09/27 Bill Gates(02)You Hope It Doesn’t Stretch Past 2022a

Bill Gates on the Pandemic: ‘You Hope It Doesn’t Stretch Past 2022.’

By David Wallace-Wells

Bill Gates. Photo: Jeff Pachoud/AFP via Getty Images

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.

Two years.
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.