In the early part of the twentieth century, a new kind of American philanthropy emerged in China and India, transforming the scale and intensity of interregional connections in shaping public health and medicine. This new movement was part of a global reconfiguration of philanthropy in the light of the First World War. These newly created philanthropic foundations embodied the notions of progressive thinking, as explicitly highlighted in their faith in expert knowledge and their ability to tackle societal issues. Unshackled by the prospects presented by the First World War, this new philanthropic movement, led by the RF, intervened first in Europe and subsequently across the world, with China and India becoming a part of the special commission in the global south. Epitomized by the expanding work of the RF, this new form of philanthropy transported disease control techniques pioneered in the American South to China and India (Amrith 2016).
Historically American Foundations have played prominent roles in filling gaps created by public and private sectors in the United States and globally. With longstanding distrust in governments and commitments to free markets, private philanthropic foundations like Rockefeller and Gates are products of the American polity (Stevenson 2014). American philanthropic intervention in disease control in China and India started with the RFs hookworm campaign from 1909 to the 1920s and expanded to other infectious diseases like Malaria, Yellow Fever, and Tuberculosis. The Rockefeller Foundation, since the early years of its inception, has been very influential in the global development of public health, not only through its grant-making but also by participating in shaping concepts and policies. There has always been an overt focus on technological solutions to social issues. The RF’s interest in commerce, religion, and science embodied the role of non-governmental forces that shaped American relations with China and India over the decades. Although they encountered different geopolitics, culture, and society, the foundations were nonetheless very successful in their pursuit of conceptualizing public health in both countries.
Following its predecessors, the Bill and Melinda Gates Foundation (BMGF), have become an active player in public health since the early 21st century in China and India, engaging in significant public health issues like Tuberculosis, Malaria, and HIV/AIDS. The presence of BMGF has become so prominent in the global health forum that it has become a significant figure in setting health policies. BMGF has also grown to be the leading player in many influential global public-private partnerships in healthcare. Since its inception, BMGF has sought to emulate RF, both in terms of the issues it has chosen to focus on and the strategies it has relied on to bring about change. What Rockefeller started in the 20th century, public health has been taken over by BMGF to a whole new level in terms of funding and influence. Whereas the RF worked in close contact with the national governments and helped shape healthcare policy both within the US and internationally, BMGF is more linked with private sector partnerships. The foundation’s major input in the government is to promote the private sector in delivering healthcare services (Kilby 2021).
Rockefeller Foundation and the Malaria Campaign
RF's malaria project took off in the foundation's early years with demonstration projects in limited areas. These projects embodied the latest public healthcare experiments to gather malariological insights from the field with a plan to develop feasible control strategies. The demonstration projects were merely focused on technical interventions and neglected the social aspects of the disease (Eckl 2014). As infectious diseases were observed to lower productivity in China and India, Malaria control, like Hookworm, was seen as a strategic investment for economic productivity. Over the years, out of the clusters of measures adopted (mosquito control, screening, administering quinine, sterilization of carriers), mosquito control and malaria policy became primarily a fight against the vector.
The rising cases of malarial fevers in colonial plantations became detrimental to the growth of the British colonial economy and its growth of trade. At the same time, trade with a disease-prone area carried the disease-causing germs to other colonial localities. However, the interest in trade provided only one of the reasons for the expansion of the RFs activities; equivalently imperative was American military and diplomatic interest in the global south and its markets. As Dr. Paul Russel, one of the malaria experts of the RF, stated: ‘a malaria eradication program is a dramatic undertaking that would penetrate the homes of people and would benefit the U.S politically and financially’ (Kabir 2003). The RF’s interest in entering malaria in China and India was accompanied by a vital interest – research in tropical diseases- a booming area of significance in the 20th century.
International malaria research in colonial India in the 20th century was one of the incremental increases in specialized knowledge about malaria, the identification of various anophelines, formation of malaria ‘brigades,’ mapping of malaria through malaria surveys, and various ‘controlled experiments’ to eliminate infected anophelines (Bhattacharya 2012). The RF’s focus on antimalarial activity in colonial India encompassed research, studying the nature of the disease, the parasites, and control techniques. RF’s interest in malarial research in China was initiated in the early 1920s through the establishment of the Division of Parasitology in RF established Peking Union Medical College. “Supported by the RF, the division developed as one of the leading research and teaching centers of tropical medicine in China and the world, until the PUMC was closed by the invading Japanese army in 1941” (Shen 2017). Through the efforts of Feng Lanzhou, a Chinese medical entomologist trained under the RF auspices in tropical medicine, the research foci of the division shifted from human parasitology to insect-borne diseases (Shen 2017). Echoing RF’s standard strategy of malarial control, many of Feng’s works were focused on revealing the so-called “natural infection” rates of malaria in anophelines indicating malaria can be best prevented through mosquito control (Lanzhou 1932). Health activities in tropical diseases by the RF, hence, was sought to provide, even when the trade interests were not immediate, locations that could be used as tropical observatories where research on diseases as varied as hookworm, yaws, yellow fever, malaria, filariasis, and plague, could be carried out with much ease (Kabir 2003).
