A perennial feature of the Covid-19 pandemic has been the guessing game of whether things are getting better or worse—and how policy approaches (masks, shutdowns) and changes in the weather will affect the coronavirus. Dozens of research institutes have published educated guesses about what’s coming next, but none have had the impact or reach of the University of Washington’s Institute for Health Metrics and Evaluation.

In the early days of the pandemic, the IHME projected a far less severe outbreak than other models, which drew the attention of Donald Trump, who was eager to downplay the danger. At a March 31 press briefing, the White House’s coronavirus response coordinator, Debbie Birx, with the president at her side, used IHME charts to show that the pandemic was rapidly winding down.

“Throughout April, millions of Americans were falsely led to believe that the epidemic would be over by June because of IHME’s projections,” the data scientist Youyang Gu noted in his review of the institute’s work. “I think that a lot of states reopened based on their modeling.”

The IHME brushed aside the widespread criticism that emerged—“Many people do not understand how modeling works,” its director, Chris Murray, explained in a Los Angeles Times op-ed—and continued to push headline-grabbing projections that drew alarm from its peers. For example, while many researchers limit their projections to a few weeks into the future, Murray used his regular appearances on CNN to chart the course of the pandemic many months in advance, putting the IHME’s highly contested estimates in a position to guide policy-making ahead of other models.

“It seems to be a version of the playbook Trump follows,” says Sam Clark, a demographer at Ohio State University. “Absolutely nothing negative sticks, and the more exposure you get, the better, no matter what. It’s really stunning, and I don’t know any other scientific personality or organization that is able to pull it off quite like IHME.”

The institute’s uncanny resilience, unconventional methods, and media savvy have long made it controversial in the global health community, where scholars have watched its meteoric rise over the past decade with a mix of awe and concern. Years before Covid, the IHME gained outsize influence by tracking hundreds of diseases across the planet and producing some of the most cited studies in all of science.

But it has also spawned a legion of detractors who call the IHME a monopoly and a juggernaut and charge the group has surrounded itself with a constellation of high-profile allies that have made it too big to peer review, the traditional method of self-regulation in science. Fueled by more than $600 million in funding from the Bill & Melinda Gates Foundation—a virtually unheard-of sum for an academic research institute—the IHME has outgrown and overwhelmed its peers, most notably the World Health Organization (WHO), which previously acted as the global authority for health estimates.

Today the IHME’s sprawling estimates have become the gold standard for understanding an increasingly broad array of topics related to health and development—particularly in the data-poor developing world, where record keeping is sparse. Its website offers interactive maps that allow users to drill down to virtually any village in sub-Saharan Africa, for example, to find out how many years of education people have; how malaria, HIV, and lower respiratory infections are changing over time; who has access to piped water; or how many men are circumcised. These estimates—educated guesses, really—help guide billions of dollars in aid spending and tell health ministers, charities, researchers, and journalists where things are getting better or worse.

“In a relatively short period of time, the IHME has exerted a certain kind of hegemony or dominance on global health metrics production,” says Manjari Mahajan, a professor of international studies at the New School. “It’s a kind of monopoly of knowledge production, of how to know global health trends in the world. And that produces a concentration of…power that should make anybody uncomfortable.”

Critics say this monopoly power can be seen in the ways the IHME appears to play by a different set of rules from the rest of the scientific community. Many describe its estimates as a black box.

“It’s quite impossible to criticize or indeed comment on their methods, since they are completely opaque,” says Max Parkin, from the International Network for Cancer Treatment and Research.

In 2019, Peter Byass, then a professor of global health at Sweden’s Umeå University, told The Nation, “From a scientific point of view, that makes it impossible for anyone to replicate or verify the estimates.”

Despite such criticisms, the IHME’s dominion keeps expanding—thanks in large part to Richard Horton, the editor in chief of The Lancet, who has put the credibility of the famed medical journal behind it, publishing more of the institute’s studies than any other periodical. While most scholars are lucky to publish one research article in The Lancet during a decades-long career, the IHME’s Murray has published more than 100.

The relationship between The Lancet and the institute was further underscored last year when Murray nominated Horton to receive the $100,000 Roux Prize from the IHME. It was a striking conflict of interest that raised eyebrows among scholars but virtually no public criticism. Challenging Horton could mean foreclosing on future publishing opportunities in a leading journal.

