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Gavin: Hello and welcome to the Lancet voice. It's basically Christmas 2021 and I'm Gavin Cleaver. For our last podcast of the year, we've got editor in chief of the Lancet, Richard Horton on to chat with me and my co host, Jessamy Bagnall. We'll be covering a look back at 2021 and peering into the crystal ball of global health for 2022.

Before we get to that, I just wanted to say how grateful we are to have so many of you from around the world listening to the Lancet Voice this year. And we'd love to hear from some of you about what you'd like to see in 2022. You can contact us on podcasts at lancet. com or just tweet me and Jessamee.

Our Twitter handles are our names, that's at Gavin Cleaver or at Jessamee Baganal. With our thanks out the way, let's turn straight to Richard Houghton, Editor in Chief of The Lancet, in conversation with Jessamy and myself.

Jessamy: Thanks for joining us, Richard. It's been such a busy year geopolitically and from a research point of view. Could you discuss some of the highlights for you and anything that we published that you think has really Influence these. Thanks, 

Richard: Jessamy. Yes, it's incredible to think when we were closing out 2020, we'd only just published the first paper about a vaccine.

So it was the paper from Andy Pollard's team in Oxford looking at AstraZeneca vaccine and it was we were all super excited about it. And so this year has really been the year of vaccine rollout. But also the year of variants and I think in a way we've almost been in this struggle between these two forces of getting the AstraZeneca vaccine, the Pfizer BioNTech vaccine, and then all the other vaccines out in terms of clinical trials.

And across the Lancet journals, not just the weekly, but infectious diseases and others, we have had just a ton of trials at different stages of development published, which have really shown the immense ability of the scientific community worldwide to respond to this pandemic. But then, of course, as we've had the vaccines rolling out, we've had Variants, alpha, beta, and then of course really 2021's been the year of delta if we'd been talking a week ago I'd have just said it was the year of delta but now it's the year of delta and omicron we're still in the middle of some flux about this, but that's been the, I think that's been the tension during the course of the year, chasing.

The evolution of variants with the vaccines. Now, at the same time we have also had some I think, papers which have shown perhaps a light on the pandemic, which we haven't paid enough attention to in the public discourse. And the one that I really want to underline is around mental health.

We've been, understandably, and I'm not being critical here at all, we've understandably focused on deaths. We've understandably focused on the morbidity, serious morbidity that the virus causes. But I think we've focused less on the extraordinary impact of the pandemic on anxiety disorders and depression.

And we did publish a paper during the course of the year which showed a dramatic increase by about a quarter of prevalence anxiety and depression and in a way that's the shadow hanging over society as we struggle with this and as we go through this whole Omicron phase now that's going to take over around the world, you can feel it.

You can feel the sense of, oh, my God, society is going to close down again. Here, we're talking in the UK about end of year as we approach the holidays, and people's plans for having gatherings or parties or get togethers or end of year celebrations. They're all being squashed. So you can see how this is really having a dampening effect on people's lives.

And, this is a year where normally families would travel and get together. Maybe not now because of this new variant. So I think that the mental health dimensions I would really emphasize. And then one positive. Because I don't want this to be all negative. One positive, there has been, and it is controversial, but one positive I take from this is that the pandemic has accelerated the way we think about the delivery of healthcare.

And we published a paper during the course of this year that was looking at telehealth. in the way that antenatal care was delivered in Australia. And this way of having a remote, you don't have to pitch up to your doctor to have a consultation. And this was phenomenally successful in Australia in providing antenatal care.

And really gives us the opportunity to rethink models of care. Now, of course, in this country, in the UK, there's become a huge fight between the government and general practice with government ministers accused and the press accusing general practitioners of refusing to see patients and the only face to face consultations are worthwhile.

That's just And I'm glad that we were able to publish some evidence that supported that. Yeah, I would say it's been a mixed year, but there have been some bright spots that we should cling on to. 

Gavin: Do you think we might look back as this is a leap forward for telehealth? This, the pandemic, if we're looking back at it, like for a silver lining, like you said, that maybe this will be the point at which telehealth became a kind of more accepted solution for healthcare.

Richard: Oh, absolutely. I can tell you the I've had the opportunity, let me put it like that, to have some first hand experience of this. And it's actually been fantastic. You have audio appointments, you have video appointments the IT systems in In hospitals have all been upgraded so that you will get text messages that then give you links to facilities where you can have your video appointments.

This is really remarkable. You can get medicines then delivered. to your home. You don't even have to go to the pharmacy to pick things up. Within the space of 12 to 18 months, we've almost taken a decade and contracted it into that time frame. Mainly because we had no option. If you were going to deliver any sort of care, you, there had to be a step change.

