Wednesday, October 22, 2014

2011 Annual Letter from Bill Gates

There are few people that I admire more than Mr. Bill Gates.  During my lifetime, he has been by far the most impressive business person in the areas that are important to me as a business owner.  As a teen ager, he had the creativity and vision to see the PC and Operating System opportunity when most others didn’t.  He then had the business sense to leverage the opportunity to create a successful business around it.  After that,  he succeeded at maintaining an active control of the company he founded thru ought an amazing growth trajectory over the next 20 years or so, which few Founders can say.  And now, he is successfully utilizing his successes, both monetarily and politically, to fuel his passion for making the world a better place for everyone.  How could you ask for more?
 
We have posted here the recent release of the 2011 Annual Letter from Bill Gates, for your reading pleasure…..
There are few people that I admire more than Mr. Bill Gates.  During my lifetime, he has been by far the most impressive business person in the areas that are important to me as a business owner.  As a teen ager, he had the creativity and vision to see the PC and Operating System opportunity when most others didn’t.  He then had the business sense to leverage the opportunity to create a successful business around it.  After that,  he succeeded at maintaining an active control of the company he founded thru ought an amazing growth trajectory over the next 20 years or so, which few Founders can say.  And now, he is successfully utilizing his successes, both monetarily and politically, to fuel his passion for making the world a better place for everyone.  How could you ask for more?
 
We have posted here the recent release of the 2011 Annual Letter from Bill Gates, for your reading pleasure…..

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Full Text Version

Annual Letter   from   Bill Gates
 
 = Page 1 =
Vaccinators being trained at the Kabuga Health Centre for the upcoming polio campaign (Kano, Nigeria, 2010).
2
 
 = Page 2 =
2011 Annual Letter   from   Bill Gates
2011 
s I sit down to work on my third annual letter, governments in every corner of the world are facing tough 
decisions about how to reduce spending. Although foreign aid accounts for less than 1 percent of governments’ 
total budgets, it is one place being considered for cuts. As a result, health and agricultural assistance that saves 
A  lives and puts poor countries on a track for self-suciency is at risk.
e world’s poorest will not be visiting government leaders to make their case, unlike other constituencies, so I want to 
help make their case by describing the progress and the potential I see in key areas of health and development. erhaps 
it is ironic for someone who has been so lucky to talk about the needs of those who have not.
I believe it is in the rich world’s enlightened self-interest to continue investing in foreign aid. If societies can’t provide 
for people’s basic health, if they can’t feed and educate people, then their populations and problems will grow and the 
world will be a less stable place.
Whether you believe it a moral imperative or in the rich world’s enlightened self-interest, securing the conditions that 
will lead to a healthy, prosperous future for everyone is a goal I believe we all share.
Many people don’t have a clear image of the beneits aid actually provides. at’s not surprising, because aid covers 
many diferent areas. Also, in the past some aid was sent to countries to buy friendship without real regard for its 
impact. However, today a signiicant portion of foreign aid is spent on hugely beneicial programs that improve people’s 
lives in both the near and long term.  
Despite the threat to aid budgets, one thing that makes me optimistic about the future is the courage of leaders who are 
inding ways to make the welfare of poor people a priority. Under David Cameron’s leadership, the United Kingdom 
set a great example by keeping its promise to grow aid spending despite the cuts it had to make. It is inspiring to see a 
leader stand up for what he believes is right, even when it isn’t easy.
Ending Polio
Aid for the poorest has already achieved a lot. For example, because of donors’ generosity, we are on the threshold of 
ending polio once and for all.
olio is a terrible disease that kills many and paralyzes others. Fity years ago it was widespread around the world. 
When you talk to people who remember polio in the United States, they’ll tell you about the fear and panic during an 
outbreak and describe grim hospital wards full of children in iron lungs that maintained their breathing. At its peak in 
the United States in 1952, polio paralyzed or killed more than 24,000 people.
Reduction in countries with sustained transmission of polio, 1988-2010
Afghanistan
countries   countries
India
in  in
Nigeria
1988  2010  Pakistan
125  4
Child suffering from polio reads a comic book attached 
to the rim of an iron lung (ca. 1955).
3
 
 = Page 3 =
Estimated number of polio cases per year  Estimated number of polio cases per year
350,000
300,000
3,500
3,000
250,000  2,500
2,000
1,500
200,000
1,000
500
150,000
0
2000  2001  2002  2003  2004  2005  2006  2007  2008  2009  2010
100,000
50,000
0
1988  1990  1992  1994  1996  1998  2000  2000  2002  2002  2004  2004  2006  2006  2008  2008   2010   2010
Source: WHO/Polio database
Crowded polio ward at Hynes Memorial Hospital (Boston, 1955).
4
 
 = Page 4 =
2011 Annual Letter   from   Bill Gates
2011 
As a result of mass mobilizations to administer the polio vaccine, polio was eliminated in the United States and most 
developed nations decades ago. Most people who live in rich countries assume the disease is long gone and that it 
doesn’t kill or paralyze children anymore. But it is still a frightening presence in a number of places around the world.
In 1988 the global community adopted the goal of ending polio altogether. At that time more than 350,000 children 
a year worldwide were killed or paralyzed by the disease. Since then, vaccination coverage has increased signiicantly 
and the number of cases has gone down by 99 percent, to fewer than 1,500 last year. ere are now just four countries 
where polio transmission has never been stopped: India, Nigeria, akistan, and Afghanistan.
at’s incredible progress, but the last 1 percent remains a true danger. Eradication is not guaranteed. It requires 
campaigns to give polio vaccine to all children under 5 in poor countries, at a cost of almost $1 billion per year. We 
have to be aggressive about continuing these campaigns until we succeed in eradicating that last 1 percent.
erefore, funding is critical to success. Organizations such as otary International and the governments of India, the 
United States, the United Kingdom, and apan are all major contributors to the polio campaign. Our foundation gives 
about $200 million each year. But the campaign still faces a 2011-12 funding gap of $20 million. If eradication fails 
because of a lack of generosity on the part of donor countries it would be tragic. We are so close, but we have to inish 
the last leg of the journey. We need to bring the cases down to zero, maintain careful surveillance to ensure the virus is 
truly gone, and keep defenses up with polio vaccines until we’ve conirmed success. 
hy is it so important to end polio Eradication will have three huge beneits. 
e irst is that getting rid of polio will mean that no child will die or be paralyzed by 
the disease in the future. One thing most people don’t realize is that if we don’t inish 
W
the job on eradication, we will lose a lot of the ground we’ve gained over the past two decades. 
e disease will not stay at its current low level. If we don’t get rid of it, it will spread back into 
countries where it’s been eliminated, and it will kill and paralyze children who used to be safe. 
Only eradication will guarantee that all children are safe.
e second beneit is that the money that will be saved by eradicating polio far exceeds what we are spending on 
eradication eforts now. e long-term beneits of the last couple of billion dollars spent on eradication will be truly 
phenomenal. A recent estimate added up the cost of treatment that won’t be necessary and the enhanced economic 
contribution of adults who won’t get polio. Eradication could save the world up to $50 billion over the next 25 years.
e third beneit is that success will energize the ield of global health by showing that investments in health lead to 
amazing victories. e eradication efort illustrates so well how a major advance in the human condition requires 
resolve and courageous leadership. o win these big important ights, partnerships, money, science, politics, and 
delivery in developing countries have to come together on a global scale. 
he history of polio and polio eradication is fascinating. One of the best books I’ve read on the subject is David 
Oshinsky’s   Polio: An American Story  . olio was the irst disease that raised signiicant money from the broad 
public. e March of Dimes was created to combat the disease. Although resident oosevelt and lots of 
  Hollywood stars helped the campaign, its huge success came from neighborhood-based fundraising. I remember March 
of Dimes volunteers ringing our doorbell when I was growing up and asking for a donation. By any measure, the public’s 
generosity in supporting that charity made it one of the most successful health-related fundraising campaigns ever.  
e March of Dimes funded research into the irst polio vaccine, which was invented by Dr. onas Salk and introduced 
in 1955. It was such an important priority to get the polio vaccine out widely that the U.S. government sponsored the 
campaign, which it had never done before. e campaigns of the late-1950s were wildly successful, and by 191 the 
number of cases in the United States was down to just 11. 
A second polio vaccinethis one in the form of liquid drops that children swallow instead of an injection in the arm
was invented by Dr. Albert Sabin and licensed in 193. By 199 there was no more poliovirus in circulation in the 
United States. Dr. Salk’s and Dr. Sabin’s vaccines are still the key tools used for eradication today. 
5
 