Some experts are also reluctant to criticize the IHME for fear of upsetting the Gates Foundation, one of the most important funders in global health and academic research more generally. According to the Web of Science database, more than 20,000 academic papers cite funding from the Gates Foundation, which has poured over $8 billion into universities in the past two decades, according to The Nation’s analysis of its charitable giving. Scholars have even used the term “the Bill chill” to describe their reluctance to bite the hand that feeds them.

“We are receiving millions of dollars for our polio campaign in Afghanistan and Pakistan from the Gates Foundation. We cannot jeopardize that campaign. Publicly criticizing the work of the IHME could potentially alienate the Gates Foundation,” one UNICEF official, who asked for anonymity, admitted to Mahajan in a study she published in 2019.

While the Bill chill may have diminished criticism, the Gates Foundation’s influence isn’t absolute and doesn’t travel very far into the social sciences, where scholars like Mahajan have taken a magnifying glass to the IHME. Even in research fields that the foundation funds, scholars appear increasingly willing to voice criticism of the IHME, including assertions that the powerful triumvirate of Gates, Horton, and Murray has advanced its work in a way that routinely sidesteps the checks and balances that govern scientific enterprise.

“Who is making such criticism, and where has the criticism been published or stated publicly?” an IHME spokesperson responded when asked about the institute’s controversial reputation. After The Nation forwarded several scholarly reviews, the institute struck a different tone: “This criticism is not new…. Part of the process over the past 12 years of creating a leading source of global health data is reckoning with criticism. IHME welcomes it and other critiques as one aspect of improving the Institute’s work.”

Murray is the IHME’s driving force and a towering figure in the world of global health—one of the rare scientists about whom biographies are written while they are still alive.

The 2015 book Epic Measures: One Doctor. Seven Billion Patients, by Jeremy M. Smith, describes Murray’s approach to health estimates as an extension of his medical training. Instead of treating individual patients, he’s diagnosing the globe, using Big Data to show governments and aid groups which diseases need the most attention and money.

Gates has long been a fan of Murray’s work, including a 1993 World Bank study he coauthored on the global burden of disease. “I saw…that 12 million children are dying every year,” Gates told Scientific American in 2014. “Wow! It was mind-blowing to me that these preventable diseases—pneumonia, diarrhea, malaria and some other infections that infants get—had such a huge impact. That was the first time it dawned on me that it’s not hundreds of different diseases causing most of the problem—it’s a pretty finite number.”

Based on Murray’s estimates, Gates saw an opportunity to make a big impact, and his foundation went on to donate almost $40 billion to global health and development, becoming one of the most powerful political actors in the field.

Though the WHO already had a robust health metrics program in place, Gates decided to create a competing group in 2007, luring Murray from Harvard to the University of Washington in Seattle, where the Gates Foundation is headquartered. Gates described his support of the IHME as designed “to make sure that everybody views this as the definitive source of information.” (The Gates Foundation and the IHME refused multiple interview requests and did not respond to most questions sent by e-mail.)

A renowned technocrat, Gates undoubtedly liked Murray’s Big Data approach, but may also have seen him as someone cut from the same cloth: entrepreneurial, combative, and hard-driving, someone with the rare combination of technical know-how and business acumen—and a desire to dominate.

“Chris is supergood, but he likes controversy—and he doesn’t back down,” Gates acknowledged in 2014. “For the job of administering the normative database, he’s not absolutely the perfect person.”

To be sure, the field of global health is littered with war stories of researchers who have had run-ins and blowups with Murray, many of them beginning the same way: with a request to Murray to show his work. Colin Mathers is one of them. These days a private consultant, he says that in his previous position managing health statistics at the WHO, he worked as a scientific adviser to the IHME but left because Murray would not share basic information about how he formulated the estimates. “We felt that without access to the data, we couldn’t put our names to the results,” Mathers explains.

Sam Clark of Ohio State University says that when he asked the institute to provide the source code for a tool it used in its estimates, it engaged in years of “obfuscation and blatant noncooperation” and later published a scientific paper attacking his work.

Another academic researcher asked to speak anonymously, saying he wanted to avoid provoking Murray, who turns “professional disagreements into personal accusations.”

Even the hagiographic Epic Measures describes Murray as believing that “scientific progress relies on picking fights.” The book recounts an incident in which he accused an academic researcher of inflating child mortality estimates 10 percent higher than his own. “He knows that deaths translate into money for child health programs. Deaths are money,” Murray is quoted saying. “Who’s right? That’s the only question. All that matters is being right.”

