[Four health organizations, working closely together, spent almost
$10 billion on responding to Covid across the world. But they lacked
the scrutiny of governments, and fell short of their own goals, a
POLITICO and WELT investigation found.]
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HOW BILL GATES AND PARTNERS USED THEIR CLOUT TO CONTROL THE GLOBAL
COVID RESPONSE — WITH LITTLE OVERSIGHT  
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Erin Banco, Ashleigh Furlong, Lennart Pfahler
September 14, 2022
Politico
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_ Four health organizations, working closely together, spent almost
$10 billion on responding to Covid across the world. But they lacked
the scrutiny of governments, and fell short of their own goals, a
POLITICO and WELT investigation found. _

, Illustrations by Dan Page for POLITICO

 

When Covid-19 struck, the governments of the world weren’t prepared.

From America to Europe to Asia, they veered from minimizing the threat
to closing their borders in ill-fated attempts to quell a viral spread
that soon enveloped the world. While the most powerful nations looked
inward, four non-governmental global health organizations began making
plans for a life-or-death struggle against a virus that would know no
boundaries.

What followed was a steady, almost inexorable shift in power from the
overwhelmed governments to a group of non-governmental organizations,
according to a seven-month investigation by POLITICO journalists based
in the U.S. and Europe and the German newspaper WELT. Armed with
expertise, bolstered by contacts at the highest levels of Western
nations and empowered by well-grooved relationships with drug makers,
the four organizations took on roles often played by governments —
but without the accountability of governments.

While nations were still debating the seriousness of the pandemic, the
groups identified potential vaccine makers and targeted investments in
the development of tests, treatments and shots. And they used their
clout with the World Health Organization to help create an ambitious
worldwide distribution plan for the dissemination of those Covid tools
to needy nations, though it would ultimately fail to live up to its
original promises.

The four organizations had worked together in the past, and three of
them shared a common history. The largest and most powerful was the
Bill & Melinda Gates Foundation, one of the largest philanthropies in
the world. Then there was Gavi, the global vaccine organization that
Gates helped to found to inoculate people in low-income nations, and
the Wellcome Trust, a British research foundation with a multibillion
dollar endowment that had worked with the Gates Foundation in previous
years. Finally, there was the Coalition for Epidemic Preparedness
Innovations, or CEPI, the international vaccine research and
development group that Gates and Wellcome both helped to create in
2017.

(Left to right) Gavi CEO Seth Berkley, former German Chancellor Angela
Merkel, Gates Foundation Co-founder Bill Gates, and former President
Donald Trump. | Getty Images and AP Photos

KEY TAKEAWAYS

1 The four organizations have spent almost $10 billion on Covid since
2020 – the same amount as the leading U.S. agency tasked with
fighting Covid abroad.

2 The organizations collectively gave $1.4 billion to the World
Health Organization, where they helped create a critical initiative to
distribute Covid-19 tools. That program failed to achieve its original
benchmarks.

3 The organizations’ leaders had unprecedented access to the
highest levels of governments, spending at least $8.3 million to lobby
lawmakers and officials in the U.S. and Europe.

4 Officials from the U.S., EU and representatives from the WHO
rotated through these four organizations as employees, helping them
solidify their political and financial connections in Washington and
Brussels.

5 The leaders of the four organizations pledged to bridge the equity
gap. However, during the worst waves of the pandemic, low-income
countries were left without life-saving vaccines.

6 Leaders of three of the four organizations maintained that lifting
intellectual property protections was not needed to increase vaccine
supplies – which activists believed would have helped save lives.

FOLLOW THE MONEY
[[link removed]] | METHODOLOGY
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Civil society organizations active in poorer nations, including
Doctors Without Borders, expressed discomfort with the notion that
Western-dominated groups, staffed by elite teams of experts, would be
helping guide life-and-death decisions affecting people in poorer
nations. Those tensions only increased when the Gates Foundation
opposed efforts to waive intellectual property rights, a move that
critics saw as protecting the interests of pharmaceutical giants over
people living poorer nations.

“What makes Bill Gates qualified to be giving advice and advising
the U.S. government on where they should be putting the tremendous
resources?” asked Kate Elder, senior vaccines policy adviser for the
Doctors Without Borders’ Access Campaign.

Bill Gates (center), shown above with Britain's Prince Charles (right)
and Canada's Prime Minister Justin Trudeau (left) in November 2021,
co-founded one of the largest philanthropies in the world. | Pool
Photo by Phil Noble

Soon, however, governments in the United States and Europe were
offering their own crucial support to the four groups. The
organizations spent at least $8.3 million lobbying the U.S. and E.U.,
according to an analysis of lobbying disclosures. When, this past
spring, the leaders of CEPI sought to replenish the group’s coffers,
it spent $50,000 in part to advocate for $200 million in yearly
funding from the U.S. government, according to filings and interviews
with Capitol Hill staff.

The overtures worked. While President Joe Biden’s efforts to obtain
an additional $5 billion in funding for the administration’s
international work combatting the virus were floundering in Congress,
he still managed to slip $500 million for CEPI into his budget
proposal — $100 million a year for five years.

The money, which has yet to be approved, would help what most global
health experts agree is an important cause, not only in humanitarian
terms but in helping prevent poorer nations from becoming breeding
grounds for new variants. And most believe that the Gates Foundation
and the other groups deserve credit not only for their work to help
save lives but for being almost the only game in town with sufficient
scope to fight a pandemic.

But the groups’ extensive politicking and financial might in the
U.S. and Europe helped to enable them to direct the international
response to the most important health event of the past century at a
time when governments were caught flat-footed, according to the
investigation.

Many people believe that the Gates Foundation and the other groups
deserve credit not only for their work to help save lives but for
being almost the only game in town with sufficient scope to fight a
pandemic. | Moises Castillo/AP Photo

The investigation, which relied on more than four dozen interviews
with U.S. and European officials and global health specialists,
charted the step-by-step journey through which much of the
international response to the Covid pandemic passed from governments
to a privately overseen global constituency of non-governmental
experts. It also detailed the significant financial and political
connections that enabled them to achieve such clout at the highest
levels of the U.S. government, the European Commission and the WHO.

The officials who spoke to POLITICO and WELT hail from the top tiers
of the governments in the U.S. and in Europe, including in the health
agencies. They were granted anonymity to speak candidly about how
their respective administrations approached the international response
to Covid and what missteps occurred during the course of their tenure.
Many of them dealt directly with representatives of the four global
health agencies, some on a daily basis.

POLITICO and WELT examined meeting minutes as well as thousands of
pages of financial disclosures and tax documents, which revealed that
the groups have spent nearly $10 billion since 2020 — the same
amount as the leading U.S. agency charged with fighting Covid abroad.
It is one of the first comprehensive accountings of expenditures by
global health organizations on the global fight against the pandemic.

Now, critics are raising significant questions about the equity and
effectiveness of the group’s response to the pandemic — and the
serious limitations of outsourcing the pandemic response to unelected,
privately-funded groups.

“I think we should be deeply concerned,” said Lawrence Gostin, a
Georgetown University professor who specializes in public-health law.
“Putting it in a very crass way, money buys influence. And this is
the worst kind of influence. Not just because it’s money —
although that’s important, because money shouldn’t dictate policy
— but also, because it’s preferential access, behind closed
doors.”

Gostin said that such power, even if propelled by good intentions and
expertise, is “anti-democratic, because it’s extraordinarily
non-transparent, and opaque” and “leaves behind ordinary people,
communities and civil society.”

While dozens of global health organizations participated in the
world’s response to Covid, the POLITICO and WELT investigation
focused on these four organizations because of their connections to
one another — both Gavi and CEPI received seed funding from the Bill
& Melinda Gates Foundation — and because they together played a
critical role in advising governments and the WHO.

The WHO was crucial to the groups’ rise to power. All had
longstanding ties to the global health body. The boards of both CEPI
and Gavi have a specially designated WHO representative. There is also
a revolving door between employment in the groups and work for the
WHO: Former WHO employees now work at the Gates Foundation and CEPI;
some, such as Chris Wolff, the deputy director of country partnerships
at the Gates Foundation, occupy important positions.

Much of the groups’ clout with the WHO stems simply from money.
Since the start of the pandemic in 2020, the Gates Foundation, Gavi,
and the Wellcome Trust have donated collectively more than $1.4
billion to the WHO — a significantly greater amount than most other
official member states, including the United States and the European
Commission, according to data provided by the WHO.

“You have to remember that when you’re dealing with the Gates
Foundation, it’s almost like you’re dealing with another major
country in terms of their donations to these global health
organizations,” a former senior U.S. health official said.

Working closely with the WHO, the four groups played a central role in
creating an initiative known as the Access to Covid-19 Tools
Accelerator, or ACT-A, that focused on securing and delivering tests,
treatments and vaccine doses to low- and middle-income countries
across the world. COVAX — a special consortium operated by Gavi,
CEPI and UNICEF — is the vaccine pillar of the ACT-A initiative.

But ACT-A missed its delivery goals for 2021 on all three fronts —
for testing, vaccine distribution and treatments, according to an
independent review
[[link removed]] by
Dalberg Global Development Advisors, a policy advisory firm based in
New York.

The ACT-A diagnostics team set a target of making 500 million tests
accessible to low-and middle-income countries by the middle of 2021.
It procured just 84 million tests by June 2021, only 16 percent of its
target, according to the report. The therapeutics team originally set
a goal of delivering 245 million treatments to low- and middle-income
countries by 2021 but later changed the target to 100 million new
treatments by the end of 2021. As of June of that year, the
therapeutics team had allocated only about 1.8 million treatments.

COVAX set the aim of delivering 2 billion vaccine doses by the end of
2021. By September of that year, it had only delivered 319 million
doses.

Although COVAX significantly accelerated the delivery of doses later
in 2021 and in 2022, governments have struggled to get shots into
arms. As of August 2022, only about 20 percent of Africans were
vaccinated — a dangerously low percentage — according to the
Africa CDC.

The leaders of the groups say that they were unable to meet their
goals largely because wealthy, Western governments were slow to step
up and make available the huge tranches of vaccine and therapeutics
that were needed to protect the world. The groups say they provided a
crucial voice for the suffering and needs of poorer nations, without
which the progress may have been far slower.

 

“Putting it in a very crass way, money buys influence. And this is
the worst kind of influence. Not just because it’s money […] but
also, because it’s preferential access, behind closed doors.”

Lawrence Gostin, Georgetown University professor who specializes in
public-health law

“The Gates Foundation focused on supporting a global response that
would ensure low- and middle-income countries had affordable,
equitable access to the best data and tools available to tackle the
crisis,” Mark Suzman, CEO of the Gates Foundation, said in a
statement. “In some areas we saw successes. On the most critical
issue of equitable vaccine access, the world as a whole failed as
high-income countries initially monopolized available supply.” The
foundation declined to make Gates available for comment.

On the struggle to deliver vaccine doses to low- and middle-income
countries on time, Seth Berkley, the CEO of Gavi, said in an interview
that the organization actually met one of its original targets of
distributing 950 million doses by the end of 2021 to low-income
countries, even though it failed to deliver on one of its original
promises to distribute 2 billion doses. (COVAX delivered the 950
million doses by January 2022.)

“It’s very easy to sit there outside and to criticize what we’re
doing. What we need to do is to be evaluated fairly based upon the
actions we took at the time with the knowledge we had at the time,”
Berkley said.

A spokesperson for CEPI put it this way: “While there is much that
we can improve upon, it would be inaccurate to apportion all the blame
for the failures of the global response to the very organizations that
did more than anyone else to try and solve the problems of vaccine
supply and inequity.”

”The challenge we faced was the need to bake in access to vaccines
for poor countries right at the point when companies were able to sell
promising product to the highest bidder,” the spokesperson said.

Jeremy Farrar, the Wellcome Trust director, struck a similar note.
“Comprehensive pandemic preparedness and response requires the sort
of funding and international cooperation that only governments can
muster,” he said.

Farrar, however, defended the ACT-A partnership as “the best
mechanism we have for delivering lifesaving Covid-19 tools across the
world.”

“Before ACT-A was set up, there was no formal mechanism in place to
coordinate and accelerate the development, production and equitable
access to Covid-19 interventions globally,” he said. “While ACT-A
may not be perfect … the global response would have been poorer and
far more fragmented without it.”

The POLITICO and WELT investigation found, however, that ACT-A’s
structure diminished accountability. ACT-A representatives set
funding priorities and campaigned for donations
[[link removed]].
But the money — $23 billion in total — went directly to the
entities involved in the initiative, such as Gavi and CEPI. Although
ACT-A’s website keeps track of how much money was raised, it is
nearly impossible to tell exactly where all of it went.

Based on each organization’s individual Covid database, it is not
possible to delineate exactly how the groups spent the money raised
through ACT-A. It is also difficult to determine in the
organization’s grants and investment data how much they donated
specifically for ACT-A programming. For example, the organizations do
not use “ACT-A” or similar terminology in their descriptions of
their grants and investments.

“In theory, I think that was a great idea,” said Gayle Smith, who
led the U.S. State Department’s global Covid-19 response last year,
referring to ACT-A. But she questioned its accountability.

“In practice … there was no single director,” Smith said.
“Who’s the big boss of this whole enterprise? In a global
emergency like this, we need to be able to get the countermeasures to
everyone everywhere as quickly as possible.”

Bruce Aylward, who coordinates the work of the ACT-Accelerator at the
WHO, said ACT-A was purposely set up with a decentralized structure in
order to cut down on bureaucracy. He said that each agency was in
charge of their own accounting and solidifying agreements directly
with donors.

Smith and others closely involved in the global Covid fight say there
should have been a stronger hand at the tiller.

