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Routledge Handbook on the Politics of Global Health

Richard Parker, Jonathan García

Disrupting global health

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Jacob Levich
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19
Disrupting global health
The Gates Foundation and the vaccine business

Jacob Levich

Recent critiques of the Bill & Melinda Gates Foundation (BMGF) acknowledge, to varying degrees, the
malign effects of ‘philanthrocapitalism’ on the people’s health (Aschoff, 2016; McGoey, 2015). Yet these
effects are typically portrayed as the unintentional consequences of misguided benevolence. The multi-​
billionaires mean well, it is suggested, but are somehow too naïve to recognise the inherent limitations of
market-​based solutions to health crises.
It is more realistic to assume that Bill Gates and his ilk are highly sophisticated capitalists who know
what they want and how best to get it. While critics are correct in pointing out that BMGF has failed to
deliver the public health miracles it promises, this line of argument may be missing the point. BMGF is only
secondarily concerned, if at all, with saving lives; primarily, it is devoted to expanding worldwide markets
and facilitating commerce on behalf of Western capitalism. The Foundation’s embrace of the practices and
organisational norms of corporate capitalism is neither accidental nor misguided, but is central to a delib-
erate strategy for bringing ‘disruptive innovation’ to the public health field.
The concept of disruptive innovation entered management theory in the late 1990s at a time when
global capital, liberated by the fall of the Soviet Union, had set about tearing down old monopolies in order
to make room for new ones (Lepore, 2014). The term is flattering to entrepreneurs, because it connotes
bold, original thinking, but in reality it describes a process as old as capitalism itself: the more or less ruthless
restructuring of existing systems and norms to create space for even more profitable replacements.
Originally associated with high-​tech startups, the concept soon became central to business ideology and
is now applied to neoliberal ‘reforms’ in every sector: workforce reductions made possible by automation
and digital outsourcing, union-​busting measures aimed at the privatisation of public schools, the substitu-
tion of private health insurance markets for health care entitlements, etc. Newly minted philanthrocapitalists
were naturally inclined to impose familiar business practices on their charitable endeavours; hence, ‘disrup-
tion’ has become a watchword and a guiding principle throughout the field of philanthropy. For Bill Gates,
who became the world’s richest human being through notoriously anti-​competitive business practices
(Gavil and First, 2014), the public health field offered a global laboratory for further experimentation with
disruptive strategies.

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Vaccines and the pharma business

BMGF’s style of disruption is nowhere more evident than in the area of vaccines, Bill Gates’s par-
ticular focus and historically the central business of his foundation. When Seth Berkeley, CEO of the
Gates-​controlled vaccine consortium GAVI, advised a conference of pharmaceutical entrepreneurs
that ‘GAVI is a disruptive instrument’, he was not merely mouthing a management shibboleth. He was
describing, in a rare moment of frankness, the true business of the Gates Foundation. Today, traditional
systems of vaccine procurement and distribution are rapidly giving way to vast public–​private supply
chains, steered and substantially funded by the Gates Foundation in collaboration with the pharma-
ceutical industry (Gates, 2013).
The symbiosis between the world’s most powerful charitable enterprise and Big Pharma, infamous for its
cynicism and criminality, arises from the particular requirements of pharmaceutical capital. Despite annual
revenues approaching US$1 trillion, the industry has been unable to reverse a declining rate of profit and
finds itself in a perpetual state of crisis. The search for exploitable new molecules is becoming increasingly
frantic and expensive (Roy, 2012). Advertising costs, meanwhile, are skyrocketing as the industry attempts
to wring revenue from wary and financially strapped customers (Dobrow, 2015).
Industry publicists like to frame the business as a noble quest to meet society’s relentless demand for
new cures. In reality, Big Pharma manufactures and shapes demand, not vice versa. The nature of the drug
business, like every industry under capitalism, is conditioned by the need to dispose of surplus profit-
ably: ‘In order to absorb potential economic output and forestall excess capacity, business interests must
continuously search for new markets to exploit …’ (Wrenn, 2016, p. 63).
Market pressures are particularly acute in the pharma business because of unusually high development
costs and a narrow patent window. Pharmaceutical firms rely on high-​reward ‘blockbuster drugs’ –​those
with annual sales of US$1 billion or more –​to boost stock prices and generate sometimes astonishing profit
margins (Anderson, 2014). However, US and EU patent protections grant pharmaceutical firms a 20-​year
period of exclusive rights to new drugs.
Consequently, Big Pharma must take exceedingly aggressive measures to maximise profits as the so-​
called ‘patent cliff ’ approaches. The ostensible market for newly developed drugs –​i.e., people who actually
suffer from the conditions that the medications are meant to treat –​is rapidly saturated. New buyers must
then be found, or manufactured. Multi-​million-​dollar advertising campaigns are devised to push treatments
for dubious conditions such as ‘restless leg syndrome’ or ‘female sexual dysfunction’ (Allen, 2009). Doctors
are pressured to write off-​label prescriptions that permit the dispensing of medications for unapproved uses
(Stafford, 2008). These unethical but technically legal tactics are supplemented with a wide range of criminal
activities, including falsifying the results of clinical trials, suppressing information about side effects, and paying
kickbacks to health care professionals (Groeger, 2014; Srinivasan, 2010b). Such practices are so common in the
industry that massive criminal fines are considered merely ‘the cost of doing business’ (Tozzi, 2015).
Big Pharma’s well-​deserved notoriety is not due to exceptional wickedness on the part of executives
and shareholders. Rather, it reflects a logical response to imperatives that shape every facet of the pharma-
ceutical industry:

• The largest possible markets for approved ‘blockbuster drugs’ must be found, expanded, and ruthlessly
exploited. Where no market exists, it is necessary to create one –​or many.
• The scramble for new blockbusters is ceaseless and fraught. Factors that hinder rapid commercialisation
of new drugs –​e.g., safety testing requirements or national regulatory regimes –​must be ameliorated,
subverted, or outflanked.
• The substantial capital investment required to bring drugs to market  –​i.e, R&D, safety testing, and
marketing –​must be reduced or defrayed wherever possible. Subsidies from government and charitable
institutions that support high drug prices must be pursued energetically.

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• Investment must be steered towards products targeting large worldwide markets, like vaccines, in pursuit
of an attractive risk-​return tradeoff. A drug of dubious efficacy that targets a large population may be
more profitable than a highly efficacious drug targeting a rare disease.

This state of affairs has serious implications for the health and well-​being of the world’s poorest billions.
Increasingly, Big Pharma seeks to supplement declining sales in wealthy Western countries by exploiting
largely untapped ‘pharmerging markets’ (Smedley, 2015, n.p.). Since 70 per cent of the world’s population
lives in countries so designated, profits are potentially enormous.
The growing number of sick people in the South offers unprecedented scope for selling putatively
therapeutic medicines; vaccines, by contrast, promise revenue because they can be sold to vast numbers of
healthy people. Revisions to national immunisation calendars can expand the addressable population for
patented vaccines by hundreds of millions. No wonder emerging markets are seen as ‘the next big growth
engine in Pharma’ (Mooraj, 2013, n.p.).
For these reasons, manufacturing new channels of demand in poor countries is a business neces-
sity. Barriers to entry  –​price controls, regulatory regimes, lack of health care infrastructure  –​must be
outflanked by innovative tactics. Extensive collaboration with Western NGOs, PPPs, foundations, and pri-
vate firms is considered essential to overcoming such obstacles, both in ‘top-​tier’ markets (i.e., BRICS) and
in the poorest nations of the global South (Badoria, et al., 2012; Levy, 2015). Hence the requirement for
‘disruptive innovation’: existing mechanisms of health care delivery must be restructured or even destroyed
in order to make way for a profit-​directed value chain.
In another sense the people of the South figure prominently in Big Pharma’s business strategies. Cost-​
cutting on the development side is seen as an answer to declining revenues; offshoring is an effective
expedient. Hence the relocation of clinical trials to emerging markets, where drug safety testing is seen as
relatively cheap, speedy, and lax. GlaxoSmithKline CEO Jean-​Pierre Garnier has frankly characterised this
process as ‘massive arbitrage’ facilitated by globalisation: ‘arbitrage in labour cost, in financial cost, but also
in pools of skilled employees and in regulatory and administrative hurdles’ (Petryna, 2009, p. 82).
According to anthropologist Adriana Petryna, ‘the geography of clinical testing is changing dramatic-
ally. In 2005, 40 percent of all trials were carried out in emerging markets, up from 10 percent in 1991’
(Petryna, 2009, p. 13). In India in 2011 more than 150,000 people were involved in at least 1,600 clinical
trials, conducted on behalf of British, American, and European firms (Buncombe and Lakhani, 2011).
R&D offshoring is now so widespread in the global South that clinical trials are considered a ‘normal part
of healthcare delivery’ (Petryna, 2007, p. 22). As a South African newspaper declared, ‘We are guinea pigs
for the drugmakers’ (Child, 2013).
Thus the imperatives of the pharmaceutical business have created a perfect storm centering on the
people of the South. It is in this context that BMGF’s interventions are critical to the industry. With its
worldwide organisation, resources, and muscle, BMGF is ideally situated to facilitate profitable connections
between Big Pharma, the global health bureaucracy, and state health ministries. It functions as an essential
link in a pharmaceutical value chain that extends all the way from BMGF’s US$500 million headquarters
in Seattle to the poorest villages of Africa and South Asia.

