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.

A core principle underlying the Gates Foundation’s work is closing the innovation gap between rich countries and everyone else. People in poorer parts of the world shouldn’t have to wait decades for new technologies to reach them. That’s why we've worked for 25 years to accelerate access to life-saving medicines and vaccines in low- and middle-income countries.

It's also why, today, the Gates Foundation and OpenAI are announcing an initiative called Horizon 1000 to support several countries in Africa, starting in Rwanda, as they apply AI technology to improve their health care systems.

Over the next few years, we will collaborate with leaders in African countries as they pioneer the deployment of AI in health. Together, the Gates Foundation and OpenAI are committing $50 million in funding, technology, and technical support to back their work. The goal is to reach 1,000 primary healthcare clinics and their surrounding communities by 2028.

Today’s AI can help save lives

A few years ago, I wrote that the rise of artificial intelligence would mark a technological revolution as far-reaching for humanity as microprocessors, PCs, mobile phones, and the Internet. Everything I’ve seen since then confirms my view that we are on the cusp of a breathtaking global transformation.

All over the world, AI, in the form of LLMs and machine learning models, are improving far more quickly than I first anticipated. From science to education to customer service and more, AI tools are reshaping every facet of our lives.

I spend a lot of time thinking about how AI can help us address fundamental challenges like poverty, hunger, and disease. One issue that I keep coming back to is making great health care accessible to all—and that’s why we’re partnering with OpenAI and African leaders and innovators on Horizon 1000.

Not enough doctors in the house

We have seen amazing successes in global health over the past 25 years: child mortality has been cut in half, and there are now real pathways to eliminating or controlling deadly diseases like polio, malaria, TB, and HIV. But one stubborn problem that keeps slowing progress is the desperate shortage of health care workers in poorer parts of the world.

In Sub-Saharan Africa, which suffers from the world’s highest child mortality rate, there is a shortfall of nearly 6 million health care workers, a gap so large that even the most aggressive hiring and training efforts can’t close it in the foreseeable future.

These huge shortages put health care workers in these countries in an impossible situation. They’re forced to triage too many patients with too little administrative support, modern technology, and up-to-date clinical guidance. Partly as a result, the WHO estimates that low-quality care is a contributing factor in 6 to 8 million deaths in low- and middle-income countries every year, and that’s not even counting the millions who die because they aren’t able to access health care at all.

Rwanda leads the way

Today’s AI can help save those lives by reaching many more people with much higher-quality care.

Rwanda currently has only one health care worker per 1,000 people, far below the WHO recommendation of about four per 1,000. It would take 180 years for that gap to close at the current pace of progress. So, as part of the 4x4 reform initiative, Minister of Health Dr. Sabin Nsanzimana recently announced the launch of an AI-powered Health Intelligence Center in Kigali to help ensure limited health care resources are being used as wisely as possible.

As part of the Horizon 1000 initiative, we aim to accelerate the adoption of AI tools across primary care clinics, within communities, and in people’s homes. These AI tools will support health workers, not replace them.

On the horizon

Minister Nsanzimana has called AI the third major discovery to transform medicine, after vaccines and antibiotics, and I agree with his point of view. 

If you live in a wealthier country and have seen a doctor recently, you may have already seen how AI is making life easier for health care workers. Instead of taking notes constantly, they can now spend more time talking directly to you about your health, while AI transcribes and summarizes the visit. Afterwards, AI can handle much of the onerous paperwork, so doctors and nurses can focus on the next patient.

In poorer countries with enormous health worker shortages and lack of health systems infrastructure, AI can be a gamechanger in expanding access to quality care. I believe this partnership with OpenAI, governments, innovators, and health workers in sub-Saharan Africa is a step towards the type of AI we need more of: systems that help people all over the world to solve generational challenges that they simply didn’t know how to address before. I invite others working on AI to think about how we can put these massively powerful tools to the best use.

This announcement is a great example of why I remain optimistic about the improvements we can make. I’m looking forward to seeing health workers using some of these AI solutions in action when I visit Africa, and I plan to continue focusing on ways AI technology can help billions of people in low- and middle-income countries meet their most important needs.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Lina Finda’s work sounds simple. “My job is to listen,” she says. But the reality is much more complicated. On a typical day, she has to walk into a village in southern Tanzania or a meeting hall in Uganda and gauge reactions to the idea of ending malaria by an unusual method: releasing more mosquitoes.

It’s not as crazy as it seems.

