Philanthrocapitalism, Past and Present: the Rockefeller © 2014 Anne-Emanuelle Birn

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Please cite this article as: University of Toronto Received: 2013/04/07; Accepted: 2014/08/18; Posted online: 2014/11/1 Correspondence: [email protected] Anne-Emanuelle Birn, Philanthrocapitalism, past and present: The Rockefeller © 2014 Anne-Emanuelle Birn. This is an Open Access Foundation, the Gates Foundation, and the setting(s) of the international/ article distributed by Hypothesis under the terms of the global health agenda. Hypothesis 2014, 12(1): e8, doi:10.5779/hypothesis. Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0/), which permits unrestric- v12i1.229. ted use, distribution, and reproduction in any medium, provided the original work is properly cited. Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda Anne-Emanuelle Birn

exigencies, and reach of global health INTRODUCTION International health Each of these two über-powerful foun- challenges the leadership and capacity philanthropy, comparing the goals, para- philanthropy, American-style, is back. dations emerged at a critical juncture in of public multilateral agencies, pushing digms, principles, modus operandi, and Almost exactly a century after the the history of international/global health. ahead an overlapping global health gov- agenda-setting roles of the Rockefeller Rockefeller Foundation began to use Each was started by the richest, most ernance arrangement with a huge role and Gates Foundations in their historical John D. Rockefeller’s colossal oil profits ruthless and innovative capitalist of his allotted for the private sector10. Both contexts. It proposes that the Rockefeller to stake a preeminent role in shaping day1,2. Rockefeller and Gates alike fended foundations (and their founders) were/ Foundation’s early 20th century initia- the institutions, ideologies, and practices off public opprobrium for their cutthroat are deeply political animals, all the while tives had a greater bearing on interna- of international health (as well as medi- monopolistic business practices3,4, and claiming the technical and purportedly tional health when the field was wide cine, education, social sciences, agri- both have been subject to uneven doses neutral scientific bases of their efforts11,12. open—in a world order characterized of adulation (for example on the cover culture, and science), the Bill and Given the confluence of largesse and by forceful European and ascendant of magazine) and skepticism re- Melinda Gates Foundation has emerged Time leadership at distinct historical moments, U.S. imperialism—than do the Gates garding their philanthropic motives5-8. as the current era’s most influential various questions come to the fore: How ABSTRACT In recent years the Bill and Foundation’s current global health efforts Both foundations have focused on gen- global health (and education, develop- and why have U.S. philanthropies played Melinda Gates Foundation has emerged amidst neoliberal globalization and fad- erating and applying new knowledge. ment, and agriculture) agenda-setter. such an important role in the produc- as this era’s most renowned, and argu- ing U.S. hegemony. It concludes that the One appeared when the international The high profile of its eponymous soft- tion and shaping of international/global ably its most influential, global health Gates Foundation’s pervasive influence health field was in gestation; the other ware magnate founder and his wife, cou- health knowledge, organizations, and player. A century ago, the Rockefeller is nonetheless of grave concern both to as it faced midlife crisis. One sought to pled with the Foundation’s big-stakes ap- strategies? What are the ideological, Foundation—likewise founded by the democratic global health governance establish health cooperation as a legiti- proach to grant-making and “partnering,” institutional, and human welfare implica- richest, most ruthless and innovative and to scientific independence—and mate sphere for (inter)governmental ac- has made it a de facto leader in the global tions? Have these foundations marked capitalist of his day—was an even more urges scientists to play a role in contest- tion, creating, largely from scratch, the health field. a singular, unimpeachable path in this powerful international health actor. This ing and identifying alternatives to global principles, practices, and key institutions field or are there meaningful alternative article reflects critically on the roots, health philanthrocapitalism. of the international health field9; the other approaches towards achieving global

Illustration : Bechara Saab HYPOTHESIS Vol.12, No.1 | 2014 | hypothesisjournal.com Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda REVIEW 2 / 27 Birn

health equity? What are the continuities from tax deductions (both individual and its limits and the ways in which it might (later Pan American Sanitary Bureau the concept of international health, it and what has changed in the philanthro- corporate donations are tax-deductible15, be contested. [PASB]) in December 1902, based in was the major influence upon the field’s

pists’ prerogatives? a practice that itself removes billions from THE BIRTH OF MODERN INTERNATIONAL Washington D.C. under the aegis of the 20th century agenda, approaches, and the public coffers). Up to a third or more, U.S. Public Health Service20. In their early actions22,23. Such questions are particularly salient HEALTH The rise of modern international depending on the tax rate, of the endow- decades, both the OIHP and PASB in an era in which “philanthrocapitalism” health is typically traced to the first Rockefeller’s efforts were part of a new ment monies of private philanthropies remained focused on establishing and has been cited not as a venal endeavor— International Sanitary Conference held American movement—“scientific phi- are thus subsidized by the public, which monitoring sanitary conventions and col- through which profits amassed via in Paris in 1851, viewed as the begin- lanthropy.” Launched by Scottish-born, has no role in how priorities are set or lecting disease statistics. Another early the exploitation of workers and natural ning of steady progress in international rags-to-riches steel magnate Andrew how monies are spent. agency was the International Committee resources are then harnessed through surveillance and infectious disease re- Carnegie in an 1889 essay, “The Gospel of the Red Cross, founded in Geneva in the very same exploitative business This article compares the goals, para- porting in the name of epidemic secu- of Wealth,” published in The North 1863 to provide aid to the victims of war. approaches in the name of improving digms, principles, modus operandi, and rity16,17. But the (mostly European) par- American Review, this approach called These organizations joined longstanding human welfare—but hailed unabashedly agenda-setting roles of the Rockefeller ties were so suspicious of one another for the wealthy to channel their fortunes intra-imperial health activities carried out as a means to “save the world”13 accord- and Gates Foundations in their historical that it took 11 conferences and over 50 to the societal good by supporting sys- by colonial administrators, military forces, ing to “big business-style strategies”14. contexts (albeit in the case of the Gates years to set up a full-time agency—the tematic social investments rather than and missionaries, all with the aim of pro- Foundation bound by events that are Office International d’Hygiène Publique haphazard forms of charity24-26. The re- Of note, over recent decades, business tecting troops, high-yielding colonial pro- still unfolding). It proposes that the (OIHP)—established in Paris in 1907. nowned Carnegie left a legacy of thou- models have proliferated in the (global) duction and trade, and colonial settlers, Rockefeller Foundation’s early 20th cen- The political and economic rivalries sands of public libraries and bathhouses public health field, with Gates Foundation at the same time as staving off unrest tury initiatives had a greater bearing on among the participants delayed the sign- along with donations to higher education, efforts emblematic of an overall trend to- among the colonized21. international health when the field was ing of accords, limited their enforcement, the arts, and peace studies, an example wards for-profit style management, lead- wide open—in a world order charac- and resulted in a contentious “Britain ver- heeded by various fellow millionaires. ership training, and goal-setting, as ENTER THE ROCKEFELLER FOUNDA- terized by vigorous European and as- sus France and everybody else” stance Just as these institutions were well as the privatizing of public health TION Notwithstanding the benign fashion with cendant U.S. imperialism—than do the at most of the meetings18. being created, a new player emerged activities. which this early philanthropy is now re- Gates Foundation’s current global health on the scene, one that would go be- Meanwhile, some countries, notably the garded, the philanthropist-“robber bar- At the outset it is crucial to stress that un- efforts in today’s age of neoliberal global- yond political and economic self- United States and Mexico, developed ons” of the day were reviled for the prov- like government entities, which are sub- ization and fading U.S. hegemony. And interest, war relief, and information ex- their own systems of epidemic surveil- enance of their philanthro-profits: the ject to public scrutiny, private philanthro- yet the pervasive influence of the Gates change to fundamentally transform lance through sanitary consuls, paid exploitation and repression of workers. pies are accountable only to their own Foundation should be of grave concern the nascent international health field. informants, and, later on, public health Philanthropy was regarded by many con- self-selected boards, and decision mak- both to democratic global health gover- The Rockefeller Foundation (RF) was officers stationed in key ports worldwide temporaries as a cynical way to counter ing is usually in the hands of just a few nance and to scientific independence. established in 1913 by oil mogul-cum- in order to inspect outgoing migrants and working class unrest, growing political executives. In North America and certain philanthropist John D. Rockefeller “to The ultimate aim of this comparison is merchandise19. Indeed, reaching agree- radicalism, and claims on the state and other settings, philanthropic foundations promote the well-being of mankind to reflect critically on the roots, exigen- ment in Europe took so long that the as a means of tempering threats to busi- are exempt from paying most taxes, and throughout the world.” Not only did the cies, and reach of contemporary global Americas prefigured European efforts by ness interests, and to capitalism itself, in contributions to philanthropies benefit RF virtually single-handedly popularize health philanthropy, as well as to identify founding an International Sanitary Bureau the tumultuous late 19th and early 20th

HYPOTHESIS Vol.12, No.1 | 2014 | hypothesisjournal.com Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda REVIEW 3 / 27 Birn

century Progressive Era27. Domestically The question of which public health and laboratory technicians fanned out of 1890) reached a climax in the after- delimited programs to control yaws, ra- in this period, philanthropy played an problem to tackle and where, amidst across 11 Southern U.S. states and math of the Ludlow Massacre of 1914, bies, influenza, schistosomiasis, mal- ambiguous role in struggles around gov- such need, was settled by a troika of worked with churches and agricultural during which two dozen striking min- nutrition, and other health problems) in ernment-guaranteed social protections Rockefeller advisors: Frederick T. Gates clubs (though few health departments, ers and their families were killed at a almost 100 countries and colonies (see by promoting “voluntary” efforts in place (a Baptist preacher and JDR’s right- given the reluctance of local doctors and Colorado mine owned by a Rockefeller- Figure 1). It also founded 25 schools of of citizen entitlements; since then, com- hand man [no relation to Bill Gates]), the paucity of public health infrastruc- controlled coal producer. Journalists, public health in North America, Europe, pared to most European and many Latin Charles Wardell Stiles (a medical zool- ture) to eliminate the disease through: muckrakers, laborers, and the popula- Asia, and South America and spon- American countries, the private and phil- ogist), and Wickliffe Rose (a Southern administration of an anti-helminthic drug; tion at large readily linked Rockefeller sored 2,500 public health professionals anthropic sectors in the United States educator), who perceived anemia-pro- promotion of shoe-wearing and latrines; business and philanthropic interests, to pursue graduate study, mostly in the have played a large part in the provision voking hookworm disease to be a cen- and dissemination of public health pro- seeking to delegitimize the latter and U.S.9,34,36. of social services—both curbing the tral factor underpinning the economic paganda (in terms of both public health motivating the Rockefeller family to pur- Interestingly, the IHB/D itself identified size and scope of the U.S. welfare state “backwardness” of the U.S. South and an education positive publicity for the sue what it perceived as neutral, un- and its most significant international contri- and giving private interests undemocrat- important obstacle to its industrialization Rockefeller effort—until the spread of objectionable spheres of philanthropic bution to be “aid to official public health ic purview over social welfare28-32. and economic growth35. That hookworm a groundless yet widely believed rumor action, such as health, medicine, and organizations in the development of could be diagnosed easily through ob- that the Rockefellers were trying to sell education23. John D. Rockefeller (JDR) expanded on administrative measures suited to local servation of a fecal sample under a mi- shoes, after which time the Rockefeller Carnegie’s ideas—building from the for- As a result, over the course of some four customs, needs, traditions, and con- croscope and that it had a quick-fix treat- name remained mostly in the back- mer’s initial eleemosynary donations to decades, the RF was at the fulcrum of ditions” p743,37. Thus, while highly influ- ment (initially thymol crystals coupled ground)35. Following the success—in hospitals, churches, and universities to international health activity. From their ential in shaping the enduring modus with a purgative) to reduce dramatically terms of igniting popular interest in pub- support public education, science, and perch in the heart of New York City’s operandi of international health through worm burden and anemia—techniques lic health, not eradication per se—of the medicine—funding both research and business district, the RF’s profession- technically-based disease campaigns that had been used in campaigns in hookworm campaign, the RF swiftly cre- large-scale campaigns aimed at social al executive staff, advised by an ac- and transnational public health training, Costa Rica and U.S.-occupied Puerto ated an International Health Board (IHB, melioration. Public health became the tive board of trustees, oversaw a global the RF’s self-defined gauge of success Rico—sealed their decision. The fact reorganized as the International Health ideal vehicle through which Rockefeller enterprise of health cooperation orga- was its role in generating political and that hookworm was not a leading cause Division [IHD] in 1927). philanthropy could apply expert find- nized through regional field offices in popular support for public health, creat- of death, or that treatment occasionally ings to the public well-being. This was a The choice of international public Paris, New Delhi, Cali (Colombia), and ing national public health departments provoked fatalities, was immaterial. prescient choice, for public health was a health seemed safe given the larger Mexico, and country-based public across the world, and advocating for and nascent field in the United States, begin- These three and other advisors helped environment, especially the harsh work- health work led by hundreds of RF of- sustaining the institutionalization of in- ning to professionalize but with a limited orchestrate the Rockefeller Sanitary ing conditions and militant activism ficers stationed around the world22. By ternational health. The associated local, government foothold, giving Rockefeller Commission for the Eradication of surrounding Rockefeller’s domestic the time of its disbandment in 1951, national, and multilateral institutions interests considerable room to test out Hookworm Disease, an enormous, business interests. Negative publicity the IHB/D had spent the current day came to embody the RF agenda in their ideas and practices33,34. handsomely-funded campaign against for the Rockefeller family (which rose equivalent of billions of dollars to carry very structures. hookworm that lasted from 1910 to 1914. with the breakup of its oil monopoly, out scores of hookworm, yellow fever, Teams of physicians, sanitary inspectors, mandated by the Sherman Antitrust Act and malaria campaigns (as well as more

