The philanthropy of Bill Gates must be approached with caution
Bill Gates is soothing his $200-billion headache by giving his fortune away – most of it to Africa – over the next two decades. That means increasing Gates Foundation disbursements to $9-$10-billion annually, compared with $8-billion in 2024.
This nearly trebles the foundation's average charitable outlay of about $3.4-billion each year since the Gates family got into philanthropy in 1994.
The increase is astounding in absolute dollar terms, but when adjusted for past and future inflation, the purchasing power of the expanded Gates largesse (supplemented by Warren Buffett's substantial billions) just about keeps pace with the real value of their original benefactions.
This is still the biggest philanthropic gift in modern history. But why is Mr Gates giving away 99% of his estimated $108-billion wealth?
A question of motive
Perhaps the philanthropist – once the world's richest man, but now in 13th position – suffers from the same anxiety as lesser persons: securing his legacy and being remembered kindly?
Or possibly, the 70-year-old is concerned for his soul as he enters the 'last chapter' of his undoubtedly brilliant career? Gates had a Catholic upbringing, but as befits a fiercely rational scientist, he is agnostic. Nevertheless, his reflection that 'to whom much is given, much is expected' suggests a spiritual base.
He is also fond of quoting Andrew Carnegie's Gospel of Wealth: 'The man who dies rich dies disgraced.'
The question of motivation is important in our age of suspicion where obvious goodness is not accepted at face value. Gates is the frequent target of outlandish conspiracy theories that say more about his detractors than about him.
What Bill Gates does matters to us
A more practical question concerns the implications flowing from his intent. Gates is entitled to do what he wants with his private wealth. But this libertarian licence is somewhat conditioned by the thought that the Microsoft co-founder amassed his fortune thanks to people like you and me buying his products and services – 345 million of us contributed $211-billion in revenue in 2023 alone, giving us a legitimate stake in Gates' affairs.
His philanthropic endeavours are also our business because of his outsized influence on public policy, particularly when this sways the choices nations make to affect the life chances of 44% of the world population. They are the world's poor (those living on less than $3.65 per day) living in 128 low- and middle-income nations.
However, to put this in perspective, the Gates Foundation's projected outlay of $9-billion a year is small change compared with the $294-billion needed annually to close the financing gap for the Sustainable Development Goals (SDG) among the 48 developing economies covering three-quarters of the global population.
Therefore, Gates' influence is not from money alone, but from how his powerful pulpit proselytises his heartfelt causes. This results in unease because of the distortionary consequences for country-level health and development.
A narrow approach
The causes dear to Mr Gates are: stopping preventable deaths among mothers and children; eliminating headline infectious diseases; and reducing poverty through education and agriculture.
These are worthy aims with compelling evidence, garnered not least through the Foundation's own massive research and innovation investment, that they are achievable by scaling up solutions derived from fast-moving scientific and technological advances, including artificial intelligence.
Mr Gates' humanitarian credentials are not in doubt. But his approach to tackling a problem 'because it is there' necessitates an all-consuming, laser-like focus on narrowly selected challenges, and lavishing vast sums of money via highly technocratic prescriptions. The venture capital method is problematic for several reasons.
It means de-prioritising other equally pressing needs and making highly contentious value judgements on the issues that are more or less worthy. We normally do that through debating the choices we want our governments to make, and holding them accountable, however imperfectly.
Private philanthropies are not held responsible in the same way, especially when their well-meaning interventions can shift at will or when they shut shop, as the Gates Foundation will do in 2045.
Questioning cost benefits
Could its legacy become an unsustainable burden for successor generations? Take, for example, the laudable Gates goal to eradicate wild polio that, after decades of successful global efforts, lurks only in Afghanistan and Pakistan.
These fragile states extract high marginal costs for allowing the last wild virus to be chased down. Whether that is achievable is conditioned by prevailing social and political circumstances.
So, how much is worth spending on eradication when existing strategies to protect the rest of the world through vaccination, surveillance and outbreak response could be more cost-effective? The counter-argument is that permanent polio eradication would save the world $40-50-billion. But is that sufficiently significant in a multi-trillion-dollar world?
