Alan Stolier, MD/


Bill Gates

In 2015 Ezra Klein, founder of the Vox Network asked Bill Gates a question. What are you most afraid of? Gates reply is now well known. He was afraid of a flu-like pandemic “ripping through our hyperglobalized world.” Klein recently interview Gates asking for his vision of life after COVID-19. For me, it’s difficult to ignore Bill Gates when he has something to say. So, I thought I would share some highlights of this conversation.

He was sad that the disease got into exponential growth in the USA and much of Europe leading to more deaths than he had expected. Though physical distancing and social isolation had a favorable impact, it came a huge price. Klein asked him why he thought that we were not reaching death tolls comparable to the 1918 influenza. Gates’ reply was interesting. He noted that most of the world’s population lived in developing countries and that we are yet to find out what’s going to happen in these countries. It is much more difficult to socially isolate in these countries so that it may be too early to predict the overall death toll.

He noted that flu kills an average of 40,000 people per year and yet we still do not fully understand why the flu is seasonal. He pointed out that the best study on asymptomatic carriers of COVID-19 comes from Singapore and appears to be about 6%. He said that other studies showing higher numbers were carried out in a different way and in his opinion (and likely the opinion of the scientists that he consults with) gave unrealistically high numbers.

Gates pointed out that we now little yet about the immune response to the corona virus. For instance, if the response was weak then we would likely not be protected from a second infection. What we need to do is to look at the antibody titer. Currently, most serology tests are just binary, yes or no. We will need titers to get an accurate picture of immunity. For those unfamiliar, there were 2 studies on prevalence of COVID-19 using a binary antibody serology. One was from Santa Clara County carried out by Stanford.  They found COVID-19 prevalence was 2.49% to 4.16% which represented 85-fold more than the number of confirmed cases!  The second study performed by USC in the Los Angeles area for 2.8%-5.6% of the cohort had antibodies. In this case it was estimated that adults in the county that were tested had antibodies representing 28-55 times the number of cases documented. Gates suggested that the false positive rate of these binary studies is extremely high. He said that the Diamond Princess, Singapore study which is ongoing suggests the number is more like 2 to 3 times. There are quantitative serologic tests on populations in 5 different countries ongoing, some of which Gates has sponsored.

Gates was asked why we focused more of threats from each other than from nature. He suggested that the minor epidemics we did have did not hit the US. Places like Taiwan and South Korea were hit with MERS and SARS, and because of that, they had the playbook. They went through all the steps necessary to contain this virus and in the process “saved them 10% of GDP and immense human suffering.” We have not been affected in so long it was not a priority. Gates identified 3 steps in preparing for an epidemic.

  1. Identify all PCR machines and get supplies for the machines. (By the way, Gates’ foundation has found that swabbing the tip of the nose is just as effective as deeper, lending itself to home testing and saving protective gear.)
  2. Therapeutics (requires very few patients)
  3. Vaccines (RNA and DNA based vaccines look very exciting, but we have never been down this path. If it works, it will serve as a platform for future vaccines and allow for quicker responses).

Finally, when asked whether he was worried about a second spike, he said “I’m super worried about it. Unless they’re very gradual and pick the things that we know don’t  raise the rate of infection over one, then you’re going to have this heterogeneity where parts of the US will be doing well and other parts will be doing poorly. The temptation to interdict travel between those parts will be very difficult.

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