RF INTERNATIONAL HEALTH IN AN AGE 1910 the U.S. was flexing its muscles as OF IMPERIALISM Through its interna- an emerging world power through re- tional health work, the RF courted politi- gional economic penetration and com- cians and civil servants across the globe, mercial ascendance, intertwined with generated deep loyalty among health disease control and the safeguarding of professionals (and connected local elites trade. The U.S. invasion of Cuba in 1898 to prestigious international medical net- (and repeated subsequent military oc- works), instilled a belief in public health cupations), a clear expansionist move, among local populations throughout the had been justified as a means of stem- world, and helped to build and modern- ming the annual threat of yellow fever ize dozens of public health institutions. outbreaks along the U.S.’s Eastern Yet the RF’s efforts went well beyond seaboard45.

health, stabilizing colonies and emerg- The U.S. Army’s Cuban sanitary inter- ing nation-states by helping them meet vention was also the precursor for its the social demands of their populations, massive ten-year mosquito-combating encouraging the transfer and internation- endeavor that ultimately enabled the alization of scientific, bureaucratic, and long-awaited completion of the Panama cultural values, stimulating economic Canal in 1914: starting in the late 19th development and growth, expanding century, tens of thousands of French consumer markets, and preparing vast and Caribbean canal construction work- regions for foreign investment, increased ers had been felled by yellow fever and productivity, and incorporation into the malaria. The RF stepped into the yellow expanding system of global capitalism. fever fray in 1914, worried that the ca- Unlike international health’s prior asso- nal would hasten the spread of epidem- ciation with aggressive military and colo- ics from and to Asia and the Pacific and nial power, RF international health sought convinced that Latin America (and busi- to generate goodwill and promised social Figure 1 | Administering hookworm treatment at Karapa (India) nesses with ties to the region) could be advancement in place of gunboat diplo- Source: Rockefeller Foundation, 100 Years: The Rockefeller Foundation, rid of yellow fever’s disruptive effects on 23,38-44 accessed August 26, 2014, http://rockefeller100.org/items/show/1681. macy and colonial repression . trade and people (due to the ability of its Courtesy of the Rockefeller Archive Center. All the same, RF international health vector, the Aedes aegypti mosquito, to emerged at the height of U.S. imperial- survive shipboard for days on end and ism, enabling the IHB/D’s influence even infect previously unexposed residents through a contrasting approach. Circa

of receiving ports with the often lethal yel- because malaria and yellow fever his- not successful, however; malaria had simultaneously, such as clean water and U.S.-style technical public health mod- low fever virus). torically affected other climatic regions, already been greatly reduced thanks to sanitation systems23. els, instead framing the expansion of lo- including those of Europe and North prior Italian public health efforts, and anti- cal health units in terms of broader soci- Over three decades, the IHB/D con- Despite the need for—and ample evi- America. The latter considered diseases malaria measures had to be continued etal health needs23. The RF, for its part, ducted major campaigns across Latin dence of—local adaptation and nego- in terms of their role in emergent global for decades afterwards53. was not a monolith: it changed over time, America (and research in West Africa) tiation23,54, the RF drove the agenda of capitalism: while the hearty yellow fever and had to deal with shifting political pri- to reduce the presence of A. aegypti The RF was careful to avoid disease cam- purportedly joint work with governments, mosquito was a menace to commerce, orities at home and abroad. mosquitoes through spraying of insec- paigns that might be costly (other than masterfully transforming disease cam- hookworm drained worker productivity in ticides, swamp drainage, and distribu- yellow fever control, which was regarded paigns into permanent, national agen- In its early years, the RF—though legally profitable plantations and extractive in- tion of larvicidal fish, and it funded and an indispensable investment for U.S. cies and locally-supported public health separate from the Standard Oil compa- dustries, and malaria was considered a masterminded the decades-long devel- business interests and port dwellers), offices. With its own field officers posted nies and other Rockefeller firms—shared hindrance to economic development48-51. opment of the Nobel-prize winning 17D overly complex and time-consuming, “on the ground” to guide activities and overlapping managers and trustees yellow fever vaccine (identified in 1936), The RF’s attention to malaria, then a major or distracting to its technically-oriented interact with politicians, health workers, who reflected the interests of the “cap- all showcasing growing U.S. scientific disease priority across much of the world, public health model: most campaigns and the public, the RF could rely on tains of industry.” The RF’s first presi- expertise to European rivals. But while involved, for the most part, research on were narrowly construed and carried a committed staff to infuse its ideolo- dent was JDR’s only son, JDR Junior, yellow fever control ended costly com- technical magic bullets, or, paradoxically, out one by one, ensuring that targets (for gies and practices into institutions and who in 1917 moved from the presidency mercial interruptions, it, like hookworm, joint efforts in which technical strategies insecticide spraying, administration of policies. It trained thousands of public to chair the RF Board of Trustees until was of minor epidemiological concern were accompanied by large-scale gov- medicines, etc.) would be met accord- health doctors, nurses, and engineers 1940. The IHB/D’s board and advisors, to Latin America, where even during epi- ernment policies to address social con- ing to the quarterly reports employed by as fellows in North America, Europe, in turn, included RF trustees as well as demics it killed a relatively small num- ditions. In the 1930s, the RF claimed the RF’s burgeoning bureaucracy (akin and at national training stations: molded leading men from the worlds of medicine ber of people, primarily newcomers23,46,47. credit for eliminating Anopheles gambiae to those used by Rockefeller-controlled as a cadre of leaders, fellows served (such as William Welch, first Dean of the Nonetheless, given the U.S.’s growing from Brazil, responsible for an immense companies). This meant that even with as powerful interlocutors who were en- Johns Hopkins School of Medicine and economic and political dominance of the outbreak of malignant tertian malaria, spectacular efforts against yellow fever, couraged to bypass local healers and founder of the RF-funded Johns Hopkins region, the RF was able to score a health with more than 100,000 cases and the RF rarely addressed the most im- knowledge and affiliate with international School of Hygiene and Public Health; diplomacy coup, foreshadowing U.S. 14,000 deaths in 1938 alone. But this portant causes of death, namely infantile colleagues23,55. various U.S. Surgeon-Generals, etc.), President Franklin Roosevelt’s “good was an “introduced” African mosquito diarrhea and tuberculosis (TB) (the RF education (including the presidents of To be sure, these efforts met with resis- neighbor” policy towards Latin America rather than an endemic problem, and campaign against TB in France dur- Harvard and the University of Chicago), tance and reshaping54. In Mexico, for in the 1930s. RF involvement was backed by an ex- ing WWI being a notable exception), as and banking/finance (among others, the example, venerated RF-trained public tensive, years-long campaign under at the time these ailments lacked read- president of Chase National Bank)22,34. In short, Rockefeller international health health physician Miguel Bustamante, the nation-building administration of ily available technical tools and re- Though accused of protecting and pro- combined tropical medicine with geo- who rose to become Mexico’s deputy Brazilian strongman President Getulio quired socially-oriented investments moting Rockefeller oil interests in Mexico economic concerns. The former involved health minister and Secretary-General Vargas52. The RF’s DDT-based attempt over long periods. Moreover, the RF ap- and elsewhere—certainly a controver- controlling so-called tropical diseases of of the PASB, worked with the RF but re- to repeat species eradication on the is- proach precluded employing measures sial issue in the IHB’s yellow fever con- the colonized, tropical band—so-called, sented and withstood the imposition of land of Sardinia in the late 1940s was that might improve multiple diseases trol activities in the Gulf of Mexico56—the

