Every year, the Bill and Melinda Gates Foundation releases a Goalkeepers report, tracking the world’s progress toward the U.N.’s Sustainable Development Goals. The news is almost always pretty good. This year’s edition is … not like that. “Almost every time we have opened our mouths or put pen to paper,” the Gateses write in the report’s introduction, “we have celebrated decades of historic progress in fighting poverty and disease. But we have to confront the current reality with candor: This progress has now stopped.” Their annual report tracks global progress on 18 different metrics. “In recent years, the world has improved on every single one. This year, on the vast majority, we’ve regressed.”
For a nonmedical civilian, Bill Gates has occupied an unusually central role in the story of the coronavirus pandemic almost since it arose. Gates, who spent much of the past decade warning the world about the risks of a respiratory pandemic, found himself funding a flu study this spring that was among the first documenting community spread of COVID-19 in the U.S. He has devoted much of the foundation’s resources to infectious disease and global immunization programs over the years and now has funded a lot of expedited research into possible coronavirus vaccines and treatments — indeed, he helped pre-fund the manufacturing of seven candidate vaccines, long before knowing whether they would work. (He also became the center of an unfortunately pervasive coronavirus conspiracy theory.) While Gates has been worrying about, and working toward, our ability to respond to the coronavirus in the short term, judging from the Goalkeepers report, he may be even more worried about what the pandemic means for the long-term trajectory of global development.
In early September, I spoke with him about how much damage has been done to that trajectory; how the world, and the U.S. in particular, failed so spectacularly in containing SARS-CoV-2 barely a decade after very successfully containing SARS-CoV-1 (and even more recently containing MERS and H1N1); how bleak the fall looks to him in terms of the pandemic; and when, and in what form, we can expect real global relief from vaccines to arrive. (Unfortunately, not that soon, he says.)
I thought we should start with the Goalkeepers report itself. To me, this report is always a perspective giver — it makes me remember that, however grim things look, many things are getting much better in so many areas of the world. This year’s report offers a very different message — you talk about losing 25 years’ worth of progress on vaccination and the long-term effects of missed schooling. In the West, a lot of us tend to think this pandemic is going to pass — we’ll get through it and, on the other side, things will resemble the way they were before. How do you see the global impact? How big, how bad, and how lasting are these setbacks?
It’s a super-good question. As you say, the gradual progress in literacy and reducing malnutrition, reducing childhood death, extending life spans — that largely goes unnoticed, and it’s the most amazing story there is. This year, it’s just bad news.
But how bad?
In the very best case, two years from now, you would be, for some of the health things in particular, ideally back at where you were at the beginning of 2020.
That is, if we’re lucky enough that several of these vaccines work, including the ones that are low cost enough that we can scale the manufacturing. And if we get the factories going and we get the money to buy it for the entire world.
That’s the very best case.
In that case, during 2021, the pandemic is going down, and in 2022, the global pandemic comes to an end. Could we sit here two years from now and say, “Okay, during that time, not only did we end the pandemic; did we also restore the vaccination services and catch up to the kids that got missed? Could we restore the malaria work and HIV work that was lost to the pandemic?”
On the economic statistics, these countries don’t have the ability to raise their government debt like the rich countries do. And so what we’ve done with the CARES Act, the first $3 trillion, there is no equivalent that can take place in Nigeria or most of the developing countries. India’s done a bit because they’re a low-middle income country, but once you get below the India level, there hasn’t been a lot of aid generosity. Poor countries have had to deal with this largely on their own. The only good news in developing countries is the death rates have been actually fairly low.
Across sub-Saharan Africa, the fatality rate appears to be much lower than in Europe, the U.S., or Asia.
Ninety percent percent of that is due to the age structure of their population. Their societies are about 20 to 25 years younger on average. These are very young countries. And even though the newspapers highlight the cases of younger people who do get the disease, some of whom die, those are very small numbers.
I saw one analysis suggesting the disease was 10,000 times more deadly for a 90-year-old than a 9-year-old.
Early in the epidemic, where some of the medical personnel were getting huge doses, you did have people in their 20s and 30s who had died. That largely has stopped. Yes, there are some cases, but it’s like flu, where, in a typical year, you have 60,000 deaths in the U.S. from flu. Four hundred of those are people under the age of 60. So it’s really very age-specific. This thing, even more now, is very age-specific.
India isn’t as young, and the density of their slums is such that they’ve actually had a pretty tough epidemic. South America is coming out the worst — they’re old enough to have a lot of deaths, and yet they’re poor enough that their slums have just super-high density. And of course their health system, although they’re better than Africa, they still have been overloaded.