 = Page 5 =
Polio timeline
3000 BC  1952  1963  1979  2007
Egyptian paintings and   Worst polio outbreak   Albert Sabin’s oral   Last case of naturally   The World Health 
carvings depict people   in United States   polio vaccine licensed  occurring polio in the   Organization declares 
with withered limbs   history, with 658,000   United States  polio eradicated in the 
and walking with canes  reported cases  Americas, Europe, and 
the Western Paciic 
1928  1955   1970s  1988  2010
First iron   Jonas Salk’s   National immunization   Polio still exists in     Sustained transmission 
lung used at   injected polio   programs launched,   125 countries and   of polio in four countries, 
Children’s   vaccine introduced  leading to control of   paralyzes an estimated   but outbreaks in 16 
Hospital in   the disease in many   350,000 children;   countries are reminders 
Boston  developing countries  Global Polio Eradication   that polio anywhere is a 
Initiative created  threat everywhere
Clockwise, from top: Rotary vaccination teams pick up vaccines and other supplies at the Patna Junction railway station (Bihar, India, 2010). World Health Organization 
workers unpack polio vaccine from boxes designed to keep it cold (Bihar, India, 2010). Billboard advertises the ongoing polio campaigns in Patna (Bihar, India, 2010).
 
 
 = Page 6 =
2011 Annual Letter   from   Bill Gates
2011 
o this day, the smallpox campaign is the only successful human disease 
eradication campaign in history. At its peak, smallpox killed over 2 million 
people  every  year  and  also  blinded  and  disabled  large  numbers.  e 
eradication campaign started in 19, the last naturally acquired case of 
smallpox was in 19, and the world was certiied as being free of smallpox 
in 199. wo excellent books on the smallpox eradication are Dr. D.A. 
Henderson’s   Smallpox: he Death of a Disease   and the forthcoming   House on 
Fire   by another key smallpox warrior, Dr. Bill Foege. 
Smallpox had a number of characteristics that made it easier to eradicate 
than polio. Almost everyone who got smallpox developed a distinct rash. In 
contrast most polio infections are not noticed because less than one in 100 
people infected are paralyzed, even though all those infected can transmit 
the virus. is means by the time a paralytic case is found, the poliovirus has 
probably spread. 
Also, the vaccines against polio are not as efective as the smallpox vaccine, 
which was so powerful that a single vaccination protected almost everyone. 
In the case of the most common polio vaccine, at least three doses are 
required to get 85 percent of children fully protected. In many countries of 
Girl winces as she gets vaccinated against smallpox (Nigeria, 1969).
the developing world, even more doses are needed to reach the immunity 
levels needed to stop transmission of the virus. 
But the polio campaign also has some huge advantages that the smallpox campaign did not have. e advanced science 
we have today lets us sequence the DNA of the polio virus and develop an understanding of the history of transmission, 
which guides our work. We also have far better communications and modeling tools than were available in the 190s, 
and those are being used in smart ways to respond rapidly to every outbreak.
n 2003 I would have said we were just a couple of years away from ending polio, and I would have been wrong. at 
year there were false rumors in Nigeria that the polio vaccine caused women to become sterile. is allowed the 
disease to have a resurgence and to spread to many other countries. e experience of 2003 serves as a reminder to 
be humble as we move forward. But humility does not mean fatalism.  I
Fortunately those false rumors have been almost completely eliminated through the leadership of key political and 
religious igures. In 2009 when I visited Northern Nigeria to meet with the most important traditional leader, the 
Sultan of Sokoto, he committed to the campaign. It was fantastic to see him publicly giving his support. He also gave 
me a horse to thank me but I told him I couldn’t take it. 
Last year both India and Nigeria had substantially fewer cases than ever before. In India the number of cases went 
down from 41 in 2009 to just 41 in 2010. In Nigeria, thanks in large part to the renewed leadership in the northern 
part of the country, the number went down from 388 to just 18. But alongside the phenomenal progress was another 
reminder that gains can be lost without sustained action. 
e majority of cases in 2010 were in countries that had been polio-free until the virus travelled back across borders 
and caused outbreaks in areas where people had gotten lax about vaccination. ere was a large outbreak in ajikistan 
in the irst half of 2010 and another in Congo in the second half. In both regions there were a number of immunization 
campaigns organized as a response. oday the outbreaks appear to be under control.
What those outbreaks in formerly polio-free countries prove is that eradication is a global project requiring every 
country to do its part. ery few projects demand global participation. In most areas each country can pursue its own 
approach, and countries can compare outcomes to see which approach is the most successful.
hilosopher and historian Will Durant once observed that the only thing that could get countries to join forces would 
be an alien invasion. o my mind, terrible diseases are surrogates for an alien invasion. If we are to succeed, the world 
needs leadership from a global institution and signiicant, coordinated resources from rich countries to fund activities 
in the poorest countries. 
 
 
 = Page 7 =
© GAVI 
Clockwise, from top left: Health worker vaccinates a woman against tetanus (Freetown, Sierra Leone, 2009). Child receives oral polio vaccine from 
house-to-house vaccination team (Kano, Nigeria, 2010). Mother has her baby vaccinated against rotavirus (Corozal, Nicaragua, 2009).
Rise in measles vaccine coverage and diphtheria, tetanus, and pertussis (DTP3) vaccine coverage, 1980-1995  Rise in measles vaccine coverage and diphtheria, tetanus, and pertussis (DTP3) vaccine coverage, 1980-1995
100%
90%
80%
70%
60%
50%
40%
30%
20%
DTP3
Measles
10%
1980  1981  1982  1983  1984  1985  1986  1987  1988  1989  1990  1991  1992  1993  1994  1995
Source: UNICEF
8
 
 = Page 8 =
2011 Annual Letter   from   Bill Gates
2011 
For polio, the World Health Organization WHO has played the central role with otary International, the Centers 
for Disease Control, and UNICEF as key partners. olio eradication has beneited immensely from having otary’s 
support. otary had the vision to get involved in 1985 and has kept polio eradication as its top priority. Everywhere I 
go to learn about polio, I see otary members helping out with the hard work. 
I feel sure that with continued support we will be able to show signiicant progress building on this year’s work. e site 
www.polioeradication.org   tracks the key parts of the campaign including fundraising and the latest cases. I will make 
a number of trips focused on polio this year, including additional trips to India and Nigeria, and will write a report for 
the foundation website. For anyone who wants to support the polio campaign, which would be fantastic, visit   www.
rotary.org   and click on the EndolioNow logo.
he Miracle of Vaccines
In the same way that during my Microsot career I talked about the magic of sotware, I now 
spend my time talking about the magic of vaccines. accines have taken us to the threshold of 
eradicating polio. ey are the most efective and cost-efective health tool ever invented. I like 
to say vaccines are a miracle. ust a few doses of vaccine can protect a child from debilitating 
and deadly diseases for a lifetime. And most vaccines are extremely inexpensive. For example, 
the polio vaccine costs 13 cents a dose. 
is year 1.4 million children will die from diseases for which there are already vaccinesdiseases like measles, 
pneumonia, and tetanus. ose lives can be saved if we can reduce the costs of vaccines and raise enough money to 
buy and distribute them. If we simply scale up existing vaccines in the ive countries with the highest number of child 
deaths, we could save 3 million lives and more than $2.9 billion in treatment costs alone over the next decade. In 
addition, researchers are inventing new vaccines for malaria, AIDS, and tuberculosis, and these would save millions 
more lives. But generous aid is required to realize the true lifesaving potential of vaccines. e most direct way of saying 
this is that every $2,000 cut in the most efective aid spending causes a child to die.
few  years  ago  I  was  looking  into  the  history  of  vaccination 
coverage.  In  1980  less  than  20  percent  of  children  worldwide 
received  the  vaccinations  for  diseases  including  measles, 
A  diphtheria, tetanus, and whooping cough pertussis that children in rich    
countries were receiving. Less than 15 years later, in 1995, vaccination 
rates had been raised to over 0 percent. ust this year I inally got around 
to learning why there was such a huge increase. e head of UNICEF 
at  the  time,  im  Grant,  led  the  way.  e  book   Jim  Grant—UNICEF 
Visionary   tells his amazing story. Since there are only a few used copies 
of this in circulation UNICEF recently made a free version available at   
www.unicef.org/publications/index_4402.html  .
I’m surprised by how little attention his story gets and how long it took 
me to ind out about it. I was inspired by reading how he drove global 
Jim Grant reads with a child at a community center    © UNICEF
progress even during the tough economic decade of the 1980s. We can   (Abidjan, Cote d’Ivoire, 1994).
draw lessons from his leadership now, in our own tough economic times. 
As is oten the case with courageous eforts, many people resisted im Grant’s push, viewing it as too top-down. 
However, he managed to enlist a number of countries to lead the way, and as the number of deaths in those countries 
dropped dramatically he was able to persuade almost every country to run strong vaccination campaigns. It is especially 
amazing that he did this in an age when there was no Internet and no email. im Grant’s achievement is the greatest 
miracle of saving children’s lives ever.
9
 
