Living Proof Project: Why We Are Impatient Optimists

October 27, 2009
Remarks by Bill and Melinda Gates, co-chairs

ANNOUNCER:  Ladies and gentlemen, please welcome Bill and Melinda Gates. 

BILL GATES:  Thank you. 

Well, good evening.   It's great to see all of you here.  If you came for the hockey game, you need to go across the street. If you came for Shakespeare, you need to come another night.

A lot of times when people come to the capital, it's to criticize government programs and talk about how they should change.  How often do you hear about a very large, bipartisan program that's working better than expected? 

Well, tonight we want to talk about one.  We're here to say two words tonight you don't often hear about government programs:  Thank you.

Back in 2000, when Melinda and I started our foundation, we saw there were incredible inequities in health.  There were millions of poor people dying of diseases that we'd cured in this country.  And we decided to make that a major focus of our giving.

Now, about the same time, the U.S. government was starting to increase its own spending on global health.  In fact, it's been increasing for each of the last 10 years. 

And so we're here to thank America's leaders and America's taxpayers, and we want to show you the proof that these investments are really working.  We want you to hear this good news and then help us share it with other people so that we can do even more.

MELINDA GATES:  When it comes to global health, Bill and I are optimists, but I have to say that we are impatient optimists.  We're optimistic because of the people that we meet on the ground, in the developing world, whose lives are absolutely transformed by American investments.

Just a couple of years ago, Bill and I visited an AIDS clinic in Durbin, South Africa, and we expected to see in this clinic what we see a lot of places in the developing world, an overworked staff, long waiting lines, not many drugs available. 

But, in fact, we saw something completely different than that in this AIDS clinic.  We saw a well trained staff, we saw an ample supply of medical drugs, and we saw patients being counseled about how to live with HIV.  And this clinic was completely paid for by the American people.

So, as we left, we thought, my gosh, if every American could see what we see when we travel around now on the ground now, particularly in Africa, they would understand how amazing these investments have been.  And yet when we come back home and you pick up the newspaper, you look on the Internet, you hear just the opposite, you hear all the negative stories.

So, we are optimists:  The world is definitely getting better. 

But it's not getting better fast enough, and it's certainly not getting better for everyone.  For every two people who go on the antiretroviral treatments that we saw in this clinic in Durbin, South Africa, five more people become infected.

Now, we know how to prevent these infections, but they do happen anyway, and that's the kind of thing that makes us impatient optimists.

We want you to hear tonight the good news that we are seeing in global health so you'll be just as optimistic as we are.  And it's why we're here launching this initiative called the Living Proof Project.  It's about real people whose lives have been transformed and changed, people who are literally alive today because of the U.S. commitments.  They are the living proof. 

BILL GATES:  I want to start by showing you what I think is the most beautiful picture I've ever seen.  Not that one.  No, not even that one.  Not that one either.  Yep, it's the chart.

This shows the progression of child mortality in the last 50 years.  What you see is that in 1960, over 20 million children died before their fifth birthday.  And it goes down every year until last year it was measured at under 9 million children dying.

Now, during this time the number of births and therefore the number of children rose by about 25 percent.  So, we are reducing the number of deaths by more than a factor of two while there's even more children alive. 

I think this is one of the greatest accomplishments of the last hundred years. 

Now, why did it happen?  There's two things that came together.  The first is higher incomes that meant a better diet, better sanitation, and that accounts for part of it.  The second was the smart spending on global health.

Now, the United States gives over a quarter of all the money given for global health.  So, you might think, wow, this is a huge amount of money, it must be a large part of what the country spends.  Well, actually it's a lot less than most people think.  The overall federal budget, of course, is 3.6 trillion.  That's the pie that we start with here.  Foreign aid, which often people say is perhaps 10 or even 20 percent of the budget, is actually a bit less than 1 percent.  And of that foreign aid, the piece that goes on global health, the things we'll talk about tonight, is around 8 billion.  And so roughly that's .22 percent or a little less than a quarter of 1 percent.

Now, this number has gone up.  Back in 2001, it was about a billion and a half.  In 2005, it was just over 3 billion.  So, it's reached its peak level, this 8 billion, this year.

Now, how does that compare to other givers?  Well, our foundation, by making global health our top priority, and spending a bit over half of all the money we spend on it, we put in 1.8 billion a year, so less than a fifth as much overall for global health.

We're committed to global health.  For our entire lives we'll be doing the best we can, spending the majority of the foundation's grants on this cause.

