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Jessamy: Hello and welcome to a special episode of The Lancet Voice to mark, finally, the end of 2020. I'm Jessamy Bagonall. 

Gavin: And I'm Gavin Cleaver. Welcome to the final episode of 2020. You don't need me to tell you what happened this year, let's be honest, but we're excited to offer you a look back through the story of 2020 via some of the best science published across the Lancet group of journals.

It's been a major and very strange year for everyone here at the Lancet, and it's starting to get very busy indeed when we published on January 24th. The first paper to document the clinical features of patients infected with what was then called 2019 novel coronavirus. Jessamy and I spoke with editor in chief of The Lancet, Dr.

Richard Horton, about how this paper has held up and we asked him, what was it like at The Lancet in January 2020? 

Richard: We certainly saw at the beginning of January that something strange was happening in China, this new pneumonia, and it was being quite widely reported in the UK press with some lurid headlines.

Killer virus, I remember one of them was, and I was anxious about that kind of reporting because the danger of a false alarm or causing panic didn't seem a wise place to be. But then we started getting these papers submitted. And this particular paper, the January 24th first clinical description paper, is actually much more than that, because if you read that paper, the whole of it, everything that's happened in the past 11 or 12 months is actually described in that paper.

Not just a brand new virus for which there's no treatment and no vaccine, but a virus that's causing multiple organ damage, very severe disease, tipping people into hospital and then into intensive care with a surprisingly high mortality. And the paper also then goes on to discuss the consequences, the importance of personal protective equipment, the importance of testing.

And then at the very end of the paper they make allusion to the pandemic potential. That's their phrase of this virus. And of course, we're talking about January the 24th, before the International Health Regulations Emergency Committee has recommended a public health emergency, before WHO, because it was in March when WHO called, Call this a true pandemic before anybody had really grasped the severity and I can remember we got the paper We put it through peer review.

We accepted it and then we published it But it was all happening very fast and I can remember sitting down after we published it and actually, you know in the calm Nothing else going on reading the paper from beginning to end And I think at that point, the penny dropped, that actually this wasn't just another virus.

This was something super serious. And of course, we'd published alongside this a paper describing person to person transmission, and it's amazing now to think about it, but back in January, people weren't even sure about that. And I think then it really hit me that actually, oh my God. I remember putting a tweet out in January around this time saying, have we got enough intensive care capacity to cope with this?

Is anybody looking at this? So yeah, this was the, this is like the index paper for me. This is really time zero where it all began. 

Gavin: One of the things that's really stuck with me is the incredible intensity, speed and skill of the Chinese response. Early on what were your impressions of the early response in China?

Richard: I have two feelings about that the early one and the one now, I think at the time the response that China imposed, which was an incredibly severe lockdown of the kind that you just couldn't normally imagine in peacetime settings. It seemed very draconian. And of course, I hadn't lived through SARS in 2002, 2003.

And in fact, there are several, there have been several influenza epidemics before that. Asian flu in the 1950s and 60s. And I think if you've lived through those experiences, then your society is primed that when something like this happens, when a new virus pops up, you respond incredibly quickly.

So it did look to me very tough. And it wasn't totally clear. How it the virus was going to reach Europe and how it was going to affect Europe now looking back It's extraordinary China's response I mean They basically had this very sharp peak and then this very sharp cutoff and they haven't seen it come back Whereas of course we're now starting to talk about a third wave in 2021 so China's response was primed by their history, but nevertheless Needs to be recognized as stunningly successful and there's a lot we that we need to learn from that 

Jessamy: Richard, I remember just on that writing an editorial with you back in March which I think we called too little too late, but it was just after the WHO joint mission to China had just been published at the end of February, and they talked about this sort of whole of society response and, all of these things basically about the success at that point.

Did you think that was something that Western societies that, the UK, other places in Europe, America could do, or what were your feelings? When you read that report and you saw. That kind of, exactly how you say it, it was so draconian. Did you think this is not going to be able to happen in other countries?

Or what were your thoughts? 

Richard: I think when I read that report, and then also as we, as by Early March, we'd seen that the virus had started popping up in places outside of China and of course was in Italy and had reached Europe via Germany. I think, having seen what the experience was in China and the pressure on the health system and intensive care, It was clear that was the only way to respond, and this idea of somehow a containment strategy that was simply trying to push the epidemic further out in time was clearly the wrong strategy.

So that clearly was this strategy that worked in New Zealand, it was the strategy that worked in South Korea, in China, and we've struggled because we weren't able to do that, but New Zealand was able to do that. So New Zealand is Yes, it's a small country but nevertheless, they were able to have a very aggressive fast reaction and successfully reach a state of pretty much zero COVID.

I think that's one of the lessons to come out of this too, that people talk about should we go for zero COVID, or is it more this focus protection idea? Zero COVID is the only way to maximally suppress prevalence in your population and thereby be able to open up your economy. This, the approach that we're taking now, which is this cycle between lockdown and it comes back, lockdown and it comes back.

