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.