This is the lightly edited transcript of a conversation between Bill Gates, co-chair of the Bill & Melinda Gates Foundation, and the FT’s Vanessa Kortekaas, which took place on April 2, via Skype.
FINANCIAL TIMES: So I want to start by going back in time to five years ago. As many people know, you warned that the greatest risk of global catastrophe wasn't a war, but a highly infectious virus. Why didn't anybody listen? And if some people did, what was done to prepare for the pandemic that exists now?
BILL GATES: Well, not enough was done. A system wasn't built. We didn't really do the number of simulations to try and figure out, OK, how are we going to connect up the diagnostics? How are we going to get the vaccine going? There were some investments. For example, our foundation, Wellcome Trust and a number of governments created Cepi (the Coalition for Epidemic Preparedness Innovation), which is about making vaccine platforms that are ready when we get surprised to manufacture a new vaccine faster than has been done in the past.
So some work was done but, in retrospect, the saddest thing is to be able to say yes, that was right. But the whole point of the speech was to drive the research and the planning and the simulation which would have allowed us to stop this at a very early stage.
FT: And in terms of the global response now, many countries, including the UK and the US, have been criticised for not doing enough testing and not doing it fast enough. What is your assessment of the global response so far and, specifically, of President Trump's response to this crisis in the US?
BG: Well, I'm sure there'll be plenty of time, once we're on top of this, to look at before the epidemic hit, what more could have been done, when the epidemic hit. I don't think any country has a perfect record. Taiwan comes close.
They really were talking about it, and it's unfortunate they weren't part of the WHO (World Health Organization) to really get those warnings paid attention to. Most countries didn't see it as [becoming] as big a problem as it's ended up being. And of course, when you have exponential growth, that means if you miss, you know, three doubling times, it's eight times as big and much, much harder to get under control.
So a few countries, particularly those that have the experience of dealing with Mers or Sars, they were the fastest to respond. South Korea is an example of that. China, which had a lot of cases, now is in a very different state where they are able to get most people going back to school and back to work. And so there's lessons about, what did they do to drop the numbers? And what are they doing to avoid a rebound? Because until we get a vaccine that we've given to a high percentage of the global population, we will be at risk of rebound.
FT: And what would you say is the single most important thing that needs to happen now? The World Health Organization has said test, test, test. Is testing the key here? Or what about, for example, the role of technology? We've seen some Asian countries use technology to spread information so quickly, which has helped them fight the virus. What do you think is the single most important thing that has to happen right now?
BG: Well, testing is what guides you to see, do you need to do more social isolation, or have you gotten to a point where you can start to open up a bit? It can't just be numbers of tests though. You have to have the results coming back in less than 24 hours, and you have to prioritise who gets tested. The demand for tests exceeds supply in every country. And some countries really stepped in, like South Korea, and made sure the right people were being tested. They have a unified system that could look at the individual cases and weigh the criteria.
The US does not have that. We have so many different companies, labs. And most of tests go in without any criterion. And so now we have these backlogs that really devalue what can be done with those tests. So the fact that the numbers have gone up doesn't mean that we're doing this well at all.
That is still ahead of us to get organised on prioritising properly. So your contacts, if you test positive here, before they become infectious, that they need to isolate. The PCR test is sensitive enough to catch it even before you'll have symptoms. And that's the ideal case — where you don't go on to infect anyone else, which is the key to bringing those numbers down.
So today, the appropriate testing and isolation are the primary tactics. In the mid-term, getting some drugs that will reduce the hospitalisation and death rate, that will be very important. And the ultimate solution is a highly effective, safe vaccine. But getting billions of doses is hard. And our foundation works in all of those areas.
We're providing funding even now in parallel to scale up the manufacturing of the most promising vaccines — way more than we will end up picking. Because even though that's a few billion dollars of manufacturing capacity, the fact that it will be ready because we do it in parallel, that anything that cuts a month off of the time until we vaccinate is worth literally hundreds of billions, if not trillions.
FT: And can you just briefly expand more on that investment. So as you say, your foundation has announced $100m investment to go towards this global response. Can you just outline some of the areas where that's going to?
BG: Yeah, a lot of that's going to help the capacity in the developing worlds step up. Some actually helped China with the early response. Some is now helping in Europe and the US. We think a lot about the developing countries. And they have the biggest challenge because the social isolation is much harder for them. Just getting the food supply to work reliably — the distance, when you live in [an] urban slum area, you're not going to be able to be quite as separated as would be ideal there.
So those countries, even though their numbers are quite small today, sadly, it's very likely that many of those countries won't be able to contain it unlike, say China, which is at point 0.01 per cent, or some of the other countries. A lot of the rich countries should be able to keep it to a few per cent infected. These countries, many of them will experience a widespread epidemic so that, over time, the majority of their people are infected. And that will lead to hospital overloading, deaths from other conditions, and very substantial burden for those countries.