productivity-related, market-opening, rectly, international health’s institutional other leftist activism, to draw on, listen to, century, when famed father of cellular tal in convincing Latin Americans to side and quarantine-busting benefits accrued framework. and even bankroll progressive political pathology Rudolf Virchow called for “full with the Allies23,61-66. through RF international health efforts perspectives, including those of often vo- and unlimited democracy,” not medical Its activities and organization provided In a nutshell, what enabled this scope of were for the most part not geared directly cal, avowed socialist and other leftwing intervention, to address Upper Silesia’s the groundwork for a new, legitimate in- influence over agenda-setting and in- to growing and profiting Rockefeller busi- researchers and public health experts, 1848 typhus outbreak (to the surprise of ternational health system featuring its stitution-building was the RF’s powerful nesses per se, but rather more broadly such as Rajchman, who constituted an the Prussian authorities who had com- own bureaucracy and mode of conduct. presence at the international level, com- aimed at foreign, and some domestic, in- important contingent of health leaders missioned his investigation). Social medi- The League of Nations Health Organ- bined with its tentacles reaching into vir- dustries and investors. and prestigious scientists of the day58. cine in the 20th century likewise aimed isation (LNHO), founded after WWI, was tually every kind of public health activity. Although support for leftist approaches to integrate attention to the socio-polit- THE RF APPROACH AND ITS PERVASIVE partially modeled on the RF’s International The RF’s public presence was bolstered was always subordinate to the dominant ical conditions underlying health with INFLUENCE Modern international health, Health Board and shared many of its val- by behind-the-scenes involvement in RF model, IHD funding of prominent overall public health efforts59. The RF as pioneered by the RF, was neither nar- ues, experts, and know-how in disease setting health priorities via its senior staff, health leftists, most notably famed Johns was curious about, for example, how the rowly self-interested nor passively diffu- control, institution-building, and edu- trained fellows, and the engagement of Hopkins historian of medicine and na- Soviet Union’s experiment in social medi- sionist. Instead, the RF actively sought cational and research work, even as it IHB/D officers—not only with politicians tional health insurance advocate Henry cine was working in the 1930s, funding national partnerships to spread its pub- challenged narrow, medicalized under- and leading physicians, but also with Sigerist and socialist Yugoslav public Sigerist’s research—though not that of lic health gospel. The RF’s philanthropic standings of health. In spite of the capa- traditional healers, townsfolk, and oth- health leader Andrija Stampar, reveals his Soviet counterparts—in this area60. status, its purported independence from ble direction of leftwing Polish hygienist ers—as well as the RF’s requirement that the RF’s ideological flexibility at certain both government and business interests, Ludwik Rajchman, the LNHO was mired The RF also helped build the U.S.’s public health campaigns be increasingly conjunctures59. Indeed, the RF remained its autonomy, and its limited accountabil- in League of Nations politics, and bud- “international health as foreign policy” funded at the national (and regional) level. tolerant and even intellectually open to ity enabled its success. Its work patterns getary constraints meant that it could re- proficiency. When in the mid 1930s But this was not a purely one-sided en- alternatives to its techno-medical focus included rapid demonstration of specific alize only part of its ambitious agenda. Germany started to use medical aid deavor. The RF’s activities entailed ex- and afforded long-time RF officers the disease control methods based on prov- Rather than being supplanted by the to befriend Mexico, Brazil, and other tensive give and take, and were marked leeway and independence to pursue en techniques and a missionary zeal in LNHO, the IHB/D became its major countries in the region as it sought al- by moments of negotiation, cooptation, these interests, albeit under financial, its own officers. To ensure the endurance patron and lifeline, funding study tours, lies and essential resources including imposition, resentment, and outright time-horizon, and other constraints. As of its approach, the RF marshaled nation- projects, and eventually much of its oper- oil, rubber, and minerals—and these rejection, as well as productive coopera- well, the RF was involved in large-scale al commitment to public health through ating budget44,57. The IHD also took over countries began to play off the tion, and the RF responded dynamically intelligence gathering around science hefty national co-financing obligations some of the LNHO’s key activities during Angloamerican-German rivalry—the RF to shifting political, scientific, economic, and public health developments; what (budget “incentives”) that typically went WWII. redoubled its public health efforts in cultural, and professional terrains. was going on in leftwing efforts was ger- from 20% of the cost of a campaign to Latin America. This heightened RF in- Uniquely for the era, it operated not only The institutionalization of international mane to these activities. 100% over just a few years. volvement, requested by the U.S. State as a philanthropy but also as, at one and and national public health presupposed The political economy-oriented social Department (which was enlisting phil- the same time, a national, bilateral, mul- At the same time that the RF was in- various political rationales, including left- medicine approach advocated by anthropic foundations to stem German tilateral, international, and transnational volved in country-by-country activities, wing versions that emerged in the inter- Sigerist, Stampar, and other figures was intrusion in the region), was instrumen- agency23. it was also mapping, directly and indi- war years. The RF was thus compelled, in not new, having emerged in the 19th this era of anti-fascist, labor, socialist and Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda 7 / 27 Birn

After the World Health Organization the International Clinical Epidemiology problematic, legacy for global health. flexibility, based on the local cultural and international organizations have adopted (WHO) was established in 1948, the IHD Network and helped launch the Task These include: 1. Agenda-setting from moral economy and political context23,51. the policies and activities in which the was closed down, with some of its func- Force for Child Survival; and in the above: international health initiatives are IHD has pioneered,” through inheri- While these principles evolved generi- tions absorbed by the RF’s new Division 1990s it established the Public Health donor-driven, with the agenda of coop- tance of personnel, fellows, practices, cally, rather than as part of a master of Medicine and Public Health67. Even Schools Without Walls, started a Health eration formulated and overseen by the and equipment69. The RF’s most direct scheme—and they certainly fed on after the RF drew back from its lead role Equity Initiative, and was a co-founder international agency, whether through imprint on the WHO took place through alignments between the RF and a in international health, it kept a hand in of the Children’s Vaccine Initiative and direct in-country activities or the award- Dr. Fred Soper, who had spent almost variety of national interests—their du- various activities related to health and International AIDS Vaccine Initiative. ing of grants; 2. Budget incentives: ac- two decades at the helm of the IHD’s rability reflects the “marked asymme- international development—through Around this time, the RF, which also tivities are only partially funded by donor large-scale campaigns against malaria tries in political and medical power”p215,54 funding the “Green Revolution” (involv- changed under Cold War pressures and agencies; matching fund mechanisms and yellow fever in Brazil before becom- that characterize most international and ing crop hybridization and other tech- with the rise of neoliberal ideology, shift- require recipient entities to commit sub- ing head from 1947 to 1958 of the PASB global health interactions, then and now. nological and agri-business approach- ed from its traditional support for the pub- stantial financial, human, and material (as of 1949, WHO’s regional office for The RF at times seemed to part with es to increasing agricultural output), the lic sector towards subsidizing the private resources to the cooperative endeavor; the Americas, changing its name to Pan its own principles, for example, as dis- Population Council (aimed at curbing sector—amidst considerable internal de- 3. A technobiological paradigm: ac- American Health Organization [PAHO] in cussed, by funding studies of national population growth in “Third World” coun- bate. In particular, the RF helped to in- tivities are structured in disease control 1958). According to RF President Chester health insurance and backing leftwing tries), and smaller-scale social science novate a new international health funding terms based upon: a) biological and in- Barnard, the PASB was designed to “cov- scientific activists who advocated for and medical research55. modality—the public-private partner- dividual behavioral understandings of er most of the purposes which the IHD broad social medicine efforts rather than ship—to fund its vaccine initiatives68. And disease etiology; and b) technical tools pursued in Latin America. Under [Soper] In the 1970s the RF re-materialized in the RF’s narrower take. Moreover, some yet even the RF’s role in this development applied to a wide range of settings; 4. A IHD policies and philosophies have been the international health sphere under of the national and international public would be eclipsed by other players, and priori parameters of success: activities adopted. The PASB will eventually take John Knowles, its first physician-presi- health institutions supported and in- the RF would not regain the internation- are bound geographically, through time over our functions”69. dent, who was (in)famous both for de- fluenced by the RF transcended the al health pull it had in the first half of the constraints, by disease and interven- crying medical profiteering and for tout- The IHD model of international health principles outlined above to engage in 20th century. tion, and/or according to clear exit strat- ing the notion of individual responsibility cooperation was further entrenched politically and socially grounded under- egies, in order to demonstrate efficiency for health. Still guided by trustees from In a very tangible sense, in the WHO with the 1953 election of THE RF LEGACY standings and practices of public health. and ensure visible, positive outcomes; 5. industry and academia, now joined by the IHD’s dismantling served as a self- Dr. Marcolino Candau as its Director- But these were accompaniments to, rath- Consensus via transnational profession- (mostly) men from the worlds of politics fulfilling prophecy of success: thanks to General, a post he held until 1973. er than at the heart of, the RF’s interna- als: activities depend on professionals and civil society, the RF confined itself its own efforts, it was no longer needed. Candau, who had worked with Soper tional health approach. trained abroad (often alongside donor to a few key international health pur- But Rockefeller international health did in the IHD’s campaigns in Brazil, over- agency staff) who are involved in inter- The RF’s legacy would bear heavily on suits: in the late 1970s it inaugurated the not disappear. The principles that were saw the establishment of WHO’s global national networks, easing the domestic the WHO67. As Lewis Hackett, who over- Great Neglected Diseases of Mankind largely invented by the RF and that per- malaria and smallpox eradication cam- translation of donor initiatives and ap- saw IHD programs in South America and Program and sought to circumscribe the meated the IHB/D’s country dealings, as paigns, among others, as well as a mas- proaches; and 6. Adaptation to local Italy for over thirty years, noted, “To a WHO’s shift to primary health care (see well as the international health field as sive effort to provide public health train- conditions: activities are afforded limited greater or lesser degree, all the ahead); in the 1980s the RF established a whole, have left behind a powerful, if Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda 8 / 27 Birn

ing fellowships to over 50,000 health per- multiple settings, and dozens of newly neocolonialism in development aid, de- that resulted in a declaration of smallpox care’s emphasis on “cost-effective” ap- sonnel from across the world68,70. independent nations gained a voice, at mand respect for sovereignty in decision eradication in 198074,76-81). proaches, for example immunizations least nominally, at the international poli- making, and denounce unfair internation- and oral rehydration therapy, became The longevity of the RF’s interlocking But in the 1970s, the WHO’s disease- cy-making table51. al trade arrangements and the lack of de- the main driver of UNICEF’s child sur- principles of international health was, focused, donor-driven approach began mocracy in UN agencies. vival campaigns of the 1980s, under its however, more than a matter of brag- From 1946 through the early 1990s, to be challenged both by member coun- director James Grant, the son of an emi- gadocio and personal networks of in- these actors—and the international As international health became a pawn tries—especially G-77 countries, which nent IHD man85. fluence. As we shall see, each of the health field writ large—were shaped by in the Soviet-American competition for were seeking cooperative efforts that ad- RF principles has continued ideological two main factors: the Cold War and the power and influence (the Soviet bloc dressed health in an intersectoral fash- Just as WHO was trying to escape the salience and bureaucratic convenience, political and ideological rivalry between pulled out of the WHO in 1949, returning ion—and from within headquarters, un- yoke of the RF’s international health as witnessed in the structure, strategies, American (Western bloc) capitalism and only in the mid 1950s), many countries der the visionary leadership of its Danish principles, it became mired in a set of and tenets of the global health field today. Soviet (Eastern bloc) communism; and, also learned to play the rivals against one Director-General Halfdan Mahler (first political, financial, and bureaucratic

