Evidence-based explanations of the coronavirus crisis, from how it started to how it might end to how to protect yourself and others.

In 2015, I asked Bill Gates a simple question: What are you most afraid of?

He replied by telling me about the death chart of the 20th century. There’s the spike for World War I. The spike for World War II. But between them sat a spike as big as World War II. That, he said, was the 1918 Spanish flu pandemic, which killed an estimated 65 million people. Gates’s greatest fear was a flu like that, ripping through our hyperglobalized world.

Gates had funded modeling that imagined precisely that scenario. Within days, it would be in all urban centers around the world. Within months, tens of millions could die.

Bill Gates saw this coming, and he tried to warn the world. He did TED talks and media interviews. He published in medical journals. He made policy proposals and spent millions on vaccine research. And he failed. The virus came, and we weren’t ready. Now we all live in the aftermath of Gates’s nightmare.

Gates has reoriented his foundation and committed hundreds of millions of dollars to the world’s fight against the coronavirus. He recently published a long essay detailing what we know and don’t know about the virus and the disease it causes, Covid-19, and what we need to invent and deploy to safely return to normalcy.

I spoke with Gates on Friday to explore those questions, plus a few more. What does it feel like to be at the center of so many coronavirus conspiracy theories? What happens if we reopen too soon? Why are different cities seeing such different outcomes? Do rich and poor countries need different responses? What are the true chances of a vaccine in 18 months?

But above all, I wanted to ask him the inverse of the question I asked him in 2015: What does he hope for? What is his vision for life after the coronavirus?

You can listen to our full conversation by subscribing to The Ezra Klein Show wherever you get your podcasts. A transcript of my discussion with Gates, lightly edited for length and clarity, follows.

Ezra Klein

On February 28, you wrote in the New England Journal of Medicine that Covid-19 “has started behaving a lot like the once-in-a-century pathogen we’ve been worried about.” Two months have passed since then. Has what we’ve learned since then made you more or less worried?

Bill Gates

Sadly, the disease got into exponential growth in a lot of Europe and the United States. So the toll there is greater than I would have expected. We’re still learning about how to do testing. In the US, even the numbers overstate where we are because we’re not prioritizing the right people, we’re not getting results back in a timely fashion. So it’s been a mixed bag. The fact that social isolation really knocks the numbers down — that’s good news. But, of course, that comes at an incredible price.

Ezra Klein

When we spoke in 2015, you talked about a model you ran that found that a 1918-like influenza could kill 33 million people worldwide in six months. We don’t look to be hitting that death toll. Do you think that’s because this is not as deadly or contagious as what we saw in 1918, or because we as a global community are doing a better job of responding than the models might have predicted?

Bill Gates

We don’t really know what’s going to happen in developing countries, where most of the world’s population lives. The actual reported cases out of those countries are pretty small to date. But unless there’s some magical factor, the likelihood that the vast majority of the deaths will be there is very high. It’s harder for them to socially isolate and to do what we’ve done. So I think it’s premature to predict the eventual death toll.

Ezra Klein

Let’s talk about the developing world picture for a moment. A month ago, my reporting had me worried that Brazil was about to be a disaster; that South Africa, with its heavily immunocompromised population, would be a disaster; that India would be in terrible shape. So far, it’s not been as bad as I think a lot of people worried it would be. Why do you think that is?

Bill Gates

That, to me, is the most mysterious thing. I hope there’s some reasons other than that they’re just not testing enough people and people are afraid to seek out testing, or that the people who do world travel are separated from the bulk of the population, so diffusion to a worker that lives in the slum may have taken an extra month or two.

They do have a better age structure, but they have more air pollution, lots of HIV, lots of malnutrition — which are associated with very bad outcomes. There’s one city in Ecuador that’s experiencing exponential growth. And, so I’m looking up, do they have a subway in Guayaquil?

You know, New York and London are even worse than pure density measures, or even the international travel would predict. What activities lead to these super-spreading events?

Ezra Klein

This is the tricky part, to me. The pieces don’t quite fit together. Why does New York City look the way it does, but San Francisco has kept this under control? And if the answer is just early social distancing, why doesn’t Florida, which closed much later and had very poor political leadership and has a much older population, look worse? It’s the same with some of the developing countries. It feels to me like there are variables here that we are not seeing or we are not measuring correctly.

