Editor-in-chief of The Lancet Richard Horton looks back at two centuries of medical publishing, previews how we will be marking the journal’s 200th anniversary, and explains what the milestone means to him.
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GAVIN: Hello and welcome to the Lancet Voice, a podcast exploring the world of health through stories and conversations. I'm your host Gavin Cleaver. And along with my co-host, Jessamy Bagenal, we're delighted to have you with us. It's the start of 2023 and this year marks the 200th anniversary of the Lancet, founded in 1823. Who better to speak with to mark the occasion and to look forward to everything we've got planned this year than Richard Horton, editor-in-chief of the Lancet? Dr. Horton has been with The Lancet for 30 odd years, and he joins us to discuss what The Lancet is, where it's been and where it's going as it heads into its third century.
JESSAMY: Richard, thank you so much for joining us. So this is a podcast for a general audience. We wanted to ask you, what is The Lancet? What was it 200 years ago, and what is it now?
RICHARD: Well, thanks Jessamy. It's great to be here on a very special year. The Lancet, of course, is a medical newspaper. But when Thomas Wakley launched it, he had something far more ambitious in mind, which was to tear down the prevailing medical establishment, particularly in London, which he saw as utterly corrupt. So if one tries to draw a theory out of that, it is that The Lancet was indeed a journal, but it was also an idea and it was a very radical, indeed revolutionary idea, which was of course, perfectly in tune with the times. I mean, we are talking 1823, the romantic era. And of course people think of the romantic era as beautiful Lakeland poetry and pretty flowers. But actually the romantic era was intensely political, because it was all about the disillusionments with the Industrial Revolution. The industrial Revolution had promised good fortune for the country.
And what it had actually produced was desperate poverty, inequality and pollution and the sense of disappointment that was then present was expressed in, in multiple ways in English political life. And one of those ways was Thomas Wakley launching The Lancet.
JESSAMY: You can be as selective as you like in the next question or as historical, whatever, whatever you like. But can you give us some examples of the positive or negative impact The Lancet has had on issues in health over the last 200 years?
RICHARD: Well, that's a very tough question. 200 years summarized briefly. On the positive side, we've tried to be the journal that… I mean, the best way I can put it is be a one stop shop for medical knowledge, so that if you read The Lancet every week, you would've kept abreast with all the major developments in general medicine.
Now, of course, we can't cover every detail of every specialty in detail. I mean, that mission that I've just described might have been possible in 1823, but it's very difficult to do in 2023. That said, I do think that the Lancet does give an informed view on progress in medicine. I think we try and do more than that.
We're not a mirror of medicine. We try to, and this is very Wakley-esque, we try to intervene in areas that we consider to be neglected or important or where there are opportunities to do so, and that's something we've tried to do in the last 20 years. In particular, the downside of the answer, I think is one that we've only really come to appreciate quite recently, and that is that we have to face up to the fact that we are a journal that was founded at a time of British imperial power, and that means that we have to diagnose ourselves as part of the products of colonization. The wealth of Britain at the time when The Lancet was launched had come from the Industrial Revolution, but the wealth that allowed the industrial revolution to came from the African slave trade. So there's no getting around the fact that The Lancet flourished in Britain in the 19th century can be traced back directly to the slave trade. And indeed, when you look at The Lancet, it was founded as a journal for colonial practitioners as well as London doctors and surgeons.
This is not a very pleasant realization to, to appreciate that the journal that we work at was an instrument of imperialism, but we were, and so there's a certain amount of coming to terms with that and thinking, what do we do about that, and it's an issue that we're going through right now and it's something that I don't want to sweep under the carpet. And during the course of 2023, it's something that I want us to discuss and debate and, and reflect on with some, with, with a critical eye.
GAVIN: So, Richard, perhaps you could talk to us about what we're going to focus on in our anniversary. And tell us why The Lancet chose these particular spotlights, these areas.
