Second Order Learning As a Result of Past Pandemics: Through the Lenses of Knowledge- Based Organisations Towards a Transformative Innovation Policy (Tip)

SECOND ORDER LEARNING AS A RESULT OF PAST PANDEMICS: THROUGH THE LENSES OF KNOWLEDGE- BASED ORGANISATIONS TOWARDS A TRANSFORMATIVE INNOVATION POLICY (TIP)

Jozsi Scholten, Charlotte Huijskens and Veronique Dörr

TIPCWP 2020-04

SECOND ORDER LEARNING AS A RESULT OF PAST PANDEMICS: THROUGH THE LENSES OF KNOWLEDGE-BASED ORGANISATIONS

Authors: Jozsi Scholten, Charlotte Huijskens and Veronique Dörr

Date: 01-08-2020

Table of contents

Executive summary 3. Introduction 6. - COVID-19 6. - Methodology 6. Part I: Theoretical framework 8. - I.I. Transitions theory 8. - I.II. The role of knowledge-based organizations 9. - I.III. Types of learning 10. - 1.IV. Research question and sub-questions 11. Part II: Case studies 12. - II.I. SARS – Canadian Institute of Health Research 12. - II.II A/H1N1 – Bill & Melinda Gates Foundation 21. Part III: Discussion 34. - III.I. Limitations of our research 34. - III.II. Next steps 35. Part IV: Conclusion 37. - IV.I. Lessons learned 37. Bibliography 38.

Cite this paper as: Scholten, J., Huijskens, C., Dörr, V. 2020. Second Order Learning as a Result of Past Pandemics: Through the Lenses of Knowledge-based Organisations. TIPC Working Paper, TIPCWP 2020-04. Online access: http://www.tipconsortium.net/?post_type=publication&p=9711

Executive summary

The report details the results of the study of learning processes in response to pandemics in knowledge-based organizations. Specifically, it refers to two case studies: the case of SARS and the Canadian Institute of Health Research (2003 – 2013), and A/H1N1 and the Bill and Melinda Gates Foundation (2009 – 2019). These pandemics are chosen because of the similarities with COVID-19 since both are transmitted through air, happened recently and are caused by an influenza or corona virus. The two organizations are chosen because of their global focus and membership in the Global Research Collaboration for Infectious Disease Preparedness (GloPID-R). This study was conducted over the course of two months, from the beginning of June 2020 until the end of July 2020, as an internship in the context of the Masters Programme in International Relations in Historical Perspective in the Transformative Innovation Policy Consortium (TIPC). It consisted of two case studies, each focusing on a different pandemic and a different knowledge-based organization to examine how past pandemics have served as a landscape shock accelerating learning within international knowledge-based organizations.

The first case study, which analyzed learning within the Canadian Institutes of Health Research (CIHR) due to the SARS outbreak in 2003, pointed out the following:

a. The initial challenges the CIHR faced with the introduction of the SARS outbreak were primarily related to the lack of research capacity, funding, and leadership on a national level. The CIHR acted on this through the creation of the CSRS, the Canadian SARS Research Consortium, initially; followed by the Pandemic Preparedness Strategic Research Initiative; which specifically worked to develop more cooperative interactions between various federal & provincial health institutions, enhance pandemic response speed, and improve research capacity by creating linkages between research bodies.

b. Learnings are not traceable to a reflexivity process of actors within the CIHR. The shortcomings were addressed almost exclusively from external parties; in particular the National Advisory Committee that investigated the handling of the CIHR during the SARS outbreak. The internal assessments of the CIHR are almost entirely result- oriented, demonstrating no critical reflection on deficiencies.

c. First order learning occurred through the revision of the CIHR’s funding mechanisms and through its initiation of workshops to develop network linkages. The creation of entirely new programs and research initiatives such as the CSRS and the PPSRI could be indicative of second order learning. The sources available however illustrate that the CIHR was reliant on external feedback and guidance to make structural changes. This indicates that the SARS outbreak did contribute to a change in the behaviours of the Canadian Institutes of Health Research, but that the CIHR did not visibly experience double-loop learning in this process.

The following lessons from this case study could be relevant for TIPC:

a. The lack of critical self-assessment, and in turn double-loop learning, found within the CIHR could be a predicament common amongst organizations of its nature. Its responsibility to the public, as well as its annual review by the Ministry of Health (and in turn its assigned spending budget), could create an environment in which challenging the underlying foundations of an organization are heavily disincentivized. Despite this being a speculative observation, it could be an interesting notion to explore for similar organisations nonetheless. As TIPC sets out to question whether lessons are learned through such crises, it can be compelling for publicly funded organisations to review whether there are inherent barriers for reflexivity to occur. In TIPC’s effort to experiment with transformative evaluation techniques, it may look to endorse practices of reflexivity in both the consortium and within partnered government agencies.

b. The CIHR also demonstrated the difficulty of steering a network of individuals and scientific teams outside a hierarchical organization during the SARS outbreak. The CIHR case indicated that the fundamental elasticity of research work, in which participants have the latitude to choose their collaborators and their research focus, could make it naturally difficult to govern, especially under the time constraints of crisis. Despite that TIPC does not set out to mark priorities, it could still be fruitful to understand the need for clear coordination and responsibility alignment. This is especially pertinent in face of a crisis, such as COVID-19 today, in which the role of research institutions is magnified. To align the coordinative efforts and proposed responsibilities of various stakeholders could be pragmatic for TIPC in its goal to build a research agenda, and in externally applying its recommendations.

c. There are also simultaneous positive learnings to be associated with the CIHR’s handling of SARS. Its application of pre-mobilized development funds that would allow for teams to immediately receive funding without delays in the usual granting process exhibited CIHR’s agility in adopting new protocols. The CIHR did demonstrate its willingness for experimentation through changes to its funding practices, as well as its initiation of off-shoot organisations such as the PPSRI. This could serve as a reference point as to how federal and /or national organizations can maneuver within bureaucratic constraints.

The second case study, which analyzed learning within the Bill & Melinda Gates Foundation due to the A/H1N1 outbreak in 2009 pointed out the following:

a. The Gates Foundation has a very extensive evaluation policy and distinguishes itself with its desire to continue learning. The Foundation has incorporated the developmental evaluation approach in its evaluation policy which opens up the possibility of second order learning, meaning that reflexive learning within the Foundation could occur by means of its evaluation policy. While this research did not find signs of any reflexive learning methods being incorporated in the Foundation it did find sources that point to the presence of reflexive methods, for instance the launch of the Gates Foundation’s “culture change” initiative in 2017.1

b. The H1N1 pandemic triggered first order learning in the Gates Foundation as the decision of the Foundation to launch CEPI, invest in vaccine development programs

1 Bill & Melinda Gates Foundation, Innovative practices for leading culture (Bill & Melinda Gates Foundation, 2017).

and hold annual high level pandemic exercises after 2009 was influenced by Gates’ individual experience along with information from outside while missing the reflexive element or changes in norms, objectives and structures.

c. Second order learning did occur in the Gates Foundation between 2009-2019 as a reorganization of the Foundation included a restructuring of its global programs after a reflection on its routines and worldview. In addition, the reorganization also changed the Foundation’s objective from solely producing lifesaving technologies to also investing in modifying the conditions for these innovations.

d. However, second order learning in the Gates Foundation did not occur due to the H1N1 pandemic but because of outside criticism, the arrival of Trevor Mundel as a president brought a different view of how the Foundation should restructure its work, the arrival of Cristopher Elias who pointed to the problem of the “innovation pile-up”, and a personal experience of Jeff Raikes which pointed him to the importance of integrating the different global programs.

e. The extensive reorganization shows the ability of private organizations, such as the Gates Foundation where financial resources mostly come from the private fortune of the heads themselves, to address structural problems quickly if the current strategy is not having the desired outcome

The following lessons from this case study could be relevant for TIPC:

a. Even if organizations incorporate learning, double loop or second order learning into its evaluation policy, it remains crucial for them to address its learning limitations. Therefore, it could be helpful for TIPC to understand that addressing learning limitations is part of learning, even if second order learning methods are incorporated into the organizations evaluation policy.

b. The H1N1 pandemic did not cause the landscape shock triggering reflexive learning in the Gates Foundation. As the role of disasters as inherent component of socio-technical systems has been extensively studied, for instance by Haiko van der Voort and Hans de Bruijn it could be that similar studies can help shed light into the way in which pandemics can lead to learning.2

c. The Gates Foundation dramatically changed its focus from solely producing lifesaving technologies towards investing in practical necessities needed to help people in developing countries. An insight drawn from this, especially interesting for TIPC which focuses on transforming through innovations, is the importance of social context in achieving the desired outcome of helping people with new practices, innovations and technologies.

Closing observations: While second order learning was identified in the two historical case studies, the pandemics did not seem to accelerate it happening within the organizations. The examples of second order learning that were identified seem more associated to external feedback (CIHR), outside

2 Haiko van der Voort and Hans de Bruijn, “Learning from disasters. Competing perspectives on tragedy,” IEEE Technology and Society magazine (2009), 28-36.

5 criticism, a personal experience of the CEO and the arrival experts who brought new perspectives (Gates Foundation). This research indicated that private and public funded knowledge based organizations differ in its ability to address problems in its underlying structures and objectives. This could be caused by its responsibility to the public in the case of the CIHR’s, while the Gates Foundation is only accountable to its three trustees: Bill, Melinda and Warren Buffet. Making it easier for private organizations such as the Gates Foundation to undertake reflexive changes.

Introduction

The outbreak of COVID-19 in December of last year resulted in a global health crisis of unprecedented scope. As of July, 14 2020 more than 13 million cases have been confirmed across 188 countries, resulting in the loss of life of 572,000 people. The catastrophic impact of COVID-19 has left the arduous impression that global health care systems were by no means ready or capable of handling a medical crisis of this scale. By extension, socioeconomic structures have unveiled their inherent failures through the disparate societal effects on economic and physical wellbeing. The unveiling of systemic weaknesses can however emphasize the need for transformative change in tackling and mitigating future pandemics. This raises the question of how pandemics can facilitate the underlying urgency for transformative change. An effectious way to gauge the degree of transformation occurring is second order learning, in which the fundamental assumptions, values and identities of a society, organization or individual are re-evaluated. The role of knowledge-based organizations may be particularly relevant in facilitating this evolution. Reviewing how pandemics particularly affect the learning of knowledge-based organizations can therefore prove to be highly valuable in assessing the ability of health-care systems to respond and prepare for future pandemics. From a conventional perspective, it can also serve as a learning lesson to TIPC and its members as to how crises can facilitate transformative change in knowledge-based organizations. In light of the disastrous effects of COVID-19, this report sets out to historically analyze the transformative learning processes within organizations induced by pandemics. By evaluating the principal reaction of one knowledge-based organization to a pandemic, the report attempts to conclude whether pandemics serve as a catalyst for radical (second-order) change within organizations. In turn, this will contribute to revealing whether pandemics assist in transforming society into a more resilient direction or whether it will continue on its unsustainable trajectory of development. Furthermore, findings from this research could be used in future research that sets out to investigate the role of COVID-19 in accelerating second order learning within knowledge-based organizations. Two case studies will be examined: the Bill & Melinda Gates Foundation in relation to the H1/N1 virus and the Canadian Institute of Health Research (CIHR) in relation to SARS. The main research question this report therefore poses in regard to the two case studies seeks to answer:

How has A/H1N1 / SARS contributed to a change in norms, structures and objectives in the Bill & Melinda Gates Foundation / CIHR?

Methodology The research for both case studies was qualitative-oriented. Evaluating the two pandemics, SARS and H1N1, was primarily done through the review of secondary sources consisting of medical journals such as WebMD, Nova science, Emerging health threats journal, and through

6 the publications of public health organizations such as the WHO, Centers for Disease Control and Prevention and Canadian Ministry of Health. Considering the differences between the two cases, CIHR and the Gates Foundation utilized a slightly different approach. The sources used in the research for the Gates foundation relied more on individual accountancies, whilst the CIHR research consisted primarily on internal and external assessments by the CIHR and other federal bodies. For this reason, the individual methodology for each case is briefly described:

Bill and Melinda Gates Foundation & H1N1: The eighteen sources used in this case study come from the period 2009-2019 and consist of two policy papers about the company’s evaluation process, two annual reports presented by the CEO of the Foundation, three interviews with CEO’s, two interviews with policy advisors at the Foundation and nine statements or speeches of Bill Gates. This timeframe is chosen as changes or learning processes are not always visible at the spot, and evidence of the learning process can also be found a few years after the pandemic of 2009. Since the sources are mostly individual statements from officials working at the Foundation it is important to note, as mentioned in the theoretical framework, that individual learning can instigate organizational learning when individuals, acting from their mental images and maps, detect a match or mismatch between outcomes and expectations, which confirms or disconfirms organizational “theory in use”.3 Ideally this research would focus on changes in beliefs, assumptions and behaviors but since those are not as observable in past times, this case study investigates reflexivity and potential changes in underlying norms, structures and objectives in the Gates Foundation between 2009-2019.4 As mentioned in the theoretical framework, Argyris and Schön refer to double-loop learning when a modification of the organizations norms, policies and objectives occurs.5 In addition, the authors consider a change in underlying structures as an important component of transformative learning.6

Canadian Institutes of Health Research & SARS: The twelve sources used in this case study range from a period of 2003-2011 (with the expectation of two contemporary sources that reflect on SARS learnings) and consist of three annual or midterm internal assessments of the CIHR, two individual reports by CIHR employees, one external assessment by the Ministry of Health regarding CIHR handling of SARS, and six secondary sources relating to SARS research and third party reflections on CIHR practices. Similarly, to the other case study, this timeframe has been chosen as it reflects longer term learnings from the CIHR that transpired after the original 2003 outbreak of SARS. This case also heavily utilized an external assessment by the Ministry of Health due to the lack of internal reflectivity found within other available sources.

