Los Angeles Times Staff Writer
December 17, 2007
2007-12-17 13:07:38.0 Jane: What prompted you to write this piece? It's received some harsh comments from those affronted at the idea of criticizing the generousity of the Gates Foundation; did you anticipate this outcry?
2007-12-17 13:09:15.0 Charles Piller: The Gates Foundation deserves a lot of credit for attempting to tackle very tough problems. We tried to be clear that the work is very important, despite strong challenges to its effectiveness. I'm not surprise some disagreed.
2007-12-17 13:09:32.0 Sarah: I just returned from a year spent in Lesotho working in an HIV/AIDS clinic. As I imagine you know, in Lesothi, CHAI, the Clinton Foundation's AIDS Initiative, is far more actively involved in HIV prevention and treatment than the Gates Foundation. In fact, Lesotho's health minister, quoted in your article, was, until recently, an employee of the Clinton Foundation. Why don't you mention the work of the Clinton Foundation in your article? Does your criticism of the Gates Foundation extend to the Clinton Foundation?
2007-12-17 13:10:44.0 Charles Piller: I did know about the Clinton work. It's very important there, and dedicated to taking a comprehensive approach to healthcare and health systems. CHAI supports Partners in Health to that end. Thanks for pointing this out.
2007-12-17 13:10:51.0 Jane: What gave you the idea for this story? What was your goal in writing it?
2007-12-17 13:11:54.0 Charles Piller: The Gates Foundation is the most important private philanthropy. We felt that because of its influence and importance, that a close look at its programs would be helpful to understanding whether they are as effective as they can be.
2007-12-17 13:12:52.0 Stephen: It's hard to calculate its effectiveness though in such a complex envirnoment where so many others are working, don't you agree?
2007-12-17 13:13:42.0 Charles Piller: The goal was to shine a light on those programs in the spirit of contributing to overall understanding of how to tackle the important issue of health. And yes, effectiveness can be a hard thing to measure. That's why we took months to both scrutinize the available data and try to find some "ground truth" in field reporting.
2007-12-17 13:15:14.0 Chris: it seems, however, that your primary point was that while the GF is doing some things that are really worthwhile, there are other things it is not addressing, and without those other things, the overall impact is less than it could be. This sounds like you are expecting the GF to solve all the world's problems at once.
2007-12-17 13:16:18.0 Charles Piller: This is also a moving target--the Gates Foundation and its grantees are continually doing course corrections. We hope that the issues raised in our story might contribute to improved programs over time. I don't think that Gates can do it all. But as so influential an organization, what they do has a great impact.
2007-12-17 13:16:20.0 Stephen: It's too bad that you did not provide at least some kind of landscape in which to present Gates' contribution though.
2007-12-17 13:17:02.0 Stephen: Well then
2007-12-17 13:17:05.0 pcharles: I was very turned off by the unnecessarily provocative title, and the intentionally inflammatory (and negative) choice of words throughout the piece.
2007-12-17 13:17:19.0 Sarah: A lot of people are focusing on what they perceive to be your negative opinion of the Gates Foundation. Do you think you might have written a better article if you had focused more broadly on the issue of how to address the complex issues surrounding vertical vs. horizontal health interventions in the developing world?
2007-12-17 13:17:22.0 Charles Piller: Yes, our story could have presented more than it did about Africa and the Gates Foundation. We hope to tackle the issues more in the future.
2007-12-17 13:17:40.0 Stephen: Well then, how about giving credit to Gates for being a catalyst to prompt so many other organisations and donors to join the caue of tackling the serious issues of global health. You did not do that.
2007-12-17 13:18:53.0 Charles Piller: Actually, we tried to give them credit. The story was tyring to tackle the additional issues in more detail.
2007-12-17 13:18:57.0 Stephen: PCharles, I completely agree with you and the LA Times editors should be taken to task for this just as much as the reporters. Very irresponsible I thought.
2007-12-17 13:19:08.0 Dom: I recently spoke with two residents of Malawi about faith-based aid programs operating in their country. They said that the best ones were those who came in asking questions rather than acting as if they had all the answers. How much of the problem with the Gates Foundation's implementation do you think stems from a Western attitude that 'we know what you need.'
