When historians write about the first quarter of the 21st century, I think they may sum it up this way: Twenty years of unprecedented progress followed by five years of stagnation.
This is true for nearly every issue the Bill & Melinda Gates Foundation works on, from poverty reduction to primary school enrollment. But nowhere is the contrast more stark or tragic than in health.
Between 2000 and 2020, the world witnessed a “global health boom.” Child mortality fell by 50%. In 2000, more than 10 million children died every year, and now that number is down to fewer than five million children. The prevalence of the world's deadliest infectious diseases fell by half, too. Best of all, the progress was happening in regions where the disease burden had been the highest. Sub-Saharan Africa and South Asia saw the most improvement.
This health boom had many causes. A new generation of political leaders embraced humanitarianism. Hundreds of thousands of health workers fanned out across the globe, bringing the latest medicine to places that doctors had rarely visited. But one often overlooked factor was a small—yet crucial—increase in funding.
Starting in 2000, the world's wealthiest countries began steadily increasing their funding to supplement low-income countries as they increased their own investments in health. This funding fueled the work of organizations like Gavi, the Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which gave poorer nations access to life-saving vaccines, drugs, and other medical breakthroughs.
Aid is relatively small. By 2020, wealthy countries were spending less than one quarter of 1% of their budgets on aid. That’s an average of $10.47 on health per person in the poorest countries. But that $10.47 made a remarkable difference.
Then COVID-19 hit, and progress came to a screeching halt.
Development assistance for health is provided by governments and private organizations in high-income countries to low- and middle-income countries.
Today, the world is contending with more challenges than at any point in my adult life: inflation, debt, new wars. Unfortunately, aid isn’t keeping pace with these needs, particularly in the places that need it the most.
For instance, more than half of all child deaths still occur in sub-Saharan Africa. Since 2010, the percentage of the world’s poor living in the region has also increased by more than 20 percentage points. Despite this, during the same period, the share of total foreign aid to Africa has dropped from nearly 40% to only 25%—the lowest percentage in 20 years. Fewer resources mean more children will die of preventable causes.
The global health boom is over. But for how long?
That's the question I have been wrestling with for the past five years: Will we look back on this period as the end of a golden era? Or is it just a brief intermission before another global health boom begins?
I’m still an optimist. I think we can give global health a second act—even in a world where competing challenges require governments to stretch their budgets.
To do this, we’ll need a two-pronged approach. First, the world has to recommit to the work that drove the progress in the early 2000s, especially investments in crucial vaccines and medicines. They’re still saving millions of lives each year, and we can't afford to backslide.
But we also need to look forward. The R&D pipeline is brimming with powerful—and surprisingly cost-effective—new breakthroughs. Now we just need to put them to work fighting the world’s most pervasive health crises. And it starts with good nutrition.
Every now and then, somebody will ask me what I would do if I had a magic wand. For years, I’ve given the same answer: I would solve malnutrition.
This summer, UNICEF released its first report on child food poverty. The findings were stark. Two-thirds of the world’s children—more than 400 million kids—are not getting enough nutrients to grow and thrive, putting them at higher risk for malnutrition. In 2023, the WHO estimated that 148 million children experienced stunting, and 45 million children experienced wasting—the most severe forms of chronic and acute malnutrition. It prevents them from growing to their full potential—and, in the worst cases, from growing up at all.
When a child dies, half the time the underlying cause is malnutrition.
And now a significant headwind is making malnutrition harder to solve: climate change. We worked with our partners at the Institute for Health Metrics and Evaluation to better understand how difficult the headwind is:
It’s an important projection, and it should inform where country leaders devote their aid money to reverse the current trends and the growing burden of malnutrition.
Obviously, fighting climate change is crucial. But what these data show is that the health crisis and the climate crisis are the same thing in the poorest countries near the equator. In fact, the best way to fight the impacts of climate change is by investing in nutrition.
Most people associate malnutrition with hunger. We’ve all seen the awful photos of starving children. That’s the most visible kind of malnutrition—but it’s not the only kind.
Malnutrition also includes what doctors call “hidden hunger.” Kids can be eating enough calories and still not getting the right nutrients. When this happens to very young children, it interrupts the development of their bodies and brains. The effects are irreversible.
