Co-chair Bill and Melinda Gates Foundation, Bill Gates recently shared insights on the impact of COVID-19 on the world and Africa in 2020. In an interview with select journalists from across the continent, Gates, who looked at the current status of the global fight against the virus and how partners can support countries in Africa and elsewhere to ensure an equitable global response, also touched on the potential of future pandemics and what the world can do to prepare beforehand. Chiemelie Ezeobi brings excerpts
You have talked before about the dangers of a vaccine grab, and yet this is exactly what we’re seeing unfold. What are your assessments of the impact of the rush for this kind of vaccine nationalism is going to have on Africa and what kind of trajectory you’d like to see with the COVID-19 pandemic?
The key for the vaccines is getting more approved and getting more factories into production. A lot of the work that the foundation has done is to back a variety of vaccines. Back in 2015 in my TED talk I talked about the risk of a pandemic, and how we weren’t prepared. At that time, not much was done. The foundation, Wellcome Trust, the UK, Japan and Norway did create a group called CEPI which has helped a lot with a number of these vaccines.
With medicines we always have this challenge with the big markets, the sales opportunities are in the rich countries. That’s why for diseases like HIV or malaria, the foundation reaches out to these companies and says “We need to have some equitable approach.”
The first two vaccines that were approved are fairly costly to make and hard to scale up. They’re very good vaccines, Pfizer and Moderna, but it’s the next three, including AstraZeneca, Johnson & Johnson and Novavax that will give us the highest volumes, the ease of scaling and the thermal stability. And so, we’re hopeful that, particularly with some factories in India, that the foundation has helped to finance, which have larger factories than the factories in the West, within the next few months a large number of doses will come out of there and be targeted almost entirely to the developing world, which is the goal of what we call COVAX. It’s a dynamic situation, I’ve been talking with governments and companies about this going back to last March, and so we have a chance here to get a lot of vaccines.
In Africa, the epidemic itself in a direct sense has been the worst in South Africa. The rest of Africa, with a few exceptions, hasn’t been super bad. But of course, the economic effects are there and any life that’s lost is really terrible. So we need to first get the 20 per cent coverage, and then move to 70 to 80 per cent coverage and I’d say the foundation is at the forefront of that but it’s still unclear how well all these efforts will go.
Is there a plan for the Bill and Melinda Gates Foundation to assist poorer countries such as Nigeria for instance, in developing COVID-19 vaccine production capacity?
There are a very high-volume of factories in the developing world, primarily in Indonesia and India. Making a new vaccine factory is a more than five-year effort. Definitely, to be ready for the next pandemic, I think that there will be factories using this mRNA approach, that are put in multiple places in Africa so you’ll have guaranteed quick supply.
For this epidemic we need to take advantage of the large capacity that people like Serum, BioE, and many others have, which are the developing world manufacturers who can in volume, make four to five times as many vaccines as all the Western companies put together.
So, the factories really are there. We can’t get new ones overnight but these highly scalable vaccine constructs, the next three, the numbers can be very large. As soon as that can happen, the best. The plan for the next round is to globally have lots of mRNA capacity, and to advance that technology so that it’s more scalable, more thermal stable and cheaper, over the next five years, that should be possible if we get the rich countries to make large investments. I’ll certainly be a huge advocate for that.
As you say in the letter, until vaccines reach everyone then new clusters of disease will keep popping up, but when we look at The Economist, last December they projected that the vaccine will be widely available in Africa in 2022 or 2023. What can be done to improve the supply?
Well, the agreement we have with India is that those factories, at least half the capacity will be dedicated to going to supply, through GAVI, to Africa and other developing countries. Every day, of course, we’re trying to speed this up. The history of vaccines is that until GAVI was created in the year 2000, the really key vaccines for saving literally millions of lives were not cheap enough for the poor countries, and the coverage levels were very low.
And so GAVI deserves more visibility for what it did, funded by many governments and our foundation, to get diarrhoea vaccines and pneumonia vaccines into all the children in the world. And so the GAVI approach, where GAVI buys the vaccines at the very lowest price with that donor money, has worked very well. That’s why deaths of children under five, since the year 2000, in the world at large has been cut in half. It’s an even higher percentage if you just focus on Africa.
So, we have that success story. GAVI had a hard time getting money from the United States, until recently, which was fairly key, so both Melinda and I were working on that. We were successful in getting a $4 billion allocation for GAVI. In the meantime, we were giving money to get these factories ready.
So, the whole vaccine model that emerged on GAVI, that’s what we’re trying to use here. Now, doing it very very quickly is a challenge because you never want to build a factory that can’t make quality vaccines.
You really would prefer to use vaccines that have gone through the toughest regulatory process, like the US regulator or the UK regulator, and then receive the WHO blessing. Right now, we’re working on those processes but you don’t want to speed them up where you would compromise safety for those factories or for those trials so we have to balance those things as we push ahead.