That’s because the mosquitoes she’s talking about in this case carry a gene that blocks the malaria parasite from developing, so the mosquito can’t get you sick even if you get bitten. (I just wrote about the project researching these malaria-free mosquitoes, Transmission Zero, along with the other tools that are helping us fight this disease.) Release enough of them into the wild and, in theory, the trait spreads on its own until the local mosquitoes can no longer transmit the disease.

The science is advancing, and it’s exciting. But none of these malaria-free mosquitoes have been released in Africa yet. Whether that ever happens is a decision that will be made by African governments and the people who live where these mosquitoes would circulate. Finda co-founded the African Conversations Initiative to make sure those people have a say. Her team is now working in eight countries: Tanzania, Kenya, Uganda, Rwanda, Zambia, Ghana, Nigeria, and Senegal.

The question that started it

Finda first learned about the potential of malaria-free mosquitoes in 2017, at the beginning of her PhD in public health.

“My thought was, oh my God, we might eliminate this disease in my lifetime,” she says.

All the scientists in the room with Finda were equally impressed and excited. But she knew this kind of idea would never leave a lab if there wasn’t community trust and buy-in.

So she asked herself a question: “How might other people react to this?” She dedicated the rest of her career to understanding the answer.

Listening and learning

Her first attempts to explain malaria-free mosquitoes went poorly. The process that creates malaria-free mosquitoes is hard to describe, and Finda assumed that a farmer with no formal schooling would never get there. So she gave up on finding the right words and told the truth instead: She didn’t know how to talk about it. “I was honest with the community members and saying, I really don’t know what to call this or how to talk about it.”

The response surprised her.

One of those community members was Aloyce Kimario, a farmer who also teaches at a primary school outside Ifakara. He had never heard of malaria-free mosquitoes before Finda came to see him. He had, however, spent his whole life rearing animals.

The pigs he keeps are a local breed, hardy against the diseases that circulate around Ifakara. But they’re small. When he wants animals big enough to sell well, he crosses them with a heavier breed and hopes the piglets come out with the best traits of both sides. There’s a Swahili phrase for this, kubadilisha mbegu, which translates to “changing the seed.”

So, Finda started asking farmers to describe their ideal animal. One told her he wanted a pig that was 90 percent of the heavy breed and 10 percent of the local one.

“So what this technology does,” she told him, “is it makes sure that you get exactly what you want.”

Aloyce can now explain the science behind malaria-free mosquitoes, and the case for them, without any help from Finda, in terms other farmers immediately understand.

What she wishes scientists understood

Finda admits to underestimating what local farmers would be able to grasp, and she says she sees the science community making the same mistake. Worse, she says, “they assume that when someone opposes something it is because they don’t know it, and if they could know it, then they would definitely accept it.”

“From my years of listening to everyone, I have learned that these groups are quite knowledgeable,” she says. They may not use the scientific terminology, “but they understand it in their context.”

Finda’s team has now sat down with national malaria programs, regulators, scientists, civil society organizations, faith leaders, and youth groups from more than 25 African countries. Each group worries about something the others don’t, and all of the worries are valid.

“You don’t ever hear someone say, I want to develop a solution for this disease. Let me go talk to a priest,” Finda says.

But that’s exactly what Finda did. One of the leaders she convened was the presiding bishop of the Moravian Revival Church in Tanzania, who had learned about genetically modified organisms while studying theology in the UK but had never encountered the idea applied to mosquitoes. He prayed about it and came out in favor. According to Finda, many Muslim leaders she connected with reached a similar conclusion. They just had to be asked.

Making sense of the numbers

Still, Finda has encountered substantial opposition and even anger.

When she presented the latest national malaria mortality figures to a group of community leaders in Nigeria, they took the statistics as an accusation and nearly threw her out. “You are saying that many people have died of malaria in Nigeria. Show us where they are buried,” they demanded. “Why aren’t our hospitals flooded with malaria patients?”

Finda learned a lesson from this that I’ve had to learn and relearn myself: It’s not the scale of lives lost or saved that captures people’s attention. It’s the individual stories.

“The mothers want to talk about the children they lost,” Finda says. “Those numbers do not mean anything at all.”

So now, when she meets with people, she starts by asking about their own experiences. Aloyce, the teacher-farmer, told her he gets malaria roughly twice a year. So do his children, with some episodes landing them in the hospital. The bishop told her his firstborn child died of it.

Finda herself got malaria around the age of six. Her mother was traveling, so it fell to Finda to administer chloroquine, the recommended treatment at the time, to herself and her toddler brother twice a day for seven days, while both of them were vomiting. She shares this experience, too.