3 Agryris and Schön, Organizational learning, 19. 4 Chris Agryris and Donald A. Schön, Organizational learning: A theory of action perspective (London: Addison-Wesley Publishing Company), 2. 5 Argyris and Schön, Organizational Learning, 3. 6 Ibidem.

Theoretical framework

This research will build on existing literature in Transitions Studies. In this research field, one key area of work is the role of learning in processes of transformations of socio-technical systems.7 As described in the seminal work by Grin, Rotmans and Schot, learning is crucial to transitions, specifically second order learning, second order learning is the type of learning that leads to changes in fundamental assumptions, values and identities, which is often what is required to support processes of transformation.8 While second-order learning can occur under normal conditions, transitions literature argues that special circumstances can provoke this type of learning. In particular, crises can provoke second order learning such as the 2008 financial crisis or the September 11 attacks, as they shine light on established courses of action and their underlying convictions, and illuminate that these systems are no longer appropriate.9 In the multilevel perspective (MLP), these shocks are understood as components of sociotechnical landscape, and they have great importance in the dynamics of change of socio-technical systems as they manifest challenges which are difficult or impossible to be solved within the dominant regimes, therefore opening 10 up the space for niches to grow. Recently, Schot and Kanger have explored the role of these external, large scale shocks in the context of longer-term transformations, under the theory known as Deep Transitions. They define a deep transition as “a series of connected and sustained fundamental transformations of a wide range of socio-technical systems in a similar direction.”11 Pandemics, such as COVID-19, could be considered as one of these external shocks, but the role of these type of events in learning and larger processes of change remains largely unexplored in the transitions literature.12 The notion that crises increase the possibility for second order learning to take place, will serve as embarkation for this research. The SARS and H1/N1 pandemics function as case studies for this research as they are classified as negative surprises or crises, thus serving as potential drivers for second order learning. The aim of this empirical research is to explore the lessons that can be learned as a result of severe crises, in this case the SARS and H1/N1 pandemics. In particular, we are interested in understanding the effects of these pandemics in knowledge-based organisations, particularly in terms of second-order learning, and this approach derives from the fifth proposition of Schot and Kanger relating to the importance organisations play in the frenzy phase of deep transitions.13 Knowledge organizations are of particular importance in the promotion of new approaches to science, technology and innovation policy towards transformation.14 To fully develop a transformative innovation policy approach, it is essential for these organizations to create a new understanding of their role in society and develop new practices by engaging in second order learning. Furthermore, according to the Deep Transition framework, these organizations are able to “bring together

7 John Grin, Jan Rotmans and Johan Schot, Transitions to Sustainable Development: New Directions in the Study of Long Term Transformative Change (New York: Routledge, 2010), 280-281. 8 Grin, Rotmans, Schot, Transitions, 280-281. 9 Ibidem. 10 Johan Schot, “Confronting the Second Deep Transition through the Historical Imagination,” Technology and Culture 57, no. 2 (2016) 449. 11 Johan Schot and Laur Kanger, “Deep transitions: Emergence, acceleration, stabilization and directionality,” Research Policy 47 (2018), 1045. 12 Johan Schot, Bipashyee Ghosh and Geraldine Bloomfield, “Conversations on COVID-19: Consequences for the Second Deep Transition and the Sustainability Revolution,” 25-03-2020, https://deeptransitions.net/2020/03/25/conversations-on-covid-19-consequences-for-the- second-deep-transition-and-the-sustainability-revolution/ accessed on 26-06-2020., Marie Claire Brisbois, “Transitions: working on change – or working for change?” 22-04-2020 https://turningpoint2020.wordpress.com/2020/04/22/transitions-working-on-change-or-working-for-change/ accessed on 26-06-2020. 13 Schot and Kanger, “Deep transitions,” 1054. 14 Johan Schot and Edward W. Steinmueller, “Three frames for innovation policy: R&D, systems of innovation and transformative change,” Research policy 47, no. 9 (2018): 1554-1567.

9 experiences and ideas from different sectors, nurture mutual learning processes, help to establish networks between various stakeholders, and shape expectations about the future of the niches.”15 Therefore, it becomes particularly relevant to study knowledge organizations that operate at national and transnational, in relation to the potential for second order learning triggered by disruptive events such as the aforementioned pandemics. We could speculate that, in fact, in their intermediary and connection role, these organizations may contribute to larger change within socio-technical systems. Therefore, in the scope of the timeframe we have to explore the second order learning as a result of past pandemics, this research will focus on the influence of these past shocks and landscape ruptures on knowledge-based organisations. The potential for knowledge organizations in transformational processes, together with the notion that crises increase the possibility for second order learning, thus are central principles within this research. Following that organisations play an important role in transitions, it is worth to explore to what extent organisations have learned in the past, from past crises and past pandemics.

Second order learning in organizations Different theories exist on learning and different types of learning can occur. Hjorth and Bagheri argue that system thinking, which includes System Dynamics, is a powerful methodology to deal with sustainable developments.16 They advocate that linear and mechanistic thinking should give way to systems thinking, i.e. non-linear and organic thinking, in order to offer solutions to modern problems, such as sustainability issues.17 System Dynamics (SD) is one branch of system thinking which draws on a variety of different fields to provide a general framework for understanding and influencing how things change over time. SD and its notions of feedback and secondary effects could also function as a method to enhance learning in systems which can bring about the improvement of the process and the performance. When zooming into the learning process, Hjorth and Bagheri distinguish two loops in a learning process. In the first loop, “decisions are influenced by information feedbacks from the real world; however, they are deeply influenced by strategies and decision rules, which are formed by our mental modes of the real world.” This notion of learning could also be described as first order learning since the reflexive element is missing, together with a change in beliefs, assumptions and/or behaviours. In the second loop, “the information feedbacks modify the structure of our mental models which will prompt us to update the decision rules.”18 This process is called second order learning, since the fundamental structures are subject of learning and the learning process contributed to change these underlying structures. The concept of transformative learning, “involves critical reflection of assumptions that may occur either in group interaction or independently.”19 Thus, demonstrating transformative learning can take place on a personal, or collective level. When concretising critical reflection, Mezirow includes the following understandings: “critical reflection requires understanding the nature of reasons and their methods, logic and justification.” He follows with the notion that transformative learning involves these same understandings, although in addition, “emphasizes insight into the source, structure and history of a frame of reference, as well as judging its relevance, appropriateness, and consequences”20 The concept of transformative learning is consequently similar to second order learning as the underlying structures and frames are subject of learning.

15 Schot and Kanger, “Deep transitions,” 1054. 16 Peder Hjorth and Ali Bagheri, “Navigating towards sustainable development: A system dynamics approach,” Futures 38 (2006), 74. 17 Hjorth and Bagheri, “Navigating towards sustainable development,” 74. 18 Hjorth and Bagheri, “Navigating towards sustainable development,” 81. 19 Jack Mezirow, “Transformative Learning as Discourse,” Journal of Transformative Education, 1, no.1 (2003): 61. 20 Mezirow, “Transformative,” 61.

Argyris and Schön define the concept of organizational learning as “organizational learning involves the detection and correction of error.”21 Similar to Hjorth and Bagheri, different loops of learning are distinguished, specifically single-loop learning and double-loop learning. Argyris and Schön referred to Merizow’s transformative learning as double-loop learning, “double-loop learning occurs when error is detected and corrected in ways that involve the modification of an organization's underlying norms, policies, and objectives.”22 To clarify what entails single-loop learning, Argyris and Schön claim the following: “when the error detected and corrected permits the organisation to carry on its present policies or achieve its present objectives, then that error-detection-and-correction process is single-loop learning.”23 In short, the modification or change of underlying structures, is an important component of transformative learning. According to Argyris and Schön, organizational learning takes place when members of an organization behave as learning agents for their organisation, responding to occurring changes in the internal and external environment of the organisations, through detecting errors in the organizational theory of action and correcting these errors. Organizational double-loop learning entails responding to the detected errors, restructuring the organizational theory-in-use by not just modifying organizational strategies but by critically revising the organisational norms themselves, to assess the inconsistencies and to create more effective norms.24 Beers, van Mierlo and Hoes underline that the pathway towards a sustainability transition goes hand in hand with learning.25 In agreeance with Argyris and Schön, they argue for the importance of a reflective practice, where significant steps towards change are interwoven with the underlying assumptions of one.26 A second element to take into consideration is reflexivity, which seems to be the central component in the main theories on second order, double-loop or reflexive learning. In TIPC’s ‘A Top-Line Guide to Deep Transitions’, reflexivity is referred to “the ability of actors to reflect on their own routines, and worldviews, the routines, position and worldviews of other actors, and the rationality”.27 In this research on second order learning as a result of past pandemics, reflexivity will be the main indicator for second order learning to be distinguished in the sources. In addition, second order learning - also referred to as deep learning - implies a learning process in which underlying routines are questioned. It includes a fundamental rethink of the definition of problems and which solutions would be suited for solving these problems. First order learning is described as a process in which problem solving and routines are sharpened, optimized and defined, whereas second order learning would fundamentally question the underlying routines.28 According to this, reflexivity can be distinguished as a more appropriate indicator for second order learning. After distinguishing different types of learning by various scholars, this research is based on the reflexive component of learning which can be found in transformative, second order and organizational double-loop learning. As mentioned by Armitage, Marschke and Plummer, the importance of the learning process and learning as a normative goal is widely recognized, however the authors argue it is necessary to carefully determine factors that decide

21 Chris Argyris and Donald A. Schön, Organizational Learning: A Theory of Action Perspective, (Reading: Addison-Wesley Publishing Company, 1978), 2. 22 Argyris and Schön, Organizational Learning, 3. 23 Ibidem, 2-3. 24 Ibid. 29. 25 Pieter J. Beers, Barbara van Mierlo and Anne-Charlotte Hoes, “Toward an Integrative Perspective on Social Learning in System Innovation Initiatives,” Ecology and Society 21 (2016) 1, 3. 26 Beer, Mierlo and Hoes, “Toward,” 1-3. 27 Transformative Innovation Policy Consortium (TIPC), “The Theory Behind TIPC’s Work: A Top-Line Guide to Sustainability Transitions,” 6, http://www.tipconsortium.net/wp-content/uploads/2018/05/4123_TIPC_Guide_to_deep_transitions-1.pdf . 28 TIPC, “The Theory Behind TIPC’s Work,” 6.

11 if learning occurs and, by who, how and which type of learning occurs.29 If this careful examination is lacking, vague notions of learning will be encouraged.30 In line with this reasoning, and in order to discover whether the SARS and H1/N1 pandemic served as a catalyser for these changes, following research question and sub questions will serve as a guide when analysing the sources.

Research question: How has A/H1N1 / SARS contributed to a change in norms, structures and objectives in the Bill & Melinda Gates Foundation / CIHR?

▪ What kind of changes can be inferred from what we observe? ▪ Who was involved in that change? ▪ Were these changes reflexive? ▪ What lessons were learned? ▪ What were the conditions that led to the change? ▪ What made the change stick? ▪ What can we learn from this change?

29 Derek Armitage, Melissa Marschke and Ryan Plummer, “Adaptive co-management and the paradox of learning,” Global Environmental Change 18 (2008), 87. 30 Armitage, Marschke, Plummer, “Adaptive,” 87.

