For 20 years, Bill Gates has been easing out of the roles that made him rich and famous—CEO, chief software architect, and chair of Microsoft—and devoting his brainpower and passion to the Bill and Melinda Gates Foundation, abandoning earnings calls and antitrust hearings for the metrics of disease eradication and carbon reduction. This year, after he left the Microsoft board, one would have thought he would have relished shedding the spotlight directed at the four CEOs of big tech companies called before Congress.
But as with many of us, 2020 had different plans for Gates. An early Cassandra who warned of our lack of preparedness for a global pandemic, he became one of the most credible figures as his foundation made huge investments in vaccines, treatments, and testing. He also became a target of the plague of misinformation afoot in the land, as logorrheic critics accused him of planning to inject microchips in vaccine recipients. (Fact check: false. In case you were wondering.)
My first interview with Gates was in 1983, and I’ve long lost count of how many times I’ve spoken to him since. He’s yelled at me (more in the earlier years) and made me laugh (more in the latter years). But I’ve never looked forward to speaking to him more than in our year of Covid. We connected on Wednesday, remotely of course. In discussing our country’s failed responses, his issues with his friend Mark Zuckerberg’s social networks, and the innovations that might help us out of this mess, Gates did not disappoint. The interview has been edited for length and clarity.
WIRED: You have been warning us about a global pandemic for years. Now that it has happened just as you predicted, are you disappointed with the performance of the United States?
Bill Gates: Yeah. There’s three time periods, all of which have disappointments. There is 2015 until this particular pandemic hit. If we had built up the diagnostic, therapeutic, and vaccine platforms, and if we’d done the simulations to understand what the key steps were, we’d be dramatically better off. Then there’s the time period of the first few months of the pandemic, when the US actually made it harder for the commercial testing companies to get their tests approved, the CDC had this very low volume test that didn’t work at first, and they weren’t letting people test. The travel ban came too late, and it was too narrow to do anything. Then, after the first few months, eventually we figured out about masks, and that leadership is important.
So you’re disappointed, but are you surprised?
I’m surprised at the US situation because the smartest people on epidemiology in the world, by a lot, are at the CDC. I would have expected them to do better. You would expect the CDC to be the most visible, not the White House or even Anthony Fauci. But they haven’t been the face of the epidemic. They are trained to communicate and not try to panic people but get people to take things seriously. They have basically been muzzled since the beginning. We called the CDC, but they told us we had to talk to the White House a bunch of times. Now they say, “Look, we’re doing a great job on testing, we don’t want to talk to you.” Even the simplest things, which would greatly improve this system, they feel would be admitting there is some imperfection and so they are not interested.
Do you think it’s the agencies that fell down or just the leadership at the top, the White House?
We can do the postmortem at some point. We still have a pandemic going on, and we should focus on that. The White House didn’t allow the CDC to do its job after March. There was a window where they were engaged, but then the White House didn’t let them do that. So the variance between the US and other countries isn’t that first period, it’s the subsequent period where the messages—the opening up, the leadership on masks, those things—are not the CDC’s fault. They said not to open back up; they said that leadership has to be a model of face mask usage. I think they have done a good job since April, but we haven’t had the benefit of it.
At this point, are you optimistic?
Yes. You have to admit there’s been trillions of dollars of economic damage done and a lot of debts, but the innovation pipeline on scaling up diagnostics, on new therapeutics, on vaccines is actually quite impressive. And that makes me feel like, for the rich world, we should largely be able to end this thing by the end of 2021, and for the world at large by the end of 2022. That is only because of the scale of the innovation that’s taking place. Now whenever we get this done, we will have lost many years in malaria and polio and HIV and the indebtedness of countries of all sizes and instability. It’ll take you years beyond that before you’d even get back to where you were at the start of 2020. It’s not World War I or World War II, but it is in that order of magnitude as a negative shock to the system.
In March it was unimaginable that you’d be giving us that timeline and saying it’s great.
Well it’s because of innovation that you don’t have to contemplate an even sadder statement, which is this thing will be raging for five years until natural immunity is our only hope.
Let’s talk vaccines, which your foundation is investing in. Is there anything that’s shaping up relatively quickly that could be safe and effective?