It's not even lockdown. It's partial lockdown and it comes back. This is a recipe for disaster because we'll never get out of this cycle because we never suppress the prevalence of the virus sufficiently to. extinguished community transmission. So we really have got the worst of both worlds, but it is possible to do.

We've seen it in democracies. 

Jessamy: No, absolutely. And just pivoting slightly from an editor's point of view, when we started to see all of this research coming in and different stories from around the world, what was your feeling? Did you think, we, obviously it was on the one hand quite exciting and on the one hand terrifying.

Richard: It was just so difficult to keep up with the avalanche of research that was being submitted. And the uncertainty, actually, Jess and me, I think that was the thing that I struggled with, in an early stage, there was this, we were publishing comments and letters about do steroids work or don't they work, you've got your patient on intensive care, do you give them a dose of it?

steroid or don't you? Will it save a life or wouldn't it? This, we didn't have the results of the recovery trial. We didn't know that dex could reduce mortality on intensive care by a third. So there was this real uncertainty. We didn't, all the debate about masks, we didn't know enough about the transmission.

Initially, we thought transmission was very much by droplets quite large droplets. So it was all about surfaces, all about disinfecting surfaces. And it was only really when we got to June that people had started sampling the air in places and realizing that actually these micro droplets could just hang and that the aerosolization of the virus was a risk and therefore mask wearing became more.

So I think what's so difficult is that you're trying to get a grip on what's happening and form judgments about what to do, but the science is changing literally week by week. And that's really hard. And for us, we're trying to make judgments about what's important and what isn't important. And it's difficult because, you have a paper, it might be really important.

But, on the other hand, it might take you in a direction that's completely the wrong direction to go. I found that very hard, and of course the corollary of that was that you're, and this certainly was for me, my entire working life for this year has basically been about COVID.

And I have not had the space to think about, almost anything else. And so there is just like the health system in the first lockdown basically forgot about every other kind of patient with heart disease, cancer, or whatever. And I recognize this is my personal failing. I've not had the bandwidth to be able to think about anything else.

And that's not good for The Lancet. It's not good for The Lancet journals at all. The avalanche of material was just so overwhelming. There was no way to climb out of that pit of papers which was which was consuming us. And it's not as bad as it was, but in some ways the challenges are even more difficult because now we can look up and look ahead.

And I'm worried that we're underestimating the length of time it's going to take to get out of this. And everybody's now talking about all we just have to do is get to Easter next year, and as soon as Easter comes, the vaccine will be out there, and we can all return to normal. And that isn't true.

Now it's about managing expectations, and that's a challenge in itself. 

Jessamy: SARS CoV 2 has not just been a virus that has caused destruction from COVID 19. The pandemic has had innumerable knock on effects, and some of that impact will not truly be computed for years to come. For many low and middle income countries, years of progress in tackling health have come under threat.

On May 12th, the Lancet Global Health published a paper from Timothy Roberton and colleagues, analyzing the early estimates of indirect effects of the pandemic on maternal and child mortality in low and middle income countries. We spoke with Editor in Chief of The Lancet Global Health, Dr Zoe Mullen, about the cost of 2020 to health.

Zoe: Yeah, I think it is difficult without a doubt, and every country situation is going to be different they're going to have different resources, different human resources, of course but I think the key is, and this is perhaps already apparent for low and middle income countries, is not to lose perspective and focus on a vertical issue in this case, one, one infectious disease despite how it occupies everyone's, Mind.

So I think, it's a case of thinking in advance about how an urgent response to something like a pandemic or another emergency can be integrated into existing health services. So not displacing them thinking about women are going to still need to give birth. How can we COVID proof or whatever it is, proof those health services and but also thinking about how these sort of far reaching mandates on transport commerce.

social contact and education are going to affect mental and physical health and what, what's, what would result from that in terms of health needs. So I think a few governments have thought about that. And then also a few people, a few governments have thought about how to communicate the need for all these measures and how important it was.

Not to avoid essential health services because it disruptions aside to whether or not the health services are actually there. I think it's pretty clear that a lot of people have just been making their own decision not to attend. So communication is really important. And so in terms of a balancing act, that's something that can be done without the need to balance something or another.

That there's no excuse for not communicating well in, in times like this. So I think this balance, can be maximized by broad consultation across almost all sectors and working out how this is going to be managed. And of course, that well, thought out communication strategies.

Gavin: I think one thing that's really worth highlighting is that it does seem like a lot of lower middle income countries have coped admirably with the pandemic compared to high income countries. And it's quite. Intriguing, given that high income countries have thrown so much money at this problem.

Why do you think that lower middle income countries have seen this kind of relative level of success in dealing with the pandemic? 

Zoe: Certain examples have, are amazing. If you look at Vietnam, for example, this is a lower middle income country. It's only seen 35 deaths for a population of 97 million.

