Richard Horton, editor of Lancet, argues in a new essay in The New York Review of Books that the Gates Foundation has chosen “the wrong road” in the fight to reduce, eliminate and perhaps even eradicate the scourge of malaria, which harms the peoples of the sub-Saharan far more than any other region in the world. Horton, himself a physician as well as the leader of a peerless medical journal, skillfully deconstructs the “silver bullet” strategy that Bill and Melinda Gates have directed their foundation (for which I once consulted) to pursue. The limits of pursuing of a vaccine are well known; Horton is only the latest to highlight that controlling the disease depends on the construction of adequate health-care systems in sub-Saharan Africa, not simply the development of effective and affordable vaccines, then delivered in what he calls the “verticalist” manner favored by Gates (which Horton defines as “a top-down effort to parachute in [to Africa] a technology.”
The trouble with Horton’s argument, while intellectually sound, is that “the right road” is not self-evident. If Africans themselves do not generate an effective health-care system, who should? If outside donors are tasked with funding, managing and even implementing health-care for Africans in Africa (say in the manner of Paul Farmer’s bottoms-up approach in Rwanda or the U.S. government’s top-down AIDS-treatment programs throughout the region), then the very same problems of sustainability, cost and dependency arise. Horton wants to encourage an alternative — investing in national health systems — when even such investments, when made and coordinate by outsiders, are themselves “silver bullets” whose efficacy can be undermined by the deficits of social trust, political wealth and path-dependent corrupt arrangements with local health specialists that threaten the various existing malaria-specific campaigns, the Gates effort notably. The missing option in the debate over African health care is the Africans themselves. International experts — whether “verticalists” of the Gates sort or “horizontalists” of the Horton/Lancet species — will inevitably be limited by their failure to account for the importance of African self-determination. Why do the well-meaning people in the international community continue to forget that there is no substitute for Africans creating and sustaining good government and moral societies for themselves and by themselves?
In the struggle for African self-mastery, the international community might play a useful role in forging incentives for their own health-care systems to avoid poaching the very African-raised doctors and nurses who work in Birmingham and Cleveland, London and New York, rather in their own countries of origin. That a medical doctor and vaccine crusader have little or nothing to say about complex patterns of migration by health specialists reared Africa is understandable. We are all limited by partial understandings of the world, borne of mission-orientation. Yet both Horton the horizontalist and Gates the verticalist would do well to display a greater appreciaton for the decisive role that Africans will play in the solution to their own systemic problems. And part of that appreciation may be connecting the health-care deficits in Nigeria with the presence of highly capable Nigerian health-providers in London and Detroit.