With most serious childhood diseases, the kids who survive eventually grow up fine. But the kids who survive malnutrition never truly escape it. It follows them to school. A child who has a severe brush with malnutrition before the age of three will complete five fewer years of schooling than well-nourished kids. And the malnourished kids who do remain in school tend to do poorly and take longer to complete each grade than their peers.
As these kids become adults, it continues to haunt them. Studies show that people who went hungry as kids earn 10% less over their lifetimes and are 33% less likely to escape poverty.
Nations can’t grow if their people can’t. The economic costs of undernutrition are significant: It is estimated that every year, the cost of undernutrition is US$3 trillion in productivity loss because malnutrition has stunted people’s physical and cognitive abilities. In low-income countries, that loss ranges from 3 to 16 percent (or more) of GDP. It’s the equivalent of a permanent 2008-level global recession.
Today, one in every five of the world’s children suffers from stunting, and climate change threatens to increase that number. We should ask: What will that mean for the global economy in 20 years when these children are in the prime of their working lives?
Few economists think of the malnutrition rate as a critical economic data point—but they should start. Nutritional deficits quickly translate into financial deficits.
By now, it’s clear: Malnutrition makes every forward step our species wants to take heavier and harder.
But the inverse is also true. If we solve malnutrition, we make it easier to solve every other problem. We solve extreme poverty. Vaccines are more effective. And deadly diseases like malaria and pneumonia become far less fatal.
That’s why I believe we can jumpstart a second global health boom by getting kids the right nutrients.
This is especially true now, because we have more tools to ensure kids gets healthier even as the world gets hotter.
The science of nutrition has experienced a renaissance over the past decade. Animal scientists have discovered how to breed more productive livestock, while food scientists have found new ways to fortify more nutrients into the staples of people’s diets—like salt, flour, and bouillon cubes. Doctors are even beginning to unlock the mysteries of the microbiome, the teeming universe of bacteria that lives inside our digestive tracts.
As you read on, you’ll hear from people on the front line of nourishing people around the world. Together, they’re showing us how we can jumpstart another golden age for health: with a lot of grit, creativity, and enormous generosity toward their fellow human beings.
One of the hardest things to do in global health is scaling a solution.
No global health problem requires a larger-scale solution than malnutrition. Every single person on the planet needs to eat a healthy, nutritious diet every day.
Brazil, India, Kenya, Rwanda, and dozens of other emerging nations have leaned into this challenge. They’ve found gaps in their food systems and are repairing them to deliver the right macro- and micronutrients to as much of the population as possible.
For these countries, building a more nutritious food system produces a double benefit. It lowers the malnutrition rate, improving health outcomes. It also can lead to a remarkable amount of economic growth.
New agricultural technologies are being developed to increase the amount of milk that cows produce in Kenya.
Improving dairy productivity and supply in just five countries—Ethiopia, India, Kenya, Nigeria, and Tanzania—could prevent millions of cases of childhood stunting between 2020 and 2050.
In Nigeria, fortifying bouillon cubes wouldn't just prevent anemia, it would also avert more than 11,000 deaths from neural tube defects.
Ethiopia is exploring adding folic acid to iodized salt. This “double-fortified” salt could eliminate nearly 75% of all deaths and stillbirths due to neural tube defects each year.
If low- and middle-income countries adopted Multiple Micronutrient Supplements, the world’s most complete prenatal vitamins, almost half a million lives could be saved by 2040.
Now, throughout the world, it costs only a few dollars to take MMS, which contains 15 vitamins and minerals proven to significantly reduce the risk of adverse birth outcomes.
Milk is a nutrient-rich food that addresses many of the nutritional deficits children face, including calcium, vitamins (including A and B12), protein, and healthy fats—it makes them healthier and even more climate-resilient over the long term.
But producing enough of it, ensuring it is affordable, and preventing it from spoiling remains a challenge in low-income regions.
But new agriculture technologies are changing that. Some technologies use DNA and data to select cows that give birth to more productive offspring. Others help farmers produce more high-quality forage or repurpose crop waste for nutritious cow feed. As a result, Kenyan cows are now producing 6 to 10 times more milk than before. That’s more milk to drink at home and more income for dairy farmers and vendors, most of whom are women.
It’s also better health for children: New analysis from the International Food Policy Research Institute shows that improving dairy productivity and consumption in five countries—Ethiopia, India, Kenya, Nigeria, and Tanzania—could prevent as many as 109 million cases of childhood stunting by 2050.