 = Page 9 =
Infant being immunized at a district hospital (Dowa, Malawi, 2010).
10
 
 = Page 10 =
2011 Annual Letter   from   Bill Gates
2011 
he beneits of widespread vaccination are mostly explained in terms of the lives vaccines save, and based on that 
measure alone, vaccines are the best investment to improve the human condition. However, there are two other 
equally important beneits that are not as widely known partly because they are harder to quantify. 
 
e irst is the reduction in sickness. I don’t mean just the acute sickness where a child is clearly sufering from the 
disease, but also the permanent disabilities caused by the disease. is is most noticeable when the disability presents 
with a clear symptom such as being paralyzed by polio or going deaf because of a pneumococcal infection. However, 
the largest disability is the efect on mental development. For example, severe cerebral malaria damages your brain 
even if you survive. When children have lots of diarrheal episodes or parasites in their intestines, they don’t get enough 
nutrition for their brains to develop fully. 
e huge infectious disease burden in poor countries means that a substantial part of their human potential is lost by 
the time children are 5 years old. A group of researchers at the University of New Mexico conducted a study, covered in 
he Economist  , showing the correlation between lower I and a high level of disease in a country. Although an I test 
is not a perfect measure, the dramatic efect you see is a huge injustice. It helps explain why countries with high disease 
burdens have a hard time developing their economies as easily as countries with less disease. 
e second great beneit of vaccination is that as the childhood death rate is reduced, within 10 to 20 years this reduction 
is strongly associated with families choosing to have fewer children. While it might seem logical that saving children’s 
lives will cause overpopulation, the opposite is true. 
I mention this amazing connection oten, since I remember how I had to hear it multiple times before the full 
implications of it became clear. It is the reason why childhood health issues are key to so many other issues, including 
having resources for education, providing enough jobs, and not destroying the environment. Only when Melinda and 
I understood this connection did we make the full commitment to health issues, especially vaccination.
e connection of health to education, jobs, and the environment points back to the tremendous value of high-quality 
international aidand why it’s essential that donor nations not cut their spending on it. Melinda and I have committed 
$10 billion from the foundation over the next 10 years to help make this the Decade of accines. However, this will fall 
well short of what is needed. 
e group which helps poor countries purchase vaccines and increase vaccine coverage is the GAI Alliance and like 
the polio campaign its success will depend on donor generosity.  
Correlation between IQ and disease burden in 184 selected countries
IQ
110
100
90
80
70
60
2.0  2.5  3.0  3.5  4.0  4.5  5.0
Disease burden*
Source: Christopher Eppig, 
*he logarithm of disability-adjusted life years (DALYs) lost to 28 representative and important human infectious diseases.
University of New Mexico
11
 
 = Page 11 =
Bed nets to protect against malaria being manufactured at the A to Z Textile Mills (Arusha, Tanzania, 2009).
Shanti Devi holds her newborn daughter (Koelikhera Village, India, 2004). Melinda observes newborn babies at Bwaila Hospital (Lilongwe, Malawi, 2010).
12
 
 = Page 12 =
2011 Annual Letter   from   Bill Gates
2011 
he foundation’s website does a great job of outlining all of our strategies, but in the remainder of my letter I want 
to highlight a few speciic areas. e world has made some crucial breakthroughs, and with bold leadership I 
think we can do even more. 
 
Malaria: Progress on Multiple Fronts 
e ight against malaria is making very good progress. e death toll, overwhelmingly of young 
children in Africa, went down from 985,000 in 2000 to 81,000 in 2009. Of the 99 countries 
with malaria, 43 have decreased cases of the disease by more than 50 percent. urkmenistan and 
Morocco were recently declared malaria-free. For these communities the reduction in both death 
and sickness makes a huge diference. And it is possible only because of increased donor spending, 
which reached $1.5 billion in 2009. 
e oll Back Malaria group, with strong support from the WHO and our foundation, has set an aggressive goal 
to provide bed nets to almost every household that needs them in the next few years. As coverage goes up from its 
current level of 42 percent, it will have a dramatic impact. In Senegal, where 80 percent of households own a bed net, 
the number of malaria cases went down 41 percent in a single year. Many amazing grassroots groups are helping with 
the delivery of bed nets. e Nothing But Nets campaign, for example, has gotten hundreds of thousands of individual 
citizens and organizations like the United Methodist Church and the National Basketball Association involved in the 
ight against malaria. 
We are also working on lowering the cost of the anti-malaria drugs containing artemisinin, which are expensive enough 
that people are still using less efective drugs instead. e approaches range from breeding the plant that provides 
artemisinin to have a higher yield, to using very advanced synthetic chemistry that can make artemisinin starting with 
simple sugars. 
As is the case with all infectious diseases, the ultimate tool against malaria would be a low cost, highly efective vaccine. 
e S,S vaccine, developed in partnership with the pharmaceutical manufacturer GSK, is in its inal phase-3 trial 
stage. Interim data will be available later this year, and we should have inal results by 2015. A number of other vaccine 
candidates that might be even more efective or might be combined with S,S are also making progress, and several 
will start human trials this year.
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 irst 
28 days of life, or the neonatal period. e good news is that we are headed in the right direction. 
In 1995 there were an estimated 5. million neonatal deaths. e most recent estimates show the 
number down to around 3. million. 
Unlike the deaths that take place ater 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. ou 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 irst 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 efectively, 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   www.gatesfoundation.org/womendeliver  . e 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. ey were born within hours of each other. Each had sufered the 
13
 
 = Page 13 =
Clockwise, from top left: Pregnant mother gets tested for HIV at the NDA Health Center (Dimbokro, Cote d’Ivoire, 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). Physician examines a six-year-old girl (Siem Reap Province, Cambodia, 2010). 
14
 
 = Page 14 =
2011 Annual Letter   from   Bill Gates
2011 
same conditionthey were unable to breath at birth. Sadly, it was clear that only one would survive. at 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. e 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.
HIV/AIDS and the Need for Leadership
rogress continues in ighting the AIDS epidemic, but the pace is slow. e rate of HI infection 
has been reduced by almost 20 percent over the last 10 years, to fewer than 2. million infections 
per year. e number of people dying from AIDS has gone down by more than 20 percent in 
the last ive 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. 
e war against AIDS is being waged on two frontstreating those who are already infected and preventing new infections. 
reatment continues to be scaled up, with more than 5 million people receiving HI drugs. is is a great success story. 
ich 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 HI. Because we don’t have a 
cure for AIDS, treatment has to continue for a patient’s entire life. at 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 costsover four times as much as is provided 
in aid today. o 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. e diculty of funding treatment makes it clear how 
important it is to prevent new cases. e sooner we make progress the better. ere needs to be a sense of urgency 
that doesn’t exist yet.
revention breaks down into several diferent areas. e easiest should be preventing mother-to-child transmission 
since it simply involves giving a mother drugs to prevent transmission to her child. ere 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. 
en we have prevention approaches that rely on new tools. We now have three tools that have shown signiicant 
impact. e irst is male circumcision, which I discussed last year. Amazingly, teenagers in communities with high 
HI 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 beneit 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 ield, 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,  rE  re-Exposure  rophylaxis, 
Talking to reporters at the XVII International AIDS Conference   ©  IAS
involves someone without HI taking an anti-HI drug on a regular   (Vienna, Austria, 2010).
15
 
