particularly excited by two new approaches that some of the candidates are taking: RNA and DNA vaccines. If one of these new approaches pans out, we’ll likely be able to get vaccines out to the whole world much faster. (For the sake of simplicity, I’m only going to explain RNA vaccines. DNA vaccines are similar, just with a different type of genetic material and method of administration.)

Our foundation—both through our own funding and through CEPI—has been supporting the development of an RNA vaccine platform for nearly a decade. We were planning to use it to make vaccines for diseases that affect the poor like malaria, but now it’s looking like one of the most promising options for COVID. The first candidate to start human trials was an RNA vaccine created by a company called Moderna.

Here’s how an RNA vaccine works: rather than injecting a pathogen’s antigen into your body, you instead give the body the genetic code needed to produce that antigen itself. When the antigens appear on the outside of your cells, your immune system attacks them—and learns how to defeat future intruders in the process. You essentially turn your body into its own vaccine manufacturing unit.

Because RNA vaccines let your body do most of the work, they don’t require much material. That makes them much faster to manufacture. There’s a catch, though: we don’t know for sure yet if RNA is a viable platform for vaccines. Since COVID would be the first RNA vaccine out of the gate, we have to prove both that the platform itself works and that it creates immunity. It’s a bit like building your computer system and your first piece of software at the same time.

Even if an RNA vaccine continues to show promise, we still must continue pursuing the other options. We don’t know yet what the COVID-19 vaccine will look like. Until we do, we have to go full steam ahead on as many approaches as possible.

It might not be a perfect vaccine yet—and that’s okay.

The smallpox vaccine is the only vaccine that’s wiped an entire disease off the face of the earth, but it’s also pretty brutal to receive. It left a scar on the arm of anyone who got it. One out of every three people had side effects bad enough to keep them home from school or work. A small—but not insignificant—number developed more serious reactions.

The smallpox vaccine was far from perfect, but it got the job done. The COVID-19 vaccine might be similar.

If we were designing the perfect vaccine, we’d want it to be completely safe and 100 percent effective. It should be a single dose that gives you lifelong protection, and it should be easy to store and transport. I hope the COVID-19 vaccine has all of those qualities, but given the timeline we’re on, it may not.

The two priorities, as I mentioned earlier, are safety and efficacy. Since we might not have time to do multi-year studies, we will have to conduct robust phase 1 safety trials and make sure we have good real-world evidence that the vaccine is completely safe to use.

We have a bit more wiggle room with efficacy. I suspect a vaccine that is at least 70 percent effective will be enough to stop the outbreak. A 60 percent effective vaccine is useable, but we might still see some localized outbreaks. Anything under 60 percent is unlikely to create enough herd immunity to stop the virus.

The big challenge will be making sure the vaccine works well in older people. The older you are, the less effective vaccines are. Your immune system—like the rest of your body—ages and is slower to recognize and attack invaders. That’s a big issue for a COVID-19 vaccine, since older people are the most vulnerable. We need to make sure they’re protected.

The shingles vaccine—which is also targeted to older people—combats this by amping up the strength of the vaccine. It’s possible we do something similar for COVID, although it might come with more side effects. Health authorities could also ask people over a certain age to get an additional dose.

Beyond safety and efficacy, there are a couple other factors to consider:

• How many doses will it be? A vaccine you only get once is easier and quicker to deliver. But we may need a multi-dose vaccine to get enough efficacy.
• How long does it last? Ideally, the vaccine will give you long-lasting protection. But we might end up with one that only stops you from getting sick for a couple months (like the seasonal flu vaccine, which protects you for about six months). If that happens, the short-term vaccine might be used while we work on a more durable one.
• How do you store it? Many common vaccines are kept at 4 degrees C. That’s around the temperature of your average refrigerator, so storage and transportation is easy. But RNA vaccines need to be stored at much colder temperature—as low as -80 degrees C—which will make reaching certain parts of the world more difficult.

My hope is that the vaccine we have 18 months from now is as close to “perfect” as possible. Even if it isn’t, we will continue working to improve it. After that happens, I suspect the COVID-19 vaccine will become part of the routine newborn immunization schedule.

Once we have a vaccine, though, we still have huge problems to solve. That’s because…

We need to manufacture and distribute at least 7 billion doses of the vaccine.

In order to stop the pandemic, we need to make the vaccine available to almost every person on the planet. We’ve never delivered something to every corner of the world before. And, as I mentioned earlier, vaccines are particularly difficult to make and store.

There’s a lot we can’t figure out about manufacturing and distributing the vaccine until we know what exactly we’re working with. For example, will we be able to use existing vaccine factories to make the COVID-19 vaccine?

What we can do now is build different kinds of vaccine factories to prepare. Each vaccine type requires a different kind of factory. We need to be ready with facilities that can make each type, so that we can start manufacturing the final vaccine (or vaccines) as soon as we can. This will cost billions of dollars. Governments need to quickly find a mechanism for making the funding for this available. Our foundation is currently working with CEPI, the WHO, and governments to figure out the financing.

Part of those discussions center on who will get the vaccine when. The reality is that not everyone will be able to get the vaccine at the same time. It’ll take months—or even years—to create 7 billion doses (or possibly 14 billion, if it’s a multi-dose vaccine), and we should start distributing them as soon as the first batch is ready to go.

Most people agree that health workers should get the vaccine first. But who gets it next? Older people? Teachers? Workers in essential jobs?

I think that low-income countries should be some of the first to receive it, because people will be at a much higher risk of dying in those places. COVID-19 will spread much quicker in poor countries because measures like physical distancing are harder to enact. More people have poor underlying health that makes them more vulnerable to complications, and weak health systems will make it harder for them to receive the care they need. Getting the vaccine out in low-income countries could save millions of lives. The good news is we already have an organization with expertise about how to do this in Gavi, the Vaccine Alliance.

With most vaccines, manufacturers sign a deal with the country where their factories are located, so that country gets first crack at the vaccines. It’s unclear if that’s what will happen here. I hope we find a way to get it out on an equitable basis to the whole world. The WHO and national health authorities will need to develop a distribution plan once we have a better understanding of what we’re working with.

Eventually, though, we’re going to scale this thing up so that the vaccine is available to everyone. And then, we’ll be able to get back to normal—and to hopefully make decisions that prevent us from being in this situation ever again.

It might be a bit hard to see right now, but there is a light at the end of the tunnel. We’re doing the right things to get a vaccine as quickly as possible. In the meantime, I urge you to continue following the guidelines set by your local authorities. Our ability to get through this outbreak will depend on everyone doing their part to keep each other safe.