by Swetha Ananth and Natalie Rauscher

Can (mega) philanthropy cure the world? In an attempt to answer this complex question, this article will offer a glimpse into the world of mega philanthropy, focusing on global health and more specifically on the area of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS)-related efforts. American philanthropy has played a significant role in this field for over two decades. In fact, American foundations have been active in the field of global health almost since the beginning of foundations in the early 20^th century. But today, arguably the most significant foundation in the field of global health is the Bill and Melinda Gates Foundation (henceforth Gates Foundation).

The Gates Foundation and global health challenges

The Gates Foundation, founded in 2000, is endowed with about $50 billion which makes it the largest private foundation in the world. Contributors are mainly the Gates family and Warren Buffet, legendary American billionaire investor. (Economist 2021) Since its inception, the Gates Foundation has distributed $60 billion in grants across different disciplines. (Burki 2022)

Since the beginning, a focus point of the foundation’s work has been global health. In this field it has been instrumental in establishing global health initiatives and partnerships with several international actors including the World Health Organization (WHO), the GAVI Alliance, the World Bank and the Global Fund to Fight AIDS. Many more initiatives, universities and non-governmental institutions have received grants from the Gates Foundation. (McCoy et al. 2009: 1645) It is now the second-biggest funder of the WHO, only behind the United States government and, according to the OECD, the Gates Foundation’s budget on global development is competing with that of many states, ranking 12^th among nations like the US, Germany or the EU. (Economist 2021) In 2021 alone, the foundation spent over $1,7 billion on its global health program. The total of “charitable support” that the Gates Foundation provided in 2021 lay at $6.7 billion. (see 2021 annual report).

But what exactly does the Gates Foundation focus on in the field of global health? In its latest report from 2021, there are several separate projects inside the Global Health program that received funding. Malaria and Vaccine Development tops the list with $276 million and $230 million of grants each. Spending on HIV comes third with $220 million in 2021. Other areas in the global health program include maternal health, technology solutions, tuberculosis, special initiatives in global health, neglected tropical diseases, pneumonia, enteric and diarrheal diseases, integrated development and innovative introduction. Additionally, the Gates Foundation has a more general ‘Global Development’ Program that includes health subjects such as Polio, family planning, or maternal and newborn health.

In absolute terms, the Gates Foundation has increased its spending on global health projects but given the overall spending increase, global health spending has remained around 26-30% of total spending by the foundation over the years (see Table 1). HIV and Malaria have always been among the most important specific diseases targeted by Gates Foundation grants.

Table 1: Gates Foundation Spending on Global Health

Year	Global Health Spending	Total Spending
2016	~ $1,19 Billion	~ $4,5$ Billion
2017	~ $1,26 Billion	~ $4,7 Billion
2018	~ $1,34 Billion	~ $5,0 Billion
2019	~ $1,45 Billion	~ $5,09 Billion
2020	~ $1,79 Billion	~ $5,8 Billion
2021	~ $1,75 Billion	~ $6,7 Billion

Yet, the share of global health funding spent specifically on HIV has actually decreased over the years (Table 2). Some of it can certainly be explained by redirecting the attention to the Covid-19 pandemic and the focus on vaccine research, especially in the years 2020-21. Other reasons could be that other (governmental and nongovernmental) actors have taken over initiatives after initial investment by the Gates Foundation.

Table 2: Gates Foundation Spending on HIV

Year	Spending of Global Health Budget on HIV
2021	~ $220 Million (~ 12%)
2020	~ $196 Million (~ 10%)
2019	~ $191 Million (~ 13%)
2018	~ $215 Million (~ 16%)
2017	~ $228 Million (~ 18%)
2016	~ $215 Million (~ 18%)

Although the Gates Foundation remains the biggest private funder in the field, the overall trend seems to be that global philanthropic funding to fight HIV/AIDS remains relatively flat and that there is a retreat by other philanthropic actors, according to an article in Health Affairs called Are Funders Still Focusing on HIV/AIDS?. This is a concerning trend given that there are still millions of people getting infected with HIV around the globe each year.

HIV/AIDS: A Forty-year-old global threat

Among the spectrum of infectious diseases, viral outbreaks have had the deadliest and the most society-altering consequences. For example, the Spanish flu in 1918 took approximately 2 million lives within a short period of time. The emergence of AIDS in the early 1980s, and more recently, COVID19 are also key examples. AIDS, caused by HIV, is an immunocompromised condition that is a consequence of destruction of specific immune cells by the virus. The virus has a long period of latency (asymptomatic phase) that can last for several years before rapid decline in immune function, onset of symptoms and AIDS begin (Figure 1). Research and development in the early 1990s led to the development of potent antiretroviral therapy (ART) that till-date keeps the virus under control and improves immune cell counts in most patients offering them a normal lifespan provided they undergo lifelong treatment (Figure 1).

