Public Health’s “Benevolent Dictator”: Is Gates ruling us, or are we just ruled by money?

Last week, Laura Freschi and Alanna Shaikh published a piece in Alliance magazine that raised some interesting and thought-provoking question about the role of the Gates Foundation in setting the global health agenda.  They conclude that Gates is becoming a “public health dictator” because of his financial resources and the power and influence that come as a result.  They are, of course, not the first to complain about Gates’s focus on technological solutions to global health challenges.  Some of the most recent grumblings were in response to the Foundation’s “reinvent the toilet” campaign this year, but similar concerns have been voiced for years.  The Foundation places too much emphasis on technological innovation and “quick fixes”; their undue influence diverts funding from other priorities; their goals are not realistic.  These are all valid concerns which deserve to be voiced (heck, we have already written about it here), particularly in a field where nearly everyone has a different opinion on how problems should be solved.

But a dictator?

A dictator? Nah. Look at that face.

The Gates Foundation is directed by the priorities of Bill Gates, an entrepreneur who made obscenely large piles of money and who now wants to use some of it to make the world better.  Those piles are accomplishing just that by funding the initiatives that he likes, thinks are important, and/or believes will work.  After all, Gates made his money through technological innovations, so it is perfectly logical that the same types of ideas would be close to his heart – and, to be fair, it is his money.  It is also fair to criticize those initiatives, particularly if the interventions are ineffective or do more harm than good.

But now pundits are demanding accountability from the Foundation, calling on it to justify what it does:

If expensive polio and malaria eradication efforts, pursued not just by Gates but by the entire global health community at Gates’ urging, fail, to whom will
Gates be accountable for that failure?

We demand accountability from our governments because they spend our money – we have the right to demand that our tax dollars be used effectively.  But why, exactly, should Gates be accountable to anyone for wasting his own money?  More importantly, why would the “entire global health community” do something just because he told us to?

Dictators are people who arbitrarily enforce laws, throw people in jail for criticizing them, and deny their citizens free and fair elections.  Gates does not punish anyone whose global health solutions don’t appeal to him – he just doesn’t give them money.  He never lead any kind of “global health coup” or insist that we all adhere to his development philosophy.  Yes, the Foundation has lots of money, and would-be philanthropist who wants to launch his NGO would treat Gates like a god if he ever saw him on the street – but that is precisely the point: he has undue influence because we give it to him.  To paint Gates as a “global health dictator” because causes are prioritized based on what will get Gates Foundation funding villifies the wrong party.  What does it say about us as a body of professionals if we allow ourselves to be led by the nose by the guy with the most money?

The Economist raised another interesting point when it examined the same debate back in 2008:

At least in part, the gripes against the Gates Foundation are the churlish growls of a jealous crowd of bureaucrats and labourers at less influential charities. Some people at the WHO…openly worry that the foundation is setting up a new power centre that may rival their organisation’s authority. Such conspiracy theorists point to the foundation’s recent grant of over $100m to the University of Washington to evaluate health treatments and monitor national health systems—jobs supposed to be done by the UN agency.

Therein lies an irony. The WHO, one of whose captains now calls the Gates Foundation monopolistic, used itself to hold a monopoly in the fight against malaria, and it did a lousy job as a result.

I do think Shaikh and Freschi (and also Tom Paulson of Humanosphere) are on to something when they question the Foundation’s giving money to media organizations to increase coverage of global health topics.

Among the grantees is a growing list of media outlets including the Guardian newspaper (UK), ABC, PBS and the BBC – all to underwrite coverage of global health issues. While these grants all came with assurances of editorial independence, it’s hard to believe that such partnerships won’t influence the nature of the coverage in some way.

Even if it is objective, it never looks good when you fund your own media coverage.  Somebody probably should have thought that one through.

At any rate, the debate about what Gates is doing (and what he should be doing) with his money will undoubtedly rage for as long as he has money.  But if we believe that the Gates Foundation is distorting global health priorities because of its purchasing power, then we need to take a long, hard look at how we define our priorities.

ASPH Calls for Comments on its Draft Global Health Competencies

ASPH has recently released a draft of its Global Health Competency Model, a set of competencies recommended for graduates of master’s level programs in global health.  They are based on the organization’s MPH core competencies and are divided in to seven “domains,” or categories.  According to the draft,

…formal educational programs for global health professionals are highly fragmented in terms of the institutions offering such programs and quite varied in terms of the outcomes and qualifications expected of graduates. As the number of institutions offering formal training in global health grows, ASPH has taken leadership in developing a competency model based on the necessary roles and functions of the global public health system of the future. This approach recognizes that global health and public health represent a unified front with a long tradition of bringing scientifically-validated programs, policies, and services to bear upon the world’s most pressing health needs. A Lancet article in February 2010, in which ASPH global health leaders sought to emphasize the common framework of global health, international health, and public health, stated that “[g]lobal health and public health are indistinguishable,” further defining the scope of this initiative.

The document (pdf) can be viewed here.  Below is a screen grab of the competencies.

