‘It’s his money and he has the absolute right to spend it how he wishes. But because the amount of money is so huge, it has the potential to distort the research field and government priorities.’

The Gates Foundation has had an enormous impact in the field of global health, but what do those working in the area think of its contribution? Caroline Hartnell spoke to Richard Horton, editor of medical journal the Lancet, about how the foundation’s growing involvement and investment is affecting global health work. With over 20 years working for the journal in both the UK and the US, he has seen many changes in the field − both positive and worrying – as a result of Gates’ domination.

Can you tell me a bit about what the field of global health looked like when you started working in it, and how it has changed recently?

In the old days of global health, there was only one organization that set the agenda for research and practice, and that was the World Health Organization (WHO). Global heath used to be a domain focused mainly on tropical medicine, and was very low down in terms of political priorities for governments and also priorities for university scientists. In the last decade or so, global health has become much more complicated and diverse, with new institutions such as the Global Fund to Fight AIDS, TB and Malaria and GAVI (Global Alliance for Vaccines and Immunization), which are much more powerful financing mechanisms than the UN, and civil society organizations entering the ring, which are often much more Important in advocacy than WHO. We have also seen other non-state actors such as foundations play an increasingly powerful role, both in terms of the money they have to fund research and practice and in terms of their political voice. By far the most significant player in that arena is the Gates Foundation.

In your speech to the Global Health Metrics and Evaluation Conference, you expressed misgivings about the way the global health agenda is being set now. How much of a worry is this, and how much of it do you think is down to the Gates Foundation?

The foundation has transformed the landscape of global health in the past decade. It opened a door to a bonanza of funding and that has created the possibility for a step change in the way we think about global health. The demand by the research communities to take part in global health research, the political spotlight put on global health, and the commitment of civil society to global health have all increased as we’ve seen foundations – particularly Gates – enter the field.

This, for the most part, has been very good, but there have been downsides and it’s important to recognize those and see if we can correct them. I think the most important thing is to really understand the nature of what foundations do, and that’s a very tricky area. Here you have an individual (Bill Gates) who is clearly enormously wealthy and successful as a businessman, and he’s chosen to do a very brave thing – to invest his personal fortune in his own foundation. It’s his money and he has the absolute right to spend it how he wishes. But because the amount of money is so huge, it has the potential to distort the research field and government priorities. If Bill Gates has a particular priority and invests hundreds of millions of dollars in that priority, then people will follow the money, and so by making these commitments, he becomes one of the most – if not the most – powerful voice in setting the research agenda.

That puts an enormous responsibility on him to think about the impact of his choices. Vaccines are an incredible technology that have changed the face of public health over the past few centuries. (Pictured: A new bivalent polio vaccine has contributed to a significant drop in polio cases this year). By making vaccines the number one priority of his foundation, as he has done, he has done very well in terms of the demand created for people to work on them. But where does that leave other areas of global health – health systems and other diseases that cause an enormous burden, such as non-communicable diseases or mental ill-health? The results of his investments are that the things he chooses as priorities tend to do phenomenally well, and the things he doesn’t choose tend to do phenomenally badly, because they get very little attention.

So do you think his areas of interest are too narrow?

I think there is a balance between his perfect right to spend his money how he wishes and his responsibility to listen to experts in other areas of global health to advise him on the best portfolio of investments he could make to have the biggest impact. Of course he wants his investments to have the best return they can possibly have, but in order to do that in a balanced and fair way he needs to take the advice of people who can give him that broader picture.

I think many of us outside the foundation worry that he is a very decisive thinker and a decisive decision-maker, but he’s less good at listening to voices who caution him to take a broader picture of global health. It puts us in a paradoxical position of on the one hand being enormously admiring of the commitment he’s made, but on the other hand being worried that the decisions he makes could be damaging to other spheres of global health.

You talked about the areas that he’s not supporting doing phenomenally badly. Do you think they are actually doing worse than they did before or are they just suffering compared with the areas he supports?

I think they are suffering whichever way you look at it. It’s impossible, given the hypothetical, to know whether they are doing worse because of his funding of other areas or not. However, if you take mental health, for example, we know that it is a leading cause of disability – not just in the rich world but also in low- and middle-income countries. Tackling it requires investment to scale up, and health workers who can address mental health problems, address stigma, raise the issue higher in political priorities, address new treatment methods and packages of treatments that can be taken to scale…

Mental health gets virtually no support from the Gates Foundation, and as a result it languishes. People who would be interested in doing global health-related research get sucked into priority areas and drawn away from other important areas. It is an unintended (and I do believe that it is unintended) adverse consequence of his funding: areas that were not strong before are potentially even less strong now. It means that other funders have to try to step in to help, and that’s also difficult because other foundations have reacted to the Gates Foundation by either withdrawing from health as a sector completely or radically changing their approach.