“We don’t really know what’s going to happen in developing countries, where most of the world’s population lives”

Bill Gates

The flu, which has been around for a long time, kills on average 40,000 people every year. And the amount we don’t know about the flu is amazing. We don’t understand why the flu is seasonal. It’s such a profound thing that there’s this three-month period where it’s very active and then almost nine months where you have a hard time finding it, depending on which hemisphere you’re in.

Infectious disease hasn’t gotten the depth of [attention] that, say, cancer or heart disease has, because it’s largely gone from the rich countries that drive scientific priorities. That’s a big part of what our foundation does: to work on the things that kill the most people, including the remaining infectious disease burden. So it’s not that stunning to me. This is a very novel syndrome that we’re facing here.

Ezra Klein

One thing I appreciate about your paper is that you have a section about what we don’t know. What are the big things you wish we knew that we simply don’t?

Bill Gates

The seasonality and weather effects. It’s looking more and more like indoor infection is a dramatic part of the infection, and that the way our circulation works in closed spaces like subways really works against you.

Are asymptomatics just slightly being exposed and therefore not in the chain of infection very much? The best study on that in Singapore shows about 6 percent [of cases came from asymptomatic transfer]. But other people have done the studies different ways that give, I think, unrealistically high numbers.

We don’t know enough about the human immune response yet. That’s very important, because if it’s a very weak response, then you’re not protected from a second infection. I don’t think that’s likely. Until we actually are looking at this blood plasma to see what the titers of the antibodies are, not this binary serology thing that’s not helpful, we’re very much in uncharted territory.

Ezra Klein

To go back to what you just said about the binary serological tests. We’ve seen some of these in Santa Clara and LA counties. For those not familiar with this debate, what they found is a much higher prevalence of the disease and a much lower lethality rate. Why do you think those studies aren’t reliable or helpful?

Bill Gates

The false positive rate on that serology test is very, very high. It’s just the way the statistics work. When you have 98 percent who certainly aren’t infected, false positives completely overwhelm the real data. So that study would say there’s like 10 times as many people who’ve been exposed as who’ve shown symptoms. Most other things — like Diamond Princess, Singapore, where you go through the viral loads — showed more like two to three times.

That will get resolved. We have quantitative serological tests that are being applied at the population level in about five different countries, including some work that I’m sponsoring. So we’ll get to the bottom of that. You know, it would be better if more people have been exposed, if that’s associated with immunity, but that’s also unknown.

Ezra Klein

I was looking back at a paper you published in 2015 about preparing for pandemics. And the point you made there that was telling: We are constantly rehearsing for war against an enemy of another country. We’re constantly rehearsing as part of NATO or US military war games.

Pandemics are a well-known thing, they’ve happened throughout history. We knew one was going to come eventually. And we were not doing these pre-rehearsals. Why do you think it is that we are so much more focused on threats from each other than threats that come from nature?

Bill Gates

I think part of it is that the minor epidemics we had really didn’t hit the US. If you look at the Asian countries that did well, many of them wrote down: step one, identify all PCR machines. [Polymerase chain reaction machines, used by laboratories to copy small segments of DNA.] Step two: get supplies for PCR machines. We haven’t done that in a reasonable way today, even though we have more machines per capita than anybody else.

Places like Taiwan or South Korea, because they were hit with MERS or SARS, had the playbook. They opened the playbook, they went through those steps, and it’s saved them 10 percent of GDP and immense human suffering that they took respiratory disease in a serious way.

The fact that [a novel infectious disease] hasn’t been in this country for so long allowed us to not think about it as a priority. I wish I’d been more successful in getting these investments made in advance. I think back: How could I have been louder, more articulate? Very little was done.

Ezra Klein

In the essay you wrote on April 23, you argued that we don’t just need policy to reopen — there are innovations we need but don’t yet have. What are some of the innovations that we need?

Bill Gates

There are three categories. There’s scaling up testing, which if you had a miraculous level of, you might want to test everyone before they went on a cruise ship or went into a theme park or came to work in a warehouse. We’re a factor of a thousand away from that. And we can’t let the finite capacity go to that because we have higher priorities. So testing is the first big category. I’d put contact tracing into that as well because it’s all one regime for reducing infection.

