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through the deployment of new technologies, including what we then called the “information superhighway,” later known as the internet.

      About 15 years ago, these three forces intersected with a fourth undercurrent that would shape the rest of my life and career to date. At the turn of the century—while I was head‐down running a pioneering internet company, worrying about Y2K, and wondering if people would ever use credit cards online—in New York City, every member state of the United Nations had endorsed eight Millennial Development Goals (MDGs). These were benchmarks that would measure global efforts to tackle poverty, improve health, and address inequity by 2015. I had no idea this was happening, but my then‐boss and friend Bill Gates and his wife, Melinda, were part of it, alongside other philanthropists and political leaders. Under the enlightened leadership of UN Secretary General Kofi Anan, the MDGs would hasten a revolution in the fields of global development and social innovation.

I could not resist this. Such a powerful global movement presented a fertile field to till with the lessons I'd learned through a lifetime of work in leadership and social activism. So, in 2007, I left Corbis to return to promoting opportunities for impact at the intersection of innovation and social justice, becoming global director of social innovation at McKinsey & Company, where I worked on social sector projects worldwide. I also served on several corporate and nonprofit boards, including at PATH, then known as the Program for Appropriate Technology in Health, a global nonprofit focused on innovations to advance human well‐being. I fell in love with PATH's mission, later serving as interim director of its India program, and then its CEO for almost eight years. That fourth undercurrent and my experiences working within it are the primary basis for the ideas in this book.

      Leading PATH provided me with a master class in practical activism. I learned a great deal about when to push, where to pull back, and how to get stuff done—a lot of stuff. During my tenure, we raised more than US$2.5 billion for global health innovations and helped to develop hundreds of vaccines, drugs, diagnostics, tools, and digital systems that are reaching hundreds of millions of people and changing human health. In fact, riding this current in global development has deepened my belief in the power of practical activism. Because, frankly, the progress I've seen is astounding. Dare I say, it makes me even more optimistic—even in the wake of crises like COVID‐19. Consider:

       In 1979, one child out of eight died before turning five. Today, it's less than one in 20.

       Forty years ago, 30 percent of people on this planet subsisted on less than $2 a day. Today, extreme poverty affects fewer than 10 percent.

       Innovations in treatment for tuberculosis and malaria have saved more than 20 million lives since the start of this century.

       And in most places, HIV infection rates are declining, with a dramatic drop in deaths due to AIDS.

None of these milestones was inevitable. Each resulted from the hard work of people around the globe—research scientists, community health workers, activists, and legislators. Still, the question I am asked more often than any other is how I remain optimistic in the face of so much suffering. The work itself provides my answer. In fact, despite some terrifying headlines, there has never been a time of greater health and prosperity in human history. The past four decades have proven that cooperation between government, business, and the social sector can shrink poverty rates that once looked intractable and eliminate diseases that seemed undefeatable. There is no reason we can't do the same with present‐day ills, including climate change, biosecurity threats, and widening economic inequality.

      As you will see in the coming pages, most of my time at PATH was spent figuring out better ways to meet the needs of the developing world. But the reasons I've found for optimism abroad exist at home too. For instance, consider the devastating crisis of opioid addiction. This remains a full‐scale disaster in the United States, estimated to cost our economy some $400 billion in medical interventions, foster care, and special education over the next 20 years. But slowly, we are beginning to develop procedures for stemming that tide, primarily by treating addiction as a public health problem rather than a moral failing, and getting anti‐addiction medication to more people. Still, in Seattle, a city shaped by the likes of Boeing, Microsoft, and Amazon, the clash of extreme affluence and dire need is evident on our streets every single day. At home as abroad, the key to progress is acknowledging a dire reality while remembering that it is fully within our capability to bend the arc of the future toward better ends.

My colleagues and partners at PATH taught me much about channeling outrage into optimism. Every day, they demonstrated the heavy lifting of practical activism, what it takes to jump in, work behind the scenes on complicated issues, and commit to life‐changing impact over decades of relentless effort. They also helped me to shape my energy more productively, helping me understand the critical role of compromise in getting stuff done.

      Compromise does not mean weakness; if used well, it is almost always a sign of strength. But it's not an easy balance, and often means working with influencers in business or philanthropy whose politics do not align with mine. It has landed me in front of world leaders whose record on human rights is abysmal. It has found me advocating for issues that some would consider counter to my own interests—campaigning for an income tax in my home state of Washington, for instance. Compromise has pushed me toward doing things that were awkward but important, like getting married at a walk‐in chapel in a San Jose strip mall so that Bob and I could be part of the early same‐sex marriage movement ahead of California's controversial Proposition 8 vote—though a marriage certificate was not important to us personally. Compromise has often forced me to weigh ends against the means of reaching them. In New York City, though Bob and I never got to live in married‐student housing, we did influence the university's policies around housing for students to come.

More recently at PATH, we worked with parliamentarians in Uganda who were contemplating laws that could sentence gay people to death. Should their attitudes preclude our engagement with that country around public health? Not if the goal is improving equity and safeguarding human rights. And while PATH endorsed imperatives on inclusivity, we regularly sought common ground with conservative policymakers to push progress on other issues. I am adamant, for example, about women having access to family planning choices, but I am also always willing to sit down with anti–family planning policymakers to see if we can come together on maternal and child‐health programs. Similarly, we worked with partners from Uganda, to Myanmar, to Ukraine and other countries where there are clear problems regarding human rights, authoritarianism, or corruption. Because the children who live in those places have as much right to better health as children everywhere.

      These kinds of tensions in practical activism have been most pronounced through my lifelong work with China. Following a short talk I gave at the 2011 TED Conference in Long Beach, California—intended to do some myth‐busting about China's work in Africa—I was immediately pilloried by both sides: those who felt I was an apologist for China's aggressive engagements across Africa, and those who were angry that I'd criticized China's human rights and environmental record from a TED stage. This moment captured the essence of the challenges around engaging with China as it has become a global superpower. Yes, there is much to condemn and many policies about which to be wary. But there is also so much to gain. China is within reach of eliminating chronic poverty from its population of 1.5 billion people. After fighting some 30 million cases of malaria and facing down more than 30,000 deaths each year through the mid‐twentieth century, China is now on the verge of being declared malaria‐free by the World Health Organization (WHO). How can we ignore progress like that? What can we learn from a country that has brought more people into the middle class faster than any other in human history? China also has extraordinary assets in science and technology that could advance progress in fighting hunger and disease worldwide. Over the years PATH and its partners have chosen to focus on these opportunities, collaborating with China to access new vaccines and drugs for the developing world; help forge better policies related to digital health systems; and simultaneously navigate the ever‐changing political waters that engagement with China inevitably demands.

This practical approach to activism has enabled me to bridge divides that seem insurmountable, or at least logistically improbable.