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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

What’s for dinner?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.

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.

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

There’s no question the United States missed the opportunity to get ahead of the novel coronavirus. But the window for making important decisions hasn’t closed. The choices we and our leaders make now will have an enormous impact on how soon case numbers start to go down, how long the economy remains shut down and how many Americans will have to bury a loved one because of COVID-19.

Our foundation has been working to slow the outbreak for several months. To date, we’ve invested $105 million in efforts to create new therapeutics, expand access to testing, and limit the virus’s impact here in Seattle.

As a result of this work, I’ve spoken with experts and leaders in Washington and across the country. It’s become clear to me that we must take three steps.

First, we need a consistent nationwide approach to shutting down. Despite urging from public health experts, some states and counties haven’t shut down completely. In some states, beaches are still open; in others, restaurants still serve sit-down meals.

This is a recipe for disaster. Because people can travel freely across state lines, so can the virus. The country’s leaders need to be clear: Shutdown anywhere means shutdown everywhere. Until the case numbers start to go down across America—which could take 10 weeks or more—no one can continue business as usual or relax the shutdown. Any confusion about this point will only extend the economic pain, raise the odds that the virus will return, and cause more deaths.

Second, the federal government needs to step up on testing. Far more tests should be made available. We should also aggregate the results so we can quickly identify potential volunteers for clinical trials and know with confidence when it’s time to return to normal. There are good examples to follow: New York state recently expanded its capacity to more than 25,000 tests per day.

There’s also been some progress on more efficient testing methods, such as the self-swab developed by the Seattle Coronavirus Assessment Network, which allows patients to take a sample themselves without possibly exposing a health worker. I hope this and other innovations in testing are scaled up across the country soon.

Even so, demand for tests will probably exceed the supply for some time, and right now, there’s little rhyme or reason to who gets the few that are available. As a result, we don’t have a good handle on how many cases there are or where the virus is likely headed next, and it will be hard to know if it rebounds later. And because of the backlog of samples, it can take seven days for results to arrive when we need them within 24 hours.

This is why the country needs clear priorities for who is tested. First on the list should be people in essential roles such as health-care workers and first responders followed by highly symptomatic people who are most at risk of becoming seriously ill and those who are likely to have been exposed.

The same goes for masks and ventilators. Forcing 50 governors to compete for lifesaving equipment—and hospitals to pay exorbitant prices for it—only makes matters worse.

Finally, we need a data-based approach to developing treatments and a vaccine. Scientists are working full speed on both; in the meantime, leaders can help by not stoking rumors or panic buying. Long before the drug hydroxychloroquine was approved as an emergency treatment for COVID-19, people started hoarding it, making it hard to find for lupus patients who needed it to survive.

We should stick with the process that works: Run rapid trials involving various candidates and inform the public when the results are in. Once we have a safe and effective treatment, we’ll need to ensure that the first doses go to the people who need them most.

To bring the disease to an end, we’ll need a safe and effective vaccine. If we do everything right, we could have one in less than 18 months—the fastest a vaccine has ever been developed. But creating a vaccine is only half the battle. To protect Americans and people around the world, we’ll need to manufacture billions of doses.

Without a vaccine, developing countries are at even greater risk than wealthy ones, because it’s even harder for them to do physical distancing and shutdowns. The further down the income ladder people live, the more important it is that they go to work every day just to feed their family.

If they live in the poorest parts of sub-Saharan Africa or India, staying home simply isn’t an option. Even if they do stay home, they can’t just wall themselves off from their neighbors; in slums, the houses are packed together so closely that there’s no way to keep your distance. All the work that rich countries are doing now to develop vaccines will save lives in those places, too.

We can get a head start on manufacturing all of the doses we’ll need now by building the facilities where these vaccines will be made. Because many of the top candidates are made using unique equipment, we’ll have to build facilities for each of them, knowing that some won’t get used. Private companies can’t take that kind of risk, but the federal government can. It’s a great sign that the administration made deals this week with at least two companies to prepare for vaccine manufacturing. I hope more deals will follow.

In 2015, I urged world leaders in a TED talk to prepare for a pandemic the same way they prepare for war—by running simulations to find the cracks in the system. As we’ve seen this year, we have a long way to go. But I still believe that if we make the right decisions now, informed by science, data, and experience of medical professionals, we can save lives and get the country back to work.

A version of this post originally appeared on the website of the Washington Post.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

People often ask me which technologies have the most potential to change our lives in the decades ahead.

AI is always near the top of the list. It can help us make sense of complex biological systems—like the microbiome in the human gut—and give us new insight into tough problems in global health, such as premature birth.

Gene-based tools are another technology that I always mention. For example, advances in that field are giving researchers powerful new tools to investigate potential cures for AIDS, sickle-cell disease, and other conditions.

These tools can also give us key insights into new diseases, such as the novel coronavirus that recently emerged, so that we can develop diagnostic tests, treatments, and vaccines faster.

Thanks to these and other breakthroughs, science is giving us the opportunity to improve lives more rapidly than ever. But we’ll only make the most of that potential if we ensure that these tools reach everyone who needs them, including the poorest people in the world.

That’s the focus of much of our work at the Gates Foundation. Today I’m honored to be giving a speech on this subject at the annual meeting of the American Association for the Advancement of Science. Here’s what I plan to say:

Remarks as prepared
Seattle, WA
February 14, 2020
American Association for the Advancement of Science

Thank you. It’s great to be here today.

The Coronavirus

I want to take a few minutes to talk about the novel coronavirus, which I know is on everyone’s mind.

Our foundation has committed up to $100 million to address this new coronavirus because we believe it poses a serious threat to global health. This money will support efforts to detect, isolate, and treat confirmed cases, help countries in sub-Saharan Africa and South Asia take steps to prepare for the epidemic and protect their most vulnerable citizens, and accelerate the development of vaccines, treatments, and diagnostics.

We believe that multilateral organizations and national governments must make every effort to stop this outbreak, but we also want to help the world be better prepared if it becomes a global pandemic. Above all, we believe that the world will need to be guided by science, not fear, in the weeks ahead.

The Diseases of Poverty

A few blocks from here is the foundation that Melinda and I started in 2000. When we decided to focus on philanthropy, we knew that the core of our work would be eliminating the gross inequities in health that we had seen a few years earlier on our first trip to Africa.

One area where we believed we could make a difference was investing in R&D to address diseases of poverty. Today, I want to talk about several exciting and important tools of modern science that have the potential to help us solve some of the biggest health problems—not only in low- and middle-income countries, but everywhere.

To be sure, health in lower-income countries has improved. Over the last 25 years, we’ve nearly eradicated polio. Child mortality has been cut in half. And we’ve significantly reduced deaths from HIV, TB, and malaria.

But there is still room for a lot more improvement.

This year, more than 5 million children under the age of five will die. HIV, TB, malaria, and other diseases still kill millions of people every year. And nearly a quarter of a billion children are malnourished. Almost all of this disease burden is carried by people in the poorest countries on the planet.

Innovation with Equity in Mind

To make further inroads against the diseases of poverty, we need every sector to engage. Governments need to continue funding of basic research; partners like our foundation need to nurture the best ideas through discovery and translation; and the private sector needs to develop solutions that are commercially viable, affordable, and scalable in countries with limited resources and fragile health care systems.

The private sector has much to gain from pursuing breakthroughs that benefit people in lower-income countries. Over the next few decades, developing economies will continue to expand. By 2050, the population of sub-Saharan Africa will more than double to almost 2.5 billion. That’s more than twice the forecasted population of the Europe and North America combined.

Yet, today, the overwhelming percentage of investments in health R&D reflect market opportunities in rich countries. If we stick to this model, market forces will continue to prioritize development of costly products designed to meet the needs of the few and unaffordable to most. Imagine if we turned this traditional market model on its head and committed to designing new vaccines, therapeutics, and diagnostics with equity in mind.

Today, we have an opportunity with the evolution of tools like AI and gene-based technologies to develop a new generation of health solutions that can benefit everyone, everywhere. This is what really excites me about the future.

The Potential of AI and Gene Therapy

As a 7^th grader at the Lakeside School here in Seattle, I became fascinated not only with computers, but also with Shakey, the Mobile Robot. Life Magazine called Shakey the “first electronic person.” That might have been overstating it a bit, but Shakey was an early example of how artificial intelligence could be applied. It had a limited ability to perceive objects in its environment and adapt its movement. It could plan simple travel routes, and it had the ability to rearrange simple objects. For its time, Shakey was really cool.

Since Alan Turing laid the groundwork for artificial intelligence in 1950, AI has gone through a kind of boom-and-bust cycle—enthusiasm would grow and then expectations weren’t met.

But we are finally beginning to realize the potential of AI. The computational power available for AI applications is doubling every three and half months—far surpassing the historical metric of Moore’s Law. This processing capability is being coupled with troves of new data, and we are learning to annotate this data in smarter ways. That’s enabling us to realize some of the promises of AI: the ability to synthesize, analyze, see patterns, gain insights, and make predictions across many, many more dimensions than a human can comprehend.

This data revolution will apply to virtually all of the disciplines represented here today. What I’m most excited about is how it can help us make sense of complex biological systems and accelerate the discovery of therapeutics to improve health in the poorest countries.

And, with recent breakthroughs in gene-editing technologies like CRISPR, we are on the verge of a new era of precision diagnostics, therapeutics, and vaccines that has the potential to improve health—not only for rare genetic disorders, but also for diseases that predominately afflict people in poor countries.

It’s amazing to think how far we’ve come since Crick, Watson, and Franklin laid the foundation for modern genetics. It was only 15 years ago that the Human Genome Project gave us the ability to read our DNA and identify specific sequences that cause or contribute to disease. It was only 8 years ago that CRISPR gave us the ability to edit DNA precisely.

Now, with the latest CRISPR gene-editing approaches, it’s believed that up to 89% of genetic variants known to be associated with human disease can be corrected.

Last year, researchers began using the molecular scissors of CRISPR in clinical trials to remove, edit, and inject people’s cells back into their bodies.

In short, artificial intelligence and CRISPR have emerged as powerful tools with the potential to revolutionize healthcare and many other fields.

The Product Pipeline for Global Health

I’d like to share a few examples of innovations in the pipeline that make me optimistic about the future.

Our foundation is working with the National Institutes of Health to develop affordable, gene-based cures for sickle cell disease and HIV. The goal is to move these solutions into clinical trials in the next 7-10 years. This would be a huge breakthrough.

Of the 38 million people worldwide living with HIV, 95 percent live in lower-income countries and one-third aren’t receiving treatment. Imagine if we could cure every one of them.

Sickle Cell Disease is also a major health burden in lower-income countries. Fifteen million babies will be born with sickle cell disease in the next 30 years, the vast majority in Africa. Although exact numbers are hard to come by, at least half and maybe as many as 90% of these children will die before their fifth birthday.

In recent years, we’ve seen gene-based therapies introduced for some rare genetic diseases as well as for sickle cell disease. Ongoing trials are promising, with early results showing clinical benefit to more than a dozen people with sickle cell disease. But the treatments are prohibitively expensive—likely to cost $1 million or more per person.

And they require highly trained doctors and state-of-the-art hospitals to administer the cures—which involve in vitro editing of bone marrow stem cells for reinfusion, and toxic bone marrow conditioning regimens.

The focus of our work with the NIH on sickle cell disease is to develop effective, durable, safe, and affordable gene-based cures that don’t require costly hospital stays.

We hope to create in vivo gene editing techniques that can be delivered with a single injection using vectors that target and edit blood-forming cells in the bone marrow—with high efficiency. This approach could reach millions of patients in primary care facilities at a fraction of the cost.

Similarly, with HIV, the purpose of our collaboration with the NIH is to investigate the use of in vivo gene editing and other technologies that could drive a functional cure for those infected with HIV in an affordable, scalable way. A high bar, for sure, but it’s the kind of bold approach to designing therapeutic innovation with equity in mind that excites me.

Gene editing shows great promise for our work in malaria, too. The world has made huge progress against malaria in the past two decades. Since 2000, deaths have dropped from about 1 million per year to 400,000 per year. But further progress requires new tools and strategies.

Researchers are exploring the use of CRISPR to create “gene drives” that suppress the handful of mosquito species most responsible for malaria transmission. They are also working on introducing genes that could eliminate the parasites as they pass through a mosquito’s gut on their way to its salivary glands.

Newborn Health

One area where I see great potential for progress is newborn health. As you’ll see on this chart, nearly half of the 5.3 million children under age 5 who die this year will die in the first 28 days of life.

Deaths from complications associated with premature births account for the single largest percentage of neonatal mortality. The reason the number of deaths is so high is that there is still so much we don’t know about the root causes of prematurity and neonatal mortality. We are funding several studies to help solve this mystery.

First, by applying artificial intelligence to a range of complex data sets, we are learning about the biological pathways leading to prematurity and low birth weight.

Second, we’re combining clinical data with information from low-cost devices like a hand-held ultrasound and wearable sensors—and using AI to identify indicators that a pregnant woman may be at risk of giving birth before full term. We can do something similar to look for signs that newborns may be in trouble.

Third, researchers are exploring the associations between maternal undernutrition, the maternal microbiome, and premature birth. By distinguishing abnormal changes in the microbiome during pregnancy, we may be able to give pregnant women microbial therapeutics—as well as nutritional interventions—to improve fetal growth and reduce the risk of pre-term birth.

The Microbiome

It is increasingly clear that the gut microbiome and nutrition—and the interplay between the two—are also big factors in child health and development.

An estimated 225 million children worldwide are severely malnourished—and malnutrition is an underlying cause of more than 40 percent of under-five child mortality. Children who are malnourished often have underdeveloped microbiomes that make them more vulnerable to disease and to cognitive impairments that last a lifetime.

There is also evidence that children in wealthy countries who grow up in super-hygienic environments – with an abundance of processed foods and antibiotics—have poor gut health that may make them more susceptible to obesity, diabetes, allergies, and maybe even auto-immune disease.

But there’s still a lot we don’t know about the microbiome—including which bacterial species are most critical for health and whether augmenting these species can reduce malnutrition. Deciphering the human microbiome is not an easy task. It contains more than 100 trillion organisms and 200 times more genetic material than the human genome.

Using artificial intelligence, scientists hope to analyze the composition of the trillions of microbes in our body and identify the patterns, interactions, and changes we can't see that indicate a higher risk of disease—or, conversely—a protective shield against disease.

One tool that’s helping us understand how to optimize the gut microbiome is technology called “organs-on-a-chip.” In simple terms, this technology allows in vitro modeling of human organs in ways that mimic how organs perform normally . . . and when they are diseased.

