Introduction - No Funding for You
To better understand health care dysfunction, I interviewed doctors and health professionals, and published the results in Poses RM. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003; 14(2): 123-130. (link here). In that article, I postulated that US physicians were demoralized because their core values were under threat, and identified five concerns:
1. domination of large organizations which do not honor these core values
2. conflicts between competing interests and demands
3. perverse incentives
4. ill-informed, incompetent, self-interested, conflicted or even corrupt leadership
5. attacks on the scientific basis of medicine, including manipulation and suppression of clinical research stuides
After that my colleagues and I have tried to raise awareness of these and related issues, now mainly through the Health Care Renewal blog. We also set up FIRM - the Foundation for Integrity and Responsibility in Medicine, a US non-profit organization, to try to provide some financial support for the blog.
Since we were mostly health care academics, we assumed we could get some financial support for the blog and FIRM from foundations with interests in improving health care. Had we not identified important causes of health care dysfunction that had been largely anechoic, but once identified could be addressed, thus presumably improving health care costs, quality, and access? It seemed reasonable at the time.
However, we failed to find any prominent foundations willing to help. We have occasionally gotten small amounts of money from a few small foundations, but not recently. Meanwhile we have not seen any major health care foundations supporting any iniatives by anybody meant to address any of the issues we discuss on Health Care Renewal. In particular, while outright health care corruption seems one of the most outrageous issues we discuss, we have never found a foundation willing to take that on - at all.
We should not have been surprised. We later discovered that the leaders of many health care foundations had conflicts of interests which likely decreased their enthusiasm for even considering issues such as ... conflicts of interest and their risk of generating health care corruption. (See below for further discussion.) Recently, however, we have found some enlightenment on how such foundations, and other change agents and do gooders working the health care sphere, have managed to ignore such important problems
Why Expect Those Who Profit from Current Dysfunction to Lead Real Reform?
Last week, the New York Times published an essay by Anand Giridharadas, author of the just published Winner Take All: Elite Charade of Changing the World. The author's thesis was that society has handed over the responsibility for reform to those who benefit most from the status quo.
'Change the world' has long been the cry of the oppressed. But in recent years world-changing has been co-opted by the rich and the powerful.
America might not be in the fix it’s in had we not fallen for the kind of change these winners have been selling: fake change.
Fake change isn’t evil; it’s milquetoast. It is change the powerful can tolerate. It’s the shoes or socks or tote bag you bought which promised to change the world. It’s that one awesome charter school — not equally funded public schools for all.
He suggested that the very wealthy seduce us with their dedication to change, even while sponsoring
world-changing initiatives funded by the winners of market capitalism do heal the sick, enrich the poor and save lives. But even as they give back, American elites generally seek to maintain the system that causes many of the problems they try to fix — and their helpfulness is part of how they pull it off. Thus their do-gooding is an accomplice to greater, if more invisible, harm.
What their 'change' leaves undisturbed is our winners-take-all economy, which siphons the gains from progress upward.
a strong interest in convincing the public that they can help out within the system that so benefits the winners.
After all, if the Harvard Business School professor Michael E. Porter and his co-author Mark R. Kramer are right that 'businesses acting as business, not as charitable donors, are the most powerful force for addressing the pressing issues we face,' we shouldn’t rein in business, should we?
This is how the winners benefit from their own kindness: It lets them redefine change, and defang it.
In a 2017 essay in Medium which previewed the ideas that would appear in the book, Giridharadas had summarized the problem thus
change-makers [focus] on the difference they make to those they choose to help. Yet they risk avoiding the causes of the disease and remedies that would actually cure it. And they avoid these things in part because facing them could implicate powerful people, or perhaps even themselves.This is a powerful idea. As a society, at least in the US, we have abandoned true reform, including reform of health care, for faux reform controlled by those who would lose the most were true reform to take place instead. We have handed the problem of excessive drug prices over to the executives of pharmaceutical companies who benefit most from currently outrageous pricing. We have handed the problem of a dysfunctional health care insurance system over to executives of insurance companies who benefit most from high cost commercial insurance plans that cover as little as possible. We have allowed corporations accused of unethical and criminal practices to make lax legal settlements that pretend they will be able to improve themselves without penalties accruing to the managers on whose watch the bad behavior occurred. And we have let health care foundations led by top health care corporate managers and their cronies to sell change that matters.
Broadening Understanding of the Conflicts of Interest Affecting Leadership of Health Care Foundations
Gridharadas has given us a broader view that explains why many big foundations fail to fulfill their glorious mission statements.
Example: the Robert Wood Johnson Foundation
For example, the Robert Wood Johnson Foundation boasts,
The inspired vision of our founder, General Robert Wood Johnson II, was to improve health and health care in America, especially for those most in need. Energized by our legacy of taking on challenging issues, we are dedicated to building a Culture of Health that provides everyone in America a fair and just opportunity for health and well-being.
