The scientific advances we need to stop
COVID-19.
By Bill Gates | April 23, 2020 24 minute read
The coronavirus pandemic pits all of humanity
against the virus. The damage to health, wealth, and well-being has already
been enormous. This is like a world war, except in this case, we’re all on the
same side. Everyone can work together to learn about the disease and develop
tools to fight it. I see global innovation as the key to limiting the damage.
This includes innovations in testing, treatments, vaccines, and policies to
limit the spread while minimizing the damage to economies and well-being.
This memo shares my view of the situation and
how we can accelerate these innovations. (Because this post is long, it is
also available as a PDF.) The situation changes
every day, there is a lot of information available—much of it contradictory—and
it can be hard to make sense of all the proposals and ideas you may hear about.
It can also sound like we have all the scientific advances needed to re-open
the economy, but in fact we do not. Although some of what’s below gets fairly
technical, I hope it helps people make sense of what is happening, understand
the innovations we still need, and make informed decisions about dealing with
the pandemic.
Exponential growth and decline
In the first phase of the pandemic, we saw an
exponential spread in a number of countries, starting with China and then
throughout Asia, Europe, and the United States. The number of infections was
doubling many times every month. If people’s behavior had not changed, then
most of the population would have been infected. By changing behavior, many
countries have gotten the infection rate to plateau and start to come down.
Exponential growth is not intuitive. If you say
that 2 percent of the population is infected and this will double every eight
days, most people won’t immediately figure out that in 40 days, the majority of
the population will be infected. The big benefit of the behavior change is to
reduce the infection rate dramatically so that, instead of doubling every eight
days, it goes down every eight days.
We use something called the reproduction rate,
or R0 (pronounced “are-nought”), to calculate how many new infections are
caused by an earlier infection. R0 is hard to measure, but we know it’s below
1.0 wherever the number of cases is going down and above 1.0 wherever the
number of cases is going up. And what may appear to be a small difference in R0
can lead to very large changes.
If every infection goes from causing 2.0 cases
to only causing 0.7 infections, then after 40 days you have one-sixth as many
infections instead of 32 times as many. That’s 192 times fewer cases. Here’s
another way to think about it: If you started with 100 infections in a
community, after 40 days you would end up with 17 infections at the lower R0
and 3,200 at the higher one. Experts are debating now just how long to keep R0
very low to drive down the number of cases before opening up begins.
Exponential decline is even less intuitive. A
lot of people will be stunned that in many places we will go from hospitals
being overloaded in April to having lots of empty beds in July. The whiplash
will be confusing, but it is inevitable from the exponential nature of
infection.
As we get into the summer, some locations that
maintain behavior change will experience exponential decline. However, as
behavior goes back to normal, some locations will stutter along with persistent
clusters of infections and some will go back into exponential growth. The
picture will be more complex than it is today, with a lot of heterogeneity.
Have we overreacted?
It is reasonable for people to ask whether the
behavior change was necessary. Overwhelmingly, the answer is yes. There might
be a few areas where the number of cases would never have gotten large numbers
of infections and deaths, but there was no way to know in advance which areas
those would be. The change allowed us to avoid many millions of deaths and
extreme overload of the hospitals, which would also have increased deaths from
other causes.
The economic cost that has been paid to reduce
the infection rate is unprecedented. The drop in employment is faster than
anything we have ever experienced. Entire sectors of the economy are shut down.
It is important to realize that this is not just the result of government
policies restricting activities. When people hear that an infectious disease is
spreading widely, they change their behavior. There was never a choice to have
the strong economy of 2019 in 2020.
Most people would have chosen not to go to work
or restaurants or take trips, to avoid getting infected or infecting older
people in their household. The government requirements made sure that enough
people changed their behavior to get the reproduction rate below 1.0, which is
necessary to then have the opportunity to resume some activities.