Linking different organ chips together—for example, intestine, liver, and kidney chips—can enable researchers to model human drug kinetics.

Culturing a human intestinal microbiome-on-a-chip can enable researchers to probe the complex interactions between microbiome, host, nutrients, and pathogens in a systematic way.

Researchers are using this technology to study the vaginal microbiome and therapeutics that could reduce the incidence of pre-term birth and risk of HIV infection. We’re also supporting other “organ-on-a-chip” studies, including one that’s using lymphoid organoids to understand vaccine responses.

This technology has the potential to shave years off the time it takes to evaluate the safety and efficacy of new drugs, vaccines, and other therapeutics—and save hundreds of millions of dollars associated with research and clinical trials.

Climate Change and Agricultural Adaptation

I’ve been talking about the innovation we need to build on recent progress in global health. Many people are surprised when I say that progress in global health also depends on the fight against climate change.

There are two parts to addressing climate change. Mitigation and adaptation. Mitigation is about what we need to do to get to zero on greenhouse gases that are warming the climate.

Adaptation is about helping people cope with the changing climate. It’s unfortunate, but true, that the people who are most affected by climate change today account for a tiny amount of the world’s greenhouse gasses. Specifically, the 2 billion smallholder farmers and their families who rely on the food they grow to survive.

Increasingly, climate change is putting their livelihoods—and their lives—at risk. More extreme weather conditions mean more floods, more droughts, and more plant pests and diseases that can wipe out a crop.

When smallholder farmers lose their harvest, their kids may not have enough to eat and that makes them susceptible to the effects of malnutrition.

To adapt, farming families need seeds and livestock that have been bred to thrive in the more extreme conditions caused by climate change.

The world’s largest agriculture research group, CGIAR, has developed dozens of new varieties of maize and rice that can withstand drought—including one called “scuba” rice that can survive for two weeks under floodwaters.

A team of scientists led from the University of Cambridge is using evolutionary genomics to help maize and other cereals partner more effectively with microorganisms in the soil to capture nutrients and water.

For farmers with poor soils and no access to fertilizer, this process could supply the nitrogen needed to increase production. That’s good for food security, farmers’ livelihoods, and the environment.

Conclusion

Earlier this week, Melinda and I released our 2020 annual letter. It’s something we’ve done every year for the last 10 years. This year, we reflected on the progress in global health since we started our foundation 20 years ago and the challenges that remain. And we talk about where things stand with the primary focus of our work in the US—improving K-12 and postsecondary education.

These issues share one very important feature in common. They are both key to a healthier, better, and more equal world. Disease is both a symptom and a cause of inequality, while public education is a driver of equality.

When we first started our foundation, we were optimistic about the power of innovation to drive progress. Looking at progress in global health over the last two decades and the amazing advances I talked about today, I’m more optimistic than ever that we are closer to the goal of giving every person the opportunity to live a healthy, productive life. Thank you.

Where will you be when the ball drops at midnight on New Year’s Eve?

I expect to spend midnight this year in the exact same place I spent midnight last year: asleep in bed. That doesn’t mean I’ll let the holiday go by without recognition, though. Melinda and I love to use this time of year to reflect. How did the last twelve months go? And what do we hope to accomplish in the years ahead?

I was fortunate to travel the world this year. I got to meet some amazing people and see incredible innovations that I’m hopeful will make life better for millions. As December comes to a close, I feel more optimistic than ever about the progress we are making. At the same time, I’m also aware that gross inequities continue to separate the lucky from the unlucky all over the world—and that I have immense privileges as a result of this inequality.

Instead of updating you on what I’m working on—as I did in last year’s end-of-year post—I want to use this year’s post to write about inequality. Specifically, I want to focus on one particular issue that came to the forefront in 2019 and will be top of mind for many in 2020: America’s tax system. This isn’t exactly the most festive topic to cover during the holidays, but it’s one of the most important debates happening in our country right now.

Although I mostly spend my time talking about the issues I’m really focused on—global health, education, and climate change—I get asked about taxes a lot. I understand why it comes up so often; I’m a natural focal point for this debate.

The truth is, I’ve been pushing for a fairer tax system for years. It was nearly two decades ago that my dad and I started calling for an increase in the federal estate tax and for an estate tax in our home state of Washington, which has the most regressive tax system in the country. In 2010, he and I also backed a voter initiative that—had it passed—would’ve created a state income tax. (My dad even wrote a book about why we need to tax accumulated fortunes.)

It isn’t always popular to stand up for higher taxes, so it’s great that many Americans are having this conversation. I want to be as clear as possible about my views.

I start with the understanding that the U.S. government simply does not bring in enough money to meet its obligations. This isn’t a value judgment; it’s just a fact. The government collects about 20 percent of GDP in taxes while spending about 24 percent. And the cost of commitments is going up.

Meanwhile, the wealth gap is growing. The distance between top and bottom incomes in the United States is much greater than it was 50 years ago. A few people end up with a great deal—I’ve been disproportionately rewarded for the work I’ve done—while many others who work just as hard struggle to get by.

That’s why I’m for a tax system in which, if you have more money, you pay a higher percentage in taxes. And I think the rich should pay more than they currently do, and that includes Melinda and me.

Although I’m not an expert on the tax code, here are some steps I think America should take to make its tax system more fair.

We should shift more of the tax burden onto capital, including by raising the capital gains tax, probably to the same level as taxes on labor.

Today the U.S. government depends overwhelmingly on taxing labor—about three quarters of its revenue comes from taxes on wages and salaries. Most people get almost all of their income from salary and hourly work, which is taxed at a maximum of 37 percent. But the wealthiest generally get only a tiny percentage of their income from a salary; most of it comes from profits on investments, such as stock or real estate, taxed at 20 percent if they’re held for more than a year.

That’s the clearest evidence I’ve seen that the system isn’t fair. I don’t see any reason to favor wealth over work the way we do today.

I’m also in favor of raising the estate tax and closing the loopholes in it that many wealthy people take advantage of. A dynastic system where you can pass vast wealth along to your children is not good for anyone; the next generation doesn’t end up with the same incentive to work hard and contribute to the economy. It’s one of the many reasons that Melinda and I are giving almost all of our wealth back to society through our foundation, rather than passing all of it along to our children.

Other steps toward a fairer tax system include removing the cap on how much income is subject to Medicare taxes, closing the carried-interest loophole that allows investment-fund managers to pay the lower capital gains rate on their income, and taxing large fortunes that have been held for a long time (say, ten years or more). Very wealthy people often have large investments they’ve held for long periods, and if those investments aren’t sold or traded, the money is never taxed. That doesn’t make sense.

And fixing taxation at the federal level is only a part of the solution. We also need to make state and local taxes fairer, since they represent a large portion of Americans’ tax bills. For example, I still think we should adopt a state income tax in Washington.

When I say the government needs to raise more money, some people ask why Melinda and I don’t voluntarily pay more in taxes than the law requires. The answer is that simply leaving it up to people to give more than the government asks for is not a scalable solution. People pay taxes as an obligation of law and citizenship, not out of charity. Additional voluntary giving will never raise enough money for everything the government needs to do. If Melinda and I signed over our foundation’s entire endowment to the state of California, it wouldn’t be enough to fund their public schools for even one year. A vibrant economic system depends on setting expectations for who pays how much.

But in addition to fair taxes, Melinda and I think there’s value to society in allowing the wealthy to put some money into private foundations, because foundations play an irreplaceable role that’s distinct from what governments do well. In particular, philanthropy is good at managing high-risk projects that governments can’t take on and corporations won’t—for example, trying out new approaches to eradicating malaria, which is something our foundation is working on. If a government tries an idea for improving global health that fails, someone wasn’t doing their job. Whereas if we don’t try some ideas that fail, we’re not doing our jobs.

The country does need to be thoughtful about how high taxes should be raised. One of the reasons that innovators flock to the United States is that this country makes it easy to start a business, invest capital, and earn a profit. We shouldn’t destroy those incentives, but we’re a long way from that point now. Americans in the top 1 percent can afford to pay a lot more before they stop going to work or creating jobs. In the 1970s, when Paul Allen and I were starting Microsoft, marginal tax rates were almost twice the top rate today. It didn’t hurt our incentive to build a great company.

It’s great that Americans are debating who should pay more in taxes and how. I’ll continue to focus on the issues our foundation works on as well as climate change, so I will not take a position on the proposals that are being debated during this campaign season. But I believe we can make our system fairer without sacrificing the incentive to innovate. We’ve updated our tax system before to keep up with changing times, and we need to do it again, starting with raising taxes on people like me.

At the beginning of this post, I mentioned two questions Melinda and I like to reflect on this time of year: How did the last twelve months go? And what do we hope to accomplish in the years ahead? As we end this decade and look forward to what the 2020s will bring, I hope to see progress not only in how taxes are collected but how they’re spent to build a healthier, more equitable world for all.

Melinda and I believe that driving progress is wealth’s highest purpose. Even before we were married, we decided that we would use the resources from Microsoft to make people’s lives better. Our wealth comes with an obligation to give back to society, and in 2020, we’re committed to continue living up to that obligation: through our taxes, through our foundation, and through our personal giving.

Melinda and I are currently writing a lot more about that commitment in our Annual Letter, which will come out at the beginning of February.

I wish you and your loved ones a wonderful year ahead.

I’m obsessed with a website called Dollar Street. Created by Factfulness co-author Anna Rosling Rönnlund, Dollar Street imagines a world where everyone lives on the same street and the houses are ordered by income. The poorest live on one end, and the richest live on the other end.

Income can often tell you more about how people live than location can. Whenever I visit a new place, I look for clues about which income level local families live on. Are there power lines? What kind of roofs do the houses have? Are people riding bikes or walking from place to place?

The answers to these questions tell me a lot about the people there. If I see power lines, I know homes probably have electricity in this area—which means that kids have enough light to do their homework after the sun sets. If I see patchwork roofs, families likely sleep less during the rainy season because they’re wet and cold. If I see bikes, that tells me people don’t have to spend hours walking to get water every day.

The significance of income level is brilliantly illustrated by Dollar Street. Anna sent photographers to profile hundreds of homes from countries all over the world. You can sort these homes by income, location, or even household object (so for example you can have it show you just beds, or dish soap, or cooking utensils). Each house is meticulously tagged and includes a biography of the family that lives there. You can explore 135 objects belonging to each family, from their front door to the shoes they wear. The user interference is simple and intuitive to use.

Dollar Street really comes alive when you start comparing objects. I found the photos of toothbrushes to be particularly interesting. The families at the poorest end of the street use their fingers or sticks to clean their teeth. But once you reach a certain income level, everyone starts using a plastic toothbrush with bristles.

The more time you spend on Dollar Street, the clearer it becomes that all of us have the same basic wants and needs. People tend to spend money on the same things once they increase their income whether they live in China or Cameroon. At the end of the day, we all want a solid roof over our head, a more efficient way to get around, and better tools to take care of ourselves. It’s a beautiful reminder that we have more in common with people on the other side of the world than we think.

Anna and her team at Gapminder have managed to capture the most complete picture of humanity I’ve seen yet. I could spend hours exploring Dollar Street, and I hope you check it out.

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

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

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

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

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

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

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

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

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

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

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

I’ve never been shy about my passion for fertilizer. It’s a magical innovation that’s responsible for saving millions of lives from hunger and lifting millions more out of poverty by boosting agricultural productivity.

So, you can imagine my delight when I recently stepped into a warehouse in Tanzania and got a glimpse of thousands of tons of fertilizer piled as high as snow drifts. The warehouse in Dar es Salaam is part of a new fertilizer distribution center, the largest of its kind in East Africa. Watching workers fill bags with the tiny white pellets containing nitrogen, phosphorous, and other plant nutrients was a powerful reminder of how every ounce of fertilizer has the potential to transform lives in Africa.

But that potential is only realized when it reaches the hands of the world’s poorest farmers—a challenge that’s proven difficult in Africa, where fertilizer use is very low, and, as a result, agricultural productivity is too. (Farmers’ yields in many parts of Africa are just a fifth of those of U.S. farmers.)

The warehouse I visited is one critical piece of the solution for improving both the supply and demand for fertilizer in Africa.

There are many reasons fertilizer use has not caught on in Africa. Cost is one of the biggest problems. Poor roads and other weak infrastructure make transporting fertilizer expensive, driving up its price for many African farmers by about 25 percent compared to their counterparts in other parts of the world. Then, there’s the issue of supply, which is not always dependable because of weak distribution systems in many parts of the continent. Limited access to credit prevents farmers from purchasing fertilizer even if it is available. And a lack of agricultural training means that farmers may not see the value of investing in it or understand how to use it properly.

So how can a warehouse solve these challenges? Let’s start with the warehouse itself. With room for 350,000 metric tons of fertilizer—in 2016, Tanzania used a total of 277,000 metric tons—the warehouse built by Yara, a Norwegian agricultural company, can hold an ample supply to prevent shortages.

At the same time, Yara is working with the government of Tanzania and dozens of other businesses and nonprofit organizations to stimulate demand for fertilizer by providing training to smallholder farmers on how to use it to boost crop yields.

Around 80 percent of Tanzania’s workforce is engaged in farming and related industries. Growing more food through greater fertilizer use would have a huge impact on the country’s prosperity.

What I saw at work in Tanzania is part of a broader effort underway in Africa to use agricultural as an engine to power economic growth across the continent. New innovations in farming—from better fertilizer and crops that are more productive, nutritious and drought and disease resistant—will make it possible for African farmers to increase their yields in the years ahead. With greater productivity, farming families will be able to sell their surpluses to supplement their family's diet with vegetables, eggs, milk, and meat.

We’ve seen the impact of helping farmers grow more food before with the “Green Revolution,” a historic transformation of agriculture in Latin America and South and Southeast Asia during the 1960s, which doubled food production and staved off widespread famine. The increase in agriculture production was made possible by improved seeds and fertilizer use.

As Africa experiences its own agricultural revolution, however, the world must be sure to learn from the past. One of the consequences of the Green Revolution was excessive fertilizer use, leading to water pollution and other environmental impacts. That’s why our foundation continues to work with partners to help train farmers how to apply fertilizer in the proper amounts that will increase yields while also promoting environmental sustainability. We’re also working on digital soil mapping and soil testing to provide farmers with valuable insights into how to improve the health of their soil so they can remain productive for generations to come.

