How the pandemic will shape the near future

Chris Anderson. Welcome, Bill Gates.

Bill Gates: Thank you.

CA: All right. It's great
to have you here, Bill.

You know, we had a TED conversation

about three months ago
about this pandemic,

and back then I think fewer than --

I think that was the end of March --

Back then, fewer than
a thousand people in the US had died,

and fewer than 20,000 worldwide.

I mean, the numbers now are,
like, 128,000 dead in the US

and more than half a million worldwide.

in three months.

In three months.

What is your diagnosis of what is possible
for the rest of this year?

You look at a lot of models.

What do you think best
and worst case scenarios might be?

BG: Well, the range of scenarios, sadly,

is quite large, including that,

as we get into the fall,

we could have death rates

that rival the worst of what we had
in the April time period.

If you get a lot of young people infected,

eventually they will infect
old people again,

and so you'll get into the nursing homes,

the homeless shelters,

the places where we've had
a lot of our deaths.

The innovation track,
which probably we will touch on --

diagnostics, therapeutics, vaccines --

there's good progress there,

but nothing that would
fundamentally alter the fact

that this fall in the United States
could be quite bad,

and that's worse than
I would have expected a month ago,

the degree to which we're back
at high mobility,

not wearing masks,

and now the virus actually
has gotten into a lot of cities

that it hadn't been in before

in a significant way,

so it's going to be a challenge.

There's no case where we get
much below the current death rate,

which is about 500 deaths a day,

but there's a significant risk
we'd go back up

to the even 2,000 a day
that we had before,

because we don't have the distancing,

the behavior change,

to the degree that we had
in April and May,

and we know this virus
is somewhat seasonal,

so that the force of infection,

both through temperature, humidity,
more time indoors,

will be worse as we get into the fall.

CA: So there are scenarios
where in the US,

like, if you extrapolate
those numbers forward,

we end up with, what,

more than a quarter of a million deaths,

perchance, even this year
if we're not careful,

and worldwide I guess the death toll
could by the end of the year

be well into the millions, with an s.

Is there evidence that the hotter
temperatures of the summer

actually have been helping us?

BG: They're not absolutely sure,

but certainly the ?? model
definitely wanted to use the season,

including temperature and humidity,

to try and explain why May
wasn't worse than it was.

And so as we came out
and the mobility numbers got higher,

the models expected more infections
and deaths to come out of that,

and the model kept wanting to say,

"But I need to use this seasonality

to match why May wasn't worse,

why June wasn't worse than it was."

And we see in the Southern Hemisphere,

you know, Brazil,

which is the opposite season,

all of South America
is having a huge epidemic.

South Africa is having
a very fast-growing epidemic.

Fortunately, Australia and New Zealand,

the last countries
in the Southern Hemisphere,

are at really tiny case counts,

and so although they have
to keep knocking it down,

they're talking about, oh,
we have 10 cases,

that's a big deal,
let's go get rid of that.

So they're one of these amazing countries

that got the numbers so low

that test, quarantine and trace

is working to get them,

keep them at very near zero.

CA: Aided perhaps a bit
by being easier to isolate

and by less density,
less population density,

but nonetheless smart policies down there.

BG: Yeah. Everything is so exponential
that a little bit of good work

goes a long ways.

It's not a linear game.

Contact tracing, if you have
the number of cases we have in the US,

it's super-important to do,

but it won't get you back down to zero.

It'll help you be down,

but it's too overwhelming.

CA: OK, so in May and June in the US,

the numbers were actually slightly better
than some of the models predicted,

and it's hypothesized that that might be
partly because of the warmer weather.

Now we're seeing, really,
would you describe it

as really quite alarming upticks
in case rates in the US?

BG: That's right.

In, say, the New York area,

the cases continue to go down somewhat,

but in other parts of the country,

primarily the South right now,

you have increases
that are offsetting that,

and you have testing
positive rates in young people

that are actually higher

than what we saw even
in some of the tougher areas,

and so clearly younger people
have come out of mobility

more than older people
have increased their mobility,

so the age structure

is right now very young, but
because of multigenerational households,

people work in nursing care homes,

unfortunately that will work its way back,

both the time lag and the transmission
back up into the elderly,

will start to push the death rate back up,

which it is down,

way down from 2,000
to around 500 right now.

