2011 Annual Letter from Bill Gates

Our Focus for 2011
This year we're focusing on vaccines, particularly the polio vaccine. Learn more about our work in this area, as well as HIV/AIDS, malaria, agriculture, and education.

Videos Watch videos from Bill Gates, see a vaccine animation, learn about the polio fight in India, and more. Watch now

Infographics Track polio cases by country, follow a polio timeline, see the United States' ranking in education, and more. Learn more

On-Demand Webcast Watch the recorded version of this event with Bill Gates, Diane Sawyer, and a panel of experts. Learn more

2011 Annual Letter from Bill Gates:
Continuing the Conversation

Last year I launched www.gatesnotes.com and started a Twitter feed (@BillGates) to share my thoughts on the work we’re doing and what I’m learning from leaders and innovators. One great benefit of these tools is that they allow me to hear back from people. Over the next year I’ll be trying some new ways of adding interactivity to the site so I can get even more feedback. Melinda is also very interested in spurring a broader conversation about the issues she’s focused on at the foundation. Last year she started posting regularly to the foundation’s blog. She also hosted a terrific TEDx event (www.tedxchange.org/pastevents) in New York that brought together interesting speakers on global health and development. Next year, building on her relationship with TED, she’ll be hosting a series of “TEDxChange” events in communities around the world—in places like Kenya and India. The goal of these TEDxChange events is to give people a chance to hear about health and development from people who live in the places where the work is happening.
Despite government budget difficulties and the complexity of solving the key problems the foundation’s work addresses, Melinda and I remain optimistic. We meet so many remarkable leaders whose work is making the world a better place.
My father, our co-chair, set the foundation’s direction from the start and he always helps us keep in mind what is important. Jeff Raikes, our CEO, continues to add great people and improve the way we do our work. Not everyone can go to the field, or even donate. But every one of us can be an advocate for people whose voices are often not heard. I encourage everyone to get involved in working for solutions to the challenges those people face. It will draw you in for life.

Bill Gates
Co-chair, Bill & Melinda Gates Foundation
January 2011

2011 Annual Letter from Bill Gates: The Giving Pledge

Warren Buffett is a remarkable friend and mentor to both Melinda and me, and we have learned so much from spending time with him and working with him on foundation projects. A few years ago Warren suggested that he, Melinda, and I should get together with some of the most generous givers in the country and see what we could learn from them. We started out by having dinners where everyone talked about why they give, what they are passionate about, and what they wish they could do better. The dinners evolved into discussions of the challenges of giving effectively. It became clear that there was a lot of collective knowledge and that we could inspire each other and in some cases work together. There was a strong sense we should broaden the discussion to a larger group including people who were earlier in their giving career. This led to the idea of the Giving Pledge. It is simply a commitment to give the majority of your wealth away during your lifetime or through your will. We hope that over the long term it will encourage people to start earlier, collaborate more, and make their giving even more impactful.
We are excited that 58 people have already joined the Giving Pledge. You can see the letters describing their thinking about giving at www.givingpledge.org. The United States is the most generous country in the world. More than 15 percent of the large estates go to charity. That is significant, but there is room for that to increase. Warren has said, “We want the general level of giving to step up. We want the Pledge to help society become even more generous. We hope the norm will change towards even greater and smarter philanthropy.”
Although this effort is focused on those people in the United States with the greatest wealth, we are encouraged by and support similar efforts that focus on other groups. For example, some of the top business people in China and India asked if we would meet with them to stimulate discussion about giving in their country. Warren and I had the meeting in China in November and we were very happy with how many people came and how the conversation turned out. All three of us will be attending a similar meeting in India in the first half of the year.

Clockwise, from top left: Geetanjali in her bakery with her son and daughter (New Delhi, 2010). Woman carries maize to market (Kunsu, Ghana, 2010). Kamla Devi at her roadside flower shop (New Delhi, 2010). Child receives oral polio vaccine (Kano, Nigeria, 2010). Students learn about biotech in Dr. Kinchington’s 10th grade class at the Science and Technology Academy (Pittsburgh, Pennsylvania, 2010).

2011 Annual Letter from Bill Gates: Excellence in Teaching

In the United States, the foundation’s biggest investments are in education. Only a third of students are graduating from high school prepared to succeed at college-level work, and even fewer are going on to get a degree that will help them compete for a good job. No one should feel comfortable with those results. Davis Guggenheim's amazing and popular movie Waiting for “Superman” made a powerful argument against the status quo. It showed a broad audience that schools with the right approach can succeed, even with inner city students that typical schools do not educate well. As more people understand the gap between what is possible and what is actually happening in most schools, I believe the momentum for reform will grow.
Since 1980 U.S. government spending per K-12 student increased by 73 percent, which is 20 percent faster than the rest of the economy. Over that time our achievement levels were basically flat, while other countries caught up. A recent analysis by the Programme for International Student Assessment (PISA) showed the United States is about average (compared to 35 developed countries) in science and reading and below average in math. Many Americans have a hard time believing this data, since we are so used to being the global leader in educational achievement and since we spend a lot more money on education than many other countries.