And you compare that to the UK. It is a stark contrast, but Vietnam was one of the first countries to be hit by SARS in 2003 so is in many ways prepared. So the population was already familiar with mask wearing and isolation procedures, but the government there also took very early action on border restrictions.

Took testing, tracing and isolating extremely seriously and, enacted it extremely successfully. And they also instigated a really creative public education campaign. So this is a sort of, a perfect example of how to manage a situation. And this is a low middle income country with, not all the resources that we have in the West to throw at things.

Then Mongolia, which has. the largest border with China of any country. It hasn't seen any deaths at all. We published a health policy piece on how this was managed back in July. But that also showed that like for Vietnam, early and aggressive strategies, including travel restrictions, active surveillance.

And quarantine mandates for incoming travelers were really taken extremely seriously by the government. The quarantine was managed not in people's homes, where I think we all know it doesn't always go very well. People aren't too good at complying with it, and they don't really understand maybe, or they're not supported.

in, in, in actually being isolated from other people. So in, in a lot of low, lower income countries, where you can imagine that the the home situation is very difficult in terms of trying to isolate. You're living in a small place probably with a large perhaps extended family. How are you going to reasonably isolate from those other individuals?

So that, so a lot of lower middle income countries particularly have used quarantine camps. So people who are quarantining or who have mild symptoms of COVID are are cared for in in quarantine camps. And you can say maybe, this type of thing isn't going to work elsewhere.

But if you think back to last year, would we in the West be thinking we'd all be wearing masks in supermarkets? We would have laughed at the idea, so I think, taking very, what seemed like drastic measures have undoubtedly worked in some low income countries. Mongolia closed their schools very early, actually.

But what I think was wonderful was that they introduced a distance learning program via state TV. So all these kids were sitting at home learning via the TV and, most, most middle income countries population may have a TV. And so the, and the state was providing the education.

I thought, and I thought that was wonderful. 

Gavin: Yeah, some great successes there. And I think it's really important that high income countries actually learn a lot of lessons from from these low and middle income country successes. Because, in lots of these countries, life is carried on in a far more meaningful way than it has has in a lot of high income countries.

Really important to highlight those successes just to sum up then. 2020 has been a kind of difficult year generally, but what have some of your highlights been and what are you looking forward to in 2021 as well? 

Zoe: I don't know whether this is a highlight, but we just, we've just seen a massive increase in submissions this year which is wonderful.

Of course, I guess every journal wants to see more submissions, but I think we've had, we've probably got four times as many papers come through the system this year as we did last year. Absolute kudos to the researchers out there who have been Working themselves to the bone to produce this work in a really difficult situation.

And of course, to our reviewers as well, who often are the same people doing the research, for turning around some of these papers in a matter of days, I don't, I can't, I don't have the words to express my admiration really. But it's just been wonderful to be part of that.

I'm also massively grateful to my team, everyone around me in the Lancet journals, how we've all pulled together and. Managed to work through all these massive changes. And I think what's so we've all obviously been moved to working from home. And I think what's, what is one positive thing that's come out of this this pandemic is the fact that organizations have now come to appreciate that people have lives.

And that now working flexibly is okay and it works and it should be the, it should be the right thing. So I think actually that's a positive and a highlight that's come out at this year. But I think of the most obvious highlight is the just amazing collaboration, dedication, and sheer hard work and determination of all those researchers working on the COVID vaccines.

That we've now got three extremely promising vaccines on the brink. Of actual deployment in countries is absolutely unbelievable. And that's just so exciting to hear. So next year, I think, will be a year of optimism, I hope, with the vaccines as I say, on the brink of deployment.

I'm looking forward to having a few launches of some nice, interesting projects that have nothing to do. with coronaviruses in the title. And being, being able to focus attention a little bit more on, on some of those other issues. 

Gavin: With disease, lockdowns and worry, 2020 has not been an easy year for mental health.

Indeed, the knock on effects of 2020 on mental health could be felt for some time. On July 21st, the Lancet Psychiatry published an article looking at the potential impact of the COVID 19 pandemic on population mental health. We spoke with editor in chief of the Lancet Psychiatry, Dr. Niall Boyce, about the problems for mental health that this year presented.

Niall: So this is a study which has been going for many years, and it uses a very well validated instrument for looking at mental health. And this is something called the GHQ 12. Now it's maybe not the most It's not a precisely diagnostic tool. It asks questions relating to general well being and asks if you're feeling them a bit more or a bit less.

But it's generally a very good way to get the sort of snapshot of how people are feeling. To reiterate, first of all, this is a project which has been going a long time, so we can really put people in context. The other thing is that it's using an instrument that we're all very familiar with, we know how it works.

And then finally, of course, it's got quite a lot of people in it. The UK Household Longitudinal Survey has normally got around 40, 000 households in it, which is around 50, 000 participants, and when it came to getting people from the survey to participate in this particular bit of it, which was a web based survey on the response to the pandemic, they managed to get around 17 and a half thousand.

