For decades, following failed efforts in the mid-20th century to eradicate malaria, global policy aimed to control the disease. However, in a single moment late in 2007, Melinda Gates switched the world back onto eradication. Today that aim is more distant than five years ago because of drug resistance, a paucity of new drugs, the failure of bed nets, and slim prospects for an effective vaccine. These developments raise questions about eradication and how the world sets global health policies.
Speaking at the first World Malaria Forum, convened by the Gates Foundation in 2007, Melinda Gates said the moment represented a “historic opportunity not just to treat malaria or to control it—but to chart a long-term course to eradicate it.” Director general of the World Health Organization (WHO), Margaret Chan, converted on the spot and, from the audience, stood to voice her approbation. Thus was a policy decided that affected hundreds of millions people. The small audience of blue-ribbon researchers and policy makers sat stunned. Eradication had been embarrassing or even catastrophic decades before. In just minutes and without peer review, eradication was back.
The last disease officially targeted for eradication was polio. In May 1988, the World Health Assembly, governing body of WHO, unanimously endorsed a polio eradication resolution. Regarding whether there would be a vote on malaria eradication, a Gates Foundation spokesperson said: “Not as far as I know.” However eradication remains the de facto goal of malaria policy.
Towards the end of 2007, the head of malaria at WHO, Arata Kochi, spoke out against these incursions on WHO turf. He circulated a memo describing a "cartel" of leading malaria researchers assembled and funded by the Gates Foundation. Kochi noted “intense and aggressive opposition” from Gates-backed scientists and the foundation. His memo recommended that WHO “stand up to such pressures and ensure that the review of evidence is rigorously independent of vested interests.” Kochi was replaced after his memo leaked to the New York Times.
Behavioral economics
Over the last dozen years, WHO has been slowly going broke. By the time of the 2007 Gates Malaria Forum, the purchasing power of WHO’s budget had fallen by almost 25 percent compared with 2000.
Going down: WHO’s weighted purchasing power. (Source: WHO)
Adding to these difficulties, half the WHO budget formerly came directly from member nation contributions. Increasingly, however, WHO has been forced to scurry, hat in hand, competing for grants with many non-government organizations and other entities. By 2006, such “voluntary” contributions tied to specific activities reached three quarters of WHO’s budget, and they have stayed there. By 2010, the Gates Foundation was the second largest voluntary contributor to WHO, providing $220m, more than the United Kingdom. According to Chris Murray, professor of global health at the University of Washington, “the behavior of organizations is profoundly affected by where they get their money from.” Most funding for global health comes from nation states, yet the foundation wields a disproportionate influence. According to Murray, “the influence of the Gates Foundation far exceeds the fraction of development of assistance for health that channels through their resources.” The reason, he continued, “is the way they have been funding and who they have been funding around the world.”
Gates’ man in Geneva
The United States is by far the largest funder of WHO, contributing 23 percent of WHO’s discretionary budget, nearly twice that of the next largest contributor, Japan. As the leading WHO funder, the US begins with more influence than any other nation.
Wielding that influence is Nils Daulaire. In late 2010, President Obama nominated Daulaire to be the US representative to the WHO executive board. Prior to his nomination, Daulaire served for more than a decade as president and CEO of the Global Health Council. In 2000, Daulaire’s non-profit became responsible for selecting the winner of the $1m Gates Award for Global Health. Since 2000 the Global Health Council received more than $36m from the Gates Foundation, about 40 percent of the Council’s revenue, according to Daulaire.
Daulaire said he "does not see the Gates Foundation or private entities as having a rightful role in establishing WHO’s priorities.” He dismisses suggestions that the Gates Foundation has an outsized role although he said: “There are member states who believe the Gates Foundation has more influence than it ought.” Daulaire said it is “entirely wrong” that the United States is increasing the foundation’s role.
