[Ip-health] New York Times: Bill Gates, the Virus and the Quest to Vaccinate the World

Thiru Balasubramaniam thiru at keionline.org
Mon Nov 23 00:39:59 PST 2020


Bill Gates, the Virus and the Quest to Vaccinate the World
The billionaire is working with the W.H.O., drugmakers and nonprofits to
defeat the coronavirus everywhere, including in the world’s poorest
nations. Can they do it?

The New York Times
By Megan Twohey and Nicholas Kulish
Nov. 23, 2020, 3:00 a.m. ET

The head of one of the world’s largest vaccine manufacturers had a problem.
Adar Poonawalla, chief executive of the Serum Institute of India, needed
$850 million for everything from glass vials to stainless steel vats so he
could begin producing doses of promising coronavirus vaccines for the
world’s poor.

Mr. Poonawalla calculated that he could risk $300 million of his company’s
money but would still be more than a half-billion dollars short. So he
looked to a retired software executive in Seattle.

Bill Gates, the Microsoft founder turned philanthropist, had known Mr.
Poonawalla for years. Mr. Gates had spent billions to help bring vaccines
to the developing world, working closely with pharmaceutical executives to
transform the market. In doing so, he became the most powerful — and
provocative — private player in global health.

By the end of their conversation this summer, Mr. Gates had made a promise:
The Bill and Melinda Gates Foundation would provide a $150 million
guarantee so the Indian factory could move ahead with production. By
September, the foundation had doubled its commitment.

It is part of an $11 billion effort to lay the groundwork to procure
coronavirus vaccines for more than 150 countries, though it could
eventually cost far more when the doses come through. Funded largely with
public money, the initiative is led by two global nonprofits that Mr. Gates
helped launch and bankroll, along with the World Health Organization, which
relies on the Gates Foundation as one of its largest donors.

Working behind the scenes is the world’s second-richest man, neither a
scientist nor a doctor, who sees himself and his $50 billion foundation as
uniquely prepared to take a central part. Mr. Gates and his team are
drawing on connections and infrastructure the foundation has built over two
decades to help guide the effort.

“We know how to work with governments, we know how to work with pharma,
we’ve thought about this scenario,” Mr. Gates said in a recent interview.
“We need — at least in terms of expertise and relationships — to play a
very, very key role here.”

As the first vaccine candidates sprint toward regulatory approval, the
question of how to immunize much of the world population has taken on added
urgency. But nine months in, the success of the vaccine effort, known as
Covax, is not at all certain.

So far, it has pulled in only $3.6 billion in funding for research,
manufacturing and subsidies for poor countries. Three companies have
promised to deliver vaccines, but it is not yet known whether they will be
effective. And it may be difficult to secure the necessary billions of
doses in an affordable, timely way because the United States and other
wealthy countries have cut separate deals for their citizens.

In recent months, Mr. Gates, who emphasizes that he is one of many involved
in the vaccine effort, has hosted online round tables with drug company
officials. He has pursued financial commitments from world leaders: In one
week alone, he and his wife and co-chair, Melinda Gates, spoke with
President Emmanuel Macron of France, Chancellor Angela Merkel of Germany,
President Ursula von der Leyen of the European Commission and Crown Prince
Mohammed bin Zayed of Abu Dhabi.

In Washington, he has consulted frequently with Dr. Anthony S. Fauci, the
nation’s chief infectious disease expert and a longtime collaborator on
vaccine initiatives, and talked to Senator Mitch McConnell, a polio
survivor who has been supportive of programs to eradicate that and other
scourges. And to help staff the vaccine effort, his foundation has provided
millions of dollars for McKinsey & Company consultants.

“Some people will say, ‘Why should it be him?’” said Dr. Ariel
Pablos-Méndez, former director of knowledge management at the W.H.O. “He
has the star power. He has the resources. He cares. There are many players
that do things, but not at the scale of Gates.”

If the initiative, aided by Mr. Gates’s fortune and focus, manages to help
protect the world’s poor from a virus that has already killed more than 1.3
million people, it will affirm the strategies he has promoted in his
philanthropic work, including incentives for drug companies.

If the endeavor falls short, however, it could intensify calls for a more
radical approach.