2007-12-17 13:20:15.0 Charles Piller: I believe that the GAtes folks are working in good faith and with determination to help. It's hard to do well in these complex issues. But describing weaknesses is not meant as an attack on their motives.
2007-12-17 13:20:22.0 pcharles: Much of your story seemed to imply that many of the problems that you described were a result of the activities of the Gates Foundation. My take on this has been that the Gates Foundation have made remarkable progress despite the problems that you describe.
2007-12-17 13:21:38.0 Charles Piller: No question. The Gates Foundation does important work. And their learn from their mistakes, as they often have said. In my talks with them, they emphasized that they are building new programs when they see a way they can help. Not everyone sees the progress the way they do, however.
2007-12-17 13:21:51.0 Administrator2: How do you think other (currently in existence or future) charities can benefit from the experiences of the Gates Foundation?
2007-12-17 13:22:22.0 pcharles: Mr. Pillar- your statements here are in rather striking contrast to an article entitled "...victims of the Gates Foundation..."
2007-12-17 13:22:57.0 Charles Piller: Other charities already take their lead from Gates. And some have chosen different approaches, such as the Clinton Foundation. My guess is that everything Gates does is studied carefully for ideas by other charities.
2007-12-17 13:23:10.0 Stephen: You missed a real opportunity in this story. You could have evaluated the Gates Foundation as a catalyst to perhaps creating a new energy behind tacking global health issues and maybe, just maybe achieving the millenium development goals. You could have said that and then talked about the UK's announcement about the Internatinal Health Partnership and similiar new initiatives that are aimed at addressing health system strengthening. And then, watched it to see if it actually developed or is just a hot air.... that is where the debate is now.
2007-12-17 13:24:09.0 Stephen: Instead, you blamed Gates for pouring billions into Africa but not paying for a $35 valve.....
2007-12-17 13:24:57.0 Charles Piller: To be sure, the story left out much of the debate. But I think we covered some of the key issues clearly. And many health experts with experience in Africa share concerns about hte directions taken by large donors, of course.
2007-12-17 13:26:15.0 Charles Piller: The Gates foundation is indeed a catalyst--all the more reason to look closely at what it is doing, in order to help provide information that will increase its influence in the most favorable and successful ways. At least that's what we hope will result from the debate stimulated by the story.
2007-12-17 13:27:10.0 Sarah: But your article doesn't offer a helpful discussion of how to move forward to address these issues--you seem a bit myopically focused on taking Gates to task. I agree with stephen that this seems like a missed opportunity. You have a voice that most of us don't have, and it's disheartening to see reporters like you miss an opportunity to constructively advance such an important debate.
2007-12-17 13:27:12.0 Jane: Is there a charity or foundation that is, in your opinion, doing it "right" and filling in those gaps that you identified?
2007-12-17 13:28:16.0 Stephen: What you brought to the forefront is the need for a holistic approach to health care in Africa. But Gates had to start somewhere and unfortunately, you bashed them
2007-12-17 13:28:26.0 Charles Piller: Well, there are many that have tried a comprehensive approach. Three mentioned in my stories are worth a look: Doctors without Borders, Partners in Health and the Clinton Foundation. Irish Aid, an arm of the Irish government, is also giving funds in very creative ways.
2007-12-17 13:29:19.0 Chris: I imagine that if you examined any one of them closely with the approach you used with GF, you would find that despite the good each of them does, people are still dying from causes they do not address
2007-12-17 13:29:36.0 Administrator2: What is the most important constructive change that could be made in foundations like the Gates' in order to improve the work they are doing?
2007-12-17 13:29:59.0 Chris: Isn't that inherent in the nature of our world, with so many interrelated causes impacting people?
2007-12-17 13:30:06.0 Charles Piller: Thanks for the comment about "bashing" Gates. This story was written to point out some observations of our research, not as an attack on the Foundation. Much praise has rightfully been received by them as well.
