HUFFINGTON POST
04/30/2017 05:46 pm ET Updated May 01, 2017

Bill Gates Won't Save You From The Next Ebola

The Gates Foundation says responding to deadly outbreaks isn't its forte. But the Ebola crisis showed just how much global public health depends on the foundation.
Ji Sub Jeong/HuffPost

In late August 2014, Tom Frieden, then director of the Centers for Disease Control and Prevention, traveled to West Africa to assess the raging Ebola crisis.

In the five months before Frieden’s visit, Ebola had spread from a village in Guinea, across borders and into cities in Liberia and Sierra Leone. Médecins Sans Frontières, the first international responder on the scene, had run out of staff to treat the rising numbers of sick people and had deemed the outbreak “out of control” back in June.

But when Frieden arrived in West Africa, the World Health Organization, the United Nations agency charged with coordinating the global response to disease outbreaks, had only just declared Ebola to be an international public health emergency. Although WHO had announced a $100 million Ebola action plan the week prior to that declaration, many major donors were still sitting on the sidelines.

Frieden returned to the United States desperate to find more help. On Aug. 30, one day before a scheduled call with President Barack Obama, he emailed his point person for one of the key organizations in global public health. That person wasn’t at a U.N. affiliate or any other public agency — he was Chris Elias, president of the global development program at the Bill and Melinda Gates Foundation.

“We do not have a specific strategy or budget for emerging infections, but these are extraordinary times and I’d be willing to make the case internally if it makes sense,” Elias wrote back hours later.

“Situation is incredibly dire,” Frieden replied very late that night. “I should brief you, Bill, and others next week. All of Africa is at risk. Support now is worth many times what support in a few weeks would be worth. Literally every day counts.”

Frieden emailed again on Sept. 1. “I think Bill should hear directly and soon,” he wrote. “The situation is catastrophic.”

Freedom of Information Act request/HuffPost

Elias wrote back on Sept. 3 to say he had spoken with Bill Gates and foundation CEO Sue Desmond-Hellmann, who asked him to talk to Frieden, WHO and UNICEF about “what, if any, role the Foundation could/should play in supporting” the Ebola response. Frieden and Elias would later speak over the phone, although the CDC director did not talk to Gates himself about Ebola. Gates was “not in the office this week,” Elias wrote. (These and other emails sent during the Ebola crisis were obtained through Freedom of Information Act requests.)

Frieden’s frantic emails point to the current reality in global health: No single non-governmental institution or individual wields more influence, and no one’s support is more powerful, than the Gates Foundation and its namesake founders, Bill and Melinda Gates. The foundation has $39.6 billion in assets. It spent $2.9 billion on developmental assistance for global health in 2015 alone ― more than every country in the world except the U.S. and the U.K.

In the first half of the 20th century, it was the Rockefeller Foundation that pioneered and directed efforts to control diseases worldwide, coordinating the work of doctors, researchers and public health specialists from multiple countries to focus on international health issues for the first time.

I should brief you, Bill, and others next week. All of Africa is at risk. Support now is worth many times what support in a few weeks would be worth. Literally every day counts. CDC Director Tom Frieden, writing in August 2014

It wasn’t until the United Nations formed WHO in 1948 that a publicly funded global health body, accountable to the nations of the world, took the lead. “Governments have a responsibility,” the preamble to WHO’s constitution says, “for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.” The goal, it continues, is to “promote and protect the health of all peoples.”

WHO has frequently fallen short of that goal. It absorbed much of the blame for the Ebola outbreak that began in 2014 and eventually killed more than 11,300 people. Its disease surveillance failed early on to detect the spike in cases of the hemorrhagic fever, and in a tweet that didn’t age particularly well, a WHO official initially downplayed the threat.

Those failures, and others, have led some to question the decision to trust international bodies like WHO with global health — and even propose returning to a more philanthropy-focused model. Stephen Moore, an economist who advised President Donald Trump’s 2016 presidential campaign, recently called for ending all non-emergency U.S. foreign aid, much of which goes to international organizations such as WHO. Trump’s budget blueprint proposes cuts in payments to the entire U.N. system.