Lifelong treatment is required as HIV can exist in a silent phase (‘latency’) in certain cellular compartments in the body during ongoing treatment. Upon treatment interruption, the inactive virus can become active and contribute towards rapid progression of the disease. Research in this area is focused on defining the specific compartments the virus chooses for its latent behavior and the underlying mechanism to develop targeted treatment during early phases of infection. Access to ART and following an uninterrupted treatment regimen is difficult in middle-to-low-income countries such as Africa and Asia, where newly infected cases are constantly on the rise adding up to currently 38 million active cases in the world (Figure 2).

There is no preventative vaccine yet, however, researchers have been trying several strategies for the past two decades. Vaccines against the influenza virus that causes the flu or coronavirus are developed based on a specific molecule that is a part of the virus (called an ‘antigen’) that is known to elicit good immune responses which would render protection during natural infection. However, HIV infection results in the existence of an extremely high number of mutants (different versions of the virus that can possess different magnitude of functions) within the same person and a single molecule that mimics this in uninfected individuals has not been identified so far. Most vaccines developed for HIV failed to elicit a good immune response in healthy adults and even if they did, they were unable to control progression of disease in high-risk patients that were infected post vaccination. Therefore, more collaborative research is essential to reduce the global HIV burden and improve the quality of life, especially in areas that have high infection rates.

The Gates Foundation has been at the forefront of funding several open questions in the field. The strategy of the foundation in fighting HIV/AIDS has been to fund existing infrastructure and push them towards result-oriented performance. This has helped set up a working framework in several regions that are hotspots for infection, granting treatment and prevention access to thousands of infected patients and high-risk individuals, respectively. Significant contributions have been made towards improving the lives of communities in regions of sub-Saharan Africa, where a high number of people live with active infection, by offering access to healthcare, posttreatment follow up and treatment adherence management activities. Vaccine development and cure are supported by funding larger research institutions such as the American National Institutes of Health (NIH) or multinational pharmaceutical companies like Novartis. For example, the latter has set up specialized research groups funded by the foundation to conduct preclinical studies that will hopefully lead to “single shot” cures like gene therapy for different diseases, including AIDS. The latest grants bestowed by the Gates Foundation in the field include a $4,5 million grant to the WHO to support HIV prevention and over $282,000 grant to the London School of Hygiene and Tropical Medicine to look at the role of stigma around HIV prevention and treatment.

Philanthropy in global health: The good and the bad

As we have seen, the Gates Foundation has been active in the field of global health for over two decades and has contributed to a wide array of efforts. The fight against HIV/AIDS has always been on the forefront of the Gates’ agenda. Being such a big player in the field, there has always been a significant amount of criticism mounted at the Gates Foundation.

Generally, foundations are organizations with little transparency and outside scrutiny in comparison to other international institutions. In the case of the Gates Foundation, a small number of American billionaires are essentially stirring the field of global health in many regards without democratic control. Additionally, already in 2009, the medical journal The Lancet criticized the Gates Foundation for still spending most of its funds in the Global North, not in the areas they wanted to target. The Lancet found that 40% of the Gates Foundation spending went to supranational organizations, and 82% of the rest was going to recipients based in the USA. One third of funding was directed to research and development or to basic science research. (McCoy et al. 2009: 1645) In the context of the fight against HIV/AIDS, this is, to a certain extent, understandable as basic research in the field is often done at Western research facilities. But not all the funding goes to basic science research. Therefore, the criticism against the Gates Foundation in this context seemed warranted at the time. Since the article appeared in The Lancet in 2009, there has been some improvement in this regard. The share of grants by the Gates Foundation going to both the Asian and African continent has steadily increased since 2009 with approaching between 10-20% of grant share over the years. (Economist 2021) Many of the grants, especially in research and development, still go to the Global North, however. This is due to several circumstances including established research facilities involved in cutting-edge research.

Connected to the criticism about spending in the Global North vs. the Global South, meaning that more money is spent in developed, Western countries rather than in the developing world, is another criticism launched at the Gates Foundation. This revolves around its strategy that insists on an ‘effective approach’ modeled on business practices which emphasizes the need for measurable results and pushes for ‘technological solutions.’ (Economist 2021) This approach of ‘effective philanthropy’ is certainly not a new or unique one to the Gates Foundation. In fact, many American foundations and especially the ones active and founded in the 21^st century have embraced a mindset that is close to that of business and tech investors. The problematic aspect of such an approach is that some progress is not easy to measure and implementation of new ideas and practices in a different cultural context might not be as straightforward as a foundation and its program officers imagine. Additionally, the pressure to create desired results and to keep up the money stream can lead to a lack of resources in other areas, e.g. in the general health care sector or can create overburdening bureaucracy, especially for smaller actors.  (Economist 2021) This is certainly connected to the funding of HIV/AIDS research or other viral diseases by foundations like the Gates’. By funding these subjects with enormous sums, other vital areas such as general capacity in the health care sector might be neglected which can in turn have detrimental effects on overall health and access to care. Criticism in this regard has been launched at the Gates Foundation because they allegedly were not taking into account the diversity of the contexts they were operating in around the globe. Answering to this criticism of a lack of diversity to some extent, the Gates Foundation launched their DEI (Diversity, Equity and Inclusion) Initiative in 2020. This initiative is directed inwardly at the foundation itself and wants to address the criticism targeted at lack of diversity. But it also wants to eventually change the engagement with organizations and grantees around the globe. Whether this will prove successful and will be more than just publicity remains to be seen.

