Public Health’s “Benevolent Dictator”: Is Gates ruling us, or are we just ruled by money?

Last week, Laura Freschi and Alanna Shaikh published a piece in Alliance magazine that raised some interesting and thought-provoking question about the role of the Gates Foundation in setting the global health agenda.  They conclude that Gates is becoming a “public health dictator” because of his financial resources and the power and influence that come as a result.  They are, of course, not the first to complain about Gates’s focus on technological solutions to global health challenges.  Some of the most recent grumblings were in response to the Foundation’s “reinvent the toilet” campaign this year, but similar concerns have been voiced for years.  The Foundation places too much emphasis on technological innovation and “quick fixes”; their undue influence diverts funding from other priorities; their goals are not realistic.  These are all valid concerns which deserve to be voiced (heck, we have already written about it here), particularly in a field where nearly everyone has a different opinion on how problems should be solved.

But a dictator?

Bill Gates.
A dictator? Nah. Look at that face.
The Gates Foundation is directed by the priorities of Bill Gates, an entrepreneur who made obscenely large piles of money and who now wants to use some of it to make the world better.  Those piles are accomplishing just that by funding the initiatives that he likes, thinks are important, and/or believes will work.  After all, Gates made his money through technological innovations, so it is perfectly logical that the same types of ideas would be close to his heart – and, to be fair, it is his money.  It is also fair to criticize those initiatives, particularly if the interventions are ineffective or do more harm than good.

But now pundits are demanding accountability from the Foundation, calling on it to justify what it does:

If expensive polio and malaria eradication efforts, pursued not just by Gates but by the entire global health community at Gates’ urging, fail, to whom will
Gates be accountable for that failure?

We demand accountability from our governments because they spend our money – we have the right to demand that our tax dollars be used effectively.  But why, exactly, should Gates be accountable to anyone for wasting his own money?  More importantly, why would the “entire global health community” do something just because he told us to?

Dictators are people who arbitrarily enforce laws, throw people in jail for criticizing them, and deny their citizens free and fair elections.  Gates does not punish anyone whose global health solutions don’t appeal to him – he just doesn’t give them money.  He never lead any kind of “global health coup” or insist that we all adhere to his development philosophy.  Yes, the Foundation has lots of money, and would-be philanthropist who wants to launch his NGO would treat Gates like a god if he ever saw him on the street – but that is precisely the point: he has undue influence because we give it to him.  To paint Gates as a “global health dictator” because causes are prioritized based on what will get Gates Foundation funding villifies the wrong party.  What does it say about us as a body of professionals if we allow ourselves to be led by the nose by the guy with the most money?

The Economist raised another interesting point when it examined the same debate back in 2008:

At least in part, the gripes against the Gates Foundation are the churlish growls of a jealous crowd of bureaucrats and labourers at less influential charities. Some people at the WHO…openly worry that the foundation is setting up a new power centre that may rival their organisation’s authority. Such conspiracy theorists point to the foundation’s recent grant of over $100m to the University of Washington to evaluate health treatments and monitor national health systems—jobs supposed to be done by the UN agency.

Therein lies an irony. The WHO, one of whose captains now calls the Gates Foundation monopolistic, used itself to hold a monopoly in the fight against malaria, and it did a lousy job as a result.

I do think Shaikh and Freschi (and also Tom Paulson of Humanosphere) are on to something when they question the Foundation’s giving money to media organizations to increase coverage of global health topics.

Among the grantees is a growing list of media outlets including the Guardian newspaper (UK), ABC, PBS and the BBC – all to underwrite coverage of global health issues. While these grants all came with assurances of editorial independence, it’s hard to believe that such partnerships won’t influence the nature of the coverage in some way.

Even if it is objective, it never looks good when you fund your own media coverage.  Somebody probably should have thought that one through.

At any rate, the debate about what Gates is doing (and what he should be doing) with his money will undoubtedly rage for as long as he has money.  But if we believe that the Gates Foundation is distorting global health priorities because of its purchasing power, then we need to take a long, hard look at how we define our priorities.

Global Health News Last Week

POLICY

  • Assistant Senate Majority Leader Richard Durbin (D-IL) and Senator Bob Corker (R-TN) introduced the Water for the World Act of 2011, a bill in the Senate which will make providing safe and clean drinking water around the world a priority for US foreign aid.
  • More than 60 world nutrition experts met at WHO headquarters last week to revise guidelines and to identify solutions to tackle the growing problems of both malnutrition and obesity around the world.
  • Ministers of health and other high-level health officials from throughout the Americas called for a series of actions to reduce the toll of chronic noncommunicable diseases, in a declaration issued last week in Mexico City.
  • The Global Fund announced that former President of Botswana Festus Mogae and former U.S. Health and Human Services Secretary Michael O. Leavitt have agreed to lead a high-level panel of experts that will conduct an independent and thorough review of the Global Fund’s financial safeguards.
  • UN agencies are concerned that reduced donor funding due to the recession, combined with free trade agreements, will reduce the availability of low-cost HIV medications in developing countries.
  • The United Nations General Assembly will convene a high-level meeting in September this year to discuss the financial burden caused by non-communicable diseases (NCD) on countries.