That means private charities such as the Gates Foundation might play an even larger role in protecting public health, which calls for scrutiny of the role that philanthropy has played in recent years. Nobody would be better off if Bill Gates pulled his money. But governments and private foundations are not interchangeable — in how they set their goals, in how they work with others, in how they are held accountable.

When the Gates Foundation takes aim at a disease, it can elicit billions of dollars from governments and reshape the world’s agenda for scientific research. Take polio: The foundation has spent nearly $3 billion since 2003 on eradicating the disease. It is the largest global funder of the effort and has rallied other private foundations and national governments behind the cause. The foundation’s influence also runs deep within WHO. At the time of the Ebola outbreak, it was the organization’s second-largest donor, following only the U.S. government.

Yet when a disease does not have the Gates Foundation’s attention, the global health community can struggle to do much at all. The Ebola crisis demonstrated that the foundation is disinclined to take on certain crucial work that governments and intergovernmental organizations are generally expected to handle. By the time of Frieden’s desperate email — five months after the first cases in Guinea were reported — the foundation had announced just $1 million to fight Ebola.

Less than 15 years ago, the Gates Foundation was a minor player on the global health scene, and WHO was far more prominent and capable.  

In February 2003, a severe flu-like disease appeared in China’s Guangdong province. The disease spread quickly, but the governments of China and other affected nations refused to acknowledge the problem. It was the 21st century’s first big outbreak: severe acute respiratory syndrome, or SARS.

Under the vigorous leadership of then Director-General Gro Harlem Brundtland, WHO moved rapidly. The organization signaled an emergency when the outbreak was still small, with less than 200 reported cases and only four deaths. Working with the CDC and other health officials from around the world, WHO dispatched more than 60 medical teams to assess conditions on the ground. Four months after declaring an emergency, WHO announced it had successfully contained the disease.

At the time, the Gates Foundation was only a few years old and led by the Microsoft billionaire’s father, William Gates Sr.

“Brundtland wasn’t very concerned with Bill Gates,” Jon Lidén, one of the director-general’s senior staff, recalled in a 2013 interview. WHO leadership saw the foundation as “a very small operation,” Lidén said, “run from a garage and a bit odd.”

But with judicious application of the world’s largest private fortune, the Gates Foundation rapidly expanded its influence. The first target was immunization. In 1999, the foundation put forward $750 million to form a public-private partnership called the Global Alliance for Vaccines and Immunization, or Gavi, with the goal of reinvigorating stalled efforts to vaccinate the world’s children — a job that had previously been the responsibility of WHO and UNICEF. On paper, WHO and UNICEF were the foundation’s equals at Gavi, with each entity holding a position on the board. But the Gates Foundation didn’t just provide unrestricted funding, opting instead to lodge its money in a separate entity, the Vaccine Fund, which Gavi had to petition to access.

In 2008, Gavi and the Vaccine Fund merged. The rearranged board drastically reduced WHO’s and UNICEF’s strength — they were now just two of 28 voting members. The U.N. agencies effectively became subcontractors on a Gates-led project.

Also starting in 1999, the Gates Foundation applied its generous grant-making to malaria research, almost single-handedly reviving the field. Bill Gates mused during a speech in San Jose, California, that with a $50 million grant, he’d been told he’d “just doubled the amount of private money that goes to malaria.”

But the foundation didn’t want to just fund more research; it wanted to transform the way the world fought malaria. At a Gates-organized forum in Seattle in October 2007, Melinda Gates challenged the world’s top malaria researchers to shift their strategy from control to eradication. The foundation’s call set the malaria world “abuzz,” Science magazine reported. At the time, many researchers believed malaria eradication efforts were likely to end in failure. U.S.-backed DDT spraying in the 1950s and ‘60s had provided a temporary respite from the disease. But many people lost the immunity acquired when malaria maintains a constant presence, and as mosquitoes developed resistance to the pesticide, the disease resurged and the eradication effort collapsed.