But it's America's investments and the investments that it causes others to make that are saving the large number of people, and so that's what we'll be talking about tonight.

Let's look at another really beautiful picture.  This is a child receiving a vaccine.  Right now, the child might not be too excited about it, but this is the best way to save lives that the world has. 

Investments in vaccines have an incredible payoff.  Let me give you some living proofs of this.  Smallpox was a terrible disease.  Back even in the 1950s, over 50 million cases a year were experienced around the globe.  Now, a quarter of those people died.  Of the remainder, many were scarred or made blind.  So, it had an unbelievable disease burden.

There was actually a type of vaccine going all the way back to 1796.  In fact, the very word vaccine comes from the gener work on trying to inoculate a young boy.

But that vaccine was not very reliable, it wasn't delivered to many people, and it wasn't until the 1970s that the world decided that we could get the vaccine out to everyone.

It was tough because the disease would break out in different places.  And a brilliant public health expert, Bill Fahey, came up with the idea of looking at each outbreak and understanding who you had to vaccinate in that area, and very quickly going in and doing that, and that tactic worked.  By 1977, this disease had been eradicated, the first and so far the only disease to be eliminated from the planet.

Well, this was actually an amazingly inexpensive activity.  It was 130 million from the U.S. over the 10-year period.  And because of that, no country has to spend on vaccinating people or treating them.  The savings for the U.S. alone since the eradication is over 17 billion.

So, when you think, okay, would I spend 130 million over 10 years to save the 17 billion, and to save untold human misery as well, of course you would take that bargain.  And that's why I say vaccines are a phenomenal value.

Now, smallpox is the only disease that we're completely done with.  We have another disease which we're fairly close on, and that's polio.

Polio has been eliminated in the United States, and it's an amazing story.  There's books like the "Polio:  An American Story" by David Oshinsky that tell this story.  It goes back to President Roosevelt and creating the March of Dimes and getting lots of contributions.  It goes back to the great scientific work of Salk and Sabin and figuring out how to make vaccines safe and get them out in very large numbers.

And so today, we just take it for granted that no kids in the United States have this disease.  It's been gone for over 30 years.

Now, there is progress around the world.  The U.S. government is the biggest funder on this.  Rotary International has really activated people and made this an important cause.  And between their efforts and others, over 2 billion people have been immunized.  That's a lot of polio drops.

And we are seeing progress.  Let's take and show representation that is equal to how many people had polio back in 1988.  So, we'll light up part of the audience and that represents that number.  Then if we take how much polio we have today, it would be down a great reduction from this, it would be down literally to one person.  Sorry.  And so that's a 99 percent reduction.

We have four countries left where we have a substantial number of cases:  India, Nigeria, Pakistan and Afghanistan.  And unfortunately as the disease transmits there, it does tend to spread out, and so we get a small number of cases in other countries as well.

So, this is a very tough disease to go after.  The cases are more silent than the smallpox cases.  Many of them show no symptoms at all, and when you do see the symptoms, it's well after the disease has struck and perhaps spread to other children.

When I was in a slum outside of Delhi about a year ago, I met a nine month old named Hosmon (ph), who you see here, and Hosmon is a polio victim.  I talked with her mother, and her mother talked about how Hosmon doesn't know it yet, but she'll never be able to go out and play with her friends, never kick a ball.  And certainly when you see Hosmon, talk to her mother and think about the consequences, the reaction is we need to end this.  We are so close, we cannot let up now.  We have the pieces in place.   We have vaccines, we have lab tests, we have surveillance infrastructure, and we've got a global commitment. 

So, we're going to have to keep putting in resources for a number of years, and then when we achieve this triumph, it will invigorate the whole field of global health.  Just like the smallpox elimination did, this will be another really incredible victory.

Well, now Melinda is going to come out and talk about another great chance to save a lot of lives, and that's rotavirus.

MELINDA GATES:  So, in the early 1990s, Bill and I read a newspaper article about something called rotavirus, and we said, my gosh, what is this thing called rotavirus?  We'd never heard about it.  And yet when we read in this article, we learned that yet 500,000 children were affected by rotavirus and died every single year.  We said, oh my gosh, this can't possibly be true, rotavirus, but if it is true, there must be something that we can do about it.

So, what is rotavirus?  Rotavirus is a diarrheal disease that many, many children get in the poor world.

