Bill Gates on the World Ahead

Well, sadly, I think the most pessimistic view of how unprepared we were has actually played out, particularly in the United States. And so, with something that can grow exponentially, like infectious disease, a little bit of preparedness, where you can act early, makes such a difference. And a few countries have distinguished themselves, but most countries have not.

Well, the US had a lot of assets going into this. First of all, we weren't ground zero. China was ground zero. Then it moved over into Europe. And so, the US had more time to get ready. The US has more PCR machines than all the other countries per capita. We're very blessed with an expensive medical infrastructure. And we have groups like CDC and BARDA. So, the US had done more to get ready than other countries had in advance. Now, there was some de-staffing of these things under this administration, but even so, I would have expected us to get the commercial providers up and going like South Korea or Germany or Australia did. The fact that that actually was made harder by FDA regulations and that somebody actually thought the public health testing capacity, which actually was bungled, would have enough capacity. It was really insane, which speaks to just not getting the leadership to have a framework of what needed to be done. There were so many phone calls about we've got to get diagnostic capacity up and we have to get quick results. I participated in a lot of those calls and yet to this day that's just a complete mess.

Well, you can look at the period before the epidemic hits and say even though the US didn't do a very good job, most other countries didn't. There were a few that had been hit by SARS or MERS that had a little bit of practice understanding that diagnosis and contact tracing is super important. So, they're among the countries that did the best. So, I'd give the US like a C-minus, but all countries, many would get an even worse grade for how ready they were before this thing hit. Then once it hits, I had a thing called the Seattle Flu Study which was looking at all respiratory viruses and because the study protocol didn't include coronavirus, we weren't really authorized but the principal investigator decided to look and saw the first community spread of coronavirus here in the United States. And that should have set off such alarms to get the domestic testing to change the criteria of who got tested. This notion that the travel ban was some beneficial thing, that's just not true because we didn't test those people. We didn't quarantine those people. And so then, after the pandemic starts, there hasn't been any coherence. Now, the R&D funding, I will say that the BARDA money, the purchase agreements, that's where the US actually gets the highest grade in the world. Europe hasn't funded nearly as much of that R&D which is a global public good. Now we need to complement that with funding the factories and the procurement for the global response which the US has been absent so far but I'm still hopeful that if there's another supplemental bill we'll get about 8 billion for international COVID activities into that bill.

Well, certainly humility is called for because the damage whether it's economic, educational, mental health is so large. Other than a world war, this is the worst thing that's happened in over a century. And so, we should all say, "Wow, we didn't understand about masks. We didn't understand about asymptomatics." Even the medical profession, we haven't taken understanding these different respiratory diseases quite as seriously as we should. So, everyone has lessons here. And of course, as long as the pandemic's ongoing, we mostly should focus on, "Okay, how do we get monoclonals done and available to everyone? How do we get the vaccine done?" This looking back, a lot of that can be preserved for when we bring the thing to a close. The idea of which interventions work well, these trials, that's another area that has been such a mess with no leadership at all that we're still confused about plasma. There probably are some drugs that have been missed. The only thing we actually have of significance is the UK trial that the foundation helped fund that showed dexamethasone is having a good result. And you would have expected the US to get a lot going on to prove out other interventions.

Well, there's actually a question in the US system of who's in charge of making sure that consistent trials get done. The FDA is just there to say at the end, "Okay, you did this well." They're not there to instigate trials. NIH is more on the research side. CDC is public health. BARDA is more a procurement thing. So, under that HHS umbrella, who was supposed to really orchestrate these trials is actually unclear. If you'd had particularly like leadership of that and seen that as a priority between the various groups, including NIH, you could have done it well. The UK, in fact, although they had many things in this epidemic, they even did a few things worse than the US, which is hard. In terms of organizing trials, they were very coherent in having the common criteria patient recruitment, and coming up mostly with negative results. We thought more approved medicines. We did this library of medicines, the repurposing library. We were disappointed that there are few enough antivirals in there that remdesivir showed modest benefit and two other antivirals are still being pushed forward, although that's been a bit slow. We need to have a gigantic library of antivirals available for the next time and then get trials that give very quick results on which of those have an impact.

