Sometimes it feels that everyone in global health is a big fan of Bill Gates. Even those outside of global health think he's pretty damn great for all of the work he does with the Bill and Melinda Gates Foundation.
As people like to tell me at parties, I must also be a big fan of Bill Gates as he, Melinda Gates and Warren Buffett have given away so much of their personal wealth to combat some of the worst diseases on the planet. You can't really argue with a question like that: say that you don't like Gates or the Foundation you look like you don't care about Polio eradication or Mothers dying in childbirth. If you say that you do like the Foundation because you dig philanthropy/don't want to offend/lose out on any future research grants, then you become a bigger part of the Gates fan club. And it is the fan club and the lack of public criticism of the Foundation that for me is the biggest problem of the Bill and Melinda Gates Foundation.
In a recent article I published in the journal Global Governance I draw on the work of David Beetham to argue that the Bill and Melinda Gates Foundation has a legitimacy problem. The problem here is that to be a legitimate actor in global health, someone has to challenge your role/position/ideas. Not just through accountability or monitoring and evaluation processes (which I'm sure the Foundation is pretty rigorous on) but a more mundane questioning of the authority of an actor.
Think about it, most sources of power in democratic societies are questioned - either by the electorate or opposition if you think of governments, or by the media, academics or public campaigns if not the government. It is very rare for an actor to have power in a democratic system without some sort of check or questioning of that power: the actor can still have power, but they just have an annoying (I imagine politicians have stronger words for such folks) person/group/party/paper that question it.
The Gates Foundation has a lot of power in global health through the setting of research agendas; membership of the Health8; financing of UN institutions, non-governmental organisations and university projects; and prominence in the international media (when Bill Gates talks about health, people listen), but very rarely does anyone question that power. There is the odd academic publication, but given the scale and scope of the Foundation, there is very little visible public criticism of the role of the Foundation in global health.
The comeback to this would be that the Foundation is legitimate in other ways. It funds established institutions, seems to align with the priorities of global health, and fundamentally Bill Gates is so famous, rich and clever he must know what he's doing when he puts his mind to something.
If people believe the Foundation is legitimate and act on this by accepting funding, then that makes the Foundation legitimate. This type of argument draws on claims to legitimacy based on adherence to rules and charisma (and by charisma here I don't mean the slick easy going guy on talk shows but the established success, respect and presence of an individual), i.e. the Gates Foundation must be legitimate as everyone believes in Bill Gates. The charismatic basis for legitimacy is clearly reflected in the Gates Foundation's narrative of the work it does.
However a central problem with the charismatic basis of legitimacy is that the Foundation engages in self-legitimation - it creates an image of Bill and Melinda Gates that suggests they are legitimate because of their past endeavours and personal interest - and ignores how in occupying a position of power the Foundation is able to shape some of the rules and norms it supposedly adheres to.
By focusing on legitimacy I want to go beyond the questions of whether I like Bill Gates (I imagine we'd get on just fine, once I get over the whole charisma bit) but to think about wider questions of authority in global health: who has it and how it can be checked.
The subject of Gates is everyone's favourite dinner party chat in global health, people have stories, but no-one wants to publicly share them as they tend to be critical. And who can blame them? As funding of research continues to dry up, the Gates Foundation offers a unique opportunity to do well-paid advanced research. But we need to get to a point that this still happens and we can still ask questions of those with the authority and influence to make decisions.
Perhaps the only thing that most philosophers agree on when it comes to legitimacy is that if there is something worse than criticism it is be considered illegitimate. So for the future legitimacy of global health and the Bill and Melinda Gates Foundation let's be more open in our critique. The Foundation can take it.