The wealthier countries are seeing reduced
infections and starting to think about how to open up. Even as a government
relaxes restrictions on behavior, not everyone will immediately resume the activities
that are allowed. It will take a lot of good communication so that people
understand what the risks are and feel comfortable going back to work or
school. This will be a gradual process, with some people immediately doing
everything that is allowed and others taking it more slowly. Some employers
will take a number of months before they require workers to come back. Some
people will want the restrictions lifted more rapidly and may choose to break
the rules, which will put everyone at risk. Leaders should encourage
compliance.
Differences among countries
The pandemic has not affected all countries
equally. China was where the first infection took place. They were able to use
stringent isolation and extensive testing to stop most of the spread. The wealthier
countries, which have more people coming in from all over the world, were the
next to be affected. The countries that reacted quickly to do lots of testing
and isolation avoided large-scale infection. The benefits of early action also
meant that these countries didn’t have to shut down their economies as much as
others.
The ability to do testing well explains a lot of
the variation. It is impossible to defeat an enemy we cannot see. So testing is
critical to getting the disease under control and beginning to re-open the
economy.
So far, developing countries like India and
Nigeria account for a small portion of the reported global infections. One of
the priorities for our foundation has been to help ramp up the testing in these
countries so they know their situation. With luck, some factors that we don’t
understand yet, like how weather might affect the virus’s spread, will prevent
large-scale infection in these countries.
However, our assumption should be that the
disease dynamics are the same as in other countries. Even though their
populations are disproportionately young—which would tend to mean fewer deaths
from COVID-19—this advantage is almost certainly offset by the fact that many
low-income people’s immune systems are weakened by conditions like malnutrition
or HIV. And the less developed a country’s economy is, the harder it is to make
the behavior changes that reduce the the virus's reproduction rate. If you live
in an urban slum and do informal work to earn enough to feed your family every
day, you won’t find it easy to avoid contact with other people. Also, the
health systems in these countries have far less capacity, so even providing
oxygen treatment to everyone who needs it will be difficult.
Tragically, it is possible that the total deaths
in developing countries will be far higher than in developed countries.
What we need to learn
Our knowledge of the disease will help us with
tools and policies. There are a number of key things we still don’t understand.
A number of studies are being done to answer these questions,
including one in Seattle done with the University
of Washington. The global collaboration on these issues is impressive and we
should know a lot more by the summer.
·
Is
the disease seasonal or weather dependent? Almost all respiratory viruses (a group that
includes COVID-19) are seasonal. This would mean there are fewer infections in
the summer, which might lull us into complacency when the fall comes. This is a
matter of degree. Because we see the novel coronavirus spreading in Australia
and other places in the Southern hemisphere, where the seasons are the opposite
of ours, we already know the virus is not as seasonal as influenza is.
·
How
many people who never get symptoms have enough of the virus to infect others? What about people who are recovered and
have some residual virus—how infectious are they? Computer models show
that if there are a lot of people who are asymptomatic but infectious, it is
much harder to open up without a resurgence in cases. There is a lot of
disagreement about how much infection comes from these sources, but we do know
that many people with the virus don’t report symptoms, and some portion of
those might end up transmitting it.
·
Why
do young people have a lower risk of becoming seriously ill when they get
infected? Understanding the
dynamics here will help us weigh the risks of opening schools. It is a
complicated subject because even if young people don’t get sick as often, they
might still spread the disease to others.
·
What
symptoms indicate you should get tested? Some countries are taking the temperature of lots of people
as an initial screening tool. If doing this helps us find more potential cases,
we could use it at airports and large gatherings. We need to target the tests
we have at the people at greatest risk since we don’t have enough tests for
everyone.
·
Which
activities cause the most risk of infection? People ask me questions about avoiding prepared food or door
knobs or public toilets so they can minimize their risk. I wish I knew what to
tell them. Judgements will have to be made about different kinds of
gatherings like classes or church going and whether some kind of spacing should
be required. In places without good sanitation, there may be spread from fecal
contamination since people who are infected shed the virus.
·
Who
is most susceptible to the disease? We know that older people are at much greater risk of both
severe illness and death. Understanding how gender, race, and co-morbidities
affect this is a work in progress.
