NOW with Bill Moyers; 219; Bill Moyers talks with Bill Gates

Transcript, May 9, 2003

ANNOUNCER: Tonight on NOW WITH BILL MOYERS, Bill Gates talks with Bill Moyers about health and wealth.

MOYERS: You were clearly competent at making money. Did you doubt your competence in giving it away?

GATES: I actually thought that it would be a little confusing during the same period of your life to be in one meeting when you're trying to make money, and then go to another meeting where you're giving it away. I mean, is it going to erode your ability to make money? Are you going to somehow get confused about what you're trying to do?

MOYERS: It's a nice confusion. It's a very nice confusion.

GATES: I didn't want to mix those two things together. The big milestone event for me though was… a report was done, it's called The World Development Report 1993. that talked about these diseases. And I remember seeing the article, and it showed that rotavirus kills over a half-million children per year.

And I said to myself, that can't be true. You know, after all, the newspaper, whenever there's a plane crashing and 100 people die, they always report that. How can it be that this disease that's killing half a million a year, I've never seen an article about it until now?

And it wasn't even an article about that. It was just a graph that had, you know, these 12 diseases that kill, most of which I had never heard of.

ANNOUNCER: The crisis in global health, using high tech and new knowledge to fight deadly disease.

All that tonight on NOW WITH BILL MOYERS, the weekly newsmagazine from PBS.

ANNOUNCER: From our studios in New York, Bill Moyers.

MOYERS: Welcome to NOW. Tonight, a departure from our usual format to focus on one very vital subject and one very wealthy man.

Most of us know about Bill Gates, how he went from a drop-out at Harvard to the founder of the software giant Microsoft to the richest man in the world, at one point earning an estimated average of $4.5 million an hour.

What is not so well known is that Bill Gates has decided to give his money away — most of it, that is.

Through the Bill and Melinda Gates Foundation, he's taken on the challenge of global health, especially among the poorest of the poor.

It may surprise you to learn that only 10% of medical research is dedicated to diseases that cause 90% of the world's health problems. Bill Gates is trying to close that gap.

Global health, of course, is suddenly on everybody's mind. Right now, the world has been focused on the outbreak of SARS, Severe Acute Respiratory Syndrome.

It reminds us just how quickly a mysterious epidemic can spread across the planet.

But whether SARS burns out, remains or mutates into some other deadly strain, this issue remains: that many of the most catastrophic diseases are in the poorest parts of the world, invisible to the rest of us.

That's the wake-up call Bill Gates wants us to answer, as you'll hear in just a few minutes. First, this report by my colleague, producer Bryan Myers.

ACOSTA: Okay, we're going to go right up here…

MOYERS: Patients are a little more worried these days when they come into Traveler's Medical Service in New York City. The clinic provides vaccinations to tourists and businesspeople headed to exotic destinations overseas.

ACOSTA: Have you taken into consideration the current SARS situation in that part of the world, particularly China?

MOYERS: It seems like only yesterday that war and terrorism were the traveler's biggest concern. Now it's the outbreak of SARS, the deadly respiratory virus that appeared suddenly in China and spread like wildfire throughout eastern Asia.

ACOSTA: There has been a fair amount of concern among people that tend to travel to that region, particularly among the business community. Many corporations have ceased travel to the region completely.

MOYERS: Fears of an epidemic spread even faster than the virus itself. The airport in Hong Kong was deserted; so was this normally crowded market in Toronto. In some cities, there's been a run on masks. SARS became big news, the lead story day after day.

But while doctors say people going abroad should take SARS seriously, they also urge clients not to panic.

ACOSTA: It's really important for people to keep SARS in perspective mainly because there are so many other illnesses that statistically people are likely to get when they travel if they don't take the proper precautions.

MOYERS: While there have been around 7000 cases of SARS worldwide and about 500 deaths, public health officials have moved swiftly to contain the epidemic. Just a few hundred cases have been reported in North America. And in Hong Kong, new infections are slowing. Just this past Tuesday, the head of the World Health Organization held out hope that SARS can be eliminated altogether.

The epidemic has been a wakeup call. It's reminded us of a crucial fact: a strong public health response can make a huge difference in the face of a deadly disease. But lost in all the headlines is another fact: hundreds of millions of people still suffer from diseases that remain invisible to us.

Take malaria for instance. Two weeks ago, the United Nations released this report: 300 million people fall ill to malaria each year; more than one million of them die. Yet with all the commotion over SARS, that report barely made the evening news.

BRANDLING-BENNETT: Well, I think that's a usual and perhaps understandable human response, that something that's new and threatening does get attention

.

MOYERS: Nonetheless, says Dr. David Brandling-Bennett, SARS has served to remind us of the continuing challenge of global health. He's a top official at the Pan-American Health Organization, an arm of the UN's World Health Organization. Dr. Brandling-Bennett calls illnesses like malaria, measles, and tuberculosis the "forgotten diseases." Although they long ago ceased to be a big problem here in America, they continue to be chronic killers in the third world.

