Bill Gates: We will have a coronavirus vaccine, but the disease will keep coming back if there's a US 'leadership vacuum'

• Billionaire philanthropist Bill Gates has been warning about the threat of a pandemic for years.
• Gates told Insider US coronavirus testing is "worthless," and that the US response could have been much better with a "modest amount of money."
• But he's confident that scientists will eventually develop a vaccine that's "very effective, and very safe." He worries that if the vaccine is not shared equitably, the virus will "just keep coming back."
• "The 'go it alone thing,' whether it's as an individual or as a country, I do worry about that," he said.

"Slow." "Unfortunate." "Confused." "Worthless."

When you hear Bill Gates talk about the US coronavirus response, his words don't carry the billionaire philanthropist's erstwhile optimistic tone.

"This pandemic is a huge setback," he told Insider.

This is precisely the kind of setback he's been warning of for years, saying we need to prepare for pandemics in the same serious way we prepare for wars.

"It could have been not nearly as bad, with a very modest amount of money," he said.

Still, he suggests there is room for hope.

The Gates Foundation co-founder said he's confident the US could put an end to the pandemic by mustering the country's wartime fighting strength (and money) to lead a global coronavirus vaccine drive.

Insider spoke with Gates in a wide-ranging interview, where he laid out his thoughts on the coronavirus vaccine race, what he'd fix first about the US pandemic response, how to get your neighbors and friends to wear their masks, and what he thinks Joe Biden might do on day one if he becomes the next president.

The US testing system is 'absolutely useless'

Gates grew frustrated in the early days of this year, watching countries like Australia and South Korea pump out coronavirus tests as the US fumbled. One of his own research projects, the Seattle Flu Study, later discovered the first homegrown US coronavirus cases had emerged in January and February, weeks before federal authorities acknowledged community spread.

Gates saw one common denominator among other countries with the best coronavirus responses: they "had been forced to think through the procedures, because they had exposure to the SARS or MERS viruses."

"There are countries that responded very quickly," Gates said. "Number one on the checklist is you call up the commercial PCR [testing] companies and you get them going."

Even now, coronavirus test results in the US take days or weeks, not hours, to get back, which means patients may unwittingly infect others and grow the number of cases in their communities exponentially during that time.

Gates says this is a "worthless" testing system — and it's the first thing he'd fix if he were in charge.

"The saddest thing today is that the majority of the testing is absolutely useless, because the results don't come back in 24 hours," he said.

'The US is the worst of the rich countries in terms of mask usage, which is unfortunate'

Mask compliance in the US is also abysmally low. Gates says this is the second thing, after testing, that he'd fix about America's coronavirus response.

"We need more masks," he said. "The US is the worst of the rich countries in terms of mask usage, which is unfortunate."

But Gates doesn't think forcing people to put on face coverings is the best idea. Instead, he suggests peer pressure as a tactic.

"What you need is that if you're walking around without a mask, people go, 'Hey, buddy, that's inappropriate,'" he said.

"Most good social behaviors, like not littering, it's not because the federal government increased the littering penalties. It's because you get this sense of we're in it together … You really need everyone that you respect, who you listen to, to be setting out that message, and the US just isn't there."

Public health experts should 'apologize' for confusing messages about masks

The fierce anti-mask movement isn't all rebellion. It's partly fueled by confusion and scientists' evolving understanding of a novel pathogen.

At the beginning of the pandemic, "we didn't understand the role of masks," Gates said.

"This respiratory disease actually doesn't involve coughing the same way that almost every other respiratory disease does."

Public health experts, he said, need to "apologize" for not explaining very well how the thinking shifted, as they learned more about asymptomatic and pre-symptomatic spread.

"Even the idea that, 'Oh, masks need to be saved for the health workers.' Yeah, we confused people. So our communication skills starting a few months ago needed to be better at saying why we'd had a counter-revelation," he said.

Despite all this, he finds it baffling that people still grumble about putting masks on.

"The sacrifice of wearing a mask is almost so trivial that you almost hate to use the word 'sacrifice,' but since it's not working without that, you know — wow. I guess we have to push it in some stronger way," he said.

The virus may not be seasonal, but Gates says things could still get much worse this fall

Masks or no masks, as more Americans return to work and school in the months to come, the coronavirus outbreak could get much worse.