Yet during the pandemic, the IHME’s early projections proved dramatically wrong—and damaging to public health, some say. But this reckoning has come only because the high stakes of Covid have brought a new level of scrutiny and competition from other researchers and because the institute has had to contend with the emergence of actual data on infections and deaths.

In much of the IHME’s other work in health metrics, these feedback mechanisms do not come to bear in the same way, even though its estimates may be just as influential and, in some cases, just as wrong. This includes its efforts to track hundreds of diseases in the most remote corners of the planet.

“It’s impossible to do what they’re trying to do rigorously…. The data is just not there to really quantify the impact of some of these diseases,” notes Ruth Etzioni, a professor of public health sciences at the Fred Hutchinson Cancer Research Center. “Instead of saying, ‘You know what? That’s not possible,’ [the IHME says,] ‘Here are some numbers.’ You’ve naturally got yourself in an overpromising situation.”

The IHME counters that “no estimate of a problem is interpreted as an estimate of no problem.” And in an e-mail, it defended its estimates as transparent and published with statistical confidence intervals that inform users about the limitations of its work.

But Etzioni sees a pattern in the IHME’s pushing its findings into the limelight while relegating “key caveats and uncertainties” to the fine print. She points out that even when the institute made a major mistake in its early Covid projections—it had been using a bad model—it never issued a clear mea culpa.

“Instead of being straightforward and telling the public that they had a new model, Chris Murray told everyone that the numbers had gone up because we were reopening [from lockdowns] and not socially distancing anymore,” Etzioni says via e-mail. “What happened early in the summer when the IHME revised its estimate downward dramatically (which served the White House and consequently gave the IHME huge press) and…then turned out to be utterly wrong was nothing short of a debacle.”

In a normal year on the planet, approximately 60 million people die. Fewer than half of these deaths, including many in the developing world, will have medical records citing a cause. Knowing why and where people are dying is crucial to improving global health, which is what makes the IHME’s estimates are so important and influential.

Gates extols the way the IHME’s work on global health “democratizes information,” bringing together 281,586 global data sources from national health ministries, private insurers, and the scientific literature at a public-facing academic institute.

The problem, according to global health scholars, is that even if all of the IHME’s data were publicly available (it’s not), they would not have the capacity—or the endless philanthropic patronage—to trace the institute’s steps as it turns this mess of numbers into meaning.

“It is a great thing that [Murray] has done this, but there has to be some way of being more democratic,” says Dinesh Mohan of the Indian Institute of Technology in Delhi, who adds that the IHME can’t be held accountable in the absence of competitors and peers. “I would love to see more such initiatives and more openness and discussion without being called spoilsports.”

Some critics go further, describing the IHME as data imperialism—a Seattle-based organization, funded by a multibillionaire, that has too much control over the numbers that guide health planning for poor people of color in the Global South.

Parkin, who formerly worked on cancer estimates for the WHO, says the IHME’s granular mapping of global health gives “the impression that everything is known,” which is “progressively disempowering countries” from improving their own data collection infrastructure—and from building toward a global health landscape driven by actual data instead of estimates.

The IHME pushes back on allegations that it has too much power, insisting that “for nearly all outcomes that we publish, there are alternative sources of estimates.” (Elsewhere, it has called itself “arguably the de facto source for global health accounting.”)

While there are other groups working in health metrics, the IHME’s reputation as a monopoly stems from its ability and willingness to put a number on anything and everything, which has made it a go-to source for researchers, journalists, and governments. Stéphane Helleringer, a demographer at New York University, says the overreliance on the IHME’s numbers may be inadvertently distorting global health through what he calls “circular research.”

Because the IHME often doesn’t have clear data—for example, comprehensive records about malaria deaths in a given region—it makes estimates from other data points, such as the distribution of bed nets that protect people from malaria-carrying mosquitoes. (The more bed nets in a given region, the less malaria there should be.) Helleringer points to a 2015 study that refers to the IHME’s malaria mortality estimates—based in part on bed net distribution—to show that lives are being saved through an aid program that distributes bed nets.

