Despite its pre-existing involvement with the WHO, the Gates Foundation’s statement surprised many. The public wondered how it could be possible for a private actor to replace the contribution of a state to an international organization. In reality, there is nothing to be surprised about. For at least a century, philanthropic foundations have funded international organizations involved in health issues, including fighting pandemics, or even conducted what we call today global health policy. Actually, the continuities are so fundamental that the foundations from the early twentieth and the early twenty-first century seem to choose to globally fund health policies for similar reasons. Because the arguments are similar, and the means they used comparable, the criticisms raised against philanthropic foundations generally and their health policies also remain remarkably stable. The similarities between the past and the present suggest that the criticisms are here to stay. Indeed, certain observers would venture that older and newer philanthropic foundations are built upon the same questionable bases: unequal income distribution and lack of transparency and accountability.
Philanthropy’s Affinity to Health
Why do some of the largest philanthropic foundations spend their money on health? Is it only because saving human lives is good, or is there more to it? For a foundation like the Rockefeller, whose mission as stated in its charter is “to promote the well-being of mankind throughout the world,,” it may seem the obvious way to go, but the reality is that when a foundation has such a general purview, someone has to make the choices, namely the foundation’s trustees and officers. A main reason why these philanthropoids, as they are called, consider health a good area of engagement for a foundation is that saving human lives is a relatively uncontroversial goal. Who can oppose the use of money, technology, and expertise to combat illness, frequently in places that lack resources that are taken for granted in affluent countries? Uncontroversial goals have always been crucial for foundations because the origins of their endowment activities attract public scrutiny, which trustees dislike, and criticisms.
A proof of the affinity between philanthropy and health is that the Gates Foundation has a predecessor in the Rockefeller Foundation’s health programs. This philanthropy financed the interwar League of Nations’ Health Organization, the precursor of the WHO. Even more important for understanding where the Gates Foundation’s and the WHO’s global health policies come from is the Rockefeller Foundation’s International Health Division. Between 1913 and 1951, the IHD operated in up to eighty countries, combated illnesses, most notably tuberculosis, yellow fever, and malaria, and established a world-famous laboratory, in what is now the Rockefeller University. In its premises in Manhattan’s Yorkville important research was conducted, leading to the invention of the yellow fever vaccine. The IHD is so closely linked to the history of global health that the IHD and some allied organizations like the Pan-American Sanitary Bureau became the model on which the WHO was built after World War II. The same closeness to the IHD is told of the WHO’s Global Malaria Eradication Program (1955). The fact that some high-ranking personnel left the IHD to occupy crucial positions in the WHO reinforces this impression of continuity between the foundation and the international organization. Actually, the establishment of the WHO hollowed out the IHD of its purpose and contributed to its demise. The IHD also experienced a problem well-known to the Gates Foundation, namely deciding whether the goal should be to control an illness or to eradicate it. The latter option requires a concentration of resources, which is disproportional to the number of remaining patients. Accordingly, the Gates Foundation has been very much criticized for the money spent on eradicating polio and for allegedly pressuring the WHO and many governments to set the same priority.
Pretences of Novelty Masking Power Ambitions Combined with Blind Specialism?
Both at home and abroad, foundations have tried to exploit a divide between what is considered routine use of technology in affluent metropoles, and what governments can actually offer in the periphery. Thus, the Rockefeller Foundation built its health policy around the “export” of simple technologies – latrines and hand-washings to combat hookworm, drainage, and DDT to eradicate malaria – first from the Northeast to the South of the U.S. and from there to the rest of the world. While the treatments and medicines may be more complex today, the main idea that drives most of the Gates Foundation’s health-giving is the same. Most of its Global Health spending is allocated to making vaccines and drugs that are widely available in the Global North also available in developing, mainly African countries. Making them available may require adapting them to local conditions, but adaptation rather than innovation characterizes what foundations do. In reality, the Gates and other foundations do not obtain leverage by producing cutting-edge treatments, but by making well-trodden, even if slightly modified solutions available in places where they are not. The present corona crisis does not seem to be different. During the early months of 2020, many have heard about the Gates Foundation’s giving to the COVID-19 Therapeutics Accelerator. However, these and other initiatives with imposing names boil down to the pursuit of decades-old or even century-old treatments like antivirals and vaccines. Even if COVID-19 is new, these treatments are not as truly cutting-edge research as, say, immunotherapies to treat solid cancers. In short, foundations obtain leverage in global health by making known solutions available in places where they were not.
