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AUDIE CORNISH, HOST:

From NPR News, this is ALL THINGS CONSIDERED. I'm Audie Cornish.

ROBERT SIEGEL, HOST:

And I'm Robert Siegel.

Last month, Bill Gates, of the Bill & Melinda Gates Foundation, hosted the fundraiser to end all fundraisers. It was the Global Vaccine Summit in Abu Dhabi. Countries were pledging in tens of millions of dollars to fund a project that Gates and his foundation have been committed to for over a decade: eradicating polio worldwide.

The funding target is $5.5 billion. They've gotten pledges for 4 billion. And Bill Gates says his foundation is good for $1.8 billion of that $4 billion. He joins us in the studio once again. Welcome to the program.

BILL GATES: Great to be here.

SIEGEL: And we should acknowledge that the Gates Foundation also happens to be a funder of NPR. But we're here to talk about polio. And let's start with this colossal sum of money. Why should it be more than 10 times more costly to eradicate polio than it was to eradicate small pox, the only disease that has been eliminated by medical science?

GATES: Well, that was a miracle back in 1980. Things were a lot more expensive. And polio is a bit harder. You have to give the vaccine three times, whereas in small pox we had a vaccine that you only had to give once. With small pox, it had a characteristic rash so you could detect a case very easily. Here, you only know that somebody has it if they get paralyzed. And so that's quite a bit later, and so the surveillance is a lot harder. But we can still achieve this.

SIEGEL: At the conference in Abu Dhabi, you acknowledged what everyone in the field knows, that there've been setbacks here. The eradication of polio seemed within reach eight or nine years ago, and people were looking forward to that date. And despite a lot of progress, there's also been slippage. What is it about $5.5 billion that says there won't be slippage again?

GATES: Well, the key is that you've got to get the vaccine three times to over 90 percent of the children and then the disease dies out. And so we've been missing people where you have nomadic people moving around or the map is not quite right. Now we're using satellite maps to find everyone.

We've had vaccination teams that haven't gone everywhere they should go, and now we can use GPS tracker at the end of the day to compare where they went. We see it - their location every three minutes to the map. So if we can get this done, not only do we stop kids being paralyzed but the world saves the two billion, you know, they're spending right now to protect children all over the world.

SIEGEL: But if - as I've read, the most problematic countries for polio remain Afghanistan, Pakistan and Nigeria. What those countries seem to have in common is, frankly, violent political disorder and mistrust of authority. In Pakistan, it even led to attacks on vaccination teams. Those problems don't sound like the kind you solve with more money.

GATES: Well, certainly, getting more kids to have routine immunization, the social mobilization, organizing the women's groups, there are ways that resources will help there. We have less than 300 cases of polio a year now, and they're all in those three countries, in fact, in parts of those countries. And so paying the vaccinators, getting the word out, studying the maps, well, yeah, this money, and I've been through it very carefully, this is what we need to get the job done.

SIEGEL: But when we hear that there were, you say less than 300, I think 223 cases reported in those countries last year, I mean, there are critics who would say that eradicating polio, bringing it to zero has become your white whale, that you could settle for the colossal reduction in cases that we've had and perhaps spend billions on other public health concerns that would extend, you know, prevent the death of children by diarrhea and other illnesses.

GATES: Well, certainly our foundation does spend lots on those things, but polio is special because once you get it done, you save two billion a year that will be applied to those other activities. And so you simplify the work of the health workers and all that other money gets freed up, as well as no kid being paralyzed. And in fact, a lot of this five and a half billion is being used to strengthen the health systems of these countries, which will be a big asset for all the different diseases.

SIEGEL: I have to say that there's a personal dimension of this from me. I have - somewhere in my home is buried the little polio pioneer pin I was given as one of the public school kids who got the test Salk vaccine. I was part of that group. And I was raised with the fear of polio every summer until the vaccine was found.

So it's - but even so, there do seem to be, even to me, some cost-benefit concerns here. I mean, zero just seems to be a - well, you know, we could have zero car deaths if we all drove around like NASCAR with helmets and fireproof suits, but airbags and seatbelts seem to do a great job of reducing fatalities.

GATES: But infectious disease is special. Once you get to zero, all of the expense to protect people goes away. So you have two choices. You can spend less and have the disease spread back and paralyze lots and lots of kids, or you can double down and really get to zero. So with smallpox, you know, we haven't had to spend any money at all on that, and it was killing over two million per year, scarring lots more than that. And so it - there's no better deal economically than getting to zero if you could do it.

SIEGEL: Yeah. But I would assume, as you get to the last 1 percent of children to vaccinate and the last half percent and the last tenth of 1 percent of children to vaccinate that the cost per vaccination must rise astronomically as you're doing this.

GATES: Well, we only need to get to 90 percent of the kids. That is if 90 percent are protected, the disease will die out. You'll have a few cases, but they'll be very local and it won't last more than a few years. So we don't have to get to 100 percent. Ninety percent is very hard. I'll be the first to admit. And the violence is a big challenge.

SIEGEL: How much of that 5.5 billion would it take to complete vaccination of a sufficient number of children in Afghanistan? And how do you do that if indeed the country is being contested in a civil war, let's say?

GATES: Well, the polio is in a very small part of Afghanistan. It's a common epidemic with Pakistan because of kids moving back and forth. Last year, we had 16 cases there. So far, we have two. It's just where there's the U.S. Army is fighting. So if the U.S. Army withdraws, then this is going to get a lot easier because we're getting access to all the kids there. The Taliban has given letters of passage.

SIEGEL: The Afghan Taliban.

GATES: The Afghan Taliban. Now, that's different than in Pakistan. In Pakistan, there are inaccessible areas, which are a big challenge.

SIEGEL: And what is the hook for you and polio? What is special to you that has engaged the foundation for so long? Is it just the frustration that this should have happened eight years ago and it hasn't happened and you want to get to zero or why?

GATES: Well, our focus is reducing childhood death, and so we prioritize whatever is the most impactful thing to cut down the millions of children who die. And vaccines are, therefore, our primary focus. Polio is one where the cost savings would be poured into diarrhea, pneumonia, the big killers, malaria also. And in fact, we'd love, after polio gets done, to get the world rallied around a malaria eradication plan. But we can't do that until we get the savings and the credibility that will come from this success.

SIEGEL: Well, it's good to see you again. Thank you very much for talking with us about the polio eradication campaign.

GATES: Thank you.

SIEGEL: Bill Gates of the Bill & Melinda Gates Foundation and, as you may recall, also of Microsoft.

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