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How billionaire philanthropy provides reproductive health care when politicians won’t

How philanthropists brought us modern contraception — and where we’d be without them.

Pro-choice supporters pose for photos outside the Planned Parenthood Reproductive Health Services Center in St. Louis, Missouri, May 31, 2019.
Saul Loeb/AFP/Getty Images
Kelsey Piper is a senior writer at Future Perfect, Vox’s effective altruism-inspired section on the world’s biggest challenges. She explores wide-ranging topics like climate change, artificial intelligence, vaccine development, and factory farms, and also writes the Future Perfect newsletter.

There’s a new backlash against billionaire philanthropy. Some of its leading voices have argued that “every billionaire is a policy failure” and that it’d be better if billionaires didn’t exist at all — even if that meant the disappearance of philanthropy by billionaires.

The conversation has done a lot of valuable work, encouraging more scrutiny of charitable activity, pointing out where philanthropy is a fig leaf for misconduct, and forcing institutions to grapple with when it’s wrong to accept money that was unethically acquired.

But while I agree with much of this critique, it does have its blind spots. The overall vision laid out by opponents of billionaire philanthropy sees taxation and government policy as the prime levers to effect positive change in the world. That may be true in many cases, but it’s not true in all of them. And one issue in particular would suffer greatly if billionaire philanthropy was reduced in scale or ceased to exist tomorrow: reproductive health care.

Reproductive health care, more than most issues, has been enormously shaped by individual billionaire philanthropists. Many of the critical breakthroughs in the field were philanthropy-funded, as are many basic services today.

The reason for philanthropy’s big role in this issue area? It’s a matter of both logistics and politics. US foreign aid to support reproductive health worldwide is too vulnerable to the whims of the American electorate. Under Republican administrations, funding for access to contraception in both the US and abroad is typically slashed. Meanwhile, abortion is never funded by federal spending under Republicans or Democrats. Other countries provide international aid programs, but the impact of small changes in US policy is still substantial.

This is how we’ve arrived at a point where Bill Gates and Warren Buffett, two of the biggest philanthropists in the world, are the leading providers of access to contraception worldwide, and Buffett is the leading provider of abortion access for poor women in the U.S.

If you could snap your fingers and rid the world of billionaire philanthropists instantly, hundreds of millions of women worldwide would lose access to contraception. And in the US, only the rich would have access to legal abortion.

“The ideal solution is for the federal government to fund accessible high-quality voluntary family planning for anyone who wants it,” Liz Borkowski, a researcher in the Department of Health Policy and Management at George Washington University, told me. “Obviously, this is not what we’re seeing.”

Much opposition to billionaire philanthropy has focused on the injustice of letting the few decide policy for everyone else. And to be sure, “taxes, not billionaires, should fund key services” is a noble idea. But without a plan to dramatically change the funding priorities of the US government, the idea of doing away with billionaire philanthropy can lead to consequences that many of its supporters would probably agree are unjust.

In the realm of reproductive health care, making the idea a reality would mean ripping the rug out from under vulnerable women. The best critiques of billionaire philanthropy are those that are mindful of where it’s doing harm, where it’s doing good — and where it’s doing good that otherwise might not get done at all.

Why philanthropy became essential for reproductive health care

From the very beginning, the government has been hands-off, even hostile, when it came to access to contraception. In fact, at the time the first contraceptives were developed, most governments banned them.

The research that made the first birth control pill possible was funded by multimillionaire heiress Katharine McCormick. McCormick had started funding medical research in the hopes that learning more about hormone treatments could help her husband with a suspected adrenal disorder. She funded foundational research in the field, as well as the publication of the journal Endocrinology.

Starting in 1953, she began funding research into the first hormonal birth control pill. Overall, she spent more than $2 million on the development of the pill, which was approved by the FDA in 1957 for menstrual disorders and in 1960 for contraception. (It was not until 1965 that the Supreme Court ruled in Griswold vs. Connecticut that the Constitution protected American women’s right to take contraception.)

The crucial role of philanthropy in reproductive health care has carried through to the modern day.

The IUD is the safest option for birth control for many women, has the lowest rate of unintended pregnancy, and dramatically reduces teen pregnancies and abortions when it’s widely available. But early IUDs were ineffective and had safety problems, scaring pharmaceutical companies out of the field for decades. Philanthropists stepped in; efforts to bring safer European IUDs to market in the US, and to raise public awareness of their benefits and drawbacks as an option, were made possible by grants from the Susan Thompson Buffett Foundation.

The Susan Thompson Buffett Foundation, named for the late wife of hedge fund billionaire Warren Buffett, is also the biggest funder of access to abortion for low-income women in the United States. A law called the Hyde Amendment prohibits the use of any federal government funds for abortion, except in cases of rape or incest or where the life of the pregnant person is in danger. This means that poor women on Medicaid who can’t afford an abortion but need one (and don’t meet the Hyde Amendment standards) could very well have no recourse.

