Bill Gates. Photo / Calla Kessler, The New York Times
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 USD$850 million so he could begin producing doses of promising coronavirus vaccines for the world's poor.
Poonawalla calculated that he could risk $300 million of his company's money but would still be more than $500 million short. So he looked to a retired software executive in Seattle.
Bill Gates, the Microsoft founder turned philanthropist, had known Poonawalla for years. 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, 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 more. Funded largely with public money, the initiative is led by two global nonprofits that Gates helped launch and bankroll, along with the World Health Organisation, 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. 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," 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 immunise 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, Gates has hosted online roundtables with drug company officials. He has pursued financial commitments from world leaders. He has consulted frequently with Dr. Anthony Fauci, the nation's chief infectious disease expert and a longtime collaborator on vaccine initiatives. And to help staff the vaccine effort, his foundation has provided millions of dollars for McKinsey & Co. consultants.
If the initiative, aided by Gates' 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 endeavour 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 maximise 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 the current plan for a global vaccine deal, poor countries would receive only enough doses to inoculate 20% 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 deal-makers. "We don't have a choice about which vaccine we would like to use. It is whatever they impose on us."
'The Bill Chill'
As a novel coronavirus linked to a live animal market began spreading rapidly in Wuhan, China, 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.
Two weeks later, Dr. Seth Berkley — chief executive of Gavi, the Vaccine Alliance, a nonprofit the Gates philanthropy helped found — flew to Seattle. He and Gates considered how to get Covid-19 vaccines to the developing world. On March 13, two days after the WHO declared a global pandemic, Gates conferred online with 12 top pharmaceutical executives, including the heads of Pfizer and Johnson & Johnson, both of which have leading vaccine candidates.
Gates became interested in immunisations in the late 1990s. 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, Gates helped create a new business model involving subsidies, advance market commitments and volume guarantees. The incentives drew in more manufacturers, resulting in many more lifesaving vaccinations.
With a $100 million initial pledge, Gates helped create the Coalition for Epidemic Preparedness Innovations to invest in drugs and experimental vaccines. 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% effective, and applied to the Food and Drug Administration for emergency authorisation.
Some public health officials disagreed with Gates' 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 criticised 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 WHO, the United Nations agency charged with international public health. Gates felt frustrated with what he viewed as the organisation's rigid bureaucracy and constraints on dealing with the private sector.
Some at the WHO had concerns about his growing reach.
"The Gates Foundation presence has been, at best, an adjunct to WHO 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 WHO stress their mutual respect for each other.
Capitalism at Work
In March, Gates was urging drugmakers to move fast, cooperate with one another, open up their libraries of drug compounds and even share production responsibilities.
The Gates Foundation employs former pharmaceutical executives in its top ranks. 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.
Some public health advocates and on-the-ground providers like Doctors Without Borders thought 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 Gates and drug industry executives.
He and others believed that vaccine-makers would not maximise production for the developing world, especially when rich countries were clamouring for doses, because it wouldn't serve their bottom line. India and South Africa, in asking the World Trade Organisation 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.
But 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 jeopardised and that their control over their vaccines would ensure quality and safety.
"This capitalism thing — there actually are some domains that actually works in," 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 the Gateses 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.
Bill Gates had a long record of getting rich countries to provide funding for public health initiatives in poorer countries. Politicians saw him as a steward of public dollars with a nose for good investments.
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.
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, subsidised doses for up to 20% of their populations by the end of next year, but the wealthier nations could sign up for more.
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 grants.
"It's going to be subsidised, yes, but countries still have to budget for their copay 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.
Zevallos, the Ecuadorian 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,'" Zevallos said. "I'm disappointed."
Berkley, the Gavi director, acknowledged the frustration. "Did we communicate with everybody as well as we should? Absolutely not," he said. "But we did our best to try to do that."
At the same time, 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."
With coronavirus cases multiplying worldwide, 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."
Written by: Megan Twohey and Nicholas Kulish
Photographs by: Calla Kessler
© 2020 THE NEW YORK TIMES
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