THE COLD WAR AND THE RISE OF NEO- corollary to this, the paradigm of eco- another, sometimes stimulating improved elected in 1973, holding this office until crises that tested both its legitimacy nomic development and modernization, social conditions, other times exacerbat- 1988). The primary health care movement, and its budget. The oil shocks and eco- LIBERALISM In the decades following perceived by Western powers as the ing unequal power and control over re- as enshrined in the seminal 1978 WHO- nomic crises of the late 1970s and 1980s WWII, a dizzying array of organizations sole path to progress for the de- sources72-74. Under Indira Gandhi, for ex- UNICEF Conference and impeded many member countries from connected to international health were Declaration of colonized Third World71. In this context, ample, India received as much or more 82 and WHO’s accompanying paying their dues. As well, member founded or revamped, from bilateral Alma-Ata Eastern and Western blocs deployed aid from Washington as from Moscow, “Health for All” policy, called for health countries accused WHO of having too aid and development agencies, to the international health initiatives—the for- with both superpowers eager to accede to be addressed as a fundamental hu- many personnel at headquarters and not World Bank and International Monetary mer providing big ticket infrastructure in- to New Delhi’s requests for foreign devel- man right—through integrated social and enough in the field. Fund (IMF), to United Nations (UN) agen- cluding hospitals, pharmaceutical plants, opment assistance75. public health measures that recognize cies including UNICEF, the Food and Around the same time, the rise of neo- and clinics; the latter, offering some of the economic, political, and social con- Agriculture Organization and the United The WHO (largely controlled by Western liberal political ideology lauding the the same plus RF-style disease cam- text of health, rather than through top- Nations Development Program, to nu- bloc interests) continued to operate in “free” market while denigrating the role paigns; and both sponsoring huge num- down, techno-biological campaigns83,84. merous international and local nongov- the RF vein, characterized by profession- of government in redistributing wealth, bers of fellowships for advanced training ernmental organizations (NGOs), hu- alization and bureaucratic growth and Social medicine’s resurrection in the providing for social welfare, and regulat- in the respective blocs—as a means of manitarian and advocacy movements, flagship technically-oriented global dis- 1970s in the guise of primary health care ing industrial and economic activity re- forging alliances with (and seeking to po- research institutes, private founda- ease campaigns: first against yaws (with created bitter divisions within and be- sulted in a parting with the RF’s interwar litically dominate) low-income countries. tions, business groups, and so on. The penicillin) and TB (with BCG), then, fate- tween WHO and UNICEF70. The RF re- model of strong, publicly-supported inter- postwar liberation movements in Asia, By the 1950s it was clear that the recon- fully and unsuccessfully, against malaria surfaced to play a small but instrumental national health institutions. The admin- Africa, and (later) the Caribbean trans- figuration of world power brought few (based on the insecticide DDT, following role in promoting selective primary health istration of conservative U.S. President formed the prior purview of imperial benefits to the former colonies, and in its extensive use during World War II); care—a reduced, technical (and highly Ronald Reagan froze the U.S.’s financial powers over their colonial holdings into 1964 the G-77 movement of non-aligned and culminating with an ambitious—if contested) counterpart to Alma-Ata’s contribution in order to reprimand WHO a more complex geopolitical dynamic, (with either the Soviets or the Americans) divisive in some locales—technically fea- broad social justice agenda for primary for its essential drugs program (which had in which multiple actors operated in countries was founded to confront sible, vaccine-based smallpox campaign health care. Selective primary health established a generic drug formulary) Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda 9 / 27 Birn

and for the 1981 International Code of activities, as had been stipulated in its economic, social, and epidemiologic richest person from 1995–2007, and related to internal decision-making and Marketing of Breast Milk Substitutes, both 1946 Constitution. In this period, the domains”p6,51. Notwithstanding the in- again in 2009 and 2013)100 together with operating practices, such as meeting perceived by U.S. business interests as World Bank—pushing for efficiency re- voked distinctions—there is a muddled his wife Melinda (and chaired by the minutes, memos, and correspondence. deliberate anti-corporate strategies86. By forms and privatization of health care understanding of the “global” in glob- couple plus Bill Gates Senior), is by far According to its global health division, the early 1990s less than half of WHO’s services—had a far larger health bud- al health97,98 and considerable confla- the largest philanthropic organization in- the BMGF’s primary aim in this area is budget came from annual dues subject get than WHO, and many bilateral agen- tion between international and global volved in global health. The September “harnessing advances in science and to “democratic” World Health Assembly cies simply bypassed WHO in their in- health—the “new” definition of global 2013 endowment stood at US$40.2 bil- technology to reduce health inequities”107 decisions. Instead donors, who by now ternational health activities94. The WHO health bears many similarities to its inter- lion, including 7 installments (ranging through the innovation and application of included a variety of private entities in ad- hobbled along thanks to public-private national health predecessor99. from US$1.25 to 2.0 billion) of a US$31 health technologies, encompassing both dition to member countries, increasingly partnerships95 (PPPs, discussed ahead), billion donation made in 2006 by U.S. treatment (via diagnostic tools and drug In sum, during the Cold War the RF was shifted WHO’s budget away from dues- which have provided business inter- mega-investor Warren Buffett (also development partnerships) and preven- far overshadowed by bigger players funded activities to assignment ests, such as pharmaceutical corpora- a BMGF Trustee and advisor to the tion (through, for example, vaccines and a priori in the ideological war of West vs. East, of funds to particular programs and ap- tions, a major, arguably unjustified, role foundation)101. microbicides). Initially, the foundation and international health philanthropy (in proaches87. Today almost 80% of WHO’s in international public health policymak- sought to avoid expanding its portfolio a new guise) would return in a signifi- With total grants of US$28.3 billion budget is earmarked, whereby donors ing96. Throughout the 1990s internation- too quickly, focusing on a few disease- cant way only after the huge infusion of through 2013 and recent annual spend- designate how their “voluntary” contribu- al health spending was stagnating, and control programs mostly as a grant-mak- resources seen as necessary to win the ing around US$3 billion (2012 grants to- tions are to be spent88. the future of WHO and the entire field ing agency. This has changed over the Cold War began to dry up. The fact that taled US$3.4 billion)101—approximately seemed to be in question. past few years, with efforts reaching over Once the Cold War ended, the anti- this reemergence coincided with the 60% of which has gone to global health 100 countries, the establishment of of- Communist rationale for Western bloc As these events were unfolding, interna- rise of neoliberalism was pivotal: interna- efforts (the remainder to development, fices in the United Kingdom, China, and support for WHO disappeared (WHO tional health was renamed global health. tional philanthropy would now operate in agriculture, global advocacy, education, India, and the growth of its staff to more faced unprecedented invective in a This new term has been adopted broadly a context attacking the role of the state libraries, and local initiatives in the U.S. than 1,100 people101. 1994 BMJ series penned by its now ed- over the past two decades and is meant and favoring private sector, for-profit Pacific Northwest)102,103—the BMGF’s itor-in-chief)89-91, leaving in its wake the to transcend past ideological uses of in- approaches. global health budget has surpassed the The BMGF, like the RF before it (noting promotion of trade, the commodifica- as a “handmaiden” of budget of the WHO in several recent here that the RF’s pioneering international ternational health ENTER THE GATES FOUNDATION In tion of health, disease surveillance, and colonialism or a pawn of Cold War rival- years104-106. Its sheer size—and the celeb- health role is not acknowledged by the 2000, into this crisis of authority, and health security as justifications for in- ries and development politics. Global rity and active engagement of its found- BMGF, though the BMGF Web site does almost a century after the Rockefeller ternational health92,93. By this time, apart health “impl[ies] a shared global suscep- ers—turned the Gates Foundation into cite the RF’s past expertise in upping ag- Foundation filled the previous era’s vac- from its role addressing tibility to, experience of, and responsi- a leading global health player virtually ricultural productivity through its role in health security uum, a new entity appeared that would surveillance, notification, and control bility for health. ... In its more collective overnight. the Green Revolution), operates accord- once again mold the international/global of resurgent infectious diseases (such guise, global health refers to health and ing to co-financing incentives. Echoing health agenda. The Bill and Melinda Publicly accessible sources of infor- as TB), and, especially, pandemics (for disease patterns in terms of the interac- the RF, the BMGF follows a technically- Gates Foundation (BMGF), established mation about the Seattle, Washington- example influenza), WHO was no lon- tion of global, national, and local forces, oriented approach—with programs de- by Bill Gates (Microsoft founder and based BMGF are limited to its Web ger at the heart of international health processes, and conditions in political, signed to achieve positive evaluations its first, longtime, CEO and the world’s site, which does not cover documents Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda 10 / 27 Birn

through narrowly-defined goals—and factors enabling the reach of the BMGF. adheres to a business model emphasiz- Its emergence on the scene precisely ing short term achievements. at the apex of neoliberal globalization— a moment when overall spending for Many global health agencies are keen global health (counting WHO and other to join with the BMGF: indeed, it has an multilateral as well as bilateral organiza- extraordinary capacity to marshal other tions) was stagnant, when suspicion by donors to its efforts, including bilateral political and economic elites (and, via donors, which collectively contribute ten a hegemonic media, by voters in many times more resources to global health countries) of public and overseas de- each year than does the BMGF itself104,108 velopment assistance was at a near but with considerably less recognition. all-time high, when many low- and mid- This extends to some organizations that dle-income countries were floundering in the past took on social justice ap- under the multiple burdens of HIV/AIDS, proaches, for instance Norway’s NORAD re-emerging infectious diseases, and development agency109. Associations with soaring chronic ailments, compound- successful, high-profile activities that ed by decades of World Bank and IMF- show a “big bang for the buck”, poten- imposed social expenditure cuts—has tially within a single political cycle, are exaggerated the BMGF’s renown as a pursued even if in the long term the tech- savior for global health112-114. nical bang may turn out to be far smaller than it could have been through com- Without a doubt, the Gates Foundation bined social, political, and public health has been widely lauded for infusing measures, such as improving neighbor- cash and life into the global health field hood and working conditions, abolishing and encouraging participation of other the military, or building redistributive wel- players (see Figure 2)13,115,116. But even Figure 2 | Bill Gates speaks about the European investments in global https://www.flickr.com/photos/gatesfoundation/5592533339/in/ fare states110. those who recognize this role decry the health and development (here showing a slide of measures supported by photolist-8TYQMK-8NBcsS-9wfdTL-8JAyxu-9wvda8-8Ny7yZ- the Global Fund) that are saving lives at Living Proof campaign event at 9wcbYK-9uSeGu-9wccbH-9wccjB-9wfdCC-9wcch4-9T2L8e-9vTvJ7- Foundation’s lack of accountability and Money and the ability to mobilize it, grow the Museum Dapper. Paris, France. April 4, 2011. 9vVgW5-9vVgRC-9vVgJu-9vVgFE-9vXoRE-9uyTSz-9vTvrd-91JQqW- real-time transparency (over what are, it, and showcase its effectiveness— Source: Flickr, accessed August 27, 2014 9T2Ucr-9usxEg-9uBTPh-9uBT8E-8JAyfs-9uyRM8-9uyT3Z-8JAyyq- after all, taxpayer-subsidized dollars) “Living Proof Paris” 9d8Nhs-9BZWrX-9uyTDi-9uySnX-9T5yfm-9teffS-9C7EmC-9T2RAP- validated by BMGF-funded research bhnUXR-9T5JeJ-9uyS5M-anHaYX-9uBUbh-9usyGH-8DFfgX-8GFGAr- and the undue power of the BMGF and based on the dominant technoscien- 8DFfw4-8DFffP-8DJmXs-8GJSFj/ other private actors, including those entific biomedical model111—together with Courtesy of the Gates Foundation via Creative Commons License (no couraged under the Gates Foundation’s changes were made to the image) https://creativecommons.org/licenses/ founders Bill and Melinda Gates’s high- by-nc-nd/2.0/ visibility protagonism, are not the only Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda 11 / 27 Birn