BRANDLING-BENNETT: The things that are happening routinely, which may be of much larger magnitude, of course, we tend to ignore, or become accustomed to, unfortunately. "Complacency" is what we call it.

MOYERS: AIDS is one third-world killer that has made its way to the United States. But even with AIDS, there's a difference. Easier access in America to treatments and preventive measures have kept AIDS from exploding the way it has in the third world. Poor countries where AIDS is epidemic, says Dr. Brandling-Bennett, should have access to similar help.

BRANDLING-BENNETT: Many of these diseases, the effort really depends upon slogging it out and a lot of hard work, not on highly sophisticated technology.

MOYERS: What it takes are health care workers, armed with low-cost drugs. Consider these figures from the World Health Organization: a tablet of the most popular anti-malarial medicine costs just 12 cents. A measles vaccine: 26 cents. A six-month course of treatment for TB: as little as ten dollars. And a year's supply of condoms to prevent the

transmission of HIV? 14 dollars.

BELLAMY: We're not talking about a huge sum of money.

MOYERS: Carol Bellamy runs UNICEF, the United Nations Children's' Fund. For years, UNICEF has been taking on the big global killers.

BELLAMY: Malaria is the number one killer of children in Africa — 3000 children dying every day, one every three minutes. It is a preventable disease. It doesn't require some five-star hospital.

MOYERS: With malaria, it's a race against time. A new strain of malaria that is resistant to the most popular treatment — that twelve-cent tablet — is on the increase in Africa.

BRANDLING-BENNETT: That really signaled the appearance of a very serious problem, because we would no longer be able to treat children simply, with a very safe and very cheap drug.

MOYERS: Besides that 12-cent pill, there are other malaria drugs that work. But they cost more, are more toxic, and sometimes more difficult to use. Worse, if these more expensive drugs should prove ineffective, doctors like Brandling-Bennett may be out of treatment options.

BRANDLING-BENNETT: The imperative is that the situation is more likely to get worse than it is better. For example, with malaria, we don't have another generation of drugs waiting to come online.

BELLAMY: The fact is, there is little demand, major demand in the richer or the industrialized countries for the remedies that are necessary to respond to these kinds of diseases that are found in so many of the poor countries.

MOYERS: That's reflected in the budgets of the big American drug companies. In the year 2000, they spent 21 billion dollars on research and development. But only 13% of that went to infective and parasitic diseases. Because of that, both UNICEF and the WHO are also pushing non-pharmaceutical solutions for diseases like malaria. Bed netting treated with insecticide to repel malarial mosquitos has proven both effective and cheap — the nets cost around $4.00 each.

Diarrhea is another crippler that doesn't need a drug to solve. You may be surprised to learn that 1.5 million children die each year from diarrhea, an illness most of us consider nothing more than a nuisance.

BELLAMY: In the poorest countries, if there's no simple intervention they become dehydrated, they are not taken care of well, they don't have adequate nutrition, and they die.

MOYERS: The solution to water-borne illnesses like diarrhea can be as simple as a new village well.

So if treating and preventing such diseases can be so simple, and so cheap, why are so many people still dying across the third world? Certainly inept or corrupt governments in these countries can be an obstacle, but, says Carol Bellamy of UNICEF, the big industrialized nations have not made attacking these diseases a big enough priority.

BELLAMY: It means that foreign assistance needs to still be invested in healthcare, good healthcare and good education. If you know what to do and you know that by doing it you can save lives, it's really time to do it.

MOYERS: It's hard to come up with an overall price tag on what it would cost to launch an all-out effort to rid the third world of major diseases, but if past experience is any guide, it's not an impossible task.

Meet Luis Cortez. This is Luis in 1994, at age three. Luis was the very last case of polio recorded in all of North and South America. Polio, once one of the world's most dreaded diseases, eradicated in the western hemisphere through an ambitious immunization program.

And in what's considered nothing less than a milestone in public health, another of history's great plagues, smallpox, has been eradicated worldwide — once again, an immunization program worked. And what did that program cost? Just $325 million.

BRANDLING-BENNETT: We were talking about relatively a low-tech enterprise. Most of the money was spent on employing local people who could track down the disease and people who'd been exposed to make sure they got vaccinated.

MOYERS: With governments on their own failing to cope with the public health challenge, non-profit organizations are trying to fill the gap. One of them is the Bill and Melinda Gates Foundation. Funded by the Microsoft computer fortune, it is one of the richest foundations in the world , with assets of over $20 billion. Gates' father, Bill Gates Sr., runs the foundation.

Last year, we accompanied Bill Gates, Sr., and former President Jimmy Carter as they traveled to Africa for a firsthand look at the worst epidemic of all: AIDS.

CARTER: If you take all the wars put together in the history of humankind, there has never been such a devastating cost in human lives as is resulting from HIV/AIDS.