By 2007, however, the Gates Foundation had already handed out $1 billion in malaria research grants. The freshly funded scientists were loath to speak out. WHO Director-General Margaret Chan endorsed Gates’ call to action immediately — without consulting her top advisers, according to Science’s report.

There were a few dissenters. Later that year, WHO malaria head Arata Kochi circulated a memo describing a “cartel” of leading malaria researchers funded by the Gates Foundation. His memo later leaked to The New York Times, and he was relieved of his role soon after.

At WHO, there hasn’t been any outward opposition to or criticism of the Gates Foundation’s role in malaria funding in the nine years since Kochi was removed. Anthony Fauci, the head of infectious disease research at the National Institutes of Health, had once been a skeptic about eradicating malaria, but wrote in a 2009 CNN column that Gates’ advocacy had changed his mind: “As the idea began to sink in and we assessed the research landscape, a new sense of optimism emerged.”

Malaria eradication eventually won support from the highest levels of government. In a last-minute addition to his January 2016 State of the Union address, Obama said the world was “on track” to end HIV/AIDS. “We have the chance to accomplish the same thing with malaria,” he said, promising to push Congress to fund eradication.

After changing the global establishment’s views on malaria, the Gates Foundation took aim at what is now its biggest health priority: eradicating polio. WHO had launched its effort to eliminate the disease in 1988. Although the number of cases was dramatically reduced, the campaign missed its 2000 deadline and was well over budget. Bill Gates saw an opportunity not just to revive the polio effort, but to advance the whole idea of eradication. “The credibility, the energy from that will allow us to take the new tools we’ll have then and go after a malaria plan,” he explained in a 2014 interview.

The Gates Foundation became the world’s largest underwriter of polio eradication in 2008 and the unofficial leader of the project, which includes the CDC, WHO, UNICEF and Rotary International. The foundation’s money has helped bring polio to the brink of extinction.

The massive exertion required to eradicate every last vestige of the disease has also arguably drawn WHO staff and attention away from other priorities.

Where Bill Gates decides to spend enormous sums of money on public health, others follow.
Stan Honda/AFP/Getty Images
Where Bill Gates decides to spend enormous sums of money on public health, others follow.

WHO relies on voluntary contributions from countries and private donors, including the Gates Foundation, for around 80 percent of its budget. That makes the organization vulnerable to outside pressure, global health experts Devi Sridhar and Lawrence Gostin wrote in a 2011 study. Such contributions are often tied to the donors’ pet programs, which “skews global health priorities,” Gostin and Sridhar said.

The 20 percent of WHO’s budget that comes from U.N. member states’ mandatory contributions can be used as the agency sees fit. But those contributions are based roughly on the size of the countries’ economies. Following the 2008 financial crisis, WHO was forced to make budget cuts. Before the Ebola outbreak, it had slashed its outbreak and crisis department by 51 percent and reduced its African regional office’s epidemic staff from 12 to four, according to a 2014 Reuters report.

As the Ebola crisis began to unfold, WHO resources were disproportionately committed to fighting polio. 2014 WHO study found that 38 percent of the organization’s 2,201 staffers in Africa were funded through polio funds the prior year. Polio was easily WHO’s best-funded program worldwide, with a budget of more than $700 million for 2014-15, over three times larger than the budget for outbreak and crisis response.

Money follows money. The Gates Foundation had not only spent enormous sums of its own to underwrite polio eradication; it has also attracted others to the campaign. A Gates-orchestrated donor conference in Abu Dhabi in April 2013 garnered commitments of $4 billion from wealthy governments and private philanthropies, after the foundation primed the pump with $1.8 billion.

With ample funding, polio’s place on the list of global health priorities rose — to the detriment of other efforts, such as childhood immunization for other potentially fatal but vaccine-preventable diseases like measles. A 2014 report from the polio program’s independent monitoring board warned that the program treated routine immunization “as a poor cousin” to its eradication efforts.

