Like many others, I enjoyed Sophie Harman’s recent paper on the legitimacy of the Gates foundation in global health governance (GHG). I’m not sure I understood everything (I’m one of these people who see their IQ decrease by at least 1 % with every year that passes, unfortunately), so I won’t attempt a review of the paper here. I hope Sophie soon writes a blog, though, to list some of the key messages (for people who don’t have access to the paper).
Before acting upon her suggestion at the end of the paper, and criticize the Gates foundation (with the one and only purpose to boost its legitimacy, that goes without saying! 🙂 ), I’ll just make a few quick comments on the paper itself.
I was a bit surprised that the impact (real and perceived) of the Gates foundation on global health didn’t feature prominently in this story on the legitimacy of the foundation in global health governance. But maybe that was due to the normative angle of the paper? The Gates foundation does have impact, and in many global health areas actually (even if it’s impact according to its own metrics and values perhaps, and no doubt sometimes distorts (other) global health priorities). But all in all, I think the Foundation’s global health results are undeniable and certainly add to its legitimacy in GHG.
Less important, perhaps, but still interesting to note was the paragraph related to the ‘personalized gender roles’ of Bill & Melinda. This issue actually warrants a paper in itself, I’d say, maybe from Ilona Kickbusch, Asha George or some of the other women in global health leaders? I don’t feel qualified to dwell on this issue. It’s worth to give a few of the quotes in the paper in full, though:
“Since the launch of the BMGF, however Melinda has occupied a specific public role that is often depicted in gendered terms of being the understanding, humanizing, and maternal caring woman to Bill’s hard number-crunching, technology-loving, politician-partnering man.”
“…personalized gender roles are clearly used to promote a specific image of the BMGF and Bill & Melinda’s place within it: Bill as the man who knows how to make money and make money work, and Melinda as the intelligent woman who cares’.
These personalized gender roles don’t bother me too much, as I’m not sure it’s actually a deliberate strategy of the foundation (true, I might be naïve, this is an American foundation after all), to me it looks more as if Bill and Melinda are playing to their respective strengths and interests. For Bill, that certainly seems to be the case; for Melinda, given her Microsoft background, I can imagine she also has some (many?) of the skills now more commonly associated with Bill. But as I said, it doesn’t bother me much, and they seem to complement each other, which is nice as far as I am concerned.
What I certainly agree with, in Harman’s paper, is that the Gates foundation needs (more) public contestation if it wants to be legitimate. After all, you don’t want global health governance to feel like the Chinese state (although the latter has, no doubt, also shown substantial (development) “impact” in recent decades!).
So let me make a humble contribution, as I don’t frequent the corridors of global health power, the way Tim Evans and others do. I haven’t really experienced the ‘Bill Chill effect’ of the foundation on global health institutions, myself, in the words of Harman (I could tell you about some other institutions’ chill effects, but will leave that for some other time).
Let me first say this, though: I do admire Bill. On the continuum of billionaires, with Trump (as a caricature of all that’s not very appealing about men, Americans ànd billionaires) on one side of the spectrum and some ideal type billionaire who would only care for global social justice (and do so in a way that generally improves the planet and the fate of people now, and generations in the future) on the other extreme of the continuum, I’d put Gates somewhere around the 80th percentile. Being a bit of a populist global health observer, I frankly admire his determination and eye for detail. And yes, his determination to go for global health impact and results, even if I don’t always agree with his focal areas and certainly not with his view of the world. Yes, his foundation distorts global health priorities, sometimes (often?), but you can’t blame him for filling gaps left by states (for example, when it comes to WHO core assessed state contributions). Well, just an example.
Chinese people sometimes say about Mao that he was 70 % right and 30 % wrong; it would be interesting to get global health scholars and observers’ take on Bill Gates in this respect. I don’t want to put an exact figure on this question (not being an economist), but the benefits of his foundation do outweigh the downsides, I’d say. By quite a bit, actually. Which, as I mentioned, adds to its legitimacy.
However, it’s obvious (at least to me) that his “brand” of global health is way too influential, certainly in the new SDG era (which requires a very different paradigm, and no, it’s not the one ‘leveraging the private sector’ and all the rest of it ).
Solomon Benatar put it eloquently in a recent IJHPM comment : “…The contemporary dominant belief system and its frames for global thinking are characterized by an emphasis on individualism, freedom, philanthropy and an economy dominated by market considerations, all of which give priority to monetary value and short-term interests in all aspects of life.” “… The best-known metaphor in healthcare is war against disease and this is framed within scientific innovation, competitiveness and the ‘right’ to health/healthcare. These combative and technological metaphors and frames are extrapolated to global health and buttressed by linking health to competitive economic growth as development, and to an adversarial notion of ethics (Human Rights). Such ways of thinking have been described as ‘the common sense’ of dominant practices that need to be critically re-evaluated and replaced with a new paradigm.”
