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There is a real risk that billions of dollars from the Gateses, no matter how leveraged, will not be nearly enough to reverse the slip-sliding decline in health in poor countries. There is an equally great risk that they will waste billions of dollars trying. To hedge their bets, they invest not in one malaria treatment, for example, but in many. And they try to stay flexible. After they were criticized for investing too heavily in new inventions, they put more money into distributing fixes that already exist. They also don't scare easily: when it was discovered that one kind of spermicide actually increased transmission of HIV, the foundation intentionally pumped millions into the study of other similar products to keep the momentum going.
But it may be decades before they know if they have made the right choices. Foege, the former CDC director, compares what is happening in science today to the Middle Ages. "When you could finally bring the architects, the builders and the artisans together, you could finally build a cathedral," he says. "But the artisans working on the cathedrals knew they would never live to see them. And you can't see any evidence that their work suffered because of that."
Perhaps one reason so many cathedrals got built in the Middle Ages is that it is easier to raise a great edifice when there is a benevolent potentate in charge--with a long view and obscene sums of money. Today we have Bill Gates, hands stuffed in his pockets, squinting up at the framework of his unfinished cathedral.