Bill Gates started his charity as a business strategy to combat his company's bad reputation, but thank God he did

The Rich, Sometimes, Are the Best Medicine -- by DONALD G. McNEIL Jr.

THE Bill and Melinda Gates Foundation recently announced that it would give $450 million toward eclectic inventions to aid the world's poor: more nutritious bananas, easier-to-use vaccines and chemicals that leave mosquitoes unable to smell their would-be victims, for example.

In the six years since its creation, the foundation has poured money into efforts to make vaccines for AIDS and malaria and paid for clinical trials of experimental tuberculosis drugs. As philanthropists, the Gateses have also become activists; they spent several days last week in India and Bangladesh drawing attention to projects they had helped.

Indeed, the Gates Foundation money - all $29 billion - and its ability to attract publicity has landed like a bomb in the conservative arena of global health, adding urgency and a sense of possibility to the challenge of solving the world's health problems.

But the Gateses were not the first to see that money could sometimes move mountains in public health. They are following in the footsteps of the industrial giants of the late-19th century, said Dr. Howard Markel, director of the University of Michigan's Center for the History of Medicine.

These men also brought their fortunes to bear on social problems, and believed that they could succeed in philanthropy in much the way they had succeeded in business.

The donors of the robber-baron years started their philanthropy while still alive - a novel idea then. Andrew Carnegie, for example, gave away hundreds of millions of dollars to build libraries long before his death.

The largest bequest in American history prior to Carnegie's time was from Johns Hopkins, a Baltimore merchant, who left $7 million to found the eponymous university and hospital in 1873 - after he died.

But the closest parallel to the Gates approach to philanthropy is that of John D. Rockefeller, said Dr. Markel and Robert E. Kohler, a medical historian from the University of Pennsylvania.

Rockefeller built Standard Oil. Like Mr. Gates, he was the richest man of his time, and like him he was reviled as a greedy monopolist.

Rockefeller, like Mr. Gates, hired a professional to run his charities. And he, like Mr. Gates, used his money systematically to identify and attack important public health problems.

Rockefeller hired Frederick T. Gates, a former minister (and no relation to the Microsoft co-founder) as his philanthropic executive. Mr. Gates read an 1892 medical textbook that convinced him that diseases had causes, like germs and worms, that could be fought by science - not a universally accepted idea at the time.

The most famous health campaign he started with Rockefeller money was the drive, begun in 1907, to rid the rural American South of hookworm. Called "the germ of laziness" because it caused anemia and made victims lethargic and dull-witted, hookworm afflicted up to a third of Southerners.

The foundation set up clinics that administered purgatives and - because the worm is shed in feces and picked up by bare feet - taught people to dig deep privies and wear shoes. More Rockefeller money underwrote some of the 20th century's great public health drives, many using research done at Rockefeller University. Clinics were built in 50 other countries to eliminate hookworm worldwide. The effort failed because the worm can survive in soil and reinfect people; but the problem diminished, especially in parts of Asia.

In 1915, the foundation declared war on yellow fever; by 1932, scientists had realized that monkeys were also a reservoir for the virus, making eradication impossible, but by then Rockefeller scientists had invented the vaccine still used today.

Patty Stonesifer, chief executive of the Gates foundation, said she and William H. Gates Sr., the father of the software pioneer and co-chair of the foundation, consider the Rockefeller campaigns especially instructive. "We stood on their shoulders," she said.

Ms. Stonesifer also said that several initiatives that the Gates Foundation is now identified with - having poured hundreds of millions of dollars into them - were actually started with Rockefeller money. They include the International AIDS Vaccine Initiative, the Global Alliance for TB Drug Development, the International Partnership for Microbicides and the Medicines for Malaria Venture.

The Gates Foundation was also influenced by Irene Diamond, who, with her husband, Aaron, financed early AIDS research.

Ms. Stonesifer, who met Mrs. Diamond before her death in 2003, said she was attracted to her boldness. "She was very early on trying to get condoms distributed in New York schools to prevent AIDS," Ms. Stonesifer said. (Mrs. Diamond enjoyed being known in her 90's as the Condom Queen.)

Not every assault on a grim pestilence is led by one filthy-rich field marshal. The long drive to eradicate polio - which has reduced the incidence of the disease by 99 percent since the 1980's - has been handled by a partnership of governments, dedicated but relatively anonymous executives, and a network of hundreds of local American Rotary Clubs, which adopted the disease as their special mission in 1979.

Rotarians, however, are unlikely to generate broad public awareness of previously ignored health problems, nor do they evince the kind of impatience with the pace of progress that is second nature to wealthy entrepreneurs.

As Ms. Stonesifer said admiringly of the Rockefeller campaign against hookworm: "A lot of people would say, 'you've got to reduce poverty to get rid of hookworm.' But the Rockefellers said, 'You don't need a 20-year intervention. You can use shoes.' "

Finally, Rockefeller's spending on public health brought him a new kind of fame, arguably a more positive one than came from becoming rich.