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Answer by Tirumalai Kamala:

There are two parts to this question, one, estimating how much of Gates Foundation money funds vaccines, and two, speculating why.

Part One shows data from peer-reviewed studies that suggests that more than half of Gates Foundation money goes to vaccines and technology-heavy efforts, and that technological bias is the main driver for this.

Part Two shows the much smaller proportion of Gates Foundation money that funds cheaper public health effort such as clean water and insecticide-treated bed nets for malaria, and a huge chunk that funds alternatives to traditional US higher education.

Part One
Is there published peer-reviewed scrutiny of Gates Foundation grants?  Yes, at least one. McCoy, David, et al. “The Bill & Melinda Gates Foundation’s grant-making programme for global health.”The Lancet 373.9675 (2009): 1645-1653. Page on utah.edu

What did this study explore? It examined 1094 global health grants given by Gates Foundation between January 1998 until December 2007.
The study and a few others make key observations on how much Gates Foundation money is spent on what and why.

What

  1. More than half but not all goes to vaccines. From McCoy et al.


2. ‘Another striking finding is the large number of US-based recipients of grants, a feature that is common among US foundations in general.‘. McCoy et al Page 1650, 2nd column, 3rd para.

3. ‘The finding that one organisation, PATH, was awarded nearly $1 billion stands out and raises the question as to whether some organisations might be better characterised as agents of the foundation rather than as independent grantees‘. McCoy et al Page 1650, 2nd column, 3rd para.

4. ‘The University of Washington (also based in Seattle), received grants worth nearly $280 million in the same period, and the Institute for OneWorld Health, together with Johns Hopkins University, Harvard University, and Columbia University were together given grants worth a total of $559 million. This large amount of funding concentrated within a small number of US-based institutions raises questions about their privileged status among organisations operating in global health‘. McCoy et al Page 1650, 2nd column, 4th para.

5. ‘Grant making by the Gates Foundation seems to be largely managed through an informal system of personal networks and relationships rather than by a more transparent process based on independent and technical peer review. Although a panel of six individuals exists to advise on and assess the foundation’s strategies, the process by which individual proposals for projects are solicited, adjudicated, and funded is unclear‘. McCoy et al Page 1650, 2nd column, 5th para.

6. A 2012 report by the OECD (Organisation for Economic Co-Operation and Development), Meeting Global Challenges through Better Governance: International Co-operation in Science, Technology and Innovation, OECD Publishing. Resolve a DOI Name 10.1787/9789264178700-en Page on ieabioenergy.com makes similar criticisms as well as some praise.

From Page 70-71, Section 3.4 Conclusions,
Lack of solicitation. Most grants do not appear to be awarded through direct competition or completely open requests for proposals. The Foundation often approaches (or is approached by) an organisation which it has found to be a leader in a particular area and negotiates a project directly. The process is flexible, rapid and non-bureaucratic but may be seen to lack transparency and legitimacy in terms of democratic decision making. Because the Gates Foundation is based on private money, legitimacy and accountability issues may differ from those relating to funding based on public money. Legitimacy issues arise basically because the size of the Foundation enables it to define to a large extent the global health agenda, a role formerly assigned to more democratically controlled organisations, mainly the WHO‘.

Preparatory work. The Gates Foundation puts a lot of effort into studying the state of knowledge and the important actors before entering a specific area. It therefore has a high level of knowledge of a subject before entering into new partnerships. This seems to allow for better alignment of the goals of the Foundation and its grantees.

Concentrated decision-making. The Foundation’s broad strategic decisions are made by a handful of people, mainly the trustees, so that a very small group of people determine where large amounts of money go. This is seen as problematic, as strictly speaking they are not experts, despite their commitment to global health issues. According to interviewees, the lack of a well-functioning board with people from diverse backgrounds and countries is a weakness. The way priorities are set is seen not only as a problem of legitimacy but also as an obstacle to innovation. This relates to findings in innovation literature that users, rather than states, small groups of individuals or single companies, are normally in the best position to pick technologies.

It could be that the two major activities of the Foundation – creating impact based on science, technology and innovation and engaging other actors through advocacy – require very different actions to gain legitimacy. Whereas the first might benefit from a broader and more heterogeneous set of activities and involved actors, the latter could benefit from a more representative high-level board. A related criticism is insufficient transparency regarding the priority-setting process and the solicitation and awarding of grants.

Follow-up through milestones. Whereas other funders follow up on projects through annual reports on results, the Gates Foundation defines, together with grantees, a set of milestones to be reached during various stages of the projects. The actual effects are not really clear, but it does put stronger emphasis on progress and impact in line with the Foundation’s orientation.

Deliverables. The Gates Foundation makes clear that it is ultimately not interested in scientific publications or new technologies for their own sake but rather in impact. Grantees are well aware of this and some praise the Foundation for being more flexible in terms of deliverables’. Also see Section 3.5. Lessons Learned.

