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Originally published Sunday, August 3, 2008 at 12:00 AM

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Not many speak their mind to Gates Foundation

The Gates Foundation says it wants to hear from its critics. But with so many in the global health world dependent on the foundation's cash, honest feedback is hard to come by.

Seattle Times science reporter

As with all good parodies, there's a grain of truth in a fake news story on the Web that says Bill Gates could face another antitrust investigation — this time for "monopolistic charity practices."

With a $38 billion endowment that exceeds the gross domestic product (GDP) of most countries it helps — and another $30 billion pledged by investor Warren Buffett — the Bill & Melinda Gates Foundation has come to dominate the philanthropic world in the same way Microsoft towered over the software landscape.

Yet the two organizations' public personas couldn't be more different.

While Microsoft has drawn equal measures of praise and scorn for its business practices and products, the Seattle-based foundation gets lots of hugs and very few slaps. After all, what's not to like about saving lives, fighting poverty and improving schools?

But philanthropy experts and even some foundation leaders are uneasy with all the adulation.

"The danger isn't in what people do tell you — it's in what they don't," departing foundation CEO Patty Stonesifer warned in the 2007 annual report.

In other words, Stonesifer says, the Gates Foundation needs honest feedback and criticism to help it figure out how best to improve the health of the world's poor, boost food production in Africa and improve schools in the U.S.

Honesty can be hard to come by, though, when you're handing out staggering amounts of cash.

And some question how sincere the foundation is about listening to critics.

"They're not really fostering tough debate," said Pablo Eisenberg, a columnist for The Chronicle of Philanthropy and senior fellow at the Georgetown Public Policy Institute. "They have not solicited and gone after people who will tell them the truth."

Particularly in the field of global health, where funding for diseases of the developing world was anemic before Gates' $9.5 billion dollar infusion, few are willing to risk wrath by pointing out flaws in the foundation's approach.

"It would be suicidal for someone who wants a grant to come out and publicly criticize the foundation," said Mark Kane, former leader of a Gates-funded program to expand childhood immunizations in the developing world. "The Gates Foundation is very sensitive to PR."

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Chilling effect

Countless blogs and Web sites spout off on Microsoft's every twitch. A single blog, The Gates Keepers (http://gateskeepers.civiblog.org/blog), watchdogs the Gates Foundation. Few people ever weigh in with comments. The moderators say they remain anonymous out of fear of lawsuits and what they call "Bill Chill."

"If we criticize the Foundation in our own names our funding will be cut or we will lose our jobs," reads one exchange.

That chilling effect could undermine the foundation's goals, says Phil Buchanan, executive director of the Center for Effective Philanthropy, which helps foundations evaluate their work. "If you want to achieve the greatest possible positive impact, you've got to figure out how to hear things from people on the ground who might know more than you about some pretty important things."

It's a dilemma every foundation faces, but due to its sheer size and influence on the world stage, the stakes are even higher for the Gates Foundation.

"They're probably at greater risk of being isolated from critical feedback than any other foundation in the world," Buchanan said.

Foundation officials say they've taken steps to solicit outside advice, including the establishment of advisory boards. But Stonesifer acknowledges they need to work harder to listen for voices that aren't getting through.

"We don't need to agree with all of it," she said. "We have to hear it."

Dream team assembled

Criticizing the Gates Foundation can seem churlish, like attacking Mother Teresa's wardrobe.

Few question the Gateses' sincerity, commitment and smarts. In the same way Bill Gates lured the best and brightest to Microsoft, his foundation has assembled a dream team drawn from around the world. And no one can say they aren't tackling the world's top killers, including malaria, tuberculosis and AIDS.

One of the foundation's earliest ventures helped expand immunizations for more than 200 million children, preventing an estimated 3 million deaths.

"For the most part, the Gates Foundation does wonderful stuff," says Stephen Gloyd, professor of global health at the University of Washington.

The handful of critics who have publicly raised concerns come largely from academia or think tanks — and don't have to fret being frozen out of the foundation's largesse. Most say the foundation is too focused on tech-oriented solutions, like vaccines. Poor nations would benefit more, they argue, from basic improvements like clean water and well-staffed health clinics, along with changes in global economic policies that aggravate poverty.

"It doesn't help to create a few islands of excellence in a sea of despair, and unfortunately, that's kind of what they're doing," says Gloyd, who has received $1 million of Gates funding for syphilis screening and treatment in Mozambique. "To me it represents a huge opportunity lost."

Nominal oversight

Others worry that Gates' enormous resources make it a bull in a china closet that could trample small nations' priorities and fragile health systems. And unlike government and business, which answer to citizens and shareholders, foundations aren't held accountable by anyone.

The federal government has nominal oversight to ensure tax-exempt money benefits society. But in general, foundations report only to their boards. For the world's richest philanthropy, that means Bill, Melinda and Warren.

