I asked Bill Gates why there are still so many hungry children

Bill Gates helped launch a global health revolution at the turn of the 21st century, one in which multilateral humanitarian efforts arrested the AIDS crisis in Africa and began to make strides against longtime killers like tuberculosis and malaria. People in the Global South were living longer. A more equitable future appeared within our grasp.

But that progress has since stalled. Between 2000 and 2020, the worldwide child mortality rate fell by 50 percent, but it has remained stagnant over the past four years. Global development funding to support health efforts grew by 6.6 percent a year on average from 2000 to 2020, increasing less than $15 billion annually to about $50 billion. But that growth has slowed with the pandemic, falling to just 2.3 percent.

Now, a new report from the Bill and Melinda Gates Foundation projects global health investments could actually decline over the rest of the decade. 

The stinginess comes at a particularly bad time. We are in a critical fundraising cycle for the major global health organizations. Gavi, the vaccine alliance that provides immunizations to people in low-income countries, is currently seeking $9 billion to replenish its funds for the next five years. The Global Fund to Fight AIDS, Tuberculosis, and Malaria, which supports prevention and treatment for those diseases in developing countries and was seeded with a donation from the Gates Foundation, will begin its replenishment drive next year. 

But there are real and growing concerns that these groups may fail to reach their fundraising targets.

As a result, the world could lose ground against infectious diseases and especially child malnutrition, and those challenges are only set to grow in the future. Climate change threatens humanity’s food supply and thus its ability to feed itself. Without intervention, the number of children in the world who experienced stunting is expected to grow by 40 million by 2050 and the number who experience wasting will increase by 50 million. 

How can the world get back on track? Gates, as the chair and chief funder of a foundation that has delivered nearly $78 billion in grants chiefly for global health programs since 2000, is one of the most influential people trying to figure that out. In a recent interview with Vox, Gates conceded the challenges facing global health advocates, offered his own explanations for why investments have fallen off, and previewed the developments in the field he thinks hold the most promise for regaining the momentum of the early 21st century.

Our conversation has been lightly edited for length and clarity.

Dylan Scott

You framed the report around the stalled investment in global health that coincided with the pandemic. There seems to be a real realignment within the public and among policymakers in the US and in other countries, the countries that have driven a lot of global health investment. So what is your theory of why that is? How do you change people’s minds back if their views are starting to shift on this issue? 

Bill Gates

The world committed itself to keep making progress in reducing childhood death through the UN sustainable development goals that were set in 2015. We were spoiled during that period, between 2000 and 2015, because helping Africa, cutting the childhood death rate, it really had a lot of attention.

There was some low­-hanging fruit in that vaccines were being given in rich countries that we were able to reduce the cost of dramatically and we got Gavi to finance and get them distributed out to a very high percentage of all the world’s children. That’s why we got the childhood mortality cut by a factor of two, from 10 million kids a year dying to under 5 million.

If it was just the pandemic, then getting back on track actually wouldn’t be that hard because the pandemic’s over. The things that are happening alongside that are, first of all, that the African countries got cleared of their debts around the turn of the century. And that was a super­-worthy cause that predates the foundation. Over these years, though, they’ve built up debts. Now, as macroeconomic conditions have changed, the interest rates on those debts have gone up a lot, particularly for them because they’re risky borrowers. So African countries are now spending more on interest payments than on health and education combined. 

That’s a pretty dramatic thing. Then the aid levels coming out of the rich countries have actually gone down. That’s a surprise. Rich country budgets are squeezed by wanting to raise defense spending, wanting to help Ukraine, having aging populations with higher health costs, and not wanting to raise taxes.

So there’s a squeeze in the rich countries’ budgets, even though aid is well under 1 percent of the US government budget. We’ve seen cuts in the UK, in Germany, in France, and the European Union. 

That is really tragic because the assumption was that as these Asian countries — Vietnam, Indonesia, India — graduated from being aid-eligible because of their economic growth, we’d have more money per person to put into the low-­income countries that remain, which are mostly in Africa. But that has not turned out to be the case.

I want to help get those aid budgets up so we can provide the debt relief, so we can fund Gavi. Even Gavi is going to have a tough time raising as much money as it did five years ago. The Global Fund raises every three years, so next year, they’ll be going around. And I don’t know if they’ll be able to raise as much.

That’s despite the fact that whether you see it through the moral lens or the climate adaptation lens or stopping pandemics before they get to rich countries or global stability — whatever it is, these are the best investments possible. 

Dylan Scott

Does the global health movement need to find a new argument, as we expect these new countries to make more investments?

Bill Gates

Lots of countries have transitioned from low-­income to middle-­income: Brazil, Mexico, and Indonesia, India, Vietnam. Very few countries have transitioned from middle-­income to high-­income. South Korea is this famous example. Depending on where you set the threshold, you could say Chile or Poland are examples. But there’s not that many. 

As you move from low-income to middle-, you are self­-sufficient, so you’re not drawing on whatever the aid budget is. As you move from middle- to high-, which China’s right on the threshold of, then hopefully you become a donor in some way. But we haven’t gotten too many new donors. We’re still extremely reliant on five countries: Japan, Germany, France, the UK, the US.

That’s like 70 percent of the aid right there, even though you have a few like Sweden and Norway who by the percentage of their economy are the most generous at about 1 percent each. But the big money is in the Big Five. But the cuts there are so gigantic, we won’t make up for them with new donors. 

When somebody says to me the old arguments don’t work, I’m like, “Wow, we don’t care about children dying anymore?” I mean, it seems like, “Oh my God, what the hell?”

I admit that the way that we get to people, including the younger generation, is changing. I think we have to renew our energy and how we connect on this. There’s no substitute for getting people to go see this and come back and bear witness to it.

