Bill Gates, co-founder of Microsoft and the Bill and Melinda Gates Foundation, wants to add $4 billion to the fiscal stimulus package under debate in Congress so that poor countries can get Covid-19 vaccines.Credit...Jeenah Moon for The New York Times

On Monday, the Bill and Melinda Gates Foundation released the fourth of its annual Goalkeeper reports, which track the slow but steady progress the world has made toward more than a dozen health-related goals set forth by the United Nations in 2015.

This year’s was unrelentingly grim. The coronavirus pandemic has scorched away years of work: More families are in dire poverty, malnutrition is increasing, far fewer children are getting immunized.

The assessment comes as the United States, stung harder by the virus than any other country, is retreating from the global health stage and seems focused primarily on saving itself. Could it ever return to its role as the world’s leader in both competence and generosity? In an interview with The New York Times, Mr. Gates devoted a half-hour to explaining why he was optimistic that it would.

“It’s my disposition,” he said. “Plus, I’ve got to call these people up and make the pitch to them that this really makes sense — and I totally, totally believe it makes sense.”

By “these people,” he was referring to leading figures in the White House and Congress, whom he has personally lobbied to do “this”: namely, add an extra $4 billion to the fiscal stimulus package now under debate in Congress so that poor countries can get Covid-19 vaccines.

Ultimately his goal is far more ambitious: to double American foreign aid from less than 0.25 percent of gross domestic product to 0.5 percent or more. He sees the pandemic as an opportunity to do that.

“As they say,” he added cheerily, “the U.S. government — after it’s tried every other thing — does the right thing.”

As he did in Silicon Valley while battling competitors and antitrust regulators, Mr. Gates can calculate his chances of success with a ruthless logic.

That has rarely been as true as it is now, as a once-in-a-century pandemic devastates the impoverished countries where he focuses his giving.

The damage has been wrought less by the virus — so far it has killed much smaller percentages of the populations of Asia and Africa than of the Americas and Western Europe — than by the economic impact, which has been far greater in countries where people and governments “have no spare reserves to draw on,” Mr. Gates said.

The collapse of tourism, declines in remittances from relatives working abroad, the shutdown of ports, mines and oil wells, school closings and new stresses on fragile health care systems have all created enormous suffering.

Not since 1870 have so many countries been in recession at once, according to the Goalkeeper report. Between 1990 and 2020, the percentage of the world’s population living in extreme poverty, which is now defined as living on less than $2 a day, shrank to less than 7 percent from 37 percent. In just the past few months, 37 million people have fallen back below the line, the report estimated.

“The longer the pandemic lasts, the worse its economic scars will be,” it added.

The percentage of the world’s children who received all the vaccines recommended by the World Health Organization rose last year to a record high of 84 percent. That figure has now dropped to 70 percent — back where it was 25 years ago. Deaths from malaria, malnutrition, childbirth complications and diseases like measles and diphtheria have begun to increase.

Nonetheless, Mr. Gates was optimistic that the lost ground would be recovered “in two to three years.” The pipelines of money from tourism, remittances, World Bank loans and other sources would begin flowing again as soon as the whole world was vaccinated, ending the pandemic; he expected that to be accomplished by sometime in 2022.

Until then, however, there will be a period of intense pain and even greater inequity between rich countries and poor ones.

One of the starkest conclusions in the foundation’s report is that nearly twice as many deaths could be prevented if Covid-19 vaccines were distributed to all countries based on their populations rather than to the 50 richest countries first.

That will not happen soon, Mr. Gates conceded. The Trump administration has publicly refused to join the international collaborative agreement known as Covax, under which the World Health Organization; GAVI, the Vaccine Alliance; and the Coalition for Epidemic Preparedness Innovations have joined forces to make sure both rich and poor countries receive new coronavirus vaccines simultaneously.

Instead, Operation Warp Speed, the Trump administration's unilateral effort to fast-track vaccine development, has paid out $11 billion to six vaccine companies in return for ensuring that at least 100 million doses from each company, and options for millions more, are exclusively earmarked for the United States.

Although that position “looks selfish,” Mr. Gates said, he did not feel it was unjustified. Realistically, he said, “You’re not going to succeed in getting the U.S. to treat itself as just a random 5 percent of the world’s population.” American taxpayers, he noted, have paid two-thirds of the costs of the clinical trials and of manufacturing doses even before the trials end.

