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Bill and Melinda talk to the staff at Gugulethu CHC in Cape Town, South Africa about HIV and tuberculosis. (Photo: The Gates Notes LLC)

Over the past two decades, the Bill and Melinda Gates Foundation has given out $53.6 billion, most of it seeking to improve global health and U.S. education.

In a new annual letter, 20 years after starting the philanthropy, Bill and Melinda Gates explain what has worked, what hasn’t, and why they’re increasingly focusing on two additional issues, climate change and gender equality, with “a major sense of urgency.”

Bill Gates’ new book is due out this spring.

“The best thing we can do to help people in poor countries adapt to climate change is make sure they’re healthy enough to survive it,” Bill Gates writes in the letter, drawing a direct line between one of the Gates Foundation’s traditional focus areas, global health, and another crisis that has been getting a lot of his attention, time and money: the climate.

The Microsoft co-founder’s book on climate change, “How to Avoid a Climate Disaster,” is due out this spring. He foreshadows some of his thoughts in the letter, writing with a mixture of optimism and inevitability that humans will need to both mitigate and adapt to climate change.

“Climate change is one of the most difficult challenges the world has ever taken on,” Bill Gates writes. “But I believe we can avoid a climate catastrophe if we take steps now to reduce emissions and find ways to adapt to a warmer world.”

Melinda Gates’ book on gender equality, “The Moment of Lift,” was published last year. In the new annual letter, she addresses the topic in the context of the upcoming 25th anniversary of the historic Beijing World Conference on Women, saying she hopes the energy and attention given to that anniversary will result in meaningful action.

“If we miss another opportunity, if we let the spotlight sputter out again, we risk contributing to a dangerous narrative that inequality between men and women is inevitable,” she writes, adding that “the reason these problems look unsolvable is that we’ve never put the necessary effort into solving them.”

Reflecting on the past 20 years, Bill and Melinda Gates acknowledge “disappointments, setbacks and surprises,” in addition to accomplishments. “We think it’s important to be transparent about our failures as well as our successes — and that it’s important to share what we’ve learned,” they write.

They point to successes experienced by the Gates Foundation and its partners in addressing extreme poverty, childhood mortality, wider distribution of vaccines, and other initiatives.

But they’ve learned, for example, that it isn’t enough to merely come up with treatments for HIV and AIDS. Deploying them successfully is a whole other challenge.

“In the beginning, we put a lot of resources into HIV preventatives that needed to be taken every day,” Bill Gates explains. “For a lot of reasons, those didn’t turn out as we hoped.”

“Local health programs have struggled to deliver a daily pill in a way that’s appealing and fits into people’s lives,” he adds. “Today we’re focused on longer-lasting preventatives. Imagine if, instead of having to take a pill every day, a person could get one injection every other month, an implant in his or her arm, or even a vaccine to entirely remove the risk of getting the virus.”

Gates Foundation Graphic

Another big surprise: the immense challenge of U.S. education.

“If you’d asked us twenty years ago, we would have guessed that global health would be our foundation’s riskiest work and our U.S. education work would be our surest bet,” Melinda Gates writes. “In fact, it has turned out just the opposite.”

“We certainly understand why many people are skeptical about the idea of billionaire philanthropists designing classroom innovations or setting education policy,” she writes. “Frankly, we are, too. Bill and I have always been clear that our role isn’t to generate ideas ourselves; it’s to support innovation driven by people who have spent their careers working in education: teachers, administrators, researchers, and community leaders.”

However, she adds, “one thing that makes improving education tricky is that even among people who work on the issue, there isn’t much agreement on what works and what doesn’t.”

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Bill Gates cites the need to combine “clear and consistent standards” with flexible solutions.

“It became clear to us that scaling in education doesn’t mean getting the same solution out to everyone,” he writes. “Our work needed to be tailored to the specific needs of teachers and students in the places we were trying to reach.”

Bill and Melinda Gates write in the letter that there’s “no question that this new decade is beginning at a time of tremendous unrest and uncertainty around the world.” In a note, Melinda Gates adds that they’re “closely following the coronavirus outbreak.” The Gates Foundation recently committed $100 million to fighting coronavirus.

The past 20 years have given them a “much deeper understanding of how important it is to ensure that innovation is distributed equitably,” Bill and Melinda Gates write in the conclusion to the letter. “If only some people in some places are benefiting from new advances, then others are falling even further behind.”

Read the full letter.

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