Part II: Case studies

In these case studies, we will investigate how past pandemics contributed to second order learning within international knowledge-based organizations. SARS and H1N1, have been chosen as pandemics that can be considered landscape shocks to accelerate or trigger second order learning. We are particularly interested in understanding the effects of pandemics in international knowledge based organizations as these are of particular importance in the promotion of new approaches to science, technology and innovation policy towards transformation. Therefore, we examined learning within the Canadian Institutes of Health Research and Bill & Melinda Gates Foundation. Both case studies are divided in five sections, which differ slightly due to the difference in organizations and pandemic processes. The first case study is structured as follows: Part I sets out to outline the origin of the SARS disease and the foundation of the CIHR. Part II reviews the CIHR response to SARS. Part III analyzes the learning lessons SARS posed to the CIHR. Part IV sets out to reveal which changes were implemented as a result of these learning lessons. Part V finally concludes whether these changes are reflexive in nature, and by which order learning they can be categorized. In the second case study this is done in the following way: Part I provides a brief introduction of the H1N1 pandemic of 2009 and an overview of the Gates Foundation including its extensive evaluation and learning policy. Part II discusses changes in the Foundation between 2009-2019 along with bringing attention to the actors involved. Part III analyzes if the identified changes in the Gates Foundation can be seen reflexive and what lessons were learned. Part IV examines what conditions might have led to these changes and if the pandemic of 2009 can be considered the “push” that accelerated second order learning. Part V explicates what insights could be drawn from the findings of this research.

Part II.I. SARS – CIHR Canada was the third worst hit country by Severe Acute Respiratory Syndrome (SARS) in February of 2003, due to a viral outbreak caused by a superspreader carrying the disease that had just flown from Hong Kong to Ontario. This led to 251 cases in Canada, with 44 people dying, resulting in a staggering mortality rate of 17.5%.31 Faced with an unprecedented outbreak of an infectious disease, Canada’s public and private health organisations scrambled to effectively mitigate its spread. Given the lack of national protocols in coordinating collaborative resolutions amongst its various (federally funded) health bureau’s, the Canadian Institutes of Health Research (CIHR) was inadvertently tasked with leading the research element of this previously unknown disease.32 The Canadian Institutes of Health Research had been established in 2000 as the main federal agency responsible for funding health and medical research in Canada, supporting as many as 13,000 researchers and trainees as part of the government’s investment in health research33. Through designated panel reviews from Canada’s academic community, the CIHR approves the funding of research trajectories and regularly checks on these initiatives to ensure their upkeep of scientific standards and outlined progression. Led by 13 institutes, each individually led by a scientific director and advisory board, they collaborate to shape a national research agenda for Canada. These institutes in turn comprise researchers, policy-makers, provincial and international government representatives, and private health organisations.

31 Government of Canada, Canadian Institutes of Health Research. “Internal Assessment for 2011 International Review - CIHR Institute of Infection and Immunity.” CIHR, 2 Aug. 2011, cihr-irsc.gc.ca/e/43717.html. 32 Government of Canada, Ministry of Health, National Advisory Committee, and David Naylor. Learning From SARS: Renewal of Public Health in Canada, Health Canada, 2003, pp. 1–46. 33 Government of Canada, Canadian Institutes of Health Research. “Internal Assessment for 2011 International Review - CIHR Institute of Infection and Immunity.” CIHR, 2 Aug. 2011, cihr-irsc.gc.ca/e/43717.html.

Given the overarching role the CIHR plays in assigning the prioritization of health research into pandemics and other sudden health crises, as well as being a connecting node amongst the various regional medical organisations in Canada34, the response of the CIHR to SARS can provide valuable learning lessons as to how such an essential organization can maneuver its own behaviours to effectively tackle invasive pandemics and disruptive change. In doing so, the research sets out to establish which first and second order learnings CIHR experienced as a direct result of the SARS outbreak.

Part I: Severe Acute Respiratory Syndrome The SARS epidemic made its first appearance in Guangdong, China in November of 2002 when a local farmer contracted the disease and died shortly afterwards in the People’s Hospital of Foshan. No diagnosis could be made, as SARS proved (in hindsight) to be the first identified strain of the coronavirus species, a new form of severe acute respiratory syndrome-related corona infections.35 In 2017, Chinese scientists were able to trace the outbreak of SARS to horseshoe bats in Yunnan, a province in South-West China. In 2019, Coronavirus (SARS-CoV- 2) made its appearance, which in essence was a related and succeeding virus strain of SARS. In comparison to COVID-19 however, SARS was a relatively rare disease. By late June of 2003, there had only been 8,422 identified cases of SARS, with a fatality rate of 11%. SARS produced identical symptoms to that of COVID-19, with patients experiencing flu-like reactions such as a sore throat, a cough, and a near guaranteed fever of above 38 degrees celsius.36 The cause of death would generally be associated with pneumonia and/or a shortness of breath in older patients. Transmission was equally comparable, with contact with an infected person’s mucous membranes or respiratory droplets leading to infection. This could be the result of casual contact with persons in close proximity. A key feature of the SARS outbreak was that it was completely unknown to scientists and medical staff until February of 2003, being prescribed commonly as a severe case of influenza for most of its victims beforehand. In late February of 2003, Italian doctor Carlo Urbani was treating a patient in the French Hospital of Hanoi when he became aware of the fact that he was dealing with a new and highly contagious disease.37 He notified the World Health Organization of this, which led to extensive global research and the eventual identification of the SARS genome by Canada’s National Microbiology Laboratory in April of 2003. Until this date, no vaccine or effective treatment has been found for SARS despite the numerous efforts of global and national health organisations.38 Similarly to COVID-19, preventative measures had been the cornerstone solution for mitigating its further spread, with clinical isolation and quarantine providing the most effective means. This entails structured sanitation protocols in health care spaces, disinfection means such as sanitizers and hand-washing, and simple hygiene measures. No new cases were identified as of 2004, with health experts delineating that this mitigation was the result of isolation of infected patients, simple sanitation and preventative measures. The lack of understanding of SARS’s infectious traits in the early months of the outbreak has been associated with the initial difficulties of mitigating infection. This in turn made the CIHR instrumental to Canada’s struggle with SARS; as the solution was to be found through research rather than alternative means.39

34 Ibidem. 35 “SARS: Timeline of an Outbreak.” WebMD, WebMD, 16 Nov. 2004, www.webmd.com/lung/news/20030411/sars-timeline-of-outbreak. 36 Ibidem. 37 Ibidem. 38 Press, The Canadian. “Canadians at Forefront of COVID-19 Research as SARS Outbreak Informs Response.” National Post, National Post, 3 Mar. 2020, nationalpost.com/pmn/news-pmn/canada-news-pmn/canadians-at-forefront-of-covid-19-research-as-sars-outbreak- informs-response. 39 Low, Donald E. “SARS: LESSONS FROM TORONTO.” Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary., U.S. National Library of Medicine, 1 Jan. 1970, www.ncbi.nlm.nih.gov/books/NBK92467/.

Canadian Institutes of Health Research The Canadian Institutes of Health Research was formally founded in 2000 under the Canadian Institutes of Health Research Act. It is an independent federal agency of the Government of Canada that reports to Parliament through the Minister of health. CIHR’s mandate is to “excel, according to internationally accepted standards of scientific excellence, in the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products and a strengthened Canadian health care system.”40 CIHR was designed to respond to the evolving need for flexible adaptation of health research in the face of growing or spontaneous health crises, whether in the form of burgeoning obesity or a sudden pandemic. CIHR sets out to achieve its mandate by: ● Funding both investigator initiated research as well as research on strategic priority areas; ● Building research capacity in underdeveloped areas and training the next generation of health researchers; and ● Promoting knowledge translation to enable the application of research results into new policies, practices, procedures, products and services. CIHR implements this mandate of knowledge creation, capacity development, and knowledge translation across four designated pillars of health research; biomedical, clinical, health services and population health research. With an annual spending budget of roughly $1 billion, the CIHR chooses which research tracks, institutes, teams and individual researchers it sponsors through the decision making of its Governing Council.41 The Governing Council develops CIHR’s strategic directions, approves CIHR’s budget, evaluates CIHR’s overall performance, establishes CIHR institutes, appoints Scientific Directors to lead institutes, appoints Institute Advisory Board members, and provides advice to the Minister of Health. CIHR’s overall scientific advice comes from its Science Council, which is comprised of CIHR’s Senior Management (i.e., President and Vice- Presidents) and Institute Scientific Directors. The Science Council reviews all of CIHR’s major funding programs and science-related policies and practices prior to implementation. Given the CIHR’s role as federal financier of health research, its function extends as being a key connector between the various provincial and local health & research institutions, and in accommodating the collaboration between these bodies in the event of a medical crisis. The CIHR therefore has three key responsibilities in the event of a global pandemic: facilitating partnerships across Canada’s medical community, effectively and quickly allocating funding, and as a result; researching and unravelling the emergence of a new infectious disease.42 This responsibility would fall particularly on the CIHR Institute of Infection and Immunity (III), which comprises one of the 13 institutes of CIHR.

Part II: CIHR reaction to SARS Within days of the WHO’s global alert on SARS (April 10, 2003), the CIHR Institute of Infection and Immunity launched a request for proposals for research into the causes and consequences of SARS, initiating the first phase of SARS research in Canada. Within two weeks, 18 research teams across Canada had assembled and submitted proposals.43 It took

40 Government of Canada, Canadian Institutes of Health Research. “Internal Assessment for 2011 International Review - CIHR Institute of Infection and Immunity.” CIHR, 2 Aug. 2011, cihr-irsc.gc.ca/e/43717.html. 41 Government of Canada, Canadian Institutes of Health Research. “Internal Assessment for 2011 International Review - CIHR Institute of Infection and Immunity.” CIHR, 2 Aug. 2011, cihr-irsc.gc.ca/e/43717.html. 42 Ibidem. 43 Bernstein, Alan. “CIHR Research: SARS: Make No Mistake - There Will Be a Next Time.” Healthcare Quarterly, 15 June 2003, www.longwoods.com/content/16486.

15 another 10 days for a rapid peer review to be conducted by the CIHR’s Governing Council, with four applications being approved. The underlying goal of these newly funded projects was to collect and analyze patient samples, develop new diagnostic tools, investigate immune responses to the SARS virus and examine the mode of disease transmission. This initial handling of SARS by the CIHR posed two challenges; designing the appropriate research modules and securing adequate funds to launch the new research trajectories immediately.44 Within the traditional granting scheme of the CIHR delays in securing funding is to be expected due to the necessity for peer review processes by the Governing Council, and in some cases, the Scientific council. Normally such funds would only be approved to projects that have a clearly delineated research proposal, structure and implementation schedule. Given the immediacy of the situation however, and the near- unascertained nature of SARS, this was extremely difficult to do. The CIHR institute of Infection and Immunity was however able to take the backsliding route of committing $250,000 from the institute’s operating funds to launch its programs.45 Discussion with the CIHR’s partners revealed a strong interest amongst provincial government and health institutes to assist in the initial funding, making $1.7 million available. These funding partners included Ontario Research and Development Challenge Fund, the Canadian Network for Vaccines and Immunotherapeutics, and Health Canada.46 In the following weeks, various provincial governments and health organizations such as the Michael Smith foundation for Health Research would continue to allocate funds towards the CIHR who in turn distributed it to the approved SARS-related research projects. In this process, a new model of funding for public health emergencies was established, allowing for rapid mobilization of research efforts. Table 1 demonstrates which four research projects were the first to be approved and funded within three weeks of WHO’s announcement of SARS. These initial four research teams would go on to decode the genome of the disease, proving to be extremely valuable in further understanding and mitigating its spread. As stated by Alan Bernstein, then president of the CIHR, “In a unique trans-Canada partnership, four CIHR-funded research teams dropped what they were doing and in just 11 weeks from recognizing a new coronavirus associated with SARS, completed and announced to the world the complete sequence of this virus on April 13.”47

44 Government of Canada, Canadian Institutes of Health Research. “Internal Assessment for 2011 International Review - CIHR Institute of Infection and Immunity.” CIHR, 2 Aug. 2011, cihr-irsc.gc.ca/e/43717.html. 45 Singh, Bhagirath. “Innovation and Challenges in Funding Rapid Research Responses to Emerging Infectious Diseases: Lessons Learned from the Outbreak of Severe Acute Respiratory Syndrome.” The Canadian Journal of Infectious Diseases & Medical Microbiology = Journal Canadien Des Maladies Infectieuses Et De La Microbiologie Medicale, Pulsus Group Inc, May 2004, www.ncbi.nlm.nih.gov/pmc/articles/PMC2094971/. 46 Ibidem. 47 Bernstein, Alan. “CIHR Research: SARS: Make No Mistake - There Will Be a Next Time.” Healthcare Quarterly, 15 June 2003, www.longwoods.com/content/16486.