So the education and economic damage from this pandemic may not get solved for more than a decade. And yet actually mapping those into something people can recognize. GDP — of course GDP is this super-abstract thing. Deaths — people understand deaths. But if you said, “Okay, every kid in the U.S. misses two years of education,” how would you map that to something where people would know to cry? It’s not easy.
So — how did this happen? In the U.S., we’ve been so focused on the failures in the White House and the inability to put together a national strategy. And obviously that has been a failure. But we’ve also had failures at the FDA, particularly in its supervision of testing, and the CDC, particularly in its muddled guidance on things like mask-wearing. And while the U.S. has done especially poorly, particularly when judged against expectations, it’s also the case that when you look globally, almost nowhere outside of East Asia have things been handled very well. As recently as the first SARS, the global public-health apparatus was able to contain it — a similar respiratory infection, though of course there are important differences. But the response to this one has also been different. So what went wrong, in your view?
Well, first, SARS is just not as infectious as coronavirus. And you have asymptomatics who can infect people. That’s really bad because they don’t self-identify — they’re asymptomatic.
They don’t know they have the disease and don’t know to avoid contact with others.
Polio has this problem. It’s a huge difference between smallpox and polio. Smallpox, we handed people a card, and said, “Find somebody with a rash that looks like that and we’ll give you a payment.” And even illiterate people would bring in people with rashes and say, “Give me my payment.” You could find people, and it wouldn’t have spread. Whereas with the asymptomatics, by the time you find the kid who’s paralytic, the disease can be a thousand miles away. So asymptomatics are really bad and being infectious before you become symptomatic is bad too — that’s called presymptomatics; those are really bad. You can say that’s all one phenomenon.
Two, we thought this was a coughing disease. All respiratory diseases are coughing diseases. They make you cough. Flu, in order to get out and survive, it causes you to cough. And this disease isn’t about coughing. About 20 percent of people do develop a cough, but this thing can spread in many other ways.
Heavy breathing, singing, speaking …
Actually the louder you talk, the more this upper-respiratory-tract super-spreader phenomenon takes place. It’s taken us a long time to figure that out. And that’s part of the reasons why masks are a big deal, because people who aren’t coughing are still spreading this thing. And it wasn’t until sometime in April that people started to say, “Wow, these masks are kind of cheap. How the hell did this thing spread in that restaurant in China? How the hell are we seeing these massive spreading events?” You have a wedding party, and you infect 50 people. You have a biogen conference, you infect 50 people.
It’s hard to imagine a single person coughing directly on 50 different people.
We were naïve medically about it. If it had been a flu, we would have been less stupid, though we’re way more stupid about flu than we should be. That’s why I was doing the Seattle flu study that happened to—
Happened to catch it — the first detection of community spread in the U.S.
These 40,000 travelers coming back: If you’re not going to test them or quarantine them, then why did you do your travel ban? Your travel ban is laughable because 40,000 people came from China. And, by the way, these Europeans are still coming in and it’s gotten there. And that’s what happened out on the East Coast, by and large. So the U.S. response — you would have expected the U.S. to have the best response. We have the most PCR machines per capita by so much it’s unbelievable. I mean, it’s crazy. And yet we end up being as bad as health systems that have spent half as much, countries that don’t have a CDC.
So there’s a variety of things that went into our relative underperformance. Some countries like Norway, Denmark, they did a lot of things right, but they also probably had fewer cases coming into their country. It’s very hard to measure that. Vietnam, it’s easy to celebrate — relative to its GDP, it has the best education system and the best health system. This is ignoring this pandemic. It’s very weird that some of these communist countries in terms of global good, the public good, they do very, very well. Cuba, even Kerala, which is the most socialistic part of India, has by far the best health system.
South Korea is an amazing story of contact tracing. They thought, “Hey, who has PCR machines?” And they got testing to be free and quick, and they never had long turnarounds on tests. That’s a unique U.S. stupidity, that we let the commercial guys get so rich on these tests that they take backlogs. There was no benefit to paying anybody for a test that takes more than 24 hours.
And when you see some results only coming back a week later, the person’s whole infectious period may have passed.
It’s just pure throw-the-money-away type insanity. It’s incenting the worst behavior. So in the U.S., we’ll be studying the mistakes the CDC actually made, and then the muzzling of the CDC, for years to come.
You walked through Vietnam and South Korea. Those are two very different countries with very different income levels. And, really, if you look at all of East Asia, you see a real diversity of public-health capacities and different levels of wealth. And compared to how the West, defined broadly, has done, just about every country in East Asia did remarkably well. They contained the disease much better than even the best nations of Europe did. What could we have done to make our response work as well as theirs? Why didn’t the global public-health apparatus make sure that what was working in Asia was advised in the West?
Well, there is no global health apparatus.
Okay, fair enough.