FT: And let's talk more about that big picture then for the developing world. We're at this point, it seems like quite a scary point, where, as you say, the virus is just starting to spread in developing countries. We know it's already spread throughout Africa, but hasn't quite taken off yet. How big of an impact do you think it will have in terms of deaths and the number of infections? And how worried are you about the ability of developing countries to fight this?
BG: We could get lucky, and there could be something about [the] weather that means that some countries have lower force of infection — we don't know that. Our assumption has to be, because we are seeing in some southern hemisphere places like Australia, quite a bit of infection, that it's not dramatically seasonal and that it's just gotten started slower in Africa. I hope something shows up that changes that.
It's very easy to say this disease has about a 1 per cent case fatality rate. And when you overload your hospitals you can get up to 2-3 per cent rate. Now, then again, Africa has a younger population, so that brings your numbers down. But the comorbidities in terms of smoke inhalation, both indoor and outdoor, TB, HIV, malnutrition, those are much higher there. And so you'd have quite a bit of uncertainty. But it's not impossible that you'd see [a] 2 per cent overall death rate, which is a horrific situation, potentially, even worse, as you have panic and other healthcare is very disrupted.
FT: You mentioned the difficulty of self-isolation. Is the whole lockdown approach that we see in developed countries, is that doomed to fail in developing countries because for some people it's just not practical? If they have to go outside to collect food or sell goods for their livelihood or, as you say, if they live in cramped conditions or slums, how can that possibly work?
BG: It's a super good question. Many of the developing countries are going to do their best on this. So India is doing it. Now, it's early days. They have to figure out — do food delivery people, are they allowed to still do their jobs or not? So these things are tricky to put into place the exact, you know, what is essential? Can you go out and walk your dog, or which businesses should be there? And the US didn't do much practice thinking about this. So we're figuring it out.
For the developing countries, I'd say it's definitely worth trying to flatten the curve. But the likelihood that you'll be successful and only have a few per cent infected — somewhere as you go down level of income, particularly in those urban slum areas — I worry that it will not be effective. But even if it delays and spreads things out, the number of health workers who get infected, the overload of the medical system, there is value to it in terms of the speed of which the infection gets into the broad population.
FT: You've said you're an optimist. And the world could use some good news or at least some hope. Is there reason to be optimistic about the ability of these poorer countries to fight this crisis, to fight the virus? Where are the pockets of hope?
BG: Well, the rural areas, the force of infection should be reduced particularly if people understand about the mixing. Although, right now, you have people leaving urban areas going back to the rural areas, so it won't be zero. We will get a vaccine. And the role of our foundation is to make sure that medicines like this are available to the entire world. We have partners like Gavi who will help us with that distribution. I'm sure governments will step up on this.
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And so over the next couple of years, hopefully in 18 months, we'll get that vaccine, and things can be so you’re not completely changing the economy because of coronavirus. And economies can come back. As painful as this is, as unprecedented as it is, the deaths, those you can't reverse. And so right now, people are scared. People are doing less economically.
Governments are trying to make sure that's a lot of people, so that the case infection rate goes to below 1 [per cent]. But yes, eventually, these tools — hopefully one of the platforms we've been investing in, actually for a decade, like the RNA vaccines — those are the most flexible and easiest to ramp up. So we're hoping that that's the way we get to the vaccine that gets us out of this terrible problem.
FT: And I want to talk more about the vaccine in a minute. But in terms of the obligation that rich countries have to help poor countries — rich countries are struggling to support their own citizens through this crisis. So what is the obligation that rich countries have to help the developing world?
BG: Well, that's always a question. There are countries that spend more than 0.7 per cent of GDP in regular times helping the poorest get things like measles vaccines and greatly uplift their countries so that they're stable and participating in the world economy. The UK is a generous donor, Sweden, Norway. Germany has become a lot more generous.
And so you can see that ranking there. I do think, despite the fact that you've got huge domestic problems and huge economic problems, you know that idea that you can keep that 0.7 per cent or even go up as much as a factor or two above that — because the impact of those dollars on helping things not completely deteriorate, helping hold things together, helping accelerate that vaccine manufacturer — I think the case on that will be compelling. But everybody's dealing with an immense number of priorities.
Then, again, they’ve decided to not operate under the normal fiscal constraints. And so the idea of, say, tens of billions helping buy those vaccines and get that manufacturing — it used to be in the aid game, that was a very, very big number. Now, when you're talking about making it easier to not have infection coming back into your country, you can make both a humanitarian and a self-interested argument that even a few per cent [of GDP] going against that for the rich countries would be a wise investment.
FT: Do you think this is the most concerted global effort ever to find a vaccine? And could we see one before 18 months’ time?
BG: If everything went perfectly with the RNA vaccines — the Moderna is already in a human trial. You could do a little better than that. But remember, we're talking about making billions of doses. And even just to have the glass vials, the pill, finish the distribution, 18 months would be . . . a lot has to go well — not everything — to hit that. There are many constructs being worked on.
