photo of Bill Gates by Kuhlmann /MSC, via Wikimedia Commons
In what I now know were the last days of my pre-pandemic normal life, I read – and set aside – a prescient article by Bill Gates in which he anticipated the scientific, medical and humanitarian battle that lay ahead.
“Global health experts have been saying for years that another pandemic whose speed and severity rivaled those of the 1918 influenza epidemic was a matter not of if but of when,” Gates wrote in the column posted by the New England Journal of Medicine on Feb. 28. “In the past week, Covid-19 has started behaving a lot like the once-in-a-century pathogen we’ve been worried about. I hope it’s not that bad, but we should assume it will be until we know otherwise.”
When I came across that article on the morning of March 1 – a Sunday – I thought it might be somewhat alarmist. The 1918 “Spanish flu” took a deadly toll among all age groups; the new coronavirus seemed to be primarily deadly for the elderly and people otherwise compromised. Otherwise, as far as we knew, its flu-like symptoms seemed to pass fairly quickly in those who developed symptoms at all.
That evening, my wife and I attended a black-tie charity event at the Boca West Country Club near our Florida home. There were no masks in sight. Health experts in this country were still weeks away from recommending them. A few leery attendees in the crowd of about 900 avoided handshakes and cheek-kissing; most did not. There were no reported cases in Florida at the time. As far as I know, there were no cases later attributed to the event.
This was pure luck. The virus was indeed well established in this country by that time, and South Florida is a hub of cruise ship activity, where the epidemic found some of its early accelerant. But hindsight, and hindsight bias, is almost as slippery as the virus we are fighting. It routinely infects us even when we are aware of the risk.
Consider the current political jibber jabber about what President Donald Trump “knew” about the virus and when he supposedly knew it. Trump had access to essentially the same information as Gates, whose Bill and Melinda Gates Foundation has been on the front lines of fighting infectious disease for years. Gates, unlike Trump, was not burdened during January and February with extraneous considerations such as running the world’s largest economy, eliminating Iran’s chief architect of international mayhem, and getting past a pointless and partisan impeachment proceeding. Gates had time to focus on the problem that was rapidly spreading from China around the world.
Yet even Gates did not know that we would soon be dealing with a pandemic whose one-year death toll would rival the worst influenzas of the past half-century (if still nowhere near the 1918-19 pandemic’s toll of at least 20 million). He only knew that it was possible. When Gates wrote his column, the World Health Organization had not yet declared COVID-19 a pandemic. While Trump also knew (or should have known) of the risk, how much weight to give it – and how aggressively and early to respond – were judgment calls. Those decisions were his and other leaders’ to make, just as the decision to attend that March 1 gala was mine.
“There are two reasons that Covid-19 is such a threat,” Gates wrote. “First, it can kill healthy adults in addition to elderly people with existing health problems. The data so far suggest that the virus has a case fatality risk around 1%; this rate would make it many times more severe than typical seasonal influenza, putting it somewhere between the 1957 influenza pandemic (0.6%) and the 1918 influenza pandemic (2%).
“Second, Covid-19 is transmitted quite efficiently. The average infected person spreads the disease to two or three others — an exponential rate of increase. There is also strong evidence that it can be transmitted by people who are just mildly ill or even presymptomatic. That means Covid-19 will be much harder to contain than the Middle East respiratory syndrome or severe acute respiratory syndrome (SARS), which were spread much less efficiently and only by symptomatic people.”
Perceptions and responses moved very quickly in those final weeks of winter. Just two days after the event in Boca Raton, I made the decision to have most of my employees begin working from home. I took my last airplane flight on March 6 and went into virtual lockdown immediately afterward. On March 12, Trump announced sweeping restrictions on travel to and from Europe. California’s first “shelter in place” order, in six Bay Area counties, took effect March 17. Similar orders soon followed in the rest of California, New York and elsewhere.
Even as he warned of an impending pandemic, Gates did not recommend closing large swaths of the economy, making people stay home, or even making mask-wearing mandatory. I don’t mean this as a criticism of Gates. Neither he nor anyone else understood how bad things could get, or how quickly – at least not until disaster in northern Italy unfolded on screens around the globe. It also took time for evidence and consensus to develop about the benefits of face covering and the effectiveness of social distancing. Anticipating the pandemic and responding in ways time has proven to be effective are entirely different things.
Gates urged rapid aid to low- and middle-income countries to bolster their care systems, as has been done for Ebola outbreaks in Africa. Such aid was not a priority when even developed economies were in a global tug of war for access to protective medical gear and ventilators in the chaotic weeks of March and April.
But we have done about as well as we could have to execute his call “to build a system that can develop safe, effective vaccines and antivirals, get them approved, and deliver billions of doses within a few months after the discovery of a fast-moving pathogen.” We can’t be sure about the delivery of “billions of doses” yet, but the private and public sectors have spared no expense to lay the necessary groundwork.
Gates did not become (at various times) the world’s richest person without knowing something about how and when to spend money. His message about the costs of dealing with an emerging pandemic – or of not dealing with it – was squarely on target, even if that, too, was not obvious when he shared his thoughts.
“Billions of dollars for antipandemic efforts is a lot of money. But that’s the scale of investment required to solve the problem. And given the economic pain that an epidemic can impose — we’re already seeing how Covid-19 can disrupt supply chains and stock markets, not to mention people’s lives — it will be a bargain.” On that point and others, Gates was right on the money.