Now, children in our country get diarrhea and it's pretty simple.  You go to the drugstore and you get an over the counter medication, or you might take them to the doctor, and they live.  But that's not the case in the developing world, because poor children become severely dehydrated.

But because our country doesn't face rotavirus, there's really very little incentive to create a vaccine. 

But I'm pleased to tell you tonight that we do have a new vaccine for rotavirus.  It was developed by Dr. Paul Offit.  He worked in his lab for over 26 years tirelessly on this vaccine, and he was supported by the pharmaceutical company Merck.

It's a fantastic success story.  It's a case where we've created a vaccine for the poorest children on the planet, and it's just beginning to reach them.

And I'd like to show you a short video of what it's like to get a vaccine like that from Dr. Offit's lab in Pennsylvania out to a remote village in Nicaragua.

(Video segment.)

MELINDA GATES:  So, you've just seen what it takes to get a vaccine into one country, and because of the U.S. investments and the commitments that we've made as a country, we're now going to start delivering it to every poor child that needs it in all the developing countries that need it around the world.

You know, often in the U.S. we talk about if somebody here saves one life that they're a hero.  But what do you say to somebody who's already saved hundreds of lives, and possibly is on their way to saving hundreds of thousands of lives?  And I think the only thing that I know what to say to that person is thank you.  And so I'd like to have Dr. Paul Offit stand and be recognized tonight.  Thank you, Paul.

Vaccines really are the great miracles of our lifetime, vaccines for smallpox, polio, measles.  Since 1980, we've been able to bring down cases of diphtheria 93 percent, tetanus cases 85 percent, measles 93 percent.

So, where we have these vaccines, where we have this lifesaving advance, we need to deliver those to the developing world.  And where we haven't yet invented the vaccines, we need to do that.

Now, some vaccines, like in the case of HIV/AIDS, are years or possibly even decades away.  And so I think a right question would be tonight, in the interim is there still an argument for optimism, particularly when it comes to AIDS, and I would tell you yes there is.

There are 3 million people today in Africa receiving antiretrovirals.  That's up from 155,000 people just five years ago.  People are alive because of the investments as a country we've made in things like the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and because of the President's Emergency Plan for AIDS Relief, otherwise known as PEPFAR.

PEPFAR has been incredibly generous.  This is a case where American people recognized the fact that we could get these drugs in our country, but you couldn't get them in the developing world.  And so what was happening?  Poor people were dying.  The American people said, poor people shouldn't die just because they can't afford these drugs.

Now, I'll let you in on a little known fact, and that is there has been a huge price decline in these drugs over the last two years, thanks to what's happened, and it's because of that drug price decline that America's generosity can have a much larger impact than it would have otherwise.

Now, there were many partners who were involved in this work, and I want to show you though first a little bit about what's happened with these costs of the drugs.

We put up a chart here that's going to show the cost of just first line drugs for antiretrovirals in Uganda.  Now, this chart is going to show only the cost of the drugs.  It doesn't include personnel costs or the cost to deliver the medications, but it's a great proxy for how much progress we've actually made.

So, in 1998, the cost for the drugs was $12,000 per person per year; can't buy many drugs like this for poor people in the developing world at that price.  But as I said, many partners got involved in this and recognized that the price was too high.  And pharma agreed eventually to two-tiered pricing; that is, a price for the developing world that would be much, much lower.   So the cost dropped to $7,000 per person per year, then 2,000, then 140.  Last year, it was less than $90.

So, a decade ago, where $12,000 would have bought enough drugs for one person, that now buys enough drugs for 130 people.

So, that's the chart and some of the statistics on AIDS, but I want to show you the human face of AIDS.  I want you to see what we're dealing with here. 

I've a film of a little girl and her name is Avelile, and she lives in South Africa. 

Avelile is seven years old.  And as you can see, she weighs about the same amount as a one year old.  Her mother had HIV and she passed the virus onto her daughter during childbirth.  And her mother died during childbirth.  And Avelile became very, very ill, and quite frankly the nurses were not very hopeful about her condition.

Now, this is Avelile one year later.  She got antiretrovirals and medical care.  It's hard to believe this is the same little girl.  She's not just alive, she's thriving.  You can see why they call this the Lazarus effect.

So, this is what treatment does.  This is what it does and what we have to build on. 

But I have to tell you that the cost of the drugs has now leveled off at that $90 price that I showed you, and that makes it hard to fund treatment for everybody that needs it, because as I said earlier, for every two people that get infected who get the treatment, five more people are becoming infected.