Enter the Gates Foundation

The Gates Foundation’s ties with the pharmaceutical industry are intimate, complex, and longstanding.
Soon after its founding, BMGF invested US$205 million in pharmaceutical companies, including Merck &
Co., Pfizer Inc., Johnson & Johnson, and GlaxoSmithKline (Colorni, 2013). The relationship has grown in
subsequent years, creating a revolving door that now routinely shuttles executives between BMGF, Gates-​
controlled NGOs, and pharma’s big five (Herper, 2011a). The leadership team for BMGF’s Global Health
Division includes former executives of AstraZeneca, Baxter International Healthcare Corp., Eli-​Lilly,

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Novartis, Parke-​Davis, Pfizer, and Wyeth (BMGF, 2017c). PATH, described by The Lancet as virtually an
‘agent of the Foundation’ (Global Justice Now, 2016, p. 21), functions openly as a facilitator for more than
60 corporate partners, creating ‘market-​based solutions’ for pharmaceutical companies such as Merck and
Sanofi.
It is unsurprising, then, that BMGF’s goals align closely with the needs of the pharmaceutical industry.
The Foundation is openly committed to supporting R&D strategies tailored to the realities of the
developing world, where ‘[t]‌o speed the translation of scientific discovery into implementable solutions, we
seek better ways to evaluate and refine potential interventions –​such as vaccine candidates –​before they
enter costly and time-​consuming clinical trials’ (BMGF, 2017a, n.p.). In plain language, BMGF promises
to assist Big Pharma in its efforts to circumvent Western regulatory regimes by sponsoring cut-​rate drug
trials in the periphery. At the same time, BMGF steers the budgets of sovereign nations towards investments
that create markets for Western transnational corporations (TNCs), even when such investments require
radical reallocations of funds away from traditional public health programmes. The goal, as frankly stated
in a USAID report, is to ‘leverage market actors and dynamics to stimulate demand’ (USAID, 2014, p. 51).
BMGF entered the field in 1999 with a US$50 million contribution establishing the Malaria Vaccine
Initiative. Here Bill Gates saw an opportunity for his fledgling foundation to dominate, instantly and
decisively, an entire field of charitable endeavour: ‘With one grant … we became the biggest private funder
of malaria research. It just sort of blows the mind’ (Strouse, 2000, n.p.). Since then, BMGF’s involvement in
vaccine production and delivery has been transformative, integrating private corporations and investment
capital into a field where, until quite recently, the profit motive had played a relatively minor role.
State-​sponsored immunisation programmes spread widely during the twentieth century and doubtless
saved millions of lives, especially in countries that were able to integrate vaccine administration into robust
public health programmes. For the pharmaceutical industry, vaccines became a source of steady but meager
profits. The most widely administered vaccines were not patented: when Jonas Salk was asked who owned
the patent on his polio vaccine, he replied ‘the people’, adding, ‘There is no patent. Could you patent the
sun?’ (Hiltzik, 2014, n.p.). Although Big Pharma spokesmen were happy to take credit for immunisation
successes, vaccines were in fact a ‘neglected corner of the drugs business’ (The Economist, 2010, n.p.);
industry involvement was a matter of manufacturing doses and selling them in a buyer’s market shaped by
government procurement programmes that tended to depress prices. Margins were so slim that by the mid-​
2000s many firms contemplated exiting the business altogether (The Economist, 2010).
Countries in the non-​socialist periphery, meanwhile, found it difficult or impossible to emulate the
immunisation successes of the first and second world. Relying on financial and technical support from
UN institutions, limited national immunisation programmes developed unevenly across the global South
during the postwar era, but these were severely hampered by lack of resources and infrastructure (Miller
and Sentz, 2006). Austerity regimes imposed by the West after the fall of socialism were further devastating
to the national public health apparatus required for effective vaccine distribution. In business terms, the
addressable market remained immense, but the supply chain was dysfunctional and the buyer base was
small, concentrated, and increasingly cash-​poor. By the late 1990s, money for procurement was scarce
or nonexistent, and Western pharmaceutical firms had little incentive to pursue profits in low-​income
countries.
This bleak business landscape was radically altered by the intervention of the Gates Foundation.Working
in close collaboration with pharma, BMGF and its subsidiary organisations disrupted and revitalised the
industry with novel schemes to pry open emerging markets.Within a decade of BMGF’s initial investments,
vaccines were no longer a neglected sector but had become the cornerstone of Big Pharma’s prodi-
gious revenues –​indeed, the global vaccine market was recently projected to reach US$77.5 billion by
2024 (Grand View Research, 2016). In an encomium to the vaccine strategies of ‘one of history’s greatest
business visionaries’, Forbes praised Bill Gates for demonstrating ‘how power and capital –​both literal and
political –​can be spent to maximize positive impact on the world.’ He had done so, the article conceded

