Bill Gates, co-chair of the Bill and Melinda Gates Foundation, speaks with reporters on the 2020 Goalkeeper’s Report. Excerpts:

 

Fourth annual Goalkeeper’s report

We’re hosting this call to answer any questions about our fourth annual Goalkeeper’s report. Obviously, this is the report card tracking the progress towards the United Nations’ Sustainable Development Goals.

Now, the first three years, we were able to report the steady and gradual progress towards those goals, and so hence the very positive story about the reduction in childhood deaths, the reduction in malnutrition, the improvements in literally, all things that the Development agenda, in the last few decades, had made great progress on. You know, every single one of the goals was moving in the right direction.

Of course, this year is different,  it’s unique. The COVID-19 pandemic not only stopped progress, but it pushed us backwards, and that varied quite a bit by the different areas. It was hard to track because things have changed a lot in a short period of time, and even in different places and countries, the impacts are quite different.

For routine immunisations, over the last 25 years that went up from 70% to 84%, and now it’s back down to 70%, so that’s a huge setback. Extreme poverty, we have 37 million more people in extreme poverty, and of course, that’s after 20 years where that number had gone down.

So, you know, the GDP drop, broadly, is very large, and for the developing countries, the impacts are really quite great because they can’t borrow money in the same what that rich world governments have, and so much of their work is physical work, and so simply connecting up to the internet doesn’t let them do their jobs.

So, you know, we need a cooperative response for several things. The first thing is to end the pandemic. Ending the pandemic is what will let us get back to where we were at the start of 2020. Critical to ending the pandemic will the availability of a vaccine, and it’s great we have a lot of efforts underway. You know, I feel almost certain that many of those efforts will succeed and that by early next year we’ll have a number of vaccines, and then the question will be how much can we manufacture, and how do we get them out to the ones most in need?

You know, it shouldn’t just be the rich countries winning a bidding war, but rather have equity weigh in on that allocation. Misallocating the vaccine would cause dramatic additional deaths, as we see from the model done at Northeastern.

When we do Goalkeeper’s, we want to keep in mind our tagline that progress is possible but not inevitable, and we feel much, we believe that we’re still optimistic, we can get on track. You know, will that take us two years or three years? Will there be exemplars on getting back on track that we can all learn from? With our commitment to help with the pandemic and then help the countries move back towards these goals.

So, we do believe we’ll overcome this and get back on track.

Vaccines development

The regulators should take a hard look at that, and you know, they’ve done a fantastic job of that, for all the vaccines that have gotten approval. It is true that, when you have viral vectors, you can trigger an underlying autoimmune condition that would have shown up at some point, and so they’ll be looking into whether there’s a connection to the vaccine, or is it something that would have been there anyway.

You know, the Gold Standard regulators, the European regulator, including the UK and MHRA, and the US FDA, they deal with this stuff all the time, and so it’s not at all surprising to have the one adverse event. Unless they find other such ones, they’ll make the judgment about whether to resume that trial, but you know, whatever goes on with these vaccines, it underscores the fact that, having taken many different approaches is quite valuable, and there are six that have a very good chance of having approval by early next year, through a Gold Standard regulator, that will hopefully avoid having – countries having to consider using something that hasn’t gone through a Gold Standard regulator.

Hoarding the first vaccines

Well, you know, one positive thing is that the United States has done very substantial funding for the research and the trials. In return for that, the idea that there is some capacity set aside, that prioritises doses going to the United States, I don’t think that’s out of line. The one thing the United States has not done, as yet, that I’m very hopeful it will, is allocate substantial resources for the vaccine procurement and other drugs and diagnostics for the pandemic. If they would couple that with their funding of the R&D, and facilitate these vaccines being made in many factories, then you’d have the complete picture there.

So, no one is saying that there shouldn’t be any recognition of where the trials are done, where the R&D funding has come from, but the way to deal with this problem is to have that capacity be as large as possible. And so, as you’ve noticed, our foundation with partners is putting together something that’s never been done before, which is to have the vaccine created by one company, also being manufactured in parallel, not only in that company’s factories, but also in other companies.