So if the eligible people that was about 41%, which isn't actually a bad response rate, all things considered. So it's longitudinal. It's got good numbers. It's got a. a pretty familiar instrument and I think that we had faith that this was going to be as good a reflection we could get as to what was happening before and what was actually happening during the first month of lockdown.

Thanks 

Jessamy: Niall, so could you tell us what exactly it showed and what the implications are? 

Niall: Okay, the first thing to say is how The researchers chose to use their measure. So the GHQ 12, as I said, is essentially a short form questionnaire. And it's questions based around things that we'd say relate to general well being.

So things like mood, things like motivation, things like sleeping. And they've got that. Two outputs from this, one of which was that they dichotomized the score, so they had a threshold cutoff above which you'd be considered to be having what you call clinically significant mental distress, and the other thing was just the mean of the scores.

With that in mind the amount of mental distress which they treat as clinically significant went up in the years before the pandemic to the lockdown, that was an increase from 18. 9 percent to 27. 3%, so that's quite a jump. And then if you just look at the mean of the GHQ scores, that went up from 11.

5 to 12. 6%. So that may be unsurprising that during a novel virus emerging, which if we cast our minds back, we didn't know then how vulnerable people were. We didn't know what was going to happen in terms of food supply chains, in terms of jobs. Things were just so uncertain. Vaccines were this sort of distant glimmer.

I don't think anyone was really seriously thinking of them. So maybe it's unsurprising that people would be unhappy and would be stressed under those circumstances. But what's interesting when you then dig down into those data is that you find particularly vulnerable groups, and those vulnerable groups were the young, so people aged 18 to 24 and 25 to 34, women, also people with young children, and interestingly, people who were employed before the pandemic hit.

I think that if we look at these groups, we can begin to hypothesize why these are particular demographics which would find this whole experience particularly stressful. 

Jessamy: So when we talk about clinically meaningful, what do we mean in this context and What then does that tell us about, potential ways that we can combat some of the stress that people have been under during the pandemic from a mental health point of view?

Niall: Clinically meaningful is essentially that very imperfect borderline between what Freud would have called normal human unhappiness and something which might respond to professional assistance, professional treatment. But of course this is a very imperfect thing. I have to stress that this questionnaire, these tools were really looking at the kinds of disorders that we call anxiety and depressive disorders rather than psychoses or anything like that.

And with the kinds of problems that I'd say would fall into this category, they do respond pretty well to psychological therapies, in some cases to antidepressant medication, and so they, they give an indication as to what services might need to provide. One of the very interesting things about mental health in this pandemic is that for many years, people have been talking about digital mental health and it's never quite taken off.

But in the first couple of weeks and months of this pandemic there was a huge increase in the digital delivery and people experimenting and trying things out with the digital delivery of mental health services. And I wonder if this is one maybe positive. Legacy of the pandemic that mental health services will be made available to more people than ever before will be able to get to people who previously wouldn't been able to access them.

That's maybe something for the future. And certainly, if you were to look at a way to fill a treatment gap quickly, psychiatrists take a long time to train mental health nurses take a long time to train. What you want to do is to use what we know and to deploy it and digital is just great for that.

Do 

Gavin: you think in the long term we'll see more services delivered digitally as a result of this, permanently? 

Niall: I think that is very likely to be a permanent change. I think especially if people find this an acceptable way to receive services. I have some concerns in that I think that there are certain individuals and certain diagnostic subgroups where really you do need that degree of personal attention and you need to almost get people out of the house.

So it's not, to use the cliche, one size fits all solution. But in terms of being able to deliver services to places which are maybe geographically remote to people who find it very hard to attend appointments in person, there's absolutely huge potential and huge potential in terms of global mental health as well as data networks, wireless data networks develop in low income and middle income countries.

Gavin: What kind of history is there of mental health research and the effect on mental health of global events like this? 

Niall: It's been, a more recent concern, and when we look at global events, of course the big crisis we tend to think of are the world wars of the last century. And in those cases, I think most of the attention that was paid to mental health was to do with combatants.

However parallels have been drawn between the current pandemic and the situation of people in the UK and specifically people in London. During the blitz of the early 1940s when London experienced very heavy bombing and many casualties. We published a paper which was reviewing and comparing and contrasting those situations by a historian who's.

based at the Institute of Psychiatry, Psychology and Neuroscience called Edgar Jones, which showed that many of the sorts of concerns which are expressed about the way the general public react many of the the sorts of things that people experience are actually quite similar. So I think that we can learn from the past.

I think we've got to be very careful about thinking that things are completely analogous, but certain things do seem to be. quite similar. For instance, people's deep attachment to home and the fact that when people are very stressed by these situations, there does seem to be this kind of homing instinct that kicks in.

People tend to feel that they've made certain sacrifices for a greater effort and they have to feel that's valued. And I know that Edgar and his paper was, a little bit unsure as to how people would respond. On to further lockdowns. And indeed, I think that we've seen maybe a bit more of a sense of fatigue and a bit more pushback against the second lockdown.

