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Gavin: Hello, welcome to another episode of The Lancet Voice. It's July 2022. I'm Gavin Cleaver and I'm here as ever with Jess and me Bagnall. Today we're talking about impact. How do we measure impact? What makes something central? What makes it consequential? And how important is it to be able to say something?

is impactful. Now, of course, you're going to have to hold on here for a little bit of blowing our own trumpet, and I really hope that's an idiom which translates properly wherever you're listening to this. As in the scientific publishing community, we use impact factors to measure scientific impact, and in the most recent impact factor results, nine Lancet journals became top ranked in their field, including the Lancet itself becoming the number one general and internal medicine journal for the first time.

The Lancet's impact factor rose from 79 in 2020 to 202. in the most recent measures in 2021. But the impact factor itself can be a bit of a controversial measure. Editors have a bit of a love hate relationship with it, and the number can be extremely consequential for researchers and their career prospects.

This week, Editor in Chief of The Lancet, Richard Horton, joins me and Jessamy to discuss the impact factor measurement, what it captures and does not capture, and what he makes of The Lancet's success.

Jessamy: So, an impact factor is a measure of how often a journal is cited, but what makes citations so important, Richard? Jessamy. 

Richard: I think respect, you know, I can remember long, long, long days past writing articles to submit to journals and you assemble references based upon the fact that you found them the most influential articles to your thinking or your work.

And by implication, therefore, that influence implied respect for the people who were writing those articles. So I think at the heart of the impact factor, and it's such a controversial two words, but at the heart of the impact factor, there is something very important, which is about the way we view one another as scientists and the attitudes we have to those scientists and the respect that we have for their work.

Gavin: And it's central to kind of build up the body of science like that as well, isn't it? 

Richard: It is, it is, it is. I mean, I think You can think of the impact factor, it is a metric and we'll talk about this, I'm sure that's about judgments and, you know, league tables and all this stuff. But, but at its most fundamental, it's actually about how we value the work of other scientists, colleagues and that's why I think it's something that, you know, we shouldn't trivialize or just dismiss.

There is something about you know, the long lineage of the way knowledge is constructed and built up our, our vision of the world, our view of the world and the pieces of information that we choose to select to construct that vision of the world. That's quite an important, that's really quite a big, deep thing.

And so impact factor is. in some senses describing our vision for the world. 

Jessamy: Where does it come from, the impact factor for our listeners? Well, not 

Richard: from that, actually. The original idea was was nothing quite so grand. It was a guy called Eugene Garfield, who back in the 70s wanted to so library, you know, all these journals were being published and library, and we didn't have Google and we didn't have we didn't have PubMed.

And so librarians were struggling to work out. which journal should they buy and subscribe to. And so what the impact factor was supposed to do was to, was supposed to provide a guide to librarians to say, well look, if this journal's got a high impact factor, then maybe it's a journal that you should be subscribing to for your readers in the library.

So it was, it was really a tool for librarians to help them select journals and then it kind of You know, got a bit out of hand and grew into the monster that it is today. 

Gavin: How important was it when you first started at The Lancet and Impact Factor? Like, what's the, what's the difference that's happened over the last few decades?

Richard: It was, it was there, but it wasn't very important. In fact, in fact when I became editor I actually caused our impact factor to decline, not increase, so which was a very clever thing to do. Because we started publishing, we, we launched a new section in the journal called Research Letters and published a lot of them every week.

And they all became cited, and it was a great section, lots of ideas. But they were citable items, but they weren't actually cited very much. So, our impact factor fell, and then we thought, okay, maybe this isn't such a smart idea. We need, we need to make sure that we don't do this, because we've dropped in the impact factor table.

And then at the same time, we started to see that some countries well in fact a lot of countries, then started to use the impact factor to make decisions about where research money started to get spent. And as the research enterprise grew in emerging economies, such as China, and even in high income countries, such as the UK with the Research Excellence Framework, or the REF as it the REF as it's called now the impact factors then became very important for the allocation of money.