My visit to the warehouse was a highlight of my trip to Tanzania. Just before wrapping up my tour, I paused briefly to watch workers stack bags of fertilizer onto flatbed trucks for their long journey to farms hundreds of miles away. It was exciting to think about the farmers who would use them and the positive impact the fertilizer would have on their next harvests and their country’s future.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Elvis Eze, 28, grew up in Nigeria battling malaria both as a patient and as a physician working in a Lagos hospital. He now serves as a Youth Ambassador for Malaria No More UK, helping to mobilize funding and support to bring an end to malaria in his lifetime. Eliminating malaria is one of the Global Goals that will be discussed at this year’s Goalkeepers event. I had the privilege of meeting Dr. Eze at last year’s Malaria Summit in London. I invited Dr. Eze to share his inspiring story as one example of the many dedicated people in the world who are helping the world achieve the Global Goals. – Bill Gates

I remember growing up in Nigeria with fond nostalgia. I lived with my parents and four siblings in a middle-class Lagos neighborhood. Our days were filled with street football, video games, and card games.

What was there not to love?

Looking back, there was one thing that frightened all of us: malaria.

The mosquito-borne disease was always striking someone close to me, or sometimes even me. The fatigue, muscle aches, burning fever, and the lost play days and school days were my biggest worry as a child.

I still wonder about my childhood friend, Lukman, who was ill with malaria one day and never came back to our school. Were his parents forced to pull him from our school because of his mounting medical bills? Or, was he one of the tens of thousands of young children who lose their lives to malaria in Nigeria every year?

My experience with malaria is hardly unique. Worldwide, there are about 200 million cases recorded every year. The World Health Organization estimates that a child dies from malaria every two minutes. Nigeria alone accounts for 25 percent of the world’s malaria cases. In fact, the disease is such a regular occurrence in my country that people speak about it the same way the weather is talked about in London or the flu in the winter months. It is just an accepted part of life—and for many, an accepted cause of death.

It wasn’t until years later, when I became a doctor, that I realized that none of us needed to accept malaria as a matter of fate. We could do much more to fight it.

In 2014, I was working as a junior doctor in the emergency room in Lagos, where we regularly treated children suffering from malaria. One night, the hospital was overcrowded mostly with malaria cases. I can still remember seeing the children going through bouts of seizures, losing consciousness, and, at times, dying. I also recall the helplessness on the faces of their parents as they lived out their worst nightmare.

This was my tipping point. At the end of this one painfully long night shift, my mind was clouded with anger, sorrow, and loss. And yet, at that moment, I was thinking clearly about one thing: I needed to take action against malaria.

There was no reason for children to be experiencing the suffering I was witnessing in the emergency room. Malaria is a preventable and treatable disease. I had experienced firsthand how it was possible to administer life-saving treatments to children and give them their childhood back. Still, malaria is killing 435,000 people worldwide every year, most of them children. As a doctor, I knew I could continue to treat malaria patients in my care and advise families how to use bed nets and other prevention techniques. But I also wanted to use my voice to raise awareness of the disease and mobilize more resources in the global fight against it.

That opportunity came in 2015, when I was invited to the United Kingdom to work as a health officer for the Commonwealth Secretariat. I helped establish the Commonwealth Youth Health Network, a platform for young people to advocate and engage on health-related global issues, including the Global Goals. As a member of the network, I learned how Sri Lanka, which was one of the most malaria-infested countries in the world, had been able to eliminate the disease in 2016. Sri Lanka’s achievement was a powerful reminder that progress against malaria is possible.

In 2018, I participated in the Malaria Summit in London, where I shared my story and joined the call for heads of government to end malaria. All 53 countries of the Commonwealth made the bold commitment to halve malaria in their countries by 2023, which would prevent 350 million malaria cases and save 650,000 lives.

One lesson I’ve learned from my experience is how my voice could be a powerful tool to influence change in the fight against malaria. And your voice can be, too. I’d like to invite you to speak up as part of the Malaria Must Die campaign and record your voice for the world’s first voice petition to end malaria. Our goal is to help the Global Fund to Fight AIDS, Tuberculosis and Malaria, which finances over half of all malaria efforts worldwide, get fully funded for its vital work.

When I became a doctor, I took the Hippocratic oath, like all doctors before me. It’s an oath I think about often as I seek to provide all my patients with the highest quality of life possible. I’ll be reminded of this oath again this week when I attend this year’s Goalkeepers event, which will focus on efforts to accelerate progress on the Global Goals. Much like my oath as a doctor, the Global Goals are a promise by the world to save and improve the lives of our fellow citizens of the world. With your help, I know it will be a promise the world can keep.

I have probably learned more about farming in Africa from Sam Dryden than from any other person. Sam has spent decades working in agriculture, including a stint at the Gates Foundation, and he is passionate about improving the lives of the poorest. So when he asked me to contribute to a series of articles in Foreign Affairs on the future of farming and its role in fighting poverty, I was happy to do it. My essay is below. 

One thing I’ve learned in my work with Microsoft is that the process of innovation tends to take longer than many people expect, but it also tends to be more revolutionary than they imagine. We are seeing this dynamic play out right now in the way digital technology is fundamentally reorganizing life for the poorest people in the world.

Twenty years ago, when the Internet was brand new, a lot of people thought computers would quickly become part of daily life in developing countries. And when I say “a lot of people,” I include myself. But those people weren’t thinking about all the facts.

In 1997, I traveled to South Africa for the first time. I spent most of my time in big office buildings in downtown Johannesburg. One day, though, I took a side trip to Soweto, where Microsoft was donating computers and software to a community center—the same kind of thing we did in the United States.

But it became clear to me very quickly that Soweto was not like the United States. I had seen statistics on poverty, and I had seen a lot of poor communities, but this was the first time I had ever really seen true poverty. I was struck by what I didn’t see. No electricity. No running water. No toilets. No roads.

The community center had no consistent source of power, so they had rigged up an extension cord that ran about 200 feet from the center to a diesel generator outside. Looking at the setup, I knew right away that the minute I left, the generator would get moved to a more urgent task, and the people who used the community center would go back to worrying about challenges that couldn't be solved by a PC.

When I gave my prepared remarks to the press, I said: “Soweto is a milestone. There are major decisions ahead about whether technology will leave the developing world behind. This is to close the gap.”

But as I was reading those words, I knew there was much more to the story. What I didn't say was: “By the way, we're not focused on the fact that three quarters of the people in this region are eking out a living on tiny farms that don’t produce enough food. But we're sure going to bring you computers.”

In the past 20 years, however, digital technology has gradually insinuated itself into poor people’s lives in ways I never could have predicted. For example, about two-thirds of Africans now have mobile phones, and pretty soon cellular coverage will be more or less universal. The power of a phone in every pocket is turning out to be extremely disruptive in exciting ways—and the poor finally have a chance to use technology in ways that solve the real problems they face in their lives.

CELL PHONES AND THE FINANCIAL SERVICES REVOLUTION

Mobile phones have recreated the economics of providing financial services to the poor. In an analog era when banking required buildings, piles of paperwork, security guards, and tellers, the cost per transaction was high enough that no company could even conceive of profiting by serving poor people who transacted in tiny amounts. As a result, the poor led their financial lives informally, paying exorbitant amounts in fees and interest to borrow, save, and send money.

But phones get rid of all that expensive infrastructure. Transaction costs are so low that companies can make money by serving the poor. And in the process of competing for poor people’s business, these companies will develop new financial products that meet poor people’s unique needs. One example is a new company called M-KOPA, which lets 250,000 customers in three African countries pay for solar electricity (instead of kerosene) in small daily installments through their cell phones. In short, digital financial services can create one thriving formal economy that includes everyone.

In fact, since developing countries aren’t stuck with a legacy analog banking system, I believe that for the foreseeable future the boldest ideas in financial services will be coming from upstart companies in poor places instead of the big companies we’ve all heard of.

DIGITAL AGRICULTURE

If there is another example of a market that simply does not work for the poor, it’s agriculture. But digital technology can change that, too.

Right now, hundreds of millions of Africans rely on farming for a living, but they don’t grow as much—and they don’t sell as much of their surplus—as they could. As a result, Africa had to import $40 billion worth of food last year. Something is not functioning properly when half of the continent’s labor produces food, and the continent still buys its food from somewhere else!

So what is going wrong? Why aren’t African smallholders tapping into that $40 billion market?

The main problem stems from the fact that agricultural markets, like banks, exist on a formal plane, whereas smallholders exist on an informal one. So farmers and markets cannot communicate effectively. Smallholders don’t know what the market will pay. They can’t grow crops according to the market’s specifications because they don’t know the specifications. They have no way to learn the farm-management practices that would let them double or even triple their yields. Instead, they grow mostly what they can eat or trade locally, the way they’ve always grown it.

As long as this information disconnect exists, there will be a related physical disconnect. The rails and roads that would take crops from the farm gate to the market don’t exist, because the market doesn’t want the crops the farmers are growing in the ways and volumes they’re growing them. So farmers are isolated, stuck with no money and no voice that the marketplace can hear.

But digital technology can act almost like a secret decoder ring that links the formal and informal sectors. Smallholders are already using mobile phones to communicate within their networks, to talk to family and friends. The institutions that make up the formal marketplace communicate in much the same way. So it is now possible to generate a two-way conversation between Africa’s producers and Africa’s consumers—and this is an entirely new conversation. Each party will be able to express its needs to the other for the first time ever.

Imagine a smallholder farmer who can discover, easily, that yams are expected to fetch a high price this year. She can also contact a local cooperative to combine her yams with those of her neighbor, satisfying the buyers’ volume requirements. Because she is assured of sale at harvest, she can afford to take out a loan, using her phone, to buy fertilizer or better storage or whatever else she needs to maximize her yield. In the meantime, instead of waiting for a visit from an extension worker who may or may not know about yams and the soil in this particular region, she can get advice tailored by crop and soil type via digital video or text.

When information can flow easily, when data is democratized, the cost of doing business in agriculture goes way down, just as transaction costs go way down when financial transactions are digital. The excessive time and money farmers, agribusinesses, and cooperatives spend managing the risk of doing business with unknown partners is a drag on efficiency. When these partners can know each other easily—can function as nodes in a single marketplace—agriculture will thrive.

It’s not as easy as the above paragraphs may make it seem. Building a digital agriculture system that actually accomplishes these goals will take innovation and investment. But the point is that before it wasn’t possible, and now it is. The added variable of digital technology has changed the agricultural development equation.

OTHER DIGITAL APPLICATIONS FOR AGRICULTURE

While mobile phone technology—and the way it can collapse the formal and the informal—is perhaps the most revolutionary of the digital opportunities in agriculture, there are many others.

Take seeds. Advances in genomics are fundamentally changing the way breeders do their work. It took researchers 13 years to sequence the human genome. Now they can do it in 27 hours. The cost of sequencing a genome has been reduced more than 10-fold in the past five years.

Cassava is a powerful example of what breeding—powered by the revolution in genomics—can do. It’s hard to breed cassava, and every breeding cycle takes five years, which means it usually takes a full decade to release a new variety.

But scientists can now use computer algorithms to link sequence data from the cassava genome to the performance of cassava plants in the field. This technique was first developed to predict levels of milk production in cows.

Breeders in developing countries will be able to predict how a tiny cassava seedling will perform. Consequently, the breeding cycle can be shortened from five years to two years. And it’s not just a shorter cycle. It’s also higher-quality, because breeders can focus on the most desirable traits early in the process. This will also allow for more participatory breeding, a process in which farmers themselves have input into the development of the new varieties they’ll be growing.

The digital revolution also provides opportunities to collect better data. In an age when a satellite can determine instantly how much wheat is in a field, it is a shame that we ask countries to use limited resources to send enumerators around with pen, paper, and tape measure. What we get is a lot of wasted time and inaccurate or incomplete data. The digital revolution can improve the quality of critical data while freeing up people to do other high-impact work.

CONCLUSION

I still can’t predict precisely how—or when—these changes will take hold. The beauty of innovation is that once the technology and tools are widely available, people with every possible insight and point of view start working on solutions to problems others can’t even see. Ultimately, it’s the way human beings, with our vast stores of ingenuity, deploy the power of the technology and tools that makes the biggest difference.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It’s Mosquito Week again on the Gates Notes. In this post I write about how the malaria parasite changes shape to foil your immune system. I’ve also written about ingenious new genetic techniques for fighting mosquitoes and maps that could help us defeat malaria.

I remember an old episode of the original Star Trek where the bad guy is a shapeshifter who turns himself into a second Captain Kirk. There’s a great scene at the end where Spock has to figure out which one is the impostor.

Shapeshifters are not just the stuff of science fiction, though. We have them right here on earth. Some are innocuous, like a caterpillar turning into a butterfly. But there’s another shapeshifter that’s responsible for more than 400,000 deaths every year. I’m talking about the group of microscopic parasites that cause malaria.

Malaria is one of the most fascinating and frustrating diseases our foundation works on, and its ability to change shape is one of the main reasons why. These parasites have figured out ingenious ways to fool your immune system. They have also (mostly) evaded our best efforts to make a malaria vaccine.

To understand how, it helps to know a bit about how your immune system works.

Your system is very good at detecting unusual objects in your body. It looks at the proteins on the surface of an invader and says, “I’ve never seen the funny shape on the outside of this thing. I’m going to attack it.” After the invader is defeated, your body remembers what it looked like and will go after it if it ever shows up again. Vaccines work by taking advantage of this process. When you get a measles shot, it contains a little bit of the virus; it won’t make you sick, but your body learns how to defend itself against future infections.

Unfortunately, malaria is a lot more complex than viruses or bacteria. For one thing, it is caused by parasites. Parasites don’t look as weird to your body as viruses or bacteria do. In fact, they more closely resemble your own cells, so your immune system has a harder time fighting them off.

Another problem is that the malaria parasite goes through three different stages in your body. It looks radically different in each stage, and as the infection goes on, you have all three going on at once.

Stage 1 begins when an infected mosquito bites you and injects a little saliva under your skin. This dose of saliva might contain only 100 parasites (called sporozoites in this stage). They are small and don’t cause any inflammation in your body, so your immune system doesn’t bother to look for them. You’re not feeling any symptoms yet.

Within an hour or two, the sporozoites make their way to your liver for stage 2. Coming out of your liver, they take a new form (called merozoites) and start invading your red blood cells. This invasion causes the symptoms—fever, chills, and so on—that make malaria such a miserable and deadly disease.

Now your body knows it’s sick and your immune system kicks in. But this is where the parasite’s shapeshifting comes into play.

Remember how the measles vaccine helps your immune system learn to identify the virus by looking for certain proteins on its surface? That works because those proteins look the same on each clone of the measles virus in your body. With malaria, each one can present up to 60 different proteins—and thanks to a mechanism that tells the parasite to alter its surface periodically, they shuffle these proteins around in different combinations every few days.