So there are certainly things which we can learn from historical situations, which can inform the present day. 

Jessamy: Nile, there have been so many sort of negative things about the pandemic and obviously it's been must be, very challenging as an editor in chief. dealing with all your submissions and working from home, et cetera.

But what were the highlights for you over the last nine months? 

Niall: I think that the thing which you can sometimes feel as an editor is that you get a lot of research submissions, you go to a lot of conferences, and sometimes you worry that research is being done for the sake of research. The conference presentations are being done for the sake of conference presentations.

And that's, by no means, applies to everyone, but it can be a feeling you get that this whole business of research can become detached from the actual need. I've been really impressed by the fact that almost as soon as it was clear how big the pandemic was going to be, I was contacted by researchers with the Academy of Medical Sciences, with the mental health charity, MQ, who were just so keen to Do research and to conceptualize research in a way that would help with this pandemic and really help with the legacy for future events like this.

So that ended up in the form of the position paper which we published in the Lancet psychiatry earlier this year. So one of the good things for me has been to see a real reattachment between researchers and the communities which. They wish to serve. And I think as well as that, there's just so much more awareness now of the importance of lived experience.

And, I'm seeing more and more of that in terms of research, in terms of the way that research is talked about and planned. And of course, the fact that we're all on Zoom and accessing these things remotely means that the big financial and transport barriers to do with conferences are no longer there.

So people can be part of the conversation wherever they are. And this is something which has been great with the webinars, which Lancet Psychiatry has been doing with United for Global Mental Health, where instead of having one big conference once every year, once every two years, where people have to spend money to register and they have to travel there and they have to spend days there, they can go on Zoom or whatever program they're using, once every fortnight for an hour and be part of a global conversation which is just constantly updating and that's been I think a very positive development and I hope it's one that continues as and when things return to normal.

Jessamy: A key aspect of the past year has been society's reliance on frontline workers from the medical professionals who ultimately tackled the virus at great personal cost to those who had to leave the relative safety of their houses to keep countries running. A July 31st paper from the Lancet Public Health looked at the relative risk of COVID 19 for frontline health workers compared to the general public.

We spoke with a senior editor of the journal, Dr. John Carson, about what 2020 told us about key workers. 

John: The effect's been pretty devastating on frontline workers in a lot of ways. Not only as this paper shows, they're exposed to greater risk from the disease itself, but also just the strain that they've been under must be terrible for mental health and resilience.

I think it's, I think we already had massive respect for healthcare workers in a lot of countries, but this has just reinforced it. But then it's also raised some issues around the way that we look after and support healthcare workers, so the paper, some of the things that it highlights is one, not only where healthcare workers are much higher risk of contracting Corona virus.

But one of the key issues was the availability. This was in the early stages in March, April of the disease. One of the key issues was the availability of adequate protective equipment, which was inadequate at that time in a lot of countries. We know when we're watching it from the UK perspective. Yeah.

So I think healthcare workers have been under the additional strain of dealing with this concern they must've had. about having to reuse or not having PPE available. Concern for themselves and concern for the patients. 

Gavin: Yeah, as we say, it's forced them to put themselves in harm's way, really. In public health terms, what lessons do you think we can draw from the way this pandemic has been handled?

Of course, you mentioned PPE there, and that's something that I'm sure will be more at the forefront of people's minds in future. Yeah, what are the kind of broader public health lessons do you think? 

John: I'd say a few key things that we've learned, well with regard to frontline workers and healthcare workers, in a situation like this, financial support is vitally important.

And as you said, we've seen that people that work on the frontline, so people Working in, in essential roles, key worker roles have been especially exposed to this disease. And I think it's become clear that if you want people to be able to follow public health advice, then you need to provide them with the financial support and the situation to be able to do that.

And that's not been the case in all countries where it was probably financially possible to do from a public health perspective, I think this pandemic has So I've shone a light on something that was already known, but the inequalities in health and exposure to risk so that there are inequalities there in terms of the fact that these people that are working in front leading roles, not just healthcare, but working in supermarkets, working in delivery and logistics and stuff, they were out there putting themselves at risk and they faced a disproportionate risk to people like us who could work from home.

I work away from offices in terms of broad public health. There are a lot of lessons to learn hopefully from this experience. In the early days of pandemic, what struck me was that from a political level, at least a lot of countries seem to approach it. at a national level and there wasn't the degree of international cooperation from governmental level public bodies that and from politicians that I might have expected.

It seemed very odd to me that different countries seem to be approaching this in their own special way. rather than trying to coordinate action. But then more specifically, so we can probably learn lessons from some of the countries or some of the places that seem to get it right on coronavirus, although it's always a very difficult thing to do, places like Taiwan, Singapore.

Germany to an extent and Hong Kong. We actually published a paper tracking the coronavirus response in New Zealand. And that was an exemplar of how you have a robust public health response to a pandemic like this. And some of the key lessons that came from that were acting early, taking it seriously, almost overreacting to an extent having clear and consistent public health messaging from leaders.

