Fifteen years ago, the biggest funders of the World Health Organization were the United States, United Kingdom and Japan.
These days, another major player is closing in on the top spot — one without a president, prime minister or any other elected leader. Last year, the UN health agency’s second-largest financier was a private foundation controlled by the world’s wealthiest couple: Bill and Melinda Gates.
Since 2000, the Microsoft co-founder and his wife have turned their foundation into a philanthropic juggernaut, with a $43.5 billion (US) endowment that rivals the GDP of Panama or Lebanon.
Armed with his signature assets — staggering wealth, shrewd business sense and profound faith in technology’s transformative power — Gates is betting billions on the notion that everything from polio to malaria can be eliminated with the right mix of money and innovation.
The gamble has already helped save millions of lives in the world’s poorest countries. It has also birthed a new global health superpower, one governed by Gates’ powerful vision, chequebook and celebrity.
“The Gates Foundation has transformed the global health system in its 15 years of existence,” said Lawrence Gostin, a professor of global health law at Georgetown University. “It is, undeniably, the most powerful and influential global health charity in history.”
In the global health sphere, the Gates name has become as ubiquitous as the Microsoft logo was in the early days of personal computers. And just as PCs once revolutionized how people communicate, the Gates Foundation has been a disrupter, cracking open vast new opportunities while transforming the very system it has infiltrated.
But disruptive forces have unintended consequences. After 15 years and billions of dollars, one question stands out:
What happens when one man — without medical training or public oversight — has this much power over the health of the world?
In the beginning
The creation story of the Bill and Melinda Gates Foundation begins in the fall of 1993, with a romantic stroll along a Zanzibar beach.
Bill Gates and Melinda French — his fiancée and then-employee at Microsoft — were on their first trip to Africa, an experience that opened their eyes to suffering. Together, they walked along the sand and made a decision: they would find a way to help.
When Melinda later proposed focusing on global health, her husband was skeptical. Gates was more concerned with population control and worried that “improving the world’s health might even run counter to that goal,” according to a 2005 New Yorker profile.
But Gates was surprised to discover that improving health actually lowered populations; poor people in poor health tend to have more children. He was even more stunned by how little money it actually took to make profound, or even exponential, improvements in the developing world.
“We go to events where people are raising money for various illnesses where lives are being treated as if they were worth millions of dollars,” Gates told The New Yorker. “And here we were learning that you can save even more lives for a few hundred each. We really did think it was too shocking to be true.”
In 2000, the couple merged the William H. Gates Foundation and Gates Learning Foundation to form the Bill and Melinda Gates Foundation. Their timing could not have been better.
In the late ’90s, aid was shrinking even as health issues were growing more complex. Developing countries — many plagued by infectious diseases and the crippling emergence of HIV/AIDS — also found themselves grappling with rising rates of chronic illnesses, such as cancer and obesity.
“The Gateses were a breath of fresh air,” said Dr. Zulfiqar Bhutta, a child health expert from Pakistan now based at the SickKids Centre for Global Child Health. “Most people would write a cheque and move on and feel good about it. (They decided) not to just write a cheque, but to see that the money went to the right causes and that they, as a foundation, played a specific role in driving the agenda.”
Setting the agenda
Today, Bill and Melinda have become a kind of royal couple in foreign aid circles: touring African villages, attending high-level meetings, and holding court with world leaders like Prime Minister Stephen Harper, who met with Gates in Ottawa this February.
The Gates brand has also caught the attention of the broader public, thanks to the couple’s widely covered annual letter (a Gates-style state of the union) and fondness for audacious, TED-worthy ideas. Think urine-generated electricity or human-scented “cologne” for cows that can lure disease-carrying mosquitoes away from people — both projects with Upworthy appeal that have received Gates money in the last few years.
“The foundation has played a leadership role — a catalytic role — in getting greater attention to the problems of low-income countries,” said Dr. Robert Black, a professor at Johns Hopkins University and leading global health researcher.
The word “catalytic” actually comes up frequently at the Gates Foundation. Its Holy Grail is innovation that will lead to truly transformative change. In their latest annual letter, the Gateses tout the potential of mobile banking to “help the poor transform their lives” and agricultural innovations — like maize seeds engineered to withstand drought — that could help Africa feed itself in 15 years.
In this spirit, Gates also launched the foundation’s signature Grand Challenges in 2003. Aimed at stimulating research for neglected global health problems, the program gives seed money to Eureka ideas that are just crazy enough to work — but perhaps too crazy for traditional research funders.
Grand Challenges has delivered ideas like the Wolbachia bacteria project, in which researchers have released thousands of mosquitoes purposely infected with a naturally occurring bacterium that acts like a vaccine against dengue fever, the most common mosquito-borne virus afflicting humans.
It has also launched several partnered spinoffs, including one in Canada, on which Ottawa has spent millions for grants distributed through Grand Challenges Canada. A recent recipient is Isaac Lyatuu in Tanzania, a 34-year-old software developer who wants to test his idea of using chicken feathers — a common waste product in his country — to manufacture malaria nets.