And so, here, a number of the alliances tie Western vaccine manufacturers like J&J, AstraZeneca and Novavax, with the Indian manufacturers, including companies like Serum, who is the world’s pipeline vaccine manufacture Bio E, or others, and so if we can get many billions of doses made during calendar 2021, then the allocation you can serve multiple goals. If you have very limited manufacturing capacity, then that makes the dilemma of the tradeoff that much worse.

 Vaccine development and distribution

Well, I’m seeing a lot of countries, you know, through the COVAX facility, talk about how they meet their own needs, and how they make sure that particularly the developing countries have access. The benefit of global cooperation on this is very, very high, because even if you’re a country that has very few cases, we’ve seen that you have to keep very strict measures in place. And even so, you get outbreaks because, as long as the vaccine isn’t circulated into the world at large, creating a perfect barrier between your country and the rest of the world is very, very difficult to do.

So, of all the causes in global health, where not only is there a humanitarian and strategic reason for helping out developing countries, here, even in a very direct sense, there’s a selfish reason that that’s what allows us to go back to normal.

You know, the good news is that all these vaccines, you know, the cost per dose will probably be two or three dollars on the margin, and not funding the R&D or the trials, but just the pure manufacturing costs, and so this means that, given the trillions that are being lost, economically, that the idea that some number of billions need to be allocated to get vaccine coverage up to levels where you can stop the spread of the disease, globally, you know, it’s a pretty obvious investment, that every month earlier that you get that done, literally, it pays off in the trillions, and yet the cost to do it is in the billions.

So, I’d say we are seeing that countries are cooperating in terms of letting trials be done in the places where there are the most cases. There are some very good trials being done in Brazil and South Africa, as well as the UK and the United States. We’re seeing people talk about these manufacturing agreements, which would be quite novel, and the groundwork that we’ve helped facilitate for a lot of those pairings is already in place. There are some additional pairings that we’d like to get into place.

So, as soon as we get all the rich countries putting out essentially the special donor money, and figuring out how, for vaccines, they use this GAVI fund, and for diagnostics and therapeutics, they use the Global Fund. As soon as that comes into focus, along with some of the R&D money that’s gone through CEPI, I think we have a chance of rating this as a great example of global cooperation.

UN SDGs

Well, the SDGs represent the values that we have for humanity as a whole, and so although some of the numeric targets you might want to go back and say, okay, this is no longer realistic because at a minimum you’re going to have two to three years before you can get back on track, I’d say that the reinforce of the goals, if anything, it’s reinforced by the pandemic.

After all, the pandemic has in almost every dimension made inequity worse. The poorer countries are suffering far more than the richer countries because of a lack of fiscal resources to draw on. The well-off workers who can do their work on a virtual basis are suffering less than the hands-on workers who are generally paid less. We even see pretty substantial racial inequities where in many of the developed countries it’s Blacks and Hispanics are suffering at much higher rates than other races.

Because the SDGs are about achieving basic norms for all of humanity, getting rid of extreme poverty, having education and having toilets, having great vaccines, so-called universal health care, these setbacks just underscore that those inequities, sadly, which were going down year by year, now they’ve gone up a lot.

Whether we’ll be able to find the additional resources for this is tricky because the rich countries are (inaudible) more that they’ve had a great deal of suffering, both economically and in terms of health as well.

I doubt anybody would pick one of the goals and say, okay, let’s drop this goal. Some of the goals already had very aspirational targets that weren’t likely to be achieved by 2030. An exception to that is we actually were involved in helping to pick the neonatal death goal, MMR, and the under-five mortality rate, U5MR, and the maternal mortality rate, and we did get those set that if things had gone well and a lot of the exemplary practices were adopted, they were achievable. Now they’re probably somewhat out of reach, but I don’t know if the UN will choose to go back and change that target. I mean, at the UN, anything that goes on there it’s completely up to the General Assembly, which is where all those decisions are made.