favored PPP model, over the public Overall, the BMGF’s Global Health as well as markets for new sanitation The BMGF’s approach is (as was the Further, Gates’s assertion directly con- good117-119. Program supports research on and de- products and services”124. RF’s) reductionist, perhaps best exem- tradicts an abundance of public health velopment of diagnostics, preventives, plified in Bill Gates’s keynote speech at and demographic research that dem- THE BMGF APPROACH, ITS REACH Leading BMGF grants in the global treatments, and disease campaigns ad- the 58th World Health Assembly in May onstrates that the modern mortality de- AND LIMITS As the “pied piper” of glob- health arena have included US$1.5 bil- dressing HIV/AIDS, malaria, TB, pneu- 2005. Having a private sector orator ad- cline since the 19th century has been al health, the BMGF collaborates with lion to the GAVI Alliance (which the BMGF monia, diarrheal diseases, and “neglect- dress this annual gathering, at which the consequence of, first, improved liv- and supports a range of PPPs, the U.S. was instrumental in launching, and still ed diseases” (all of which have existing WHO member countries set policy and ing and working conditions, followed by National Institutes of Health, the World has a heavy hand in overseeing)101,125 to technical tools for control, from medi- vote on key matters, was unprecedent- a combination of these socio-political ap- Bank, the WHO, and other multilateral increase access to childhood and other cines to vaccines and oral rehydration ed; his bravura in invoking the model of proaches with medico-technologies that agencies, as well as universities, pri- vaccines; US$456 million to the PATH salts to insecticide-impregnated bed smallpox eradication based on vaccina- emerged since WWII81,129-136. Unlike the vate businesses, advocacy groups, and Malaria Vaccine Initiative101; over US$500 nets), in addition to financing translation (sidestepping its non-patented sta- early 20th century RF, which was open NGOs. As in the case of the RF in the million in grants to the Aeras Global TB tional sciences. The BMGF also provides tus) to set the course of WHO into the to social medicine research that showed past, the vast majority of BMGF glob- Vaccine Foundation126; and US$355 mil- funding for research on cervical cancer future was astounding: “Some point to the importance of anti-poverty, real health monies go to (or via) entities lion to Rotary International for polio eradi- both screening methods, recently generating the better health in the developed world distributive efforts technical interven- in high-income countries120. As of early cation, augmented in 2013 with a pledge and significant ethical criticism orf the studies and say that we can only improve health tions, Gates’s stance now suggests that 2014, almost three quarters of the to- for matching funds of up to US$35 mil- it supports in India123. when we eliminate poverty. And elimi- (he sees that) there is a sufficient critical tal funds granted by the BMGF Global lion per year through 2018127. The BMGF nating poverty is an important goal. But mass of pro-business politicians and sci- Health Program went to 50 organiza- In a shift since 2011, the BMGF’s Global has also provided approximately US$3 the world didn’t have to eliminate poverty entists that leftist alternatives can be ig- tions, 90% of which are located in the Development Program now oversees a billion for HIV/AIDS control (also cover- in order to eliminate smallpox—and we nored or summarily rejected. United States, United Kingdom, and number of global health-related activi- ing topical microbicides and vaccine don’t have to eliminate poverty before we Switzerland120,121. For example, since ties in the areas of: family planning; “inte- development)101,120,121. In a similar vein, the BMGF’s Grand reduce malaria. We do need to produce 1998, Seattle-based PATH (Program grated delivery”; maternal, neonatal, and Challenges in Global Health initiative, The BMGF’s most prominent global and deliver a vaccine”128. for Appropriate Technology in Health), child health; nutrition; polio; vaccine de- created in 2003 and enhanced in 2008 health efforts involve support for vac- PATH Drug Solutions, and PATH Vaccine livery; and water, sanitation, and hygiene Strikingly, Gates appealed to his audi- through Grand Challenges Explorations, cine development—in 2010 it committed Solutions have together received over (the latter was already part of the Global ence with a deceptively simple techno- funds scientists in several dozen coun- US$10 billion over 10 years to vaccine US$1.6 billion in grants from the BMGF Development Program). As in the glob- logical solution to an enormously com- tries to carry out “bold”, “unorthodox” research, development, and delivery. To Global Health Program, approximately al health arena, these efforts focus on plex problem just two months after WHO research projects137, but only if they view be sure, vaccines are important and ef- 15% of global health grants disbursed to innovating and delivering tools, proce- launched its Commission on Social health in circumscribed, technological fective public health tools, but it is essen- date, including close to US$614 million dures, and other targeted interventions, Determinants of Health, established terms, not through integrated technical tial to consider the nature of the BMGF’s in grants for malaria research; over often with private enterprise partners. precisely to counter overly biomedical- and socio-political understandings11,138. vaccine investments, as well as what is US$177 million in grants for neglect- The BMGF’s growing attention to sanita- ized understandings of health and to While the approximately one billion dol- neglected by this approach, such as, ed and infectious diseases; and over tion, for example, supports “development investigate and advocate for address- lars spent on the Grand Challenges in its most fundamentally, adequate living and US$305 million in grants for enteric dis- of radically new sanitation technologies ing the range of fundamental structural first decade is hardly the BMGF’s largest working conditions. eases and diarrhea121,122. and political factors that influence health. initiative, it offers a valuable means for Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda 12 / 27 Birn

publicizing and validating its approach founded in 2003)—to provide just one il- Yet the lack of interest on the part of the initiatives that are not narrowly techno- UNFPA, UNAIDS, the World Bank, the in the scientific community, with serious lustration from the recent social policies BMGF and most mainstream donors biomedical and that provide support to Gates Foundation, the GAVI Alliance, consequences. Even Challenge 16, to of leftwing governments across Latin (whose ideological agendas reject these some governments aiming to ensure and the Global Fund to Fight AIDS, “Discover New Ways to Achieve Healthy America—doubled access to primary kinds of redistributive measures) in sup- publicly-funded national health care sys- Tuberculosis and Malaria—the world’s Birth, Growth, and Development”—a health care (reaching near universality), porting, highlighting, or even consider- tems. In 2006, for example, the BMGF leading global health institutions. The question inherently linked to an array with 3200 health clinics built in the coun- ing Venezuela’s integrated approaches gave a US$20 million startup grant to H8 holds meetings, like the G8, at which of social factors—identifies “molecular try’s poorest neighborhoods, places that as a legitimate and effective (though not launch the International Association the mainstream global health agenda pathways” as the primary roadblock to had never before enjoyed such local flawless) route to global health equity of National Public Health Institutes144,145 is shaped behind closed doors146, and understanding what underlies poor infant infrastructure or attention to human speaks volumes. (In the 1980s, by con- (based at the Emory University Global organizations considerably influenced health, without reference to the living con- need. According to WHO figures and trast, though most mainstream bilateral Health Institute [USA], the Mexican by Gates and the BMGF constitute a ditions of newborns and their families139. other appraisals, in the first decade of aid agencies and development banks National Institute of Public Health, and plurality. Venezuela’s Bolivarian Revolution, in- pulled out of revolutionary Nicaragua, France’s Institute for Public Health Disavowing the messy and complicated THE BMGF AND THE RISE OF PPPS IN fant mortality experienced an accel- a handful, notably the Scandinavians, Surveillance), which helps support nu- politics of addressing health in the con- A NEOLIBERAL ENVIRONMENT Among erated decline, going from 19 to 13.9 stayed on, eager to assist the country in merous public health institutes in low- text of social conditions is certainly se- the key levers of BMGF influence are deaths/1000 live births, with under five its implementation of primary health care and middle-income countries, including ductive for those promoting technical PPPs147-149, a global health funding and mortality dropping from 26.5 to 16.7 and universal education51.) Cuba. In 2007 the BMGF provided US$5 and managerial solutions for ill health. operations modality enabled by the deaths/1000 births141. million to the WHO-based Global Health Yet whether or not one is interested in ad- Of course, societies fighting for social massive entry of private capital into the Workforce Alliance (GHWA)121, which dressing the underlying causes of pre- This initiative drew from Venezuela’s justice do not offer a politically palatable health and development arena at the end seeks to address the health personnel mature death and disease, there is no 1999 Constitution, which declared health pathway in a neoliberal environment of the Cold War. Philanthropic and busi- shortage across low-income regions. scientifically sound quick fix. According to be a human right guaranteed by the marked by extreme concentration of ness interests have long been involved Yet these grants are at the margins of to Bill Gates himself, many of the Grand state, coupled with “bottom-up” political wealth and power. The BMGF, emble- in international health, but it was not the BMGF’s efforts, both in monetary Challenges are not expected to yield demands for health and social services, matic of elite interests in contemporary until the 1990s that PPPs were formal- and publicity terms, and do not in and results until 15 or more years out, far nutrition, housing, education, and im- society, disregards the underlying ized as a central element of global health, of themselves represent an alternative to longer than he originally envisioned140, a proved employment142,143. Undoubtedly causes of ill health in the first place, over- one that, following the prescription the BMGF . time frame in which large-scale social the likely billions of dollars (including looks what role the unprecedented accu- modus operandi of privatizing public goods put forth and political investments in, for exam- the exchange of Venezuelan oil for the mulation of wealth in the hands of a few Indeed, despite the manifold shortcom- by the World Bank and IMF, con- ple, comprehensive primary health care- service of thousands of Cuban doctors) has played therein, and remains fiercely ings of a technology-focused, disease- sciously draws on profit-making prin- based systems and health equity—had invested in this effort are far greater than proud (staking a moral high ground) of by-disease approach to global health, ciples as a driver of policies, product they been supported—could have paid what the BMGF or even all overseas its generosity and technical savoir-faire, this model prevails at present, abetted by development, and other activities150-152. off, and on a far grander scale. development aid put together might all the while remaining underscrutinized the BMGF’s prime sway at formal glob- (It was actually the RF that had suc- spend on primary health care in a by scientists and the wider public alike. al health decision-making bodies. The cessfully pushed this approach in the In the space of less than a decade, single country, and one would never ex- BMGF’s role has been magnified by the mid 1990s153; however the catalytic part Venezuela’s “Barrio Adentro” program Admittedly, the BMGF has also engaged pect or desire such a role for donors. formation of the “H8”—WHO, UNICEF, it played was soon upstaged by Gates (“Inside/Within the Neighborhood,” in smaller-scale patronage of certain Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda 13 / 27 Birn