Overall, however, there definitely seems to be a willingness to address some points of criticism at the Gates Foundation. As mentioned, more money is spent in Africa and Asia and the sole focus on technological solutions and measurable results is also changing in the Gates Foundation as they have taken on new issues such as family planning, women’s rights or capacity building in the health care sector. A more holistic approach that takes into account different cultural contexts and actors is especially pushed by Melinda French Gates inside the foundation (Economist 2021) which she also describes in her book The Moment of Lift.

Is philanthropy curing the world?

We set out with the question whether mega philanthropy can cure the world and as anticipated – there is no easy answer! The Gates Foundation is the biggest private player in the field of global health today and their funding in many areas is crucial. Their work in the field has also produced a lot of attention around neglected diseases that still haunt many regions of the Global South. But how successful have they been?

Many global health issues cannot be fought by a single entity such as government bodies, biopharmaceutical companies or philanthropy alone. The strategy of the Gates Foundation, therefore, relies on scaling up existing interventions with high potential rather than investing in new ventures to enable cross functionality with an aim of more successful outcomes. Due to these large collaborations, it is difficult  to precisely measure the success of a single investing body. However, other areas of focus such as treatment expansion and prevention have directly benefitted several low income and minority communities in regions of south-east Asia and Africa.

Overall, both new infections and deaths from HIV/AIDS have been falling since the late 1990s and early 2000s (Figure 3) and whereas it is clear that the Gates Foundation has not – and will not – cure HIV/AIDS on their own, their funding has been and continues to be one vital component in the overall response to HIV/AIDS. The continued effort to fund projects in the area of HIV/AIDS by the Gates Foundation remains crucial, especially because other private donors and governments seem to somewhat turn away from the issue. This is an overall concerning trend because there are still millions of people getting infected with HIV around the globe every year. (Prina 2020)

Generally, mega philanthropy has not and cannot cure the world on its own but can give important impulses. To truly address issues and to maintain control and transparency, governments and international organizations must lead efforts in the field of global health. Nevertheless, private actors like the Gates Foundation are part of the equation and one can see that despite continued criticism, the Gates Foundation has tried to address certain aspects. This includes the direction of funding away from the Global North into the Global South, especially to Asia and Africa, and a change in assessment and implementation of measures towards a more holistic approach that tries to take into account local contexts and cultures. A push for more diversity and equity inside the organization is also ongoing. Although questions about transparency of funding continue, after over 20 years of activity in a global context the Gates Foundation has seemingly tried to learn from experience that ‘scaling up’ results is complex and only possible by addressing the diverse contexts the organization is operating in.

Overall, it seems that the influence of US philanthropy in the field of global health is here to stay and has an important part to play. At the same time, the outsized influence of a handful of wealthy donors over the direction of global health policy will continue to face further scrutiny in the future.

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This article was a result of interdisciplinary collaboration through the Young Marsilius Fellowship 2021-22

Authors

Swetha Ananth is a postdoctoral researcher at the University Hospital Heidelberg interested in exploring viral biology. She actively shares opinions about being a scientist and her multicultural experiences from living in different continents through her blog.

Have a look at Swetha’s Blog here

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Natalie Rauscher is working as a postdoctoral researcher at the Heidelberg Center for American Studies. Her research interests include discourses on the future of work as well as the rise of the platform economy in the United States. She is also working on topics like social movements, social media, American philanthropy and think tanks, and the impact of natural catastrophes in the United States. In December 2020, she successfully completed her Ph.D. in American Studies. She is a founding member of the HCA Graduate Blog.

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References

Burki, Talha. 2022. “Fresh questions over Gates Foundation governance.” The Lancet 399 (5): 508.

Economist. 2021. “The Gates Foundation’s approach has both advantages and limits.” The Economist.

McCoy, David, Gayatri Kembhavi, Jinesh Patel, and Akish Luintel. 2009. “The Bill & Melinda Gates Foundation’s grant-making programme for global health.” The Lancet: 1645-1653.

Prina, Lee L. 2020. “Are Funders Still Focusing on HIV/AIDS?” Health Affairs 39 (9): 1647-1648.

Header Image: HIV Virus Transmission electron micrograph of HIV-1 virus particles (red) replicating from the plasma membrane of an infected H9 T cell (blue).
Image captured at the NIAID Integrated Research Facility (IRF) in Fort Detrick, Maryland. Credit: NIAID

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