With his wife, Melinda, he outspent the entire U.S. government by almost $300 million last year in the battle against global health threats such as AIDS, malaria, and tuberculosis.
The man who led the computer software revolution now accounts for more than a quarter of what all industrialized countries spend for the health needs of underdeveloped nations. His foundation gave $1.44 billion last year, compared with about $5 billion from industrialized nations.
It's a stunning figure and, Gates believes, a shameful one. It's time, he says, for the rich nations to act less like Scrooge.
"The world hasn't been allocating its resources properly at all in global health," the Microsoft founder said in a rare interview from his office in Redmond, Wash. "Rich governments should be doing more."
The Bill & Melinda Gates Foundation made 60 separate grants in the last year, including $171.2 million in 10 awards to New England organizations.
The Gates contributions underscore the emerging role that private individuals are having in international affairs. Ted Turner, founder of Cable News Network, is another example, offering last week to put up $34 million to bridge the shortfall in U.S. dues payments to the United Nations, after giving the U.N. $1 billion three years ago.
Gates, 45, said he traces his interest in helping the poorest of the poor to the days when he would "travel internationally, in my 20s, to Brazil and see the favelas right next to the rich city, or to Mexico."
"I remember saying to myself, `Wow, there's a big difference here,' " he said. "It was kind of strange staying at a resort and having guards making sure this artificial world wasn't invaded by the real world. I didn't know then about children's deaths in poor countries. I knew the vaccines were there ... but not much else."
Now he can't seem to learn enough.
Over the last several years, Gates has spent hundreds of hours seeking information about the problems and successes of global health, an issue that he believes is more important than any other because the lives of millions of children hang in the balance.
He hosts dinners in his palatial home at which guests talk, for instance, about the intricate details of Rotavirus gastroenteritis, a killer of nearly 1 million people a year.
By night, he devours books on the issue, such as one on the history of malaria. By day, he fires off e-mails to two of his most trusted global health advisers, Gordon Perkin and William Foege, asking about different types of immunity, for instance.
"Several times a week, sometimes every day, he sends us e-mails that probe intricate issues related to global health," said Trevor Neilson, director of public affairs for the Seattle-based Gates Foundation. "Very often it takes our entire staff an afternoon to find answers to these questions."
His foundation's health staff consists of just seven people, puny compared with other philanthropic groups that have hundreds of program officers. Gates has endowed his foundation with $21.8 billion, making it the world's largest philanthropic institution. Since late 1997, it has earmarked just over $2 billion for global health. The foundation will give about $1 billion a year – with slightly more than half going to the issue of global health – "throughout my lifetime and beyond," Gates said.
"I am a cultist when it comes 'Geez, am I going to find something that would have a clear impact?' A bit of me thought that I would find that the world really has allocated its resources well and I would have only a marginal effect. I was stunned to find that in terms of research and delivery in health care how little of the world's resources are focused on this."
Still, his motivation is bound to be questioned by some, especially considering the U.S. government's antitrust suit against Microsoft and the potential years of legal battles ahead.
But global health experts don't raise the issue, in part because it doesn't seem to matter to them if Gates is seeking to ease his tax bill or improve his image, in part because it seems that no one wants to criticize the hand that feeds them.
But they do note Gates's enthusiasm, his personal commitment, and the impact that comes from his dollars and the publicity from the grants.
To them, he is nothing less than a blessing.
Over the past year, the Gates Foundation earmarked $1.44 billion for health programs for poor countries, which included some funds that will be spent over the next several years.
Meanwhile, the U.S. government allocated $1.16 billion last year for basic health care in poor nations, according to figures from the World Health Council. The U.S. amount does not include some funds for research at the National Institutes of Health. For the coming year, Congress – pushed by Senators Patrick J. Leahy of Vermont, John F. Kerry of Massachusetts, and Bill Frist of Tennessee – has allocated $1.49 billion for international health.
But philanthropy can only go so far, Gates says. Wealthier governments, he believes, must shoulder more responsibility.
In 1978, the United States and other nations signed an accord committing them to help "all the peoples of the world" to attain by the year 2000 "a level of health that will allow them to lead a socially and economically productive life." But as 2000 ends, some African countries are projected to see average life expectancy fall below 30 years in the next decade, because of the AIDS pandemic.
In 1988, rich countries spent an average of $15 per person infected with HIV, the virus that causes AIDS; a decade later, the allocation was $3 per person, according to research by Harvard's Amir Attaran and Jeffrey Sachs.
World Bank figures show that industrialized countries spend roughly 0.25 percent of their gross domestic product on assistance to the poorest nations, with the United States the stingiest of all, giving 0.1 percent of GDP. The World Bank estimates that all global health aid from industrialized countries totals $5 billion annually.
But now some hold out hope that Gates can help change things, even if the foundation's money has yet to show concrete results. It is too early to judge its impact on health systems in the poorest countries, yet many believe that Gates' single-minded focus is already inspiring many political leaders.
"This is not some obscure or quirky millionaire who has a pet project," said Nils Daulaire, president of the Global Health Council. "This is one of the smartest strategic thinkers in the business world, who says this really matters for the future of the world. The governments of the industrialized countries in the world really need to wake up."
It wasn't until the end of 1998, after Gates had set up a foundation and begun giving millions of dollars to public health and education, that he realized the depth of the health needs of people in poor nations. He decided that dealing with the basics – providing immunizations to children – should be his first focus.
"I knew we were going to do vaccines," said Gates, who at the time had just given $125 million to a program that tries to provide vaccines to all children. "So I had all these vaccine experts over to our house.
"Well, it was late in the dinner, and I said if I was going to do more, what would we do?" Gates said.
Seth Berkley, head of the New York-based International AIDS Vaccine Initiative, spoke up. "Seth said, `Well, there's AIDS,' " Gates recalled. "Somebody else thought malaria should get more focus, because hardly anything was being spent on it."
So the foundation stepped up its giving, allocating $25 million to Berkley's group, $50 million for a malaria vaccine initiative, and then a whopping $750 million to the Global Fund for Children's Vaccines, which would assist developing countries to distribute routine vaccines, as well as provide money to develop new ones.
"I spend a lot of time thinking now whether we are striking the right balance, funding the right balance, working with the right institutions, measuring the problems in the right way," Gates said. "The last two years have been a positive trend ... of governments, philanthropists and the private sector facing up to a horrific problem.
"With the Cold War ended, what is the thing that we should all be looking at?" he asked. "I think the greatest inequality is the fact that 5 billion people on earth don't have access to the medicines that a billion people have. I'm sure for my whole lifetime, even beyond, that world health is going to be our top priority."
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