Nils Daulaire at the 2011 World Health Assembly (Source: US Mission Geneva)
Following Daulaire’s nomination, reform of WHO rose to the top of its agenda. WHO “hit a financial wall” in 2011,” according to Daulaire. He said the United States was not a prime mover on reform which he described as driven by economic considerations. But in a statement before the 2011 World Health Assembly, Daulaire said the "financing discussion has sparked an important discussion on the role of WHO at the center of global health and how to ensure the organization is best placed to respond to the challenges of the 21st century." Making these determinations would be a private consulting firm paid by the Gates Foundation.
WHO's executive board passed a proposal that addressed “the overall design of the program of reform,” one which would reengineer WHO head offices and the entire organization. The comprehensive review and changes would extend to “all expected results, indicators, targets and baselines.” Money for this rewrite of WHO’s institutional DNA had “been secured from the Bill & Melinda Gates Foundation,” according to the resolution. Daulaire said he had no involvement arranging the Gates funding. WHO staff are “given the license to hunt” for funds, he said. The Gates Foundation declined comment concerning its involvement in WHO reform.
The reform resolution also called for creation of a new entity, the World Health Forum. Its charter was to “define the rules of engagement in global health,” particularly among its many players. The Forum might potentially have revised the central role of WHO and the World Health Assembly, perhaps institutionalizing a role for privately-funded organizations, including corporations. Planning for the first World Health Forum, originally scheduled for the end of 2012, was to be funded by the Gates Foundation. But the proposal “received little support,” Margaret Chan told the executive board in November 2011, and the idea was shelved.
Nonetheless, the World Health Assembly (WHA) has adopted key policies initiated by the Gates Foundation, setting the global health agenda in the near and long term. The WHA adopted the foundation’s “Decade of vaccines” vision, first articulated by Bill Gates. Vaccines are hardly new to global health. But the idea of placing at them at the center of global health for the next ten years originated from the Gates Foundation. A foundation press release referred to “the January 2010 call by Bill and Melinda Gates for the next ten years to be the Decade of Vaccines. “ In 2011, Gates addressed the WHA, pressing for his vaccines vision. "Our priorities are your priorities," he said. He pointed to a shared interest in child and maternal mortality before talking "about how you can provide the leadership to make this the Decade of Vaccines." In 2012, the WHA gave Gates' vision its stamp of approval.
Shorter term, the Gates Foundation’s highest priority is polio eradication. Following a vote at the 2012 WHA, polio eradication is now the sole health emergency worldwide. The US delegation co-sponsored both the decade of vaccines and polio resolutions. “We were an early mover on polio,” said Daulaire of the polio resolution. But Daulaire claimed that on polio, WHO led and the foundation followed. In email he wrote: “The Gates Foundation's wishes and priorities were not a consideration in the WHO debate, but it's nice that they are on board.” Chronologically, however, the Gates Foundation ratcheted polio to its top priority in 2010, with WHO following two years later.
With WHO’s disempowerment has come a drift toward irrelevance. “WHO would like to be a partner and work with you,” Margaret Chan importuned at a Gates-funded gathering of global health influentials in 2010. But confidence in WHO’s capacities has dwindled. In a particularly embarrassing revelation, academics Chris Murray and Alan Lopez reported in 2004 that WHO couldn’t count: “The sum of deaths claimed by different WHO programs exceeded the total number of deaths in the world.” Each disease department exaggerated deaths in a bid to maximize funding. Also, because WHO is comprised of member states, political considerations also influenced estimates, according to Murray and Lopez. They concluded: “the only viable solution will be to create a new, independent, health monitoring organization.”
Independent of who(m)?
In 2007, the Gates Foundation awarded Murray a 10-year, $105 million grant for a new Institute for Health Metrics and Evaluation (IHME), affiliated with the University of Washington. Murray’s group took a wrecking ball to WHO’s already crumbling credibility. Using new methods, IHME published different estimates than WHO for child, maternal and, most recently, malaria mortality.
IHME has become an alternative, perhaps preferred alternative, for global health metrics, displacing WHO and other UN-related entities. The Lancet endorsed IHME’s methods and results by cosponsoring a conference with IHME on maternal and child mortality in 2010. At the conference, Lancet editor Richard Horton said global health metrics had “broken out of traditional citadels,” bringing a “democratization of health.”