Then you have the therapies or drugs. And then finally you have the vaccine. So those are the three buckets.

Ezra Klein

Let’s start then with testing. There have been reported shortages of things like reagents and swabs. There’s been a lack of focus. But in your view, what is between us and the kind of testing regime you wish we had?

Bill Gates

We’re showing the FDA that basically any swab works. You can swab yourself, put it in a plastic bag, and send it back, as long as it gets to the machine in a reasonable time frame. So the swabbing thing shouldn’t be a limiting factor.

In terms of the actual machines, there are ways of running them that can make it faster. We’re exploring those. But the machines still aren’t being used effectively. Even today, we’re not enumerating which ones still have idle capacity and making sure that the right things are fed into that. And is this a federal thing? Some states have a lot of PCR machines. Some states have very few. They briefly involved FEMA, but they didn’t have the background for this.

Ezra Klein

I heard you give an interview with TED a month ago, where you said the same thing on swabs: that your foundation has shown the FDA that swabbing the tip of the nose was as sensitive as the more intrusive test. You’re making the same point today. So are regulators moving fast enough right now? And if not, is there some other process we need to be spinning up given it’s an emergency?

Bill Gates

There’s definitely progress. It’s moving at a much higher speed than it would absent a crisis. The pieces are coming into place to avoid the swab front end being a limiting factor. That’s a likely thing to happen in the next couple of months.

Ezra Klein

Let’s go to the next group of innovations. Are there medications short of vaccines right now that you think are promising and that we can have in a quicker time than the vaccines?

Bill Gates

Absolutely. A therapeutic is easier. If your therapeutic has a dramatic benefit, you know, you can see that with just 100 patients. So you can go through a large number at a time. This is happening right now — we have studies going on. The UK is doing a good job on this. Germany is doing a good job.

There are particular compounds — and not necessarily the ones that get mentioned — that look very promising. There’s one where you look in the blood of recovered patients and find the best antibodies. And then you either directly use that blood or you manufacture that antibody. That one has got quite a bit of promise. So we’re orchestrating, who’s got the best antibodies? Who has that manufacturing capacity? And trying to get that up and going well before the end of the year.

“I don’t think the coronavirus will prove to be an impossible target but I can’t guarantee it”

Ezra Klein

Given what we just talked about, how much do you think the limiting factor here is going to be manufacturing supply chain capacity six months from now?

Bill Gates

For some of these vaccine constructs, it’s hard to scale up the manufacturing, partly because they are novel or just because the chemistry is very complex. And you’re in a new regime when you talk about making billions of a vaccine. We don’t make billions of any vaccine. We make hundreds of millions, but for those, we’ve had decades to work on their efficiency.

Even the fill finish at the very end where you put it in a glass bottle, that’s a special pharmaceutical-grade glass — the world doesn’t have enough of that. So we’re working to get that underway because all the vaccine approaches need to be put into a bottle at some point in time. I hope we get to the point where it’s the manufacturing piece because those investments are at most billions to save trillions.

Ezra Klein

Let me ask a dumb question about vaccines. I see a fair amount of confidence that there will be a vaccine in, say, 18 months. And yet, we’ve not got an HIV-AIDS vaccine. There are a lot of coronaviruses that we’ve wanted vaccines against forever. How likely is it that in two years, 3 billion people have been vaccinated for this effectively?

Bill Gates

Very likely.

Ezra Klein

Why?

Bill Gates

This target is not as difficult as HIV. That is — the spike protein isn’t changing its shape like it is with HIV. And for SARS, we actually did get a vaccine. Then the disease was gone. And so we never did a phase three trial. We even have an antiviral for Ebola.

So I don’t think the coronavirus will prove to be an impossible target but I can’t guarantee it. Even now, we’re starting to see animal data. So by the end of the summer it will be pretty clear. And I think at least some of the top 10 constructs will look very promising.

Ezra Klein

Tell me a bit about your project to set up different vaccine manufacturing platforms in advance, knowing that we’re not yet sure which kind of facility we’re going to need.