Before the epidemic came, we saw huge potential in the RNA vaccines—Moderna, Pfizer/BioNTech, and CureVac. Right now, because of the way you manufacture them, and the difficulty of scaling up, they are more likely—if they are helpful—to help in the rich countries. They won’t be the low-cost, scalable solution for the world at large. There you’d look more at AstraZeneca or Johnson & Johnson. This disease, from both the animal data and the phase 1 data, seems to be very vaccine preventable. There are questions still. It will take us awhile to figure out the duration [of protection], and the efficacy in elderly, although we think that’s going to be quite good. Are there any side effects, which you really have to get out in those large phase 3 groups and even after that through lots of monitoring to see if there are any autoimmune diseases or conditions that the vaccine could interact with in a deleterious fashion.
Are you concerned that in our rush to get a vaccine we are going to approve something that isn’t safe and effective?
Yeah. In China and Russia they are moving full speed ahead. I bet there’ll be some vaccines that will get out to lots of patients without the full regulatory review somewhere in the world. We probably need three or four months, no matter what, of phase 3 data, just to look for side effects. The FDA, to their credit, at least so far, is sticking to requiring proof of efficacy. So far they have behaved very professionally despite the political pressure. There may be pressure, but people are saying no, make sure that that’s not allowed. The irony is that this is a president who is a vaccine skeptic. Every meeting I have with him he is like, “Hey, I don’t know about vaccines, and you have to meet with this guy Robert Kennedy Jr. who hates vaccines and spreads crazy stuff about them.” (...)
What goes through your head when you’re in a meeting hearing misinformation, and the President of the United States wants you to keep your mouth shut?
That was a bit strange. I haven’t met directly with the president since March of 2018. I made it clear I’m glad to talk to him about the epidemic anytime. And I have talked to Debbie Birx, I’ve talked to Pence, I’ve talked to Mnuchin, Pompeo, particularly on the issue of, Is the US showing up in terms of providing money to procure the vaccine for the developing countries? There have been lots of meetings, but we haven’t been able to get the US to show up. It’s very important to be able to tell the vaccine companies to build extra factories for the billions of doses, that there is procurement money to buy those for the marginal cost. So in this supplemental bill, I’m calling everyone I can to get 4 billion through GAVI for vaccines and 4 billion through a global fund for therapeutics. That’s less than 1 percent to the bill, but in terms of saving lives and getting us back to normal, that under 1 percent is by far the most important thing if we can get it in there.
Speaking of therapeutics, if you were in the hospital and you have the disease and you’re looking over the doctor’s shoulder, what treatment are you going to ask for?
Remdesivir. Sadly the trials in the US have been so chaotic that the actual proven effect is kind of small. Potentially the effect is much larger than that. It’s insane how confused the trials here in the US have been. The supply of that is going up in the US; it will be quite available for the next few months. Also dexamethasone—it’s actually a fairly cheap drug—that’s for late-stage disease.
I’m assuming you’re not going to have trouble paying for it, Bill, so you could ask for anything.
Well, I don’t want special treatment, so that’s a tricky thing. Other antivirals are two to three months away. Antibodies are two to three months away. We’ve had about a factor-of-two improvement in hospital outcomes already, and that’s with just remdesivir and dexamethasone. These other things will be additive to that.
You helped fund a Covid diagnostic testing program in Seattle that got quicker results, and it wasn’t so intrusive. The FDA put it on pause. What happened?
There’s this thing where the health worker jams the deep turbinate, in the back of your nose, which actually hurts and makes you sneeze on the healthy worker. We showed that the quality of the results can be equivalent if you just put a self-test in the tip of your nose with a cotton swab. The FDA made us jump through some hoops to prove that you didn’t need to refrigerate the result, that it could go back in a dry plastic bag, and so on. So the delay there was just normal double checking, maybe overly careful but not based on some political angle. Because of what we have done at FDA, you can buy these cheaper swabs that are available by the billions. So anybody who’s using the deep turbinate now is just out of date. It’s a mistake, because it slows things down.
But people aren’t getting their tests back quickly enough.
Well, that’s just stupidity. The majority of all US tests are completely garbage, wasted. If you don’t care how late the date is and you reimburse at the same level, of course they’re going to take every customer. Because they are making ridiculous money, and it’s mostly rich people that are getting access to that. You have to have the reimbursement system pay a little bit extra for 24 hours, pay the normal fee for 48 hours, and pay nothing [if it isn’t done by then]. And they will fix it overnight.
Why don’t we just do that?
