BUT THEIR EXTENSIVE ROLE RAISES QUESTIONS ABOUT HOW MUCH WE RELY ON PHILANTHROPY RATHER THAN BUILDING GOVERNMENT SYSTEMS THAT WORK.
WITHOUT THE EFFORTS OF THE BILL AND MELINDA GATES FOUNDATION, THE COVID-19 CRISIS WOULD ALMOST CERTAINLY BE WORSE.
sat down for a seafood dinner in Seattle. It wasn’t a Valentine’s Day meal: Melinda, his wife of 26 years, couldn’t attend. He was grab-bing takeout with a handful of experts who worked with him at the headquarters of the foundation that he and Melinda cofounded in 2000 to take on global health challenges. As it drizzled outside, he pressed them on the current state of the novel coronavirus outbreak in China, where thousands of people had fallen sick. A small number of cases were now beginning to
show up in other parts of the world.
“I kept saying, ‘Hey, won’t China be able to keep it from spreading to other countries?’ ” he tells me when we chat in late June. “They said, ‘No, there’s less than a 25% chance that this will be contained to China.’ I thought, Oh, my God. . . . This is mind-blowing. Here it is.”
The new coronavirus, which the World Health Organization had named SARS-CoV-2 four days earlier, was the nightmare scenario that Bill Gates had been predicting for years: a deadly virus with the potential to sicken millions of people and devastate the global econ-omy. He had warned in 2010 that the H1N1 outbreak was a “wake-up call” for the world to prepare for a deadly pandemic. Five years later, as Africa was reeling from an Ebola outbreak, he told an au-dience at the TED conference that the biggest killer the world was likely to face in the near future was “a highly infectious virus rather than a war,” and that a coming virus could potentially be far worse than Ebola: Ebola doesn’t spread through the air, and only the sick-est patients, those likely to be bedridden, are infectious. However, he told the crowd, “You can have a virus where people feel well enough while they’re infectious that they get on a plane or they go to a mar-ket.” He echoed the same concerns at other conferences and to poli-ticians, including, in 2018, President Donald Trump. “When I spoke to the current administration,” Bill Gates says, “I highlighted that this is something that they can show leadership on, and connected it to a desire to improve [U.S.] security defense. I thought it was a theme that might play well, but we see now that we weren’t ready.”
Being right, Bill and Melinda have learned duringthe 20 years they’ve spent battling to improve globalhealth, offers little comfort.
And yet they continue to describe themselves as “impatient optimists,” believing both that major challengesare solvable, and that change needs to happen as soonas possible. The couple, who make all major decisions together, have chosen to devote their lives to puttingthis philosophy into action to fight global inequities,even when that comes at a personal cost, as the Gates’swork has made them the subject of both political scrutinyand outlandish conspiracy theories. (See sidebar,“Gates Versus the Infodemic.”) The pandemic has forcedthem and their foundation to move even faster. Strategy “usually evolves over years, and not weeks,” says Jennifer Alcorn, the foundation’s deputy director of philanthropic partnerships. When the outbreak became apandemic, it presented the biggest challenge that the Gates Foundation has ever faced. The world has neverconfronted the need to create a vaccine for 7 billion people.But Bill Gates believed that the organization was ina unique position to help. “We have the relationshipswith governments—rich world governments, developing world governments—and the private sector and the universities,” he says. The foundation has collaborated closely in the past with all of these groups on other vaccines, as well as therapeutics and other tools that willbe needed to combat the virus.
The Gates Foundation has become enmeshed in every aspect of the fight against COVID-19. It has poured $250 million into the development of vaccines, drugs,and low-cost COVID tests. It has worked to strengthen health systems and mitigate the economic effects of the crisis. It has also helped set up new systems designed tomake vaccines and antivirals available and accessibleto the whole world, despite the growing tide of “vaccine nationalism”—competition between countries to hoard supplies. In fact, the organization gave an additional$300 million to help make vaccines that cost no morethan $3 a dose, to be distributed through networks that the foundation helped create. “Thank goodness, we’renot starting from where we were 20 years ago, with acrumbling vaccine system [and having] to rebuild it,” Melinda Gates says. “So as soon as this vaccine is available,it will run straight through this system.”