philanthropy, which by this time had far most influential PPPs, the Global Fund companies found a sympathetic ear with sector, represented by pharmaceutical US$864 million of WHO’s biennial bud- more resources than the RF68). and the GAVI Alliance, both H8 mem- the country’s Competition Tribunal. Merck/MSD, and private foundations, gets of over US$4 billion (approximately bers, underscores the primacy of the Settling out of court, the companies represented by the BMGF160, which has 20–25% of the total), likely an underes- There are now dozens of major global BMGF in shaping and enhancing the agreed to issue voluntary generic given close to US$1.5 billion161 to the timate given that several major partner- health PPPs in existence, with budgets power of the PPP model. licenses for AIDS drugs, an outcome Global Fund, do. The Global Fund, like ships, including Roll Back Malaria, are ranging from a few million to billions of that inspired activists in other countries many PPPs, offers “business opportuni- not captured in this figure166,167. PPPs have dollars. These include Stop TB, Roll Back The Global Fund to Fight AIDS, to follow suit158. However, once the flow ties”162—lucrative contracts—as a prime undermined WHO’s authority and ability Malaria, the International AIDS Vaccine Tuberculosis and Malaria—inaugurated of philanthropic and bilateral donations feature of its work, illustrating how global to function: the WHO’s Executive Board Initiative, and the Global Alliance for as a Swiss foundation in 2002 with a made medicines more accessible in the health is being captured by business only belatedly (in 2007) recognized the Improved Nutrition, many of which were US$100 million grant from the BMGF—is absence of IP reform, the deep tensions interests in a way that was not part of numerous problems posed by PPPs, launched by the BMGF or receive(d) the largest PPP. Aimed at bypassing the between egregious pharmaceutical prof- the original RF strategy, which saw such as fragmentation of global health funding from it152. While portrayed as an perceived bureaucratic encumbrances its and the health of the global poor was, international health in the public, not the efforts and policy, low cost-effectiveness, opportunity to expand funding and vis- of the UN155-157 (which could alternatively at least in a limited fashion, attenuated159. profiteering, domain, even if ultimately and insufficient accountability168,169. ibility, these “collaborations” between be read as “independent and account- benefiting thepriv ate sector. the private sector and public agencies able decision-making bodies and pro- The voting members of the Global Fund’s Yet WHO has not attempted to present (both multilateral and national)—which cesses”) in funding services and thera- governing board are split 50/50 between Similarly, the GAVI Alliance has been systematically data about its participa- extend far beyond the BMGF to include pies to combat these three diseases, the representatives of donor governments critiqued for placing too much emphasis tion in PPPs152 and since 2012–13 has a range of business interests such as Global Fund has further debilitated the (8 members), private philanthropy(1), and on new and novel vaccines (often de- stopped issuing a section on PPPs in pharmaceutical companies and their WHO and any semblance of democratic the private sector(1) on one hand; and, veloped by its pharmaceutical partners) the biennial budget, admitting it “did not philanthropic spinoffs—have granted global health governance. on the other, representatives of low- and rather than ensuring that known effective always have full control of the results the business sector and profit-oriented middle-income countries (7), “communi- basic vaccination is universally carried and deliverables”170. Further evidence of The establishment of the Global Fund approaches an enormous and unprece- ties”(1), and NGOs from “developed”(1) out163 and for being largely “top-down”, WHO’s tergiversation regarding the prob- also served to weaken an important dented role in international public health and “developing”(1) countries. The Global paying scant attention to local needs and lems of PPP and private sector involve- transnational movement for intellectual policymaking without quid pro quo ac- Fund raises money, reviews proposals, conditions164. Critics have also faulted the ment in its work is a 2010 World Health property (IP) reform that surged in the countability154. They also show a marked and disburses grants and contracts, rath- GAVI Alliance for the heavy represen- Assembly resolution that calls on coun- late 1990s to address the grossly im- difference from the RF’s early and mid er than implementing programs directly. tation of industry on its board165 and for tries to “constructively engage the private moral profiteering of pharmaceuti- 20th century goal of pushing for public As of 2013, the Global Fund had distrib- directly subsidizing the profits of already sector in providing essential health-care cal companies that impeded access health, at both national and international uted upwards of US$22.9 billion to some mega-profitable Big Pharma through services”171. to HIV/AIDS drugs in low- and middle- levels, to be in the realm of public sector 1,000 programs in over 140 countries, dubious contracts and incentives, all in income countries, particularly in Africa. Certainly some global health PPPs responsibility—and accountability. and in December 2013 donors pledged the name of “saving children’s lives”165. For example, a case filed by the AIDS have helped spur research and devel- an unprecedented additional US$12 By no means is the BMGF the only play- Law Project (a human rights advocacy WHO’s work has also become tethered opment and enabled better diffusion of billion for the next 3 years. Incredibly, er in the PPP sphere (and PPPs are not organization) in South Africa in to the activities of PPPs. In recent years, pharmaceuticals. Product Development WHO and UNAIDS have no vote on the exclusive to the health arena), but the 2002 against excessive pric- activities with multiple PPPs have con- Partnerships in particular have raised board of the Global Fund, but the private prominent part it has played in the two ing by foreign pharmaceutical stituted between US$700 million and hundreds of millions of dollars for Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda 14 / 27 Birn

medicines for “neglected diseases”172. But researchers to do work of value to industry benefited capitalist interests once the 2011187. Several other senior BMGF ex- with some forms of cervical cancer) on the whole, as I have noted elsewhere, partners” p4,177, suggesting an underhand- public health work was carried out. ecutives hail from GlaxoSmithKline and among girls of low-income backgrounds.

188,189 “they bring most of the same problems ed way for private industry to influence THE BMGF AND CONFLICTS OF Merck . Gates Foundation initiatives The Indian parliament has alleged that as mainstream health donors writ large: global health research and the way sci- (in health, agriculture, and other areas) the trials violated ethical standards be- INTEREST In recent years the BMGF imposition of outside agendas, poor entific results are reported. As well, bilat- may well benefit these corporations cause the girls’ consent was not fully in- has been accused of investing its en- harmonization with stakeholders and eral donors have become increasingly in addition to Coca-Cola, McDonald’s, formed and adverse events were not ad- dowment in profiteering pharmaceutical national governments, underfunding, and invested in PPP activity154. When PPP Monsanto, Nestlé, Procter & Gamble, equately monitored or reported, while companies and polluting industries—in- vilification of the public sector” p106,51—in- benefits such as direct grant monies, tax and other companies in which the PATH claims that since this was an ob- cluding ExxonMobil (whose forerunner sidious effects indeed. Ultimately, “nar- subsidies, reduced market risk, reputa- Gates Foundation, Berkshire Hathaway, servational study of an already approved was founded by John D. Rockefeller) and rowly-targeted PPPs entrench vertical, tion enhancement, expanded markets, and Gates family members are major vaccine, not a clinical trial, these provi- Chevron, which have been linked to envi- [top-down, single disease-focused] and IP rights are taken into account178, shareholders184,190. sions were not “necessary”196–199. ronmental and health crises in the Niger programs … [there is no PPP for social the net result is that most PPPs channel Delta and other oil-rich regions182-185— The conflict of interest between the phar- As noted by advocates for affordable justice in health!], jeopardizing health public money into the private sector, not as well as in “private corporations that maceutical industry (including their own life-saving medicines, the Gates systems and impeding integrated ap- the other way around96,179. stand to gain from the Foundation’s phil- corporate global health foundations, of- Foundation’s stance on IP raises seri- proaches” p106,51 to health. In sum, PPPs—heavily shaped by the anthropic support of particular global ten barely disguised marketing and pub- ous questions. Bill Gates himself admits These concerns are aggravated by the BMGF—allow private interests to com- health initiatives” p269,183. lic relations endeavors) and the BMGF is that his foundation “derives revenues incongruity between the profit-making promise the public health agenda, pro- palpable125. Yet conflicts of interest are from patenting of pharmaceuticals”200. While the Gates Foundation, perhaps re- mandates of corporations and WHO’s vide legitimacy to corporations’ activities downplayed by these actors and rarely A crucial issue has to do with the ex- sponding to criticism, pulled out of many commitment to health as a human right. through association with UN agencies, articulated publicly, since most observ- tent of coordination between the IP ap- of its direct pharmaceutical holdings in PPPs have marshaled billions of dollars conflate corporate and public objectives, ers (and grant recipients) fear offending proaches of Microsoft and the BMGF. 2009185, its vested interest in the pharma- to global health104,173, at the same time and raise a host of conflicts of interest, the powerful foundation191,192 (a few inves- While the two entities are legally sepa- ceutical industry remains through BMGF as opening the door to extensive com- whereby private partners seek to com- tigative journalists and Web sites serving rate, there are troubling shared inter- mega-donor Warren Buffett’s Berkshire mercialization174-176 and private sector in- mercialize their own products through as courageous exceptions193–195). ests, including the BMGF’s 2011 hiring Hathaway holdings (in which 50% of fluence in policymaking (for instance PPP involvement180. Moreover, most global of a Microsoft patent attorney into its the Gates Foundation endowment is One example of such conflicts, regarding UNITAID’s promise of a “market for health PPPs favor RF-style, short term, global health program200. Microsoft, infa- invested) in Johnson & Johnson, Sanofi- the questionable dealings of the BMGF’s health commodities” and the University vertical approaches to disease control, mously, has been charged and fined for Aventis, and other pharmaceutical com- India office, highlights that “Gates lob- of Toronto’s McLaughlin-Rotman Centre compounded by profit-making impera- a range of monopolistic practices and panies184. The immediate past president bied with the health ministry for the intro- for Global Health’s “commercialization tives181. In contrast to the RF of the past, has been a strong supporter of IP proof the BMGF’s global health program, Dr. duction of Merck’s rotavirus vaccine”190. pillar”), making global health a bigger however, PPPs promote profit-making at tections as a (legal) means of corner- Tachi Yamada, was formerly an executive The BMGF has also funded controversial business opportunity than ever before99. the front end of global health work, as op- ing markets4. Microsoft played a lead- and board member of pharmaceutical studies in India (carried out by its largest According to one ex-pharmaceutical posed to strategic public health activities ing part in assuring the passage of the giant GlaxoSmithKline186, and his suc- global health grantee, PATH) of Merck’s executive, public-private “partnerships (against yellow fever, for example) that World Trade Organization’s (WTO) TRIPS cessor, Dr. Trevor Mundel, was a senior and GlaxoSmithKline’s vaccines against may provide incentive for academic agreement protecting IP and continues executive at Novartis AG from 2003 until the human papillomavirus (associated Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda 15 / 27 Birn

its lobbying efforts with other corpora- of the poor, its role in numerous PPPs, into the (corporate cartel-controlled) denounced for being self-serving and other commodity sectors, were built on tions to expand IP rights119. As critics and its close connection to Novartis now global food chain—are neither publicly a violation of the principle of separation rising inequality217. That is, these profits pointedly note, the BMGF’s endowment that Mundel heads global health at the accountable nor regulated211. In addition of public and private interests, today were made thanks to: the depression of “was amassed through labour practices BMGF—should address the dilemma of to profound concerns about AGRA’s role they are viewed by private capital—and wages and worsening of labor conditions and monopolistic intellectual property profit motive versus access to medicines in the research and promotion of genet- rationalized by a disquietingly quiet for the vast majority of workers world- strategies [not to mention militarism201,202] head on, even if this is unpalatable207. (On ically-modified organisms (GMOs) and public—as desirable outcomes that wide; tacit or explicit support of milita- that are contrary to the stated health aims April 1, 2013 the Indian Supreme Court the development of privately patented ought to be encouraged rather than rism and civil conflicts to ensure access of the Gates Foundation”p268,183. ruled against Novartis208). seeds (in this regard, AGRA differs from eschewed as problematic and unethical. to valuable commodities; trade and for- the earlier RF-sponsored efforts, which eign investment practices that flout pro- The BMGF, for its part, was a major The BMGF’s involvement in the Alliance PHILANTHROCAPITALISM REDUX: kept hybridized seeds in the public do- tective regulations; and the externalizing sponsor of WHO’s Commission on for a Green Revolution in Africa (AGRA), COMPARING THE RF AND THE BMGF main, given that this was before gene (transferring from private, corporate Macroeconomics and Health, which (including US$264.5 million in BMGF The mounting trend of business-founda- patenting was legalized in 1980212), local responsibility to the public and future concluded that IP rights are a critical in- grants as of 2013)101, like its global health tion collaboration has crystallized in the watchdogs have also linked AGRA to the generations) of the social and environ- centive to research and development of efforts, illustrates the profound contra- term “philanthrocapitalism”, which touts fostering of private ownership and cor- mental costs of doing business, includ- drugs203, a position: historically disputed diction between the aims of philanthro- the philanthropic largesse and social- porate control of Africa’s genetic wealth ing toxic exposures and contamination of by the experience of, to name but one ex- py (or philanthrocapitalism, see ahead) entrepreneurial mission of the new 1990s without the sharing of credit or benefits the air, soil, and waterways, deforestation, ample, the development of the Salk polio and the needs of poor populations209. billionaires as unprecedented and capa- with the cultivators213. and the effects of climate change218-220. vaccine165; shown to be incorrect for low- AGRA, like the RF’s Green Revolution ble of “saving the world.” While the US$2 income countries that have joined TRIPS programs before it, focuses on techno- As we saw, the RF was suspected of billion plus annual spending of U.S. phi- Second, the tenet that business models in the last 15 years204; and increasingly logical and market models for increased selling shoes in the case of the U.S. lanthropy has indeed made a second en- can (re-)solve social problems—and are challenged by advocates today205,206. agricultural output. This emphasis hookworm campaign and of seeking trée into the international health and de- superior to redistributive, collectively de- comes at the expense of equitable, dem- to enhance the profits of Rockefeller oil velopment arena, the philanthrocapitalist liberated policies and actions employed Another indicator of the BMGF’s trou- ocratic, and sustainable approaches interests in Latin America (and certainly approach, past and present, merits ques- by elected governments—masks the re- bling corporate allegiances has been based on securing land rights for small located its campaigns in settings that tioning on a number of grounds14,214-216. ality that private enterprise approaches its refusal to take a stance in the case producers (all the more pressing in a were to its long-term business advantage, have been accompanied, facilitated, and of Novartis’s lawsuit against the Indian First, just as late 19th and early 20th cen- context of large-scale foreign land grabs such as the oil-rich state of Veracruz, made inevitable by neoliberal deregu- government (for denying a new patent to tury philanthropy derived from the prof- in countries facing dire hunger and mal- Mexico), but the press and populace in lation, privatization, government down- Novartis for a cancer drug that it deemed its of exploitative industries of the day nutrition problems) and supporting local the early 20th century were sufficiently sizing, and emphasis on short-term re- was an instance of evergreening—mak- (oil, steel, railroads, manufacturing), the and regional food distribution networks210. vigilant that the RF was unable to directly sults over long-term sustainability. These ing only minor chemical changes to an colossal profits earned during the 1990s mix its business and philanthropic ends. models rest on the belief that the mar- existing medication to extend the life of While AGRA promises help for small farm- and 2000s by a small number of people The ideological metamorphosis under ket is infallible, despite ample evidence its patent) on the issue of access to life- ers (at least the most prosperous among in the information-technology, insurance, contemporary neoliberalism is such that to the contrary. All the financial incen- saving medicines. Many advocates be- them), its food security efforts—which real estate, and finance industries (and whereas in the past public health activi- tives in the world will not create a vac- lieve that the BMGF—with its extensive ultimately aim to integrate African food related speculation), as well as industries ties directly linked to profit-making were IP expertise, its aim to improve the health consumption and agricultural production linked to the military, and mining, oil, and Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda 16 / 27 Birn