MOYERS: Of the 40 million people in the world with HIV, 70% of them live in sub-saharan Africa. Three million die of HIV/AIDS worldwide each year. For Gates and Carter, this trip is a fact-finding mission. In Nigeria, they, along with Mrs. Carter, gather information from a group of prostitutes who face the threat of AIDS.

GATES, SR.: Have any of you seen anyone dying of AIDS ?

WOMAN: Yes.

STELLA: In my hometown, there are more than 200 people I can mention.

MOYERS: Unprotected sex with prostitutes is one reason why HIV and AIDS are so widespread in Africa. The men who are their customers travel home, spreading the disease from village to village.

STELLA: Sunday, last week, a man slapped me. Why? Because I tell him to use condoms.

GATES, SR.: How busy are they, how many customers?

WOMAN: I think I have 15 people. Ten people. Fifteen or ten in a day.

GATES, SR.: In my own case, the most important thing is to deliberate about what the foundation can do further than it already is about the problem and to speak out, speak out to our government, to our Congress, to our public about the importance of the United States stepping up. The United States has to step up.

MOYERS: That's Bill Gates, Sr. talking. And his better-known son has been making the case too, speaking about why the family foundation gives a billion dollars a year to try to close the gap between rich and poor. Recently, the younger Gates came to the Columbia University's Mailman School of Public Health to talk about the subject. I interviewed him surrounded by public health students and faculty.

MOYERS: When I first heard that you were going to give away billions of dollars to global health I was skeptical. I mean, no one can doubt that you know everything there is to know about information technology, but global health? And I thought, here's a man surrounded by power and privilege whose every need and every comfort are met. How could he possibly see the world through the eyes of an impoverished woman with HIV in India or a hungry, starving child in Mozambique? How could he possibly get inside of their way of seeing the world so that what he did wasn't just a rich man's hobby?

GATES: Certainly I'll never be able to put myself in the situation that people growing up in the less developed countries are in. I've gotten a bit of a sense of it by being out there and meeting people and talking with them. And one of the gentlemen I met with AIDS talked about how he'd been kicked out of where he'd lived and how he felt awful he'd given it to his wife and their struggle to make sure their child didn't have it, and the whole stigma thing, which, you know, that's hard to appreciate. In this country when you get sick, people generally reach out, you know, that's the time to help other people and yet some of these diseases it's quite the opposite.

So when I was thinking about where my resources that I'm the steward of be able to make an impact, I thought "okay, what's the greatest inequity left?" And to me, and the more I learned about health and the unbelievable inequity, it kind of stunned me, it shocked me, every step of the way.

MOYERS: You could have chosen any field, any subject, any issue and poured billions into it and been celebrated. How did you come to this one? To global health?

GATES: The two areas that are changing in this amazing way are information technology and medical technology. Those are the things that the world will be very different 20 years from now than it is today.

I'm so excited about those advances. And they actually feed off of each other. The medical world uses the information tools to do their work. And so when you have those advances you think, "Will they be available to everyone? Will they not just be for the rich world or even just the rich people in the rich world? Will they be for the world at large?"

The one issue that really grabbed me as urgent were issues related to population… reproductive health.

And maybe the most interesting thing I learned is this thing that is still surprising when I tell other people which is that, as you improve health in a society, population growth goes down.

You know I thought it was…before I learned about it, I thought it was paradoxical. Well if you improve health, aren't you just dooming people to deal with such a lack of resources where they won't be educated or they won't have enough food? You know, sort of a Malthusian view of what would take place.

And the fact that health leads parents to decide, "okay, we don't need to have as many children because the chance of having the less children being able to survive to be adults and take care of us, means we don't have to have 7 or 8 children." Now that was amazing.

MOYERS: But did you come to reproductive issues as an intellectual, philosophical pursuit? Or was there something that happened? Did come upon… was there a revelation?

GATES: When I was growing up, my parents were almost involved in various volunteer things. My dad was head of Planned Parenthood. And it was very controversial to be involved with that. And so it's fascinating. At the dinner table my parents were very good at sharing the things that they were doing. And almost treating us like adults, talking about that.

My mom was on the United Way group that decides how to allocate the money and looks at all the different charities and makes the very hard decisions about where that pool of funds is going to go. So I always knew there was something about really educating people and giving them choices in terms of family size.

GATES: I have to say I got off the track. When I started Microsoft, I thought, "Okay, now I have my, you know, my passion. At least for the next 40 years or so." And when my mom said to me, "Oh, you have to do a United Way campaign," I said to my mom, "Mom, this is serious stuff now. That was all nice to talk about but you know I've got to pay these people and if we don't get enough contracts... and this is a very competitive environment. And so this whole notion that we're gonna sit around and drink tea and do United Way campaigns, I don't think we have time for that."

But she kept working on me and saying, "No, this is a good thing." And had me meet with other people.