IHME's Murray had lectured his students that “the behavior of organizations is profoundly affected by where they get their money from.” And IHME’s research and publicity on malaria, specifically bednets, may reflect Gates Foundation influence. IHME claimed bednets prevented deaths from malaria in a press release although their research did not support such a claim. (See the previous story in this series: Bednets are failing.)
From overstatement, IHME passed to non-statement on bednets. Earlier this year, a headline-making IHME paper in the Lancet on malaria mortality was silent on whether bednets saved the lives of African children even though hundreds of millions of nets have been distributed in one of the world's largest health interventions.
The paper did say, however, that bednets did not reduce deaths of adults in Africa. Only in email did IHME's Stephen Lim write “ITNs [bednets] were a statistically significant predictor of African child mortality,” meaning bednets did save children under five in Africa from dying of malaria. If true, however, it is unclear why the peer-reviewed paper omitted such an important finding. IHME declined to answer questions in email regarding the statistical basis for the claim. Lead author of the paper, Chris Murray, did not reply to an email asking for confirmation of Lim's statement.
A Lancet editorial accompanying the IHME study said that "One aspect of the findings that is unlikely to raise objections is the implication that interventions scaled up since 2004 have been phenomenally successful in reducing the number of malaria deaths." The successful interventions included, said the editorial, the distribution of anti-malarial drugs and 230 million bednets. But the only finding on bednets in the IHME paper was a negative one, that nets did not save adults.
Lancet, heal thyself
In 2010, the Lancet ran a series on malaria elimination. An accompanying comment, co-written by Horton, concluded that the goal of elimination was “worthy, challenging, and just possible.” Although none of the Lancet articles carried notice that the series was externally funded, support came at least in part from the Malaria Elimination Group (MEG) which is funded by the Gates Foundation.
The series labeled MEG as a "collaborating partner." Other Lancet series, health and climate change, for example, identify collaborators and funders separately. Other series (e.g. health in Brazil) have neither collaborators nor funders.
Asked about funding of the malaria series, Lancet spokesperson Tony Kirby initially said in email that “ 'supported' means led, devised, and written by members of MEG.” The usual financial connation of "supported" did not apply.
However, in subsequent correspondence, Kirby acknowledged a funding role for MEG: “All external funds are raised by the partners we work with to do the academic work and analysis that forms the basis of the Series, to have a peer review meeting, and for a launch.” Asked whether the external funds for the malaria series ought to have been disclosed to readers, Kirby did not reply.
The Lancet puts malaria elimination under the microscope and examines the technical, operational, and financial challenges that confront malaria-eliminating countries.
However, a group with malaria elimination as its goal largely authored and provided funding for the series published in the Lancet which provided no disclosure of the external funding.
"There is a definite lack of transparency," wrote Ana Marusic in email of the non-disclosure by the Lancet. Marusic co-authored a New England Journal of Medicine paper updating the conflict of interest policy for the International Committee of Medical Journal Editors (ICMJE). The Lancet, according to its website, is a signatory to ICMJE's guidelines. "Financial relationships," read the ICMJE requirements, "are the most easily identifiable conflicts of interest and the most likely to undermine the credibility of the journal, the authors, and of science itself."
Alongside the malaria series, the Lancet published a laudatory profile of the head of MEG entitled, “Richard Feachem—scaling the heights of global health leadership.” MEG is coordinated by the Malaria Elimination Initiative, part of the Global Health Group at the University of Califormia, San Francisco. Feachem declined say to what portion of his funding for malaria comes from the Gates Foundation. His group won Gates grants for malaria of $9 million in 2010 and $5 million in 2007.
More ambigously yet still potentially worrisome, in late 2011, the Lancet received a paper reporting the spread of drug resistant malaria to western Thailand. Recognizing the importance of the findings, the Lancet fast-tracked the submission for publication within four weeks. However, the paper was then taken off the fast track. It languished for months. According to one of the paper’s authors, who did not wish to be identified, only the publication of a related paper in Science caused the Lancet to publish it, nearly six months after submission. The authors wondered if their paper had been intentionally suppressed because it seemed like bad news for malaria elimination efforts. “We never comment on internal procedures relating to our papers,” wrote Lancet spokesperson Tony Kirby in email.