Amid the pandemic, some public health officials and advocates argue that
vaccine makers, many of which have benefited from unprecedented public
funding, should be compelled to share their technology, data and know-how
to maximize production. India and South Africa, for example, are pushing to
suspend the global enforcement of intellectual property rights involving
the virus.

Dr. Zweli Lawrence Mkhize, South Africa’s health minister, said that the
usual practices did not apply in this crisis. “There has to be a degree of
broader consultation that looks at what is best for humanity,” he said in
an interview.

In the current plan for a global vaccine deal, poor countries would receive
only enough doses to inoculate 20 percent of their populations by the end
of next year. Some models show that there will not be enough vaccines to
cover the entire world until 2024.

“The consequence of longtime Gates strategies is that they go along with
corporate control over supply,” said Brook Baker, a Northeastern University
law professor and policy analyst for Health GAP, which advocates equitable
access to drugs. “In a pandemic, that is a real problem.”

Meanwhile, officials from some countries participating in the vaccine
initiative complain that they were barely consulted until recently. “They
are pushing us, cornering us, in order to make us pay,” Juan Carlos
Zevallos, Ecuador’s health minister, said of the dealmakers. “We don’t have
a choice about which vaccine we would like to use. It is whatever they
impose on us.”

As Mr. Gates has made public appearances to win support for the initiative,
he has increasingly become the target of conspiracy theories that could
undermine vaccination efforts.

Some falsely claim that his foundation tested vaccines that killed
thousands of children in Africa and India, while others link him to bogus
depopulation efforts. One poll from May found 44 percent of Republicans
believed that the global immunization effort was a cover for Mr. Gates to
implant microchips to track people. That claim is baseless.

Mr. Gates remains undaunted. “I’ve never heard either Bill or Melinda say
anything to the effect of ‘We’ll just work on something else, this is too
tough,’” said the billionaire investor Warren Buffett, who entrusted the
Gates Foundation with $31 billion of his own fortune to give away. “The job
is to work on tough problems.”

‘The Bill Chill’
As a novel coronavirus linked to a live animal market began spreading
rapidly in Wuhan, China, Mr. Gates watched from his office outside Seattle.

On Feb. 14, he and leaders at his foundation, fearing a global threat,
gathered to plan a response. From that point on, Mr. Gates recalled, “we’re
on Code Red.”

Two weeks later, Dr. Seth Berkley — chief executive of Gavi, the Vaccine
Alliance, a nonprofit the Gates philanthropy helped found — flew to
Seattle. Over breakfast, he and Mr. Gates considered how to get Covid-19
vaccines to the developing world. On March 13, two days after the W.H.O.
declared a global pandemic, Mr. Gates conferred online with 12 top
pharmaceutical executives, including the heads of Pfizer and Johnson &
Johnson, which both have leading vaccine candidates.

He felt prepared for this moment, having built up global institutions and
given away $55 billion to date, four times the influential Ford
Foundation’s endowment.

Mr. Gates became interested in immunizations in the late 1990s, when
Microsoft was facing an antitrust case that cast him as a modern-day robber
baron. Vaccines involved creating new technology, his specialty. Their
impact was measurable — inexpensive doses could protect hundreds of
millions against devastating disease. They were also about making deals.

Many Western drug companies had stopped producing vaccines back then,
finding them unprofitable. But through his giving, Mr. Gates helped create
a new business model involving subsidies, advance market commitments and
volume guarantees. The incentives drew in more manufacturers, including
ones from the developing world, resulting in many more lifesaving

He brought a “technocratic expertise and power rather than a discourse of
human rights and activism,” said Manjari Mahajan, an associate professor of
international affairs at the New School who has written about Mr. Gates’s
role in public health.

His foundation has spent more than $16 billion on vaccine programs, a
quarter of that going to Gavi, and given $2.25 billion to the Global Fund
to Fight AIDS, Tuberculosis and Malaria. Both organizations are based in
Geneva, where the W.H.O. has its headquarters.

With a $100 million initial pledge, Mr. Gates helped create the Coalition
for Epidemic Preparedness Innovations, in Oslo, to invest in drugs and
experimental vaccines. (The coalition and Gavi are leading the coronavirus
vaccine effort with the W.H.O.)