Access to COVID-19 Tools Accelerator

It’s quite a range of items that come under ACT-A. We’ve got in Africa Strive Masiyiwa doing the African Medicines Initiative where he’s done a great job getting personal protective equipment and things like dexamethasone out to countries in Africa. That’s kind of an exemplar. There’s been countries where they’ve raised money locally to support some of those efforts.

You know, I wish in a way that we had even more tools available. Right now, in terms of treatments, nothing is proven to have substantial effect beyond dexamethasone, not plasma or even Remdesivir is fairly expensive, right, still, because the way it’s synthesized and the impacts and the studies are quite modest.

Hopefully, in the months ahead, through additional new modulators, perhaps some additional antiviral drugs, there’s a few that are in testing stages, and perhaps most promising, monoclonal antibodies will be added to the list of things that significantly impact the death rate, and then, you know, the good news is that we’ll have those. The challenge will then be that how do we get the manufacturing and generosity up. It’s more than the vaccine that we want to be able to get out and make available.

The vaccine is the most important, and here we don’t yet have all the money to do that procurement. Once the U.S. shows its interest, which historically in global health, like smallpox eradication or HIV or malaria or even polio, it’s been a huge leader, I think it’s likely we’ll be pretty close to the funding we need to do that procurement, certainly for all the vaccines that we’ll be able to get during calendar 2021.

It’s been a challenge, but the European leaders, Macron, Merkel, Johnson have all made significant commitments for their countries and have been very helpful, have tried to put together a coalition around this to make sure that the poor countries are not excluded.

The COVID-19 response and preparedness for a pandemic

Well, the entire world was unprepared for this pandemic, and it’s unfortunate that practicing and really figuring out how to orchestrate the key resources quickly, the rich countries, the developing countries, nobody really was as ready. A few countries that have experienced MERS and SARS did respond fairly quickly and they’ve been rewarded by having relatively modest epidemics.

In terms of Africa know, a lot of the health capacity that’s there is funded by the polio program. And so, you know, those resources were able to shift their focus and help out with the planning, figuring out what the steps should be to minimize the impact of the epidemic.

Other than South Africa and some countries in northern Africa, the actual number of infections and deaths has not been large in Africa. Sadly, as our report documents, there’s probably been more negative effects on health because of the disruption to the health system, including malaria bed nets, HIV drugs, TB drugs and routine immunization or measles campaigns.

And so, you know, that’s why the report really underscores for Africa where the health numbers are the most challenging, that getting those things back on track and getting back to the kind of yearly improvement that we were seeing is super-important.

You know, I spent a lot of time talking to some of the state governors in Nigeria about their plans, and in fact, Aliko Dangote and I spent three hours today going through three of the states, we’ll do the same tomorrow, trying to understand what bottlenecks they’re running into and how the international actors can help them, because even before the pandemic, those primary healthcare systems were far short of what they should be, and the goal is to get up to covering every child.

Increasing inequality in the world due to the pandemic

Sweden is a very generous foreign aid donor, right up there at the top with Norway by the common metric, which is 1 percent of GDP. Point-seven that the UK achieves is considered fantastic and anything above that is excellent. Sweden, I believe, has been coming in around 1 percent or even slightly more

Swedish citizens should feel very proud of that generosity, and even with the domestic challenges, maintaining that has set a really great example, because I am worried that some donors, you know, either in the quality of their aid to the amount of the aid, will look at this pandemic and not make it the priority that they used to. But Sweden’s encouragement on this has always been helpful.

Sweden can also participate in the R&D where we need hopefully some of these vaccine platforms that come out of this pandemic will let us get a malaria, TB or HIV vaccine a lot sooner. Hopefully, other technologies will help us provide seeds to African farmers so that as they’re facing climate change, they’re not facing increased malnutrition where the current levels of malnutrition are very high, and Africa faces not only climate change but also very substantial population growth in areas where even the very basics of growing enough food is already very, very difficult.

Our foundation has had a great relationship with Sweden and I wish all donors were as generous. The more the better, but they’re at a very generous global.