This is where philanthropy has stepped in — and in many states, it’s the only source of funding for abortion care outside the scope of Hyde guidelines. By some estimates the foundation has spent $1.5 billion on abortion access in the US from 2001 to 2014, making it the largest single funder in the area.

Internationally, the situation is a little different. The US government provides substantial funding for access to contraception and women’s health care. Under Republican administrations, though, this funding has been subject since Reagan to the so-called “Mexico City Policy” (also known as the “global gag rule”), where funding is unavailable to any institution that provides abortions, refers patients to other organizations that provides abortions, or offers women counseling about their options that includes the information that abortion is legal in their country.

Pro-Choice Rally “Fight4Her” Held Outside White House
People attend a rally in front of the White House at Lafayette Square on March 29, 2019, to demand the end of the “global gag rule.”
Astrid Riecken/Getty Images

Under Reagan, Bush Sr., and Bush Jr., these policies applied only to NGOs seeking funding for family planning and reproductive health. Under Trump, this policy applies to a broader set of organizations — NGOs that work in maternal and child health, nutrition, neglected tropical diseases, global health security, HIV under PEPFAR, and malaria under the President’s Malaria Initiative.

The way the Mexico City Policy goes on-and-off with a change of administration from Democratic to Republican has made it easy to study its effect. What studies have found is that the policy dramatically reduces how many women have access to contraception. Research comparing countries highly affected by the policy to countries barely affected has found that, when the Mexico City Policy goes into effect, contraceptive use falls by about 13 percent and pregnancies rise by 12 percent, driving a 40 percent increase in abortion rates.

Notably, the Mexico City Policy is profoundly undemocratic. When the citizens of a country have democratically chosen to make abortion legal — usually in certain highly limited circumstances — the U.S. government policy is to make funding for reproductive health and other services conditional on aid organizations agreeing not to inform women about their legal rights. This is a case where philanthropy can enable outcomes that are more “democratic” — more respectful of local self-determination, local law, and public opinions — than the behavior of the democratic U.S. government.

What philanthropists do — and what they can’t

What are philanthropists doing to close the access gap? The Gates Foundation writes that it aims to provide “contraceptive information, services, and supplies to an additional 120 million women and girls in the poorest countries by 2020 without coercion or discrimination, with the longer-term goal of universal access to voluntary family planning.”

It’s vital work — the Guttmacher Institute estimates that more than 220 million women who don’t want to get pregnant are not using a modern contraceptive and voluntary family planning services. Every year, 80 million of them become pregnant, and at least one in four of those unintended pregnancies results in an unsafe abortion.

Ryan Cherlin, a senior program officer in family planning at the Gates Foundation, told me, “We’re in a position as a private foundation to do the kind of things that others either can’t or won’t.” Support from donor governments for contraception and family planning services “really has ebbed and flowed, in part due to currency fluctuations and political fluctuations.”

That leaves a lot of critical work that only gets done through philanthropy. Ann Starrs, Director of Family Planning at the Gates Foundation, told me philanthropy does critical work in two key areas: R&D, and testing of ambitious new programs with government partners. (They also directly provide services, but in those areas governments are often willing to pitch in.)

Governments have a shorter time horizon than philanthropists, and in the area of reproductive health care, they historically have not invested in developing new forms of contraception — even though the best evidence suggests that having more options is much better for women. And the long development times and slow uptake of new options make commercial investment in the area limited.

“The foundation has historically had a significant proportion of the budget going to contraceptive technology R&D,” Starrs told me. Some projects they’re developing at the moment? “We’ve been supporting the development of a monthly oral contraceptive pill,” Starrs told me, as well as a birth control “patch” that lasts six months. In the past, they’ve also funded research into better condoms. Women choose a form of contraception by balancing health considerations, religious considerations, side effects, safety, and reliability. Having more options can make an enormous difference.

The other area where philanthropy plays a crucial role is in testing new programs that are riskier. A foundation like Gates can test a new access program and collect data on how it works — and then make the case to national governments that the program fits with their existing health care programs, pays for itself, and is worth offering at scale. They try to do these programs hand-in-hand with local partners and with enthusiastic buy-in from local governments — and the goal is, eventually, for contraception to be provided as part of health care, fully funded by governments and integrated with a primary healthcare system.

The intervention of philanthropists in this area has attracted critiques. Is it just an extension of the horrific early 20th century eugenics movement, which many philanthropists of the time eagerly embraced? Do philanthropists care about women’s health care for the sake of those women, or just as a form of population control?

“One important consideration whether it’s a philanthropist or a government is to avoid reproductive coercion,” Borkoski told me. Organizations have to train their staff not to encourage one method over another. They have to measure the success of clinics by how many women feel adequately served, not by how much contraception is given out. They have to support women in accessing the health care to have large families when that’s what they want. Even when this is heavily emphasized, as it should be, organizations are often assumed to have a eugenic agenda.

