Special Report
Four health organizations, working closely together, spent almost $10 billion on responding to Covid across the world. But they lacked the scrutiny of governments, and fell short of their own goals, a POLITICO and WELT investigation found.
Illustrations by Dan Page for POLITICO
By Erin Banco, Ashleigh Furlong and Lennart Pfahler
09/14/2022 10:00 PM EDT
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When Covid-19 struck, the governments of the world weren’t prepared.
From America to Europe to Asia, they veered from minimizing the threat to closing their borders in ill-fated attempts to quell a viral spread that soon enveloped the world. While the most powerful nations looked inward, four non-governmental global health organizations began making plans for a life-or-death struggle against a virus that would know no boundaries.
What followed was a steady, almost inexorable shift in power from the overwhelmed governments to a group of non-governmental organizations, according to a seven-month investigation by POLITICO journalists based in the U.S. and Europe and the German newspaper WELT. Armed with expertise, bolstered by contacts at the highest levels of Western nations and empowered by well-grooved relationships with drug makers, the four organizations took on roles often played by governments — but without the accountability of governments.
While nations were still debating the seriousness of the pandemic, the groups identified potential vaccine makers and targeted investments in the development of tests, treatments and shots. And they used their clout with the World Health Organization to help create an ambitious worldwide distribution plan for the dissemination of those Covid tools to needy nations, though it would ultimately fail to live up to its original promises.
The four organizations had worked together in the past, and three of them shared a common history. The largest and most powerful was the Bill & Melinda Gates Foundation, one of the largest philanthropies in the world. Then there was Gavi, the global vaccine organization that Gates helped to found to inoculate people in low-income nations, and the Wellcome Trust, a British research foundation with a multibillion dollar endowment that had worked with the Gates Foundation in previous years. Finally, there was the Coalition for Epidemic Preparedness Innovations, or CEPI, the international vaccine research and development group that Gates and Wellcome both helped to create in 2017.
(Left to right) Gavi CEO Seth Berkley, former German Chancellor Angela Merkel, Gates Foundation Co-founder Bill Gates, and former President Donald Trump. | Getty Images and AP Photos
Civil society organizations active in poorer nations, including Doctors Without Borders, expressed discomfort with the notion that Western-dominated groups, staffed by elite teams of experts, would be helping guide life-and-death decisions affecting people in poorer nations. Those tensions only increased when the Gates Foundation opposed efforts to waive intellectual property rights, a move that critics saw as protecting the interests of pharmaceutical giants over people living poorer nations.
“What makes Bill Gates qualified to be giving advice and advising the U.S. government on where they should be putting the tremendous resources?” asked Kate Elder, senior vaccines policy adviser for the Doctors Without Borders’ Access Campaign.
Bill Gates (center), shown above with Britain's Prince Charles (right) and Canada's Prime Minister Justin Trudeau (left) in November 2021, co-founded one of the largest philanthropies in the world. | Pool Photo by Phil Noble
Soon, however, governments in the United States and Europe were offering their own crucial support to the four groups. The organizations spent at least $8.3 million lobbying the U.S. and E.U., according to an analysis of lobbying disclosures. When, this past spring, the leaders of CEPI sought to replenish the group’s coffers, it spent $50,000 in part to advocate for $200 million in yearly funding from the U.S. government, according to filings and interviews with Capitol Hill staff.
The overtures worked. While President Joe Biden’s efforts to obtain an additional $5 billion in funding for the administration’s international work combatting the virus were floundering in Congress, he still managed to slip $500 million for CEPI into his budget proposal — $100 million a year for five years.
The money, which has yet to be approved, would help what most global health experts agree is an important cause, not only in humanitarian terms but in helping prevent poorer nations from becoming breeding grounds for new variants. And most believe that the Gates Foundation and the other groups deserve credit not only for their work to help save lives but for being almost the only game in town with sufficient scope to fight a pandemic.
But the groups’ extensive politicking and financial might in the U.S. and Europe helped to enable them to direct the international response to the most important health event of the past century at a time when governments were caught flat-footed, according to the investigation.
Many people believe that the Gates Foundation and the other groups deserve credit not only for their work to help save lives but for being almost the only game in town with sufficient scope to fight a pandemic. | Moises Castillo/AP Photo
The investigation, which relied on more than four dozen interviews with U.S. and European officials and global health specialists, charted the step-by-step journey through which much of the international response to the Covid pandemic passed from governments to a privately overseen global constituency of non-governmental experts. It also detailed the significant financial and political connections that enabled them to achieve such clout at the highest levels of the U.S. government, the European Commission and the WHO.
