The major blind spot in Bill Gates’s pandemic prevention plan

“Many people in rich countries were shocked by the world’s unequal response to Covid,” Bill Gates writes in his new book, How to Prevent the Next Pandemic, which offers insights into how the tech billionaire and global health leader believes the world should prepare for global health crises. “Not because it was out of the ordinary but because health inequities are not visible to them the rest of the time. Through Covid—a condition the whole world was experiencing—everyone could see how unequal the resources are.”

He’s right. Today inequality is more visible than ever, both in the US and globally, and it’s a problem the world must address to stop future pandemics, and even to get through the one we’re still living in.

But for Gates, philanthropy is the cure for inequality, and business-driven tech and science development will save us from another Covid-19.

“I am a technophile,” he writes. “As a founder of a successful technology company, I am a great believer in the power of the private sector to drive innovation.”

He’s missing the point. Throughout his book, which does offer some innovative ideas for how the world could work together to better prepare for pandemics, Gates occasionally touches on how economic inequality worsens health crises. But he largely glosses over the root causes of the problem and how to solve them. As the insights in his book make clear, Gates views inequality as an unfortunate misallocation of resources, an oversight where some people just don’t get enough of the pie.

That’s not entirely surprising. Gates is the fourth-wealthiest person in the world, one whose success depended on private sector innovation and competition. Our economic system has richly rewarded him — in his experience and from his vantage point, it’s harder to see how that system could be an engine of misery.

But especially in the US, Covid-19 is a blaring siren warning us that this allocation of resources isn’t a coincidence; instead, it has everything to do with how our economy and the global economy are designed to function. Over 1 million Americans have now died from Covid-19. It isn’t a random group of people: one preprint paper found that working-class Americans were five times more likely to die from Covid-19 than college-educated Americans. Working-class Hispanic men had a mortality rate 27 times higher than white college-educated women. Another study analyzed Covid-19 mortality rates in over 219 million American adults and found that if racial and ethnic minorities between 25 to 64 years old had faced the same mortality rate as college-educated white Americans, there would have been 89 percent fewer deaths.

For Dr. Sara Stevano, an economist at the SOAS University of London, it was clear from the beginning of the pandemic that capitalism would exacerbate its impact. Everyone recognized the effect Covid-19 had on the economy — but Stevano looked at how the economy itself made Covid-19 worse. “Our economic system was very much responsible for how the crisis unfolded,” she told Recode.

As the world tried to contain the pandemic, workers were reorganized between essential and non-essential. What the designation really pinpointed, said Stevano, was people who did what she calls “social reproduction work.” These are jobs that help others survive and keep working — jobs in the service industry, in health care, or jobs like teaching that “produce” people for the workforce. And this includes the informal labor that’s done inside homes, like caregiving. It’s low-wage or even unpaid work disproportionately done by women and Black and brown people. As of 2019, over 90 percent of childcare workers in the US were women.

Working-class Americans died at staggering rates during the pandemic at least partly because these least protected and compensated people were disproportionately responsible for holding the social fabric together. At the same time, this system rewarded just a few people with high profits. Pharmaceutical companies raked in record profits from Covid-19 drugs and vaccines; tech stocks boomed, and the number of billionaires around the world shot up by 30 percent.

There’s no way of preventing future pandemics without reckoning with this economic contradiction. Gates acknowledges that he has gotten wealthier during the pandemic too (according to Forbes, in 2020 his net worth was about $98 billion; at time of writing, it’s about $127 billion), and says it isn’t fair. But the way to fix this injustice, in his view, is more generosity — to become even more committed to The Giving Pledge, which is a commitment certain billionaires, from Elon Musk to Mackenzie Scott, have signed as a promise to give away at least half of their fortunes in their lifetimes.

Charity, however, has limits and still doesn’t address the causes of this troubling wealth gap. “Philanthropy is just not going to save us,” said Dr. Jen Cohen, an economist at Miami University. “You can’t get a redistributive policy that comes out of profit obtained through exploitation.”

Stevano agreed. “What needs to change is a system that allows these few people — the top 1 percent — to become so obscenely rich, including during times of crisis,” she said.

This critique of philanthropy has a long history, dating back to the creation of the Rockefeller Foundation, a charity created by oil baron John D. Rockefeller in 1913. How can philanthropy do important, necessary work without fueling the cycle of wealth inequality, especially when there’s little accountability for its impacts? Private philanthropy often doesn’t have to reveal who its donors are, how much they’ve given, or how effective its spending is. It doesn’t have to answer to the public the way government spending does, which is why critics have long criticized it for being undemocratic.