And, and then we had to take it seriously. And, you know, we always. It's a double edged sword because on the one hand we hate it because it stifles creativity and forces you to try and work within limits in your journal that, that you don't cause a catastrophic drop in the impact factor. But on the other hand it is important because people's careers and funding.

Do depend upon it, so we can't ignore it. 

Jessamy: What kind of other functions does a journal create and activities that they do that the impact factor doesn't measure? 

Richard: Well, a lot. I mean I mean it's a great question because this is what gets to the point of how reductive the impact factor can be. I mean for, for the Lancet, I think the most important thing that we do is And it sounds a bit pretentious to put it like this, but I don't mean to sound pretentious.

It's thought leadership. We're trying to, you know, the power of ideas to shape the global conversation around medicine and health and medical science. You know, that's really, really important. I mean, the progress of humanity has depended upon the generation of ideas. And being able to put those ideas to use and science has been one of the most fertile tools that human beings have invented to generate ideas.

It's not the only tool, but it's been a very productive tool. And so. A journal, at its heart, should be about publishing new ideas, and those ideas, some will live and some will die, but the important thing is to keep generating those ideas, which can then be adopted or not by, by others. So, that, to me, is the sort of heart of what we do.

We're dealing in original thinking. And then somewhere along the way We have these metrics that try and measure what we do and the impact factor is one of them. Fundamentally, it's really about it's a bit, it's about creativity. And I mean, this is where I think it's a, it's, it's a very unfortunate thing that in the history of knowledge, the arts have separated from the sciences.

Because at their, at their point of origin, they're identical. They're, they're about creating things. And. Richard Faiman always talked about the i the importance of, of imagination in science and that creative spark at the heart of, of knowledge, whatever that knowledge is, history dance, music, science, medicine that's at the root of what we're doing.

So that's, that, that's the sort of fundamental, I would say. 

Jessamy: And you kind of touched earlier on, you know, some of the criticisms that people have of the impact factor in. I suppose leading on it would be great to hear what those criticisms are but do you think also then there's a that it's difficult for journals to get past the impact factor to, to maybe provide these other functions of original thought and creativity when.

Many people are so worried about the impact factor. 

Richard: Yeah, I mean, I, I've, I've sat on editorial board meetings where the, the discussion has been almost about nothing else but the impact factor and how to get the impact factor up. And if your goal is only to get the impact factor up and every decision you take for the journal is about increasing your impact.

I mean, honestly. You know, that's not what journals were created for. Philosophical transactions are the raw society. Henry Oldenburg, when he created that journal, didn't know about the impact factor, and that wasn't the purpose of philosophical transactions. And nor should the creation of any journal be about the impact factor.

And the Lancet as grateful as I am for the impact factor that we, we've just been given, that's not why we exist. This is where the relationship becomes very difficult. I don't think in our discussions every day at the Lancet, and you know this, both of you, we don't talk about decisions in the context of impact factor.

You know, we don't write an editorial thinking how many citations will this editorial get. We don't publish articles based upon the number of citations. Sometimes you notice that reviewers will say in their reviewer comments, this article will be highly cited. But when we discuss a paper at the manuscript meeting, I mean, I would say to you, Jessamy, you sit in those meetings.

Have we ever had a discussion where we say, we must publish this paper because this is going to get a massive number of citations? I mean, I can't ever remember a conversation where we've done that. And indeed, in the old days, before global health became as big as it is, I used to get a lot of criticism from our publishers at the time, because we were publishing papers about malaria in Kenya or Malawi.

And they would say, well, who the hell's going to read this? You know, it's not going to sell any copies of the lancet. It's not going to get reprint orders from drug companies, and it's not going to get any citations. So, you know, this is, this is where I think, you know, the fundamental values of the journal are more important.

And if you get those rights, I think then the impact factor will follow you. If you get those wrong, then it Probably won't, but the most important thing is getting the values of the journal right. 

Gavin: You have touched on it there, but it's become more important over time, hasn't it? For scientists and for the publishing industry.

Do you think that's down at all to maybe the kind of added commercialization of how grants are given out and things like that? 