When vaccine doses started flowing into COVAX, many poor countries and
provinces were ill-equipped to handle them. And during the long
delays, many potential beneficiaries lost faith in the global health
system.

“I think that if we had had the vaccine earlier the coverage would
have been much, much, much better,” said Stephen Bordotsiah, the
municipal director of health services in the Bolgatanga region of
Ghana, which received significant doses from COVAX.

During the long delays in the rollout of the Covid vaccines, many
potential beneficiaries lost faith in the global health system. |
Paula Bronstein/Getty Images

While ACT-A devoted most of its time and resources to securing doses,
little money went to improving health systems on the ground. Of the
$23 billion that ACT-A and its receiving agencies — including Gavi
and CEPI — raised, only $2.2 billion went to the strengthening of
health systems, according to the WHO initiative’s own funding
tracker.

Aylward blamed any of ACT-A’s deficiencies on “factors that were
beyond the control of the accelerator,” he said, including a lack of
government financing for distribution of Covid tools to low-income
countries. “Every politician stood up there and said all the right
things. They wanted to do the right things,” Aylward said. “We got
to create the enabling environment to let them do that.”

Now, the four groups are spending millions of dollars to lobby the
U.S. and EU to embrace their priorities for the next pandemic, some of
which include strengthening local health systems. Other initiatives
involve investing more money in research and development, hoping to
create next-generation vaccines and expanding surveillance networks
across the globe.

Meanwhile, many global health specialists question whether the groups
are capable of performing the rigorous post-mortems necessary to build
a stronger global response system for the future.

 

“No one’s actually holding these actors to account. And they’re
the ones that are really shaping our ability to respond to
pandemics.”

Sophie Harman, professor of international politics, Queen Mary
University of London

“No one’s actually holding these actors to account,” said Sophie
Harman, professor of international politics at Queen Mary University
of London. “And they’re the ones that are really shaping our
ability to respond to pandemics.”

Each of the four organizations said they are doing at least some
internal reflection of their Covid work.

CEPI is wrapping up an assessment of its work over the past five
years, including on Covid, and plans to publish it in full in
September. Representatives for the Gates Foundation and Wellcome said
their respective organizations have completed internal reviews, though
no formal publication of those findings exist on the groups’
websites. Gavi has also commissioned an outside firm to conduct a
review of COVAX and plans to publish its findings. It’s unclear when
that report will be made public. The group published a general
document about lessons learned from Covid
[[link removed]] on
its website on Wednesday.

Representatives of ACT-A said the consortium reviewed its Covid work
following the publishing of the Dalberg report in 2021. It addressed
its recommendations and said how it would improve in a strategic
planning document
[[link removed]] published
on its website in October 2021. It is also tracking that work
internally, a spokesperson for ACT-A said.

CHAPTER 1

FILLING A VOID

Just days before New Year’s Eve 2019, a man in France checked
himself into a hospital, complaining of a fever and shortness of
breath. Doctors didn’t know at the time — and wouldn’t realize
until months later — that the man had likely developed one of the
first cases of Covid-19.

The virus had been circulating in China in the weeks preceding the
man’s hospitalization, but the Beijing government refused to share
details about the newly dubbed SARS-CoV-2. It wasn’t until New
Year’s Eve that the WHO was first notified about the cases of
“viral pneumonia,” which was spreading at an alarming pace.

Top officials across the U.S. and Europe watched the news from afar,
viewing the virus as a problem for Beijing — not the rest of the
world. Top Trump administration officials, including the president,
brushed off warnings. In Europe, a risk assessment from the European
Center for Disease Control and Prevention on Jan. 9 stated “the
likelihood of introduction to the EU is considered to be low, but
cannot be excluded.”

Then, on Jan. 18, the CDC confirmed the first U.S. case of Covid.

Public health officials in the U.S. and Europe scrambled to figure out
how to respond, frantically attempting to close borders and isolate
people who tested positive.

The faltering response shouldn’t have been a surprise: In 2019, the
Trump administration concluded an exercise in which top health
officials determined the U.S. was unprepared to fight a global
pandemic. Three years earlier, in 2016, the United Kingdom had carried
out a simulation exercise for a hypothetical influenza pandemic, which
showed that its health system would become overwhelmed in such an
event.

Top officials across the U.S. and Europe viewed the virus, which
originated in Wuhan, China, shown above in January 2020, as a problem
for the Chinese government — not the rest of the world. | Dake
Kang/AP Photo

Neither the U.S. nor Europe had done much in the interim to boost
their preparedness — though they were considered by the global
health community as perhaps the most capable of all regions of the
world to handle a pandemic. But there were other players —
non-governmental organizations — who were far better prepared,
having dedicated themselves to fighting Zika, Ebola and similar
outbreaks that crossed national boundaries.

The largest was the Bill & Melinda Gates Foundation, whose vast
influence is also the connective thread between the groups.

Bill Gates and Melinda French Gates started the foundation in 2000,
using money from Bill Gates’ Microsoft days to kickstart the
philanthropy. In 2006, Warren Buffett, the CEO of Berkshire Hathaway,
a large holding company, announced that he would donate most of his
fortune to the foundation.

The foundation draws on a $70 billion endowment
[[link removed]] to
grant billions of dollars every year to organizations working on some
of the world’s toughest health problems. Bill Gates recently pledged
that he would give virtually all of his fortune to the foundation and
that the organization would increase its spending from nearly $6
billion annually to about $9 billion by 2026.

One of the largest philanthropies in the world, the Gates Foundation
helped create both Gavi and CEPI and has representatives on both of
their boards.

Gavi was founded in 1999 with $750 million from the Gates Foundation
to strike vaccine deals with pharmaceutical companies for low-income
countries. The vast majority of its financing is made up of donations
from governments. The organization focuses solely on immunization and
its board is made up of multiple representatives from the global
south.

CEPI launched in 2017 with the financial backing from the Gates
Foundation, the Wellcome Trust, Norway and India, with the mission of
funding vaccine research and development. In the last five years, the
organization, which is helmed by Richard Hatchett, a former Obama
administration official, has become one of the world’s leading
nonprofits in vaccine development, garnering donations from powerful,
Western governments.

Dawn O’Connell (right), a former CEPI employee, is the leader of one
of the most important branches in the Department of Health and Human
Services for pandemic preparedness in the U.S. | Pool Photo by Greg
Nash

The Wellcome Trust, which was created in the 1930s in the United
Kingdom by a founder of what was one of the largest pharmaceutical
companies in the world, operates with an endowment of about $38
billion, according to its website. It is one of the largest charitable
foundations in the world and dedicates significant funding to
biomedical research and scientific data modernization. The director of
the trust, infectious disease expert Jeremy Farrar, until recently was
an adviser to the British government on health emergencies.

 

Staff members at Wellcome, CEPI and the Gates Foundation include
former U.S. and European officials — employees who now help the
organizations draw on political and financial support for their
missions. Former staffers of the organizations work in government,
too. For example, Dawn O’Connell is the leader of one of the most
important branches in the Department of Health and Human Services for
pandemic preparedness in the U.S. She used to work for CEPI, helping
raise funds for the organization. And Nicole Lurie, the current U.S.
director of CEPI, used to work in that same position in the health
department.

The global health nonprofits moved quickly in 2020 to fill the
leadership void left by governments still grappling with their
domestic responses, according to lobbying disclosures, meeting minutes
and interviews.

Leaders of the Gates Foundation, Gavi, CEPI and Wellcome deployed
their lobbying and advocacy networks and used their political
connections to push U.S. and European officials to commit billions of
dollars to Covid programs the organizations helped envision and lead.

The extent of their access to global decision-makers attests to their
central role in helping establish the global Covid response: The
groups briefed top officials in the European Commission about
investments in tests, treatments, shots and the importance of sharing
those products with the rest of the world. In the U.K., the
organizations usually met several times a month with ministers to
discuss topics such as Covid testing, clinical trials and
manufacturing capacity. Some of those meetings included Prime Minister
Boris Johnson. Bill Gates and Melinda French Gates — his former wife
— spoke directly to then-German Chancellor Angela Merkel about the
distribution of Covid vaccine, according to German government
documents obtained by POLITICO and WELT.

Bill Gates (left), shown above in 2018, spoke directly to then-German
Chancellor Angela Merkel (right) about the distribution of Covid
vaccines. | Markus Schreiber/AP Photo

Meanwhile, in the U.S., leaders of the organizations were also in
contact with senior U.S. health officials. Emails obtained by
Republicans on Capitol Hill
[[link removed]] illustrate
the extent to which Farrar, the director of Wellcome, was in touch
with officials in some of the highest levels of the U.S. government on
a sensitive health and national security issue. The emails, released
this year, show Farrar in the early weeks of the pandemic discussing
the possibility of Covid having leaked from a lab in China with top
U.S. health officials including Anthony Fauci and National Institutes
of Health Director Francis Collins.

 

Top Trump officials also said they spoke often with Bill Gates and his
foundation’s staff about how to fast-track the development of
medical countermeasures, including vaccines, and how to distribute
them to developing countries. These meetings would grow in number and
intensity as the pandemic unraveled. During the Biden administration,
officials met with members of the four organizations on a weekly
basis, according to two current and one former senior U.S. officials.
The U.S. government is also on Gavi’s board and met with the
organization often to discuss internal matters.

“We relied heavily on their advice throughout the pandemic, but
especially in the early days,” said a former U.S. official about the
federal government’s interactions with representatives from the
organizations.

But even though the foundation’s expertise was obvious — Bill
Gates and Melinda French Gates had made fighting viruses a major part
of their life’s work — the fact that crucial decisions were being
refracted through American billionaires and the massive network
they’d established raised concerns among some officials as well as
grassroots activists on the outside.

“These big men of global health and how they … captured the agenda
and managed to influence what people are thinking around pandemic
preparedness and response – I think that’s really important [to
consider],” Harman said. “[There’s] a revolving door of where
these people are educated, where these people have worked, how they
get the jobs that they’re in – it’s all a really close
network.”

The foundation’s clout and that of its allies wasn’t merely a
function of being the only game in town; it was also the product of
concerted lobbying and advocacy work.

 

“They’re very good lobbyists. The people are very capable and
passionate about their goals. They, of course, also come for funds.”

 A European Union official

“They’re very good lobbyists. The people are very capable and
passionate about their goals,” a European Union official said.
“They, of course, also come for funds.”

Over the last two years, Gavi and CEPI have spent at least $1.3
million on lobbying aimed at obtaining U.S. and European cash to fund
their own enterprises and the causes they supported, according to
lobbying records. Wellcome also lobbied in Europe — spending at
least $1.1 million — to gain political support for its programs.

Meanwhile, the Gates Foundation in 2019 set up a lobbying firm known
as the Gates Policy Initiative, led by Rob Nabors, former White House
deputy chief of staff for policy in the Obama administration. There
are no lobbying disclosure forms on file for the firm.

A spokesperson for the foundation said U.S. law prohibits private
foundations from engaging in lobbying and that the Gates Policy
Initiative is a separate organization from the foundation that does
not coordinate with it on programmatic activities. In a statement, a
spokesperson for the Gates Policy Initiative said the organization is
funded through a “direct gift” provided from Bill Gates and
Melinda French Gates and that it has not engaged in activities that
would require the filing of lobbying disclosure forms.

 

The Gates Foundation’s leaders were also their own best lobbyists.
Multiple former Trump officials and staff on Capitol Hill said Gates
and his team frequently met with lawmakers and administration
officials, including Health Secretary Alex Azar, about the
government’s spending priorities in fighting the pandemic. Azar
could not be reached for comment.

In the EU and the U.K., from 2020 to early 2022 there were over 100
meetings related to Covid or pandemic preparedness between officials
of the four organizations and senior Commission or U.K. officials,
according to lobbying records. Leaders of the organizations attended
some of the meetings, as did the U.K. prime minister and the head of
the European Commission, Ursula von der Leyen. In Germany, CEPI and
Gavi sent numerous letters to the German chancellor’s office over a
two-year period in an effort to elicit more funding for their
respective organizations.

European Commission President Ursula von der Leyen was one of the many
leaders who attended meetings related to Covid or pandemic
preparedness with officials from the four global health organizations.
| Ian Forsyth/Getty Images

All the concerted outreach paid off, both in terms of money and clout.

Since 2020, CEPI and Gavi have raised billions of dollars as a result
of their lobbying. Between 2020 and 2021, the European Commission gave
CEPI over $100 million, while the U.K. contributed more than $330
million, Germany paid over $430 million and the U.S. gave $8 million.
In the case of Gavi, for the period of 2021 to 2025, the U.S. has
pledged over $4.8 billion, the U.K. has allocated over $2.6 billion,
Germany has promised over $2 billion and the European Commission over
$1 billion.

Making plans

FROM THE VERY FIRST WEEKS of the Covid crisis, the organizations
served as coordinators for the global health community. They convened
meetings with key health organizations and made calls to researchers
and officials across the globe. They also reached out to
pharmaceutical companies to gauge their willingness and ability to
quickly scale the production of medical countermeasures should it be
required. Bill Gates gave television interviews
[[link removed]] in
the early months of the pandemic, taking on the posture of a world
leader.

 

On its website, the Gates Foundation says it believes
[[link removed]] working
with governments is an “effective tool” but that “philanthropy
doesn’t — and shouldn’t — take the place of government.”

But throughout the first three months of the pandemic, the four
organizations jumped ahead of the governments in charting the global
nature of the response. They identified companies to work with to
develop medical countermeasures. The Gates Foundation and Wellcome
began to invest and announce grants to companies working to produce
tests and treatments for Covid, according to the POLITICO and WELT
financial analysis.