So, we have to move upstream, we have to work on reducing the number of infections, and that means focusing on prevention.

Now, we haven't made as much progress so far on prevention as on treatment, but there is still some good news.  We're starting to do a better job protecting babies.  In 2004, just 10 percent of the mothers who were HIV positive when they were pregnant were able to get the lifesaving medicines they needed in low income countries, 10 percent.  But in 2008, that number is 45 percent; that is women in the developing world can get the drugs they need to not pass on HIV during the childbirth process.  So, there are thousands of children who won't go through what Avelile experienced.

So, with America's help we're also finding that the countries themselves are finding really innovative ways to prevent HIV, and education is a really key step here, because with education you can start to demystify HIV, both how you get it, how you can contract it, and what you do about it, and you ultimately break down the stigma about the disease.

I'd like to give you just one example tonight.  In Namibia there's a five-man a cappella group named Vocal Motion.  They started 10 years ago in their hometown of Rundu, and they won Namibia's version of American Idol.

And what they do through a PEPFAR funded program since 2006 is they tour Namibia singing prevention messages, and they performed before 85,000 students in Namibia.  They're kicking off a short U.S. tour, and they're here tonight, as you see, and they've agreed to sing for us.

(Musical segment.)

MELINDA GATES:  That was beautiful.  I bet you didn't know HIV prevention could be so gorgeous.

So, Bill and I are hopeful about HIV, both because of what's happened so far, but also because of what's yet to come.  And I would like to talk a little bit about yet what is to come.

Researchers have been working to simplify treatment.  When the PEPFAR program first started, and when antiretrovirals were first getting out there early on, it took 16 pills a day when you were on antiretrovirals.  That's now been simplified, and it's down to one pill a day.  And the pills are much safer on the human body, and much easier for the patients to take.  Now, the next step, of course, would be if you could get an injection where you just got it once a month, because that would, of course, even more simplify the treatment, and the more you can simplify the treatment for people, the more they're going to adhere to it.  The more they'll tolerate it.  They'll reduce transmission, and ultimately, of course, we'll save lives.

On the prevention side, there are also a few other reasons to be optimistic.  And one of them that you might not know about is male circumcision.  Research has found in the last couple of years that, in fact, a male can be protected by up to 60 percent if he's circumcised from not contracting the virus from his female partner.  Now, if we had a vaccine that was that effective, we would be jumping for joy.  But we are working as a community to make sure that male circumcision happens, particularly in Sub-Saharan Africa.

Researchers, though, are also working on pills, microbicide gels, indirectable drugs, because we need to have everything we can find to work on protection against this virus.  Right now, there are seven clinical trials going on of drugs that are being tested against high risk cases of HIV, and we'll start to see the results of those trials in 2011.

Now, of course, a vaccine is the ultimate prevention tool.  We are making slow, but real progress.  Scientists have gained the crucial insights, the characteristics of this virus, and how it invades the immune system.  And every time they learn something about this, it makes it possible to have a more promising vaccine candidate come forward.  You may have heard about the trials that we all learned about from Thailand last month, the 16,000 healthy volunteers that participated in that trial.  It showed that a vaccine could actually provide partial protection against HIV infections, and that was an important advance.  That advance was funded almost entirely by the U.S. Government.

So, let me be clear, this virus is ingenious.  An effective vaccine could be years, it might realistically be decades away.  But American tax dollars are contributing to progress where not long ago there was completely a sense of hopelessness.  So, we need to keep making these investments.

BILL GATES:  HIV is the most recent disease to affect millions.  The oldest is probably malaria.  There are Chinese medical texts from over 5,000 years ago that talked about malaria.  And the symptoms are the same today as they were back then, chills, fever, weakness, inability to work or eat.  And if you're undernourished, or quite young, there's a good chance it will kill you.  In fact, over 800,000 deaths a year are caused by malaria, and an additional burden from all the suffering from malaria.

Now, this disease used to be all over the world, not just in the poor countries.  In the United States, it was most severe in the deep south, but it was also significant here in Washington, D.C.  In fact, there was a proposal that a wall at the height of the Washington Monument be built around the entire city to somehow block it out.

So, if you look at 1900, the map of where malaria was, it was basically everywhere.  In fact, it wasn't until a bit after 1900, that a British military doctor figured out that it was transmitted by these mosquito bites. 

