Gates Foundation vs the Lancet

The Lancet has published an academic paper analyzing the deployment of funds at the Gates Foundation against a backdrop of the actual burden of disease. The bottom line is the Gates Foundation does not come out looking too good, seemingly interested in whizbang gadgets and not in focusing on the job at hand. Another really interesting and sad note was the extent to which being nearby the Gates Foundation, geographically or culturally gets you in the money. PATH and the University of Washington raked in the cash. African researchers? Not so much.

At the same time, the Lancet published an editorial and a commentary. Of course, being academics, you know the knives are going to come out and some serious backstabbing is going to happen. (“They fight so hard because the stakes are so low.” Sigh.) They saved the really rude things for the editorial, a particularly cowardly form of academic infighting, as that way no one has to put their name on the insults. At least the commentary is signed, though in keeping with the fact they will be held accountable for their words, they are much more restrained.

The thing that most pissed me off about the Lancet’s editorial is the stuff about transparency. They whine and moan about how the Gates Foundation didn’t come ask them what to do. You know what, all you Masters of the Public Health Universe? You had your chance. You wasted 100 fucking years, and things just got worse and worse. Some of you were wanking, writing useless papers. Some of you were too busy teaching the next generation of wankers to go out and find out what its like to be poor. The rest of you were on public health tourism packages, in business class and five star hotels. There are no poor people in the Addis Ababa Sheraton… except the waiters, but you don’t notice them anyway, I suppose.

If the Gates Foundation wants to know what works, the only way to know is to go ask the people doing it, those laboring in obscurity in tiny, underfunded local NGOs, and those laboring in sweaty, dirty, dangerous, uncomfortable places with overfunded and overexposed NGOs like MSF.

As for the commentary, it’s major point (made three times over, according to my underlines on the copy I read on the bus) is that the Gates Foundation should be investing in putting into practice things that we already know work, instead of whizbang things for the future. The whizzy MPH speak for this is “service delivery”: i.e. making sure the pharmacy wasn’t cleaned out by thieves the night before the sick baby arrives in the ambulance that someone remembered to put fuel into.

I would be amenable to this argument, except that we already know why service delivery is so bad. It’s because a few people in this world are corrupt assholes, and something is wrong with the cultures where service delivery is bad that lets the corrupt assholes ruin things for those who just want to be healthy. The fact that people are corrupt assholes is not a problem. England has plenty of corrupt assholes (in fact, they seem to be in charge of the parliament here), but the NHS keeps running anyway. In Switzerland every year there are probably two or three doctors who lose their license for insurance fraud, billing for stuff they didn’t do. What’s the difference between the corrupt assholes in Switzerland and places where service delivery is failing patients? It’s good governance and accountability.

Even a short little career in humanitarian aid like I have had can make you cynical, and I’ll freely admit I am cynical. But I see hope everywhere I look, too. Good people trying to make their health system work get torn down by the system, and the system is made of a thousand corrupt assholes, from big corruption (the Minister of Health of Uganda for example) all the way down to little corruption (the numerous minor staff problems we faced every single week in Saclepea, Liberia).

The answer is that people won’t be healthy until they and their neighbors take responsibility to make a health system that works. It doesn’t matter how much the Lancet whines to the Gates Foundation, and it doesn’t really matter what the Gates Foundation invests in anyway. The demand for healthy communities needs to come from educated, organized, and disciplined communities. Whatever helps get us there, we should invest in. Whatever is unrelated to that is a distraction and not an ethical use of time and money.

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