Furthermore, would it be better for long-suffering Afghans and Pakistanis to switch their earmarked polio funds into broader health and social services that bring wider progress that eventually catalyses polio eradication at a lesser eventual cost? However, this could take longer than 2045. Understandably, Mr Gates is impatient while we wish him a long life.
Vertical focus on selected conditions
Comparable concerns are raised by verticalised strategies that capture large Gates resources for diseases such as malaria, measles and tuberculosis.
Inevitably, that skews multilateral health co-operation through boosting global funds such as for Aids, TB, malaria, and for vaccines. They also distort our global health institutions such as the World Health Organization, whose $6.8-billion budget for 2024-25 (before recent cuts) included a 10% ring-fenced allocation just for polio.
The Gates focus on maternal and child mortality raises further questions because the underlying causes are difficult to shift. Take South Sudan, with the world's most appalling maternal mortality rate of 1,223 per 100,000 births. Against the country's backdrop of conflict, displacement, poverty, misgovernance, disaster, climate change, absent infrastructure and absent trained personnel, the contribution of technical healthcare innovation is useful, but relatively marginal.
How much is therefore worth spending on maternal and child health alone while the all-ages crude death rate hovers above 1,190 per 100,000 population? If Mr Gates asks the people of South Sudan how to spend his money, what difficult choices would they make?
Bill Gates is highly methodical as befits a smart techbro. His lodestar is metrics, which means getting only what he measures, not more, such as reducing Aids deaths by two-thirds between 2000-2023, or now aiming to halve under-fives' mortality from five million in 2019.
A list of other conditions for statistically demonstrable demolition awaits.
Technocratic versus holistic paradigms
Reducing specific disease burdens helps, but does not equate to health. This is constitutionally defined by WHO as 'physical, mental and social wellbeing and not merely the absence of disease'.
The metrics for that are not precise and, therefore, less amenable to narrow technical fixes. Take, for example, addictive behaviours and cognitive disorders such as dementia, or making reproductive health choices. Obesity was, until recently, in the same category of complex aetiology. But now we have the GLP-1 agonists revolutionising weight loss, and there are promising new therapies for dementia.
Gates may yet be proved right with the invention of pills and jabs for all types of ailments. If enough resources are thrown at selected problems, some are bound to stick, but at huge opportunity costs for other important challenges.
Nevertheless, at least Bill Gates is fixated on saving present humanity here, while the world's richest man, Elon Musk, is investing heavily to send sizeable numbers of refugees from a doomed Earth to Mars by the 2040s, so as to keep the human genome alive.
Philanthropic influences on democratic policymaking
The Gates and Musk outlook brings into focus the technocratic versus holistic approach to life. The impact of the mega-rich on American policy in the Donald Trump era is a possible harbinger of similar influences on the world stage that may lead to comparable tectonic shifts for global health and development structures, approaches, and financing.
The consequences should concern us.
But there is a counter-reaction. Shifting geopolitics means that top-down solutions are no longer acceptable. That applies even for poor countries suffering from heavy budgetary cuts at the WHO and bilateral donors.
They may welcome more Gates support, but want the dignity of charting their own paths without constant hectoring on what is good for them. While that worked with the partially successful Millennium Development Goals, it is resented in the era of assertive nationalism, shrinking aid and failing Sustainable Development Goals.
A debatable legacy
Against this world mood, the Gates Foundation will face considerable headwinds despite, and perhaps because of, its supersized purse. Does it have strategies for that, or the flexibility to alter course, considering the straitjacket of its religion-like mission?
Perhaps the Gates legacy would be more likely to endure if his foundation listened more, preached less, and was open-minded to extend beyond its narrow silos. Otherwise, the risk is of countries left high and dry in two decades, as is happening now with donors walking away from previous commitments.
There are greater implications still of how supersized private charities end up directing our societies. Do citizens want that?
Large-scale philanthropy – however humanitarian-minded – is yet another ideology in our divided world. It is best imbibed in small doses under strict advice. DM
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