As the valedictorian of her Dallas high school, Melinda Gates delivered a graduation speech that included a quote attributed to Ralph Waldo Emerson. “To know even one life has breathed easier because you have lived,” she told her classmates, “this is to have succeeded.”
Decades later and billions of dollars wealthier, Ms. Gates says the quote is still ringing in her ears. “That’s been my definition of success since high school,” she said. “So if I have an extra dollar, or a thousand dollars, or a million dollars, or in my case, which is absurd, a billion dollars to plow back into making the world better for other people, that’s what I’m going to do.”
As the wife of Bill Gates, the Microsoft co-founder, Ms. Gates now has the capital, clout and connections to have an impact however she pleases. She is one of the richest people in the world, a leading voice in global health and an advocate for women’s economic empowerment. As a face of the Bill and Melinda Gates Foundation, she is also a lightning rod for critics who say billionaires have too much sway over public policy, as well as for conspiracy theorists who harbor darker fantasies.
The Gateses have been sounding the alarm about infectious diseases — and the need to fund vaccination efforts — since the late 1990s. That was when, during travels in Africa and India, the extreme poverty they saw prompted them to reflect on how they might use their wealth to make a difference.
“We just kept saying: ‘What’s going on here? Why isn’t the infrastructure here for roads? Why aren’t we seeing more people who are doing well economically? What’s happened?’” Ms. Gates said. “We started to think about what philanthropy’s role might be and realized that the best place to intervene, if you want somebody to live a full and productive life, was to start with health.”
Since then, the Gates Foundation has given away more than $55 billion, much of it directed at efforts to eradicate disease in the developing world. It has helped to all but wipe out polio, and has poured money into programs aimed at ensuring that poor countries have easy access to vaccines.
When the coronavirus pandemic hit, the foundation turned its attention to the vast and complex project of developing vaccines for the new virus, and ensuring that they could be widely distributed. So far, the foundation has contributed nearly $500 million to coronavirus response efforts. Earlier investments by the foundation are paying off as well — one of the drugmakers it previously funded, BioNTech, has developed a successful Covid-19 vaccine with Pfizer.
Ms. Gates is more optimistic today than she was a couple months ago. Vaccines that appear to be safe and effective are beginning to be deployed. Treatments for the virus have improved. And President-elect Joseph R. Biden Jr. has made beating back the pandemic his top priority.
“The Biden administration will re-enter the global stage and be a participant in making sure the whole world gets vaccines,” Ms. Gates said. She added that the virus team assembled by Mr. Biden was “a very strong, eminent group who are wise and thoughtful and very reasonable.”
Yet Ms. Gates was realistic about the challenges ahead. Vaccine hesitancy is on the rise, disinformation is running rampant on social media, many Americans still refuse to wear masks, and cases are surging again.
“We still have a stretch of very dark months ahead of us," she said.
This interview was condensed and edited for clarity.
You and Bill have been warning about the risk of pandemics for a long time. How has the last year diverged from your expectations?
You can project out and think about what a pandemic might be like or look like, but until you live through it, it’s pretty hard to know what the reality will be like. So I think we predicted quite well that, depending on what the disease was, it could spread very, very, very quickly. The spread did not surprise us.
What did surprise us is we hadn’t really thought through the economic impacts. What happens when you have a pandemic that’s running rampant in populations all over the world? The fact that we would all be home, and working from home if we were lucky enough to do that. That was a piece that I think we hadn’t really prepared for.
What do you think should have been done earlier at the start of the pandemic?
We can look at how this disease traveled around the world and see that the countries who locked down first, they’re doing better. Many African countries saw it coming and locked it down early. Their replication rate just never got as high as many other countries. And that is a good thing.
We should have said sooner that if you’re going to go out, wear a mask. I mean, the fact we’re even still debating that in the United States makes zero sense. Most people get in a car today and know that to save their own life, they ought to wear a seatbelt. Most people would agree that having drunken drivers on the road is a bad thing, not only individually but for us as a society, because it causes more deaths.
Well, masks are just the right thing to do right now. It is insane that we’re at this point in this pandemic, in the United States, and we’re still debating whether people should wear a mask when they go in a store to buy their groceries.