A spokesperson for the foundation said one of the advantages of its
grants was the ability to “deliver fast and flexible funding” and
to “fill resource gaps,” adding that before the Covid pandemic was
even declared, the organization had granted $10 million to the global
response.

By the end of January, CEPI had already decided to invest $5 million
in four vaccine development projects, according to its board minutes.
The Gates Foundation would go on to invest in vaccine development as
well by extending grants to, for example, the University of Washington
and NYU, and to Oxford University.

Meanwhile, in the recesses of the Trump administration’s health
agencies, officials in January 2020 began discussing vaccine
development with pharmaceutical companies, but contracts with those
entities would not finalize until months later. It would take until
April to fully develop Operation Warp Speed —the team that worked in
coordination with the Department of Health and Human Services to
fast-track the development of the vaccine and to scale its production.
In the meantime, the U.S. focused primarily on responding to Covid
domestically, dedicating limited resources to fighting the virus
abroad.

By contrast, the leaders of the organizations began to develop systems
for distributing those tools abroad, particularly to low- and
middle-income countries.

“In previous global health crises, the U.S. government really had
played that lead role of helping organize the world around getting
vaccines and drugs, and other countermeasures to where they’re most
needed. But the U.S. under the Trump administration wasn’t playing
that role,” said Tom Bollyky, director of the global health program
at the Council on Foreign Relations and an adviser to CEPI. “It
really was left to organizations like the Bill and Melinda Gates
Foundation, Gavi and others, to try to help marshal governments around
a plan.”

Former Trump officials said Gates and his team frequently met with
people in the administration, including Health Secretary Alex Azar
(right), about the government’s spending priorities in fighting the
pandemic. | Drew Angerer/Getty Images

Paul Mango, former deputy chief of staff for policy at the health
department under Trump, confirmed that the U.S. did not start
developing a plan for international vaccine distribution until July of
2020 —more than five months after the virus first emerged. But, he
said, the U.S. began working as early as February of 2020 to identify
potential vaccine candidates, though the administration did not
finalize its financial investments in those companies until months
later.

“We had to evaluate a number of different characteristics of the
company and the vaccine before we invested,” he said in an
interview. “We wanted to see if phase one and two of the clinical
trials revealed good data. That took a couple of months.”

A seat at the table

BEYOND BEGINNING TO GRANT millions of dollars, CEPI and the other
organizations set up international consortiums to shapeshift the
world’s initial response to the pandemic through the WHO.

While governments are responsible for developing their own domestic
responses to infectious disease outbreaks, the WHO acts as a conduit
for member states — composed of 194 countries — to receive
guidance as well as financial help in investigating, containing and
fighting viruses like Covid. The WHO receives billions of dollars
annually, operates out of 150 country offices across the globe and
employs thousands to work on health issues from child mortality to HIV
to nutrition.

Member states vote on policy provisions at the yearly World Health
Assembly in Geneva. The Gates Foundation and the other three
organizations do not have voting power, but their donations give them
an important seat at the table. Wellcome, the Gates Foundation and
Gavi have collectively donated $1.4 billion to the WHO since 2020 and
about $170 million specifically for Covid-related programs since 2020,
according to WHO data.

On a policy level, their clout is even more visible. Until October of
last year, Farrar, the CEO of Wellcome, led one of the WHO’s
scientific advisory groups
[[link removed]] that
explored research and development priorities on Covid.

“They have very, very powerful influence within multilateral
organizations — equal to or above governments,” said another
former senior U.S. health official. “When you’re talking about …
combined … over a billion dollars, that carries with it a lot of
hope and sway.”

Wellcome, the Gates Foundation and Gavi have collectively donated $1.4
billion to the WHO since 2020. | Sean Gallup/Getty Images

At the end of January, 2020, representatives from the Gates Foundation
and Wellcome were a regular presence at meetings with the WHO and top
officials from the U.S. about the virus’ spread, Covid sample
sharing and vaccine and drug clinical trials, according to meeting
minutes. They even helped organize and fund the first truly
international meeting at the WHO to lay the groundwork for the
world’s response to the virus.

 

Wellcome, in collaboration with the Gates Foundation, offered the WHO
funding to host a research meeting in Geneva to connect top health
officials from governments across the world with researchers,
scientists and other major global organizations, according to WHO
meeting minutes. The goal of the meeting: begin a worldwide
conversation about how to begin to study and invest in Covid tests,
therapeutics and vaccines.

David Vaughn, deputy director of vaccine development at the Gates
Foundation, and Josie Golding, the lead of Wellcome’s epidemic
responses, hosted a preparatory meeting Feb. 4, 2020, with U.S.
officials and members of the WHO Scientific Advisory Group, according
to another set of WHO meeting minutes. In the meeting, the
organizations’ representatives suggested that potential funders come
together to discuss the WHO’s research and development blueprint —
a framework for how the international community could respond to the
virus.

By the end of the global conference in the second week of February,
attendees had agreed on a comprehensive road map for the world’s
response to Covid, including how funders would support vaccine, drug
and test development. WHO officials called for $675 million to respond
to Covid.

The Gates Foundation announced that it would dedicate
[[link removed]] $100
million to the effort. At a CEPI board meeting, Hatchett said the
organization had signed four agreements for Covid vaccine development
and that the organization was working closely with the WHO,
dispatching two staff members to work on vaccine development.

Health official Nancy Messonnier’s public warning in late February
forced the Trump White House to recognize the potential threat of
Covid-19. | Samuel Corum/Getty Images

All this global planning was occurring at a time when the Trump White
House was not acknowledging the Covid threat — before health
official Nancy Messonnier’s public warning
[[link removed]] in
late February set off alarm bells.

It would take still longer for national security and health officials
to convince the president to take the virus seriously and consider
steps to control the spread nationwide.

A dangerous spread

BY THE MIDDLE OF February, 2020, Covid had begun spreading to Africa
— where each of the organizations, but particularly the Gates
Foundation, had worked extensively. Africa’s first recorded case was
a 33-year-old man in Egypt, worrying global health officials that a
large-scale outbreak would completely overwhelm the continent’s
health systems.

The Africa Centres for Disease Control and the WHO moved quickly to
send medical supplies and tests to stop the spread of the virus. But
it was too late. The global health organization described the outbreak
as a worldwide pandemic a month later on March 11. Another month after
that, Covid cases topped 10,000 in Africa.

The four global health organizations mobilized quickly to try to
prepare low-income countries, including in Africa, for the coming
assault of cases, the POLITICO and WELT financial analysis showed. In
March, the Gates Foundation granted $47 million to dozens of different
organizations, including the CDC Foundation, the WHO and to
institutions to help detect Covid and develop monoclonal antibodies.
Former CDC director Tom Frieden’s Resolve to Save Lives (formerly
known as Vital Strategies) received close to $1 million to help
strengthen epidemic preparedness capacity for Covid in the African
region.

 

“It was made very, very clear that the United States would never be
sending people — particularly not the military — to other nations
to do that type of work.”

A former senior U.S. official

Despite the spread worldwide, at home the Trump administration
downplayed the danger posed by the virus well into March, claiming
that the U.S. had contained Covid. And the administration maintained
that it would focus on controlling Covid at home, dedicating resources
to the American people, rather than spearheading efforts to help fight
the virus overseas.

“During the Trump administration, even us talking about doing global
work was just constantly shot down,” said one of the former senior
U.S. officials. “When USAID got their funds to provide external
Covid aid, the response funds were going to Gavi … to do that work
on behalf of the United States. It was made very, very clear that the
United States would never be sending people — particularly not the
military — to other nations to do that type of work.”

The European Commission took a different approach
[[link removed]].
It pledged €232 million, roughly the same in U.S. dollars, to aid
the global Covid response, including €15 million to Africa and the
Institute Pasteur of Dakar in Senegal for diagnosis and surveillance
efforts, according to the POLITICO and WELT investigation. The
Commission also put up $2.6 million
[[link removed]] specifically
for the WHO office in Kenya.

Meanwhile, Hatchett, CEO of CEPI, was in the midst of trying to garner
more support for his own organization and its fight to invest in the
development of the vaccine. He wrote to Merkel on March 4, requesting
Germany to help close its financing gap — $375 million. “Without
this investment, CEPI will not be in a position to continue the
COVID-19 vaccine development programme,” Hatchett wrote in a letter
obtained by the POLITICO and WELT-team. Nine days later, CEPI
announced a €140 million funding boost from Germany.

The Trump administration consistently maintained that it would focus
on controlling Covid at home, dedicating resources to the American
people, rather than spearheading efforts to help fight the virus
overseas. | Alex Brandon/AP Photo

At the virtual March 26 G-20 Covid summit, leaders said in a statement
that they would commit to donating resources to the WHO, CEPI and
Gavi. “We call upon all countries, international organizations, the
private sector, philanthropies and individuals to contribute to these
efforts,” the statement said.

The U.S. and EU would eventually dedicate hundreds of millions of
dollars to aiding the global fight against Covid, but the majority of
their contributions to vaccine procurement and distribution would not
come for more than a year —until the summer and fall of 2021. Their
resistance to sharing doses would delay the global vaccination
campaign, denying millions in low-income countries of first doses at a
time when people in the U.S. and Europe were receiving their second.

That hesitation left a gap in global health policy.

The four organizations spent significant amounts of money, starting in
the spring of 2020, to lobby members of Congress to give the
organizations money so they could aid low-income countries, according
to lobbying disclosures. In 2020, Gavi and CEPI spent more than
$435,000 on lobbying Congress and senior officials in the U.S. Agency
for International Development, the White House and the Department of
Health and Human Services. CEPI pushed for specific language in
legislation that would authorize the U.S. government to support its
mission at $200 million a year.

“CEPI and the friends of CEPI … [were] lobbying Congress hard on
this issue and have pushed the language into almost every vehicle that
looks like it is moving,” a former senior U.S. health official said.

The spokesperson for CEPI confirmed the lobbying activities, saying
the organization has “consistently” asked the U.S. government for
$200 million annually. “This ask has been supported by several NGOs
and civil society groups,” the spokesperson said.

Eventually, in October 2020, the Trump administration, through USAID,
pledged $20 million to CEPI. The bulk of the additional U.S. funding
pledges for the global fight against Covid, including $4 billion to
Gavi, would not come through until 2021.

As a response to the growing gap in international Covid funds and
programing, Wellcome, the Gates Foundation and Mastercard in March
2020 created the Covid-19 Therapeutics Accelerator — a collaboration
to raise money for Covid treatments — and committed up to
[[link removed]] $125
million in funding. The accelerator set out to quickly develop and
test drugs to fight Covid.

The investment marked one of the first partnerships to launch a
program to help fast-track the development of a tool that could help
save lives from Covid. It also marked one of the first major
collaborations between the organizations and the pharmaceutical
industry during the pandemic.

‘Moonshot’

AS THE WINTER MONTHS of 2020 gave way to spring and millions of
people across the globe contracted the virus, the global health
organizations began to coordinate and unleash similar investment
strategies, playing key roles in identifying which pharmaceutical and
scientific firms would be earmarked for funding.

Over the following two years, they would grant hundreds of millions of
dollars to dozens of the same organizations. For example, Wellcome and
the Gates Foundation gave $452 million to 18 of the same
organizations, including several companies producing vaccines, tests
and therapeutics, according to the financial analysis.

As the organizations continued to invest in the development of the
Covid shots and medicines, they also began to envision programs that
would help with their distribution.

At the beginning of April 2020, the Gates Foundation produced papers
on programs that could help with equitable distribution of vaccine
doses, tests and therapeutics.

The foundation’s papers focused on the development of ACT-A — the
Access to Covid-19 Tools Accelerator, originally dubbed a “task
force” that aimed to “support the equitable delivery of effective
[and] affordable” Covid tools within a short time period, according
to draft copies. The initiative, designed with significant input from
Gavi and CEPI, was supposed to be the answer to ensuring people in
low- and middle-income countries had access to life-saving medicines
and vaccines.

ACT-A was supposed to be the answer to ensuring people in low- and
middle-income countries had access to life-saving medicines and
vaccines. | Patrick Ngugi/AP Photo

The Gates Foundation, CEPI, Gavi, Wellcome and several other
organizations at one point proposed leading the consortium on their
own, along with several other organizations, according to interviews
with one of the former senior U.S. officials and another global health
official at the WHO.

However, the WHO pushed to oversee the accelerator, worrying some of
the leaders of the global health organizations that the process would
get bogged down in bureaucracy, according to two people who worked
with the organizations on setting up ACT-A. While the WHO oversaw the
initiative in name, the organizations played a significant role in
leading its operations. Other organizations involved in helping lead
ACT-A included Unitaid, UNICEF, and the World Bank.

The organizations pushed back on the idea that they ever tried to
establish the program outside the ranks of the WHO. The Gates
Foundation said it “never proposed leading the consortium” on its
own. Similarly, CEPI said the “WHO was involved all along as an
essential partner.”

Representatives of the foundation also circulated an early paper that
outlined the formation of COVAX — the present-day vaccine sharing
initiative to get doses to low-income countries overseen by Gavi,
according to a draft of the document. COVAX eventually became a part
of ACT-A and morphed into the vaccine pillar of the initiative.

Asked about the paper and the foundation’s involvement in the
formation of COVAX, the spokesperson for Gavi said the original idea
for the vaccine initiative was born out of a January 2020, discussion
between the leaders of Gavi and CEPI.

COVAX is the present-day vaccine sharing initiative to get doses to
low-income countries. | Diomande Ble Blonde/AP Photo

The Gates COVAX paper made its way to U.S. health officials who
briefed Azar, the then-U.S. health secretary, on the paper before a
call with Gates in March 2020, according to a former senior Trump
official.

