Via Financial Times

When Dr Richard Horton turns up for our Zoom lunch, I feel a pang of disappointment. I am at home but attired for a real-life work meeting: black frock, inoffensive earrings and a dab of make-up. The editor-in-chief of The Lancet, the prestigious British medical journal founded in 1823, “arrives” in a black hoodie. He has apparently forgotten his light-hearted promise to wear a jacket, though happily remembered that we are dining together. “Look, I’ve got my lunch,” he says proudly, thrusting a brown paper bag towards the camera. He offers to wait until mine is delivered.

I am not surprised that our loose sartorial agreement has crumbled in the face of his to-do list. It was The Lancet that, in January, first published clinical reports of a mystery pneumonia from Wuhan. Since then, a trickle of papers on Covid-19 has become a torrent of crucial, freely accessible information helping to shape the public health response in real time.

That has landed the 58-year-old with an arguably more important secondary role: critic-in-chief of the UK government’s handling of the Covid-19 outbreak. Since February, he has accused ministers and their advisers of failing to see the coming storm, keeping up a barrage of criticism in The Lancet, in newspapers and on television. The UK response to the pandemic, he told the BBC on March 26, is a “national scandal”. I go to the heart of the matter: does the government have blood on its hands?

“I’m not going to use those words, but I do believe lives could have been saved had we acted earlier,” he says. “If we had used February to scale up capacity for testing and contact tracing, and to begin surge capacity for intensive-care bed use, it’s absolutely clear we would have saved lives and saved the NHS. Even if it wasn’t the extreme lockdown we see now, we should have been reducing social mixing and winding down economic activity, like promoting working from home and physical distancing, so that we started to cut the lines of transmission.”

We are speaking against the backdrop of an increasingly rancorous debate over the UK’s response. He has despaired at how the science and politics of this pandemic have been handled at every turn: from the lack of testing at the beginning to what he says is the “charade” of the daily press conferences and the “strategic failure” of the government to plan adequately. He, along with others, has demanded transparency on the opaque epidemiological models that shaped the UK’s originally laissez-faire response, which included floating the idea of “herd immunity”.

I have delegated the catering at my end to my 17-year-old daughter Rosa. She settles on an Italian via Just Eat. The doorbell rings; a few minutes later, she serves me four slices of Hawaiian pizza and waves hello to my interviewee. Horton and I briefly discuss how unsettling the pandemic is for children.

Horton is sitting in a study with the obligatory bookshelf in the background. He unpacks his lunch and angles his camera down to flaunt a carefully arranged Mediterranean feast. His spicy meze platter comprises chicken, homemade tzatziki and hummus, baba ganoush and fresh chilli sauce. I can’t help feeling a little jealous.

Horton has to be one of Britain’s longest-serving editors. He joined The Lancet in 1990 and was appointed editor-in-chief five years later, aged just 33. He makes no apology for being overtly political. “Some of the great advances, like the 19th-century sanitary movement and the birth of the NHS, were not technical accomplishments but political struggles. The idea you can strip out politics from medicine or health is historically ignorant. The medical establishment should be much more politicised, not less, in attacking issues like health inequalities and poor access to care.” Notably, one of his idols is Michael Marmot, a London-based academic who has pioneered the study of how social inequality affects health.

It was studying physiology and medicine at the University of Birmingham that first opened Horton’s eyes to how other people lived. “I can remember as a student going into high-rise flats where the carpets were soaked with urine,” he says. “The bathrooms were completely unsanitary, the kitchens were loaded with unwashed dishes and cutlery, and everywhere was dirt. I’d never seen anything like it before.”

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After a middle-class upbringing he only discovered in his forties that he was adopted, that his birth father was Norwegian and that he had five half-siblings: “It was a shock. I went from being an only child to having this enormous family. Being half-English and half-Norwegian changed the centre of gravity of who I thought I was and I’ve been having a love affair with Norway ever since.”

