Bill Gates talks best (and worst) case scenarios for the coronavirus pandemic in the months ahead, explaining the challenges of reducing virus transmission, providing an update on promising vaccine candidates, offering his thoughts on reopening and even taking a moment to address conspiracy theories circulating about himself. Stay tuned for his critical call to fellow philanthropists to ramp up their action, ambition and awareness to create a better world for all. (This virtual conversation, hosted by head of TED Chris Anderson, was recorded June 29, 2020.)

All right, it's great to have you here, Bill.

You know, we had a TED conversation about 3 months ago about this pandemic, and back then, I think fewer than, I think that was the end of March, back then, fewer than 1, 000 people in the US had died, and fewer than 20, 000 worldwide.

I mean, the numbers now are like 128, 000 dead in the US and more than half a million worldwide in 3 months.

What is your diagnosis of what is possible for the rest of this year?

What do you think best and worst-case scenarios might be?

Well, the range of scenarios, sadly, is quite large, including that as we get into the fall, we could have death rates that rival the worst of what we had in the April time period.

And if you get a lot of young people infected, eventually, they will infect old people again, and so you'll get into the nursing homes, the homeless shelters, the places where we've had a lot of our deaths.

The innovation track, which probably we'll touch on, diagnostics, therapeutics, vaccines, there's good progress there, but nothing that would fundamentally alter the fact that this fall in the United States could be quite bad.

And that's worse than I would have expected a month ago, the degree to which we're back at high mobility, not wearing masks, and now the virus actually has gotten into a lot of cities that it hadn't been in before in a significant way.

There's no case where we'd get much below the current death rate, which is about 500 deaths a day, but there's a significant risk we'd go back up to the even 2, 000 a day that we had before, because we don't have the distancing, the behavior change, to the degree that we had in April and May.

And we know this virus is somewhat seasonal, so that the force of infection, both through temperature, humidity, more time indoors, will be worse as we get into the fall.

CAVANAUGH, MD So there are scenarios where in the US, if you extrapolate those numbers forward, we end up with, what, more than a quarter of a million deaths per chance, even this year, if we're not careful.

And worldwide, I guess, the death toll could, by the end of the year, be well into the millions with an S.

Is there evidence that the hotter temperatures of the summer actually have been helping us?

They're not absolutely sure, but certainly the HME model definitely wanted to use the season, including temperature and humidity, to try and explain why May wasn't worse than it was.

And so as we came out and the mobility numbers got higher, the models expected more infections and deaths to come out of that.

And the models kept wanting to say, but I need to use this seasonality to match why May wasn't worse, why June wasn't worse than it was.

And, you know, so it's – And we see in the Southern Hemisphere, Brazil, which is the opposite season, all of South America is having a huge epidemic.

South Africa's having a very fast-growing epidemic.

Fortunately, Australia and New Zealand, the last countries in the Southern Hemisphere, are at really tiny case counts.

And so although they have to keep knocking it down, they're talking about, oh, we have 10 cases, that's a big deal, let's go get rid of that.

So they're 1 of these amazing countries that got the numbers so low that test, quarantine and trace is working to get them, keep them at very near 0.

Aided perhaps a bit by being easier to isolate and by less density, less population density, But nonetheless, smart policy is down there.

Yeah, everything is so exponential that a little bit of good work goes a long ways.

You know, contact tracing, if you have the number of cases we have in the US, it's super important to do, but it won't get you back down to 0.

It'll help you be down, but it's too overwhelming.

CA1 OK, so in May and June, in the US, the numbers were actually slightly better than some of the models predicted, and it's hypothesized that that might be partly because of the warmer weather.

Now, we're seeing, really, would you describe it as really quite alarming upticks in case rates in the US?

In, say, the New York area, the cases continue to go down somewhat.

But in other parts of the country, primarily the South right now, you have increases that are offsetting that.

And you have testing positive rates in young people that are actually higher than what we saw even in some of the tougher areas.