The Gates Foundation’s role
In normal times, the Gates Foundation puts more
than half of its resources into reducing deaths from infectious diseases. These
diseases are the reason why a child in a poor country is 20 times more likely
to die before the age of five than one in a rich country. We invest in
inventing new treatments and vaccines for these diseases and making sure they
get delivered to everyone who needs them. The diseases include HIV, malaria,
tuberculosis, polio, and pneumonia. Whenever there is an epidemic like Ebola,
SARS, or Zika we work with governments and the private sector to help model the
risks and to help galvanize resources to create new tools to stop the epidemic.
It was because of these experiences that I spoke out about the world not being
ready for a respiratory epidemic in my 2015 TED talk. Although not enough was
done, a few steps were taken to prepare, including the creation of the
Coalition for Epidemic Preparedness Innovation, which I will discuss below, in
the vaccine section.
Now that the epidemic has hit, we are applying
our expertise to finding the best ideas in each area and making sure they move
ahead at full speed. There are many efforts going on. More than 100 groups are
doing work on treatments and another 100 on vaccines. We are funding a subset of
these but tracking all of them closely. It is key to look at each project to
see not only its chance of working but also the odds that it can be scaled up
to help the entire world.
One urgent activity is to raise money for
developing new tools. I think of this as the billions we need to spend so
we can save trillions. Every additional month that it takes to get the vaccine
is a month when the economy cannot return to normal. However, it isn’t clear
how countries will come together to coordinate the funding. Some could go
directly to the private sector but demand that their citizens get priority.
There is a lot of discussion among governments, the World Health Organization,
the private sector, and our foundation about how to organize these efforts.
Innovation to beat the enemy
During World War II, an amazing amount of
innovation, including radar, reliable torpedoes, and code-breaking, helped end
the war faster. This will be the same with the pandemic. I break the innovation
into five categories: treatments, vaccines, testing, contact tracing, and
policies for opening up.Without some advances in each of these areas, we cannot
return to the business as usual or stop the virus. Below, I go through each
area in some detail.
Treatments
Every week, you will be reading about new
treatment ideas that are being tried out, but most of them will fail. Still, I
am optimistic that some of these treatments will meaningfully reduce the
disease burden. Some will be easier to deliver in rich countries than
developing countries, and some will take time to scale. A number of these could
be available by the summer or fall.
If in the spring of 2021 people are going to big
public events—like a game or concert in a stadium—it will be because we have a
miraculous treatment that made people feel confident about going out again.
It’s hard to know precisely what the threshold is, but I suspect it is
something like 95 percent; that is, we need a treatment that is 95 percent
effective in order for people to feel safe in big public gatherings. Although
it is possible that a combination of treatments will have over 95 percent
effectiveness, it’s not likely, so we can’t count on it. If our best treatments
reduce the deaths by less than 95 percent, then we will still need a vaccine
before we can go back to normal.
One potential treatment that doesn’t fit the
normal definition of a drug involves collecting blood from patients who have
recovered from COVID-19, making sure it’s free of the coronavirus and other
infections, and giving the plasma to people who are sick. The leading companies
in this area are working together to get a standard protocol to see if this
works. They will have to measure each patient to see how strong their
antibodies are. A variant of this approach is to take the plasma and concentrate
it into a compound called hyperimmune globulin, which is much easier and faster
to give a patient than unconcentrated plasma. The foundation is supporting a
consortium of most of the leading companies that work in this area to
accelerate the evaluation and, if the procedure works, be ready to scale it up.
These companies have developed a Plasma Bot to help recovered COVID-19
patients donate plasma for this effort.
Another type of potential treatment involves
identifying the antibodies produced by the human immune system that are most
effective against the novel coronavirus. Once those antibodies have been found,
they can be manufactured and used as a treatment or as a way to prevent the
disease (in which case it is known as passive immunization). This antibody
approach also has a good chance of working, although it’s unclear how many
doses can be made. It depends on how much antibody material is needed per dose;
in 2021, manufacturers may be able to make as few as 100,000 treatments or many
millions. The lead times for manufacturing are about seven months in the best
case. Our grantees are working to compare the different antibodies and make
sure the best ones get access to the limited manufacturing capacity.
