"Viruses are creeping up on us. This one is bad. The next one could be even worse."
Even before the Dominic Cummings debacle, Richard Horton, editor-in-chief of The Lancet, loses his temper when I bring up the government's daily Covid-19 briefings. "It's a betrayal of science," he says. "It's a betrayal of science's responsibility to the public. It's actually an abuse of power." He is incensed by the two scientists standing like altar boys and girls either side of the hapless minister du jour. "They're supposed to be giving independent advice to the government. But they don't give independent advice. They support government. Our scientific community has become the public relations wing of a government that has abjectly failed to respond to this pandemic."
There is, I suggest, another problem — "gotcha" questions asked by the usual cabal of political journalists. Horton groans. "Political reporters don't always know the scientific literature very well. So it's hard, even impossible, for them to ask detailed questions about the science."
Now here we are in the days after the travels of Boris Johnson's chief adviser have come to light and Horton is even angrier. "His self-importance is breathtaking," he says. "When there are parents with children undergoing treatment for cancer who were separated and unable to be together, his inability to show the slightest regret seems beyond conceit.
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"Where was the leadership from the medical establishment? Why are scientific advisers still willing to stand next to politicians every day giving cover to a government whose actions are undermining public health advice? Why are the elected presidents of royal colleges and scientific societies silent? The leadership of British science and medicine is in a collusive affair with government, frightened to disengage and criticise in case they lose their place at the political table."
Horton has form when it comes to anger — his own and that of others. In fact, considering the rows he's got into over the 25 years he has been editing The Lancet, it's a miracle he has hung on to the job for so long. The worst controversy followed his publication of an article in 1998 by Andrew Wakefield that linked the MMR vaccine to autism. This fired up the anti-vaccination movement, which was blamed for worldwide outbreaks of measles. The paper was deeply flawed. Horton did not publish a retraction until 2010, when he admitted the paper had been "utterly false" and said The Lancet had been deceived. His hands, he argues, were tied.
"What I was criticised for was not retracting the paper more quickly," he says. "I understand that frustration. In some ways I would have loved to have retracted the paper sooner. But when allegations of research misconduct are made, there is a due process that must be followed. Irritating though it may be to some, anyone accused of misconduct is still innocent until proven guilty. As soon as the General Medical Council found Andrew Wakefield guilty of misconduct, we retracted his paper. But we had to await their judgment." For his critics, this was not good enough.
Is he sorry for publishing the paper in the first place? "I said years ago that I was sorry for the adverse effects of publishing this study," he says.
There were more controversies. In 2005 Horton was widely criticised for a Lancet article supporting Sir Roy Meadow, who had been charged with giving misleading evidence in the case of Sally Clark, a lawyer wrongly convicted of murdering her two young sons. Clark appealed her life sentence and was released after serving three years, but she never recovered from her experience and died accidentally of alcohol poisoning in 2007.
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In 2006 there was a row over a Lancet article that claimed there were 655,000 Iraqi deaths in the Iraq War (far higher than other estimates, and widely scorned) and at a demo Horton accused Tony Blair of killing children.
"I see my role as being an advocate for the science we publish," says Horton. "So if we publish a paper on civilian mortality through the Iraq War, I see my role as then saying, 'OK, Tony Blair, our government could well be responsible for half a million civilian casualties because of your bombing strategy.' A paper gets submitted. It's good work. We publish it and then I see my role as being an advocate for taking that work into the public sphere."
This is either foolhardy or brave. In the case of the MMR vaccine paper and the Clark case, it was just plain wrong.
Last week The Lancet also had to retract a paper about the drug taken by Donald Trump, hydroxychloroquine. The drug was being tested worldwide following claims that it could prevent or treat Covid. The Lancet paper suggested that, in fact, it caused more deaths among those who had taken it. Around the world, research was suspended.
But the lead author of the paper then admitted the evidence provided for the research by the US company Surgisphere might be flawed. Horton retracted the paper saying: "This is a shocking example of research misconduct in the middle of a global health emergency."
Despite all this, Horton is still standing. More than that, the pandemic has turned the 58-year-old into an international figure.
After a robust appearance on Question Time in March, during which he described the government's procrastination as a "national scandal", he has become a key critic of the orthodoxy, a provocateur and proud defender of independent, medical science.
