Billanthropy

Emily Tweed profiles one of the world's largest philanthropic organisations, the Bill and Melinda Gates Foundation

When you or I daydream about being the richest person in the world, chances are that spending it all on health initiatives in developing countries rather than luxury cars and high fashion isn't what first springs to mind. But that's exactly what Bill Gates-who made that daydream reality in the early 1990s, thanks to the success of Microsoft-has dedicated a sizeable chunk of his fortune. And in so doing he is changing the face of both philanthropy (or Billanthropy, as the Economist put it) and global health.

Gates is most famous for his role as the cofounder of Microsoft, the company widely credited with bringing about the revolution in information technology that put a personal computer in every home and office. The extraordinary success of Microsoft has made him the world's richest person for the past 12 consecutive years. ¹ But, as he stated in a speech to the Global Foundation in 2000, he "decided at a very young age … that whatever wealth I had, I would want to give back to society."

GATES FOUNDATION

The Bill and Melinda Gates Foundation, named after the entrepreneur and his wife, was created in 2000 by merging a number of charitable foundations to which the Gates had been contributing for several years. With an endowment of $31.7bn (£16bn; €24.5bn), the foundation is by far the world's wealthiest charitable organisation: a status that gives it considerable clout in setting the philanthropic priorities of our era.

The new face of philanthropy

As the Gates see it, these priorities are the resolution of inequities in the United States and around the world. The foundation spends in three main areas: education and community projects in the US, global development, and global health. It is the last of these that has attracted most attention: long a pet project of the Gates, the global health programme accounts for the lion's share of their grants, with more than $6bn already distributed.

Bill Gates often cites an article he read-about the half a million children that die each year from diarrhoeal disease caused by rotavirus infection-as the moment he first became aware of the inequalities that exist in global health. "I thought, ‘Rotavirus?'-I've never even heard of it. How could I never have heard of something that kills half a million children every year?" He had not heard of it because most of these deaths are in developing countries.

Rotavirus, although a common cause of gastroenteritis in children worldwide, is rarely fatal in developed countries because of easy access to medical attention and lifesaving treatments such as oral rehydration therapy. Gates and his wife Melinda went on to read that two thirds of deaths in children under 5 years old in developing countries are caused by health problems that, like rotavirus, are preventable or treatable with existing tools. "We couldn't escape the brutal conclusion that-in our world today-some lives are seen as worth saving and others are not. We said to ourselves, "This can't be true. But if it is true, it deserves to be the priority of our giving."²

The foundation's global health arm funds initiatives in areas from basic scientific research to immunisation campaigns; from neglected tropical diseases such as schistosomiasis and visceral leishmaniasis to "the big three" infectious killers-HIV, malaria, and tuberculosis (see box 1). In all these areas, the guiding principles are to widen access to existing interventions, such as drugs and vaccines, and to fund research into the development of new ones. As Patty Stonesifer, chief executive officer of the foundation, put it in a recent address, "We believe that the world can do the most for equity in global health by focusing the powers of science and technology on the problems of its poorest people-and then making sure that advances in those areas reach the people who need them. Solutions need to be developed, and they need to be delivered."

This emphasis on "solutions" is typical of the foundation's approach: grants aim to fund the creation and implementation of "techno-fixes" that will have a long term impact on a particular health problem. Examples include $258m for research into a preventive malaria vaccine, $124m for the development of vaginal microbicides able to prevent HIV transmission, and $23.3m for the development of cheap methods for diagnosing tuberculosis.

Another characteristic of the foundation's strategy is to channel funding through intermediaries such as universities, national health ministries, and non-governmental organisations, effectively subcontracting these institutions to fulfil specific tasks. For instance, the Center for Global Development has received a grant of $13.8m to analyse the economics of global health, and $3.6m was given to the University of Maryland to support the introduction of the Haemophilus influenzae type B vaccine in west Africa.

Vaccines-access, research, and development

As well as supporting the work of existing institutions, the foundations' money is also enabling the creation of new ones: a five year grant of $750m in 2000 helped the Global Alliance for Vaccines and Immunisation (GAVI), an international coalition to increase access to vaccines and research and development, to get off the ground.

GAVI is often held up as a model of the foundation's strategy and an example of its successes. A public-private alliance between UN agencies, governments, vaccine manufacturers, non-governmental organisations and research institutes, GAVI illustrates how the Gates' foundation uses collaboration to tackle challenges that would not be achievable by any one organisation working alone.