Because the federal government sets that reimbursement system. When we tell them to change it they say, “As far as we can tell, we’re just doing a great job, it’s amazing!” Here we are, this is August. We are the only country in the world where we waste the most money on tests. Fix the reimbursement. Set up the CDC website. But I have been on that kick, and people are tired of listening to me.
But as with many of us, 2020 had different plans for Gates. An early Cassandra who warned of our lack of preparedness for a global pandemic, he became one of the most credible figures as his foundation made huge investments in vaccines, treatments, and testing. He also became a target of the plague of misinformation afoot in the land, as logorrheic critics accused him of planning to inject microchips in vaccine recipients. (Fact check: false. In case you were wondering.)
My first interview with Gates was in 1983, and I’ve long lost count of how many times I’ve spoken to him since. He’s yelled at me (more in the earlier years) and made me laugh (more in the latter years). But I’ve never looked forward to speaking to him more than in our year of Covid. We connected on Wednesday, remotely of course. In discussing our country’s failed responses, his issues with his friend Mark Zuckerberg’s social networks, and the innovations that might help us out of this mess, Gates did not disappoint. The interview has been edited for length and clarity.WIRED: You have been warning us about a global pandemic for years. Now that it has happened just as you predicted, are you disappointed with the performance of the United States?
Bill Gates: Yeah. There’s three time periods, all of which have disappointments. There is 2015 until this particular pandemic hit. If we had built up the diagnostic, therapeutic, and vaccine platforms, and if we’d done the simulations to understand what the key steps were, we’d be dramatically better off. Then there’s the time period of the first few months of the pandemic, when the US actually made it harder for the commercial testing companies to get their tests approved, the CDC had this very low volume test that didn’t work at first, and they weren’t letting people test. The travel ban came too late, and it was too narrow to do anything. Then, after the first few months, eventually we figured out about masks, and that leadership is important.
So you’re disappointed, but are you surprised?
I’m surprised at the US situation because the smartest people on epidemiology in the world, by a lot, are at the CDC. I would have expected them to do better. You would expect the CDC to be the most visible, not the White House or even Anthony Fauci. But they haven’t been the face of the epidemic. They are trained to communicate and not try to panic people but get people to take things seriously. They have basically been muzzled since the beginning. We called the CDC, but they told us we had to talk to the White House a bunch of times. Now they say, “Look, we’re doing a great job on testing, we don’t want to talk to you.” Even the simplest things, which would greatly improve this system, they feel would be admitting there is some imperfection and so they are not interested.
Do you think it’s the agencies that fell down or just the leadership at the top, the White House?
We can do the postmortem at some point. We still have a pandemic going on, and we should focus on that. The White House didn’t allow the CDC to do its job after March. There was a window where they were engaged, but then the White House didn’t let them do that. So the variance between the US and other countries isn’t that first period, it’s the subsequent period where the messages—the opening up, the leadership on masks, those things—are not the CDC’s fault. They said not to open back up; they said that leadership has to be a model of face mask usage. I think they have done a good job since April, but we haven’t had the benefit of it.
At this point, are you optimistic?
Yes. You have to admit there’s been trillions of dollars of economic damage done and a lot of debts, but the innovation pipeline on scaling up diagnostics, on new therapeutics, on vaccines is actually quite impressive. And that makes me feel like, for the rich world, we should largely be able to end this thing by the end of 2021, and for the world at large by the end of 2022. That is only because of the scale of the innovation that’s taking place. Now whenever we get this done, we will have lost many years in malaria and polio and HIV and the indebtedness of countries of all sizes and instability. It’ll take you years beyond that before you’d even get back to where you were at the start of 2020. It’s not World War I or World War II, but it is in that order of magnitude as a negative shock to the system.
In March it was unimaginable that you’d be giving us that timeline and saying it’s great.
Well it’s because of innovation that you don’t have to contemplate an even sadder statement, which is this thing will be raging for five years until natural immunity is our only hope.
Let’s talk vaccines, which your foundation is investing in. Is there anything that’s shaping up relatively quickly that could be safe and effective?
Before the epidemic came, we saw huge potential in the RNA vaccines—Moderna, Pfizer/BioNTech, and CureVac. Right now, because of the way you manufacture them, and the difficulty of scaling up, they are more likely—if they are helpful—to help in the rich countries. They won’t be the low-cost, scalable solution for the world at large. There you’d look more at AstraZeneca or Johnson & Johnson. This disease, from both the animal data and the phase 1 data, seems to be very vaccine preventable. There are questions still. It will take us awhile to figure out the duration [of protection], and the efficacy in elderly, although we think that’s going to be quite good. Are there any side effects, which you really have to get out in those large phase 3 groups and even after that through lots of monitoring to see if there are any autoimmune diseases or conditions that the vaccine could interact with in a deleterious fashion.