“The aim is to deploy vaccines in record time (‘moonshot’),”
the paper said.

Instead, though, the initiative moved slowly.

In the first several months after ACT-A’s formation, the consortium
struggled to identify a clear structure — one that would allow for
minimal bureaucracy and the free flow of ideas, according to three
people involved in its creation.

Meanwhile, grassroots organizations fretted
[[link removed]] about
their lack of inclusion in the planning. Board members of the civil
society delegations wrote to the main players in ACT-A in June 2020,
calling for civil society representatives to be meaningfully engaged
in the consortium’s decision making process.

“Too often civil society and communities are asked their opinion too
late, and as a result, initiatives lose valuable insight on
implementation, demand generation, gender perspectives and launch
considerations,” the letter said
[[link removed]].

COVAX, the vaccine pillar of ACT-A, would not bring on civil society
representatives — people who speak for a broader range of
constituencies — officially until October 2020
[[link removed]],
months after its creation.

One EU official said the organizations — at least in the early days
of ACT-A — were not transparent about their decision-making. While
there were almost daily exchanges between EU officials and the
organizations, the person said, there was a lack of consultation on
major decisions, with not enough detail on where the donations from
countries were going.

“They received huge amounts of funds and they should have been more
transparent [about] what it was used for,” the official said.

A representative for ACT-A pushed back on the idea that the consortium
was not transparent in its decision-making. The representative pointed
to the ACT-A website that outlines how the initiative makes decisions
through a series of councils and working groups that include
government officials and civil society representatives. Still, U.S.
and European officials, as well as other global health advocates, said
they were confused by ACT-A’s structure and could not understand its
financing structure.

 

“We took the view that a centralized kind of one organization trying
to tell everybody else what to do wouldn’t work.”

Peter Sands, executive director, the Global Fund

Founders of the WHO consortium said they designed ACT-A without a
clear leader on purpose.

Peter Sands, the executive director of the Global Fund, defended
ACT-A’s structure.

“There is a sort of issue that people raised, which is, there was
nobody in charge. It wasn’t that it was designed like that. It was
designed intentionally as a collaborative leadership model,” Sands
said. “We took the view that a centralized kind of one organization
trying to tell everybody else what to do wouldn’t work.”

Aylward, the lead for ACT-A at the WHO, described the structure as a
“huge success,” adding that it was an intentional decision to have
the agencies involved in the initiative run their own budgets,
programming and donor talks in order to “get money out the door
quickly as possible.

”But money did not flow to ACT-A or the agencies running the
programs quickly enough to help distribute life-saving Covid tools to
low-and middle-income countries.

The battle to establish systems to get vaccine doses and treatments to
countries in need was just beginning — and it would take almost
another year to convince wealthy Western governments to do
significantly more to help.

CHAPTER 2

A RUSH FOR VACCINE DOSES

Throughout the spring and summer of 2020, the global health
organizations poured money into vaccine development.

In July, CEPI announced it would donate $66 million to Clover
Biopharmaceuticals to help the company through its clinical trials.
CEPI, Wellcome and the Gates Foundation invested up to $449 million in
Oxford University — including partnerships with the school and other
companies — for vaccines. Wellcome granted $2.4 million to the Wits
Health Consortium in South Africa to help with research on detecting
and surveilling Covid.

Meanwhile, CEPI and the other organizations faced questions from their
own boards and the global health community about equitable
distribution – how to ensure that low-income countries would get a
fair share of their charitable giving. How would the organization,
along with its partners, convince wealthy, Western countries to help
those living in low-income countries? The die seemed to be cast: In
previous infectious disease outbreaks, tests, treatments and vaccines
had shown up in developing countries last.

Board members raised concerns about entering into agreements with
vaccine companies without fully applying
[[link removed]] equitable
access provisions — provisions that would require the companies to
adhere to certain rules of distribution. Only later would these
provisions be put in place, according to an external review
[[link removed]] of
the equitable access conditions tied to CEPI’s vaccine deals. The
review found that while CEPI had a “robust commitment to equitable
access” its agreements were characterized by “relatively high
levels of trust between parties,” with language such as
“reasonable” and “best efforts” used.

Defending the need for these initial agreements that lacked full
equitable access provisions, the CEPI spokesperson said this was done
“to release small sums of money, which would allow development of
the vaccines to rapidly progress in the face of an impending global
health emergency.”

“This happened at a time when there were no safe, effective vaccines
available at all and when speed was absolutely critical,” the
spokesperson said.

CEPI launched in 2017 with the financial backing from the Gates
Foundation, the Wellcome Trust, India and Norway. Shown above, Norway
Prime Minister Erna Solberg (center) with CEPI Deputy Director
Frederik Kristensen (left) during a visit to CEPI's Oslo office in
April 2020. | Heiko Junge/NTB Scanpix via AP

Berkley, the CEO of Gavi, said he was concerned early on in the
pandemic about the extent to which Western governments would finance
and donate to an operation that primarily served low- and
middle-income countries. His organization and the broader COVAX
initiative have been criticized by other leading global health
advocates for not factoring in that reality earlier and finding a
workaround.

“When it first became clear that this disease was appearing, Richard
[Hatchett] and I sat down and said, we know what happened with the
last swine flu pandemic, where wealthy countries bought up all the
doses that were … available for the developing world, we have to try
to do something different about that,” Berkley said. “When Richard
and I had that meeting, President Trump was down the street saying
that there was no problem – that [Covid] was going to be over
quickly. So, we were a little bit swimming upstream. We had no
money.”

Global health advocates, too, worried that not enough was being done
to ensure low-income countries across the world had access to
life-saving medicines and shots. They argued pharmaceutical companies
— and the funders of their products — needed to do more to expand
access to the vaccine, namely through the sharing of intellectual
property.

 

“We were a little bit swimming upstream. We had no money.”

Seth Berkley, CEO, Gavi

In May 2020, the WHO issued a statement calling on industry,
governments and the global health community to “pool knowledge,
intellectual property.”

Doctors Without Borders supported the call to action. “Sharing this
type of information will allow more manufacturers to quickly produce
medical tools to fight COVID-19 and make sure more people have access
to them,” the organization’s statement from that time
[[link removed]] said.

On its website, the Gates Foundation says
[[link removed]] that
when it grants money, it requires its partners to adhere to its global
access principles — measures that require them to make vaccine doses
widely available at an affordable price. During the pandemic, the
foundation pushed back publicly on pressuring pharmaceutical companies
to share its intellectual property, saying doing so would do little to
spur rigorous vaccine development in the short term.

In one instance, the foundation appears to have helped urge a vaccine
maker to partner with a pharmaceutical company to help scale
production, according to a report by Bloomberg News
[[link removed]],
which cites a call between Bill Gates and reporters. That urging led
Oxford University — a longtime Gates grantee — to share its rights
with just one company — AstraZeneca — rather than sticking to
the university’s own guidance
[[link removed]] that
any deal it makes include non-exclusive and royalty-free licensing.

In May 2020, the WHO issued a statement calling on industry,
governments and the global health community to “pool knowledge,
intellectual property.”

Doctors Without Borders supported the call to action. “Sharing this
type of information will allow more manufacturers to quickly produce
medical tools to fight COVID-19 and make sure more people have access
to them,” the organization’s statement from that time
[[link removed]] said.

On its website, the Gates Foundation says
[[link removed]] that
when it grants money, it requires its partners to adhere to its global
access principles — measures that require them to make vaccine doses
widely available at an affordable price. During the pandemic, the
foundation pushed back publicly on pressuring pharmaceutical companies
to share its intellectual property, saying doing so would do little to
spur rigorous vaccine development in the short term.

In one instance, the foundation appears to have helped urge a vaccine
maker to partner with a pharmaceutical company to help scale
production, according to a report by Bloomberg News
[[link removed]],
which cites a call between Bill Gates and reporters. That urging led
Oxford University — a longtime Gates grantee — to share its rights
with just one company — AstraZeneca — rather than sticking to
the university’s own guidance
[[link removed]] that
any deal it makes include non-exclusive and royalty-free licensing.

Oxford University, a longtime Gates grantee, shared its intellectual
property rights with just one company — AstraZeneca. | Frank
Augstein/AP Photo

When the university struck the deal
[[link removed]],
it gave AstraZeneca sole rights — a step that scientists at the
university had resisted early on in the development of the vaccine,
according to a report by the Wall Street Journal
[[link removed]].

“[Bill Gates] flipped the Oxford position on open licensing,” said
James Love, director of Knowledge Ecology International, a
non-governmental organization that focuses on intellectual property,
who played a key role in negotiations around generic HIV treatments in
the early 2000s. “He had access to heads of state. He had outsized
influence on CEPI and Gavi.”

The Gates Foundation pushed back against that assertion, saying the
foundation did not tell Oxford University to go exclusively with
AstraZeneca and had no role in those negotiations. The spokesperson
for CEPI said the organization’s “policy on and approach towards
intellectual property ownership is independent.”

“We discussed with the University of Oxford the importance of
aligning with a multinational company to ensure their researchers have
the full range of capabilities and resources they need to bring their
vaccine candidate to the world,” said Trevor Mundel, president of
the global health program at the Gates Foundation.

 

“[Bill Gates] flipped the Oxford position on open licensing. He had
access to heads of state. He had outsized influence on CEPI and
Gavi.”

James Love, director of Knowledge Ecology International

Soon after the announcement of the deal, CEPI and Gavi revealed plans
[[link removed]] to
give $750 million to AstraZeneca to secure 300 million doses for
COVAX. AstraZeneca also reported reaching a deal with the Serum
Institute of India — an institute that received significant funding
from the Gates Foundation — to supply one billion doses to low- and
middle-income countries.

Gavi launched the COVAX Facility — a project to pool procurement for
doses that the COVAX effort could then deliver to low- and
middle-income countries at an affordable price — in June, 2020. It
would go on to sign two additional advance purchase agreements with
some of the first vaccines on the market, including Pfizer.

Scaling up

THE U.S. OFFICIALLY LAUNCHED Operation Warp Speed on May 15. By the
summer it began expanding its vaccine development portfolio, investing
$1.6 billion in Novavax’s manufacturing and an initial $1.95
billion
[[link removed]] to
Pfizer for the large-scale manufacturing and nationwide distribution
of 100 million doses. It pledged $2.1 billion to support the
development of Sanofi and GSK’s vaccine
[[link removed]].

In an effort to scale production to provide equitable access to
low-income countries, representatives from the Gates Foundation pushed
U.S. officials to share the immune correlates of protection from Covid
vaccines — immune markers that can help other institutions develop
their own vaccine products, according to an individual with direct
knowledge of the situation.

Trump announced the official launch of Operation Warp Speed during an
event at the White House on May 15, 2020. | Alex Brandon/AP Photo

The Gates Foundation had granted money to organizations working on
Covid vaccine development across the world that were in need of the
correlates to help develop the shots.

If shared, the immune correlates of protection can help the company
establish efficacy without going through an efficacy trial — one
that can take months to complete. U.S. officials agreed and NIH
eventually published the correlates in 2021.

By August 2020, representatives of the Gates Foundation, CEPI, Gavi
and Wellcome also began to raise questions about whether the U.S.
would share doses with the rest of the world. Representatives from the
foundation, including Bill Gates himself, would go on to conduct
several meetings with senior European officials to discuss commitments
to ensure equitable access to vaccines.

Emilio Emini, then one of the leaders working on HIV and tuberculosis
at the foundation, spoke with U.S. officials at Operation Warp Speed
about U.S. vaccine investments, according to two former U.S. officials
and people who worked on the government’s Covid vaccine projects.
Emini would later go on to work with the Biden administration on
vaccine distribution.

But no commitment to equitable distribution was forthcoming.

“The position that the administration was having was to say,
‘let’s not spend a lot of time discussing what we do with the
vaccine doses because the key is to first have vaccine doses.’ We
will get vaccines that work and then we’ll address that problem,”
a person with direct knowledge of the situation said.

A promise of equity

BY SEPTEMBER 2020, nearly 1 million people across the world had died
of Covid and governments were counting the days until the vaccine came
online.

At least four pharmaceutical companies were in or moving into the
third phase of their clinical trials and officials in the U.S. and
Europe were growing more confident that the world would see its first
vaccine dose come to market by the turn of the year.

By September 2020, nearly 1 million people across the world had died
of Covid. | Ed Wray/Getty Images

But within the top ranks of the four organizations and ACT-A, there
was only anxiety. The virus was continuing to spread rapidly across
the world, and poor countries were being left behind.

On Sept. 10, 2020, representatives of the four global health
organizations, including Melinda French Gates, appeared at the first
official meeting of ACT-A — five months after its creation. The
event marked the official push by the consortium to begin ramping up
donation campaigns and pressing governments to build out their
international responses to the virus. ACT-A’s finance committee,
made up of government officials and leaders of the agencies, called
for a total of $38 billion to be donated to the agencies involved in
the initiative, including CEPI and Gavi.

Gavi, in coordination with the WHO, CEPI and UNICEF, took the lead in
setting up a pooled procurement and financing mechanism for
[[link removed]] COVAX
— a mechanism that, for example, helped low-income countries secure
the Serum Institute’s AstraZeneca doses at $3 per dose. Wellcome
helped finance the therapeutics pillar. Several other organizations
helped fund and lead the diagnostics and health systems pillars of
ACT-A. Meanwhile, the Gates Foundation financed the development of
both vaccines and treatments through commitments to Gavi, according to
the POLITICO-WELT financial analysis.

In WHO readouts from ACT-A facilitation council meetings in the fall
of 2020, the consortium announced internally that it had struck deals
to make more than 120 million Covid tests available to low-income
countries for $5 per unit. The Gates Foundation, through two separate
volume guarantees, helped finance the deal with SD Biosensor and
Abbott. The agreement marked one of the first major wins for the WHO
consortium.

