Bill and Melinda Gates Grade the World’s Health

At 61, he could speak with the avuncular magniloquence of a professor emeritus; instead, he layers on supporting data like a star pupil seeking an A-plus. He rebuts skeptical inquiries and insists on teaching from his own syllabus — and on flicking his own birch switch.

The report card will be issued annually, Mr. Gates said. He gave himself only a C+ on the first draft, promising sharper analytics in the future.

He isn’t actually handing out grades to the world’s health authorities — but is sending them home with a note for mom. Your kid has real potential but is becoming a discipline problem.

In some areas, like infant mortality, he considers the progress made “pretty miraculous.” In 1990, more than 11 million children died before their fifth birthday; now, fewer than 6 million do.

AIDS deaths have plummeted since 2004, and malaria deaths since 2005. Rates of childhood stunting, mothers dying in childbirth, and the miseries wrought by rare tropical diseases all have gone steadily down.

In poor countries, vaccine use is way up, though only about 75 percent of children get all the shots they need. More people have toilets these days.

Progress in other areas has been slower. Smoking is down, but tobacco companies are fighting back. Contraceptive availability is up, but almost half the women who want birth control still lack it.

Access to basic health care is up, according to the new report. But the gap between rich and poor countries remains vast, because too much money goes to top hospitals instead of rural clinics.

One key finding: Most of the progress was not bought by donors, but came organically as hundreds of millions of people scrambled out of the most abject tiers of penury.

In 1990, 35 percent of the world lived below the international poverty line (currently $1.90 a day); now, only 9 percent do. Most of the great leap upward was in just two economic powerhouses: China and India.

The report’s scarier themes lie in its projections for the next 15 years.

Assuming economic progress continues, improvements in most health categories will churn dutifully on, or at worst plateau. But since the 2008 economic crisis, donors have been losing their will to give.

If that persists, the report says, chaos threatens. H.I.V. infections could double, returning to levels not seen since the 1990s. And malaria could climb back to the peak hit in 2005.

H.I.V. and malaria are particularly vulnerable to fluctuations in…

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