So finally I thought, "Okay, I'll fit it into my framework," which is getting the employees to kind of feel more bonded, more of a team. You know, and appreciate the unique position they're in. And so we made a United Way Fund. We had contests around it. We had the agencies come in.

But a little bit I had drifted away from thinking about these philanthropic things. And it was only as the wealth got large enough and Melinda and I had talked about the view that that wealth wasn't something that would be good to just pass to the children. Because wealth of any kind of magnitude like that, it's actually more — I haven't asked them their opinion yet — but more of a handicap than it is of a benefit.

So you know once you decide that over 95 percent of it's going back to society, then you do start talking about where it will go. And so Melinda and I were having those conversations. But we only had one or two projects that we thought we'd get into early. We thought, "Okay, this is mostly for many decades from now."

MOYERS: You were clearly competent at making money. Did you doubt your competence in giving it away?

GATES: I actually thought that it would be a little confusing during the same period of your life to be in one meeting where you're trying to make money, and then go to another meeting where you're giving it away. I mean is it gonna erode your ability, you know, to make money? Are you gonna somehow get confused about what you're trying to do?

MOYERS: It's a nice confusion. It's a very nice confusion.

GATES: So, you know, I didn't want to mix those two things together. The big milestone event for me though was… a report was done, it's called "The World Development Report 1993" that talked about these diseases. And I remember seeing the article and it showed that rotavirus kills over a half-million children per year. And I said to myself, "That can't be true."

You know after all, the newspaper, whenever there's a plane crashing and 100 people die, they always report that. How can it be that this disease is killing a half-million a year? I've never seen an article about it until now. And it wasn't even an article about that. It was just a graph that had you know these 12 diseases that kill, most of which I had never heard of.

And so I thought, this is bizarre. Why isn't it being covered? You know, and there's a mother and a father behind every one of these deaths that are dealing with that tragedy.

And so then I got drawn in a little bit.

And there was one dinner after we'd given our first vaccination grant. I think it was 125 million. All these doctors came. And they're… they thought, "Okay, this is a dinner where I'm supposed to just say thank you, thank you. And, you know, try not to use the wrong fork or something."

So they're there, and you know it's a nice dinner. But after about 15 minutes I say to them, "Yeah. Well, it's okay. You've thanked me enough. But what would you do if you had more money?" And they're all kind of like, "Well, does he really mean that? Is he serious?"

I said "Yeah, what if you had, you know, ten times as much money. What would you do?" And then the guy who's worked his whole life on Hepatitis B speaks up and the guy who's working on AIDS speaks up, and the guy who's working on Immucocal speaks up.

And so it started opening the door to saying, you know, it's sort of a 'bad news' story in that governments are not giving the money, they're treating human life as being worth a few hundred dollars in the world at large. And that's, you know, almost a factor of a thousand difference between how it's treated in the rich world versus in the rest of the world.

MOYERS: Oscar Wilde once said that "it's the mark of a truly educated man" — and I'm sure he would today say woman — "It's the mark of a truly educated man to be deeply moved by statistics." What is that capacity that enables someone to transform a fact or figure on a page to a human being a long way off? What is it?

GATES: I think there is a general difficulty of looking at a number and having it have the same impact as meeting a person. I mean if we said right now, there's somebody in the next room who's dying, let's all go save their life. You know, everybody would just get up immediately and go get involved in that.

When my daughter who's seven saw this video, you know, showing the kid who's got difficulty walking because of polio, her reaction was: "Who is that? Where are they? Let's go help them.

Let's go meet that kid. What if he gets polio in his other leg?"

You know, so she's immediately drawn in to that human on the screen.

It's a lot easier to connect to the story of the one person or the five people. Now, you know, because I'm mathematically literate, you know, I know that when there's 3 million kids every year dying of things that are completely preventable with the technology we have today. You know, I can try and magnify how I feel about that one situation by a factor of 3 million. It's tough. But at least you know it's super important.

MOYERS: What does it say to you that half of all 15 year olds in South Africa and Zimbabwe could lose their lives to AIDS? What does it say to you that 11 million children, roughly, die every year from preventable diseases?

What does it say to you that of the 4 million babies who die within their first month, 98 percent are from poor countries? What do those statistics tell you about the world?

GATES: It really is a failure of capitalism. You know capitalism is this wonderful thing that motivates people, it causes wonderful inventions to be done. But in this area of diseases of the world at large, it's really let us down.

MOYERS: But markets are supposed to deliver goods and services to people.

GATES: And when people have money it does. You know when our foundation is not involved in the diseases of the rich world. Not, you know, those are very important, but the market is working there. Between the basic research that the government funds, through NIH, the bio-tech companies, the pharmaceutical companies, you know, incredible things will happen with cancer and heart disease over these next 20 or 30 years. Because that's a case where capitalism is at work.

MOYERS: There's a profit in it. There's a profit in it.

