How Bill Gates and partners used their clout to control the global Covid response — with little oversight

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.

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.

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.

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 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.

“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. 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.

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,” 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 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 published on its website in October 2021. It is also tracking that work internally, a spokesperson for ACT-A said.

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.

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 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.

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.

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 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,” 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.

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 in the early months of the pandemic, taking on the posture of a world leader.

On its website, the Gates Foundation says it believes 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 martial governments around a plan.”

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 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.”

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 $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. 

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 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 Vital Strategies received close to $1 million to help strengthen epidemic preparedness capacity for Covid in the African region.

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. 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 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.

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 $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.

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.

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 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.

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, 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.

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.

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 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 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.

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.

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 said.

On its website, the Gates Foundation says 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, 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 that any deal it makes include non-exclusive and royalty-free licensing.

When the university struck the deal, 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.

“[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.

Soon after the announcement of the deal, CEPI and Gavi revealed plans 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 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.

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.

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.

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.

Oversight and political leadership for ACT-A came through the facilitation council, a committee co-hosted by the WHO and the European Commission that included representatives from various countries, including the consortium’s co-chairs, South Africa and Norway. But the day-to-day decisions took place through the principals group, which included representatives from governments, industry and civil society, as well as global health organizations. Officials from the U.S. and Europe were also in regular contact with ACT-A’s various working groups.

Gavi, in coordination with the WHO, CEPI and UNICEF, took the lead in setting up a pooled procurement and financing mechanism for 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 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 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 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, 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 of an ACT-A facilitation council meeting that month.

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 — 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.

“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, 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.

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.

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.”

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.

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.”

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.

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.

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.

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.

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 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, 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.”

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 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 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 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.

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 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.

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.

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 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.”

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 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. Most of the U.S. doses did not arrive in low-income countries until weeks later.

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 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.

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 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.

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.

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 in August 2021. “These power structures crippled the functions of [ACT-A], including [COVAX].”

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.”

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.

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.

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.

“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.

“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 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.

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, 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.

“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 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.

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,” 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 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.

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.”