The preparation is worth it

Finda thinks we are still at least a decade away from any government decisions to release malaria-free mosquitoes. In the meantime, African-led research will continue to advance scientific understanding that can inform these decisions and those required to strengthen regulatory systems to govern them. Everything she does is working up to that moment, and aimed at making it as anticlimactic as possible.

“When it is released in the newspapers or the radio or TV,” she says, “that should not be the first time that people hear about this technology.”

For many people, because of Finda’s work, it won’t be.

A genetic cheat code

Moving ahead responsibly

 

I spend a lot of time thinking and worrying about malaria. After all, it’s one of the big focuses of my work at the Gates Foundation. But for most Americans, the disease is a distant concern—something that happens “there,” not here.

That’s true today. It wasn’t always.

It was especially rampant in the South, from the Carolinas and the Mississippi Delta down to Florida and all along the Gulf Coast.

Every summer, people braced for the start of “fever season.” In her Little House on the Prairie books, Laura Ingalls Wilder wrote about what she called “fever ‘n’ ague.” A laundry list of presidents—including George Washington, Andrew Jackson, Abraham Lincoln, and Ulysses S. Grant—battled the disease.

During the Civil War, Confederate General Robert E. Lee was even counting on malaria to weaken Union troops, confident that “the climate in June will force the enemy to retire.” (It ended up crippling his own army more.)

Without modern medicine, or any understanding of how the disease spread, people reached for whatever remedies they could find: drinking vinegar and whiskey, rubbing onions on their skin, and boiling bitter herbs into tea. Powdered quinine, a substance derived from cinchona bark, actually worked—but it was expensive and hard to obtain, so few people had access to it.

For most people, the fevers kept returning year 
after year and summer after summer.

The first breakthrough came at the turn of the 20th century. Scientists finally proved that malaria was transmitted by mosquitoes—not, as had been previously thought, by contaminated water or poor air quality. (Malaria means “bad air” in medieval Italian.) It was a crucial discovery. Finally, people knew what to target. Across the South, some communities began draining swamps to try to control their mosquito populations. But most of these efforts were basic and improvised. What was needed was the kind of massive, coordinated, well-funded approach that only the federal government could mount. Enter one of the most ambitious and impactful infrastructure projects in American history: the Tennessee Valley Authority.

Enter one of the most ambitious and impactful infrastructure projects in American history


the Tennessee Valley Authority.

The TVA wasn’t created to fight malaria. Launched in 1933 as part of the New Deal, its mission was mainly economic: to bring electricity and jobs to the rural South, where some of the country’s poorest people lived, during the Great Depression. But the region also had some of the nation’s highest malaria rates, with 30 percent of its population infected. TVA leaders quickly realized their work wouldn’t succeed unless public health improved too.

So they incorporated malaria prevention into their projects. As engineers built dams and power plants across the region, they also drained thousands of acres of swamps, reshaped rivers, regraded land, and upgraded housing—which all helped to destroy mosquito breeding grounds. At the same time, public health campaigns educated people on installing window screens and eliminating standing water around their homes after storms. Then came World War II.

Then Came


world war II

As military bases popped up across the South, malaria became a growing threat to soldiers and defense industry workers. So the U.S. responded by launching a new program in 1942: the Office of Malaria Control in War Areas, headquartered in Atlanta. It was the federal government’s first centralized program created explicitly to fight malaria—and it laid the groundwork for what would become the Centers for Disease Control and Prevention, or CDC, which officially took over the malaria effort in 1947.

The goal of the campaign, which began with wartime control before transitioning to peacetime eradication, was simple but ambitious: Stop mosquitoes from spreading malaria, and stop people from carrying it.

ON THE MOSQUITO FRONT

The campaign launched the largest insecticide operation in U.S. history and paired it with an aggressive effort to destroy mosquito breeding grounds. Teams of sprayers went door-to-door with tanks of DDT strapped to their backs, covering millions of homes in what was essentially a chemical shield against mosquitoes. In some areas, airplanes dusted entire counties with insecticide. Meanwhile, construction crews drained ditches by hand or with bulldozers. In Florida, they used dynamite to blast open drainage paths from mosquito-infested marshland.

ON THE HUMAN SIDE

Quinine and later chloroquine—its synthetic successor—were distributed widely, especially in rural areas with high infection rates. These drugs cleared the parasite from the bloodstream, which meant that even if someone was bitten by a mosquito, they wouldn’t pass the disease on. Mobile teams traveled from town to town, testing and treating entire communities. In the Mississippi Delta, they even set up roadside treatment stations where people could stop for a dose on the way to work or school.