There is a class of drugs called antivirals,
which keep the virus from functioning or reproducing. The drug industry has
created amazing antivirals to help people with HIV, although it took decades to
build up the large library of very effective triple drug therapies. For the
novel coronavirus, the leading drug candidate in this category is Remdesivir
from Gilead, which is in trials now. It was created for Ebola. If it proves to
have benefits, then the manufacturing will have to be scaled up dramatically.
The foundation recently asked drug companies to
provide access to their pipeline of developed antiviral drugs so researchers
funded by the Therapeutics Accelerator can
run a screen to see which should go into human trials first. The drug companies
all responded very quickly, so there is a long list of antivirals being
screened.
Another class of drugs works by changing how the
human body reacts to the virus. Hydroxychloroquine is in this group. The
foundation is funding a trial that will give an indication of whether it works
on COVID-19 by the end of May. It appears the benefits will be modest at best.
Another type of drug that changes the way a human reacts to a virus is called
an immune system modulator. These drugs would be most helpful for late-stage
serious disease. All of the companies that work in this area are doing
everything they can to help with trials.
Vaccines
Vaccines have saved more lives than any other
tool in history. Smallpox, which used to kill millions of people every year,
was eradicated with a vaccine. New vaccines have played a key role in reducing
childhood deaths from 10 million per year in 2000 to fewer than 5 million per
year today.
Short of a miracle treatment, which we can't
count on, the only way to return the world to where it was before COVID-19
showed up is a highly effective vaccine that prevents the disease.
Unfortunately, the typical development time for
a vaccine against a new disease is over five years. This is broken down into:
a) making the candidate vaccine; b) testing it in animals; c) safety
testing in small numbers of people (this is known as phase 1); d) safety
and efficacy testing in medium numbers (phase 2); e) safety and efficacy
testing in large numbers (phase 3); and f) final regulatory approval and
building manufacturing while registering the vaccine in every country.
Researchers can save time by compressing the
clinical safety/efficacy phases while conducting animal tests and building
manufacturing capacity in parallel. Even so, no one knows in advance which
vaccine approach will work, so a number of them need to be funded so they can
advance at full speed. Many of the vaccine approaches will fail because they won’t
generate a strong enough immune response to provide protection. Scientists will
get a sense of this within three months of testing a given vaccine in humans by
looking at the antibody generation. Of particular interest is whether the
vaccine will protect older people, whose immune systems don’t respond as well
to vaccines.
The issue of safety is obviously very important.
Regulators are very stringent about safety, to avoid side effects and also to
protect the reputation of vaccines broadly, since if one has significant
problems, people will become more hesitant to take any vaccines. Regulators
worldwide will have to work together to decide how large the safety database
needs to be to approve a COVID-19 vaccine.
One step that was taken after the foundation and
others called for investments in pandemic preparedness in 2015 was the creation
of the Coalition for Epidemic Preparedness Innovations (CEPI). Although the
resources were quite modest, they have helped advance new approaches to making
vaccines that could be used for this pandemic. CEPI added resources to work on
an approach called RNA vaccines, which our foundation had been supporting for
some time. Three companies are pursuing this approach. The first vaccine to
start human trials is an RNA vaccine from Moderna, which started a phase 1
clinical safety evaluation in March.
An RNA vaccine is significantly different from a
conventional vaccine. A flu shot, for example, contains bits of the flu virus
that your body’s immune system learns to attack. This is what gives you
immunity. With an RNA vaccine, rather than injecting fragments of the virus,
you give the body the genetic code needed to produce lots of copies of these
fragments. When the immune system sees the viral fragments, it learns how to
attack them. An RNA vaccine essentially turns your body into its own vaccine
manufacturing unit.
