In an interview ahead of the foundation's release of its annual letter, Bill and Melinda Gates warned that a pullback in support for global health initiatives by some wealthy governments could undercut years of progress in battling polio and other infectious diseases and potentially set the stage for renewed outbreaks.

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After more than two decades in the global problem-solving business, Bill and Melinda Gates find themselves at an inflection point.

The Bill & Melinda Gates Foundation, with its $50.7 billion endowment, has had considerable success acting as what Melinda calls a “catalytic wedge”— testing out new and often unconventional approaches to everything from malaria prevention to rural polio eradication, then using the resulting data to push for large-scale government programs. Since 2000, that approach has helped the foundation and its many partners save tens of millions of lives — and has given rise to similar efforts across a broad set of social and environmental challenges, among them climate change and women’s empowerment.

But in the past few years, global philanthropy’s power couple has also confronted less encouraging developments.

In the Gates’ annual letter — which this year is titled “Things We Didn’t See Coming,” and which is dedicated to the late Paul Allen, Bill’s partner in co-founding Microsoft — Bill and Melinda point to an emerging political dynamic that could blunt future global health initiatives and even reverse some recent gains.

Simply put, some wealthy countries are shifting away from their historical role in international affairs to focus on national security and domestic issues — a pattern epitomized by recent White House threats to cut foreign aid. This “go-it-alone approach,” Bill writes, “could cause a major setback.”

In the near-term, that inward turn could undermine the foundation’s fundraising efforts for the four global programs that have long topped its priorities: the Global Polio Eradication Initiative, the Vaccine Alliance, the Global Fund (which works on AIDS, TB and malaria), and the Global Financing Facility, which funds maternal and child health initiatives.

Over the next 18 months, the Gates Foundation will join a broad effort to persuade donor governments and organizations, such as the World Bank, to “replenish” these programs with a total of more than $20 billion. Although private donors contribute heavily to these initiatives — the Gates Foundation has contributed $10 billion to the four programs since 1999 — most of the funding comes from governments — and there are signs that some are pulling back. At a World Bank “replenishment” conference for the Global Financing Facility last year, donors met just half of the $2 billion funding target, according to the global-development news site

During a recent interview at the couple’s Seattle-area offices, Bill Gates warned that decreased government support could lead to some “pretty bleak” scenarios. Of particular concern would be a loss of support for eradicating infectious diseases such as polio or Ebola, which could set the stage for renewed outbreaks. “If you let [infectious disease] get out of control, the numbers grow pretty rapidly.”

To avoid such scenarios, the Gates are stepping up their public advocacy. While the couple’s annual letters have traditionally focused on the technical side of the foundation’s efforts, recent editions have emphasized the risks of emerging nationalism and the turn away from global initiatives. “We need to remind people that disease travels cross borders,” said Melinda during the interview. “It wasn’t that long ago that we had Ebola in the United States and in Europe, and that really scared people.”

In some respects, the Gates’ pragmatism is simply an extension of the foundation’s original principal: follow the data. When Bill and Melinda began to consider where to target their philanthropy, back in the 1990s, they expected to focus mainly on “upstream R&D” for new vaccines and other cutting-edge health technologies. Instead, the foundation and its partners often found that, as important as new technologies are, millions of lives can be saved by improving the delivery of existing, often inexpensive technologies, such as mosquito bed netting to knock down rates of malaria.

That data-driven strategy has led the Gates to some unexpected, and often controversial places. They have raised hackles with their support for charter schools and performance assessments for teachers. But they’ve also been surprisingly cautious about another hot-button educational initiative: the digital classroom. Even while promoting more technology in the classroom — this year’s letter argues that “textbooks are becoming obsolete” — Bill Gates acknowledges that the data on classroom technologies still isn’t “so strong that anybody is saying, you know, ‘Today, go and scale that up to every classroom.”

On climate policy, the Gates Foundation is also unconventional. Where many climate-change strategies emphasize cutting carbon emissions in the transportation and power sectors, the data show that those sectors produce only a third of total carbon emissions. The bigger emissions challenges are in sectors like agriculture and the manufacture of cement and steel.

Cutting emissions in those sectors will be much more challenging, not least because the solutions must address extremely complicated industrial processes yet be affordable enough to persuade developing nations to adopt them. Developing countries “aren’t going to pay twice as much for their steel or electricity,” said Bill, so “expecting adoption there is even less realistic than expecting [it in] rich countries.”

For all their concerns about global philanthropy, Bill and Melinda point to many success stories, too. Mobile phones are allowing women in the developing world to assume control over critical areas like banking and contraception to a degree that would have been unimaginable 20 years ago. Sub-Saharan African governments are making large, data-driven investments in their young people — investments that, if uninterrupted, could allow the continent to “double its share of the global labor force by 2050, unlocking a better life for hundreds of millions of people,” according to this year’s letter.

Likewise, despite the rise of an anti-science, anti-data rhetoric among some politicians, both Bill and Melinda say the still find a very pro-data stance among many of the government officials who are actually running government policies. “Data may not make headlines all the time,” said Melinda. But “when you go behind the scenes and have discussions with rational people in the government about where they’re going to put their taxpayer dollars, they’re very interested in data.”

The danger, Bill added, is that in today’s political climate, with its growing impulse to turn inward, those sorts of conversations will happen less frequently, and the data-driven health initiatives “don’t even get consideration.” Because “once this stuff gets consideration,” he says, “the positive case is likely to happen.”


Correction: The interview with Bill and Melinda Gates took place at their offices, which are not part of the Bill & Melinda Gates Foundation, as reported in an earlier version of this story.