Part III: CIHR learnings in light of the SARS outbreak When reviewing the initial reaction of the Canadian Institutes of Health Research to SARS in the immediate aftermath of its outbreak; CIHR did unequivocally well in initiating key research tracks in light of what was a dire and unexpected situation. The CIHR reacted as exceptionally as it could given its own structural and bureaucratic limitations. As put by one of the sponsor partners of CIHR in the aftermath of the outbreak; “CIHR showed great leadership and a sense of urgency in bringing together the scientific community in Canada from academia, public health and industry to respond to the SARS crisis.”48 This therefore leaves the question of what underlying features the CIHR could improve to be more structurally prepared for pandemics, and what lessons have been learned from SARS. This question was posed and most comprehensively answered by the National Advisory Committee. The National Advisory Committee was established in early May of 2003 by the Ministry of Health and Government of Canada with the mandate to provide “a third party assessment of current public health efforts and lessons learned for ongoing and future infectious disease control.”49 Titled Learning From SARS: Renewal of Public Health, the committee published a report in October of 2003 to assess the reaction of various federal and provincial health and governmental bodies to the SARS outbreak. The review of CIHR’s role takes centre stage in the report (particularly Chapter 10, P 188, Reflections on Research Response to Pandemics) and provides a more thorough and honest review of shortcomings and successes. In comparison, the internal reports from the CIHR and specifically its Institute of Infection and Immunity from 2003 to 2009 generally gloss over such reflective learnings whilst emphasizing achievements. The reflections and learnings on CIHR’s handling of SARS will be reviewed in regards to three main categories: leadership and organization, funding, and research capacity.

Leadership and organization The National Advisory Committee, as well as individual employees of the CIHR such as Bhagirath Singh50, recognized that there was a clear lack of effective overall leadership on researching during the SARS outbreak. Effective linkage of laboratory research at a national level was extremely limited to local and provincial levels. This was in part due to the fact that the CIHR, as well as other national health bodies, operated under no particular authority during the event of a public health crisis. Establishing a restructured national public health system that should have this role, with the authority to direct and coordinate research, establish national databases and research platforms, ensure appropriate ethical and privacy safeguards, and provide swift resources to fund epidemic response research is essential. Moreover, data and breakthrough information on SARS should be brought together effectively and centrally; the splintering of such data to local research bodies hinders the ability for regional researchers to build upon each other's findings and can create wasteful duplicate research probes at the cost of CIHR funds. Given the natural interplay of various inputs of clinical, epidemiologic, laboratory, and pathological data necessary to fully understand a disease such as SARS, creating a national SARS database can substantially improve the national collaborative effort against infectious diseases. Lastly, there are characteristic difficulties with steering the funded research teams of the CIHR, particularly the governance of research. Given that the CIHR’s funded programs consist of a network of individuals or scientific teams outside a hierarchical organization, in which participants have the latitude to choose their collaborators and their research focus, it can be

48 Government of Canada, Canadian Institutes of Health Research. “Internal Assessment for 2011 International Review - CIHR Institute of Infection and Immunity.” CIHR, 2 Aug. 2011, cihr-irsc.gc.ca/e/43717.html. 49 Government of Canada, Ministry of Health, National Advisory Committee, and David Naylor. Learning From SARS: Renewal of Public Health in Canada, Health Canada, 2003, pp. 1–46. 50 Singh B. (2004). Innovation and challenges in funding rapid research responses to emerging infectious diseases: Lessons learned from the outbreak of severe acute respiratory syndrome. The Canadian journal of infectious diseases & medical microbiology = Journal canadien des maladies infectieuses et de la microbiologie medicale, 15(3), 167–170. https://doi.org/10.1155/2004/925872

17 challenging to steer such teams into a new research direction in a short time frame when a medical crisis arises. The National Advisory Committee recognized the value of having clear coordination protocols in the event of sudden research reprioritizations. One avenue by which the Committee suggested this be achieved was to have assigned managers or contact persons from within the various scientific teams who could be contacted. In turn, these individuals would also have the repute within their own teams to lead adjustments in reaction to health crises. By doing so, the network of researchers that comprise CIHR’s programs could be well equipped to responsively handle emergency scenarios.

Funding The difficulty the CIHR had with assigning rapid funding to the emerging SARS outbreak is that it still functioned within its normal guidelines of peer-reviewing projects through its General Council. Furthermore, the standardized expectation of having a clear research proposal with time trajectories and end goals was near impossible within the confines of time constriction (and lack of information regarding SARS). The only reason the CIHR was able to hold an accelerated competition for funding was due to a quirk in their finances for the fiscal year of 2003, in which it was able to still use its operating funds. The CIHR therefore needs special funding envelopes in order to have the capacity to respond to new threats, or to entirely fund new institutions that have the ability to do so.

Research capacity During 2000 to 2004 the CIHR had a commitment of $71.4 million† Canadian dollars to research spending on infectious diseases. In comparison to other national spending budgets on disease research, this is a fraction of what is necessary in light of the threat SARS and future corona-associated viruses pose. As discussed previously though, without the coordination between the CIHR, other federal agencies, and regional institutes, increasing the budget will do little for the research capacity of the CIHR. The SARS experience argues that the CIHR needs to continue to connect and integrate with academic and private sectors through joint appointments, collaborations, interchanges, and formal and informal networks. By fostering these linkages, the CIHR should be able to prioritize linking research in government and academic institutions, thereby building the teams and processes for rapid epidemic investigation in the scenario of another epidemic. The National Advisory Committee makes two specific recommendations in light of what it recognized as the most instrumental learnings to take forward; that the CIHR should establish a task force on emerging infectious diseases to recommend research priorities and funding mechanics, and that the CIHR (in partnership with the Canadian research community)

18 should develop clear protocols for leadership and coordination of future epidemic research responses.

Part IV: Changes within the CIHR post-SARS In recognition of the need to have a coherent national research strategy for SARS, the Canadian SARS Research Consortium (CSRS) was established in June 2003 by the CIHR to further coordinate the research effort.51 The CSRS was created to solely focus on bringing together funding partners, eliminating duplicative efforts and developing more cooperative interaction between different research groups. Under CSRS, with its sponsoring members including the CIHR, Health Canada, Ontario Research and Development Challenge Fund, and numerous others, the CSRS started to unravel diagnostic assays for SARS, the epidemiological modelling of the disease outbreak, how to avoid it, and examine strategies for future actions, as seen in table 3 above.52 In doing so, the formation of the CSRS provided a preliminary infrastructure which could serve as a model for future outbreaks of pandemics in Canada. The findings of the CSRS, pertaining to its development for future strategies, led to the recognition that an entirely new program would need to be launched in order to concentrate future efforts. This led to the foundation of the Pandemic Preparedness Strategic Research Initiative (PPSRI) in May of 2006 by the CIHR (led by its Institute of Infection and Immunity).53 The CIHR received $21.5 million in new funding from the Government of Canada, in combination with an additional $18.5 million from partnered agencies, to lead this new initiative. The goal of the PPSRI was to coordinate strategies, stimulate new research, and build capacity in priority areas identified by the PPSRI task group. In order to develop a clear national strategy and collaborative effort in tackling future pandemics, the CIHR organized several ‘Influenza Research Priorities’ Workshops in collaboration with the Public Health Agency of Canada (PHAC), with individuals attending representing researchers, private sector organizations, and public health systems and organizations at every level.54 This would aid the PPSRI in its agenda-setting moving forward. In consultation with researchers and stakeholders, PPSRI identified four priority areas in research: vaccines and immunization, the virus, prevention and treatment, and ethical, legal and social issues.55 The PPSRI utilized its funding budgets to encourage researchers to specialize in influenza and pandemic research in an effort to build national expertise necessary for a potential pandemic outbreak. PPSRI grant recipients were also required to include trainees in their research programs in an effort to increase the number of qualified personnel in this area. In an

51 McKarney, Lesley. “SARS Outbreak Prompts Rapid Funding Response.” Science AAAS, 11 Dec. 2017, www.sciencemag.org/careers/2003/04/sars-outbreak-prompts-rapid-funding-response. 52 McKarney, Lesley. “SARS Outbreak Prompts Rapid Funding Response.” Science AAAS, 11 Dec. 2017, www.sciencemag.org/careers/2003/04/sars-outbreak-prompts-rapid-funding-response. 53 Government of Canada, Canadian Institutes of Health Research. “Midterm Evaluation of the Pandemic Preparedness Strategic Research Initiative.” CIHR, 14 Sept. 2009, cihr-irsc.gc.ca/e/40030.html. 54 Ibidem. 55 Ibidem.

19 effort to ensure the rapid response rate to pandemics, the PPSRI offers application development funds, “so that, in the event of an outbreak, research teams will be able to submit abbreviated applications for expedited peer review and funding.”56 In essence, this would allow for research teams to immediately mobilize and receive funding without the usual delays associated with the CIHR’s granting process. Lastly, the CIHR and its Institute of Infections and Immunity collaborated with the Public Health Agency of Canada to establish an Influenza Research Network consisting of Canadian researchers who develop methodologies to evaluate influenza vaccines and immunization programs.

Part V: reflexive changes as a result of SARS As is revealed in Part IV, the CIHR was certainly adaptive in its ability to change after the SARS outbreak in Canada. The question that remains is whether these learning lessons qualify as reflexive or double loop. The initial challenges the CIHR faced with the introduction of the SARS outbreak were primarily related to the lack of research capacity, funding, and leadership on a national level. The clear shortcomings could be addressed through the creation of a task force on emerging infectious diseases that would set nation-wide research priorities and revamp funding mechanics to address the immediacy of research prioritization during such crises. Secondly, by developing clear protocols for leadership and coordination of future epidemic research responses, the CIHR could be better prepared for such events in the future. The CIHR acted on this through the creation of the CSRS initially; followed by the Pandemic Preparedness Strategic Research Initiative; which specifically worked to develop more cooperative interactions between various federal & provincial health institutions, enhance pandemic response speed, and improve research capacity by creating linkages between research bodies. Interestingly enough however, as briefly mentioned in Part III, these learnings did not seem to come from a reflexivity of actors within the CIHR. These shortcomings were addressed almost exclusively from external parties; in particular the National Advisory Committee that investigated the handling of the CIHR during the SARS outbreak. The internal assessments of the CIHR that are available publicly, including the annual CIHR report from 2006-2007 and the internal assessment for 2011 by its Institute of Infection and Immunity, are almost entirely result-oriented, demonstrating no critical reflection on deficiencies. In the sources found, this lack of reflexivity extended from an organizational perspective to an individual perspective. CIHR researcher Bhagirath Singh, who produced a reflective paper, “Innovation and challenges in funding rapid research responses to emerging infectious diseases: Lessons learned from the outbreak of SARS” 57 in which the role of the CIHR is examined, briefly mentions issues in the CIHR’s funding mechanism of peer reviewing, but fails to question any of the underlying routines, objectives, and policies of the CIHR. Similarly, the president of the CIHR during the SARS outbreak, Albert Bernstein, in a published article to Longwoods, is focused on appraising the CIHR’s role without engaging potential learnings.58 The conglomeration of these sources produce the notion that the CIHR was not reflexive, and was in fact not engaging in double- loop learning or if it was, then we cannot find evidence for it. Nevertheless, first order learning occurred through the revision of the CIHR’s funding mechanisms and through its initiation of workshops to develop network linkages. The creation of entirely new programs and research initiatives such as the CSRS and the PPSRI could be indicative of second order learning at a network level; an understanding that meeting the requirements of successful future pandemic response within the existing framework of the

56 Ibidem. 57 Singh, Bhagirath. “Innovation and Challenges in Funding Rapid Research Responses to Emerging Infectious Diseases: Lessons Learned from the Outbreak of Severe Acute Respiratory Syndrome.” The Canadian Journal of Infectious Diseases & Medical Microbiology = Journal Canadien Des Maladies Infectieuses Et De La Microbiologie Medicale, Pulsus Group Inc, May 2004, www.ncbi.nlm.nih.gov/pmc/articles/PMC2094971/. 58 Bernstein, Alan. “CIHR Research: SARS: Make No Mistake - There Will Be a Next Time.” Healthcare Quarterly, 15 June 2003, www.longwoods.com/content/16486.

CIHR (and within its conventional norms, policies, and objectives) would not work, therefore making the creation of such offshoot programs necessary. The sources available however do not illustrate this consideration, rather pointing towards the conclusion that the CIHR was reliant on external feedback and guidance to make structural changes. This indicates that the SARS outbreak did contribute to a change in the behaviours of the Canadian Institutes of Health Research, but that the CIHR did not visibly experience double-loop learning in this process.