There are also at least five leading efforts
that look promising and that use other approaches to teach the immune system to
recognize and attack a viral infection. CEPI and our foundation will be
tracking efforts from all over the world to make sure the most promising ones
get resources. Once a vaccine is ready, our partner GAVI will make sure it is
available even in low-income countries.
A big challenge for vaccine trials is that the
time required for the trials depends on finding trial locations where the rate
of infection is fairly high. While you are setting up the trial site and
getting regulatory approval, the infection rate in that location could go down.
And trials have to involve a surprisingly large number of people. For example,
suppose the expected rate of infection is 1 percent per year and you want to
run a trial where you would expect 50 people to be infected without the
vaccine. To get a result in six months the trial would need 10,000 people in
it.
The goal is to pick the one or two best vaccine
constructs and vaccinate the entire world—that’s 7 billion doses if it is a
single-dose vaccine, and 14 billion if it is a two-dose vaccine. The world will
be in a rush to get them, so the scale of the manufacturing will be
unprecedented and will probably have to involve multiple companies.
I am often asked when large-scale vaccination
will start. Like American’s top public health officials, I say that it is likely
to be 18 months, even though it could be as short as nine months or closer to
two years. A key piece will be the length of the phase 3 trial, which is where
the full safety and efficacy are determined.
When the vaccine is first being manufactured,
there will be a question of who should be vaccinated first. Ideally, there
would be global agreement about who should get the vaccine first, but given how
many competing interests there are, this is unlikely to happen. The governments
that provide the funding, the countries where the trials are run, and the
places where the pandemic is the worst will all make a case that they should
get priority.
Testing
All of the tests to date for the novel
coronavirus involve taking a nasal swab and processing it in a Polymerase Chain
Reaction (PCR) machine. Our foundation invested in research showing that having
patients do the swab themselves, at the tip of the nose, is as accurate as
having a doctor push the swab further down to the back of your throat. Our
grantees are also working to design swabs that are cheap and able to be
manufactured at large scale but work as well as ones that are in short supply.
This self-swab approach is faster, protects health care workers from the risk
of exposure, and should let regulators approve swabbing in virtually any
location instead of only at a medical center. The PCR test is quite
sensitive—it will generally show whether you have the virus even before you
have symptoms or are infecting other people.
There has been a lot of focus on the number of
tests being performed in each country. Some, like South Korea, did a great job
of ramping up the testing capacity. But the number of tests alone doesn’t show
whether they are being used effectively. You also have to make sure you are
prioritizing the testing on the right people. For example, health care workers
should be able to get an immediate indication of whether they are infected so
they know whether to keep working. People without symptoms should not be tested
until we have enough tests for everyone with symptoms. Additionally, the
results from the test should come back in less than 24 hours so you quickly
know whether to continue isolating yourself and quarantining the people who
live with you. In the United States, it was taking over seven days in some
locations to get test results, which reduces their value dramatically. This
kind of delay is unacceptable.
There are two types of PCR machines: high-volume
batch processing machines and low-volume machines. Both have a role to play.
The high-volume machines provide most of the capacity. The low volume machines
are better when getting a result in less than an hour is beneficial. Everyone
who makes these machines, and some new entrants, are making as many machines as
they can. Adding this capacity and making full use of the machines that are
already available will increase the testing capacity. The foundation is talking
to the manufacturers about different ways to run the big machines that could
make them more than twice as productive.
Another type of test being developed is called a
Rapid Diagnostic Test (RDT). This would be like an in-home pregnancy test. You
would swab your nose the same way as for the PCR test, but instead of sending
it into a processing center, you would put it in a liquid container and then
pour that liquid onto a strip of paper that would change color if it detects
the virus. This form of test may be available in a few months. Even though it
won’t be as sensitive as a PCR test, for someone who has symptoms it should be
quite accurate. You would still need to report your test result to your
government since they need visibility into the disease trends.
