The bill gates problem, p.42
The Bill Gates Problem, page 42
Gates’s reluctance to fund Hotez might relate to their differing conceptualization of public health and the role of vaccines. A good example of this is the new malaria vaccine that the pharma giant GSK rolled out in 2021. The vaccine was widely criticized for its low efficacy and for the large sums of time and money that went into its development. Even the Gates Foundation, which funded the vaccine, publicly distanced itself, telling the news media that it was going in a different direction.
Hotez has a different take: “For these more complicated targets like malaria, like schistosomes [the parasites that cause schistosomiasis], like hookworm, it’s unlikely you’re going to get a vaccine that is as effective as a measles vaccine or a polio vaccine. They’re going to be partially protective. And what I’ve said to the Gates Foundation and the WHO and others is we have to think about those types of vaccines in a new way, that they’re not going to be replacement technologies. They’re going to be companion technologies. Even though we’ll have a malaria vaccine, we’re still going to need bed nets and antimalaria drugs. But this [vaccine] will be an important ally. And the world hasn’t really understood how to think about vaccines in that context.”
This is a real-world assessment of vaccines from a medical doctor and vaccine developer. Bill Gates, a college dropout with no medical training, has a very different take. He calls vaccines “magic” and markets them as “miracles.” From that mind-set, a “partially protective companion technology” isn’t going to get Gates where he wants to go—achieving the goal he set to eradicate malaria.
In a 2003 interview, Gates expressed great confidence that his foundation could develop a highly effective malaria vaccine: “Absolutely. No doubt.… You know, I’d say, quite certainly within the next 20 years and ideally in the next 10 we’ll have a good vaccine for malaria.… But because of computer technology now, medical advances will move at an incredible pace. The next 20 or 30 years will be the time to be in medicine. Many of the top problems, I’d say most of the top problems, we’ll make huge advances against.” In 2009, Gates expanded these forward-looking claims: “We’re on the verge of some big advances—malaria, diarrhea, AIDS prevention. Each one of these things in the next two or three years—we’re going to achieve some very big milestones: getting some new vaccines out, discovering new approaches.”
In 2010, then CEO of the Gates Foundation Jeff Raikes elaborated on this: “We’re not really the organisation that’s involved in bed-nets for malaria. We’re much more involved in finding a vaccine.”
As it turns out, bed nets appear to have been the single most important intervention against malaria—and the Gates Foundation has, in fact, given billions of dollars to the Global Fund, which distributes them. But it is also true that, under the foundation’s leadership, progress against malaria has leveled off, even before the pandemic. Though we have many tools to treat and prevent malaria, we continue to see hundreds of millions of cases each year and hundreds of thousands of deaths, mostly of children. Gates’s “huge advances” and “big solutions” and innovation agenda, which the news media have endlessly, uncritically hyped, have not delivered.
As Hotez’s lab continues to advance several vaccine candidates—against hookworm, schistosomiasis, and Chagas disease—he struggles, he told me, not only to find funding but also to imagine what will happen if the vaccines are successful. Without Gates Foundation support, how will he negotiate a marketplace that is essentially governed by the Gates Foundation? The foundation and its surrogates, in many ways, own the infrastructure in which Hotez’s vaccines will succeed or fail. And, of course, there’s an extremely large body of evidence demonstrating that Bill Gates does not like competition.
“I’m confident there will be evidence of effectiveness [of our vaccines], but whether they get to market depends on unknown forces,” Hotez told me. “What’s exhilarating about what we’re doing is that, without the Gates Foundation, there’s no road map for these vaccines. That’s what’s exhilarating but also what’s terrifying, what keeps me up at night.”
Conclusion
In the same way that Captain Ahab’s dogged pursuit of the mighty whale Moby Dick led him into increasingly irrational and self-destructive behavior, polio has become something of a white whale for Bill Gates, an obsession that has clouded his common sense and good reason. “I’ve sort of, in a sense, put the foundation’s reputation on the line that we’re to going to get smart and do whatever it takes [to eradicate polio],” he says in the Netflix docuseries Inside Bill’s Brain. “If you try to eradicate and fail, that’s very bad because you tarnish the entire reputation and credibility of the whole global health effort.”