And also showing that politicians and the public health experts were working hand in hand very clearly. Some of the work from China also suggested that one of the keys to them being able to tackle the pandemic there was it had very good local public health systems. And that was almost, yeah, that was very important to the way that they address coronavirus in China, having the local public health capacity and be able to disseminate advice.

in that way. And then I suppose taking the public along with you just from an outside perspective again, but you look at somewhere like New Zealand and Jacinda Ardern and her government. And I think it was obvious that they really tried to keep the public up to date with what was going on and what their plans were.

And in that way, they probably carried a lot more public support in terms of implementing the measures. than other countries necessarily did. 

Jessamy: Thanks, John. I was just wondering whether we might talk a little bit more about the paper. So this was obviously about frontline healthcare workers, the majority of which are female.

And I was just interested to hear what you would like to see in terms of data and research coming through. Obviously, Healthcare workers are extremely important, but as you've mentioned previously, they're not the only frontline workers. There's grocery shop workers, there's the informal care UK.

There's also, informal care in nursing homes and elsewhere, all of which we have very poor data on at the moment. What would you like to see in the coming months? or year in terms of research on that population that would answer some questions for us, particularly about, what the sort of gold standard is for protection for them.

How we're going to implement mass testing potentially in these, in this population. What's your view? 

John: As you say, the study that we published on healthcare workers was using data from an app, so it was almost live data that was being collected early in the year, which is great in some ways because it was massive and it was fast, but it also has limitations because the sample was self selecting.

It used people were confirming their symptoms and their tests. themselves through the app, et cetera. So there are some limitations, although it was a good piece of work for the time that it was done and what was available. So what we hopefully will see in the future is retrospective analysis of all the data that's been collected over the course of the pandemic which should be much stronger in some ways hopefully be able to link those with, healthcare records. So then we might be able to explore in greater depth and more confidently the underlying vulnerabilities or the associations of vulnerabilities to this disease and infectious diseases like this. In terms of the key questions, I think it's so broad in terms of what we need to learn from it, because obviously we need to learn about how we improve responses to infectious disease and the symptoms and stuff like that.

But also there's just an awful lot of social science that probably needs to happen or social medicine, the science that needs to happen in response to this. Because again, we've seen, it's just really highlighted the kind of fractures and the inequalities in people's health and people's ability.

to be healthy. Those are the kind of lessons that we could hopefully learn from this experience. But it'll need, I think, interdisciplinary work from people that work in health and people that work in public health, but it needs to touch on things like psychology. It definitely needs to touch on economics and sociology and other social studies as well.

So that, that's the kind of cross discipline, what disciplinary work that I'm hoping to see further in the future. 

Gavin: It's fair to say that for a lot of countries, the COVID 19 pandemic has been a completely new experience. Of course, with every new experience comes the chance to learn some lessons.

How will countries deal with a second pandemic, should such a thing occur? What will we all do differently next time? On September 24th, The Lancet published a paper from Emily and Han and colleagues outlining the lessons learned from the easing of COVID 19 restrictions over the summer. We went back to Edison Chief of The Lancet, Dr Richard Horton, to ask him What are the big lessons we've learned from 2020?

Richard: I think for the past 40 years, our approach to society is one of efficiency. That we've created a just in time culture, that we've been very concerned about driving down costs. All perfectly good. reasons behind this drive for efficiency. But the problem with efficiency is that when you have an immediate crisis, you've got no capacity to absorb the shock.

And that's what we found with the first lockdown. So It's building a resilient system, which means that you do have embedded in your society sufficient capacity to think that if a shock comes, you can carry on doing what you were doing, and you can absorb the shock. We often say the NHS Succeeded during the first lockdown.

It clearly didn't because patients with heart disease and cancer and so on and so forth got absolutely no, no support. So that's number one. We need a resilient health system. David Heyman puts it very nicely where he says global health security equals individual health security.

Individual health security means universal health coverage. And. a sufficient capacity to be resilient. But that's the lesson for other countries as well. And, we've often made the case for universal health coverage on grounds of rights of health and health equity, all of which are morally correct.

But now we have another argument which actually is even more powerful in many ways. And that is that national security economic security, actually depends upon having a health system that can protect against these pandemic shocks. That probably is one of the most important lessons that comes out of this, that your health system is actually an instrument for security.

Do 

Gavin: you think this sense of resilience is something that we've not really thought enough about in the past? It's slack, built into health systems. 

Richard: Not wishing to be overly political, but I think what we've witnessed in the past 40 years, since the era of Margaret Thatcher and Ronald Reagan, is this rise of neoliberalism.

And the core idea of neoliberalism is rolling back the state and allowing the market to resolve. All of the tough decisions in society and rather than the state intervening the market is the arbiter of the allocation of scarce resources. Now, that intensification of the market in our society really has been the direction of travel since Thatcher and Reagan.