 = Page 15 =
Lab technicians at the Diamond AIDS Research Center (New York City, 2008).
Farmer prepares dried maize (corn) for sale (Monopo, Mozambique, 2010). Farmer separates maize from stalks (Malawi, 2010).  © Charlie Barnwell, World Food Programme
1
 
 = Page 16 =
2011 Annual Letter   from   Bill Gates
2011 
basis to block infection. A rE trial showed a strong prevention beneit for the participants who consistently used the 
drugs and a weaker impact when all the participants were included. With both microbicides and rE I think countries 
with large epidemics should igure out how to do large community trials as soon as possible. is 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 ind a way to cut through all the complexity. With HI it is more dicult since there are many countries involved. 
But we need to work creatively to shorten these delays.  
e best tool would be a vaccine for HI. e scientiic progress on this has gone well. e positive results of the trial 
in ailand were a turning point for the ield, and blood samples from the volunteers are being studied in depth for 
lessons about why that vaccine worked but only to a limited degree. 
ere has also been an explosion in the discovery of antibodies that block HI 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 efective HI 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 ive years. e ield needs to look into how to shorten this so 
that progress matches the urgency of the problem. 
Agriculture’s Great Promise 
Outside of health the area where we invest the most to help poor people is agriculture. ere 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 wanda, Ethiopia, and anzania, investments 
in seeds, training, access to markets, and innovative agricultural policy are making a real diference. 
Ghana made agriculture a priority and cut hunger by 5 percent between 1990 and 2004. e increase in food production 
has led to economic development in other areas. 
But the growth in other countries has been slower. ese are complex issues, and it’s going to take strong leadership 
to make sure farmers have the opportunity to seize their potential. Koi Annan, who chairs the Alliance for a Green 
evolution 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 rogramme 
WF, the world’s largest humanitarian agency for ighting 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 WF to be used as food aid. ey had trouble 
meeting WF’s complicated requirements and delivering food in bulk quantities that met WF’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 WF. When the West African country of Niger experienced a famine last summer, WF 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. 
e 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 inance ministers of the United States, 
Spain, Canada, and South Korea to launch the Global Agriculture and Food Security rogram with initial commitments 
of nearly $1 billion over three years. is 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. 
1
 
 = Page 17 =
Selected countries’ performance in mathematics, reading, and science, 2009
Mathematics  Reading  Science
Shanghai-China  600  Shanghai-China  556  Shanghai-China  556  Significantly above 
the OECD average
Singapore  562  Korea  539  Finland  539
Hong Kong-China  555  Finland  536  Hong Kong-China  536
OECD average
Korea  546  Hong Kong-China  533  Singapore  533
Chinese Taipei  543  Singapore  526  Japan  526  Significantly below 
Finland  541  Canada  524  Korea  524  the OECD average
Liechtenstein  536  New Zealand  521  New Zealand  521
Switzerland  534  Japan  520  Canada  520
Japan  529  Australia  515  Estonia  515
Canada  527  Netherlands  508  Australia  508
Netherlands  526  Belgium  506  Netherlands  506
Macao-China  525  Norway  503  Chinese Taipei  503
New Zealand  519  Estonia  501  Germany  501
Belgium  515  Switzerland  501  Liechtenstein  501
Australia  514  Poland  500  Switzerland  500
Germany  513  Iceland  500  United Kingdom  500
Estonia  512  Slovenia  500
United States  500
Iceland  507  Macao-China  499
Liechtenstein  499
Denmark  503  Poland  497
Sweden  497
Slovenia  501  Ireland  497
Germany  497  PISA   focuses on young 
Belgium  496
Norway  498  Ireland  496  people’s ability to use their 
France  497  France  496  Hungary  496  knowledge and skills to meet 
Slovak Republic  497  Chinese Taipei  495  United States  495  real-life challenges. This 
Austria  496  Denmark  495  Czech Republic  495
orientation reflects a change 
Poland  495  United Kingdom  494  Norway  494
in the goals and objectives of 
Sweden  494  Hungary  494  Denmark  494
curricula themselves, which 
Czech Republic  493  Portugal  489  France  489
are increasingly concerned 
United Kingdom  492
Macao-China  487  Iceland  487  with what students can do 
Hungary  490
Italy  486  Sweden  486  with what they learn at school 
Luxembourg  489  Latvia  484  Austria  484
and not merely with whether 
United States  487  Slovenia  483  Latvia  483
they have mastered specific 
Ireland  487  Greece  483  Portugal  483
curricular content.
Portugal  487  Spain  481  Lithuania  481
Source: OECD PISA 2009 database
Geoffrey Canada talks with students at Harlem Children’s Zone, in a scene from   Waiting for “Superman”   (New York City, 2009).
18  © Paramount Pictures/Participant Media
 
 = Page 18 =
2011 Annual Letter   from   Bill Gates
2011 
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 3 percent, which is 20 percent faster than the rest 
of the economy. Over that time our achievement levels were basically at, while other countries caught up. A recent 
analysis by the rogramme for International Student Assessment ISA 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. 
ISA 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 5 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. ere are four levels of proiciency 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 ISA analysis available at   www.pisa.oecd.org  , two key things diferentiate the U.S. education system 
from most other countries’ systems. e irst 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. ey igured it out on their own. at’s why our foundation is investing to help devise measurement 
and support systems to help good teachers become great teachers.
Our project to learn what the best teachers doand how to share this information with other teachersis making 
signiicant progress. With the help of local union aliates, 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 ennessee 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 sourcestest scores, student surveys, videos, principals, 
and fellow teachersso 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   Visiting the Ridgeway Middle School with Melinda to learn about the 
Measures of Effective Teaching project (Memphis, Tennessee, 2010).
medical costs. I recently gave a speech to the chief state school ocers   
19
 
 = Page 19 =
Welding student Jaurie Vaughn at the Tennessee Technology Center (Nashville, Tennessee, 2010).
20
 
 = Page 20 =
2011 Annual Letter   from   Bill Gates
2011 
  www.gatesfoundation.org/ccsso   about how they might need to ind money to reward excellent teaching by shiting 
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 ennessee echnology Center in Nashville, an institution 
that provides young adults with technical training and certiicates. It gets signiicantly better results than its peer 
institutionsgraduating 1 percent of its studentsbecause 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 diference for students.
e foundation is funding the development of online tools to help both K-12 and college students learn. ioneers like 
Sal Khan are already showing how efective 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. e 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 ill the gaps in your knowledge. Also, Khan Academy is creating an online dashboard to help teachers use the site 
as part of their curriculum. e 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.
he Giving Pledge 
Warren Bufett 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. e dinners evolved into discussions of the challenges of giving efectively. It became clear that there was a lot of 
collective knowledge and that we could inspire each other and in some cases work together. ere was a strong sense we 
should broaden the discussion to a larger group including people who were earlier in their giving career. 
is led to the idea of the Giving ledge. 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 ledge. ou can see the letters describing their thinking 
about giving at   www.givingpledge.org.   e United States is the most generous country in the world. More than 15 
percent of the large estates go to charity. at is signiicant, but there is room for that to increase. Warren has said, We 
want the general level of giving to step up. We want the ledge to help society become even more generous. We hope 
the norm will change towards even greater and smarter philanthropy.
Although this efort is focused on those people in the United States with the greatest wealth, we are encouraged by and 
support similar eforts 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 irst half of the year.
21
 
 = Page 21 =
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 lower 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).
22
 
 = Page 22 =
2011 Annual Letter   from   Bill Gates
2011 
Continuing the Conversation 
Last year I launched   www.gatesnotes.com   and started a witter feed   @BillGates   to share my 
thoughts on the work we’re doing and what I’m learning from leaders and innovators. One great 
beneit 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 terriic EDx event 
  www.tedxchange.org   in New ork that brought together interesting speakers on global health and development. 
Next year, building on her relationship with ED, she’ll be hosting a series of EDxChange events in communities 
around the worldin places like Kenya and India. e goal of these EDxChange 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 diculties 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. ef aikes, our CEO, continues to add great people and improve the way we do our work. Not everyone 
can go to the ield, or even donate. But every one of us can be an advocate for people whose voices are oten 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 
anuary 2011
23
 
 = Page 23 =
Guided by the belief that every life has equal value, the Bill & Melinda Gates Foundation works to help all people lead 
healthy, productive lives. In developing countries, it focuses on improving people’s health and giving them the chance to lift 
themselves out of hunger and extreme poverty. In the United States, it seeks to ensure that all people—especially those 
with the fewest resources—have access to the opportunities they need to succeed in school and life. Based in Seattle, 
Washington, the foundation is led by CEO Jeff Raikes and Co-chair William H. Gates Sr., under the direction of Bill and 
Melinda Gates and Warren Buffett. Learn more at   www.gatesfoundation.org  .
PO Box 23350, Seattle, WA 98102   |   +1.206.709.3100   |   info gatesfoundation.org   |   www.gatesfoundation.org  @
facebook.com/billmelindagatesfoundation   |   twitter.com/gatesfoundation
 2011 Bill  Melinda Gates Foundation. All ights eserved. Bill  Melinda Gates Foundation is a registered trademark in the United States and other countries.
 