For Lyatuu, who nearly died from malaria as a child, this is his first-ever research grant. “I think it’s a brilliant idea,” he said of Grand Challenges. “Everybody has to start somewhere. It helps out building capacity in developing countries.”
But the foundation’s highest-profile work has been with vaccines — something with obvious appeal for someone like Gates. After all, vaccines are catalytic; a shot in the arm can dramatically reduce death and disease.
The foundation has been a “game changer” for immunization programs in the developing world, said Black at Johns Hopkins — largely through its role in establishing Gavi, the Vaccine Alliance, an innovative and hugely successful approach for delivering vaccines to the world’s poorest.
If polio ever gets wiped out, it will also be largely thanks to the Gates Foundation, which is now the second-largest funder of the 27-year eradication effort and joined as a partner just as the campaign was entering its final, and most expensive, stretch.
“If the Gates Foundation hadn’t put its funding out, the whole thing would’ve come crashing down,” Bhutta said.
The money man
To truly understand the Gates Foundation’s sphere of influence, however, is to follow the money.
In 15 years, the foundation has distributed more than $32.9 billion (US) in grants, with the bulk going to global health and development. In these areas, the foundation spends more annually than the WHO — to which Gates contributed $263 million last year, more than Japan, Germany and Canada combined. (Canada contributed $95 million US.)
Roughly 1,400 studies are published every year with a funding credit to the Gates Foundation, according to a report in Science magazine. Even media coverage of global health is paid for by the Gates Foundation, which spent $35 million in 2013 on “strategic media partnerships,” including with outlets like National Public Radio in the U.S., the Spanish newspaper El Pais and the London-based Guardian.
The charity claims no editorial control over the journalism it bankrolls. But at the very least, the financial arrangement can result in a kind of Escher-like maze of Gates money: a December 2012 blog post about a Lancet study on the Guardian’s “global development” site, for example, is actually a Gates-funded article about Gates-funded research citing Gates-funded data.
“It feels like they’re everywhere,” an anonymous source told the Guardian in a 2010 article (which was not funded by the foundation). “Every conference I go to, they’re there. Every study that comes out, they’re part of. They have the ear of any (national) leadership they want to speak to. Politicians attach themselves to Gates to get PR.”
To follow this trail of Gates money is to wind up in the most important corridors of global health power. The foundation has given hundreds of millions not just to the WHO but also to the World Bank, UNICEF, UNAIDS, United Nations Population Fund, Gavi and the Global Fund to Fight AIDS, Tuberculosis and Malaria — seven organizations that belong to the “Health 8,” an informal alliance that effectively sets the global health agenda.
The eighth member of the H8? That would be the Gates Foundation.
Foundation spokesman Chris Williams emphasized that “it is not our goal to dictate the global health agenda.”
“We know that we have considerable influence, and we seek to exercise it responsibly and transparently,” he wrote in an email.
Where’s the accountability?
But the foundation’s pervasive — almost ubiquitous — presence is troubling to global health advocates like Dr. David McCoy, a senior clinical lecturer with Queen Mary University of London in England, who has been a vocal critic of the Gates Foundation.
“Whether or not Gates is well meaning or not, I think this is just an unhealthy situation to have,” said McCoy, a member of the steering committee with the People’s Health Movement, a global grassroots network. “There are not enough checks and balances.”
At the Gates Foundation, decisions are made behind closed doors and the charity is “accountable to none other than itself,” a WHO official once complained in an internal memo, which was leaked to the media in 2007.
The Lancet, one of the world’s leading medical journals, has also voiced concern over the foundation’s guiding principle: that it is “driven by the interests and passions of the Gates family.”
“An annual letter from Bill Gates summarizes those passions, referring to newspaper articles, books, and chance events that have shaped the Foundation’s strategy,” the Lancet wrote in a 2009 editorial. “For such a large and influential investor in global health, is such a whimsical governance principle good enough? Whose advice has the Foundation taken in devising its strategy?
“Sadly, the Foundation has acquired a reputation for not always listening to its friends.”
A frequent criticism of the foundation is that it is overly infatuated with technological solutions. “Technology can be enormously helpful in improving global health,” said Anne-Emanuelle Birn, a University of Toronto professor who wrote a 2005 critique of the foundation’s Grand Challenges program. “But it must be integrated with sociopolitical approaches to improving health,” she said in a recent interview.
Overly emphasizing technology also “lets world leaders off the hook” by allowing them to avoid grappling with systemic issues, like corruption and social inequality, according to a 2011 article in Alliance Magazine written by global health and development experts.
“It’s easier to develop a diarrhea vaccine than to get the feces out of the water supply,” wrote Laura Freschi and Alanna Shaikh. “But clean water provides benefits far beyond diarrhea prevention.”
Catalytic breakthroughs have also proven far more difficult to achieve than Gates had originally hoped. After more than a decade of Grand Challenges — and more than $1 billion in distributed grants — the program has yet to deliver anything groundbreaking.
“I was pretty naive about how long the process would take,” Gates admitted in October.
But the Gates Foundation is comfortable with failure and Bill and Melinda “believe that an important role of philanthropy is to innovate and take risks where markets, governments, and international institutions cannot,” said press secretary Williams.