Why
Why is Gates funding skewed to technology-heavy efforts like vaccines rather than cheaper public health efforts such as clean water? Again, from McCoy, David, et al. “The Bill & Melinda Gates Foundation’s grant-making programme for global health.” The Lancet 373.9675 (2009): 1645-1653.Page on utah.edu

  1. funding was disproportionately allocated to the development of new technologies rather than towards overcoming the barriers to the use of existing technologies.20 This technological bias reflects the priorities of Bill Gates himself. In his recent annual letter, he stated that “optimism about technology is a fundamental part of the foundation’s approach” and he described the key approach to eliminating the main causes of early childhood mortality as “the invention of a handful of new vaccines and getting them into widespread usage”’. Page 1651, column 1 para 4, column 2 para 1.
  2. One argument used to make the case that the Gates Foundation over-emphasises technology and new vaccine development is that many existing cost-effective technologies do not reach the people who need them because of poverty or health system failings’. ‘Thus, rather than viewing the hundreds of thousands of child deaths from rotavirus infection as a clinical problem that needs a vaccine solution, a better approach might be to view it as a public health problem that needs a social, economic, or political intervention to ensure universal access to clean water and sanitation‘. Page 1652, column 1, para 3.
  3. A similar criticism about Gates’ over-reliance on technology as opposed to investment on cheaper infrastructure investment into clean water, hygiene and electricity is made by a 2014 University of Michigan, Department of Afroamerican and African Studies Bachelor of Science thesis by Jaclyn Sylvain. Page on umich.edu. See Chapter 3 from page 48 onwards.
  4. A 2014 peer-reviewed paper by Professor Anne-Emmanuelle Birn at the University of Toronto Dalla Lana School of Public Health also spotlights Gates’ technological bias (Birn, Anne-Emanuelle. “Philanthrocapitalism, past and present: the Rockefeller Foundation, the Gates Foundation, and the setting (s) of the international/global health agenda.” Hypothesis 10.1 (2013). Page on hypothesisjournal.com).

    It also highlights pertinent cases of conflicts of interest in the operations of the Gates Foundation. These range from its indirect pharmaceutical holdings, to its patenting of pharmaceutical drugs to its outsize influence on sovereign governments. For example, the study (see page 14, columns 4 and 5) highlights inadequate informed consent and adverse events monitoring of a Gates’ funded HPV trial of young low-income girls in India that has raised questions in the Indian parliament.

Part Two
OTOH, there are a few comparatively small-scale examples of Gates funding efforts other than vaccines, including yes, clean water. And a huge $2 billion between 2000 and 2008 on US higher education.

  1. The Carter Center has been waging an arduous and gutsy campaign to eradicate the Guinea worm. Guinea what? The Guinea worm causes Guinea worm disease or Dracunculiasis (Dracunculiasis), a ghastly and painful disease that incubates up to a year and releases female worms as long as 2 to 3 feet in length! Humans become infected when they drink water contaminated with water fleas containing guinea worm larvae. Access to clean water is the main way to eradicate Guinea worm disease.

    When the Carter Center got involved in Guinea Worm eradication efforts in 1986, there were 26500 affected villages (1) with approx. 3.5 million cases  per year (2). The reported total number of cases in 2014 was a mere 126 (3)! The Gates foundation awarded the Carter Center its 2006 Award for Global Health for their Guinea worm eradication efforts (4), and in 2008, with the UK government pledged $55 million for its final eradication (5).

  2. Malaria prevention. Low tech prevention measures such as insecticide-treated bed nets go a long way in preventing malaria (6). In 2006, the Gates foundation pledged a dollar-for dollar $3 million to the non-profit Nothing But Nets (7).
  3. Higher education in the US. Efforts apparently not very effective but huge sums spent (approx. $2 billion from 2000 to 2008). From PRIVATIZING ED


Bibliography for Part Two.

  1. ‘Watch Out, Guinea Worm, Here Comes Jimmy Carter’
  2. Eradication Program
  3. Jimmy Carter’s Work to Defeat Guinea Worm Highlighted in New Exhibit
  4. Carter Center News and Publications
  5. Carter Center Receives Historic Guinea Worm Challenge Grant from Gates Foundation
  6. Insecticide-treated bed nets and curtains for preventing malaria
  7. Bill Gates Recognizes Nothing But Nets in Newsweek

In sum, it’s illuminating there are only a handful of peer-reviewed studies that scrutinize the how, how much and why of funding decisions by the world’s largest private foundation for Public Health, the Bill and Melinda Gates Foundation. Professor Anne-Emmanuelle Birn suggests ‘most observers (and grant recipients) fear offending the powerful foundation‘ (Page 14, column 4, para 2). These few studies suggest less-than-optimal transparency of taxpayer-subsidized dollars and a technological bias that funds vaccines and technology-heavy public health efforts at the expense of cheaper, more tractable public health measures such as clean water, hygiene, child nutrition and infrastructure development.

Why is Bill Gates funding vaccine programs for African children, instead of supplying immediate relief through food and clean water?

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