The foundation, which has about 1,600 employees, also funded academic
researchers, installed its executives on the boards of multiple nonprofits
and directly invested in drug companies.

One of them was the German company BioNTech, which got a $55 million equity
investment in September 2019. The business, partnering with Pfizer,
announced last week that their jointly developed Covid-19 vaccine appeared
to be 95 percent effective, and applied to the Food and Drug Administration
for emergency authorization.

Some public health officials disagreed with Mr. Gates’s priorities, arguing
that he should have directed more money to health systems. Others worried
about a private individual wielding so much influence. But few people
publicly criticized his foundation, fearful of losing its support. That
self-censorship was so widespread it acquired a nickname: “the Bill Chill.”

At times, frictions were evident with the W.H.O., the United Nations agency
charged with international public health. Mr. Gates felt frustrated with
what he viewed as the organization’s rigid bureaucracy and constraints on
dealing with the private sector.

Some at the W.H.O. had concerns about his growing reach. The malaria
division chief complained in a 2007 memo that the foundation’s growing
dominance of malaria research was stifling a diversity of viewpoints among
scientists and undercutting the agency. The same year, the foundation began
building up an institute that rivaled the W.H.O.’s role in health metrics.

“The Gates Foundation presence has been, at best, an adjunct to W.H.O. and
at worst a hostile takeover and a usurpation,” said Amir Attaran, a
University of Ottawa professor of law and medicine.

Today, the foundation and the W.H.O. stress their mutual respect for each
other. Publicly, Mr. Gates has made a point of praising the agency. “I
can’t think of anything that we disagree with them,” he said in the

Officials from the agency — which receives hundreds of millions of dollars
annually from the foundation, its second-largest donor — said Mr. Gates had
helped it become more efficient. “Gates pushes the science, pushes for the
answers, because that’s a little bit of that private-sector mentality,”
said Dr. Bruce Aylward, senior adviser to the W.H.O.’s director general.

As the coronavirus vaccine effort got underway, it was folded into a
broader mission, coordinated by the W.H.O., to also provide Covid-19
diagnostic tests and therapies to the developing world. The agency wanted
to take more of a leadership role in the vaccine deal making, but the Gates
Foundation and global nonprofits said they worried that drugmakers would
not cooperate. They worked to focus the agency’s role on regulating
products and advising countries on distributing them, among other

“We’re always talking with W.H.O.,” Mr. Gates said. “But a lot of the work
here to stop this epidemic has to do with innovation in diagnostics,
therapeutics and vaccines, which isn’t really their bailiwick.”

Farah Dakhlallah, a W.H.O. spokeswoman, said that the organization had an
“unmatched” ability to coordinate a global health response, and that the
initiative leveraged “the comparative advantages” of its partners in the
fight against Covid-19.

Capitalism at Work
In March, Mr. Gates was urging drugmakers to move fast, cooperate with one
another, open up their libraries of drug compounds and even share
production responsibilities.

“The first set of meetings, it was: ‘How are we going to find an active
drug? How are we going to kick off vaccine development quickly? How are we
going to shift manufacturing capacity?’” recalled Vasant Narasimhan, the
chief executive of Novartis.

The Gates Foundation employs former pharmaceutical executives in its top
ranks, including Dr. Trevor Mundel, who had been global head of development
at Novartis, and Emilio Emini, previously a senior vice president of
vaccine research at Pfizer. Working with the Coalition for Epidemic
Preparedness Innovations, they helped steer money into Covid-19 vaccine
candidates and biotechnologies that could be quickly manufactured and
suitable for the developing world.

Oxford University said it would offer “nonexclusive, royalty-free licenses”
of its work to manufacturers. But as it developed one of the most promising
vaccine candidates, the university debated whether it was equipped to
conduct clinical trials and transfer its technology to manufacturers around
the world.

Sir John Bell, who leads the development of Oxford’s health research
strategies and chairs the Gates Foundation’s scientific advisory committee,
reached out to Dr. Mundel. The advice was direct: “We told Oxford, ‘Hey,
you’ve got to find a partner who knows how to run trials,’” Mr. Gates said.