How the Gates Foundation has responded to the pandemic offers a rare window into the way in which this powerful philanthropic organization operates—how it places its bets, how it dispenses its $49.8 billion endowment,and how it uses its soft power to further larger aims. The foundation’s outsize presence has inspired hope, suspicion, and meaningful critiques—mainly forits ability to influence outcomes without the same accountabilitycitizens expect of public health officials. “A fundamental question is, Well, because you have the money, should you be able to control the architectureof global health?” asks Brook Baker, a Northeastern University law professor focused on intellectual propertyrights and universal access to treatments for HIV/AIDS and COVID-19. “In many people’s minds, the Gates Foundation is playing a bigger role in establishing thefoundation of global health than anything else, includingthe WHO.” (The foundation is one of WHO’s largestfunders as well.) Counters Rajeev Venkayya, president ofthe global vaccine development unit at Takeda Pharmaceutical and a former director of vaccine delivery at the Gates Foundation: “[They’re] driving the global healthagenda not just because they have money but becausethey have a lot of value to add in designing effective programs.”Both of these perspectives have merit. As theCOVID-19 crisis continues, with more than 1 million deaths so far and governments struggling to manage the problem, the Gates Foundation has helped fill critical gaps. But the pandemic response also raises questionsabout philanthropy’s function in public health,and how the world can truly be prepared for the next deadly virus.
sarah gonzales
illustrations by
adele peters
by
_GATES
VERSUS
THE
PANDEMIC
ON THE EVENING OF FRIDAY, FEBRUARY 14, BILL GATES
focus on pandemic preparedness. But the Ebola outbreak in West Africa, which spanned from 2014 to 2016, sparked a shift. The organization, which had been working in the region on polio eradication, joined the international effort to fight the virus. The countries hit by Ebola—namely, Guinea, Liberia, and Sierra Leone—were ill-equipped for multiple reasons, from weak health systemsto a lack of epidemic planning.
One of the biggest challenges was the slow pace of vaccine development. When Ebola cases spread in 2014, a vaccine had been in development for over a decade. It wasn’t deployed until more thana year after the outbreak began, after thousands of people had died.“The system to move a vaccine from upstream research to manufacturing was broken,” says the Gates Foundation’s Alcorn. “It just took too long.” Researchers were duplicating work and not communicating quickly enough with governments.
In response, the foundation partnered with the U.K.’s Wellcome Trust, the governments of Norway and India, and the World Economic Forum to launch the Coalition for Epidemic Preparedness Innovations (CEPI) at Davos in January 2016. “CEPI’s overall organizational mission statement has two components,” says CEO Richard Hackett. “One is developing vaccines against emerginginfectious diseases, and the second is ensuring access.” During the COVID-19 crisis, the foundation has used CEPI as its primary means of funding vaccine R&D. “If CEPI didn’t exist, it would have taken much longer for other global health players to put thesefunding arrangements in place to get these programs going,” saysTakeda’s Venkayya, who is also a CEPI board member. “They hadalready done the diligence. They knew which companies werebest positioned. They knew which platforms had the best chanceof technical success. They have the contracting arrangements and scientific advisory groups and everything else.”
Even so, “I wish I had gotten more than CEPI done,” Bill Gates says, arguing that “CEPI is about 5% of what should have been done” by the global health community in the years after Ebola. To fill in the gap over the years, the foundation has used both its grant-making powers and strategic equity investments to fund teams that are developing new vaccines. This includes as-yet-unproven platforms that rely on messenger RNA (mRNA)—a technology that the foundation had first planned to use to combat such diseases as malaria, but that now might play a key role in battling the current pandemic. (See graphic, “The Bet on mRNA.”) The Gates Foundation invested $52 million in a German mRNA startup named CureVac in 2015; a year later, it gave Massachusetts-based Moderna a $20 million grant to support its development of mRNA-based HIV therapeutics, which helped the company further its underlying platform that can also be used to make vaccines. The foundation made an initial equity investment of $55 million in BioNTech, another German startup working on mRNA technology, in 2019. (While the foundation typically makes grants, it sometimes invests in companies to negotiate terms that require a funded product be globally accessible and affordable.) The goal of all of this spending, in part, was to encourage these companies to focus on mRNA vaccines for communicable illnesses. “If you’re looking at where the money is,” in medical funding, “it’s in oncology and cancer immunotherapy,” says Lynda Stuart, deputy director of vaccines and host-pathogen biology at the Gates Foundation. Without a push, companies working in the space “wouldn’t necessarily gravitate to infectious disease vaccines.”
As the virus was beginning to spread, the Gates Foundation encouraged its other vaccine development partners to turn to COVID-19. Researchers at Oxford University started work on a coronavirus vaccine made from a weakened form of the common cold virus, a platform that CEPI had supported for other vaccines such as MERS. Novovax, a biotech startup the foundation had previously funded, also entered the race to create a vaccine.