RICHARD: Yeah, thanks Gavin. It's difficult when you come to an anniversary like the 200th birthday of The Lancet because the first feeling you have is one of relief that you made it into 200 years. And then you want to, in a sense, mark it through some sort of celebration. But that didn't really feel right to me, at least. I think our feeling was that we wanted to say, yeah, 200 years is okay, but there's still a lot of work to do. So what do we want to focus on? So we, we embarked on a process of consulting all of the editors across the journal. In fact, I think all staff across the journal, and tried to distill people's priorities into a set of themes, which we've called spotlights.
And we have five of them, and the five that we've chosen are child and adolescent health, climate and health, mental health, universal health coverage, and research for health. And the reason why we've chosen those five is that we see those as particular, either particular challenges like climate, or particular opportunities like child and adolescent health, or neglected topics like the importance of research for health. So we want to try and draw attention to these five themes over the, over the year we're going to be commissioning new content, having multimedia videos, podcasts, webinars to pick up specific themes, partnering with other organizations to draw attention to specific issues.
So we're trying to use the journal and journals, all of our journals as a platform next year to really amplify messages around these five spotlights. So to use the year in a sense as a campaigning opportunity, not just a celebration.
GAVIN: And of course those are extremely broad areas, but we have kind of specific asks within each area, which are ways that we want to move these particular fields forward. How can these be achieved by a medical journal?
RICHARD: Well that's a great question because, you know, it's a bit hubristic to think that we can end stigma and discrimination in mental health. And of course we can't on our own. But I think one of the lessons we've learned through the series and commissions we've published over the past 20 years is that we don't want to work alone. We want to work in partnership with others, and we're more effective if we work in partnership with others. And if we do that, then actually I think we can achieve some of the asks that we've set out. We've chosen asks that are difficult. We haven't chosen easy things to be our objectives. I remember Richard Peter, one lesson that I always learned from Richard Peter was, you need to choose the big questions to ask, otherwise in research, it's not worth it. So that's what we've tried to do. We've tried to choose the big asks because if we were successful, the return would be enormous. So through partnerships, I think that we can advance the cause of universal health coverage. We can put children at the heart of societal policies. We can end stigma and discrimination in mental ill health. We can accelerate action on climate and health by bringing health in as an important domain of the climate crisis. So I think this is where we're trying to make step change through extraordinary partnerships.
GAVIN: Yes. So when you mentioned universal healthcare there, it reminded me of, of one, I think one of my Lancet highlights of 2022, which was the Nigeria Commission and how that directly fed into the advancement of Nigerian health coverage, which was amazing, wasn't it?
RICHARD: Well, the Nigerian Health Commission was, it was amazing and surpassed all the expectations that I had of it, not because I didn't think they could produce a fabulous commission report, but what they were able to do was to unlock a political process.
If it had been a commission written in London, this would not have been possible. And I think this ties together with what we were just talking about, which is the decolonization agenda. Decolonization is lots of things, but one thing it certainly is, is making space for other people to talk and people who haven't always had the chance to do so in the pages of The Lancet and we very specifically in the case of Nigeria made space for Nigerians and Nigerian diaspora to, to tell the story of their country and to write the future opportunities for their country. And rather than do what Western writers do, which is to be very critical of political regimes in sub-Saharan Africa and to be generally quite negative what this commission actually did was enormously imaginative and optimistic in its vision for Nigeria. You know, there's a demographic dividend of the most unbelievable proportions of very, very rapid growth in population from over 200 million now to close to 800 million by the end of the century, which you can view in two ways.
It's a really tough challenge to integrate that many people into a developing society. But the other way of looking at it, and this is what the commission did, was to see this as an amazing generational opportunity. You're producing all of these young people who have fabulous minds and fabulous opportunities for the future, and this could turbocharge the advance of Nigerian society.
