The Template Goes Global

The Division's stated principles were that public health is a function of government, that its own aid was temporary, and that all aid should strengthen national health departments. Hookworm campaigns served as the entry point for building those departments. By 1924 the campaigns had been adopted in 52 countries on six continents. The Division's $94 million is a separate sum from the General Education Board's $94 million for American medical schools, described in Chapter 1.

Estimates of the Foundation's share of the Health Organisation's budget run from more than a third to nearly half, depending on the years and the measure. The Division gave the Organisation $1.3 million between 1922 and 1930. That money paid for training public health experts, an epidemiological intelligence service, and the biological standardization of sera and vaccines.

The United Nations Relief and Rehabilitation Administration took over most of the Health Organisation's functions from 1943. Birn records that UNRRA was "devised and planned by IHD veteran Selskar Gunn." Division director Wilbur Sawyer headed its health operations after retiring from the Foundation in 1944. UNRRA employed almost 1,400 health professionals and spent up to $80 million a year. Birn writes that the League body and UNRRA "acted as a pipeline for WHO's first generation of personnel."

Max Theiler's team at the Foundation's yellow fever laboratory in New York produced the attenuated 17D strain by late 1936. Field vaccination in Brazil began in February 1937.

Foundation officer Fred Soper built the method that later campaigns copied: eradicate the mosquito species that carries the disease, using a single chemical applied by a large, centrally commanded workforce. In Brazil he eliminated the invading Anopheles gambiae from the northeast with the larvicide Paris green, at a cost of $430,000 over three years, completing the work in 1940. From 1946 the Foundation ran a larger test in Sardinia through a special agency, ERLAAS. The Rockefeller Archive Center records ten thousand tons of DDT applied by 32,000 sprayers. The campaign's first superintendent, John Austin Kerr, questioned whether eradication was feasible in June 1946, and resigned about a year later.

Officials reported 99.9 percent success against the mosquito. Malaria disappeared from the island, although the mosquito species survived the campaign. A 2009 history in the CDC's journal states that ending transmission did not require eradicating the vector. Its figure for the DDT used is 267 metric tons.

Fred Soper was elected director of the Pan American Sanitary Bureau in January 1947 and held the post until 1959. Birn records that "the RF paid Soper's salary the first year, and he remained an RF staff member during his first four years at PASB." In 1950 Foundation president Chester Barnard wrote that the Bureau would "eventually take over our functions" in Latin America. Soper built a $1 million reserve for the Bureau, and the WHO's 1949 agreement with it left the Bureau largely independent. Birn concludes that his moves "forced WHO into a decentralized structure, based on geographically-organized regional offices."

The second Director-General, Marcolino Candau, served from 1953 to 1973. He "had been an RF fellow and had worked with Soper" in Brazil. In October 1954 Foundation president Dean Rusk questioned Candau over lunch, which Birn describes as "unofficial RF approval" of his tenure. Under Candau the WHO ran the malaria and smallpox eradication campaigns and awarded more than 50,000 training fellowships.

The Foundation turned down WHO funding requests as often as it accepted them in the 1950s and 1960s. Division officer Lewis Hackett wrote that "all the international organizations have adopted the policies and activities in which the IHD has pioneered." The Foundation's 1950 annual report stated that the task of health promotion had been "taken over on a global scale" by the WHO. Birn's conclusion is that "because its approach was firmly in place at WHO, the RF's presence was superfluous."

The program reduced malaria substantially before 1969. Thirty-seven of the 143 countries endemic in 1950 were free of malaria by 1978, and reported cases in India fell from about 110 million in 1955 to under a million in 1968. After 1969, parasite resistance to chloroquine, mosquito resistance to DDT and falling investment reversed much of the progress, and malaria incidence rose worldwide.

Under Grant, UNICEF built its child-survival program on that package: growth monitoring, oral rehydration, breastfeeding and immunization, known as GOBI. Some supporters of the Alma-Ata declaration read selective care as complementary to it, and others as a contradiction. Under Grant's leadership, which lasted until January 1995, UNICEF moved away from comprehensive primary health care.

Earmarked money must be spent on the purpose the donor names. About nine-tenths of WHO income is voluntary, and almost all of that is earmarked. The study's authors conclude that because every grant is earmarked, the foundation can work through the WHO while keeping tight control over how its money is spent. In 2014 Birn compared the Rockefeller and Gates foundations directly and called Gates's "pervasive influence" a "grave concern both to democratic global health governance and to scientific independence."

The Rockefeller Foundation itself is now a minor WHO donor. The WHO counts its contributions since 2000 at more than $25.6 million, about a thirtieth of the Gates Foundation's voluntary contributions in the 2024–25 biennium alone.

The BioNTech investment predated the company's COVID-19 program, and the foundation gave no direct support to the Pfizer–BioNTech vaccine candidate. The same foundation funds Gavi, which buys vaccines for low-income countries, and directs $2.9 billion of its WHO grants to vaccine programs.

In May 2010 the Rockefeller Foundation and Global Business Network published four hypothetical scenarios, one of which, "Lock Step," imagined a 2012 influenza pandemic followed by authoritarian control; the report says its scenarios "are not predictions," and the "Rockefeller Playbook" texts circulated since 2020 do not appear in it and are fabricated.

The exercise was funded by the Open Philanthropy Project; the Gates Foundation co-hosted it and supplied one of its exercise leads. On 24 January 2020 the Center stated that it had made no prediction and that its model inputs were not similar to the new coronavirus. The Center's 2017 SPARS scenario had already used a fictional coronavirus. The third recommendation called for keeping travel and trade open and criticized "the closure of customer-facing businesses," which governments ordered in 2020.

Federal practice during the pandemic took a form close to recommendation seven. In 2020–22 federal officials pressed social media platforms to remove or demote content about COVID-19. The Fifth Circuit found that the White House, the Surgeon General's office, the CDC and the FBI likely coerced or significantly encouraged the platforms' decisions. In Murthy v. Missouri (26 June 2024) the Supreme Court reversed the injunction for lack of standing and did not rule on the First Amendment question.

These instruments were negotiated by states. The departure of the largest government donor leaves a larger share of the WHO's voluntary income with private and quasi-private funders, chief among them the Gates Foundation and Gavi.

The Rockefeller Foundation shaped international health from 1913 through a private agency, its fellows and officers, and a single model of disease control. That model entered the League's Health Organisation, UNRRA, the Pan American Sanitary Bureau and the WHO through personnel the Foundation had trained and placed.

The Gates Foundation exercises the same function through earmarked money. It directs 59 percent of its WHO money to polio, launched the alliance that buys vaccines for the world's poorest countries, and has held equity in vaccine developers. Its co-hosted 2019 exercise recommended that governments and platforms suppress false messages, and federal officials pressed platforms to do so the following year. The Supreme Court decided Murthy v. Missouri on standing, and no court has ruled on the merits of that coordination.