And so clearly younger people have come out of mobility more than older people have increased their mobility.

So the age structure is right now very young, but because of multi-generational households, people who work in nursing care homes, unfortunately that will work its way back.

Both the time lag and the transmission back up into the elderly will start to push the death rate back up, which is down, you know, way down from 2, 000 to around 500 right now.

CA1 And is that partly because there's a three-week lag between case numbers and fatality numbers?

And also, perhaps, partly because there have been some effective interventions and we're actually seeing a possibility that the overall fatality rate is actually falling a bit now that we've gained some extra knowledge.

Yeah, certainly, your fatality rate is always lower when you're not overloaded.

And so, Italy, when they were overloaded, Spain, even New York at the start, certainly China.

There, you weren't even able to provide the basics, the oxygen and things.

A study that our foundation funded in the UK has found the only thing other than remdesivir that is a proven therapeutic, which is the dexamethasone, that, for serious patients, is about a 20 percent death reduction.

And there's still quite a pipeline of those things.

You know, hydroxychloroquine never established positive data, so that's pretty much done.

But the list of things being tried, including eventually the monoclonal antibodies, we will have some additional tools for the fall.

And so you always have, when you talk about death rates, the good news is some innovation we already have, and we'll have more even in the fall.

We should start to have monoclonal antibodies, which is the therapeutic, the single therapeutic that I'm most excited about.

CA1 I'll actually ask you to tell me a bit more about that in 1 sec, but just putting the pieces together on death rates.

So in a well-functioning health system, so take the US when places aren't overcrowded, what do you think the current fatality numbers are approximately going forward, like as

If you found every case, yes, you're well below 1 percent.

You know, by the time you bring in the never-symptomatics, it probably is below 0.5.

This disease could have been a 5% disease.

The transmission dynamics of this disease are more difficult than even the experts predicted.

The amount of pre-symptomatic and never symptomatic spread, and the fact that it's not coughing, where you would kind of notice, hey, I'm coughing.

Most respiratory diseases make you cough.

This 1, in its early stages, it's not coughing.

It's singing, laughing, talking, actually still, particularly for the super-spreaders, people with very high viral loads, causes that spread.

And so even the experts have to say, wow, this caught us by surprise.

The amount of asymptomatic spread and the fact that there's not a coughing element is not a major piece, like the flu or TB.

Yeah, that is devilish cunning by the virus.

I mean, how much is that non-symptomatic transmission as a percentage of total transmission?

I've heard numbers, it could be as much as half of all transmissions are basically pre-symptomatic.

Yeah, if you count pre-symptomatics, then most of the studies show that's like at 40 percent.

The amount of virus you get in your upper respiratory area is somewhat disconnected.

Some people will have a lot here and very little in their lungs.

And what you get in your lungs causes the really bad symptoms in other organs, but mostly the lungs.

And so the worst case in terms of spreading is somebody who's got a lot in the upper respiratory tract, but almost none in their lungs, so they're not care-seeking.

And so if you add in the never symptomatic to the pre-symptomatic, do you get above 50 percent and the transmission is actually from non-symptomatic people?

You know, we see certain hot spots and things.

But that's a huge question with the vaccine.

Will it, besides not avoiding you getting sick, which is what the trial will test, will it also stop you from being a transmitter?

CA 1-D2 So that vaccine is such an important question.

But before we go there, any other surprises in the last couple of months

that we've learned about this virus that really impact how we should respond to it?

We're still not able to characterize who the super spreaders are in terms of what that profile is, and we may never.

If you could identify them, they're responsible for the majority of transmission, a few people who have very high viral loads.

This mode of transmission, if you're in a room and nobody talks, there's way less transmission.

That's partly why, although planes can transmit, it's less than you would expect just in terms of time proximity measures, because unlike, say, a choir or a restaurant, you're not exhaling in loud talking quite as much as in other indoor environments.

What do you think about the ethics of someone who would go on a plane and refuse to wear a mask?

If they own the plane, that would be fine.