Public health messaging played a huge role, too. One memorable cartoon featured a mosquito named Bloodthirsty Ann—yes, short for Anopheles—that taught troops how to reduce their risk of contracting malaria. Its creator was a young army captain named Theodor Geisel, who eventually became better known as Dr. Seuss.

Perhaps the most impressive part of the program was its scale and speed. In just a few years, tens of thousands of public health workers across fifteen states were hired and trained. Doctors, nurses, scientists, teachers, technicians, and trusted community figures knocked on doors, gathered data, treated patients, and made sure no outbreak went unchecked. In 1951, America declared victory over malaria.

In 1951


AMERICA DECLARED VICTORY OVER MALARIA

I think about this history a lot when I’m visiting Sub-Saharan Africa, where the parasite still kills 600,000 people a year. Because in many ways, the strategy hasn’t changed: Stop transmission, clear infections, and build public health systems that prevent malaria from roaring back.

Malarious area of the United States 

But the U.S. had some key advantages that made elimination much easier. Compared to the species responsible for most malaria today, our mosquitoes weren’t as efficient at transmitting the parasite. Our climate also limited transmission to the summer months; in tropical regions, people get infected year-round. And by the 1940s, our country had relatively strong infrastructure, even in rural areas, that many malaria-endemic countries today still lack.

ON THE TREATMENT SIDE

So the challenge today is much bigger. Fortunately, today’s malaria-fighting toolbox is much bigger—and better—too.

Instead of blanket spraying DDT, which has since been banned, modern prevention relies on safer insecticide-treated bed nets and indoor spraying techniques that use smaller doses of more targeted chemicals. Sugar baits, which lure mosquitoes to ingest a lethal dose of insecticide, are already helping reduce their numbers. And gene drive technology could soon block the parasite inside the mosquito itself—so even if someone gets bitten, they won’t get infected.

Chloroquine has been replaced by artemisinin-based combination therapies, or ACTs, which are more effective and less prone to resistance. New drugs like tafenoquine are helping eliminate recurring strains. Seasonal chemoprevention protects children during peak transmission months. And the first malaria vaccine has been approved, with more on the way.

Malaria elimination is never easy. But unlike a century ago, it’s no longer a mystery. The world knows how to stop this disease. We’ve done it before. And with the right investments and innovations, we can do it again—this time, for everyone.

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

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

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

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

Sometimes when I tell people I’m optimistic about the future, they look at me like I’m crazy. How could I say that when there’s so much violence in the world, the international order seems to be collapsing, and AI may end up doing more harm than good?

I see all these problems too, and I’m deeply concerned about them. (I am working on a long memo about the risks and benefits of AI that I plan to publish later this month.)

But through my work with the Gates Foundation and other organizations, I also get to see signs of progress that help me stay optimistic.

To me, being hopeful about the future doesn’t mean you ignore the bad news. It’s actually the opposite: You look directly at it and then search for people who are doing something about it. In most cases, you’ll find them. And then you will start to see the broader trend of progress they are contributing to.

Here are some of my favorite signs of progress.

IN THE PAST:

• We’ve cut the number of children who die every year by more than half, from more than 9 million in 2000 to fewer than 5 million now.
• For the first time, we have a blood test for Alzheimer’s and drugs that may slow its progress.
• Electric vehicles now make up about one in four new cars sold worldwide, with sales topping 20 million in 2025.
• There are 1.5 billion fewer people living in extreme poverty today than in 1990, even though the population has risen 50 percent since then.
• Nearly 95 million girls have been fully immunized with HPV vaccine, so they’re much less likely to develop cervical cancer later in life.
• More than 86 percent of the world’s adults can read and write, up from about 68 percent in 1979.

IN THE PIPELINE:

• The newest obesity drug in trials produces nearly 30 percent weight loss, almost as good as what surgery achieves. The same class of drugs is expanding fast into related conditions, including sleep apnea, fatty liver disease, and hopefully, osteoarthritis.
• Scientists are developing a single-shot cure for sickle cell disorders, which kill tens of thousands of people every year, and it could be available within five years. The underlying technology is also being used to develop a single-shot HIV cure.
• We’re close to eradicating polio, which is endemic in only two countries. We’re nearly done with Guinea worm disease as well, cutting it from 3.5 million cases in 1986 to just ten last year.
• The mRNA technology behind some COVID vaccines is now being used for cancer vaccines, with nearly 100 in clinical trials for melanoma, lung, pancreatic, and other cancers.
• A new tuberculosis vaccine is in final-stage trials. If it works, it will be the first new TB vaccine in more than a century and could prevent tens of millions of cases over the next 25 years.