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in less grandiloquent terms, by ‘creat[ing] a lasting market for big pharma that wouldn’t cost them their
shirts’ (Herper, 2011b, n.p.).
BMGF’s philosophy holds that charitable endeavours need to be evaluated in much the same terms as
business deals (BMGF, 2017d). Vaccines offered an irresistible opportunity to ‘meet the needs of the poor
in ways that generate profits and recognition for business’ (Gates, 2008, n.p.) by employing commercial
strategies adapted from Microsoft and Wall Street.These can best be summarised in the language of business
theory, part of the ideology that structures the thinking of contemporary capitalists:

• First mover advantage: As the first significant occupant of a neglected market segment, BMGF could
create the business conditions that would make the rules for subsequent players, ensuring its continued
ascendancy in the field.
• The vertical market: A problem that might be addressed via ‘vertical’ health initiatives (programmes
aimed at particular diseases as opposed to broad-​based public health efforts) was readily adaptable to
Microsoft’s vertical marketing strategies and would be congenial to the Foundation’s preference for
benchmark-​friendly quick fixes over infrastructural investments.
• Actionable measurement: By applying the simplistic business math that Gates sees as the solution to
society’s ills, a field traditionally entrusted to public authorities could be more effectively managed
via the supposedly superior wisdom of the private sector. Vertical programmes, due to their narrow
scope and goals, would lend themselves naturally to numerical data analysis aimed at ‘optimizing scarce
resources for maximum impact’ (BMGF, 2017b, n.p.).
• Value Unlocking: Partial privatisation of vaccine administration could be said to liberate the value of
public capital, resulting in a projected $100 billion in economic benefits for poor countries (Lee, et al.,
2013). At the same time, new forms of development funding aimed at harnessing the profit motive
could be touted as unlocking the value of private markets.
• Leverage: A pre-​existing but underfunded and feeble institutional apparatus (e.g., WHO’s immunisa-
tion department; state public health ministries) could easily be subordinated and steered by strategic
investments. In combination with public–​private partnerships founded and ultimately controlled by
BMGF, the Foundation could wield vast resources with relatively little investment of its own.

In sum, Bill Gates found in the vaccine market conditions that would facilitate his wholesale appropriation
of a key public health sector. Almost overnight, BMGF became the originator and final arbiter of global
vaccine policy, ensuring that decisions affecting lives and health of the underdeveloped world would be
centralised in Seattle. According to Melinda Gates, Bill’s partner in all things philanthropic, the choice was
clear: ‘Where’s the place you can have the biggest impact with the money?’ (Herper, 2011b, n.p.).