As a result, by the time your immune system has figured out how to attack one shape, the parasite has transformed, and your body’s defenses are useless. Your immune system adjusts, but not before the parasite has shifted again. It’s as if there’s a door on the surface of the parasite, but it keeps changing the locks so your body never has the right key.

Finally, in stage 3, a few of the merozoites develop into male and female cells. These hang out in your bloodstream, waiting for the next mosquito to come bite you. Once they’re in the mosquito’s stomach, they form new sporozoites, which make their way to the bug’s saliva glands and get injected into the next human, where the cycle starts all over again.

So that is the life cycle of malaria. What does all this mean for the effort to control and eventually eradicate this disease?

You might think we could create a vaccine that simply recognizes all the different shapes of the parasite. Unfortunately, that’s not practical. The only vaccine we have ever done that with is for a type of pneumonia. It is very expensive to manufacture and covers only a dozen shapes or so, versus the 60 shapes in one malaria infection and the many hundreds across all malaria parasites worldwide.

The malaria community (including our foundation) has been working for years on a vaccine to protect you in stage 1, before the infection takes hold. This vaccine, called RTS,S, teaches your immune system to hunt for a bit of protein that is always on the surface of the parasite. Unfortunately, the protection provided by RTS,S is not strong enough for long enough to help us make real headway toward eradication. And there are other forms of protection (such as bednets and insecticides) that are more cost-effective for saving lives.

People often ask me if it’s frustrating to fund work that takes so long to come to fruition. My answer is: not at all. Of course, I’m disappointed that we don’t have a long-lasting vaccine yet. But this is hard work. Parasites are such complex organisms that there are no effective vaccines for any of the human diseases that they cause. Besides, the research on RTS,S has given scientists a lot of insight into how malaria works and new clues about how to stop it. In fact, much of what we know about how your body responds (or fails to respond) to this type of parasite came from research on RTS,S.

The malaria community is now building on this knowledge. For example, scientists are working on new approaches that we hope will trigger the immune system to create long-lived, antibody-generating cells. Another promising idea is to create synthetic antibodies rather than trying to get your immune system to make natural ones. These monoclonal antibodies have revolutionized the treatment of cancer and inflammatory disease, and they could do the same for infectious diseases like malaria.

Knowing how complex malaria is helps me appreciate how much progress the world has made in fighting it. Deaths from malaria have dropped 42 percent since 2000, thanks to investments in bednets that prevent it and medicines that cure it. When I see how far we have come and how much we have learned, I am as optimistic as ever that we can beat this clever shapeshifter.

It’s Mosquito Week again on the Gates Notes. This year I’m exploring some of the science behind malaria and other mosquito-borne diseases. You can read below about how maps are revolutionizing the fight against malaria. I’ve also written about how the malaria parasite is a clever shapeshifter and how genetically editing mosquitoes could help us defeat the disease.

Imagine calling the fire department and telling them: “There’s a house burning somewhere in the city!” They ask you for the address or at least some nearby streets, but you’re not sure. Without more specifics, it’s just about impossible for them to help.

For decades, the malaria community has faced a similar problem, but on a national scale. In many of the countries with a lot of malaria, we have had a national estimate of how prevalent it is, but very little reliable information about the breakdown within the country. That means health officials have to distribute bednets across an entire region, hoping to get everyone who might be at risk while also covering people who aren’t.

This problem is especially urgent now. After more than 15 years of steady progress against the disease, the improvement is slowing down. Funding for malaria has also flatlined. If we simply stick with the same tools and the same strategies, progress will stall, and the disease might make a comeback. We need to do more with what we have.

I am happy to report that things are changing, thanks to better data. A combination of new technology and improved systems is helping us target lifesaving interventions in the places where there’s the greatest risk of malaria—making sure that each dollar spent has the biggest possible impact.

I admit that data isn’t as sexy as shapeshifters or the X-shredder. Yet the topic is super-important. It is a big focus for our foundation’s malaria strategy, one of the key things we bring to the table given our interest in technology and innovation. This post will get more in-the-weeds than I usually do on TGN, but if you are as obsessed with malaria as I am, I hope you’ll find it interesting.

Health experts estimate the burden of disease in two ways. One is to use anonymous information collected by health workers. But this information has a lot of gaps and gets aggregated as it moves up the chain from the clinic to the district to the province. This would be roughly equivalent to adding up the cases in every hospital in a U.S. state and only reporting the total. It obscures a ton of local variation, and by the time all the data is processed, the report may be a year out of date.

The other source is surveys. Health workers go out to a community and test a few volunteers for malaria, then repeat this at sites across the country. But this process is expensive and time-consuming, which limits the number of samples a country can take and how often it can take them.

The malaria community is tackling the problem in two ways. A nonprofit called the Malaria Atlas Project (funded by our foundation) started by gathering all the data they could find from every endemic country. They discovered something surprising: Although there were big gaps on the map where we had very little information, overall there was a lot more data than anyone expected.

Using the information they had, along with data on local conditions that affect the spread of malaria (such as the temperature, humidity, and the location of health clinics), MAP started building computer models that give us a much clearer picture of what’s going on.

The results are remarkable. We now have data-rich maps with pixels that are just 5 km square. Instead of blanketing entire regions with bednets and other anti-malaria measures, health officials can target efforts where they will do the most good.

Now comes the next step: getting even better data so we make maps with an even higher resolution. To accomplish this, our foundation and other partners are helping countries strengthen their systems for monitoring disease. In the poorest places, this might mean disaggregating their data and making sure it is accurate and timely. For others, it means equipping health workers with mobile phones or tablets so they can enter the information digitally. More than 60 countries already use the same software to report health data, vastly simplifying the process of collecting and analyzing information.

Below you can see a dramatic example of what the future of mapping looks like. Both are maps of Haiti. The one on the left uses the 5x5 km resolution, built with aggregated data. (Remember, this was already a huge leap forward from national estimates.) The one on the right uses data from individual health facilities to create pixels that are just 1x1 km square. See how much more detailed it is? When you need to maximize scarce resources, this kind of information is invaluable.

There is more to come. One promising approach uses genetic analysis of the malaria parasite to make the maps even more robust, for example revealing how the disease is transmitted from place to place.

Genetic data is also helping us identify insecticide-resistant mosquitoes and drug-resistant forms of the disease. In Vietnam, health officials recently noticed an alarming spike of cases in one region of the country. Then genetic analysis of the parasite in that region revealed that they were fighting a drug-resistant strain of malaria. They quickly switched to a more effective drug and expect to see the number of cases drop soon.

This kind of work is best done at the local level. So we’re funding programs that help scientists in developing countries do more of this analysis themselves, rather than sending samples off to a lab in the U.S. or Europe. Increasingly, scientists in Senegal, Thailand, and other countries are doing their own analysis, which both speeds up the process and puts local experts in the leading role where they belong.

There is a lot of innovation in the malaria field right now, including work on vaccines and other parasite-killers and a way to fight the disease using test-tube mosquitoes. Better data and malaria maps will help us put all these breakthroughs to their best use, and bring us closer to the day when this disease is gone forever.

I’m a big fan of the MIT Technology Review’s annual list of ten breakthrough technologies—so when they asked me to choose this year’s list, I jumped at the chance. It’s been a lot of fun working on the issue and picking which innovations to include. I think all ten entries will have a significant impact in the years to come, and I’m excited for you to learn more about them.

Here’s the opening essay I wrote for the issue. You can see the full list of breakthrough technologies here.

I was honored when MIT Technology Review invited me to be the first guest curator of its 10 Breakthrough Technologies. Narrowing down the list was difficult. I wanted to choose things that will not only create headlines in 2019 but captured this moment in technological history—which got me thinking how innovation has evolved over time.

My mind went to—of all things—the plow. The plow is an excellent embodiment of the history of innovation. Humans have been using them since 4000 BCE when Mesopotamian farmers used sharpened sticks to aerate soil. We’ve been slowly tinkering with and improving them ever since, and today’s plows are technological marvels.

But what exactly is the purpose of a plow? It’s a tool that creates more: more seeds planted, more crops harvested, more food to go around. In places where nutrition is hard to come by, it’s no exaggeration to say that a plow gives more years of life to people. The plow—like many technologies, both ancient and modern—is about creating more of something and doing it more efficiently, so that more people can benefit.

Contrast that with lab-grown meat, one of the innovations I picked for this year’s TR10 list. Growing animal protein in a lab isn’t about feeding more people. There’s enough livestock to feed the world already, even as demand for meat goes up. Next-generation protein isn’t about creating more—it’s about making meat better. It lets us provide for a growing and wealthier world without contributing to deforestation or emitting methane. It also allows us to enjoy hamburgers without killing any animals.

Put another way, the plow improves our quantity of life, and lab-grown meat improves our quality of life. For most of human history, we’ve put most of our innovative capacity into the former. And our efforts have paid off: worldwide life expectancy jumped from 34 years in 1913, to 60 in 1973, and has reached 71 today.

Because we’re living longer, our focus is starting to shift toward well-being. This transformation is happening slowly. If you divide scientific breakthroughs into these two categories—things that improve quantity of life versus quality of life—the TR10 list from 2009 looks not so different from this year’s. Like most forms of progress, the change is so gradual that it’s hard to perceive. It’s a matter of decades, not years—and I believe we’re only at the midpoint of the transition.

To be clear, I don’t think humanity will stop trying to extend lifespans anytime soon. We’re still far from a world where everyone everywhere lives to old age in perfect health, and it’s going to take a lot of innovation to get us there. Plus, “quantity of life” and “quality of life” are not mutually exclusive ideas. A malaria vaccine would both save lives and make life better for children who might have otherwise been left with developmental delays from the disease.

We’ve reached a point where we’re tackling both ideas at once, and that’s what makes this moment in history so interesting. If I had to predict what the TR10 will look like a few years from now, I bet technologies that alleviate chronic disease will be a big theme. This won’t just include new drugs (although I would love to see new treatments for diseases like Alzheimer’s on the list). These innovations might look like a mechanical glove that helps a person with arthritis maintain flexibility or an app that connects someone experiencing a major depressive episode with the help they need.

If we could look even further out—let’s say the TR10 list 20 years from now—I would hope to see technologies that center almost entirely on well-being. I think the brilliant minds of the future will focus on more metaphysical questions: How do we make people happier? How do we create meaningful connections? How do we help everyone live a fulfilling life? 

I would love to see these questions shape the 2039 list, because it would mean that we’ve successfully fought back disease (and dealt with climate change). I can’t imagine a greater sign of progress than that. For now, though, the innovations driving change are a mix of things that extend life and things that make it better. My picks reflect both. Each one gives me a different reason to be optimistic for the future, and I hope they inspire you, too.

My selections include amazing new tools that will one day save lives, from simple blood tests that diagnose cancer to toilets that destroy deadly pathogens. I’m equally excited by how other technologies on the list will improve our lives. Wearable health monitors like the wrist-based EKG will warn heart patients of impending problems, while others let diabetics not only track glucose levels but manage their disease. Advanced nuclear reactors could provide carbon-free, safe, and secure energy to the world.

One of my choices even offers us a peek at a future where society’s primary goal is personal fulfillment. Among many other applications, AI-driven personal agents might one day make your email inbox more manageable—something that sounds trivial until you consider what possibilities open up when you have more free time.

The thirty minutes you used to spend reading emails could be spent doing other things. I know some people would use that time to get more work done—but I hope most would use it for more fulfilling pursuits, like connecting with a friend over coffee, helping your child with her homework, or even volunteering in your community.

That, I think, is a future worth working toward.

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

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

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

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

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

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

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

BILL GATES:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Governments have an opportunity not only to learn from what’s been done in the past, but to do things in new ways. One of the exciting prospects is the role they can play in accelerating use of digital technology to leapfrog traditional models and costly infrastructure associated with banking and delivery of government services.

By using mobile phones, tens of millions of people are already storing money digitally and using their phones to make purchases as if they were debit cards.

A good example of this is M-PESA in Kenya. These services don’t just give people a better way to move money around, they give people a place to save cash to fund a startup of a micro enterprise or pay a child’s school fee. They create informal insurance networks of friends and families who can help with unexpected shocks. And they increase the profitability of small businesses by lowering transaction costs, making it easy to order products and supplies, and having greater security of financial assets.

A digital financial connection can also help governments deliver services more efficiently. Studies from India show the government able to save tens of billions a year by connecting households to a digital payment system and automating all government payments.

The early evidence suggests that similar programs in Africa can also yield substantial benefits. For example, recent research in Uganda showed that providing people with digital cash transfers rather than direct food subsidies not only saved the cost of delivery, it also improved nutrition because recipients used the money to purchase a greater diversity of foods and to space out meals as needed.

Governments can accelerate this digital transformation by implementing policies that encourage commercial investment, innovation, and healthy competition.

Countries like Kenya, Tanzania, and Nigeria are already investing in the building blocks of this new digital financial platform. And I believe they’ll see substantial positive returns.

If there’s one thing I’m sure of, it’s this: Africa can achieve the future it aspires to.

That future depends on the people of Africa working together across economic and social strata and across national borders to lay a foundation so that Africa’s young people have the opportunities they deserve.

Recently, I had a meeting with students at Addis Ababa University. I started asking them the kinds of questions you would ask college students in the United States like, “What do you want to do after you graduate? What fields are you thinking of going into?”

They looked at me like I was kind of crazy for asking those questions. Each of them had a plan for their future. They felt their parents had sacrificed for decades so they could go to this university. They weren’t weighing their options, they had come to the university to get specific training, and they were eager to take that training and use it to make their country more prosperous.

They saw themselves as part of a large community with great needs.And they were going to dedicate themselves to serving that community by meeting those needs.

I see that sense of purpose when I come to Africa, and especially when I talk to young Africans. I think it’s a unique asset that people see the need to change and that they want to give back.

The students here believe not only in themselves, they also believe in their countries and the future of the continent. Our priority is to make sure they have the opportunity to turn those beliefs into action because young people with this sense of purpose can make the difference between stagnation and faster progress.

Nelson Mandela said, “Young people are capable, when aroused, of bringing down the towers of oppression and raising the banners of freedom.” But our duty is not merely to arouse, our duty is to invest in these young people, to put in place the basic building blocks so they can build the future.

And our duty is to do it now because the innovations of tomorrow depend on the opportunities available to children today.

I’m sure it’s clear to everyone that these are big and complicated challenges. But it’s just as clear that people with bravery, energy, intellect, passion, and stamina can face big, complicated challenges and overcome them.

There is so much more work to be done to create a future in which we can all live together, but there are also so many people who are eager to get to work.

Let’s do everything within our power right now to help build the future that Nelson Mandela dreamed of and the future that we will achieve together.