I love telling these stories. Here’s a video where you can see the amazing impact of the Green Revolution.

I find that trying to keep a positive attitude is valuable in itself. It keeps me grounded so I don’t swing toward one political extreme or another. I think the world might be less polarized if more people had a sense of the positive things that are going on in addition to the problems we need to solve.

You can find more videos here about progress. If you see one that strikes a chord for you, I’d encourage you to share it.

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

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

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

These were some of the highlights from the week:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The first challenge was knowing exactly what was killing children.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

m-mama is making sure those minutes count.

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

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

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

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

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

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

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

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

1.

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

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

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

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

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

2.

Will the world prioritize scaling innovations that improve equality?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Followed by chills, fever, and nausea.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We should be too.

The world is so close to ending polio.

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

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

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

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

Her name is Shumaila Rehmani.

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

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

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

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

But Shumaila doesn’t give up.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I wish that were true. But it is not.

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

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

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

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

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

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

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

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

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

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

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

A Record of Progress—and What is at Risk

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thank you.

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

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

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

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

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

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

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

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

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

Planning for the next 20 years

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

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

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

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

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

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

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

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

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

What the Gates Foundation hopes to accomplish

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The last chapter of my career

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This experience taught me a couple important lessons.

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

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

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

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

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

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

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

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

Thanks so much for the visit, Mary!

What’s for dinner?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Going Gaga

I couldn’t help but feel a little nervous.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I write a lot about new inventions that are improving people’s health and saving lives around the world. But some breakthrough ideas don’t involve any new technology at all. Let me tell you about one of my favorite examples—a solution that is readily available, requires no special equipment, and is so cheap any government can support it.

It’s called kangaroo mother care—continuous skin-to-skin contact between mothers and low-birth weight or premature babies. Combined with exclusive breastfeeding, this practice prevents neonatal deaths by regulating the baby’s temperature, accelerating weight gain, and reducing the risk of infections. What’s more, it encourages mother-infant bonding at a critical time of the child’s development.

Two Colombian pediatricians, Edgar Rey and Hector Martinez, developed kangaroo mother care in the 1970s. The doctors were struggling to care for preterm infants in Bogota, where few incubators were available. Looking for a solution, they drew inspiration from how kangaroos care for their young. Baby kangaroos, born the size of a lima bean, develop inside the pouch on their mother’s belly where they can feed and stay warm.

Years later, study after study has proven the benefits of skin-to-skin contact between mothers and their newborns. For preterm babies, it’s even better than warming them in an incubator. And even as new lifesaving technologies are introduced to facilities to support newborns, kangaroo mother care is an opportunity to keep mothers at the center of their baby’s care.

When kangaroo care has been adopted on a national scale, the impact is truly remarkable. Rwanda, for example, cut its newborn mortality rate by 30 percent between 2008 and 2015, largely due to the spread of kangaroo mother care along with encouraging exclusive breastfeeding and cutting the umbilical cord in a hygienic way.

Surprisingly, despite its clear benefits, kangaroo mother care is not practiced widely. But it should be. Every year, about 2.7 million newborns die during their first month of life. The majority of newborn deaths occur in parts of the world where there are no hospitals or clinics nearby, and no access to skilled birth attendants.

Many of these lives could be saved with simple, affordable health interventions like kangaroo mother care. Our foundation, along with many other organizations, have been working to spread the word about kangaroo mother care with policymakers and health officials so more parents can be trained to use this lifesaving practice.

If you need another reason to be convinced of the power of kangaroo mother care:  A recent study found that this practice is a gift that keeps on giving. Kangaroo mother care had “significant, long-lasting social and behavioral protective effects” on children as they entered young adulthood. Parents who practiced kangaroo mother care were more protective and nurturing, and their children were less likely to miss school and less likely to be aggressive or hyperactive. These positive effects were still present in the children 20 years later! Now that’s a smart investment in our children’s future.

I’m a big fan of America’s investments in the health and well-being of the world’s poor. Unfortunately, not everyone feels the same way. In fact, some in Washington D.C. have proposed dramatic cuts in foreign assistance.

That would be a terrible mistake. Last month I wrote about how foreign aid helps keep Americans safe. In this post, I want to show how smart health and development programs promote America’s economy, and how cutting back on these investments could backfire on American workers.