The officials who spoke to POLITICO and WELT hail from the top tiers of the governments in the U.S. and in Europe, including in the health agencies. They were granted anonymity to speak candidly about how their respective administrations approached the international response to Covid and what missteps occurred during the course of their tenure. Many of them dealt directly with representatives of the four global health agencies, some on a daily basis.
POLITICO and WELT examined meeting minutes as well as thousands of pages of financial disclosures and tax documents, which revealed that the groups have spent nearly $10 billion since 2020 — the same amount as the leading U.S. agency charged with fighting Covid abroad. It is one of the first comprehensive accountings of expenditures by global health organizations on the global fight against the pandemic.
Now, critics are raising significant questions about the equity and effectiveness of the group’s response to the pandemic — and the serious limitations of outsourcing the pandemic response to unelected, privately-funded groups.
“I think we should be deeply concerned,” said Lawrence Gostin, a Georgetown University professor who specializes in public-health law. “Putting it in a very crass way, money buys influence. And this is the worst kind of influence. Not just because it’s money — although that’s important, because money shouldn’t dictate policy — but also, because it’s preferential access, behind closed doors.”
Gostin said that such power, even if propelled by good intentions and expertise, is “anti-democratic, because it’s extraordinarily non-transparent, and opaque” and “leaves behind ordinary people, communities and civil society.”
While dozens of global health organizations participated in the world’s response to Covid, the POLITICO and WELT investigation focused on these four organizations because of their connections to one another — both Gavi and CEPI received seed funding from the Bill & Melinda Gates Foundation — and because they together played a critical role in advising governments and the WHO.
The WHO was crucial to the groups’ rise to power. All had longstanding ties to the global health body. The boards of both CEPI and Gavi have a specially designated WHO representative. There is also a revolving door between employment in the groups and work for the WHO: Former WHO employees now work at the Gates Foundation and CEPI; some, such as Chris Wolff, the deputy director of country partnerships at the Gates Foundation, occupy important positions.
Much of the groups’ clout with the WHO stems simply from money. Since the start of the pandemic in 2020, the Gates Foundation, Gavi, and the Wellcome Trust have donated collectively more than $1.4 billion to the WHO — a significantly greater amount than most other official member states, including the United States and the European Commission, according to data provided by the WHO.
“You have to remember that when you’re dealing with the Gates Foundation, it’s almost like you’re dealing with another major country in terms of their donations to these global health organizations,” a former senior U.S. health official said.
Working closely with the WHO, the four groups played a central role in creating an initiative known as the Access to Covid-19 Tools Accelerator, or ACT-A, that focused on securing and delivering tests, treatments and vaccine doses to low- and middle-income countries across the world. COVAX — a special consortium operated by Gavi, CEPI and UNICEF — is the vaccine pillar of the ACT-A initiative.
But ACT-A missed its delivery goals for 2021 on all three fronts — for testing, vaccine distribution and treatments, according to an independent review by Dalberg Global Development Advisors, a policy advisory firm based in New York.
ACT-A missed its delivery goals for 2021 on all three fronts — for testing, vaccine distribution and treatments. | Jerome Delay/AP Photo
The ACT-A diagnostics team set a target of making 500 million tests accessible to low-and middle-income countries by the middle of 2021. It procured just 84 million tests by June 2021, only 16 percent of its target, according to the report. The therapeutics team originally set a goal of delivering 245 million treatments to low- and middle-income countries by 2021 but later changed the target to 100 million new treatments by the end of 2021. As of June of that year, the therapeutics team had allocated only about 1.8 million treatments.
COVAX set the aim of delivering 2 billion vaccine doses by the end of 2021. By September of that year, it had only delivered 319 million doses.
Although COVAX significantly accelerated the delivery of doses later in 2021 and in 2022, governments have struggled to get shots into arms. As of August 2022, only about 20 percent of Africans were vaccinated — a dangerously low percentage — according to the Africa CDC.
The leaders of the groups say that they were unable to meet their goals largely because wealthy, Western governments were slow to step up and make available the huge tranches of vaccine and therapeutics that were needed to protect the world. The groups say they provided a crucial voice for the suffering and needs of poorer nations, without which the progress may have been far slower.
