Unintended Consequences

Problems in global health are rarely well served by philosophical binary or good intentions alone. Global health is a highly politicized field, one in which questions of implementation, priorities, and ethics make the question, “How can we eliminate problems in global health?” one that requires a far more complex answer than is immediately obvious.

The very complexity of this issue demands that we cast a critical eye on all well-intentioned efforts to remedy global health deficiencies worldwide, no matter who leads these efforts or the monetary backing accompanying them. Bill Gates’ recent pledge of $10 billion toward global immunization of children is no exception.

Gates’ pledge is atypical in the field of global health. Manifest in his massive donation is the will of an individual who is acting with almost full agency, thanks in part to his own considerable wealth. This has obvious benefits: A single person can often move much more quickly than some of the less agile organizations involved in global health, since they do not have to contend with the same political forces and special interests. Gates’ immense wealth grants him a type of influence in the field that resembles state power, but unlike the decisions of a government or large institutions, such as the World Health Organization, his actions remain unchecked by the authority of a democratic will. The unrestricted power that results can change the very landscape of global health, altering both priorities and methods of healthcare implementation, sometimes with negative results.

This is not the first time that Bill Gates has affected a health-related cause. For years now, Gates has exerted his influence over efforts to treat HIV/AIDS in traditionally underserved regions, including sub-saharan Africa. A Los Angeles Times investigation explored the effects of Gates’ involvement and found that, contrary to the assumption that more money solves more problems, the Gates Foundation’s implementation of efforts to treat HIV/AIDS produced mixed results. Some of these findings call into question whether Gates’ initiatives create even a net-positive impact. The negative effects include an epiphenomenal dearth of qualified clinicians in other parts of Africa like Lesotho or Rwanda, also known as “brain drain,” the weakening of local systems of health due to a shift in focus, and a diversion of attention and personnel from other health-related issues, such as basic care.

Proponents of such initiatives may find it satisfying to rest on the anodyne logic that any aid is good aid. Others note that while it is easy to argue for critical analysis of health care delivery methods, people are dying all around the world. Both of these arguments are a disservice to the seriousness and complexity of the issues. Organizational approaches to global health are not always ideal, but at the very least they benefit from heterogeneous influences and collective input from individuals who all share equal standing. Gates’ authority does not benefit from this kind of democratic input—he has advisers, but ultimately he and his wife are the ones in charge.

Gates’ generosity is surely laudable, and his intentions are beyond reproach. However, his methodology is less commendable. His status as the primary financial backer and head of the Gates Foundation creates a lack of accountability, and his actions can therefore have unintended results. The conclusion here is not that Gates should have refrained from funding a noble cause in global health, but rather that he should act through accountable organizational structures, like that of the World Health Organization. While such institutions are not immune to unintended consequences, their collective wisdom, abundant expertise, and historical awareness serve as better safeguards against unintended consequences than the will of one man could ever provide.

Derrick Asiedu ’12, a Crimson associate editorial editor, is a social studies concentrator in Leverett House.