There is a school of thought that says now is not the time to criticise the government and its scientific advisers about the way they have handled the Covid-19 pandemic. Wait until all the facts are known and the crisis has subsided, goes this thinking, and then we can analyse the performance of those involved. It’s safe to say that Richard Horton, the editor of the influential medical journal the Lancet, is not part of this school. An outspoken critic of what he sees as the medical science establishment’s acquiescence to government, he has written a book that he calls a “reckoning” for the “missed opportunities and appalling misjudgments” here and abroad that have led to “the avoidable deaths of tens of thousands of citizens”. The Covid-19 Catastrophe: What’s Gone Wrong and How to Stop It Happening Again is a short polemical book, building on a series of excoriating columns Horton has written in the Lancet over the past few months. He lambasts the management of the virus as “the greatest science policy failure for a generation”, attacks the Scientific Advisory Group for Emergencies (Sage) for becoming “the public relations wing of a government that had failed its people”, calls out the medical Royal Colleges, the Academy of Medical Sciences, the British Medical Association (BMA) and Public Health England (PHE) for not reinforcing the World Health Organization’s public health emergency warning back in February, and damns the UK’s response as “slow, complacent and flat-footed”, revealing a “glaringly unprepared” government and a “broken system of obsequious politico-scientific complicity”. On the page, Horton can sound strident, even arrogant, but that’s not his manner in person at all, at least not in our long Zoom conversation. He’s charming, open, self-critical and full of easy laughter. I suggest that, as bad as things look at the moment, surely people like the chief medical officer, Chris Whitty, and the chief scientific officer, Patrick Vallance, have been doing their best. “Individually, they’re great people,” he says. “I’m not criticising individuals, but the system was a catastrophic failure.” As editor of the Lancet, he’s particularly aggrieved that the series of five academic papers the journal published in late January first describing the novel coronavirus in disturbing detail went unheeded. “In several of the papers they talked about the importance of personal protective equipment,” he reminds me. “And the importance of testing, the importance of avoiding mass gatherings, the importance of considering school closure, the importance of lockdowns. All of the things that have happened in the last three months here, they’re all in those five papers.” He still can’t understand why the government’s scientific advisers didn’t consult their counterparts in China. The world of medicine is a small one, he says, and everyone knows the people responsible for coordinating the Chinese government’s response. “These are people they could have literally sent an email to, or picked the phone up to, and said, ‘Hey, we read your paper in the Lancet, can it really be as bad as that? What is going on in Wuhan?’ And if they’d done that they would have found out that this was indeed as bad as described.” He doesn’t know if such conversations took place, but he can’t see why, if they did, the response was so sluggish that the UK is second in the world, trailing only the much larger nation of the US, in the league of Covid-19 deaths. What he does know, from the published reports of Sage meetings, is that scientists were “trying to be as sensitive to economic issues as they were to health issues”. That, he says, “is a dangerous place to be” because it compromises the ability of the advisory group to protect health. While the arena of public health is no stranger to heated disputes, it’s common for the antagonists to maintain a diplomatic front in public. Horton, who appeared on Question Time back in March and declared the government’s delay in locking down a “national scandal”, has never been shy about speaking out, but even by his own forthright standards, he seems to have abandoned all instincts for restraint. One reason for his lack of caution may be that he has stage 4 melanoma cancer. Though a trained doctor himself, he didn’t take much notice of a growth on his temple until his daughter insisted he got it looked at. He has twice had the growth removed and is currently on a course of immunotherapy. His friend David Nabarro, who is a special envoy for the WHO looking at the Covid-19 pandemic, says that Horton has always been concerned with the social and economic structures that shape health outcomes, but that his illness has made him even more determined to voice his opinions.