But as the ACT-A fundraising began to grow in strength over the course
of the fall of 2020, representatives from civil society and health
advocates in the broader global health community began to raise
questions about the inner workings of the consortium and how decisions
were being made.

For example, it was unclear to outside global health observers how
much ACT-A’s partner agencies were receiving from those fundraising
efforts and how they were using the money to strike deals with the
pharmaceutical industry — a potential inefficiency, if price
controls were not in place, or conflict of interest.

 

“We have struggled to gain access to the documents and the
correspondence… [that would have made it] possible to scrutinize how
decision-making processes have actually happened, and to establish
whether they have been subject to democratic control.”

Katerini Storeng, associate professor, University of Oslo’s Centre
for Development and the Environment

“We don’t have democratic accountability mechanisms that allow us
to scrutinize those interactions,” said Katerini Storeng, associate
professor at the University of Oslo’s Centre for Development and the
Environment, and head of a research project on public-private
partnerships for pandemic preparedness. “A lot of them [ACT-A
meetings] are not formal meetings. … We have struggled to gain
access to the documents and the correspondence… [that would have
made it] possible to scrutinize how decision-making processes have
actually happened, and to establish whether they have been subject to
democratic control.”

Representatives who worked with ACT-A at the WHO say the initiative
was never supposed to resemble a formal organization or legal entity,
rather a loose structure that allowed the groups to scale production
of tests, treatments and vaccine at the same time. So, given the
urgency of the situation, there weren’t a lot of checks and
balances.

“ACT-Accelerator has been set up as a light and simple support
structure,” ACT-A’s first update from September 2020 said. “Some
of this … needs to be in the form of constructive criticism and
learning rather than sort of trying to blame people. There was a lot
of real time problem solving in an extremely uncertain environment,”
said Sands, the executive director of the Global Fund.

The take-care-of-your-own ethos in wealthier countries effectively
drained money from the global fight against Covid. | KB Mpofu/Getty
Images

The four organizations promised — both through their grants and
investments as well as through the formation of ACT-A — to strive to
give everyone in the world, no matter where they lived, equal access
to life-saving medicines and shots. But as the pandemic began to
unravel economies, killing millions, Western countries retreated even
further inward to manage the health crisis, dedicating resources to
national efforts rather than the fight against the virus abroad.

The take-care-of-your-own ethos in wealthier countries effectively
drained money from the global fight against Covid, and arguably served
to misallocate resources, since the virus knew no national boundaries.
It also gave non-governmental organizations funding the effort unusual
sway over policy.

“There is a flaw in the design of global health,” said a top
German health official. “That flaw is that these philanthropists are
needed to improve global health. Lots of things work thanks to them,
but some don’t.”

By October of 2020, the U.S. had shown few signs that it was willing
to scale its international response to Covid. It had committed minimal
resources to the global response.

The Centers for Disease Control and Prevention was one of the few U.S.
agencies working to help low-income countries abroad fight the virus.
In comparison, European Union member countries, together with the
European Commission and the region’s investment bank, had pledged
over €11 billion for vaccines, tests, treatments and economic
recovery in poorer countries. And the Gates Foundation had granted
more than $402 million to various organizations to fight Covid.

By that same time, Wellcome had granted $29.3 million on things like
Covid data modeling, infection control, as well as research studies on
vaccines and therapeutics. And Gavi, together with the Gates
Foundation, signed a deal for another 100 million vaccine doses from
the Serum Institute, bringing the total to 200 million. The foundation
put up $300 million
[[link removed]] for
the partnership that was meant to provide doses for both India and
other low- and middle-income countries.

But this plan, too, fell victim to national concerns. The Serum
Institute, based in India, would a year later halt all exports to
COVAX during the country’s summer surge that killed millions of
people. That disruption would set COVAX deliveries back by months.

A push for donations

IN THE LEAD-UP TO the U.S. election in November 2020, President
Donald Trump’s efforts to downplay the severity of the Covid threat
ran up against the fact that the president himself had contracted it
and more than 220,000 people in the country had died. In Europe, cases
surged. In Switzerland, ICU beds were at capacity in November
[[link removed]],
with the situation being described as “critical.” Italy’s death
numbers soared into the 700s per day — higher than at any time since
April 2020.

As numbers continued to spike across the globe, the four organizations
tried to lock down a clear international allocation mechanism for
tests, treatments and vaccine doses.

But by November 2020, ACT-A still faced a significant financial gap.
It only had $10 billion in the bank.

“Urgent and stronger political support and full financing of the
ACT-Accelerator is needed,” according to a WHO summary
[[link removed]-(act)] of
an ACT-A facilitation council meeting that month.

 

“It didn’t take a rocket scientist to foresee that a global
mechanism was going to be very quickly butchered by the reality of
high-income countries that are just going to pursue their own
individual agendas first.”

Kate Elder, senior vaccine policy adviser, Doctors Without Borders

A COVAX report from November 2020, said COVAX intended to provide
access to at least 2 billion doses to low- and middle-income countries
by the end of 2021. By the end of that month, WHO said COVAX had
raised $2 billion
[[link removed]] —
enough to help it secure 1 billion doses. But COVAX would need another
$5 billion to reach its target by the end of 2021, the WHO said at the
time.

Leaders of COVAX, including those at Gavi, continued to try to procure
doses on the open market, but limited manufacturing capacity blunted
progress. Western countries had already placed orders, eating into the
manufacturing schedule.

“It didn’t take a rocket scientist to foresee that a global
mechanism was going to be very quickly butchered by the reality of
high-income countries that are just going to pursue their own
individual agendas first,” said Elder, the senior vaccine policy
adviser at Doctors Without Borders.

Berkley said COVAX included high-income countries in its original
calculation for dose-sharing with the hope that their inclusion would
get them “more interested in supplying developing countries.” But
that didn’t end up happening until much later — toward the middle
of 2021.

Meanwhile, in Africa, members of the African Union and the Africa
Centers for Disease Control and Prevention launched a different
initiative to procure and deliver doses on the continent. They created
the effort, dubbed the African Vaccine Acquisition Task Team, to
ensure that the people of Africa would have access to vaccine doses.
African leaders were beginning to show signs that they did not have
confidence in COVAX.

African leaders, in response to losing confidence in COVAX, developed
their own vaccine initiative. Shown above, an inmate receives a Covid
vaccine in Harare, Zimbabwe. | Tafadzwa Ufumeli/Getty Images

“This was a deliberate global architecture of unfairness,” Strive
Masiyiwa, who helped secure doses for the African Union, said at a
summit the following year, speaking about vaccine inequity. “Imagine
we live in a village, and there is a drought. There is not going to be
enough bread, and the richest guys grab the baker and they take
control of the production of bread and we all have to go to those guys
and have to ask them for a loaf of bread: That is the architecture
that is in place.”

Beyond the concerns regarding funding, civil society organizations and
other health advocates also grew increasingly frustrated that the
unelected leaders of these global health organizations — mostly men
from Western countries — did little to include other actors,
including representatives from the low-income countries they were
trying to help.

One senior U.S. official equated the leaders to a “cabal.”

“It’s just the same people calling the same people every time
there is an outbreak,” one current senior U.S. official said.
“There’s very little diversity.”

All four organizations pushed back on this assertion, saying they
regularly engage with civil society representatives and officials from
low-income countries they work to serve.

Masiyiwa, the vaccine procurer for the African Union, joined the board
of the Gates Foundation in 2022.

A new lobbying push

THROUGHOUT THE FALL OF 2020, the Gates Foundation and representatives
from CEPI, Gavi and Wellcome ramped up their lobbying and advocacy
efforts.

Bill Gates, Farrar, Berkley and Hatchett all spoke with U.S. officials
and lawmakers to garner their support for COVAX, ACT-A and donating
vaccine doses abroad, according to two former senior U.S. officials.

In the last quarter of 2020, CEPI and Gavi collectively spent more
than $100,000 on lobbying in the U.S. in part to help finance the
organizations’ Covid operations, according to lobbying disclosure
forms. CEPI requested lawmaker support for $200 million annually from
USAID, the disclosures said. The organization’s representatives also
met several times with senior USAID officials to develop a way for the
agency to support CEPI financially, according to a former senior Trump
health official. Gavi spent about tens of thousands of dollars
lobbying Congress and officials at USAID for similar reasons.

In Europe, internal government meeting schedules show Ursula von der
Leyen, the European Commission president, met with Bill Gates in
November to discuss increasing manufacturing in Africa. In the fall
and winter of 2020, CEPI, the Wellcome Trust and the Gates Foundation
also held seven meetings with senior European Commission officials. In
the U.K., Gates and representatives from the pharmaceutical industry,
including Pfizer and Johnson & Johnson, met with Prime Minister Boris
Johnson about the need to increase capacity and supply of treatments
and vaccines worldwide.

The Gates Foundation hired Eurasia Group, a consultancy led by Ian
Bremmer, a U.S. political scientist, to write several papers
addressing European governments on the need for a global approach to
fighting Covid. In one of the papers
[[link removed]],
the group said that Germany’s “share of funding for the ACT-A
program would more than pay for itself.” Tobias Kahler, head of the
foundation’s Germany, Europe, Middle East and East Asia team,
circulated the papers, appealing to German officials to pledge more
money to ACT-A efforts.

The lobbying efforts seemed to work.

In February 2021, then-German Finance Minister Olaf Scholz promised
€1.5 billion additional for COVAX.

The European Union announced in November that it would contribute an
additional €100 million in grant funding to support the COVAX
Facility to secure access to the future Covid-19 vaccines for low- and
middle-income countries. The pledges complemented the original €400
million in guarantees the EU committed for COVAX earlier in the year.

And in December, the U.S. Congress approved a $4 billion commitment to
Gavi through an emergency funding bill.

In response to intense lobbying, Congress approved $4 billion in
funding for Gavi through an emergency funding bill in December 2020. |
Samuel Corum/Getty Images

Despite the new commitments to Gavi at the end of 2020, ACT-A said it
needed $4 billion immediately and an additional $23 billion in 2021 to
help end the pandemic, according to a report its facilitation council
put out that month [[link removed]].

Meanwhile, in the U.S., officials from the health department and the
National Security Council began drafting a list of countries that
would eventually receive American-made vaccine doses, according to two
former senior U.S. officials. They established running lists of both
U.S. allies as well as countries that couldn’t afford the vaccine
and needed help procuring doses or who had helped invest in vaccine
development.

But Trump White House officials and leaders of Operation Warp Speed
resisted calls from inside the administration’s health community to
begin brokering deals with other countries for shipments, arguing
Americans needed them first, one of the former U.S. officials said.

Vaccines come online

COVID DOSES BEGAN ROLLING OUT en masse in the U.S. and across Europe
in January 2021. Immunocompromised adults and the elderly were first
in line.

By February, the U.K. celebrated administering 15 million doses. But
other parts of Europe, particularly in Eastern Europe, had yet to
administer any doses.

The crisis roiled the region as European officials faced accusations
that the European Medicines Agency had taken too long to approve the
Pfizer, Moderna and AstraZeneca shots. The U.S. had brokered
meaningful relationships with pharmaceutical companies through
Operation Warp Speed. Europe, however, was slow to establish similar
connections, making it nearly impossible for European officials to
deliver on their distribution promises. By the end of March, only 11
percent of Germans had received their first dose.

Although the vaccination campaign was just getting underway, the Gates
Foundation was already trying to prepare politicians for coming
pandemics. In an annual letter to German Chancellor Angela Merkel,
Bill Gates and Melinda French Gates wrote: “It is not too soon to
start thinking about the next pandemic.” The letter advocates
increasing investment in R&D, calling organizations like CEPI
“invaluable.”

CEPI and Gavi sent numerous letters to the German chancellor’s
office over a two-year period in an effort to elicit more funding for
their respective organizations. | Pool Photo by Francisco Seco

If the vaccine rollouts across Europe were slow, they were essentially
non-existent in low-income countries — especially in some African
nations, particularly those in sub-Saharan Africa. In the first week
in January, deaths on the continent rose by 50 percent from the two
weeks prior, with cases in South Africa accounting for the majority,
according to data published by the Africa CDC.

It wasn’t until almost three months after people in the U.S. and EU
received their first doses that Africa administered its first shot on
March 1, 2021. Armed with the first shipments, Côte d’Ivoire and
Ghana doled out their first doses. Officials in Ghana said in
interviews that the bulk of the first tranche went to health care
workers and people who were immunocompromised.

Still, COVAX was unable to secure enough doses to deliver to
vulnerable populations in low-income countries. There was no
additional manufacturing capacity that would allow for the production
of at-cost doses.

 

“This was a deliberate global architecture of unfairness.”

 Strive Masiyiwa, vaccine procurer for the African Union

Representatives of the four organizations urged Western countries to
begin thinking about donating doses to COVAX.

“That was not part of the COVAX idea, originally, because we don’t
believe that a pandemic should be dealt with through donations. We
believe there ought to be orders and plans for countries and a
diversity of doses,” Berkley said. “One of the problems is we
couldn’t get doses at that point. And so we opened up for donations.
That was complicated.”

CHAPTER 3

PROMISES UNKEPT

While people in the U.S. and Europe lined up to receive shots,
believing that the worst of Covid would soon be behind them, African
nations struggled to contain the spread.

At a series of meetings at the WTO in the spring of 2021, the sense of
imbalance was so strong that officials from across the world debated
whether to implement an intellectual property waiver for Covid vaccine
so low-income countries could begin developing the shots on their own.

