Bill Gates in action at the 2008 World Economic Forum, with Indra Nooyi of PepsiCo to his right, and Robert Zoellick of the World Bank two to his left
Los Angeles. My main topic this month is the significance of the 'new philanthropies' and their impact on global public health, and in particular population nutrition in less resourced and impoverished countries. My context is this month's UN Summit on the prevention and control of non-communicable diseases, which are now rampant in Asia, Africa and Latin America. A vital source for this commentary is an analysis by scholars from the Harvard School of Public Health and the London School of Hygiene and Tropical Medicine (1), available here. One of them, David Stuckler, writes in World Nutrition this month on the Summit.
My pictured example is the biggest philanthropist in the world, whose interest in saving the world is specifically in public health, and his foundation, whose budget is greater than that of the World Health Organisation, and which after the US government is the biggest funder of WHO. This is the Gates Foundation, about to become the largest single shareholder in the Coca-Cola company and in Kraft Foods (1), and which, as stated on its website, is 'driven by the interests and passions of the Gates family'. Bill Gates, above, is speaking on the theme of 'the new drivers of development' at the 2008 World Economic Forum meeting in Davos.
People's Health Movement
On to the world assembly in Cape Town
At the end of July I attended the annual meeting of the USA circle of the People's Health Movement in Los Angeles. The setting was bucolic: the Loyola Marymount University campus, seen above in term time. It was good to be with grassroots activists in the US, now having a hard time because of the financial turmoil the US is going through. I brought with me the solidarity of the global People's Health Movement.
Discussions were fertile and we all shared plenty of ideas on where the movement wants to go in its domestic US work over the next two years. Attention was also given on how to best contribute to the organisation of the Third People's Health Assembly, to be held in Cape Town in July next year. This coming event is creating a great deal of excitement the world over, particularly among grassroots organisations working in health. What a great job they are doing in the US. Defending the right to health in this great nation is certainly not an easy task – let alone working against militarism and against big time polluters, as some militant groups here do.
The new philanthropies in world health affairs
Masters of our universe
Bill Gates in 2008: addressing the UN General Assembly, and with friends behind the Millennium Development Goals at the World Economic Forum
Here is Bill Gates, currently the world's second wealthiest person. Among all the new philanthropists I have picked him, because the Gates Foundation, with assets of $US 30 billion, is by far the largest foundation whose main interest is population health (1). He has become devoted to the UN Millennium Development Goals. Above (left) he is advocating them at the UN General Assembly in 2008. Also in 2008 he is (right) upholding them with colleagues UN secretary-general Ban Ki-moon, the late Nigerian president Yuma Yar-Adua, former UK prime minister Gordon Brown, Queen Rania of Jordan, and (far right) Bono. No people of the type shown in the photographs being held up were, as far as I know, present in Davos.
When we consider the significance and impact of the 'new philanthropies', it is fair and reasonable to think of Bill Gates and his foundation, because of its scale and his presence. But there are others.
HAVE YOU EVER WONDERED WHERE THEY
AND THEIR PEOPLE COME FROM? AND
WHETHER THEIR INTENTIONS ARE PRISTINE?
Institutional relationships in global health are a growing area of study, but few if any previous analyses have examined private foundations. It is almost as if analysts feel that foundations are beyond criticism or even appraisal. Bill Gates certainly thinks so. The intentions and policies of the directors of foundations are rarely considered. This is now beginning to change (1-4)
There are broadly three different types of private foundation whose declared purpose is to protect and improve public health, including nutrition. Some were set up a long time ago, often by vastly wealthy US industrialists, and over decades have sought distance from their founders. These include the Rockefeller and Ford Foundations. Some are similar, except that the founders are themselves alive and active in pursuit of influence on internal affairs in ways they see as akin to their view of the world. The Gates Foundation is the outstanding example, but there are others, for instance the Fundación Carlos Slim Helú, named after the world's currently wealthiest person. Other foundations are obviously different; they are set up by and controlled by transnational and other giant food and drink companies. These include the Coca Cola Foundation, the PepsiCo Foundation, the Kraft Foods Foundation, and many others.