I think it’s fair to say that Bill Gates is the ‘poster boy’ of this sort of thinking, or, more accurately perhaps, that he has actually done a great deal in order to make this sort of discourse and paradigm become mainstream/dominant.
True, he seems to have recently made the switch from vertical diseases to health systems, even if a bit reluctantly (I’m sure he likes the ‘resilience’ part of ‘resilient health systems’ the most, though!). But now, Bill has to make the switch to the SDG/planetary health era. Put differently, we need “SDG Bill” to come alive. Unfortunately, for this latest transformation, he will have to question his core values. Bill needs a new paradigm, no less. Not sure he can pull that off ( I’d certainly call that a ‘Grand Challenge’ for Bill! )
Arguably, what Bill (and many others in the global health elite) stand for, works, at least to some extent, in separate (global health) areas/sectors (vaccines, product development, polio…), even if some (rightly) say his sort of global health initiatives and partnerships have distorted health systems in the past.
But at the global and planetary level, because of the values and paradigm it projects, I’m afraid “Gates-style” global health doesn’t work. Worse, it makes ‘planetary health’ near impossible.
Buse & Hawkes et al already did so last year, and just last weekend Benatar also argued, far more eloquently than I can (and also more far-reaching than Buse et al), for a paradigm shift in global health: “Global health, appropriately understood as an ecocentric concept, embraces the idea of healthy people on a healthy planet. This notion goes beyond anthropocentric considerations on health to include the importance of the interconnectedness of all life-forms and human well-being on an ecologically threatened planet. Prominent values and frames within this system would include a deep sense of physical, moral and spiritual interdependence with nature (animals, plants and the ecological system) that sustains all life, and a spirit of solidarity, co-operation, sharing and social responsibility that respects the public commons and future generations”
Bill’s vision and paradigm are, let’s face it, based on competition and addressing market failures, even if ‘partnerships’ feature quite prominently as well. That might work very well in certain areas and sectors, but we need the global economic system to be based on another sort of core value in the 21st century. I’m not saying Gates is (all by himself) responsible for our current version of capitalism, but global citizenship, one of Bill’s key aims, will just not happen in a global economic system based on ruthless competition. Worse, it becomes more and more obvious that the current global economic system and the values on which it is based lead to more and more polarization and xenophobia. That clearly doesn’t facilitate global health aims & global social justice.
Moreover, for the ones who like to think that only IS fighters are suicidal, this global economic system also leads human beings to slow-motion suicide, in a sort of slow-motion ‘Danse macabre’. We are all suicidal, and people like Gates who are the (human) ‘faces’ of this system and lend it credibility & legitimacy can be considered global capitalism’s Al Baghdadis (I’m exaggerating a bit, here, but you get the point). Sadly, not even 72 virgins will be waiting for us, if we go further down this eco-destructive road.
I don’t expect the likes of Victor Dzau, Chris Elias or Julio Frenk to push Bill towards “SDG Bill”, that we hope is somewhere hidden in there, but others should. Anywhere where Bill shows up, ask him these questions.
If Bill reads a bit about the globalization backlash we’re currently witnessing in much of the North (and I’m sure he does), he will recognize that for many people, it has become clear that economists and international technocrats, the global financial sector, multinationals, … need to be put (again) ‘on a leash’ in the 21st century. Properly “regulated”, instead of the other way around (as Jason Hickel rightly says in a recent contribution, pointing to ISDS in trade & investment agreements as a case in point of the latter). Just zooming in on multinationals, for example, one should never have too much faith in corporate social responsibility. After all, Coca Cola (sponsor of the Olympic Games for many decades already) proudly used the slogan, ‘Ein Volk, Ein Reich, Ein Getrank’ in Berlin ‘36…
So, if the Gates foundation wants to be really ‘legitimate’ in GHG in the new SDG era, Bill needs to make a ‘Great Leap Forward’ into real SDG thinking. If he fails to do so, I’m afraid his line of global health thinking/paradigm needs to be(come) marginal(ized) by the rest of us. We need something else (than ‘addressing global health market failures with technological breakthroughs and other innovations), to deal with 21st century challenges.
I don’t expect this to happen soon, but I hope that by 2030 great minds will have “converged” on this. True, Bill probably believes, like many (most?) of us, that this system (capitalism) best fits ‘human nature’. Still, we need to find something different now, and it’s urgent.
An “SDG Bill” would, for example:
It’s clear: SDG Bill could do so much that we could even turn him one day into a Marvel character. A new franchise could be in the making (ahum, that sounds a bit too capitalist, I’m aware)!
(Sophie, I hope I boosted the Foundation’s legitimacy with this short contribution! )