Bill Gates

Well, [the Coalition for Epidemic Preparedness Innovations] is the group we created to do a lot of this work. We’ve been directly funding these people. Some of them have new RNA approaches and one has a DNA approach. These new approaches have certain advantages, but you don’t want to totally bet on them because you’ve never actually made a vaccine that way before. So if you look at the risk level, it’s probably the more classic subunit vaccines, even though they get started a little bit later. Understanding the mechanisms and the manufacturing is straightforward for those.

Ezra Klein

Talk to me about some of these new approaches. What makes them different and what could make them better?

Bill Gates

Usually what you do is you put a part of the shape of the virus in, and then the immune system sees that, realizes it’s a foreign thing, and decides it should be ready immediately to make antibodies if it ever sees this again. So usually you’re injecting at least part of the shape of the virus. Sometimes you do the whole virus, but it’s attenuated so it doesn’t multiply too much. Sometimes you take the virus and you kill it and stick it in.

Most of the new vaccines are subunit vaccines, where you don’t put the whole virus in. You just put a little piece of it — like the spike protein in the case of coronavirus. Instead of putting the whole shape in, what you do is you put in the code, the instructions to make that shape. What you have to manufacture is just RNA, which is trivial because it’s just these known codes that you string together.

That’s why it’s a promising approach that these new companies are taking: If it works, it will be the platform for quick response in future pandemics.

Ezra Klein

If we had been heavily investing in vaccine production capacity over the past five or 10 years, do you think we’d be in a different place today?

Bill Gates

Oh, absolutely. We would be able to do this in a year.

There are a number of things that you have to practice to understand: Who should step up and make the decisions? Where do we pool this money? How are the regulators going to make the tradeoff of getting it out quickly versus having a big safety database?

There’s a political instinct of people to look good or not look bad. The crisis is a tough time to think through all the pieces that are necessary. It’s nice to not have that breathing down on you as you make these scientific decisions.

Ezra Klein

Are there regulatory approaches we could do that would make this move much faster? People talk, for instance, about “human challenge trials” — does any of that seem possible to you?

Bill Gates

It’s up to regulators to decide. Mostly when you have a serious disease like this, it’s unethical to use human challenge trials. So I don’t think that will be used here. On paper, yes, that gives you a quicker way to see if your vaccine is effective so you could shorten the schedule. But who are those volunteers? Are they fully informed? For malaria that’s allowed because we have drugs that are entirely curative. But for TB, HIV, it’s not allowed. And unless there was some breakthrough innovation, it shouldn’t be allowed.

Ezra Klein

Right now in the US, we have not filled the testing and contact tracing structure or innovations, much less these secondary therapeutic or vaccine innovations. And yet a number of states are moving toward reopening. How worried are you about significant second spike problems?

Bill Gates

I’m super worried about it. Unless they’re very gradual and pick the things that we know don’t raise the rate of infection over one, then you’re going to have this heterogeneity where parts of the US will be doing well and other parts will be doing poorly. The temptation to interdict travel between those parts will be very difficult.

Without the testing, [reopening] is really a blind thing. I hate to be a broken record on this, but, where’s the testing prioritization? For most places, in late May, early June, we’ll have the case numbers down. So if you use that time to fix the testing, get the contact tracing going, then opening up will make sense. And that shouldn’t be some political thing. It should be a scientific thing.

Ezra Klein

You’ve mentioned a couple of times the problem of testing prioritization, which I think is an issue people are less familiar with. Can you talk about what it should be versus what it is?

Bill Gates

Some people have access to testing who have no symptoms, and some people with symptoms have no access to testing. So a substantial percentage of the testing is not helpful. It’s almost corrupt in the sense that if you have a close relationship with your doctor in a hospital, you’ll get onto their PCR machine no matter what your circumstances are. And if you don’t have that type of connection, even if you’re a health care worker, you can get tests back five days later. So it’s a hard one to understand why people aren’t outraged about this.

Ezra Klein

As a technologist, what do you think about these contract tracing ideas to do massive scale digital surveillance, using phones and Bluetooth to enforce quarantine using digital information?