GAVI
BMGF’s raid on the immunisation field commenced with the creation of GAVI, the Global Alliance for
Vaccines and Immunization, perhaps the most influential ‘public–​private partnership’ in public health.
Launched by BMGF in 2000 with the ‘explicit goal to shape vaccine markets’ (GAVI Alliance, 2017b, n.p.),
GAVI is a consortium connecting major international institutions (WHO, UNICEF, the World Bank) with
the big powers of the pharmaceutical industry (Janssen, GSK, Merck, Sanofi Pasteur, Pfizer, et al.) –​all
mediated and steered by the Gates Foundation.
GAVI supplied the leverage Gates needed to direct global policy. BMGF seeded the organisation, holds
a permanent seat on its board of directors, and has contributed more than US$4 billion to its operations
(GAVI Alliance, 2017a). Vividly described as a ‘900 pound gorilla’ (Kingah, 2001, p. 132), GAVI sets the
agenda for all players in the vaccine field: its approval is both a necessary and a sufficient condition for the
launch of vaccine-​related initiatives.

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From the outset GAVI promised to: (a) accelerate introduction of new vaccines, (b) expand the use of
‘existing cost effective vaccines’; and (c) fast-​track R&D for new vaccines ‘relevant to developing coun-
tries’ (BMGF, 1999, n.p.). Notably, however, GAVI funds have rarely been used to support the distribution
to global South countries of vaccines traditionally deemed necessary for Western children –​diphtheria,
mumps, pertussis, tetanus, et al.1 Instead, GAVI has consistently focused on promoting precisely the new
and expensive ‘blockbuster vaccines’ that pad Big Pharma’s profit margins.The bulk of its early investments
were geared towards immunisation against pneumococcal disease (with a vaccine developed by Pfizer),
hepatitis B (GlaxoSmithKline and Merck), and the flu-​like bacterial infection Hib (Merck and Sanofi).
As of 2012, four of the five top-​selling vaccine products –​Pfizer’s Prevnar-​13, Sanofi ’s PENTAct-​HIB,
GSK’s Cervarix and hepatitis vaccine franchise  –​had been heavily subsidised and promoted by GAVI
(EvaluatePharma, 2012).
In 2009 GAVI pioneered the use of a new type of development financing, the Advance Market
Commitment (AMC), as a means of subsidising the sale of Pfizer’s new pneumococcal vaccine, Prevnar,
to low-​income countries (GAVI Alliance, 2009). Through GAVI, BMGF and five wealthy countries –​
Italy, the United Kingdom, Canada, Norway, and Russia –​offered a contract guaranteeing a viable market
for the drug, committing to buy new vaccines at a negotiated high price purporting to cover develop-
ment costs. The pilot country was ravaged Rwanda, which was converted overnight into a market for
1.6 million doses of the patented vaccine (Sheikh and Ngoboka, 2009). As a condition of the deal, Rwanda
agreed to add Prevnar to its routine national immunisation programme, though it was unclear how the
country might hope to finance its commitment to future purchases once GAVI subsidies lapsed. Soon
thereafter, Benin, Central African Republic, and Cameroon were also enlisted, expanding the market by
further millions. AMC financing proved so lucrative that by 2012 Prevnar had become the world’s leading
vaccine product, with projected 2018 sales of US$6.7 billion (EvaluatePharma, 2012). GAVI, meanwhile,
had demonstrated ‘proof of concept’ of an elaborate neoliberal scheme that transferred public funds to
private coffers.
A more recent addition to GAVI’s array of services is ‘innovative development financing’, a debt-​based
mechanism that taps capital markets to subsidise vaccine buyers and manufacturers. Through an inter-
mediary, the International Finance Facility for Immunisation (IFFIm), GAVI floats bonds on the Japanese
urudashi market. The bonds are secured by the promise of government donors to buy millions of doses of
vaccines at a set price over periods as long as 20 years.The system is hailed in development circles as a neo-
liberal ‘win-​win’: although capitalists take a cut at every stage of the value chain, poor countries are said
to benefit from access to vaccines that might not otherwise be affordable. Bondholders receive a tax-​free
guaranteed return on investment, suited to an era of ultra-​low interest rates. For GAVI, this ‘organizational
form without country presence’ offers a powerful means of steering peripheral vaccine markets from the
core while outflanking the political inconveniences of traditional development aid. Hence IFFIm now
annually supplies as much as 39 per cent of GAVI’s cash (EvaluatePharma, 2012).
Pharmaceutical firms, meanwhile, are able to peddle expensive vaccines at subsidised prices in a cash-​
poor but vast and risk-​free market: ‘by creating a predictable demand pull, IFFIm addresses a major con-
straint to immunisation scale-​up:  the scarcity of stable, predictable, and coordinated cash flows for an
extended period’ (Atun, et al., 2012, p. 2045). Although GAVI’s involvement in vaccine pricing is typically
praised as though the organisation is dedicated to setting price ceilings, in fact it acts invariably to raise
the floor.
Occasionally criticised but seemingly irresistible is GAVI’s role in blurring the distinctions between pri-
vate enterprise and public policy. In some cases BMGF/​GAVI has effectively annexed the health ministries
of poor countries (Ghosh, 2016, n.p.). The organisation seems entirely unabashed by its role in reconsti-
tuting what some have called ‘pharmaceutical colonialism’. In Sri Lanka, for example, GAVI intervened in
2002, offering to subsidise a high-​priced vaccine supplied by Crucell, a subsidiary of Johnson & Johnson.
The vaccine, known as pentavalent Hib, was a cocktail adding Haemophilus influenzae type b immunity to

