I don’t know much about Richard Horton, the editor of The Lancet (one of the world’s top medical journals); but what is clear is that he’s uber-woke. He was, for example, responsible for this controversial cover:
There have been other political covers, other woke editorials by Horton, and a fair few woke articles that, in saner times, wouldn’t be published in The Lancet. But once someone like Horton is handed his bully pulpit (and is presumably supported by “allies”), he can go hog wild with proselytizing and virtue flaunting. Yes, he may mean well, but his latest op-ed is so over the top, so full of the drive to reform everything in the world, and so unhinged in its tone, that there was a reason I once called The Lancet “the medical Scientific American.”
Here’s my own brief summary of Horton’s op-ed that you can (and should) read by clicking the screenshot below. These are my words:
“Global health” is a manifestation of colonialism and white supremacy, an exclusive and structurally racist club that must be decolonized and dismantled. We shouldn’t waste our time pursuing the traditional version of this practice, which won’t be decolonized until the entire world is fixed: rid of war, racism, unequal wealth, climate skepticism, and all other manifestations of right-wing politics.”
But what is “global health”? Well, I use the Lancet’s own definition:
. . . . we offer the following definition: global health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasises transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care.
This, then, involves not just improving health of people throughout the world, but achieving “equity in health,” which to me means that everyone gets equal opportunities to access health care. Well, that seems fine: equal opportunity for everyone is what I want. Note, however, that they emphasize “equity in health,” not simple “equity,” which means representation of all underserved groups of people in professions—presumably healthcare here—in proportion to the groups’ occurrence in the population. But, as you see below, “equity in health” has been reinterpreted by Horton, half intoxicated with wokeness, into simple equity in everything, which leads him to not only indict “global health” for racism and colonialism, but also to call for sweeping reforms of the entire planet. Yes, most of these reforms would be nice, but right now there are sick people to cure, and we can’t wait centuries until everyone has more comparable incomes before we start making people well.
Click to read:
Seriously, Horton has gone the Scientific American route. I don’t mind him noting the underlying cause of health disparities, but here he picks up a megaphone, mounts a soapbox, and shouts his own views to the world. I will quote him so that you’ll see that I’m not making this up. I’ve put the more interesting claims in bold:
Global health has become fashionably unfashionable. The case against global health is strong. Global health is the invention of a largely white and wealthy elite residing in high-income, English-language speaking countries. The discipline claims to be concerned about the health of people living in low-income and middle-income settings. But the resources—human, infrastructural, and financial—underpinning global health are mostly concentrated in those countries already replete with power and money. “Helicopter” research is not uncommon. The contribution of scientists and research funders to sustainable advances in health care in the countries of their alleged concern is minimal. More often, the relationship between western medical science and the countries they work in is extractive. Global health institutions are mostly led by western-educated men. Global health agencies are only superficially member-state organisations. In truth, influence lies with those nations providing the greatest resources. Global health has enabled public health schools and university departments to continue to enrich themselves through exorbitant student fees and generous research grants. Global health journals are no better. Most are creatures of western medical publishing houses, even those that proclaim radical open access histories. The unearned privileges of a few suppress the justified demands of the many. It is hard to avoid the conclusion that global health is little more than an exclusive club, disguising its colonial origins and practices in the stirring language of equity and justice.
That’s a big passel of accusations. (He doesn’t note that modern science is also largely the invention of a “white and wealthy elite”.) First , I take issue with his claim that the desire to give everyone equal access to health care is the product of a “white and wealthy elite”, whose faux concern for sick people throughout the world really masks a desire to enrich themselves and their “colonialist” countries. Could it be that the powerful and rich countries like Britain and the U.S. (once colonialist, but no longer) simply had the resources and the moral wherewithal to do something about global health?
By the way, I happen to know a few people in global health, and I detect no whiff of colonialism about them, but rather a dogged determination to give medical care to people in poor countries. And believe me, they have not gotten rich doing so. Those are, of course, anecdotes, but Horton gives no data at all.
But you can see where he’s going. He wants global health “decolonized,” which presumably means that the initiatives of rich, white, colonialist countries would give way to those of poorer countries. But right now that’s not possible—at least not without the help and funding from wealtheir nations. I also note that to do so we must solve “inequities,” and by that he doesn’t mean just healthcare inequities, but even inequities in everything, including journal fees, which have already been tackled.
The view that global health is a colonial project underlies the call for decolonisation. As Franziska Hommes and colleagues wrote in The Lancet Global Health in 2021, the goal of decolonisation must be “to critically reflect on [global health’s] history, identify hierarchies and culturally Eurocentric conceptions, and overcome the global inequities that such structures perpetuate”. The democratic promise of global health to be an inclusive enterprise has been broken. Some critics argue that global health can never solve inequity. Some go further and suggest that global health is structurally racist. It is hard to disagree with these conclusions. Although global health journals might mean well, the operation of waiver policies for article processing charges has created a culture of humiliation for scientists who cannot afford western journal open access fees. Journals have worsened Northern ventriloquism, where scientists from lower-income settings feel forced to adhere to high-income norms and standards to be permitted to publish in their pages. In Global Health in Practice, Olusoji Adeyi offers a compelling analysis of how imperialism and colonialism became the “founding pillars” of global health. And his observation that “The din of protest against colonialism in global health is getting louder and it has merit” should provoke those of us who work in global health to pause. For Adeyi is surely right that “the Global North decides the narrative and assumes the omniscience to tell the Global South what the latter needs, when it can have it, how to do it, and on whose terms it must be done”.