The U.S. and the European Union pushed back against the waiver,
frustrating health advocates who viewed the move as indicative of
their close alignment with the pharmaceutical industry.

(Left to right) Moderna CEO Stéphane Bancel, WTO Director General
Ngozi Okonjo-Iweala and Pfizer CEO Albert Bourla. | Getty Images and
AP Photos

African officials publicly voiced concerns about the lack of
distribution on the continent, fearful that they would need to jockey
diplomatically for donations in order to protect their people. Others
expressed dismay that massive pharmaceutical companies had refused to
share their intellectual property and technical know-how with
low-income countries — a step many argued would help with production
in Africa.

“The fact is that each additional day the vaccine shortage
continues, people will pay with their lives,” WTO Director General
Ngozi Okonjo-Iweala declared at a March 2021 WTO meeting between
representatives of the U.K.-based Chatham House, a think tank, and
leaders from the manufacturing industry. She called on vaccine
manufacturers to ramp up production in developing countries.

The pharmaceutical industry and some leading global health
institutions had long pushed back against waiving intellectual
property protections, arguing it would do little to scale
manufacturing, particularly in the case of Covid. One former senior
Trump official who worked on the U.S. response to Covid agreed with
that contention, calling the argument for intellectual property
sharing “bullshit.”

“The idea that these African countries had the capacity to
manufacture on their own — even with the intellectual property
waivers — is naive,” the former official said.

 

“The idea that these African countries had the capacity to
manufacture on their own — even with the intellectual property
waivers — is naive.”

A former senior Trump official

For other health advocates, the sharing of intellectual property and
technical know-how was seen as a chance to provide a dramatic boost in
self-sufficiency for traditionally excluded countries, one that would
carry over into the next crisis.

“You’ve had this critical moment with Covid-19 like you had with
the AIDS crisis, where there could be a moment where we can say …
the current system of patents and access to medicines is unfair. This
could be an opportunity for us to change this,” said Harman, the
professor of international politics at Queen Mary University of
London. “Instead … you’ve seen these institutions like Gavi,
with the backing of the EU, and the U.K. government … switching and
saying, what we’ll do is we’ll just create this very convoluted
model that doesn’t work.”

The WHO, which publicly advocated for intellectual property waivers
for Covid treatments, tests and vaccines, attempted to introduce
measures that would provide a temporary solution for the lack of
vaccine distribution in low- and middle-income countries. However,
none of them solved the immediate access problem.

For example, in May of 2020, the WHO created the COVID-19 Technology
Access Pool, also known as C-TAP, a mechanism that would allow
pharmaceutical companies to share both their intellectual property and
how to produce their Covid products. The Medicines Patent Pool, an
organization that facilitates voluntary licensing and pooling drug
patents, implemented similar mechanisms for HIV drugs, and was
supposed to play a key role in facilitating the licensing deals.

But, Love said, the Gates Foundation pushed for C-TAP not to include
vaccines. Another person familiar with the C-TAP discussions confirmed
that view.

“C-TAP and Medicines Patent Pool were told to stay away from
vaccines in 2020,” he said.

The argument from the foundation, according to the person familiar:
Intellectual property wasn’t a concern in relation to vaccines and
as such vaccines didn’t need to be part of the new mechanism.

 

In May 2020, the WHO created the COVID-19 Technology Access Pool, also
known as C-TAP, a mechanism that would allow pharmaceutical companies
to share both their intellectual property and how to produce their
Covid products. | Leon Neal/Getty Images

At the time, global health advocates blamed the downfall of C-TAP and
its inability to get off the ground on the refusal of pharmaceutical
companies to engage in sharing their intellectual property or provide
more open licensing for their drugs and vaccines. That campaign,
advocates say, was supported by Bill Gates, who has been a stringent
supporter of protecting intellectual property rights throughout his
career
[[link removed]].

Bill Gates wasn’t the only person in the global health community who
at the time pushed back against intellectual property waivers. Other
organizations, including Gavi and CEPI, and Western governments did
not outwardly support the measure, either.

Hatchett, the CEO of CEPI, acknowledged on an Economist podcast
[[link removed]] in
May 2021, that intellectual property was “one aspect of the barriers
that are perhaps inhibiting vaccine production.”

“But I think there are pathways to creating that global capacity
that don’t require a waiver of intellectual property rights,” he
quickly added.

Gavi’s Berkley has also not publicly supported an intellectual
property waiver on Covid vaccine technology. He would go on to say in
April 2022, in front of the Canadian foreign affairs committee that a
waiver would not have made a difference in getting doses to low-income
countries earlier. “The critical issue is know-how,” he said.
“Patents have not been the blocking factor here.”

Pharmaceutical companies steered clear of C-TAP. The day before the
launch of the initiative, which was supposed to allow for the sharing
of intellectual property, the CEOs of the leading pharmaceutical
companies attended a joint press conference when a journalist asked
about C-TAP’s creation.

Pfizer chief executive Albert Bourla said that
[[link removed]], while he was “very
respectful of the opinions of many people, of everyone” and had
heard the conversations around intellectual property, “I have to say
at this point in time, I think it’s nonsense and at this point in
time it’s also dangerous.”

“It’s very easy to sit there outside and to criticize what we’re
doing. What we need to do is to be evaluated fairly based upon the
actions we took at the time with the knowledge we had at the time,”
Gavi CEO Seth Berkley said. | Alessandra Tarantino/AP Photo

With C-TAP not delivering, ACT-A leaders proposed the so-called
Vaccines Capacity Connector — a system that would allow for the
increase of the global supply of Covid vaccines. The pitch focused on
getting industry on board with voluntary technology transfers and
increasing vaccine manufacturing capacity in low- and middle-income
countries, according to a copy of the background document outlining
the pitch, obtained by POLITICO and WELT. According to the metadata of
the document, a WHO official authored the paper, but reporting at the
time from Geneva Health Files indicates it was a joint effort
[[link removed]] from
those involved in ACT-A.

Part of the plan called for an in-house technology transfer hub to
give low- and middle-income countries the chance to acquire the
know-how and necessary licenses to produce a Covid vaccine. In
abbreviated notes for the opportunities for the hub, it stated “IP
not a barrier in [low- and middle-income countries].”

Fifa Rahman, civil society representative to ACT-A’s facilitation
council, raised concerns about the Vaccines Capacity Connector at a
March, 2021 meeting, saying that it had “heavy industry involvement,
and has virtually zero involvement of LMICs [low- and middle-income
countries] and civil society.”

“The background document bizarrely states that IP is not a problem
in LMICs which is clearly wrong because we saw a lot of LMIC’s
mention IP today,” Rahman told the council members, according to a
public recording of the meeting.

The Vaccine Capacity Connector never publicly launched. Instead, the
WHO launched a vaccine hub in South Africa
[[link removed]] supported
by the Medicines Patent Pool and ACT-A as well as several European
governments. Since then, the hub has produced what it believes is a
copy of Moderna’s vaccine. Moderna, which received $1 billion in
research funding from the U.S. government and about $1 million from
CEPI, has refused to work with the hub, meaning that in order to bring
a vaccine to market, the hub will need to repeat the lengthy trials
already carried out by the company.

In March, Moderna announced that it would never enforce its
coronavirus patents in selected low- and middle-income countries, as
well as South Africa. However, Moderna CEO Stéphane Bancel ruled out
working with the hub directly, saying in an interview with POLITICO
[[link removed]] it is “not a good use of our
time.”

“We’re still a small company, and we have 44 programs in
development. And so if I need to send engineers to the mRNA hub, I
need to be explaining which product I’m not going to do or delay,”
he said.

Africa left behind

BY THE END OF MARCH 2021, the U.S. had secured enough doses to begin
sharing with the rest of the world, according to two people with
direct knowledge of the matter who previously worked on the U.S.
vaccine response.

Over the prior few months, Operation Warp Speed’s deals with
American vaccine makers produced hundreds of millions of doses.

Despite the increasing supply, doses moved out slowly, even to people
in the U.S. The federal government had developed a complex allocation
structure whereby states would order and receive a portion of the U.S.
total every week. And state governments had constructed strict rules
about who could receive their first shots. Officials at the top rungs
of the newly installed Biden White House resisted calls from both
inside and outside the government to begin donating doses
internationally, fearful they needed to hold onto the doses in case a
new variant emerged or Americans needed more than two doses in the
future.

As U.S. stockpiles of the vaccines continued to build, the Biden
administration struggled to convince parts of America to sign up for
the shot. | Steven Senne/AP Photo

And there remained the question of how to allocate the doses among
needy countries, whenever the U.S. was ready to distribute them.

Biden health department officials, some of whom helped draft an
international allocation framework in the Trump administration,
suggested the new administration adopt the same formula.

As U.S. stockpiles continued to build, the Biden administration
struggled to convince parts of America to sign up for the shot. Many
of those living in the southern and southwestern portions of the
country, hesitant about the benefits and potential downsides of the
vaccine, refused to get innoculated. Senior U.S. health officials
began to worry about the impacts on the American population — both
vaccinated and unvaccinated — if the virus were to mutate.

Then, at the end of April, the Delta variant, first identified at the
end of 2020, began to cause massive upticks in cases and deaths in
India, whose Serum Institute was a major exporter of vaccine doses.
The institute, heavily supported by the Gates Foundation and Gavi,
promptly stopped shipments
[[link removed]] in
April, 2021. Images from that time period showed people burning bodies
in mass graves. As many as 2.4 million people died as a result of the
wave, according to a report India released this year.

In April 2021, the Delta variant began to cause massive upticks in
cases and deaths in India. Many victims were burned in mass funeral
pyres. | Anindito Mukherjee/Getty Images

The Gates Foundation, CEPI and Gavi pressed Biden officials — as
they had done all year — to begin rolling out doses to other
countries.

“[There’s] a lot of money sitting in those [organization’s],”
said a person that works closely with one of the four global health
groups. “But it’s dwarfed by the power that the rich countries
have. At the end of the day, if you have manufacturers that are
operating within your borders, you have a lot of say on where that
supply goes.”

In Germany, the Gates Foundation spent €5.7 million, about $5.73
million, in 2021 lobbying various agencies and officials in part to
increase German support for the global vaccine effort.

The foundation relied on 28 staff members registered to lobby in the
German Parliament as well as specialists hired from the Brunswick
Group, an advisory and consulting group. Wellcome similarly spent
significant amounts of money in Germany — nearly $1 million. For its
part, Gavi spent between €25,000 and €49,999 on direct lobbying in
Europe in 2020, holding five meetings in February with commission
officials about COVAX and the EU’s plan to share vaccines, according
to lobbying disclosures. From the start of the pandemic Gavi had 17
meetings with senior Commission officials mainly focusing on Covid and
COVAX.

 

“At the end of the day, if you have manufacturers that are operating
within your borders, you have a lot of say on where that supply
goes.”

A person that works closely with one of the four global health groups

In the U.S., CEPI and Gavi continued to spend tens of thousands of
dollars to lobby members of Congress on multiple pieces of legislation
that would provide additional funding for the U.S. global response
through agencies like USAID. And people familiar with the Gates
Foundation’s outreach in Washington said its representatives often
took part in meetings with legislative members and staff on the topic
of Covid and pandemic preparedness.

The U.S. didn’t make any promises about donating doses en masse in
officials’ meetings with the organizations in the spring of 2021,
according to a former U.S. health official. The Biden administration
had already begun donating small amounts of doses
[[link removed]] bilaterally
— directly to its allies — but had yet to commit large amounts
internationally, or to COVAX. The bilateral strategy frustrated people
at COVAX who argued the consortium was the best way to deliver the
shots.

“As soon as the government started demonstrating that they thought
it could get [the shots] out faster than COVAX, they did receive some
calls … discouraging that,” a former senior U.S. official said,
referring to calls made by officials at the four organizations.

However, the U.S. did agree to host COVAX’s investment program on
April 15 in an effort to raise money for the consortium. At the
conference, the U.S. announced that it would donate $2 billion to
COVAX through 2022 — part of the $4 billion it had already pledged
to Gavi in a December, 2020, spending bill.

In total, Gavi raised $10 billion for 2021, up from $1.5 billion in
2017, according to the organization’s financial statements. But even
with the funding, the organization still needed to find and secure
vaccine supply in a crowded market.

To help get supplies moving, France in April donated 105,600 doses of
Covid vaccines from its domestic tranche to COVAX, with an additional
commitment of 500,000 doses. It marked the first donation of doses
COVAX secured from a high-income country, Gavi said in a statement at
the time. French President Emmanuel Macron called for other wealthy
countries to follow suit. The same month, the U.S. also announced
plans to donate an initial tranche of 60 million doses of the
AstraZeneca vaccine. It would take until July for the U.K. and Germany
to set out their donation pledges. EU leaders agreed to donate at
least 100 million vaccines by the end of the year.

After U.S. officials held dozens of meetings and calls with leaders of
the four organizations, including the Gates Foundation, the Biden
administration eventually agreed to share doses with the world. But
that decision came months after American officials and others working
within Operation Warp Speed — whose name changed during the Biden
era — had established that the U.S. itself had procured enough to
meet demand.

“In a way, the Gates Foundation filled a gap ordinarily the U.S.
would have done,” said a person involved in advising the
international dose-sharing allocation network. “If they had not
helped drive the effort around sharing doses or constructing COVAX, I
am not sure who would have.”

 

“In a way, the Gates Foundation filled a gap ordinarily the U.S.
would have done.”

A person involved in advising the international dose-sharing
allocation network

Adrienne Watson, the spokesperson for the National Security Council,
said the “U.S. has … pioneered the global vaccination effort.”