The Gates Foundation’s role in elevating polio on WHO’s to-do list was “pretty significant,” Nils Daulaire, the former U.S. representative to the WHO executive board, said in a 2014 interview. “They have enormous influence in terms of pushing their priorities. So certainly the fact that Bill Gates took polio eradication as a personal priority and a personal challenge had a very meaningful impact on the global community and WHO’s decision to take this on as a major priority.”

WHO leaders “have to make priority decisions all the time,” Daulaire added. “And those decisions are not autonomous. … A variety of key donors have a lot of influence in terms of what WHO does, [including] the U.S., the Gates Foundation, the European Union, the U.K., other major industrial economies.”

Daulaire should know. In January 2014, he asked Director-General Chan to declare polio a public health emergency.

The fact that Bill Gates took polio eradication as a personal priority and a personal challenge had a very meaningful impact on ... WHO’s decision to take this on as a major priority. Nils Daulaire, former U.S. representative to the WHO executive board

Five months later, Chan did. WHO justified the declaration by citing “the international spread of polio to date in 2014.” At that point in the year, there had been just 65 polio cases in countries where the disease is endemic and just nine elsewhere. In the same period, nearly 250 people in two countries had already been diagnosed with Ebola — and 166 of them had died.

WHO was notably slower in its response to Ebola. When SARS hit China in 2003, the organization had swiftly declared an emergency, sparking international efforts before the epidemic slipped beyond control. But not until Aug. 8, 2014 — three months after the polio declaration and more than four months after the first cases of Ebola were detected in West Africa — did WHO label the Ebola outbreak an emergency.

Other issues also slowed the world’s reaction to Ebola, including a lack of trained medical teams able to deploy to the countries most in need. As that undersized response chased a growing outbreak, the cost ballooned.

On July 27, news had broken that two American health care workers had contracted the virus in Liberia. Four days later, WHO announced the $100 million plan to “take the response to a new level,” Chan said. Over 700 people had died by then. “This will require increased resources,” she added. Frieden said the CDC was “surging” its response, noting that while “it will not be quick and it will not be easy, we do know how to stop Ebola.”

The Gates Foundation hadn’t taken much action against Ebola at that juncture. Steve Landry, director of multilateral partnerships at the foundation, explained in a statement to HuffPost that emergency response “is not a core capacity of the Gates Foundation.”

“We focus our global health investments on building long-term, sustainable access to health through the development of new products and by strengthening the delivery of proven, high-impact health interventions,” Landry said. The foundation designates approximately $20 million annually for emergency response grants, compared to total foundation disbursements of about $4 billion a year. Still, as a private entity, it can authorize and disburse funds faster than national governments or international organizations ― which is perhaps why one of Frieden’s first missives after touring Ebola-ravaged West Africa would go to the Gates Foundation.

Initially, the foundation had lifted restrictions on an existing grant, allowing WHO to use those funds for Ebola. “[O]n the WHO front we had a request for funding and have given them latitude to tap into the strategic fund we have with them ― to be deployed as need[ed] so they should have enough funding for now,” wrote Trevor Mundel, the foundation’s president of global health, in a July 30 email to the directors of the U.K. philanthropy Wellcome Trust and the NIH. Mundel added that the foundation had also made “a smaller grant to Unicef for activities on the ground” of $1 million.

Then on Aug. 4, health authorities in Nigeria, the most populous nation in Africa, announced the first case transmitted within that country’s borders. Soon, there were 18 more cases in two Nigerian cities, Lagos and Port Harcourt, which have a combined population about as large as that of the three previously affected countries together.

It was “the moment at which the world is at the edge of an abyss,” Frieden later told HuffPost.

Médecins Sans Frontières staff, the first international responders on the Ebola outbreak, were overwhelmed
Carl De Souza/AFP/Getty Images
Médecins Sans Frontières staff, the first international responders on the Ebola outbreak, were overwhelmed by the rising numbers of sick people.