(As I said in my previous post, these security and economic arguments aren’t what inspired Melinda and me to get involved in global health. What inspired us was the chance to save children from dying of preventable diseases. But over the years I’ve come to see the connection to America’s security and economy as well.)

I start from the simple premise that everyone is better off when there are more middle-income countries in the world. As a country climbs up the economic ladder, you see concrete improvements in the lives of its people. Richer countries are less likely to go to war and more capable of preventing global epidemics. And they can afford to buy more products from other countries, including the United States.

Here’s one example from my experience with Microsoft. From our earliest days, we intended to expand into markets beyond the United States. In 1986, we chose Tokyo for the site of our first foreign office. That bet paid off phenomenally well. For a time, we sold more software in Japan than anywhere else.

You may be thinking, “Of course an ambitious software company would want a foothold in Japan.” But it wasn’t always so obvious. Just a few decades before we opened our Tokyo office, Japan had been devastated by World War II. Its economy and infrastructure lay in ruins. How did they recover? Among other things, through smart aid programs from the United States and others. By the 1980s Japan’s economy was booming, and the country presented a great opportunity for companies like us. To this day, sales there are a key part of Microsoft’s success and these sales have produced many jobs in Japan and America alike.

Microsoft’s experience in Japan is part of a larger trend that’s still going on today, as more countries join the ranks of the middle class. Countless U.S. companies are doing business in places that used to get American aid but have become self-sufficient, including South Korea, Brazil, Mexico, Vietnam, and Thailand.

Here’s another way that U.S. investments abroad help American businesses: by connecting them directly with new customers and suppliers. America’s chief aid agency, USAID, uses its expertise to encourage private companies to collaborate on projects. For example, they have worked with Cargill and Land O’Lakes to help dairy farmers in East Africa raise their productivity, increasing the value of the companies’ exports to places like Kenya and Uganda. As the companies’ CEOs wrote, “This benefits not only the farmers in Africa, but food producers and their workers in the United States and it promotes goodwill in a part of the world that can be a market for more American goods in the future.” USAID has also worked with Walmart to train thousands of women farmers in sub-Saharan Africa, and with Starbucks, Keurig, and others to help coffee farmers in Latin America improve their crops so they can join the global market.

These and other efforts are part of America’s global economic leadership. Pulling back now would mean retreating from the world stage at a time when other countries are doubling down on their investments. It would deprive American companies of potential new markets and make them less competitive, while also harming the health and productivity of some of the poorest people in the world. It wouldn’t be robbing Peter to pay Paul; it would be robbing Peter and then robbing Paul too.

So it’s good for the American economy when other countries join the middle class. But how much credit does aid deserve for making that happen?

It’s a hard question to answer; growth has many causes. My own conclusion, based on years of looking at the evidence and discussing it with experts, is that although aid may not directly cause growth, there is a strong indirect connection between the two. Moving to the middle class requires a strong education system and good infrastructure, nutrition, and healthcare—and smart, targeted aid can promote those things pretty effectively.

Fighting AIDS, for example, saves lives, and it increases productivity because societies are stronger when they have healthy teachers, police officers, and entrepreneurs. Countries that worked with PEPFAR—America’s phenomenally successful effort to slow the AIDS epidemic—improved three times more on one measure of economic development than their non-PEPFAR counterparts.

Their per-capita income also grew quickly. Between 2005 and 2015, for example, Tanzania’s per-person income went up more than 37 percent. Zambia’s went up 55 percent. Ethiopia’s rose 107 percent. And as these countries grew, so did their appetite for American goods. In the same time frame, U.S. exports to Tanzania rose by more than 77 percent, U.S. exports to Zambia went up 189 percent, and to Ethiopia, 241 percent.

Many other countries are making similar gains. The point is not that aid directly makes poor people richer. It’s that aid helps create a foundation for growth. Along with many other factors, it helps remove some of the barriers that keep people from making the most of their talents. And when people in one place do better, the rest of us do better too.

We can build on this progress if the United States helps maintain the momentum. Investments in aid—which account for less than 1 percent of the federal budget—are an essential part of the solution. We need to keep making them on behalf of Americans and people around the world. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1.

Make and deliver better tools.

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

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

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

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

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

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

2.

Improve disease monitoring.

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

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

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

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

3.

Strengthen health systems.

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

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

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

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

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

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

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

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

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

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

Unfortunately, it’s pure Hollywood fiction.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I’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.