ASPH is calling for comments on the draft by Friday, September 23.  Comments may be sent to ghcompetency@asph.org.

There is No Silver Bullet

There is no silver bullet and frankly you probably don’t need one. It is far more important to be able to find the right kind of gun, be able to load the gun, be able to aim the gun, and perhaps most importantly, be able to figure out where the werewolf is. –Matthew Oliphant

Vampire Selene uses bullets with silver nitrate to fight off werewolves in "Underworld." Unfortunately, we do not have "silver nitrate bullets" for global health problems.

I always scratch my head a bit when the global health community is dismayed at the revelation that one of its previously hailed “silver bullets” is revealed to not be the miracle cure it was thought to be. The latest disappointment making its way across the blogosphere right now is microfinance: after shady lending practices and harassment of borrowers (driving some to suicide) were uncovered on the part of commercial microlenders in India, the development community began wringing its hands at the unfolding political scandal. The forced retirement of Muhammad Yunus, founder of the Grameen Bank, Nobel laureate, and pioneer of the microfinance institution, looks like the proverbial nail in the coffin of microfinance’s status as the one-stop solution for ending poverty. Now experts are holding panel discussions to debate whether or not microfinance “works.”

This is not the first time we have found ourselves crestfallen at the failure of a silver bullet. When evaluating the results of his “Grand Challenges in Global Health,” Bill Gates admitted that the organization had been “naïve” in its expectations of breakthroughs in vaccine development. He underestimated the time it takes to move new products from the lab through clinical trials and manufacturing. “I thought some would be saving lives by now,” he said, “and it’ll be more like in 10 years from now.” Tell me about it: I worked for a biotechnology start-up in college, and the time it took to get approval for phase I clinical trials allowed bad management to completely unravel the company – it took less than five years. By the time we got the green light from the FDA, the company was being bought out, and we never got to test the product.

Many are also astounded at the current descent from grace of Greg Mortenson, of Three Cups of Tea fame. Details of his inspiring Quixote-esque story of building schools for girls in rural Pakistan and Afghanistan are now being questioned, and donors are appalled at reports of mismanaged funds and schools being used as storage sheds. But don’t we already know that graft happens, and rookies make (sometimes colossal) mistakes? How reasonable was it to expect the Central Asia Institute, Mortenson’s charity, to “fix” Afghanistan by building schools? On the other hand, why are countries and large-scale donors pulling funding and creating a fuss over the graft that the Global Fund revealed through its own investigations?

Why are we continually disillusioned when the simple solutions to the complex problems of global health and poverty turn out to not be so simple? Part of the problem is marketing. Saundra Schimmelpfennig, who has made it her mission to point out and tackle issues surrounding charity (mis)representation and shady fundraising practices, points out that

Whether it’s TOMS A Day Without Shoes or CAI’s Pennies for Peace, schools and teachers are using what are essentially commercials for a charitable product to teach children about the larger world and philanthropy. As is the case with most commercials, these “awareness raising activities” often distort or over-simplify the problems faced in ways that benefit their own organization.

This is extremely worrying as the children brought up on these myths and misconceptions are going to turn into businessmen, philanthropists, and lawmakers. How will the decisions they make be impacted by a distorted view of what the world is like and how to really help?

Another part seems to be that despite each revelation, we are constantly drawn to the prospect that we will somehow still find that magic “something,” that the next innovation or big idea will be the much-sought-after silver bullet. Despite coming to terms with his naiveté, Gates is now saying that energy innovation is the key to beating climate change. Programmers are busily developing cell phone apps in the hope that cell phones can help end poverty.

The problems that we devote our careers to tackling are nowhere near simple, and it is unreasonable to expect to find simple solutions to them. Heck, we don’t even adequately fund the silver bullets we already have. As professionals more knowledgeable than me continually point out, our best bet is to strengthen health systems, focus on measurable improvements, admit and learn from failure, and – perhaps most importantly – have a little patience.

CFHI Video: Dr. German Tenorio, Oaxaca Director of Health, speaks on global health

Global Health News Last Week

The IH Newsletter is up! The Winter 2011 edition features several articles written by section members on various topics, a social media corner, fellowships and internships, and member publications. Check it out, and please consider contributing to the Spring edition!

On Tuesday, USAID administrator Dr. Rajiv Shah gave the 2011 David E. Barmes Global Health Lecture at NIH. His speech, titled “Addressing Grand Challenges:The Role of Science in Global Health Development,” can be viewed here. The transcript can also be downloaded, or you can read it on USAID’s website here. Also, you can check out commentary by Amanda Glassman, Sarah Arnquist, and K4Health.

Cholera, as usual, remains in the news: experts say the outbreak in Haiti has plateaued, while the one in Papua New Guinea rages on, and it is just getting started in Ghana. Meanwhile, health officials in Bangladesh prepare to launch the world’s largest cholera vaccine trial near Dhaka, the capital.

Scientists from Edinburgh University claim that the malarial parasite is particularly deadly because it competes with other strains of the infection by focusing on producing quickly-replicating cells, thus “duking it out” in the bloodstream. On a more positive note, Kenyan scientists believe that a spider that is attracted to the smell of human sweat may aid in the fight against the disease.