Nigeria rapidly quashed its local outbreak by identifying every person the infected traveler had met and isolating and testing those with symptoms. In written responses to HuffPost questions and in public statements, both WHO and the Gates Foundation attributed the success of Nigeria’s response to the vast system of disease surveillance it had created to eradicate polio.

But this infrastructure was unique in the region. The current $5.5 billion polio eradication plan directs $1.5 billion to Nigeria as one of three major-focus countries in the world and the only one in Africa. Fortune magazine called the presence of the disease surveillance program there “one of the most important and lucky breaks in the fight against Ebola.”

There were other measures that might have prevented the spread of Ebola into Nigeria in the first place. When WHO declares a public health emergency, it can compel member states to implement travel restrictions. The emergency declaration on polio, for instance, required travelers from Pakistan to show proof of polio vaccination. But absent a WHO-declared emergency, there had been no such requirement for Ebola screening in West Africa. On July 31, the CDC raised its travel warning for the region to the highest level and said it was “assisting with active screening and education efforts on the ground in West Africa to prevent sick travelers from getting on planes.” It turned out that by then, Ebola had already been in Nigeria for 11 days.

On Aug. 6, the Gates Foundation publicly announced the $1 million it had already released to UNICEF to “help address the immediate need on the ground.” The grant would “provide critical medical and hygiene supplies, coordinate response efforts, and reach affected and at-risk communities with life-saving information,” Sue Desmond-Hellmann wrote in a blog post.

But another post on the Gates website the following day downplayed the crisis. A Nigerian-born doctor warned that cerebro-spinal meningitis “could end up being far more destructive than the current Ebola epidemic” without the massive vaccination program the foundation was accustomed to sponsoring. “Unlike Ebola,” the author wrote, meningitis “can be easily prevented.”

WHO’s Aug. 8 emergency declaration did little to change the funding shortage.

“What you would expect is the whole world wakes up and goes, ‘Oh my gosh, this is a terrible problem, we have to deploy additional people and send money,’” WHO’s leading official for Ebola, Bruce Aylward, said in a 2015 Associated Press interview. Aylward had previously served as assistant director-general for polio and emergencies, but took the helm of the Ebola effort after the emergency declaration. Instead of pouring in resources, Aylward said, the world responded by imposing overly broad travel bans and isolating the affected region.

By the time the Ebola crisis was over, more than 11,300 people had died.
Carl De Souza/AFP/Getty Images
By the time the Ebola crisis was over, more than 11,300 people had died.

By Aug. 15, the estimated human toll in the three most-affected countries had climbed past 2,000 cases and 1,000 deaths. Liberia, where the outbreak was accelerating the fastest, stepped up to commit $20 million to fight Ebola within its own borders — an incredible sum in a country where the entire health budget for that year was $11 million.

Ebola had become a regular topic at White House press conferences and saturated international news. But WHO and the CDC, lacking both money and personnel, were still struggling to handle the crisis and to obtain more funds. Over email, Chan and Frieden agreed they would scale back their request for medical personnel on the ground — and even then, they didn’t expect to get what they asked for.

“Our team in the field in Liberia thinks this estimate of need is very far below what the actual need is,” Frieden wrote Chan on Aug. 20. “This may be a moot point, however, since even getting the lower level of need met will be very difficult.”

“You are exactly right, we feel this estimate falls short of the actual need,” Chan replied.

That same day, Liberian President Ellen Johnson Sirleaf ordered the military to quarantine an entire slum in the capital city of Monrovia in a desperate attempt to gain the upper hand on the outbreak. Some new estimates doubled the number of infected people in the city.

“All agree numbers are much larger than reported,” Keiji Fukuda, WHO’s assistant director-general for health security, wrote to Frieden and Chan on Aug. 21. By that point, WHO was arranging for palliative care “under controlled conditions” — that is, planning for contained deaths to try to reduce the spread of the disease. (Fukuda did not respond to a request for comment for this story.)

