• Public policy

‘I can buy the Salvation Army. Andrew Undershaft, weapons manufacturer.’

From the play Major Barbara by George Bernard Shaw

Over 100 years ago, George Bernard Shaw, speaking through his protagonists, weapons manufacturer Andrew Undershaft and Undershaft's daughter Salvation Army Major Barbara, explored the uneasy relationship that existed, and exists still, between ill-gotten gains and the public good.1 Now, a century later, a similar uneasy relationship exists. But this time it is not cannons versus religion, but tobacco versus public health. Nor is it biting satire sprung from the imagination of a playwright. It is real-life drama now unfolding in Latin America.

Authors Burch, Wander and Collin2 are to be congratulated for lifting the corporate veil to reveal at least some of the workings of the enterprises and philanthropy of one of the world's richest men: Carlos Slim Hélu of Mexico. He is also one of the world's big tobacco barons: his principal fortune was made in tobacco, his other successful enterprises were fuelled by tobacco money, and tobacco money is at the root of his health philanthropy. Carlos Slim owns 20% of the Mexican tobacco company CIGATAM, a Philip Morris subsidiary and he has profited handsomely from other investments in Philip Morris, where he now sits on the Board of Directors.

Bluntly put, Carlos Slim has used his telecommunications and investment enterprises to funnel tobacco money through to his philanthropic health institute, Instituto Carlos Slim de la Salud (ICSS). The stated mission of this charity is to improve health in Caribbean and Latin American region, where the health consequences of tobacco use rank among the most serious health problems. Yet, as documented by Burch, Wander and Collin, the tobacco control measures undertaken by ICSS are weak and of the type favoured by tobacco companies, as in this case they probably are. As a Director of Philip Morris, Carlos Slim is duty bound to advance the interests of his company and its shareholders.3 By undertaking health philanthropy that earns praise for its work on malaria, dengue, nutrition and vaccination while simultaneously being ineffective at tobacco control, Carlos Slim succeeds admirably at advancing the interests of Philip Morris and its shareholders.

But the problem grows ever larger. Every person, government and institution that associates itself with ICSS or benefits from its largesse is caught up in a tobacco industry ‘whitewash’ and is complicit with industry interference in public health. Governments which are party to the Framework Convention on Tobacco Control and which accept technical and financial assistance from ICSS are acting against the advice given to parties on how to prevent tobacco industry interference.46.4 Parties should not allow acceptance by any branch of government or the public sector of political, social, financial, educational, community or other contributions from the tobacco industry or from those working to further its interests, except for compensations due to legal settlements or mandated by law or legally binding and enforceable agreements.

Carlos Slim's foundation has recruited the government of Spain and the Bill and Melinda Gates Foundation as partners in Salud Mexoamerica 2015, a project to reduce health inequalities affecting the poorest populations in Central America and southern Mexico,5 even though the use of tobacco-derived funds puts all eight of the beneficiary countries in conflict with the FCTC guideline cited above, and leaves Spain vulnerable to having contravened another treaty guideline:6.2 Parties should not endorse, support, form partnerships with or participate in activities of the tobacco industry described as socially responsible.

The Bill and Melinda Gates Foundation is not a country and therefore not subject to the provisions of the FCTC. Nevertheless, its partnership with the ICSS places the countries and NGOs with whom it works on tobacco control in a very awkward position. Simon Chapman has called for the Gates Foundation to be consistent in how it manages conflict of interest with tobacco companies, and to cut its ties to the ICSS just as it cut its ties to the Canadian International Development Research Centre (IDRC) over an earlier issue of conflict of interest.6 In the case of IDRC, the Gates Foundations acted within just a few weeks of the conflict of interest coming to light.7 However, 2 months later, when it knew or ought to have known full well of Carlos Slim's connections to the tobacco industry, the Foundation announced its new collaboration with ICSS and Carlos Slim on 14 June 2010. If the Gates Foundation has not yet severed ties with the Instituto Carlos Slim de la Salud, it seems unlikely that it ever will.

What is to be done? Should all Latin American and Caribbean countries turn their backs on much-needed financial support for health programming? Should the government of Spain withdraw its support from the ICSS, thereby reducing Spanish support for health improvement in less-developed Hispanic countries? Should governments and NGOs around the world refuse support for tobacco control from the Bill and Melinda Gates Foundation because of the Gates Foundation's association with Carlos Slim? While these solutions may well resolve the questions of conflict of interest and appearance of conflict of interest, they would not necessarily advance tobacco control or public health in general.

An immediate solution may result if Carlos Slim were challenged to decide whether he is ultimately a health philanthropist or a tobacco company executive. He cannot be both. Should he decide to become a true health philanthropist, he would sell all his tobacco company assets on the open market (not to his friends and family) and sever all his formal and informal ties to the tobacco industry and all his other businesses. He would engage himself more fully in his philanthropic work and embrace full FCTC implementation in Latin America and the Caribbean as a high priority and integral part of ICSS activities. Whatever Carlos Slim's response, a long-term solution is needed to the thorny problem of conflict of interest for philanthropic giving in the entire sector of health, social and economic development. The problem is made all the more urgent by the newfound willingness of the world's billionaires to engage in large-scale philanthropy.8 What is needed is a sector-wide set of rules negotiated by and for all interested parties in the system, philanthropists and recipient governmental and non-governmental organisations alike.

Burch, Wander and Collin suggest that WHO's efforts to date in this regard leave a need that is ‘insufficiently addressed’.2 This is perhaps not surprising since WHO's primary focus is its Member States. To date, it has served the concerns of large philanthropies and NGOs less well. We now urgently need a tripartite process to bring governments, philanthropists and civil society together to develop guidelines that comprehensively address funding for health, social and economic development. Effective philanthropy for international development requires a sound rules-based system for managing potential conflict of interest. The saga of Carlos Slim's uneasy money recounted in these pages tells us that these rules are needed sooner rather than later.