'The Lancet' critique of the Gates Foundation: on the mark?

The articles complain that Gates is doing too much in global health, or not enough. Amid the confusing complaints and muted praise is a clear call for more transparency.
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Bill Gates in Davos, Switzerland. (World Economic Forum)

The articles complain that Gates is doing too much in global health, or not enough. Amid the confusing complaints and muted praise is a clear call for more transparency.

Bill and Melinda Gates have put themselves in charge of the developing world'ꀙs health problems, and much of the global health community their Foundation so extensively funds doesn'ꀙt wholly like it. Recent articles in The Lancet, a leading medical journal, have surfaced numerous latent criticisms. Although the articles themselves are hardly free of fault, their call for increased transparency is difficult to dismiss.

In its all-out attack on global health problems, the Bill & Melinda Gates Foundation has achieved a dominant position in setting priorities, devising policies, and awarding money. Criticism has been an inevitable result, but ambient grumblings recently changed to something more like a chorus of disapproval. The Lancet, in whose pages the great problems and solutions of global health are aired, directly asked what the Gates Foundation has done for global health.

The quick answer is 'ꀜa great deal,'ꀝ of course. But the editorial coupled with the main articles cited only two examples: creation of the vaccination program, GAVI, and establishment of the (Seattle-based) Institute for Health Metrics and Evaluation. That'ꀙs it.

Accompanying this barely-audible praise was a superficial analysis of Foundation spending patterns. The Lancet usually features research of byzantine complexity based on painstakingly collected data. But in this instance, the study simply analyzed a spreadsheet of grants gleaned from the Gates Foundation web site. Under a partial guise of discovering patterns in grant-making over a decade, the article soon turns into a vehicle for extensive fault-finding.

Further, in a reflection of conflicts within the global health policy community, The Lancet'ꀙs own articles don'ꀙt agree on what the Gates Foundation should do. The Foundation is accused of both doing too much research and also too much service delivery. Elsewhere not the amount of research but the kind is wrong.

One pattern of interest is that Seattle is a giant beneficiary of Gates Foundation largesse. The University of Washington received $280 million, more than any other university. The non-profit PATH (Program for Appropriate Technology for Health) outdistanced every grantee except one (GAVI) with nearly $1 billion in grants. The money should be spread around, the authors argue, with more transparent grant processes. Furthermore, PATH should be viewed as wing of the foundation rather than an independent entity.

The authors find independence in general to be in short supply: 'ꀜAll the key contributors to global health,'ꀝ they say, 'ꀜhave an association with the Gates Foundation through some sort of funding arrangement.'ꀝ This view is corroborated by a Seattle-based Gates grantee, who observed that 'ꀜeveryone is a client,'ꀝ up to and including the World Health Organization (WHO). WHO in fact comes near the top (fourth) among Gates grantees. The National Institutes of Health (NIH) has received relatively small sums, $57 million over a decade. Although the Lancet authors did not look into possible interlocking board arrangements, the Gates Foundation director of infectious diseases, Regina Rabinovich, sits on a key board within NIH. Is this conspiracy, or just remarkably effective execution of a noble vision?

That the foundation exerts enormous influence on global health is well known. Demonstrating this influence, Melinda Gates singlehandedly committed the world to a campaign to eradicate malaria. At a 2007 malaria conference convened by the foundation, she challenged the assembled luminaries to embrace eradication. This surprised WHO Director General Margaret Chan who, put on the spot, took up the microphone and spontaneously declared a newfound belief in eradication. The rest of the global health community, including an initially skeptical NIH, fell into line. However, some have serious misgivings about eradication.

It is tempting (but incorrect) to conclude that the Gates Foundation controls global health more than anyone ever has. The Lancet study misleadingly suggests that not even the Rockefeller Foundation wielded such power. On the contrary: the world was simpler and smaller in John D. Rockefeller'ꀙs time. In 1913, Rockefeller'ꀙs wealth was equivalent to an incredible than 2.2% of GNP. Now, in a vastly wealthier world, Gates worth peaked at 0.7%. The Rockefeller Foundation pioneered global health and ran it until handing leadership to the World Health Organization in the 1950s.

Gates has indeed seized the mantle of leadership, returning it to private hands. However, while the Gates Foundation foundation does sit on the 'ꀜH8,'ꀝ and is the only private entity enjoying such status, there are seven other members. And below this top-tier of agenda-setters and policy-makers, there is a vast universe of institutions possessed of tremendously diverse viewpoints. That the foundation has engineered a virtual chain command through this tangled skein is a notable feat. Into this mechanism, The Lancet would introduce more independent research and assessment, in hopes of finding 'ꀜthe right and most cost-effective set of approaches, strategies, and investments.'ꀝ

It's unlikely that the Foundation would unhand its levers of power. The Lancet invited a reply, which the Foundation flatly declined — credit them for not answering in disingenuous public relations-speak. However, in its stony silence, the foundation risks appearing dismissive and arrogant — characteristics noted about Microsoft but distinctly incompatible with philanthropy.

The critique puts Gates on the horns of a dilemma: give up power by increasing transparency and opening up processes, or look bad in the court of opinion. But it might just blow over. For all The Lancet'ꀙs preeminence, its jurisdiction is modest. The Seattle Times broke the story; an Associated Press article appeared in the Washington Post. But The New York Times hasn'ꀙt found the news fit to print.

Based on his past remarks, Gates probably looks upon The Lancet'ꀙs prescription for changing its processes as worse than the disease. In early 2007, Gates wrote: 'ꀜWe must be willing to look at the failure of collective action and see how we can change it.'ꀝ Among those failures: malaria research spending stood at a paltry $84 million a year, a figure which has tripled during the Gates era.

Clearly, the Gates Foundation consciously affects the spending patterns of national governments and international bodies. It makes decisions affecting billions of people and mounts campaigns of mammoth scale and duration. The Lancet asks: "to whom is the Gates Foundation accountable for the promotion of such policies?"

Gates is big on grappling with huge challenges, and here is one: how to solve the problem of collective action. It looks intractable &mdash but it hasn't been around as long as malaria.


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