The Gates Foundation's first 25 years: How it changed global health and philanthropy

SEATTLE — In its first 25 years, the Gates Foundation became one of the world's largest charitable foundations and one of the most powerful institutions in global health — an accomplishment that carried both accolades and controversy. Bill Gates and Melinda French Gates had grand ambitions for their foundation, but little experience in global health or philanthropy. They were moved by stories like those written by New York Times columnist Nicholas Kristof about children dying from diseases caused by a lack of sanitation. In characteristic Gates style, they tackled these problems with rigor, data and close oversight. As a result, the Bill & Melinda Gates Foundation — formed in 2000 by the merger of two family foundations and funded by Gates' Microsoft wealth and later, by tens of billions from investor Warren Buffett — inserted itself into the architecture of global health. Along the way, the foundation's leaders redefined what it means to be philanthropists. "As I was learning about what children die of, you know, HIV and diarrhea and pneumonia, were all things that I was stunned how little was going into helping the poor countries," Gates said in an interview with The Associated Press. He responded in a way few others could, by pouring billions into the foundation, which spent $100 billion in its first 25 years, with about half going toward global health. Thanks to its largesse, as well as the expertise of its employees, its connections to governments and companies, and the profile of its founders, the Gates Foundation now garners at least the same influence, if not more, in almost any global health forum as many countries. That era now has an end date. Gates announced Thursday that the foundation will close in 2045, pledging that he plans to donate 99% of his remaining fortune, which would be $107 billion today, to the nonprofit by then. Gates said the foundation can maintain its culture and workforce over that time. "We'll be showing that we're doing the most we can and give a lot of predictability to the field by (saying,) 'We'll be here all of those 20 years, but not thereafter,'" he said. With great power, comes much scrutiny The foundation's influence over global health policy and its partnerships with companies and other private sector actors have long drawn questions. Researcher Linsey McGoey, a professor of sociology at the University of Essex, who wrote the book "No Such Thing as a Free Gift " about the foundation, asks how charitable it is to "give away" money to a foundation the donor controls. Others like Anuj Kapilashrami, global health professor at the University of Essex, argue the foundation's preference for low-cost treatments and interventions does not inherently help build the capacity of health systems. "We do not tackle the causes, the underlying drivers of what is producing ill-health, but we choose areas and health issues where we can just push these magic bullets: commodities, drugs (and) bed nets," she said. Mark Suzman, who has been with the foundation for 18 years and CEO since 2020, said close supervision of grantees and the foundation's data-driven processes are key to its success. "We are not a 'write the check, call us in three years and let us know what it looks like,'" kind of funder, Suzman said. "We'll be calling you up probably every week, and we'll have some opinions. But we want your opinions back." The foundation is proud of the many vaccines, medical devices and treatment protocols it has helped develop. It is optimistic about a pipeline of innovations, including potential vaccines for malaria and HIV, as possible accomplishments in its remaining 20 years. David McCoy, a physician who was then at the University College London, argued back in 2009 that only a small portion of the foundation's spending went directly to organizations located in the countries where they work, with most going to international organizations like the World Health Organization or to groups located in the U.S. and Europe. Suzman said he has been an internal champion of shifting more of the foundation's work from Seattle to in-country offices. Lifting private partnerships in global health The foundation's flagship issue, and the main way it measures its success, is in reducing preventable childhood deaths. The Gates Foundation helped establish two major public-private partnerships: Gavi, the vaccine alliance that funds and distributes vaccines for children, and the Global Fund, which, along with governments, funds the treatment and control of HIV, tuberculosis and malaria. The foundation says the two organizations have saved tens of millions of lives and are some of the most important examples of its impact. However, Amy Patterson, politics professor at The University of the South, Sewanee, says public-private partnerships like Gavi and the Global Fund diminish the power of civil society groups and citizens compared to public health systems. "It certainly has moved us from thinking about health as a state responsibility, which raises questions about accountability and participation," said Patterson, who has researched the management of AIDS in African countries, including the role of civic groups. "That is not to discount the millions of lives saved, or children immunized, or women who have access to reproductive health, or the innovations that have brought efficiency," Patterson said. "But if you think about the social contract between states taking care of their people, how do we have that same kind of accountability in this type of a system?" Championing philanthropy and setting the bar for billionaires A huge moment in the early history of the foundation came in 2006 when Buffett pledged to donate a percentage of his Berkshire Hathaway shares annually, almost doubling the foundation's resources. Buffett teamed with Gates and French Gates again in 2010 to launch a new commitment for billionaires: to give away more than half their money in their lifetimes or at the time of their death. The Giving Pledge now has more than 240 people agreeing to those terms, far exceeding Gates' expectations. However, certainly not every billionaire has. Gates hopes others will surpass his giving. "I'd love to be beat in all of this work," he said. "Somebody should try and pay more taxes than I did, and save more lives than I did, and give more money than I did, and be smarter than I've been." He acknowledged that cuts to foreign aid and health funding under President Donald Trump's current administration, wars, and economic turmoil significantly challenge the foundation's hopes of eradicating polio, controlling malaria, and reducing the number of child and maternal deaths in the next 20 years. "The metric that we should be measured against is the success of the whole global health field. Did we draw people in? Did we keep governments engaged, and therefore, do we get childhood death rates down from the 5 million to cut it in half again?" he said. "I can't promise you we will, because without the partners, that's not doable. And the current trend line is not positive for that." The Associated Press receives financial support for news coverage in Africa from the Gates Foundation and for news coverage of women in the workforce and in statehouses from Melinda French Gates' organization, Pivotal Ventures. Associated Press coverage of philanthropy and nonprofits receives support through the AP's collaboration with The Conversation US, with funding from Lilly Endowment Inc. The AP is solely responsible for this content. For all of AP's philanthropy coverage, visit https://apnews.com/hub/philanthropy.