Oversight: Congress and malaria
Gates Foundation: well-represented at congressional hearing on malaria (Source: CSPAN)
The United States is one of the largest funders of anti-malaria efforts through the $5 billion President's Malaria Initiative. In December of 2011, the House Committee on Foreign Affairs held a hearing on global efforts to eliminate malaria. The goal of elimination was set by the Gates Foundation—and the committee mostly heard from the Gates Foundation concerning progress. Only one member of the six-person panel came from an organization not funded by the foundation: Richard Bate of the American Enterprise Institute.
By contrast, panelist Regina Rabinovich served as the Gates Foundation's director of infectious diseases. The other panelists came from PATH, Malaria No More, the Medicines for Malaria Venture and the US Global Leadership Coalition, each recipient of $10 million or more from the Gates Foundation.
PATH runs the Gates-backed Malaria Vaccine Initiative which has shepherded the RTS,S vaccine into final clinical trials. PATH won the very first Gates Foundation grant in global health, $250,000 for family planning and birth control in 1995. In 2011, PATH received 14 grants totaling $81 million, according to the Gates Foundation website. (See the third story in this series: The long struggle: vaccines against malaria.)
Malaria No More has won more than $10 million in Gates funding to support advocacy efforts. In 2009, Malaria No More partnered with Ashton Kutcher who raced CNN to one million Twitter followers to raise awareness for bednets.
The Medicines for Malaria Venture has received significant Gates Foundation funding in its pursuit of new anti-malarial drugs, most recently a $134 million grant. (See the second story in this series: After artemisinin: searching for the next front-line malaria drug.)
The US Global Leadership Coalition (USGLC) lobbies Congress on foreign aid, "advocating for increases in the International Affairs Budget," according to its website. USGLC has received more than $11 million in Gates funding for advocacy since 2007.
The 2011 panelists raised concerns and caveats about progress against malaria, but the hearing represented an "opportunity to testify on the great strides we have made and are making toward eliminating malaria," as Malaria No More's David Bowen testified. Bowen echoed the comment of an earlier panelist and emphasized that malaria was "an underpublicized and underappreciated success story..."
Some testimony overstated progress. The Gates Foundation’s Regina Rabinovich testified: “When I visited The Gambia ten years ago, there were three children to a bed for a disease that has almost disappeared from The Gambia ten years later.” However, malaria “is far from disappearing,” according to Umberto Dalessandro, who works on control and elimination for the Medical Research Council in The Gambia. Malaria has been greatly diminished but most of the country remains at medium-high levels of transmission, according to the Malaria Atlas Project. The Gambia is not pursuing elimination.
Malaria in The Gambia: Darker means more malaria. Areas in white are neighboring countries (Source: Malaria Atlas Project)
Richard Bate of the American Enterprise Institute was the only panelist without financial ties to the Gates Foundation. Bate also testified about malaria in 2004. The composition of the panel then was very different. Besides Bate, the other two panelist came from government organizations, representatives from USAID and the World Health Organization. By 2011, Congress heard mostly the voice of the Gates Foundation. WHO has been supplanted. And USAID, which directs most of the US foreign aid budget, today is helmed by Rajiv Shah who spent seven years at the Gates Foundation.
Bill & Melinda Gates: peerless, reviewless
When Melinda Gates switched the world to malaria eradication in 2007, it wasn’t on the basis of peer-reviewed science but because she was able to see “all the way to the horizon,” as she put it at the 2011 Gates Malaria Forum. By contrast, she does not advocate tuberculosis eradication because of scientific unknowns.