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the traditional DTwP shot; it was this new formula that made the drug patentable and thus profitable. The
voices of critics, who argued that ‘new, “relatively useless” vaccines were being allowed to piggy-​back on
standard essential vaccines like DPT’, went unheard (Bindu, 2016, n.p.).
Since the sticker price for pentavalent Hib was nearly 20 times greater than the drugs it replaced, GAVI
offered Sri Lanka temporary subsidies, so long as the country committed to adding the vaccine to its
national immunisation schedule.
Within three months of the vaccine’s introduction, 24 adverse reactions including four deaths were
reported, leading Sri Lanka to suspend use of the vaccine (WHO, 2013). Subsequently 21 infants died from
adverse reactions in India. Critics pointed out that Hib is a minor public health issue in South Asia, and
that adverse reactions could be projected to cause the deaths of 3,125 children for every 350 lives saved
by the vaccine (Kalyanam, 2013). Thus the customary argument in favour of new vaccines –​that the sig-
nificance of a few drug-​related deaths is far outweighed by the number of lives saved –​was flipped on its
head. Nevertheless, WHO, a GAVI partner, promptly stepped in to declare the vaccine safe –​whereupon
Sri Lanka reversed the suspension (Narendran, 2011).
Once pentavalent vaccine was firmly ensconced in Sri Lanka’s national immunisation programme,
GAVI began to phase out its financial support. In effect, GAVI secured Sri Lanka’s legal commitment to
buy patented vaccines on an ongoing basis, using subsidised prices as a loss leader, and then left the country
on the hook with a perpetual obligation to buy. GAVI calls this process ‘graduation’ (Saxenian, et al., 2014).
In a write-​up appearing on GAVI’s promotional website, Sri Lankan health minister Ananda Amarasinghe
purported to reveal ‘the secrets behind the country’s immunisation success story.’ Collaboration with GAVI
has been effective, Dr. Amarasinghe suggests, because ‘our colonial masters [emphasis added] established a
good foundation’ (Endean, 2015, n.p.). Evidently no irony was intended.