Yeah, it is kind of unbelievable that every dimension of inequity has been exacerbated here. And our Goalkeepers report that is done in the framework of these Sustainable Development Goals, we do that every year around this UN General Assembly, every other year that's been this positive story of gradual progress, less children dying, less malnutrition, longer lifespans, and so we get to say to the world, "Hey, pay attention to that steady progress and let's look at the heroes and the exemplars and let's drive that even faster." This report had to deliver the news that if you only look at COVID deaths, you're actually missing the scale of the setback because it's also routine immunization, malaria, getting HIV medicines, and things are so disrupted that even gathering the numbers for that was very, very difficult. But we dropped our routine immunization levels by over 14% that we've spent the last 25 years pulling that together. So, there's going to have to be a stronger equity agenda, hopefully on a global basis, once we get out of this, because the developing countries haven't had the fiscal resources like the United States. They don't have as much of their economy with office workers that can be done over the internet. Even though their younger age populations have meant the actual death rate in these countries has been below the rich countries.

Well, it was interesting how hard it was to gather the data. Mostly when we gather data, we rely on the fact that if we sample countries over time, they're all progressing down the same path. Here, you have very different government policies and the spread of the disease is so different in different countries. So, our error bars on the facts we were putting forward were even larger than they normally are. That was very concerning. Things like the extreme poverty number where 37 million people driven into extreme poverty. That's really just gut-wrenching because the idealistic view is that that's something we should get rid of altogether. And yet, I do worry that the pandemic, because it did hit rich countries, their generosity actually might be less. Most of the time when we talk about infectious diseases, our problem is that the world doesn't pay attention to malaria or TB. Here, because people care so much about getting the vaccines, they're actually saying, "Okay, we should maybe be even less generous." And in the case of the vaccine, use the rich country's ability to pay more and have it all be allocated to them. And so, not only does the pandemic last longer in developing countries, the kind of generosity that historically has helped might even go down.

Well, that allocation algorithm, one way to help with that is to have so much volume that you're not making super hard trade-offs. And so, our vaccine expertise in the foundation, we're trying to help with that. And if multiple get approved, actually, the volumes could be quite large. We should look at the risk levels and, based on that, you would say that various inner-city communities, including blacks and Hispanics, would have somewhat higher priority. So, that algorithm, which the CDC should be getting people to sign up saying, "Hey, I want the vaccine." And giving some of this criteria, the same way that we wanted a CDC website for people seeking a test. Here we should have a CDC website for people saying they're willing to take the vaccine where you understand their age and ethnicity and location and then you can come up with what the equitable priority ranking should be. I'm not seeing that sense of gathering the data to come up with those algorithms. So, it's kind of bizarre that you have these over optimistic projections that the vaccine will come soon, but when you read the 67 page report about how it's distributed, it doesn't actually concretely identify the criteria or how the information is going to be gathered to do the prioritization. And so, it's just like everything with this, the vacuum of leadership and the unwillingness of people to step forward because it'll say, "Oh, this thing's a mess. We need to fill in these answers." I see the India plan for vaccine distribution is more concrete than what's here in the US.

Well, the progress on overall health statistics, this thing called the Global Burden of Disease which is hosted at IHME at the University of Washington that we've been involved in helping Chris Murray and his team build that up. The health statistics in the US are better today than they've ever been. In fact, it's fascinating to go and browse and look at gender differences and changes over time or difference between different states. In the dynamic of the epidemic, we've fallen behind a little bit and we don't have quite as many standards of how things are reported and a little bit, CDC got interfered with for their normal function. But the US can be an exemplar on this. The push towards digitization has, thank goodness, because it helps you connect up to telehealth. Medicine has gotten a big boost from the epidemic that paper records are much harder to move around and so slowly but surely the US on the overall data and even the digital health records, I do think will be an exemplar there.

