Collaborating against COVID

On January 23, 2020, 12 days after the first reported COVID-19 death in Wuhan, China, and three days after the first reported case in the United States, Trevor Mundel, the president of global health at the Gates Foundation, wrote a note to Bill Gates and Melinda French Gates on behalf of our outbreak monitoring team.

“Unfortunately,” he wrote, “the coronavirus outbreak continues to spread with the potential to become a serious pandemic (too early to be sure but essential to act now).” Upon receiving the message, Bill and Melinda immediately approved US$5 million to help the world respond to the threat of the emerging coronavirus.

That was the first step in what would turn out to be perhaps the most pivotal moment in the foundation’s two-decade existence: an opportunity, and an imperative, to make the most of our resources and voice to help address the biggest global public health crisis in over a century.

In the years that followed, we supported governments in the Global South and other partners to develop vaccines and diagnostics, expand supply chains and delivery systems for drugs and diagnostics, and help get vaccines into arms—all at an unprecedented pace. We also advocated relentlessly for equity in the world’s response. That initial $5 million toward addressing COVID-19 became $100 million by February 5, 2020, and $250 million by April 15, 2020. All told, our foundation has committed more than $2 billion to address the pandemic.

This was on top of two decades of investments and partnerships to combat infectious diseases that proved critical for responding to COVID-19 as well: the multilateral organizations founded to develop and distribute vaccines, diagnostics, and therapeutics; the public health infrastructure that helps countries track and respond to threats; and the health systems that communities rely on for quality care. Our longtime support for scientific innovations like mRNA technology also proved invaluable. We had long believed that mRNA could prove a game-changer for preventing and treating infectious diseases. Then, in 2020, scientists used it to develop safe and effective COVID-19 vaccines in just 10 months, the fastest turnaround in history.

Not every choice we made since COVID-19 struck had the intended impact. The pandemic created a global emergency where time and data were scarce. Like others around the globe, we have moved quickly, with incomplete and ever-changing information. While we persistently made the case that vaccines and other tools should be distributed based on need, not on wealth, in the end that effort didn’t fully succeed: Most countries prioritized nationalism over equity when allocating resources. More than 6 million people have died of COVID-19, and many more have had their lives devastated by the pandemic’s ripple effects. We have a lot to learn from where the world’s efforts, and our own, fell short.

At the same time, according to an analysis published in The Lancet, COVID-19 vaccines saved 20 million lives in their first year. The pandemic was a time of great trauma, to be sure, but also one of remarkable innovation. And that’s due in part to the work of the Gates Foundation and our partners—on COVID-19 directly and to help build, over decades, the systems, technologies, and institutions that set the stage for the world’s response. We are proud of the role our foundation has played to catalyze and coordinate action in the face of this global challenge.

Hitting the ground running

When COVID-19 hit, we knew we had to help the world respond quickly and prioritize the needs of those at highest risk. As a philanthropic foundation, we cannot supplant the role of governments to fund emergency response, decide what that response should be, or spend nearly as much money as wealthy countries can. What we can do is gather stakeholders to collaborate, take risks with our resources that governments and private companies can’t or won’t, and use our voice to call attention to challenges and solutions—all at a rapid pace.

In the case of the pandemic, we knew one of the most important actions we could take would be to apply our expertise and partnerships to make early investments in areas where we believed we could have positive impact, including a focus on access and equity.

“Epidemics introduce a paradox to the world,” Mark Suzman wrote on March 9, 2020, just as the magnitude of the crisis was becoming clear. “Viruses like COVID-19 spread rapidly but developing vaccines and treatments to stop them moves slowly. If we want to make people, particularly the most vulnerable, safer from outbreaks then we need to find a way to unwind this paradox: to speed up R&D and slow down the spread.”

With that in mind, our focus from the start was to find ways to accelerate outbreak detection and the development of new diagnostics, vaccines, and treatments. We also aimed to help build the architecture to support an equitable and coordinated rollout of COVID tools so that as many people as possible, including those so often left behind, would benefit.

Many of our earliest efforts involved helping partner institutions in Africa and South Asia launch their response to the emerging threat. For example, in mid-February we worked to help Africa CDC and other partners train multiple scientific teams to molecularly diagnose COVID-19 using polymerase chain reaction (PCR) analysis, so that more African nations could immediately identify where COVID cases were appearing.

We focused on these regions first because we knew from other crises, such as H1N1 and Ebola, how disease outbreaks disproportionately affect the poorest and most vulnerable populations and can quickly overwhelm public health systems with already limited capacity. “If we can help African and South Asian countries improve their capacity to detect COVID-19 and respond effectively to a sudden surge in cases, healthcare services can avoid being swamped,” Valerie Nkamgang Bemo, our deputy director for emergency response, said in February 2020. “And we can save thousands of lives.”