A lot of people talk about the serology test,
where you give blood and it detects whether you have antibodies against the
virus. If you do, it means you have been exposed. These tests only show
positive results late in your disease, so they do not help you decide whether
to quarantine. Also, all the tests done so far have problems with false
positives. Until we understand what level of antibodies is protective and have
a test with almost no false positives, it is a mistake to tell people not to
worry about their exposure to infection based on the serology tests that are
available today. In the meantime, serology tests will be used to see who can
donate blood and to understand the disease dynamics.
A lot of countries did a good job focusing the
PCR capacity on the priority patients. Most countries had their government play
a central role in this process. In the United States, there is no system for
making sure the testing is allocated rationally. Some states have stepped in,
but even in the best states, the access isn’t fully controlled.
Testing becomes extremely important as a country
considers opening up. You want to have so much testing going on that you see
hot spots and are able to intervene by changing policy before the numbers get
large. You don’t want to wait until the hospitals start to fill up and the
number of deaths goes up.
Basically, there are two critical cases: anyone
who is symptomatic, and anyone who has been in contact with someone who tested
positive. Ideally both groups would be sent a test they can do at home without
going into a medical center. Tests would still be available in medical centers,
but the simplest is to have the majority done at home. To make this work, a
government would have to have a website that you go to and enter your
circumstances, including your symptoms. You would get a priority ranking, and
all of the test providers would be required to make sure they are providing
quick results to the highest priority levels. Depending on how accurately
symptoms predict infections, how many people test positive, and how many
contacts a person typically has, you can figure out how much capacity is needed
to handle these critical cases. For now, most countries will use all of their
testing capacity for these cases.
There will be a temptation for companies to buy
testing machines for their employees or customers. A hotel or cruise ship
operator would like to be able to test everyone even if they don’t have
symptoms. They will want to get PCR machines that give quick results or the
rapid diagnostic test. These companies will be able to bid very high
prices—well above what the public health system would bid—so governments will
have to determine when there is enough capacity to allow this.
One assumption is that people who need to get
tested will isolate themselves and quarantine those in their household. Some
governments police this carefully, whereas others simply assume people will
follow the recommendation. Another issue is whether a government provides a
place for someone to isolate themselves if they can’t do it at their home. This
is particularly important if you have older people in close quarters at your house.
Contact tracing
I mentioned in the testing section that one of
the key priorities for testing is anyone who has been in close contact with
someone who has tested positive. If you can get a list of these people quickly
and make sure they are prioritized for a test like the PCR test (which is
sensitive enough to detect a recent infection), then these people can isolate
themselves before they infect other people. This is the ideal way of stopping
the spread of the virus.
Some countries, including China and South Korea,
required patients to turn over information about where they have been in the
last 14 days by looking at GPS information on their phone or their spending
records. It is unlikely that Western countries will require this. There are
applications you can download that will help you remember where you have been;
if you ever test positive, then you can voluntarily review the history or
choose to share it with whoever interviews you about your contacts.
A number of digital approaches are being
proposed where phones detect what other phones are near them. (It would involve
using Bluetooth plus sending a sound out that humans can’t hear but that
verifies that the two phones are reasonably close to each other.) The idea is
that if someone tests positive then their phone can send a message to the other
phones and their owners can get tested. If most people voluntarily installed
this kind of application, it would probably help some. One limitation is that
you don’t necessarily have to be in the same place at the same time to infect
someone—you can leave the virus behind on a surface. This system would miss
this kind of transmission.
I think most countries will use the approach
that Germany is using, which requires interviewing everyone who tests positive
and using a database to make sure there is follow-up with all the contacts. The
pattern of infections is studied to see where the risk is highest and policy
might need to change.
In Germany, if someone is tested and confirmed
positive, the doctor is legally required to inform the local government health
office. The doctor must provide all personal data—name, address, phone
number—so that the health office can contact the person and ensure they isolate
themselves.
Then the local health office begins the process
of contact tracing. They interview the infected person, find out how to contact
all the people he or she has met in the past couple of weeks, and contact those
people to ask them to self-isolate and get a test.