Perhaps to avoid that controversy, many organizations working in reproductive health care don’t comment on their work. Bloomberg reports that Buffett has avoided publicity for his work on IUDs and access to birth control, because of fears that it’d damage his reputation in the investment world where he made his fortune. When he began his work on access to contraception, it was a taboo topic, and in many circles it still is. (The Buffett Foundation responds to inquiries about its college scholarships only and does not respond to any other inquiries; we were unable to reach them for comment.)

Perhaps as a result, reproductive health care has been nearly absent from the conversation about billionaire philanthropy. But it shouldn’t be.

Hundreds of millions of people — yes, it really is that many — enjoy access to reproductive health care only because of philanthropy. First, there’s the billions that go into direct provision of services worldwide. But there’s more than that. Ten percent of American women use an IUD, developed through billionaire philanthropy, and it’s billionaire philanthropists who are working to develop the next generation of contraceptives, from developing even more reliable, lower-side-effect options for women to innovating the first reversible contraceptive options for men.

While this isn’t a knockdown rebuttal of the arguments against billionaires, it’s a fact that criticisms of billionaire philanthropy need to grapple with. A world without ultra-rich philanthropy would be a world without the Pill or the IUD, and a world where access to contraception was entirely subject to political tug-of-war, to be pulled away whenever Republicans are in power. That world might be more democratic (in some ways), but it would hardly be more just.

When philanthropy is necessary

Stanford political scientist Rob Reich is one of the prominent critics of billionaire philanthropy, calling them “virtually by definition, the voice of plutocracy.” In his book Just Giving: Why Philanthropy Is Failing Democracy and How It Can Do Better, he argues that philanthropy isn’t accountable to the American people, circumvents the normal political process, and ought to be subject to a lot more scrutiny.

However, Reich argues that there are some circumstances where philanthropy is an invaluable tool for democratic societies:

First, foundations can help to diminish government orthodoxy by decentralizing the definition and distribution of public goods. Call this the pluralism argument. Second, foundations can operate on a longer time horizon than can businesses in the marketplace and elected officials in public institutions, taking risks in social policy experimentation and innovation that we should not routinely expect to see in the commercial or state sector. Call this the discovery argument.

Both of these characterize philanthropist investment in reproductive health care.

Foundations operating on a longer time horizon than businesses or elected officials were able to fund development of the Pill and of the IUD, and will likely contribute to similar developments in the future, as new research programs are underway to develop male birth control, better pills, and better IUDs, with higher reliability and reduced side effects.

And foundation spending on reproductive health care is a great example of diminishing government orthodoxy. In the 1950s, that “orthodoxy” was the opposition of most Americans to the existence of contraceptions — an opposition that nearly vanished once they were actually developed and were safe and widely available.

Now, Americans overwhelmingly support the right to access contraception — but in practice, for poor women, that access is still often the object of political tug-of-war. Just last month, a new “domestic gag rule” resulted in dramatically curtailed government spending on access to family planning in the US. Forty percent of the 4 million Americans who access contraception through the only federal family planning program, Title X, access it through Planned Parenthood. The gag rule prompted Planned Parenthood to leave the Title X program, meaning all Planned Parenthoods (even ones that don’t provide abortions) are ineligible for funding from the government for the medical care they do provide.

Between on-and-off gag rules and a lack of investment in better, future contraception, the government simply isn’t ensuring that women have control over when they become pregnant — and as long as the two major parties continue to take turns in power, this will remain true. This is a case where philanthropy is uniquely valuable — and, in fact, essential to the functioning of a democratic society.

Other critiques of billionaire philanthropy admit of fewer exceptions.

Take the stance of Dan Riffle, Alexandria Ocasio-Cortez’s policy adviser, known for his Twitter handle “Every Billionaire is a Policy Failure.”

“The bigger Jeff Bezos’s and Bill Gates’s slices of the pie are, the smaller everybody else’s slices of the pie are going to be,” he has said. “It boggles the mind that somebody thinks that that philanthropy or charity is the way that we can best address systemic societal inequality.”

It’s possible to hold this position even once you’re aware of the history of reproductive health care. One could believe that the harms done by billionaires are so significant as to override the benefits they’ve provided through programs like these, or believe that it is actually wrong for women to have access to birth control when the government has not funded its development, or believe that the government would be pressured to change if only billionaire philanthropy stopped. But for the most part, critiques like Riffle’s have not chosen any of those responses; they’ve just ignored the question.

That doesn’t seem like the right way to think about a problem as weighty as this one. Critics of billionaire philanthropy should, like Reich, put forward a nuanced critique that admits exceptions like these — or face up to the possibility that women’s health care could be collateral damage in their vision of a more just world.

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