Absent that money, the only available vaccines would be those from Russia or China, which Mr. Gates considered untested and potentially weak. “You can’t call up Johnson & Johnson or AstraZeneca and say, ‘Hey, here’s a chance to lose $500 million.”

If just three of the several vaccines that the United States is backing succeed, he said, the country would have more doses than it could use, and the rest could be shared with the world.

Also, Mr. Gates said he expected that by early next year, regardless of who wins the presidential election, the United States would come around to paying much of the estimated $4 billion needed to get vaccines to all the world’s poor.

He noted that Congress had repeatedly kept funds for AIDS, malaria and childhood vaccines in the foreign aid budget, despite numerous attempts by the White House over the past decade to slash those items; the programs are popular both with liberals and Christian conservatives.

And doing so is in America’s interest, Mr. Gates said. In a world dependent on tourism and business travel, no country is safe until every country is: “There’s a better global argument for generosity on this one than there is for H.I.V. or malaria.”

Mr. Gates has lobbied both Treasury Secretary Steven Mnuchin and Mitch McConnell, the Senate majority leader, to put the $4 billion for vaccines in the deadlocked stimulus bill and said he was “60 to 70 percent confident” that the item would survive the negotiations.

Congressional leaders “have a sense that the U.S. has a moral presence in the world,” he said. And the payoff on that investment “will be in the trillions.”

But his ultimate ambitions are far greater. Once the coronavirus threat is gone, he said, “we should go after the modest U.S. foreign aid budget and try to get it to double.”

Surveys consistently show that Americans are aware that the United States is the world’s largest donor of foreign aid. But when asked to estimate what percentage of the nation's gross domestic product goes toward to foreign aid, the typical guess is 5 percent. In fact, the real figure is less than 0.25 percent.

By that measure, Britain and Germany spend almost three times as much, and Sweden and Norway are four times as generous, spending a full 1 percent of G.D.P.

This pandemic offers a chance for the United States to step up, Mr. Gates said.

The last such opportunity came in the 1980s and ’90s, with AIDS; the disease hit the United States so hard that many Americans developed some sympathy for its victims. In 2003 George W. Bush capitalized on that feeling and poured $15 billion into the President’s Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria, which sought to combat those diseases in Africa and elsewhere.

Now that Americans better understand the threats posed by emerging viruses — Mr. Gates warned about them in a TED Talk in 2015 — they might be willing to pay more to head them off, he said.

Doing so would be cost-effective. “In the health field, we really do know how to spend money and have impact,” he said. “We’ve learned a lot in the last 20 years.”

Two decades of distributing AIDS drugs, polio vaccines, diagnostic kits and other goods has put in place a medical infrastructure — corps of doctors, nurses, community health workers, laboratories, pharmacies, emergency operations centers — that with minimal new spending and training can be shifted to fighting other diseases.

Mr. Gates said that he sometimes felt “kind of lonely” visiting congressional leaders to espouse foreign aid. But he has succeeded in persuading even some rigid fiscal conservatives by employing two tactics often used by advocacy groups that receive grants from the Gates Foundation.

One is having retired generals from the Global Leadership Coalition explain to members of Congress how pennies spent on humanitarian aid can save billions of dollars that might be needed later to defeat militant movements that thrive when countries are starving.

The other is sending members of Congress and their spouses to Africa. Nothing shows how effective foreign aid can be, he said “than having a senator sit and listen to a woman say that, as soon as her crops are more productive, she’ll be able to pay the school fees for her kid.”

Also, he added, those senators may calculate that it is smarter to encourage small countries “to have strategic relationships with us versus, say, China.”

Journalists, in turn, help “put a human face on the story.” (The foundation does not underwrite reporting by The Times, but it does pay for global health coverage by many other outlets.)

Ultimately, he said, if this pandemic produces “an administration and a Congress that are more open-minded, you could really do a grass-roots thing.”

“You can get everybody who’s a doctor, everybody who was ever in the Peace Corps, everybody who was touched by H.I.V., everybody who’s been touched by this pandemic, and pull them together to say, ‘Hey, maybe the U.S. aid budget should be 1 percent or even 2 percent of the government budget, versus what it is right now,’” he said.