By the mid-twentieth century, malaria control had become a crucial building block for the control of other diseases of public health importance. The malaria campaign followed an independent, vertical approach that kept malaria outside the mainstream public health development (Litsios 2001). In other words, the foundation's malaria program not only disregarded the social dimension of the disease but also dismissed technological pluralism in its approach to the problem. They promoted a biomedical rather than a social understanding of health problems, preferred time-limited investments over sustained spending, and favored solutions that promised recognizable results. The RF brought this biomedical-managerial frame to its logical end when they developed a preoccupation with malaria eradication and shaped global policies accordingly (Eckl 2014).
Enter The Gates Foundation
With the RF rolling back from its global fight against malaria at the dawn of the period dominated by the public sector, the Gates foundation entered China and India in disease control when the predominance of the public sector had long passed its zenith. With the creation of the Public-Private Partnership (PPP), the new institutional setting was more favorable for the Gates foundation activity than it had been for the RF. The PPP model offered a much more extensive array of philanthropic investment avenues. The Gates TB program, as highlighted on its foundation website, states its strategy as aimed to address key gaps along the TB care pathway through new approaches to protecting against infection, progression from infection to disease, and improving diagnosis and treatment. “Our efforts,” the foundation states, are diversified based on the understanding that vaccines, diagnostics, drugs, and enhanced care delivery are essential to addressing the TB epidemic, a typical biomedical framework of the American Foundations, from which they hardly diverged.
There has been an emerging burden of MDR/XDR TB in both China and India in the recent decade. Two decades of bringing down the caseload in the form of national programs have not yielded many results. China and India have been highlighted as the top two countries with the highest cases of TB (Bhatter 2012). In both countries, the foundation engages with governments and other partners—including the World Health Organization (WHO), USAID, and the World Bank—to pilot innovative approaches to modernizing TB control. With the government of India, WHO, USAID, and the World Bank, the foundation plans to expand TB-control efforts into the private health care sector, where most Indian patients seek care. In China, by providing adequate support, the foundation aims to help the government shift to hospital-led TB care. The nature of the foundation’s TB program in both countries is framed within the ‘Public Private Partnership’ (PPP) model crafted to suit the narratives of the ‘technical biomedical interventions,’ which has long been the encyclopedia of the American philanthropic model of health.
RF and BMGF in the Age of Global Health Governance
Both RF and BMGF act as transnational actors of influence, gaining legitimacy by advancing the creation and development of strategies and institutional frameworks of public health within which they seek to function. RF and BMGF have both devoted enormous funding to strengthening public health in developing countries, with China and India figuring as crucial interest areas for philanthropic funding in the global south. Embedded within global health governance, public health has traditionally been a top area of interest for charitable foundations. These philanthropic entities resemble a multilayered system of overlapping and differentiated institutions and actors that goes beyond the traditional world of governments and inter-state diplomacy (Stephen and Zurn, 2019). With an ability to exert intense political influence and a lack of legitimacy and accountability, they consider themselves problem solvers of global health concerns by applying new and innovative methods. The main reason to consider public health a safe area of engagement for the foundations is because saving human lives is a relatively uncontroversial goal. Using money, technology, and expertise to combat illness, especially in countries that lack resources, uncontroversial goals have always been crucial for foundations because the origins of their endowment activities attract public scrutiny, which trustees dislike and criticize. Using their immense wealth and influence with political and scientific elites, both foundations have promoted solutions to global health problems that, in many instances, undermine other international organizations like the UN and WHO (Vidal 2016).
The scientific revolution of the 19th century, which became the guiding principle of American philanthropy, is still seen to govern public health and medicine in present times. Being two of the most populous countries in the world with an ability to contribute to the more extensive research in public health, a study of the influential role of RF and Gates helps us better understand how public health governance driven by private philanthropy plays a vital role in shaping knowledge production in health and medicine, and the ideological and institutional implications of this knowledge production in the framing of public health policies. The RF’s interest in commerce, religion, and science embodied the role of non-governmental forces that shaped American relations with China and India over the decades. Although they encountered different geopolitics, culture, and society, the foundations were nonetheless very successful in their pursuit of developing and advancing public health along scientific lines in both countries.
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Centre of Social Medicine and Community Health, Jawaharlal Nehru University
China-India Visiting Scholar, Ashoka University