I think what we've seen with COVID 19 in the most dramatic terms is a rebirth of the state. In the United Kingdom, we have a conservative government that spent more in a year than Labour governments did over their entire time in office. Now that is telling you something important, that the state has a central part to play in protecting the lives of its citizens.

So when we come out of this, it's not about going back to where we were before, returning to normal. There is an opportunity for a reset for an alternate society where we restore the balance between the state. and the market. And it is the death of neoliberalism. It's the end of an economic era which certainly brought benefits to a very small proportion of our population but did not distribute them equally.

And now is a moment where we can really have a kind of revitalization of a national vision for the kind of society we want. And that's the conversation we need to be having now. We're not having it yet, and that's because we're still in the middle of the pandemic, but it's a conversation that we must have.

And it's not about, I don't like the phrase building back better. It's about, Thinking about the kind of society we want to live in, what we owe to each other, and that's the prize, in a way, that we can take out of this terrible tragedy. 

Gavin: Do you think it feels a bit like history has happened very fast this year?

Richard: Yeah, that's a great way of putting it, actually, yes. We are living through history, and it's hard to make sense of it. I think the difficult thing to do is to separate yourself from the melee of the day to day activity and pause and just think about what all this means. What have we actually learned?

And sometimes, you, sometimes I do stop and try and just say, okay, let me, let's just think what have we learned from this experience that we need to take forward? It's, it's not easy to do, but I think we have to do it. And politically, we certainly haven't done that yet, but we have to encourage that national conversation.

Jessamy: I couldn't agree with you more, Richard. I think we've been having similar conversations and I actually feel quite hopeful about it in a way. I don't know whether you do. 

Richard: Definitely. I'm broadly speaking a very optimistic person about most things in life and I do feel optimistic about the possibility.

I'm not very happy about the way we were managing the debate about the vaccine. I'm not very happy about the way we're managing public expectations. I'm not very happy about the way our multilateral institutions have led on the pandemic, but I do think that the public has been mobilized and certain politicians have been mobilized in a way that does give us the possibility of a different conversation.

Jessamy, this is going to be up to us. We've got to, and I mean us as citizens, we've got to lead this. It, it can't be government that does this. It's got to be us that demands of government. A different future, and we haven't started to see that yet. But I think over the next six months that's got to become a bigger priority.

If you had 

Gavin: 2020 again, Richard, what would you do differently? 

Richard: If I'm honest, I would have tried to do more to get the information that we published out to the public. Just to give you an example. Normally, on Twitter, the people you end up talking to are people in your own little narrow circle which for me was very much the medical and public health community.

But this year as the, as we were publishing all this material I suddenly found that the groups I was interacting with were much more about the general public. And they were asking questions about what was safe, what wasn't safe, what treatments to use, what treatments not to use, masks, physical distancing, what was the evidence for all this.

And I think that there was clearly a massive appetite amongst the public for reliable information. What I would now do if I was rolling back ten months would be to think about a way of translating what we were publishing into information that was understandable by the public. And we didn't do that.

And we didn't do it because we didn't have time. But also, we didn't, I certainly didn't think about that. But actually, I think at a moment like this, the public needed to see what the evidence was. We had these crazy debates about two meters or one meter physical distancing, eye protection, no eye protection.

We were publishing a lot of work summarizing the evidence on this so we could have done more to get that out there for the public. One of the other observations about this year is how central science is in our culture. We tend to define culture as the arts, the humanities, theater, music, and so on. But what we've seen this year is that science is an absolutely crucial part of our national culture.

That means that scientific institutions, and we are one of those institutions, need to take more seriously our public responsibility. We're not just here for other scientists or doctors or health professionals, we're here for the public. And that means there's a responsibility on us about how we translate what we publish for the public.

So that's probably my biggest takeaway from this year. Why the public duty? 

Gavin: I was going to ask, 2020 is almost over. What are you looking forward to in 2021? 

Richard: It will be important to roll out a vaccine. My concern about that is that even if we do have a vaccine rolled out in the first four or five months of next year to scale it's going to take longer than four or five months to extinguish this virus.

The virus does reinfect people, so it is endemic in our society. We don't know the duration of protection of the vaccine, so it's going to take a few years, actually, to get to an equilibrium where we've reached herd immunity. For a virus that's got a reproduction number of 2. 5, that means you've got to get to about 60 percent of the population to achieve herd immunity.

If it's 90 percent effective, that means you've got to get to about 67 percent of the population to get to herd immunity. That's quite a high percentage. And remember, every year in the world, there are something like 130 million children born, so that's a new cohort that has to be, that's going to have to be vaccinated, because that's a new, 130 million susceptible people.

So it's a, this is a, still a massive challenge. If it's, if 67 percent is the figure for herd immunity, That means, worldwide, that means five billion people are going to have to be vaccinated to get global herd immunity. That's a big deal, isn't it? That's a massive ask. I'm not saying it's not possible, and I'm optimistic, and it's great we have a vaccine, or vaccines, but let's not underestimate the challenge because the challenge is huge, and it's actually going to take a few years, not a few months.

