09/28 Bill Gates(03) You Hope It Doesn’t Stretch Past 2022b

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.