“The U.S. has done more than just lead the global COVID-19
vaccination effort over the past 15 months,” Watson said. “The
U.S. [is] the first – and still the only country – to give up our
place in line for delivery of vaccine doses we ordered.”

In May, the U.S. pledged to donate another 80 million doses to the
rest of the world by the end of June, a large percent of which it
promised to COVAX. The commitment was supposed to help support the
WHO’s goal of vaccinating 70 percent of the world by the middle of
2022. The announcement was one of a series throughout the summer of
2021 to ramp up U.S. donations abroad. By the middle of the summer,
the U.S. made another pledge — this time for 500 million Pfizer
doses for low-income countries.

Gavi’s Berkley finally began to see a dawning awareness by the
leaders of Western countries of the need to stamp out Covid in poor
countries, lest they become petri dishes for new variants.

“From the beginning, we said, ‘You’re only safe unless
everybody’s safe.’ I think most people nodded and said ‘Yes.’
I’m not sure they believed it until Delta in India,” Berkley said.
“I think people then said, ‘Okay, now we understand it.’”

But as June rolled around, COVAX was still struggling to get large
tranches of doses to low-income countries across the world. It had
delivered
[[link removed]] 64
million doses in nearly five months. By comparison, the U.S. had
already inoculated 62 percent of eligible adults and was averaging 2.2
million shots per day
[[link removed]].
Most of the U.S. doses did not arrive in low-income countries until
weeks later.

As June 2021 rolled around, COVAX was still struggling to get large
tranches of doses to low-income countries across the world. |
Guadalupe Pardo/AP Photo

As parts of the global health community, as well as officials in
low-income countries, grew frustrated by the growing vaccine inequity,
Bill Gates continued to push the pharmaceutical industry’s line that
the sharing of intellectual property would not improve immediate
access.

Asked on Sky News [[link removed]] on
April 25, 2021, whether it would be helpful to allow vaccine recipes
to be shared, he answered with an emphatic, “No.” He said there
were “only so many vaccine factories in the world” and that it was
difficult to set up capacity in another country.

“The thing that is holding things back in this case is not
intellectual property,” he said.

But in the minds of other leading global health advocates, it was one
— but not the only — barrier to vaccine equity.

Western governments hoarding doses was perhaps the biggest obstacle to
COVAX securing doses and distributing them to low-income countries.
But short of convincing leaders of some of the most powerful countries
in the world to divert significantly more doses to vulnerable people
across the world, the sharing of technology and intellectual property
seemed like the surest way to begin the process of ensuring equity,
global health advocates said at the time.

Three days after Gates’ interview on Sky News, the deadlock on a
Covid vaccine intellectual property waiver began to weaken.

On April 28, Bill Gates held a virtual call with U.S. Trade
Representative Katherine Tai. The two discussed increasing vaccine
distribution and the proposed waiver on intellectual property under
discussion at the World Trade Organization. It was the second meeting
Tai had with a member of one of the four global health organizations.
Earlier in April, she spoke with Berkley about the same issue,
according to a readout of the meeting.

After months of pleas from people and governments around the world,
the U.S. decided to support a waiver for intellectual property rights
related to vaccines. | Alastair Grant/AP Photo

Despite the pushback from high-profile figures such as Gates, on May
5, Tai announced that the U.S. would support a waiver for intellectual
property rights related to vaccines. The bombshell blindsided the EU
while leaders scrambled to reassess their positions. Macron and
Italian Prime Minister Mario Draghi both publicly indicated they could
be open to the waiver.

The day after the U.S. announcement, Bill Gates and Melinda French
Gates got on the phone with Merkel, according to German government
documents obtained by POLITICO and WELT.

The German Chancellery declined to release further information about
the phone call, arguing a disclosure could have adverse effects on the
negotiating position of Germany in the international organizations and
could harm bilateral diplomatic relations.

But on the same day as the call with Gates, a Merkel
spokesperson told a German newspaper
[[link removed]] that
the protection of intellectual property was a source of innovation and
that the U.S. proposal would have severe implications for vaccine
production.

The foundation did not respond to a question about what Gates
specifically discussed with Merkel. But the spokesperson said: “We
are part of a broad global health community, and we recognize that
some doors are open to us that are closed to others. We take that
responsibility very seriously and use our voice to spotlight the
perspectives of our partners in low-income countries.”

On May 7, Gates Foundation CEO Suzman said in a statement that the
foundation supported a “narrow waiver during the pandemic.”

When asked for comment about Bill Gates and Melinda French Gates’
call with Merkel, the spokesperson for the foundation said its
representatives “regularly advocated for high-income countries to
share doses with low-income countries and for full funding of COVAX
and the ACT-Accelerator (ACT-A).” It declined to comment on the
specifics of the call.

“We are part of a broad global health community, and we recognize
that some doors are open to us that are closed to others,” the
spokesperson said. “We take that responsibility very seriously and
use our voice to spotlight the perspectives of our partners in
low-income countries.”

Vaccinations slowed

THROUGHOUT THE SUMMER AND FALL of 2021, it was becoming clear on the
ground that low- and middle-income countries were running into
problems getting the shots off the tarmac and into arms.

Pharmaceutical companies had written language into their contracts —
contracts host governments in places like Africa needed to sign —
that barred the company from potential liability issues. Disputes over
that indemnification language and the legal negotiations that came
along with them stymied COVAX’s ability to offload doses.

And in some countries, there were not enough health care workers
available to administer the doses. In an attempt to help the African
Union reach its target of vaccinating a significant portion of the
continent’s population by 2022, the World Bank committed more
resources to the Africa Vaccine Acquisition Task Team to support the
purchasing and distribution of shots for up to 400 million people.
Part of that money went to helping countries build stronger systems
for delivering and administering the jab.

In some countries, there were not enough health care workers to
administer the available doses of the Covid vaccines. | Tafadzwa
Ufumeli/Getty Images

But even as the COVAX effort began to move forward slowly, the rest of
ACT-A was still trying to get off the ground.

On Oct. 15, the ACT-A facilitation council published a sobering
assessment of its successes and failures by Dalberg, the outside
consultancy. It provided a mixed review of the consortium since its
inception and noted ACT-A’s lack of transparency. It said the group
had insufficient involvement from civil society, and that there were
perhaps multiple conflicts of interests due to the influential
industry representatives within ACT-A.

“This uncertainty around ACT-A’s scope made it hard for some
stakeholders to tell where its responsibility began and ended,” the
report said.

The report highlighted one ACT-A initiative that seemed to be working
well.

In 2020, the Global Fund, which was helping lead the therapeutics
pillar at ACT-A, and UNICEF helped launch an initiative to secure and
deliver oxygen to low- and middle-income countries — a tool
countries like India, which was struggling to cope with increasing
numbers of cases with the Delta variant, desperately needed in 2021.

By June 2021, the Global Fund and UNICEF had allocated $233 million
for oxygen procurement and 800,000 oxygen provisions, according to the
strategic review by Dalberg. The organizations also made an additional
$219 million available for countries experiencing Covid surges,
including $75 million to India, for oxygen supply, according to data
provided by WHO representatives working with ACT-A.

But the other ACT-A initiatives — the efforts to secure and
distribute tests, treatments and vaccines — were on track to miss
their original end of the year targets, the report said.

For Covid tests, the rapid influx of players in the space should have
made the target of 500 million tests available to low- and
middle-income countries by mid-2021 more easily attainable. But by the
end of June, the diagnostics pillar significantly missed its goal,
only procuring 16 percent of the 500 million tests, according to the
2021 independent review of ACT-A.

 

“In the fullness of hindsight, it is now eminently clear that the
power structures have favored the Global North over the Global
South.”

Olusoji Adeyi, former senior adviser for human development, World Bank

ACT-A agencies revised down their targets from delivering 245 million
treatments by 2021 to 100 million by the end of 2021. By mid-June,
just 1.8 million treatments had been allocated.

A spokesperson for Wellcome did not comment on the specific timing of
distribution of treatments but described the speed with which they
were discovered as “phenomenal.”

“The major global treatment trials … set up in a matter of
weeks,” the spokesperson said.

With Covid tools — tests, shots and treatments — trickling into
low- and middle-income countries, officials and advocates on the
ground grew increasingly frustrated.

“In the fullness of hindsight, it is now eminently clear that the
power structures have favored the Global North over the Global
South,” Olusoji Adeyi, former senior adviser for human development
at the World Bank who was involved in consultation about ACT-A and is
now president of the policy analysis and advisory firm Resilient
Health Systems, told the Lancet
[[link removed](21)01861-4/fulltext#:~:text=A%20review%20of%20the%20Access,health%20leaders%20and%20civil%20society.] in
August 2021. “These power structures crippled the functions of
[ACT-A], including [COVAX].”

CHAPTER 4

A FAILING AND A PUSH TO MOVE ON

Despite the increasing number of pledges to COVAX in the fall of 2021,
including another 500 million dose donation from the U.S., the vaccine
spigot was running far more slowly than expected.

Representatives of Gavi and UNICEF launched a massive push to get
doses to low-income countries, particularly in Africa, in hopes of
delivering 800 million doses by the end of the year — more than 1
billion fewer than it had originally set out to distribute by that
time.

Meanwhile, it was becoming increasingly clear that it would be nearly
impossible to meet the WHO’s goal of vaccinating 70 percent of the
world by the middle of 2022.

“It was naive to think we could reach that goal,” one person
directly involved in the COVAX effort said. “Goals are good. But
they’re only good if you meet them.”

The spokesperson for Gavi said: “The 70 percent target was a WHO
global target, not a COVAX target.”

Despite the increasing number of pledges to COVAX in the fall of 2021,
it seemed nearly impossible to meet the WHO’s goal of vaccinating 70
percent of the world by the middle of 2022. | Rafiq Maqbool/AP Photo

But even as the doses kept coming in, the rate of vaccination slowed.
In the time it took to get doses out to countries in Africa, rumors
had spread in local communities that the vaccine was unsafe.
Volunteers in sub-saharan Africa spent hours with community members
trying to convince them to get a shot
[[link removed]].

For the people living in a rural village five hours northeast of
Accra, Ghana, vaccine hesitancy was rooted in a deep mistrust of
almost everyone involved in procuring the doses — the vaccine
makers, the West and the global health organizations trying to promote
it on the ground. When the vaccine first became available, people in
Ghana watched on CNN as Americans and Europeans lined up to get their
shots. It took six more months for doses to arrive in their country.

It wasn’t just hesitancy and apathy that slowed the rollout of
vaccines in some African countries. Some health advocates point to
COVAX’s own failure to properly prepare countries for the logistical
hurdles of distributing vaccines.

Researchers from Matahari Global Solutions, the People’s Vaccine
Alliance, and the International Treatment Preparedness Coalition
interviewed numerous experts on the ground for an August, 2022, report
and found there were many reasons why vaccination rates lagged.

“We have the complexity of the drought, security issues, and issues
related to political instability,” Mamnunur Rahman Malik, WHO
representative for Somalia, told researchers in the report
[[link removed]].

The report said proximity to vaccination centers, distrust in
government, unpredictable vaccine supply and war were also central to
low rates of vaccination — factors Berkley insists were out of
COVAX’s control.

Health workers on the ground were also having to make impossible
trade-offs, the report said, as some countries chose to deploy their
limited resources to push Covid vaccines instead of the usual
childhood immunizations.

It wasn’t just hesitancy and apathy that slowed the rollout of
vaccines in some African countries. Some advocates point to COVAX’s
failure to prepare countries to distribute vaccines. | Tafadzwa
Ufumeli/Getty Images

The African vaccination effort eventually slowed in 2022. In the U.S.
the vaccination coverage range is at 67 percent. But in Africa, only
about 20 percent of people were fully vaccinated as of August, leaving
tens of millions people, including the elderly and immune-deficient,
vulnerable to the worst effects of the disease, according to the
Africa CDC.

“The Covid vaccines that we have administered in the country has
also led to a situation where we have seen that children are suffering
from measles, because it is the same immunization services we have
used for rolling out the Covid-19 vaccine. And in doing so, what has
happened is that we have compromised the childhood immunization
[program],” Malik said in the report.

The African vaccination effort eventually slowed in 2022. In the U.S.
the vaccination coverage range is at 67 percent. But in Africa, only
about 20 percent of people were fully vaccinated as of August, leaving
tens of millions people, including the elderly and immune-deficient,
vulnerable to the worst effects of the disease, according to the
Africa CDC.

 

“By the time we got the Pfizer and Moderna … people had a lot of
negative feedback.”

Stephen Bordotsiah, municipal director of health services, Bolgatanga
region, Ghana

“Frankly speaking, if you look at the earlier vaccines that we had,
we had mainly AstraZeneca doses from COVAX and with those ones people
complained a lot of side effects. It discouraged a lot of people from
taking the shots,” said Bordotsiah, the municipal director of health
services in the Bolgatanga region of Ghana. “By the time we got the
Pfizer and Moderna … people had a lot of negative feedback. Now, we
have a lot still left in the system.”

Berkley said he is proud of the work COVAX did — that it helped
achieve almost 50 percent vaccination coverage with the primary series
in the countries the Gavi board has designated as either low or
middle-income.

“If you stand back, that is extraordinary compared to history,”
Berkley said. “But the goal was to try to have equitable access
everywhere. And I think we all knew we would never get perfectly
there.”

The other ACT-A programs to distribute treatments and tests also began
to slow as 2022 approached.

Shifting gears

WHILE PUBLIC-HEALTH OFFICIALS were struggling to ramp up vaccinations
in Africa, the focus of the rest of the global health community began
to pivot. The leaders of the four organizations moved away from solely
addressing the Covid pandemic to talking about ways to prepare for the
next pandemic.