CA: And is that partly because
there's a three-week lag

between case numbers and fatality numbers?

And also, perhaps, partly because

there have been
some effective interventions

and we're actually seeing the possibility

that the overall fatality rate
is actually falling a bit

now that we've gained
some extra knowledge?

BG: Yeah, certainly
your fatality rate is always lower

when you're not overloaded,

and so Italy when they were overloaded,

Spain, even New York at the start,

certainly China,

there you weren't even able
to provide the basics,

the oxygen and things.

A study that our foundation
funded in the UK

found the only thing
other than remdesivir

that is a proven therapeutic,

which is the dexamethasone,

that for serious patients

is about a 20 percent death reduction,

and there's still quite
a pipeline of those things.

You know, hydroxychloroquine
never established positive data,

so that's pretty much done.

There's still a few trials ongoing,

but the list of things being tried,

including eventually
?? antibodies,

we will have some additional
tools for the fall.

And so when you talk about death rates,

the good news is some
innovation we already have

and we will have more

even in the fall.

We should start to have
monoclonal antibodies,

which is the single therapeutic
that I'm most excited about.

CA: I'll actually ask you to tell me
a bit more about that in one sec,

but just putting the pieces
together on death rates:

so in a well-functioning health system,

so take the US when places
aren't overcrowded,

what do you think

the current fatality numbers
are approximately going forward,

like as a percentage of total cases?

Are we below one percent, perhaps?

BG: If you found every case, yes,

you're well below one percent.

People argue, you know, 0.4, 0.5.

By the time you bring in
the never symptomatics,

it probably is below 0.5,

and that's good news.

This disease could have been
a five percent disease.

The transmission dynamics of this disease

are more difficult
than even the experts predicted.

The amount of pre-symptomatic
and never symptomatic spread,

and the fact that it's not coughing,

where you would kind of notice,
hey, I'm coughing.

Most respiratory diseases make you cough.

This one, in its early stages,
it's not coughing,

it's singing, laughing, talking,

actually still particularly
for the super-spreaders,

people with very high viral loads,

causes that spread,

and that's pretty novel,

and so even experts have to say,
wow, this caught us by surprise.

The amount of asymptomatic spread

and the fact that there's not
a coughing element

is not a major piece like the flu or TB.

CA: Yeah, that is devilish cunning

by the virus.

I mean, how much is
that non-symptomatic transmission

as a percentage of total transmission?

I've heard numbers it could be
as much as half of all transmissions

are basically pre-symptomatic.

BG: Yeah, if you count pre-symptomatics,

then most of the studies show
that's like at 40 percent,

and we also have never symptomatics.

The amount of virus you get
in your upper respiratory area

is somewhat disconnected.

Some people will have a lot here
and very little in their lungs,

and what you get in your lungs

causes the really bad symptoms,

and other organs,

but mostly the lungs,

and so that's when you seek treatment.

And so the worst case
in terms of spreading

is somebody who's got a lot
in the upper respiratory tract

but almost none in their lungs,

so they're not care-seeking.

CA: Right.

And so if you add in the never symptomatic

to the pre-symptomatic,

do you get above 50 percent
of the transmission

is actually from non-symptomatic people?

BG: Yeah, transmission
is harder to measure.

You know, we see certain
hotspots and things,

but that's a huge question
with the vaccine:

will it, besides avoiding
you getting sick,

which is what the trial will test,

will it also stop you
from being a transmitter?

CA: So that vaccine,

it's such an important question,
let's come on to that,

but before we go there,

any other surprises
in the last couple months

that we've learned about this virus

that really impact how
we should respond to it?

BG: We're still not able to characterize
who the super-spreaders are

in terms of what that profile is,

and we may never.

That may just be quite random.

If you could identify them,

they're responsible
for the majority of transmission,

a few people who have
very high viral loads.

But sadly, we haven't figured that out.

This mode of transmission,

if you're in a room and nobody talks,

there's way less transmission.

That's partly why,
although planes can transmit,

it's less than you would expect
just in terms of time proximity measures,

because unlike, say,
a choir or a restaurant,

you're not exhaling in loud talking

quite as much as in
other indoor environments.

CA: What do you think about the ethics
of someone who would go on a plane

and refuse to wear a mask?

BG: If they own the plane,
that would be fine.

If there's other people on the plane,

that would be endangering
those other people.

CA: Early on in the pandemic,

the WHO did not advise
that people wear masks.

They were worried about taking them away
from frontline medical providers.

In retrospect, was that
a terrible mistake that they made?

BG: Yes.

All the experts feel bad

that the value of masks,

which ties back somewhat
to the asymptomatics,

if people were very symptomatic,

like in Ebola,

then you know it and you isolate,

and so you don't have
a need for a mask-like thing.

The value of masks,

the fact that the medical masks
was a different supply chain

than the normal masks,

the fact you could scale up
the normal masks so well,

the fact that it would stop
that pre-symptomatic,

never symptomatic transmission,

it's a mistake,

but it's not a conspiracy,

it's something that we now know more.

And even now, our error bars
on the benefit of masks

are higher than we'd like to admit,

but it's a significant benefit.

CA: All right, I'm going to come in
with some questions

from the community.

Let's pull them up there.

Jim Pitofsky: "Do you think reopening
efforts in the US have been premature,

and if so how far should the US go
to responsibly confront this pandemic?"

BG: Well, the question
of how you make tradeoffs

between the benefits, say,
of going to school

versus the risk of people getting sick
because they go to school,

those are very tough questions

that I don't think any single person

can say, "I will tell you
how to make all these tradeoffs."

The understanding of
where you have transmission,

and the fact that young people
do get infected

and are part of the multi-generational
transmission chain,

we should get that out.

If you just look at the health aspect,

we have opened up too liberally.

Now, opening up in terms of mental health

and seeking normal health things

like vaccines and other care,

there are benefits.

I think some of our opening up

has created more risk than benefit.

Opening the bars up
as quickly as they did,

is that critical for mental health?

Maybe not.

So I don't think we've been
as tasteful about opening up

as I'm sure, as we study it,

that we'll realize some things
we shouldn't have opened up as fast,

but then you have something like school,

where even sitting here today,

the exact plan, say,
for inner city schools for the fall,

I wouldn't have a black-and-white view

on the relative tradeoffs involved there.

There are huge benefits

to letting those kids go to school,

and how do you weigh the risk?

If you're in a city

without many cases,

I would say probably the benefit is there.

Now that means that
you could get surprised.

The cases could show up,
and then you'd have to change that,

which is not easy.

But I think around the US
there will be places

where that won't be a good tradeoff.

So almost any dimension and inequity,

this disease has made worse:

job type, internet connection,

ability of your school
to do online learning.

White collar workers,

people are embarrassed to admit it,

some of them are more productive

and enjoying the flexibility
that the at-home thing has created,

and that feels terrible

when you know lots of people
are suffering in many ways,

including their kids not going to school.

CA: Indeed. Let's have the next question.

"For us in Rwanda,

early policy interventions
have made the difference.

At this point, what policy interventions
do you suggest for the US now?"

Bill, I dream of the day
where you are appointed

the coronavirus czar

with authority to actually
speak to the public.

What would you do?

BG: The innovation tools

are where I and the foundation
probably has the most expertise.

Clearly some of the policies
on opening up have been too generous,

but I think everybody

could engage in that.

We need leadership

in terms of admitting

that we've still got a huge problem here,

and not turning that
into almost a political thing

of, oh, isn't it brilliant what we did.

No, it's not brilliant,

but there's many people,

including the experts,

where there's a lot
they didn't understand,

and everybody wishes a week earlier
whatever action they took,

they'd taken that a week earlier.

The innovation tools,

that's where the foundation's work

on antibodies, vaccines,

we have deep expertise,

and it's outside of the private sector,

and so we have kind of a neutral ability
to work with all the governments

and the companies to pick.

Particularly when you're doing
break-even products,

which one should get the resources.

There's no market signal for that.

Experts have to say, OK,
this antibody deserves the manufacturing.

This vaccine deserves the manufacturing.

Because, we have very limited
manufacturing for both of those things,

and it'll be cross-company,

which never happens in the normal case,

where one company invents it

and then you're using
the manufacturing plants

of many companies

to get maximum scale of the best choice.

So I would be coordinating those things,

but we need a leader
who keeps us up to date,

is realistic,

and shows us the right behavior,

as well as driving the innovation track.

CA: I mean, you have to yourself
be a master diplomat

in how you talk about this stuff.

So I appreciate, almost,
the discomfort here,

but you talk regularly with Anthony Fauci,

who is a wise voice on this
by most people's opinion.

But to what extent is he just hamstrung?

He's not allowed to play the full role

that he could play in the circumstance.

BG: Dr. Fauci has emerged,

where he was allowed to have some airtime,

and even though he was stating
things that are realistic,

his prestige has stuck.

He can speak out in that way.

Typically, the CDC would be
the primary voice here.

It's not absolutely necessary,

but in previous health crises,

you let the experts inside the CDC

be that voice.

They're trained to do these things,

and so it is a bit unusual here

how much we've had to rely on Fauci

as opposed to the CDC.

It should be Fauci,
who is a brilliant researcher,

so experienced, particularly in vaccines,

in some ways he has become,
taking the broad advice

that is the epidemiology advice

and explaining it in the right way,

where he'll admit,

"OK, we may have a rebound here,

and this is why we need
to behave that way."

But it's fantastic that his voice
has been allowed to come through.

CA: Sometimes.

Let's have the next question.

Nina Gregory: "How are you
and your foundation

addressing the ethical questions
about which countries

get the vaccine first,

assuming you find one?"

And maybe, Bill, use this as a moment

to just talk about where
the quest for the vaccine is

and what are just some of the key things
we should all be thinking about

as we track the news on this.

BG: There's three vaccines that are,

if they work, are the earliest:

the Moderna, which unfortunately
won't scale very easily,

so if that works, it'll be mostly
a US-targeted thing;

then you have the AstraZeneca,
which comes from Oxford;

and the Johnson & Johnson.

Those are the three early ones,

and we have animal data

that looks potentially good,

but not definitive,

particularly will it work in the elderly,

and we'll have human data
over the next several months.

Those three will be gated by
the safety and efficacy trial.

That is, we'll be able
to manufacture those,

although not as much as we want.

We'll be able to manufacture those
before the end of the year.

Whether the Phase 3 will succeed,

and whether it'll complete
before the end of the year,

I wouldn't be that optimistic about.

Phase 3 is where you need
to really look at all the safety profile

and efficacy,

but those will get started.

And then there's four or five vaccines

that use different approaches

that are maybe three
or four months behind that:

Novavax, Sanofi, Merck.

And so we're funding factory capacity
for a lot of these --

some complex negotiations
are taking place right now on this --

to get factories that will be dedicated
to the poorer countries,

what's called low- and middle-income.

And the very scalable constructs

that include AstraZeneca
and Johnson & Johnson,

we'll focus on those,

the ones that are inexpensive

and you can build a single factory
to make 600 million doses.

So a number of the vaccine constructs

are potential.

I don't see anything
before the end of the year.

That's really the best case,

and it's down to a few constructs now,

which typically you have
high failure rates.

CA: Bill, is the case

that you and your foundation
weren't in the picture here

that market dynamics would likely
lead to a situation

where as soon as a promising
vaccine candidate emerged,

the richer countries
would basically snap up,

gobble up all available initial supply --

it just takes a while
to manufacture these --

and there would be nothing
for the poorer countries,

but that what effectively you're doing,

by giving manufacturing guarantees

and capability to some
of these candidates,

you're making it possible that
at least some of the early vaccine units

will go to poorer countries?

Is that correct?

BG: Well, it's not just us, but yes,

we're in the central role there

along with a group we created called CEPI,

Coalition for Epidemic Preparedness,

and the European leaders agree with this.

Now we have the expertise
to look at each of the constructs

and say, OK, where is there
a factory in the world

that has capacity that can build that?

Which one should we put
the early money into?

What should the milestones be

where we'll shift the money
over to a different one?

Because the kind of private sector people

who really understand that stuff,

some of them work for us,

and we're a trusted party on these things,

we get to coordinate a lot,
particularly the manufacturing piece.

Usually, you'd expect the US

to think of this as
a global problem and be involved.

So far, no activity
on that front has taken place.

I am talking to people in the Congress
and the Administration

about when the next
relief bill comes along

that maybe one percent of that

could go for the tools

to help the entire world.

And so it's possible,

but it's unfortunate,

and the vacuum here

the world is not that used to

and a lot of people are stepping in,

including our foundation,

to try and have a strategy,

including for the poorer countries

who will suffer a high percentage
of the deaths and negative effects,

including their health systems
being overwhelmed.

Most of the deaths will be
in developing countries,

despite the huge deaths we've seen
in Europe and the US.

CA: I mean, I wish I could be
a fly on the wall and hearing

you and Melinda talk about this,

because of all of
the ethical crimes, let's say,

executed by leaders
who should know better,

I mean, it's one thing
to not model mask-wearing,

but to not play a role

in helping the world when faced
with a common enemy,

respond as one humanity

and instead catalyze a really unseemly
scramble between nations

to fight for vaccines, for example.

That just seems that surely history
is going to judge that harshly.

That is just sickening.

Isn't it? Am I missing something?

BG: Well, it's not quite
as black and white as that.

The US has put more money out

to fund the basic research
on these vaccines

than any country by far,

and that research is not restricted.

There's not, like, some royalty
that says, "Hey, if you take our money,

you have to pay the US a royalty."

They do, to the degree they fund research,

it's for everybody.

To the degree they fund factories,
it's just for the US.

The thing that makes this tough is that
in every other global health problem,

the US totally leads smallpox eradication,

the US is totally the leader
on polio eradication

with key partners -- CDC, WHO,
Rotary, UNICEF, our foundation.

So the world, and on HIV,

what under President Bush's leadership,
but it was very bipartisan,

this thing called PEPFAR was unbelievable.

That has saved tens of millions of lives.

And so it's that the world
always expected the US

to at least be at the head of the table,

financially, strategy, OK, how do you
get these factories for the world,

even if it's just to avoid the infection
coming back to the US

or to have the global economy working,

which is good for US jobs

to have demand outside the US.

And so the world is kind of,
there's all this uncertainty

about which thing will work,

and there's, OK, who is in charge here?

And so the worst thing,

the withdrawal from WHO,

that is a difficulty

that hopefully will
get remedied at some point,

because we need that coordination

through WHO.

CA: Let's take another question.

Ali Kashani: "Are there any
particularly successful models

of handling the pandemic
that you have seen around the world?"

BG: Well, it's fascinating that,
besides early action,

there are definitely things where
you take people who have tested positive

and you monitor their ??,

which is a oxygen saturation
level in their blood,

which is a very cheap detector,

and then you know to get them
to the hospitals fairly early.

Weirdly, patients don't know
things are about to get severe.

It's an interesting physiological reason
but I won't get into.

And so Germany has
a quite a low case fatality rate

that they've done through
that type of monitoring.

And then, of course,
once you get into facilities,

we've learned that the ventilator
actually, although extremely well-meaning,

was actually overused
and used in the wrong mode

in those early days.

So the health, the doctors

are way smarter about treatment today.

Most of that I would say is global.

Using this ??
as an early indicator,

that'll probably catch on broadly,

but Germany was a pioneer there.

And now, of course, dexamethasone,

fortunately, it's cheap, it's oral,

we can ramp up manufacture.

That'll go global as well.

CA: Bill, I want to ask you something about what it's been like for you personally through this whole process? Because, weirdly, even though your passion and good intent on this topic seems completely bloody obvious to anyone who has spent a moment with you, there are these crazy conspiracy theories out there about you. I just checked in with a company called Zignal that monitors social media spaces. They say that, to date, I think on Facebook alone, more than four million posts have taken place that associate you with some kind of conspiracy theory around the virus.