By October, more than 200 COVID-19 vaccines were in development, but only 11 had reached Phase III clinical trials (human safety and efficacy tests, the last step before regulatory approval). Of those, four—from Moderna, BioNTech, Novovax, and the University of Oxford—had received early backing from CEPI. The Gates Foundation has also made direct grants to support Oxford and Novovax trials in South Africa. (In addition, it is funding contenders that are at an earlier stage of development, such as Icosavax’s nanoparticle vaccine construct.) “The vast majority of candidates fail by the time they get to Phase III,” Gates Foundation CEO Mark Suz-man told me in May. “So it makes sense right now to have multiple shots on goal.”
WHEN THE GATES FOUNDATION FIRST LAUNCHED, IT DIDN'T
coronavirus was taking off in China that “this feels like exactly a moment where the foundation does have a comparative advantage . . . the resources, the expertise, the talent we’ve been able to pull together, the experience we’ve developed over the last 20 years.” The foundation’s imperative, as he and others see it, is to seek out “gaps” where the rest of the global health community hasn’t focused. That’s why the foundation committed more than $250 million by mid-April to try to protect people at the greatest risk in Africa and South Asia, and why it created a “therapeutics accelerator,” in partnership with Wellcome and Mastercard, after the Gates team saw that nothing was in place to help speed up the search for COVID-19 treatments. This new organization convinced pharmaceutical companies to share proprietary libraries of molecular compounds so that the global research community could screen existing drugs and learn which might be able to effectively treat COVID-19 patients effectively (though, to date, it has not announced any major discoveries). “While the [U.S.] government was very deeply focused on the accelerator for vaccines [Operation Warp Speed], Gates understood the importance of therapeutics,” says Sylvia Burwell, the former U.S. Secretary of Health and Human Services under President Obama and a Gates Foundation alum.
The scope of the organization’s power gives it significant influence over which projects get funded by others. After CEPI launched a call for proposals in February for vaccine developers to work on a coronavirus vaccine, the Gates Foundation, which sits on the organization’s scientific advisory council and is one of its key funders, recommended that it back Novovax, a 33-year-old company that the foundation had previously funded, seeing promise despite the fact that Novovax had never taken a product to market in all of that time. CEPI ended up funding nine vaccines but committed the most money—$388 million—to Novovax. The U.S. government, seeing the support from CEPI, went on to give the company $1.6 billion through Operation Warp Speed. (When I ask the Gates Foundation about whether its 2015 grant helped it develop its vaccine platform, a spokesperson says, “Novovax has been an active collaborator” with the foundation and that the company’s “technology and expertise in the vaccine space led us to conversation with them and other partners on [its] COVID-19 vaccine candidate.” HHS declined to comment for this story.)
The Gates Foundation also uses its extensive network of relationships to forge private partnerships. As researchers at Oxford worked on a new COVID-19 vaccine, for example, the foundation helped push the team to begin working with a large pharmaceutical company on mass production. “We said, ‘Hey, you’re doing brilliant work,’ ” Gates later explained on a press call. “But to do a Phase III trial, to understand how you get manufacturing all over the world, you need to team up. And we told them a list of people to go and talk to.” Oxford soon began working with AstraZeneca, the multinational pharmaceutical company whose market cap exceeds $130 billion. This relationship came after Oxford had reportedly planned to share the technology through open licensing, an approach that some health organizations, including Doctors Without Borders, believe keeps vaccine prices more affordable worldwide—an illustration of the conflict between some in the world of global health and the Gates Foundation over how best to achieve their shared goals about access and equity.
The Gates Foundation “was formed with the belief that Bill and I have that all lives have equal value,” Melinda tells me in June. Since the beginning of the pandemic, the organization has repeatedly made the case for equity to world leaders, such as German chancellor Angela Merkel. “What we can do as a foundation is go to rich world governments and ask them, when they help different vaccine companies set up bioreactors to start manufacturing this vaccine, to actually set aside money, to put money in a fund that buys bioreactors for low- and middle-income country vaccines,” she says.
Last spring, Bill Gates explained in an op-ed in The Washington Post and to Trevor Noah on The Daily Show that vaccine factories would have to start production before it was clear which vaccines would succeed. “Of all the vaccine constructs, the seven most promising of those—even though we’ll end up picking at most two of them—we’re going to fund factories for all seven,” Gates told Noah. At the time, it was widely reported that the foundation itself was giving billions to this effort, because of how Gates had phrased things. It later became clear that the foundation would merely seek to catalyze the vast sums that would be necessary with some seed funding. “Bill and Melinda have said they’re very willing to put money toward [manufacturing],” says Scott Dowell, deputy director of global health at the foundation, which he joined in 2014 after a career at the CDC, “but the amount of money that you’re talking about . . . on the chance that all five or six of these [vaccine candidates] work well, then you’re talking $50 billion to $60 billion. That doesn’t just jingle out the pockets even of Bill and Melinda. It requires quite a bit of work of coalition building and persuading.”
