In the statement announcing the billionaire couple’s break-up, the Foundation chaired by Bill and Melinda Gates stressed that the pair ‘will continue to work together to shape and approve foundation strategies, advocate for the foundation’s issues and set the organization’s overall direction.’

The couple are entitled to their privacy, but this announcement has socio-political ramifications – so it’s only natural that their pending divorce has thrown many into uncertainty over the Foundation’s sustainability and stability. For the field of global health, a lot hangs in the balance.

The Gates Foundation was established over twenty years ago. In that time, it’s been a growing power within the global health arena. The Gates themselves have metamorphosised from tech giants into ‘health experts’, channelling all their wealth into ‘philanthrocapitalist’ ventures, and that wealth affords the Foundation a position of authority in global health governance from which it can influence policy and steer the agendas of international health organisations.

Its legitimacy is built on its sustenance of new global health institutes, especially those in public-private partnerships—including institutions such as GAVI, the Vaccine Alliance, and the Global Fund to fight HIV/Aids and Malaria—and its investment in the health programmes of older institutions like the WHO, to which it makes the second largest monetary contributions after the US government. Speculation about private philanthropic ventures has usually skirted around the worrying implications of influence monopolies, particularly over something as sensitive as global health – but the Gates Foundation is already there.

In the context of Covid-19, we can see the consequences of this kind of monopoly. At the start of the pandemic, the Foundation pledged to spend a fraction of its billions—a mere few millions—on the development of innovative Covid-19 medical technologies, partnering with both global health institutes and pharmaceutical corporations to accelerate their discovery and distribution. Bill and Melinda also promised to use their ‘moral voice’ to respond to the predictable health technology nationalism that has now taken hold.

But what’s unfolded since is far from ‘morally’ sound. Instead, the solutions the Foundation continues to advocate are based on its own priorities: that means merging its own monopoly with that of its long-time ally, the pharmaceutical industry, to support intellectual property (IP) rights, and take technocratic, top-down approaches that mostly exclude lower-to-middle income countries from decision-making – all while avoiding public scrutiny.

This threat to the involvement of community groups and health leaders globally, particularly in the Global South, means a response of the kind seen during the HIV/AIDS epidemic is rendered impossible. The historical example is instructive: until the late 1990s and early 2000s, the pharmaceutical industry kept antiretrovirals—medicines needed to treat HIV—inaccessible and unaffordable. In response, a Global South-led movement incorporating civil society groups, patient advocacy groups, government officials and politicians, global health students, non-governmental organisations, healthcare workers, lawyers, and academics organised to overcome the constraints of an IP-based health system that was leaving millions of people without medicine.

Public pressure encouraged developing countries to use legal measures to foster generic competition for antiretroviral medicines and forced pharmaceutical corporations to stop interfering with the effort to save lives. Today, over 90 percent of all medicines used in HIV interventions to treat an estimated 25 million people are low-cost generic medicines; without them, and without increased funding, the lowered transmission rates and improved life expectancies of those living with HIV and AIDS would not have been possible.

In many ways, the Covid-19 outbreak has been sustained by the same normalised injustices in the pharmaceutical system. Early on in the pandemic, countries in the Global South compelled the WHO to unveil a technology sharing pool, C-TAP, that would have removed intellectual property barriers for Covid-19 treatments and vaccines. Then, in October 2020, anticipating a future of monopoly vaccine patents and competition for survival, a coalition of mainly Global South countries led by India and South Africa brought a patent waiver proposal to the World Trade Organisation.

Rather than taking the obvious step to improve access, the Gates Foundation continued to oppose such a waiver. Bill Gates instead advocated a plan that would licence companies to hold exclusive rights to lifesaving medicines, no matter how much they benefited from public funding. Given his foundation’s vast influence over global health, his vision ultimately won out in form of the Covax programme, which aimed to make access for poorer countries easier through donations made by and sales made to richer ones.

The Foundation’s position then changed suddenly in May 2021 to align with President Biden’s public backing for the waiver, but only on a temporary and ‘narrow’ basis, and, reportedly, only after Bill met with a US trade representative to argue in support of patents. The consequences of such an influential body’s months-long equivocation are easy enough to imagine, if not to see.

The sixteen richest countries in the Global North have now administered more than half of the world’s vaccine shots, and the end of their pandemics are in sight. Countries in the Global South, on the other hand, will likely have to wait until at least 2024 to achieve mass Covid-19 immunisation in what is clearly becoming a vaccine apartheid. A patent-free People’s Vaccine, which all countries do their part to aggressively distribute, is the only reasonable solution. But we can’t wait for the Gates Foundation to back it.

The heart of the problem is that the Foundation claims to be driven by morality and to fund issues with the highest need, but in refusing to condemn monopoly medicine, it instead reinforces the systemic problems inherent in an industry that operates for private profit rather than public benefit. And is it any surprise? A health foundation run by billionaires is never going to propose a solution radical enough to undermine asymmetries of the status quo that made their fortunes possible.

For years now, elected politicians and civic campaigners have been asking about the moral salience of unelected and unaccountable individuals holding so much power in a field that speaks to the radical egalitarian ideals of something—in this case, health—for everyone. In the case of Covid, the Foundation has undermined the legitimacy of global health efforts by increasing conspiracy-style speculation about dark forces manipulating our bodies for their own benefit. These kinds of mutterings ultimately put everyone at increased risk – but the Gates, wrapped up in their own magnanimity, do not take notice.