The Microsoft cofounder and cochair of the Bill & Melinda Gates Foundation is spending much of his prodigious fortune¹ trying to change the world—by tackling the diseases that hurt the poorest of the poor. But this year, a generation’s worth of progress is being threatened by a once-in a-century pandemic. Can an all-in bet on science and innovation set us back on course?

THIS EDITED Q&A HAS BEEN CONDENSED FOR SPACE AND CLARITY.

PANDEMIC VS. PROGRESS

Since 2017, the Bill & Melinda Gates Foundation has issued an annual scorecard, called the Goalkeepers Report, on how we’re doing in the fight against global poverty and disease. In the latest assessment, you began with words I’m guessing you’ve never uttered before: “This progress has now stopped.”

Gates: Yes, the United Nations developed these goals for humanity, which are about basic needs: getting rid of extreme poverty, providing access to education and health care. And so that creates a framework for us to do a report card every year and try to highlight the countries that are doing things well—we call them exemplars—so that we can get others to adopt best practices. The visibility of gradual progress is very low: Since 2000, we’ve cut childhood death rates in half, for example, but the progress is mostly invisible to people.

This year’s report, however, is quite a contrast. Due to the direct effects of the pandemic, in terms of the deaths it has caused, but also due to its gigantic indirect effects on fragile health systems in the developing countries, we’ve regressed. So routine immunization rates, which we’ve worked to raise to 84% over the last 25 years, are down 14 percentage points in the past year. The pandemic has pushed almost 37 million more people into extreme poverty—until 2020, that number had been going down every year for two decades.² So the call here is to say, “Hey, we’ve got to bring this pandemic to an end.” And then we have to work to catch up and get back to where we were at the start of 2020 on things like vaccination and education, so that we can resume that positive trajectory.

One opportunity for optimism, perhaps, is what seems to be a new wave of collaboration among companies in the wake of COVID-19. Is this new sense of shared purpose in the private sector real?

Well, the pharma industry is certainly stepping up to play their role. A lot of the big companies are agreeing to put their best people on both therapeutics and vaccines, so that’s pretty spectacular. And that’s why we have six vaccine constructs [methods of building vaccine], each of which could possibly be through an FDA Phase III clinical trial and receive an emergency-use license by early next year. The likelihood is that at least two, three, or four of those will probably prove to be both safe and efficacious. Then we’ll be faced with the challenge of scaling up manufacturing to a completely unheard-of level. The form of cooperation that’s never been done before is having a company that did not invent the vaccine provide its factories so that they can scale up that manufacture. Serum Institute of India, for example, has deals with AstraZeneca and [Maryland-based vaccine maker] Novavax. So we’re facilitating those pairings because the Indian manufacturers are much higher volume. They’ve got 5,000-liter tanks and huge built-in extra capacity.

New therapies

The Gates Foundation has also invested heavily in possible medicines to treat COVID-19. What progress are you seeing there?

So far, in the way of therapeutics, there’s dexamethasone [a steroid hormone first approved by the FDA in 1958], which is the only treatment that has significant impact. Even [Gilead Sciences’ antiviral agent] remdesivir, right now, is still showing pretty modest results. But there’s a pipeline of things being tested, including a number of monoclonal antibodies [lab-produced proteins that act like human antibodies, homing in on specific targets], which have the best chance of having fairly dramatic outcomes.³ We don’t know for sure, but the cure rates could be very high, like 70% or 80%. Some of that data will start being published in the next month or two. The Gates Foundation reserved capacity at a factory owned by Fujifilm to manufacture an antibody product. We have to provide them with the thing by sometime in October, so we’re scrambling. If the antibodies don’t work out or if we don’t have the right ones, then we’ll lose some of that money. But that’s fine, because the potential impact of having that capacity, which is significant, would let us get it out to developing countries without having just the rich countries take all that capacity just for their usage.

The Gates Foundation—in a similar vein as BARDA, the U.S. government’s Biomedical Advanced Research and Development Authority—de-risks a lot of the riskier investments that private companies make for the common good. How else can governments encourage innovation on the more revolutionary fronts of science and medicine?

The U.S. is exemplary in this. We’ve got $42 billion a year of NIH money that often lays the research foundation for understanding the biology so that the product innovation can go on and companies can then develop medicines based on that biology. There is all sorts of friction about what drug prices should be, which is a big, complex topic, but the U.S. system—in terms of creating high-paying jobs and leading companies here and in getting the availability of new medicines to the U.S. very quickly—that’s working pretty well.

You mentioned drug pricing. Can these COVID-19 vaccines and medicines be made cheaply enough that the world can afford them?

I have a regular discussion with the pharma CEOs. Their response to the pandemic and this great work that pharma people are doing has reminded many of their capacities and how they can be helpful to the world—as opposed to the industry being viewed as kind of selfish and uncooperative. In the last big, big health crisis we had, when the HIV epidemic came along, the industry didn’t have a willingness initially to do tiered pricing, to get the drugs out to the developing countries [at prices they could afford], and they ended up in a lawsuit with former South African President Nelson Mandela.⁴ Eventually, they did the right thing. And that’s why I think the commitment today by some of these companies to put resources into the vaccine manufacture, and to do it on a nonprofit basis, is pretty valuable.⁵

Trust in science

It’s hard enough producing enough safe and effective vaccines against COVID-19. Persuading billions of people to take them may be harder yet.