Frieden arrived in Liberia on Aug. 24. Just before returning to the U.S. a week later, he emailed the Gates Foundation’s Elias on Aug. 30, asking for an audience with Bill Gates. Less than an hour after arriving back in Atlanta on Sept. 1, he briefed President Obama by phone.

Frieden and Elias exchanged emails over the next several days to set up a time to talk on the phone. Elias also offered to reroute a trip through Washington, D.C., to meet in person. Frieden declined, preferring to speak on the phone sooner.

The two talked by phone on Sept. 6. (Asked later why he didn’t contact Bill Gates directly, Frieden said, “My route to connect to him is Chris.”) Money to insulate other countries from the Ebola threat topped Frieden’s list of needs. “Ideally there would be public sector dollars for this,” he wrote Elias the next day. “Foundation support to jumpstart it would be extraordinarily important.”

At that time, the CDC had received no additional federal funds to battle the outbreak, making it difficult even to fly staff to West Africa, Frieden told HuffPost.

Ideally there would be public sector dollars for this. ... Foundation support to jumpstart it would be extraordinarily important. Tom Frieden, writing to the Gates Foundation

Elias quickly moved new funds into the CDC Foundation, a nonprofit entity that allows private sector partners to support the CDC’s work. The money was “for you to use at your discretion without seeking prior permission,” he wrote Frieden on Sept. 7. But just as with UNICEF and WHO, the sums were not large. “I was thinking to start with $2 million,” Elias wrote.

On Sept. 9, Frieden sent Elias a request on CDC Foundation letterhead seeking “at least $25 million” in outside support from foundations to fund emergency operations centers and border checkpoints in 57 countries in order to “harden” them against outbreaks. “Had these capabilities been in place in West Africa a year ago,” the proposal reads, “the outbreak would now be under control.” Foundation support could “jump-start progress while the remaining resources are identified.”

Elias’ team responded to Frieden’s latest requests with impressive alacrity, pledging $50 million to the Ebola cause on Sept. 10. There was $5 million for WHO, $5 million for UNICEF and $2 million for the CDC. The rest went to various non-governmental entities operating in the region — such as Oxfam America, the Red Cross and the Tony Blair Africa Governance Initiative — and to biomedical research.

On Sept. 16, Scott Dowell, the foundation’s Ebola coordinator, wrote to Frieden that the foundation “would like to push hard for Ebola solutions, including a near term focus on hyper immune globulin production.” Frieden replied the same day clarifying the CDC’s top priorities for funding. “Actually, our top ask of [the foundation] is to ‘harden’ or help make more ‘fire-resistant’ the countries to which this might spread,” he wrote.

If treatment with hyperimmune globulin — essentially, blood transfusions from Ebola survivors — had worked, it would have been a huge victory. At that point, however, hyperimmune globulin wasn’t known to be effective, and scientists would eventually determine that it didn’t work. According to information provided to HuffPost by the Gates Foundation, its largest single grant for Ebola, $11.2 million, funded a clinical trial testing the blood of Ebola survivors as a treatment.

The Gates Foundation made another pledge in October, upping the total it directed toward the Ebola crisis to $75 million.

Freedom of Information Act request/HuffPost

A massive initiative to stop Ebola was finally launched in September — nearly half a year after the first reported cases. On Nov. 5, Obama requested $6 billion for the U.S. response, which, in an unprecedented move, would be headed by the Defense Department. Congress appropriated $5.4 billion in emergency funding the following month.

That it took six months and more than 4,000 bodies to commit serious resources to Ebola struck many as a sign of major problems in the world health infrastructure. But Bill Gates sidestepped questions about the slow global response in a late September 2014 interview with Politico, calling the Ebola epidemic “very unique.” In an Oct. 6 blog post, he praised the effort made: “Although you can never move too fast at a time like this, it’s easy to forget just how much has been done.” And he defended the U.S. performance in an interview with news site Ozy later that month. “It’s amazing how the United States has responded to this,” he said.

The next year, Gates reflected on those early difficulties in addressing the Ebola crisis. He wrote in a March 2015 New York Times op-ed that he hoped the experience would spur investment in public health systems, while also blaming the existing public health organizations.