Horton has been labelled a left-winger by his critics. He rejects the tag, saying he has voted Conservative, Labour, Liberal Democrat and Green. His philosophy is, however, faithful to the spirit of Lancet founder Thomas Wakley, a surgeon and social reformer once described as an “honest denouncer of invidious distinctions betwixt the rich and the poor”. Wakley named the journal after a surgical instrument and a type of window: it was meant to symbolise piercing corruption and letting the light in.

Accordingly, Horton has shone the light of The Lancet on a range of political causes: he has praised the climate protest group Extinction Rebellion, urging healthcare workers to join non-violent protest; he published an emotively worded letter in support of the people of Gaza penned by a geneticist in Italy later accused of having anti-Semitic sympathies; and he ran a study claiming that civilian deaths related to the Iraq war had been undercounted.

None has made him the most popular man in the room. Dr Michael Fitzpatrick, a GP and former Lancet columnist, described Horton to me as “very personable and easy to deal with, but a bit of a showboater and a pariah in the medical establishment”.

In truth, Horton has never been forgiven for publishing a 1998 paper by Andrew Wakefield that raised unfounded doubts about the safety of the measles, mumps and rubella (MMR) childhood vaccine. Despite years of controversy, the paper wasn’t fully retracted until 2010, after the General Medical Council ruled Wakefield had been dishonest (he was later struck off). The uncertainty caused childhood vaccination rates to plummet and energised the anti-vaccination movement. The MMR debacle became one of the biggest ongoing calamities in public health.

“There’s no escaping the serious damage that was done,” Fitzpatrick tells me. “He [Horton] wasn’t apologetic enough about what happened.”

Does Horton regret what happened with MMR? “I’d be mad not to, but I can’t simply retract papers I don’t like. There has to be due process [via the GMC tribunal].” Has he ever come close to being sacked? “I don’t know,” he smiles. “You’d have to ask my publishers. All good editors get fired eventually.”

It is time to change the subject. We have a pandemic to discuss.

Chart showing unprecedented spike in weekly death registrations in UK and Wales. Y axis, red line shows number of deaths in 2020. X, blue dots represent deaths for that week in one particular year from 1970-2019

When we meet, the shortage of personal protective equipment among health workers is dominating media coverage. Hospital trusts have threatened whistleblowers with disciplinary action; Horton has offered to act as conduit for their dispatches from the pandemic front line: “Workers have been bullied and forced to see patients who clearly have or are suspected of having Covid-19 without PPE. When they raise concerns, they are belittled or threatened. It’s horrifying to see the lack of concern by some NHS management.” War zones, one doctor told him, are better prepared than the world’s sixth-largest economy.

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The NHS was left playing catch-up, Horton says, because the government either ignored or did not act on information in a timely manner. The first paper suggesting the existence of a new contagious virus appeared in The Lancet on January 24. Horton now wants to know why that chilling assessment was seemingly passed over in Whitehall. “Why wasn’t that paper read by the Scientific Advisory Group for Emergencies, or the New and Emerging Respiratory Virus Threats Advisory Group, or NHS England, or the chief medical officer or the chief scientific adviser?” he asks.

“We had all of these committees and all of these offices and all of these organisations, but somehow they didn’t connect. We’ve had the biggest science policy failure in a generation.” He dismisses the idea that such a devastating outbreak could only have been predicted with hindsight: “How can it be hindsight? It’s there in black and white on January 24, written in a paper from China, telling people, ‘Please act now, this is urgent, there’s a crisis.’ ”

A week later, another Lancet paper warned that, since the virus was no longer contained in Wuhan, and that “self-sustaining outbreaks in major cities globally could become inevitable . . . Preparedness plans and mitigation interventions should be readied for quick deployment globally.”

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Horton’s combative public persona conceals a personal struggle: in 2018, he was diagnosed with advanced melanoma. His experience as an NHS patient adds to his sense of outrage at the pressures facing health workers. “I don’t think I’ve ever been in an institution where people have been so genuinely kind and thoughtful,” he says. “That’s why I’m so angry that we didn’t act sooner. I’m angry because I know how good the NHS can be. Politicians and policymakers and scientists let down the NHS and its staff. And that’s unforgivable.”