Part VI: Lessons learned for TIPC The findings of the CIHR’s response and reflexivity to SARS could reveal certain relevant learning lessons for TIPC. Considering that we were unable to distinguish whether double-loop learning was not taking place or was in fact taking place on a more discrete level does deflate our ability to base these learnings on descriptive evidence. By extension, the lessons learned for TIPC, and in general, should be received with due deliberation given this drawback. Within the sources publicly available, CIHR did demonstrate a lack of critical self- assessment. Its responsibility to the public, as well as its annual review by the Ministry of Health (and in turn its assigned spending budget), could create an environment in which challenging the underlying foundations of an organization are heavily disincentivized. Despite this being a speculative observation, it could be an interesting notion to explore for similar organisations nonetheless. As TIPC sets out to question whether lessons are learned through such crises, it can be compelling for publicly funded organisations to review whether there are inherent barriers for reflexivity to occur. In TIPC’s effort to experiment with transformative evaluation techniques, it may aim to endorse practices of reflexivity in both the consortium and within partnered government agencies. There are also simultaneous positive learnings to be associated with the CIHR’s handling of SARS. Its application of pre-mobilized development funds that would allow for teams to immediately receive funding without delays in the usual granting process exhibited CIHR’s agility in adopting new protocols. The CIHR did demonstrate its willingness for experimentation through changes to its funding practices, as well as its initiation of off-shoot organisations such as the PPSRI. The CIHR also demonstrated the difficulty of steering a network of individuals and scientific teams outside a hierarchical organization during the SARS outbreak. The National Advisory Committee recognized the fundamental elasticity of research work, in which participants have the latitude to choose their collaborators and their research focus, could make it naturally difficult to govern, especially under the time constraints of crisis. Despite that TIPC does not set out to mark priorities, it could still be fruitful to understand the need for clear coordination and responsibility alignment. This is especially pertinent in face of a crisis, such as COVID-19 today, in which the role of research institutions is magnified. To align the coordinative efforts and proposed responsibilities of various stakeholders could be pragmatic for TIPC in its goal to build a research agenda, and in externally applying its recommendations.

Part II.II: A/H1N1 – Bill & Melinda Gates Foundation

Part I: The A/H1N1 pandemic and the Gates Foundation

The A/H1N1 pandemic In June 2009, the World Health Organization (WHO) declared the outbreak of the A/H1N1 virus to be an influenza pandemic.59 This decision was made because of the rapid spread of the virus along with few people having any existing immunity to the virus.60 Two months earlier, the outbreak had started in Mexico and had already reached California in April. 61 In July, 168 countries and overseas communities had reported at least one laboratory confirmed case of H1N1, which indicates the fast circulation of the virus.62 A consequence of these rapid spread is that the virus disrupted socio-technical systems, for instance in Mexico where the administration of Felipe Calderón had to ban all public gatherings, shut down schools and close all non-essential services.63 The pandemic costed Mexico at least four billion dollar, about 0,5% of GDP by the end of 2009 and nine billion dollars overall.64 However, since the virus primarily affected children and young middle-aged adults with healthy immune systems, the impact of the outbreak on the global population was less severe than that of previous pandemics.65 The Center for Disease Control (CDC), one of the organizations that played an important part in responding to the outbreak, estimates that the global death toll from the 2009 pandemic is more than 284,000.66 Despite being less severe than suspected, the outbreak of the virus did provide some important lessons. Some of which are discussed by Professor of microbiology, Peter Collignon in his article “Lessons we need to learn from our global experience”.67 He argues, for instance, that the pandemic highlighted the importance of improved techniques that can decrease the spread of the virus in local communities and hospitals.68 Furthermore, a different approach of producing vaccines should be established as vaccines became only available at the end of the pandemic thence contributed little to preventing new infections.69 Finally, Collignon suggests to rethink when and how pandemics are declared as in hindsight the majority of people infected got relatively mild symptoms.70 The outbreak also instigated research focused on national approaches in handling the H1N1 virus. In Australia, the government decided to shift tactics from general containment to focusing its resources solely on protecting vulnerable groups in society. This approach is called the “protect phase” and is discussed more thoroughly by Emily Waller.71 The response of the Mexican government is for instance examined by former Minister of Health Jose A. Cordova- Villabos as well as Sophal Ear.72 He emphasized workplace issues in Mexican laboratories

59 Sarah A. Lister and Stephen C. Redhead, “The 2009 influenza pandemic: An overview,” in The H1N1 influenza pandemic of 2009, ed. Charles R. Bartolotti (New York: Nova Science Publishers, 2010): 1-35, 1. 60 World Health Organization, “Pandemic (H1N1) 2009- update 60,” Accessed at 21 July 2020. https://www.who.int/csr/don/2009_08_04/en/ 61 Lister and Redhead, “The 2009,” 2. 62 Centers for Disease Control and Prevention, “2009 H1N1 Pandemic (h1N1pdm09 virus),” Accessed at 21 July 2020. https://www.cdc.gov/flu/pandemic-resources/2009-h1n1-pandemic.html 63 Vanda Felbab-Brown, “Lessons learned from Felipe Calderón’s swift response to H1N1 in 2009,” Brookings, March 7, 2019. 64 Felbab-Brown, “Lessons,”. 65 Centers for Disease Control and Prevention, “2009,”. 66 University of Cambridge, “New analysis of swine flu pandemic conflicts with accepted views on how diseases spread,” ScienceDaily, July 1, 2014. Accessed at 21 July 2020. “https://www.sciencedaily.com/releases/2014/07/140701101501.htm 67 Peter Collignon, “Swine flu; lessons we need to learn from our global experience,” Emerging health threats journal 4, no. 1 (2011): 1-6. 68 Collignon, “Swine flu,” 2. 69 Collignon, “Swine flu,” 3. 70 Collignon, “Swine flu,” 2. 71 Emily Waller, Mark Davis, Niamh Stephenson “Australia’s pandemic influenza ‘Protect’ phase: emerging out of the fog of pandemic,” Critical Public Health 26, no. 1 (2016): 99-113. 72 Jose A. Cordova-Villalobos, Alejandro E. Marcias, Mauricio Hernandez-Avilla, Guillermo Dominguez-Cherit, Hugo Lopez-Gatell, Celia Alpuche-Aranda, Samuel Ponce de León-Rosales, “The 2009 pandemic in Mexico: Experience and lessons regarding national preparedness policies for seasonal and epidemic influenza,” Gaceta Médica de México 153 (2017): 102-110., Sophal Ear, “Swine flu: Mexico’s handling of A/H1N1 in comparative perspective,” Politics and the life sciences 31, no. 1-2 (2016): 52-66.

22 which prevented them from detecting the virus at an early stage.73 For instance, the facilities lacked efficient tools or technologies and were faced with hierarchical systems discouraging them from warning authorities.74 In addition, trust issues between the Mexican government and Mexican academia caused the handling of the virus to rest mostly on the cooperation with the Canadian and American governments without the scientific support of national academia.75 This relation and dynamic between central actors during the pandemic, for instance between scientists, authorities and media, has been the subject of research in Norway. Kristan Bjørkdahl and Benedicte Carlsen looked at this interrelationship between actors in their research.76 One lesson that was generated from this research was that a somewhat negative view of the media troubled the communication between them and the authorities, while good communication is extremely crucial during a pandemic.77

The Gates Foundation The Gates Foundation is the world’s largest private grant-making foundation and a leading actor among private philanthropic organizations.78 It is based in Seattle, Washington and was launched in 2000 with the primary goal to globally enhance healthcare and reduce extreme poverty.79 The Gates Foundation is active in 138 countries across several continents and is guided by the belief that every life has equal value. This belief led the Gates Foundation to support innovative programs that leverage advancements in science, technology, health, agriculture and education to the benefit of the most neglected populations around the world.80

Figure 1: Organizational structure Gates Foundation from the article of Rachel Koch (2019).

73 Ear, “Swine flu,” 62. 74 Ibidem. 75 Ibdem. 76 Kristan Bjørkdahl and Benedicte Carlsen, “Fear of the Fear of the Flu: Assumptions about media effects in the 2009 pandemic,” Science communication 39, no. 3 (2017): 358-381, 362. 77 Bjørkdahl and Carlsen, “Fear,” 381. 78 OECD, Meeting Global Challenges through Better Governance. International co-operation in science, technology and innovation (OECD publishing, 2012), 64. 79 Bill & Melinda Gates Foundation, “Who we are,” Accessed at 21 July 2020. https://www.gatesfoundation.org/Who-We-Are 80 Rachel Koch, Lina Roa, Jordan Oyda, Monica Kerrigan, Ernest Barthelemy, John G. Meara, “The Bill & Melinda Gates Foundation: An opportunity to lead innovation in global surgery,” Surgery 165 (2019): 273-280, 273.

The Foundation is managed, as illustrated in figure 1, by Bill Gates, Melinda Gates and Warren Buffet and supported by the CEO and executive team that meets regularly to ensure all projects of the Foundation perform efficiently. This group shapes the vision and strategic direction of the Gates Foundation and coordinates efforts among its various components.81 The Foundation’s work and initiatives are divided into the Global Health division led by Trevor Mundel, the Global Development division led by Christopher Elias, the Global Growth and Opportunity division led by Rodger Voorhies, the U.S program led by Allan Goldston and the Global Policy & Advocacy division led by Gargee Ghosh. 82 In 2003, the Gates Foundation launched in cooperation with the Canadian Institutes of Health Research (CIHR) and Wellcome Trust (also an independent global charitable foundation) the ‘Grand Challenges Program’, to address the pressing needs of developing countries.83 The Program is currently engaged in fourteen major global health challenges including research for new vaccines, drugs, diagnostic products and other technologies for treating diseases in developing countries.84 By awarding the most promising research projects a grant, the Program tries to engage the world’s most creative minds in solving global health issues.85 Most of the financial resources of the Gates Foundation have come from the Gates’ personal wealth and contributions held in an endowment.86 The latter is a donation of the investor Warren Buffet who pledged a part of his fortune, 10 million shares of Berkshire Hathaway stock, to be paid in annual installments, to the Gates Foundation.87 In response to this gift the Foundation created the Bill & Melinda Gates Foundations Trust to hold donated investment assets.88 The Foundation distinguishes itself with its very extensive evaluation policy rooted in its core values; collaboration, rigor, innovation and optimism.89 The Foundation for instance considers evaluation to be “a collaborative learning tool that provides itself and its partners with feedback so that it can learn, adjust, and decide how best to achieve the desired outcomes”.90 This indicates that the Gates Foundation based its evaluation policy on “developmental evaluation” described by Michael Quinn Patton as: “Developmental evaluation is a way of being useful in innovative settings where goals are emergent and changing rather than predetermined and fixed, time periods are fluid and forward-looking rather than artificially imposed by external deadlines, and the purposes are innovation, change, and learning rather than external accountability (summative evaluation) or getting ready for external accountability (formative evaluation)”.91 In its evaluation policy, the Gates Foundation outlines four instances where evaluation is warranted: ● “When new evidence is needed to fill a knowledge gap or evaluate significant policy decisions, ● When partners of the Gates Foundation need a better understanding of how investments of a specific program are performing,

81 Koch, Roa, Oyda, Barthelemy, Meara, “The Bill,” 274. 82 Ibidem. 83 OECD, Meeting Global, 70. 84 Ibidem. 85 Global Grand Challenges, “Ending the Pandemic threat: A grand challenge for universal influenza vaccine development,” Bill & Melinda Gates Foundation, April 27, 2018. Accessed at 21 July 2020. https://gcgh.grandchallenges.org/challenge/ending-pandemic-threat-grand- challenge-universal-influenza-vaccine-development 86 OECD, Meeting Global, 70. 87 Bill & Melinda Gates Foundation, “Warren Buffet,” Accessed at 21 July 2020. “https://www.gatesfoundation.org/Who-We-Are/General- Information/Leadership/Executive-Leadership-Team/Warren-Buffett 88 https://www.influencewatch.org/non-profit/bill-and-melinda-gates-foundation/ 89 Bill & Melinda Gates Foundation, “Evaluation policy,” Accessed at 21 July 2020. https://www.gatesfoundation.org/How-We- Work/General-Information/Evaluation-Policy 90 Bill & Melinda Gates Foundation, “Evaluation policy,”. 91 Michael Quinn Patton, Developmental Evaluation. Applying complexity concepts to enhance innovation and use (New York, London: The Guilford Press, 2011), viii.