That’s actually not true. Failing to eradicate polio would tarnish Bill Gates’s reputation, not that of the “whole global health effort.” Leading voices in global health have long questioned Gates’s crusade to eliminate polio from the earth. As Donald A. Henderson, credited with leading the world’s only successful eradication (a WHO effort against smallpox), noted in 2011, “Fighting polio has always had an emotional factor—the children in [leg] braces, the March of Dimes posters.… But it doesn’t kill as many as measles. It’s not in the top 20.” Henderson, now deceased, said in another interview, “When you’re doing polio, you’re not doing other things. Through 2011, in several countries—Nigeria, India and Pakistan—they were giving polio vaccines but they were not, for example, giving the DPT [diphtheria-tetanus-pertussis] vaccine or the measles vaccines.”
In the decade ahead, medical experts would continue to question whether the money and energy going into polio eradication may actually have hurt broader aims of public health, citing, for example, refrigerators at medical clinics in poor nations so fully stocked with polio vaccines that there was no physical space for measles doses. “Would there have been other ways to spend that money which would have saved even more children from really nasty diseases?” Oliver Razum, an epidemiologist at Bielefeld University, asked in 2021.
What this criticism speaks to are “opportunity costs”—what potential successes we miss out on when we choose to follow Gates’s priorities; what work doesn’t get funded when taxpayers’ money is directed to Gates’s public-private partnerships; how many more people might benefit, or even how many more lives might be saved, if we pursued a different pathway. With polio, few would argue that we shouldn’t vaccinate children, but many public health professionals endorse a strategy aimed at controlling polio, not the ends-of-the-earth eradication strategy the Gates Foundation has pursued, which takes an order of magnitude more resources. Instead of funding armies of vaccinators to go door-to-door to administer polio vaccines, why not put that money into funding clinics where people can receive the polio vaccine alongside other medical treatment?
The Gates Foundation has put more than eight billion dollars into polio, and by the early 2010s, Bill Gates was telling the media that eradicating polio “is the single thing I work on the most.” Nevertheless, taxpayers in rich nations, and in poor nations, have put more money into polio—billions of taxpayer dollars have flowed into the project at the urging (or de facto lobbying) of the Gates Foundation. The foundation has also pushed the WHO to keep polio as one of its very top priorities, which has diminished its capacity to work on far more consequential public health problems, like pandemic preparedness, TB, malaria, and HIV/AIDS.
The global polio eradication campaign, which preceded Bill Gates but which likely would not have continued without his foundation’s support, has driven down cases of wild-type polio into the double digits—fewer than a hundred people around the globe carry the virus that causes paralysis. And this progress has given Gates the momentum he needs to keep the donor money flowing into his pet project. “Polio is at a very magical point where we have so few cases that if we really intensify our efforts we’ll completely eradicate the disease, making it only the second time that’s been done,” he said in 2013. “And that means you’ll save all the costs of vaccination in the future and nobody’s at risk of ever being paralyzed again. We’re orchestrating a lot of donors and new science to get this thing finished in the next three to five years.”
Gates missed his target, and in recent years his campaign has presided over a rise in polio—and its sudden reappearance in wealthy nations. That’s because the eradication effort has depended on oral immunization—the media sometimes publishes images of Bill Gates squeezing drops of the vaccine into the mouths of children—that includes a weakened strain of the polio virus. The idea is to give the immune system a small taste of polio and build up an ability to fight it. The problem is that the weakened virus found in the oral vaccine can mutate and be passed on to others, infecting those who are not immunized. Rarely but reliably, the oral polio vaccine will actually cause paralysis—and outbreaks that lead to more cases. (Wealthy nations, like the United States, use a different polio vaccine that does not contain a live virus and cannot cause vaccine-derived paralysis.) According to reporting in the British Medical Journal by writer Robert Fortner, more than one thousand people throughout Africa were paralyzed in 2020 by vaccine-derived polio.