SUZMAN SAYS THAT HE REALIZED AS THE NOVEL
vaccine alliance called Gavi launched a new initiative called the Covax Facility, which asked the world’s governments to pool resources to support a portfolio of vaccines, with the guarantee that each participating country would receive a portion of doses of the vaccines that succeed. By October, 90 wealthier countries, including the U.K. and Germany, had pledged to assist 92 poorer ones, and the group committed to deliver 2 billion doses of vaccine by the end of 2021. (As of November, the United States had not joined.) The vaccine developers working with CEPI have agreed to supply vaccines as a condition of their funding. To incentivize manufacturers to produce enough supply for each country, Gavi has sought to amass an initial seed fund of at least $2 billion to buy vaccines for countries that can’t easily compete in the global market. “The role of Gavi will be critical in the time of COVID for a little country like Guinea to somehow rock on up and try and figure out how it can get COVID vaccine in the global market,” says Violaine Mitchell, deputy director for vaccine delivery at the Gates Foundation. Without it, she says, “they would just be completely shut out.”
This approach, known as an Advance Market Commitment (AMC), has been used by Gavi before and has the Gates Foundation’s support. Beginning in 2005, Gavi used an AMC to try to help bring down the cost of the pneumococcal vaccine by guaranteeing a large market for it. But the price tag was still relatively high—coming down from a starting point of $120 a dose in rich countries—because of the current system of pharma regulation and IP laws that grant temporary monopolies, allowing manufacturers to charge more than they would given true market competition. “If we wanted to actually address access, we would address the biomedical R&D paradigm,” says Kate Elder, senior vaccines policy adviser for Doctors Without Borders, who has criticized the pneumococcal vaccine AMC for enriching Pfizer and Glaxo-SmithKline while diminishing Gavi’s ability to serve a wider variety of health issues because it has to devote so much of its budget to this one vaccine. Others echo this concern, saying that the Gates Foundation hasn’t pushed for the deeper changes that could lower costs in the industry, such as governments covering the cost of R&D for critical products in exchange for companies later selling those products at no profit. The organization “has a really naive understanding of the role of the private sector,” says Linsey McGoey, a professor at the U.K.’s University of Essex and author of 2015’s No Such Thing as a Free Gift, a book that examines the challenges of the Gates Foundation’s philanthrocapitalist model. “They see it as an unqualified force for good.”
This unbridled faith that market forces will benefit everyone amid this pandemic, and not merely serve the interests of capital, pops up routinely in conversation with Gates Foundation executives. “I think the pharmaceutical companies are going to make good on what they promised, I really do, because the whole world is watching,” Melinda says. Bill tells me, “Nobody’s trying to make money selling this vaccine to developing countries.”
Yet within a contract between AstraZeneca and a Brazilian manufacturer—one of the only such agreements where some of the terms have been made public—the pharmaceutical company gets to decide that the pandemic is “over” as early as July 2021, after which it could charge what it believes the market will bear.
When pressed on why private companies need to own the rights to these vaccines, Gates makes clear that he believes it’s the wrong problem to focus on. “This is about making a complex biological product that will have been through a safety review—this isn’t about IP,” he says, raising his voice slightly and laughing in frustration. “It’s irritating that this issue comes up here.” Even if someone else had the intellectual property for a particular vaccine, he says, they couldn’t easily scale up the factories to make it. A spokesperson for Gavi, while acknowledging that IP could be a barrier to licensing vaccines as quickly as possible, agrees that the bigger challenge is the close collaboration needed between producers and manufacturers to prepare factories.
IN JUNE, WHO, CEPI, AND A 20-YEAR-OLD-GATES-BACKED
even as manufacturers scrambled to build new facilities, “there will absolutely be inadequate immediate supply,” says Stuart, the Gates Foundation’s deputy director of vaccines, “and that’s not just talking about poor countries.” Then the world will have to make difficult choices about who gets the first doses. “I think you start with the 60 million healthcare workers around the world,” says Melinda Gates. “They are the ones keeping all of our communities safe, so they deserve to get the vaccine first. Then you start to look at the most vulnerable populations.”
