A conversation with Bill Gates on how public health has fared in the midst of the pandemic

The Covid-19 pandemic has, of course, been devastating over the past year. But by other measures of public health, the year wasn’t quite as calamitous as Bill Gates and Melinda French Gates feared when they wrote their annual report in 2020.

That doesn’t mean the first year of the Covid pandemic hasn’t been hard.

The foundation’s 2021 Goalkeepers report, published late Monday, shows an additional 10 million children around the globe didn’t get key childhood vaccines this past year, because of public health service disruptions. Another 31 million people were pushed into extreme poverty by the pandemic. And employment among women is expected to remain 13 million jobs lower around the world this year than it was in 2019.

Covid-19 has deepened what was already a profound chasm between the rich and the poor, Bill Gates told STAT.

“Every dimension of inequity — rich versus poor in the U.S., inner city schools versus suburban schools, Blacks versus Caucasians, rich countries versus middle-income versus low-income [countries] — this has exacerbated every dimension of inequity that I can think of,” Gates said.

Gates spoke to STAT as part of a wide-ranging interview timed to the release of the Goalkeepers report. Excerpts from the interview have been lightly edited for clarity and length.

What are the things that you found most concerning in the Goalkeepers Report this year?

The most concerning thing is the economic situation in low-income countries. Their economic losses are very high and they’re not able to stimulate their economies in the same way that most of the rich countries and some of the middle-income countries have done. And the indebtedness levels are building up. So the borrowing is going to be restricted. That was true even before the pandemic, but it’s gotten worse now.

And so the extreme poverty number in some ways is the most depressing number. And global trade, tourism into the low-income countries — all of those things, there’ll still be some lower level of activity for several years to come. Particularly if you end up with a situation where Covid is still circulating in these low-income countries and so people are making it hard to travel in or travel out, just to restrict the spread of the disease.

Up until the Delta variant came along, the low-income countries … were not having nearly as bad an epidemic as almost all the middle-income and rich countries, for a variety of reasons. Young age, outdoor work and … a lot of the populations are out there in the rural areas. Now, although it’s still not dire in most African locations, if you look at the Institute for Health Metrics and Evaluation figures, they are forecast to have a fair number of deaths. So they’re going to get hit hardest at the tail.

Some of the things did not go exactly as we expected. The [non-Covid] vaccination rates so far only dropped by 7%, and we had predicted that that might go down by 14%. Malaria deaths, which we predicted might go up quite a bit, have actually stayed flat, partly because we have been able to get the [treated] bed nets out. The Global Fund [to Fight AIDS, Tuberculosis and Malaria] has done a very good job on that. But the economic numbers are sort of the ultimate measure that poor countries have had a very bad epidemic just because of the economic factors.

Your foundation likes to focus on the positive, trying to encourage people to effect change by highlighting the positive as opposed to always the negative. But just last week the annual report of the Global Fund came out and it had a much more dire take on some of the metrics in your report. Do you ever wonder whether focusing on the positive downplays the urgency of the situation?

There’s a tradeoff. If you don’t explain the progress the world has made in reducing poverty and reducing childhood deaths, then you’re really not creating an accurate picture.

There really is good news there. And I think if you only give the bad news — which both on health stuff and climate, sometimes that’s how messages are delivered — people might think, well, it’s hopeless, I should just go ignore all this stuff.

So I think we struck a pretty good balance. But now with the Delta wave, we have to acknowledge that we’re not at the end yet. And we fell short on getting vaccines out everywhere that we should have.

Did you expect we’d be closer to the end of the acute phase of the pandemic than we are at this point?

There’s two big things that have made things less far along in getting to the end than I expected. One is that a number of the vaccines have just taken longer to ramp up big manufacturing — and that includes Novavax and Johnson & Johnson. I’m in no way impugning those companies. This is hard stuff, new stuff. So it’s very complicated. I was, in retrospect, over-optimistic about ramping up the volume of those vaccines.

