Two recent publications on the COVID-19 pandemic have attracted my interest in the past couple of weeks – the Lancet Commission report “On lessons for the future from the COVID-19 pandemic” and a Politico Special Report on “How Bill Gates and his partners took over the global COVID response”. Both are useful assessments of the failure of a global approach to the pandemic, and I commend them both as the world moves to preparing for the next pandemic. But they miss the boat in different ways with regard to the multi-stakeholder nature of the global effort. One ignores its usefulness, while the other criticizes how it unfolded in the COVID-19 pandemic. In this commentary, I explain why I am concerned about both approaches. I believe that the pandemic opened up new opportunities for multi-stakeholder collaboration at the global level, and I sincerely hope that this kind of collaboration will continue to evolve in a positive direction in spite of the setbacks.
The Lancet Commission report was issued in mid-September following the deliberations of its multinational commission chaired by Professor Jeffrey D. Sachs of Columbia University. The in-depth Politico report by reporters Erin Banco, Ashleigh Furlong and Lennart Pfahler and based on a joint Politico/WELT investigation, also appeared in mid-September. The Lancet report concentrates on the failure of governments to work together, while the Politico report concentrates on the flaws of the way that four major non-state actors promoted their own vision of a global effort that was itself a failure. The Lancet report urges for a more collaborative approach among nation-states, which is, of course, welcome in itself. But it misses the point of how non-state actors were actively involved in mobilizing a global effort and could continue to to contribute to such global efforts more directly.
The Politico report, on the other hand, criticizes the very way that this effort by non-state actors unfolded – and also ended up being in conflict with the expectations of a wide array of NGOs on the fundamental issue of intellectual property. The report does identify the remarkable engagement of two philanthropic foundations – the Bill & Melinda Gates Foundation and the Wellcome Foundation – to mobilize global action on the pandemic but then proceeds to criticize their role as lacking in public accountability. The report further complicates the scene by associating two other non-state actors, GAVI and CEPI – with them and further argues that they were instrumental in distorting the global effort with their combined embrace of intellectual property rights for the pharmaceutical industry.
The Lancet Report
It is heartening to read the commission’s frank critique of the failure of global “prosociality”, to use the new word introduced by the Lancet publishers in their press release for this report. The group did acknowledge that there were indeed some bright spots. including the public/private partnership for rapid vaccine development and the transnational scientific collaboration in vaccine development; the speed with which vaccines were developed was phenomenal. And yet, access to vaccines proved to be extremely uneven in the first year or so of their availability. While vaccine supply is no longer a barrier for access, since their dissemination has encountered other logistical constraints and vaccine hesitancy, the commission report does recognize the need for corrective measures on all fronts.
In particular, vaccine availability does need to be improved in future pandemics. The commission report describes this as “vaccine strategic sustainability”. Given the related distributional issues, though, the report also emphasizes the need for increasing investments for a better “first line of defense” for health systems generally and universal health care for all. The commission also hopes to “ignite a renaissance” in multilateralism that also links future pandemic preparedness with both climate change and sustainable development.
Regrettably, though, the Commission members limit themselves to a multilateralism that reinforces national sovereignty. They “encourage nation-states to enrich their deliberations and decisions with the voices of civil society, the private sector, local governments, parliaments, academic, and young people, among others”. This is fine and good at the national level, but why not also at the global level? This is my main disappointment with the Commission’s report.
It is, in fact, a report that is very nation-state focused in all of its recommendations. Better WHO governance and increasing resource allocation to the WHO, revising the WHO’s International Health Regulations and maybe even adopting a new pandemic treaty, and establishing a new Global Health Board with heads of governments – these are are all highlighted in the report. And these are all very nation-centric.
The Commission is also critical of special health funds like GAVI, the Global Fund, Every Woman Every Child, and even the World Bank’s Pandemic Emergency Financing Facility – as well as the COVAX Facility itself. The preference in the report is for the creation of a new “Global Health Fund”. Or, in the alternative, the merger of GAVI with the Global Fund for HIV/AIDS, Malaria and TB. This more limited consolidation might not be such a bad idea, especially since the Global Fund has had a lot more success in raising and disseminating money and does have a broader focus on capacity building among low and middle and income countries rather than just vaccine distribution.