If there's other people on the plane, that would be endangering those other people.

Early on in the pandemic, the WHO did not advise that people wear masks.

They were worried about taking them away from frontline medical providers.

In retrospect, was that a terrible mistake that they made?

All the experts feel bad that the value of masks, which ties back somewhat to the asymptomatics, you know, if people were very symptomatic, like an Ebola, then you know it and you isolate, And so you don't have a need for a mask-like thing.

The value of masks, the fact that the medical masks was different supply chain than the normal masks, the fact you could scale up the normal masks so well, the fact that it would stop that pre-symptomatic, never symptomatic transmission, It's a mistake.

And even now, our error bars on the benefit of masks are higher than we'd like to admit, but it's a significant benefit.

CA1 All right, I'm going to come in with some questions from the community.

Jim Pitofsky, do you think reopening efforts in the US have been premature?

And if so, how far should the US go to responsibly confront this pandemic?

Well, the question of how you make trade-offs between the benefits, say, of going to school versus the risk of people getting sick because they go to school, those are very tough questions that, you know, I don't think any single person can say, you know, I will tell you how to make all these trade-offs.

The understanding of where you have transmission and the fact that young people do get infected and are part of the multigenerational transmission chain, we should get that out.

If you just look at the health aspect, we have opened up too liberally.

Now, opening up in terms of mental health and seeking normal health things like vaccines or other care, there are benefits.

I think some of our opening up has created more risk than benefit.

You know, opening the bars up as quickly as they did, you know, is that critical for mental health?

So I don't think we've been as tasteful about opening up as I'm sure we, as we study it, that we'll realize there, we should have, some things we shouldn't have opened up as fast, but then you have something like school where Even sitting here today, the exact plan, say, for inner-city schools for the fall, I wouldn't have a black-and-white view on the relative trade-offs involved there.

There are huge benefits to letting those kids go to school.

If you're in a city without many cases, I would say, you know, probably the benefit is there.

Now, that means that you could get surprised.

The cases could show up, and then you'd have to change that, which is not easy.

There will be places where that won't be a good trade-off.

So almost any dimension of inequity, this disease has made worse.

Job type, internet connection, you know, ability of your school to do online learning.

You know, white-collar workers, you know, people are embarrassed to admit it, some of them are more productive and, you know, enjoying the flexibility and enjoying the flexibility that the at-home thing has created.

And that feels terrible when you know lots of people are suffering in many ways, including their kids not going to school.

For us in Rwanda, early policy interventions have made the difference.

At this point, what policy interventions do you suggest for the US now?

Bill, I dream of the day where you are appointed the coronavirus czar with authority to actually speak to the public.

BGP Well, the innovation tools are where I and the foundation broadly has the most expertise.

Clearly some of the policies on opening up have been too generous, but I think everybody could engage in that.

We need leadership in terms of admitting that we've still got a huge problem here and not turning that into almost a political thing of, oh, isn't it brilliant what we did?

No, it's not brilliant, but there's many people, including the experts, who didn't, there's a lot they didn't understand, and, you know, everybody wishes a week earlier, whatever action they took, they'd taken that a week earlier.

The innovation tools, that's where, you know, the foundations work on, you know, antibodies, vaccines, you know, that's, we have deep expertise, and it's outside of the private sector.

And so we have kind of a neutral ability to work with all the governments and the companies to pick, you know, particularly when you're doing break-even products, which 1 should get the resources?

It's experts have to say, okay, this antibody deserves the manufacturing.

Because we have very limited manufacturing for both of those things, and it'll be cross-company, which never happens in the normal case, where 1 company invents it and then you're using the manufacturing plants of many companies to get maximum scale of the best choice.

So, you know, I would be coordinating those things.

But we need a leader who keeps us up to date, is realistic and shows us the right behavior, as well as driving the innovation track.

1 I mean, you have to yourself be a master diplomat in how you talk about this stuff, so I appreciate almost the discomfort here.

But you talk regularly with Anthony Fauci, who's a wise voice on this, by most people's opinion.