Bill Gates

It’s complex to characterize those. Some are more like a memory aid to remind you where you’ve been. So if you get called up for an interview, you can think through: yeah, I did go to that shop, and that shop. That can be helpful.

If you just use Bluetooth, the distance is too large, so the false positives will just be overwhelming. It’d be hundreds per person in many cases. Some people are going further and using an ultrasonic sound to see which phones are nearby. But even that’s not perfect because a lot of the infections occur in a place where a virus particle was left on a surface. One person leaves with their phone; somebody else comes up an hour or two later and touches that virus and gets infected. There’s no telephone proximity there.

But the German approach, which does require manpower, can work very well. As long as that database is managed properly, it doesn’t jam the privacy issue quite the way that some of the Asian approaches do.

Ezra Klein

In 2015, I asked you what you’re afraid of, and you told me a lethal, pandemic respiratory flu. We’re living through that nightmare now. So let me ask you the reverse of it. Thinking three or five years into the future beyond just the vaccine. What do you hope for?

Bill Gates

I hope that this draws the world together. After World War II, we created new institutions and we successfully avoided having another world war. That’s a phenomenal thing. We haven’t blown off a nuclear weapon as part of a conflict. And we did that by binding ourselves together through a variety of institutions — including the WHO on health. So as bad as that was, the outcome was positive.

This is a tragic event. Whatever good comes out of this will in no way make up for the problems that it causes. But it should say to us, this science is important — let’s use it to avoid pandemics. We’re not going to be out of this until we get rid of it from the entire world. Interdicting travel is a very brute force measure that has lots of negative effects. Even if we have to do that temporarily, it’s not where we want to be.

Everybody brings to the epidemic their hopes that they had before. And I’ve always believed in global cooperation. You can accuse me of just saying, “Everybody’s going to be convinced of my thing.” But I really do believe that the World War II analogy applies here.

Ezra Klein

But there’s a darker version of that, too. People could take the lesson that we’re too interconnected, that our borders are too open, there’s too much immigration. We’ve already seen Donald Trump trying to shut down green cards. Do you worry about this leading to a pulling back from global cooperation?

Bill Gates

In the case of World War II, we know that Germany and Japan had something to do with causing the war. In that case, it wasn’t just some bat somewhere that some guy ate.

You could have said then that it would permanently change attitudes toward people from Japan or Germany — and during the course of the war, we did horrible things we regret because of that. But that’s gone. My dad was part of the occupation in Japan and he couldn’t believe how friendly and cooperative they were. Very quickly, we helped them build up. They did build up. The sense of mutual benefit was very strong there through those institutions.

We took a much worse situation and crafted it into the institutions and the economic growth and innovation that we’ve had between World War II and now. I hope that this looks like that.

Ezra Klein

In the beginning of your essay you say this is like a world war, but we’re all on the same side. And what is striking to me about this period that we’re in is the effort to create sides. In America, there’s the effort to increase blame toward China — trying to get the UN to call Covid-19 the “Wuhan virus.” And China has responded in kind.

This is something where obviously there needs to be not just global public health cooperation but economic cooperation to get out of it. And yet, there are leaders who see short-term gain in the kind of enmity that’s going to make it harder for them to get their country out of the problem.

Bill Gates

I think in the end the US will show up in a strong way, even though it certainly hasn’t to date. The US Congress has been the most generous on HIV funding for the entire world. It’s been one of the most generous to GAVI in terms of funding vaccines. The US government has helped the health of the entire world. It’s been a huge part of the reduction in death.

In this case, not only is it humanitarian, it’s about strategic relationships and it’s about making sure the disease isn’t coming back into the US as we participate in global commerce that we benefit immensely from. So I think what you’re seeing in the short term, in terms of how the US is engaging, isn’t where we’ll end up. There are many voices that are going to push us to work with Europe and work with other countries and be part of the innovations that will bring this to an end.

Ezra Klein

The US has talked about pulling back funding from the World Health Organization. There are people, I think rightly, disappointed in parts of the WHO’s response. How should we think about the World Health Organization? Why would it be important going forward to continue funding?

Bill Gates

There’s a big fire. The fire department was 20 minutes late. This is like saying, “Let’s fire all the firemen.” Yes, we should do a postmortem. But many people didn’t respond as quickly as they should have. This is not the time to start shifting blame.