He was recently on US TV following a Lancet editorial telling Americans to elect a president who cares more about health than politics. Is a medical journal supposed to tell other nations whom to elect? After Covid-19, yes.
"Sovereignty is dead," he says. "The people of Britain have a legitimate interest in who is leading the United States, just as the US population has a legitimate interest in who leads the United Kingdom. We all have a legitimate interest in each other. Because if something goes wrong in the UK and somebody gets on a plane at Heathrow and flies to New York and takes the virus there, it's on us."
There's another thing. A prominent scientist I know who had criticised Horton in the past declined to criticise him now because of the severity of Horton's cancer. His daughter spotted something on his temple and nagged him to get it checked out. The diagnosis was melanoma. It was removed but it has returned twice. He is now on a course of immunotherapy, which is due to finish in July.
"It's a strange feeling because it's fifty-fifty," he says. "It's very strange to wake up in the morning and think that your future is literally the toss of a coin."
Disconcertingly, he looks formidably fit and well sitting under a parasol in his garden in Muswell Hill, north London. He also looks distinctly Norwegian — hollow-cheeked, stern but friendly — probably because he is. He found out only when he was in his forties. His Norwegian father had an affair while working in London and then returned to Scandinavia not knowing his lover was pregnant. "She didn't tell him because she was in another relationship. To cut a long story short, I turn up on his doorstep fortysomething years later and say, 'Hi, Dad.' "
A mother-and-baby home for "fallen women" took his mother in and put baby Richard up for adoption with a family in the West Country. "I was lucky, I had two parents who were wonderful, who brought me up, and then they passed away — and then I discovered my father who was in Norway, which is great. I have a mother and I've had two families."
He grew up in the 1970s, and now his lockdown playlist consists of anything by Joy Division. He recommends one song in particular: Isolation.
It's a bit grim. Having qualified as a doctor and worked at the Royal Free Hospital, his true vocation descended on him when, in 1990, he joined The Lancet. He was writing articles all over the place, and advising the World Health Organisation and the United Nations, before becoming editor-in-chief in 1995. He is an activist by temperament. He supports the environmental group Extinction Rebellion and is on the board of Physicians for Human Rights. Health, he insists, is a political matter.
"To advance health in society means that you have to engage in politics. I do want to use the science we publish for political ends. But rather than just say, 'Well, I'm going to take a Conservative or a Labour or a Liberal Democrat position,' what I'm trying to do is take the position of saying, 'This is the best available science, which is telling us something. Now let's look at the politics of what the implications are.' "
This, he claims, sets him against most of the scientific establishment. "The royal colleges, the Academy of Medical Sciences, the Royal Society — they pull their punches. They want to be at the table of government, they want to be on the inside. And that means that they don't call it as it is. They should be saying, 'We need a programme of renewal of our health system, of our social care system.' Where is the Royal Society and the academy on that?"
He advances this cause with characteristic aggression in his new book, The Covid-19 Catastrophe: What's Gone Wrong and How to Stop It Happening Again. So what did go wrong? Well, Horton is a fan and a friend of the World Health Organisation — he describes Donald Trump's decision to cut funding it in the middle of a pandemic as "a crime against humanity" — but he says it made one big mistake. "They should have called an emergency world health assembly on January 31 to talk about how are we going to approach this pandemic. We need to have a co-ordinated global response to this. They didn't do that. I don't know why they didn't do that, but they didn't do that. And what that meant was that you had 194 countries struggling to mount their own responses, with the chaos that we've seen."
By the end of January we knew what we were dealing with. The genetic sequence of Covid-19 had been passed to the WHO on January 12. It showed that this was not a flu-like bug, it was more like Sars. The Lancet had been uncertain at first, but in the last week of January Horton published five papers setting out the problem and the appropriate responses.
"A new virus, untreatable, filling intensive care, rising mortality, strange pathology not seen before … We need to have testing, we need to have personal protective equipment," he says. "And there's a risk of a global pandemic. It's all in those five papers. But people were still thinking about influenza as the model running through February, when in fact we should have been planning for Sars."
The British government's response in February was, we now know, utterly wrong-headed. They denied they were pursing herd immunity, but it's the only possible interpretation of their soft-touch actions.
"Herd immunity was a perfectly reasonable strategy to follow if you thought it was flu," says Horton. "With flu there's a 0.1% mortality rate. So it's not pleasant, but it's manageable."