RESEARCH

  • A study done is Malawi by the World Bank attracted attention (and criticism) from Businessweek. Young women were given to stay in school and deter them from accepting money and gifts from “sugar daddies” in exchange for sex. The study found that HIV infection rates were 60% among schoolgirls who received cash compared to those who received nothing.
  • A recent review of malaria treatment clinical trial results, published in the Chochrane Library, shows that artesunate was more effective that quinine at treating severe malaria.
  • A personalized text messaging reminder service significantly boosted antiretroviral (ARV) adherence over a six-week period compared with a standard beeper reminder system, according to a study published in the March issue of AIDS Patient Care and STDs.
  • About 600 people gathered at the Global Health Metrics and Evaluation conference in Seattle to discuss issues surrounding the evaluation of effectiveness of health programs.

PROGRAMS

  • Global health blogger Alanna Shaikh discusses how micro-credit and the Green Revolution, two of international development’s biggest successes, are being re-evaluated.
  • The Nepalese government is planning launch a large vaccination campaign against elephantiasis in 40 high-risk districts.
  • Dubai’s Ministry of Health introduced Pneumococcal Conjugate Vaccine PCV13, a vaccine that protects young children from the worst effects of illnesses including pneumonia, blood infections and meningitis.
  • The National Influenza Center of the Chinese Center for Disease Control and Prevention has been designated as a World Health Organization Collaborating Centre for Reference and Research on Influenza, making China the first developing country to house such an institution.

DISEASES AND DISASTERS

  • Europe is concerned by the growing incidence of drug-resistant TB, particularly in children.
  • The world continues to follow the aftermath of the earthquake and tsunami in Japan, including the unfolding situation at the Fukushima Dai-ichi nuclear power plant. The WHO has assured that there is no danger to individuals being exposed to radiation in nearby nations (e.g. China).
  • As if Haiti needed any more bad news, a study published in the Lancet says that the UN estimate of 400,000 cholera cases in Haiti this year is nearly half of what the real projection should be for the recovering nation. Meanwhile, health officials in Lagos have called on residents to observe high standards of personal and environmental hygiene and have designated emergency numbers to call in case of suspected cases; the Ghana Health Service has set up cholera centers in Accra to deal with the outbreak there; and the interim federal government of Somalia on Tuesday denied reports of an outbreak of cholera in the country, responding to an Associated Press story over the weekend that Somali doctors had reported that more than 20 people had died from the disease.
  • In the February 2011 issue of PLoS Neglected Tropical Disease Journal, contributing editor Serap Aksoy discussed the triumphs behind the control of human African trypanosomiasis, or African Sleeping Sickness.
  • Although women get diagnosed for tuberculosis (TB) later than men, treatment outcomes among women are better than men with higher TB treatment success rate and lower default (drop-out) rate in the female patients. The finding was announced at a meeting on TB and women in New Delhi, India.
  • While the total number of newly reported HIV positive people and AIDS patients are still low in Japan compared with other countries, the number of newly HIV-infected people in Japan has doubled in the past decade due to public complacency and lower awareness.

Giving Mom(s) a Piece of the Pie: Adding MNCH to the Global Fund

Last week, APHA, along with 58 other organizations, put its John Hancock on an open letter to the board of the Global Fund (pdf), calling on the Fund to “to fully fund the current mandate of the Global Fund; to strengthen the Global Fund’s engagement in maternal, newborn, child, and reproductive health (MNCH); and to mobilize additional resources to support such engagement.” Family Care International, which authored and coordinated the letter, reported an encouraging response from the Global Fund: the board committed to providing guidance to countries on how to integrate MNCH into their requests and to exploring the possibility of “broadening its engagement” as it develops its strategic plan for the next five years.

The prospect of adding MCNH to the Global Fund, while popular, is not without controversy. MCH advocates have been calling on donors to scale up these programs for many years, and proponents argue that organizations like the Global Fund have the drive and resources to implement and coordinate the programs that are so desperately needed to prevent the millions of needless maternal and newborn deaths each year. Others maintain that the Fund’s vertical approach is not appropriate for this issue: Alanna Shaikh argues that a narrow approach focusing on a few factors that affect maternal mortality would not be very effective, and that the funds would be better used by improving health systems in general. The Fund’s shortage of funds is an additional complication – it made headlines this past October when pledges from donors reached a meager $11.7 billion, short of the $13 billion it had set as the bare minimum to maintain its current programs and miles away from the $20 billion it had hoped to raise to expand operations.

IH members raised some very good points in the discussion leading up to the sign-on. MNCH is obviously a top priority and well deserving of attention, and the Global Fund’s current scope is limited in what it can currently do to address these issues. However, the call to expand the Fund’s activities must come with a commitment to help raise the funds needed to do so and to ensure that the energy put toward maternal health works with, and not against, the other programs. It will interesting to see the direction the Fund takes with this as it moves forward.