The Gates Foundation has been a massively positive influence on malaria
research. But it is not above criticism.
Since the mid-1990s, Microsoft has been fending off complaints about its vast
power over the software market. Now the Bill and Melinda Gates Foundation (BMGF)
may be in for the same treatment regarding its international health care
efforts. An internal memo written by the head of malaria control at the World
Health Organization (WHO), Arata Kochi, claims that the BMGF is undermining
scientific creativity and “could have implicitly dangerous consequences on the
policy-making process in world health.”
Over the past decade, the BMGF has dispersed more than $9 billion to promote
global health causes, with much of the money spent to fund research on
infectious diseases such as HIV-AIDS and malaria. Indeed, the BMGF has spent
roughly $1 billion on anti-malaria efforts, an enormous contribution to a field
long neglected by the international health community. Thanks to the leadership
and funding provided by the BMGF and the U.S. government, today progress is
final being made in the struggle against the insect-borne disease.
But according to Kochi, the BMGF’s research support comes with strings
attached. Kochi worries that studies funded by the BMGF must adopt “a uniform
framework approved by the Foundation,” which leads to homogeneity of
thinking—anathema to scientific progress. The BMGF has created a “cartel,” says
Kochi, with research leaders linked so closely that “each has a vested interest
to safeguard the work of others. The result is that obtaining an independent
review of scientific evidence…is becoming increasing difficult.”
The WHO malaria chief also says that the BMGF is fiercely determined to see
that the research it funds leads to concrete policy changes. The drive for
policy relevance is a valid imperative, but it can cause problems, Kochi notes,
when “the evidence of the research is not fully supportive of policy.” For
example, preventive malaria treatment for pregnant women is still a debatable
intervention—but Kochi says he is “under continuous pressure” to promote it as
general policy because it is favored by the BMGF.
Some in the global health community are furious over Kochi’s letter and want
him to resign (although none will say so publicly). Yet malaria specialists who
are not affiliated with the BMGF, such as Amir Attaran, a professor at
University of Ottawa, agree with Kochi, as do several other experts I have
spoken with.
I sense resentment among certain scientists not funded by the BMGF, and I am
not convinced that the BMGF is undermining scientific research: it may dominate
funding, but few other outfits are making a substantial contribution. That said,
when the BMGF does make a mistake in its anti-malaria advocacy, it can cause
real harm—and on at least two issues, the BMGF's recent actions raise concerns.
First, the BMGF’s October 2007 Malaria Forum issued a clarion call to
eradicate the disease completely. This desire, while commendable, will not be
attainable in the foreseeable future. But it is spurring all sorts of futile
research exercises, such as investigating the commodity requirements for
eradication. These discussions are a waste of resources, because the health
systems in many of the countries most affected by malaria are simply too fragile
to cope with a huge influx of money and commodities.
The evidence for this is incontrovertible: massive HIV-AIDS funding has
overwhelmed and distorted health systems across Africa, from Sierra Leone and
Liberia to Rwanda and Lesotho. New HIV-AIDS programs drew scarce medical staff
away from more cost-effective and important existing programs, like child
immunization, as donors apparently failed to understand the effects of their
actions on severely undermanned health systems. Every malaria expert I’ve spoken
with thinks eradication is a pipe dream; and if malaria eradication initiatives
are run like many HIV-AIDS programs, the unintended consequences could be fatal.
Second, the BMGF is firmly behind the Affordable Medicines Facility for
Malaria (AMFm), an independent endeavor suggested by Nobel Laureate economist
Kenneth Arrow. The AMFm wants to spend $2 billion subsidizing high-quality
drugs, in the hope that they can drive out substandard products from African
street markets (where most Africans get their drugs). In theory, it could work.
But not enough is known about the private drug market in most African nations to
say for sure whether such an investment would distort the market or otherwise be
counterproductive. Perhaps that $2 billion would be better spent on prevention.
Indeed, many anti-malaria activists are worried that AMFm is being pushed too
fast, without enough pilot studies or analyses. And yet, as with eradication,
support from the BMGF has a chastening effect on dissenters.
This is dangerous—especially since, according to the WHO, substandard
anti-malaria medicines indirectly kill 200,000 children a year in Africa—but it
is not the fault of the BMGF. The malaria community should show more backbone
and integrity. If activists and scientists believe the public will lose interest
in combating malaria merely because there is a strong debate over how to do it,
then they don’t deserve the BMGF’s funding.
To be sure, the BMGF has championed key innovations in other aspects of
malaria control. For example, it is funding the first public-sector search for
alternatives to the insecticide DDT. Meanwhile, the National Institutes of
Health seem more intent on funding epidemiological studies to find any harm from
DDT, regardless of how spurious.
In short, the BMGF has been a massively positive influence on malaria
research. But Arata Kochi is right, and brave, to insist on some reflection.
Dissent is the lifeblood of good science—and, ultimately, it leads to better
public policy.
Related Items:
|
Commentaries 