Horton thinks the global mortality rate of Covid-19 may be 1%. It may well be much lower in developed countries with sophisticated health systems — "We're now on the downslope" — but in Africa and South America there may be carnage. A 1% world mortality rate would mean deaths in the tens of millions. We may never know — health reporting is wildly inconsistent and often politically controlled.
On top of that there was nothing unexpected about this pandemic. Everybody knew it was going to happen. But nobody seems to have done very much. Horton points out that Exercise Cygnus, a pandemic simulation run by Public Health England in 2016, clearly showed how unprepared we were. "There was a whole series of recommendations about what we needed to do in order to get our act together to respond to a pandemic. In 2016. And now we're in 2020. We didn't do enough."
"I don't put any blame on individuals. There's a system failure. What I've called it is a regime of science policy making. We've got amazing scientists, but somehow in the bringing of those scientists together, in the way that they were advising government, and then in the ministerial response to that, and the structures of Public Health England, NHS England and the chief medical officer's office and so on, the system didn't work. We predicted all of this."
And when, at the end of January, the true nature of the virus was clear to everybody, the British seem to have failed to make the right phone calls.
"China's a weird country in some ways. There are almost 1.4 billion people, but you can almost count on the fingers of one hand the people who are the influential decision-makers in medicine."
Horton reels off a list of Chinese scientists who would have been happy to help — George Gao, Chen Wang, Chen Zhu. So why weren't those calls made?
"I don't know, I don't understand … Maybe there's something about British exceptionalism and maybe there's French and Italian exceptionalism, there's certainly American exceptionalism. We think, 'Well, we've got our own scientists, we trust them, we don't need to go to anybody else.' I think there was also a view that maybe the Chinese don't quite know how to handle this. Can we really trust them anyway? Can we trust the data that's coming out of China? Why else did it take us until March, until we got the data from Italy, to plug it into the Imperial [College London] models? We knew what was happening in January."
What we must now accept, he says, is that pandemics are more likely. "Look at the population growth and the way urbanisation is taking place. It's not just in China. If you go to many cities in emerging middle-income countries you will find these live animal markets. These are incubators for viruses that will leap from animals to humans. Viruses are creeping up on us. Our space for manoeuvre is narrowing. Pandemics are the new normal. We had better understand that. And get used to it."
Several times he repeats the mantra that lies at the heart of his book: "Sovereignty is dead." Covid-19 does what the UN has never managed — it is a diabolical mocker of our frontiers and borders, a fiendish reminder of our common humanity, a perverse peacemaker bringing nations together.
"The health of somebody living in China depends upon my health, and my health depends upon their health. We all have an interest in each other's health. This is why the approach of excluding China in the way President Trump is doing is so mistaken. There are many things to be unhappy about in China, but if you make China an enemy and exclude them from the international system, you are only going to increase the chance of a pandemic happening again. This one is bad. The next one could be even worse."
Apart from overcoming what Covid-19 has exposed as the petty prejudices of national pride, Horton also wants to see a radical social programme "to address the social gradients in society". This involves the systematic protection of the most vulnerable: not just the old and infirm, but also black and minority ethnic groups, who seem to have been disproportionately affected. Health and social care must be integrated, and the links between housing, poverty and health dealt with. Inequality must be crushed. This is the moment, he says, "when we can articulate a different vision".
It sounds utopian, but, under the circumstances, utopianism seems to be fair enough. Horton sees his job as promoting what, at any given time, seems to be our best guess at the truth. He has often been wrong, but the history of science is a long chain of corrections and revisions. It cannot be otherwise. Being wrong is part of the job — ask Isaac Newton. Horton is, from first to last, a provocateur and a moralist with a puritanical — and maybe Norwegian — streak. In his book he describes Covid-19 as "a moral provocation".
"We create the risks that threaten us. We are not the dominant, omnipotent species that we thought we were. Covid-19 is a crisis about life, not health. People are ends, not means. We have edged closer together. We have rediscovered the idea of community. Our world is organised and ordered by separation and partition — countries, languages, faiths and ideologies. We must end our estrangement. My health depends upon your health. Your health depends upon my health. Our liberties depend on our wellbeing. We must answer the question: what do we owe each other? We need to discover our global identity. We are social beings, political beings — and mutual beings too."
Who, now, can argue with that?
Written by: Bryan Appleyard
© The Times of London