Thank you.

If you were living on $2 a day, what would you do to improve your life?

That’s a real question for the nearly 1 billion people living in extreme poverty today. There’s no single right answer, of course, and poverty looks different in different places. But through my work with the foundation, I’ve met many people in poor countries who raise chickens, and I have learned a lot about the ins and outs of owning these birds. (As a city boy from Seattle, I had a lot to learn!) It’s pretty clear to me that just about anyone who’s living in extreme poverty is better off if they have chickens.

In fact, if I were in their shoes, that’s what I would do—I would raise chickens.

Here’s why:

• They are easy and inexpensive to take care of. Many breeds can eat whatever they find on the ground (although it’s better if you can feed them, because they’ll grow faster). Hens need some kind of shelter where they can nest, and as your flock grows, you might want some wood and wire to make a coop. Finally, chickens need a few vaccines. The one that prevents the deadly Newcastle disease costs less than 20 cents.
• They’re a good investment. Suppose a new farmer starts with five hens. One of her neighbors owns a rooster to fertilize the hens’ eggs. After three months, she can have a flock of 40 chicks. Eventually, with a sale price of $5 per chicken—which is typical in West Africa—she can earn more than $1,000 a year, versus the extreme-poverty line of about $700 a year.
• They help keep children healthy. Malnutrition kills more than 3.1 million children a year. Although eating more eggs—which are rich in protein and other nutrients—can help fight malnutrition, many farmers with small flocks find that it’s more economical to let the eggs hatch, sell the chicks, and use the money to buy nutritious food. But if a farmer’s flock is big enough to give her extra eggs, or if she ends up with a few broken ones, she may decide to cook them for her family.
• They empower women. Because chickens are small and typically stay close to home, many cultures regard them as a woman’s animal, in contrast to larger livestock like goats or cows. Women who sell chickens are likely to reinvest the profits in their families. Read more about women and chickens in Melinda’s blog post.

Dr. Batamaka Somé, an anthropologist from Burkina Faso who has worked with our foundation, has spent much of his career studying the economic impact of raising chickens in his home country. In this video he explains why he is so passionate about poultry.

A big bet on chickens

Our foundation is betting on chickens. Alongside partners throughout sub-Saharan Africa, we are working to create sustainable market systems for poultry. It’s especially important for these systems to make sure farmers can buy birds that have been properly vaccinated and are well suited to the local growing conditions. Our goal: to eventually help 30 percent of the rural families in sub-Saharan Africa raise improved breeds of vaccinated chickens, up from just 5 percent now.

When I was growing up, chickens weren’t something you studied, they were something you made silly jokes about. It has been eye-opening for me to learn what a difference they can make in the fight against poverty. It sounds funny, but I mean it when I say that I am excited about chickens.

Four years ago, the world was stunned by the Ebola outbreak in West Africa. Panic broke out all over the globe. Governments scrambled to contain the infection. By the time the last patient tested negative for the disease, the outbreak claimed thousands of lives and caused billions of dollars in economic losses.

The 2014 Ebola outbreak was a stark reminder of how vulnerable our society is to epidemics of infectious diseases. We weren’t ready then, and we’re still not ready now—but we can be. We don’t know when the next epidemic will strike, but I believe we can protect ourselves if we invest in better tools, a more effective early detection system, and a more robust global response system.

When the Massachusetts Medical Society asked me to deliver this year’s Shattuck Lecture, I knew I wanted to talk about epidemic preparedness. I was honored to address their annual meeting earlier today. Here is the full text of my prepared remarks:

BILL GATES:

Thank you, Dr. Drazen, for that kind introduction. It’s an honor to be invited to deliver the Shattuck Lecture.

Most of the speeches I give on global health are about the incredible progress and exciting new tools that are helping the world reduce child mortality and tackle infectious diseases. Thanks to better immunization and other interventions, child mortality has been reduced by more than 50 percent since 1990. We are on the verge of eradicating polio. HIV is no longer a certain death sentence. And half the world is now malaria-free.

So usually, I’m the super-optimist, pointing out that life keeps getting better for most people in the world.

There is one area, though, where the world isn’t making much progress, and that’s pandemic preparedness. This should concern us all, because if history has taught us anything, it’s that there will be another deadly global pandemic.

We can’t predict when. But given the continual emergence of new pathogens, the increasing risk of a bioterror attack, and how connected our world is through air travel, there is a significant probability of a large and lethal, modern-day pandemic occurring in our lifetimes.

Watching Hollywood thrillers, you’d think the world was pretty good at protecting the public from deadly microorganisms. We like to believe that somewhere out there, there is a team ready to spring into action – equipped with the latest and best technologies.

Government agents like Jack Bauer in 24. Harvard professors like Robert Langdon in Inferno. And WHO epidemiologists like Dr. Leonora Orantes in Contagion – who even risked getting kidnapped as she pursued “Patient Zero.”

In the real world, though, the health infrastructure we have for normal times breaks down very rapidly during major infectious disease outbreaks. This is especially true in poor countries. But even in the U.S., our response to a pandemic or widespread bioterror attack would be insufficient. 

Several things in the last decade have made me pay closer attention to the risk of future pandemics. One was the outbreak of Swine Flu in 2009. While H1N1 wasn’t as lethal as people initially feared, it showed our inability to track the spread of disease and develop new tools for public health emergencies.

The Ebola epidemic in West Africa four years ago was another wake-up call. As confirmed cases climbed, the death toll mounted, and local health systems collapsed. Again, the world was much too slow to respond.

And, as biological weapons of mass destruction become easier to create in the lab, there is an increasing risk of a bioterror attack.

What the world needs – and what our safety, if not survival, demands – is a coordinated global approach. Specifically, we need better tools, an early detection system, and a global response system.

Today, I’d like to speak with you about some of the advances in tools – vaccines, drugs, and diagnostics – that make me optimistic we can get a leg up on the next pandemic. And I’ll talk about some of the gaps we must address in preparedness and response.  

Interestingly, the first Shattuck Lecture – given back in 1890 – focused on a pandemic . . . the Russian flu that struck Massachusetts the previous year. The Russian flu was not especially deadly. But it was the first flu pandemic to spread across continents connected by rail travel – and between continents connected by fast ocean liners. The virus circled the globe in just four months.

But the world was soon in for much worse. Less than 30 years later, the Boston area was one of the first places in the U.S. to feel the deadly effects of the 1918 flu. Military personnel getting off and on ships at the Commonwealth Pier – near where we are meeting today – helped carry the pathogen across the U.S. and back to the battlefields of World War I.

This animation shows how quickly the virus spread across the United States. It took five weeks and killed 675,000 people.

The death toll was so great that average life expectancy in the U.S. for that period dropped by 12 years.

Worldwide, the 1918 flu killed an estimated 50 million people, perhaps more. 

We have better tools today than we did a century ago. We have a seasonal flu vaccine, although it’s not always effective, you have to get one every year, and most people in the world never get the shot. We also have antibiotics for secondary infections of bacterial pneumonia.

Despite these advances, this animated simulation by the Institute for Disease Modeling shows what would happen if a highly contagious and lethal airborne pathogen – like the 1918 flu – were to occur today.

Nearly 33 million people worldwide would die in just six months.

That’s the sobering news. The good news is that scientific advances and growing interest on the federal level, in the private sector, and among philanthropic funders makes development of a universal flu vaccine more feasible now than 10 or 20 years ago.

Our foundation is involved in a variety of research partnerships, including a collaboration between the Icahn School of Medicine at Mount Sinai, GlaxoSmithKline, and PATH.

Their work focuses on several vaccine candidates that did well in animal trials and which are now in human trials.

We are also supporting efforts by others, including the National Institute of Allergy and Infectious Diseases, whose vaccine candidate is expected to advance to human safety trials in about a year.

To broaden efforts even further, today we are launching a $12 million Grand Challenge in partnership with the Page family to accelerate the development of a universal flu vaccine. The goal is to encourage bold thinking by the world’s best scientists across disciplines, including those new to the field. 

Lucy and Larry Page are also supporting efforts by the Sabin Vaccine Institute to encourage innovative approaches that eliminate the threat of a deadly flu pandemic.

However, the next threat may not be a flu at all. More than likely, it will be an unknown pathogen that we see for the first time during an outbreak, as was the case with SARS, MERS, and other recently-discovered infectious diseases.

The world took an important step last year to begin addressing this risk with the launch of a public-private partnership called the Coalition for Epidemic Preparedness Innovations (CEPI).

With funding commitments of more than $630 million, CEPI’s first order of business is advancing the development of vaccines for three of the priority diseases on the WHO list for public health R&D: Lassa fever, Nipah virus, and Middle East Respiratory Syndrome.

CEPI is also working on rapid-response platforms to produce safe, effective vaccines for a range of infectious diseases – almost as quickly as new threats emerge. Later this year, CEPI will announce grants to several companies working with a variety of technologies – including nucleic acid vaccines, viral vectors, and other innovative approaches. The goal is to be able to develop, test, and release new vaccines in a matter of weeks or months, rather than years.

I’m a big fan of vaccines, but they may not be the answer when we have to respond immediately to rapidly spreading infectious disease pandemics. Not only do vaccines take time to develop and deploy; they also take at least a couple of weeks after the vaccination to generate protective immunity. So, we need to invest in other approaches like antiviral drugs and antibody therapies that can be stockpiled or rapidly manufactured to stop the spread of pandemic diseases or treat people who have been exposed.

Earlier this year, the Shionogi pharmaceutical company received approval in Japan for a new influenza anti-viral, Xofluza This single-dose drug stops flu in its tracks by inhibiting an enzyme that the virus needs to multiply. 

And PrEP Biopharm, a development stage biopharmaceutical company, has demonstrated in human challenge studies that pre-activating the innate immune response through intranasal delivery of a double-stranded viral RNA “mimic” can prevent both influenza and rhinovirus.

Since the host’s innate immune response is non-virus specific, such an approach has the potential to offer protection against other types of respiratory viruses as well.

Monoclonal antibody therapies have also made incredible advances in the last couple of decades, leading to several products for cancer and autoimmune diseases. During the Ebola outbreak in West Africa several years ago, researchers were able to identify and test a promising combination of monoclonal antibodies to treat infected patients.

And a growing pipeline of broadly neutralizing antibodies are being discovered in some individuals exposed to infectious diseases. For example, a small percentage of people infected with HIV develop antibodies with high potency and breadth of coverage sufficient to protect against many strains of the virus. The same is true for some people infected with the flu.

Different sets or cocktails of these exceptional antibodies may protect against a pandemic strain of a virus even if it has genetically evolved. It is conceivable that we could create libraries of these antibodies, produce manufacturable seed stocks, and have them ready for immediate use in an outbreak—or ready to scale up manufacturing if a pandemic ensues. If we can learn how to use RNA or DNA gene delivery effectively, we may not need to make the antibodies at all.

Rapid diagnosis is also critical, especially at the beginning of an outbreak when quarantine, treatment, and other public health measures are most effective. To that end, researchers at the Broad Institute and at UC-Berkeley have developed a highly-sensitive point-of-care diagnostic test that harnesses the powerful genetic engineering technology known as CRISPR.

But instead of using CRISPR to edit DNA, they have programmed an associated protein called Cas13 to hunt for specific pieces of RNA. When Cas13 locates the relevant genetic sequence, it releases a signal molecule that indicates the presence or absence of the target.

In a paper published yesterday in the journal, Science, the Broad researchers highlighted the field-use potential of this new diagnostic. Using paper strips similar to a pregnancy test – and with minimal sample processing – the diagnostic can check a patient’s blood, saliva, or urine for evidence of a pathogen.

What’s more, it can test for multiple pathogens at once. It could, for example, identify if someone is infected with Zika or dengue virus, which have similar symptoms.

There are also some interesting advances that leverage the power of computing to help predict where pandemics are likely to emerge and model different approaches to preventing or containing them. 

Over the last few years, researchers at the Institute for Health Metrics and Evaluation at the University of Washington have developed a sophisticated computer model that combines data from dozens of sources with geospatial mapping to predict the pandemic risk of infectious diseases.

They recently looked at the pandemic potential of four viral hemorrhagic fevers in Africa – including Ebola. Their analysis confirmed that Guéckédouprefecture in Guinea – where the West African Ebola outbreak originated – was indeed one of the most likely places where an individual Ebola case could lead to a widespread epidemic.

The research also pinpointed dozens of other African communities that are at high risk of outbreaks of hemorrhagic fevers.

Meanwhile, researchers at the Institute for Disease Modeling are pushing the boundaries of computational epidemiology to provide a deeper understanding of both the spread of infectious diseases and the effectiveness of different control and eradication strategies.

In the effort to eliminate malaria, for example, IDM is combining surveillance data with computational modeling to tailor antimalarial efforts to unique local conditions. They are also using quantitative analysis and modeling to evaluate various control strategies for HIV, TB, and to eradicate polio. This kind of research could provide valuable information to help predict disease transmission and identify prevention measures and intervention tactics for epidemics and pandemics.

At the Munich Security Conference last year, I asked world leaders to imagine that somewhere in the world, there is a weapon that exists – or that could emerge – that is capable of killing millions of people, bringing economies to a standstill, and casting nations into chaos.

If this were a military threat, the response – of course – would be that we should do everything possible to develop countermeasures. In the case of biological threats, that sense of urgency is lacking.

The world needs to prepare for pandemics the way the military prepares for war. This includes simulations and other preparedness exercises so we can better understand how diseases will spread and how to deal with things like quarantine and communications to minimize panic.

We need better coordination with military forces to ensure we can draw on their mobilization capacity to transport people, equipment, and supplies on a mass scale.

We need a reserve corps of trained personnel and volunteers, ready to go at a moment’s notice. And we need manufacturing and indemnification agreements in place with pharmaceutical companies –with expedited review processes for government approval of new treatments.

Last month, Congress directed the administration to come up with a comprehensive plan to strengthen global health security – here and abroad. This could be an important first step if the White House and Congress use the opportunity to articulate and embrace a leadership role for the U.S. in global health security.

No other country has the depth of scientific or technical expertise that we do – drawing on the resources of institutions like the NIH, the CDC, and advanced research organizations like DARPA and BARDA.

Our biopharmaceutical industry is the global leader in biomedical innovation. And, on the world stage, the U.S. is an influential member of international forums like the UN, the WHO, the G7, and the G20.

The point is that the U.S. can and should play a leadership role in creating the kind of pandemic preparedness and response system the world needs.

As I said at the start, I’m fundamentally an optimist, and that gives me hope that we can get prepared for the next big pandemic.

The global community eradicated smallpox, a disease that killed an estimated 300 million people in the 20th century alone. 