Whereas others working in global health have to take future access into account, “in Richard’s case,” says Nabarro, “he knows there’s a fairly high chance he won’t be around to be invited back. He’s got fewer opportunities to try to bring about change. He’s got to be much more precise, much more focused, and at times more ruthless. So I suppose that means what we’re seeing now is the real essence of Richard Horton.” In our conversation Horton makes a single oblique reference to his “rather unpleasant illness” and only then to make the point that, in being shielded, he has learned the true significance of the phrase “key worker”. The experience has made him regard anew not just the hospital staff who have been treating him at the Royal Free in north London – a hospital where he worked as a doctor in the liver unit in the late 1980s – but also, amid a large cast of previously undervalued workers, the couriers who brought him vital medicine when he ran out. “These people,” he says, his voice full of emotion, “they’re the ones who are making our society work.” Horton believes this pandemic is a watershed moment in history, an event that is much larger than simply a crisis in health. “Covid-19 has held a mirror up to our society,” he says, “and forced us to look at who really is vulnerable, who really does make society work, who has to literally put their lives on the line while the rest of us are secluded in our houses. We’ve discovered something about ourselves that we may have been conveniently able to hide before but we can’t hide any more. And so the question is what do we do with that knowledge now?” While he doesn’t have an answer to that question, he does believe that the “moral provocation” of Covid-19 is not one that we can afford to ignore. For Nabarro, Horton’s concern for social justice is a product of his childhood. “He was adopted at three months,” he explains. Horton’s birth father was a Norwegian who returned home not knowing that his brief affair had produced a child. It wasn’t until more than 40 years later that Horton tracked him down, struck up a relationship, and discovered five half-siblings.
“I’m absolutely certain that that’s what’s made him somebody who’s capable of looking at situations a bit outside himself,” says Nabarro. Despite his ill-health, Horton is a boyish-looking 58 who, incredibly, has been editor of the Lancet for a quarter of a century. In that time he’s turned the journal into a major international success, frequently setting the agenda for global health. Last year he received the $100,000 Roux prize for lifetime achievement in population health, being cited as one of the field’s most “committed, articulate, and influential advocates”. Despite the success and recognition Horton has enjoyed, Dame Sally Davies, the former chief medical officer, believes he is still motivated by a haunting chapter in his past. “I think with Covid,” she says, “he’s repaying his debts.”
The debts refer to Horton’s role in publishing Andrew Wakefield’s discredited paper claiming a link between the MMR vaccination and autism. The panic that ensued led to a significant drop in vaccinations across the world, growth of the anti-vaccination movement, and lethal outbreaks of measles. Although the science was questioned from the beginning, Horton strongly defended Wakefield, whom he knew from their time working together at the Royal Free. It took 12 years before Horton finally retracted the paper, after a General Medical Council inquiry found Wakefield to have been guilty of dishonesty and deception. Many people in medical science have never forgiven Horton for awarding Wakefield such a prestigious platform as the Lancet, nor for the delay in retracting the paper. One eminent figure told me: “On his headstone it ought to say, ‘I published Wakefield on MMR and autism’.” Fiona Godlee, editor of the rival British Medical Journal (BMJ), says that MMR is to Horton “what Iraq is to Tony Blair”. As David Salisbury, who was director of immunisation at the department of health at the time of the MMR crisis, put it: Horton “made a catastrophic mistake in publishing that article, and that had enormous consequences both in the UK and globally”. According to Dame Sally, it still rankles her CMO predecessor Sir Liam Donaldson that Horton did not properly apologise. A big supporter of Horton, she describes him as “a great person doing a good job”, but she wishes he’d given a “more fulsome apology”, if only to placate the naysayers. Horton says that he has made many public apologies but not, perhaps, to the particular people involved, like Salisbury. In hindsight, he says, he would have loved to have retracted the paper sooner but he believed, and still does, that Wakefield deserved his day in court. The whole subject, says Godlee, was one about which Horton used to be very defensive. She says the pair fell out after she ran a series of pieces in the BMJ which were highly critical of Horton. Thereafter, she says, he avoided her, refusing to go to any events at which she was present. But they are now on a more friendly footing.