The World Health Organization is what helps all countries understand what’s going on with epidemics. They have a very small budget. In movies they show guys flying around and knocking out bioterrorism. They have no budget for that. Their budget is less than a thousandth of what just the US spends on health care. So people who imagine they should have made a vaccine — that’s not their role at all. They’re just not funded to do it. They’ve done a lot of good things. They’re a necessary institution.

At the end of the day, I don’t think the US will reduce its contributions and fire lots of people from WHO in the middle of a crisis like this. I think that will blow over. At least, that’s my hope.

“I think in the end the US will show up in a strong way, even though it certainly hasn’t to date”

Ezra Klein

We knew a pandemic was going to come eventually, but we didn’t prepare for it. So imagine we take the lesson, societally, that we need to prepare for the other risks out there: What are the other ones we need to be preparing for right now?

Bill Gates

Well, things are tough enough. I don’t want to dwell on bioterrorism, but whatever the fatality rate of this thing is, it’s not anywhere near bioterrorism — smallpox or another pathogen that was intentionally picked for a high fatality rate as well as delayed symptoms and a high infectious rate. Fortunately, what we need to do to be ready for a naturally caused pandemic is a subset of what we need to do to be ready for a bioterrorism-induced pandemic, too.

Ezra Klein

I’m wondering how much you think about how we operate industrial animal production globally. This likely comes from wet markets in China and there’s been a lot of concern about confined animal feeding operations in other countries. The UN has said the way we raise animals is the weak link of the global public health chain. Do we need to rethink that approach?

Bill Gates

You’re not going to ever drive zoonotic diseases — diseases that cross species barriers — to zero. This will always be a risk and we can prepare for that risk. You can reduce the risk a little bit by having fewer wet markets and less bushmeat, but it’s very hard to regulate in the rural areas of sub-Saharan Africa. If you had to say where’s the next one likely to come from, that would be it. That’s very dangerous.

Ezra Klein

Do you think there’s a different trade-off that should be made between social distancing and keeping economies going in those countries compared to the richer countries?

Bill Gates

Absolutely. If you push so hard that people don’t have access to food, you’re going to create civil unrest. That’s the opposite of social distancing. In these developing countries, nuanced policies are much harder to implement because your capacity is just lower. I think we need a lot of innovation to make policies that are appropriate for developing countries. And right now, they’re largely trying to do what worked in rich countries.

Ezra Klein

There has been a rise of conspiracy theories around you: that, because you were predicting something like coronavirus, perhaps you created it, to profit off it, or to use a vaccine to control people. So why did you create the coronavirus and what is it like to be at the center of that kind of conspiracy theory?

Bill Gates

It’s kind of sad, really. Who would have thought that Lysol would have to remind people not to inject disinfectant in their body? Some people actually act on these things. Misinformation is dangerous, particularly in this type of crisis where people’s willingness to believe wild things is heightened.

We’re all in a very tough situation — me less than others, but broadly. So somebody says we should blame this country or that person, who’s different than us. That is dangerous stuff. And so I’m sorry to see that getting going. I don’t think it’s that widespread, but I hope it’ll die out.

Ezra Klein

Something that has struck me throughout this entire calamity is just how much any effective response relies on social trust and solidarity. We seem to be in a moment where our ability to break down the trust people have in institutions outpaces our ability to raise it.

I’m curious if you have any reflections on that.

Bill Gates

If you look at trust figures for most politicians, they’re up pretty dramatically. Where politicians are willing to admit what they don’t know and show that they’re trying to do their best by bringing in experts, I think it’s great that the trust levels are up.

Compliance on the social distancing has been very high. Over time, people’s patience will wear thin, particularly if they’re getting a confusing message from their leadership. But overall, you’d have to feel pretty good about the attitude in the country. If you said to me, we were going to shut all this stuff down, I’d have predicted more of a backlash.

People understand death and survival. Most of the questions that are being asked are very fair questions. Sadly, the topics are complex enough that getting across what we know and what we don’t know is fairly hard. That’s why I made the effort to write the memo. And, a month or two from now, I’ll know more, and maybe I’ll write again.

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