The New Grand Challenges: Social Justice and Health Equity

Written by: Ryan Schlegel

Date: January 29, 2015

$1 billion over ten years is a mammoth investment for philanthropy. Since the Bill and Melinda Gates Foundation launched its Grand Challenges initiative in 2004, roughly a quarter million dollars on average has left its coffers each day bound for one of 43 special projects. Each project sought to generate an innovative technological solution to a pressing health issue selected by the Gates Foundation. It was venture capitalism adapted for international development, and the magnitude of the investments led to high expectations. If successful, the bold new ideas generated would help make significant progress on our world’s most pressing health issues.

However, when Gates spoke at an event marking the ten year anniversary of the Grand Challenges program at the end of 2014, he used the word “naïve” to describe the original vision for Grand Challenges. And he admitted that the foundation’s approach has yet to have any significant impact on the lives of people on the ground.

It is rare and refreshing to hear a foundation executive, especially one whose influence looms so large over the sector, speak with candor about a lack of progress toward philanthropic goals. The Gates Foundation is a trendsetter for many other philanthropic institutions working in public health and education. A frank admission of failure – even of success meaningfully postponed – by the most influential philanthropist since the Gilded Age cannot be underestimated. It is an encouraging sign of progress for all of us with an interest in greater philanthropic transparency and openness. And it should fuel ongoing efforts to work with foundations on developing ways to honestly assess their grantmaking, such as with efforts like NCRP’s Philamplify initiative.

Gates’ honesty will hopefully inspire more honest feedback at his foundation and sector-wide, not to mention herald significant reassessment of Grand Challenges strategies. The initiative’s laser-like focus on precise scientific solutions neglects consideration of social and political determinants of health, to the detriment of those it seeks to serve, and its own. As Terri Langston convincingly suggested in Towards Transformative Change in Health Care, the social determinants of health must be accounted for when designing health interventions. And a foundation also must be intentional in identifying intended beneficiaries and using a social justice approach that addresses the structural causes of health disparities.

Approaches to public health grounded in the principles of strategic philanthropy – in Grand Challenge’s case, funding research to change the genome of a bacteria to carry a vaccine or to mass-sterilize malarial mosquitos – are undoubtedly valuable contributions to the field. But the strategic approach must be coupled with a social justice framework to create lasting results. To neglect the political and economic conditions that create and perpetuate public health issues is to spit into the wind. As The Economist puts it in an article about Grand Challenges, the Victorians didn’t eradicate cholera by treating those who caught it, they found a political solution: building effective sewers.

In many of the countries and communities where Grand Challenges’ work hopes to have the most impact, including throughout Sub-Saharan Africa and the Indian Subcontinent, poverty and political marginalization predict health outcomes (in fact, this unfortunate trend is also well-documented in the U.S.). Women, LGBTQ people, people of color and the poor are more likely to suffer and die from the diseases Grand Challenges grantees are diligently investigating in labs. And the reasons why this is the case don’t lie under a microscope. An insular technocratic approach to public health problem-solving undercuts progress toward goals. When the philanthropic sector searches for solutions to the issues that make life difficult and sometimes brutally short in the developing world, they ought to consider carefully the role power, and the lack thereof, plays. Solutions developed in the absence of input from the very people a philanthropic initiative seeks to help are more likely to fail. Nor can we ignore the local context and power dynamics that determine health outcomes. Funding for organizing and advocacy must be a component of any public health portfolio.

The Gates Foundation appears to have realized the benefits of fusing strategy and justice. In the fall of 2014, they announced two new programs for the Grand Challenges portfolio, Putting Women and Girls at the Center of Development and All Children Thriving. The first especially hints at a major social and political issue that affects public health: gender bias, be it in the form of sexual violence, legal restrictions or educational disparities. And it is encouraging that the foundation is acknowledging the political context of the Grand Challenges work. Many have pointed out the power of Grand Challenge’s targeted and specific strategy. The foundation should continue to adapt the targeted specificity they have used to solve technical issues to achieve social justice goals.

Around the world, public health concerns are not just biological facts, but rather the result of a complicated web of social, economic and political factors. It is important for any funder engaged in public health, especially one with the enormous influence of the Gates Foundation, to recognize the limits of an approach like Grand Challenges. No doubt the science behind the research is ambitious and well-intentioned, but the outcomes will always be constrained by the political reality of those whose lives are at risk. Hopefully Bill Gates’ candor will also come with an understanding of the socio-political reality of his important work.

Ryan Schlegel is research and policy assistant at the National Committee for Responsive Philanthropy (NCRP). Follow @NCRP on Twitter.