Has the foundation ever really addressed ill-informed, incompetent, self-interested, conflicted or even corrupt health care leadership, or attacks on the scientific basis of medicine, including manipulation and suppression of clinical research studies?
Should we expect anything more - or less - from a foundation whose current 15 person board of trustees is chaired by:
- a retired corporate vice president and general counsel of Johnson & Johnson
and which otherwise includes:
- a retired corporate compliance officer and vice president, Technical Resources, of Johnson & Johnson
- a surgeon who was founder of the for-profit Columbia/ HCA, now HCA hospital system
- a retired vice president of government affairs and policy responsible for federal, state, and international relations for Johnson & Johnson.
- a retired vice president, chief information officer, and a member of and the first woman to serve on the Johnson & Johnson Executive Committee.
- and another retired retired corporate vice president of Johnson & Johnson
Example: the Bill and Melinda Gates Foundation
The Gates Foundation boasts
We see equal value in all lives. And so we are dedicated to improving the quality of life for individuals around the world.
Yet in 2006, Transparency Internationa published a report on health care corruption, which asserted that corruption is widespread throughout the world, serious, and causes severe harm to patients and society.
the scale of corruption is vast in both rich and poor countries.
Corruption might mean the difference between life and death for those in need of urgent care. It is invariably the poor in society who are affected most by corruption because they often cannot afford bribes or private health care. But corruption in the richest parts of the world also has its costs.Has the Gates Foundation ever addressed health care corruption and the conflicts of interest that are risk factors for corruption? Should we expect more, or less from foundation that is now run by a multi-millionaire former pharaceutical executive as foundation CEO?
As we noted here, Dr Susan-Desmond Hellmann, the CEO of the Gates Foundation was previously President of Drug Development at Genentech, Dr Desmond-Hellmann had defended the then sky high pricing of bevacizumab. Of course, Dr Desmond-Hellmann, as a top executive, personally profited from such pricing. In her last year at Genentech while the company was still independent, her total compensation was over $8,000,000. As we discussed in 2014, while she was the Chancellor of UCSF, questions arose about her committment to public health when it was revealed she and her husband had large stock holdings in the tobacco company Altria. Yet she continued to dismiss the importance of her many apparent conflicts of interest.And there have been many accusations that the foundation she runs is more about promoting corporate interests in health care than actually promoting health, see the 2016 Global Policy Forum report per this Guardian article, this article in the Independent that accused the foundation of having a
ideological commitment to promote neoliberal economic policies and corporate globalisation
and a PLoS Medicine article [Stuckler D, Basu S, McKee M. Global health philanthropy and institutional relationships: how should conflicts of interest be addressed? PLoS Med 8(4): e1001020. doi:10.1371/journal.pmed.1001020. Link here. ]
'There is a revolving door between the Gates foundation and pharmaceutical corporations. Many of the foundation’s staff had held positions at pharmaceutical companies,' the report adds.For more details about Dr Desmond-Hellmann, look here.
As we noted, in 2012, the Global Fund to Fight AIDS, Tuberculosis, and Malaria as struggled with corruption issues, but even after these wake up calls, the Gates Foundation, one of its major donors, has done nothing to address corruption beyond its doors. Likewise, while the Health Alliance International has also struggled with corruption, the Doris Duke Foundation has shown no interest in health corruption initiativies (look here).
As we noted in 2011, uninterested in health care conflicts of interest and corruption are the Ford, Rockefeller, Kellogg and Robert Wood Johnson Foundation which were noted to have significant holdings in Coca-Cola, Kellogg, PepsiCo, Pfizer, GlaxoSmithKline, McDonalds, Nestle, NovoNordisk, YumBrands, Pizza Hut, KFC, Johnson & Johnson, and Sanofi-Aventis, while the Ford Foundation held shares in a tobacco company, Lorillard, and the Kellogg and Rockefeller Foundations "were indirectly invested in tobacco corporations through conglomerate equity funds...."
So health care interested foundations, which may derive financial benefit, and may be led or governed by people who mightily benefited from the dysfunctional health care status quo, are likely to continue fake reform to appear socially responsible, but avoid challenging their and their cronies sources of wealth.
Giridharadas suggested in an interview in New York Magazine,
What all that does is create this moral glow. And under the haze created by that glow, they’re able to create a probable monopoly that has harmed the most sacred thing in America, which is our electoral process, while gutting the other most sacred thing in America, our free press. And they do it under the cover of changing the world.
Unfortunately, he apparently has not come up with what to do about this problem. The best conclusion I can reach derives from the end of a review of his book by Joseph Stiglitz in the New York Times,
Democracy and high levels of inequality of the kind that have come to characterize the United States are simply incompatible. Very rich people will always use money to maintain their political and economic power. But now we have another group: the unwitting enablers. Despite believing they are working for a better world, they are at most chipping away at the margins, making slight course corrections, while the system goes on as it is, uninterrupted.
So I say first, beware of fake reform pitched by those who benefit most from the current dysfunction, call it out, and whatever you do, do not continue enabling it.