The government is clearly rattled by such criticism. A Sunday Times article entitled “Coronavirus: 38 days when Britain sleepwalked into disaster”, published last weekend, drew a lengthy rebuttal from the Department of Health and Social Care. The rebuttal includes a quote from Horton on January 23 calling for “caution” and accusing the media of “escalating anxiety by talking of a killer virus” to dismiss the idea that a scientific consensus around a coming pandemic was building in late January.

The quote originated, he clarifies, from a tweet urging caution on lurid coverage rather than government policy. Besides, the World Health Organization declared a public-health emergency on January 30. “I do think it’s a misrepresentation, absolutely,” he says. “Between January 24 and 31, there was daily mounting evidence and concern that this was tipping into a pandemic.”

Meanwhile, the scientific community is desperate to second-guess what the virus will do next. “We are already seeing it’s got the potential to come back,” he says, noting China’s uptick in cases. “That’s very worrying indeed, and it’s why we need a vaccine as quickly as possible.

“But there’s still a vast amount to learn. Why did the outbreak take off so dramatically in Italy but not Germany? Testing is one possibility, but we don’t know for sure. Testing is absolutely crucial, and if we’re going to get out of these lockdowns we definitely need to scale up our capacity.”

Focus of Covid-19 deaths has switched from Asia to Europe — and now the US. Streamgraph and stacked column charts, showing regional daily deaths of patients diagnosed with coronavirus

Western countries have fared poorly in their coronavirus response compared to Asian countries, he thinks, because they saw the threat through the lens of influenza. China and Hong Kong feared a rerun of Sars, a much deadlier illness, and clamped down quickly. The cognitive bias, he says, has cost us dearly.

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Horton also worries about complacency setting in once this pandemic has run its course: “It would be very dangerous to say this is our 1918 [Spanish flu pandemic], and to think these things only come around once a century. The conditions still exist in countries for zoonotic diseases [which jump the species barrier from animals to humans] to develop. We’ve had five or six of them in the last 20-30 years. This is the big one for now but there might be an even bigger one to come.”

Rosa brings a coffee cupcake, but we have moved on to talking about Horton’s cancer and it seems disrespectful to eat it. It was his 19-year-old daughter Isobel, from Horton’s marriage to paediatrician Ingrid Wolfe, who urged her father to get a mole on his right temple checked out. Since his diagnosis, Horton has undergone surgery three times and is left with scars and an uncertain prognosis. He is now on immunotherapy. Every day is “the toss of a coin”.

Therapy soothed his darkest moments: “I thought I didn’t have very long to live, maybe weeks or months . . . It was extraordinarily helpful to be able to sit in a room with someone who is on your side and be able to say anything.” Solace now comes in the form of books — currently The Birth of Biopolitics by Michel Foucault, on how governments exercise power over the lives of their citizens — and a nightly glass of Lagavulin whisky.

He is still nervous about touching his face because he fears finding the cancer has returned. But for now he feels — and looks — strong: “I wake up and think I’ve got to make the most of every day, because I don’t know how many I will have.”

He will push for a public inquiry into the coronavirus pandemic, and for the WHO to be strengthened, not weakened. The inaction that followed the WHO’s emergency declaration, he clarifies, was down to member states and not to China, to whom he says the world should be grateful to for its warnings and containment efforts.

That attitude might surprise those in the medical profession who criticised China’s initial response to the outbreak. But the idea that China should pay reparations for the resulting economic losses is, he says, ridiculous, and he calls Donald Trump’s decision to suspend WHO funding a “crime against humanity”.

He is now writing a book about why, despite the warning signs, the Covid-19 pandemic caught the world by surprise. Meanwhile, that formidable to-do list leaves no time to answer his critics:

“You said earlier that people think I’m a pariah. Maybe in previous years that might have upset me. But now? I really don’t care what people think of me. If I’m not here in six months or a year . . . f*** them. Seriously.”

Anjana Ahuja is an FT science commentator

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