This approach relies on the infected person to
report their contacts accurately, and also depends on the ability of the health
authorities to follow up with everyone. The normal health service staff can’t
possibly do all this work even if the case numbers are fairly low. Every health
system will have to figure out how to staff up so that this work is done in a
timely fashion. Everyone who does the work would have to be properly trained
and required to keep all the information private. Researchers would be asked to
study the database to find patterns of infection, again with privacy safeguards
in place.
Opening up
Most developed countries will be moving into the
second phase of the epidemic in the next two months. In one sense, it is easy
to describe this next phase. It is semi-normal. People can go out, but not as
often, and not to crowded places. Picture restaurants that only seat people at
every other table, and airplanes where every middle seat is empty. Schools are
open, but you can’t fill a stadium with 70,000 people. People are working some
and spending some of their earnings, but not as much as they were before the
pandemic. In short, times are abnormal but not as abnormal as during the first
phase.
The rules about what is allowed should change
gradually so that we can see if the contact level is starting to increase the
number of infections. Countries will be able to learn from other countries that
have strong testing systems in place to inform them when problems come up.
One example of gradual reopening is Microsoft
China, which has roughly 6,200 employees. So far about half are now coming in
to work. They are continuing to provide support to employees who want to work at
home. They insist people with symptoms stay home. They require masks and
provide hand sanitizer and do more intensive cleaning. Even at work, they apply
distancing rules and only allow travel for exceptional reasons. China has been
conservative about opening up and has so far avoided any significant rebound.
The basic principle should be to allow
activities that have a large benefit to the economy or human welfare but pose a
small risk of infection. But as you dig into the details and look across the
economy, the picture quickly gets complicated. It is not as simple as saying
“you can do X, but not Y.” The modern economy is far too complex and
interconnected for that.
For example, restaurants can keep diners six
feet apart, but will they have a working supply chain for their ingredients?
Will they be profitable with this reduced capacity? The manufacturing industry
will need to change factories to keep workers farther apart. Most factories
will be able to adapt to new rules without a large productivity loss. But how
do the people employed in these restaurants and factories get to work? Are they
taking a bus or train? What about the suppliers who provide and ship parts to
the factory? And when should companies start insisting their employees show up
at work?
There are no easy answers to these questions.
Ultimately, leaders at the national, state, and local levels will need to make
trade-offs based on the risks and benefits of opening various parts of the
economy. In the United States it will be tricky if one state opens up too fast
and starts to see lots of infections. Should other states try to stop people
moving across state boundaries?
Schools offer a big benefit and should be a
priority. Large sporting and entertainment events probably will not make the
cut for a long time; the economic benefit of the live audience doesn’t measure
up to the risk of spreading the infection. Other activities fall into a gray
area, such as church services or a high school soccer game with a few dozen
people on the sidelines.
There is one other factor that is hard to
account for: human nature. Some people will be naturally reluctant to go out
even once the government says it is okay. Others will take the opposite
view—they will assume that the government is being overly cautious and start
bucking the rules. Leaders will need to think carefully about how to strike the
right balance here.
Conclusion
Melinda and I grew up learning that World War II
was the defining moment of our parents’ generation. In a similar way, the
COVID-19 pandemic—the first modern pandemic—will define this era. No one who
lives through Pandemic I will ever forget it. And it is impossible to overstate
the pain that people are feeling now and will continue to feel for years to
come.
The heavy cost of the pandemic for lower-paid
and poor people is a special concern for Melinda and me. The disease is
disproportionately hurting poorer communities and racial minorities. Likewise,
the economic impact of the shutdown is hitting low-income, minority workers the
hardest. Policymakers will need to make sure that, as the country opens up, the
recovery doesn’t make inequality even worse than it already is.
At the same time, we are impressed with how the
world is coming together to fight this fight. Every day, we talk to scientists
at universities and small companies, CEOs of pharmaceutical companies, or heads
of government to make sure that the new tools I’ve discussed become available
as soon as possible. And there are so many heroes to admire right now,
including the health workers on the front line. When the world eventually
declares Pandemic I over, we will have all of them to thank for it.
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