He's not allowed to play the full role that he could play in this circumstance.

Fauci's emerged where he was allowed to have some airtime, and even though he was stating things that are realistic, his prestigious stuff, he could speak out in that way.

Typically, the CDC would be the primary voice here.

You know, it's not absolutely necessary, but in previous health crises, you let the experts inside the CDC be that voice.

And so it is a bit unusual here how much we've had to rely on Fauci as opposed to the CDC.

It should be Fauci, who's a brilliant researcher, you know, so experienced, particularly in vaccines.

In some ways, he's become taking the broad advice that's the epidemiology advice and explaining it in the right way, where he'll admit, OK, we may have a rebound here, and this is why we need to behave that way.

But it's fantastic that his voice has been allowed to come through.

NINA GREGORY Nina Gregory, how are you and your foundation addressing the ethical questions about which countries get the vaccine first, assuming you find 1?

And maybe, Bill, use this as a moment to ask to just talk about where the quest for the vaccine is and what are just some of the key things we should all be thinking about as we track the news on this.

There's 3 vaccines that are, if they work, are the earliest.

The Moderna, which unfortunately won't scale very easily.

So if that works, it'll be mostly a US targeted thing.

Then you have the AstraZeneca, which comes from Oxford, and the Johnson & Johnson.

And we have animal data that it looks potentially good, but not definitive, particularly will it work in the elderly?

And we'll have human data over the next several months.

Those 3 will be gated by the safety and efficacy trial.

That is, we'll be able to manufacture those, although not as much as we want.

We'll be able to manufacture those before the end of the year.

Whether the Phase III will succeed and whether it'll complete before the end of the year, I wouldn't be that optimistic about.

You know, Phase III is where you need to really look at all the safety profile and efficacy, but those will get started.

And then there's 4 or 5 vaccines that use different approaches that are maybe 3 or 4 months behind that, Novavax, Sanofi, Merck.

And so We're funding factory capacity for a lot of these.

Some complex negotiations are taking place right now on this to get factories that will be dedicated to the countries, the poor countries, it's called low and middle income, and the very scalable constructs that include AstraZeneca and Johnson & Johnson, we'll focus on those, the ones that are inexpensive and you can build a single factory to make 600 million doses.

So a number of the vaccine constructs are potential.

You know, I don't see anything before the end of the year that's really the best case.

And it's down to a few constructs now, which, you know, typically you have high failure rates.

CA1 Bill, is it the case that if you and your foundation weren't in the picture here, that market dynamics would likely lead to a situation where as soon as a promising vaccine candidate emerged, the richer countries would basically snap up, gobble up all available initial supply.

It just takes a while to manufacture these, and there would be nothing for the poorer countries.

But that what effectively you're doing by giving manufacturing guarantees and capability to some of these candidates, you're making it possible that at least some of the early vaccine units will go to poorer countries.

GOLDSTEIN Well, it's not just us, but yes, we're in the central role there, along with a group we created called CEPI, Coalition for Epidemic Preparedness, And the European leaders agree with this.

Now, we have the expertise to look at each of the constructs and say, OK, where is there a factory in the world that has capacity that can build that?

Which 1 should we put the early money into?

What should the milestones be where we'll shift the money over to a different 1.

Because the kind of private sector people who really understand that stuff, some of them work for us and we're a trusted party on these things, we get to coordinate a lot of it, particularly that manufacturing piece.

Usually, you'd expect the US to think of this as a global problem and be involved.

So far, no activity on that front has taken place.

I am talking to people in the Congress and the administration about when the next relief bill comes along, that maybe 1 percent of that could go for the tools to help the entire world.

And so it's possible, but it's unfortunate.

And the vacuum here, the world is not that used to, and a lot of people are stepping in, including our foundation, to try and have a strategy, including for the poor countries, who will suffer a high percentage of the deaths and negative effects, including their health systems being overwhelmed.