Richard: Yeah, absolutely. I think it's down to the commercialization of knowledge generally. Knowledge is a commodity that's bought and sold. You know, the idea of knowledge is a public good, that it's there for everybody, that it should be owned by everybody, that's a It is an idea that I think all of us as editors would sign up to, but that's not really the environment that we're living in currently.

I think the open access movement has done a lot to promote the idea of science as a public good, and that's, and that's great. But there's been a long, long period where the commodification of knowledge has actually restricted the availability of information to people, controlled the availability of information to people in a way that's been hugely damaging.

So, I think we're coming out of that era now. Interestingly, it poses a lot of challenges to the publishing model, but on balance, now knowledge is more available to more people than it's ever, than it ever has been, and that has to be, and the, and the COVID 19 pandemic has accelerated that change, and that's got to be a good thing.

Gavin: I was going to ask actually, in relation to the COVID 19 pandemic and the kind of acceleration, do you think there's been a kind of wider acceptance of people going to scientific manuscripts directly? 

Richard: Yes, absolutely and I think You know, there are many elements of that, aren't there, Gavin? I mean, first of all, the rise in pre print culture.

It's much more routine for authors to post their work on pre print servers where work has not even been peer reviewed, so that there can be immediate access. I think a lot of us were worried about that when that started. Could that be damaging? But again, I think the pandemic has proven that that's actually a very effective means of getting information out there.

And I think there were one or two examples of pre prints that had to be withdrawn. But there are also examples of papers that have been through the peer review process that have had to be withdrawn. So I think again, The net result of pre prints has been rapid, transparent access to original research, and you just have to caveat it by saying it hasn't been peer reviewed.

Again, one of the, and I'm not sure whether this is, this was a temporary phenomenon, I think it is a temporary phenomenon, but The fact that you had scientists on news programs 24 7 discussing new research at a remarkably detailed level I've never seen anything like that in my lifetime. It catapulted the scientists to the position of a public intellectual, a public figure, like never before.

That brought You know, I don't think it was easy for scientists. They, particularly women, had a huge amount of abuse by putting themselves in the public sphere in that way. But the science, because we made everything, all publishers made COVID science available free immediately on publication, that did have a transformative effect on the way knowledge was discussed in public.

I think the difficulty with that was that we had a lot of communication. We didn't necessarily have a lot of understanding. So just to give a, you know, there are a few examples of that. Science corrects itself, but Sometimes in a non science literate media, that can look as if we've made mistakes rather than it's correcting ourselves.

So at the beginning of the pandemic, we didn't understand that SARS CoV 2 was transmitted through aerosol. We thought it was droplets. And so we didn't take airborne spread as seriously as we should. And hence the advice over masks changed over time. The public, I think, thought, well, hang on. You said one thing and then you change your mind to another.

What the hell's going on? Whereas we all said, well, now we understand it better. So I think that there is a public understanding element to the science, which we didn't get across very effectively. The same with vaccines, you know, vaccines were an amazing, an amazing innovation. Who would have thought it, but no vaccine is 100 percent safe.

And 100 percent effective. So the fact that there were failures and there were adverse reactions I think, and the fact that vaccines were brought on to availability very fast, that unfortunately did end up fueling. A misinformation or disinformation movement, which was very, very hard to control.

So we ended up being victims of our own success there. So, there's some lessons to learn, I think, for the wider issue of scientific literacy in society, both, you know, in government, in policy, in the media, and in the general public. 

Gavin: Yeah, it's interesting, isn't it? Because from what you say there, it almost feels a little bit like the phrase follow the science that we heard so much of during the pandemic was slightly weaponized almost.

Richard: Yeah, there's no one science. You know, if you look at the UK response, you have the Scientific Advisory Group on Emergencies, and then you have the Independent Scientific Advisory Group on Emergencies. So if you say follow the science, well, which scientists? do you want to follow? Because different scientists interpreted the same data differently.