2007-12-17 13:31:36.0 Charles Piller: Partners in Health has an interesting perspective--that the "limits" in what can be done in Africa are artificial. Some of their programs have demonstrated that the weaknesses in health aid programs are not inherent, but a matter of design.
2007-12-17 13:32:39.0 Administrator2: If they're right about that, what design changes are they calling for to improve health care in Africa?
2007-12-17 13:32:54.0 Stephen: Your lead in the story about a woman who benefited from ARTs thanks Gates but her baby died b/c Gates doesn't also fund the $35 valve that would have saved the child's life was not research. It was a misconstrued comparison that was completely inappropriate and was sadly, sensationalist.
2007-12-17 13:34:19.0 Charles Piller: My sense is that the Gates Foundation will change its approach to these issues over time. PArt of the problem is that they have to give away a lot of money each year, and that in itself can be a challenging burden to do in the most creative ways. As for the comparison of ART treatment and oxygen valves--I take your point. But bear in mind that these are not abstract issues or blind comparisons to the people in those nations whose babies are dying so often.
2007-12-17 13:34:53.0 Charles Piller: They view the comparison is life and death, and eminently fair.
2007-12-17 13:35:07.0 Stephen: Indeed, but thank goodness that Gates is trying to at least solve part of the problem.
2007-12-17 13:35:26.0 Administrator2: How much are they spending annually? And how much of it is directed at Africa specifically?
2007-12-17 13:35:31.0 Michael: They might view the comparison as fair, but I doubt they'd put all of the blame for the lack of a valve on the Gates Foundatoin
2007-12-17 13:35:35.0 Michael: You are the one who chose to do that
2007-12-17 13:36:32.0 Charles Piller: Gates, right now, gives a bit over $1.5 billion annually. It's hard to calculate precisely what goes to Africa, but the continent recieves much of the funding that does not go directly to US or research programs.
2007-12-17 13:37:33.0 NJS: Given that resources, even the Gates Foundation's resources, are finite, are you suggesting that existing money be diverted away from vertical programs in favor of health systems strengthening? Few people would disagree that health systems need to be improved and that more money needs to be invested, but should Gates-funded programs cut back on existing activities? Whereas Nyoba's daughter may not have died in a better health system, Nyoba may not have survived long enough to have a child without her AIDS drugs
2007-12-17 13:39:39.0 Charles Piller: Even the Gates Foundation can't pay for everything. But thinking carefully about what could have the most benefiicial effects is the goal, I think. The point, in part, is that things that don't cost a lot of money are lost in the rush to solve other problems. This is not inevitable--it's a matter of setting up programs more effectively. Few in the world of global healt dispute that point.
2007-12-17 13:40:07.0 pcharles: Having worked in developing countries on issues of vaccine design and testing, I can attest to the difficulty of trying to do "everything." A holistic approach sounds wonderful, but is virtually impossible to achieve in practice. Where do you draw the line? I have visited villages where there was no running water, little food, and virtually no healthcare. If we (as medical researchers) tried to feed, clothe, and provide medication for all of the needs that we saw, there would be no time to or funding to do what we were there in the first place.
2007-12-17 13:41:42.0 Charles Piller: Yes, the probems require tough choices. We tried to point out in the story that some decriptions of the programs benefits have not been demonstrated in the experience of the people, or in the data that are collected.
2007-12-17 13:42:02.0 Administrator2: What first drew your attention to the Gates Foundation and do you plan on expanding the scope of your investigation to include other charities?
2007-12-17 13:42:25.0 Charles Piller: Tough choices don't mean settling for less than a better outcome.
2007-12-17 13:43:08.0 Charles Piller: We chose to look at Gates because it's the biggest and most importnat foundation on the planet. We may look at other philanthropies in future.
2007-12-17 13:43:39.0 pcharles: I think there must be a point at which the world hold the governments in developing countries accountable for their actions. I think it is far more likely that the money that could have been used for a valve was spent on buying machine gun ammunition than that it went away in some sort of brain-drain, higher salary for GF nurses scenario.
