Bill Gates,  newly free from his role on the Microsoft board, has taken to Reddit to answer the community’s questions about the pandemic, the government response, and what the world can do to be better prepared. Always candid but never cynical, Gates gives some heartening but realistic advice.

Worth noting at the outset is that Gates and the Foundation have been warning about and preparing for an epidemic of this type for years. His 2015 TED talk in particular is extremely prescient, and he wrote a detailed article (PDF) around then for the New England Journal of Medicine detailing the lessons we should learn from the Ebola outbreak. The Foundation also participated in the creation of the Center for Epidemic Preparedness Innovations in 2017. (A recent simulation with Johns Hopkins that has been getting attention for its eerie parallels to the present situation is not in fact a prediction or good comparison.)

You can read all his responses (and the thousands of questions and comments) at the AMA, of course, but the most interesting ones have been lightly edited and condensed below.

Q: What do you think about the current state of testing nationwide?

“The testing in the US is not organized yet…Things are a bit confused on this right now.”

Bill Gates: The testing in the US is not organized yet. In the next few weeks I hope the government fixes this by having a website you can go to to find out about home testing and kiosks. Things are a bit confused on this right now. In Seattle the U of W is providing thousands of tests per day but no one is connected to a national tracking system.

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Whenever there is a positive test it should be seen to understand where the disease is and whether we need to strengthen the social distancing. South Korea did a great job on this including digital contact tracing.

We need to democratize and scale the testing system by having a CDC website that people go to and enter their situation. Priority situations should get tested within 24 hours. This is very possible since many countries have done it. Health care workers for example should have priority. Elderly people should have priority. We will be able to catch up on the testing demand within a few weeks of getting the system in place. Without the system we don’t know what is missing – swabs, reagents etc.

Q: What about this Imperial College study suggesting 1-4 million Americans will die with current approaches, but total shutdown would limit deaths to a few thousand?

Fortunately it appears the parameters used in that model were too negative. The experience in China is the most critical data we have. They did their “shut down” and were able to reduce the number of cases. They are testing widely so they see rebounds immediately and so far there have not been a lot. They avoided widespread infection. The Imperial model does not match this experience. Models are only as good as the assumptions put into them. People are working on models that match what we are seeing more closely and they will become a key tool. A group called Institute for Disease Modeling that I fund is one of the groups working with others on this.

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One tool that is helping us is looking at the genetics of the virus to understand the tree of infection.

Q: Can the 18 month estimate for a vaccine be shortened?

“My retiring from public boards was not related to the epidemic.”

Bill Gates: This is a great question. There are over 6 different efforts going on to make a vaccine. Some use a new approach called RNA which is unproven. We will have to build lots of manufacturing for the different approaches knowing that some of them will not work. We will need literally billions of vaccines to protect the world. Vaccines require testing to make sure they are safe and effective. Some vaccines like the flu don’t for the elderly.

The first vaccines we get will go to health care workers and critical workers. This could happen before 18 months if everything goes well but we and Fauci and others are being careful not to promise this when we are not sure. The work is going at full speed.

Q: (Deleted, but regarding Gates stepping down from the Microsoft board)

Bill Gates: My retiring from public boards was not related to the epidemic but it does reinforce my decision to focus on the work of the Foundation including it’s work to help with the epidemic.

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