Does global health really need Richard Horton?

I blame twitter. I’m off it for a couple of years and the day I re-enter the fray, I stumble across “a little twitter spat” (as Politico called it) between the Editor of The Lancet, aka the recently ennobled Richard Horton, and WHO’s Director of Communications Gaby Stern. Coincidentally, and to my great surprise, I was on a panel discussion with Horton a couple of weekends back organised by the student-led Kings Think Tank. I mean, it’s not often you get to sit so close to one of your heroes now, is it? But, much like sex, heroes often fail to live up to expectations. I don’t know whether Horton thinks of himself as a ‘disruptor’ (think Glass Onion), but he is often portrayed as such; he’s certainly opinionated, and he has a platform – a little-known journal called The Lancet – from which to project his views. The print version of those views even has a name – “Offline”. The twitter spat, the panel discussion, and his most recent ‘Offline’ Offline: ACT-A—ça suffit are the subject of this career-ending post – does global health really need Richard Horton? The title is deliberately provocative, and it’s posed as a question because – for me – the jury is still out (just).

So, the twitter spat between Horton and Stern. By way of context, Horton was at a workshop at the absurdly beautiful, romantic, yet deliberately ascetic (some of the accommodation is positively monastic) surroundings of The Rockefeller Foundation Bellagio Centre. Straight out of an E.M.Forster novel, the Bellagio Centre is where anyone who wants to be someone wants to have their workshop. According to Horton, “the goal” of the workshop “was to chart an alternative to the catastrophic failures of the global health system that delivered scandalous inequities during COVID-19”.

Ex-PM of New Zealand Helen Clark, you will recall, co-chaired (with ex-President of Liberia Ellen Johnson Sirleaf) the Independent Panel for Pandemic Preparedness and Response (IPPPR), an ‘independent’ Panel which included two previous heads of the Global Fund to Fight AIDS, TB and Malaria (Mark Dybul and Michel Kazatchkine), a Chairman of the Board of Governors of both the World Bank and the IMF, a consultant to the World Bank, another ex-President, a previous head of MSF, a founder of a youth movement, a couple of academics and an ex-Director of WHO’s PHI/IP. The IPPPR had a clear mandate, as described in WHA73.1 Covid-19 Response.

“to initiate, at the earliest appropriate moment, and in consultation with Member States, a stepwise process of impartial, independent and comprehensive evaluation, including using existing mechanisms, as appropriate, to review experience gained and lessons learned from the WHO coordinated international health response to COVID-19 – including (i) the effectiveness of the mechanisms at WHO’s disposal; (ii) the functioning of the International Health Regulations (2005) and the status of implementation of the relevant recommendations of previous IHR Review Committees; (iii) WHO’s contribution to United Nations-wide efforts; and (iv) the actions of WHO and their timelines pertaining to the COVID-19 pandemic – and to make recommendations to improve capacity for global pandemic prevention, preparedness, and response, including through strengthening, as appropriate, the WHO Health Emergencies Programme” [my emphasis].

WHA73.1 (10)

It’s not possible to provide an “impartial, independent” evaluation. To horribly misapply historian Howard Zinn’s famous remark, “you can’t be neutral on a moving train”. Furthermore, the Panel clearly got a bit carried away with the exercise, imaginatively re-interpreting their mandate from “improving capacity” to “transforming the international system” (p45 of the IPPPR’s Final Report Covid-19: Make it the Last Pandemic). I don’t know about you, but I’m a little uneasy about leaving the transformation of the international system of pandemic preparedness to an ex-PM of New Zealand and an ex-President of Liberia ably supported by a bunch of their friends. As a process, it’s not democratic, it’s not inclusive, it’s not even evidence-based – what is the evidence to support the recommendation for a Global Health Threats Council, for example, or a replenishment mechanism? Heck, how likely is it that a pandemic treaty is going to resolve our problems? Turns out, not likely.

Anyhow, not content with delivering their IPPPR Final Report, Clark et al (we’ll come to the et al in a minute) met in Bellagio a few weeks back with much grander aims – to “chart an alternative” to our current global health system. I’m sorry, but who asked you to do that? It’s one of my absolute pet hates about global health: there’s always a bunch of self-important and self-appointed experts somewhere who want to tell the world how to do things better. Typically, and with no sense of irony, they will point out the failures of ‘the system’ and then, through their practice, make them worse. Global health not inclusive, is it reinforcing power imbalances, is it unaccountable or too elitist? I know, let’s invite some ‘players’ round to The Rockefeller centre in Bellagio and sort things out once and for all – that’ll do it. And then, once we’ve done that, we’ll present our ‘output’ to the world through a prestigious journal (hey, Helen, you did remember to invite Richard, didn’t you?) and kick up an absolute fuss if no-one listens to us, especially if WHO doesn’t listen to us, that commie, neo-fascist, woke, 40s, 50s, 60s, 70s, 80s, 90s, 00s, 10s, 20s throwback of an international so-called ‘health’ Organization.

Which brings us neatly to Gabby Stern’s tweet to Richard Horton.

A fair enough request, don’t you think? “Any more details on the composition of this group charting an alternative to the work being done by the countries of the world?” Stern asks. It’s a perfectly understated but killer tweet. For me at least, Stern’s tweet politely articulates the frustration that so many of us working in global heath feel when we read yet another ‘think piece’ or ‘commission’ or ‘independent working group’ presenting the views of its latest ‘room-with-a-view’ chinwag. If you listen carefully, you can hear our collective sigh ‘oh do fuck off with your new-fangled/mangled framework or 4, 5, 6, 9 point plan or policy recommendations’. In this latest example, Clark et al’s self-styled designers of the new global health architecture are just busting to get their views in first. And like any good evangelist, they most definitely won’t be content with just having an opinion; oh no, they will have to be heard. Horton doesn’t understand this, as is evident in his reply to Stern. Brace yourself.