We also knew that India, the world’s largest producer of vaccines and the third-largest producer of pharmaceuticals by volume, would be critical to the global COVID-19 response, so we began working with manufacturing partners there to set the stage for a rapid rollout of vaccines. We also worked closely with health officials and other partners to help train medical personnel, secure critical resources such as oxygen, expand genetic sequencing, and strengthen COVID response across the country, particularly in Uttar Pradesh and Bihar.

Our top priorities

As the world has battled successive waves of the virus and its variants, our foundation has focused on addressing COVID-19 in work that has fallen into three categories:

• Accelerating outbreak detection
  You can’t protect against an infectious disease without a clear, up-to-the-minute understanding of where it’s emerging and how it’s behaving differently in different places. That requires tools to test individuals for the pathogen, systems to model its spread, and genomic technology to identify variants. We funded the Africa CDC to rapidly establish testing capacity across the continent and expand its ability to detect variants through pathogen genomics; worked with the Africa Medical Supplies Platform and partners to facilitate access to portable LumiraDx testing devices, which provide accurate results in 12 minutes; worked with organizations to improve predictive analytics systems for modeling COVID-19’s spread; and helped make available 120 million rapid antigen tests for lower-income countries in collaboration with Africa CDC, the Clinton Health Access Initiative, FIND, and Unitaid.
• Developing new diagnostics, treatments, and vaccines
  It can take years and even decades to develop effective vaccines and other life-saving innovations. The world couldn’t afford that kind of wait with COVID-19. We helped launch the COVID-19 Therapeutics Accelerator, to coordinate philanthropic and private-sector R&D funding, and the Access to COVID-19 Tools Accelerator, to speed up the rollout of tools across the product development spectrum, from research to manufacture to procurement and delivery. We also directly funded R&D via companies including Bio E, the Serum Institute of India (SII), and SK Bioscience to develop COVID-19 vaccines and supported the tech transfer of vaccine candidates to SII, to help produce 200 million doses of COVID-19 vaccines at low cost for lower-income countries. And we provided funds to the Coalition for Epidemic Preparedness Innovation—a longtime partner that has been instrumental in all stages of pandemic response—to accelerate the development of next-generation vaccines that combat all coronaviruses.
• Prioritizing equitable access
  At the Gates Foundation, our work is guided by the conviction that all lives have equal value. We focused on mitigating the inequitable impact of the pandemic and ensuring that as many people as possible, in as many places as possible, could benefit from life-saving innovations. This was a matter of advocacy—bringing life science companies together to codify industry commitments to equitable access, for example, and calling attention to the gender gaps that widened during the pandemic. This was also a matter of material support.

We committed more than $200 million to Gavi’s COVID-19 Vaccines Advance Market Commitment to finance the purchase of vaccines for lower-income countries. We supported governments and regional institutions in lower-income countries to bolster emergency operations, improve data collection, train health care workers, set up treatment centers, and engage communities through effective communications. And in the United States, we funded emergency aid to help K-12 schools and colleges address the pandemic’s disproportionate impact on students of color, expand access to data so policymakers could better understand student needs, support advances in online learning, and establish COVID-19 testing labs at historically black colleges and universities.

Looking ahead

There is still a great deal of work to do to end the acute phase of the pandemic. New and more infectious variants continue to emerge, families and nations are still feeling the economic burdens of COVID-19, health systems have been weakened by the toll of the virus, and many people in lower-income countries are still waiting for vaccines.

That wait is unacceptable. At the Gates Foundation, as thrilled as we were to see safe and effective vaccines, diagnostics, and treatments created in record time, we are dismayed that those tools have been distributed so inequitably. “Leaving half the world without access to vaccines only means that more people will suffer and die, both at home and abroad,” Mark Suzman wrote in February 2021.

In many ways, this inequity is the problem of global health and development writ large, and the issue the foundation has been working to address since our inception. Too often, the world’s attention and resources are spent on the needs of wealthy nations, while the challenges prevalent in lower-income countries are neglected. In the first two decades of this millennium, immense strides were made to change that equation. But COVID has stalled that progress and shown that a pandemic can threaten hard-won gains at any time.

What would effective global action look like to avert the next pandemic? Continued investment to combat longstanding infectious diseases through strengthened primary health systems and effective multilateral institutions. Global coordination in surveillance and a shared commitment to equity. Improved vaccine manufacturing capacity around the world.

And what does action look like at the Gates Foundation? We saw how the systems we helped build up in stable times mitigated potential damage in a time of crisis. We remain steadfast in our guiding principles: advancing global health, supporting innovation, building partnerships, and working to ensure equity for all. And we are compelled to help accelerate progress. Moving forward, we plan to increase our annual outlay from $6 billion before the pandemic to $9 billion by 2026, to ease the many shocks of COVID-19 and restore forward momentum on global health and development.

We hope that this continued commitment and additional investment will not only make the world more resilient, but will also help us fulfill our goal of a world where everyone, no matter where they come from, has the opportunity to lead a healthy, productive life.