Most of the deaths will be in developing countries, despite the huge deaths we've seen in Europe and the US.

CAWTHONER-JOHNSON I mean, I wish I could be a fly on the wall in hearing you and Melinda talk about this, because of all of the ethical crimes, let's say, executed by leaders who should know better, I mean, it's 1 thing to, you know, not model mask-wearing, but to not play a role in helping the world, when faced with a common enemy, respond as 1 humanity and instead, you know, catalyze a really unseemly scramble between nations to fight for vaccines, for example.

That just seems that surely history is going to judge that harshly.

Well, it's not quite as black and white as that.

The US has put more money out to fund the basic research on these vaccines than any country by far.

There's not like some royalty that says, hey, if you take part of the money, you have to pay the US a royalty.

To the degree they fund research, it's for everybody.

To the degree they fund factories, it's just for the US.

The thing that makes this tough is that in every other global health problem, the US totally leads smallpox eradication.

The US is totally the leader on polio eradication with key partners, CDC, WHO, Rotary, UNICEF, our foundation.

So the world, and HIV, what, under President Bush's leadership, but it was very bipartisan, this thing called PEPFAR, was unbelievable.

You know, that has saved tens of millions of lives.

And so it's that the world always expected the US to at least be at the head of the table financially, strategy, OK, how do you get these factories for the world, even if it's just to avoid the infection coming back to the US or to have the global economy working, which is good for US jobs, to have demand outside the US.

And so the world is kind of, you know, there's all this uncertainty about which thing will work, and there's this, OK, who's in charge here?

And, you know, so the worst thing, the withdrawal from WHO, that is a difficulty that hopefully will get remedied at some point, because we need that coordination through WHO.

Ali Khashoggi, are there any particularly successful models of handling the pandemic that you have seen around the world?

Well, it's fascinating that besides early action, there are definitely things where you take people who have tested positive and you monitor their pulse ox, which is oxygen saturation level in their blood, which is a very cheap detector, and then you know to get them to the hospitals fairly early.

Weirdly, patients don't know things are about to get severe.

It's interesting physiological reason, but I won't get into.

And so Germany has quite a low case fatality rate that they've done through that type of monitoring.

And then, of course, once you get in facilities, we've learned that the ventilator actually, although extremely well-meaning, was actually overused and used in the wrong mode in those early days.

So the health, the doctors are way smarter about treatment today.

Using this Poxoxis as an early indicator, that'll probably catch on broadly.

And now, of course, dexamethasone, fortunately, it's cheap, it's oral, we can ramp up manufacture.

Bill, I want to ask you something about what it's been like for you personally through this whole process, because, weirdly, even though your passion and good intent on this topic seems completely bloody obvious to anyone who's spent a moment with you, There are these crazy conspiracy theories out there about you.

I just checked in with a company called Zignal that monitors social media spaces.

They say that to date, I think on Facebook alone, more than 4000000 posts have taken place that associate you with some kind of conspiracy theory around the virus.

I read that there was a poll that more than 40 percent of Republicans believe that the vaccine that you would roll out would somehow plant a microchip in people to track their location.

I mean, I can't even believe that, that poll number.

And then some people are taking this seriously enough, and some of them have even been recirculated a bit on Fox News and so forth.

Some people are taking this serious enough to sort of make really quite horrible threats and so forth.

You seem to do a good job sort of shrugging this off.

But really, like, who else has ever been in this position?

What on earth world are we in that this kind of misinformation could be out there?

And, you know, it's a new thing that, you know, there's conspiracy theories.

I mean, Microsoft had its share of controversy, but at least that related to the real world, you know?

And we definitely had antitrust problems, but at least I knew what that was.

When this emerged, I have to say, my instinct was to joke about it.

People have said that's really inappropriate because it's a very serious thing.

It is gonna make people less willing to take a vaccine.

And of course, once we have that vaccine, it'll be like masks, where getting lots of people, particularly when it's a transmission-blocking vaccine, there's this huge community benefit to widespread adoption of that vaccine.

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