Similarly, the foundation does not intend to be the sole supporter of endeavours of this kind but instead wants to attract further funding by raising awareness of a particular concern and providing the initial financial commitment. For example, although at first the foundation was GAVI's only backer, other funds began to trickle in, and $3.5bn has now been collected in pledges from governments of high and middle income countries to finance the alliance's future. The foundation has since committed another $750m to GAVI, but this time spread over 10 years rather than five, and accounting for 20% rather than 50% of the alliance's total resources. Thus, although GAVI was originally born from Gates's money, it is now being weaned, with other donors more willing to step in now that the foundation has shown that progress in this area is possible. As a section called Lessons Learned on the foundation's website states, "Sometimes you have to be the first dollar in."

And those dollars have achieved a lot. GAVI estimates that its work over the past six years has prevented 1.7 million deaths, with 15 million additional children receiving basic vaccinations and 115 million receiving new vaccinations-for example, against hepatitis B and yellow fever. The Gates believe that this is one of their greatest successes, and many in the international health community agree.

One of the foundation's strengths is the sheer extent of its wealth, in stark contrast to current global spending on many of its target causes and the health budgets of many of the countries in which the foundation works.

But it is how the foundation is spending as well as just how much, that is making the difference. Like Gates' work at Microsoft, the foundation stands out for its ambition and innovation. Take its Grand Challenges in Global Health initiative, for example. This was launched in 2003 to identify and fund research into solving the main obstacles to improving health in developing countries. A set of 14 "grand challenges" were chosen by an expert panel from more than 1500 ideas submitted by scientists around the world. These challenges range from inventing new, easier ways to store and deliver vaccines to using genetic modification to improve the nutritional content of staple crops, such as rice (see box), and will be tackled by 43 projects funded by $450m of foundation money (in addition to contributions from the UK Wellcome Trust, the US National Institutes of Health, and the Canadian Institutes of Health Research).

Surprise-he aims high

Although some of the Grand Challenge's goals might be considered long shots, such as the attempt to genetically modify mosquitoes to prevent transmission of malaria and other vector borne diseases, this is arguably where the foundation's money is most necessary. Other funding agencies, such as the National Institutes of Health, whose research priorities are chosen by peer review processes, shy away from funding such risky ventures, despite their potential. The Bill and Melinda Gates Foundation, on the other hand, is a private foundation and so has more freedom to choose which research and interventions it will fund.

The unusual terms of the foundation's grants are also changing the way research is traditionally done. The $287m given to HIV vaccine research via the Gates coordinated Global HIV/AIDS Vaccine Enterprise came with the condition that participating institutions share all data, specimens, and intellectual property rights, and that collective progress is constantly monitored to allow pursuit of successful lines of enquiry and abandonment of those that fail to yield results. A recent editorial in Nature Immunology described the enterprise as a "much-needed experiment" that might "revolutionize the entire vaccine field."³

However, a high-profile global health spending spree of this magnitude was never likely to be uncontroversial, let alone one masterminded by Bill Gates, whose business practices at Microsoft have themselves come in for fierce criticism. Some have suggested that the foundation's largesse in global health might discourage governments and other charitable organisations from contributing to projects in this area, or that it will create another Gates monopoly, in which the foundation dictates the agenda for international health research. Others counter that the foundation's operating approach is designed to avoid such problems, by acting as a catalyst for further funding from other sources (as in the case of GAVI), and by deciding research priorities by extensive consultation with the scientific community (as in the case of the Grand Challenges initiative). And the foundation does have friends in high places: the former acting director general of the World Health Organization, Anders Nordstrom, has praised it for stimulating "new knowledge, new products, or just new thinking."

Nevertheless, scrutiny of its work is unlikely to die down in the near future. June 2006 brought the announcement of a gift of more than $30bn from Warren Buffet, a friend of Bill Gates, and his number two in the world's wealthiest list. As the foundation wrestles with the challenge of how to spend its burgeoning endowment wisely, and as Bill Gates gives up the day to day running of Microsoft to concentrate on his philanthropic work, the foundation's influence in global health is likely to continue for some time yet. Watch this space.


Emily Tweed, student, University of Cambridge
Email: emilytweed43@gmail.com

Competing interests: None declared.

Unless stated otherwise, facts and figures come from www.gatesfoundation.com.

studentBMJ 2007;15:45-88 February ISSN 0966-6494

1. Luisa Kroll L, Fass A. The world's billionaires. 2006. www.forbes.com/billionaires
   
2. Gates B. Address to the World Health Assembly, Geneva, Switzerland, May 16, 2005. www.hivvaccineenterprise.org/_dwn/news/GatesSpeech_May05.pdf
   
3. A "systems approach" to vaccines. Nat Immunol  2006;7:891.