That freedom allows foundations to move quickly and tackle problems no one else will.

The downside is a tendency to become arrogant and out of touch, says Joel Fleishman, professor of public policy at Duke University and author of "The Foundation: A Great American Secret." Because the Gates Foundation is such a powerhouse in global health, its missteps could reverberate around the world.

"Clearly, they're dedicated to the public interest — but if the Gates Foundation isn't getting it right, what are the controls?" asked Dr. Sally Stansfield, one of the foundation's first employees. She now runs a Gates-funded program at the World Health Organization (WHO) in Geneva to help developing nations collect health data.

All doors open to Bill Gates, giving him the ear of world leaders. The foundation is the only private entity in the H8, an alliance of international health organizations that mirrors the G-8 alliance of powerful nations. Some fear world health agendas could now be shaped to fit the interests of three wealthy Americans.

The New York Times reported in February that Dr. Arata Kochi, the combative leader of WHO's malaria programs, complained the foundation's dominance in malaria research was creating a "cartel" that stifled divergent views and tried to force its priorities on WHO.

Kochi no longer holds that job. A WHO spokesman would only say he was "on leave," and that his absence was not related to comments about the foundation.

"Huge expectations"

When Dr. Tachi Yamada was hired to lead the Gates Foundation's global health program, he warned that the young organization's honeymoon period was about to end.

"Huge expectations are placed on us," he said. "Inevitably we're going to disappoint people."

Yamada says he's grappling with ways to get more feedback on the effectiveness of the foundation's work.

Before launching major initiatives, the foundation consults experts and stakeholders, from scientists to politicians and nongovernmental organizations. To avoid duplication of effort, they work closely with international organizations like WHO, the World Bank and other foundations. All global health grants over $1 million get outside review.

"We're not a fortress," Yamada said.

Critics helped convince him the foundation needed to do more to ensure new drugs and technologies can get to the people who need them. Over the next five years, about 20 percent of the foundation's global health spending will be devoted to "delivery," he said. Outside researchers urged the foundation to take bigger scientific risks, leading to the "Grand Challenges Explorations" program — small grants to encourage off-the-wall ideas.

In other cases, the foundation has appeared to shrug off criticism. After the Los Angeles Times revealed some of the foundation's financial investments run contrary to its charitable goals, the foundation initially promised to review all its investments but quickly withdrew that pledge.

Advisory panels as guides

Three new advisory panels, one in each main focus area, will help guide foundation priorities in the future — but won't have decision-making power. Some of the advisers are associated with groups or governments that receive Gates funding.

Since nearly everyone in global health gets Gates money — or hopes to — Yamada acknowledges it can be nearly impossible to avoid such conflicts of interest.

"What is the alternative?" he asked. "That we decide we're just not going to give money to certain groups?"

Advisory panels are a good step, agreed Eisenberg, the Chronicle of Philanthropy columnist. But he says the most effective way to open the foundation to outside opinion is to expand its board.

"They need to bring in people who are tough, willing to challenge them and push the envelope."

Another way for foundations to be open is to share details about programs that worked, and those that failed — an area where Gates falls short, said Fleishman, the Duke professor. He hit a brick wall when he sought examples after Melinda Gates said in a speech that they are "learning from their mistakes."

A few case studies are posted on the foundation's Web site, including some that stumbled.

"It's my sense that they need to do more of that," Fleishman said. "They are unwilling so far to be as transparent as I think they should be."

The most effective form of transparency is hard data, and Yamada pointed out that the foundation invested $105 million in the Institute for Health Metrics and Evaluation at the UW to scrutinize health programs and statistics. The first program the institute will examine is the Gates Foundation's $258 million effort to stem the spread of AIDS among sex workers and truckers in India.

All of the institute's data and analyses will be public.

"I don't want a whitewash," Yamada said.

But data don't help the foundation hear from grass-roots groups, advocates and the disadvantaged, Eisenberg said.

"That's not who Bill and Melinda talk to," he said. "They need to speak to a wider range of people, uncomfortable as that may be."

Listen and respond

The foundation, which has already worked with the Center for Effective Philanthropy to conduct anonymous surveys of its grantees, is now expanding those efforts to reach the people most affected by the foundation's programs. Their first attempt will be to ask U.S. students what they think of Gates-funded school programs.

How the Gates Foundation listens and responds to people on the ground will have a lot to do with how it is perceived by the rest of the world, said Kavita Ramdas, who leads the Global Fund for Women and serves on the foundation's global development advisory panel.

"The Gates Foundation must prepare itself to be criticized and should welcome that criticism," she said. "You only criticize those from whom you expect much."

Seattle Times reporter Kristi Heim contributed to this report.

Sandi Doughton: 206-464-2491 or sdoughton@seattletimes.com

Copyright © 2008 The Seattle Times Company

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