GATES: Right. Here what we have is, with the poor world diseases, not only don't the people with money have the disease, but they don't see the people who have the disease. If we took the world and we just re-assorted each neighborhood to be randomly mixed up, then this whole thing would get solved.

Because you'd look out your window and you'd say, you know, there's mother over there whose child is dying. You know, let's go help that person. This problem, the lack of visibility, it's partly you don't read about it, you don't see it. It's the silence that's allowing this to happen.

MOYERS: Was there an "Aha!" moment? Was there a moment of eureka when you realized what you're just saying and said, "This is where we're gonna put our billions"?

GATES: I know when I saw that article on the World Development Report, I said, "This can't be true, but if it is true, this deserves to be the priority of our giving." And so I took the article and Melinda read it. I gave it to my dad and said, "You know, can you have the people you're working with, tell me is this some aberration here? Or if this is true, give me more things to read."

It was a shock, but then, you know, it was an answer to say that governments weren't doing it.

And so maybe we could help step in. And maybe not just our resources, but maybe we could galvanize some interest and attention and IQ to go and look at these problems and think you know if I have the technology that can, you know, stop mosquitoes from carrying these diseases. Or allow vaccines to be delivered without a refrigerator, you know, I have saved millions of lives by coming up with those ideas.

MOYERS: I talked on Saturday to one of the leading public health officials in the world. One of the pioneers in this field. And he said you once asked him for a list of books. And he provided you with a list of books. And the next time he had seen you just a few months later, you'd read 17 of them. I mean, do you ever read anything for fun? Do you ever read your e-mails?

GATES: There was about six months where I was carrying around about 10 issues of THE MORBIDITY & MORTALITY WEEKLY REPORT. And people would see that on my desk at work and what the heck? You're reading THE MORBIDITY & MORTALITY WEEKLY REPORT. You know I'd say to them, "Yes, here's this one from the 1980s when AIDS came out. This is a real collector's item here."

Actually it's taken a lot of different books to get, you know, the different perspectives and try and understand what could be done.

MOYERS: It's one thing to read a book, it's one thing to read a statistic, one thing to read a graph, it's another thing to read a human being's face. Did you go into the field?

GATES: Yes. And it's awkward. I'm not you know particularly good at this. Maybe I'll never be good at it. But to walk around to each patient and ask, you know, "What is your problem?" And be respectful of, you know, their desire for privacy.

But I think it is very important. If people got out like that, you know, these problems would get addressed.

MOYERS: There was a trip you took to Soweto in South Africa that was decisive in your thinking. Tell me about that.

GATES: Well we took a computer and we took it to this community center in Soweto. And generally there wasn't power in that community center. But they'd rigged up this thing where the cord went like 200 yards to this place where there was a generator, you know, powered by diesel. So this computer got turned on. And when the press was there it was all working just fine.

And it was ludicrous, you know. It was clear to me that the priority issues for the people who lived there in that particular community were more related to health than they were to having that computer. And so there's certainly a role for getting computers out there. But when you look at the, say, the 2 billion of the 6 billion the planet who are living on the least income, you know, they deserve a chance. And that chance can only be given by improving the health conditions.

The thing that's so stark is that you're in Johannesburg, which is sort of a first-world location, and you're talking with banks about their software and you know it's, you feel like it's not that much different than being in the United States.

And then you drive about 5 miles and you're in one of the most poor areas you've ever been in. You know, those houses that are built out of the corrugated iron which you know and the heat is just unbearable.

It's very jarring to go from this experience in the city and to this other experience and have them be so close together. You think, "Well, how come it's so different in such a small distance?"

MOYERS: What is your answer to how it is that the resources of the world are so misallocated?

GATES: It's a mistake.

MOYERS: But somebody has to make a mistake. Who makes it?

GATES: I think we make it every day by thinking that national borders are you know allow huge inequities to exist across those borders.

And I do think this next century, hopefully, will be about a more global view. Where you don't just think, "Yes, my country is doing well," but you think about the world at large. There is one excuse that people have for not paying attention to this. It's not a valid excuse but... and that is that things have been improving despite the research money not being applied the right way. Infant mortality or life expectancy — even in the countries in the worst situation — infant mortality is lower today than it was in the best country 120 years ago.

Now there are things that come along like the AIDS epidemic that send it in the other direction. And we shouldn't be willing to wait, you know, and have it take 50 or 100 years for these medicines, the new vaccines, that kind of treatment, to be widespread.

MOYERS: Have you made any progress on safe birth, reproductive family planning issues?

GATES: Yes. There's a measurable impact when you can go in and educate families, but primarily women, about their different choices.

There's real impact that you can have in this area. Anything to do with reproductive health. Whether it's maternal mortality, infant mortality, there's new ideas. There's more people getting involved.

MOYERS: One of my colleagues accompanied your father and Jimmy Carter when they went to Africa not long ago. The footage was striking. There was your father and Jimmy Carter, the former President of the United States sitting on the doorstep talking about condoms as if you were talking about computers. Are you comfortable dealing that openly with people's habits? People's behavior?