 = Page 24 =

 

Annual Letter   from   Bill Gates
 
 = Page 1 =
Vaccinators being trained at the Kabuga Health Centre for the upcoming polio campaign (Kano, Nigeria, 2010).
2
 
 = Page 2 =
2011 Annual Letter   from   Bill Gates
2011 
s I sit down to work on my third annual letter, governments in every corner of the world are facing tough 
decisions about how to reduce spending. Although foreign aid accounts for less than 1 percent of governments’ 
total budgets, it is one place being considered for cuts. As a result, health and agricultural assistance that saves 
A  lives and puts poor countries on a track for self-suciency is at risk.
e world’s poorest will not be visiting government leaders to make their case, unlike other constituencies, so I want to 
help make their case by describing the progress and the potential I see in key areas of health and development. erhaps 
it is ironic for someone who has been so lucky to talk about the needs of those who have not.
I believe it is in the rich world’s enlightened self-interest to continue investing in foreign aid. If societies can’t provide 
for people’s basic health, if they can’t feed and educate people, then their populations and problems will grow and the 
world will be a less stable place.
Whether you believe it a moral imperative or in the rich world’s enlightened self-interest, securing the conditions that 
will lead to a healthy, prosperous future for everyone is a goal I believe we all share.
Many people don’t have a clear image of the beneits aid actually provides. at’s not surprising, because aid covers 
many diferent areas. Also, in the past some aid was sent to countries to buy friendship without real regard for its 
impact. However, today a signiicant portion of foreign aid is spent on hugely beneicial programs that improve people’s 
lives in both the near and long term.  
Despite the threat to aid budgets, one thing that makes me optimistic about the future is the courage of leaders who are 
inding ways to make the welfare of poor people a priority. Under David Cameron’s leadership, the United Kingdom 
set a great example by keeping its promise to grow aid spending despite the cuts it had to make. It is inspiring to see a 
leader stand up for what he believes is right, even when it isn’t easy.
Ending Polio
Aid for the poorest has already achieved a lot. For example, because of donors’ generosity, we are on the threshold of 
ending polio once and for all.
olio is a terrible disease that kills many and paralyzes others. Fity years ago it was widespread around the world. 
When you talk to people who remember polio in the United States, they’ll tell you about the fear and panic during an 
outbreak and describe grim hospital wards full of children in iron lungs that maintained their breathing. At its peak in 
the United States in 1952, polio paralyzed or killed more than 24,000 people.
Reduction in countries with sustained transmission of polio, 1988-2010
Afghanistan
countries   countries
India
in  in
Nigeria
1988  2010  Pakistan
125  4
Child suffering from polio reads a comic book attached 
to the rim of an iron lung (ca. 1955).
3
 
 = Page 3 =
Estimated number of polio cases per year  Estimated number of polio cases per year
350,000
300,000
3,500
3,000
250,000  2,500
2,000
1,500
200,000
1,000
500
150,000
0
2000  2001  2002  2003  2004  2005  2006  2007  2008  2009  2010
100,000
50,000
0
1988  1990  1992  1994  1996  1998  2000  2000  2002  2002  2004  2004  2006  2006  2008  2008   2010   2010
Source: WHO/Polio database
Crowded polio ward at Hynes Memorial Hospital (Boston, 1955).
4
 
 = Page 4 =
2011 Annual Letter   from   Bill Gates
2011 
As a result of mass mobilizations to administer the polio vaccine, polio was eliminated in the United States and most 
developed nations decades ago. Most people who live in rich countries assume the disease is long gone and that it 
doesn’t kill or paralyze children anymore. But it is still a frightening presence in a number of places around the world.
In 1988 the global community adopted the goal of ending polio altogether. At that time more than 350,000 children 
a year worldwide were killed or paralyzed by the disease. Since then, vaccination coverage has increased signiicantly 
and the number of cases has gone down by 99 percent, to fewer than 1,500 last year. ere are now just four countries 
where polio transmission has never been stopped: India, Nigeria, akistan, and Afghanistan.
at’s incredible progress, but the last 1 percent remains a true danger. Eradication is not guaranteed. It requires 
campaigns to give polio vaccine to all children under 5 in poor countries, at a cost of almost $1 billion per year. We 
have to be aggressive about continuing these campaigns until we succeed in eradicating that last 1 percent.
erefore, funding is critical to success. Organizations such as otary International and the governments of India, the 
United States, the United Kingdom, and apan are all major contributors to the polio campaign. Our foundation gives 
about $200 million each year. But the campaign still faces a 2011-12 funding gap of $20 million. If eradication fails 
because of a lack of generosity on the part of donor countries it would be tragic. We are so close, but we have to inish 
the last leg of the journey. We need to bring the cases down to zero, maintain careful surveillance to ensure the virus is 
truly gone, and keep defenses up with polio vaccines until we’ve conirmed success. 
hy is it so important to end polio Eradication will have three huge beneits. 
e irst is that getting rid of polio will mean that no child will die or be paralyzed by 
the disease in the future. One thing most people don’t realize is that if we don’t inish 
W
the job on eradication, we will lose a lot of the ground we’ve gained over the past two decades. 
e disease will not stay at its current low level. If we don’t get rid of it, it will spread back into 
countries where it’s been eliminated, and it will kill and paralyze children who used to be safe. 
Only eradication will guarantee that all children are safe.
e second beneit is that the money that will be saved by eradicating polio far exceeds what we are spending on 
eradication eforts now. e long-term beneits of the last couple of billion dollars spent on eradication will be truly 
phenomenal. A recent estimate added up the cost of treatment that won’t be necessary and the enhanced economic 
contribution of adults who won’t get polio. Eradication could save the world up to $50 billion over the next 25 years.
e third beneit is that success will energize the ield of global health by showing that investments in health lead to 
amazing victories. e eradication efort illustrates so well how a major advance in the human condition requires 
resolve and courageous leadership. o win these big important ights, partnerships, money, science, politics, and 
delivery in developing countries have to come together on a global scale. 
he history of polio and polio eradication is fascinating. One of the best books I’ve read on the subject is David 
Oshinsky’s   Polio: An American Story  . olio was the irst disease that raised signiicant money from the broad 
public. e March of Dimes was created to combat the disease. Although resident oosevelt and lots of 
  Hollywood stars helped the campaign, its huge success came from neighborhood-based fundraising. I remember March 
of Dimes volunteers ringing our doorbell when I was growing up and asking for a donation. By any measure, the public’s 
generosity in supporting that charity made it one of the most successful health-related fundraising campaigns ever.  
e March of Dimes funded research into the irst polio vaccine, which was invented by Dr. onas Salk and introduced 
in 1955. It was such an important priority to get the polio vaccine out widely that the U.S. government sponsored the 
campaign, which it had never done before. e campaigns of the late-1950s were wildly successful, and by 191 the 
number of cases in the United States was down to just 11. 
A second polio vaccinethis one in the form of liquid drops that children swallow instead of an injection in the arm
was invented by Dr. Albert Sabin and licensed in 193. By 199 there was no more poliovirus in circulation in the 
United States. Dr. Salk’s and Dr. Sabin’s vaccines are still the key tools used for eradication today. 
5
 
 = Page 5 =
Polio timeline
3000 BC  1952  1963  1979  2007
Egyptian paintings and   Worst polio outbreak   Albert Sabin’s oral   Last case of naturally   The World Health 
carvings depict people   in United States   polio vaccine licensed  occurring polio in the   Organization declares 
with withered limbs   history, with 658,000   United States  polio eradicated in the 
and walking with canes  reported cases  Americas, Europe, and 
the Western Paciic 
1928  1955   1970s  1988  2010
First iron   Jonas Salk’s   National immunization   Polio still exists in     Sustained transmission 
lung used at   injected polio   programs launched,   125 countries and   of polio in four countries, 
Children’s   vaccine introduced  leading to control of   paralyzes an estimated   but outbreaks in 16 
Hospital in   the disease in many   350,000 children;   countries are reminders 
Boston  developing countries  Global Polio Eradication   that polio anywhere is a 
Initiative created  threat everywhere
Clockwise, from top: Rotary vaccination teams pick up vaccines and other supplies at the Patna Junction railway station (Bihar, India, 2010). World Health Organization 
workers unpack polio vaccine from boxes designed to keep it cold (Bihar, India, 2010). Billboard advertises the ongoing polio campaigns in Patna (Bihar, India, 2010).
 