So, this terrible disease received a lot of attention, and by 1970, the rich countries had made unbelievable progress.  In fact, it was eliminated from the rich countries.

How did this happen?  We had DDT as an insecticide.  We had a number of drugs that were quite effective.  But once it was eliminated from these rich countries, the energy dropped off.  It was there in the poor countries, but there wasn't that kind of market demand.  There wasn't the incentive.

DDT had side effects when it was used broadly particularly in agricultural applications, and there started to be resistance, both to the insecticides, and the popular drugs.  And so government funding went away from these programs, and malaria, in fact, reached its peak death toll subsequent to 1970.

So, let's look at where we are today.  Well, in the last decade, new energy has gone into working on malaria, particularly investments by the U.S. Government.  There are new organizations, like Malaria No More, Nothing But Nets, that are drawing in people to help with this cause.

When Melinda and I a few years ago had a meeting of malaria experts, we raised in the discussion the idea of could it possibly be eradicated, you know, starting, reducing the map, but eventually getting all the countries.  And people felt, yes, that is something that could eventually be done.  The strategy today you see on this map is to take the countries in yellow, and go all out to try to achieve local elimination.  In the countries in red where it's more difficult, the idea is to dramatically reduce the number of deaths, to get new drugs out there, and get other new interventions.  So, we have a long way to go, but we are making substantial progress for the first time since the 1970s.

The American funding is paying for a lot of things.  It's paying for indoor spring, which is using DDT, but in a very focused way.  It's paying for bed nets that are very, very effective.  And between 2004 and 2008, Africa received over 190 million bed nets.  They still need more, but that gets you to one or every four people in Sub-Saharan Africa, and in the years ahead we'll reach total coverage.

Now, when you go in with these interventions, what's the effect?  It wasn't known for sure.  There was a lot of hope that if you scaled up for a big community, and did multiple things, that it would really bring the cases down.  Well, in the last three years, that's what we've seen.  In Rwanda, the cases are down 45 percent.  In Cambodia, they're down over 50 percent, in Zambia also over 50 percent; the Philippines even more, 76 percent, and Eritrea, down over 80 percent.  And even in those countries, there's more that can be done.

So, I'm optimistic about this disease.  We have not only the U.S. Government, but now more nonprofits, we have drug companies pitching in to help out with various things, the cost of the key drugs that are very effective will continue to go down quite a bit.  There's great work going on on a vaccine.  In fact, there's a partially effective vaccine going into late stage trials, and hopefully would be available as a new tool within the next five years.  And there's lots of research that isn't proven yet, but some of which will give us new things.  The idea of spatial repellents that don't require the indoor walls, that it just is like a chemical window screen, and it keeps the mosquitoes out.

We're doing computer modeling, very sophisticated approach, to understand exactly what we need to do to achieve these eliminations, and that's guiding us so that our investments are most effective.

It's hard to predict when an eradication might be possible.  Year by year, we're going to make progress, and my work at Microsoft taught me that when you're making year by year progress, sometimes people can expect too much in the short-term, but they often underestimate what can happen as a result of those long-term efforts.  And so here I would say, it can't be eradicated in the short-term, but in the long-term I do think this is a significant possibility.

So, let me take some of the things that Melinda and I have talked about, and summarize.  Smallpox was eradicated; polio, down 99 percent, still some work to do, but a great chance of eradication there; measles, down 93 percent; AIDS, four times as many mothers receiving these preventative drugs; and with malaria, many things including the 190 million bed nets out there in just the last for years.

Now, America is the biggest contributor to every one of these things.  Europe is also very generous.  In fact, I believe that generosity here leads to more generosity.  The U.S. has the biggest economy, as we step up to our part of this it really is very helpful at maintaining and increasing the donations that come from others.

So, the conclusion here I think is pretty inescapable.  The spending that the United States does on health for the world's poorest people is the best investment we make for improving and savings lives, bar none.  The way to reduce the number of children who die is to support this spending on global health.

Now, there are people who even look at what we've talked about and they have doubts about whether this will work out, whether it's an appropriate thing to do.  There are skeptics everywhere.  Some of them might even be here in Washington, D.C.  So, we want to address some of the more common arguments that we run into.

The first one is really about corruption.  After all, if you look back at the history of aid some of it was not done very carefully, some of it ended up in the pocket of the local dictator.  So, why is this different?  Well, here, particularly for the health interventions, we can measure the impact.  We can see that vaccines are really getting out to those children. W e can make sure that the resources are not being taken away from the desired impact.

