Since then, however, Ethiopia has made such remarkable strides in growing its economy—and just as important, in building a comprehensive social safety net—that the Bill & Melinda Gates Foundation now says it’s on track to “almost eliminate extreme poverty by 2050.”

Rwanda, a country torn apart by genocide barely a generation ago, has spent the years since that horror protecting its current generation of children by investing in health care—doubling down on vaccination efforts and supporting a widespread community health worker program. The result: Between 2000 and 2015, the mortality rate of kids under 5 fell at a record pace.

Fifteen-year-old students in Vietnam, a country where per capita GDP is less than 1/25th what it is in the United States, sharply outperform their American and most European counterparts on international math and science tests. Why? One reason, again, is investment. Vietnam spends nearly 6% of its GDP on education, according to the World Bank. (The U.S. spends about 5%.)

All three of these surprising achievements are highlighted in the Goalkeepers 2018 Data Report, written by Bill and Melinda Gates and released on Sept. 18. But the dispatch—an assessment of the progress made so far on the United Nations’ 17 Sustainable Development Goals and done with the help of the University of Washington’s Institute for Health Metrics and Evaluation—is anything but rah-rah. For every encouraging data point, indeed, there is one that alarms. For every promising advance in the global war on poverty and disease is a perilous outcome if we lose focus or steam.

“What I like about this year’s ­Goalkeepers report is that it’s precise, ­homing in on countries where there has been genuine progress as well as the places where it still needs to happen,” says Dr. Sue Desmond-Hellmann, who was a leading cancer researcher, a biotech executive, and the chancellor of the University of California, San Francisco, before becoming CEO of the Gates Foundation in 2013. “It’s fantastic that a billion people, for example, have lifted themselves out of poverty since 2000—that’s just astounding. But if you look at the numbers, three-quarters have been in China and India,” she says.

The result is a concentration of the planet’s remaining poor largely in one place: Africa. And if the current population and economic trends hold, it’s going to get worse. By 2050, 86% of the world’s extreme poor—those surviving on the equivalent of $1.90 a day—will be living in sub-Saharan Africa. Close to half of this total, moreover, will reside in just two countries: the Democratic Republic of the Congo (DRC) and Nigeria.

Which brings us back to that Janus-like dualism in the report. “The promise is, if you invest in health, if you invest in education, great things happen,” says Desmond-Hellmann. If we apply the same strategy that worked in much of Asia and India, we could have “a third wave of poverty reduction in sub-­Saharan Africa, another wave of empowered people and opportunity. The peril is, if it doesn’t happen, you’re going to have African youth [nearly 60% of the continent’s population is under the age of 25] who won’t have that opportunity and who will struggle with inequality.”

The latter environment is a petri dish for instability, violence, mass migration, and—as we’re seeing now with a continuing outbreak of deadly Ebola in a war-torn region of Central Africa—a potential threat to global health as well. In their report, however, Bill and Melinda Gates de-emphasize such concerns in favor of what they see as a more compelling reason for action—an investment case: a chance to harness “young people’s enormous potential to drive growth.” Africa’s youth, they write, “are the activists, innovators, leaders, and workers of the future.”

(Read The Goalkeepers 2018 Report from the Bill & Melinda Gates Foundation.)

Their blueprint for tapping into this giant reservoir of human capital focuses on four key areas.

Invest in health

The Gates Foundation’s primary focus is tackling the major health challenges of the developing world—eradicating malaria, HIV, tuberculosis, pneumonia, and the diarrheal diseases that still sicken and kill many children, despite the enormous progress that’s been made so far in preventing infections. A central part of the strategy going forward is the same as it has been until now: vaccination—which offers “the greatest bang for the buck” in public health, Desmond-Hellmann says. “Vaccines and bed nets [to prevent bites from malaria-carrying mosquitoes] are low-cost ways that governments can protect their children.” (Bed nets alone have prevented more than 500 million cases of malaria.) “We, as a foundation, can work with those governments—we can talk to the Minister of Health and the Minister of Finance about the wonderful returns on investment,” she says.

Innovation here is critical. Rotavirus, a major cause of diarrhea, is preventable now because of vaccines made by Merck and GSK. Ebola may well be, too, if a new experimental Merck vaccine, now being tested, proves to be effective. “You might say, ‘Why do I care about DRC? Why do I care about Nigeria?’ Well, Ebola reminds us again that a health crisis anywhere is a health crisis everywhere,” says Desmond-Hellmann. “And having the vaccine available is a direct result of investment by the private sector.”

Invest in education

“Vietnam,” says the Gates Foundation CEO, “drove their gross domestic product growth 300-plus percent over 25 years by investing in education.” But the ROI here isn’t just economic. “One of the strongest determinants of a child’s health is the educational status of his or her mom,” the CEO says. “And so when you invest in education—and particularly include both boys and girls, which most of the world happily does now—you’re investing in the future of those young women as mothers, too, as well as in the health of their children.”

Invest in sanitation

Many philanthropies have made providing access to clean water their goal. The Gates Foundation is turning its attention to another social determinant of health: sanitation. Says Desmond-­Hellmann: “It’s part of our theme that we’ll do things that others can’t or won’t.”

The foundation has “made a lot of investments in toilets, particularly in India, which has a massive national program to have safe toilets for all their citizens,” she says. Another focus is helping communities that don’t have a sewer system (and can’t afford to build one) to leapfrog into a less expensive approach called “fecal sludge management”—a system that safely transports, dries, and treats the waste.

Support family planning

Rapid population growth makes it harder for regions to break the chains of poverty. In Africa, even a 50% reduction in the poverty rate would leave the number of poor people essentially the same because the population is projected to nearly double by 2050, the Goalkeepers 2018 Data Report points out.

Desmond-Hellmann says the foundation’s aim is simple: making sure that every woman who wants contraception can get it. “Our philosophy is that a woman should be able to have the number of children she wants and with whom she wants. And that is, for me, female empowerment, not colonialism.”