“Putting it in a very crass way, money buys influence. And this is the worst kind of influence. Not just because it’s money […] but also, because it’s preferential access, behind closed doors.”
Lawrence Gostin, Georgetown University professor who specializes in public-health law
“The Gates Foundation focused on supporting a global response that would ensure low- and middle-income countries had affordable, equitable access to the best data and tools available to tackle the crisis,” Mark Suzman, CEO of the Gates Foundation, said in a statement. “In some areas we saw successes. On the most critical issue of equitable vaccine access, the world as a whole failed as high-income countries initially monopolized available supply.” The foundation declined to make Gates available for comment.
On the struggle to deliver vaccine doses to low- and middle-income countries on time, Seth Berkley, the CEO of Gavi, said in an interview that the organization actually met one of its original targets of distributing 950 million doses by the end of 2021 to low-income countries, even though it failed to deliver on one of its original promises to distribute 2 billion doses. (COVAX delivered the 950 million doses by January 2022.)
“It’s very easy to sit there outside and to criticize what we’re doing. What we need to do is to be evaluated fairly based upon the actions we took at the time with the knowledge we had at the time,” Berkley said.
A spokesperson for CEPI put it this way: “While there is much that we can improve upon, it would be inaccurate to apportion all the blame for the failures of the global response to the very organizations that did more than anyone else to try and solve the problems of vaccine supply and inequity.”
”The challenge we faced was the need to bake in access to vaccines for poor countries right at the point when companies were able to sell promising product to the highest bidder,” the spokesperson said.
Jeremy Farrar, the Wellcome Trust director, struck a similar note. “Comprehensive pandemic preparedness and response requires the sort of funding and international cooperation that only governments can muster,” he said.
Farrar, however, defended the ACT-A partnership as “the best mechanism we have for delivering lifesaving Covid-19 tools across the world.”
“Before ACT-A was set up, there was no formal mechanism in place to coordinate and accelerate the development, production and equitable access to Covid-19 interventions globally,” he said. “While ACT-A may not be perfect … the global response would have been poorer and far more fragmented without it.”
The POLITICO and WELT investigation found, however, that ACT-A’s structure diminished accountability. ACT-A representatives set funding priorities and campaigned for donations. But the money — $23 billion in total — went directly to the entities involved in the initiative, such as Gavi and CEPI. Although ACT-A’s website keeps track of how much money was raised, it is nearly impossible to tell exactly where all of it went.
Based on each organization’s individual Covid database, it is not possible to delineate exactly how the groups spent the money raised through ACT-A. It is also difficult to determine in the organization’s grants and investment data how much they donated specifically for ACT-A programming. For example, the organizations do not use “ACT-A” or similar terminology in their descriptions of their grants and investments.
“In theory, I think that was a great idea,” said Gayle Smith, who led the U.S. State Department’s global Covid-19 response last year, referring to ACT-A. But she questioned its accountability.
“In practice … there was no single director,” Smith said. “Who’s the big boss of this whole enterprise? In a global emergency like this, we need to be able to get the countermeasures to everyone everywhere as quickly as possible.”
Bruce Aylward, who coordinates the work of the ACT-Accelerator at the WHO, said ACT-A was purposely set up with a decentralized structure in order to cut down on bureaucracy. He said that each agency was in charge of their own accounting and solidifying agreements directly with donors.
Smith and others closely involved in the global Covid fight say there should have been a stronger hand at the tiller.
When vaccine doses started flowing into COVAX, many poor countries and provinces were ill-equipped to handle them. And during the long delays, many potential beneficiaries lost faith in the global health system.
“I think that if we had had the vaccine earlier the coverage would have been much, much, much better,” said Stephen Bordotsiah, the municipal director of health services in the Bolgatanga region of Ghana, which received significant doses from COVAX.
During the long delays in the rollout of the Covid vaccines, many potential beneficiaries lost faith in the global health system. | Paula Bronstein/Getty Images
While ACT-A devoted most of its time and resources to securing doses, little money went to improving health systems on the ground. Of the $23 billion that ACT-A and its receiving agencies — including Gavi and CEPI — raised, only $2.2 billion went to the strengthening of health systems, according to the WHO initiative’s own funding tracker.
Aylward blamed any of ACT-A’s deficiencies on “factors that were beyond the control of the accelerator,” he said, including a lack of government financing for distribution of Covid tools to low-income countries. “Every politician stood up there and said all the right things. They wanted to do the right things,” Aylward said. “We got to create the enabling environment to let them do that.”