The Gates and other new foundations also hype their innovative use of information technologies. They look like the unquestioned preserve of tech magnates. ((On how the branch in which a fortune is amassed seems to influence billionaires’ approach to philanthropy, see Michael Callahan, The Givers: Wealth, Power, and Philanthropy in a New Gilded Age. New York: Knopf, 2017.)) After having funded the WHO’s Health Metrics Network, in 2017, the Gates Foundation awarded 279 million USD to Seattle’s Institute for Health Metrics and Evaluation, where 300 employees pursue a new “health metrics science.” This dwarfs the earlier subsidies of the Rockefeller Foundation to the League of Nation’s Health Organization to pay for its International Health Yearbooks. Interestingly, state-of-the-art use of information was actually a trademark of early philanthropoids, who were adept at Taylorist “scientific management”. Rockefeller, Carnegie, and others adapted their business innovations into “scientific philanthropy”. Philanthropists’ thirst for information also encompassed their grantees and other partners, about whom they systematically compiled information. They processed this information according to technology that was “state of the art” at the time, giving them an advantage when dealing with their partners. Nowadays, the Gates Foundation accumulates mind-numbing amounts of information on our health while the foundation’s internal decision-making process, the knowledge generated during their own campaigns, and the evaluations thereof remain secret. Bluntly put, this imbalance between the information commanded by large donors and recipients has always existed, but it seems as if in global health observers hold lances while the Gates Foundation possesses “informational” laser weapons. Such imbalances do not go unnoticed. As an old saying goes, if an organization hamster information from the outside world and then declares all information related to its activities as secret, then this organization strives for power. The critics of the Gates Foundation agree.
In any case, information is most useful if manipulated by experts, but who are the people in charge of global health? Hiring decisions are, to a large extent, a consequence of choices about which illnesses philanthropists should fight in order “to help all people lead healthy, productive lives,” as per the Gates Foundation’s fact sheet. But in reality, the choice is not among illnesses, but among world views: what should be favoured, health prevention, which encompasses the social aspects of health, or medical interventions, which rely on technology to heal the ill? During its existence, the Rockefeller Foundation’s IHD resorted to both, but the Gates Foundation is conspicuous for favouring medical approaches. This choice has implications for the type of information coveted by the “health metrics scientists” and for recruitment. In IHD, educators committed to prevention played an influential role, at least in its early decades, with medical doctors eventually taking over. As of today, at the Gates Foundation’s Global Health program, you must hold a STEM-degree to be part of the most senior staff. The tension between these understandings of health cut across recruitment, the significance and type of information, but also even global health’s spatial setting and its time frame. Should field operations in collaboration with local authorities receive more funding, or the people working in the lab and crunching data? What furthers global health more, long-term education in health or punctual interventions to end an outbreak? Or another scheme to reach eradication? Intense criticisms, and perhaps the mistakes of its first decade in global health, have led the Gates Foundation to minimally relax its single-minded emphasis on technology and medical interventions. More might come.
New Fortunes, Identical Criticisms
The governance of philanthropic foundations has led to acrimonious polemics since they were established for the first time in the early 20th century. The origin of this continuity in critique is that the fundamentals have not changed since: the Rockefeller, Ford, Gates and similar foundations are established in perpetuity, fill their endowments with tax-free income from the donor families, and are governed by a self-reproducing board of trustees (I leave untouched the origin of the income, which critics invariably relate to monopolistic business practices and labor exploitation). Before the 1910s, these all-purpose foundations were considered illegal and afterwards frequently seen as immoral. ((As in most of the contributions to Rob Reich, Chiara Cordelli, and Lucy Bernholz (eds.), Philanthropy in democratic societies: history, institutions, values. Chicago: The University of Chicago Press, 2016.)) Against a backdrop of increasing inequality in affluent societies, in the U.S. this debate about tax-free foundations continues until the present, now fuelled by the staggering size of the fortunes that the Gates and other techies have accumulated in the last twenty years. One main issue is the lack of both transparency and accountability. Unlike the Rockefeller and the Ford Foundations, which in most cases permit access to internal documents older than ten years, the Gates Foundation only offers access to annual and other reports, a grants database, publications funded by them, audits, and certain tax forms. This is not much, I would argue, compared to the foundation’s weight in Global Health. But even if more sources on the foundation’s reasons and procedures were available, legally the three trustees would continue being accountable only to themselves. They – Bill and Melinda Gates and Warren Buffett – are sovereign, although the foundation’s endowment is fed with income detracted from the U.S. government’s budget. The small size of the board of trustees distinguishes the Gates Foundation from other large U.S. philanthropies. White, male, and Anglo-Saxon foundation boards were the norm until the 1970s. Despite the presence of Melinda Gates, the composition of the board makes even the friendliest observers of this philanthropy raise their eyebrows, particularly because the foundation claims to care especially for the health of people in Africa. Can you be unrepresentative and unaccountable, but nonetheless well-meaning, let alone effective? Perhaps we will know soon, because COVID-19 has already enhanced tensions among the actors involved in global health, including the White House and the Gates Foundation. Demands for more transparency may increase since now the health of citizens from the U.S. and other affluent WHO-donor countries is at stake.
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