Richard Horton, Editor-in-Chief of The Lancet, argued in a 2014 editorial that global health, despite its stated goals to assist the Global South, primarily benefits the Global North.  This controversial take on a seemingly altruistic field has been met with some support, with most citing the net flow of benefits that seems to invariably flow in the direction of the Global North.  While true in effect, Horton’s argument missteps in oversimplifying global health as merely “an instrument for a new era of…imperialism”.  Rather, one must look at the factions vying for influence within Global North nations and the rapidly changing global health governance to understand the full picture.

Horton makes several compelling statements in support of a view of global health as a manifestation of neocolonialism.  He astutely points out that journals, including The Lancet, publish articles about the Global South written predominantly by authors from the Global North, neglecting academic opinion from the areas involved.  From an economic standpoint the North overwhelmingly benefits, as the majority of global health grants are awarded to recipients in the Global North.  Universities from the North similarly profit by expanding their brand when they establish satellite campuses and research centers throughout the South.   Likewise, multinational corporations from the Global North exploit their support of programs in the Global South as a means to whitewash their public image.  Lastly, he argues that intergovernmental organizations hold Global South nations to a double standard when it comes to human rights violations.

From a superficial survey, one could not be faulted in believing, as Horton put it, that global health is “a foreign policy instrument of the hyper-rich”.  However, that approach oversimplifies Global North nations as singular neocolonial actors.  In reality, global health is not a calculated neocolonial model.  Since its inception under the name of Tropical Medicine, via International Health to now Global Health, this endeavor has seen a balance of altruism and a concern for one’s own interests.  The degree to which one is favored over the other has been dependent on those driving policy and funding, as well as the political climate at the time.  It is from these areas that the latest challenges to the field have come.

There has never been ubiquitous support for global health initiatives.  However, in the past few years we have seen an entrenchment by several key Global North nations in nationalist doctrines.  The result has been zealous antagonism to the liberal internationalism that has guided the global health initiatives of the 20^th and 21^st centuries. Consequently, the funding and legislative mechanisms within many Global North nations are raising more obstacles than before for those with global health agendas.  In the US, for example, President Trump’s proposed 2018 fiscal budget sought a reduction in foreign aid by one third. Congress didn’t quite agree, but the trend is clear.   Assertive nationalism (“America First”, …) has created an environment where the success of a global health initiative relies (even more than before) on the degree to which the donor receives a return on their investment.  Horton has highlighted evidence of this in industry, academia, and foreign policy.  Historically, these ulterior motives have been shrouded by messages of support and solidarity for global health challenges. Recently though, we have seen such policies unabashedly broadcasted, such as the reappropriation of funding once committed to Global South nations as the health threat to the donor nation diminishes.  Even still, proponents of global health have fought through the skepticism.

Despite the worrying political trends in several Global North nations, we are still seeing substantial support from the general public in these countries for the funding of global health initiatives and recognition of its importance.  There have been increasing calls within the medical community to grow and formalize global health training among physicians from the Global North. The US has seen a rise in focused post-graduate medical programs, while Australia is pushing to establish some of its own.   Legislatively, resistance to harmful mandates has led to reinstatement of U.S. funding for the United Nations Populations Fund.  In recent years, we’ve also seen a push for more sustainability through a realization of self-determination of the Global South.  Perhaps most importantly, we have seen improved health and quality of life across the Global South due in part to global health efforts over the past fifteen years.  These accomplishments have transcended the political discourse.  Regardless of the attitude of policy drivers, global health as a field continues to thrive.  It has shown that there is support for humanitarian ideals and that opposition of these ideals only succeeds in emboldening its proponents.

Horton is right in arguing that global health has resulted in tremendous investment being recycled back into the Global North.  That is an unfortunate reality and a telling reflection of the times.  However, to call it neocolonialism is an oversimplification and to say it is not worthwhile discounts the victories that have been achieved.  There is hope yet for global health as long as good people from all around continue to fight tooth and nail to improve health on a global scale.