“The eradication initiative was aware at some point, as they moved toward eradication,” Fortner told me in an interview, “that vaccine-derived cases were going to be greater in all likelihood than cases from the wild virus.” The problem, he said, was that Gates and other partners didn’t move quickly enough, and they still don’t seem to have a solution. When I interviewed Fortner in July 2022, it was one day after the news media reported that a man in New York had been paralyzed by vaccine-derived polio.
In some respects, the eradication campaign might have been doomed to fail from the beginning because it operated in such a top-down fashion, proceeding from ideology, or vanity, rather than science and democracy. Historian William Muraskin of Queens College quotes Gates Foundation employees openly explaining their “blame-and-shame” strategies to pressure local leaders to get in line with Gates’s eradication agenda, while also using inducements—or, as they condescendingly call them, “goodies.” Even before the foundation became the leading voice on polio, the eradication effort, Muraskin reports, “worked to deter research, distort publications, silence and banish critics, all in the name of achieving the public good.” Muraskin writes:
No matter how much goodwill global health people may have … they take upon themselves the right to judge which local, regional and national leaders are “illegitimate,” and then work to bypass, co-opt, “educate,” manipulate or otherwise circumvent these stumbling blocks to achieve their noble goals. Who made them judges over developing world leaders? Who appointed them, who elected them, who are they accountable to? They seem blind to the similarities between their claims to beneficent interventions today and the similar claims of the Western colonial powers in the past. The basic attitude is the same: we know what is best for these people, their rulers are oppressive, incompetent and corrupt. In the past, the “wise men” of the West simply took the countries over. Today, they just work to “guide” them in the right direction. In the past, it was Christianity and Civilization that gave them the right. Now it is Universal Values, Humanitarians, and Global Public Goods.
In Bill Gates’s determination to eradicate polio, we see how blurred the line becomes between his good intentions and his enormous ego. Every big man wants to point to something big he’s done. U.S. president Donald Trump tried (and failed) to build a continuous border wall with Mexico. Industrialist and philanthropist Andrew Carnegie built thousands of libraries, many of which still stand today and carry his legacy. The bridges, parkways, and parks Robert Moses built indelibly changed New York, and some still bear his name.
So, where is Bill Gates’s big accomplishment? Microsoft Windows? A collection of exaggerated claims around the lives he has saved, undergirded by research he funded? The “Giving Pledge,” his bullying effort to push more of his billionaire peers into philanthropy? Gavi, his complex procurement mechanism that, essentially, fund-raises money from governments to buy vaccines from Pfizer?
Gates needs to eradicate polio to rationalize all the wind and swagger he’s brought to his charitable work, to substantiate the endless claims and promises he’s made about curing disease. And he will, apparently, go to extreme lengths to accomplish this, no matter the opportunity costs, no matter the experts’ criticism, and no matter the damage it causes.
In reporting this book, I often asked sources to name what they thought Bill Gates’s biggest accomplishments were. Virtually everyone struggled to come up with specific examples, instead pointing in the general direction of the billions of dollars he has given away. “I was there when the Gates Foundation was born,” one grantee told me. “Can you imagine all of us nerdy scientists looking at this pot of money as a way to now make our lives more meaningful? Not just easier, but more meaningful—taking our lab and staff and developing it into a product. It was transformational. You can’t overlook the importance of a champion for the poorest of the poor who nobody gives a shit about.” The source added, “We need champions and need advocates.… It’s better to have a flawed champion than no champion at all.”