"The fall could be tough, we'll be indoors more, it will be colder — we know those are things that push the disease up," Gates said.

The World Health Organization voiced a similar concern recently, saying that even though the coronavirus does not yet appear to be seasonal like the flu, there are a "melange" of factors that can drive disease rates up.

In the fall and winter, there's the additional burden of more seasonal flu cases that will tax the healthcare system. People may also come together more indoors for work, school, and socializing — increasing the odds that infections may spread.

Gates still holds out hope the US could lead the world's vaccine response

Gates said the US drive for vaccine funding and research is the one big thing the country has gotten right in its coronavirus response.

More than 160 different coronavirus vaccine candidates are being developed around the world. But two of the four speediest trials that are testing vaccines in humans right now are US-based: Moderna and Pfizer/BioNTech. Gates sees this aggressive spirit of competitive research as a win, one he's "confident" will, at some point, produce a successful shot.

"Thank goodness we have many vaccines. If we only had the one, the Moderna vaccine, I'd have to say to you, 'Boy, the likelihood of that really driving things back to normal is not super high,'" he said. "Even if the first vaccine to get approved is only modestly effective, somewhere in this set of vaccines is going to be something that's very effective, and very safe."

Still, Gates says vaccines will never put an end to the pandemic if they aren't shared with the world.

"The disease will just keep coming back," he said.

The US has, until recently, shared his passion for this kind of globally-minded public health, playing a key role in eradicating smallpox and funding billions of dollars in HIV treatments globally every year.

But Gates says things are different now, with the US buying up tens of millions of vaccine doses from around the world for itself before they're even approved for use.

"The world has been looking to the US to say, OK, as you're funding all this [research and development] and factories for your own use, do you care about anybody else, or are you creating a leadership vacuum here?" Gates said. "Without the US, the coalition to stop the disease globally just doesn't come together."

He is pressing US lawmakers to spend more on coronavirus response worldwide

Gates is pressing for Congress to allocate more money in its coronavirus spending bill this week to fund the global vaccine drive, and invest in research and development for coronavirus treatments globally.

The current Republican relief plan being circulated offers $3 billion for global vaccines. Gates says the figure should be more than double that: $8 billion all in for global health, with half the money going towards vaccines and half for treatments.

"That would be less than 1% of the bill," Gates said. "But it would, from a humanitarian point of view, and strategic point of view, and getting the epidemic not to come back, it would send a clear message that the US is not being self-centered on this."

Those extra billions could be critical to building vaccine factories for other areas of the world in the months to come, before a shot is ready. That's why Gates says it's critical for the money to be allocated before congressional recess, and the fall election season.

"If it doesn't get into the bill, then you're probably six months before you could get anything," he said. "And that means the factories aren't being built."

Imagining a Biden victory

If Joe Biden wins the presidential election, Gates has an idea for what he should do first upon entering office: listen to the pros.

"Hopefully, there's some vaccine progress," Gates said. "Certainly, he may want more expert advice."

Gates said Biden would "probably choose not to leave the WHO" but more than that, he hopes that he would be a leader who appoints "strong people" to help him out.

"There are lots of people who are involved in the global response to Ebola, and smallpox, and polio, who would love to help out the US bring this thing to a close," he said.

"You really have to view the pandemic as a problem that you're willing to talk about, and willing to admit we've made some mistakes and that we're going to keep learning, and let the voice of the CDC and experts like Dr. Fauci not be restricted, in terms of allowing them to speak to the public — and not be drowned out by whatever treatments you have a personal thought about."

Gates sees the coronavirus like a World War that may be won with strong US leadership

President Trump has referred to himself as a wartime president during the coronavirus pandemic, but Gates doesn't think this is a war the US is winning. There's not enough national unity or willingness for individual sacrifice.

"The 'go it alone thing,' whether it's as an individual or as a country, I do worry about that," he said. "This is a collective thing."

Despite this, Gates said he's optimistic that we can "avoid the next pandemic being like this."

He imagines that diagnostic tools built for the coronavirus could one day help diagnose other diseases, like HIV, malaria, or the seasonal flu. Remote work is also changing the calculus for "how we use telemedicine" and "how many business trips we need to make," he said.

"The world keeps getting smarter," he tells me. "Innovation and generosity in combination will get us out of this thing."