GATES: Well, it's interesting. AIDS is a disease that is hard to talk about.

MOYERS: That visit that my dad did, the health minister had never been in that neighborhood. And so they invited him to come and people didn't think he would. But he actually did come and then got involved and said, "Okay, we're gonna do free condom distribution to this neighborhood because of the impact that that can have."

MOYERS: Someone told me, actually a couple of weeks ago that we'd actually be better off if you'd spend more money on distributing condoms than on this research on AIDS at the moment. That it's the immediate need that people have to, you know, about their behavior that is the biggest problem the world faces with AIDS. What do you think about that?

GATES: The ideal thing would be to have a 100 percent effective AIDS vaccine. And to have broad usage of that vaccine. That would literally break the epidemic. Because that it's not known how long that'll take, and the best case is probably in a 10 to 15 year timeframe, we also have to put huge energy into treatment of the people who have it today.

We've got to put a lot of money into changing behavior. Which we've funded a number of things in that. And there's even an intermediate intervention that we think is very important, which is a microbicide.

MOYERS: A what?

GATES: A microbicide.

MOYERS: What is that?

GATES: Okay, that's a gel that a woman could use to block sexual transmission without the male even knowing that it's being used, ideally.

MOYERS: That requires a great discipline of passion and the question that arises, you know how to motivate your Microsoft employees. You know how to affect their behavior by the rewards that you hold out. How does the world affect the behavior of people at a sexual level?

GATES: It's a bit… that's a very tough problem. It's particularly tough if political leaders aren't willing to speak out. You know, there's been really just a few countries where the politicians said, this is so important for the welfare of our citizens. And even though it involves, you know, drug use and sex workers, they were gonna get up and say that it was a crisis for the country. That happened in Thailand.

MOYERS: Right.

GATES: That's the only country that really caught the potential epidemic at the early stage. It happened in Uganda but it happened after the disease had already progressed to about a 20 percent prevalence.

It's not happening to the degree it should in other countries. And anyone who thinks it's confined to Africa is gonna get quite a wake-up call that already in India there's been five and 10 million people who have AIDS. And it's only a question of how many tens of millions or, you know, perhaps more than 100 million people in India who will get this disease.

And yet, intervening early is when you can the biggest effect.

MOYERS: I interviewed Dr. David Ho a couple of weeks ago. He made the great research breakthrough — TIME's "Man of the Year" for it. He's now worried about China, where his forbearers came from.

GATES: I was in China just two weeks ago talking to the Health Minister and talking to Jiang Zemin about raising the profile there.

And they have — for their level of income — quite a strong health system. And quite, you know, a willingness to say, "Okay, if this is about sex workers we'll go in and we'll register the sex workers. And we're gonna make sure that certain behavioral changes are taking place," like Thailand did.

And so I think the right thing will happen there. They will need international support. They'll need more encouragement to make sure it gets done.

MOYERS: What do you think about the Bush administration's retreat from women's health issues, reproductive rights around the world. Not only their retreat from it, but their outright opposition and their effort to impede it?

GATES: We've got to make sure that that money really gets allocated. And we've got to make sure it gets used effectively.

MOYERS: But they're not supporting contraception. They're not supporting condom distribution. They're not supporting safe sex.

GATES: Part of the problem is that the citizenry doesn't speak up enough and make it a big issue.

MOYERS: You mean make global health a grassroots issue?

GATES: That's right. And yet, if you grab somebody and say, "Do you care about this thing…"

MOYERS: Yeah.

GATES: You can engage them very quickly. But it's not on the agenda.

MOYERS: How do we do that?

GATES: And so well, I'm thinking a lot about that. I'm interested in any ideas. Because this is about human welfare. You know, how we deal with the AIDS epidemic should be one of the greatest ways that the world gets measured. The report card for this era these next few decades, a big part of that grade should be, "Did we apply all of the world's resources and activities and visibility against the AIDS crisis?" And yet, to the average voter, you know, it's not on the radar screen. There's only about $6 a year being given to world health issues by the U.S. and we're quite a laggard in our giving.

We have to go out and regalvanize people that the role of the United States is not just what we do in the area of security, it's also sharing our advances and our resources. And if somebody wants to think about the chance of terrorism in the decades ahead, I think this issue of how young people outside the U.S. think of our country; what is the role of the U.S. in terms of creating opportunity for them?

And if we don't step up to these health issues, you know, we're really not answering that critical issue.

MOYERS: What would you like the average American to know about global health?

GATES: I think understanding the basic facts about the AIDS epidemic is important. I think knowing how little resources are going into these things. Knowing that this is not a case of government waste. I mean, there's this notion of government spending in general and foreign aid that often ends up in some dictator's bank account.

In the area of world health, we're actually coming into the country with vaccines. And you're working at the village level to measure coverage there. There we can be very effective. This is not money that 20 years from now we're gonna wake up and say, "How was that money spent?" We'll know how it was spent because we look at the stopping the disease progression.