cine against poverty, racial and gender nomic (and political) power is decidedly and lives of the 2.5 billion people living The consuming public has been drawn in the United States, with repercussions discrimination, and inequality. undemocratic. on less than US$2 per day—has reached into such “marketized philanthropy”, still vividly evident today. entirely new dimensions and should draw whereby consumer purchases, for ex- Here, we see a contrast to the old RF, Over the past century and a quarter, In the global health arena of more recent concerted attention from all believers in ample through Product RED, both gen- which, although implementing and eval- philanthropy has frequently served, decades, the argument that the public health as a social justice imperative. In erate profits for (philanthro-) capitalists uating its public health activities accord- directly or indirectly, to enhance do- sector is incapable of addressing soci- the early 20th century, the RF allowed finance global health projects and ing to a business model, explicitly called nors’ business and investment interests, and etal needs contemptuously disregards a variety of voices into its international agencies driven by philanthrocapitalist for public health to be just that: in the many of which are linked to industries the full-fledged assault on public spend- health enterprise, even as it privileged a interests229. Yet “despite … pretensions to public sphere. Because Rockefeller him- that are highly exploitative and damag- ing and infrastructure on the part of inter- reductionist approach. Today, even the ‘activism’” these are “fundamentally self was a fiercely competitive capitalist ing to the environment. Celebrating and national financial institutions’ conditional- RF—though now a much smaller global depoliticizing” approaches, cheerled bent on maximizing private profits from encouraging the munificence of elites is ities and structural adjustment programs health player compared to the BMGF— and channeled by celebrity philanthro- his own investments and companies, the counterproductive to the goal of creating in the 1980s and 1990s, not to mention has been narrowed to a “global health humanitarians who, along with philan- issue that comes to the fore now is how equitable, sustainable societies. If any- the wave of predatory private bank lend- as business” mentality, as per the larger throcapitalists, are marketing their own the current context of philanthrocapital- thing, people living on working class and ing, unfair trade practices, and hegemon- philanthrocapitalist trend. “brands,” while “legitimat[ing], and in- ism has led to such a distinct configura- modest incomes—who rarely receive ic leverage over the WTO by powerful deed promot[ing], neoliberal capitalism tion under the BMGF. recognition (or tax breaks, for that mat- For instance, after equivocating for countries (and influential industries there- and global inequality”230. ter) for their donations—are proportion- almost a century on whether or not to in, including the U.S. tobacco industry Third, the very tax-exempt status of foun- ately far more generous than the rich, support universal health insurance in Philanthropists, past and present, typ- and food conglomerates) since the mid dations and tax-deductibility of philan- and their giving, unlike that of the wealthy, the United States, the RF has finally en- ically rationalize their actions as neces- 1990s51,119,232. For example, the govern- thropic and charitable donations is an af- may entail considerable personal sacri- dorsed this goal, internationally, rec- sary to address “market failures”231. Of ments of Subsaharan African countries front to democracy. The faith that giving fice223. In the early 20th century, as we ommending “models that harness the course, (global) public health, like many were pressured to cut public education, can “change the world” is in many ways a have seen, the millions involved in so- private health sector in the financing other social goods and services, by defi- health, and other social spending in or- preposterous manifestation of the notion cial and political struggles for decent, and provision of health services for poor nition resides in the market failure realm der to meet the terms of loans made nec- that “the rich know best,” as though more equitable societies were savvier people”224. Echoing the World Bank and because it is externalized from the costs essary because of falling export prices autonomous, donor decisions should re- and far more skeptical than much of the BMGF-supported WHO Commission of doing business51. That philanthropy related to global trade and financial forc- place representative and accountable the public today about the supposed on Macroeconomics and Health’s “in- (and, more pointedly, philanthrocapi- es beyond their borders, then blamed for welfare states and systems of redistri- generosity of those responsible for sus- vesting in health” approach225-227, through talism) steps in to promote capitalist inadequately addressing infant mortal- bution119,221. As former U.S. Secretary of taining—and gaining from—these very which “investing in health” is justified approaches as superior to the public ity, AIDS and other health crises, in turn Labor Robert Reich has noted, “govern- societal injustices. both as good for the economy a sector in regulating and delivering ser- leading these countries to become “cli- ments used to collect billions from ty- and profitable and legitimate private-sector vices is self-serving and unsubstantiated. ents” of the Global Fund233. coons and then decide democratically Certainly many of the accusations lev- activity, the RF is also promoting “impact In the early 20th century, as we saw, phi- what to do with it”222. Ceding decision- eled against contemporary philanthro- In part to fend off such critiques, the investing”, inducing venture capitalists lanthropists were effective at staving off, making power over social priorities to capitalism were also leveled at the RF. BMGF, as did the RF, has adopted pro- to “address social and/or environmental then limiting, a full-fledged welfare state the class that already wields undue eco- Yet the current infusion of profit making gressive, value-based rhetoric: respect problems while also turning a profit”228. for philanthropic ends—on the backs for partners, being “humble”, fair and Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda 17 / 27 Birn

focused priority-setting, “ethical” com- The Gates Foundation has pursued most composition of the boards of key PPPs, In an interesting twist, in late 2013, the have stood in its way) has led to growing portment, and a lofty goal of “increas[ing] of the RF’s international health princi- including the GAVI Alliance and the BMGF announced a grant to Fiocruz, resentment of its current global health opportunity and equity for those most in ples—though not its institutionalization Global Fund, and its executives and staff Brazil’s national health institute, to fund power240. Though most global health re- need”234. The BMGF’s high-minded, self- practices—almost to the letter: through members are often members of, or even the production of childhood vaccines searchers have remained silent, a brave defined mission, like the RF’s grand mot- technobiological and cost-effective ap- chair, these boards—particularly inter- for distribution within Latin America (a few have spoken out regarding the extent to of the past, does not, however, exempt proaches, the use of budget incentives, im boards of new organizations that set departure from its backing of the GAVI to which the Gates Foundation’s directive it from scrutiny and accountability. a priori success measures, and priority- broad policy directions. Alliance’s model of funding private phar- style and dominance over funding ave- setting from above, with a nod to local maceutical firms). Brazil, which has re- nues have squeezed out legitimate alter- But the similarities do not end there. Like But the BMGF has far less interest in insti- adaptation. Even the BMGF’s reluctance mained largely outside the BMGF orbit, native scientific approaches. For exam- the RF of yore, the Gates Foundation’s tutionalization, health care systems and to address non-communicable diseas- has attracted widespread attention in ple in late 2007, the then head of WHO’s sway and dominance over the global infrastructure, and does not tolerate, es140—with their long-term, politically recent decades for its unified, publicly- malaria program decried the BMGF’s health agenda stems in part from the as did the RF in the early 20th century, complex, and costly implications and run universal health care system (SUS)— attempts to influence WHO’s malaria magnitude of its donations, its ability to social medicine approaches. While its lack of a technical quick-fix—is reminis- established under its post-dictatorship policies in a highly critical memo (he mobilize resources quickly and allocate influence as a “global citizen”236 (as dis- cent of the RF distancing itself in the early 1988 Constitution—and its South-South was moved to another position after his substantial sums to large or innovative tinct from the RF’s closer alignment with 20th century from TB, diarrhea, and other cooperation efforts that emphasize pri- memo came to light241), possibly portend- efforts, the renown of its patron, its tech- U.S. foreign policy objectives in the first diseases requiring major social and polit- mary health care and human resourc- ing further outcry into the future115. nology-driven and cost-effective empha- half of the 20th century) is both hailed ical investments (TB and rotaviruses are es training. But Brazil’s health system ses, as well as the clout and leverage it and feared214,237, the BMGF’s role is argu- The Gates Foundation’s technological now addressed by the BMGF, through is presently under enormous pressure garners from the extraordinary range of ably more contestable than that of the focus is perhaps inevitable given the technical tools, such as vaccines and to increase the involvement of the pri- organizations which it partners with or RF in the past. This is because, ironically, expertise and provenance of its founder. therapies, that were not available in the vate sector239. Perhaps the BMGF’s new- funds138,140. whereas in the interwar years the RF As in the case of the RF in the 1910s, it early 20th century, though as under the found support for Fiocruz means that it was closely linked to just one interna- is filling a gap which it perceives is not As did the RF in the past, the BMGF has RF, these efforts are divorced from living needs the credibility of Brazil’s public tional health agency (the LNHO), the being addressed by existing players also populated important policymaking and working conditions). sector and infrastructure policies more BMGF has ties to multiple organizations (including WHO, USAID, Wellcome Trust, roles at key agencies. Most prominently , than Brazil needs the BMGF. More likely, For the BMGF, transnational consensus in a now highly fragmented global health European Union, U.S. National Institutes USAID’s director, Dr. Rajiv Shah, formerly the entry of the BMGF to Brazil signals, is generated through: advisory boards world (in part due to the BMGF itself). of Health, and other major develop- held several Gates Foundation leader- whether intentionally or not, a far great- that include low- and middle-income Thus, the field is home to extensive, di- ment and research funders): the Gates ship positions before joining the Obama er role for the private sector in SUS than country public health and scientific verse, and dynamic constituencies that Foundation has become a salve to the administration. Under Shah, USAID, with was envisioned by the constitution. leaders; the reach of its research fund- have various routes to shaping global collective concerns of capitalist inter- an annual budget of over US$20 billion ing (and the validation provided by the health, extending to vibrant global pub- Overall, the BMGF’s averseness to en- ests that global health is too important to in recent years, considers itself a “busi- funded research generated); the myr- lic interest civil society movements, and gaging with individuals and institutions leave to a purportedly democratic entity ness-focused development agency fo- iad partnerships it has incubated; as the emergent global health diplomacy of wielding contrasting viewpoints and ap- (namely, the WHO). cused on results”235. well as the associated media coverage BRIC countries and other South-South proaches (and apparent vindictiveness, The tide may be turning, slowly, away (see ahead)140. The BMGF shapes the cooperation238. against those at WHO and elsewhere who from the BMGF’s technological and Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda 18 / 27 Birn