 
 = Page 6 =
2011 Annual Letter   from   Bill Gates
2011 
o this day, the smallpox campaign is the only successful human disease 
eradication campaign in history. At its peak, smallpox killed over 2 million 
people  every  year  and  also  blinded  and  disabled  large  numbers.  e 
eradication campaign started in 19, the last naturally acquired case of 
smallpox was in 19, and the world was certiied as being free of smallpox 
in 199. wo excellent books on the smallpox eradication are Dr. D.A. 
Henderson’s   Smallpox: he Death of a Disease   and the forthcoming   House on 
Fire   by another key smallpox warrior, Dr. Bill Foege. 
Smallpox had a number of characteristics that made it easier to eradicate 
than polio. Almost everyone who got smallpox developed a distinct rash. In 
contrast most polio infections are not noticed because less than one in 100 
people infected are paralyzed, even though all those infected can transmit 
the virus. is means by the time a paralytic case is found, the poliovirus has 
probably spread. 
Also, the vaccines against polio are not as efective as the smallpox vaccine, 
which was so powerful that a single vaccination protected almost everyone. 
In the case of the most common polio vaccine, at least three doses are 
required to get 85 percent of children fully protected. In many countries of 
Girl winces as she gets vaccinated against smallpox (Nigeria, 1969).
the developing world, even more doses are needed to reach the immunity 
levels needed to stop transmission of the virus. 
But the polio campaign also has some huge advantages that the smallpox campaign did not have. e advanced science 
we have today lets us sequence the DNA of the polio virus and develop an understanding of the history of transmission, 
which guides our work. We also have far better communications and modeling tools than were available in the 190s, 
and those are being used in smart ways to respond rapidly to every outbreak.
n 2003 I would have said we were just a couple of years away from ending polio, and I would have been wrong. at 
year there were false rumors in Nigeria that the polio vaccine caused women to become sterile. is allowed the 
disease to have a resurgence and to spread to many other countries. e experience of 2003 serves as a reminder to 
be humble as we move forward. But humility does not mean fatalism.  I
Fortunately those false rumors have been almost completely eliminated through the leadership of key political and 
religious igures. In 2009 when I visited Northern Nigeria to meet with the most important traditional leader, the 
Sultan of Sokoto, he committed to the campaign. It was fantastic to see him publicly giving his support. He also gave 
me a horse to thank me but I told him I couldn’t take it. 
Last year both India and Nigeria had substantially fewer cases than ever before. In India the number of cases went 
down from 41 in 2009 to just 41 in 2010. In Nigeria, thanks in large part to the renewed leadership in the northern 
part of the country, the number went down from 388 to just 18. But alongside the phenomenal progress was another 
reminder that gains can be lost without sustained action. 
e majority of cases in 2010 were in countries that had been polio-free until the virus travelled back across borders 
and caused outbreaks in areas where people had gotten lax about vaccination. ere was a large outbreak in ajikistan 
in the irst half of 2010 and another in Congo in the second half. In both regions there were a number of immunization 
campaigns organized as a response. oday the outbreaks appear to be under control.
What those outbreaks in formerly polio-free countries prove is that eradication is a global project requiring every 
country to do its part. ery few projects demand global participation. In most areas each country can pursue its own 
approach, and countries can compare outcomes to see which approach is the most successful.
hilosopher and historian Will Durant once observed that the only thing that could get countries to join forces would 
be an alien invasion. o my mind, terrible diseases are surrogates for an alien invasion. If we are to succeed, the world 
needs leadership from a global institution and signiicant, coordinated resources from rich countries to fund activities 
in the poorest countries. 
 
 
 = Page 7 =
© GAVI 
Clockwise, from top left: Health worker vaccinates a woman against tetanus (Freetown, Sierra Leone, 2009). Child receives oral polio vaccine from 
house-to-house vaccination team (Kano, Nigeria, 2010). Mother has her baby vaccinated against rotavirus (Corozal, Nicaragua, 2009).
Rise in measles vaccine coverage and diphtheria, tetanus, and pertussis (DTP3) vaccine coverage, 1980-1995  Rise in measles vaccine coverage and diphtheria, tetanus, and pertussis (DTP3) vaccine coverage, 1980-1995
100%
90%
80%
70%
60%
50%
40%
30%
20%
DTP3
Measles
10%
1980  1981  1982  1983  1984  1985  1986  1987  1988  1989  1990  1991  1992  1993  1994  1995
Source: UNICEF
8
 
 = Page 8 =
2011 Annual Letter   from   Bill Gates
2011 
For polio, the World Health Organization WHO has played the central role with otary International, the Centers 
for Disease Control, and UNICEF as key partners. olio eradication has beneited immensely from having otary’s 
support. otary had the vision to get involved in 1985 and has kept polio eradication as its top priority. Everywhere I 
go to learn about polio, I see otary members helping out with the hard work. 
I feel sure that with continued support we will be able to show signiicant progress building on this year’s work. e site 
www.polioeradication.org   tracks the key parts of the campaign including fundraising and the latest cases. I will make 
a number of trips focused on polio this year, including additional trips to India and Nigeria, and will write a report for 
the foundation website. For anyone who wants to support the polio campaign, which would be fantastic, visit   www.
rotary.org   and click on the EndolioNow logo.
he Miracle of Vaccines
In the same way that during my Microsot career I talked about the magic of sotware, I now 
spend my time talking about the magic of vaccines. accines have taken us to the threshold of 
eradicating polio. ey are the most efective and cost-efective health tool ever invented. I like 
to say vaccines are a miracle. ust a few doses of vaccine can protect a child from debilitating 
and deadly diseases for a lifetime. And most vaccines are extremely inexpensive. For example, 
the polio vaccine costs 13 cents a dose. 
is year 1.4 million children will die from diseases for which there are already vaccinesdiseases like measles, 
pneumonia, and tetanus. ose lives can be saved if we can reduce the costs of vaccines and raise enough money to 
buy and distribute them. If we simply scale up existing vaccines in the ive countries with the highest number of child 
deaths, we could save 3 million lives and more than $2.9 billion in treatment costs alone over the next decade. In 
addition, researchers are inventing new vaccines for malaria, AIDS, and tuberculosis, and these would save millions 
more lives. But generous aid is required to realize the true lifesaving potential of vaccines. e most direct way of saying 
this is that every $2,000 cut in the most efective aid spending causes a child to die.
few  years  ago  I  was  looking  into  the  history  of  vaccination 
coverage.  In  1980  less  than  20  percent  of  children  worldwide 
received  the  vaccinations  for  diseases  including  measles, 
A  diphtheria, tetanus, and whooping cough pertussis that children in rich    
countries were receiving. Less than 15 years later, in 1995, vaccination 
rates had been raised to over 0 percent. ust this year I inally got around 
to learning why there was such a huge increase. e head of UNICEF 
at  the  time,  im  Grant,  led  the  way.  e  book   Jim  Grant—UNICEF 
Visionary   tells his amazing story. Since there are only a few used copies 
of this in circulation UNICEF recently made a free version available at   
www.unicef.org/publications/index_4402.html  .
I’m surprised by how little attention his story gets and how long it took 
me to ind out about it. I was inspired by reading how he drove global 
Jim Grant reads with a child at a community center    © UNICEF
progress even during the tough economic decade of the 1980s. We can   (Abidjan, Cote d’Ivoire, 1994).
draw lessons from his leadership now, in our own tough economic times. 
As is oten the case with courageous eforts, many people resisted im Grant’s push, viewing it as too top-down. 
However, he managed to enlist a number of countries to lead the way, and as the number of deaths in those countries 
dropped dramatically he was able to persuade almost every country to run strong vaccination campaigns. It is especially 
amazing that he did this in an age when there was no Internet and no email. im Grant’s achievement is the greatest 
miracle of saving children’s lives ever.
9
 