And health sits at the heart of that in many ways. One, because you need a healthy population in order to deliver that opportunity. And second, because research in health and building a health system is one of the dividends that that population could actually deliver. I think if this had been a commission written by a school of public health in the West then the president or Prime Minister wouldn't have paid any attention to it, but because it was actually written by Nigerians for Nigerians, the government picked it up and within a matter of weeks or months, had signed the principle recommendation regarding insurance, universal insurance, health insurance into law and that was an amazing achievement by the commission.
GAVIN: It's extraordinary, isn't it? Do you think these are an example of the kind of changes that need to be made kind of to meet some of the asks next year? You know, the ways in which we approach things?
RICHARD: Well, I think what it showed for me is that a, a rigorously scientific piece of work by respected individuals can trigger a political process, which was surprisingly impactful. Uh, now this isn't the only time this has happened. It’s a very good example, but we've seen Lancet series and commissions have an effect on policy and politics in the past, and I think for me, one of the great examples of what a scientific journal can do and why we shouldn't be just a mirror of medicine, we should think of ourselves as actors and even activists in the arena of political debate, we come with a specialist lens on that political debate, medicine, medical science, global health. But these issues are of such profound importance to people in society that I, I think we do have something directly to contribute to those debates. We will make mistakes. We don't get it right all the time. We need to learn constantly. I think if you take risks, you will make mistakes. But I think that the sum total of what we've done over the last 20, 25 years with this work has been enormously positive. And it's our job to optimize it continually for the future.
JESSAMY: We've discussed on this program before as a three, you know, the many ways in which COVID-19 and technology, the way that we interact with that technology, has changed medical research and influenced the way that medicine and research works and its impact on society. You recently wrote, “We have not developed effective means to select, organize, and present new research in a way that optimizes understanding and application.”
And that was in response to the Confidence in Research report. So I just wondered, it does feel a bit of a crossroads, and as you say, we are 200 years old. We are partway there, but there's still a huge amount of work to do. What is the future of medical journals like The Lancet?
RICHARD: You won't be surprised if I say that I have a very optimistic view about the future for The Lancet. I don't necessarily have an optimistic future about all journals. I think in this era of online publication, the, the way most journals operate is that they simply become repositories of new research. And if your journal is simply a repository of new research, you basically impartially publish 10% or 20% of the research that's submitted to you. I'm not actually sure you need a journal for that. What you need is a database that's searchable, freely available and you could collapse literally thousands of journals into a database because most journals are just repositories.
I think there is a place and it’s not just The Lancet, there are other journals too like this, there is a place for a publication that tries, and I really, I'm trying to say this with all humility and not in any pretentious way, but we do try and stand for something. And you know, I'll be the first to say that you may disagree with what we stand for. And that's fine. But we do try and stand for something.
There are things we believe in as a journal, and so when you come to The Lancet to write for us or to publish with us, you are joining a community that has a set of values and a set of objectives, and that's what these asks are partly about for our anniversary year, you come to us with a set of values and objectives.
And you are part of that community. I think there will be a place in the future for publications that carve out a very specific space for themselves because they will appeal to a particular audience. And we are not just a repository. You know, I always hear, you know, people comment about how terrible publication bias is. Publication bias is a really bad. Well I completely disagree. Our job is publication bias. That's what we do. We are biased. We choose things. We choose research, and we choose ideas, and we choose to write based on what we think's important. You may disagree with us very strongly, and that's absolutely fine, and sometimes we will be right and sometimes we will be wrong.
Our job is to be biased. Otherwise you don't need us as human beings. You can have a computer just choosing articles, a proportion of articles. So we react to the world and through the reactions that we have and the values that we have, such as they are, we make the choices we make. And I think there will be a place for a journal that, that has high scientific standards, um, and a clear set of values that it applies to those standards.
So I'm very optimistic about the future.
GAVIN: Thanks so much for joining us for this episode of The Lancet Voice. This podcast will be marking The Lancet’s 200th anniversary throughout 2023 by focusing on the spotlights with lots of different guest hosts from across the Lancet Group. Remember to subscribe if you haven't already, and we'll see you back here soon.
Thanks so much for listening.