It’s a truism that foundations lack accountability – unlike (democratic) governments and companies, which are at least in theory accountable to voters and shareholders. The justification for this – in the eyes of the philanthropy world, and presumably the wider world – is the assumption that foundations probably do quite a lot of good, and almost certainly don’t do any harm.

Judging from many of the contributions to the Alliance special feature on ‘Living with the Gates Foundation’, the emergence of the Bill and Melinda Gates Foundation is beginning to undermine this assumption. It’s not that Gates isn’t doing good, or that it is doing harm; it’s more that the resources the foundation brings to bear are so huge and the scale of its ambitions so great that it clearly could do serious harm – by distorting the fields in which it works. Richard Horton talks of Bill Gates becoming ‘one of the most – if not the most – powerful voice in setting the research agenda’ for global health.