The Politico Report
The Politico report provides an in-depth look at how the Bill & Melinda Gates and Wellcome Foundations were active non-state actors that promoted a global effort for controlling and ending the COVID-19 pandemic. The report does seem to imply that two other global actors, GAVI and CEPI, were also non-state actors – and that the four of them worked together to advance an effort that lacked in accountability. The report also argues that the oversight set up through the ACT-Accelerator at the WHO was inadequate to track where funds went for pandemic-specific initiatives on vaccines, therapeutics. diagnostics and health system strengthening.
What the report missed, though, is that GAVI and CEPI are multi-stakeholder entities, unlike the Gates and Wellcome foundations, and that their governance reflects the dominant role of governments as the source of their funds while also bringing in the voices of the private sector and civil society representatives (as well as foundations). As I followed the formation of the ACT-Accelerator in its initials stages, in March and April of 2020, I had the distinct impression that the European Commission was playing a leadership role, with substantial financial support from its member states. The fact that the US was missing from this effort because of President Trump’s anti-global stance was, to me, very concerning. And the fact that numerous Americans with pandemic-related knowledge were circumventing this governmental boycott to participate through non-state actors in this global effort was, to me, very heartening. The Politico report does not adequately emphasize these aspects of what happened – that is, different status of GAVI and CEPI, the leadership role of the European Commission, the important and dominant role of public funds from EU countries for the global effort, and the avenues for Americans to circumvent Trump’s anti-global policies.
Finally, the Politico report does not mention the effort by GAVI to create two different funds for the pandemic. In mid-2020, GAVI proposed a COVAX Facility to mobilize resources and access to COVID-19 vaccines for the 70-plus low and middle income countries that have been recipients of GAVI vaccines for other diseases. However, GAVI also launched a parallel fund for all countries to join in a pooling of funds for a truly global distribution of COVID-19 vaccines. My recollection is that Switzerland and Singapore were supposed to be the co-chairs of this initiative – to have a global pool that would distribute vaccines proportionately to everyone. Unfortunately, this fund fell apart when participating countries like Canada supposedly benefited from an initial distribution when they had already advance purchased more than enough vaccines independently of GAVI. And of course, the US, even after it returned to its global leadership role, never did go along with this idea. It would have been nice if the Politico report had looked more closely at this failed effort.
On the other hand, both the Political report and the Commission report contain critiques of the apparent preference (mostly, it seems, by the US government) given to the development of mRNA vaccines. One could argue that the mRNA research that had been underway for a good ten years or more seemed better ready to move quickly with targeted vaccine development for COVID-19 than the more traditional vaccine sources and processes. In retrospect, though, there are some longer-term benefits of the protections from traditional vaccines that do raise questions about why so little funding was directed to them along the way.
One significant implication of the mRNA focus, furthermore, was the patentable features of this new process and their adaptability to other vaccine needs. It is no surprise, then, that Pfizer, Moderna, and their partners have been so protective of their patentability. And yet, as the Commission report points out, the US government could have done a lot more to limit or share the profits from these vaccines. Instead, the US simply reinforced the vaccine market by purchasing the vaccines back from these companies, even where the US had financed most of the development, at apparently commercial rates.
The Politico report goes further on this point and argues that the four actors (Gates, Wellcome, GAVI and CEPI) together played a role in discouraging, if not even blocking, the development of open-source vaccines. It does, in any case, seem that none of these entities is actively encouraging the waiver of intellectual property rights. And it does seem that the non-participation of a lot of major global NGOs in the COVAX Facility is because of this issue.
I recall that the early stages of the ACT-A initiative did call for broadened civil society participation but that it was only the relatively pro-business NGOs like Global Citizen that were successfully recruited. But to suggest that GAVI and CEPI are in cahoots with the pharmaceutical industry as allies of Gates and Wellcome misses the point that it is the governments with pharmaceutical industry interests that are blocking the opening up of waivers.
To wrap up, then, I continue to be a promoter of global multi-stakeholder collaboration, and the early stages of the global response to the COVID-19 pandemic gave me hope that multi-stakeholder collaboration would transform action for a truly global response. This did not happen, but I would hope that more recognition is given to the benefits of a multi-stakeholder approach for future global crises. I appreciate that the Politico report raised the issue of accountability where charitable foundations are involved in mobilizing global health initiatives like this one for COVID-19, but the challenge in such multi-stakeholder settings is to define new governance mechanisms to acknowledge the diversity of interests involved. I believe this is a better approach than to condemn the charitable foundations and others who are reaching across national borders to address a truly global issue.
Access to these two reports is available here:
https://covid19commission.org/
https://www.politico.com/news/2022/09/14/global-covid-pandemic-response-bill-gates-partners-00053969