So there was no one science, there was no one scientist. And again, we're used to that pluralism because in the letters pages of our journals we have those different views all the time. But in the public domain, in the middle of a pandemic, you know, hearing somebody say you know, close schools and somebody else say don't close schools or somebody say wear a mask, somebody say don't wear it.

I mean, it was utterly confusing to the public. For us, it was like, well, this is normal, normal service. But, but not in the, not in the wider media. 

Gavin: Well, I mean, of course, none of that particularly affects impact factors, but to, to bring it back to impact factors it's really interesting, I think. to look not just, of course, at your journal, The Lancet, but successes across the whole Lancet group of journals.

And of course, most of our readers will be aware there are a huge suite of Lancet journals for particular specialties. Now, all of them increased their impact factors, but some of them increased their impact factors quite spectacularly. The Lancet Respiratory Medicine, for example, got an impact factor that would have been higher than The Lancet's and NEJM's impact factor last year as its new impact factor.

And of course, new journals like the Lancet Microbe delivered quite incredible successes. I think it's interesting to think about, maybe you can tell us a little bit more about it, the Lancet's expansion strategy, you know, the launching of these new journals, the kind of capturing of more science under the Lancet's umbrella.

And how do you think that relates to the kind of impact factor successes that we've seen? 

Richard: Yes. I mean, we started back in 2000 with the Lancet oncology. And at the time, I mean, it seems now. Just part of routine history, but at the time it was quite controversial to launch a spinoff journal branded The Lancet.

An old colleague of mine, Jerry Kucera, who is the editor of the New England Journal of Medicine he had been asked by the Massachusetts Medical Society to also consider spinoffs of the England Journal of Medicine, so there might be an NJM cardiology or an NJM oncology. And Jerry through, you know, a man of deep principle objected and refused to allow the New England Journal name to be put on other journals.

And the reason was he thought that that was an unacceptable exploitation of the brand of the NEJM. And he just thought it was wrong, it was a commercial, a step in commercialization too far, and he wasn't going to have anything of it. And he got into a terrible, terrible fight with the Mass Medical Society, they didn't renew his contract, he left, there was a huge fuss, and then of course the new editor, a new editor came in.

And because of what had happened he also said he didn't want any exploitation as he saw it of the brand of the AJM, so they didn't do anything. We took a very different view, in that, that we didn't see it as a commercialization of the Lancet brand, what we saw it as was an opportunity, so there's the Lancet.

And the lancet stood for a set of values and we saw having a lancet oncology or a lancet neurology or lancet infectious diseases as an opportunity to amplify the message of the lancet in different specialties. That was our view editorially. Our publishers also, of course, did have a an interest in maximizing the value of the lancet to the publisher, but for us, it was about maximizing the values of the Lancet to our audience.

So there was a difference in, in motivation but the outcome was the same. And I think in the last 20 odd years, that we've now got something like 24 journals under the Lancet's umbrella. That's really what we've tried to do. I mean, the way I characterize it, and it sounds It sounds glib, but I don't mean it to be glib at all.

It's actually something that's deeply, deeply, deeply held in my heart. And that is that we are really one organization with one single team and one vision across the entire Lancet group. And we are heart. Beats at the same rate across or should be at the same rate across the organization, ideally. So that's quite, that's quite important.

I think that ethos that, that we have and I, I mean, you know, I, I then want to say it's the reason why these impact factors have, have been particularly good this year. I would like to believe that it's to do with the fact that we have a shared. commitment to a set of values that is about who we are and who we want to be.

Gavin: It does reflect so amazingly, doesn't it, on these smaller journals, quite a few of which are run by, you know, relatively small teams and now the, the, the leading journals 

Richard: in their, in their field. Nine journals, in fact, are now top of their impact factor tables, and they've done, yeah, absolutely phenomenal work.

You're right, small teams, but because they're experts in their own area, because they've chosen very, very wisely which papers they've published, they've, they've often defined new fields. In their areas. They have really, really made a massive contribution to whether it's not, it's not just COVID science, but it is including COVID science.

And Yeah, I think that's a, that's a tremendous achievement for, for the whole team. 