What do you believe are going to be the most serious challenges to conducting an effective and comprehensive vaccination campaign in this country and around the world?
We do know how to get the vaccine out, even in very remote circumstances. Some of the vaccines will be much harder than others and require very substantial cold chains, so those will be hard to get out around the globe. But there are vaccines coming right behind those, so I’m quite optimistic.
The disinformation has been incredibly harsh, and it affects people’s lives. But I’m also hopeful that as the vaccine comes out and people see that it’s safe and efficacious, they will start to take it so that they can go out and return to normal.
To what do you attribute the rise in vaccine hesitancy? Is it as simple as disinformation?
I think, quite honestly, the advent of social media. If you’re a conspiracy theorist and you get connected to somebody else who maybe has heard of the autism problem that didn’t really exist, those things start to connect, and then those conspiracies start to replicate. We’re at a point of a lot of distrust in the country and all over the world. We know people are more polarized. Disinformation is just too easy to spread, and that’s going to cost people their lives.
Say I start to believe PizzaGate and I start clicking all the theories of PizzaGate. What I’m going to get served up on my social media channel is lots more things about conspiracy theories. And if I don’t have anybody pushing back on that, and I’m going down that wormhole, I’m going to start to believe more and more and more disinformation. That’s just not good for society. Between social media and people’s own anxiety and the polarized nature of our country, all these pieces have combined to make sort of a perfect storm around vaccine hesitancy.
Are there some people who will never get vaccinated, never wear a mask? Yes. We’re already seeing that in places in the country. But I think the more important question is: Will there be a broad set of people that will take this vaccine? And I think the answer to that will be yes.
Confused by the all technical terms used to describe how vaccines work and are investigated? Let us help:
- Adverse event: A health problem that crops up in volunteers in a clinical trial of a vaccine or a drug. An adverse event isn’t always caused by the treatment tested in the trial.
- Antibody: A protein produced by the immune system that can attach to a pathogen such as the coronavirus and stop it from infecting cells.
- Approval, licensure and emergency use authorization: Drugs, vaccines and medical devices cannot be sold in the United States without gaining approval from the Food and Drug Administration, also known as licensure. After a company submits the results of clinical trials to the F.D.A. for consideration, the agency decides whether the product is safe and effective, a process that generally takes many months. If the country is facing an emergency — like a pandemic — a company may apply instead for an emergency use authorization, which can be granted considerably faster.
- Background rate: How often a health problem, known as an adverse event, arises in the general population. To determine if a vaccine or a drug is safe, researchers compare the rate of adverse events in a trial to the background rate.
- Efficacy: The benefit that a vaccine provides compared to a placebo, as measured in a clinical trial. To test a coronavirus vaccine, for instance, researchers compare how many people in the vaccinated and placebo groups get Covid-19. Effectiveness, by contrast, is the benefit that a vaccine or a drug provides out in the real world. A vaccine's effectiveness may turn out to be lower or higher than its efficacy.
- Phase 1, 2, and 3 trials: Clinical trials typically take place in three stages. Phase 1 trials usually involve a few dozen people and are designed to observe whether a vaccine or drug is safe. Phase 2 trials, involving hundreds of people, allow researchers to try out different doses and gather more measurements about the vaccine’s effects on the immune system. Phase 3 trials, involving thousands or tens of thousands of volunteers, determine the safety and efficacy of the vaccine or drug by waiting to see how many people are protected from the disease it’s designed to fight.
- Placebo: A substance that has no therapeutic effect, often used in a clinical trial. To see if a vaccine can prevent Covid-19, for example, researchers may inject the vaccine into half of their volunteers, while the other half get a placebo of salt water. They can then compare how many people in each group get infected.
- Post-market surveillance: The monitoring that takes place after a vaccine or drug has been approved and is regularly prescribed by doctors. This surveillance typically confirms that the treatment is safe. On rare occasions, it detects side effects in certain groups of people that were missed during clinical trials.
- Preclinical research: Studies that take place before the start of a clinical trial, typically involving experiments where a treatment is tested on cells or in animals.
- Viral vector vaccines: A type of vaccine that uses a harmless virus to chauffeur immune-system-stimulating ingredients into the human body. Viral vectors are used in several experimental Covid-19 vaccines, including those developed by AstraZeneca and Johnson & Johnson. Both of these companies are using a common cold virus called an adenovirus as their vector. The adenovirus carries coronavirus genes.
