The bill gates problem, p.20
The Bill Gates Problem, page 20
Using its humanitarian platform, the Gates Foundation essentially was opening up new markets for Bayer and Merck, seeming to create a new profit center for their products: the global poor. In return, the foundation could trumpet having negotiated significant price reductions—Bayer, for example, dropped the price of its hormone implant, called Jadelle, by 53 percent. “Even with lower prices, higher volumes can drive bigger profits—a classic win-win for both consumers and producers,” a Gates-commissioned report noted.
Implants are popular among contraceptive users, but also controversial. Unlike birth control pills or condoms, implants have to be both inserted and removed by professional health care providers—not an easy option for many of the poor rural women targeted by Gates’s FP2020. As one of the longest-lasting contraceptives, short of sterilization, implants also have a history of use in population control efforts, as profiled in Dorothy Roberts’s book Killing the Black Body: Race, Reproduction, and the Meaning of Liberty.
In her book, Roberts, a professor of law and sociology at the University of Pennsylvania, looks at a hormonal implant named Norplant, the predecessor to those subsidized by the Gates Foundation today. These implants were specifically designed by the Population Council for use in poor nations, Roberts reports, but were later embraced as a population control tool in the United States in the 1990s, as legislators widely considered mandates and incentives to expand their use in the Black community. States ended up driving demand for Norplant through targeted advertising, with some states making them free for poor women. While states aggressively steered women toward hormone implant insertions, clinics erected barriers to their removal—even when women experienced side effects that harmed their health. “The very features that enhance Norplant’s convenience for women also allow for its coercive deployment. Unlike every other method of birth control except the IUD, a woman cannot simply stop using it when she wants to,” Roberts writes.
The specter of eugenics that haunted Norplant in the United States should serve as a cautionary tale to the introduction of next-generation hormonal implants via FP2020. Joan Kilande, a program officer for the NGO HEPS Uganda, which works on contraceptive access, told me in an interview that there are practical reasons to put women on a long-lasting contraceptive in Uganda. In some clinics, there may be a single midwife caring for dozens of pregnant women and also waiting on women seeking contraceptives. The midwife is simply not going to have time to explain all the choices to women. And clinics aren’t necessarily going to have a wide array of different contraceptives in stock.
Of course, Kilande is clear that this isn’t how the world is supposed to work. Women shouldn’t be put in a position where they can’t make an informed choice. The question, then, is, shouldn’t the Gates Foundation use its muscle to make sure all contraceptive options are presented on an equal footing with implants in FP2020? Why not invest in making sure clinics have the resources they need to really empower women to take control over their bodies? Doesn’t the foundation have a $54 billion endowment? Aren’t autonomy and choice the ambitions of modern family planning and of Melinda French Gates?
“We can insist that all people have the opportunity to learn about contraceptives and have access to the full variety of methods,” Gates said in 2012. “I think the goal here is really clear: universal access to birth control that women want. And for that to happen, it means that both rich and poor governments alike must make contraception a total priority.”
The reality of the Gates Foundation’s work on FP2020 appeared far different. In many places, the priority was around giving women access to hormone implants, not “the full variety of methods.” The foundation at one point had $400 million on the line with its volume guarantee with Bayer and Merck—money it would have to pay out if FP2020 could not successfully move their implants into women’s arms. “The Gates Foundation was guaranteeing sales volume almost three times the global demand before the price cuts,” a Gates-funded study reported in 2016. That study also quoted Natalie Revelle, the foundation’s lead on the project: “We were sweating … I was worried about having suitcases of excess implants and walking around trying to distribute them.”
Gates’s big bet on implants helped guarantee that the foundation’s favored contraceptive would be widely available. And its decision to secure a volume that was three times larger than known demand created an obvious incentive to ramp up their use. As Anne Hendrixson notes, “Instead of simply meeting women’s needs, the [project] also drives demand.”
Demand creation should be seen as the third rail of family planning, according to one person I spoke to inside the Gates Foundation—who showed that at least some staff have digested the history of population control in the provision of contraceptives. That is, the work of family planning is supposed to turn on the needs, desires, concerns—and rights—of contraceptive users, not those of donors. Nevertheless, both FP2020 and the Gates Foundation have, in many ways, organized their work through creating demand for their own favored solutions.
The government of Malawi’s 2015 strategy document under FP2020, for example, has an entire section related to “demand creation,” including “revamping communications to promote more widespread usage” of contraceptives. The Gates Foundation’s grant making over the years is littered with similar projects, like donations to a group called DKT “to develop and demonstrate a sustainable private sector model for increasing and sustaining demand for Sayana Press [a Pfizer injectable contraceptive] in key geographies.”
With its massive investment in hormone implants for FP2020, the foundation could be seen as taking demand creation into a kind of Field of Dreams scenario—not so much “If you build it, they will come” but, rather, “If you flood the market, they’ll have no other choice.” While coercion is little studied in family planning, there are two independent reports documenting its appearance as FP2020 moved aggressively to enroll 120 million women onto contraceptives.