Gavin: Finally, it's been a big year, as you would imagine, for the Lancet infectious diseases. We spoke with Editor in Chief John McConnell about his year and we asked someone that handles research on infectious diseases every day. What stuck out for you? 

John: I think the thing that sticks out for me is how we've managed to handle such a huge increase in the number of papers submitted to my journals, the Lancet journals in general.

And obviously the vast majority of those have been about COVID 19. In fact I was looking at the NIH website which coordinates all publications on COVID 19 and they were counting over 80, 000 papers and preprints on on COVID 19 as of last week. 

Gavin: Have you been surprised this year by the kind of failure of Western countries to control the virus more effectively?

John: I've been disappointed. by the lack of coordination between policies. I think the WHO gave some reasonably, fairly clear advice early on. And that advice has not always been taken. And I think perhaps the most disappointing thing of all is if you if you go back just a year and you look at the analysis that were being done at that time of the most prepared countries for a pandemic.

The most prepared countries were the United States and the UK. But certainly the United States has done worse of all. And I think the UK is about number six in the total number of cases. So those which by all reasonable measures appear to be prepared, didn't actually implement that that preparedness.

Gavin: What have been some of the positives that you might take from 2020? 

John: I think the most positive thing of all is to show just how quickly the scientific enterprise can move if, when there's sufficient motivation. So to go from sequencing a virus to having a Having completed phase three trials and having a vaccine which has been approved at least in the UK and is probably not far away in the USA, in what is it, about 300 days or so?

That is absolutely unprecedented. So we can come together. And we can do amazing things in a short place of time if we're sufficiently motivated. 

Jessamy: What do you think this will mean for research in the future, John? 

John: Yeah, it's tricky because there's, peer review has definitely speeded up for COVID related papers, but the little analysis that I've seen indicates that is at the expense of it having slowed down somewhat for non COVID related papers.

So I'm not sure that we can maintain this speed of publication, but on the upside preprints have become at least in the outbreak related disciplines, preprints have become an accepted norm. And I would like to see that continue because I think they are very valuable in getting information out quickly.

By and large, they do lead to published papers. I heard Richard Seaver say, who was one of the co founders of bio archive and meta archive that he reckons over a period of about three years or so that about 80 percent of preprints do become published papers. And I think preprints are also valuable, at least in the setting we've seen for the past year, in getting value, useful comment to improve papers before they get to the journal stage, the formal peer review stage and also in, in weeding out a few complete duds.

There, there have been a few complete duds but the side vig process has mostly worked. And they have not gone forward and you have to say at the same time journals have published a few complete duds as well. So we're not innocent in some of the missteps that we, the journals have taken with publication, but we've been working very quickly under extreme pressure.

Gavin: We, we've talked already about the positives you take from 2020 if 2020 were to happen again, God forbid what are some of the lessons that you would take? 

John: What would you do differently? Both a positive and a negative has been the way that research that we and other journals publish has been disseminated via social media.

So I reckon, just looking at the Lancet infectious diseases, There has been a tenfold increase in social media interactions related to the papers that we publish. And that is absolutely fantastic. That means that what we publish is reaching a much broader audience. But on the downside, some of that information is being cherry picked.

By people with an agenda. It is being willfully misinterpreted by people with an an agenda. And as a result journals and editors now are being abused for the material that we publish. And I don't think that should be any part of the scientific di discourse. So the social media reach has been both a strong positive and it chimes quite a troubling negative.

Gavin: Yes, there's a lot of a lot of bad faith arguments going on out there, isn't there, on social media that have been, it's it almost feels it's come as a surprise to the scientific community, in some ways, the extent to which these issues can be manipulated on social media. 

John: Yeah, there's always been just thinking of the Lancet specifically, there's always been a few papers which the Lancet have published which have attracted attention never ending attention on social media.

But there's never been the sort of broad scope of attention that we that we get now on social media. And I think of one particular example where where perhaps we could do more to present the evidence more clearly and actually fight back a bit more is the this whole argument about do lockdowns work or not.

Now, one of the journals in our stable as e clinical medicine published a paper many months ago which had some evidence of a lack of effect over lockdowns. And that particular paper. is being waved as a flag quite vigorously by the people who don't believe that lockdowns work.

What, but at the same time, they are ignoring the mass of other information that we and other journals have published which show that lockdowns do most definitely have an effect in reducing the rate of new infections and which, of course, a few weeks later leads on to deaths. And I do wonder why or whether we should not at times as journals intervene a little bit more proactively in this, in these arguments and say, yes, okay, we published this paper but science emerges by consensus.

And this one paper is an outlier in the consensus view. 

Jessamy: Thank you for listening to this special episode of the Lancet Voice. And thank you for listening throughout 2020. Let us know what you're looking forward to in 2021 by dropping us an email at podcasts at lancet. com. We'll see you next year for some more stories about health from around the world.