UN experts maintain that the laws in many Asian countries obstruct access to HIV/AIDS care and services. Nineteen countries in the region outlaw same-sex relations, and 29 criminalize prostitution. The remarks were made just before the Global Commission of HIV and the Law took place in Bangkok, where experts from around the world gathered to discuss HIV-related legal and human rights issues. Also, China has declared its intention to bring the spread of AIDS under control by 2020.

According to the WHO, Moldova has emerged as the world leader in per-capita alcohol consumption.

Experts have been sounding the alarm about rising food prices, and many analysts have linked the crisis to the recent riots in north Africa and the Middle East.

Obama and the Republicans continue to battle over the budget, as the president requests a modest increase in global health funds while Congressional Republicans try to slash spending.

World Pneumonia Day

November 2, 2009 is the first annual World Pneumonia Day, recognizing the world’s leading child killer as a global public health issue. A network of nearly 100 IGO, NGO, research and academic institutions, foundations, and community-based organizations have joined forces to raise awareness and urge governments and policymakers to combat this preventable illness. Each year, over 2 million children under the age of five die from pneumonia and pneumonia-related complications.

Although this is a great venture, it is surprising to see that this is the first campaign of its kind. Being the leading killer of children, it is outrageous to know this disease is not only treatable, but preventable. It leads me to wonder: “Why hasn’t more been done?” Mary Beth Powers, Campaign Chief of Save the Children said in an interview about pneumonia, “The sad thing is this is a disease that is largely preventable, and highly treatable.” This is not a disease that requires decades of scientific research to find a cure. Watch the movie.

According to leading public health organizations such as the World Health Organization (WHO) and UNICEF, many deaths can be prevented through early vaccination, proper medication (antibiotics) and nutrition, and vitamin supplements, such as zinc that is not typically found in a lower-income diet. Read more about the cause, prevention and treatment of pneumonia at the World Pneumonia Day website.

I would encourage everyone to spread the word about World Pneumonia Day, so greater awareness is made. The coalition firmly believes these deaths can be avoided, and encourages others to join the fight against pneumonia by:

1. Signing the pledge to fight pneumonia
2. Joining the coalition
3. Donating to the cause
4. Educating others about pneumonia prevention, diagnosis and treatment
5. Participating in a World Pneumonia Day event

Stories from the Field: Necessary Angels

Within the public health community, Community-Based Primary Health Care (CBPHC) is a common point of discussion. But rarely has the story been told by a Pulitzer Prize-winning author or captured in pictures for the National Geographic Magazine. The December 2008 edition shared with the world the story of The Comprehensive Rural Health Project (CRHP) in Jamkhed, India. “Necessary Angels” was the fitting title to a story of history and hope for village health workers who have healed communities, saved lives and transformed the place of the untouchable caste in the process.

Dr. Sanjay Gupta for Surgeon General: a Smart Communications Choice

I was surprised when I first heard about Dr. Sanjay Gupta’s possible appointment to US Surgeon General by president elect Barack Obama.  What type of message did it send to young people in the field of public health that the pathway to leadership was through the lens of a TV camera rather than toiling in the trenches of public health programs? 

VIDEO about Community-led Total Sanitation in Indonesia – PCI

Solihin asks the crowd whether anyone wants to drink a cup of feces-contaminated water.

Project Concern International (PCI) is the first NGO in Indonesia to fully implement Community-led Total Sanitation (CLTS) and offer no subsidies to communities. Watch the video here (and listen to some cool music):

View or download VIDEO here (MPEG4)
Download high-quality video (MPEG2, 700MB)

This video is about 18 minutes in length and shows how CLTS gets started in a community. The CLTS method emphasizes the importance of “natural leaders,” community members who emerge during the triggering session and demonstrate strong motivation and resolve to help their village become “open defecation free.”

Transdisciplinarity: global health workers breaking down walls

Message from Miriam (Section Chair)

As a lifelong international MCH professional, as a faculty member, and as citizen of the world, I am so excited about chairing IH Section this year. To me, what is so special about international health is that it is a transdisciplinary field. The term “transdisciplinary” may be new to some of you, so here’s the definition, developed by Piaget (yes, the same Piaget), translated by yours truly: “concerning interdisciplinary discourse, we hope to see a higher level emerge, “transdisciplinarity,” which would not settle for interactions or reciprocities between specializations, but which would internalize such interaction within an overall construct, and break down the walls between disciplines.”

Hello APHA International Health Section Members and Friends!

It is a New Year and a new beginning for communicating among members of the International Health Section of the American Public Health Association. What is new?

• Our website has a new look. Please check it out at http://www.apha.org/membergroups/sections/aphasections/intlhealth/
• This “IH Blog”. It is a new tool (for us) to hear members about their concerns and issues related to global health.

 I would like to invite you to write for the IH Blog. If you have any suggestions concerning topics that you would like to discuss, feel free to comment.