In 2015, the American technologist and philanthropist Bill Gates warned that humanity wasn’t ready for a pandemic. Seven years on, as the world emerges (hopefully) from a pandemic for which it wasn’t ready, he thinks we have it within our power to make sure this one was the last. There will be more disease outbreaks, but we now possess the tools and the knowledge to prevent them from becoming global catastrophes.
Gates’s optimism is refreshing after the gloom of the last two years. Since we all learned a new word, Covid-19, we’ve heard a lot about what we can’t do. We can’t contain infection and remain democratic; we can’t vaccinate everybody in time to prevent new variants emerging; we can’t develop effective treatments before the pandemic is over. Gates thinks we can do all these things, as long as we take the right lessons from Covid (he also thinks we can eliminate greenhouse gas emissions by 2050, the subject of his last book). He wants us to act now, while the fear lingers and before we return to our habitual complacency.
The roadmap he lays out sounds feasible. It involves strengthening disease surveillance by exploiting the full potential of existing genomic sequencing and informatics tools; supporting ongoing research into universal vaccines, which protect not only against single pathogens but against whole families of pathogens; building manufacturing and distribution capacity for vital diagnostics, vaccines and treatments; and further streamlining procedures for obtaining regulatory approval for these tools.
It also involves strengthening primary healthcare systems around the world, because general practitioners and community nurses will double as an early-warning system and the main vehicle of prevention when the next outbreak occurs. And it involves creating a team whose full-time job is to coordinate pandemic preparedness efforts worldwide. He calls this team “Germ”, for “Global Epidemic Response and Mobilisation”, and estimates its running costs at $1bn a year – less than a thousandth of annual global defence spending, and a negligible amount compared to the trillions Covid has already cost us.
[See also: The global race to contain Omicron]
Gates’s proposals are wise, and his goals should be our goals. But how do we achieve them? Unsurprisingly, given how the Microsoft co-founder made his fortune, he puts his faith in private-sector innovation supported by governments and philanthropy – the status quo, in other words. But another thing this pandemic has taught us is that, while markets and technology can solve a lot, they can’t solve everything. And, as things stand, the private sector is as much a part of the problem as of the solution.
Credit where credit’s due: the technological developments that have been driven by this pandemic are breathtaking. The messenger RNA (mRNA) vaccines that have already saved so many lives will save many more as they are adapted to fight other major killers. And there have been less visible technological advances in recent years that stand to revolutionise our response to infectious disease. One Gates is particularly excited about is the cheap, sensitive mass-testing technology being developed by the British company LumiraDx. He also notes that innovation doesn’t have to be high-tech. “It’s mind-blowing how cheap and effective masks are,” he writes, adding that they by themselves could prevent an outbreak of respiratory disease developing into a pandemic.
Philanthropy deserves some credit too, including his own. The Bill & Melinda Gates Foundation, the philanthropic body that he set up with his now ex-wife in 2000, has made significant inroads into some major global health problems, and contributed more than $2bn to the fight against Covid. It helped create the Coalition for Epidemic Preparedness Innovations (CEPI), which played a critical role in the development of Covid vaccines, and anticipated the problem of vaccine inequity by backing the Covax vaccine-distribution mechanism.
Unfortunately, Covax failed to meet its objectives. Gates says this happened for reasons beyond its control, which is true: wealthy countries bypassed it to negotiate their own deals with vaccine-makers. But the real problem was that the vaccine-makers were calling the shots. They were able to because they own all the intellectual property (IP) rights in their products, even though the governments they were selling to bore much of the risk of the research that generated that IP.
Gates explains this himself, without seeing any contradiction. He writes that the US government not only supported the academic work on mRNA and its translation into marketable products, but it also helped the vaccine companies to continue the work once the pandemic struck. He also points out how reliant those companies were on the publicly funded infrastructure behind clinical trials in various parts of the world, including Africa.
He claims, and he’s not alone, that IP issues didn’t impede the vaccine roll-out; limited manufacturing capacity and know-how did. He may be right. Making vaccines is far more challenging than making many other drugs, partly because they’re given to healthy people, so quality-control standards are higher. But a South African company’s successful effort to copy Moderna’s Covid mRNA vaccine, after the American firm promised not to enforce its patents during the pandemic, has severely tested that claim.
And if intellectual property isn’t the obstacle, why did a consultancy hired by BioNTech, another mRNA vaccine-maker, lobby against the World Health Organisation (WHO)’s efforts to boost manufacturing capacity in Africa?
The ongoing campaign to persuade the World Trade Organisation to temporarily waive IP rights on all medical products needed to control the Covid pandemic – the efficacy of which Gates is personally sceptical about, though it’s a move his foundation now supports – came too late to have an impact on this pandemic, even if it forces partial change. But it may be possible to negotiate a new deal ahead of the next outbreak – one in which the pharmaceutical industry doesn’t set global health priorities and its products don’t automatically go to the highest bidder.
It won’t be easy, and governments may have to stump up more cash themselves to persuade the companies to relinquish some control. But the firms have to compromise too: they can still make huge profits, just slightly less huge, and without impeding public health goals in a time of crisis.
[See also: The scars of Long Covid]
Gates allows little of this. He concedes that firms should commit to more tiered pricing – where richer countries pay higher prices than poorer ones – and second-source deals, where they agree to share tools and expertise with other companies, but he would leave the world reliant on their largesse. As philosophies go, it’s at best paternalistic, at worst imperialistic. And he has other blind spots.
He writes, for example, that the United States couldn’t have envisaged data-sharing in the way that, say, South Korea did, to track the spread of the virus. That’s all he has to say about this complex subject. But while South Korea’s entirely legal data-collection efforts were considered by some to infringe privacy – and it did go further than other countries in the intimacy and precision of the details it released – others highlighted how effective those efforts were in containing the virus. American contact-tracing efforts were poor by contrast, yet US social media users haemorrhage personal data, and it is often used against them. So there is surely a debate to be had about balancing privacy and public health, and an important distinction to be made between curtailing liberalism and curtailing democracy.
Gates is right that the private sector isn’t solely to blame for our woes. We all have a part to play in solving the collective-action problem posed by pandemics – by, for example, mandating our governments to confer more powers and resources on the WHO, which coordinates the global response.
He is also right that technology alone could eliminate some problems. If scientists devised a highly effective single-dose vaccine that could be stored at room temperature, whose production could be scaled up far more quickly than is possible now – something that is, alas, not yet on the horizon – vaccine inequity might simply ebb away.
If history is anything to go by, however, new technologies will create new problems – ones the market is, again, poorly equipped to solve. The need to strike the right balance between public and private sectors is one we will have to tackle sooner or later. And, given the new disease threats we are already facing – notably avian flu, new strains of which have recently been detected in humans – sooner would be better.
[See also: What is monkeypox and how worried should we be?]
How to Prevent the Next Pandemic
Allen Lane, 304pp, £25
Laura Spinney is a writer and science journalist based in Paris. Her books include “Pale Rider: The Spanish Flu of 1918 and How It Changed the World” (Vintage)
This article appears in the 04 May 2022 issue of the New Statesman, Dictating the Future