One of the study’s authors, Eran Bendavid from Stanford University’s School of Medicine, doesn’t disagree with the criticism of his research as circular. “This is a real issue for my paper and increasingly for the global health research agenda,” he says via e-mail. “Because data is often scarce, and because IHME produces reams of it for the parts of the world where it is the scarcest, there is an enormous temptation to use their estimates as the gold standard. This is increasingly so as they have gained in prominence and visibility, with (often) multiple Lancet (+ sub-journals) publications weekly. IHME has a lot of talented people, and Bill Gates’ support has enabled them to attract even more top talent, but users of that data should be very cautious in deciding what that data can and cannot be used to infer…. And everyone could do better, including IHME and Lancet, with the recognition that highlighting the limits of their data has a cost to them, so they may be reluctant to accept it.”

For its part, the IHME wouldn’t comment on the study, saying it doesn’t police how its estimates are used.

Bendavid’s study could also be seen as circular in its close orbit around the Gates Foundation, which funds the IHME estimates he used and the aid effort he evaluated, the Global Fund to Fight Aids, Tuberculosis, and Malaria, to which Gates has given more than $2 billion.

As a leading medical journal, The Lancet is one of the most important venues for researchers to discuss, debate, and debunk developments in health and medicine. And in his time as its editor, Horton has positioned himself as a public intellectual who isn’t afraid to speak truth to power—or to follow the money when it reveals conflicts of interest.

In a 2003 editorial, The Lancet questioned whether Gates was a “philanthropist or commercial opportunist,” observing that his foundation had announced a $100 million charitable donation to fight HIV in India the day before Microsoft unveiled a $400 million investment expanding its market presence in that country.

Six years later, Horton admonished the Gates Foundation for its growing power in global health, writing, “Sometimes [it] doesn’t value…every voice that wants to contribute to the debate about public health.”

Over the past decade, however, mentions of the Gates Foundation have appeared less frequently in The Lancet’s critical commentaries than in its funding disclosures. In 2010 the foundation gave more than $700,000 to the University of North Carolina and the Mater Medical Research Institute to create content for The Lancet, beginning a trend of funding—$13.5 million to Harvard, Johns Hopkins, the WHO, and others—that has reached dozens of publications.

The Lancet has a particularly close relationship with the IHME, Gates’s signature project in science, and some see perverse incentives driving this relationship. Publishing the institute’s influential estimates has brought attention and esteem to The Lancet, whose “impact factor”—a measure of its relative importance in the scientific literature—doubled over the past decade. The IHME boasts that more than 16,000 scientific studies have cited its work. These citations boost The Lancet’s growing impact factor and have also likely increased subscriptions and advertising revenue for its for-profit publisher, Elsevier.

Horton acknowledges the “very special relationship” The Lancet has with the IHME but defends it as good science. “The reason why it’s very important to publish these papers in our journal is because it holds IHME accountable,” he says in an interview. “If you publish a paper in The Lancet…scientists can look at that paper and say, ‘OK, do I think this is high-quality science? Do I agree with what they said? And do I agree with their interpretation?’ And they can write letters to us, and they can say, ‘Actually we strongly disagree with X, Y, and Z,’ and we will publish those letters, and that holds Chris Murray and IHME accountable for their work,” Horton said. “This is the way the science is done. It’s self-corrective…. You publish the best work you can, then you see who over time falls out of view.”

The Lancet also publishes estimates from other research institutes, Horton notes, creating a robust debate that has historically been missing in global health, including during the WHO’s reign as the leading purveyor of estimates. (The WHO and the IHME produced competing estimates for years but recently agreed to work together.)

Yet scholars cite a number of irregularities in The Lancet’s oversight of the IHME, including its peer review process—in which scientists scrutinize one another’s work before publication.

“You can’t go through the 5,000 pages of tables and figures for The Lancet and say, ‘I’ve noticed a mistake on page 3,556, line 25,’” said Peter Byass, referring to the IHME’s very long and complex papers. “That’s just not going to happen.” Nevertheless, The Lancet publishes 5000-page appendices that are labeled as having been peer reviewed.

Patrick Gerland, a demographer in the United Nations’ population division, says The Lancet compounds the problem by sometimes publishing IHME studies on a fast track. “At the end of the day, [the peer-review process] pretends to be a validation of something it is not,” he adds.

Horton says he believes reviewers have “ample time” and notes that the IHME’s studies go through extensive revisions. He also points to another robust accountability measure: the vast network of scientific collaborators who check the institute’s work. “This is not a little cabal of American academics at one university funded by the Gates Foundation,” he said.