But we are challenged and we admit our message isn’t landing, so we’ve got work to do. 

Dylan Scott

Your report outlines some solutions. You’ve got new technology to increase dairy productivity. You’ve got financing through the Child Nutrition Fund. You’re focusing on making sure food is actually nutrient-­rich. You’ve got prenatal vitamins.

If I were to force you to pick the first action item, keeping in mind this idea that we just don’t have as many resources as we’re used to to accomplish these things, what would you pick?

Bill Gates

I would say that large­-scale food fortification — where you get people to stick vitamin A or folic acid into foods — the cost of that is super, super low. We have a team that’s expert in that, working with the food makers and really measuring what the vitamin deficits are. That’s a best buy.

The idea of these chickens that lay a lot of eggs or cows that make a lot of milk, the beauty of that is once you improve the genetics of the African cows, that’s a gift that keeps on giving. That’s a teaching a man to fish type thing where, as we mix the super productivity of Western dairy cows together with the heat and disease tolerance that African cows have, you can get something that’s 75 percent as productive as a [dairy cow], which is four times the milk productivity of the cows that are in Africa today.

It’ll take five years before, say, half the cows in Africa get that, but that’s a gigantic thing because that’s income for women, that’s milk for the kids where malnutrition, vitamin deficiency, and protein deficiency are gigantic. Cheap eggs, cheap chickens, and cheap milk are a big part of this. 

We’ve already cut the cost of eggs in Ethiopia in half. We see the poorest households actually using twice as many eggs as they used before because they’ve become a lot more affordable. Those egg factories and milk factories, getting those into Africa in the hands of the smallholder farmers, that’s pretty powerful.

Dylan Scott

We are learning more all the time about our gut bacteria and how that influences our digestion and physical health. What potential interventions are in the works to improve the microbiomes of children in the Global South?

Bill Gates

The probiotic stuff, that’s at an earlier stage. We have to prove out the impact, and we have to get the cost of that down a lot. It’s in our R&D work. If it works as well as we think, if we reduce the cost as much as we think, then we might even want to grow the size of the Child Nutrition Fund [a UNICEF-led program on child hunger] and add that as an intervention.

We’ve been the biggest funder of research in [microbiomes], including the original study where we took Malawi twins. We saw that one of them would be on the growth path, one would be off, and then we would look at stool samples or have them swallow capsules and figure out, “Okay, what is the makeup of a healthy microbiome?”

The kid whose growth was faltering, what we saw was their microbiome was very different [from their twin] and very inflammatory. Their ability to absorb nutrition was limited, and then you get on a negative path because as you get weaker, you can’t get out of that condition. 

One way to intervene is to put the good bacteria in and have them outcompete the bad bacteria, but we don’t know how much we’ll be able to reduce the costs of that. The ideal thing would be to come up with a food-based intervention that’s cheap. We have a trial going on studying choline, a nutrient that the good microbacteria thrive on and that the bad microbacteria don’t. It’d be a lot cheaper and more scalable if it turns out that choline, which we can make super cheap and add to vitamin supplements, pushes you toward this non­inflammatory set of microbiota species.

We know that protein pushes you in the right direction, but just saying, “Hey, every kid in the world should have lots of milk and eggs,” that’s way too expensive. We know we can make probiotics way cheaper than that. 

Dylan Scott

I’ve been hearing that the global health field itself is changing, emphasizing systems more and specific diseases or conditions less. We used to focus on one problem at a time: PEPFAR being focused on AIDS is maybe the best example of that. People thought, “We’re going to try to address this disease,” or, “We’re going to try to address this particular problem.” 

But I’ve sensed that there’s been a shift toward supporting systems and supporting institutions. Investing in health system infrastructure, for example, instead of starting a campaign focused on a specific disease. I’m curious if your own thinking about not only how to deliver aid most effectively, but also what type of aid is most likely to lead to a lasting impact, has shifted.

Bill Gates

There’s no doubt that the long-run solution is economic development. Economic growth that allows the government to collect more taxes and therefore fund more health, more education, more infrastructure, that’s the magic thing that India, Vietnam, Indonesia have shown is the way to get to self­-sufficiency. They’ve reduced their malnutrition a lot. 

But you have to say, “Okay, what enables economic growth? Why is Africa in a poverty trap?”

We know that parents choose to have enough children to have a 90 percent chance of having at least two survive to adulthood. As you reduce childhood death rates, fertility rates go down almost in lockstep. There’s this weird paradox that if children survive, population growth goes down, which is the opposite of the commonsense view.

So how do we help Africa get on an economic growth path? We need healthier children so that they can go to school and can be productive. We need to reduce population growth, and reducing the death rate is your biggest lever to do that. And as you educate girls, that becomes another factor in driving that fertility rate down, as is making a contraception widely available.

So these are all areas that the foundation works in. We want to enable economic growth. If you want to reduce children’s deaths, it’s not about some big health system; don’t think hospitals. Africans do not need doctors. They are born, they live, they die, and the majority never meet a doctor, or what the US would call a doctor. You have to look at: What’s killing these kids? What’s causing them to be malnourished?

Four things get you 85 percent of those deaths: malaria, pneumonia, diarrhea, and then a bunch of things that can kill you in your first 30 days. Those are the categories. We’ve made huge progress on malaria, diarrhea, and pneumonia. We haven’t made as much on those first 30 days, and there’s still a lot more to do on that.

No one disagrees that economic development is the end goal. But these very basic health things, that’s how for just $10 per citizen per year, you get yourself to a position where the kids are doing well at school. You’re moving off of the farms into services and manufacturing, and you will no longer be dependent on aid.

My basic theory has been refined in terms of, “Okay, why did this work so well in Asia and what’s missing in Africa?” But the overall idea of “help them help themselves” is still pretty much the same.