His TED talk in 2015 warned of the cost of a pandemic and then set out the public health response needed to fight it – a blueprint for today’s emergency.
During our – virtual – conversation, the words never cross his lips.
“In this particular crisis, there is a bit of a vacuum of leadership”, says Gates, with softly-spoken understatement. “Because the US is primarily focused on the US situation. So I have been speaking to Macron, Merkel, Ramaphosa and various others about how we can get this cooperation”.
Since the opening chapter of the pandemic in Wuhan, he has focused the considerable resources of the Bill and Melinda Gates Foundation to fight it.
He has also backed with words and cash the global institutions on the frontline, like the World Health Organisation, currently in the crosshairs of US president Donald Trump, and the Africa Centres for Disease Control , working with the African Union in Addis Ababa.
The coronavirus pandemic has come at the toughest time for a co-ordinated international approach: a decade of nationalism, culminating in the era of Trump, Brexit, Hindu supremacy, Brazilian autarky. Strong-armed regimes who blamed outsiders for their failures are hunkering down in many capitals. Trade wars and military stand-offs are the new global currency.
Yet international cooperation is exactly what is needed; not just for this pandemic but for other challenges of the 21st century – the climate crisis, transnational pandemics, terrorism, cross-border tax fugitives, and criminal networks. “These are problems that even the richest country can’t solve on its own”, says Gates.
He points to the post-war period in the late 1940s as something we could draw inspiration from, “not institutions to control things, but a forum for cooperation.”
The World Health Organisation – itself created during that period – is under siege. The US secretary of state Mike Pompeo yesterday said the US may never restore funding to the organisation. “I’m hopeful that the US criticism won’t actually result in less dollars going to the WHO because we need them now more than ever”, says Gates.
The WHO is not the only one in the firing line. There has been criticism over the manner in which African governments have copied developed countries’ reactions to the coronavirus, such as social distancing and lockdowns, that are not possible in states where social safety nets are not present.
“Developing countries don’t have the large resources that developed countries do, so I am not blaming them for their lack of preparation”, says Gates. “But […] you can’t just do what you do in rich countries”, where less people are required to get food, physical spacing is easier, and a formal economy allows the helicoptering of money more effectively.
He is concerned about the displacement effects that the pandemic may have on the continent. “Should you keep doing measles campaigns? That’s an example where the foundation has expertise, and we are concerned that by getting rid of these, the cost is greater than the benefit”.
Additionally, African countries face a challenge in understanding how to reduce infections without threatening food production or other basic needs.
“The good news is that as far as we can tell, the total number of cases in Africa is not gigantic”, says Gates. “Is that because people are not coming forward to be tested? Is it the limitations of testing capacity? Is the age structure beneficial?”
Testing has quickly become a keystone of the global response; countries like South Korea and Germany have used technology and strong state bureaucracies effectively to trace contacts.
Many African countries lack this capacity. Gyude Moore, former deputy chief of staff to Liberia’s President during the Ebola crisis told The Africa Report, “A health crisis quickly becomes a governance crisis”.
“The test that would be ideal for developing countries would be one where you can simply swab the nose by yourself, put in some liquid, and pour the liquid on a piece of paper”, says Gates, referencing the rapid diagnostic test well known across Africa for malaria testing. “We are doing our best to scale up that kind of test and get it available at very low cost and very high volume”.
Getting the diagnostic capability going in Africa was a strong focus for the Gates Foundation back in February, re-affecting workers who had been on the polio eradication campaign, and helping to source the PCR machines used for testing.
Beyond the high-tech approach, low-fi solutions will be critical – in a recent MIT-Africa hackathon, for example, the winning team came up with a way of communicating to populations living in poor, dense urban areas by piggy-backing off the logistics networks of of brewers and Coca-Cola.
Gates is keen to see more of this, and points to other possibilities, including the creation of medical facilities to house COVID-19 sufferers away from other healthcare patients, and able to provide basic oxygen.
But the focus for the Foundation is innovation in testing, treatments and vaccinations. “In terms of something that would make a big difference by this summer, the biggest hope is that one of these drugs is highly effective, and that it’s something that is cheap enough and that we can manufacture at large scale”, says Gates, and crucially, something that, “doesn’t require a health worker like an IV infusion, rather than it’s something you can take orally.”
That was why there had been hope raised by the solution promoted by France’s Professor Raoult, event though “it doesn’t look like hydroxychloroquine is going have a big benefit”, says Gates. “People did get excited because that’s an oral drug that there’s a lot of capacity to make. So we need to find something that can be scaled.”
He expects large-scale rollout of a vaccine to take around 18 months, though it could be as short as nine months, or as long as two years. For Africa, it would delivered using the GAVI vaccine alliance, set up by Gates with partners like UNICEF and the WHO in 2000 to manufacture drugs for countries that could not afford them.
More details on the search for innovation can be found on a recently-released memo on Gates’s blog.
But this is just a first part; ultimately, there will need to be a reckoning about how the world grapples with future pandemics.
And here, some believe the very idea of government itself might be refreshed in the minds. Opponents from the Reagan/Thatcher era of ideological government hostility may want to shrink the state “until it is small enough to drown in a bath-tub”, as American lobbyist Grover Norquist once said.
How does the world grapple with future pandemics?
But in the Gates conception, co-operation between governments, and government effectiveness, is simply a no-brainer: it saves money.
This is not unlike the reasons why Obama’s health care reform passed in the US – a quorum of business leaders finally noticed that the aggregate costs of healthcare were dragging down the whole economy; money that could be being spent elsewhere.
In his TED talk, Gates quoted a World Bank estimate that a pandemic would cost the world $3 trillion to fix. “Certainly the cost of this pandemic is greater than 3 trillion dollars. So even though I was shy of saying such a big number when I gave the 2015 speech, in fact we’re well beyond that”.
But the investments required to prevent this kind of disease, “the tools and platforms, the cost of that is in the tens of billions, so it’s very small compared to what is at risk economically”. Gates expects this will now get done.
Beyond that however, is the money that would have to be spent to improve healthcare systems in Africa and elsewhere and that is, “a much larger price tag”. Given concerns about aid effectiveness, and the recession about to hit rich countries, he sounds sceptical – foreign aid “can be a hard sell.”
But he hopes that money is found. “It would be just, and it would help us catch the next epidemic early on: it is just as likely to come out of Africa as Asia in the future”.
We are asking governments to step up
That suggests that it will be governments, again, as it was after the financial crisis, who will be leaned on.
What might have appeared as impossible socialism a few months ago now makes common sense.
For example, preventing, as Gates suggests, big commercial operators like cruise ship operators from outbidding public health operators over access to testing equipment. “Just letting those who pay for it get access has meant that visibility from testing has been way less than it should be”, argues Gates, who expects more from our administrators.
“So yes, we are asking governments to step up. Governments aren’t just about policies, they’re about deep expertise and competence. [This] is one of the lessons I hope people take away from this.”
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