The similarities between these types of foundation are greater than their differences. Corporations set up or fund foundations that support the corporation's direct or indirect, tactical or strategic policies. Foundations that are historically or constitutionally distant from their founding funders still work within an ideology that is consistent with big business, particularly as seen by US industrialists. Most rarely transfer money and resources to organisations that are independent, democratic, and accountable to their members, or to voters and taxpayers.
The funders and directors of private foundations may well have altruistic motives, but it is also true that there is financial benefit in setting up a foundation. It further stands to reason that the policies of any foundation will support or at least be consistent with the corporate policies and personal ideology of the people who control the foundation. Tax-exempt private foundations and for-profit corporations increasingly engage in relationships that can and do influence global health.
Where do foundations invest their money?
Many public health foundations have associations with private food and drug corporations. In some instances, they are invested in the stock of such corporations. Here below, for example, is a list of the main stockholdings of the Gates Foundation, taken from (1).
Gates Foundation stock portfolio, 2010.
Some of its holdings (1)
What this shows is that when the stock of Berkshire Hathaway donated by Warren Buffett and now being transferred to the Foundation is taken into account, the Gates Foundation will be the largest single stockholder in Coca-Cola, the biggest manufacturer of sugared soft drinks in the world, and of Kraft Foods, the biggest manufacturer of confectionery in the world. Does Bill Gates think about this, when he makes decisions, or is on platforms with executive from transnational food and drink processors? Probably not, but it seems likely that they think about it, and there is a basic community of interests here.
Does this help to explain the zealous attachment of the cash-strapped United Nations system to 'public-private partnerships' where in our field of nutrition and public health the private partners are mostly transnational food and drink processors, otherwise known as Big Snack? This also seems rather likely to me. Think about this, and the implications.
Executives move to and from food and drink industries, pharmaceutical houses, academia, UN agencies, national governments, and public health foundations. Foundation board members and decision-makers also sit on the boards of some for-profit corporations benefiting from their grants. While private foundations adopt standard disclosure protocols for employees, so as to mitigate potential conflicts of interests, these disclosures do not always apply to the overall endowment investments of the foundations or to board membership appointments.
The extent and range of relationships between tax-exempt foundations and for-profit corporations suggest that transparency only in the making of grants, may not be preventing potential conflicts of interests between global health programmes and their financing. The question of whether and how financial and institutional relationships shape foundation decision-making has yet to be properly addressed, let alone answered.
Further, it is surely fanciful to suppose that industrialists who are alive and active now, and who maintain control over foundations, are likely to change the core beliefs that made them immensely wealthy. The basic ideology that drives transnational corporations is going to be the same basic ideology that drives their foundations. Does this seem to you to be a cynical view? Surely it is common sense. But the implications are vast. It means that the strategic policies and practices of transnational corporations are pursued, albeit in a different guise, by the foundations set up in their name. Technological fixes ensue. But medical and other technologies make a relatively small impact on the broader social and economic determinants of health and nutrition. Also, the efficacy of technology cannot be guaranteed, so an over-emphasis on technology has been and is problematic.
As David McCoy says, the ways in which much private philanthropy works are hugely inefficient. For example, there are many transaction costs related to vertical top-down initiatives, and there is much collateral damage along the way. We could achieve better long-term health and nutrition improvements using an approach that tackles the social determinants.
Foundations are not all bad
David McCoy also thinks the issue is less straightforward than 'condemning private philanthropy out of hand'. For example, in discussion with People's Health Movement colleagues he has asked some important questions:
- Private philanthropy can include some expressions and actions of social solidarity for ordinary people, but we do not condemn that, do we?
- Do we need to make a distinction between post-tax and pre-tax private philanthropy?
- Many of us work for organisations that are funded in part by private money – do we condemn all that private money as well?
- Is all private philanthropy worse than public aid? Are US government aid and the World Bank loans and grants associated with structural adjustment programmes better than all examples and sources of private philanthropy?
- Are there better and worse forms of private philanthropy – in terms of the source and the spending of that wealth?
- Is there a need for us to differentiate a moral/political position from a tactical/strategic position on private philanthropy?
- Given the pre-eminence of Gates in the global health field, what is our strategy towards the Gates Foundation? Have we ever called for a debate or discussion with the Foundation? And should we?
- Do we seek to reform, or to lead a revolt on all of the above?
