Richard Horton published “The Case Against Global Health” in May 2014 as a summary of his role in a conference debate held by the Consortium of Universities for Global Health, in Washington DC. He admitted to playing devil’s advocate by supporting the proposition that “global health investments benefit countries of the Global North more than those of the Global South”. Horton concluded that global health had become an apparatus of power, self-interest, and control that denied justice and dignity to billions of people worldwide. In the end, he was, however, pleased that his opponent, Professor Nelson Sewankambo, won the debate.  In this short blog, we explore whether his opponent had indeed the strongest case, and whether the picture has changed over the last few years. If anything, it seems Sewankambo would have an even stronger case now.

Horton argued that the North-South global relationship is not a mutually beneficial partnership, but rather one where the Global North exploits opportunities for publications and accreditation within the Global South. Many of these partnerships are criticized for being ‘semi-colonial’ in nature, as the control and benefits continue to accrue in the North. However, there are plenty of successful North-South relationships that show otherwise. For example,  The AIDS Support Organization (TASO) in Uganda had a Northern research partner conduct workshops for selected TASO staff on how to write scientific abstracts. This led to several members earning scholarships and grants after having the opportunity to present their work. Mutually beneficial partnerships are also evident from papers that outline the most important factors in creating successful North-South relationships. These are based on interviews with individuals who are involved in ongoing, successful North-South partnerships that Horton argued were obsolete. Since his article in 2014, this trend has gained further momentum. A recent analysis of health policy and systems research has shown that lower middle-income countries have made progress towards global connectivity through collaborations with various institutions and regions. Therefore, it is not surprising to also see efforts to increase leadership in the South. Just last week, for example, the Infectious Disease Data Observatory (IDDO) was seeking African leadership in their new initiative to combat Ebola outbreaks. Although it may be a slow process, it is obvious that mutually beneficial relationships exist and that there is increasingly an emphasis on long term improvements and institutional capacity building within the South.

After Horton portrayed global health research as a one-sided endeavor favoring the Global North, he suggested a loss of accountability was precipitating the problem. Equal sharing of resources has been a challenge in North-South global health research partnerships. Additionally, the ethical review mechanisms of conducted research are not universal between the Global North and the Global South. Both of these issues have previously been recognized, and it is therefore inaccurate to suggest that they have gone (completely) unaddressed. Networks such as the the Consortium of Universities for Global Health have promoted global data sharing for worldwide research. Well defined partnerships and a dialogue continuum between policy makers and community leaders have been recognized as tools to improve their collaborative efforts. The World Medical Association and WHO have adopted standards to guide biomedical research in global health which have proven to be significant, especially in countries without ethical committees to govern research. These examples combat the issues Horton claims have been ignored, even if there’s arguably still plenty of room for progress.

Horton also surfaced an idea that global health’s efforts are being undermined through its ‘toxic alliances’ with companies of questionable integrity. He specifically mentioned Coca Cola’s role and its contribution to the ‘global epidemic of chronic diseases’. Horton may be correct about the soft drink that the company markets, and the rather cozy relationship of Coca Cola with the Global Fund, but he failed to include the information regarding their positive contributions to global health. In addition to being a past sponsor of Global Citizen, Coca Cola has provided millions of dollars in funding/resources to supply medicine and clean water to remote areas of the globe. Their efforts directly contribute to (at least some of) the United Nation’s sustainable development goals. This is not a testament to the authenticity of Coca Cola’s motivations, and it’s obvious that you better not drink much coke if you want to stay healthy in the long run, but the complexity of their role in global health needs to be acknowledged. The relationship between global health actors and Big Soda needs constant scrutiny, but the picture is perhaps less black & white than Horton describes it. Also, some global health actors (like WHO) seem to keep some more distance from Coca Cola and other ‘commercial determinants of (ill-)health’ than others (the Global Fund notably).

Horton deplored some of the ‘new friends of global health’, companies like Chevron, Vale and Coca Cola, all partners of the Global Fund. There he has a point. With FENSA – WHO’s Framework of Engagement with non-state actors – finally in place, funding of WHO might also become slightly more “complicated” than in the past.  To meet annual budget shortages the WHO has already been forced to rely more on voluntary donations from other entities, such as philanthropic projects, to achieve its goals. In 2017, the Bill and Melinda Gates Foundation (BMGF) was recognized for their regular contributions to the WHO by receiving official endorsement as a non-state actor. If (more) reliance on non-state actors becomes a paradigm shift for the WHO, it will be increasingly important to give due diligence in the evaluation of these relationships and address concerns of civil society.  This will also have to be monitored continuously as WHO leadership evolves and newly elected officials in WHO member states assume power.

All in all, Horton addressed legitimate concerns and attempted to shine light on several weaknesses that exist within global health; however, the outlook is not as dire as projected. Global health is constantly evolving, gaining a larger audience each year. With the help of organizations such as the WHO and improving relationships between the North and South, it will continue to make advancements in healthcare across the globe.

Colt (colt.crymes@uqconnect.edu.au) and Tyler (t.baker@uqconnect.edu.au)are MD students in the University of Queensland-Ochsner Medical Program, a proud partnership between UQ (Brisbane, Australia) and the Ochsner Health System (New Orleans, LA, United States).