“[O]nce it became clear that a serious emergency was underway, trained personnel should have flooded the affected countries within days. Instead it took months,” he wrote. “Doctors Without Borders [Médecins Sans Frontières] deserves a lot of credit for mobilizing volunteers faster than any government did. But we should not count on nonprofit groups to mount a global response.”

Gates did acknowledge in an April 2015 New England Journal of Medicine essay that WHO’s outbreak alert and response system “is severely understaffed and underfunded.”

In the years since the epidemic, the Gates Foundation has committed more money and attention to emerging infectious diseases like Ebola. But its preference for ambitious eradication plans, technological solutions and working outside the U.N. system has endured.

In 2015, the foundation committed $75 million to the Child Health and Mortality Prevention Surveillance network, or CHAMPS, which will help gather the data necessary to rapidly identify future outbreaks in poor countries. The CDC will act as a partner on that effort. More recently, the foundation committed $100 million to the Coalition for Epidemic Preparedness Innovations, or CEPI, a new public-private organization to develop vaccines for emerging threats. The World Economic Forum and the governments of India and Norway are founding co-partners, while WHO holds only “observer” status.

Guinea’s president, Alpha Condé, gave a qualified welcome to CEPI, speaking on a World Economic Forum panel with Bill Gates this past January. “Yes, we want vaccinations, but we believe with a better performing system, we will not need people to send us international experts,” he said. “We could do it ourselves.”

Other health experts have echoed Condé. Earlier emphasis on the more mundane work of building up local health care systems “might have helped trigger more attention by other donors to ensuring countries build their core capacities in line with the International Health Regulations,” said Devi Sridhar, who co-authored a blue-ribbon panel report on the lessons of Ebola, in an email to HuffPost.

The Gates Foundation is clear that it doesn’t want all the responsibilities of WHO’s job.

“The Gates Foundation strongly believes that global health needs far outweigh available resources, and governments must play a leading role in providing affordable healthcare for their citizens and investing in [research and development] for new tools to fight disease,” said the foundation’s Landry in an email. “As a philanthropy, we concentrate our funding in areas where existing funds are insufficient, our support could have catalytic impact, and we can assume risks that others can’t.”

“In response to Ebola, we had the capacity to provide fast, flexible funding to UNICEF, WHO, CDC and other first responders in August and September 2014,” said Landry. “Major donor governments like the United States and the United Kingdom then stepped in with the large-scale funding required to sustain the effort and bring the outbreak under control.”

When the next health crisis hits, officials may again find themselves looking to the Gates Foundation and other private charities for similar help. Three years after Guinea first reported the Ebola outbreak, “the world remains grossly underprepared for outbreaks of infectious disease, which are likely to become more frequent in the coming decades,” according to a meta-analysis of post-Ebola studies published in January 2017. And President Trump and other Republicans are pushing to cut U.S. funding to international health efforts ― all but ensuring that private players will be expected to fill the void.

Public funding remains critical to protecting public health, as Bill Gates has noted. “The key actor is the United States,” he said during a September 2014 panel on the Ebola outbreak and other global health challenges, “and the investments in a bipartisan way this country has stood behind for decades.” But private philanthropy, Gates added, is “on the rise” and “kind of a world of its own.”

Philanthropists can wield influence without the pressure of elections. Under the Obama administration, Gates often visited the White House, meeting not only with the president but with the director of the Office of Management and Budget in the course of budget preparation. This March, Gates traveled again to Washington, where he talked with Trump and spoke out against reducing foreign aid. As on past visits, he also met with members of Congress, emphasizing the potential impact of budget cuts on programs that his foundation has backed, according to The Hill.

Long before Trump’s election, Gates was asked if he might consider running for president. “No,” Gates answered. “I don’t think I’d be good at campaigning or even the kind of constraints you run into.” He preferred partnering with the people who get elected, he said, and having “the ability to learn every year” without the restriction of “a four-year limited term.”

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