Indeed, the IHME boasted in an e-mail of having “more than 4,300 collaborators from 147 countries and territories,” although it refused to disclose their names.

Colin Mathers, echoing many other scholars, calls the network “window dressing,” saying that many scientists join simply because doing so allows them to become coauthors on the IHME’s Lancet studies—a feather in any scholar’s cap. “You could sign on as a collaborator to IHME, and they’ll send out draft papers to you,” he explains. “You may or may not read them, you may or may not comment on them, but your name gets to be [included as] an author in the end, and IHME can then claim there are 1,200 people from [various] countries who have reviewed all the results. I don’t know how The Lancet squares that…with the standard scientific authorship requirements.”

Standard ethical guidelines in science limit authorship to those researchers who make specific, meaningful contributions. Listing hundreds of authors, as the IHME does in The Lancet and sometimes in other journals, is extremely uncommon. (The Lancet did not respond to questions about authorship.)

“When you have this many people and their roles are ill-defined, you’re losing the accountability and responsibility for it,” says David Resnik, a bioethicist at the National Institutes of Health. “It’s not really telling [you] who did what or who did more.”

The IHME insists that it complies with proper authorship guidelines, but days before offering this defense—and shortly after The Nation raised questions—it issued an internal memo announcing new guidelines and a strict new auditing process.

Perhaps the most striking irregularity in The Lancet’s relationship with the IHME concerns the $100,000 Roux Prize, which Horton accepted in 2019—and which prompted alarm even within the institute.

“I would like to understand what the long term thought process was in awarding Horton the prize,” one IHME employee said in an internal e-mail, “and how we are expected to defend that decision as staff when criticized for buying our way into the Lancet rather than being published based on the merit of our work.”

Horton argues that the award came from the IHME’s board of directors, which he views as independent of the institute. He notes that IHME board member Dave Roux, a cofounder of the private equity firm SilverLake, funds the award.

“I see it as completely separate, personally,” Horton says.

So does the IHME, which offered its own parsing: “IHME does not award the Roux Prize; it is the custodian of the prize.”

Before becoming the IHME’s director in 2007, Murray worked at the WHO, from 1998 to 2003. But he subsequently became one of its fiercest critics, arguing that its work is compromised by political influence from member states, which sometimes have an interest in presenting their countries’ health as better than it really is.

“For health evidence to be useful, it also must be credible, generated by a scientific process unimpeded by political, financial, or other types of interference,” states the IHME’s website, which cites impartiality as one of the institute’s five guiding principles.

It’s a bold proclamation, given the political and financial interests surrounding the IHME’s work—from the Gates Foundation, one of the most powerful actors in global health, to Big Pharma and Big Oil, which have been quietly pouring millions of dollars into the institute for years.

An internal memo that Murray sent in early 2018 announced the creation of the IHME’s “client services unit” and added, “This development has the strong support of IHME’s Board, of the Bill and Melinda Gates Foundation and of the University, all of which believe that engagement with the private sector will increase the global impact and reach of our work, as this sector has great influence over health.”

Murray went on to sign a three-year, $1.5 million deal between the IHME and Chevron, one of the world’s largest fossil fuel companies, “to establish the Health Measurements Strategy for Global Corporations Program.” The same month, he published a paper in The Lancet Planetary Health announcing a new initiative looking at the effects of pollution and climate change—two areas where Chevron has had huge and negative effects on human health. Murray made no disclosures about his ties to Chevron in this or subsequent papers, though most academic journals have transparency requirements regarding financial conflicts of interest.

Since 2014, the IHME has contracted extensively with pharmaceutical companies—Merck, Pfizer, Novo Nordisk, Gilead, GlaxoSmithKline, Novartis, and others—that research and develop treatments for the diseases the IHME tracks around the globe, including Covid-19. It does not appear to have ever disclosed these ties in scholarly work or in the many media appearances that Murray has made during the pandemic.

Yet by far the largest influence over the IHME’s work comes from the Gates Foundation. A spokesperson there told The Nation that the foundation has given $613 million to support the IHME through late 2019 and an additional $210 million to construct a building to house the institute and other global health researchers. These donations account for the large majority of the IHME’s funding, even though it stresses its diverse roster of sponsors, including the National Institutes of Health, which public records suggest has given it around $10 million in grants.

A public records request revealed one funding agreement in which the Gates Foundation was given approval over new hires for the IHME’s executive leadership team as well as oversight of press releases related to the work it funds (which is to say, most of the institute’s research).

