Donald Trump represents the forefront of these funding cuts, but the harsh realities of his administration are just part of the narrative. Following a surge in the 2000s, contributions to global health stagnated throughout the 2010s. The landscape of charitable giving has also shifted notably in the era of pledges. The wealthiest individuals globally have committed to donating over half of their fortunes to various causes. After Gates’ divorce in 2021, Melinda eventually departed the foundation to pursue her own philanthropic endeavors. Recently, long-time ally Warren Buffett announced his plan to channel most of his remaining wealth into a charitable trust; his children will manage this, and he will not provide any additional funds to the Gates Foundation beyond his passing. Following a slowdown after the Covid years, this year saw a decline in foreign aid—Mark Suzman, CEO of the Gates Foundation, recently wrote in The Economist about falling aid levels, describing it as “falling off a cliff.”

On the ground, progress has been uneven, particularly in the aftermath of the pandemic emergency, which led to the suspension of many routine vaccination programs, leaving the world’s poorest nations in severe debt distress. While the proportion of the global population living in extreme poverty fell by nearly three-quarters from 1990 to 2014, that progress has stalled since then.

This is the crucial moment to reflect on Gates and his team’s narrative—given the gap between post-pandemic setbacks and the challenges posed by Trump’s policies, the Gates Foundation will emphasize once more the potential of biomedical tools and life-saving innovations in the current development landscape, including advancements in AI. They envision a future where the Gates Foundation is no longer needed. This vision is undeniably attractive. But with the challenges ahead, can it truly be realized?

During two days in late April, I engaged in discussions with Gates about the current state and legacy of his philanthropy, reviewing both accomplishments and setbacks thus far, as well as the challenges yet to come. Below is a revised, condensed account of those conversations, capturing his optimistic, detailed, confident, and at times bold perspective as he describes the coming decades as an “era of miracles,” representing even more fundamental advancements than he has previously cited.

I. “Millions of Additional Child Deaths”

Let’s discuss the current tensions surrounding the Trump administration. It appears that the administration is poised to abandon foreign aid entirely, leaving millions of people and many global institutions in jeopardy. How dire is this situation?