Global Fund is a great example of this.  They do independent auditing.  They bring in people like KPMG or PriceWaterhouse, those firms do reports that are published up on the Global Fund Web site.  And, in fact, in several cases they've found places where the money wasn't being used in the best way, and that money was cut off.  So, there is real accountability.

There are other measures that we're using to make all the groups who work on these things more accountable.  The United Nations, which historically had not been that coordinated in thinking about how these things come together, adopted in 2000 the Millennium Development Goals.  And those are clear-cut, very ambitious goals to show that these new efforts are making a difference.  It measures things like the bed nets and vaccinations and it can be independently verified.

Another mechanism that's been used for broad development grants is the Millennium Challenge Corporation.  And here you actually have to qualify on a number of criteria before you're even eligible to get the aid.  You write an overall compact, you show how it's going to have a strong return, how it can be sustainable.  And so this rewards good governance, it rewards economic freedom.  In fact, there's many countries, even before they got the pact, or even who didn't get the pact, who looked at these measures and were able to take what would otherwise be unpopular measures and drive them through and therefore benefit their country, even independent of their opportunity to get aid.

Another skeptic would ask, what's the long-run picture, will we have to give this aid forever?  Are we even creating a sense of dependence?  Doesn't the aid actually in some ways hold the incentive structure back and prevent them from developing their economies?  Well, certainly, the goal here is to help countries become self-sufficient.  That is how aid in the past has really been the most impactful.

If you go back to the 1960s the set of recipient countries for aid was much, much longer than it is today, almost double the number of countries.  It included money and Peace Corps volunteers going to Brazil, or Thailand, or Egypt.  Today these countries are not net recipients of aid.  Brazil donates money and expertise to global health.  Thailand actually is paying back the loans it originally received for aid.  So, aid done properly can help a country unleash their potential.

Certainly, improving the health of a country with vaccines, and bed nets allows the country to do a lot better.  Tanzania was able to double its health budget since the 1990s, because by improving health there was more economic activity.  Poor health blocks economic activity.  So, health is really a necessary thing.  If you don't improve it in a country you're never going to get self-sufficient.  If you do improve health, then you've taken one of the key steps that's always been there to be on this road to constant improvement and being self-sufficient.

So, I think as we look ahead we'll see several things.  We will see countries graduate.  We will see them become self-sufficient.  We'll also see the number of people in these countries who need aid go down.  So, I expect, like we've seen in the past, the number of countries, say, in just the next two decades, that we give aid to, we will be able to reduce it by half.

MELINDA GATES:  I'd like to address another comment that we often hear, another skepticism.  And that is, if we improve health, aren't we just going to have more people in the world?  We can't afford to risk over-population.  Quite frankly, this is something Bill and I worried about a lot when we started working in global health.  In fact, we initially focused on reproductive health, and we wondered when we moved to these other global health areas, because we said, if there are more people on earth it's going to be a lot harder to educate them, to sustain the environment.

So, we even asked ourselves, don't these investments make things worse off for the world?  But, I think we should look at the data.  I'm going to put up here a chart from Hans Rosling.  He's a brilliant professor of public health at the Karolinska Institute in Sweden. 

This chart shows the relationship between health, as measured by life expectancy, and family size, as measured by the number of children per women.  In a minute we're going to plot every country based on where it was back in 1960, and you're going to see two clusters.  In the upper left quadrant you're going to see rich countries with good health and small families, and in the lower right quadrant you're going to see the rest of the world with poor health and large families. 

So, let's add the countries now.  Each country here is represented by a bubble, and the size of the bubble represents the population of that country.  And you'll notice two clusters:  on the upper left developed countries, good health, small family, and on the lower right you see the developing countries, poor health, and large families.

We've marked here India and Bangladesh in particular so you could follow those countries, and in a moment we're going to animate this chart, and show you what's changed since 1960.

Health is going to improve, life expectancy overall is going to go up.  But, if better health causes larger families India and Bangladesh should go straight up on this chart, because you'd expect these countries to just continue having these large families.  But, let's see what happens.  The poor countries don't move straight up, they go up, and to the left, because women choose to have smaller families when they know more children of theirs will survive into their adulthood years.

So, by 2007 you get this huge cluster of countries up in the left-hand corner, with good health and small families.  Now, this is a result of health investments that have been made.  When people have smaller families it's easier for them to feed their children, it's easier for them to send them to school, they make more money, the children have better nutrition, the economy in that country improves and life by every single measure gets better.