And the second thing is the Delta variant. Its transmissiveness, because of how well it replicates in the respiratory tract, is worse than I expected. And so those are two big things that have delayed having the supply side of vaccines fixed. But even once we get that solved, which we will in the next six months, we’ll still have the logistics of delivery, which are very tough in low-income countries.

The report calls the inequity in vaccine distribution between upper-income countries and low- and middle- income countries “a profound moral outrage.” It also talks about the need to build up production capacity in different parts of the world. But that’s a solution for the next pandemic. How does the problem get solved now?

As we get the supplies fixed over the next six months, the volumes of all vaccines will go up. [But] some people are getting picky now and, we’ll see who’s willing to take AstraZeneca, who’s willing to take the Chinese vaccines. If everybody wants to wait just for the mRNA, then that pushes the supply challenges out even further into the future.

But we are going to hit very quickly the logistical and demand limitations. And so that’s why the foundation, looking at where we have low routine immunization coverage — as places like Nigeria, Democratic Republic of Congo — we really need to get in and build now, take some of the tactics we used in polio and use those to build up capacity. But the demand, you know, is not that great, partly because the epidemic hasn’t been that bad. That’s a paradox: The better you do, the less demand you have.

You mentioned polio and I’m wondering: Are you concerned about what’s happening in Afghanistan and the prospects that might have for finally snuffing out wild polio?

Wild polio is only in Pakistan and Afghanistan. And actually, the number of cases in both countries is fairly low right now, partly because the coronavirus restrictions also reduced the transmission of polio. And so even though we don’t know how people will be able to do vaccinations in Afghanistan — that’s a very uncertain situation, it could be a huge problem or it could be OK — Pakistan has always been where most of the cases are.

And there we do have a good relationship with the government and they can see that the cases are very low and they’re very appreciative that the polio [campaign] infrastructure came along to help out with the Covid pandemic. And so, in some ways, they really want to finally get rid of that sort of stain on Pakistan, that they’re one of the last two countries. So, I can’t give you much visibility about Afghanistan, but I know the Pakistan situation is pretty hopeful.

And we are talking to the U.S. government about increasing the amount, actually doubling the amount they put into this, to get up to the same level as the foundation does, which is over $400 million a year. The U.S. up to now put in about $200 million a year.

We do think we can succeed in the next three years. But the pandemic was a huge setback.

Last year when we spoke about the Goalkeepers Report, I asked you about your thoughts about the U.S. response to the pandemic. You describe it as shocking. How do you feel about the state of the U.S. response now?

It’s still embarrassing that even though we were at the front of the line for all the vaccines, yet because of demand issues, the U.S. is well behind most of the Western European countries at this point.

You mean because of vaccine hesitancy?

Yeah — which I call demand.

Now that Delta’s here, it means there’s a lot of elderly people, some of them with weak immune systems or some who just chose not to get vaccinated, that are at risk. And it’s too bad. When we show that death number we should show, every day, that it’s the unvaccinated, overwhelmingly who are dying.

So the U.S. situation, there’s nothing that is as good as we’d like. And of course, people are tired of some things that are really bad, like not having school in. So we’re going to have school in, which I happen to agree with.

But they’re also tired of mask compliance. And that’s unfortunate because the mask inconvenience isn’t great, but it’s kind of a magical tool. We’ve been talking with a lot of pharmaceutical companies about inhaled blockers that would be a sort of new class of thing that would reduce your infection, but also prevent you from transmitting or getting sick. In fact, even the very best inhaled blocker would only match what a mask can do. Now, it might be more acceptable, but masks are hugely effective intervention. But, you know, people’s tiredness and the lack of clear message about those mean that this fall’s going to be tougher than it should be.

Last question: Did the U.S. ever get testing right?

We never got testing right. We’ve got in our innovation tool box solutions for diagnostics. And I’m a little surprised the U.S. hasn’t been more aggressive on those things.

Same with therapeutics. The ability to prove that things don’t work and prove things work continues to be not very well-coordinated. And the idea of how do you align these trials and get that stuff happening quickly, there’s still some outstanding thinking that we’ll need both for this pandemic and the next pandemic.