Bill Gates is soothing his 200-billion-dollar headache by giving his fortune away 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 around $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 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 Gates giving away 99 per cent of his estimated $108 billion wealth?
Perhaps the philanthropist – once the world’s richest man but now in lowly 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 have been debunked and say more about his detractors than about him. 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 I 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 per cent of the world population. They are the world’s poor (those existing on less than $3.65 per day) living in 128 low and middle income nations. However, to put this in perspective, the Foundation’s projected outlay of $9 billion per year is small change for 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, the Gates influence is not from money alone but from how his powerful pulpit proselytises his heartfelt causes. This causes unease because of distortionary consequences for country-level health and development.
The causes dear to 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.
Gates’s 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.
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 or not 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 lesser eventual cost? However this could take longer than 2045. Understandably, Gates is impatient while we wish him a long life.
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 ten per cent 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 1223 per 100,000 births. Against the country’s backdrop of conflict, displacement, poverty, mis-governance, disaster and climate change, absent infrastructure and 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 over 1190 per 100,000 population? If Gates asks the people of South Sudan on how to spend his money, what difficult choices would they make? Gates is highly methodical as befits a smart ‘tech bro’. His lodestar is metrics which means only getting 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 5 million in 2019. A list of other conditions for statistically demonstrable demolition awaits.
Reducing specific disease burdens help but do not equate to health. This is constitutionally defined by WHO as “physical, mental, and social well-being 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. However, 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 is bound to stick. But at huge opportunity costs for other important challenges.
Nevertheless, at least, Bill Gates is fixed 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. The Gates and Musk outlook bring into focus the technocratic versus wholistic approach to life. The impact of the mega rich on American policy in the 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 mean that top-down solutions are no longer acceptable. That applies even for poor countries suffering from heavy budgetary cuts at 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.
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 and it is best imbibed in small doses under strict advisement.
Further Reading on E-International Relations