Well, I think modeling has certain limitations. The people behind the 538 website did some really good, even a kind of a cartoon thing to show how just picking a few parameters that are unknown can cause wildly varying results. The Imperial model actually gave very big numbers, but of course it assumed that people didn't change their behavior at all. They kept going to work and everything. And so, that was kind of an upper bound to get politicians' attention. I think that was very valuable, even though of course people did sometimes voluntarily, sometimes under government mandate change their behavior. All these models are not perfect because there are so many unknown parameters. I have a modeling group inside the foundation called the Institute for Disease Modeling. And of course we fund IHME. I do think those models have been helpful. If you look at their accuracy in a 2-4 week time frame, it's been pretty good. Now, 2-3 months out, which is what you really want to know, is a lot harder. And so, for example, right now we have a divergence between the models that do think this is a seasonal disease and that people will be more lax in their behavior. So, IHME, they forecast a very tough fall in the United States. Now, I have to say they forecast the resurgence in Europe, which the other people who were more optimistic about the fall did not forecast that resurgence, which probably is laxity and seasonality causing that rebound. And so, even though we're not totally certain, it looks like we're headed for a very tough fall. IHME as a forecaster is a little bit different than them gathering the data for the history, which is their main thing. But the US government didn't even have a plan on which modelers to work with and how to work with them. So, I've taken, the governor of New York called me up and said, "Hey, how many ventilators do I need?" And thank goodness the IHME model gave him a much more realistic view than some of the other over simplistic models that he was dealing with.

Well, I'm hopeful that the things that I and other people put forward even before 2015, but very in a very clear way, there was a post Ebola, post West Africa Ebola discussion where we talked about doing the equivalent of war games, having the diagnostics people able to scale up, having ample viral libraries, getting generic vaccine platforms like hopefully what the RNA platform will become where 5 to 10 years from now it will have low cost and high scalability, which it sadly right at the moment it's not as strong as some of the other platforms in that respect. So, I think the prescription is still the same as it was before this pandemic hit. And the cost of doing it is in the tens of billions, not hundreds of billions. So, compared to defense budgets, this is not a gigantic additional burden. And in fact, if it's done appropriately, it will drive progress in things that will help us with diseases that are here today. Amazingly, BioNTech, who's Pfizer's partner, they're doing vaccines for cancer, and that's their primary business model, but our foundation partners with them because some of that work of making vaccines can help for the equity agenda around infectious diseases. So, I think we can be ready for the next time so that if something that's not much worse than this hits, the impact would be 5% of what it's been here, and I do think we can use that for making progress on other diseases, and the fiscal trade-off involved is actually pretty modest.

Yes. The lack of working on this was that people didn't think about it. Infectious diseases mostly we've made so much progress that rich countries kind of ignore them. And here, because it's hit and cost trillions of dollars. What I'm talking about as the preparedness, as a percentage of the damage this thing done, it's not even close to 1%. And it has affected everyone in every rich country. There's basically no country that hasn't had very big damage. So, yes, we are not so blithe that this time, this is not just Ebola which hit three countries in Western Africa. This is a tragedy, if you care about education, if you care about race, if you care about mental health, if you care about gender, if you care about government budgets, having money to do things that you want government to do, this has cost so much. I put $3 trillion in my TED Talk in 2015. By the time this is done, we'll be at over $20 trillion of total economic cost. So, I was way understating it there, even though when I said the term $3 trillion, I was like, "Wow." That is absolutely so gigantic. So, yes, it takes rich people getting sick, it takes rich economies being affected, but when that happens, the world gets together. And thank goodness, the state of science is such that building a PCR diagnostics that can be done at a mega testing level where you test 20% of the country every week. That technology can be done. Some of it will actually come out of GMO seed sequencing, which is extremely high volume. The vaccine platform can be done. The antivirals can be done. The monoclonals can be done. The tracking to see things earlier, that can be done. So, we're very lucky. If this had hit 20 years ago, the state of biology, digital infrastructure, you would have had to just pray that it didn't come back. Now, we do have all the things that we need, so that a pathogen like this wouldn't be a big deal in the future.

Great to talk to you.