In 2019, Leigh Senderowicz published a study that found that clinics and providers were organizing their workloads around meeting quotas, overemphasizing the advantages of some kinds of contraceptives over others, and even using scare tactics to get women on contraceptives. Some women said they felt forced to use contraceptives, while others, in order to avoid the high-pressure, hard-sell tactics at clinics, avoided post-pregnancy checkups altogether. The study also found that clinics pushed women toward hormone contraceptives, including hormone implants, while some clinics would refuse to remove hormone implants before they ran through their full five-year course. These findings are a mirror image of those catalogued by Dorothy Roberts twenty-five years ago in the United States, as poor Black women were coerced into accepting Norplant devices and then had difficulty getting them removed.
A few months after Senderowicz’s study emerged, a group of journalists working for the Dutch news outlet De Correspondent made similar findings. The reporters spent several days traveling with a mobile clinic in Uganda, where they documented demand creation in real time. In a matter of a few hours, the journalists found three women who came to the clinic seeking a contraceptive injection that lasted three months, but who, through the coaxing of the clinic staff, left with implants that would keep them infertile for three years. In another episode, they describe a woman who was having serious health issues that she believed to be side effects caused by her implant, which she wanted removed. Four times she asked the clinic to remove the implant, and four times they refused her. Instead they gave her ibuprofen and told her to be patient with the side effects. She ended up having to go to a private clinic, at significant cost to her, to have the implant removed. Her pain and bleeding immediately stopped. De Correspondent’s reports get some level of confirmation in macro-level data. According to FP2020’s reporting, in 2015, only 16 percent of contraceptive users in Uganda used hormone implants; by 2020, that number had doubled. De Correspondent also documented, troublingly, that nurses and clinics in Uganda were financially incentivized to push implants. Under the auspices of a World Bank “result-based financing” mechanism, bonuses were given according to how many years of infertility the clinics delivered: sterilizing a woman delivers 12.5 euros; a multiyear contraceptive implant or IUD brings in 5 euros; and a short-duration hormone injection is rewarded with 0.60 euros.
The head of one of the leading contraceptive providers, Reproductive Health Uganda, ultimately acknowledged the problems with such inducements. “The donors are also mainly interested in index years [how many years of infertility they are sowing into local populations], this is how the impact is measured,” Jackson Chekweko, director of the group, noted. “The problem is that is how we influence her choice. And that is wrong. And that mistake starts with the donors. But it is a two-way street. We as organizations also want to do well and promise to the donors that we will achieve those index years. As a result, you see that programs mainly emphasize permanent and long-acting contraception. This is not freedom of choice, it does not guarantee her rights.”
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FP2020 DOES NOT appear to have fully fulfilled Melinda French Gates’s claimed rhetoric around women’s empowerment and autonomy. And it also, notably, failed to meet its numeric targets. By 2020, the project had reached only 60 million women, not the 120 million targeted.
FP2020 didn’t dwell on its shortcomings, however. It simply moved the goalpost, trumpeting, “In 2019 alone, these combined efforts prevented more than 121 million unintended pregnancies, 21 million unsafe abortions, and 125,000 maternal deaths.”
The Gates Foundation was happy enough with the success that Melinda French Gates personally presided over the launch of the next iteration of FP2020—FP2030. (FP2030 refused an interview request and did not respond to my questions about FP2020.) As part of the announcement, the foundation boasted of a new $1.4 billion commitment “to develop new and improved contraceptive technologies, support family planning programs that reflect the preferences of local communities, and enable women and girls to be in control of their own contraceptive care—where, when, and how they want it.” (In total, Gates reports putting more than $4 billion into all family planning projects over the life of the foundation.)
Not long after FP2030 got off the ground, women on the foundation’s home soil faced new obstacles to their own family planning. When the U.S. Supreme Court overturned Roe v. Wade in 2022, allowing states to ban abortion, both Bill and Melinda French Gates were quick to publicly criticize the decision on Twitter—notable because the Gates Foundation has not historically supported abortion in its charitable work.
In a 2014 blog post, Melinda French Gates explained why, arguing that access to abortion and access to contraceptives should be seen as separate issues, noting, “the emotional and personal debate about abortion is threatening to get in the way of the lifesaving consensus regarding basic family planning. I understand why there is so much emotion, but conflating these issues will slow down progress for tens of millions of women. That is why when I get asked about my views on abortion, I say that, like everyone, I struggle with the issue, but I’ve decided not to engage on it publicly—and the Gates Foundation has decided not to fund abortion.”
Many chalk up this position to Melinda French Gates’s background as a Catholic. To the extent that this is true, it raises questions about the foundation’s claimed identity as an institution guided by science and reason rather than religion and ideology.