Oxford chose the British-Swedish drugmaker AstraZeneca. The Serum Institute
of India, after getting the financial commitment from Mr. Gates, agreed in
the summer to start producing the vaccine.

All the while, the United States and other countries were striking their
own deals with vaccine makers, even before they got regulatory approval.
There was some overlap between the global initiative and the American
effort, called Operation Warp Speed. AstraZeneca, Novavax and Sanofi made
commitments to both.

Mr. Gates was quick to praise the U.S. government’s enormous investment in
expediting coronavirus vaccines, saying it would benefit everyone. But the
more that countries locked down bilateral deals, the longer the rest of the
world would have to wait for doses.

Mr. Gates had valuable insights from Dr. Fauci, who leads the National
Institute of Allergy and Infectious Diseases. More than a decade ago, the
billionaire had invited Dr. Fauci to his home to join a discussion about
tuberculosis. Since then, they have coordinated efforts aimed at fighting
not just that disease but also malaria, polio and AIDS.

The two men spoke every few weeks. Dr. Fauci wanted to know how vaccine
trials in foreign countries were playing out. Mr. Gates was interested in
how the U.S. regulatory process was going and whether vaccines the American
government was purchasing would be suited for poor countries. The Pfizer
and BioNTech vaccine, for instance, requires two doses and ultracold
storage, obstacles in many places.

“He wanted to make sure, which is the classic Bill Gates, that as we do the
vaccines, that it’s the kind of vaccine that could be used in the
developing world,” Dr. Fauci said in an interview.

During the pandemic, Latin America has suffered a third of the world’s
deaths. Africa has now passed two million cases. Quarantines and trade
shutdowns have hit poor countries especially hard, where not working often
means not eating.

Some public health advocates and on-the-ground providers like Doctors
Without Borders thought Mr. Gates was doing too little to pursue equitable
access to vaccines and was too aligned with the pharmaceutical industry.

“Part of what they like about him is he’s protecting their way of life,”
James Love, director of Knowledge Ecology International, a nonprofit that
works to expand access to medical technology, said of Mr. Gates and drug
industry executives. “Because this message is always, ‘Big Pharma is

He and others believed that vaccine makers would not maximize production
for the developing world, especially when rich countries were clamoring for
doses, because it wouldn’t serve their bottom line. India and South Africa,
in asking the World Trade Organization not to enforce coronavirus-related
intellectual property rights, were seeking a way to wrest control of
vaccines from big companies and ramp up local manufacturing. Kenya,
Mozambique, Pakistan and Eswatini (formerly Swaziland) recently signed on
as co-sponsors to the request, with dozens of other countries expressing

But Mr. Gates and many public health experts thought that most companies
were taking laudable steps to help ensure access, such as nonprofit pricing
and licensing of their technology to other manufacturers. They argued that
drugmakers wouldn’t take on the costly process of creating new products if
their lucrative patents were jeopardized and that their control over their
vaccines would ensure quality and safety.

“This capitalism thing — there actually are some domains that actually
works in,” Mr. Gates said. “North Korea doesn’t have that many vaccines, as
far as we can tell.”

‘Acting Like a Lobbyist’
It was May 4, and Mr. and Mrs. Gates were on a video call with Boris
Johnson. They congratulated the British prime minister on the birth of his
son, and asked about the Covid-19 case that had sent him to the hospital.

Then they made their pitch: The world would never be safe from the virus,
and the global economy would never recover, unless poor countries received
vaccines and treatments, too.

Mr. Gates had a long record of getting rich countries to provide funding
for public health initiatives in poorer countries. From Ms. Merkel to Mr.
McConnell, politicians saw him as a steward of public dollars with a nose
for good investments.

“He has immediate access to us because of his fame and reputation and what
he’s doing with his own money,” Mr. McConnell, the Senate majority leader,
said in an interview. “In many of these countries, he’s way more effective
than the government is, and that’s certainly value added for public health
all over the world.”

Significant donations came from Britain, the European Union and elsewhere.
China pledged its cooperation last month. But Mr. Gates made no headway
with his home country.

He had asked the Trump administration and Congress for $8 billion, half for
the global vaccine effort and half for therapeutics and diagnostics in poor
countries. In private calls, Mr. Gates, who had forged ties with leaders of
both parties but remained nonpartisan over the years, made his case to Vice
President Mike Pence, House Speaker Nancy Pelosi and others.

