Bill Gates expressed confidence that a coronavirus vaccine will be available by 2021. But he remains concerned that doses won’t be made available to lower-income groups, particularly in less developed countries. 

On a conference call, Gates told reporters that the “next big question” his foundation is thinking through is how to manufacture and distribute the vaccines to those most in need. “It shouldn’t just be the rich countries winning a bidding war,” he said. “Misallocating the vaccine would cause dramatic additional deaths.”

Wealthy countries, including the United States, Japan and the United Kingdom, have pre-ordered more than 2 billion doses of coronavirus vaccines, which could leave limited supplies in the coming year. But international efforts are underway to ensure that poorer countries still have access to the vaccine, spearheaded by groups such as the World Health Organization. 

Without a vaccine, the coronavirus could do more to hurt the prospects of vulnerable populations. A new report, dubbed “The Goalkeepers Report,” released Monday by the Bill & Melinda Gates Foundation, explores how the world has already regressed because of Covid-19, with a rise in global poverty across many countries. 

The report cites modeling from Northeastern University that predicts twice as many people could die from Covid-19 if richer countries hoard the first 2 billion vaccine doses rather than distributing them equitably. The report also found that the pandemic is having a disproportionate impact on women, racial and ethnic minority groups, as well as people living in extreme poverty. 

“The pandemic, in almost every dimension, made inequity worse. The poorer countries are suffering far more than the richer countries because of a lack of fiscal resources to go on,” Gates told reporters Friday, ahead of the report’s release. He added that many workers in developing countries can’t easily work from home and are generally paid less. 

As of late August, more than 170 countries expressed interest in joining the Covid-19 Vaccines Global Access Facility, or COVAX, which aims to work with vaccine manufacturers to provide countries with “equitable access to safe and effective vaccines” and protect the most vulnerable populations, such as older people and health-care workers. Its goal is to deliver 2 billion approved Covid-19 vaccine doses by the end of 2021 by scaling manufacturing and buying supply. 

The Bill and Melinda Gates Foundation is a founding partner and donor to global vaccine alliance Gavi, which is leading the COVAX initiative alongside the WHO and the Coalition for Epidemic Preparedness Innovations, or CEPI. 

However, the Trump administration in early September said it won’t join the effort. Secretary of State Mike Pompeo has downplayed the nation’s absence from the initiative, saying “there is no nation that has been more willing and as deeply committed to delivering vaccines all around the world as the United States of America.”

Still, Gates, on the call, didn’t say that wealthy countries like the United States shouldn’t set aside capacity and prioritize doses for their populations. “I don’t think that’s out of line,” he noted, adding that the United States has supplied ample funding for vaccine development. 

That said, the U.S. could still do more to ensure that vaccines are distributed in a more fair and equitable manner. Dr. Moncef Slaoui, who is leading the Trump administration’s Operation War Speed vaccine initiative, told NPR in an interview earlier this month that he “firmly” believes a vaccine will be available before the end of the year for people in high-risk groups. Still, many officials, including White House coronavirus advisor Dr. Anthony Fauci, have predicted a Covid-19 vaccine won’t be widely available to Americans until “several months” into 2021. 

“The one thing that the United States has not done yet, but I’m very hopeful it will, is to allocate substantial resources for the vaccine procurement and other drugs and diagnostics for the pandemic,” Gates said. 

“If they would couple that with their funding of the R&D and facilitate the vaccines to be made in many factories, then you’d have the complete picture there,” Gates said. “So nobody’s saying that … there shouldn’t be any recognition of where the trials have been done, where the R&D funding came from. The way to deal with this problem is to have that capacity be as large as possible.”