What would you have to say to those who are skeptical about taking any vaccine? This is of course amidst the spread of misinformation about both the virus and vaccine development. Do you believe that this has delegitimised your efforts through your foundation?
For people who care about childhood death, vaccines are the best thing that ever happened. Smallpox killed over a million people a year, and because of vaccines, now smallpox is gone. The miracle of vaccines is very clear. When a child dies, that’s a very clear thing. We have very good statistics on what that was like before we got these new vaccines. Over 10 million children were dying under the age of five every year, with a high portion of those being in Africa.
The more people learn about vaccines, the more amazed they should be about how fantastic they are. As I said, the safety issues are challenging. You do need to go through the trials, you do need to use extremely well regulated factories. A factory can only be built in a country whose regulator is a gold standard regulator and can look at every aspect of that factory, making sure that it’s very very good. There are very few countries that have that safety review capacity that the world trusts.
We are now getting the experience with these coronavirus vaccines, I had my first dose last week. There are very, very few side effects, and it is protecting people. In fact, almost no one who has been vaccinated has had severe disease which is really quite miraculous.
I hope people will read the facts about vaccines, and how they’ve worked against other diseases, and see that now we have millions and millions of people who’ve taken this vaccine and we’re tracking that experience to make sure we were right about the overall safety. It is going to be a tragedy if a country continues to have an epidemic because of these false vaccine rumours.
I want to ask about the fates of African countries, like Rwanda especially, now that major economies have not supported the COVAX and GAVI arrangements. What does the foundation have for our countries and what can you talk about the effectiveness of this vaccine, especially now that we’re seeing new strains?
So the way GAVI has always worked is that for the countries with the low GDP per person, there’s almost no co-financing required. So we raise money from the Gates Foundation and from rich countries, and they pay for the vaccines. The same thing will take place here with the coronavirus vaccine, the GAVI money, which was difficult to raise when the US wasn’t involved, now we see a clear path to raise up to about 10 billion, just for vaccine procurement, which should be enough to finance it for most of the GAVI-eligible developing countries.
Your question about the new strains is a very good one. We will get data this week from trials that were conducted with several of these new vaccines in South Africa, and that is of course one of the countries where there is a variant circulating. It’s one of three countries right now where it’s pretty clear that the variant is slightly more infectious, and may even be slightly more fatal. What we think is that the vaccines will be only slightly less effective, but within two weeks, the data will be out.
If there is a drop in effectiveness, even by 10 per cent, we’ll still need to use the vaccine because it is still very effective. But then we’ll look at whether we need to add an additional thing to the vaccine so it covers the variants that have emerged, and we get the efficacy level back up closer to 100 per cent. So we’re investing money in that right now – I’m talking to all of the companies. It’s definitely bad news that these variants showed up, but we do expect that the vaccines will still have a pretty high level of efficacy, even before we make that new addition.
Given the commitment to vaccine equity expressed in your annual letter this year, do you support calls led by India and South Africa at the World Trade Organisation, to suspend intellectual property rights for COVID-19 vaccines?
Well the key question is, what would make more vaccines become available? If you’re going to try and tell people to take these vaccines, which are extremely difficult to make – these are biological processes where even the very best companies sometimes have bad failures and contamination. Right now, only by using vaccine companies that have the right expertise, are we able to make these.
You know, there is no royalty, so as these Indian companies like Serum and BioE are getting the rights to make these vaccines, because of the money that the foundation has put forward and because these companies are not trying to make money on these vaccines – they’ve been given without any royalty whatsoever.
So, the only limiting factor is getting the regulatory approval for the new factory to make sure it’s absolutely right and then ramping up that production in that factory. And so, you know, although there’s lots of issues about intellectual property, at this point, changing the rules wouldn’t make any additional vaccines available. We’re going to every factory we can and getting zero royalty access for ramping up that manufacture.
About the issues that have been overtaken by the events of COVID-19, and this is the other vaccinations and immunisations for the regular childhood diseases. What do you think should be the plan?
Your question is a very good one. If you take Sub Saharan Africa, and you leave out South Africa, the additional deaths over the last year, there will be a lot more that come from the reduction in vaccine coverage of the typical vaccines like the measles or rotavirus vaccine. And then there will be from COVID disease, so it’s definitely a tragedy that those coverage levels have gone down. In fact they’ve gone down to a level that we last saw about 20 years ago.
And so this is something where to save, we need to get those primary health care vaccine delivery systems for routine immunisation back functioning again. And that requires political leadership, mostly politicians don’t think about vaccine coverage in the primary health care system, but we need their support to get real focus on what is the data, which parts of the country have fallen behind, how do you do these catch-up campaigns, and certainly, the voice of the foundation and talking to political leaders, whether it’s in rich countries about their generosity, which of course they’re suffering as well and their budgets are in tough shape but you know we still feel in terms of equity, if anything, they should be more generous.
