Don’t reduce the global poor to potential consumers

This month the Bill and Melinda Gates Foundation announced its biggest-ever equity investment, giving German biopharmaceutical company CureVac $52 million to develop mRNA vaccine technology. It’s just the latest sign that the Gateses have gone in big on vaccines — so big that people avoid Bill Gates at cocktail parties, afraid he’ll drag them into a macabre conversation about tuberculosis. In many low-income countries, diseases such as malaria, rotavirus and pneumonia remain killers. In the United States, these diseases are a specter of times past: Swamp drainage, pesticide spraying and massive sanitation infrastructure projects to supply clean water and safely dispose of waste have essentially eliminated these diseases from wealthy countries.

Instead of getting tripped up on the bigger hurdles of providing clean water, sanitation infrastructure and nutritious food, the foundation is pursuing a faster, potentially easier route to eradicating disease in poor countries. The Gateses argue that with advances in biotech and logistics, we can develop vaccines for these diseases. But the pharmaceutical industry, concentrated in wealthy countries, has not developed such vaccines and is not particularly interested in doing so. As Bill Gates has wryly noted, it is more interested in cures for baldness than in cures for malaria. Why? Melinda Gates argues that there is simply no “rich world market” for products like diarrhea and pneumonia vaccines.

Their solution is to use the Gates Foundation to create those markets in poor countries. As Melinda Gates told an audience at Stanford:

So how does this initiative work? First the foundation funds the research to develop the vaccines. It channels money into organizations like PATH, a Seattle-based group that runs the Malaria Vaccine Initiative and other groups such as OneWorld Health, which works on anti-parasite drugs. The foundation then tries to change the economic signals that guide market formation in developing countries. It does this by leveraging its money to put pressure on governments to buy vaccines for poor people, thus guaranteeing the market. It greases the wheels and persuades governments and businesses to play along.

Even before Warren Buffet’s 2006 pledge to donate more than $30 billion worth of his company’s stock to the foundation, it had a bigger health budget than the World Health Organization. The foundation also relies on other, smaller foundations like the Rockefeller Foundation and the David and Lucile Packard Foundation for institutional and logistical support. To date, the Gates Foundation has successfully brought both malaria and pneumonia vaccines to market. Through its Global Alliance for Vaccines and Immunization, it has vaccinated millions of children in the developing world against polio and other diseases.

Bill and Melinda Gates are not alone in their desire to tackle thorny global problems. They are part of a chorus of new elite voices calling for a different kind of capitalism — in their case, creative capitalism. The Gateses present practical solutions to society’s problems that can be found within the logic of existing profit-driven structures of production and consumption. They promote market-based solutions to the problems of global poverty, disease and inequality. 

The Gateses say that the problem with poor countries is that they are excluded from circuits of commodity production because they have no money and so generate no demand for things like vaccines. So the foundation supplies the demand for the pharmaceutical companies, giving the companies the incentive to supply the vaccines. In doing so, health care becomes a commodity, with the hope that in the long run, the foundation won’t have to prop up the demand side and people will be able to buy the vaccines themselves. The problem is defined as a lack of commoditization, and the solution is to create a capitalist health care market.

But should health care be a commodity, something that people can buy and sell? In the United States, where health care is a commodity, access to care is highly stratified by class and race. Despite being the wealthiest country in the world, the United States ranks 46th worldwide for infant mortality rate — behind every other rich country and even much poorer countries such as South Korea and Cuba.

Anything and everything should be done to save people’s lives, because no one should die from preventable diseases. But when we frame the problem of poor people in the developing world dying from preventable diseases as a market failure problem, we close off the possibility of building a health care system in which health care is a right and does not depend on one’s ability to pay.

There is a growing global consensus on the importance of providing universal health care, as demonstrated by a 2014 World Bank event called Toward Universal Health Coverage by 2030. Margaret Chan, director-general of the World Health Organization, proclaimed that “we will not end poverty without universal health coverage.” World Bank President Jim Yong Kim and Larry Summers, an economist and a former director of the U.S. National Economic Council, echoed that sentiment.

The Gateses, however, do not agree. The foundation’s official stance is that it has no position on universal health care. The foundation’s post-2015 development report states that universal health coverage has “limitations as a global development goal” and that evidence for its positive effects on health outcomes is “mixed.” The foundation’s deep pockets give it an enormous amount of leverage to shape the way people think about health care globally. The Gates’ position that health care works best as a commodity, despite overwhelming evidence that countries with universal health care have the best health outcomes, is deeply problematic and closes the door to systems that consider the underlying causes of global health disparities.

This essay is adapted from “The New Prophets of Capital,” which will be published in Verso's Jacobin series on March 31.