I am connected to vaccines. I plead guilty to being involved in that miracle.
Hello, and welcome to the conversation. I'm Dasha Burns, Politico's White House bureau chief, and every week on this show, I invite one of the most compelling and sometimes unexpected power players in Washington and beyond in for a chat to find out how they're navigating and shaping this incredible era of American politics. This week marks our final episode in our second season, and my guest is someone who I've been looking forward to having on the show for quite a while. We finally got the chance to sit down just at the right time. The Gates Foundation recently released its annual Goalkeepers report, and it comes with a sobering fact: 2025 will be the year that child deaths increase for the first time this century. The report covers how to reduce these deaths amid cuts to global health funding. I sat down with none other than Bill Gates. In our interview, he shared his foundation's framework for doing more with less and what he calls a turning point in global health. The former CEO of Microsoft has been a full-time philanthropist for many years now, and during that time, he's seen political, ideological, and cultural changes across global health and development, the tech sector, and of course, right here in Washington. We talked about promoting vaccines in an increasingly vaccine-hesitant time, the pros and cons of AI, and the new normal when it comes to the tech industry and its relationship with DC. Bill Gates joins the conversation. Bill Gates, thank you so much for joining the conversation.
So, let's talk about your Goalkeepers report because it delivers a pretty sobering headline. It says that 2025 will be the first year this century where preventable child deaths are projected to rise. The report says this is because of cuts to global health funding made by wealthy countries. Of course, the US is one of those countries that scaled back. The numbers in your report say that in 2024, 4.66 million children died before their fifth birthday, and it says that number will rise by just over 200,000 to an estimated 4.8 million children this year. You've been at this for more than two decades. What was your reaction when you first saw these projections?
Well, it's first important to know that it's really a miracle what happened from 2000 to 2025. The Gates Foundation was created in the year 2000. I was horrified to learn 10 million children were dying every year, partly because there was so little resource for them. They weren't getting vaccines that they deserved for diarrhea and pneumonia, and the whole global health movement has a lot to celebrate that we cut that death level in half. So it's only with the understanding of how far we've come that you can say, okay, that setback after the 25 years of the greatest reduction in childhood death ever in human history, that now we're seeing that reversal. So in that context, that's disappointing, but you know, we increased the amount of money for the first 25 years, and now we're decreasing the money, and it's not surprising that that's resulting in more deaths.
When you personally looked at the situation and the changing landscape and what that's going to mean for those populations that you've been so dedicated to, what goes through your mind? The human element of it all?
Well, I get to go out in the field and see the malaria ward where a mother's there with her children dying of malaria. You know, I get to go out and see that when kids are malnourished, their risk of dying is over three times as if they're well-fed. And so, a lot of people in the US don't get to see the face of this and therefore don't feel so good about the progress. I mean, literally, there were malaria wards I went to early in the life of the foundation that were full during the malaria season, and when I go back now, there's not many kids there. This work has been very fulfilling for me, which is why I made the commitment that over the next 20 years, all of my money will go to these causes. And you know, the goal is during that time frame to get childhood deaths down and cut it in half again. And we won't get there if the numbers are going up.
Where do you see these cuts in foreign aid from the US and other countries having the most negative impacts? Like, are there particular areas of public health that are hardest hit by this?
In parts of the world like northern Nigeria, over 10% of the kids die before they reach the age of five. In the US, that number would be well below 1%, and that would mostly be difficulties at the time of birth. We don't think of children dying as a common thing here. So, it's just incredible. The ideal is to provide that to every child. Malaria's been a tough one. The US kind of abruptly fired a lot of people and cut off a lot of money in the first half of the year. So that's where the bed nets were being handed out, the nutrition food was being handed out, TB cases were being detected. But to be clear, it's not just the US that's made cuts. In fact, in the US case, it's where we have the least clarity of what the next three years will look like. But, you know, the UK made cuts, Germany made cuts. It's that overall effect that's going to make this a tough five-year time period.
It's a trend that's not just here in the United States, but really all over the world. Secretary of State Marco Rubio and other Trump administration officials have publicly rejected the argument that cuts in foreign aid have led to more deaths. I wonder if you've talked to them about that at all, and do you think their understanding of the impact of these cuts has evolved or is changing over the course of the year?