Now, there's one last counter-argument that I think I should mention, and that is the counter-argument of, it's not all good news, is it?  And I have to say, unfortunately, this one is exactly right.  There's on area that we've made very little progress on as a world, and that is keeping mothers and very young babies healthy.  We have made, as Bill pointed out earlier, amazing progress on child mortality, that is the deaths of children under the age of five-years-old.  But, in that first 30 days of life, that newborn period, we've made very little progress at all.

There are still 4 million babies that die in that first 30 days, most of them are in poor countries, and three-quarters of those babies die in the very first week of life.  Many of these deaths happen in rural, remote parts of Africa.  And what we hear from the parents when you go out and visit them is they don't even name their babies, because they tell us it's just a little bit less heartbreaking to bury a baby that has no name.

In addition to these newborn deaths, there are half-a-million mothers that die every single year in childbirth.  Now that, alone, is a tragedy.  But when you think of what happens to that family, and how it destabilizes the family, and the father, and the other children and that newborn, it's absolutely horrific.  Without a mother, the family often can fall apart.

So, I would like to introduce tonight Liya Kebede.  She's a fashion model.  You might have heard of her from Ethiopia.  In 2005, she was named WHO's Global Ambassador for Maternal, Newborn, and Child Health.  And she's seen the real challenges, and progress in Ethiopia on these newborn and maternal issues.

(Video segment.)

MELINDA GATES:  So, Liya is here with us tonight.  Liya, will you stand and be recognized. The video you've just seen shows why there's been very little progress on these newborn births.  Conditions for giving birth are very, very tough in these rural areas.  But we do have a chance to turn things around, and it starts with health workers.  We have to have people, that is that staff these very remote health clinics, and who can visit expecting mothers at home, and give them the basic medical supplies that they need.  And countries like Ethiopia are starting to make this happen.  They're seeing the benefits.  I visited Ethiopia twice in the last 12 months, and I was completely blown away to see these 30,000 health extension workers that they have trained, and these 15,000 remote rural health clinics where a woman can come in and deliver her baby, or the rural health worker can go out and visit the woman in her home.  These new workers are just starting to make a difference in Ethiopia.

Most newborns die of a few basic conditions.  They die from severe infections.  Often a woman will wash her baby right after it's born, and that can introduce an abrasion, and then an infection through the skin.  Many of these babies die of hypothermia.  And we know what one of the main causes is of mothers dying during childbirth, and that's hemorrhaging.  So, these health workers who work in these remote places, they don't have to know everything about pregnancy, they just have to know the key things that can make a really, really big difference in tackling this.  And they have to be able to treat those conditions.

Now, some of the solutions are actually really very simple, and they're cultural.  And that is, teaching a woman not to wash her baby when it's first born.  Keep the vernix on the baby, and to wrap the baby up, and keep the baby warm.  That goes a very long way in terms of preventing hypothermia.  A mother who breastfeeds her baby right away gives the baby's immune system a chance to begin to develop, and to work.

There are also two very inexpensive drugs that can prevent postpartum bleeding for a mother so that she doesn't hemorrhage during childbirth.  One of them they get when they come into a remote health clinic, or another one we're looking at eventually being able to deliver to the woman so she could take it home with herself.  And if there's not someone to attend to the birth, she could give it to her, herself.  And it's less than a dollar.

So, Bill and I are optimists, but sometimes the word "impatient" quite frankly feels too polite to me.  We're optimistic, because the world knows what the main causes are of these maternal and newborn deaths.  And we've developed low-cost solutions to these things.  But the solutions won't solve anything if we don't deliver them to the mothers who need them.

Every human life is precious, and a child's death is absolutely tragic.  So, whenever we see an urgent need, and we're not meeting it, it can be really, really frustrating for us, but it can also be deeply motivating.

BILL GATES:  One of the big reasons for these huge inequities is that he people who see the worst of it don't have the resources to defeat it.  And the people with those resources don't often see the worst of it.  We have one last piece of footage that we'd like to show you, and this was shot in a remote part of Tanzania.  It's a bit hard to watch, but I think it will give you an even better sense of what we're up against.

(Video segment.)