And training is an essential part. Programs like Livestock Enhancement and Advancement Programme (LEAP) and MoreMilk are helping dairy farmers and market sellers learn and follow best practices for safe storage and handling.
Sushama Das,
Odisha, India
Coletta Kemboi,
Maili Nne, Kenya
Large-scale food fortification is an old technology—but we’re unlocking new ways of using it to increase micronutrients in the food found in pantries all over the world.
After all, micronutrient deficiencies have an outsized impact on health. For example, vitamin A deficiencies are the leading cause of childhood blindness, while folate deficiencies are the leading cause of neural tube defects.
In the United States and Switzerland, iodized salt has been sold in supermarkets since the 1920s, which has led to the virtual elimination of iodine deficiency and the improvement of IQ scores. Leveraging that success, Ethiopia is now exploring adding another critical nutrient, folic acid, to iodized salt. They are testing a way to produce this “double-fortified” salt. This pioneering approach holds the potential to eliminate half of all deaths and stillbirths due to neural tube defects, up to 5,000 per year in Ethiopia, and helping to reduce anemia up to 4% across the country.
And now leaders at the Nigerian Ministry of Health and Social Welfare are leading a large-scale effort to fortify bouillon, already a common item in Nigerian kitchens.
Ladidi Bako-Aiyegbusi,
Nigeria
Healthy diets are crucial for good nutrition. But, in different stages of life with different needs, they’re not always sufficient. Doctors know that mothers need extra nourishment during pregnancy and the critical days that follow to stay healthy and give their children the best start in life.
These increased needs make it difficult for pregnant women all over the world to consume the full range of necessary nutrients, especially in countries where healthy foods are out of budget or out of reach.
One solution is the United Nations International Multiple Micronutrient Antenatal Preparation Multiple Micronutrient Supplements—the world’s most complete prenatal vitamin. It contains 15 vitamins and minerals proven to significantly reduce the risk of adverse birth outcomes. It is more effective and powerful than the iron and folic acid supplements that many women typically receive in low- and middle-income countries. If all low- and middle-income countries switched to MMS, which costs only $2.60 for an entire pregnancy, almost half a million lives would be saved and 25 million babies would have improved birth outcomes by 2040.
Dr. Sabin Nsanzimana,
Rwanda
Although all of the interventions we’ve covered have life-saving potential on a global scale, without resources and extensible plans for implementation behind them, they would be little more than good ideas.
That’s why the Bill & Melinda Gates Foundation worked with UNICEF and other partners to launch the Child Nutrition Fund—a new financing mechanism designed to bring these innovative solutions to life and transform the way the world addresses child malnutrition.
Before the Child Nutrition Fund, there was no dedicated platform to coordinate efforts to address child malnutrition, to encourage domestic funding, or to support local production of the nutrient-rich foods and food supplements children need most.
The Child Nutrition Fund provides solutions to all three of these problems, in one place. And we know it will be effective, because we’ve already seen these financing mechanisms in action—the Global Fund to Fight AIDS, Tuberculosis, and Malaria is a great example. It is one of the fastest-scaling, most effective institutions ever created. The interventions it has funded and deployed have saved nearly 60 million lives.
Now, the Child Nutrition Fund is using a similar approach to attack child malnutrition, head-on, in partnership with countries around the world.
Dr. Víctor Aguayo,
UNICEF
“A pregnant woman eats for two” is a common saying. But doctors have realized it needs updating.
A pregnant woman is actually eating for three ... trillion: herself, her child, and the vast network of microorganisms that lives inside her digestive tract.
Around 15 years ago, researchers began to suspect that the bacteria that live in your gut—your microbiome—may play a crucial role in health after noticing that oral childhood vaccines like polio weren’t as effective in places with high rates of malnutrition.
A series of succeeding studies revealed the fundamental problem: When undernourished children are exposed to too many pathogens in their environment, they can get what we call “environmental enteric dysfunction.”
To oversimplify a very complex set of processes: Their guts become inflamed, their intestines get blunted, and they struggle to absorb nutrients. In other words, a child with an unhealthy microbiome can eat a full and healthy diet—but still be undernourished.