● When an organization or consortium that the Gates Foundation works with could benefit from an independent performance assessment or ● When a program team needs to assess the progress of a new operational model or approach.”92 There is also a distinction between evaluation methods used by the Foundation. Firstly, they have evaluations that aim to produce causal evidence that can be used to decide whether to scale up or replicate pilots, innovations or delivery models.93 Secondly, the Foundation also uses evaluations to understand and strengthen program effectiveness and evaluations to improve the performance of institutions or operating models.94 Part of the Foundation’s evolution policy is the Central Strategy, Measurement & Evaluation team led by Jodi Nelson working at the Gates Foundation, which maintains the Foundation’s evolution policy and focuses on defining standards on how to conduct evaluations.95 As a result of the work of Nelson’s team, since 2010 the Foundation is in cooperation with the Center for Effective Philanthropy (CEP) that surveys active grantees.96 The feedback of all the Foundation’s partners collected by the Center are published in annual Grantee Perceptions Reports (GPR). Gates mentioned this new effort of the Foundation in his 2010 annual letter as follows: “Our partnerships are our lifeblood, and I said I was making it a priority for everybody at the Foundation to listen more carefully to what our partners in the field have to tell us.”97 The evaluation methods and team are complemented with an annual review of the Foundation’s strategy which provide the program teams with the chance to reflect on progress and propose areas of strategic adjustment.98 In 2011, the Foundation published the guide of its strategy review process which gives deeper insight in the evaluation process of the Foundation’s strategy.99 The guide describes the CEO and trustees as the only designated people who can request to “refresh” the strategy.100 In two other instances a “refreshment” of strategy is optional: when a long period of time has passed since the last refreshment or when there is a direct need for a significant change due to new science, policy changes, progress or lack of it.101 Figure 2, from the above-mentioned strategy review guide of 2011, illustrates the process of strategy “refreshment” of the Foundation. Since 2007, the different programs of the foundation are also supported by an advisory panel comprised of experts who provide the program with feedback that could help increase the impact of its work.102

92 Bill & Melinda Gates Foundation, “What we do,” Accessed at 21 July 2020. https://www.gatesfoundation.org/What-We-Do 93 Bill & Melinda Gates Foundation, “What we do,”. 94 Ibidem. 95 Matthew Forti, “Actionable Measurement at the Gates Foundation. A conversation with Jodi Nelson, Head of Measurement and evaluation,” Augustus 29, 2012. 96 Fay Twersky, “Interview-Jodi Nelson,” Alliance magazine, May 1, 2011. 97 Bill & Melinda Gates Foundation, “Warren Buffet,”. 98 Bill & Melinda Gates Foundation, The Strategy Lifecycle: A Guide (Bill & Melinda Gates Foundation, 2011). 99 Bill & Melinda Gates Foundation, The Strategy, 7. 100 Ibidem. 101 Bill & Melinda Gates Foundation, The Strategy, 8. 102 Bill & Melinda Gates Foundation, “Program advisory panels announced by the Bill & Melinda Gates Foundation. Panelist will provide strategic input to program presidents,” Accessed at 21 July 2020. https://www.gatesfoundation.org/Media-Center/Press- Releases/2007/09/Program-Advisory-Panels

Figure 2: Phases of the Foundation’s strategy “refreshment” from the Strategy lifecycle guide (2011).

While the Foundation is extremely orientated on learning, evaluation and innovation, it is haunted by chronic complaints about its lack of transparency and relatively poor communication skills with grant recipients and outsiders.103 As it is a private organization, the Gates Foundation is only accountable to its three trustees: Bill, Melinda and Warren Buffet.104 In 2009, Jeff Raikes who was the Foundation’s CEO between 2008-2013, addressed this issue and said the organization intended to improve its transparency.105 Raikes stepped down as CEO in 2013 as envisioned this job as a five-year commitment and desired to put more time in the Raikes Foundation.106 Other criticism the Foundation received was about the fact there are only three trustees who are deciding how billions of dollars are controlled and spent.107 The lack of a well-functioning board of global health experts from different countries supporting the decisions of the trustees, is considered a weakness of the Foundation.108 Not only who decides how the money is invested was criticized over the years but also how the actual investments are scrutinized. This happened in 2007 when the Los Angeles Times published an article about conflicting investments of the Gates Foundation in the Niger Delta. According to the research, the Gates Foundation had been devoted to protecting the health of people in the Niger Delta while at the time it invested 423 million dollars in Eni, Royal Dutch Shell, Exxon Mobil and Total of France, companies responsible for polluting the air in the Niger Delta.109 Monica Harrington who was a senior policy officer at the Gates Foundation at that time, responded to questions of the LA Times about the Foundations conflicting investments by saying the Foundation has made it a policy not to comment on individual investment holdings.110 Another structural critique is posed by Professor of global public health and director of the Centre for Public Health at Queen Mary University of London, David McCoy. In his article in the Guardian in 2009, he comments on the blind focus of the Gates Foundation on technological

103 Tom Paulson, “Top 5 points in Gates Foundation annual report,” Humanosphere, October 4, 2012. 104 Julia Belluz, “The media loves the Gates Foundation. These experts are more skeptical.” Vox, June 10, 2015. 105 Paulon, “Top 5,”. 106 Tom Paulson, Microsoft era ending at Gates Foundation - CEO Jeff Raikes steps down,” Humanosphere, April 30, 2014. 107 OECD, Meeting Global, 69. 108 OECD, Meeting Global, 73. 109 Charles Piller, Edmund Sanders, Robyn Dixon, “Dark cloud over good works of Gates Foundation,” Los Angeles Times, January 7, 2007. 110 Piller, Sanders, Dixon, “Dark Cloud,”.

26 solutions for health problems in developing countries while completely ignoring wider political and social issues.111 The toll of many diseases could, according to McCoy, for instance be lowered simply by strengthening health systems in developing countries.112 The emphasis on technological fixes is also seen as a problem of the Grand Challenges Program of the Foundation which was recognized by Gates himself, in his 2014 speech in Seattle celebrating the tenth anniversary of the Program. He said: “The Foundation underestimated the difficulties of introducing new technologies in countries where millions of people lack access to basic necessities.113

Part II: Changes within the Gates Foundation The Foundation underwent three internal changes between 2009 and 2012. The first two changes are part of a reorganization of the Foundation which was made public in the 2011 annual report of the Foundation’s CEO.114 The first part of the reorganization was a re- structuring of the Foundation’s different global programs where the major changes were made in the Global Health Program and Global Development Program. These were altered dramatically to integrate and connect the different initiatives of these two programs as this could help in having the desired outcome.115 The 2011 annual report states the Foundation had historically been focusing on solving specific problems which often prevented it from stepping back and looking at the interrelationships among the issues.116 To illustrate this re-structuring, Raikes describes in the 2011 annual report how program teams working on agriculture and vaccine development are now working together more closely on the discovery and delivery of health and development innovations.117In an interview by Tom Paulson in 2013, Raikes is asked about the reason for the reorganization. He answered that the re-structuring of the Foundation started because Dr. Trevor Mundel (former Novartis executive) and Chris Elias (former president of PATH) joined the Gates Foundation in 2011.118 Mundel became the president of the Global Health program and Elias started leading the Global Development program.119 In Raikes’ personal blog of 2012 he speaks a bit more extensively about the role of Mundel and Elias. According to Raikes, Elias brings years of on-the-ground experience in health and development the Gates Foundation needs.120 This is the reason why Elias became head of the Global development program as he brings a better understanding of the obstacles to introducing new tools and technologies and how these can be overcome.121 The reorganization also included a change of the Foundation’s focus, caused by what Raikes called in his 2012 personal blog the “innovation pile-up”.122 This “pile-up” means that the Foundation has been investing in lifesaving technologies while the people who need them are not able to take advantage of these new tools and innovations due to the lack of public health systems, training and infrastructure.123 In the same blog he clarifies his statement with the example of extremely bad or nonexistent transportation systems which make it impossible to reach the people who need the technologies.124 In addition, people need to be instructed and trained to use the technologies, and sometimes cultural practices may dissuade people from

111 David McCoy, “The giants of philanthropy,” The Guardian, August 5, 2009. 112 McCoy, “The giants,”. 113 Sandi Doughton, “After 10 years, few payoffs from Gates’ Grand Challenges,” Seattle Times, December 12, 2012. 114 Jeff Raikes, Bill & Melinda Gates Foundation Annual Report 2011 (Bill & Melinda Gates Foundation 2012):1-6, 4. 115 Raikes, Bill & Melinda, 4. 116 Ibidem. 117 Ibidem. 118 Tom Paulson, “A chat with outgoing chief of the Gates Foundation, Jeff Raikes.” Humanosphere, September 11, 2013. 119 Ibidem. 120 Jeff Raikes, “Jeff Raikes on Philanthropy,” Impatient Optimists, October 4, 2012. 121 Raikes, “Jeff Raikes,”. 122 Ibidem. 123 Raikes, “Jeff Raikes,”. 124 Ibidem.

27 adopting them.125 This new insight caused the Gates Foundation to broaden its focus from solely producing technologies to investing in the practical side, for instance in ideas of how innovations can be delivered.126 Raikes is not the only CEO of the Foundation that addressed the “innovation pile up”. His successor Sue Desmond-Hellmann, who has been the CEO of the Gates Foundation between 2014-2020, mentioned the shift from only pursuing technological fixes to also economic and public health development in an interview in 2014.127 Desmond-Hellmann makes a comparable statement as Raikes, she says: “Making medicines that no one gets, is not really worth celebrating and therefore the Foundation needed to start investing in water, sanitation, city planning, climate, the economy and mobility as well.128 The statements of both Raikes and Desmond-Hellman are similar to what Gates said in his speech in Seattle during the tenth anniversary of the Grand Challenges Program: “The Foundation underestimated the difficulties of introducing new technologies in countries where millions of people lack access to basic necessities.129 The third identified change in the Gates Foundation is its increased interest in investments and partnerships that could help during future pandemics. The Foundation for instance joined a collaboration between the Icahn School of Medicine at Mount Sinai, GlaxoSmithKline and PATH to produce vaccine candidates helpful during future influenza outbreaks.130 Furthermore, the Gates Foundation founded CEPI, together with Wellcome Trust and the governments of Norway, India, Japan and Germany.131 CEPI is the Coalition for Epidemic Preparedness Innovations which focuses on innovations to accelerate the development of vaccines needed during pandemics.132 In addition, in 2018 the Foundation launched a new grand challenge in its Grand Challenge Program called: “Ending the pandemic threat: A grand challenge for universal influenza vaccine development”.133 The aim of this new grand challenge is to find proposals that could find a universal flu vaccine which could be used in all groups around the world against both seasonal and pandemic influenza.134 Finally, in October 2019 the Foundation hosted Event 201, in cooperation with the Johan Hopkings Center for Health Security and the World Economic Forum. This was a high-level pandemic exercise in New York.135 This exercise was meant to illustrate what would be necessary during a pandemic to lessen economic and social consequences.136 This aim, to prepare the world for future pandemics, can be considered a change of behavior of the Foundation as pandemics have not been a focus point of the Foundation before 2009. Desmond-Hellmann mentioned this in an interview in 2017 by Michael Strain who is director of economy policy studies at AEI. In their conversation Desmond-Hellmann says: “the Foundation was not established to focus on pandemics, but it got involved because it is the biggest threat the world is facing, while no state is ready to manage the catastrophic impact of future pandemics.”137 The A/H1N1 pandemic showed, according to Desmond-Hellmann, that the world needs better diagnostic tools, more vaccines and surveillance systems.138 In addition,

125 Ibidem. 126 Ibidem. 127 Sandi Doughton, “Tough bosses no problem for Gates Foundation’s new CEO,” Seattle Times, June 29, 2014. 128 Doughton, “Tough bosses,”. 129 Sandi Doughton, “After 10 years, few payoffs from Gates’ Grand Challenges,” Seattle Times, December 12, 2012. 130 Bill Gates, “The next epidemic is coming. Here is how we can make sure we’re ready,” GatesNotes. The blog of Bill Gates, April 27, 2018. 131 Gates, “Preparing,”. 132 Ibidem. 133Global Grand Challenges, “Ending,” 134 Ibidem. 135 Event 201: A global pandemic exercise, “Event 201,” Accessed at 21 July 2020. https://www.centerforhealthsecurity.org/event201/ 136 Event 201, “A Global,”. 137 Michael Strain, “Interview with Sue Desmond-Hellmann: Is the world prepared for a full-scale Swine flu pandemic?,” RealClearHealth, February 10, 2017. 138 Michael Strain, “Interview,”.