Now, the four groups are spending millions of dollars to lobby the U.S. and EU to embrace their priorities for the next pandemic, some of which include strengthening local health systems. Other initiatives involve investing more money in research and development, hoping to create next-generation vaccines and expanding surveillance networks across the globe.
Meanwhile, many global health specialists question whether the groups are capable of performing the rigorous post-mortems necessary to build a stronger global response system for the future.
“No one’s actually holding these actors to account. And they’re the ones that are really shaping our ability to respond to pandemics.”
Sophie Harman, professor of international politics, Queen Mary University of London
“No one’s actually holding these actors to account,” said Sophie Harman, professor of international politics at Queen Mary University of London. “And they’re the ones that are really shaping our ability to respond to pandemics.”
Each of the four organizations said they are doing at least some internal reflection of their Covid work.
CEPI is wrapping up an assessment of its work over the past five years, including on Covid, and plans to publish it in full in September. Representatives for the Gates Foundation and Wellcome said their respective organizations have completed internal reviews, though no formal publication of those findings exist on the groups’ websites. Gavi has also commissioned an outside firm to conduct a review of COVAX and plans to publish its findings. It’s unclear when that report will be made public. The group published a general document about lessons learned from Covid 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.
Chapter 1
Just days before New Year’s Eve 2019, a man in France checked himself into a hospital, complaining of a fever and shortness of breath. Doctors didn’t know at the time — and wouldn’t realize until months later — that the man had likely developed one of the first cases of Covid-19.
The virus had been circulating in China in the weeks preceding the man’s hospitalization, but the Beijing government refused to share details about the newly dubbed SARS-CoV-2. It wasn’t until New Year’s Eve that the WHO was first notified about the cases of “viral pneumonia,” which was spreading at an alarming pace.
Top officials across the U.S. and Europe watched the news from afar, viewing the virus as a problem for Beijing — not the rest of the world. Top Trump administration officials, including the president, brushed off warnings. In Europe, a risk assessment from the European Center for Disease Control and Prevention on Jan. 9 stated “the likelihood of introduction to the EU is considered to be low, but cannot be excluded.”
Then, on Jan. 18, the CDC confirmed the first U.S. case of Covid.
Public health officials in the U.S. and Europe scrambled to figure out how to respond, frantically attempting to close borders and isolate people who tested positive.
The faltering response shouldn’t have been a surprise: In 2019, the Trump administration concluded an exercise in which top health officials determined the U.S. was unprepared to fight a global pandemic. Three years earlier, in 2016, the United Kingdom had carried out a simulation exercise for a hypothetical influenza pandemic, which showed that its health system would become overwhelmed in such an event.
Top officials across the U.S. and Europe viewed the virus, which originated in Wuhan, China, shown above in January 2020, as a problem for the Chinese government — not the rest of the world. | Dake Kang/AP Photo
Neither the U.S. nor Europe had done much in the interim to boost their preparedness — though they were considered by the global health community as perhaps the most capable of all regions of the world to handle a pandemic. But there were other players — non-governmental organizations — who were far better prepared, having dedicated themselves to fighting Zika, Ebola and similar outbreaks that crossed national boundaries.
The largest was the Bill & Melinda Gates Foundation, whose vast influence is also the connective thread between the groups.
Bill Gates and Melinda French Gates started the foundation in 2000, using money from Bill Gates’ Microsoft days to kickstart the philanthropy. In 2006, Warren Buffett, the CEO of Berkshire Hathaway, a large holding company, announced that he would donate most of his fortune to the foundation.
The foundation draws on a $70 billion endowment to grant billions of dollars every year to organizations working on some of the world’s toughest health problems. Bill Gates recently pledged that he would give virtually all of his fortune to the foundation and that the organization would increase its spending from nearly $6 billion annually to about $9 billion by 2026.
One of the largest philanthropies in the world, the Gates Foundation helped create both Gavi and CEPI and has representatives on both of their boards.
Gavi was founded in 1999 with $750 million from the Gates Foundation to strike vaccine deals with pharmaceutical companies for low-income countries. The vast majority of its financing is made up of donations from governments. The organization focuses solely on immunization and its board is made up of multiple representatives from the global south.
CEPI launched in 2017 with the financial backing from the Gates Foundation, the Wellcome Trust, Norway and India, with the mission of funding vaccine research and development. In the last five years, the organization, which is helmed by Richard Hatchett, a former Obama administration official, has become one of the world’s leading nonprofits in vaccine development, garnering donations from powerful, Western governments.
