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The billionaire and public health leader answers five of Recode’s questions about pandemic prevention and economic disparities.

The WHO estimates that the Covid-19 pandemic has killed almost 15 million people worldwide — not just from the virus, but as an indirect result of the crisis, such as being unable to get other kinds of medical care because hospital systems were overburdened. But it didn’t have to be so catastrophic. Experts say its impacts were exacerbated by a number of factors: The world was ill-prepared for a pandemic, many countries were slow to develop and provide access to Covid-19 tests, and economic inequality made everything worse.

Low- and middle-income countries are still struggling to access lifesaving vaccines, putting these populations at continued risk of contracting the virus. In the US, one preprint paper found that working-class Americans were five times more likely to die from Covid-19 than college-educated Americans. Overall, the pandemic has also widened global income inequality, in part because rich countries have been able to provide more economic relief to their residents while poorer nations have had far fewer tools to recover.

Two years after Covid-19 was declared a pandemic, Bill Gates has written How to Prevent the Next Pandemic, a book that outlines how the Bill and Melinda Gates Foundation co-founder and global health expert believes the world should prepare for future health crises — including how we can tackle the enduring problem of economic inequality that puts already-vulnerable people at even greater risk. In the US, poverty rates fell in 2021 due to pandemic relief spending like stimulus checks and the expanded child tax credit. But since then, poverty has risen again, with child poverty rates sharply rising after the expiration of the expanded child tax credit, which gave many parents a monthly cash benefit from July to December of 2021.

Here are five ideas Gates explored with Recode over email about how to factor in economic inequality when preparing for the next pandemic. The interview has been lightly edited for clarity.

Whizy Kim

In your book, you mention how people are wary of the great influence wealthy philanthropists have today — while also acknowledging that many governments didn’t adequately step up when the pandemic hit.

How can we ensure that the government is able to step up next time? Do you see it as mostly a matter of funding the right agencies (and would that require higher taxes)? Is it a matter of political will? Is it something else?

Bill Gates

I’m hopeful that after the past two years — with millions of lives lost and trillions of dollars of economic impact — every country now understands that they need to be more prepared at a government level. Philanthropy can help test new ideas and mobilize resources faster than the government, but pandemic prevention needs to be funded and supported for the long term, and it requires global collaboration. The world can’t and shouldn’t rely on philanthropy to lead that.

In my book, I write that governments need to prepare for outbreaks and prevent pandemics the way they fund preventative measures and practice for fires and earthquakes. To end preventable diseases and prevent emerging diseases from becoming pandemics, governments will need to increase their investments in R&D for vaccines and therapeutics, integrated disease monitoring, and well-funded multilateral organizations, like the World Health Organization (WHO). They’ll also need to make bigger investments to improve primary health care in all countries.

The natural place for government funding to go is the WHO, since it was created to coordinate global response to health issues. Philanthropy can’t be a voting member of the WHO. It’s up to each member country to decide that the WHO needs to focus on pandemic prevention. But right now, the WHO is not funded to do a lot of work on pandemics. It doesn’t have a significant full-time staff. It doesn’t require countries to go through drills. That needs to change if the world wants to get serious about making Covid the last pandemic.

Whizy Kim

Do you think there will always be a need and a space for private philanthropy to coexist with governments? What, if anything, about the relationship between the private and public sectors needs to change? How do we get there? Who needs to change it?

Bill Gates

Governments play the most critical role in protecting people from infectious diseases and other serious health risks. But I do believe there’s a role for philanthropy to play — for example, we can fund initiatives that governments or the private sector can’t or won’t. Most global health issues, like malaria, need to be solved outside of traditional market-based systems, because they’re never going to be profitable for the private sector. During the Covid pandemic, global collaboration between scientists, philanthropists, and global health institutions (like the ACT Accelerator) developed, tested, and deployed safe and effective vaccines faster than ever before. That’s a great example of how the three sectors can work together to solve these big problems.

Whizy Kim

How might public policies need to change so we’re better prepared for the next pandemic, and what role do you see billionaires/other wealthy philanthropists playing in that?

Bill Gates

One of the biggest tragedies that the world learned through Covid is that governments have not invested enough in the tools they need to effectively prepare for a pandemic. Countries need to step up and develop policies and invest more in enhancing disease monitoring, funding R&D, and strengthening health systems. What I’m trying to do, and the foundation is doing, is to help catalyze new ideas, particularly ones that will help give equitable access to lifesaving tools for people in lower-income countries, who are often left behind as new health innovations come to market. We also play a role in drawing in the private sector by helping companies secure financing to produce tests, therapeutics, and vaccines for low- and middle-income countries.

Whizy Kim

The public discourse around Covid-19 has been extremely polarized and politicized. What’s your takeaway on the role misinformation versus good, reliable information plays in public health outcomes?

Bill Gates

I’m concerned about the spread of misinformation and conspiracy theories about public health because it’s causing people to question their own doctors and to question science. It’s understandable that people are looking for easy answers because it’s been a very scary two years. And I think most people are worried about their own health and the health of their families and loved ones. They’re coming from the right place, but they’re being pulled in by false information.

Whizy Kim

How big a role would you say economic inequality plays in disease outcome? It has impeded vaccine and drug access in low- to middle-income countries, but we’ve seen even within the US that Black and brown communities were some of the hardest hit by Covid-19.

How do we make sure economic inequality isn’t such a major factor in surviving the next pandemic?

Bill Gates

Melinda and I started the Gates Foundation more than two decades ago because we were horrified by the inequity in health around the world. There has been phenomenal progress since then, but even today, a child born in Nigeria is about 28 times more likely to die before her 5th birthday than a child born in the United States.

When Covid emerged, these existing health inequities helped it become a global catastrophe. In my book, I suggest a plan that includes three key measures. First, we need to enhance disease monitoring by developing early warning systems that catch new viruses and outbreaks coordinated across borders, and the world needs to stand up the GERM team, a paid, full-time group committed to pandemic prevention. [Editor’s note: The Global Epidemic Response and Mobilization team is a permanent disease outbreak watchdog group that Gates’s book proposes we create.]

Second, we need to invest more in R&D for next-generation vaccines and effective treatments, and ensure manufacturing capacity in every region of the world. And we have to strengthen global health systems by investing in primary health care, especially in low- and middle-income countries, but also within low-income communities in wealthy countries.

There are programs that focus on equitable health outcomes, like the Global Fund and Global Polio Eradication Initiative, Gavi, the Global Financing Facility, and CEPI. Fully funding those organizations would make a big impact in health equity around the world. [Editor’s note: These are all global health programs that the Gates Foundation has funded. The Global Fund is a public-private partnership that finances the fight against AIDS, tuberculosis, and malaria. The Global Polio Eradication Initiative is a WHO-led public-private partnership that seeks to immunize all children at risk for polio. Gavi is a public-private partnership that strives to improve vaccine access in low-income countries. The Global Financing Facility is a World Bank-led public-private partnership that focuses on promoting the health and nutrition of women and children. And CEPI, the Coalition for Epidemic Preparedness Innovations, is a public-private partnership that invests in vaccine research.]