The Covax program is designed to provide doses to supply 20% of the population of each participating country, and public health officials are aligned with Melinda Gates’s perspective, with vaccines going first to healthcare workers and then to others most at risk, including the elderly. Although many world leaders have signed a resolution saying that vaccines should be a “global public good,” as right-wing populism spreads, the scourge of vaccine nationalism has become contagion as well, something that executives at the Gates Foundation witnessed during 2009’s H1N1 pandemic, when rich countries bought up the initial supply of a vaccine, leaving developing countries empty-handed. “The order of magnitude difference of the need means that there are going to be big challenges at a national level of governments wanting to crowd in or get first rights for their own citizens,” says Suzman. “Which is an understandable motivation.” Even Bill Gates says, “We have to accept the fact that rich world governments, particularly the U.S., will have some factories that are completely dedicated to them.” At its core, Operation Warp Speed was created to purchase Americans a spot in the front of the line for any successful vaccines funded by the government’s $10 billion program. After a $79 million investment from the U.K. government, AstraZeneca said that the first 30 million doses of its Oxford-developed vaccine would stay in the country.
AstraZeneca also made a deal with CEPI and Gavi to provide hundreds of millions of doses for poorer countries and then licensed the vaccine to India’s Serum Institute. The Gates Foundation later announced that it would provide $300 million to help Serum, which operates on a model of high volume and marginal profit, begin to scale up production quickly of 200 million doses, with each one to cost no more than $3. In Indonesia, the Gates Foundation-backed Biopharma takes a similar approach. “They will be able to help manufacture this vaccine and manufacture it at scale for not only their own countries, but also for the developing world,” Melinda Gates says.
But there’s also plenty of wiggle room in AstraZeneca’s covenant. When I ask the company if it is going to sell the vaccine at cost, a spokesperson says, “We have made a commitment to make the potential vaccine available at no profit during the period of the pandemic to support broad and equitable access around the world.” It would provide no further details on its deal with Serum.
“I mean, are we just taking their word for it?” asks Doctors Without Borders’ Elder, regarding all of the pharma companies’ no-profit promises. “All these governments are actually still allowing companies to be granted IP and to own these products, which ultimately means that companies get to decide at what scale they’re producing these medical tools, at what price they’re making them, and who they’re first selling them to. So they’re still proprietary, and they’re still monopolies.”
The governments pouring billions into development could have pushed for open-source vaccines as a global public good but haven’t because they, too, are captured by a market-based mindset. While the WHO did create a technology access pool where companies could freely share vaccines with any qualified manufacturers, it has been overshadowed by the approach the Gates Foundation preferred. That open alternative “is kind of withering on the vine,” says Northeastern’s Baker, “because the system set up for the Gates Foundation consumed all the oxygen present.”
Critics fear that the Gates Foundation’s influence—specifically the way it reinforces established power structures—has a corrosive effect that tarnishes the good that it does. Academics, including the University of Essex’s McGoey, argue that the foundation’s approach shapes health systems in poor countries without the same accountability that a government would have. The foundation’s incursion into what many people feel should be solely the role of public officials and institutions perpetuates a myth that private actors know better, further eroding trust in civic leaders at a time when public health agencies are underfunded. “What we shouldn’t do is ever come in and displace the private sector or governments, who will always have more resources than we have even as a very large foundation,” Suzman says.
The Gates Foundation is “an organization that’s ultimately accountable to three people: Bill Gates, Melinda Gates, and Warren Buffett,” says Jeremy Youde, a political science professor at the University of Minnesota who’s focused on global health politics. (In 2006, Buffett pledged the majority of his fortune to philanthropic causes, splitting it between four charitable trusts and the Gates Foundation where he serves as a trustee.) “Can we think about a way to collaborate with an organization like the Gates Foundation, while at the same time still recognizing the primacy of state and national governments within the international system? I don’t think [we’ve] quite found that right balance.”
Still, it’s inarguable that without the Gates Foundation, the world would be in a worse position in the current pandemic. The foundation’s support for CEPI, and its direct backing of vaccine platforms, has been one reason that development for a prophylactic has been able to move faster for COVID-19 than ever before. Its support for equitable distribution—while flawed—will get the vaccine to billions, a necessary step to stop the spread of the illness. The foundation has also continued to work on the other issues it’s always worked on, some of which have been exacerbated by the pandemic, from childhood vaccination rates to its economic fallout.
It’s not clear if the world will be prepared for the next global health crisis. But Bill Gates, ever the optimist, believes it’s possible. “For tens of billions of dollars—which sounds like a lot, but relative to overall government budgets or even military budgets, it’s not much—we can have the ability to have standby capacity, or quick testing, quick antivirals, quick monoclonals, and a quick vaccine. It’s pretty clear what needs to be done,” he says. “I think this time, people will take it seriously.”
The Gates Foundation is likely to put itself at the center of the next global health crisis. But that doesn’t absolve everyone else from insisting that they’re not alone.
editors@fastcompany.com
AS VACCINES ARE APPROVED FOR USE,