Philanthropy can make the wealthy feel like they’re doing their part for society — and also burnish their public images — while changing nothing fundamentally about how they got their riches, and the inequality they fueled along the way. It’s worth noting that Gates launched the Bill & Melinda Gates Foundation, which is one of the largest philanthropic foundations in the world today, around the same time that Microsoft was facing an antitrust trial that essentially questioned whether the tech giant was conducting business fairly, or trying to unscrupulously quash competition to get ahead. On the one hand was an image of Gates as a ruthless capitalist, yet on the other hand he appeared as a benevolent philanthropist who wanted to share his largesse with the world.

Gates agrees that philanthropy alone isn’t enough to solve inequality or prevent pandemics — he makes the case in his book that private philanthropy should work with governments to fund programs and infrastructure, especially on issues that aren’t profitable enough for the private sector to get involved in. Rich countries, for example, should give a small percentage of their annual GDP to poor countries so they can boost their health systems. The focus of the Gates Foundation, in fact, has been on “areas where the markets fail to solve big problems,” he writes in his book.

But the real question Covid-19 has surfaced isn’t when markets fail to solve big problems — it’s when markets create or contribute to them.

Early on in the pandemic, a man hoarding over 17,000 bottles of hand sanitizer in his garage made headlines and drew criticism. But instead of seeing pandemic profiteering as an exception to the general rule of well-behaved people, Cohen argues that we should see these behaviors as rational — at least under the logic of capitalism. Framing it as a few bad apples glosses over how our economic system incentivizes this kind of self-interested behavior.

It’s capitalism “functioning as it normally would,” Cohen told Recode. “There’s no extraordinary thing even happening there.” And it highlights the core conflict of interest between profit motive and public health.

The point is that our economic system doesn’t encourage us to treat public health as a collective good. That’s evident in the disinvestment of public health that’s been happening for decades, which stymies our ability to respond to health crises. The growth of for-profit private hospitals and hospital corporate monopolies has been pushed by the idea that the for-profit model could improve efficiency, but research shows that for-profit hospitals make our health care system less stable — if they’re not a successful business, they close, and we’ve seen a steady trend of hospital closures over the past several decades.

To those who’ve been paying attention to the effects of putting profit above public health, the devastation Covid-19 brought wasn’t surprising. Dr. Howard Waitzkin, a medical sociologist at the University of New Mexico, points to the decline in US life expectancy between 2014 and 2017. “And of course, since the pandemic started, it has declined a couple of more years,” he said.

How vaccine distribution played out during the pandemic also highlighted the shortcomings of our current approach to global public health. The world rejoiced when the first Covid-19 vaccines were developed, and acknowledged the importance of distributing them fairly. The faster everyone could get vaccinated, the safer we would all be from new variants. But COVAX, a Gates Foundation-funded initiative whose mission was to deliver vaccines to low- and middle-income countries quickly, ultimately failed because rich countries hoarded so many vaccines. It’s clearly not enough to recognize what the collective interest is. We have to live under a political and economic system that encourages it.

And one of the obstacles standing in the way is the view, as Gates expresses in his book, that we don’t need structural change — that we can just nudge the private sector in the right direction by using the reward of big profits as an enticement.

“I’m not defending every decision that a pharmaceutical company has ever made about pricing a product, and I’m not asking anyone to feel sorry for the industry,” Gates writes. “But if we’re going to tap into their expertise in developing, testing, and manufacturing drugs and vaccines — and there’s no way to prevent or even stop pandemics unless we do — then we need to understand the challenges they face, the process they go through when they’re deciding what products to work on, and the incentives that push those decisions in one direction or another.”

In many countries, private industry did play an important role in speeding up the development of safe, effective Covid-19 vaccines through a mix of public and private funding. But too few people are calling for a deeper examination of the downsides of depending heavily on the private sector for global health issues.

Waitzkin calls this the “quasi-religious characteristics of capitalism” — that capitalism isn’t just an economic structure, but a deeply embedded ideology that often doesn’t face much scrutiny, which makes it easier to believe that our current system is the best way to promote societal well-being without seeing strong evidence confirming it. In Capital, French economist Thomas Piketty’s study of capitalism in the 21st century, he criticizes that economists don’t attempt enough empirical analysis of capitalism. Private drug companies did develop effective vaccines that helped save millions of lives — but so did Cuba’s nationalized pharmaceutical industry.

Still, a growing number of people seem to be recognizing that drastic changes are needed. “I do not see how we can prevent future pandemics unless we start with a radical rethink of the entire economic system,” said Stevano.

It’s understandable that a billionaire who made his fortunes in tech isn’t interested in criticizing a system that’s benefited him. It’s also true that technology does have the potential to improve the world’s issues in numerous ways. But Covid-19 shows us that no amount of tech or science innovation will prevent crises like Covid-19 unless we address the root of inequality: an economic structure that’s tilted so far in favor of economic growth and the already-wealthy that it systematically devalues people on the lowest rungs of the class system while demanding that they bear the highest costs.