But the scientific examination of what would be needed for to eradicate malaria came three years after commitment to that goal, and science has put the horizon much further out than Melinda Gates’ own estimate. Pedro Alonso, who oversaw the Gates-funded MalERA initiative delineating the science needed for eradication, described it as a “massive research agenda.” Even the half-way point lies an unknown distance ahead. Brian Greenwood, of the London School of Hygiene and Tropical Medicine, said: “What needs to be done scientifically is more challenging than what has been done.”
Meanwhile, to sustain the eradication vision, Bill Gates leaned on non-peer-reviewed science. At the 2011 Gates Malaria Forum, he described models as “quite exciting” and presented one developed by Intellectual Ventures, run by Nathan Myhrvold the former chief technology officer at Microsoft. Myrhvold's training is in theoretical physics and mathematical economics. His two peer-reviewed papers are on dinosaurs. Based on Myhrvold’s malaria model, Gates said that adding a 50 percent effective vaccine—like the Gates-backed RTS,S—to existing interventions of insecticides, bednets, and antimalarial drugs, could locally eliminate malaria.
Bill Gates at the 2011 Gates Foundation World Malaria Forum
Remarkably, elimination advocates are uncertain which country represents the greatest victory so far over malaria. Asked what country overcame the most intense malaria transmission so far, MEG’s Richard Feachem said that was “a very good question.” He did not know the answer. No one does. The best guesses are Taiwan or Singapore, which got rid of malaria decades ago, in 1965 and 1982 respectively. Both are islands (greatly aiding elimination) and comparatively wealthy. Malaria is at least ten times more powerful in its African strongholds. However, Feachem believed that the world had paid insufficient attention to the recent accomplishments of Morocco and Turkmenistan in eliminating malaria.
Modern day Cassandra
Nearly every aspect of malaria from research to policy and advocacy is influenced and sometimes controlled by the Gates Foundation. “Everyone is a client,” Chris Murray, lectured his global health students in 2008. (Murray did not mention that IHME is as well. In 2011, Murray received a salary of $460,000 according to state records, making him the highest paid tenured professor at the University of Washington.) Vocal opponents like the former head of malaria at WHO, Arata Kochi, are removed. Many rank-and-file scientists keep quiet. “I’m not sure if I would tell a journalist I don’t believe eradication is possible,” said one anonymous Gates-funded researcher.
A number of Kochi’s 2007 allegations seem supported by current evidence. He claimed the foundation “takes its vested interest to seeing the data it helped generate taken to policy.” The foundation has funded testing and development of the RTS,S vaccine. That vaccine seems not only part of Bill Gates’ modeling exercise: the foundation’s continued support suggests it may push for licensing and deployment of the vaccine. Acting as judge, jury and advocate, warned Kochi years ago, “could have implicitly dangerous consequences on the policy-making process in world health.” He described the foundation’s decision-making as “a closed internal process, and as far as can be seen, accountable to none other than itself.” For this series, the Gates Foundation declined comment on the spread of drug resistant malaria, the failure of bednets, concerns about the effects of RTS,S on transmission and the foundation’s involvement in the remaking of WHO.
Bill and Melinda Gates are following in the footsteps of the Rockefeller Foundation, which arguably invented global health roughly a century ago. However, with the advent of the World Health Organization in 1948, the Rockefeller Foundation ceded its de facto leadership to that new institution of civil society. Today, global health appears to be passing back into private hands.
The Gateses are noble people embarked on an admirable and exceedingly difficult mission. Their foundation is a force for good. The best way to save lives, however, is not to dominate science or democratic institutions. A surfeit of zeal can actually harm the battle against malaria: “The history of special antimalarial campaigns,” reads a 1927 League of Nations report, “is chiefly a record of exaggerated expectations followed sooner or later by disappointment and abandonment of the work,” a cycle that has already been repeated.
A new one seems to have begun. In 2012, American Idol finalist Katharine McPhee told USA Today "I feel like (ending) malaria – like hunger here in the United States – is easily attainable." McPhee's statement is simply false. Although Bill and Melinda Gates are much more circumspect, their support underlies the misleading USA Today story: the article arose from McPhee's trip to Africa with Malaria No More—fueled by a $7.3 million grant from the Gates Foundation.