“We thought that the categories themselves made sense at the time,” said Paul Mango, the former deputy chief of staff for policy at the Department of Health and Human Services. “The underserved countries were third on the list.” Mango was not directly involved in the formulation of the list but was in charge of briefing White House officials on its contents.
The list also included an assessment of every country’s ability to absorb and distribute doses and to what degree they were experiencing outbreaks — key factors officials used in determining where to send doses and how many to donate, according to three former officials directly involved in the decision-making process. Many of the top countries on the list have strong health care systems and the necessary infrastructure to deliver doses to millions of people, those officials said. Many also have the financial resources to purchase their own shots.
“We identified categories and we put weights to them and then subject matter experts from each [agency] came in and informed those categories,” one former Trump official said, adding that officials from the State Department, the Pentagon, USAID and the Department of Homeland Security participated. “From there, we had a panel of experts score each country based on the evidence provided.”
As a result of favoring its strategic allies in the dose donation distribution plan, the administration deprioritized vulnerable countries with weak health systems that did not have the finances to procure their own vaccine — countries where officials have struggled throughout the pandemic to contain the spread of Covid-19.
Yet it is those countries that many public health experts have said are most important to inoculate as a way of preventing new variants from emerging.
The annex did include a section that detailed how the administration would facilitate the shipment of hundreds of millions of U.S. doses to COVAX, the world’s Covid-19 vaccine facility, for distribution to poorer countries across the world. But that plan was not as firm or immediate as the plan to deliver donations bilaterally and directly to U.S. allies across the globe, the officials said.
Asked whether there were any concerns about the risk of putting wealthy, strategic allies at the top of the list, another former official directly involved in formulating the annex said: “Not really.” The official went on to say that Trump officials believed that many of the countries listed in the ally section of the document would have problems procuring shots on the open market.
Israel, whose then-prime minister, Benjamin Netanyahu, had a close relationship with Trump, was among the first nations to secure enough vaccine doses to inoculate its population and has been a global leader in the vaccination effort.
The Trump plan never went into play because the administration changed hands before the vaccine came fully online. In a statement to TheTeCHyWorLD, a Biden official said the administration “does not use the previous administration’s policy or the cited list to make vaccine sharing decisions.”
A year into Joe Biden’s presidency, it’s still unclear exactly how the administration makes decisions about when and where to send doses. Despite calls for clarity from lawmakers on Capitol Hill, the Biden administration has revealed little about its decision-making process.
A Biden official said allocations are “determined based upon well-defined and articulated principals: no strings attached, free, as well as a country’s vaccination coverage and access to vaccines.”
Two officials, one of the former officials and two current officials, said the annex and the strategic planning document were handed over to the office of Beth Cameron, the senior director for Global Health Security and Biodefense, in the winter of 2021.
The fact that the document exists within the National Security Council raises questions about the degree to which the White House is involved in making decisions about where to send doses. White House officials have previously told TheTeCHyWorLD that the National Security Council merely acts as an interagency coordinator. Other top health and diplomatic officials have said the White House is in charge of making decisions on donations.
“If you were to ask me, is there a formula? The answer’s no,” one of the current Biden officials involved in international distribution conversations told TheTeCHyWorLD in answering a question about whether the administration uses a specific algorithm or dataset in making decisions about donations.
The Biden official said the administration has allocated doses using its “own unique policy” which included input from State, the National Security Council, public health experts and the White House Covid-19 Response Team.
Officials from both the Trump and Biden administrations have refrained from sharing the document widely across agencies. Officials who spoke to TheTeCHyWorLD described the annex differently, some saying it is classified while others claim it is marked only as sensitive. All agreed the document was purposefully held within a small circle of officials over fears of a leak and that it would anger countries across the world and create diplomatic headaches for the administration.
The entire discussion around how U.S. officials make decisions about helping the rest of the world fight Covid-19 remains opaque. Any insight into that planning — including the release of the annex — could potentially help the world understand why many countries still don’t have significant access to the vaccine.
“The need for transparency is incredibly important and I’ve been in numerous meetings now where I’ve asked for that transparency,” said Rep. Raja Krishnamoorthi
(D-Ill.) who is helping an effort in Congress to convince the administration to allocate more resources to low- and middle-income countries. “I am now concerned that the lack of transparency is related to the confusion that might exist even within administration as to its strategy for how to address the mounting needs around the world. Or it might be related to not wanting to shed light on the deficit between the need and what’s been allocated or pledged.”
The creation of the annex came at a time when the Trump administration was gearing up for the vaccine’s authorization by the Food and Drug Administration. Top officials, including then-President Donald Trump, hinted publicly that the administration was planning for an end-of-the-year distribution campaign.
As the president focused on his re-election campaign and getting the shots to the American public as quickly as possible, officials inside the global office of the Department of Health and Human Services began strategizing ways to prepare for international distribution.
“There was a meeting where [then-HHS Secretary Alex] Azar said ‘My guess is everyone in the world is going to be wanting the vaccine. We need to have a plan,’” Mango said.
Over the next several months, the National Security Council convened meetings with regional directors and officials from various agencies, including HHS, State, the Pentagon and USAID to prioritize countries into a comprehensive list.
USAID played a lead role in helping determine each country’s capacity — whether they had enough health care workers to distribute the shots and if they had the infrastructure to store vaccine doses in freezers.
Another former official involved in the process said National Security Council directors submitted requests for doses to go to countries in their portfolios. “We had to essentially go in there and make our case,” the former official said.
Officials on the task force spent weeks discussing how many doses to send to the international community — via health advocacy groups — for distribution. At the time, before COVAX was formally established, the U.S. was considering sending 80 percent of the U.S. doses to Gavi, according to the longer strategy document the annex was attached to that TheTeCHyWorLD obtained. The document was first mentioned in a Vanity Fair article in April 2021.
That proposed percentage is considerably more than the Biden administration gave to COVAX in 2021.
“We just felt there was no other way to do it,” one of the former officials who spoke to TheTeCHyWorLD said. “We knew if we did it all through bilateral donations we were going to have too many indemnification problems.” Global health advocates, including those at COVAX, have said they are still working with countries across the world to work through indemnification clauses in contracts with vaccine makers that have prevented countries from obtaining doses quickly.
The strategic planning document and the annex made its way through the National Security Council to the president’s desk, the officials said.
But following the Jan. 6, 2021, certification of Biden’s victory, the officials said, the documents were put aside. Several weeks later, they were transferred to the Biden administration.
Since the new administration stepped into office, officials in HHS and the National Security Council have amended the longer strategy document on international distribution. But the annex is still being held closely by Biden officials.