Apart from his ludicrous but deliberately invidious caricature of WHO, Horton is clearly peeved by Stern’s tweet because he knows that her implied criticism is correct. He has been called out, quite rightly, by someone who knows exactly what is going on. And so, rather than just answer her question, he ‘doth go off on one and protesteth too much’. Stern/WHO discouraging freedom of association and free speech because someone asked for a list of attendees at this niche get together? Get a grip Horton. Clark and Johnson have had their say in the IPPPR Final Report so why would Stern (or WHO Secretariat for that matter) be interested in anything further they might want to add? Job done, they should now, in the words of Johnny Quid “jog on”.

So what to say about Richard Horton? Does global health need him? I know, I know, it’s a ridiculous question. But I remember being on a panel at The British Academy maybe a decade ago discussing power in global health – The Lancet was discussed as an example in the same breath as the BRICS economies! Ten years on and you can see the chilling effect Horton can have in this twitter exchange. Stern is totally right in the implications of her tweet: an unrepresentative cadre of elites busily re-drafting the global health architecture in their own image is not a good look for global health. And yet Stern felt obliged to delete the tweet and offer an apology, as Horton describes in his recent Offline musings.

Horton has a warped understanding of WHO and seems hell bent on undermining it at every opportunity – an odd attitude considering that in 2019, he was awarded the WHO Director-General’s Health Leaders Award for outstanding leadership in global health and is also a recipient of the Roux Prize in recognition of innovation in the application of global health evidence. In our introductions to the audience of students at Kings College the other week, Horton began “the World Health Organisation, or should I say the Bill Gates Organization” and then proceeded to roll out various tired, populist critiques of the Organization, some of which you can re-read in his Offline comment. Here he goes trotting out the following paranoid, baseless pub favourite about WHO world domination:

But WHO seems to be acutely fearful of losing its commanding influence. Instead of welcoming input from two former Heads of Government, WHO’s director of communications publicly questioned the legitimacy of a group gathered to explore how pandemic preparedness could be improved. Although these messages were later deleted and an apology given, if WHO’s communications strategy continues to be so thin-skinned, countries should feel anxious about the agency’s sincerity in consulting about future pandemic prevention measures. WHO gives the no doubt incorrect impression that it is more concerned about itself than those at risk of future epidemics.

Fearful of losing its “commanding influence”? Well, not wishing to spoil the party but here’s a reminder of WHO’s mandate: “In order to achieve its objective, the functions of the Organization shall be: (a) to act as the directing and co-ordinating authority on international health work”. Or if WHO’s Constitution is too old school for you, how about this more recent summary: “The WHO has an indispensable leadership role…and should be the lead health organization in the international system” (Clark and Sirleaf’s IPPPR Final Report, p48). In a display of thin-skinedness, Horton’s ‘how very dare you’ dressing down of Stern for having the temerity to question the legitimacy of his group is just weird, followed by a non sequitur so large (because Stern asked for more details about the attendees at a meeting, member states should question WHO’s consultative function) you could drive a bus through it. You have to wonder what Horton was thinking when he wrote his latest Offline. No you don’t, he was just thinking of himself.

It’s sad to see someone you admire becoming so strident in their opposition to an organization whose work is so vital for international and global health. Concluding his Offline rant, Horton trots out one final salvo across the bows: “WHO gives the no doubt incorrect impression that it is more concerned about itself than those at risk of future epidemics”. It’s not WHO giving that impression, mate, it’s you! In Horton’s head, everything is WHO’s fault, and he is openly hostile to even the suggestion that the failures of the pandemic response could lie at the feet of its member states – “I hear that all the time” he sighed wearily when I put the point to him directly during our panel discussion.

Horton is causing trouble, but not in a good way. He’s abusing his position as Editor of one of the most influential health journals on the planet to deliberately slag off and thereby undermine WHO. If you think that’s ok, fine. Continue to curry favours in the hope of landing yourself a nice fat Chair of whichever Lancet Commission is currently on the go, sycophantically laugh at his increasingly Clarkson-esque gaffs and turn a blind eye to the actual damage he’s doing to the reputation of WHO. If you think it’s not ok, call him out for it.


Published by andrew

Categories: WHO

14 comments on “Does global health really need Richard Horton?”

  1. Thank you for writing what so many people are thinking. This is long overdue. The lancet editor seems to wield the classic “speak truth to power but not to me” style of authoritarianism. Accountability badly needed. Hope it’s possible.

  2. Wikipedia cited RH as “an advocate for the WHO” reference 8, dated 2020.
    Have times changed?

  3. Could it be that the cause of the disastrous decision to publish the Wakely article on autism and vaccination is the same underlying (possibly narcissistic antisocial) tick that leads to a “permanent attack” on the present? It doesn’t have to be ad hominem but in this case, when it is someone who has tremendous power, it is extremely delicious to savor the ridiculous Musk-esque moment. I raise a glass to this delicious blog post. Thank you.

  4. Another privately educated rich white boy pissing people off in global health. What’s the story?

  5. Long overdue commentary that merits more open debate and consideration of leadership in global health in general and where it has got us thus far.

  6. This is just to thank you for this brilliant piece, and to alert you about the need to replace ‘who’s’ with ‘whose’ in “It’s sad to see someone you admire becoming so strident in their opposition to an organization who’s work”

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