This narrative speaks to Gates’s good intentions, and it frames the merits of his work around the spectacle he created. He made the world pay attention. He is well-meaning, even if imperfect. But what’s missing from this assessment is the fact that Bill Gates hasn’t been a champion of the poor as much as of himself. He’s asked us to direct our gaze not to the plight of the global poor but, rather, to his own philanthropic efforts to save them. Whether it is taking the podium at the World Health Organization or the World Economic Forum, posing for photos with poor children in some unnamed province or state, or sitting for interviews with 60 Minutes or CNN, the focus of the Gates Foundation is not on global poverty. It’s on Bill Gates. Between the media attention, the tax benefits, the awards, the political power, and the PR, the biggest beneficiary of the Gates Foundation, then, is Bill Gates himself.
More important, the poorest of the poor never asked Bill Gates to be their champion. They didn’t review his candidacy or his policy positions and then elect him to any office. There was never any public debate over his leadership, priorities, or agenda. The same is true in wealthy nations, where taxpayers have put billions of dollars into Gates’s public-private partnerships with very little public debate or scrutiny over these expenditures. Gates simply assumed power by claiming leadership over unpopular and difficult areas—how to feed, medicate, and educate poor people.
It’s tempting to ask, at this point in the book, well, how should someone like Bill Gates spend his philanthropic dollars? This framing, however, elides more fundamental questions about power. When we allow one person—any person, no matter how benevolent or well intentioned—to acquire extreme wealth, we’re giving that person extreme power. The question, then, is not how Gates’s money could be better spent, but why we allow anyone to have this much money and power in the first place.
As a practical matter, we should also ask whether Gates’s vast wealth is really his to control. His fortune comes from one of the most widely criticized monopolies in the history of the world, which used its extreme market power to push its extremely mediocre and often infuriatingly glitchy software into our lives. Microsoft is also very widely criticized for tax avoidance. From this questionable business, can we say that Gates earned his vast wealth? That he deserves it? That it is his to use freely as a tool to advance his political worldview? That society benefits from this arrangement?
We must also consider existential questions about the ability of a billionaire—any billionaire—to drive social progress through philanthropy. The success of Gates’s giving seems to turn on the myth of the benevolent tyrant, our belief that handing over undemocratic power to one man is the price we have to pay to, say, vaccinate the poor. As we’ve seen, Gates’s outputs aren’t particularly impressive, effective, or efficient; nor are his efforts delivering the “equity” he claims is the central focus of his work. The Gates approach puts poor nations in competition for limited donor dollars in order to deliver public health to their citizens. It conceives of health care as a privilege, or a gift, rather than a human right. And it spends untold sums of money on pomp, circumstance, and public relations to make the world believe that this is the best, if not the only, solution.
All that being said, it is beyond dispute that the wealth Bill Gates controls—his $100 billion private fortune and the $54 billion endowment of his private foundation—could be of enormous benefit to society. Yes, the world needs Bill Gates’s money. But it doesn’t need Bill Gates.
Fixing our Bill Gates problem, then, means separating Gates from his money. The soft approach is to consider reforms to the Gates Foundation, finding ways to make it actually function as a charity that gives away money rather than as a political tool, tax break, and PR machine for Bill Gates. Though the Gates Foundation essentially self-regulates today, that privilege comes from Congress, which could just as easily impose new, strict regulations that force it to act in a more charitable manner. Ultimately, it’s up to our elected legislators, and to us, the people who elect members of Congress, to decide how, or if, we regulate philanthropy.
Just as Congress undertook an “agonizing reappraisal” of philanthropy in the 1960s, we are very long overdue for new rules and regulations governing billionaire philanthropists. We could also look to the IRS and the Washington State attorney general, who both have direct oversight of the Gates Foundation but have chosen not to exercise those powers, either because of a lack of resources or of political will. We could also ask the Department of Justice to investigate the anti-competitive allegations the foundation faces in pharmaceutical development.
Reformers have already proposed a number of modest new rules for private foundations that could rein in the Gates Foundation. Tax scholars want foundations to give away a larger percentage of their endowments every year instead of the currently mandated 5 percent. Making foundations pay out larger sums will accelerate their time line to bankruptcy, limiting the long-term political influence that an institution like the Gates Foundation can have.