The foundation has learned many lessons in its first 15 years, including that “technology is one part of the equation,” he added.
“We have made investments that did not work out as envisioned — many of them,” Williams said. “That’s part of the flexibility we have as a private philanthropy. Our biggest mistake would be to not adjust from what we learn.”
But for McCoy, the foundation shouldn’t have to relearn lessons that have already been absorbed by global health veterans. “There was a lot of good understanding and knowledge that was simply ignored.”
The foundation’s decisions — and mistakes — are also amplified by its influence. If Grand Challenges fails, for example, there are no electors to vote Gates out of office. But if knockoff programs like Grand Challenges Canada flop, that’s millions of Canadian taxpayer dollars that could have been spent elsewhere.
“Yes, the Gates Foundation can do what it wants,” Birn said. “But at the same time, it’s influencing far beyond the contours of its direct funding.”
One effect has been the foundation’s ability to vacuum up resources, both human and financial, sometimes at the expense of other important issues.
In January, for example, Gavi raised $7.5 billion in pledges for vaccines — an astronomical sum virtually “unheard of” in the malnutrition field, said Black, who has been studying child diseases for decades.
And even though malnutrition causes nearly half of all childhood deaths under 5, nutrition only received 3 per cent of the foundation’s $1.8 billion global development grants in 2013, according to its website.
“It’s great for vaccines but it does suck a lot of air out of the donor community,” Black said. “Potentially other important, very efficacious interventions won’t get funded — that’s not just a risk, that is a fact.”
Mixing public and private
But critics like Birn and McCoy are most troubled by the Gates Foundation’s role in leading a wider trend toward public-private partnerships, or PPPs.
Dozens of PPPs have sprouted across the global health landscape since 2000, some with billions in their budgets, Birn wrote last year in the open-access journal Hypothesis. The biggest is the Global Fund to Fight AIDS, Tuberculosis and Malaria — established in 2002 thanks to a $100-million grant from the Gates Foundation.
Such organizations are meant to bypass “the perceived bureaucratic encumbrances of the UN,” Birn wrote. But this, she suggests, also translates to skipping over “independent and accountable decision-making bodies and processes.”
“Incredibly, WHO and UNAIDS have no vote on the board of the Global Fund,” wrote Birn. “But the private sector, represented by pharmaceutical Merck, and private foundations — represented by the Bill and Melinda Gates Foundation, which has given close to $1.5 billion to the Global Fund — do.”
Such opinions are not easy to voice, thanks to what some have referred to as the “Bill Chill,” a widespread reluctance to criticize an institution that now controls so many purse strings.
In 2008, the New York Times reported on a memo from the head of the WHO’s malaria program, who complained the foundation’s “cartel” in malaria research was stifling opposing viewpoints and imposing the foundation’s agenda on the UN health agency. (That official, Dr. Arata Kochi, no longer holds this job, though the WHO has said his absence is unrelated to his criticisms of Gates.)
McCoy also received blowback for publishing a critique of the foundation’s grant-making program in 2009. “People said it was dangerous to criticize the Gates Foundation,” McCoy said. “Because it was better to have (it) doing what it did, however imperfect it was, then to run the risk of the Gates Foundation not working in global health.”
A ‘benevolent dictator’
For Bhutta at SickKids, any foundation as large and ambitious as Gates will inevitably stumble. But, he notes, “this isn’t a world of saints.”
“My dominant feeling is the world needs more people like Bill and Melinda,” he said. “I wish that more people with serious money would consider leaving a better legacy than they do right now.”
While Gates is no saint, he is somebody with unprecedented resources, influence and power, Freschi and Shaikh wrote in Alliance Magazine — which, they say, “sounds to a worrying degree like a dictator, albeit a benevolent one.”
“For now, we know that Gates has done a lot of good in revitalizing public health and there’s no conclusive evidence that they’ve done any harm,” they wrote. “But in a possible future where a significant majority of voices involved with public health either receive Gates money or would like to, how would we know?”
Gavi: A Gates victory
Since forming in 2000, Gavi, the Vaccine Alliance has become one of the most important players in global health — largely thanks to the Gates Foundation, which kickstarted the organization with $750 million (US) and continues to be a top funder.
Gavi tackles a problem that has long plagued global health: delivering vaccines to the developing world, quickly and cheaply. Historically, vaccines have taken an appalling two or three decades to reach the world’s poorest countries.
The market simply wasn’t there — pharmaceutical companies couldn’t make money selling expensive vaccines to countries that couldn’t afford them — so Gavi effectively created one. How? By buying vaccine doses in bulk (and therefore driving prices down) and raising long-term pledges from private donors, like the Gates Foundation, and governments, like Canada. Those pledges can then be used by innovative financing vehicles, which sell “vaccine bonds” on capital markets.
By its own calculations, Gavi has vaccinated half a billion children since 2000 and prevented more than seven million deaths. And perhaps none of it could have happened without Gates, whose foundation not only provided the first $750 million in seed money but persuaded other deep-pocketed players to participate.
“Here’s the truest definition of power,” Forbes Magazine wrote in 2011. “When you have the ability to not just solve a problem but also to create a sustainable market that addresses it.”