Are you concerned that in our rush to get a vaccine we are going to approve something that isn’t safe and effective?
Yeah. In China and Russia they are moving full speed ahead. I bet there’ll be some vaccines that will get out to lots of patients without the full regulatory review somewhere in the world. We probably need three or four months, no matter what, of phase 3 data, just to look for side effects. The FDA, to their credit, at least so far, is sticking to requiring proof of efficacy. So far they have behaved very professionally despite the political pressure. There may be pressure, but people are saying no, make sure that that’s not allowed. The irony is that this is a president who is a vaccine skeptic. Every meeting I have with him he is like, “Hey, I don’t know about vaccines, and you have to meet with this guy Robert Kennedy Jr. who hates vaccines and spreads crazy stuff about them.” (...)
What goes through your head when you’re in a meeting hearing misinformation, and the President of the United States wants you to keep your mouth shut?
That was a bit strange. I haven’t met directly with the president since March of 2018. I made it clear I’m glad to talk to him about the epidemic anytime. And I have talked to Debbie Birx, I’ve talked to Pence, I’ve talked to Mnuchin, Pompeo, particularly on the issue of, Is the US showing up in terms of providing money to procure the vaccine for the developing countries? There have been lots of meetings, but we haven’t been able to get the US to show up. It’s very important to be able to tell the vaccine companies to build extra factories for the billions of doses, that there is procurement money to buy those for the marginal cost. So in this supplemental bill, I’m calling everyone I can to get 4 billion through GAVI for vaccines and 4 billion through a global fund for therapeutics. That’s less than 1 percent to the bill, but in terms of saving lives and getting us back to normal, that under 1 percent is by far the most important thing if we can get it in there.
Speaking of therapeutics, if you were in the hospital and you have the disease and you’re looking over the doctor’s shoulder, what treatment are you going to ask for?
Remdesivir. Sadly the trials in the US have been so chaotic that the actual proven effect is kind of small. Potentially the effect is much larger than that. It’s insane how confused the trials here in the US have been. The supply of that is going up in the US; it will be quite available for the next few months. Also dexamethasone—it’s actually a fairly cheap drug—that’s for late-stage disease.
I’m assuming you’re not going to have trouble paying for it, Bill, so you could ask for anything.
Well, I don’t want special treatment, so that’s a tricky thing. Other antivirals are two to three months away. Antibodies are two to three months away. We’ve had about a factor-of-two improvement in hospital outcomes already, and that’s with just remdesivir and dexamethasone. These other things will be additive to that.
You helped fund a Covid diagnostic testing program in Seattle that got quicker results, and it wasn’t so intrusive. The FDA put it on pause. What happened?
There’s this thing where the health worker jams the deep turbinate, in the back of your nose, which actually hurts and makes you sneeze on the healthy worker. We showed that the quality of the results can be equivalent if you just put a self-test in the tip of your nose with a cotton swab. The FDA made us jump through some hoops to prove that you didn’t need to refrigerate the result, that it could go back in a dry plastic bag, and so on. So the delay there was just normal double checking, maybe overly careful but not based on some political angle. Because of what we have done at FDA, you can buy these cheaper swabs that are available by the billions. So anybody who’s using the deep turbinate now is just out of date. It’s a mistake, because it slows things down.
But people aren’t getting their tests back quickly enough.
Well, that’s just stupidity. The majority of all US tests are completely garbage, wasted. If you don’t care how late the date is and you reimburse at the same level, of course they’re going to take every customer. Because they are making ridiculous money, and it’s mostly rich people that are getting access to that. You have to have the reimbursement system pay a little bit extra for 24 hours, pay the normal fee for 48 hours, and pay nothing [if it isn’t done by then]. And they will fix it overnight.
Why don’t we just do that?
Because the federal government sets that reimbursement system. When we tell them to change it they say, “As far as we can tell, we’re just doing a great job, it’s amazing!” Here we are, this is August. We are the only country in the world where we waste the most money on tests. Fix the reimbursement. Set up the CDC website. But I have been on that kick, and people are tired of listening to me.
by Steven Levy, Wired | Read more:
Image: Jeff Pachoud/Getty