Some countries are talking about cutting back their foreign aid, which is unfortunate, but we’ll do our best to make sure that the moral interests of the voters in those countries, argue for not just maintaining but increasing that aid. Likewise, in Africa itself, these health issues deserve a lot more attention.
The press looking at those figures and highlighting them, I think may be a helpful factor in driving action, but we need to catch up on all those key vaccines, even things like the measles campaigns. We still have a type of polio virus that we’re still working on, and I’ve been talking to leaders about how we get those campaigns back underway again. So we have to build back, as over the next year, the epidemic and all of its impacts, including the economic impacts, slowly go away.
Taking you back to the Goalkeepers report released last year, would you say that the COVID-19 pandemic has reversed the gains in the health sector by over 25 million?
Well, there’s no doubt that the impact of putting money into the health system, particularly the primary health care system, will be very high in terms of saving children’s lives. And you’re absolutely right, Nigeria should not divert the very, very limited money that it has for health into trying to pay a high price for COVID-19 vaccines. The key is that Nigeria is still eligible, and so, for a lot of those vaccines, they will come through the GAVI facility that we’ve raised money for.
Health in general in Nigeria is very underfunded. If you look at the primary health care centres in the north and, in particular, if you look at the vaccine coverage rates, there are millions of lives that can be saved if the primary health care system operated at a level that some other countries at the same wealth of Nigeria if its system was as good. I’m an advocate for the government to have more resources and prioritise health.
Obviously I’m not a voter in Nigeria, so Nigeria can decide that independently. So my advice is that the primary health care system is what’s super important and that with those finite resources, you have to prioritise expenditure. And in that case, waiting for the GAVI vaccines would be the best thing and to put into other areas so that vaccine coverage rates, that are as low as 20% in some areas, get up to 80/90 per cent to save children’s lives.
What vaccine did you have? What shot did you have? What type of vaccine did you get? And did you have a choice in the vaccine that you took? And why did you make that choice if you did?
So, in terms of that last part, our foundation has been very involved in planning a lot of emergency things, including getting drugs like dexamethasone available. There’s also the African medical supplies effort, which we’re very supportive of, and it includes efforts to get oxygen to be available, and I’m sure our office in Africa would be glad to follow up with more specifics of what we’ve done there on the work in diagnostics that we’ve supported, the African CDC which we’ve been a big supporter of and has done a good job, and the oxygen has been a very valuable thing.
I ended up getting the Moderna vaccine, I had no choice, they don’t ask what your preference is. There are only two vaccines approved in the United States right now, Pfizer and Moderna. They’re both very good vaccines and very safe. Anything that has gone through a phase three, and is approved by the UK or US regulator, I’m a huge believer in the quality of that work. People are frustrated that it took so much time to get those approvals, but without that, you can’t know the effectiveness or the safety, and so that’s why I’m so excited that now AstraZeneca is starting to roll out, although, like most manufacturers they’ve had some challenges getting the volumes up.
That vaccine is being made in India today and so, as soon as we get the WHO pre-qualification for that which we don’t have yet but we’re hopeful on then it will become available through GAVI. And that’s a very scalable terminal stable vaccine just like the Johnson & Johnson and Novak’s that we hope also get approved. But when you get in line, it’s just whatever vaccine, you don’t get a choice.
About immunity inequality and the next pandemic, we see the US has had millions of vaccinations, while countries like Nigeria have had less than 100. The Director General of the WHO says, some poor countries have had just 25. Leveraging the lessons from this pandemic, how do we ensure this does not happen with the next pandemic?
Well honestly you should ask that question, not just about the pandemic, but you should ask that question about health, the primary health care systems in your country in terms of are they reaching the kids and is it a budget priority and whether it is well-run. I mean, the deaths from the deficits and primary health care are dramatically higher every year than the total deaths going on in Africa from this pandemic, and so I hope it causes everyone in society to look at these health issues.
There should be close to 100 per cent coverage of all the vaccines and you need to have those very functional primary health care systems because the number of lives you can save is absolutely huge. In terms of the next pandemic, we will get global capacity for this new platform, the mRNA, as we reduce its costs, which are still quite high, much higher than other vaccine constructs, and fix the thermal stability problems – you know, that’ll take between five and ten years, but we should rush to do it.
We don’t know when the next pandemic will come, but we know the cost of a pandemic in this case has been tens of trillions of dollars, and has had a negative impact in terms of education and mental health that we have a hard time measuring. You really should study what things were like before GAVI and see that story. For people who care about vaccine equity, what it has done is really a miracle, but there’s still much more to do.