28 having health systems for everyone is crucial as pandemics have the most impact at places where health systems are not working or present.139

Part III: Reflexive changes and lessons learned Are these above identified changes within the Gates Foundation reflexive? First of all, it is interesting to note that the Foundation’s extensive evaluation policy, supported by its Central Strategy, Measurement & Evaluation team and annual strategy “refreshment” is mostly orientated to first order learning. The evaluations are for the large part focused on the effectiveness of the Foundation’s work, which is considered most important, as the Foundation is very impact-orientated. This impact-orientated approach of the Foundation can be seen for instance in the requirement that research should lead to products that can have an immediate effect on the health of people living in developing countries.140 The evaluations are therefore centered on measuring results and, if necessary, improving the Foundation’s strategy to achieve the desired outcome.141 This is also the case in the 2011 strategy review guide of the Foundation, as it discusses very extensively how and why the Foundation’s strategy can be “refreshed” but the guide includes no policy or method that evaluates the Foundation’s norms, structures or objectives on which the impact strategy or overall goals of the Gates Foundation are based. However, the evaluation policy, which outlines both instances when evaluations are necessary and how evaluations are performed, indicates that the Foundation is trying to learn, develop and improve, which provides the opportunity to review its underlying norms, structures or objectives. Furthermore, in an interview in 2011, Nelson, head of the Strategy, Measurement & Evaluation team is asked by Fay Twersky about the work of her team to put systems in place that can measure results and feedback loops that will help the Foundation learn.142 In their conversation Nelson did not explicitly mention the presence of reflexive learning systems within the Foundation, however she did emphasize the Foundation is trying to advance its own organizational learning.143 While this research did not find signs of reflexive learning methods being incorporated after 2011 in the Foundations itself, it did find sources that point to the presence of reflexive methods. The Gates Foundation launched for instance in 2017 its “culture change” initiative. 144 This initiative was made public in a policy document which highlighted how the Foundation is creating a working culture needed for the impact it desires.145 The document provides insights about the role of Desmond-Hellmann who apparently instigated this change in 2015, as she envisaged “A working culture where everyone can do their best work which maximizes outcomes and boosts innovations.”146 In addition, the decision of Desmond-Hellmann was based on stories of personal burnouts and self-doubt that circulated quietly within the Foundation.147 While the evaluation systems do not seem to be reflexive, the changes part of the reorganization of the Gates Foundation are indicating some reflexivity. The main goal of the re-structuring of its Global Health and Global Development program was to work more effectively, but as Raikes mentioned in the 2013 interview: “The re-structuring of the organization was done over a year ago mostly because of Trevor Mundel and Chris Elias coming on board.”148 Raikes also had its own experience that showed him the benefits of linking the two global programs.149 This he described in the 2011 annual letter as follows:

139 Ibidem. 140 OECD, Meeting Global, 69. 141 Bill & Melinda Gates Foundation, The Strategy. 142 Twersky, “Interview,”. 143 Ibidem. 144 Bill & Melinda Gates Foundation, Innovative practices for leading culture (Bill & Melinda Gates Foundation, 2017). 145 Bill & Melinda Gates Foundation, Innovative, 2. 146 Bill & Melinda Gates Foundation, Innovative, 3. 147 Ibidem. 148 Paulson, “A chat,”. 149 Raikes, Bill & Melinda, 5.

I visited a rural health post in the Ethiopian Highlands in 2010 that is providing basic care for 500 families. Each health extension worker at the post is trained not only in immunization and maternal and child health, but also in nutrition, malaria control, sanitation, water supply safety, food hygiene, even rodent control. In all, they were trained in 16 very different areas of community health. The fact is, the people they serve have lots of challenges. The mother who’s worried about malaria also wants to feed her children nutritious food. The Ethiopian healthcare workers know that building better lives for their neighbors means that they don’t just need to get one piece of the puzzle right. They must get all the pieces right.150

The possibility of linking the programs, influenced by Mundel and Elias, has been neglected by the Foundation as its historical approach prevented it from stepping back and looking at the interrelationship.151 The adapted view of the Foundation, announced in the Raikes annual letter of 2011, meaning that the global health and global development can no longer be seen apart, indicates that the Foundation reflected on its own routine and worldview, and because of this, altered its strategy fundamentally. As the ability of actors to reflect on their own routines and worldviews is considered part of reflexivity, it means that second order learning occurred within the Gates Foundation. The second change of the reorganization is caused by what Raikes called in his blog of 2012 the “innovation pile-up”, meaning that the lifesaving technologies produced by the Foundation are not reaching people who need them due to lack of basic necessities.152 This problem of the “innovation pile-up” was already mentioned by Elias in 2006 in his published essay in “The Lancet”.153 He described the problem as follows:

Many product-development partnerships have begun to succeed in advancing bust portfolios of new drugs, diagnostics, vaccines, and medical devices. This has created a new problem, however: the potential for an innovation pile-up. Recent investments in new technology development have not yet been matched by similar efforts to strengthen health systems in resource-poor settings. The danger is that new innovations will not move smoothly into widespread use, even in places where they are desperately needed, because of weaknesses in health systems, such as shortages of health workers, fragmented or corrupt procurement and supply chains, poor quality assurance, and lack of sustainable financing.”154

Elias brought this insight to the Foundation in 2011 which shifted from solely producing lifesaving technologies to also investing in modifying the conditions for these innovations. While this adaptation corrected a detected error, it also involved a significant modification of the Foundation’s underlying norms, policies and objectives. The Foundation was not able to carry on its present policies or achieve its present objectives after the error was detected. This is discussed by Argyris and Schön who claim the following: “when the error detected and corrected permits the organization to carry on its present policies or achieve its present objectives, then that error-detection-and-correction process is single-loop learning.”155 As the current objective of the Foundation to help people with producing lifesaving technologies could not be achieved, meaning that this shift not just entails “single-loop learning”.156 To still achieve its original objective the Foundation had to supplement its goal of helping through technological fixes with more practical solutions of helping people in developing countries. This learning

150 Ibidem. 151 Raikes, Bill & Melinda, 6. 152 Raikes, “Jeff Raikes,”. 153 Christopher J. Elias, “Can we ensure health is within reach for everyone?” Lancet 368 (2006): 40-41,40. 154 Elias, “Can we ensure,”. 155Argyris and Schön, Organizational Learning, 3. 156 Ibidem.

30 process therefore included a fundamental rethinking of the definition of problems and which solutions would be suited for solving these problems. To really qualify the change due to the “innovation pile-up” as second order learning, it is also necessary to find examples of reflexivity.157 Evidence of this is present in statements of individuals of the Foundation who detected a mismatch between outcome and expectation which exhibited what could be argued to be the organizational espoused theory.158 The Foundation was not achieving its desired outcome and it had to rethink its approach and assumptions on how to solve the problems of people they were trying to help. The Foundation had to start paying attention to the practical side, which included investing in delivery systems, local health systems and trainings on how to use the new technologies. A first hint of reflexivity is present in the blog at the Bridgespan Group of Raikes in 2013 where he mentions the “innovation pile-up” and says: “We could have a hundred or more new global health interventions available in the next 10 years, and you have to really think about not only having that intervention available but how is it going to deliver.”159 Another hint of reflexivity is an interview by Tom Paulson in 2014 with Desmond-Hellmann who reacts to criticism the Foundation received the past few years for inventing better toilets without encouraging basic water and sanitation infrastructure development.160 The latter is an example of the Foundation’s focus on innovations while neglecting some of the fundamental causes of poverty that caused the “innovation pile-up”. Desmond-Hellmann responds in the interview that she as CEO intends to make humility, and an embrace of constructive criticism, important counter-points to the philanthropy’s vaunted ambitions and impatient optimism.161 This statement of Desmond- Hellmann indicates a change or addition to the underlying values and norms of the Gates Foundation due to the received criticism about the “innovation pile-up”. The third change the Foundation experienced is the shift to investing in vaccination programs and co-operations that could help during future pandemics. As Desmond-Hellmann said in the above-mentioned interview of 2017, the Foundation was not founded to address the threat of future pandemics but it had to because it is the world’s biggest threat.162 Therefore, the Foundation established CEPI in 2016, started investing in vaccine candidates, organized a high-level pandemic exercise in 2019 and launched a new Grand Challenge in 2018 focused on finding a universal influenza vaccine. This new behavior of the Foundation could be related to Gates’ view about the threat of future pandemics. In his personal blog of 2010, Gates called the H1N1 outbreak and the Ebola epidemic “wake-up calls” to pay closer attention to the risk of future pandemics.163 He therefore stressed the importance of gathering data about the disease, limiting the movement of people, reducing the severity of sickness with medicines and producing vaccines.164 It becomes even more apparent that Gates himself learned from the H1N1 outbreak as he continued to stress the necessity of preparing for future pandemics after 2010. This he does for instance in his 2017 personal blog where he mentions the need for a global response system as he finds the world’s inability to stop future pandemics worrying.165 A global response system begins, according to Gates, with strengthening local health systems in poor countries, which were hit the hardest during recent epidemics.166 Part of these local health systems are to be built on trained health workers who can provide primary health care, the ability to deliver vaccines

157 TIPC, ‘The Theory Behind TIPC’s Work’, 6. 158 Argyris and Schön, Organizational Learning, 9. 159 Jeff Raikes, “Effective Philanthropy, innovation, technology keys to global equality, says Gates Foundation CEO Jeff Raikes,” Bridgespan Group, March 30, 2013. 160 Tom Paulson, “New Gates Foundation chief to seek revolutionary simplicity,” Humanosphere, June 30, 2014. 161 Paulson, “New Gates,”. 162 Michael Strain, “Interview,”. 163 Bill Gates, “A better response to the next pandemic,” GatesNotes. The Blog of Bill Gates, January 18, 2010. 164 Gates, “A better,”. 165 Bill Gates, “Preparing for the next epidemic: a first step,” GatesNotes. The blog of Bill Gates, January 18, 2017. 166 Gates, “Preparing,”.

31 and have the capacity to monitor the well-being of their communities.167 Furthermore, in his personal blog of 2018 called “What I have learned this year at work” Gates says: “If anything is going to kill tens of millions of people in a short time, it will be a global epidemic.168 Not only in his above-mentioned personal blogs of 2012, 2017 and 2018 but also in speeches Gates mentions the threat of future pandemics. For instance, during the Munich Security Conference in Germany in February 2017, Gates pointed out the link of health security and international security by explaining that a fast-moving airborne pathogen could kill more than 30 million people in less than a year.169 Because of this link, Gates argues that the world needs to prepare for pandemics the same way as the military prepares for war.170 This includes germ games and other preparedness exercises to get a better understanding how diseases will spread, how people will respond in panic, and how to deal with overloaded highways and communications systems.171 In addition, Gates used the opportunity to give a Shattuck Lecture in 2018, which is annual talk presented by the New England Journal of Medicines (NEJM) and the Massachusetts Medical society, to point to the sobering fact that the world is not making much progress in pandemic preparedness. 172He emphasized during his talk that: “As long as scientists are still working on a universal vaccine that could protect everyone (some of which our Foundation is funding) the world needs to develop a global system of monitoring and responding to epidemics.”173 Finally, in a Ted Talk in 2015 Gates outlines how he envisions the role of the military in handling future pandemics.174 According to Gates, the military has the resources and infrastructure to act fast and are able to quickly transport a medical corps and supplies around the world.175 In addition, the military has the logistics to coordinate these kinds of operations and can secure large areas which makes them extremely effective during virus outbreaks.176 These examples indicate that Gates has learned from the H1N1 outbreak in 2009 and this affected his Foundation as it started to invest in vaccine programs, organizations and events to prepare the world for future pandemics. It is however not clear if Gates’ new view can be identified as reflexive learning of the Gates Foundation as a whole. There is no evidence that the Foundation had to, because of Gates’ experience of the H1N1 outbreak, modify its organizational strategies and revise its underlying norms or objectives. Therefore, the decision of the Foundation to launch CEPI, invest in vaccine development programs and hold annual high level pandemic exercises can be identified as first order learning as it was influenced by information from the real world while missing the reflexive element or changes in beliefs, assumptions or behavior.

Part IV: Conditions that led to the changes Are the above-mentioned changes in the Foundation caused by the H1N1 pandemic of 2009 that disrupted social-technical systems? The third change identified in this research is categorized as first order learning but can most obviously be linked to the outbreak of the H1N1 virus in 2009 as after the pandemic, Gates started to talk about the threat of pandemics in four personal blogs, three speeches and two annual letters. He called the pandemic of 2009 as mentioned before in this case study a “wake-up call”.177 The change in the investments of the Foundation, for instance visible in the research partnerships with the Icahn School of Medicine

167 Ibidem. 168 Bill Gates, “What I learned at work this year,” GatesNotes. The blog of Bill Gates, December 29, 2018. 169 Gates, “Munich,”. 170 Ibidem. 171 Ibidem. 172 Bill Gates, “Innovation for Pandemics,” The new England journal of medicine 378 (2018): 2057-2060, 2057. 173 Gates, “Innovation,” 2060. 174 Bill Gates, “The next outbreak? We’re not ready,” TED, March 2015. 175 Gates, “The next,”. 176 Ibidem. 177 Gates, “A better,”., Gates, “What I learned,”.

32 at Mount Sinai, GlaxoSmithKline and PATH or the establishment of CEPI in 2018 are changes that can be linked to the H1N1 outbreak in 2009. Furthermore, the outbreak of COVID-19 in 2020 shows how Gates is shifting his Foundation even more towards fighting pandemics. The reorganization of the Foundation around 2011 is identified in this research as second order learning because of the presence of the reflexive element and changes in the Foundation’s worldview, policies, structures and objectives. However, the link between the H1N1 outbreak and the reorganization of the Foundation is harder to draw. According to Grin, Rotmans and Schot, special circumstances entail surprises which are critical conditions for second order learning to prevail.178 Pandemics are seen as these surprises or landscape shocks but this case study did not find clear evidence of whether the H1N1 outbreak contributed to second order learning within the Gates Foundation between 2009-2019. In discussing the reorganization, neither Raikes, Desmond-Hellmann, Mundel or Elias mentioned the influence of the pandemic of 2009 on the Gates Foundation. The restructuring of the two global programs and new focus on the practical side of innovations happened due to Raikes personal experience, the expertise of Trevor and Mundel joining the Foundation and several outside critics who pointed to the Foundation’s blind focus on technological fixes. However, since this case study is based solely on published secondary material and no interviews or internal reports, it is possible that there is a link between the pandemic of 2009 and the re-organization discussed in this research.

