Lancet 中的一篇Editorial

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The Lancet
Volume 365, Issue 9463 , 12 March 2005-18 March 2005, Pages 911-912

Bill Gates: a 21st century Robin Hood?

Many people in the developed world see Microsoft's near monopoly of the software market as a tax on the rich; the Bill and Melinda Gates Foundation, which is funded by the proceeds of selling some of Bill Gates' Microsoft stock, has given over US$7·5 billion to help the poor. However, whereas Robin Hood was an enemy of the monarch, Gates gained royal approval last week when he received an honorary knighthood from the Queen for his “contributions to improving health and reducing poverty in parts of the Commonwealth and elsewhere in the developing world”. To date, the foundation has given $4·2 billion to health-related projects and recently announced that it will continue to fund the Global Alliance for Vaccines and Immunisation (GAVI) through an additional $750 million over the next 10 years.

Despite his philanthropic activities, Gates remains at the top of the Forbes 400, a list of the 400 richest people in the USA. In 1999 he was worth $100 billion. His personal wealth is now only half that amount, partly because of his generosity—he has given away over $28 billion to date—and partly because of the vagaries of the stock market. He is thought to have personally lost $12–14 billion on April 3, 2000, when a judicial ruling against Microsoft wiped $80 billion off Microsoft's market capitalisation.

The Bill and Melinda Gates Foundation was created in January, 2000, when the William H Gates Foundation merged with the Gates Learning Foundation. The Foundation aims to promote greater equity in four areas: global health, education, public libraries, and support for at-risk families in Washington and Oregon. It has an endowment worth $28·8 billion, making it the biggest charity in the world. Since US foundations are required by law to give away at least 5% of their assets each year, the Foundation is faced with the challenging responsibility of finding a good home for nearly $1·5 billion in 2005. Until now, about 60% of grants have funded global projects, the remainder US ones.

Gates' money has undoubtedly helped push global-health research onto the international political agenda. The Foundation sees its role as catalytic, acting mainly through intermediaries, with support from governments and nongovernmental organisations, rather than attempting to go it alone. Its money has changed the landscape for the global-health research community. For example, in 1999 the Gates Foundation provided $50 million to set up the Malaria Vaccine Initiative. This one gesture nearly doubled the global spending on malaria research. But perhaps his greatest success so far has been GAVI, which was launched in 2000 to improve access to vaccines in the 75 poorest countries of the world and to strengthen their immunisation services. The Vaccine Fund, GAVI's financial body, has raised $1·3 billion since then: an initial grant of $750 million from the Gates Foundation and $482 million from ten countries plus the European Union. GAVI estimated that by the end of 2003 over 670 000 premature deaths from Haemophilus influenzae type b, pertussis, and hepatitis B had been averted in children born between 2001 and 2003. Without Gates' initial generosity, it is doubtful that GAVI would have got off the ground. It is a wonderful achievement that the Gates family rightly feels proud of.

Everyone wants to get a piece of the Gates' pie and to offer advice about where the money would be best spent, including The Lancet. (The Bill and Melinda Gates Foundation supported some of the work in our neonatal survival series.) Should the Foundation's money be invested in basic research into developing new drugs or vaccines? Or should it be used to implement medical interventions that are known to work, but which governments are unable or unwilling to fund, such as vaccines? The Gates Foundation is trying to do both.

On the research side, the 14 Grand Challenges in Global Health, created by the Foundation in January, 2003, have been especially controversial. Critics, such as Anne-Emanuelle Birn, argue that the grant money, which is likely to amount to around $400 million, would be better spent elsewhere. Others would argue that this misses the point. Like any good investor, Gates is putting his money into various projects that have different degrees of risk associated with them.

Another criticism is that the Foundation's management system has failed to grow in parallel with its ever-increasing endowment. Some researchers complain that the grant application process is slow and that other funders, such as the Rockefeller Foundation and the Wellcome Trust, do a much better job at being transparent and efficient. Concern has also been raised about the Foundation's global-health management team. Although it contains technically excellent individuals (many have held high-ranking positions at the CDC or the NIH) they are all US citizens with very little field experience in low-income countries.

Furthermore, the Foundation's focus on funding US or western European researchers is all well and good, but what is really needed is a sustained commitment to help develop the abilities of researchers living in resource-poor countries. The foundation has put aside $1 billion to help 20 000 disadvantaged US students from ethnic minorities complete their undergraduate degrees. A parallel initiative for graduate research students living in developing countries would go a long way towards the Foundation's goal of improving global health. The eradication of disease and the alleviation of suffering depends more on developing the skills of talented people than on technology—a fact that a company such as Microsoft must know only too well.