business-oriented approaches to glob- had an overarching purview and leader- asserting independence from BMGF from its activities, though Rockefeller Spain’s El País, the African Media al health. As recently as 2010, former ship role. It was instrumental in establish- efforts. family business interests surely benefited Initiative, and in the United States to the BMGF global health director Yamada ing the centrality of international health from the reduction of epidemic threats to Public Broadcasting Service, National The BMGF’s active enlistment of both stated that the Foundation was refocus- activities to the realms of economic de- international commerce and the increase Public Radio, and other broadcasting public and private partners to support ing “on technologies with the biggest velopment, state-building, diplomacy, in productivity, stability, and markets outlets, and through the Kaiser Family its initiatives has enabled its sweeping health payoffs and near-term applica- and scientific diffusion, and it institution- enabled by public health improvements. Foundation, which runs a leading global influence on the global health agenda in tions”242, narrowing ever further the tech- alized patterns of health cooperation that health portal that has been accused of the space of just a few years. Yet while In a sense, the IHB/D was a massive no-biological model honed by the RF. Yet remain in place to the present day. soft-pedaling its postings on the Gates many researchers and small and size- demonstration project, with its agenda a quarter century into the US$10 billion Foundation251-253. All of this coverage di- By comparison, though its short-term ef- able organizations of all stripes have reflected in scores of national and local vertical polio campaign, and despite the rectly or indirectly generates positive fects are of great consequence and, ac- readily adapted themselves to the Gates health agencies across the world, and recently declared elimination of polio publicity for the BMGF’s approach to cording to critics, highly disconcerting, Foundation’s priorities, this 800-pound institutionalized in the WHO. That the from India243, this endeavor is undergo- global health and development as well the Gates Foundation tracks a path gorilla is not the only animal in the glob- BMGF may cast a smaller shadow than ing deep re-evaluation244-246, following the as for the foundation itself, publicity established by the RF (albeit modified al health jungle. Often forgotten is that the RF in the long run cannot quell con- resurgence of polio in Syria and Somalia which it clearly believes is necessary to by the exigencies of the Cold War and BMGF and overall global health philan- cern about the current dominance and and the appearance of wild poliovirus justify its omnipresent involvement. the ideological context of neoliberalism). thropy hovers at less than 10% of devel- power of the Gates Foundation, which in Tajikistan, Nigeria, and persistent en- Still, the BMGF presently looms large opment assistance for health, which has has emerged hand in hand with: neolib- By contrast, historically the RF was con- demic polio in Pakistan and Afghanistan in the press, in the imagination, and at grown from under 11 billion to 30.6 bil- eral globalization; a unipolar post Cold tent to underplay its role, except at the in contexts of entrenched poverty247,248, the agenda-setting table, boosted by lion dollars between 2000 and 2011, with War scenario; a huge rise in the power highest political levels and behind closed inadequate health care coverage, and the likes of singer-humanitarian Bono approximately one-third coming from the of transnational corporations, which of- doors. This resulted from the hard-hitting cultural and religious resistance to tar- and other practitioners of celebrity phi- U.S. government alone104. ten block policies in the public interest investigative journalism of the early 20th geted vaccination. Even Bill Gates, one lanthropy230. Even though “quite con- and benefit from institutionalized corrup- century, and the savviness and skepti- Undoubtedly the array of global health ac- of the campaign’s greatest proponents sciously the Gates Foundation has … be- tion; and PPPs—the handmaiden of the cism of the working class, who rebuked, tors actually or potentially being funded and donors, seems to have belatedly become the alternative to the World Health Gates approach. for example, Rockefeller interests in the by, or partnering with, the BMGF am- gun to understand that targeted eradica- Organization”250, it cannot dismiss exist- case of the Ludlow Massacre. Even in plifies its impact on the field. However, A potential indicator that the BMGF is tion needs to be integrated with broader ing agencies wholesale. After all, a glob- its public health work, the RF learned to the BMGF has tended to leave few more fragile than it appears, paradoxi- approaches, most notably strong health al health architecture (precarious and employ its name in a subdued fashion. institutional footprints in the set- cally, is its aggressive self-promotion care systems242,249. It remains to be seen disjointed as it may be) already exists, Because a principal aim of RF interna- tings in which it operates115,241. The campaign that far exceeds the early 20th whether this sentiment is translated into with countless public, private, bilateral, tional health was institutionalizing public RF in the 20th century, by contrast, century RF in such efforts. Particularly practice. multinational, regional, not-for-profit, hu- health through strong government agen- shaped the international health pan- troubling are the more than one billion manitarian, and socially-oriented agencies and services, moreover, minimizing A RICH MAN’S WORLD, MUST IT BE? orama—as well as country-by-country dollars spent on “policy and advocacy” As the cies in operation, numerous advocacy public attention to itself ultimately ad- (WITH APOLOGIES TO ABBA) public health agencies—almost single- activities, including direct funding for premier international health organization groups fighting for legitimacy, and some vanced its goals. handedly. Moreover, unlike the BMGF, global health and development cover- of the first half of the 20th century, the RF the RF itself did not seek to profit directly age to British newspaper The Guardian, Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda 19 / 27 Birn

The BMGF, for its part, while reliant on of austerity, economic and global injus- necessary first step to address these is- their scholarly independence is being on. These struggles are taking on the the public sector to help deliver many tice, violation of people’s rights, and lack sues. (Subsidiary to this is the need for threatened by the private sector and extreme greed and power of corporate of its technologies and programs (often of true democracy256, we may be at a philanthropic accountability—including philanthrocapitalist intrusion on global capitalist interests and plutocrats in the provoking an internal public-to-private turning point. It is an opportune moment the public and transparent election of health: the asymmetry of power between contemporary global economy256; so too sector ‘brain drain’)108, appears largely for specialists and the broad public alike board members and the assurance of ex- these actors and the public interest is ought scientists question the BMGF’s indifferent to the survival of the “public” to become more attuned and resistant to ternal scientific evaluation of philanthrop- such that WHO and other UN entities undemocratic influence over the global in public health. Recently the BMGF the BMGF’s presuppositions and aims. ic activities.) At the center of this proposed cooperating with the business sector health agenda, and its implicit assault

has taken some tentative steps to ex- PHILANTHROCAPITALISM AND THE effort is the urgent need to better under- (not to mention scientists within these on the building and maintaining of wel- plore the prospect of investing in primary GLOBAL HEALTH AGENDA: WHAT ROLE stand how powerful private foundations organizations) are being urged to main- fare states, just as leftwing health experts health care254, possibly in relation to are shaping the global health agenda as tain their “integrity, independence and in the past resisted and constructively FOR SCIENTISTS? Clearly, as these its unit for Integrated Health Solutions well as the production and circulation of impartiality”p4,260,261. sought to push the RF to consider inter- many examples demonstrate, capital- Development (also referred to as particular kinds of knowledge (and like- national health approaches based on so- ism trumps the love of humankind (the Scientists should not shirk their responsi- Integrated Delivery and Integrated wise the rendering invisible—due to lack cialist and other equitable, redistributive dictionary definition of philanthropy, from bility for advocating for public, account- Development), established in 2007 but of funding and attention—of other kinds welfare states59. its Greek, via late Latin, origins), mak- able government-funded support for about which little is publicly known. of knowledge and questions), and how ing philanthrocapitalism an oxymoronic the scientific enterprise, lest their cred- International health in the 20th century Perhaps the BMGF aims to change (or, this power ought to be reined in117. A key enterprise indeed. The pivotal, even ne- ibility be challenged177,262. Global health was punctuated by the philanthrocapital- more ominously, maybe it seeks to coopt issue relates to why, given its avowed in- farious, role it has come to play in inter- scientists, joining with colleagues call- ist’s prerogative. In the 21st it may well the primary health care approach); but terest in improving equity, the BMGF has national/global health in different eras ing for action on climate change (e.g. still be a rich man’s world, but we need for now its approach as a whole seems to not engaged with the social determinants draws from a series of nested factors: James Hansen)263, denouncing unethi- not settle for a rich man’s agenda for counter the relevance of an accountable of health approach to addressing global gargantuan resources enabled by profi- cal drug company tactics (e.g. Peter global health. Scientists, scholars, ac- welfare state. Having its own efforts at health inequity, which has received wide teering of titanic proportions—amidst Gøtzsche), and others (for instance, the tivists, and ethical thinkers of all stripes the forefront is not a detractor, but rather international validation257-259. relentless ideological assaults on dem- Union of Concerned Scientists), should should take notice of these untoward a boon, to its larger aims of “creative cap- ocratically-driven redistributive ap- But such a movement should not come take inspiration from the brave activ- developments and work together for ac- italism” and a public-private technology- proaches—all contextualized by a pro- solely from civil society and policy critics. ism and advocacy that have unfolded countability and democratic decision- driven model. corporate geopolitical climate within still Global health researchers, practitioners, in the public protests against IMF and making in global health.H Yet, given the growing traction of a human dominant (if declining) U.S. global capi- and grant recipients must play a vocal European Union-imposed Greek aus- METHODOLOGICAL NOTE It is important rights-based approach to health and talism. And recall that the very essence role, uncomfortable and potentially per- terity, through Spain’s mo- indignados to underscore the unevenness in the vol- well-being255, and the collective clarion of (U.S.) philanthropy is a brazen system ilous as this may be. It is not enough for bilization, in the Andean phi- buen vivir ume and nature of sources available to cry of accelerating numbers (hundreds of undemocratic decisionmaking by self- scientists who work in global health to losophy and policies, via global justice analyze each foundation. The Rockefeller each year) of large- and smaller-scale designated mega-donors. claim that they are just carrying out re- efforts battling extractive industries Archive Center (http://www.rockarch. protests across the globe in the wake of search and cannot affect the larger con- around the world, through the 200-mil- Collective activism to overturn the un- org/collections/rf/) provides compre- the 2008 global financial and economic text of global health funding and policy- lion strong Via Campesina movement, justified influence of philanthrocapital- hensive access to a wide range of pri- crises that “enough is enough” in terms making. Scientists must recognize that the global Occupy! movements, and so ism in global health would provide a mary sources related to the Rockefeller Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/global health agenda 20 / 27 Birn

Foundation, including correspondence, audiences at these events for their stimu- international child health/child rights 11 Birn A-E. Gates’s grandest challenge: transcend- 19 Carrillo AM, Birn A-E. Neighbours on notice: na- diaries, memos, meeting minutes, proj- lating questions and insights. I also wish movement from the perspective of ing technology as public health ideology. Lancet. tional and imperialist interests in the American Public ect files, information about fellows, and to thank Mary Travis Bassett, Elizabeth Uruguay; she is also leading a CIHR- 2005; 366; 514–519. Health Association, 1872–1921. Can Bull Med Hist. internal reports related to its New York Fee, Gilberto Hochman, Nikolai funded study on Social Justice-Oriented http://dx.doi.org/10.1016/S0140-6736(05)66479-3 2008; 25(1): 83–112. headquarters, and country-based and Krementsov, Nancy Krieger, and Laura South-South Cooperation in Health. 12 Berliner H. A system of scientific medicine: phil- 20 Cueto M. 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