You know, nobody wants to take responsibility for the tragedy that's going on here. In my dialogue with President Trump, he clearly cares about these issues and wants to find a generous level for the spending that the US won't be responsible for these big increases. So, I'm hopeful that what we've seen this year, where there were sudden and massive cuts, and you just can't deny that's led to lots of deaths. That net increase, remember, it's way more than that in Africa. Fortunately, India, which is not aid dependent, continues to reduce deaths. So, the aid effect is much more than the net 200,000 because countries that have graduated from aid, we don't see the increase in deaths at all. You know, they're on a fantastic track. So, a high percentage of this is in the very poorest countries of the world that only in a 20-year time frame can be expected to get out of the poverty trap and become self-sufficient. So they're not dependent on the generosity, the less than 1% of the budget that comes on their behalf. So my discussions with Secretary Rubio and President Trump makes me hopeful that they and the Congress will make sure that we get back to very close to the level of generosity that existed before 2025.
I think I'm hearing you say that there is some opportunity here because the budgets and these policies aren't set in stone yet. Elon Musk is no longer working in the government. He was responsible for taking that chainsaw to USAID and a lot of these programs. You've now built relationships in the administration. Do you feel like you're making progress on the funding front and helping them understand the impact that they could have?
I think the next six months will be very important, and it'll be determined what the Congress's role is in setting the budgets for global health. It'll be determined what these new compacts look like for the poor countries. Do they maintain a level of generosity that can get us back on track? Certainly the US commitment to the Global Fund was a positive data point. You know, they maintained the huge generosity that they've had there, which is very helpful to me as I go to the European countries and say, okay, this is a one-for-two match construct, so please don't cut this. And that helped me get the cuts in those European numbers to be way less than they would have been because they're kind of following what the US does in a lot of ways. They have aging societies, they of course have pressure to increase their defense budgets. All rich countries have very tight budgets. So that's why I always make it clear this is less than 1% of the budget. This is not what when you ask somebody in general, they'll think it's quite high, like 5 or 10%. And no, in the US case, it's never reached 1%. The big increase in the US that got us up to almost 1% was under President Bush, where he saw that people dying of HIV in Africa, that really wasn't the golden rule to let those people die when the medicines could be so very, very inexpensive. Now we have a chance because of the innovation pipeline to do things that can even more effectively cut deaths.
One of the points the report makes is that vaccines are still the best tools for global health. Here in the US, we've seen HHS Secretary RFK Jr. inject some of his longtime skepticism about vaccines into government messaging, changes on the CDC website. Does it hinder your work at all to have US officials cast doubt on vaccine safety?
Well, the US was a very generous supporter, one of the top four supporters of Gavi. The two biggest donors have been the UK government and the Gates Foundation. And that right now is not continuing. So that's certainly a disappointment. You know, I was disappointed Gavi raised less money than they did. They raise money every five years. So in June in Brussels, they raised about 25% less than they had five years ago. That will result in more deaths. Even though we bring the price of vaccines down, we graduate countries that have economic growth, new things like this RSV vaccine, we won't be able to introduce that in as many countries as we should, and so we won't save those lives.
How do you counter vaccine skepticism at home and assure globally that the public understands that vaccines are not only safe but necessary?
Well, in rich countries where these diseases are not very present, you can actually be pretty lax. You can actually have a fair number of kids go unvaccinated and you won't see the negative effects of that for quite some time. Measles usually is not in the US. It is right now. We're having record measles cases. We're going to lose our elimination status for measles. But in poor countries, the kids are malnourished and there isn't good health care. In the US, it'll be about five kids will die for every thousand that get measles. In Africa, that'll be more like 200 will die. And so very quickly, what happened with Samoa where they stopped measles vaccination and then they had a lot of deaths, people are reminded because it's so grim to watch a baby die from measles. I've been abroad and seen babies dying from measles. That's deeply affecting. But in rich countries, that doesn't happen often enough to remind people what a miracle the measles vaccine is.
Have you had that conversation with RFK Jr. or any of the folks in his world at all?
In my meetings with RFK, we agree that vaccines is an area we're not going to have a common view. And yet, there's a lot of incredible research and work going on inside HHS at the NIH that we can continue to partner on.
So, you've decided we're just not touching that. We're going to talk about the things where we can actually be productive.
We touched on it briefly, but it was clear that they weren't going to convince me that vaccination should come to an end. And so we moved to other topics.
And you didn't feel you could convince them the other way around.