Dawn O’Connell (right), a former CEPI employee, is the leader of one of the most important branches in the Department of Health and Human Services for pandemic preparedness in the U.S. | Pool Photo by Greg Nash
The Wellcome Trust, which was created in the 1930s in the United Kingdom by a founder of what was one of the largest pharmaceutical companies in the world, operates with an endowment of about $38 billion, according to its website. It is one of the largest charitable foundations in the world and dedicates significant funding to biomedical research and scientific data modernization. The director of the trust, infectious disease expert Jeremy Farrar, until recently was an adviser to the British government on health emergencies.
Staff members at Wellcome, CEPI and the Gates Foundation include former U.S. and European officials — employees who now help the organizations draw on political and financial support for their missions. Former staffers of the organizations work in government, too. For example, Dawn O’Connell is the leader of one of the most important branches in the Department of Health and Human Services for pandemic preparedness in the U.S. She used to work for CEPI, helping raise funds for the organization. And Nicole Lurie, the current U.S. director of CEPI, used to work in that same position in the health department.
The global health nonprofits moved quickly in 2020 to fill the leadership void left by governments still grappling with their domestic responses, according to lobbying disclosures, meeting minutes and interviews.
Leaders of the Gates Foundation, Gavi, CEPI and Wellcome deployed their lobbying and advocacy networks and used their political connections to push U.S. and European officials to commit billions of dollars to Covid programs the organizations helped envision and lead.
The extent of their access to global decision-makers attests to their central role in helping establish the global Covid response: The groups briefed top officials in the European Commission about investments in tests, treatments, shots and the importance of sharing those products with the rest of the world. In the U.K., the organizations usually met several times a month with ministers to discuss topics such as Covid testing, clinical trials and manufacturing capacity. Some of those meetings included Prime Minister Boris Johnson. Bill Gates and Melinda French Gates — his former wife — spoke directly to then-German Chancellor Angela Merkel about the distribution of Covid vaccine, according to German government documents obtained by POLITICO and WELT.
Bill Gates (left), shown above in 2018, spoke directly to then-German Chancellor Angela Merkel (right) about the distribution of Covid vaccines. | Markus Schreiber/AP Photo
Meanwhile, in the U.S., leaders of the organizations were also in contact with senior U.S. health officials. Emails obtained by Republicans on Capitol Hill illustrate the extent to which Farrar, the director of Wellcome, was in touch with officials in some of the highest levels of the U.S. government on a sensitive health and national security issue. The emails, released this year, show Farrar in the early weeks of the pandemic discussing the possibility of Covid having leaked from a lab in China with top U.S. health officials including Anthony Fauci and National Institutes of Health Director Francis Collins.
Top Trump officials also said they spoke often with Bill Gates and his foundation’s staff about how to fast-track the development of medical countermeasures, including vaccines, and how to distribute them to developing countries. These meetings would grow in number and intensity as the pandemic unraveled. During the Biden administration, officials met with members of the four organizations on a weekly basis, according to two current and one former senior U.S. officials. The U.S. government is also on Gavi’s board and met with the organization often to discuss internal matters.
“We relied heavily on their advice throughout the pandemic, but especially in the early days,” said a former U.S. official about the federal government’s interactions with representatives from the organizations.
But even though the foundation’s expertise was obvious — Bill Gates and Melinda French Gates had made fighting viruses a major part of their life’s work — the fact that crucial decisions were being refracted through American billionaires and the massive network they’d established raised concerns among some officials as well as grassroots activists on the outside.
“These big men of global health and how they … captured the agenda and managed to influence what people are thinking around pandemic preparedness and response – I think that’s really important [to consider],” Harman said. “[There’s] a revolving door of where these people are educated, where these people have worked, how they get the jobs that they’re in – it’s all a really close network.”
The foundation’s clout and that of its allies wasn’t merely a function of being the only game in town; it was also the product of concerted lobbying and advocacy work.
“They’re very good lobbyists. The people are very capable and passionate about their goals. They, of course, also come for funds.”
A European Union official
“They’re very good lobbyists. The people are very capable and passionate about their goals,” a European Union official said. “They, of course, also come for funds.”