And so it is a special thing that the cynicism about government spending should be suspended here because it can be handled in the right way.

MOYERS: In this country we have eliminated diphtheria and whooping cough, and all of those childhood diseases that were still prevalent when I was a kid many years ago. The vaccines exist but we do not get them to the people whose lives… the children whose lives would be saved right now if they had them. Why don't they get to the people, the kids who need them?

GATES: Well the biggest single initiative we've done is the vaccine fund. And that was 750 million to galvanize the world to say, "Okay let's enter a new phase where we raise vaccination coverage from the little bit less than 70 percent it is today." And we get the new vaccines in there.

You know the Hepatitis B, the pneumococcal, there's about four that we have here in the U.S., that are not being given worldwide.

The total cost of getting vaccines, the package to a child, is about $30. And even if we add in the new vaccines, we'd still be at less than $50 of cost for this delivery. And so that money which was supplemented to some degree by governments and others, but not as much as we had hoped, is very directly related to this vaccination coverage.

MOYERS: What do you think are the major diseases that we're gonna have to deal with in the next 25 years?

GATES: Well top of the list is certainly AIDS. It's very epidemic. And I don't think it's even recognized how bad the epidemic could become.

If you were gonna design a bad disease you probably couldn't do something worse than AIDS. The latency, the fact that you're infected and you don't actually see the health effects till six to eight years later, that causes people not to understand what's going on.

You know take something like smoking: say that instead of dying 30 years later of cancer, that instead you smoked and then you just dropped dead right then. You know, people would get the connection: "Oh. He smoked. He died. That's not good. Let's not smoke anymore."

Well AIDS is like that, where you just don't see the impact on a society. You know if people, after visiting a sex worker walked out and they just fell on the street, you know there would be a pile of bodies there and you'd say, "Okay, something's going on here."

The fact that there's these little epidemics of hemorrhagic fevers, they get incredible publicity. Ebola, marburg, lassa. You know and it's literally in the hundreds of people, but because it's all of a sudden that they die, that gets more visibility almost than AIDS gets.

GATES: You know plane crashes in India and the same day the plane crashed, 8,000 kids died of things that could have been prevented. Which gets the coverage? Well, you don't expect coverage every day, but maybe at least once a month, they ought to just say, by the way, every day this month, we don't want you to forget, just two paragraphs, you know. 8,000 people are dying every day. And we'll let you know when it changes, but so far it's been that case for a long, long time.

MOYERS: Isn't it true that in Africa more children die of respiratory illness than people die of AIDS?

GATES: Because of this latency, 5 million people were infected this year. And so AIDS will be #1 in terms of the cause of death. Infant mortality is still higher, and the biggest piece of infant mortality is acute respiratory infection.

MOYERS: Yeah.

GATES: Generally pneumonia-related diseases. And so they both should be dealt with. In fact there are vaccines, although they're still very expensive, that can deal with the respiratory problems of infants.

MOYERS: Are you looking for a vaccine for malaria? Because malaria kills a lot of people.

GATES: Yeah. In terms of what's #2, you'd probably put malaria. Malaria not only kills a million people a year, but at any time there's 300 million people who are being debilitated by the disease.

And if you took the top 10 diseases that are really troublesome in Africa, a lot of them you wouldn't know the names of. I mean you know leishmaniasis, schistosomiasis, even something like trachoma that wouldn't make the top 20.

MOYERS: Trachoma is?

GATES: It's… you get an infection in your eye and you start itching and it's the leading cause of preventable blindness. Because eventually you itch and your eye turns in and you lose your sight. And yet you know Zithromax is this antibiotic that if you give it actually can prevent the disease. And if you get enough people taking it then you stop the spread of that disease. And yet it doesn't… it wouldn't make the top 20…

MOYERS: Do you think we will find a vaccine for malaria? Some people say it's impossible. It's such a complex disease.

GATES: Absolutely. No doubt. First of all, I'm an optimist, so I should explain that. But there is, with malaria, there is innate immunity. That is if you get the disease, except for different strains, you don't get it again. And so the immune system clearly does recognize something in the course of that disease.

And so all we have to do is take the sequencing information and try and find out what that is. You know, I'd say, quite certainly within the next 20 years and ideally in the next 10 we'll have a good vaccine for malaria.

MOYERS: In business, the market kicks you in the pants if you make a mistake. In philanthropy, some of your mistakes are celebrated because you gave the money and nobody ever came back to ask what happened.

GATES: We have to be really brutal with ourselves on this. We will make mistakes.

But then again, you've got to take risks. I mean that's one of the things a philanthropist can do that governments aren't as well suited to do. A politician doesn't want to allocate money if it's a one out of three chance of doing something really good because, you know, then two out of three they'll have to stand up and say it was a waste.