- Trial protocol: A series of procedures to be carried out during a clinical trial.
You and Bill have been subject of conspiracy theories, too. Why do you think they’ve targeted you specifically?
I don’t know. I just think that fear is there, and so people are looking to point to somebody or some thing or some institution. And then once it lands on that person or institution, you get sort of a pile-on effect because of social media, and it’s deeply, deeply concerning for society. Our democracy depends on facts, and we depend on having real facts out there to keep ourselves safe and healthy.
Do you believe that the Trump administration’s politicization of the vaccine development process is contributing to that hesitancy?
Absolutely. The Centers for Disease Control and Prevention was set up to give scientific information and guidance to health commissioners in every region of the United States. That agency needs to be left to do its job in terms of real scientific fact. And same thing with the Food and Drug Administration. The F.D.A. is our gold standard. It’s how we know our vaccines are safe and efficacious. So they need to be independent organizations and left as independent so that we can trust them. Unfortunately, the opposite of that has happened during this current administration.
Do you believe the United States will be able to recover its leadership position in public health?
People are looking to the U.S. and saying: “What’s happened? What’s going on?” But I do believe our F.D.A. will hold. I do believe our C.D.C. will hold. I do believe the institutions we have will hold over the long term. I’ve traveled to many different countries and seen where they don’t have good governance or good institutions, or they don’t have a free press. We are lucky to have those things in the United States. And, yes, they have been eroded to some extent, some of them, and, yes, our position in global leadership has people scratching their heads. Can it be built back? Yes. Definitely.
Do you believe it’s appropriate for drug makers to profit from the sale of vaccines in the midst of a pandemic?
I think they should make a small profit, because we want them to stay in business. And at the end of the day, they are beholden to their shareholders. The question is how much profit. And I think during a pandemic like this, it should only be slightly above the marginal cost of the vaccine.
Do you accept the line of criticism that says big philanthropy has too much power right now, that individuals, not governments, are making decisions that shape educational policy and public policy?
I think that’s a critique that is well worth listening to and looking at. In our philanthropic work, there isn’t a single thing that we don’t work on in partnership with governments. Because at the end of the day, it is governments that scale things up and that can help the most people. There is a healthy ecosystem that needs to exist between government, philanthropy, the private sector and civil society. And when you get that ecosystem working at its best, no one party in that ecosystem has too much power.
You know, if Bill and I had had more decision-making authority in education, maybe we would’ve gotten farther in the United States. But we haven’t. Some of the things that we piloted or tried got rejected, or didn’t work, and I think there’s a very healthy ecosystem of parents and teachers’ unions and mayors and city councils that make those education decisions. I wish the U.S. school system was better for all kids.
Do you believe the tax code should be changed in ways that address some of the enormous economic disparities in this country?
Bill and I completely agree if you’re wealthy in this country, you benefited from the system, you benefited from the amazing infrastructure of the United States, and so you have an obligation to give back. And we don’t have a tax policy that is appropriately taxing the wealthiest. I’m not an expert on tax policy, but I will say this: A lot of wealthy people are making a lot off of their capital gains, versus their ordinary income. And I think that’s one place we ought to look at tax policy.
How do you reconcile the enormous privilege that you have with the acute suffering that so many people are experiencing right now?
It’s something I’ve pondered a lot. There’s no explanation how you get to be in this situation of privilege. There’s just none. But I spend a lot of my waking hours, when we’re not in a pandemic, traveling and meeting other people and doing what I call letting my heart break. I’ve worked in Mother Teresa’s home for the dying. I’ve slept on people’s farms in Africa. I do meditation every morning, and I’ve had days of tears thinking about people I know who’ve lost a loved one. It’s going to those places where your heart really hurts for everybody, not just your own sense of loss.
And so I cry a lot, and then I come back and I say, “How do I take what that person shared with me and what I learned, and how do I plow that back into the work to try and make the world better, or to convince a global leader that they ought to give more money to malaria, or care about people getting a vaccine on the other side of the world, or care about a child not getting a proper education in certain cities in the United States?” I just try to constantly remember that it’s a privilege.