Over the last two years, Gavi and CEPI have spent at least $1.3 million on lobbying aimed at obtaining U.S. and European cash to fund their own enterprises and the causes they supported, according to lobbying records. Wellcome also lobbied in Europe — spending at least $1.1 million — to gain political support for its programs.
Meanwhile, the Gates Foundation in 2019 set up a lobbying firm known as the Gates Policy Initiative, led by Rob Nabors, former White House deputy chief of staff for policy in the Obama administration. There are no lobbying disclosure forms on file for the firm.
A spokesperson for the foundation said U.S. law prohibits private foundations from engaging in lobbying and that the Gates Policy Initiative is a separate organization from the foundation that does not coordinate with it on programmatic activities. In a statement, a spokesperson for the Gates Policy Initiative said the organization is funded through a “direct gift” provided from Bill Gates and Melinda French Gates and that it has not engaged in activities that would require the filing of lobbying disclosure forms.
The Gates Foundation’s leaders were also their own best lobbyists. Multiple former Trump officials and staff on Capitol Hill said Gates and his team frequently met with lawmakers and administration officials, including Health Secretary Alex Azar, about the government’s spending priorities in fighting the pandemic. Azar could not be reached for comment.
In the EU and the U.K., from 2020 to early 2022 there were over 100 meetings related to Covid or pandemic preparedness between officials of the four organizations and senior Commission or U.K. officials, according to lobbying records. Leaders of the organizations attended some of the meetings, as did the U.K. prime minister and the head of the European Commission, Ursula von der Leyen. In Germany, CEPI and Gavi sent numerous letters to the German chancellor’s office over a two-year period in an effort to elicit more funding for their respective organizations.
European Commission President Ursula von der Leyen was one of the many leaders who attended meetings related to Covid or pandemic preparedness with officials from the four global health organizations. | Ian Forsyth/Getty Images
All the concerted outreach paid off, both in terms of money and clout.
Since 2020, CEPI and Gavi have raised billions of dollars as a result of their lobbying. Between 2020 and 2021, the European Commission gave CEPI over $100 million, while the U.K. contributed more than $330 million, Germany paid over $430 million and the U.S. gave $8 million. In the case of Gavi, for the period of 2021 to 2025, the U.S. has pledged over $4.8 billion, the U.K. has allocated over $2.6 billion, Germany has promised over $2 billion and the European Commission over $1 billion.
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 marshal governments around a plan.”
Former Trump officials said Gates and his team frequently met with people in the administration, including Health Secretary Alex Azar (right), about the government’s spending priorities in fighting the pandemic. | Drew Angerer/Getty Images
Paul Mango, former deputy chief of staff for policy at the health department under Trump, confirmed that the U.S. did not start developing a plan for international vaccine distribution until July of 2020 —more than five months after the virus first emerged. But, he said, the U.S. began working as early as February of 2020 to identify potential vaccine candidates, though the administration did not finalize its financial investments in those companies until months later.
“We had to evaluate a number of different characteristics of the company and the vaccine before we invested,” he said in an interview. “We wanted to see if phase one and two of the clinical trials revealed good data. That took a couple of months.”
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.”
Wellcome, the Gates Foundation and Gavi have collectively donated $1.4 billion to the WHO since 2020. | Sean Gallup/Getty Images
At the end of January, 2020, representatives from the Gates Foundation and Wellcome were a regular presence at meetings with the WHO and top officials from the U.S. about the virus’ spread, Covid sample sharing and vaccine and drug clinical trials, according to meeting minutes. They even helped organize and fund the first truly international meeting at the WHO to lay the groundwork for the world’s response to the virus.
Wellcome, in collaboration with the Gates Foundation, offered the WHO funding to host a research meeting in Geneva to connect top health officials from governments across the world with researchers, scientists and other major global organizations, according to WHO meeting minutes. The goal of the meeting: begin a worldwide conversation about how to begin to study and invest in Covid tests, therapeutics and vaccines.
David Vaughn, deputy director of vaccine development at the Gates Foundation, and Josie Golding, the lead of Wellcome’s epidemic responses, hosted a preparatory meeting Feb. 4, 2020, with U.S. officials and members of the WHO Scientific Advisory Group, according to another set of WHO meeting minutes. In the meeting, the organizations’ representatives suggested that potential funders come together to discuss the WHO’s research and development blueprint — a framework for how the international community could respond to the virus.
By the end of the global conference in the second week of February, attendees had agreed on a comprehensive road map for the world’s response to Covid, including how funders would support vaccine, drug and test development. WHO officials called for $675 million to respond to Covid.