PISA measured educational achievement in the Shanghai area of China, and even allowing for the fact that Shanghai is one of the most advanced parts of China, the scores relative to the United States and other countries were quite stunning. China did better in math, science, and reading than any of the 65 countries it was compared to, and it achieved these results with an average class size of more than 35 students. One of the impressive things about the Chinese system is how teachers are measured according to their ability. There are four levels of proficiency in the Chinese system, and to move up a level, teachers have to demonstrate their excellence in front of a panel of reviewers.
According to the PISA analysis (available at www.pisa.oecd.org), two key things differentiate the U.S. education system from most other countries’ systems. The first is that non-U.S. students are in school for more hours, and the second is that U.S. school systems do very little to measure, invest in, and reward teacher excellence.
Most people who become teachers do so because they’re passionate about kids. It’s astonishing what great teachers can do for their students. But the remarkable thing about great teachers today is that in most cases nobody taught them how to be great. They figured it out on their own. That’s why our foundation is investing to help devise measurement and support systems to help good teachers become great teachers.

Geoffrey Canada talks with students at Harlem Children’s Zone, in a scene from Waiting for “Superman” (New York City, 2009). © Paramount Pictures/Participant Media

Our project to learn what the best teachers do—and how to share this information with other teachers—is making significant progress. With the help of local union affiliates, we have learned a lot already. We’re learning that listening to students can be an important element in the feedback system. In classes where students agree that “Our class stays busy and doesn't waste time” or that “In this class, we learn a lot almost every day,” there tend to be bigger achievement gains.
Another great tool is taking a video showing both the teacher and the students and asking evaluators to provide feedback. Melinda and I spent several days visiting schools in Tennessee this fall and sat with teachers who were watching videos of themselves teaching. We heard from a number of them how they had already improved by seeing when students were losing interest and analyzing the reasons.
Ultimately, the goal is to gather high-quality feedback from multiple sources—test scores, student surveys, videos, principals, and fellow teachers—so that teachers know how to improve. I think it is clear that a system can be designed that teachers agree is fair, has modest overhead, and rewards the teachers who are doing the most for their students.
State budgets, the biggest part of K-12 funding, will be challenged in the years ahead because of the economic downturn, the liabilities from early retirement and pension commitments, and increasing medical costs. I recently gave a speech to the chief state school officers (http://www.gatesfoundation.org/ccsso) about how they might need to find money to reward excellent teaching by shifting some away from things like payment for seniority or advanced degrees that do not correlate with improved teaching.
I am very enthusiastic about the potential of innovation to help solve many of the problems with our education system. Melinda and I were impressed when we visited the Tennessee Technology Center in Nashville, an institution that provides young adults with technical training and certificates. It gets significantly better results than its peer institutions—graduating 71 percent of its students—because it focuses on teaching job skills that are in high demand and is oriented around meeting the needs of students who are juggling school with work and family. Sometimes something as simple as rethinking the times when classes are scheduled makes a huge difference for students.
The foundation is funding the development of online tools to help both K-12 and college students learn. Pioneers like Sal Khan are already showing how effective online tools can be. His website www.khanacademy.org continues to grow its library of 2,000 short instructional videos on topics from basic arithmetic to complicated subjects like biology and physics. The videos are a tremendous resource for students of any age.
Sal’s vision for how technology can improve learning is broader than just videos. With support from the foundation, he’s been able to expand his site to include online exercises that diagnose weak spots, pointing you to additional material to fill the gaps in your knowledge. Also, Khan Academy is creating on online “dashboard” to help teachers use the site as part of their curriculum. The dashboard tells the teacher how each student is doing, pinpoints where they’re having trouble, and suggests explanations and exercises to help.
Although it is clear that online learning works for strongly motivated students, we need to learn how to blend classroom learning and online learning, particularly for younger and less-prepared students. As these projects develop and we start to answer many of these questions, I believe technology will let us dramatically improve education despite the budget constraints.