A good example is the Rockefeller Foundation. Before the Gates Foundation, it was the pre-eminent foundation investing in global health and it has done fantastic work. But since its investments are a fraction of those of Gates, when Gates came along and made such a decisive commitment to global health, Rockefeller quite reasonably sat back and concluded that their added value was not very great, so they adjusted their strategy to withdraw a little from some of their traditional global health programmes.

As a result (again an unanticipated consequence), the diversity of funding that we once saw from foundations has receded. And because there’s less diversity than there once was, the views of Bill Gates and what he chooses to fund become even more dominant. It’s a very difficult situation: how do these other areas get funded when you don’t have strong advocates from the foundation world to fund them?

Has the Rockefeller Foundation completely withdrawn funding from global health?
When we first looked at this they were certainly considering withdrawing completely, and I think a lot of us in the global health community picked up these signals and were very anxious, so we lobbied very hard that the Rockefeller Foundation had a vital part to play by adding to this diversity. Judith Rodin, the president, listened to those concerns and did not axe the health programme, but she has changed it in fairly radical ways so that it is not working in the same areas as the Gates Foundation.

I think that was probably a wise decision because she thought that in any situation where Rockefeller was competing with Gates, Rockefeller would lose, just because of the huge sums involved. So the result of that is that while she has continued to put investments in health in a different way from before, it has left a clear playing field for Gates and some diversity has been lost, and that is a concern.

Why do you think the Gates Foundation – given the way it operates and the way it does things – is not likely to be interested in an area like mental health?

This is historically interesting. When Bill Gates set up the foundation he created a governance structure that was widely known to be very informal. That had many advantages: decisions about grants were made almost around his kitchen table, and that meant it had enormous flexibility. But as the foundation put more and more money into global health and became more powerful, it clearly needed to have a proper governance structure, and so it appointed first Rick Klausner and then Tachi Yamada as director of the Global Health Program. They had the power to shape the global health investment for the foundation by taking advice from experts and listening to political leaders to find out what was needed. Over the years we saw that the director of the global health programme did indeed listen to wise advice and was moving the foundation towards a very responsible stewardship. I think we all welcomed that.

Then Bill Gates stepped down from the day-to-day running of Microsoft and became much more involved in running his foundation. That meant that the director of global health (Tachi Yamada at the time), while he had an extremely prestigious title, was constantly looking over his shoulder because the man with the money was now in full-time engagement with his own foundation. And so the autonomy and independence that he had to run the foundation disappeared almost overnight. There was a famous memo that Bill Gates wrote when he left Microsoft and moved into the foundation – pages and pages of his analysis of what the foundation was doing right and what it was doing wrong. With that memo he essentially decapitated the leadership of the foundation and put himself in charge.

Bill Gates has a very particular view about what is likely to succeed – not just in health but in many areas of society. It’s the view that informed the great success of Microsoft, and that is that technology has the power to change lives. Of course, he’s right, but those of us who worked in global health at the time recognized that technologies don’t solve every problem. Many of the problems that societies face aren’t amenable to single technological solutions – such as inequalities in health, stigma, and maternal and child health. These areas require much more subtle and complicated interventions around strengthening governance or improving the quality and number of health workers. I think Bill Gates’ philosophy is very much driven by belief in technology, so this is the dominant thread running through every programme. And again it’s his money and he can choose what he wants to do with it, but given the power of the foundation, it is having a very distorting effect because other interventions and other concerns are simply ignored.

Are there other important areas that you think are being ignored?

Non-communicable diseases are a concern, because we’re very worried about the impact of heart disease and cancer in the world today. They are growing threats to the burden of health in low- and middle-income countries as they become richer, and there’s almost no serious investment in that arena from the Gates Foundation. And there are very few other sources of funding in that arena, so these areas get neglected completely.

Richard Horton is editor of the Lancet. Email richard.horton@lancet.com

Gates Foundation press secretary Christopher Williams comments

“Bill and Melinda have been co-chairs of the foundation since its founding, but it has been led by extremely capable chief executive officers, first Patty Stonesifer and now Jeff Raikes, as well as programme presidents and directors with deep experience and knowledge of the issues we fund. Consultation with the field and with grantees is a critical component of their work. Jeff Raikes has in fact made grantee relations and regular consultation a hallmark of his tenure as CEO.

Bill and Melinda will continue to lend their unique and powerful voice to the issues we support, and champion the cause of helping the world’s neediest and most vulnerable populations.”

It is true that we believe that new technology holds great promise, but we also believe that proven technologies can have tremendous life-saving impact if we can simply make sure that the neediest have access to them. Our focus on polio, for example, is one of our largest, and we are working very hard with our partners to take us the last mile to eradication – an effort that forces us to confront many of the very issues referenced above.

Moreover, our strategies in health and development do, in fact, focus on a variety of interventions and solutions. We recently announced, for example, a new strategy in sanitation: http://www.gatesfoundation.org/watersanitationhygiene/Pages/home.aspx

Ultimately, we will continue to invest where we think we can have the greatest catalytic impact, and we will do so in close consultation with our many dedicated partners. That’s the appropriate role for the foundation.”