He put himself in the public eye more than ever before, often appearing in
a pastel sweater that drew comparisons to Mister Rogers, and repeating in
interviews that the pandemic required an international response. “He’s made
a choice to become very public, very political, where he’s acting like a
lobbyist,” said Lawrence Gostin, professor of global health law at

But Mr. Trump had no intention of joining a global response. That became
clear in July, when he withdrew the United States from the W.H.O., which it
had provided with more than $400 million in annual contributions.

“People aren’t used to not having the U.S. step forward,” Mr. Gates said.
On the global vaccine effort, he acknowledged, the nation has been “a
no-show.” President-elect Joseph R. Biden Jr. may well take a different
position, having vowed to rejoin the W.H.O.

Leaders of wealthy countries were asked not only to help fund the
initiative — which was supporting development of nine potential vaccines —
but also to buy doses for their own populations. Among the nine was a
version from Moderna, which recently announced impressive clinical trial
results. As the deal makers framed it, even nations that already had
commitments from vaccine makers would benefit by diversifying.

Companies either would charge all countries the same price or set tiered
prices for low-, middle- and high-income nations; any could bow out if the
price exceeded $21 per dose. Poor countries could get cheap, subsidized
doses for up to 20 percent of their populations by the end of next year,
but the wealthier nations could sign up for more.

Clemens Martin Auer, a chief negotiator for the European Union, balked,
believing that the global vaccine deal was moving too slowly, that prices
would be too high and that Europe could do better negotiating on its own.

“I think the Gates Foundation has in many respects a very practical
approach when they say this has to be done in a private-public business
partnership,” he said. “But I sometimes have my impression that the Gates
Foundation doesn’t understand how well-organized governments work.”

With so much attention on wealthy nations, there was little consultation
with those the effort was intended to help most. It wasn’t until the fall
that lower-income countries learned they would have to pay $1.60 or $2 per
dose, a significant price that would require some to secure bank loans or

“It’s going to be subsidized, yes, but countries still have to budget for
their co-pay amount,” said Chizoba Barbara Wonodi, the Nigeria director at
the Johns Hopkins International Vaccine Access Center. “So they need to be
at the table when those discussions are made.”

Some middle-income countries have also felt squeezed, asked to pay prices
in a higher tier with little say as to what they would get or when they
would get it.

Mr. Zevallos, the Ecuadorean health minister, said he had spoken with
fellow ministers in the region about raising concerns through their
presidents. “They say, ‘You don’t get to choose, but you pay,’” Mr.
Zevallos said. “I’m disappointed.”

Dr. Berkley, the Gavi director, acknowledged the frustration. “Did we
communicate with everybody as well as we should? Absolutely not,” he said.
“Were we able to convene everybody as often as we could? Absolutely not.
But we did our best to try to do that.”

At the same time, Dr. Berkley said: “Have we brought together the entire
world to discuss equitable access to vaccines? Have we raised substantial
amounts of funds? All of that is true.”

A growing number of countries have committed to the endeavor, the three
drugmakers that have signed on are advancing through trials and the Gates
Foundation is also funding a portfolio of second-wave vaccines targeted at
the developing world. There is enough money to start buying doses once they
are approved, Dr. Berkley and others said, and they hope to pull together
the billions more needed to meet their goals.

With coronavirus cases multiplying worldwide, Mr. Gates said there would be
one simple way to judge the global vaccine initiative. “When did we stop
the pandemic?”

“That’s the thing this all needs to be measured by,” he said.

Sheri Fink contributed reporting from Durban, South Africa, and David D.
Kirkpatrick from Guayaquil, Ecuador.

Megan Twohey is a Pulitzer Prize-winning investigative reporter with The
New York Times. @mega2e

Nicholas Kulish is an enterprise reporter covering immigration issues.
Before that, he served as the Berlin bureau chief and an East Africa
correspondent based in Nairobi. He joined The Times as a member of the
Editorial Board in 2005. @nkulish

Thiru Balasubramaniam
Geneva Representative
Knowledge Ecology International
41 22 791 6727
thiru at keionline.org

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