The issue is just basic trust—how do people think about vaccines? With all the conspiracy theories out there, you know, we’ve got a challenge with that—not just in the developing countries, but everywhere. The most extreme example was where the polio vaccine was said to be a plot to sterilize women in Nigeria in 2003. And sadly, that led to cases spreading to a dozen countries where the disease had been eliminated.⁶ That was a huge setback. But there we got the trusted religious leaders to get the message out and give the vaccine to their children, and so, eventually, we overcame that. Today, people’s attitudes towards masks and the vaccine, will, in a concrete way, help determine how quickly we bring this pandemic to an end.

Speaking of conspiracy theories, there was an insane one floating on social media about you—that you had somehow created this pandemic. You’re arguably the best-known champion of public health on the planet. How do you get past that sort of crazy?

Well, it’s a new phenomenon. So I can’t say I have some great solution or expertise. And even though it’s so extreme—you could almost say it’s humorous—it is potentially a real problem, particularly when you have some people turning it into a political thing and even talking about taking violent action. So, I’m just learning about this. And, I’m certainly surprised that the organization that’s done more to save lives with vaccines is now being treated as though our goals are kind of the opposite.

Strangely, this is happening at a time when vaccine science in general seems to be advancing at breakneck speed. Can the race to create COVID vaccines help us develop one against, say, malaria?

We actually have a concrete project with Moderna to do a malaria vaccine construct using the messenger RNA platform [a method also being used for some COVID vaccine candidates]. That is somewhat interrupted by the pandemic, but it is an approach that we funded. We started backing these mRNA vaccines almost a decade ago. They are very promising and could be used potentially for HIV and tuberculosis as well.

Billionaire bromance

The legendary investor Warren Buffett, who just turned 90, has entrusted much of his own fortune to your foundation.⁷ What have you learned from him in your long friendship?

I’m talking to Warren actually more regularly this year than at any time during our friendship, which is almost 30 years now. And it’s because of his ability to look at what’s going on in the world and be fascinated and surprised. He and I sit and marvel over the unexpected things that are going on in many frameworks: political, macroeconomic, and in the world at large. He knows so much more about business, and he sees so much. Talking about, “Okay, are people buying furniture this year?” And the answer is yes, actually it’s at higher levels than last year. And going through each of his businesses—where has he seen the demand, and why he thinks that is? Or talking about an Austrian 100-year bond selling at 88 basis points⁸ and what that means. He hears a little bit from me on the digital realm, or about some of this health-related innovation, particularly related to the pandemic. But, you know, we never run out of things to talk about. He just brings such a sophisticated framework—and he always has this humility that goes with it, which makes it so much fun because he’s having fun. He’s also very careful about what he claims to know. You know, I’d rather talk to him about business and the economy than anyone else. 

You’re known for clearing time on your calendar for “Think Weeks,” where you hole up in a cabin, read books, and ponder the world. Why is this so essential?

Adult life is so easy to fill up with activities. The ability to step back and read deeply or think deeply or write up thoughts is largely missing. And so I work hard on my schedule to make sure I’m not filling it up with too many things. It’s been a little bit easier with no travel this year. So I think of myself as a student where I need almost like a reading period to consolidate my knowledge. It was particularly challenging when I was CEO of Microsoft. Eventually, I got to two weeks a year that I was setting aside. Since I retired from Microsoft in 2008, I don’t have to do it necessarily as one block, a week at a time, but I do set aside lots of days, and then I say, “Did I write the memo that I intended to write?” The act of writing—when you try to explain it to someone else—is where you really are forced to think things through and not be sloppy in your thinking.

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Between the lines

(1) Blank check: Since 1994, the Bill & Melinda Gates -Foundation has awarded $54.8 billion in grants (through Q4 2019).

(2) A pandemic’s economic fallout

Projected change in people earning less than $1.90 per day (intl. poverty line):

2018: -1.2%

2019: -1.5%

2020: +7.1%

Source: Gates Foundation

(3) Fast lane for meds: In March, the Gates Foundation partnered with the U.K. foundation Wellcome and Mastercard in a COVID-19 Therapeutics Accelerator designed to speed up—and scale up—the development of treatments.

(4) PR nightmare: In 1998, 39 multinational drugmakers sued the South African government (and Mandela, its former President) for circumventing patent protections on exorbitantly priced medicines for HIV/AIDS. The pharma companies would ultimately lose their legal battle—and much of their reputation.

(5) Rich and poor alike: AstraZeneca and Johnson & Johnson have promised to deliver vaccine on a nonprofit basis through the pandemic. More than 170 nations have signed on to a GAVI-led compact called the COVAX Facility, whose aim is to ensure that vaccines are distributed equitably around the world.

Death averted, compared with a no-vaccine scenario:

When a vaccine is distributed to high-income countries first: 33%

When a vaccine is distributed to countries according to their population size: 61%

Source: Gates Foundation

(6) Ending a scourge: The Gates Foundation has committed $5.5 billion to the global polio eradication effort.

(7) Give it away now: In addition to committing 10 million shares of Berkshire Hathaway stock (in annual payments) to the Gates Foundation, Buffett joined with Bill and Melinda to launch the “Giving Pledge,” an effort to encourage fellow billionaires to commit to giving the majority of their wealth to philanthropy.

(8) Long-lasting bond: In June, the Austrian government issued more than $2 billion worth of “century bonds,” yielding just 0.88%. One hundred years may seem like a long time to wait for little gain—but with much of the world looking for safety, this auction was oversubscribed.

A version of this article appears in the October 2020 issue of Fortune with the headline “The Conversation: Bill Gates.”