But science journals, as Horton admits, have already waived publication fees for scientists and doctors from poor countries. Yet even in that gesture Horton finds sin, as fee waivers have created a “cultural of humiliation.” Okay, Dr. Horton, what’s the alternative? If there are to be publication fees, should we eliminate the “humiliation” by hitting authors from poor countries with those huge (and, to my mind, exorbitant) charges? Only a Pecksniff would find in an attempt to achieve equity yet another form of inequity!
And what are the “high-income norms and standards” to which those from poorer countries need not adhere for publication? Does he mean that we should give up standards of merit when refereeing papers from that group? Apparently! Let us lower the bar for papers coming from scientists in underserved countries. Perhaps we shouldn’t require them to have control groups, or use statistics instead of “lived experience”?
Well, I might as well cite the the rest of Horton’s short article. At the end the editor seems to lose it, calling for impossible (though desirable) reforms that must replace the effort we put into global health care. What he means is that we must get rid of right-wingers—the true opponents of global health:
When I was a medical student, I remember those attached to various causes arguing with passion among and against ourselves, viewing one part of our group as betraying the real truth that we were seeking to defend. Those on the progressive wing of politics are supremely good at introspective annihilation. And that same process of internal obliteration is now unfolding in global health. While we identify enemies among ourselves, we miss the larger story of just who our opponents really are—those trying to destroy the conditions for achieving the right to health, equity, liberty, and social justice. For the real enemies of the values we stand for do not sit within the ranks of global health. They are to be found in governments that instinctively mistrust—and who wish to undermine and defund—global organisations. They will be found among those who demonise refugees. They are the climate sceptics, anti-vaxxers, and purveyors of scientific misinformation. They are those who attack the redistribution of wealth, those who believe that war brings peace, and those who defend racism under the guise of patriotism. Global health practitioners should certainly engage in robust discussions about the meaning of their discipline. But they should be clear about who our struggle is really against. It is not global health. Instead, we must work harder together to create a new political frontier and forge a new collective against the true enemies of health.
This has very little to do with making people in poor countries better, for it is a political and ideological program to which he’s calling The Lancet’s readers. (Note the language of war: “enemies”.) High-sounding words indeed, and some of them I agree with (who could help but criticize anti-vaxxers and climate skeptics?). But demonisizing refugees? That is a viable discussion in the U.S. right now, and those who call for limits in immigration can hardly all be tarred with “demonising refugees.” This is hyperbolic, divisive, and inaccurate language. In the end, Horton calls us to follow his own program, for apparently he alone has identified the “true enemies of health.”
Even on her worst days Sci. Am. editor Laura Helmuth has never written stuff like this, even if she believes it. But Horton is turning The Lancet from a medical journal into Mother Jones. I wonder how many doctors adhere to his hyperbole and to his political program. Does he represent the views of British medicine? And what gives the editor of a medical journal the right to spout his personal politics as if it were official doctrine? Yes, if there are root causes of global health inequality that can be pinpointed, he has a right to mention them. But note that he gives no evidence for his claims, and in the end calls for all readers to join him in forming The New Collective.
Curiously, in an earlier editorial opposing Brexit, Horton, citing John Gray, asserts that the idea of progress itself is a “dangerous fallacy”:
Scientists and those educated scientifically are prone to a dangerous fallacy—we believe in progress. The notion that human beings are forever moving forwards towards a better place. It is a noble vision: the accumulation of knowledge, self-correction, the application of science to enhance society’s wellbeing and wealth. The discipline of medical history is almost entirely based on this admiringly Whiggish precept. But it is mistaken, philosophically and historically. John Gray shattered the notion of progress two decades ago in his bitter polemic, Straw Dogs.
No he didn’t. Only a fool could say that progress hasn’t been possible, and medicine is one of the areas where it’s been profound. Since 1900 the average global life expectancy has more than doubled. You’d have to be a fool to say that that is not progress. (I could go on about medical progress, but there’s no point; you all know about it.)
So, in the paragraph above, Horton apparently rejects an overweening characteristic of liberalism and Englightenment values: belief that progress can be made. Yet what is he doing in this entire editorial but laying out a path for progress and “health equity”? Either he is confused or has rejected what he wrote in 2019.
It is Horton’s dead certainty that he alone is right, combined with the accusations that his opponents are rich white colonialist supremacists who promote “global health” not to help others, but to enrich themselves—that combination is the sign of wokeness. He is sure his critics are wrong, and he will brook no discussion.
As usual, I don’t like publicly calling for people’s jobs, for that’s a woke tactic. But I do think that those who publish The Lancet should take a hard look at what Horton is doing to the journal. “Bodies with vaginas” indeed!
Let me finish by saying that Horton and I probably agree on many political issues. But that doesn’t mean that were I to become editor of a science journal, I would splash my views all over its pages.