“He has changed in the process of being ill,” she says. “He and I have met and have had a hug and he invited me to his Roux prize thing.” As for his doing penance, Horton thinks that Dame Sally has a psychological point, just not in terms of Covid-19. “The MMR issue was so profoundly damaging that for me the payback that I needed to give was very much a commitment to children’s health. Not just vaccination but a whole range of different issues: newborn health, child health, adolescent health, women’s health as it pertains to child health. I would say that yes, I think there is a debt that I was trying to repay for that.” TheLancet’s publisher, Elsevier, the Dutch analytics company, has stood by Horton, not just through the MMR saga but also a number of other controversies. These include his support for Sir Roy Meadow, the paediatrician who was sanctioned for giving misleading evidence in the case of Sally Clark, the mother wrongly convicted of killing her children; a controversial analysis of civilian deaths in the Iraq war; and only two weeks ago a paper that raised concerns about the efficacy and side effects of the drug hydroxychloroquine was retracted, following widespread protests from leading figures in the field. Speaking before the paper is withdrawn, he says: “It’s because of Trump being such an ardent supporter of [hydroxychloroquine] that it’s got much more politicised than it normally would do. It’s all gone a bit crazy.” The swiftness with which he went on to respond to the furore, says Godlee, “is a sign that he’s learned a great deal”. Nevertheless Horton maintains that it’s vital that “people are allowed to make mistakes because making mistakes should be what science is about”. Despite the apparent security of his position throughout these various wrangles, he says that there was one occasion when he did think he was heading for the sack. It was after he published an “extremely negative” editorial about AstraZeneca for “spinning the most appallingly exaggerated story” about a particular drug.
By coincidence the editorial came out on the same day as the drug company’s annual investor’s meeting, causing the share price to drop. The furious AstraZeneca CEO phoned Elsevier’s chief executive and expressed his fury in uncompromising terms. The chief executive in turn called Horton and demanded to know “what the hell” he was doing.
Godlee says that the Lancet usually has a cosy relationship with big pharma, often publishing major drug trials. It’s a “pact with the devil”, she believes, that has enabled the journal to become a global powerhouse. Whatever the Lancet’s economic model, Horton has studiously built an internationally recognised position of authority that has enabled him to speak out on issues that matter to him. Very few individuals manage to be as plain-speaking as Horton, says David Heymann, the former chair of Public Health England, and still retain respect in the global health community. He speaks of one occasion when he witnessed Horton inform the notoriously sensitive Chinese delegation at a seminar in Hong Kong that China needed to be more open and participatory in global health. “There was a vice-minister of health and many top level ministers present,” says Heymann, “and I think that it may have had the benefit of encouraging them to become better development partners. He’s very good in a tough situation.” For all that, it’s far from certain that his current campaign and book will have the same effect on the British government and its senior scientific advisers. Horton believes that in order to restore their damaged reputation they need to acknowledge their mistakes. “I think that’s going to have to start with Sage, the chief scientific officer and the chief medical officer being very clear that the signals were missed from January. And there needs to be an acknowledgment that there was a collusion that took place between scientific and medical advisers and politicians which was in the end damaging to public health.” Although at least one member of Sage has admitted that an earlier lockdown would have saved lives, it seems unlikely that Whitty will issue any kind of general mea culpa just now. He is in the middle of viral storm, trying to plot a course out. It’s debatable whether he’d increase public confidence in his advice by acknowledging that he got it wrong. That’s if he even thinks he was wrong, which he probably doesn’t. Horton acknowledges that from the last conversation he had with him, Whitty “thinks that I don’t understand what he’s trying to achieve”. Yet there remains a case to answer about why we took so long to lock down, and why, despite all the warnings first from China and then from Italy, that we seemed to be caught unawares by the speed and lethality of the virus. “How long did the UK wait before it took it seriously?” asks Nabarro. “I’m not going to say, but Richard will tell you.” He has indeed told us. On that, at least, we can all agree. • The Covid-19 Catastrophe: What’s Gone Wrong and How to Stop it Happening Again by Richard Horton is published by Polity Press on 18 June (£12.99). To order a copy go to guardianbookshop.com. Delivery charges may apply