PATH
GAVI would serve to steer the overall direction of global vaccine policy, but BMGF required another sub-
sidiary to assist in the development of new vaccines at every stage of the value chain, ‘from initial discovery
through clinical trials and licensure’ (Boslego, 2012, p.700). In keeping with the principle of leverage, Gates
declined to create a new organisation ex nihilo, but instead commandeered an existing entity. This was
the Program for Appropriate Technology in Health (PATH), a Seattle-​based population control NGO to
which the Foundation was already connected through Gates’s father. BMGF showered the organisation
with funds, installed representatives on the board of directors, and was soon in a position to name as its
CEO Steve Davis, a Microsoft alumnus and former law partner of Bill Gates Sr. (Barker, 2008).The process
by which BMGF remolded PATH for its own purposes resembled what is known in the business world
as a friendly takeover.
Although PATH continued to boost contraceptives, supporting the development and distribution of
vaccines soon became its central mission. At the back end of the value chain, PATH acts to defray pharma’s
development expenses by funding research. In particular, PATH acts to connect scientists in the non-​
profit field with vaccine manufacturers and biotech firms, ensuring that the public and private spheres are
blended throughout the process (PATH, 2017). Since PATH’s grant-​making reflects the aims of BMGF and
the commercial interests of Big Pharma, academic research is inevitably steered in directions regarded by
the industry as potentially profitable, e.g., rotavirus, malaria, HIV/​AIDS, and influenza. PATH also some-
times collaborates with BRICS-​based drug firms such as the Serum Institute of India, owned by billionaire
‘vaccine king’ Cyrus Poonawalla. The partnerships arranged by PATH in this context help to ensure that
local industries do not develop independently of the requirements of Western pharmaceutical capital.
PATH is heavily involved in orchestrating and funding clinical trials necessary to bring branded vaccines
to market. To manage the trials, PATH hires Contract Research Organisations (CROs), which in turn
recruit local organisations to carry out operations cheaply on the ground, exploiting core/​periphery wage

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differentials. In this Taylorised offshoring system, pressure to achieve speedy, favourable results is immense
and ethical violations are rife (Elliott, 2012).
A review of the literature reveals a disturbing pattern in PATH-​sponsored trials, which nearly always raise
ethical questions but evidently never fail to secure the desired approvals. In 2010, for example, PATH organised
a Phase III trial of Mosquirix, a malaria vaccine developed by GlacoSmithKline (GSK), and administered the
experimental treatment to thousands of African infants across seven countries. GSK and BMGF declared the
trials a smashing success, and their publicity was uncritically reproduced by the popular press (Boseley, 2011).
In fact the vaccine was only narrowly efficacious, apparently reducing malaria rates in a range from 18 per
cent to 36 per cent. The study’s fine print revealed that the trials resulted in 151 deaths and caused ‘serious
adverse effects’ (e.g., paralysis, seizures, febrile convulsions) in 1,049 of 5,949 children aged 5–​17  months
(RTS,S Clinical Trials Partnership, 2011). The results should have raised serious questions about whether
the limited benefits outweighed the serious risks. Instead, WHO moved forward with a sweeping pilot pro-
gramme targeting sub-​Saharan Africa, anticipating universal implementation in the near future (WHO, 2016).
Other PATH-​sponsored vaccine trials in the global South revealed a similar pattern of dubious efficacy,
ethical violations, and widespread deaths and injuries (e.g., GSK’s rotavirus vaccine, tested in India in 2011
[Carome, 2004], and the BMGF-​financed MenAfriVac meningitis vaccine, tested in Chad in 2011–​12
[Suna Times, 2013]). In these cases, too, the approval of relevant health ministries was swiftly secured.
In one highly publicised case, however, popular outrage appeared to have thwarted PATH’s designs, at
least temporarily. In 2010 seven adolescent tribal girls in Gujarat and Andhra Pradesh died after receiving
injections of HPV (Human Papilloma Virus) vaccines as part of a large-​scale ‘demonstrational study’ funded
by the Gates Foundation and administered by PATH (Srinivasan, 2010a). The vaccines, developed by GSK
and Merck, were given to approximately 23,000 girls between 10 and 14 years of age, ostensibly to guard
against cervical cancers they might develop in old age.
Extrapolating from trial data, Indian physicians later estimated that at least 1,200 girls experienced
severe side effects or developed auto-​immune disorders as a result of the injections (Mehta, et al., 2013).
No follow-​up examinations or medical care were offered to the victims. Further investigations revealed
pervasive violations of ethical norms: vulnerable village girls were virtually press-​ganged into the trials,
their parents bullied into signing consent forms they could not read by PATH representatives who made
false claims about the safety and efficacy of the drugs. In many cases signatures were simply forged
(Dhar, 2013).
An Indian Parliamentary Committee found that PATH had ‘violated all laws and regulations laid
down for clinical trials by the government’ in a ‘clear-​cut violation of human rights and a case of child
abuse’ (Parliament of India, 2013). In the months following release of the committee report, no action
was taken:  the government declined to act on its recommendations; a lawsuit on behalf of the victims
remained ‘stuck in limbo’ before the Indian Supreme Court (Mittal, 2016). PATH, evidently unperturbed,
steamed forward with trials of a new flavour of HPV vaccine, Merck’s Gardasil 9, with typical consequences
including reports of coercion, lack of informed consent, and paralysing injuries (Chamberlain, 2015).
Meanwhile, India’s state and local health ministries experienced increasing pressure from the highest levels
of the global public health apparatus to embrace HPV vaccines (Narayanan, 2018).
PATH-​endorsed vaccine development resembles a juggernaut that rolls irresistibly forward despite haz-
ardous clinical trials, unsatisfactory results, or resistance from the people.According to public health journalist
Sandhya Srinivasan, ‘PATH’s research agenda is to look for ways to introduce the vaccine into the national
immunisation programme. The question is not “whether” but “when” and “how” ’ (Srinivasan, 2011).