Well, no, let’s be serious. The WHO has a budget of about $3 billion a year that’s split across so many things. You can take their total head count and say, “How many of their people were assigned to these things?” Margaret Chan was a very good WHO director before Tedros, and Tedros is a very good director. But it is a U.N. organization. It has a U.N. personnel system. Margaret did her best to work within that framework. So, yeah, it’s not perfect, but it hasn’t been chartered to do a lot of fancy things. They don’t make vaccines, they don’t have planes, they don’t have factories. The whole idea of studying masks, that’s an academic thing that they can gather up the academic stuff and just put their stamp on it because they’re the normative agency. But to expect them to have done something magical …
I haven’t looked at Cambodia. I haven’t looked at Myanmar. Certainly South Asia is really bad. The India epidemic is a horrific epidemic. They just became No. 2. They passed Brazil in terms of number of cases, and they test less per capita. So it’s —
Even worse than it looks.
About Asia broadly, there is this theory that cross-protection in that part of the world is higher because there’s more bats in that part of the world and so more coronaviruses have escaped and people there will have more cross-protection.
That is, some amount of protection, if not immunity, from exposure to other coronaviruses.
Who knows if that’s true. And that’s another one that, as we measure T-cell responses and B-cell responses — very smart people disagree on this prior cross-protection issue. There’s something there, but is that a huge deal in terms of when the epidemic starts to drop off or not? Still no agreement. There’s many things that look promising.
What other things, what other factors, are you thinking of?
It looked like people who took various vaccines like BCG or polio vaccine, that that explained why it didn’t spread as much, but that data’s all fallen apart. It doesn’t look like any vaccine that stimulates your immune system in some horizontal way is beneficial. For a while, that looked promising, but that has not held up. Otherwise, like the polio vaccine — India wouldn’t be experiencing this. Or they have BCG, which the West has largely dropped.
But we will be ready for the next pandemic if it’s like this one. If it’s not some bioterrorist evil smallpox thing that spreads super, super fast. If it’s this type of spread, we can do PCR testing. The most amazing PCR testing in the world is what we do against GMO seeds, because you want to test literally millions of these things. The foundation is now funding taking that and applying that to respiratory disease, to create what we’d have to call megatesting, which is where our country will be able to test over 20 percent of the population per week. Now nobody’s ever done that. People have talked about that as a way out of this thing. It’s very much a brute-force way. There’s nothing elegant about that at all, but to have a standby capacity that can do that, actually the costs to do so wouldn’t be prohibitive, because the machines are so efficient. We’re still proving out the approach, but it’s very likely to work.
You’d probably have to have the consent of the population to do something like that — effectively surveillance-level testing. It would solve some of the asymptomatic and presymptomatic issues that you were talking about. But it raises other issues. Personally, I think American resistance to top-down interventions tends to get somewhat overstated — after all, we did all shelter in place for a few months, completely suspending our normal lives, even if later some fraction of us refused to wear masks — but might there not be some hesitation to accept a testing regime like that? Because the testing regime you’re describing, as a way of dealing with future pandemics, would seem to require preemptive testing, effectively surveillance testing?
I’m not sure you’d see that much resistance to the idea of taking a swab and putting it up the tip of your nose and putting it into a plastic bag. It’s different than a vaccine, where that’s a needle going into your arm. If you’re potentially going to kill your grandmother, I hope you’re willing to give us a little snot just on behalf of your grandma. So, no, I think that would be okay. Already, if you’re an NBA player, I think you have to give snot on a regular basis.
And with some of these $1 tests, it wouldn’t even necessarily be that expensive.
Yeah. Well, the strip test can be made very inexpensively, but because they’re in short supply, they’re being sold more like $5 to $10. Those tests don’t have the same accuracy, though. So when you want to get to super-low cost, do you do it by super-scaling up the molecular central-lab approach? Or do you go with a lateral-flow nitrocellulose strip test, like a pregnancy test? Both paths we’re funding. We have work at Flextronics on taking the strip test down to more like a 30-to-40-cent marginal cost of production.
You were talking about being ready for the next pandemic. I’m curious how you think about the next phase of this one. The University of Washington’s Institute for Health Metrics and Evaluation, which you’re involved with, put out this much-talked-about projection a few days ago suggesting that 400,000 Americans could die by the end of the year. And a lot of that is built on the expected seasonality effect, whereby the disease gets worse in the fall after having gotten a little bit lighter in the spring and summer. But the infection fatality rate has also been steadily falling and is, especially for younger people, much, much lower than it was early in the epidemic. So I’m curious how you see both of these forces coming together between now and the arrival of a vaccine or vaccines? Is it the case that the infection fatality rate is falling quickly enough that this disease is becoming less concerning than it was in the spring? Or are we really dealing with the same disease and we’ll be faced with a quite grim fall because of the seasonality effect? Or somewhere in between?Well, IHME — if you take all the modelers’ views of the fall, IHME would be on the pessimistic side. There are some people who are more optimistic than they are. I don’t think anybody knows exactly what’s right. This is very complex stuff. As you say, the IHME and many modelers see a strong seasonal effect. And that’s what drives their projection of the daily death rate. In November, it’s at a thousand a day, and it gets up over 2,000.