Polio is kind of a different story, especially within the Trump administration. I know polio eradication has been a huge priority for you, and I know you've spoken with Trump directly about this. I've seen him talk about polio in a way that surprised me because he talks about how he has been impacted. He's seen people in his life go through it, and he is of that generation that understands more intimately what this disease is. Do you think there's an opening there on polio in particular?
I've had great conversations with President Trump about polio, and I don't think there's any chance the US is going to reduce its funding for polio eradication. You know, we've got Rotary on our side. It's not a huge part of the budget. It's like $210 million. We've been trying to get it up a little from that. It comes from both HHS and the State Department. We're very close. In my discussions with President Trump, he said, 'Look, you know, this is important to him. He'd love to be in charge when this is brought to an end, and there's every prospect of that happening.' He even engaged with me on, okay, what is it we want Pakistan to do? And so when he was on a phone conversation with the field marshal of Pakistan, he had me brought into the call, and we talked about prioritizing the security work. There's a part of Pakistan, South Khyber Pakhtunkhwa, where the army has to escort the vaccinators in. It's not the government. It's really the army that has to help us there. That's the only place in the world that we've never gotten to zero. And that's why Pakistan and Afghanistan are the only two countries that have never gotten to zero. Africa got to zero, and now polio's come back there. So we have two areas we're working on, but the most urgent is Pakistan and Afghanistan, where President Trump has been a big help.
So he's actively working with you on this.
That's right. He said to me, 'What do I need to say to the field marshal?' I kind of went through that with him, but then literally the next day, he was on the phone with the field marshal and he said, 'Hey, get Bill into this phone call.' And then I had a follow-up call with the field marshal about specifically what type of NGO work and army escort would help us. We have 400,000 kids in that area who are unvaccinated. And unfortunately, that's enough kids that they can maintain polio. So we need to get in there and vaccinate those kids.
So you think there's a real possibility that you could get to zero on polio in the Trump administration?
Absolutely. I'm very excited about that, and Rotary of course has been an incredible partner in that. The governments in the Middle East have been great. UAE, Saudi Arabia, big supporters, and also they have a voice in Pakistan and Afghanistan that's been very helpful. I'm also a big believer that innovations like coming up with a way of curing HIV, so that instead of taking medicine your whole life, you have a one-time cure, that the Gates Foundation and the NIH could make that a reality.
One of the things that you talk about in the report is the idea of doing more with less, the reality that we're living in. What is the most impactful investment that this government, this administration, and other wealthy nations can make?
Well, I'm not going to seed to these aid budgets going down. I'm the biggest advocate that we should care about people in all countries. Even 1%, which would be a huge increase on preventing pandemics and moral grounds, can be explained. Whatever money we get, we will be thankful for. And we're always looking at how it can be best spent. Half of our money goes to funding new innovations, and half goes to this delivery in the field. Bed nets, vitamins for mothers, great care when you come in to deliver. And so there are ways now that AI is not only helping on the discovery side but delivery as well. In the US, you have an expensive technician with an expensive ultrasound scan during pregnancy. In countries like Kenya, now you can have an untrained person do that scan, and the AI software will tell the woman, 'Hey, is your delivery going to be complicated?' In other words, do you need to get to a place that if they needed to, they could do an emergency C-section? And so that's already saving lots of lives as that becomes standard practice. And so it's the generosity times the innovation that makes me feel like the 20-year goal of cutting childhood death in half again is achievable, even with this year having been such a setback.
It's so interesting that the dichotomy of the setbacks but the innovations really opening the door to such promising impact. You made a splash in October when you dismissed some of what you called the doomsday outlooks on climate change and instead called for limited resources to be more focused on helping the world's most vulnerable adapt to the changes that we're seeing. You acknowledged in the memo that you'd probably get some blowback on this, and you did. Some accusations were that you were doing this for political reasons. People said you did a 180 on climate change. Were you surprised by the intensity of reaction, especially in the climate community?
We're having to make tradeoffs. The same budget that funds vaccines funds various climate activities. And so, we should make sure that money is spent on the best thing. I'm a big giver and investor in climate adaptation. I'm a big giver to climate mitigation. And I'm a big giver to global health, the largest in all three. And I'm also one of the biggest funders of advocacy of encouraging rich countries to be generous to poor countries. And so I wish all of those things were on the increase and we wouldn't have to look at tradeoffs, but some climate funding is actually pretty low impact. So, in the same way I speak out about global health funding, making sure that's well spent, I was saying to the climate community, let's adopt a metric of human well-being and look within both portfolios to make sure we're picking the right things.