 = Page 9 =
Infant being immunized at a district hospital (Dowa, Malawi, 2010).
10
 
 = Page 10 =
2011 Annual Letter   from   Bill Gates
2011 
he beneits of widespread vaccination are mostly explained in terms of the lives vaccines save, and based on that 
measure alone, vaccines are the best investment to improve the human condition. However, there are two other 
equally important beneits that are not as widely known partly because they are harder to quantify. 
 
e irst is the reduction in sickness. I don’t mean just the acute sickness where a child is clearly sufering from the 
disease, but also the permanent disabilities caused by the disease. is is most noticeable when the disability presents 
with a clear symptom such as being paralyzed by polio or going deaf because of a pneumococcal infection. However, 
the largest disability is the efect on mental development. For example, severe cerebral malaria damages your brain 
even if you survive. When children have lots of diarrheal episodes or parasites in their intestines, they don’t get enough 
nutrition for their brains to develop fully. 
e huge infectious disease burden in poor countries means that a substantial part of their human potential is lost by 
the time children are 5 years old. A group of researchers at the University of New Mexico conducted a study, covered in 
he Economist  , showing the correlation between lower I and a high level of disease in a country. Although an I test 
is not a perfect measure, the dramatic efect you see is a huge injustice. It helps explain why countries with high disease 
burdens have a hard time developing their economies as easily as countries with less disease. 
e second great beneit of vaccination is that as the childhood death rate is reduced, within 10 to 20 years this reduction 
is strongly associated with families choosing to have fewer children. While it might seem logical that saving children’s 
lives will cause overpopulation, the opposite is true. 
I mention this amazing connection oten, since I remember how I had to hear it multiple times before the full 
implications of it became clear. It is the reason why childhood health issues are key to so many other issues, including 
having resources for education, providing enough jobs, and not destroying the environment. Only when Melinda and 
I understood this connection did we make the full commitment to health issues, especially vaccination.
e connection of health to education, jobs, and the environment points back to the tremendous value of high-quality 
international aidand why it’s essential that donor nations not cut their spending on it. Melinda and I have committed 
$10 billion from the foundation over the next 10 years to help make this the Decade of accines. However, this will fall 
well short of what is needed. 
e group which helps poor countries purchase vaccines and increase vaccine coverage is the GAI Alliance and like 
the polio campaign its success will depend on donor generosity.  
Correlation between IQ and disease burden in 184 selected countries
IQ
110
100
90
80
70
60
2.0  2.5  3.0  3.5  4.0  4.5  5.0
Disease burden*
Source: Christopher Eppig, 
*he logarithm of disability-adjusted life years (DALYs) lost to 28 representative and important human infectious diseases.
University of New Mexico
11
 
 = Page 11 =
Bed nets to protect against malaria being manufactured at the A to Z Textile Mills (Arusha, Tanzania, 2009).
Shanti Devi holds her newborn daughter (Koelikhera Village, India, 2004). Melinda observes newborn babies at Bwaila Hospital (Lilongwe, Malawi, 2010).
12
 
 = Page 12 =
2011 Annual Letter   from   Bill Gates
2011 
he foundation’s website does a great job of outlining all of our strategies, but in the remainder of my letter I want 
to highlight a few speciic areas. e world has made some crucial breakthroughs, and with bold leadership I 
think we can do even more. 
 
Malaria: Progress on Multiple Fronts 
e ight against malaria is making very good progress. e death toll, overwhelmingly of young 
children in Africa, went down from 985,000 in 2000 to 81,000 in 2009. Of the 99 countries 
with malaria, 43 have decreased cases of the disease by more than 50 percent. urkmenistan and 
Morocco were recently declared malaria-free. For these communities the reduction in both death 
and sickness makes a huge diference. And it is possible only because of increased donor spending, 
which reached $1.5 billion in 2009. 
e oll Back Malaria group, with strong support from the WHO and our foundation, has set an aggressive goal 
to provide bed nets to almost every household that needs them in the next few years. As coverage goes up from its 
current level of 42 percent, it will have a dramatic impact. In Senegal, where 80 percent of households own a bed net, 
the number of malaria cases went down 41 percent in a single year. Many amazing grassroots groups are helping with 
the delivery of bed nets. e Nothing But Nets campaign, for example, has gotten hundreds of thousands of individual 
citizens and organizations like the United Methodist Church and the National Basketball Association involved in the 
ight against malaria. 
We are also working on lowering the cost of the anti-malaria drugs containing artemisinin, which are expensive enough 
that people are still using less efective drugs instead. e approaches range from breeding the plant that provides 
artemisinin to have a higher yield, to using very advanced synthetic chemistry that can make artemisinin starting with 
simple sugars. 
As is the case with all infectious diseases, the ultimate tool against malaria would be a low cost, highly efective vaccine. 
e S,S vaccine, developed in partnership with the pharmaceutical manufacturer GSK, is in its inal phase-3 trial 
stage. Interim data will be available later this year, and we should have inal results by 2015. A number of other vaccine 
candidates that might be even more efective or might be combined with S,S are also making progress, and several 
will start human trials this year.
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 irst 
28 days of life, or the neonatal period. e good news is that we are headed in the right direction. 
In 1995 there were an estimated 5. million neonatal deaths. e most recent estimates show the 
number down to around 3. million. 
Unlike the deaths that take place ater 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. ou 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 irst 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 efectively, 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   www.gatesfoundation.org/womendeliver  . e 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. ey were born within hours of each other. Each had sufered the 
13
 
 = Page 13 =
Clockwise, from top left: Pregnant mother gets tested for HIV at the NDA Health Center (Dimbokro, Cote d’Ivoire, 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). Physician examines a six-year-old girl (Siem Reap Province, Cambodia, 2010). 
14
 
 = Page 14 =
2011 Annual Letter   from   Bill Gates
2011 
same conditionthey were unable to breath at birth. Sadly, it was clear that only one would survive. at 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. e 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.
HIV/AIDS and the Need for Leadership
rogress continues in ighting the AIDS epidemic, but the pace is slow. e rate of HI infection 
has been reduced by almost 20 percent over the last 10 years, to fewer than 2. million infections 
per year. e number of people dying from AIDS has gone down by more than 20 percent in 
the last ive 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. 
e war against AIDS is being waged on two frontstreating those who are already infected and preventing new infections. 
reatment continues to be scaled up, with more than 5 million people receiving HI drugs. is is a great success story. 
ich 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 HI. Because we don’t have a 
cure for AIDS, treatment has to continue for a patient’s entire life. at 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 costsover four times as much as is provided 
in aid today. o 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. e diculty of funding treatment makes it clear how 
important it is to prevent new cases. e sooner we make progress the better. ere needs to be a sense of urgency 
that doesn’t exist yet.
revention breaks down into several diferent areas. e easiest should be preventing mother-to-child transmission 
since it simply involves giving a mother drugs to prevent transmission to her child. ere 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. 
en we have prevention approaches that rely on new tools. We now have three tools that have shown signiicant 
impact. e irst is male circumcision, which I discussed last year. Amazingly, teenagers in communities with high 
HI 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 beneit 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 ield, 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,  rE  re-Exposure  rophylaxis, 
Talking to reporters at the XVII International AIDS Conference   ©  IAS
involves someone without HI taking an anti-HI drug on a regular   (Vienna, Austria, 2010).
15
 
 = Page 15 =
Lab technicians at the Diamond AIDS Research Center (New York City, 2008).
Farmer prepares dried maize (corn) for sale (Monopo, Mozambique, 2010). Farmer separates maize from stalks (Malawi, 2010).  © Charlie Barnwell, World Food Programme
1
 
