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Bill Gates, newly free from his role on the Microsoft board, has taken to Reddit to answer the community’s questions about the pandemic, the government response, and what the world can do to be better prepared. Always candid but never cynical, Gates gives some heartening but realistic advice.
Worth noting at the outset is that Gates and the Foundation have been warning about and preparing for an epidemic of this type for years. His 2015 TED talk in particular is extremely prescient, and he wrote a detailed article (PDF) around then for the New England Journal of Medicine detailing the lessons we should learn from the Ebola outbreak. The Foundation also participated in the creation of the Center for Epidemic Preparedness Innovations in 2017. (A recent simulation with Johns Hopkins that has been getting attention for its eerie parallels to the present situation is not in fact a prediction or good comparison.)
You can read all his responses (and the thousands of questions and comments) at the AMA, of course, but the most interesting ones have been lightly edited and condensed below.
Q: What do you think about the current state of testing nationwide?
“The testing in the US is not organized yet…Things are a bit confused on this right now.”
Gates: The testing in the US is not organized yet. In the next few weeks I hope the government fixes this by having a website you can go to to find out about home testing and kiosks. Things are a bit confused on this right now. In Seattle the U of W is providing thousands of tests per day but no one is connected to a national tracking system.
Whenever there is a positive test it should be seen to understand where the disease is and whether we need to strengthen the social distancing. South Korea did a great job on this including digital contact tracing.
We need to democratize and scale the testing system by having a CDC website that people go to and enter their situation. Priority situations should get tested within 24 hours. This is very possible since many countries have done it. Health care workers for example should have priority. Elderly people should have priority. We will be able to catch up on the testing demand within a few weeks of getting the system in place. Without the system we don’t know what is missing – swabs, reagents etc.
Q: What about this Imperial College study suggesting 1-4 million Americans will die with current approaches, but total shutdown would limit deaths to a few thousand?
Fortunately it appears the parameters used in that model were too negative. The experience in China is the most critical data we have. They did their “shut down” and were able to reduce the number of cases. They are testing widely so they see rebounds immediately and so far there have not been a lot. They avoided widespread infection. The Imperial model does not match this experience. Models are only as good as the assumptions put into them. People are working on models that match what we are seeing more closely and they will become a key tool. A group called Institute for Disease Modeling that I fund is one of the groups working with others on this.
One tool that is helping us is looking at the genetics of the virus to understand the tree of infection.
Q: Can the 18 month estimate for a vaccine be shortened?
“My retiring from public boards was not related to the epidemic.”
Gates: This is a great question. There are over 6 different efforts going on to make a vaccine. Some use a new approach called RNA which is unproven. We will have to build lots of manufacturing for the different approaches knowing that some of them will not work. We will need literally billions of vaccines to protect the world. Vaccines require testing to make sure they are safe and effective. Some vaccines like the flu don’t for the elderly.
The first vaccines we get will go to health care workers and critical workers. This could happen before 18 months if everything goes well but we and Fauci and others are being careful not to promise this when we are not sure. The work is going at full speed.
Q: (Deleted, but regarding Gates stepping down from the Microsoft board)
Gates: My retiring from public boards was not related to the epidemic but it does reinforce my decision to focus on the work of the Foundation including it’s work to help with the epidemic.
Q: (In response to a deleted comment)
Gates: We should not call this the Chinese virus.
“We should not call this the Chinese virus.”
Q: What about a timeline for effective treatment?
Gates: A therapeutic could be available well before a vaccine. Ideally this would reduce the number of people who need intensive care including respirators. The Foundation has organized a Therapeutics Accelerator to look at all the most promising ideas and bring all the capabilities of industry into play. So I am hopeful something will come out of this. It could be an anti-viral or antibodies or something else.
One idea that is being explored is using the blood (plasma) from people who are recovered. This may have antibodies to protect people. If it works it would be the fastest way to protect health care workers and patients who have severe disease.
Q: “Thoughts on chloroquine/hydroxychloroquine?”
Gates: There are a lot of therapeutic drugs being examined. This is one of many but it is not proven. If it works we will need to make sure the finite supplies are held for the patients who need it most. We have a study going on to figure this out. We also have a screening effort to look at all the ideas for Therapeutics because the number being proposed is very large and only the most promising should be tried in patients. China was testing some things but now they have so few cases that that testing needs to move to other locations.
Q: Can you help with ventilator production?
Gates: There are a lot of efforts to do this. If we do social distancing (“shut down”) properly then the surge of cases won’t be as overwhelming. Our Foundation’s expertise is in diagnostics, therapeutics and vaccines so we are not involved in the ventilator efforts but it could make a contribution to have more especially as the disease gets into developing countries including Africa.
Q: What do you think of efforts to slow the spread?