This discovery has changed the way the Bill & Melinda Gates Foundation thinks about nutrition. We still support work in agricultural development and a diversity of nutritious, affordable food for a healthy diet because making sure there is enough food to eat has to be the starting point. But it’s no longer the end point. Today, we are also thinking about how to improve gut health to make sure children can absorb nutrients, develop strong immune systems, and grow as they should to thrive.
Just a few years ago, researchers hoped to identify a gold-standard microbiome: the precise contents of a healthy gut that applied to everyone, everywhere. We know now that what we really need to understand is how these metabolic networks function and design diets to complement and feed our gut bacteria. For example, we know that certain locally appropriate therapeutic foods, like specific sugars in green bananas in Bangladesh, appear to work especially well because they feed not only the child, but also the bacteria in their gut.
There is still so much we don’t know about these networks, but the good news is that they might be relatively easy to understand in children relative to adults.
Compared to the adult microbiome, which contains 100 trillion cells, the infant microbiome starts out simple. We now know that early-in-life microbes need to colonize the gut in a very specific sequence to pave the way for healthy growth, development, and immune function. During this early life stage, the infant microbiome is more easily molded. And once it sets, it impacts us for the rest of our lives.
This research isn’t just useful for addressing malnutrition in low-income nations. It has huge implications for the overnutrition problem in wealthy countries. In the United States, an estimated 60% of the population is overweight or obese, often because of high-fat, high-sugar diets. These diets alter the biology of the gut and lead to inflammation.
In rich countries and poor ones, we’re realizing that the future of human progress depends on what’s happening in our guts.
It’s a thrilling time to be standing at the frontier of nutrition. We’re on the cusp of unlocking not only a deeper understanding of the microbiome—but with it, solutions that could forever change how the world treats malnutrition, our most pervasive health crisis. But this will only be possible if the world commits to funding the progress of the future today.
That starts with a commitment that no child should die before their fifth birthday. That’s a commitment the world has made before. Halving the rate of under-5 child mortality was perhaps humanity’s most important achievement—and we can do it again, if countries around the world do three things.
If we do these three things, we won’t just usher in a new global health boom and save millions of lives—we’ll also prove that humanity can still rise to meet our greatest challenges.
I was born in Ethiopia, in a small farming village called Abrugandana. When I was two, a tuberculosis outbreak hit. My mother got sick, I got sick, and so did my sister Fantaye.
When our health took a turn for the worse, the three of us made the 75-mile journey to the hospital in Addis Ababa, on foot. I don’t know how my mother managed to get us there while barely able to breathe—but I do know that she never left the hospital alive. And I also know that Fantaye’s and my survival was a miracle, especially because tuberculosis was not the only thing ravaging my body.
Long before the outbreak, Ethiopia had been plagued by malnutrition. And because we were extremely poor, without access to the milk, food, or nutrients my growing body needed, I was not immune. At 2 1/2 years old, I weighed just 22 pounds—the average size of a 12-month-old child.
Today, there are still millions of malnourished children around the world, just like I was. But I was lucky. Because I was given a rare chance at a better life—and a better, more nutritious diet.
After being adopted by two incredible parents, my sister and I were raised in Sweden. In our house, taste and nutrition went hand in hand. And over time, I grew to understand that it’s not just about how much you eat, it’s also about what you eat.
That knowledge formed the foundation of my personal journey through food. It’s why, in my restaurants, our menus feature locally grown and nutrient-rich ingredients. And it’s why I believe my responsibility as a chef is bigger than just making good food. It’s also about giving voice to the idea that having access to a nutritious diet is a basic human right.
For millions of children around the world, that right is being denied. They are not getting the nutrients they need to grow, develop, and thrive—a reality that will only get worse as the effects of climate change intensify. That is both an outrage and a tragedy, because malnutrition is so thoroughly preventable.
That’s why I’m grateful that The Gates Foundation is confronting this crisis head-on. The work they’re doing is critical. It will help ensure that millions of children can unlock their full potential—just as I was able to.
Each year, Goalkeepers share the latest estimates on 18 indicators, ranging from poverty to education. These indicators help us understand the progress toward the Sustainable Development Goals—where innovation and investment are creating bright spots, and where we’re collectively falling short. These data remind us that progress is possible but not inevitable.
But with just six years remaining, the world is off track. Urgent action is needed to meet the SDG targets and create a more equitable and safe future for all by 2030.