 = Page 16 =
2011 Annual Letter   from   Bill Gates
2011 
basis to block infection. A rE trial showed a strong prevention beneit for the participants who consistently used the 
drugs and a weaker impact when all the participants were included. With both microbicides and rE I think countries 
with large epidemics should igure out how to do large community trials as soon as possible. is 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 ind a way to cut through all the complexity. With HI it is more dicult since there are many countries involved. 
But we need to work creatively to shorten these delays.  
e best tool would be a vaccine for HI. e scientiic progress on this has gone well. e positive results of the trial 
in ailand were a turning point for the ield, and blood samples from the volunteers are being studied in depth for 
lessons about why that vaccine worked but only to a limited degree. 
ere has also been an explosion in the discovery of antibodies that block HI 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 efective HI 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 ive years. e ield needs to look into how to shorten this so 
that progress matches the urgency of the problem. 
Agriculture’s Great Promise 
Outside of health the area where we invest the most to help poor people is agriculture. ere 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 wanda, Ethiopia, and anzania, investments 
in seeds, training, access to markets, and innovative agricultural policy are making a real diference. 
Ghana made agriculture a priority and cut hunger by 5 percent between 1990 and 2004. e increase in food production 
has led to economic development in other areas. 
But the growth in other countries has been slower. ese are complex issues, and it’s going to take strong leadership 
to make sure farmers have the opportunity to seize their potential. Koi Annan, who chairs the Alliance for a Green 
evolution 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 rogramme 
WF, the world’s largest humanitarian agency for ighting 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 WF to be used as food aid. ey had trouble 
meeting WF’s complicated requirements and delivering food in bulk quantities that met WF’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 WF. When the West African country of Niger experienced a famine last summer, WF 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. 
e 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 inance ministers of the United States, 
Spain, Canada, and South Korea to launch the Global Agriculture and Food Security rogram with initial commitments 
of nearly $1 billion over three years. is 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. 
1
 
 = Page 17 =
Selected countries’ performance in mathematics, reading, and science, 2009
Mathematics  Reading  Science
Shanghai-China  600  Shanghai-China  556  Shanghai-China  556  Significantly above 
the OECD average
Singapore  562  Korea  539  Finland  539
Hong Kong-China  555  Finland  536  Hong Kong-China  536
OECD average
Korea  546  Hong Kong-China  533  Singapore  533
Chinese Taipei  543  Singapore  526  Japan  526  Significantly below 
Finland  541  Canada  524  Korea  524  the OECD average
Liechtenstein  536  New Zealand  521  New Zealand  521
Switzerland  534  Japan  520  Canada  520
Japan  529  Australia  515  Estonia  515
Canada  527  Netherlands  508  Australia  508
Netherlands  526  Belgium  506  Netherlands  506
Macao-China  525  Norway  503  Chinese Taipei  503
New Zealand  519  Estonia  501  Germany  501
Belgium  515  Switzerland  501  Liechtenstein  501
Australia  514  Poland  500  Switzerland  500
Germany  513  Iceland  500  United Kingdom  500
Estonia  512  Slovenia  500
United States  500
Iceland  507  Macao-China  499
Liechtenstein  499
Denmark  503  Poland  497
Sweden  497
Slovenia  501  Ireland  497
Germany  497  PISA   focuses on young 
Belgium  496
Norway  498  Ireland  496  people’s ability to use their 
France  497  France  496  Hungary  496  knowledge and skills to meet 
Slovak Republic  497  Chinese Taipei  495  United States  495  real-life challenges. This 
Austria  496  Denmark  495  Czech Republic  495
orientation reflects a change 
Poland  495  United Kingdom  494  Norway  494
in the goals and objectives of 
Sweden  494  Hungary  494  Denmark  494
curricula themselves, which 
Czech Republic  493  Portugal  489  France  489
are increasingly concerned 
United Kingdom  492
Macao-China  487  Iceland  487  with what students can do 
Hungary  490
Italy  486  Sweden  486  with what they learn at school 
Luxembourg  489  Latvia  484  Austria  484
and not merely with whether 
United States  487  Slovenia  483  Latvia  483
they have mastered specific 
Ireland  487  Greece  483  Portugal  483
curricular content.
Portugal  487  Spain  481  Lithuania  481
Source: OECD PISA 2009 database
Geoffrey Canada talks with students at Harlem Children’s Zone, in a scene from   Waiting for “Superman”   (New York City, 2009).
18  © Paramount Pictures/Participant Media
 
 = Page 18 =
2011 Annual Letter   from   Bill Gates
2011 
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 3 percent, which is 20 percent faster than the rest 
of the economy. Over that time our achievement levels were basically at, while other countries caught up. A recent 
analysis by the rogramme for International Student Assessment ISA 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. 
ISA 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 5 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. ere are four levels of proiciency 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 ISA analysis available at   www.pisa.oecd.org  , two key things diferentiate the U.S. education system 
from most other countries’ systems. e irst 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. ey igured it out on their own. at’s why our foundation is investing to help devise measurement 
and support systems to help good teachers become great teachers.
Our project to learn what the best teachers doand how to share this information with other teachersis making 
signiicant progress. With the help of local union aliates, 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 ennessee 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 sourcestest scores, student surveys, videos, principals, 
and fellow teachersso 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   Visiting the Ridgeway Middle School with Melinda to learn about the 
Measures of Effective Teaching project (Memphis, Tennessee, 2010).
medical costs. I recently gave a speech to the chief state school ocers   
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Welding student Jaurie Vaughn at the Tennessee Technology Center (Nashville, Tennessee, 2010).
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2011 Annual Letter   from   Bill Gates
2011 
  www.gatesfoundation.org/ccsso   about how they might need to ind money to reward excellent teaching by shiting 
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 ennessee echnology Center in Nashville, an institution 
that provides young adults with technical training and certiicates. It gets signiicantly better results than its peer 
institutionsgraduating 1 percent of its studentsbecause 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 diference for students.
e foundation is funding the development of online tools to help both K-12 and college students learn. ioneers like 
Sal Khan are already showing how efective 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. e 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 ill the gaps in your knowledge. Also, Khan Academy is creating an online dashboard to help teachers use the site 
as part of their curriculum. e 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.
he Giving Pledge 
Warren Bufett 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. e dinners evolved into discussions of the challenges of giving efectively. It became clear that there was a lot of 
collective knowledge and that we could inspire each other and in some cases work together. ere was a strong sense we 
should broaden the discussion to a larger group including people who were earlier in their giving career. 
is led to the idea of the Giving ledge. 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 ledge. ou can see the letters describing their thinking 
about giving at   www.givingpledge.org.   e United States is the most generous country in the world. More than 15 
percent of the large estates go to charity. at is signiicant, but there is room for that to increase. Warren has said, We 
want the general level of giving to step up. We want the ledge to help society become even more generous. We hope 
the norm will change towards even greater and smarter philanthropy.
Although this efort is focused on those people in the United States with the greatest wealth, we are encouraged by and 
support similar eforts 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 irst half of the year.
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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 lower 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).
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2011 Annual Letter   from   Bill Gates
2011 
Continuing the Conversation 
Last year I launched   www.gatesnotes.com   and started a witter feed   @BillGates   to share my 
thoughts on the work we’re doing and what I’m learning from leaders and innovators. One great 
beneit 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 terriic EDx event 
  www.tedxchange.org   in New ork that brought together interesting speakers on global health and development. 
Next year, building on her relationship with ED, she’ll be hosting a series of EDxChange events in communities 
around the worldin places like Kenya and India. e goal of these EDxChange 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 diculties 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. ef aikes, our CEO, continues to add great people and improve the way we do our work. Not everyone 
can go to the ield, or even donate. But every one of us can be an advocate for people whose voices are oten 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 
anuary 2011
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Guided by the belief that every life has equal value, the Bill & Melinda Gates Foundation works to help all people lead 
healthy, productive lives. In developing countries, it focuses on improving people’s health and giving them the chance to lift 
themselves out of hunger and extreme poverty. In the United States, it seeks to ensure that all people—especially those 
with the fewest resources—have access to the opportunities they need to succeed in school and life. Based in Seattle, 
Washington, the foundation is led by CEO Jeff Raikes and Co-chair William H. Gates Sr., under the direction of Bill and 
Melinda Gates and Warren Buffett. Learn more at   www.gatesfoundation.org  .
PO Box 23350, Seattle, WA 98102   |   +1.206.709.3100   |   info gatesfoundation.org   |   www.gatesfoundation.org  @
facebook.com/billmelindagatesfoundation   |   twitter.com/gatesfoundation
 2011 Bill  Melinda Gates Foundation. All ights eserved. Bill  Melinda Gates Foundation is a registered trademark in the United States and other countries.
 
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