2011 Annual Letter from Bill Gates: Agriculture’s Great Promise

Outside of health the area where we invest the most to help poor people is agriculture. There is so much potential in agricultural development because most poor people in the world feed their families and earn their income from farming. When farmers increase their productivity, nutrition is improved and hunger and poverty are reduced. In countries like Rwanda, Ethiopia, and Tanzania, investments in seeds, training, access to markets, and innovative agricultural policy are making a real difference. Ghana made agriculture a priority and cut hunger by 75 percent between 1990 and 2004. The increase in food production has led to economic development in other areas. But the growth in other countries has been slower. These are complex issues, and it’s going to take strong leadership to make sure farmers have the opportunity to seize their potential. Kofi Annan, who chairs the Alliance for a Green Revolution in Africa, is leading the way by helping to drive a new agriculture agenda for the continent.
One program I’m especially enthusiastic about is a partnership launched in 2008 with the World Food Programme (WFP), the world’s largest humanitarian agency for fighting hunger. What I like about it is that it takes a new approach to something the world has been doing for a long time, food aid.
In the past most small farmers were not able to sell their produce to WFP to be used as food aid. They had trouble meeting WFP’s complicated requirements and delivering food in bulk quantities that met WFP’s quality standards. Our partnership works with farmers and others to resolve these issues, making it possible for them to sell to lots of additional buyers including WFP. When the West African country of Niger experienced a famine last summer, WFP bought 1,000 metric tons of rice from a farmers’ organization in Mali. When small farmers in Mali are earning extra income by feeding hungry families in Niger, it’s a clear win-win.
The near-term rise in food prices and the long-term increased demand for food will create opportunities for small farmers even in the poorest countries. In fact, increasing production in Africa will be critical for the world to have enough food. It’s encouraging that foreign aid for agriculture has now increased from its historic low of just $2.8 billion in 2003 to $5.9 billion in 2009, and it’s critical that nations don’t cut back again.
One of the most important new developments came in April when I joined the finance ministers of the United States, Spain, Canada, and South Korea to launch the Global Agriculture and Food Security Program with initial commitments of nearly $1 billion over three years. This program provides support to developing countries with strong domestic agricultural development plans that they are already investing in themselves but cannot fully fund. It has generated amazing demand, demonstrating how committed poor nations are to their own agricultural development.

Farmer prepares dried maize (corn) for sale (Monopo, Mozambique, 2010). Farmer separates maize from stalks (Malawi, 2010). © Charlie Barnwell, World Food Programme

2011 Annual Letter from Bill Gates: HIV/AIDS and the Need for Leadership

Progress continues in fighting the AIDS epidemic, but the pace is slow. The rate of HIV infection has been reduced by almost 20 percent over the last 10 years, to fewer than 2.7 million infections per year. The number of people dying from AIDS has gone down by more than 20 percent in the last five years, to fewer than 2 million annually. Given all the lives that are at stake, I am impatient enough about this that I am willing to be viewed as a troublemaker by people who are happy with the status quo. The war against AIDS is being waged on two fronts—treating those who are already infected and preventing new infections. Treatment continues to be scaled up, with more than 5 million people receiving HIV drugs. This is a great success story. Rich country generosity has been crucial and the execution in poor countries has been strong. However, there will not be enough money to treat everyone who will become infected if we don’t halt the progress of HIV. Because we don’t have a cure for AIDS, treatment has to continue for a patient’s entire life. That means costs continue to increase as you put more and more people on treatment.
Even without including people who will become infected in the future, the cost of treating the 33 million people living with AIDS today would be over $40 billion per year at current costs—over four times as much as is provided in aid today. To minimize the funding gap we need to reduce per patient costs of treatment. Drug costs have already been reduced to less than 20 percent of treatment costs. Most of the future savings will have to come from treatment models that reduce personnel, laboratory, and overhead costs. The difficulty of funding treatment makes it clear how important it is to prevent new cases. The sooner we make progress the better. There needs to be a sense of urgency that doesn’t exist yet.
Prevention breaks down into several different areas. The easiest should be preventing mother-to-child transmission since it simply involves giving a mother drugs to prevent transmission to her child. There is a lot of focus on getting from the current number of over 300,000 infections per year to zero. Another prevention approach is counseling people to change their behavior, including avoiding risky acts and using condoms.
Then we have prevention approaches that rely on new tools. We now have three tools that have shown significant impact. The first is male circumcision, which I discussed last year. Amazingly, teenagers in communities with high HIV incidence show a high willingness to be circumcised. Kenya is leading the way with over 200,000 circumcisions performed. However, there are over 10 million men in high-risk settings in Africa who would benefit from male circumcision, and we should be scaling up 10 times faster than we are.
Another new tool is a vaginal microbicide gel that a woman can use to protect herself. A recent trial showed a gel containing tenofovir protected women against infection. Now the question is how long it will take before the gel is rolled out on a large scale. As someone outside the field, I am surprised at the number of steps it takes. First the product has to be licensed, which requires approvals from regulatory groups in both the country where the product will be used and donor countries. Many of these approval steps happen serially rather than in parallel, and it is only when the entire approval process is complete that the product can be rolled out. Even then the process isn’t complete because a whole system for delivering the product needs to be put together, and again a lot of these steps proceed in a slow serial fashion.
Another new prevention tool, PrEP (Pre-Exposure Prophylaxis), involves someone without HIV taking an anti-HIV drug on a regular basis to block infection. A PrEP trial showed a strong prevention benefit for the participants who consistently used the drugs and a weaker impact when all the participants were included. With both microbicides and PrEP I think countries with large epidemics should figure out how to do large community trials as soon as possible. This would shorten the time before all patients have these lifesaving tools by many years.
If the United States had an epidemic where almost half the girls in large neighborhoods contracted a terrible disease, we would find a way to cut through all the complexity. With HIV it is more difficult since there are many countries involved. But we need to work creatively to shorten these delays.
The best tool would be a vaccine for HIV. The scientific progress on this has gone well. The positive results of the trial in Thailand were a turning point for the field, and blood samples from the volunteers are being studied in depth for lessons about why that vaccine worked but only to a limited degree.