We are on the verge of eradicating polio, a disease that 30 years ago was endemic in 125 countries and that paralyzed or killed 350,000 people a year. 

And today, nearly 21 million people are receiving life-saving HIV treatment, thanks primarily to the support of the world community.

America’s global HIV initiative, PEPFAR, was the catalyst for world action on the AIDS crisis. It’s an example of the kind of leadership we need from the U.S. on a broader effort to make the world safer from other infectious disease threats. With strong bipartisan support, PEPFAR has saved millions of lives and shown that national governments can work together to address pandemics.

Somewhere in the history of these collective efforts is a roadmap to create a comprehensive pandemic preparedness and response system.

We must find it and follow it because lives – in numbers too great to comprehend – depend on it.

Thank you for the opportunity to address you today.

In the tiny African kingdom of Swaziland*, one of the most effective tools in the fight against malaria is a telephone number: 977.

When someone tests positive for the mosquito-borne disease at a Swazi clinic, a nurse immediately dials those three digits to report the case to the country’s national emergency response center. The call triggers a text message to the national malaria program team, which dispatches investigators—armed with computer tablets that have built-in satellite maps and GPS software—to interview the patient and test all people living within a one-kilometer radius of their home. A separate team is called in to reapply insecticide to the walls of homes in the community to help protect other families from infection.

Such vigilance is one of the reasons why Swaziland may become the first malaria-free country in sub-Saharan Africa, where most malaria deaths occur.

Swaziland’s well-coordinated malaria program—including a robust surveillance and control system—has helped reduce the number of cases in the country by more than 90 percent since 2002. Now, Swaziland aims to eliminate malaria entirely within its borders by 2020.

Swaziland’s bold goal is evidence of the incredible progress the world has made against malaria. Between 2000 and 2015, the combination of increased donor investment, strengthened political commitment, and new tools (including artemisinin combination therapies, rapid diagnostic tests, indoor residual spraying, and insecticide-treated bed nets), led to a 60 percent decline in malaria deaths.

At the same time, the difficulties Swaziland has experienced trying to become malaria free are a sobering reminder of the challenges the world faces to reach its goal of eradicating the disease.  While the number of malaria cases in Swaziland has fallen to just a few hundred cases each year, tackling those final cases is more difficult than anyone imagined. Swaziland thought it would eliminate the disease by the end of 2015, and again by the end of 2017, but each time fell short of its goal. Last year, Swaziland saw its number of malaria cases rise sharply. 

Globally, progress in the malaria fight has stalled. Further progress is in peril given the plateauing funding levels which make it impossible to fill remaining gaps in prevention and treatment of malaria and address the challenges of drug and insecticide resistance. After years of dramatic declines in malaria cases and deaths, the world is starting to lose ground. In 2017, the World Malaria Report showed that for the first time in years the number of malaria cases went up.

These setbacks should not lead to despair. They should serve as a wake-up call. As I told health officials at the Malaria Summit in London last week, the world needs a new strategy to meet the challenges ahead. That means developing innovations that will keep driving down malaria cases and malaria deaths, while tailoring interventions to address the specific needs of a country or region.

Swaziland is a good example of how countries can adapt their malaria control strategies to meet their unique circumstances. One of Swaziland’s biggest challenges is the cross-border movement of people infected with the disease from outside the country. Mozambique, Swaziland’s next-door neighbor, has one of the highest malaria burdens in the world. Workers from Mozambique may come into Swaziland with malaria. And when Swazis go to Mozambique, they sometimes return with the disease, which can then be passed on to their neighbors. Unpredictable weather also poses a challenge. The sudden spike of new cases last year was driven by heavier rainfall in the region, resulting in more mosquito breeding.

Swaziland and Mozambique are part of the Elimination 8 regional malaria elimination effort, which aims to wipe out malaria from eight countries in southern Africa. Last year, as part of that effort, Swaziland and Mozambique set up malaria posts along their border. As people go back and forth between the two countries, they are offered malaria tests and treatment to help prevent the importation of new cases. Since the posts were set up last year, thousands of people have been tested and treated and the national malaria program is optimistic that the number of cases will fall this year as a result.

At the same time, Swaziland remains committed to the painstaking work of investigating every new malaria case and responding swiftly to reduce the chance the disease will spread. The country also organized intensive media campaigns to warn residents and travelers of the danger of malaria and teach them how to protect themselves. Malaria diagnosis and treatment are free to everyone in private and public clinics.

I look forward to hearing more about Swaziland’s progress in the months ahead. If successful eliminating malaria within its borders, Swaziland can achieve a major milestone toward a goal once thought impossible—making Africa malaria free. I hope to see many more countries follow its lead.

* Just before I posted this, King Mswati III of Swaziland announced that the name of the country was changing to the Kingdom of eSwatini. In order to avoid confusion, I’ve used Swaziland in this post.

Mosquitoes keep me up at night.

If you ask someone about what things scare people the most, there’s a list of usual suspects: shark attacks, heights, enclosed spaces, etc. Mosquitoes usually don’t make the cut—but they frighten me more than almost anything else.

This fear might be a bit irrational in Seattle, where I live. Our climate is too mild for the types of mosquitoes that harbor serious diseases. In other parts of the world, however, families have good reason to be afraid. Mosquitoes and the diseases they carry kill more than half a million people every year. Consider this mind-blowing statistic:

Of all the illnesses mosquitoes spread, malaria is the worst by far. More than 200 million people suffer from it every year, and a child dies from malaria every other minute of every day. If you survive, it can leave you vulnerable to other debilitating diseases and chronic anemia. It’s an awful, painful disease (I wrote about what it feels like to have malaria a couple years ago).

Melinda and I encounter a lot of suffering through our work, but one of the worst things I’ve ever seen is a child having seizures from cerebral malaria in Tanzania. I will never forget watching his small body twist in agony, as his parents waited to find out if he would survive. I wouldn’t wish that experience on anyone.

So why exactly are people more afraid of sharks than mosquitoes? The late Hans Rosling would argue that humans are hardwired to fear things that cause us physical harm. This instinct is practical if you live in poverty (on level 1 or 2), where an animal attack is more likely to kill you. But if you can afford life-saving healthcare, it can distort your perception of how significant a threat really is.

Even if you know that you’re 50,000 times more likely to get killed by a mosquito than a shark, human instinct wins out. A photo of a shark attack victim on the evening news evokes a visceral reaction, because the threat is obvious. A picture of a malaria victim in a hospital ward doesn’t trigger our fear instinct in the same way.

Despite this, I’m determined to spread the word about mosquitoes—which is why I’m bringing back Mosquito Week here on Gates Notes.

Everything I’m posting this week is dedicated to my least favorite pest. You can read some good news about a country that hopes to eliminate malaria by 2020. You can see how the bed nets the Mozambique Ministry of Health and World Vision distributed last year on behalf of the Gates Notes Insider community are making a difference. I’m going to be talking about mosquitoes on my social channels all week, and I hope you’ll join the conversation.

As long as Hollywood keeps making blockbusters about sharks, I’ll keep talking about why everyone should be more scared of a tiny bug than a 3,000-pound carnivore. Jaws is nothing compared with the flying terror that is a mosquito.

The world is making incredible progress against malaria. New innovations—including more effective drugs for treatment, rapid diagnostic tests, and better insecticides—have helped prevent more than 600 million cases of malaria and saved 6.8 million lives between 2000 and 2015. One new tool that helps protect families in Africa is a long-lasting type of bed net. Learn more about the impact these bed nets are having in the southern African country of Mozambique.

Fourteen-month-old Judite Luis battles malaria (and complications from malnutrition) at Chicuque Rural Hospital in Inhambane, Mozambique with her mother, Adozinda Augusta, at her side. Malaria is the leading cause of death among children under 5 in Mozambique. Judite died the day after this photo was taken.

A boy points out the holes in an old mosquito net used in his home. While the older generation of bed nets helped protect families from malaria in Mozambique, they had some downsides. They needed to be soaked in insecticide every six months and didn’t stand up to repeated washings when they got dirty, leading to tears that mosquitoes could fly through.

In November, thousands of families in Inhambane, Mozambique lined up to receive long-lasting insecticidal mosquito nets from the Mozambique Ministry of Health’s National Malaria Control Program and World Vision partnership. The nets protect people from mosquitoes for three years and can even be washed when they get dirty. (The bed net donation was made possible, in part, by the participation of Gates Notes readers in a bed net giveaway campaign last year. Thanks for your help!)

Clayton Pedro Albert, age 6, and his 11-month-old sister, Sharmila, go to bed under one of the long-lasting insecticidal nets. “There is no malaria in this house this year. Last year, it was so many times,” said Carolina Alberto, their mother. Across Mozambique, World Vision, in partnership with the Ministry of Health, has distributed more than 21 million bed nets. Ensuring families use their new bed nets is critical for controlling malaria. World Vision follows up with households to show families how to hang and care for their nets and remind them of the importance of sleeping under them every night.

Silvina Jorge Mahoche and her daughter, Celineza Mahoche, share their new insecticidal net. The Mahoche family has had malaria more times than they can remember. What they don’t forget are the painful symptoms: “A fever, chills, joint pain, headaches, and vomiting,” Silvina said. Since receiving the net last year, no one in the family has been sick from malaria.

Villagers return home after receiving new mosquito nets. Ensuring communities have universal coverage of nets and follow up to ensure appropriate use is critical to achieving malaria control and elimination. Some mosquitoes are now developing resistance to the pyrethroid insecticides used in bed nets—so researchers are working on next generation nets that use combinations of insecticides and appear effective against all mosquitoes, including insecticide-resistant ones. Much more work needs to be done to eliminate malaria in Africa, but continued innovation in bed nets and other tools will ensure that the world will continue to make progress against this deadly disease.

Could a plate of beans and rice help change the world?

Last month, I squeezed into a child’s-size desk to have lunch with a class of primary school students in Tanzania. I was there to join them for the launch of their new school lunch program. On the menu: red beans cooked with tomatoes and onions served over rice.

You can join us in this video. (We’ve saved a plate for you.)

Lunch was delicious. More than that, it filled me with hope. Watching my 67 lunchmates—most of them 8-year-olds—dig into their piles of rice and beans, I was reminded that even the humblest of meals can have a far-reaching impact not just for individuals, but entire nations.

Here’s why: This month, as children around the globe begin another school year, millions of students in the poorest countries (and even some in wealthy countries) will turn up for classes on an empty stomach, making it difficult for them to learn and continue their schooling. According to the World Food Program, 66 million primary school-age children attend classes hungry across the developing world, with 23 million in Africa alone.

A school lunch program, however, can make a world of difference. It encourages kids to come to school, gives them energy to learn, and improves their overall health. The benefits don’t stop at the classroom door. Economic modelling shows that every US$1 invested in school meals programs brings a US$3-10 economic return from improved health, education and productivity. And a new research paper by the World Food Program found that school meals can contribute to help achieving the Global Goals, including ending hunger, quality education, and gender equality and indirectly to reducing poverty, contributing to the economy, and helping to reduce inequality.

Not too bad for a plate of beans and rice.

Stay tuned for more stories from my trip to Tanzania in the months ahead.

We’ve come a long way since the days of blaming the stars.

Malaria has terrorized humankind for thousands of years, but for most of that time, we had no idea what caused it. The ancient Greeks thought Sirius the dog star might be responsible. A Chinese medical text from 270 BCE speculated that three demons spread the disease. As recently as the mid-1800s, doctors believed malaria was caused by the stinky fumes that wafted into cities from nearby swamps (the word malaria means “bad air” in Italian).

Today, we know exactly who our enemy is: the mosquito. Doctors no longer subject malaria sufferers to unpleasant (and pointless) treatments like blood-letting and chewing tree bark. Most importantly, we’ve made massive progress in fighting a disease that as recently as 2000 killed nearly 870,000 people in a single year.

This progress is one of the most remarkable global health stories in recent years. Malaria claimed more than 429,000 lives last year, mostly in Africa and Southeast Asia. While that figure is still way too high, it represents a 50 percent reduction overall from the disease’s peak in the early 2000s. I don’t throw the word “miracle” around lightly, but that number is nothing short of miraculous.

How did we get here? I give credit to an unprecedented scale-up in global commitment and cooperation—malaria funding rose by 1,000 percent from 2000 to 2015. This money fueled a number of amazing scientific breakthroughs, enabled us to deliver them at scale, and focused more brainpower on improving both control and treatment efforts.

This October marks a decade since Melinda and I first called for eradicating malaria. It was a controversial move at the time, but the progress made since then has convinced many that this is a realistic goal (although some are still skeptical).

If I had known back in 2007 how much progress we would make in ten years, I would’ve been thrilled by how much we’ve cut the death rate. I’d also be impressed by how many insecticidal bed nets are now in use, how new treatments are helping people with the most severe cases of malaria, and how rapid diagnostic tests have made it easier to find and treat people. But it wouldn’t all be good news.

In 2007, I thought we’d have a long-lasting malaria vaccine by now. The WHO plans to begin pilot demonstration projects of a first-generation malaria vaccine in sub-Saharan Africa next year, although without a booster dose it only protects a child for less than six months. I’m hopeful that researchers will develop a next generation vaccine that offers much longer protection within the next 10 years, but a decade ago I was overly optimistic about where we’d be today.

There are still plenty of reasons to believe we can eradicate malaria, though. In the war against malaria and the mosquitoes who carry it, we’re already fighting on every front. Consider the wide array of innovations in development right now:

• New Insecticide-Treated Bed Nets: The older generation of bed nets needed to be soaked in a special insecticide solution every six months. The long-lasting nets we will distribute in Mozambique through our giveaway protect people from mosquitoes for three years and can even be washed when they get dirty. Unfortunately, some mosquitoes are now developing resistance to the pyrethroid insecticides used in these nets—so researchers are working on next generation bed nets that use combinations of insecticides and appear effective against all mosquitoes, including insecticide-resistant ones.
• Tackling Drug Resistance: In Southeast Asia, we’ve seen some types of the malaria parasite develop resistance to the drug combinations we use to cure and prevent the disease. If this drug resistance spread to Africa, it’d be a disaster. Fortunately, we have partners on the front lines finding ways to fight back. Watch this video about the amazing work one team of researchers is doing to combat drug resistance in Thailand:

• Disease Mapping: We know more today about where malaria is occurring than we have at any other point in history. Public health experts are combining anonymous data from mobile phone records with data on malaria incidence to track the movements of infected mosquitoes. That's super valuable, because it helps countries use their limited resources in places that have the highest disease burden.
• Eave Tubes: Many houses in hot climates have a gap between the roof and the walls to keep the inside cool. By sealing these gaps and inserting special tubes just below the roofline, air still flows into the house but keeps mosquitoes out with a mesh filter. Since the tubes are too high for children to reach them, the mesh can be coated with a high enough dose of insecticide to kill even insecticide-resistant mosquitoes.
• Genome Editing: Our foundation has invested a lot of money into editing the genetic code of mosquitoes. We’re still in the very early stages of development, but scientists are exploring whether this technique could one day render a small number of key mosquito species infertile or unable to carry the malaria parasite.
• Attractive Targeted Sugar Baits: Only female mosquitoes bite people, and they only do it when they’re breeding. The rest of the time, they rely on sugar for energy. These calendar-sized traps hang on the outside of homes and contain a minimum risk toxin that kills more than 95 percent of the mosquitoes that flock to their sweet scent without affecting pollinators. Trials are underway in Mali.