Whereas a philanthropist can say, "Okay. But we will take that risk. Because the payoff would be there. And, you know, I'm not gonna get voted out of office if in fact it's a dead end."

So we should be doing the things that the normal approaches can't do, whether it's approaches to the AIDS vaccine or malaria or delivery systems. We've got to be out there and accept some kind of failure rate.

MOYERS: Is the basic problem that we don't have enough knowledge to solve global health issues? Or is it poverty? I mean if I'm forced to live on $1 a year, I'm not gonna be able to afford any medical care… I'm not gonna be able to afford an aspirin. I'm not gonna be able to afford to make that trip to that clinic.

Your children, my children, my grandchildren. We can afford, they can afford decent medical care. Isn't poverty the real issue here?

GATES: It shouldn't be. The benefit to the world, both on a humanitarian basis but even on a pure economic basis of dealing with these diseases is… it's quite clear and quite positive. I actually get angry when people try and justify these health things in economic terms. You know like you'll read a paper that says, you know, "If malaria was cured, the GNP of this country would be 30 percent higher."

That gets it so backwards. I mean it's true. Statistically it's true and I suppose there are some audiences that you've got to use that argument. But wealth is a tool to measure human welfare. It's just a tool that we created to help us sort of incentivize people and help get things done.

If death doesn't get reflected in GNP, then that doesn't mean it's unimportant. If the suffering in malaria doesn't get reflected in those numbers, it's still very important. So we shouldn't have to resort to these economic arguments.

Some people resort to security arguments. They say, "If we don't cure these diseases, the instability in these countries will be bad. And, you know, that could be scary." Or they resort to the, you know, "It's coming to your neighborhood" argument. That, you know, somebody could get on a plane from one of these places and, you know, you might get sick. I mean, "Don't worry about these people, but you might get sick."

And those, you know, those arguments, if they get more money for world health, then fine. I won't object. But they're wrong. The right argument is, you know, "This mother's child is sick. And that child's life is no less valuable than the life of anyone else." And the world has plenty of resources to go solve these problems.

MOYERS: Let's say that everybody agreed with you. That they wanted to do the moral thing. What practically could we do? You've already admitted the market doesn't get there. It doesn't get to Uganda. It doesn't get to Nepal. It doesn't get to Mozambique. It doesn't get to places where people as you and I talk are dying from malaria, tuberculosis, AIDS, all kinds of diseases.

The market doesn't do it. How do we do it? Every, you know, $27 billion is a lot of money, I think. But it's a drop in the bucket compared to what you've been describing. So what do we do practically?

GATES: For the U.S. to do its fair share, we'd have to take the $6 per citizen that is spent on foreign health issues and we'd have to raise that to $30 to $40.

And if other rich countries did their part, then there would be the money to give the vaccines, to create the new vaccines, to give oral rehydration therapy, to have the education in the villages. You know, then the whole picture of health would change quite dramatically.

MOYERS: Public health doctors I know talk about the positive feedback loop in poor countries. If parents believe their children will get better, they save more and they reproduce less, therefore there's more money for other things. Do you accept that as a workable theory?

GATES: Absolutely. And that is the most amazing fact that should be widely known. You know, essentially Malthus was wrong. If you raise wealth and you improve health, particularly if you educate women, then this virtuous cycle kicks in and a society not only becomes self-sustaining, but it can move up to a fully developed status.

The Club of Rome was writing about how we were basically headed towards a disaster. That the amount of food that the world would produce would be inadequate and you know that things would just get worse and worse and worse.

Well, now at least in the countries where health has taken hold, we're seeing literacy rates improve. We're seeing, you know, everything about life improve. Once you get this one thing right. And that was something that was quite a revelation to me. I, you know, I frankly thought that the Malthusian principles applied at least in the developing countries.

But because of computer technology now, medical advances will move at a incredible pace. The next 20 or 30 years will be the time to be in medicine. Many of the top problems, I'd say most of the top problems, we'll make huge advances against.

Just think about a kid who's curious, say, about malaria. They can go onto the Internet today and, you know, see what's going on. Try, you know, they can even see the genome if they want. They can see the papers that have been published by different labs.

So I get very excited about how the generation that's coming into health right now, the visibility, particularly of these poor world diseases, you know the information now is in their hands. And they ought to be able to do quite a bit with it.

MOYERS: Our Web site at pbs.org offers more insight and information on all the global health issues we've discussed tonight, with links to many other helpful resources. There's data on government health spending, on the relationship between the environment and human health, on the world's most dangerous diseases and much, much more. That's at pbs.org.

In my conversation with Bill Gates, we touched briefly on the topic of women's reproductive rights. It's a very important and, as ever, controversial issue here and around the world. On

next week's edition of NOW, we'll investigate.

BRITELL: There is a serious and very well-orchestrated effort that is underway right now to completely take the reproductive freedom away from women. And I think everyone is living in denial saying it will never happen.

MOYERS: Until next week, that's it for NOW.

I'm Bill Moyers. Good night.