That’s 2,000 per day — so considerably worse than we have now, and nearly as bad as the very worst of the epidemic in the spring.
They show quite a bleak fall. I hope that’s wrong, but that is serious science that has been done there, even though the confidence intervals are absolutely gigantic. So the good news is maybe they’re wrong. The other good news is maybe medical interventions come along.
How do you assess that progress?
It’s really mind blowing that the only truly proven drug intervention is dexamethazone — the U.K. study we funded is what came up with that. We don’t have good news on plasma. The Remdesivir looks like a pretty minor effect. The other antivirals, they’re moving along. The one that is a wild card here is monoclonal antibodies. That could be a very dramatic effect. And there’s Eli Lilly, AstraZeneca, Regeneron; all within the next two months will have data for us about monoclonal antibodies.
The foundation, we’ve reserved a lot of the factory capacity for monoclonal antibodies to be able to make them for underdeveloping countries in case it works. And for it to work for us, it has to be a pretty modest dose that you don’t need multi-day IV infusion. We need to be able to do a single shot in early disease.
Of course, time is always on your side, in that if you get a really bad epidemic, then you get a lot of natural immunity with unknown duration.
How worried are you about short-lived immunity?
Almost certainly it’s in the multi-year timeframe for most people.
The medical interventions are what I’m mostly focused on and making sure that those are available to the entire world. We’re partners with AstraZeneca, Novavax, Sanofi, and Johnson & Johnson to get them to allow the manufacture of their vaccines in the world’s highest-volume vaccine factories, which are in India, controlled by Serum, Bio E, and Bharat. And that’s never been done before where you invent a vaccine by company A but most of the volume gets actually produced by company B. But in this case, it’s the only way, since the demand will be very, very high. And as our report says, if you misallocate, if you just allocate based on wealth, using the forecast that things are going to stay pretty bad, you get twice as many deaths as if you go out to health workers first.
To me, the vaccine development is one of the silver linings of all of this: we’ve invented almost on the fly a method by which we can actually get these things going quite quickly. As a result, we’ve come up with some new model approaches to building a vaccine. So that’ll presumably benefit us down the line with future diseases. But for the time being, I’m curious whether you are worried about the rollout of these vaccines both in the U.S. and abroad? How it will be administered and to whom is very much an open question.
Well, we won’t use a pure merit-based allocation. The U.S. has funded the R&D and trials of these vaccines. It put out more money than everybody else put together. That’s nothing to do with this administration. The U.S. always took these issues more seriously, probably because we had the CDC. We have the scale with NIH and CDC to think about these things. And so the U.S. put out over $10 billion in R&D and funding of trials — that is a global benefit. There’s no royalty or restriction. But the only manufacturing that the U.S. has funded to date is for the United States. And so that makes us look kind of selfish. If we would just put in this extra $8 billion, $4 billion to help buy vaccines, $4 billion for therapeutics — I’m calling everybody in Congress who will listen to me and saying, if there is a supplemental bill or whatever the next bill is, give $4 billion to our vaccine alliance Gavi, give $4 billion to our Global Fund, so that you complement your R&D with the current money.
We don’t want to create a dilemma for the world where you have, say, vaccines that haven’t gone through the FDA that are being made available for free, and the ones that have gone through the FDA, there’s no procurement money for those vaccines. You don’t want to force the world to make that choice, because anything where a vaccine doesn’t work, or has a side effect, worsens people’s willingness to take vaccines in general. And the reason we’ve gone from having over 10 million kids a year die every year down to less than 5 million, that’s because of uptake of vaccines and new vaccines. So that is worth preserving.
So how quickly do you think we will be able to roll out the vaccines, globally and equitably? Are we talking about something that’s going to take all of 2021? Will it stretch into 2022?
It’ll stretch. Unless you get herd immunity at really surprising levels, like 20 or 30 percent, you’ve got 7 billion people, each of them needing two doses each — a few of the vaccines might be one dose, but most of these early ones look like two doses. So that’s 14 billion doses to administer. We don’t make anything at that volume. So even if 80 percent of all the vaccines get approved and we get all this capacity, to get the eradication it stretches into 2022. You hope it doesn’t stretch past 2022.
That’s a long time. It’s also globally. What about more locally?
We should be able to bring this to an end, in rich countries, in 2021. Then in the world in 2022.