The side-effects of doing good

Once a month Univestiy students from Taipei get together for a practice-English course, they are also Eden volunteers looking to help practice their English with foriegn volunteers and we discuss various articles. Here is one you may find interesting...

Global health
The side-effects of doing good
Feb 21st 2008 NEW YORKFrom The Economist print edition
The audacity of the Gates Foundation may have unintended consequences, but things would be worse if UN bureaucracies still dominated the field

IS IT possible—even in theory—for an organisation to work too hard for the benefit of humanity, or to devote too much money to the eradication of a deadly disease? To judge by some of the recent bickering between leading players in the field of global health, there are serious people who in answer to those questions would say, “paradoxically enough, yes.”
At the heart of the argument is the Bill & Melinda Gates Foundation, which has often been called the biggest philanthropic organisation—at least among those whose accounts and internal workings are open to public scrutiny—in the world. Since Mr and Mrs Gates (pictured above) established the charity in 2000, it has spent over $8 billion on improving global health, and won deservedly lavish praise for its efforts.
But just as huge, powerful countries can be awkward neighbours—a Canadian leader once likened his country's relations with the United States to a mouse bedding down with an elephant—lavishly funded organisations can sometimes cause resentment among other outfits which are struggling to do a similar job. And whether because of jealousy or legitimate concerns, the Gates Foundation has not been having such an easy time of late with its public image. The philanthropic world was well enough prepared for the recent announcement that Patricia Stonesifer, the foundation's charismatic boss, will move on before the end of the year—but it was surprised that no successor was named.
More seriously, perhaps, the New York Times this week published bits of an internal document from the World Health Organisation (WHO)—a letter from its chief malaria-fighter to the agency's boss, Margaret Chan—which alleged that the Gates Foundation was having a negative influence on research into killer diseases.
The letter from Arata Kochi, a feisty veteran of the global public-health scene, said the excessive sway of the Gates Foundation was distorting research priorities and quashing independent thinking by sweeping up the best scientists and keeping them “locked up in a cartel”. However unintended this effect might be, the charity's might was marring the process of peer review because researchers were now bunched into groups which were competing for Gates funding, and each member of such a group had “a vested interest to safeguard the work of the other”.
Dr Kochi's outburst prompted some other critics of the Seattle-based charity to reiterate their own long-nursed complaints. Some blame the foundation for being slow to specify areas it will definitely not invest in; as a result, they say, smaller outfits fear to enter certain fields, because of the risk that the Gates people will jump in. Others also worry that the foundation concentrates too much on glamorous science and long-term technology bets, and not enough on putting boots on the ground in places like Africa.
What do these criticisms add up to? Not much, if officialdom is to be believed. A spokesman for Dr Chan insists the charges attributed to Dr Kochi do not reflect her organisation's official views. The Gates Foundation, keen to avoid a public row, also downplays them.
And yet Dr Kochi remains unbowed. He still insists that the foundation's massive spending on malaria research is a classic case of a near-monopoly leading to market failure: in this case, a market in medical prowess. Not that he resents everything the Gates Foundation did to combat malaria: governments, he notes, had failed to invest in this area, so the foundation's decision to throw money at malaria was laudable. But there were unforeseen effects: “Gates can solve problems with money—but a lot of money leads to a monopoly, and discourages smaller rivals and intellectual competition.”
Dr Kochi also challenges the foundation's recent proclamation that the total eradication of malaria is a realistic goal. “Like going to the moon, it sounds really good,” he says—but he is still convinced that this dream is impossible to fulfil with the current tools, and that trying to do so may have bad side-effects.
Such “over-reach”, in Dr Kochi's view, amounts to a costly, risky diversion of resources away from the realistic aim of just controlling malaria. He also says the foundation bets too much on particular treatments, such as the artemisinin combination therapy (ACT)—a combination of drugs based on Chinese herbs. Although ACT does work better than older therapies, there are signs that drug-resistant strains of the disease are emerging. Dr Kochi frets about what will happen if, under the Gates influence, malaria researchers put “all the eggs in that one basket.”
How substantial are these charges? It is plain that the organisation's wealth and targeted approach do attract clusters of leading researchers to specific areas; indeed, that is the whole idea. It is also true, argues Laurie Garrett of the Council on Foreign Relations, an American think-tank, that the charity's focus on “measurable outcomes in a short time, while a fantastic improvement on the past, exacerbates the devastating shortages of health-care workers on the ground.” Even Tadataka Yamada, head of the Gates Foundation's global health efforts, admits that in the past it may have focused too much on high-profile research and not enough on boosting entire health systems.
But some good points can be made in defence of the Gates approach. First of all, argues Dr Yamada, calling this organisation an emerging monopoly is “way off base”. The foundation often collaborates with other charities, and jostles with other big agencies and newish funders, such as PEPFAR (George Bush's AIDS effort) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. This week the White House announced yet another tropical health initiative: a $350m effort to combat seven neglected diseases.
Dr Yamada also challenges the “eggs in one basket” theory. Although it is true that Mr Gates personally has argued for the eradication of malaria, and that his charity does heavily support ACT therapies, the charity also uses a range of other approaches, like malaria vaccines and bed nets. Dr Yamada says frankly that “we don't have to choose between one thing and the other: we have enough resources to do both.”
That, of course, is just the sort of cockiness that rankles with health pundits. 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, a Geneva-based arm of the United Nations, 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. Indeed, Dr Kochi himself has been refreshingly frank about the WHO's poor record in fighting the disease. The agency has also been criticised for accepting poor data from member countries which may downplay bad news. As Dr Chan says candidly, that charge “is a reality”. It is not her role, she says, to “name and shame” countries; she prefers to exert private pressure. But she acknowledges that some public pressure is essential, and applauds the role played by the media and charities in “shining the light” on previously obscure places.
A big new non-government organisation, crashing into the jungle like a young elephant, is bound to cause resentment, and perhaps bound to have unintended ripple effects. But without this elephant's input of new money and ideas, the battle-front against malaria and other deadly diseases might present an even worse picture, especially if the field were left to governments and inter-governmental bodies.