The Gates Foundation announced that it would dedicate $100 million to the effort. At a CEPI board meeting, Hatchett said the organization had signed four agreements for Covid vaccine development and that the organization was working closely with the WHO, dispatching two staff members to work on vaccine development.
Health official Nancy Messonnier’s public warning in late February forced the Trump White House to recognize the potential threat of Covid-19. | Samuel Corum/Getty Images
All this global planning was occurring at a time when the Trump White House was not acknowledging the Covid threat — before health official Nancy Messonnier’s public warning 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.
By the middle of February, 2020, Covid had begun spreading to Africa — where each of the organizations, but particularly the Gates Foundation, had worked extensively. Africa’s first recorded case was a 33-year-old man in Egypt, worrying global health officials that a large-scale outbreak would completely overwhelm the continent’s health systems.
The Africa Centres for Disease Control and the WHO moved quickly to send medical supplies and tests to stop the spread of the virus. But it was too late. The global health organization described the outbreak as a worldwide pandemic a month later on March 11. Another month after that, Covid cases topped 10,000 in Africa.
The four global health organizations mobilized quickly to try to prepare low-income countries, including in Africa, for the coming assault of cases, the POLITICO and WELT financial analysis showed. In March, the Gates Foundation granted $47 million to dozens of different organizations, including the CDC Foundation, the WHO and to institutions to help detect Covid and develop monoclonal antibodies. Former CDC director Tom Frieden’s Resolve to Save Lives (formerly known as Vital Strategies) received close to $1 million to help strengthen epidemic preparedness capacity for Covid in the African region.
“It was made very, very clear that the United States would never be sending people — particularly not the military — to other nations to do that type of work.”
A former senior U.S. official
Despite the spread worldwide, at home the Trump administration downplayed the danger posed by the virus well into March, claiming that the U.S. had contained Covid. And the administration maintained that it would focus on controlling Covid at home, dedicating resources to the American people, rather than spearheading efforts to help fight the virus overseas.
“During the Trump administration, even us talking about doing global work was just constantly shot down,” said one of the former senior U.S. officials. “When USAID got their funds to provide external Covid aid, the response funds were going to Gavi … to do that work on behalf of the United States. It was made very, very clear that the United States would never be sending people — particularly not the military — to other nations to do that type of work.”
The European Commission took a different approach. 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.
The Trump administration consistently maintained that it would focus on controlling Covid at home, dedicating resources to the American people, rather than spearheading efforts to help fight the virus overseas. | Alex Brandon/AP Photo
At the virtual March 26 G-20 Covid summit, leaders said in a statement that they would commit to donating resources to the WHO, CEPI and Gavi. “We call upon all countries, international organizations, the private sector, philanthropies and individuals to contribute to these efforts,” the statement said.
The U.S. and EU would eventually dedicate hundreds of millions of dollars to aiding the global fight against Covid, but the majority of their contributions to vaccine procurement and distribution would not come for more than a year —until the summer and fall of 2021. Their resistance to sharing doses would delay the global vaccination campaign, denying millions in low-income countries of first doses at a time when people in the U.S. and Europe were receiving their second.
That hesitation left a gap in global health policy.
The four organizations spent significant amounts of money, starting in the spring of 2020, to lobby members of Congress to give the organizations money so they could aid low-income countries, according to lobbying disclosures. In 2020, Gavi and CEPI spent more than $435,000 on lobbying Congress and senior officials in the U.S. Agency for International Development, the White House and the Department of Health and Human Services. CEPI pushed for specific language in legislation that would authorize the U.S. government to support its mission at $200 million a year.
“CEPI and the friends of CEPI … [were] lobbying Congress hard on this issue and have pushed the language into almost every vehicle that looks like it is moving,” a former senior U.S. health official said.
The spokesperson for CEPI confirmed the lobbying activities, saying the organization has “consistently” asked the U.S. government for $200 million annually. “This ask has been supported by several NGOs and civil society groups,” the spokesperson said.
Eventually, in October 2020, the Trump administration, through USAID, pledged $20 million to CEPI. The bulk of the additional U.S. funding pledges for the global fight against Covid, including $4 billion to Gavi, would not come through until 2021.
As a response to the growing gap in international Covid funds and programing, Wellcome, the Gates Foundation and Mastercard in March 2020 created the Covid-19 Therapeutics Accelerator — a collaboration to raise money for Covid treatments — and committed up to $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.