I think we will see an end to malaria in my lifetime. It’s a preventable and curable disease, and the public health community has already demonstrated that it’s possible to shrink the map and save lives. These new tools in the development pipeline will play a huge role in reaching our goal.  While we’re still decades away from wiping malaria off the map for good, one thing is clear: the mosquito has met its match.

I’ve been to lots of labs, but until recently I had never seen one that was centered on a full working kitchen. Last month I got my chance when I visited the Bread Lab, located a couple hours north of my hometown Seattle. It brings together local farmers, expert plant breeders, and world-class bakers with the goal of producing wheat for baked goods that are both delicious and good for you.

I could smell the baking bread the minute I walked in the door. Canisters of flour from different types of wheat lined the walls. Bakers were pulling warm rolls out of large commercial ovens. In the corner there was a farinograph, a machine that measures the strength of dough.

It was all very impressive. But deep down, I was a little skeptical: How would the breads actually taste? The Bread Lab emphasizes using whole grains, and not just wheat—lab director Steve Jones loves buckwheat because it’s unusually high in lysine and other nutrients. Although eating whole-grain bread might make me feel virtuous, in my experience it just never seems to taste as good as white bread.

But I got to sample lots of their baked goods, and I’m happy to report that everything I ate was delicious—even the croissants, which are especially hard to get right when you’re using whole grains.

The lab is part of Washington State University, and although most of their work is with rich-world companies including Clif Bar, La Brea Bakery, and Chipotle, they are also applying their expertise to the problem of malnutrition in poorer countries. For example, I met a Pakistani Ph.D. student, Farah Ahmad, who’s looking at ways to make chapatis, cookies, and other foods from her home country using approaches developed by the Bread Lab.

Here’s a video from my visit:

Beyond breeding, Wylarah Station uses technology to ensure that their herds receive proper nutrition. I was surprised to see their ranch hands use smart watches to track how much the cows are drinking.

In the past someone had to manually inspect all of the water troughs scattered across the ranch, driving hundreds of kilometers every day. Now they receive a notification on their watch when a sensor detects that a tank needs attention. The whole operation was a far cry from the John Wayne cowboy movies I used to watch as a kid.

Not all of AACo’s innovative approaches could work in the poor world. It’s unlikely that every farmer in Africa will be wearing a smart watch anytime soon (if ever). But as smartphone usage continues to grow across the continent, it’s easy to imagine a future where Africans might use an app to order the perfect bull DNA or make sure their cattle are eating enough—something that an African ICT company called iCow is promoting in Kenya, Ethiopia, and Tanzania with help from our foundation.

Farmers across sub-Saharan Africa are already raising cattle—beef and dairy—in massive numbers. Ethiopia, Sudan, and Tanzania are among the world’s top 15 cattle producing countries. While there are legitimate questions about whether the world can meet its appetite for animal products without destroying the environment, it’s a fact that many poor people rely on cattle for both nutrition and income. I believe they should be able to raise cattle as efficiently as farmers in rich countries do.

I’m optimistic that technology can improve the quality of African cattle. A typical dairy cow in the United States produces nearly 30 liters of milk every day. Compare that to your average cow in Ethiopia, which produces just 1.69 liters of milk a day. If you want to increase milk yield, you can’t just take a high-producing Holstein cow from Wisconsin and drop it into the tropical savannah. Unlike indigenous breeds, temperate cattle have no natural resistance to tropical diseases—like trypanosomiasis, or sleeping sickness—and they struggle to get enough nutrition from local food sources.

Instead, you could breed cattle that will flourish in the local climate. That means using artificial insemination—like the process they use at Wylarah Station—to crossbreed a native female cow (with her built-in resilience to tropical heat and diseases) with a bull from a genetic line that produces lots of milk.

Our foundation is already tackling this, but AACo’s technology could make the process much more precise than it is today. One of the things that amazed me most during my visit was how much they know about the ancestry of their cattle. The animals on their ranch have a more detailed family history than most people do. If farmers in Africa were equipped with the same level of knowledge, they could handpick the best possible cow parents and breed a better calf. But that leads us to another problem.

Because they lack adequate storage, most African farmers rely on artificial insemination stations (yes, that’s what they’re really called) to provide sperm samples. Depending on how far a farmer lives from a station, the sample can sometimes heat up too much and effectively die before it is delivered. Many farmers decide not to take the risk. Instead they get their cows pregnant the old-fashioned way, which makes it harder to control genetic integrity and can lead to calves that are less resilient or produce less milk.  

AACo is looking into methods that extend the viability of sperm samples. Similar technology is currently used in Europe to improve the success rate of fertilization, but it hasn’t been tried yet with tropical cattle. If successful, it could double the amount of time a sample can survive outside of storage and make it easier for more farmers across Africa to use artificial insemination.  

Beyond breeding, Wylarah Station uses technology to ensure that their herds receive proper nutrition. I was surprised to see their ranch hands use smart watches to track how much the cows are drinking.

In the past someone had to manually inspect all of the water troughs scattered across the ranch, driving hundreds of kilometers every day. Now they receive a notification on their watch when a sensor detects that a tank needs attention. The whole operation was a far cry from the John Wayne cowboy movies I used to watch as a kid.

Not all of AACo’s innovative approaches could work in the poor world. It’s unlikely that every farmer in Africa will be wearing a smart watch anytime soon (if ever). But as smartphone usage continues to grow across the continent, it’s easy to imagine a future where Africans might use an app to order the perfect bull DNA or make sure their cattle are eating enough—something that an African ICT company called iCow is promoting in Kenya, Ethiopia, and Tanzania with help from our foundation.

There’s a lot we can learn from Wylarah Ranch about how to more efficiently raise cattle, but I can’t ignore the big question: should we rely on animals for food at all? Eating too much meat contributes to higher levels of obesity and heart disease, and raising animals contributes to climate change. That’s why I’ve invested in companies working on meat substitutes, which could one day eliminate the need to raise and slaughters animals entirely.

Although it might be possible to get people in richer countries to eat less, we can’t expect people in low income countries to follow suit. When I went vegetarian for a year in my late 20s, all I had to do to get my daily serving of protein was buy a can of beans or a container of tofu at the grocery store. It’s not so easy for families in poor communities to get the nutrition they need.

For them, meat and dairy are a great source of high-quality proteins that help children fully develop mentally and physically. Just 20 grams of animal protein a day can combat malnutrition, which is why our foundation’s nutrition strategy wants to get more meat, dairy, and eggs into the diets of children in Africa. Cattle are also a huge economic driver in some parts of Africa. In Ethiopia alone, cattle account for 45 percent of their agricultural GDP. In addition, livestock can actually contribute to ecosystems by stimulating pasture growth, enhancing biodiversity, and recycling energy and nutrients.

As more people in poor countries move into the middle class, they will likely eat more beef and drink more milk. But we can mitigate the impact of that growth on the environment by increasing production from the cows they already have. The cowboys of Wylarah Ranch have mastered the art of raising tropical cattle. I don’t know yet how African farmers can benefit from their expertise—our foundation is just starting to dig into this—but I’m excited about the possibilities.  

Of all the charts I’ve seen, this one is the most beautiful:

Why?

First, that descending red line captures one of the most amazing stories of human progress: It shows how the number of deaths of children under 5 per year has been cut in half since 1990.

Second, hidden along that line are millions of stories of the incredible work being done by health officials, governments, donors, and parents around the world to help save all those lives.

Here’s one of those stories. It begins with some remarkable women I met in Ethiopia. They are part of an innovative program that’s improved the health of millions of children in their country.

You can meet them yourself (and join us for a cup of coffee) in this video.

Back in 1990, Ethiopia had one of the highest rates of child mortality in the world. One in five children were dying before their 5^th birthdays. With few doctors and most of its population living in rural areas, Ethiopia struggled to provide basic health services to the country. Most women in rural areas gave birth at home.

Then in 2000, the Ethiopian government made a commitment to improve its healthcare system. Ethiopia signed on to the United Nations’ Millennium Development Goals, which focused the world’s attention on fighting disease and ending poverty by using data to measure progress on health and development progress. As part of the goals, Ethiopia pledged to reduce under-five death rates by at least two-thirds by 2015.

To achieve it, Ethiopia needed to find an effective way to deliver healthcare to the remotest corners of the country. But training thousands of new doctors to staff them would take years and would be extremely costly. Instead, Ethiopia created a community health worker program. They selected thousands of people, primarily young women with at least a 10^th grade education, and trained them in a set of basic health skills—including how to deliver babies, administer immunizations, and provide family planning support—that are proven to save lives. Most of the health workers were recruited from the communities they served, helping to quickly build public trust in the new effort.

In 2012, I made my first trip to Ethiopia to see the program in action for myself. I was amazed. I visited a remote health post south of Addis Ababa run by two health workers, Yetagesu Alemu and Betula Shemesie. They spent many of their days walking from door to door in their village caring for pregnant women and families with newborns. Their health post didn’t have electricity or any high tech medical equipment. Still, their efforts had made an impact on the health of the families in their community.

What was exciting to see was how this success was being repeated in villages across the country. Despite being one of the poorest countries in the world, Ethiopia managed to dramatically reduce the rate of child mortality.  By 2012, Ethiopia had met the target for the Millennium Development Goal on child survival, with under-five death rates dropping by 66 percent since 1990.

One of the key reasons the program has been so effective is that the health workers are dedicated to measuring their progress. Covering nearly every square inch of the walls of the health post I visited were large charts, where the health workers would track births, immunizations, malaria cases, and other indicators. Each indicator helped them understand how well they were performing and which areas demanded more attention.

Today, Ethiopia has more than 15,000 health posts delivering primary health care to the farthest reaches of this rural country of 100 million people. The health posts are staffed by 38,000 health workers like Betula and Yetagesu.

Last summer, I had a chance to visit Ethiopia again. I caught up with Yetagesu and Betula over coffee and to learn more about how the health worker program was going. They told me how women who once delivered their babies at home were now choosing to give birth at health centers. Their communities also had access to ambulances that would pick up any woman who is ready to give birth. Yetagesu and Betula were also proud to report that they had received additional medical training to sharpen their health skills.

To be sure, there’s a lot more work to be done to improve health services in rural Ethiopia. Their communities need more ambulances. Just one vehicle serves 17 health posts, Yetagesu said. They also hoped the country would hire more health workers so they would have the time to provide families with more comprehensive services. And as Melinda and I discussed in this year’s annual letter, one of the biggest challenge in child survival is newborn deaths. In Ethiopia, about 44 percent of all childhood deaths occur within the first 28 days of life. We need to find innovative ways to solve this challenge.

Still, I’m confident that Ethiopia will continue to make progress in child survival. And what’s most exciting is that Ethiopia’s health program has been so successful that it now serves as a model for other countries to follow. Sharing lifesaving innovations like Ethiopia’s ensures that in the years ahead the most beautiful chart in the world will become even more beautiful. 

At a time when world leaders are understandably focused on terrorism and other security threats, another enemy is being largely overlooked—the next epidemic.

We don’t know when the next pathogen will emerge, what it will be, how it will spread, or who will be affected, but we do know that the world is not prepared to deal with it. That was the tough lesson that Ebola (and the Zika outbreak since) taught us. Ebola claimed thousands of lives, caused billions of dollars in economic losses, and showed how vulnerable our society is to epidemics of infectious diseases. As I’ve written about before, the world lacks an effective system to detect, respond to, or prevent the next outbreak.

That’s why I’m excited this week, at the World Economic Forum in Davos, to participate in the launch of a new organization that will help the world get ready for future epidemics. Backed by the governments of Norway, India, Japan, and Germany, along with the Wellcome Trust and our foundation, the Coalition for Epidemic Preparedness Innovations (CEPI) will invest in innovations to accelerate the development of vaccines we’ll need to contain outbreaks.

CEPI’s focus on vaccine development is a critical part of getting prepared for whatever pathogens threaten us next. We know from the world’s defeat of smallpox and its successful fights against polio, measles, and other diseases that vaccines are incredibly effective tools for preventing disease and saving lives. Now, this alliance of governments, philanthropies, vaccine manufacturers, academia, NGOs, and other partners needs to work together to develop new vaccines to make the world safe from future epidemics. 

Traditional approaches to making new vaccines are too slow to respond to a sudden disease outbreak. Currently, the development of a new vaccine, including testing and deployment, is a process that can typically take more than 10 years. Fast-moving epidemics don’t allow us to be that patient. In 1918, an extremely infectious and deadly strain of the flu infected about one-fifth of the world’s population and killed at least 30 million people in less than two years. Ebola and Zika were also both frightening viruses, but the way they are transmitted—through bodily fluids and mosquitoes—helped limit their spread globally. A highly-contagious airborne disease would pose a far greater threat. It would thrive in densely populated urban areas and could easily cross national borders and oceans by air travel.

My great hope for CEPI is that it will help enable the world to produce safe, effective vaccines as quickly as a new threat like this emerges. With $460 million in initial funding, CEPI will work to bring together the most advanced vaccine technologies and resources from the private and public sector that can help lead to new breakthroughs in vaccine development. CEPI’s vaccine development strategy includes two areas of focus: “just in time” vaccines for those currently unknown pathogens that will emerge, and “just in case” vaccines for pathogens that we know are at high risk of causing another outbreak, like Ebola and Middle East respiratory syndrome or MERS.

One promising area of vaccine development research is using advances in genomics to map the DNA and RNA of pathogens and make vaccines. The vaccines can be decoded by human cells to make their own vaccines and antibodies inside the body. If successful, this technology could dramatically reduce the development timeline from years to possibly months or weeks.

What’s exciting about these new technologies is that they wouldn’t just protect us from future epidemics. They also would help us to develop vaccines for existing health threats to hundreds of millions of people around the world, including HIV, malaria, and TB.