Jessamy: Beyond that kind of shared ethos, I mean, what other parts of the, the Lancet strategy do you think allowed, allowed everybody to sort of ride that COVID wave of, you know, having so many new submissions and, and to sort of maximise on that, do you think?

Richard: In some ways, we were well prepared for it. Because we have for a long time you know, maybe 20 years, really been committed to this globalist view of the world, that we are, that the peoples of the world are all interdependent one with another, and health is global, science is global, and to advance health you have to take a global view.

Now again, that's not a view that's been universally held. Donald Trump. famously said on a couple of occasions at the UN General Assembly that he was an anti globalist, believed in patriotism not globalism was his phrase, as if being committed to the global somehow meant that you were against your own country, which is just all this nonsense.

It was a very powerful view for the President of the United States to say. Our own country, the United Kingdom, it was common for people to say that if you were from elsewhere, then you were nowhere, you know, if you, if you were not rooted in your own country, then you, you weren't rooted anywhere. So you somehow had to have this nationalistic view of who you were and the science that you were doing.

And, and, and the last that we, we absolutely don't agree with that view. That's completely contrary to who we are. We do believe in a global community of scientists working to solve common problems together. And again, it sounds, it can sound a bit pretentious to say that until you hit a hit by a pandemic.

And then when you're hit by a pandemic, it's like, Oh my God, yes, because we do need to work together, you know, you can criticize China as much as you like, but Chinese scientists did an absolutely stupendously brilliant job of communicating what was going on in Wuhan as fast as they were able to do in those weeks of January.

And if you don't agree with me on that statement, and some people don't, I would say go back to the first SARS outbreak in the early 2000s and see how China did then and compare what they did in 2020 with what they did 20 years earlier. And you can see how far this country had come in Opening up its scientific communication to the world.

And it was because we had a relationship with Chinese medicine and Chinese science over the past decade. I think Chinese scientists felt that they could trust us to get their work out there in a way that was respectful and supportive of what they were trying to do. And that's, that has, that had been our ethos for a decade working with China.

And it really, I think, yielded benefits in the middle of a pandemic because we have the relationships, we have the trust, we have the confidence of scientists. When you had heads of state of other western governments criticizing China in some really, you know outlandish ways, we were trying to work behind the scenes with Chinese institutions to get their work out into the international community.

And I think that made a huge difference to our understanding of the pandemic and the response to the pandemic. 

Gavin: There's been a lot of talk, and we've been talking about COVID, of course, that The impact factors that have come out this year are inflationary as a result of so much COVID, science, so many publications, so many publications citing each other in such a short time frame.

What's your take on that and what do you think might happen next year or the next five years? 

Richard: Yeah, I've heard that. People say they've been inflated by COVID and they're biased by COVID. My response to that is That's complete and utter nonsense. In this, in this sense, the world was hit with a pandemic.

Everybody was challenged to respond to that pandemic. We did respond to it. And one aspect of that response, it's a narrow aspect. We've talked already about the reductive nature of the impact factor, there are other things, creativity, imagination, thought leadership, ideas, all of these things, we've talked about that, how important those are.

But in this one, one, one measure of our response to a global catastrophe, and it was a global catastrophe, it is a global catastrophe, the impact factor is what it is. So that is a, that is a metric that does actually objectively make some judgment about how we responded as an organization. And that's important to acknowledge and to understand why that happened.

So, inflationary bias, a one off, no. The world was challenged, we were challenged, we responded, this is a measure of that response. And I would say That tells us something very, very important about our values and why our values matter. Now what's going to happen in the future? Well, you know, it's a two year window.

So next year we will see. I think our impact factor will remain high. it be as high as this year? I don't know. In some ways I don't, you know, I sort of feel I care, but I don't care. I mean, I, I, I'm really delighted with the, with the results across the Lancet group. But what matters more than a number is the actual impact of the science that we publish and I know that the work that we publish whether it's original research or the commissions or the series we see the academic community, community as a partner.