“I worry about all the economic damage, but even worse will be how this will affect the developing countries who cannot do the social distancing the same way as rich countries, and whose hospital capacity is much lower.”
Gates: The only model that is known to work is a serious social distancing effort (“shut down”). If you don’t do this then the disease will spread to a high percentage of the population and your hospitals will be overloaded with cases. So this should be avoided despite the problems caused by the “shut down”. If a country doesn’t control its cases then other countries will prevent anyone going into or coming out of that country.
We are going into lockdown but as usual in retrospect we should have done it sooner. The sooner it is done the easier it is to get the cases down to small numbers.
The current phase has a lot of the cases in rich countries. With the right actions including the testing and social distancing within 2-3 months the rich countries should have avoided high levels of infection. I worry about all the economic damage, but even worse will be how this will affect the developing countries who cannot do the social distancing the same way as rich countries, and whose hospital capacity is much lower.
Some people like health care workers will be doing heroic work and we need to support them. We do need to stay calm even though this is an unprecedented situation.
“People like health care workers will be doing heroic work and we need to support them.”
Q: What about a national “shelter in place” policy?
Gates: Most people can shelter in their home but for people who that doesn’t work for there should be a place for them to go. We are working on seeing if we can send test kits to people at home so they don’t have to go out and so the tests get to the people who are the priority. The US still is not organized on testing.
I think people in the US will be able to largely isolate for 2-3 months. If they can access testing including a home test kit then they will understand who is infected. I keep saying how important the testing piece is.
Q: What can educators and parents do for students, especially kids from low income families?
Gates: It is a huge problem that schools will likely be shut down for the next few months. There are a lot of online resources from people like Khan Academy and Scholastic. Comcast and other internet connectivity providers are doing special programs to help with access. Microsoft and others are working on getting machines out but the supply chain is quite constrained. Unfortunately low-income students will be hurt more by the situation than others so we need to help any way we can.
Q: How should we determine which businesses should stay open?
Gates: The question of which businesses should keep going is tricky. Certainly food supply and the health system. We still need water, electricity and the internet. Supply chains for critical things need to be maintained. Countries are still figuring out what to keep running.
Eventually we will have some digital certificates to show who has recovered or been tested recently, or when we have a vaccine, who has received it.
Q: Will there be multiple waves or “rebounds” after the first?
Eventually we will have some digital certificates to show who has recovered or been tested recently, or when we have a vaccine, who has received it.
Gates: It depends on how you deal with people coming in from other countries and how strong the testing effort was. So far in China the amount of rebound being seen is very low. They are controlling people coming into the country very tightly. Hong Kong, Taiwan and Singapore have all done a good job on this. If we do it right the rebounds should be fairly small in numbers.
There are many models to look at what will happen. That article is based on a set of assumptions derived from Influenza and it doesn’t match what has happened in China or even South Korea. So we need to be humble about what we know but it does appear that social distancing with testing can get the cases down to low levels.
In China less than .01% of the population was infected because of the measures they took. Most rich countries should be able to achieve a low level of infections. Some developing countries will not be able to do that.
Q: How is the Foundation helping, and how can we help?
Our foundation is working with all the groups who make diagnostics, therapeutics and vaccines to make sure the right efforts are prioritized. We want to make sure all countries get access to these tools. We donated $100M in February for a variety of things and we will be doing more. One priority is to make sure that there is enough manufacturing capacity for therapeutics and vaccines. We have other efforts like our education group working to make sure the online resources for students are as helpful as they can be.
There will be lots of opportunity to give to social service organizations including food banks and I am sure people will be generous about this. Once we know who tests positive we can figure out how to support them so they can stay isolated and still get the food and medicine they need.
Q: How can we be better prepared for the next pandemic?
We need to have the ability to scale up diagnostics, drugs and vaccines very rapidly. The technologies exist to do this well if the right investments are made.
Gates: The TED talk I did in 2015 talked about this. We need to have the ability to scale up diagnostics, drugs and vaccines very rapidly. The technologies exist to do this well if the right investments are made. Countries can work together on this. We did create CEPI = Coalition for Epidemic Preparedness Innovation which did some work on vaccines but that needs to be funded at higher level to have the standby manufacturing capacity for the world.
I think that after this is under control that Governments and others will invest heavily in being ready for the next one. This will take global cooperation particularly to help the developing countries who will be hurt the most. A good example is the need to test therapeutics wherever the disease is to help the whole world. The Virus doesn’t respect national boundaries.
Q(?): I can’t believe Bill Gates just answered my question! (And general thanks.)
Gates: Its nice to hear something positive in this time of great uncertainty. I hope the Reddit community can spread the word about social distancing. Digital tools like this can help us stay in touch even though we are physically isolated.
