Divorces don’t usually send shockwaves through the global policy field. They almost never create uncertainty about the health of hundreds of millions of people. The split between Bill and Melinda Gates is doing both. It affects the Bill and Melinda Gates Foundation, which has an endowment worth almost $52 billion. In 2019, the foundation disbursed roughly $6 billion in aid and grants. About thereof of was spent on health in “developing” countries.
No wonder stakeholders in global health governance are worried. We’re not just talking about small nongovernmental organizations (NGOs) in Sub-Saharan Africa. The World Health Organization (WHO), to which the Gates Foundation is the second largest contributor, might also be affected by the divorce. Considering this financial firepower, it seems plausible that a foundation can influence a United Nations agency such as WHO.
An Understudied Actor
Despite some recent calls to take foundations seriously, few international relations scholars have studied foundations’ role in global politics. However, this is not the case in history or sociology. Foundations receive more attention in policy circles and the mass media.
Some of this attention is negative. To a certain extent, criticisms of the Gates Foundation and other such organizations born out of the 21th century’s tech and financial boom actually echo complaints about earlier foundations such as Ford, MacArthur, Rockefeller, and Open Society. Thus, the Gates Foundation is not the first to attract criticism for inadequate transparency and accountability, and an unrepresentative board. Regardless of its merit, criticism is relevant here because it indicates that foundations wield influence, some of them globally. Otherwise, nobody would make the effort to scrutinize them.
Why are foundations capable of wielding such influence? Some of them concentrate so many resources of all kinds that their policies can influence all actors in fields such as development, transnational activism or global health. Widespread influence might not even require that foundation officers and trustees pursue it intentionally; instead, it might be a “field effect.” A second reason explored here is that some large foundations have long invested in a specific resource, statistical knowledge, which allows them to see the global environment in which they operate.
An Asymmetry of Power
Foundations are powerful because, in terms of resources, their donor–recipient relations are highly asymmetrical. This has its paramount expression when an individual donor provides resources that are essential for a recipient’s survival. By contrast, a specific recipient rarely is essential for a donor to realize its goals, let alone to survive. This is why foundations actively seek topics and places where few donors are active, but many potential recipients need resources. This imbalance allows the donor to choose certain recipients and avoid engagement with others. (This is also the reason no one can send unsolicited applications to the Gates Foundation; they invite proposals). In such topics and places, foundation officers recognize plenty of “opportunities.” Because of this asymmetric dependency, more courses of action are open to the donor than to the recipient.
This is true regardless of the theoretical framework you use to analyze foundations. If you are an international relations realist, a Marxist, or some other form of materialist, you’ll stress the disparity in financial resources: donors have endowments, whereas recipients only have a calling. If you consider prestige is a crucial resource, you’ll emphasize that the Gates Foundation has too much of it and that local health care providers have too little. If you believe in Pierre Bourdieu’s “link between time and power,” you’ll emphasize that donors set the pace of negotiations, the application deadlines, and the time-length of grants. If you firmly believe in cultural hegemony, what I just said about the distribution of resources will confirm your preconceptions about who dominates. Thus, no matter which resource(s) you deem central, the foundation tends to come out on top.
This is also true of knowledge. International relations scholars have written about knowledge from the perspective of epistemic communities, but there is much more to it. The Gates Foundation withholds from third parties, including actual and potential grantees, valuable knowledge about how and why it makes decisions. By contrast, other foundations’ records are open for research. A crucial consequence of the Gates Foundation’s opacity is that it prevents grantees from understanding why the foundation makes certain decisions. This increases insecurity about what the foundation will do after its next program review, reducing the grantee’s ability to plan. Conversely, a foundation meets a potential grantee’s leaders, visits its premises, reviews its programs, and essentially requires it to perform a financial striptease. If no suitable grantee can be identified, a foundation can ask a reliable individual to set up a new one. In short, a foundation is in a prime position to predict a grantee’s actions, whereas, for a grantee, it is extremely difficult to predict what the foundation will do. An effect of foundations’ opacity is the one-sided accumulation of knowledge, which makes donor–recipient relations increasingly unequal.
The Premiere Producer and Financier of Health Knowledge
The knowledge asymmetry between the Gates Foundation and its grantees is enhanced by its growing control over health statistics and indicators. This statistical knowledge is one of the preconditions for a bureaucracy to be able to implement globally homogenous policies from its headquarters. That statistics are a source of power has recently been recognized by international relations scholars, but health statistics have been overlooked. Even so, they deserve attention.
The Institute for Health Metrics and Evaluation is lavishly financed by the Gates Foundation. The Institute accumulates a prodigious amount of health data and also produces its own. It has elaborated its own indicators of mortality and of treatment efficacy, as well as models for how pandemics (such as COVID-19) evolve. It also has in-house health standards and has exerted pressure to turn them into global standards that third parties, including the WHO, should accept. Because reducing complex realities to “schematic categories” redounds to “state capacity,” health statistics such as those produced by the Institute are an ideal means to influence global health.
The foundation’s critics consider this use of statistics highly problematic. Critics complain that the Institute does not allow access to the models it uses for its projections. In addition, the Institute produces estimates for poorer countries rather than collecting data. The impact of the Gates Foundation’s health policies is also measured according to the indicators of its Institute for Health Metrics and Evaluation. These problems are compounded by a further one: the amount of money the Gates Foundation has spent on global health has made it difficult to find researchers without vested interests to conduct peer reviews or to criticize the Gates Foundation. This, along with the fact that the Institute denies outsiders knowledge about its models, evokes what has been called the second, restrictive face of power: to keep as much as possible of what it does out of the debate.
The Gates Foundation may be an extreme case, but in donor–recipient relations, asymmetry in the distribution of resources is common. It characterizes the relationship of most recipients to philanthropic foundations. They are not simply partners that bankroll activists’ ideas. Nor are foundations fungible buyers that participate anonymously in a market for projects. Indeed, stakeholders assume that the Gateses’ divorce will alter the entire field of global health. Foundations have shaped development aid; cultural diplomacy; democracy promotion; race and international relations; human, women’s, and indigenous rights; and, of course, global health. Scholars will benefit from paying more attention to foundations and their officers as autonomous, powerful actors.