- Much philanthropy is used in ways that prevent the radical and structural changes required to set up a fairer and more progressive economic system. What is our stance here?
- Aren't private foundations not only unaccountable, but hasn't their power grown through the 'capture' of other institutions, including the UN?
- Their rise is linked strongly to the relative reduction in public financing with a concomitant rise in the public-private partnership paradigm. Is there any monitoring of the revolving door syndrome between United Nations-foundations-corporate sector-governments?
- Are there adequate checks and balances to prevent the capture of public financing and policy making by the private philanthropy/corporate sector?
I think there is much agreement on the historical analysis of the rise of these institutions, their minimising the tax liabilities of their corporate funders, and their capture of the UN (and many other public bodies). But the issues are complicated, and are only beginning to surface and to be understood (1-4).
FOUNDATIONS ARE PART OF THE
PRIVATISATION OF PUBLIC HEALTH AND
THE EROSION OF PUBLIC GOODS
My friend Alison Katz, on the other hand, thinks philanthropy is never positive. Her view is that the right to health and to nutrition are incompatible with private philanthropy. Private philanthropy and the diseases of poverty go together: They result from, and characterise, gross economic inequity – the root cause of preventable malnutrition, ill-health and deaths.
She believes that as nutrition professionals, we must fight for economic justice as the precondition for the right to nutrition. This implies denouncing private philanthropy.
I agree. These things were clear already over ten years ago when philanthropies became prominent. Since the 1980s, big corporations have successfully fought to pay very little tax and even no tax at all. In doing so they have eroded the tax base which is the basis for public services of all kinds, including health and nutrition. This done, the new philanthropies, often controlled by these tax-dodgers, move in and take over from public bodies. Think about it.
Of course they prefer not to pay taxes, but instead to 'give' money (even lots of money) to health (much less to nutrition). In doing so, they open up the area of health and health services to privatisation. They thus make what should remain public goods, actual tools of capital with all that implies. The implications include rapidly widening gaps in equity, and the terrifying prospect of destitution when chaotic fluctuations in the money markets occur, such as those we are once again experiencing as I write this column.
Please, do not tell us that health services in faraway lands would collapse, were it not for private foundations. It is not a question of abandoning services in Africa and leaving people adrift. It is a question of what we are fighting for in the long run, and a question of values, principles, equity and justice.
A letter to Margaret Chan
In 2007, Alison Katz sent a letter on this to Margaret Chan, director-general of WHO. She wrote it at a time when she worked for WHO, but under notice of dismissal. Nothing has changed since and conflicts of interest are still pervasive. Here is part of the letter. It never received a response. You can access the full letter here.
'It has become fashionable to focus attention on the poor, but to meet and establish partnerships with the rich. In order to address the fundamental problem of inequality, this pattern must be reversed. It is time to focus attention on the rich and powerful, because they are the experts in the mechanisms of unequal power relations and the architects of policies and strategies which produce, reinforce and accelerate inequalities. Those systems must be closely examined by WHO and opened up to public scrutiny and democratic control. To clarify, this is not a discourse on good and evil; the issue is one of antisocial and sometimes violent systems manipulated by a handful of individuals.
'Poor people do not attend G8 summits, board meetings of the latest Global Fund or philanthropic foundations, let alone the World Economic Forum – where Chief Executive Officers of transnational corporations are offered even more privileged access to political leaders than they already enjoy. But poor people also hold meetings and they are represented – if imperfectly – at the World Social Forum (and in national and regional social fora), in trade unions, social and political movements and elsewhere.
'As Director-General of WHO, you are committed to "the people of Africa who bear an enormous and disproportionate burden of ill health and premature death" and you have made this "the key indicator of the performance of WHO".' Katz goes on to say that the presence of the WHO director-general at meetings of the World Social Forum 'would represent real hope and inspiration for the world's people and an essential counterbalance to high level meetings with government leaders and their corporate backers/advisors – who are increasingly one and the same'.