At the same time, CEPI will work to minimize regulatory hurdles that further delay the deployment of vaccines. CEPI will fund studies to evaluate these newly-developed vaccines and build vaccine stockpiles before epidemics begin, so countries can move swiftly to full vaccine efficacy trials and emergency deployment during an outbreak.

As pleased as I am to see CEPI’s work get underway, it’s important for everyone to understand that this effort is just the first step toward getting us prepared for the next epidemic. It’s an important step, but CEPI alone won’t be enough to protect us. We have a lot more work to do.

We need a global warning and response system for outbreaks. It begins with strengthening local health systems in poor countries, which have gotten hit the hardest during recent epidemics. The thousands of remote health clinics around the world will be the backbone of our global effort to defeat future epidemics. They must have trained health workers who can provide primary health care, deliver vaccines, and monitor the health of their communities.

We must have a better disease surveillance system, which includes a global database so countries can share information on cases. We also need trained medical personnel ready to mount a rapid response to an outbreak.

Last, we need to continue to invest in health research to develop not just vaccines, but also new drugs and diagnostic tests that will strengthen our ability to respond quickly and effectively to the next epidemic.

Still, we’ll never know exactly when a new disease outbreak will emerge. It could arrive tomorrow, next month, next decade, or next century. But that uncertainty shouldn’t be an excuse for inaction. I hope that today’s announcement marks the first of many steps the world will take to get prepared for the next epidemic. All of our futures depend on it.

I visited South Africa earlier this year to learn more about the progress the country is making in the fight against HIV. I toured health clinics, met with doctors and researchers, and listened to the stories of people living with HIV. Again and again, our conversations turned to an often forgotten disease which is HIV’s lethal partner: tuberculosis.

Tuberculosis, or TB, is an infection of the lungs that kills about 1.8 million every year, including 400,000 people with HIV and TB. Historically, TB was dubbed “consumption” because it caused such severe weight loss that the disease appeared to “consume” its patients.

Together, HIV and TB form a deadly duo. HIV weakens the immune system, which makes it susceptible to TB infection and much harder for the body to fight the disease. Last year, about one-third of people living with HIV were also infected with TB bacteria, and about 35 percent of deaths among HIV-positive people were due to TB. Worldwide, South Africa has the largest number of people infected with TB and HIV.

Since 2000, better testing and treatment programs have helped drive down TB deaths by more than 20 percent, saving tens of millions of lives. But a new World Health Organization report found that the TB epidemic is larger than previously estimated. New surveillance and survey data revealed hundreds of thousands of new cases, the bulk of them in India. In 2015, there were an estimated 10.4 million new TB cases worldwide, up from 9.6 million cases in 2014. The WHO report also found that of the 10.4 million people with TB, 4.3 million of them did not receive quality care because of significant gaps in testing, treatment, and reporting of TB by health providers. TB deaths climbed to 1.8 million, up from 1.6 million in 2014.

One of the key concerns among health officials fighting TB is the rising threat of drug resistance, something I learned about during a previous visit to South Africa. New strains of the disease have emerged that do not respond to the most commonly used drug treatments available. Treating people with drug-resistant TB is complicated and costly. It also places incredible hardships on the patients who must undergo months of treatment using drugs which are toxic and have serious side-effects.

Last year, Simbongile, a young mother living outside of Cape Town, learned she was infected with drug-resistant TB and started the difficult road to recovery. Her story is heartbreaking, but she is among the lucky ones. In 2015, nearly 600,00 people fell ill from drug resistant TB treatment worldwide. Just 1 in 5 received treatment.

While the impact of drug-resistant TB is a serious problem, the vast majority of TB cases are drug sensitive, meaning they can be cured effectively with medicines so long as they are taken properly. Drug resistance emerges because of incorrect prescriptions by health providers, low-quality drugs, and patients stopping treatment prematurely. That’s why the best way to prevent drug resistance is to improve TB testing and treatment programs for drug-sensitive cases.

TB, like so many other diseases, primarily impacts the world’s poorest people. If you live in a wealthy country, it might be easy to think, as many people do, that TB is a disease of the past. That fact is reflected in the lack of funding for TB programs around the world. In 2016, global support for TB care and prevention fell $2 billion short of the $8.3 billion needed.

Stories like Simbongile’s, however, are a powerful reminder that TB is still an active threat and the world is in dire need for new innovations to prevent and treat it. By investing more in research and development, I know it will be possible to create a new generation of TB drugs and develop a new and effective TB vaccine.

TB is not a disease of the past, but if the world works together to fight it, I have no doubt it can be.

A few years ago, I pulled off a purposeful prank. While I was giving a TED Talk on malaria to a room full of influential people, I opened a canister and let loose a small swarm of mosquitoes. “There’s no reason that only poor people should have the experience,” I said. I let the audience squirm in their seats for about half a minute before I let on that the mosquitoes were not infected with malaria. My gimmick worked. A distant problem suddenly got very close to home.

Today, gimmicks are no longer necessary for convincing Americans of the danger of mosquito-borne diseases. The spread of Zika virus in south Florida, Puerto Rico, and other parts of the U.S. has given millions of Americans a direct understanding what it’s like to live with the fear of mosquitoes and the harm they can do, especially to pregnant women and children.

The world must focus serious attention and resources on ending the Zika epidemic. At the same time, we should keep in mind that the overwhelming toll of mosquito-related illness and death comes from malaria. Malaria is the key reason mosquitoes are the deadliest animal in the world.

Over the years, I have been in hospitals in several African countries when malaria is at its peak. I’ve seen beds out in the corridors and two children to a bed. There’s nothing more painful to see than a child experiencing cerebral malaria, when the parasite is attacking the brain and causing horrible seizures. As a parent, these memories will stay with me for life.

That’s why it gives me great joy to share a new report published todayin The New England Journal of Medicine. Rigorous new data show that the malaria death rate in sub-Saharan Africa has declined by a stunning 57% since 2000. With almost 500,000 children still dying of malaria every year, we obviously have a long way to go. But cutting the death rate by more than half is a miracle. It’s one of the greatest success stories in the history of global health.

We’ve known for some time that malaria deaths have been declining steeply. The significance of this new study, which was produced by the Institute for Health Metrics and Evaluation, is that we now have the strongest evidence ever of just how steep the decline has been.

This progress on malaria is no accident. It’s the result of an unprecedented increase in focus and commitment by rich and poor countries alike. The amount of money available to pay for bed nets, effective medications, and malaria research rose by 1,000 percent from 2000 to 2015, fueling massive new prevention and control efforts in countries hit hard by malaria.

In Tanzania, a country that has led the way with a major scale-up, the mortality rate fell more than 80 percent from 2000 to 2015. I remember visiting Tanzania years ago during the rainy season and seeing overflowing hospitals. When I went back years later, there were almost no children in the wards.

Tanzanian health authorities have launched major campaigns to distribute insecticide-treated bed nets and encourage people—especially children—to sleep under them every night. They’ve done widespread spraying of insecticides inside homes and in urban ponds, puddles, and marshes where mosquitoes breed. And they’ve used great medications that contain a drug called artemisinin, which earned its discoverer, Youyou Tu, the 2015 Nobel Prize in Medicine. If you take three days’ worth of these pills, you can get rid of the malaria parasites in your bloodstream, which helps you and also stops you from being the source of malaria spreading back to other people.

And now we have an awesome new tool in our arsenal: precision malaria maps. In the same New England Journal article I mentioned above, the authors report on cutting-edge mapping efforts that have given us an ability to see at a very high degree of granularity (5 km by 5 km) the burden of malaria in sub-Saharan Africa. That’s super valuable for short-term interventions, like helping a country determine where to deploy health staff. It’s just as valuable for long-term efforts to reduce the rate of transmission and shrink the malaria map.

When you zoom in with these high-definition maps, you can quickly home in on the hot spots where malaria is hitting hard and yet existing tools like bed nets are not being used widely enough. These maps show that in most countries it’s actually a very small percentage of the country where the disease burden is high and you need to focus your interventions.

And here’s more good news: After years of investment, we now have better diagnostics for detecting infections in people who show no physical symptoms (because people who are infected with malaria parasites but don’t show signs of illness are a big part of the chain of transmission). We have helped private-sector companies develop new, safe insecticides that will allow us to preserve the gains we have made against malaria. We have also helped bring to market simple technologies to protect families from mosquitoes, such as “eave tubes” that kill mosquitoes trying to enter homes and new traps which exploit mosquitoes’ attraction to sugar to kill them outdoors.

As a result of all this progress, I am confident that we can pursue the end goal of not just shrinking the malaria map but wiping malaria off the map altogether. Last year, Ray Chambers, the UN Secretary General’s special envoy for malaria, and I put forward a concrete plan for eradicating the disease by 2040. The potential upside is enormous: 11 million lives and $2 trillion dollars of economic impact. And the alternative to eradication—controlling the disease forever without eliminating it—is biologically and politically untenable. It would require endless investment in the development of new drugs and insecticides just to stay one step ahead of disease resistance. I also believe it would be impossible to maintain strong political commitment to fighting malaria unless we can define a clear end point. History has shown that unless countries rid themselves of malaria altogether, they eventually see the disease come roaring back on a massive scale.

To achieve eradication by 2040, we’ll need several other key innovations under development to come to fruition.

First, we’ll need new classes of drugs that completely clear malaria parasites from the body with just one dose. We should have these new cures in about a decade.

Second, we need new tools that can prevent malaria transmission. This can either be done with an effective malaria vaccine or by reducing mosquito populations. We will soon have a first-generation vaccine, but it protects a child for less than six months without a booster dose. I’m betting that within the next 10 years, researchers can produce a vaccine that provides much longer protection.

We have another potential game-changer in the works. Our foundation is supporting scientists who are using a powerful new tool called “genome editing” to introduce genetic changes in the Anopheles gambiae species of mosquito, one of the most effective transmitters of malaria in Africa. These genetic edits cause females to produce mostly male, sterile offspring. In theory, scientists could drive this trait throughout entire populations of mosquitoes in much of Africa, dramatically reducing malaria transmission in a very short time. While I’m excited about the potential of this technology, I know that changing the mosquito genome in a permanent way is something that should be done only with incredible caution and care. My hope is that it will be possible to deploy some version of this technique in a safe manner within 10-12 years.

In 1999, Melinda and I made our first major investment in malaria—a grant to establish the Malaria Vaccine Initiative. Funding for malaria research was so diminished at the time that we nearly doubled the resources with that one single grant. That blew my mind.

Today, this is no longer a lonely fight. More than 50 countries have joined together to mobilize billions of dollars through The Global Fund. And these resources are coming not just from wealthy countries. African countries such as Benin, Côte d’Ivoire, Kenya, Namibia, Nigeria, Senegal, South Africa, Togo, and Zimbabwe are contributing as well. In fact, African countries are now, for the first time ever, mobilizing more of their own resources for malaria than they’re receiving from donors.

So the next time you hear skeptics charging that foreign aid doesn’t work, point to malaria. Foreign assistance has not chased away local resources. On the contrary, it’s encouraged African nations to step up their own health efforts. And the results have been nothing short of remarkable.

If you could shuffle all of the homes in the world like a deck of cards so that people in wealthy countries lived side by side with people from poor countries, it would transform the world’s fight against poverty, hunger, and disease. It would be impossible for people to look away, impossible for them not to help.

I was naïve about the deep poverty in the world until I took my first trip to Africa with Melinda in 1993. Seeing the disparities with our own eyes made all the difference and inspired us to start our foundation.

Since then, I’ve continued to travel regularly to Africa, India, and other parts of the developing world. I always return from my trips humbled and inspired. My one disappointment is that I wish everyone could have seen what I did. I have no doubt it would help more people become aware of the challenges the world’s poorest people face. It would also leave them as optimistic as I am about the incredible progress the world is making in health and development.

During my trip to South Africa in July, I tried something new that I hope will allow people to experience what I have. I had highlights of my visit recorded in virtual reality. It’s still an emerging technology but what excites me about it is that it allows viewers to immerse themselves in another world. You can look up and down. Turn right or left. Listen to sounds all around you. I used to think there was no substitute to being there and seeing things for yourself. But virtual reality is a close second. It fulfills my dream of allowing people to see what I’m seeing and, perhaps, feel what I’m feeling, too.

In this video, you will hear the stories of young women living with HIV. Sit beside me as I drive from the leafy suburbs of Johannesburg to the dusty township of Soweto. Feel what it’s like to be in the center of a stomping gumboot dancing troupe. And be inspired by the power of South Africa’s youth, who will drive the next generation of innovations to create a future free of AIDS.

If you want to know more about my trip to South Africa, you can read about my visit here and here. I also encourage you to learn more about The Global Fund, which has helped provide lifesaving treatment to millions of people living with HIV.

Thanks for watching and look out for more virtual reality videos in the months ahead.

Next week I’ll be traveling to Durban, South Africa, to attend the International AIDS Conference. It’s an important opportunity for members of the AIDS community to discuss our ongoing efforts to fight the disease. I’ll be there to listen and learn. But I’ll also be delivering my own message.

The good news is that the fight against AIDS has seen many successes. The infection rate declined for several years and millions of people have been put on treatment, allowing them to live full, productive lives.

But we have not turned the corner. The infection rate has essentially stopped declining. That’s a particular problem in sub-Saharan Africa, which has a growing population of young people, who are most susceptible to the disease. If the infection rate stays the same while the at-risk population rises, then the number of people in sub-Saharan Africa who contract HIV each year could start going up instead of down.

One reason the infection rate has stagnated is that AIDS funding has stagnated. Another reason is that the current prevention tools have not had as much impact as any of us had hoped. Voluntary medical male circumcision is a very effective prevention approach, but the programs offering the procedure have not been scaled up sufficiently to reach all those who would benefit. The newest tool, using AIDS treatment as a way to prevent HIV infection among healthy people, has not been rolled out fast enough, and asking people to take a pill every day for prevention presents its own challenges.

There is the idea of “treatment as prevention”: Treating people who have HIV not only saves their life, it also makes them much less likely to pass the virus along to others. This is a promising approach and certainly we should treat as many people as possible so we can save their lives. But it is not yet clear to me that it is financially feasible to treat enough people to get a large prevention effect. I hope to learn more about this question at the conference next week.

For all these reasons, we need to invest more in both delivering the best prevention tools we have and developing new ones that are even more effective. For example, researchers are working on prevention and treatment tools that last for several months after a single dose, which would make it easier for people to stick to the regimes. I am also optimistic that within a decade we will have an AIDS vaccine that provides an acceptable level of protection.

In this video, I explain what it will take to make the most of these opportunities and ensure that AIDS cases keep going down: