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Chris Anderson. Welcome, Bill Gates.
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Bill Gates: Thank you.
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CA: All right. It's great
to have you here, Bill.
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You know, we had a TED conversation
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about three months ago
about this pandemic,
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and back then I think fewer than --
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I think that was the end of March --
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Back then, fewer than
a thousand people in the US had died,
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and fewer than 20,000 worldwide.
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I mean, the numbers now are,
like, 128,000 dead in the US
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and more than half a million worldwide.
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in three months.
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In three months.
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What is your diagnosis of what is possible
for the rest of this year?
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You look at a lot of models.
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What do you think best
and worst case scenarios might be?
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BG: Well, the range of scenarios, sadly,
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is quite large, including that,
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as we get into the fall,
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we could have death rates
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that rival the worst of what we had
in the April time period.
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If you get a lot of young people infected,
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eventually they will infect
old people again,
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and so you'll get into the nursing homes,
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the homeless shelters,
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the places where we've had
a lot of our deaths.
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The innovation track,
which probably we will touch on --
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diagnostics, therapeutics, vaccines --
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there's good progress there,
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but nothing that would
fundamentally alter the fact
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that this fall in the United States
could be quite bad,
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and that's worse than
I would have expected a month ago,
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the degree to which we're back
at high mobility,
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not wearing masks,
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and now the virus actually
has gotten into a lot of cities
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that it hadn't been in before
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in a significant way,
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so it's going to be a challenge.
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There's no case where we get
much below the current death rate,
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which is about 500 deaths a day,
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but there's a significant risk
we'd go back up
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to the even 2,000 a day
that we had before,
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because we don't have the distancing,
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the behavior change,
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to the degree that we had
in April and May,
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and we know this virus
is somewhat seasonal,
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so that the force of infection,
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both through temperature, humidity,
more time indoors,
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will be worse as we get into the fall.
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CA: So there are scenarios
where in the US,
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like, if you extrapolate
those numbers forward,
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we end up with, what,
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more than a quarter of a million deaths,
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perchance, even this year
if we're not careful,
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and worldwide I guess the death toll
could by the end of the year
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be well into the millions, with an s.
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Is there evidence that the hotter
temperatures of the summer
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actually have been helping us?
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BG: They're not absolutely sure,
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but certainly the ?? model
definitely wanted to use the season,
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including temperature and humidity,
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to try and explain why May
wasn't worse than it was.
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And so as we came out
and the mobility numbers got higher,
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the models expected more infections
and deaths to come out of that,
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and the model kept wanting to say,
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"But I need to use this seasonality
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to match why May wasn't worse,
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why June wasn't worse than it was."
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And we see in the Southern Hemisphere,
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you know, Brazil,
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which is the opposite season,
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all of South America
is having a huge epidemic.
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South Africa is having
a very fast-growing epidemic.
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Fortunately, Australia and New Zealand,
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the last countries
in the Southern Hemisphere,
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are at really tiny case counts,
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and so although they have
to keep knocking it down,
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they're talking about, oh,
we have 10 cases,
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that's a big deal,
let's go get rid of that.
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So they're one of these amazing countries
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that got the numbers so low
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that test, quarantine and trace
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is working to get them,
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keep them at very near zero.
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CA: Aided perhaps a bit
by being easier to isolate
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and by less density,
less population density,
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but nonetheless smart policies down there.
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BG: Yeah. Everything is so exponential
that a little bit of good work
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goes a long ways.
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It's not a linear game.
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Contact tracing, if you have
the number of cases we have in the US,
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it's super-important to do,
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but it won't get you back down to zero.
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It'll help you be down,
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but it's too overwhelming.
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CA: OK, so in May and June in the US,
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the numbers were actually slightly better
than some of the models predicted,
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and it's hypothesized that that might be
partly because of the warmer weather.
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Now we're seeing, really,
would you describe it
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as really quite alarming upticks
in case rates in the US?
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BG: That's right.
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In, say, the New York area,
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the cases continue to go down somewhat,
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but in other parts of the country,
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primarily the South right now,
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you have increases
that are offsetting that,
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and you have testing
positive rates in young people
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that are actually higher
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than what we saw even
in some of the tougher areas,
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and so clearly younger people
have come out of mobility
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more than older people
have increased their mobility,
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so the age structure
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is right now very young, but
because of multigenerational households,
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people work in nursing care homes,
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unfortunately that will work its way back,
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both the time lag and the transmission
back up into the elderly,
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will start to push the death rate back up,
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which it is down,
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way down from 2,000
to around 500 right now.
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CA: And is that partly because
there's a three-week lag
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between case numbers and fatality numbers?
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And also, perhaps, partly because
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there have been
some effective interventions
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and we're actually seeing the possibility
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that the overall fatality rate
is actually falling a bit
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now that we've gained
some extra knowledge?
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BG: Yeah, certainly
your fatality rate is always lower
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when you're not overloaded,
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and so Italy when they were overloaded,
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Spain, even New York at the start,
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certainly China,
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there you weren't even able
to provide the basics,
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the oxygen and things.
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A study that our foundation
funded in the UK
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found the only thing
other than remdesivir
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that is a proven therapeutic,
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which is the dexamethasone,
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that for serious patients
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is about a 20 percent death reduction,
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and there's still quite
a pipeline of those things.
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You know, hydroxychloroquine
never established positive data,
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so that's pretty much done.
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There's still a few trials ongoing,
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but the list of things being tried,
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including eventually
?? antibodies,
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we will have some additional
tools for the fall.
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And so when you talk about death rates,
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the good news is some
innovation we already have
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and we will have more
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even in the fall.
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We should start to have
monoclonal antibodies,
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which is the single therapeutic
that I'm most excited about.
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CA: I'll actually ask you to tell me
a bit more about that in one sec,
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but just putting the pieces
together on death rates:
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so in a well-functioning health system,
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so take the US when places
aren't overcrowded,
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what do you think
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the current fatality numbers
are approximately going forward,
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like as a percentage of total cases?
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Are we below one percent, perhaps?
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BG: If you found every case, yes,
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you're well below one percent.
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People argue, you know, 0.4, 0.5.
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By the time you bring in
the never symptomatics,
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it probably is below 0.5,
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and that's good news.
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This disease could have been
a five percent disease.
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The transmission dynamics of this disease
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are more difficult
than even the experts predicted.
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The amount of pre-symptomatic
and never symptomatic spread,
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and the fact that it's not coughing,
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where you would kind of notice,
hey, I'm coughing.
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Most respiratory diseases make you cough.
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This one, in its early stages,
it's not coughing,
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it's singing, laughing, talking,
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actually still particularly
for the super-spreaders,
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people with very high viral loads,
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causes that spread,
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and that's pretty novel,
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and so even experts have to say,
wow, this caught us by surprise.
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The amount of asymptomatic spread
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and the fact that there's not
a coughing element
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is not a major piece like the flu or TB.
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CA: Yeah, that is devilish cunning
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by the virus.
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I mean, how much is
that non-symptomatic transmission
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as a percentage of total transmission?
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I've heard numbers it could be
as much as half of all transmissions
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are basically pre-symptomatic.
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BG: Yeah, if you count pre-symptomatics,
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then most of the studies show
that's like at 40 percent,
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and we also have never symptomatics.
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The amount of virus you get
in your upper respiratory area
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is somewhat disconnected.
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Some people will have a lot here
and very little in their lungs,
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and what you get in your lungs
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causes the really bad symptoms,
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and other organs,
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but mostly the lungs,
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and so that's when you seek treatment.
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And so the worst case
in terms of spreading
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is somebody who's got a lot
in the upper respiratory tract
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but almost none in their lungs,
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so they're not care-seeking.
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CA: Right.
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And so if you add in the never symptomatic
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to the pre-symptomatic,
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do you get above 50 percent
of the transmission
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is actually from non-symptomatic people?
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BG: Yeah, transmission
is harder to measure.
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You know, we see certain
hotspots and things,
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but that's a huge question
with the vaccine:
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will it, besides avoiding
you getting sick,
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which is what the trial will test,
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will it also stop you
from being a transmitter?
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CA: So that vaccine,
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it's such an important question,
let's come on to that,
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but before we go there,
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any other surprises
in the last couple months
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that we've learned about this virus
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that really impact how
we should respond to it?
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BG: We're still not able to characterize
who the super-spreaders are
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in terms of what that profile is,
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and we may never.
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That may just be quite random.
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If you could identify them,
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they're responsible
for the majority of transmission,
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a few people who have
very high viral loads.
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But sadly, we haven't figured that out.
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This mode of transmission,
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if you're in a room and nobody talks,
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there's way less transmission.
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That's partly why,
although planes can transmit,
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it's less than you would expect
just in terms of time proximity measures,
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because unlike, say,
a choir or a restaurant,
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you're not exhaling in loud talking
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quite as much as in
other indoor environments.
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CA: What do you think about the ethics
of someone who would go on a plane
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and refuse to wear a mask?
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BG: If they own the plane,
that would be fine.
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If there's other people on the plane,
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that would be endangering
those other people.
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CA: Early on in the pandemic,
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the WHO did not advise
that people wear masks.
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They were worried about taking them away
from frontline medical providers.
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In retrospect, was that
a terrible mistake that they made?
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BG: Yes.
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All the experts feel bad
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that the value of masks,
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which ties back somewhat
to the asymptomatics,
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if people were very symptomatic,
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like in Ebola,
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then you know it and you isolate,
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and so you don't have
a need for a mask-like thing.
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The value of masks,
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the fact that the medical masks
was a different supply chain
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than the normal masks,
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the fact you could scale up
the normal masks so well,
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the fact that it would stop
that pre-symptomatic,
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never symptomatic transmission,
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it's a mistake,
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but it's not a conspiracy,
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it's something that we now know more.
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And even now, our error bars
on the benefit of masks
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are higher than we'd like to admit,
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but it's a significant benefit.
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CA: All right, I'm going to come in
with some questions
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from the community.
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Let's pull them up there.
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Jim Pitofsky: "Do you think reopening
efforts in the US have been premature,
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and if so how far should the US go
to responsibly confront this pandemic?"
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BG: Well, the question
of how you make tradeoffs
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between the benefits, say,
of going to school
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versus the risk of people getting sick
because they go to school,
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those are very tough questions
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that I don't think any single person
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can say, "I will tell you
how to make all these tradeoffs."
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The understanding of
where you have transmission,
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and the fact that young people
do get infected
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and are part of the multi-generational
transmission chain,
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we should get that out.
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If you just look at the health aspect,
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we have opened up too liberally.
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Now, opening up in terms of mental health
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and seeking normal health things
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like vaccines and other care,
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there are benefits.
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I think some of our opening up
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has created more risk than benefit.
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Opening the bars up
as quickly as they did,
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is that critical for mental health?
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Maybe not.
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So I don't think we've been
as tasteful about opening up
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as I'm sure, as we study it,
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that we'll realize some things
we shouldn't have opened up as fast,
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but then you have something like school,
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where even sitting here today,
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the exact plan, say,
for inner city schools for the fall,
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I wouldn't have a black-and-white view
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on the relative tradeoffs involved there.
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There are huge benefits
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to letting those kids go to school,
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and how do you weigh the risk?
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If you're in a city
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without many cases,
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I would say probably the benefit is there.
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Now that means that
you could get surprised.
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The cases could show up,
and then you'd have to change that,
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which is not easy.
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But I think around the US
there will be places
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where that won't be a good tradeoff.
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So almost any dimension and inequity,
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this disease has made worse:
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job type, internet connection,
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ability of your school
to do online learning.
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White collar workers,
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people are embarrassed to admit it,
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some of them are more productive
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and enjoying the flexibility
that the at-home thing has created,
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and that feels terrible
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when you know lots of people
are suffering in many ways,
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including their kids not going to school.
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CA: Indeed. Let's have the next question.
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"For us in Rwanda,
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early policy interventions
have made the difference.
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At this point, what policy interventions
do you suggest for the US now?"
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Bill, I dream of the day
where you are appointed
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the coronavirus czar
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with authority to actually
speak to the public.
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What would you do?
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BG: The innovation tools
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are where I and the foundation
probably has the most expertise.
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Clearly some of the policies
on opening up have been too generous,
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but I think everybody
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could engage in that.
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We need leadership
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in terms of admitting
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that we've still got a huge problem here,
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and not turning that
into almost a political thing
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of, oh, isn't it brilliant what we did.
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No, it's not brilliant,
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but there's many people,
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including the experts,
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where there's a lot
they didn't understand,
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and everybody wishes a week earlier
whatever action they took,
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they'd taken that a week earlier.
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The innovation tools,
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that's where the foundation's work
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on antibodies, vaccines,
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we have deep expertise,
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and it's outside of the private sector,
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and so we have kind of a neutral ability
to work with all the governments
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and the companies to pick.
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Particularly when you're doing
break-even products,
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which one should get the resources.
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There's no market signal for that.
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Experts have to say, OK,
this antibody deserves the manufacturing.
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This vaccine deserves the manufacturing.
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Because, we have very limited
manufacturing for both of those things,
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and it'll be cross-company,
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which never happens in the normal case,
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where one company invents it
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and then you're using
the manufacturing plants
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of many companies
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to get maximum scale of the best choice.
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So I would be coordinating those things,
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but we need a leader
who keeps us up to date,
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is realistic,
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and shows us the right behavior,
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as well as driving the innovation track.
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CA: I mean, you have to yourself
be a master diplomat
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in how you talk about this stuff.
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So I appreciate, almost,
the discomfort here,
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but you talk regularly with Anthony Fauci,
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who is a wise voice on this
by most people's opinion.
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But to what extent is he just hamstrung?
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He's not allowed to play the full role
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that he could play in the circumstance.
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BG: Dr. Fauci