'You have gone on record saying that "the landscape of public health has become a complex and crowded arena for action with a growing number of health initiatives" and you reminded us that WHO is "constitutionally mandated to act as the directing and coordinating authority on health". As you know, public-private partnerships have become the policy paradigm for global health work despite the evident conflict of interest which would have outlawed such arrangements thirty years ago. Agencies and organizations with public responsibilities are partnering with the private sector for one reason: It (appears to have) become the only source of funds. This situation has arisen, because under neoliberal economic regimes, public sector budgets have been slashed and tax bases destroyed. Those developments are themselves the result of the influence of transnational corporations (TNCs) and the international financial institutions on governments'.
'The solution to this problem is not for public bodies to go begging to the private sector, nor to the foundations of celebrity philanthropists with diverse agendas. The solution is economic justice, including an adequate tax base, both nationally and internationally, to cover all public services, as well as proper funding of public institutions such as WHO through regular budgets so that they may fulfil their international responsibilities unimpeded by corporate interests'.
'You have further argued that "the amount of money being made available by foundations, funding agencies and donor governments is unprecedented". This will be entirely positive if you are able to use these funds to pursue your vision and priorities, as is your right and your duty. It can be argued that, if WHO had operated exclusively on a regular budget, even with a significantly smaller workforce, but one that was dedicated to WHO's constitutional mandate, far more progress towards Health for All would have been achieved'.
'As you have said "Primary Health Care (PHC) is the cornerstone of building the capacity of health systems. It is also central to health development and to community health security". PHC will remain mostly rhetoric if it is not supported by a solid, equitable tax base and other forms of redistributive justice (debt cancellation and reparation, fair trade, abolition of tax havens, democratic control of TNC activities, etc.). WHO itself needs to set targets for the level of core funding, starting perhaps at 70% of total expenditure, and increasing annually until undue influence is removed. The private sector has no place in public health policy making at global or national level. This does not, of course, exclude responsibly designed interactions as in the past. But it does exclude partnerships, because partners must share the same goal'.
THE NEW PLUTOCRACY
PHILANTHROPY IS THE ANTITHESIS
OF THE RIGHTS-BASED APPROACH
TO NUTRITION AND TO HEALTH
They've got the whole world in their hands... Bill Gates and his partner, financier Warren Buffett; and Bill Gates spreading the word at USAID
Private philanthropy is always interested in something. Does it seem that I am being facetious when I suggest that this is furtherance of its own interests? Private philanthropy exists because of gross inequities. Diseases of poverty and philanthropy in health and nutrition will always go hand in hand. When the right to health is achieved – even partially – who will need philanthropy? Philanthropic giving is the antithesis of the rights-based approach to health and nutrition.
Private philanthropy has no place in a social justice approach to human rights, including the right to nutrition. A right cannot depend on charity, or even on expressions of top-down social solidarity. That is the nature of rights. Private philanthropy only exists because of large inequities. It almost always confers yet more power on the giver and thereby further widens those inequities. It is truly a vicious circle and our aim ought to be to move out of it.
This does not mean abandoning people to their suffering. It means working on a transition to a human rights-based approach at all times. In all our strategies we have to move towards the standards and principles of human rights and away from charity.
The People's Health Movement position
The People's Health Movement has had lengthy debates on public-private partnerships, and has protested Bill Gates opening the World Health Assembly in 2005 and again speaking there in 2011. We have vehemently and vocally opposed the privatisation of health services and have denounced the UN Global Compact. Our entire raison d'être relates to issues of conflicts of interest, the rule of money, and the capture of WHO by industry.
We do not condemn private philanthropy action as a temporary measure to stop immediate and medium term suffering. As a way of achieving our aim of health as a human right, yes, we do condemn it. It has no part to play in the structural processes to achieve the human right to health and to nutrition. We are about creating the conditions for human rights, not to dole out goodies to salve consciences, quelling popular uprisings, and preventing real change.
My own reflections
Here is what I think, based on working for over 30 years as a nutrition and health professional mostly concerned about impoverished people in all continents apart from Europe.
Ordinary people understand well that charity is an integral part of systems of inequity. If it is to be effective, and in order to improve the situation of people, social solidarity has to take the form of political action. Hence the famous phrase of Dom Hélder Câmara the Brazilian archbishop of Olinda and Recife: 'When I give food to the poor they call me a saint, when I ask why they are poor, they call me a communist'. When impoverished people protest in the streets, you do not hear them calling for more philanthropy. They are demanding their rights.