The more important reason for the foundation’s decision to avoid abortion may be political expediency and pragmatism. The Republican party in the United States opposes abortion and has long sought to forbid the use of tax dollars in funding abortion, including through the U.S. government’s massive foreign aid giving. The so-called global gag rule, expanded under President Trump, for example, mandated that any family planning organization receiving U.S. foreign aid cannot work on abortion—even in work they do outside their U.S. government funding. (President Biden rescinded the global gag rule.)
The foundation, by sidestepping abortion, avoids a major hot-button issue for Congress, which directs billions of dollars to a wide variety of the foundation’s charitable projects; USAID even served as a “core partner” on FP2020. But Gates’s political positioning is not particularly principled or noble. It makes Bill and Melinda French Gates’s comments about Roe v. Wade ring a bit hollow. How can they pretend to be champions and leaders on family planning while they’ve carefully avoided working on abortion for decades? Insofar as their work on family planning claims to support a woman’s right to make her own decisions about her body, how can the Gates Foundation segment off abortion as a “separate” issue?
We could ask the same questions around the evidence of coercion in the Gates Foundation’s family planning work—like demand creation and its clear focus on directing women to have smaller families. If the foundation wanted to be a leader and show its commitment to autonomy and choice, why wouldn’t it at least acknowledge that coercion remains a part of modern family planning and then try to address it? Doing so would draw criticism to the foundation—and it would empower opponents of contraception and abortion, and could risk losing funding partnerships with the U.S. government. But what is the other option—to pretend that it doesn’t exist? One haunting worry is that by not addressing the presence of coercion, family planners could even be seen as covering it up.
“I think a lot of people don’t want to talk about this just because they don’t want to give the anti-choice community anything to latch on to, which I’m very sympathetic to,” Leigh Senderowicz told me. “But my other response is: we accuse the anti-choice community of being anti-science and cherry-picking the data they want to see and not caring about women’s well-being. And we have to hold ourselves to a higher standard.”
Senderowicz told me she actually met with the Gates Foundation to discuss her research and an indicator she developed called contraceptive autonomy, designed to measure dimensions of contraceptive choice and coercion. While Senderowicz put “contraceptive autonomy” on Gates’s radar, she says that, to date, the foundation has not endorsed it.
What the foundation’s work in family planning helps us understand is the bigger theme of coercion in all of the Gates Foundation’s funding. A powerful funder like Gates doesn’t have to hold someone down in order to force them to do something. The foundation can simply take over a field by flooding money in the direction they want that field to move. The foundation claims to measure what the “unmet need” is and then “creates demand” for its own narrow solutions. It’s a model of power that allows the Gates Foundation to assert itself as a leader and that allows its multinational corporate partners to open new markets. But is it empowering to the people it claims to help? Is it building a world in which “all lives have equal value”?
None of this is to say that women have not benefited from the foundation’s giving. Invariably, many have benefited from the availability of subsidized hormone implants in the FP2020 program, thanks to Gates. But we could say the same thing about the eugenics-minded population control efforts by philanthropists sixty years ago. Just because many users benefit does not obviate the need to interrogate the presence of coercion and abuse.
Honoring the principles of modern family planning requires us to create a strong public health system that can both implant and remove contraceptives, that can make a variety of contraception choices available, and that can offer a suite of other services. Meeting Melinda French Gates’s high-minded rhetoric of the family planning movement—around voluntary, autonomous decision-making—also requires that these services be affordable, even to poor women. The scope of this work clearly reaches far beyond the Gates Foundation’s ambitions. More important, it reaches beyond its mandate.
We cannot and should not depend on the whims and predilections of billionaires to deliver contraceptive access—not only because this model is unaccountable but because it is unsustainable. What happens when the Gates Foundation decides that its work on family planning is too politically sensitive? Or what happens when Bill Gates dies? Or when Melinda French Gates decides to step down from the Gates Foundation? Do we look to another billionaire for answers, hoping that they are marginally more enlightened? In the here and now, millions of women may depend on the Gates Foundation for access to contraceptives, so it would be a mistake to terminate this work overnight. But it would also be a mistake to imagine that the Gates Foundation’s work on this issue is a righteous social good deserving of our praise. If we want to build a family planning movement organized around self-determination and autonomy, it means doing the difficult, messy work of building political power, of committing to a world where reproductive health—and public health, more generally—is understood as a human right, not a privilege administered by the superrich.
8
Journalism
For a few brief years in the 1990s, Bill Gates hosted overnight retreats for elite business journalists at his family’s property on the Hood Canal, outside Seattle. One account of these retreats, which became known as “pajama parties,” describes a van of reporters who “chattered excitedly, like Scouts going to summer camp” on their way to Gates’s compound, a sojourn that included a ride on a “Turbo Beaver” seaplane. After a sumptuous dinner, Gates led a bull session with the reporters, “holding court for nearly two hours.”