At the Munich Security Conference in February 2022, some of the
world’s leading global health officials talked intently about how to
move their community in a new direction — toward building systems to
help with virus detection and to deliver vaccines and treatments in
the next pandemic. Their conversation — over dinner one of the
nights at an upscale hotel 
[[link removed]]in
Munich — marked the beginning of a shift in strategy for the four
organizations, and in the larger global health community as well.

Covid wasn’t over, but it was becoming increasingly difficult to
solicit funds from Western governments for international work to fight
the pandemic. The virus was still spreading, but cases were beginning
to come down. Life for affluent Westerners was starting to resemble
its pre-Covid norms.

Bill Gates, speaking to the press, said several times that Covid was
on the decline and that money should be directed toward creating tools
like next-generation vaccines to fight the next pandemic.

The shift in emphasis sparked tensions in the global health world,
with some critics insisting that the Gates Foundation and its partners
were looking beyond Covid at a time when millions across the world
still needed access to vaccine doses. It was not the time to move on,
they said in interviews with POLITICO at the time
[[link removed]].

 

“The goal was to try to have equitable access everywhere. And I
think we all knew we would never get perfectly there.”

Seth Berkley, CEO, Gavi

The WTO was still in negotiations about a waiver on patent rights on
Covid vaccines. In February of 2022, WTO Director General Ngozi
Okonjo-Iweala spearheaded conversations with a small group of
countries, encouraging them to come to an agreement.

“We have to be very careful to work it until all sides are
comfortable with where we are,” Okonjo-Iweala said in an interview
with POLITICO
[[link removed]],
referring to the agreement. The director general was vocal about
needing to do more for low-income countries that had yet to gain
access to significant doses of vaccine. That waiver finally passed in
June.

In the midst of the WTO negotiations, representatives from the four
organizations began to lobby members of the U.S. Congress and European
parliaments about dedicating more funding specifically for pandemic
preparedness.

From late 2021 and into 2022, the Gates Foundation, CEPI and Wellcome
held at least five meetings with senior European Commission officials
on pandemic preparedness, including discussions on the work of the
newly created European Health Emergency preparedness and Response
Authority — the body tasked with ensuring the bloc has the necessary
vaccines and treatments if another health crisis hits, according to
lobbying disclosure forms.

In Germany, the Wellcome Trust organized an informal expert meeting on
pandemic preparedness and response with the head of Germany’s public
health institute, Lothar Wieler, in attendance, according to the
German government agency for disease control.

In the U.S., Gavi and CEPI have spent $230,000 on lobbying since the
beginning of 2022 alone, according to the organization’s lobbying
disclosure forms. Some of that lobbying focused on securing additional
cash for the Covid fight and for preparing for the next pandemic.

CEPI specifically lobbied members on Capitol Hill about a new pandemic
preparedness bill called the Prevent Pandemics Act, introduced by
Sens. Patty Murray (D-Wash.) and Richard Burr (R-N.C.). The bill,
which has yet to move forward, lays out how the U.S. should approach
funding efforts to prepare for the next large-scale infectious disease
outbreak.

Sens. Richard Burr (R-N.C.), left, and Patty Murray (D-Wash.), right,
introduced a new pandemic preparedness bill called the Prevent
Pandemics Act in March 2022. | Pool Photo by Greg Nash

“Tackling the COVID-19 pandemic, enabling equitable access to
vaccines, and preparing for future epidemics and pandemics are global
endeavors, which can only be achieved with political support and
sustained investment from governments and multilateral
institutions,” said the CEPI spokesperson. “Dialogue with
governments around the world is, therefore, a crucial part of CEPI’s
work.”

CEPI attempted to help shape the bill’s standards for funding of
research and development, according to two people involved in the
bill’s drafting. The organization was on the precipice of launching
a new program — one it could use to fundraise for billions of
dollars. The program, CEPI 2.0, aims to develop a vaccine within 100
days of the next pandemic. In a comment it submitted to lawmakers
working on the bill, CEPI said it was “encouraging to see the
substantive contributions in this legislation to regulatory reform, as
well as the enthusiasm around R&D work on viral families and priority
pathogens of concern.”

“In general, language should be strengthened throughout the bill to
emphasize the areas in which U.S. engagement on pandemic preparedness
should and must connect to the work of global partners, including
CEPI,” CEPI’s comment on the bill said, according to a copy
obtained by POLITICO and WELT.

The spokesperson for CEPI said lawmakers solicited the
organization’s input on the bill.

At CEPI’s donor conference in March, some of the most influential
figures in global health met in London at the Science Museum, which a
year earlier had begun to be partly repurposed as a Covid vaccination
center. But the world leaders, CEOs and staffers from global health
organizations weren’t there to talk about Covid vaccines. Instead,
the focus was squarely on the next pandemic.

CEPI asked donors for $3.5 billion so it could start developing a
library of vaccines for future pandemics. It raised less than half of
that at its most recent fundraising event, with Wellcome and the Gates
Foundation each pledging more
[[link removed]] than
most governments.

“We have a little less than half of what we thought we need,”
Nicole Lurie, the leader of CEPI’s emergency response team, told
POLITICO in an interview after the organization’s donor conference.

“This is sort of an ongoing challenge,” Lurie said, referring to
CEPI’s fundraising on pandemic preparedness. “I would say there is
still no funding mechanism for what happens when the balloon goes
up.”

Due to the shortfall, CEPI turned to the U.S. and other funders to try
and fill the gap, with Biden putting forward $500 million — $100
million for the next five years — for the organization into his
budget proposal.

In April, Gavi, alongside Germany, hosted its own conference to raise
money, focusing on COVAX — an initiative that was still coming under
fire from parts of the global health community for not finishing the
job. The organization said it needed an additional $5.2 billion to
help millions of vulnerable people get vaccinated. It secured
commitments of $4.8 billion. Germany pledged $435 million and the
European Commission promised $82 million.

Now, as the four organizations continue their shift toward the next
pandemic, there is little sign that they are setting themselves up to
perform vastly differently, in part because there has been no real
public reckoning for their failures, critics say.

It would be “a tremendous error to not spend some time taking a hard
look” at what worked and didn’t, in ensuring equitable access to
Covid vaccine, said Suerie Moon, co-director of the global health
center at the Geneva-based Graduate Institute of International and
Development Studies.

The four organizations said they have conducted internal reviews of
their Covid work, but not all of them are making those findings
public.

Repeating past mistakes?

AS THE VACCINE DISTRIBUTION slowed across the world in the early
months of 2022, millions of people in low- and middle-income countries
across the world still did not have adequate access to medical
countermeasures.

ACT-A had promised to deliver 500 million tests accessible to low-and
middle-income countries by the middle of 2021. The therapeutics team
set the target of delivering 100 million treatments to low-and
middle-income countries by the end of the same year, according to the
2021 Dalberg report on ACT-A’s goals.

Without governments stepping in to take the lead on pandemic
preparedness, the four organizations, along with their partners in the
global health community, are the only entities that are in a position
to lead in the world’s response to a devastating outbreak — again.
| Ulet Ifansasti/Getty Images

As of June 2022, ACT-A delivered just over 140 million tests. WHO
representatives said they could not accurately calculate how many
treatments ACT-A has helped deliver, but the spokesperson for the
initiative said that the consortium spent a total of $9.9 million to
get the drugs to low-and middle-income countries across the globe. It
also delivered $260 million worth of oxygen supplies.

Now, health advocates fear the mission to prepare the world for the
next pandemic is already repeating the mistakes that were made during
the current crisis, including the failure to invest in public-health
resources to administer doses.

“I think ACT-A was created — COVAX was created — with, I think,
very good intentions. I worry that we will not take the time … to
actually do the reflection of what worked and what didn’t and
why,” said Smith, of the Biden administration.

In explaining why COVAX has struggled to meet some of its vaccine
goals, Berkley said there was only so much it could do without
stronger health systems in place on the ground to absorb the doses and
get them out to the people.

“There is a reason why coverage for vaccines in general in the
developing world is lower than it is in the West,” Berkley said.
“What’s very different in this circumstance is the health systems
that we were using were already stretched to provide your basic
services. They weren’t set up to do the billions and billions of
doses, adult vaccinations, elderly vaccinations that were necessary
for this pandemic. That’s a fundamental truth. And anybody who sits
there and says, ‘the numbers weren’t the same’ is not being
realistic about what is physically possible.”

Leaders of ACT-A recognized the problem too late, critics say.
Agencies participating in the consortium tried to increase their
efforts to strengthen health systems in low-income countries during
the pandemic — to build up their public-health sectors in ways that
would allow them to more easily secure and distribute tests, vaccine
doses and drugs. But funding for the initiative came late, according
to two individuals who worked with the consortium on the issue. The
health-systems pillar received just 7 percent of the consortium’s
overall donations, according to ACT-A’s own data.

 

“This is always a problem with pandemic preparedness — if you
actually want to build resilience in global health, you actually just
build effective health systems, and basic public health care.”

Sophie Harman, professor of international politics, Queen Mary
University of London

“This is always a problem with pandemic preparedness — if you
actually want to build resilience in global health, you actually just
build effective health systems, and basic public health care,”
Harman, the professor of international politics at Queen Mary
University of London, said. “As soon as you go to the bells and
whistles of vaccines, and all these kinds of innovative technologies
— that’s really important, and really exciting. But it misses some
of the fundamental points that you need to respond to anything and
that is a good [public] health system.”

The lack of focus on traditional health system strengthening has been
a longstanding criticism
[[link removed]] of the Gates
Foundation’s work. The foundation “invests in silos or shiny
things like polio eradication, they don’t invest in building
hospitals, building primary care, laboratories, surveillance
capacities, all of the things that are the important foundations for
pandemic preparedness,” said Gostin, the Georgetown University
professor who specializes in public health law.

The Gates Foundation maintains that its employees work closely with
local public health leaders and that its representatives advocated for
greater investment in health system strengthening during Covid. The
spokesperson for the foundation said that it helps fund programs to
strengthen health systems through Gavi and the Global Fund.

“No question that not everybody agrees with how we or anybody
approached the pandemic. About including low-income country voices and
engaging with them from the beginning: That’s [at] the core of what
we do,” said Scott Dowell, deputy director for surveillance and
epidemiology at the foundation. “And I think it would be a
misunderstanding of the way the foundation works if people came away
thinking that we didn’t do that.”

Back to the future

BILL GATES’ LATEST BOOK focuses on the need to develop a special
task force that can deploy to various parts of the world where there
are outbreaks to help supplement local public health workers.

“At the global level, we need a group of experts whose full-time job
is to help the world prevent pandemics,” Gates writes in his book.
“It should be responsible for watching out for potential outbreaks,
raising the alarm when they emerge, helping contain them … and
organizing drills to look for weak spots in the system.”

When it comes to investments, the Gates Foundation, Wellcome and CEPI
have made pledges to support innovative technologies for the next
pandemic, including new kinds of surveillance systems as well as
vaccine and diagnostic technology. Few global health leaders have yet
announced pledges specifically targeted at strengthening health
systems.

Currently, leaders of the four organizations are involved in broad
conversations about financing mechanisms to help support the world’s
response to the next pandemic, including the creation of a new fund at
the World Bank. It’s unclear whether that fund could be used to deal
with the health system issue — the focus of the fund is still under
consideration.

Despite all the lobbying that’s occurred in the U.S. and Europe in
recent months aimed at pandemic preparedness, officials have moved
slowly to commit funds. For example, in the U.S., an office within the
White House last year drafted a $65 billion budget for how the federal
government would begin to scale programing to respond to another
large-scale infectious disease outbreak. But that strategy is rolling
out slowly, officials say, as the administration works to combat
monkeypox.

And as Covid cases stabilize across the world, Western governments are
pulling back on their international response work, worrying health
advocates that governments will once again fail not only to strengthen
their own health systems, but also those of low-income countries.

As discussions increase about being better prepared for the next
pandemic, few global health leaders have announced pledges
specifically targeted at strengthening health systems. | Jerome
Delay/AP Photo

The monkeypox outbreak has further fanned fears that the world is
unprepared for another pandemic and that without significant
government support people living in poorer countries won’t receive
the same kind of access to life-saving medicines as those living in
the U.S. and Europe.

“You need to have a reckoning on this. The way the G-7, and the
G-20, showed up in the pandemic was pretty disappointing, to put it
mildly,” said a person who works with one of the four organizations
and requested to remain anonymous to speak more freely about the state
of global health care. “There was a complete lack of leadership. On
this issue of equitable access, people made big statements, but they
didn’t follow through at all.”

Without governments stepping in to take the lead on pandemic
preparedness, the four organizations, along with their partners in the
global health community, are the only entities that are in a position
to lead in the world’s response to a devastating outbreak — again.

“They’re funded by their own capabilities and or endowments and
trusts. But when they step into multilateral affairs, then who keeps
watch over them?” a former senior U.S. official said. “I don’t
know the answer to that. That’s quite provocative.”

CREDITS

REPORTING: Erin Banco, Ashleigh Furlong and Lennart Pfahler
DATA REPORTING AND EDITING: Annette Choi and Sean McMinn
PROJECT MANAGEMENT AND PRODUCTION: Catherine Kim and Rishika Dugyala
ART DIRECTION AND DESIGN: Jade Cuevas and Erin Aulov
PHOTO EDITING: Catherine Kim and Chase Sutton
COPY EDITING: Gigi Ewing, Mallory Culhane, Kat Long, Jeffrey Horst
and Andrew Howard
EDITING: Peter Canellos
ILLUSTRATIONS: Dan Page

_POLITICO is the global authority on the intersection of politics,
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to nearly 200 employees. In October, 2021, POLITICO was acquired by,
and is a subsidiary of, Axel Springer SE
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