‘We may be back to normal in 2022’: Bill Gates
Hours before the Bill & Melinda Gates Foundation announced a commitment of a further $250 million to “support the research, development, and equitable delivery of lifesaving tools” in the fight against Covid-19, taking its total commitment to fighting the pandemic to $1.75 billion, Bill Gates, co-chair of the foundation, spoke to HT over a Zoom call. The conversation ranged from the development of vaccines to the stuttering progress of Gavi, the Vaccine Alliance’s Covax programme, which aims to ensure Covid-19 vaccines are accessible and affordable for poor countries, to the timing of the world’s return to normalcy. Edited excerpts:
Let’s start with vaccines. Given the progress made with vaccines over the last 12 months, and the way we have gone about finding a vaccine for Covid -- we now have a handful of vaccines, and there are perhaps going to be even more that work -- do you think we have cracked this? Is it one of those technology problems that we have solved? So the next time there is a big disease, it is not going to take us a long time to get a vaccine and we could probably have one out in 12 months?
It’s very impressive that we have a vaccine in 12 months. And, you know, we will actually have vaccines from multiple approaches by the first quarter. The mRNA approach, which our foundation and a branch of the US government called Darpa have been funding for over 10 years, has proved to be the quickest. Now, the mRNA platform is not a fully mature platform. In fact, this is the first vaccine made that way. The actual thermostability and cost and scalability of making an mRNA vaccine is not as good as it will be for AstraZeneca, Johnson & Johnson and Novavax. Some of the other constructs the world knows how to scale up, and 5-10 years from now, we will get the [mature] mRNA platform, [and it] will get rid of those problems.
Do you think there is some kind of global north-south divide with the vaccine, because many of the vaccines are sort of being snapped up by the global north and countries like India have not struck vaccine deals with too many companies?
Yes, there’s a huge challenge when you get into a pandemic, that the normal market mechanism will take the scarce resources and only make them available to the richest countries, and the richest people in those countries. And so, obviously you want governments to step up, both with the resources and with a more equitable allocation of those scarce resources. The good news on this is that if we can get a lot of vaccine factories doing something that has never happened before, which is being a second source -- that is, making like the AstraZeneca vaccine or the Novavax or Johnson & Johnson in factories in India -- then we get the capacity up, and the trade-off of having such short supply won’t be as painful. The rich countries will get somewhat more of the early allocations, but if we really push on getting these factories running, then we can make it so [that] it’s not such a severe problem. So that’s why I was super enthused that Serum (Institute of India), partly from with help from us (the Gates foundation has given $150 million to SII through Gavi) and partly from their own resources, is already manufacturing [the] AstraZeneca vaccine, and there is an arrangement that once Novavax is ready, which it will be in the first or the second quarter, Serum will also make that. And then Johnson & Johnson is talking to other Indian companies for possibly making their vaccine. So, the only way around this problem is to get a lot of capacity, and that’s why it’s important that we have these vaccines that are cheaper and easier to scale -- they get into the mix. [The] AstraZeneca vaccine will get approved in the UK before the end of the year, and then the other two in the first or second quarter. But this is a challenge, and this is the key role that the foundation is playing, to make sure that things like oxygen machines, dexamethasone, monoclonal antibodies, and most importantly, vaccines, are getting to the entire world.
Do you think Covax (the Gavi, WHO initiative) will make a difference?
It’s been a little slow because the United States has not yet shown up to put money into that. I am talking almost every day with the politicians, the Congress, about it. We need to get at least $4 billion in there, for this Gavi vaccine procurement effort. And I am hopeful, you know, but we haven’t got that yet, and there is a question that we get it before January 20th. I can’t prove it, but I think that we will get it at some point in time, and I do think that getting the US to step forward like it has in the past, for things like HIV and malaria, that it has a proud record there… I do think that will start to unlock a lot of other money, so that at least for the Gavi countries that the vaccines, that the financing for the vaccines is not a limitation, and it is clear to the manufacturers that this very low cost price, cost-based price, will be reimbursed so that they should go full speed ahead.
By the middle of next year there should be no supply problem, right? We will have enough vaccines.
Yes. I believe because these other vaccines will get approved by summer 2021, across all these different constructs; it will be more about the logistics of getting the vaccines out. I think we will raise the money and we’ll have the manufacturing capacity, and so that, you know, for the rich world in 2021 and for the world as a whole… in the first half of 2022, we should be able to get the vaccine coverage that largely brings this pandemic to an end.
Do you think things will get back to normal by the end of next year, by summer next year – kids back at school, businesses reopen completely?