We think of the academic community as a massively neglected force for social and political action. And our job as editors is to unleash the potential of the academic community for social change. That was the original spark of the Enlightenment. in the 17th century and what we're trying to do in the 21st century is reinvent that enlightenment ideal in a globalized world.

And it's never been more important as we're trying to learn the lessons of the pandemic, as we're trying to address the climate crisis, as we're trying to address all of these global threats, seeing the connection between original ideas, creativity, new knowledge, and decision making that shapes social and political choices.

It's never been more important than it is today. It's existential. This is about the future of our families. It's about the future of our children. It's about the future of our planet. And if we don't get this right, then we've got no future. So, you know, the duty on us is enormous. There couldn't be anything more.

I mean, at least for me. There couldn't be anything more important. 

Jessamy: Maybe, maybe that kind of takes us nicely to this last question. Well, we haven't even actually said the Lancet's impact factor which is 202. And is now ranked number one in the kind of medicine and internal medicine category for the first time.

going into its 200th year. I mean, what does this mean for you professionally, but also personally? I mean, you've been editor in chief for such a long time. This has been your tenure. What does it mean?

Richard: Well, that's a conversation over a drink rather than on a podcast. Professionally, I am just so proud of the people I work with for what they've achieved. I mean, I, I really, really do believe that it's the team that have done this. You know, everybody working together way beyond their, anybody's expectation.

You know, I genuinely, you know, I love the Lancer. I love the team here. I'm so admiring of what they've done. So I think professionally it is definitely a peak probably a peak that can never be quite superseded in any way. I'm, I'm really delighted that my colleagues have got the recognition that they deserve.

Personally, lots of feelings about it to be discussed another day. 

Jessamy: Okay. Let's just ask what, what, what, what next Richard? Like we've had these huge global crises that the Lancet is trying to respond to. We're trying to play our part in the way we've discussed it today. It's almost a mandate. It's a recognition of, of that work.

So what next do you think? 

Richard: So it's very important not to be complacent now. You know, it would not be unreasonable for us to be celebrating the success of these impact factors and to in some sense say that it's a vindication of what we've been doing for 20 years. I would say fine. That's partly true.

But what about the next 10, 20, 30 years? And What do we do with that success? How do we build on it? I am still, you know, there are some really, really huge changes to the world that are coming that we have not started to think about. And the one that really concerns me is that one has to be careful how one phrases this, but there is going to be the, the biggest economic shock Over the next century because of changes in population and we're going to see precipitous declines in population in some high and middle income countries that is going to cause acute political instability to the extent that we could see the conditions for conflict escalate.

We're going to see the population of Sub-Saharan Africa triple over the century. Which in, in and of itself is a really good thing because the demographic dividend that that can provide for Africa in terms of kind of injection of creative energy to the economy and to its culture is just. Fantastic.

But that's going to mean that the geopolitics of this world is going to change massively too. And we have a world that's been constructed in a post World War II environment that is not fit for purpose for the world that We're living in now, and that's definitely going to come over the next 50 years.

So, and the health fits into that because health is a geopolitical issue. War is a geopolitical, war is a health issue. The distribution of limited resources, whether that's food or medicines or healthcare that's an issue that's going to be shaped by these changes in the economy and population.

So. I think, yes, we deal with the pandemic. Yes, we deal with climate. Yes, we deal with food systems. We also need to be thinking about the re sculpting of the human family over the next century and what the implications are for health and well being. And we haven't really got to grips with that yet because some of those questions are so fundamental.

They're about power. And it means that some countries are going to have to relinquish power and we're going to have to give power to others. And that is going to be a very, very difficult, a very difficult thing to do.

Gavin: That's it for this episode of The Lancet Voice. If you want to carry on the conversation, you can find Jessamy and I on Twitter, on our handles at Gavin Cleaver and at Jessamy Bargainall. You can subscribe to The Lancet Voice if you're not already. Wherever you usually get your podcasts and if you're a specialist in a particular field Why not check out our in conversation with series of podcasts tied to each of the Lancet specialty journals Where we look in depth at one new article per month.

Thanks so much for listening and we'll see you again next time