Clockwise, from top left: Physician examines a six-year-old girl (Siem Reap Province, Cambodia, 2010). Transgender sex workers at a drop-in center (Chennai, India, 2008). Female sex workers are trained how to use condoms at a mobile clinic (Mumbai, 2009). Sign advertises the use of condoms to prevent HIV infection (Andhra Pradesh, India, 2009).

There has also been an explosion in the discovery of antibodies that block HIV infection. Scientists don't yet know how to make a vaccine that will cause patients to generate lots of these antibodies, but there are several approaches that look promising and will be ready to go to trials in the next few years.
In order to get a fully effective HIV vaccine we will almost certainly need several rounds of trials where we learn and improve the candidate vaccines. So to get a vaccine as soon as possible we need to minimize the length of the trials and the time between trials. So far each cycle has taken over five years. The field needs to look into how to shorten this so that progress matches the urgency of the problem.

2011 Annual Letter from Bill Gates: Saving the Youngest Children

Of the 8.1 million deaths per year of children under the age of 5, over 40 percent happen in the first 28 days of life, or the neonatal period. The good news is that we are headed in the right direction. In 1995 there were an estimated 5.6 million neonatal deaths. The most recent estimates show the number down to around 3.6 million. Unlike the deaths that take place after a child is 28 days old, almost all of which can be prevented by inventing and delivering vaccines, reducing these early deaths requires a range of approaches. Some require new tools such as an ointment for the baby’s skin that prevents infection and an antibiotic solution for cleaning the cut umbilical cord. However, many of the key interventions involve social and behavioral change. You can have a huge impact (on both newborn and maternal health) by increasing the number of births done by a skilled provider in a clinic. It’s also important to teach mothers to wash their hands before handling a baby, to have frequent skin-to-skin contact with their babies, and to breastfeed exclusively for the baby’s first six months. (Mother’s milk contains not only key nutrition but also antibodies that block infection until the baby’s immune system is ready to operate on its own.) Where all of these elements come together, neonatal deaths can be reduced by 50 percent or more, so it’s critical that we learn more about how to teach and motivate mothers effectively, especially at a large scale.
Melinda has been a strong leader on maternal and child health issues. She gave an especially powerful speech last year to the Women Deliver conference (http://www.gatesfoundation.org/womendeliver). The plight of mothers and their babies is something she feels deeply, and it’s something we talk about a lot.
When she came home from a trip to Malawi she shared the experience of seeing two babies in a hospital in the town of Lilongwe, lying side-by-side in the same incubator. They were born within hours of each other. Each had suffered the same condition–they were unable to breathe at birth. Sadly, it was clear that only one would survive. That baby’s mother had made it to the donor-funded hospital in time for her delivery and was able to get the care she needed. Her baby was immediately resuscitated, which saved his life. The other was not so fortunate. He was born on the way to the clinic, on the side of road, and was not resuscitated soon enough. I wish everyone had a chance to experience what Melinda did, so they could see how things are improving but also understand the urgent need to do more.

Shanti Devi holds her newborn daughter (Koelikhera Village, India, 2004). Melinda observes newborn babies at Bwaila Hospital (Lilongwe, Malawi, 2010).