BILL GATES:  I've seen that video several times now and it doesn't get easier to watch.  All Shayla needed was malaria medicine, and that costs just a little bit more than what most of us would pay for a cup of coffee every day.  Fortunately, most of us have never been through what that mother did.  If it happened here in large numbers there would be a large outcry, the government would act in ways to stop it.  The market demand would be large, and it would drive a lot of brilliant research, and resources of all types around the country would be brought to bear.  But, Shayla wasn't born in the United States, and that made all the difference.

Now, I'm optimistic that we can make progress.  We've got continuing tragedies like Shayla, and that gives us a sense of urgency.  We've got great science.  We've got more resources, and that gives us the optimism.  So, that's why Melinda says we are impatient optimists.

Let's just look at one metric of this, which is that child mortality figure.  We talked about how it's gone down from 20 million to under 9 million in less than 50 years.  My view is that it won't be too difficult to more than cut it in half again, and this time a lot faster, in well under 15 years.  How would this work?  What would it take?  Fortunately, a few interventions make a dramatic difference.  And so we actually looked, did some modeling working with some people at John's Hopkins, and tried out different scenarios on the big interventions.  If there's no new investments then, because we have additional births the death rate actually goes up a little bit, to 9.3 million.  So, let's take four interventions and apply them one at a time and see this cumulative effect.

First, let's take the vaccines we have and get them out there in a widespread fashion.  That brings us down to 8.3 million, a big difference.  Now, let's take malaria and get all the interventions out there in large numbers, and here again a big difference.  Now, we're down to 7.7 million.

Next, let's take some of the care for newborns that Melinda talked about, and get that out to a significant part of the world.  And there we see a huge reduction.  We're down to 6.3 million.  And finally, let's take two of the diseases that we have new vaccines and drugs for, the diarrhea and pneumonia, and apply those on a global basis.  And those four steps alone get us down to this target of 5 million deaths.  Now, new inventions, faster ways of getting this out can beat what I'm showing on this chart.  So, this is well within the realm of possibility.

Now, how is this all going to come together?  Well, we have countries that are leading examples of all of those things I talked about.  Rwanda practices like breastfeeding have allowed them to reduce newborn mortality.  In Ghana they've gotten their vaccine coverage up to very high percentages.  So, what it takes is the continued investments, and sharing best practices so that all the countries become as good as the ones that are leading the way.

Now, our Foundation will be doing everything we can as part of this, funding research, working closely with the U.S. government and others.  We're excited that we have more foundations, other nonprofits.  We've got the pharmaceutical companies, a broad range of actors that see this as very important.  The U.S. government role, though, is absolutely central.  Foundations like ours can do some research funding, we can test pilot programs.  But, it takes the capacity, the resources, the expertise, the leadership of the rich world countries, with the United States doing the largest share, to get out there and deliver these interventions that will save the millions of lives.

That's why I think it's important to get the word out that these investments work, that even in tough times where there no doubt are going to be tradeoffs that have to be made in government spending, that these investments are so effective that they're worth continuing.

MELINDA GATES:  We found that people are interested in supporting global health when they know that it works.  And that is why we need to share the proof, the living proof of what is working, and that U.S. investments save lives.  So, through this living proof project we want to attract great storytellers, filmmakers, and writers to bring their talents to bear on this work.  In fact, this will be a bit of my own focus over the next couple of years.

So, we've invited you here, because you can help.  Your opinions are important to what shapes the nation's beliefs.  And so, we've given you each a DVD tonight that has some of the stories that we showed you here.  Those are also available on the Web site, Livingprojectproof.org.  And we simply ask that you do one thing, and that is if you believe what you've heard tonight is to take those stories and share them with one person whose opinion you respect.  That would go actually a very long way.  If we have convinced you of anything, we hope that we've convinced you tonight that America's global health investments are, in fact, saving lives.

BILL GATES:  Some say that the United States has a responsibility to do this, because we're the richest country.  And I'd certainly agree with that.  But, I think saving lives goes beyond that, and it connects to something that's fundamental in the unique beliefs of this country, our belief in equality.  The country was founded on this idea, that everyone deserves a chance to make the most of their talents.

Melinda and I were very lucky to be born here, and we had a chance to take advantage of all of our abilities.  And every child, no matter where they're born, should have that opportunity.  So, investing in health really makes a profound statement about our belief in equality, not just for Americans, but for everyone in the world.

The United States has already done a lot for the health of the world's poorest people.  We've proven that it works.  We've proven we have the skills, knowledge, and the resources to do even more.  Tonight, you've seen the living proof.  Now, please help us share it.

Thank you, and good night.