The experienced vaccine companies bring a lot to this because understanding safety and efficacy and how you go through the trials — so we need some new ones, which, for the people we're backing are RNA/DNA. And then there's four others that are more conventional, sure to work but [with] slightly longer schedules. And we have to fund the science, the testing, and the manufacturing capacity of all of those over at least seven or eight. We need to be ready to go once you have safety and efficacy.
FT: And what responsibility do you think national governments, philanthropies, and the private sector have to co-operate in order to find these solutions? And where do tech companies fit in this picture?
BG: Well, the deep expertise of making vaccines is some at the academic level, government research level, but a lot, particularly in safety and manufacturing, is in the private sector. And the government's not used to figuring out, OK, who's good at what, and what's the right way to do that? Our foundation plays a role there because we're funding the invention of vaccines and the scale-up and low-cost vaccines. That's what we're doing all the time to reduce deaths in the poor countries.
And so [the] private sector is very important. But the overall template has to come from government. And government here, where it doesn't know who can make ventilators or how testing gets overly backlogged, that is a big challenge. We don't have . . . we didn't practise at all for what we're going through here. And even, you know, who's responsible, and is that somebody who actually has the right domain knowledge? That's not totally clear as we try to move through this.
There are people like Dr [Anthony] Fauci, who brings a scientific, data-driven view to these things. And so it's great that he's in a strong position. He and I have talked a lot about how we get all the different actors, including the US government, our foundation partners, like IHME and Gavi and various of the companies that will be key to this, bring them together.
The tech companies don't make vaccines. But they can do a lot to let people still connect together. They can do a lot to let us look at the data and have deep insights into that. All these articles are being published. And so Microsoft and many others are letting you navigate that information in a very rich way. And so they'll step up. Believe me, anything I'm calling a private company [for] that's clear, well-defined, and they know, if I'm calling, it's likely to really make a difference.
They all say yes to these things. This is so top-of-mind. We've got the entire economy shut down. So everybody's trying to pitch in. Co-ordinating that when a lot of people don't understand, OK, which tests are the most important, or which information is, it's a bit difficult. And so key people at the foundation are working night and day to try and pull these resources together. But when we have asks for these people, they are dying to help out.
FT: And what about that trade-off? You just mentioned, obviously, the economic pain. What do you think the right balance is between the trade-off of protecting people's lives and the economic hit? Do you see a situation where the global economy could be virtually at a standstill for a year or even more?
BG: Well, it won't go to zero, but it will shrink. Global GDP is going to take probably the biggest hit ever. Maybe the Depression was worse or 1873, I don't know. But in my lifetime this will be the greatest economic hit. But you don't have a choice. People act like you have a choice. People don't feel like going to the stadium when they might get infected. You know, it's not the government who's saying OK, just ignore this disease, and people are deeply affected by seeing these deaths, by knowing they could be part of the transmission chain, and old people, their parents, their grandparents could be affected by this.
And so you don't get to say, ignore what's going on here. There will be the ability, particularly in rich countries, to open up if things are done well over the next few months. But for the world at large, normalcy only returns when we've largely vaccinated the entire global population. And so although there's a lot of work on testing, a lot of work on drugs that we’re involved with, trying to achieve that ambitious goal, which has never been done for the vaccine, that rises to the top of the list.
FT: Once this pandemic, once we find solutions to this, looking far ahead into the future, do you think that people will just return to a sort of a short-termism view where we're too focused on economic gain to invest properly and prepare properly for another once-in-a-century pandemic? And what is your message right now to world leaders and global policymakers to avoid the world being caught off guard again?
BG: Well, there's no doubt, having paid many trillions of dollars more than we might have had to if we'd been properly ready, people will, this time, because it affected the rich countries. This is the biggest event that people will experience in their entire lives. We will have standby diagnostics. We will have deep antiviral libraries. We will have antibodies scale up. We will have vaccine platforms. We will have early warning systems. We will do germ games.
The cost of doing all those things well is very small compared to what we're going through here. And so now people realise, OK, there really is a meaningful probability every 20 years or so with lots of world travel that one of these [viruses] will come along. And so the citizens expect the government to make it a priority. It won't cost as much as the defence budget, say, but it will be a meaningful investment. Some of those investments will help medical work in other areas. A vaccine platform, cheap, fast diagnostics — these are not things that are only valuable for an epidemic.
FT: So you're confident then that lessons will be learned from this experience and that the pain, both in terms of the loss of life and the economic hit, will be bad enough to make people prepare for next time?
BG: Yes, but it shouldn't have required a many trillions of dollars loss to get there. I remember when I put up this slide in that [TED] talk. And I showed that it was trillions of dollars. I felt like, wow, that is so gigantic. Why are people saying $10, $20, $30 billion, which, in a government budget sense, is almost nothing — but yes, this time, we've been whacked on the head here at home, people we know. The science is there. Countries will step forward.
FT: Bill Gates, thank you for your time.
BG: Thank you.
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