Gates’s influence over the IHME can also be seen in a map of Seattle. Though the institute is part of the University of Washington, it was until very recently far off campus, a few blocks from the Gates Foundation’s headquarters. (According to Epic Measures, the IHME’s first temporary offices were in the foundation’s former headquarters.) One former IHME employee, asking to speak anonymously, says the foundation regularly requests bespoke charts and graphs for Gates’s presentations and conferences, prompting entire teams of IHME researchers to drop everything else

“It really did feel like we were consultants for the Gates Foundation, and the scientific methods we used were often in service of getting the results we wanted…or the story he [Murray] thought the Gates Foundation wanted,” the source continues. “There are thousands of hours cumulatively spent each year just on one-off requests from Bill Gates that trickle through from the Gates Foundation.”

The IHME also publishes favorable research about its sponsor, estimating that the Gates Foundation has saved 1.5 million children through its vaccination efforts and helped prevent more than 100,178 HIV infections in India through another charitable program.

The foundation, in turn, uses its bully pulpit to elevate the IHME’s work. Gates’s annual splashy Goalkeepers event, for example, features keynote speakers like Barack Obama and leans on IHME estimates to chart progress in global health and to lobby for the next places where aid groups and governments should spend their money.

Marlee Tichenor of the University of Edinburgh sees a fundamental conflict of interest in the Gates Foundation’s role as a leading “financier of global health initiatives” while controlling the “means by which we judge whether they succeed or not.” It’s a criticism that applies more broadly to all of the foundation’s work in global health, given that it funds many of the researchers, academic journals, and think tanks best positioned to evaluate its work—or to criticize its influence.

“There is not a single organization working in global health that is not somehow related—most likely financially related—to the Gates Foundation,” says Adam Moe Fejerskov of the Danish Institute for International Studies. “And, of course, that is a huge problem, because it makes us ask who is setting the agenda in terms of what is being researched and what is not being researched.”

This summer, The Lancet published an IHME study projecting that the human population would peak far earlier (2064) and at a lower level (9.73 billion) than the prevailing estimates from the United Nations had indicated. Released with an elaborate press package—including a video endorsement from Horton—the study enjoyed widespread news coverage highlighting some of its more sensational findings, such as Horton’s remark that Nigeria will become a geopolitical rival of the United States over the next century.

More than 170 scholars and advocates signed a letter of complaint to The Lancet (thus far unpublished) citing contradictions and questionable assumptions in the paper, which the signatories say reduced complex demographic issues to simplistic terms. Stuart Gietel-Basten, a demographer at the Hong Kong University of Science and Technology, observes that even if the letter eventually appears in print—months after the initial Lancet publication—it’s unlikely to have much of an impact. He offers this prediction with the world-weary fatalism not uncommon among scholars who have faced off with the IHME.

“There is this issue of it being almost too big to fail. You’ve got this big journal, lots of people involved,” Gietel-Basten says. “I don’t want to say it’s a gravy train, but it’s a big thing. It’s got so many people involved in it. But you think about it as, ‘How would we express our concerns? What are the mechanisms by which we can express our concerns?’”

Jeremy Shiffman, a political scientist at Johns Hopkins University, coauthored a commentary in The Lancet this spring that examined the “uneven playing field” surrounding the IHME and found that “many valid concerns of critics are being overlooked because metrics proponents—including the Bill & Melinda Gates Foundation, the [IHME], and The Lancet—wield far more power than critics.”

Even so, criticism of the institute is long-standing and well understood by its supporters, including the University of Washington and the Gates Foundation. In 2012 the two commissioned an external IHME evaluation, which found that the institute is “not consistent in when and to whom it shares methods, data sources, authorship and this is perceived as not being transparent” and that “the extensive resources of IHME relative to other institutions have created an unhealthy imbalance in the field.” The evaluators called on the Gates Foundation, as the IHME’s primary funder, to improve its accountability and transparency. The foundation would not comment on if or how it had done so.

Peter Byass of Umeå University told The Nation that if the IHME were publicly funded, it would have to operate in a far more open and accountable manner. “If you’ve got enough billions, you can set up a foundation, and you can make the rules entirely as you wish,” he said. The Gates Foundation “is both the rule maker and the rule keeper, in terms of how they choose to scrutinize grant holders. That’s their privilege, because that’s where they are in the marketplace.”