Buying WHO
Coopting the health ministries of poor countries was no great challenge for an organisation as powerful
as BMGF, but the creation of a genuinely global vaccine market would require steering and investment

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on an international scale. To that end, BMGF needed to ensure the collaboration of the World Health
Organization. WHO is empowered to marshal and allocate financial commitments from UN member
nations (securing, for example, the cash GAVI needs to raise the floor for drug prices); additionally, the
agency figures prominently in the regulatory process by which underdeveloped countries issue approvals
for new vaccines and other drugs. In order to assimilate WHO’s authority, BMGF employed yet another
business strategy: it took an ownership stake.
BMGF’s contributions to WHO started early and rose steadily; by 2016, BMGF was investing
US$227 million annually, underwriting fully 11 per cent of the agency’s annual budget –​more than any
member state with the exception of the US (Global Justice Now, 2016). GAVI and PATH together added
US$75 million to the total (WHO, 2017). Here BMGF’s strategy emulated the cross-​ownership deals by
which business firms routinely seek to disrupt or neutralise competitors. Gates saw no need to fund a
majority of WHO’s budget; rather, his Foundation invested just heavily enough that the agency would be
unable to function without BMGF’s ongoing participation.
Exploiting this financial leverage, BMGF was able effectively to seize control of the global health
agenda: According to public health insiders, ‘Gates’ priorities have become the WHO’s’ (Huet, et al., 2017).
Bill Gates was widely understood to have been the kingmaker in the 2017 choice of Tedros Adhanom
Ghebreyesus to succeed Margaret Chan as director-​general of WHO, where Gates is now treated ‘like a
head of state’ (Huet, et al., 2017). In the same year, despite a letter of protest signed by 30 health advocacy
groups, BMGF secured appointment as a non-​voting member of WHO’s governing board, solemnising
what had become a de facto partnership between a once-​prestigious multilateral institution and one of the
world’s most powerful capitalists (Kadama, et al., 2017).
The arrangement with WHO consolidated BMGF’s disruptive project, securing the long-​term global
interests of Western capital. Longstanding structures of health care delivery had been deliberately dismantled,
subordinating public health to the ruthless imperatives of profit-​seeking. The Gates model seemed likely
to spread, offering a template for Mark Zuckerberg, Jeff Bezos, and other billionaires embarking on large-​
scale and systematic interventions in various sectors of philanthropy. As Melinda Gates informed a 2013
Gates-​organised conference on ‘Positive Disruption’, the couple’s endeavours are ultimately intended ‘to
give more people the courage to be disruptive and in doing so, unlock the potential of many others all over
the world’ (Anderson, et al., 2013). A plausible translation of this thinly coded language might read: ‘to be
disruptive [is to] unlock potential profits from the people of the global South.’

Note
1 An exception is polio vaccine, which GAVI consistently supports in keeping with Bill Gates’ frequently stated
commitment to ridding the world of polio. Although polio is no longer a major public health threat –​only 48 cases
were reported in 2015 –​its final eradication appears to be of tremendous symbolic importance to Gates.

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