There will be… By the summer of 2021, the rich countries will have more vaccine coverage than other countries. So, the rich countries will be going mostly back to normal. But I still think because the virus will be in the world, we still will be somewhat conservative about large public events, we will still have some mask-wearing. We really need to get this virus eliminated, almost everywhere or else we have seen even in countries that have done a super good job -- like Australia or Singapore or Hong Kong or South Korea – they always run a risk of reinfection. So they’ve had to restrict tourism and other travel, but by summer that will start to open up. They won’t be totally back to normal but sometime in the first half of 2022, I do think we will be able to say that we’re back to normal.
Tell us a little bit about all the interventions that the Gates Foundation has done to, sort of, help countries and companies on the Covid front.
Well, you know, we will do a post mortem when it is all over. [There were] a lot of countries that reacted much faster, and a lot of countries where the messaging about mask-wearing was much better. Here in the United States, although the US did the best job of funding the R&D, in almost every other category, I would have expected it to be one of the best in the world, but we certainly were not. We were in some cases as bad as the worst cohort of countries in terms of how we got our testing ramped up, and how we got our agency, the CDC, to be able to be visible and talking about best practices.
Covid was, in 2020, the primary focus of the foundation?
Well, particularly if you include the idea that Covid has required us to get out bed nets, HIV medicines, it’s required us to take special efforts to maintain those efforts. Now, you know, take an area like TB; the amount of testing for TB in India has gone down quite a bit, and we will see a lot of spread [of the disease] there.
This new $250 million contribution that we are announcing today gets us to $1.75 billion, specifically for Covid – and that’s manufacturing capacity, and research and development and procurement money for a number of the tools, including the vaccines. That’s a big number, its more than most governments have done, but we spend about $6 billion a year, and so, we’re maintaining all the other priorities, as a foundation. And adding this on top. So we’ll spend more. We will spend extra money because it’s a unique situation.
A few of our efforts have been delayed, like some of the new vaccine trials or new drug trials have been delayed, so that, sadly that was money we couldn’t spend. But overall, most of the Covid stuff is on top of our other spending.
One of the interesting things is that while we seem to have seen reasonable success with vaccines, we’ve had fairly poor success rates with drugs. We haven’t managed to find drugs that can treat Covid or any of the other medicines other than the steroids.
The therapeutic area has been disappointing. You know, dexamethasone -- we funded a trial in the UK on that – is fairly low cost, that has a death reduction of about 30% at a late-stage intervention. Remdesivir may have a modest benefit but it’s not gigantic and it is fairly expensive. Now we’re trying to reformulate it to make it cheap, but we may not get that done in time to make much difference. So, the therapeutic area that I am the most enthusiastic about, that’s not out there yet, is monoclonal antibodies. We’ve partnered with Eli Lilly, and if we can prove that instead of having to do this through an IV infusion, we can give you two shots which are called subcutaneous or sub-cu shots, with 0.5 gm of the Eli Lilly antibody, we may be able to reduce the hospitalisations and death by over 70%. It’s not done yet. Eli Lilly got the emergency authorisation for the infusion approach in the United States, but now we are doing additional trial work because infusion is hard to scale up. It’s still possible that in a couple of months that could be a significant therapeutic treatment. We reserved factory capacity to make those antibodies, in a factory owned by Fuji Film; we are looking at the Eli Lilly antibody [treatment] for developing countries, and India is one of the countries we are talking about. There is still some work to be done, that may be a very powerful therapeutic.
You have been studying what’s happening everywhere around the world. Why is it that the waves are sharp and concentrated in some regions, and spread out in others? We still don’t seem to be able to explain that?
We understand some of the factors that go into that, but I have to say, it’s very surprising sometimes. We do know that cold weather allows the virus to multiply more, and it drags people indoors, and areas where you have older people; multigenerational households and more indoor activity we know are associated with a higher disease rate. But our ability to take that and put it into a model and predict here’s what’s going to happen in the countryside or New Delhi or in the US has actually been pretty weak. I fund a group called International Health Metrics and Evaluation (IHME), great forecasters, and they are willing to forecast four months into the future which other people were not willing to do, and they’ve had some things that they’ve done the best, but even they’ve been surprised. They did call this fall rebound that hit in the northern hemisphere, particularly in Europe and the United States. They did predict that.
The epidemic in some poor areas, particularly in Africa, has not been very bad, and yes, that’s partly the young population and the fact that they are outdoors a lot, but even so we are surprised how Covid in a direct sense has not been huge in Africa, although the economic disruption is causing huge problems not just in health, but also in education and jobs.