Part V: Lessons learned This case study showed that the Gates Foundation has a very extensive evaluation policy and distinguishes itself with its desire to continue learning. While this research did not find evidence of the presence of reflexive learning methods, it did indicate that the Foundation has developmental evaluation incorporated in its evaluation policy. As this type of evaluation opens up the possibility of second order learning, it means that reflexive learning within the Foundation could occur by means of its evaluation policy. An insight drawn from this finding is even if organizations incorporate learning, double loop or second order learning into its evaluation policy, it remains crucial for them to address its learning limitations. Therefore, it could be helpful for TIPC to understand that addressing learning limitations is part of learning, even if second order learning methods are incorporated into the organizations evaluation policy. This case study also indicated how the H1N1 pandemic only triggered first order learning in the Gates Foundation as second order learning happened due to other reasons. This means that the H1N1 pandemic did not cause the landscape shock triggering reflexive learning in the Gates Foundation. A reason for this could be the scale of the pandemic of 2009 as its global disrupting was far less than the current COVID-19 pandemic. As the role of disasters as inherent component of socio-technical systems has been extensively studied, for instance by Haiko van der Voort and Hans de Bruijn it could be that similar studies can help shed light into the way in which pandemics can lead to learning.179 However, this research has its limitations due to the use of only secondary sources which means that it could also be that the identified cases of second order learning in the Gates Foundation are in some way connected to the pandemic of 2009. As mentioned above, the sources used in this research indicate that second order learning did not occur in the Gates Foundation due to the pandemic of 2009. Other circumstances did, including outside criticism, the arrival of Mundel who brought a different view of how the Foundation should organize its work, the arrival of Elias who pointed to the problem of the “innovation pile-up”, and a personal experience of Raikes which pointed him to

178 Grin, Rotmans, and Schot, Transitions to Sustainable Development, 280-281. 179 Haiko van der Voort and Hans de Bruijn, “Learning from disasters. Competing perspectives on tragedy,” IEEE Technology and Society magazine (2009), 28-36.

33 the importance of integrating the different global programs contributed to reflexive learning within the Gates Foundation. An insight drawn from this finding is the ability of private organizations, such as the Gates Foundation where financial resources mostly come from the private fortunes of the heads themselves, to acknowledge that its current strategy is lacking and because of this shift its underlying objective and structure. Lastly, this case study showed how the Gates Foundation changed its focus from solely producing lifesaving technologies towards investing in practical necessities needed to help people in developing countries. An insight drawn from this, especially interesting for TIPC which also focuses on transforming through innovations, is the importance of social context in achieving the desired outcome of helping people with new practices, innovations and technologies.

Discussion

As mentioned in the summary, this research is conducted in the short period of two months. Within this limited time frame we developed a conceptual framework, our methodological approach, conducted the comparative research, and connected this into a coherent narrative. This meant that some choices were made, such as to rely on publicly available secondary sources only and we were not able to conduct interviews with people currently working at either CIHR or the Gates Foundation, or access internal reports. The research was conducted by asking the following research question: How has A/H1N1 / SARS contributed to a change in norms, structures and objectives in the Bill & Melinda Gates Foundation / CIHR? As we lacked the time to perform interviews or access to internal reports we had to conduct our case studies based solely on published secondary material. This can be considered as a limitation of our research as access to primary sources could shed a different light on our current findings. In case of the Gates Foundation it would be interesting to further examine, with sources from within the Gates Foundation, why and how the reorganization occurred after 2009. For the CIHR’s it seems difficult to distinguish between whether second order learning is happening on a more discrete basis (perhaps internally between individual employees on an unseen level). In order to further explore this, primary sources such as individual interviews with CIHR employees could shed light on this crux, and further develop the notion whether pandemics serve as transformative milestones within organizations. In addition, both case studies did not find a clear connection to second order learning within the organizations and the pandemics. This does not mean that pandemics cannot be considered as a landscape shock that accelerates reflexive learning. Neither SARS nor H1N1 had the global disrupting effect that COVID-19 is currently having on socio-technical systems. In contrast to COVID-19, the H1/N1 virus did not caused illness that required hospitalization in the vast majority of cases and SARS did not cause lockdowns and economic shutdown we have seen across the globe. Therefore, it could be that the intensity and impact of the pandemic is a decisive factor in triggering second order learning within knowledge-based organizations. These limitations provide some important next steps. First of all, it could be interesting to further investigate how pandemics serve as a specific sort of landscape shock in accelerating second order learning. Both case studies indicate that the pandemics did not cause second order learning while other factors did. Therefore, it could be interesting, especially, since transitions theory has paid less attention to pandemics as a specific type of landscape shock to investigate the role of pandemics in accelerating second order learning. Second, considering the global disrupting effect of COVID-19, it could be interesting to examine how COVID-19 accelerated learning within CIHR and the Gates Foundation. Especially since both organizations are highly involved in fighting COVID-19. The Gates Foundation for instance announced a funding of 50 million dollars to the “therapeutics accelerator” which is collaborative effort of the Gates Foundation, Wellcome Trust and MasterCard to accelerate drug development.180 Furthermore, it supports a coordinated effort to develop and deliver diagnostics with 25 million dollars.181 Lastly, it funded Gavi, the Vaccine Alliance the Gates Foundation founded in 2000, with 50 million dollars.182 In his personal blog of 2020 Gates mentioned how the Foundation is supporting the consortium “CoVlg-19 Plasma Alliance”, a group of pharma companies who are working on a potential treatment with antibodies.183 Microsoft has developed in cooperation with the CoVlg-19 Plasma Alliance the

180 Bill & Melinda Gates Foundation, “Press room: Statement from the Bill & Melinda Gates Foundation about today’s Coronavirus Global Response Summit,” May 4, 2020. Acessed at 21 July 2020. https://www.gatesfoundation.org/Media-Center/Press-Releases/2020/05/Bill-and- Melinda-Gates-Foundation-Statement-about-todays-Coronavirus-Global-Response-Summit 181 Bill & Melinda Gates Foundation, “Press room,”. 182 Ibidem. 183 Bill Gates, “The first modern pandemic. The scientific advances we need to stop COVID-19,” GatesNotes, April 13, 2020.

“Plasma Bot” that helps recovered COVID-19 patients donate plasma.184 Furthermore, the Foundation invested in research on testing, for instance it is involved in the developed of another type of test which is called the “Rapid Diagnostic Test”.185 This test can be done at home but is less sensitive then the PCR, but should according to Gates “be quite accurate for someone with symptoms.”186 There are even some aspects that hint to second order learning as Gates refers in his personal blog of 2020 to his TED talk of 2015 along with why he created CEPI in 2016.187 At the end Gates says “Melinda and I grew up learning that World War II was the defining moment of our parents’ generation. In a similar way, the COVID-19 pandemic— the first modern pandemic—will define this era. No one who lives through Pandemic I will ever forget it.” The same goes for CIHR which in March of 2019 utilized its rapid research response, an extension of its pre-development funds as explored by the PPSRI, to immediately invest C$54.2 million to support 99 research teams across Canada to develop medica, social and policy countermeasures. On march 11, 2020 the Government of Canada announced that it was investing over C$1 billion for a whole-of-government COVID-19 Response Fund, which includes C$100 million to support federal health measures such as enhanced pandemic surveillance and increased testing. In reaction to the need for increased cooperation between federal and provincial levels of government, The Canadian government established the Public Health Agency of Canada (PHAC) in 2004, responsible for public health, emergency preparedness and response, and infectious and chronic disease control and prevention. PHAC has played an integral role in authorizing and leading collaborative efforts between federal and provincial health bodies, both public and private. Through the CIHR, Canada is also a member of the Global Research Collaboration for Infectious Disease Preparedness (GloPID-R), a consortium of funders that is facilitating an international rapid response to outbreaks such as COVID-19. In retrospect, this demonstrates clear longstanding learning lessons from the SARS outbreak regarding CIHR’s adaptations. The Learning from SARS: Renewal of Public Health assessment by the National Advisory Committee heavily used in this report as an evaluation of the CIHR’s handling of SARS in 2003, highlights the implementation of changes. As one of architect authors of the report, David Naylor states in an interview with The Lancet, “I'd say the government of Canada responded in some concrete way to about 80% of the recommendations in the 2003 report”, further attributing that the 2003 SARS outbreak has vastly benefitted Canada in its current response to COVID-19. Third, a research specifically focused on the difference of the possibility of reflexive learning and changes within private and public organization could shed light on the impact of the distinctive nature of the organizations. As a federal-public organization the CIHR is entirely dedicated to funding without the multi-dimensional role of facilitation through monitoring progress, financial reciprocation and mentorship programs (as seen with comparable national organizations). Similarly, The Bill & Melinda Gates Foundation is also unique as a charitable organization as it is not reliant on a diverse portfolio of donors that it needs to gratify; it relies heavily on the financial contributions of its founders. These differences can be considered as a deviatory element in our findings. Supplementing the research with further case studies could present a clearer image on the evenhanded impact of pandemics on transformation within knowledge-based organizations. Fourth, this research examined learning and only disguised first order and second order learning while paying no attention or third loop learning as discussed by Claudia Pahl-Whostl

184 Gates, “The first,”. 185 Ibidem. 186 Ibidem. 187 Christina Farr, “Microsoft is launching a “plasmabot” to encourage people who recovered from the virus to donate their plasma as a possible treatment,” CNBC, April 18, 2020.

36 within knowledge-based organizations.188 This means that we did not include the plausibility of organizational transformations having an external transformative effect on other interconnected socioeconomic components. (For instance, exposed shortcomings of the CIHR in its funding mechanisms could lead to an overarching federal reconsideration of funding practices within other public bureau’s) Further research should consider the ripple effect of transformative changes within an organization on other integrated societal constituents.

188 Claudia Pahl-Wostl, “A conceptual framework for analysing adaptive capacity and multi-level learnng processes in resource governance regimes,” Global Environmental Change 19 (2009): 354-365.

Conclusion

The analysis of the two case studies demonstrated that the organisations in question were innately distinctive, which subsequently led to parallels in their ability to undertake reflexive changes. The Canadian Institutes of Health Research, with its national responsibility to prioritize medical research in light of emerging health crises, did exhibit adaptability and expeditious resolutions during and after the outbreak of SARS. Through the establishment of a new national task force, adapted funding mechanisms, and leadership cooperation initiatives the CIHR unequivocally demonstrated receptivity and first order learning towards a pandemic. The Gates Foundation, with an extensive agenda more generally focused on producing lifesaving technologies for the Global South, had a less pressing posture towards the outbreak of H1N1, but still demonstrated first order learning through the foundation of CEPI and its hosting of annual pandemic exercises. Paradoxically however, the Gates Foundation did show a capacity for reflexive and second order learning outside of the event of a pandemic through its evaluation policy and adaptability in reorganizing its foundation from 2009 to 2019. On the other hand, the CIHR, despite its energetic response to the SARS outbreak, did not demonstrate this same ability of internal reflexivity. Rather, the sources demonstrate that the CIHR relied on external assessments and compulsion to move forward with its refitting. These findings could be explained by private and public knowledge-based organizations diverge in their ability to address problems in underlying norms, structures and objective. Lastly, both cases did ultimately demonstrate that these pandemics did not cause the landscape shock accelerating second order learning within the organizations, and therefore did not contribute to a systemic change in the norms, structures and objectives of the CIHR and Bill & Melinda Gates Foundation. These findings can be utilized by both the TIPC organization itself and its individual members. Firstly, by demonstrating how pandemics affect the transformation of knowledge- based organizations, and by speculative extension, the transformation of larger socio-technical systems. Secondly, by demonstrating which specific learnings the two organizations employ, serving as a reference point for TIPC’s own organizations. The CIHR particularly highlighted the drawbacks of its organizational qualities, who in the practice of annual budget lobbying, could create an environment in which secord order learning is dissuaded. The CIHR also indicated the necessity for pre-mobilized development funds and archetype blueprints for research institutions during crises, by which steering and implementing emergency research agenda’s can be efficiently achieved. The Gates foundation in turn accentuated the benefit of implementing second order learning into the basis of organizational evaluation policies. Its ability to redirect objectives of producing high-end technical fixes to more pragmatic practical necessities exposed the importance of social context in achieving the desired outcome of helping people with new practices, innovations and technologies.

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