As the winter months of 2020 gave way to spring and millions of people across the globe contracted the virus, the global health organizations began to coordinate and unleash similar investment strategies, playing key roles in identifying which pharmaceutical and scientific firms would be earmarked for funding.
Over the following two years, they would grant hundreds of millions of dollars to dozens of the same organizations. For example, Wellcome and the Gates Foundation gave $452 million to 18 of the same organizations, including several companies producing vaccines, tests and therapeutics, according to the financial analysis.
As the organizations continued to invest in the development of the Covid shots and medicines, they also began to envision programs that would help with their distribution.
At the beginning of April 2020, the Gates Foundation produced papers on programs that could help with equitable distribution of vaccine doses, tests and therapeutics.
The foundation’s papers focused on the development of ACT-A — the Access to Covid-19 Tools Accelerator, originally dubbed a “task force” that aimed to “support the equitable delivery of effective [and] affordable” Covid tools within a short time period, according to draft copies. The initiative, designed with significant input from Gavi and CEPI, was supposed to be the answer to ensuring people in low- and middle-income countries had access to life-saving medicines and vaccines.
ACT-A was supposed to be the answer to ensuring people in low- and middle-income countries had access to life-saving medicines and vaccines. | Patrick Ngugi/AP Photo
The Gates Foundation, CEPI, Gavi, Wellcome and several other organizations at one point proposed leading the consortium on their own, along with several other organizations, according to interviews with one of the former senior U.S. officials and another global health official at the WHO.
However, the WHO pushed to oversee the accelerator, worrying some of the leaders of the global health organizations that the process would get bogged down in bureaucracy, according to two people who worked with the organizations on setting up ACT-A. While the WHO oversaw the initiative in name, the organizations played a significant role in leading its operations. Other organizations involved in helping lead ACT-A included Unitaid, UNICEF, and the World Bank.
The organizations pushed back on the idea that they ever tried to establish the program outside the ranks of the WHO. The Gates Foundation said it “never proposed leading the consortium” on its own. Similarly, CEPI said the “WHO was involved all along as an essential partner.”
Representatives of the foundation also circulated an early paper that outlined the formation of COVAX — the present-day vaccine sharing initiative to get doses to low-income countries overseen by Gavi, according to a draft of the document. COVAX eventually became a part of ACT-A and morphed into the vaccine pillar of the initiative.
Asked about the paper and the foundation’s involvement in the formation of COVAX, the spokesperson for Gavi said the original idea for the vaccine initiative was born out of a January 2020, discussion between the leaders of Gavi and CEPI.
COVAX is the present-day vaccine sharing initiative to get doses to low-income countries. | Diomande Ble Blonde/AP Photo
The Gates COVAX paper made its way to U.S. health officials who briefed Azar, the then-U.S. health secretary, on the paper before a call with Gates in March 2020, according to a former senior Trump official.
“The aim is to deploy vaccines in record time (‘moonshot’),” the paper said.
Instead, though, the initiative moved slowly.
In the first several months after ACT-A’s formation, the consortium struggled to identify a clear structure — one that would allow for minimal bureaucracy and the free flow of ideas, according to three people involved in its creation.
Meanwhile, grassroots organizations fretted 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.
Special Report
By Annette Choi and Erin Banco
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.
“We took the view that a centralized kind of one organization trying to tell everybody else what to do wouldn’t work.”
Peter Sands, executive director, the Global Fund
Founders of the WHO consortium said they designed ACT-A without a clear leader on purpose.
Peter Sands, the executive director of the Global Fund, defended ACT-A’s structure.
“There is a sort of issue that people raised, which is, there was nobody in charge. It wasn’t that it was designed like that. It was designed intentionally as a collaborative leadership model,” Sands said. “We took the view that a centralized kind of one organization trying to tell everybody else what to do wouldn’t work.”
Aylward, the lead for ACT-A at the WHO, described the structure as a “huge success,” adding that it was an intentional decision to have the agencies involved in the initiative run their own budgets, programming and donor talks in order to “get money out the door quickly as possible.
”But money did not flow to ACT-A or the agencies running the programs quickly enough to help distribute life-saving Covid tools to low-and middle-income countries.
The battle to establish systems to get vaccine doses and treatments to countries in need was just beginning — and it would take almost another year to convince wealthy Western governments to do significantly more to help.
Chapter 2
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