A solid tax base, redistributive tax systems, and economic justice are the answers. Transnational corporations are skilled at avoiding tax. Some pay little, some pay none. Rich people generally pay far less proportionately than poor people. Over the past 30 years, the tax burden, like every other burden, has shifted massively onto the backs of the poorest.
Do we really want to put nutrition decision-making in the hands of the wealthy much of whose money comes from avoidance of taxes, so that the public has to come begging for money that is rightfully theirs in the first place? Or, do we want decision-making to be public and democratic? That's the choice: rule by money – plutocracy – or rule by people – democracy. We already condemn the ability to pay as a criterion for access to health care and to good nutrition. We should also condemn the ability to pay as a criterion for access to decision making. When we work in health or nutrition or any public service addressing human rights, our funding should be public; we should not depend on private funding.
The more I think about this, the more it seems to me that private philanthropy provides a respectable front to the much larger hidden face of powerful and exploitative forces. We want health and nutrition for all through social justice. It is a matter of appreciation whether social justice is a revolutionary project. Compared with the current neoliberal dogma, it probably is.
People are naturally compassionate, and empathy is a human trait. When ordinary people are told the truth about how international aid or private philanthropy works, they understand very well that human rights and charity are not the same thing. People will always need to help out other people in emergencies, because human beings are like that. But in a fair world, it would be just as likely for Haiti to help out Belgium, as it would be for Australia to help out Mali.
Private philanthropy's espousal of 'creative capitalism' or 'responsible capitalism' or 'win-win capitalism' or 'markets that benefit the poor' (there are many more warm phrases) surely is obviously absurd at a time of chaotic market failures. Such phrases are surely fatuous when we find that foundations are doing nothing or little to stop systematic corporate tax evasion, and are aware that international property rights laws now promote monopolies and hinder innovation and scientific development. The very least that private foundations could do, is to address the many inequities and causes of market capture, market failure, barriers to market entry, and so on and on. These issues are crucial in the health and nutrition sector, because of its particular susceptibility to market failures. If families are thrown out of their houses, or have no money to buy shoes, usually they manage somehow. If they have no food, they die.
As Alison Katz so eloquently argues and David McCoy rightly concludes, private philanthropy has become a powerful and insidious presence in our midst. Ventilating this topic now is timely, in the month of the UN Summit on prevention and control of non-communicable diseases.
Transnational corporations and foundations are deeply implicated and involved in this global pandemic. Soon, I predict, private foundations, some directly controlled by transnational food and drink companies, others with less direct links with that part of industry whose products are a cause of the pandemic, will enter big-time, into the arena of pseudo-prevention of non-communicable diseases. But why am I saying 'soon'? This is already happening now. At the very least, we professionals need to become more aware of what is going on, where philanthropy stakeholders are coming from, and why.
- Stuckler D., Basu S., McKee M., Global health philanthropy and institutional relationships: how should conflicts of interest be addressed? PLoS Med 8(4): e1001020. doi:10.1371/journal.pmed.1001020
- Anon. What has the Gates Foundation done for public health? [Editorial]. The Lancet 2009; 373, 9675: 1527.
- Piller C, Sanders E, Dixon R. Dark clouds over good work of the Gates Foundation. The Los Angeles Times, 7 January 2007
- Wiist B. Philanthropic foundations and the public health agenda. Corporation and Health Watch, 3 August 2011.
Acknowledgement and request
You are invited please to respond, comment, disagree, as you wish. Please use the response facility below. You are free to make use of the material in this column, provided you acknowledge the Association, and me please, and cite the Association’s website.
Please cite as: : Schuftan C. The new philanthropies in world health affairs. [Column] Website of the World Public Health Nutrition Association, September 2011. Obtainable at www.wphna.org
The opinions expressed in all contributions to the website of the World Public Health Nutrition Association (the Association) including its journal World Nutrition, are those of their authors. They should not be taken to be the view or policy of the Association, or of any of its affiliated or associated bodies, unless this is explicitly stated.
I owe the analysis in the commentary to many years' experience and many discussions with countless friends and colleagues in the People's Health Movement. Many thanks to David McCoy and Alison Katz; and also to David Stuckler, Sanjay Basu and Martin McKee, whose extensive review cited above is a vital resource. This column is reviewed by Geoffrey Cannon.