2007-12-17 13:45:05.0 Charles Piller: It's a good point, and one the Dr. Yamada of the Gates Foundation also made. The health officials I spoke with in Africa said that they knew that they were responsible for their own nations' improvements. Of course, corruption or ineptitude in government is a problem worldwide.
2007-12-17 13:46:00.0 Administrator2: What was your hope, in writing this story, for the best possible outcome to develop from it? And what can readers to do help, if they're so inclined?
2007-12-17 13:46:19.0 Sarah: why didn't you acknowledge GAVI's $500 million investment in basic health systems announced at Davos last year? That seems to be a perfect example of GAVi and Gates doing exactly what you are claiming they do not do.
2007-12-17 13:47:01.0 Charles Piller: Bear in mind that the Gates Foundation is not a passive player in the policies of big aid groups or even of national governments. What they decide and do matters greatly in how such programs are constructed and run. As for the GAVI investment you mention...it's in the story, clearly noted. Sorry you missed that point.
2007-12-17 13:48:34.0 Charles Piller: This is a nuanced issue--much good is being done by Gates and their grantees. But doing good things, we thought, shouldn't indemnify the foundation from having its influence and effectiveness looked at closely.
2007-12-17 13:49:34.0 Stephen: Yes agreed but in the context of the bigger picture and in a less sensationalistic way.
2007-12-17 13:50:14.0 Charles Piller: To ignore issues--including weaknesses in how aid for health is given or administered--might contribute to more misery. If you view the reporting as sensationalistic, of course, that's your perspective and I appreciate hearing it.
2007-12-17 13:50:20.0 Administrator2: Is your investigation still going on? Is there more to come on this story?
2007-12-17 13:50:43.0 Charles Piller: At this time, I can't say precisely which direction we will be going.
2007-12-17 13:50:52.0 Sarah: I think the issue many of us have is with your focus on "what Gates is doing wrong," instead of, what would be better, which would be a focus on how we can improve global health. Normally I'd take issue with criticizing an article for what it did not aim to achieve, but in this context, I feel it's appropriate.
2007-12-17 13:51:46.0 Charles Piller: I suggest you take a look at the companion story about Partners in Health. It's addresses exactly what you are asking for.
2007-12-17 13:52:11.0 Stephen: Credit goes to you for raising the systems strengthening issue but you seemed to have an agenda against Gates in this piece. Yes, that my perspective and I k now you appreciate hearing it..... but perhaps you should ask yourself if you are being biased.
2007-12-17 13:52:29.0 Administrator2: If readers only take one piece of information away from your story, what should that one thing be?
2007-12-17 13:53:19.0 Charles Piller: Perhaps that it's best to exercise skepticism about claims of great benefits in global health--while always supporting efforts to do better and save more lives.
2007-12-17 13:53:48.0 pcharles: Sarah and Stephan- agreed. The piece was obviously biased in a "GF does this wrong, and is contributing to human misery" sort of way. I have not read the companion piece, but that is not what we are here talking about.
2007-12-17 13:54:01.0 Administrator2: Folks, we're almost out of time and will need to wrap up shortly. Please send any final questions or comments now!
2007-12-17 13:56:30.0 NJS: Are you surprised by the reader reactions to your article? There haven't been that many people coming forward to praise it for raising the issues you chose to focus on.
2007-12-17 13:58:05.0 pcharles: My final comment is simply to reiterate that I thought the title was unnecessarily provocative, and the choice of vignettes seemed mostly based on their shock value- all aimed at making the GF look bad.
2007-12-17 13:58:19.0 Charles Piller: Many of the comments online have been critical, but I've also gotten a lot of other feedback. These are challenging issues, and I think many people out there are concerned about raising concerns about the Gateses, who have given away so much money. So it's not unexpected. I'd just like to thank everyone for their thoughtful comments.
2007-12-17 13:59:25.0 Administrator2: Thank you, Charles, for taking time out to chat with us, and thank you to all who participated! If you missed any of today's chat, a transcript will be available later this afternoon at http://chat.latimes.com. Have a great day, everyone.
2007-12-17 13:59:35.0 pcharles: adios.
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