And, All credit to health systems. Of course, this is mainly in high income countries we're talking about here, but all credit. It has been a phenomenal transformation of culture. And I think we should be celebrating it and praising it, not looking for reasons to knock it down, which unfortunately some press have done.

Because I think for the vast majority of people, It's been a positive experience. Now, it hasn't been perfect and you can't replace face to face consultations completely with remote consultation, but it has a very important place, and I think we will look back, actually, Gavin, yes, we will look back and think of this as a pivotal turning point.

Jessamy: and you can see, can't you, opportunities to triage patients and to be able to strategize about who needs to be seen face-to-face and who doesn't. And there's an enormous opportunity there to for sort of resource change and to move things around. But moving on, what would you say you are most surprised about by this year?

Richard: I tell you the thing that I am a little surprised about and that is, and this is the Lancet as an organization here, because the story of the origins of SARS CoV 2, which You know, we published those first papers in January 2020. But we've got drawn in to the political debate around where did this virus come from.

In a really remarkable way. And there have been one or two news outlets in the world that have zeroed in on the Lancet. And our, the part that we allegedly played in that whole story. And The Lancet has got itself involved in that because we've published so much on, on the pandemic. So I think I'm a little bit surprised that's a story that's continued.

Because the lesson we have from AIDS was that trying to trace down, to track down, the origin story of a virus, patient zero is a fool's game. You're never going to do it. It's impossible. And if you try and track it down, you try and track down who was the first person, where was the first place that a virus came from you'll get it wrong.

We got it wrong in the story of AIDS and we'll get it wrong in the story of COVID 19, and you actually cause a lot of damage as a result of that. So I'm a bit disappointed that this story has had legs because we haven't learnt the lessons from the past at all. 

Gavin: And if you look at it in terms of mutations, there are actually quite a few patient zeroes, are there not?

When we're thinking about the different mutations of the SARS CoV 2 virus, for instance, we were just, we just speaking with Salim Abdul Karim this week and talking about how potentially the Omicron variant could have come from a different patient zero, someone who was immunosuppressed in in Africa at the time and couldn't clear the virus.

It seems, I don't know, it seems to me to 

Richard: we don't even, Gavin, we don't even know it came, if we say came from. Everybody's saying it comes from Southern Africa. We can't even say that. All we can say is, we identified the Omicron variant in Southern Africa from Botswana initially.

That just could be chance. It could have been, it could have been down the road from where I am now. That could have been where the origin was for the very, we have no idea. And this is why the travel bans and the blame game and it's just crazy. And, I think, I've been in this.

In this game for 30 years or so. And we never learn the lessons. Maybe, you're asking what's the most surprising thing, Jess? Maybe that's the most surprising thing. That we go through these cycles of outbreaks regularly. And yet we still make the same mistakes and you know this is a, this isn't good news for the future because it's a fundamental human flaw that we seem not to be able to learn lessons and that we continue to make those mistakes and you know we will have more.

epidemics, pandemics, and we have to find a better way of learning these, learning from these. 

Jessamy: And do you feel that they're, that these mistakes that we're making is a sort of confluence of factors both from the scientific community and from the sort of general media community slightly feeding off each other?

Because this sort of term of anti science, which is wrapped up in this origin story, because it's so polarizing and so political, really, comes in there. I'm just interested to understand how you see this relationship working and what anti science is, what we can do about it, and what that means for the origin story.

Richard: I, I must say, I have been surprised. So this is another surprise. I have been surprised at how the science of the pandemic has become so politically polarized. You're now, if you're against masks, the likelihood is you're a Republican or Libertarian. And if you're for masks, then you're more likely a progressive.

Socialist and you see these polarizations played out in the US Congress in the Houses of Parliament in London across all European capitals. It is remarkable, isn't it? How the science isn't about the science, it's about your political ideology. And the lens through which you look at the so called science is really your political perspective.

And that's very hard to address. If you are a libertarian conservative, it doesn't, it seems to me it doesn't matter how much evidence you have, at the moment, a new variant. but you're going to be in favor of go of going out and socializing and having have lots of parties and don't wear a mask.

It's almost independent of the evidence. You just have to live with the virus and that's all there is to it. So that's quite hard to deal with. It's not a sort of rational debate that you can have here where you say look, Here's the evidence, let's adjust our behavior according to it.

That doesn't seem to play out. And I am, I have been quite surprised about how quickly we've got into that position. And I don't, I actually, I'm not sure there is a simple solution to it, because it is about philosophies, people's personal philosophies on the world. And yet it is, and it is a form of anti science.

And it's not even the extreme anti vaccination, bill Gates is trying to, little transmitters in the vaccine to monitor our movements. It's not as weird and wonderful as that. This is sort of day to day politics of a pandemic, and it's very hard to see how we get out of that. 

Gavin: I think a lot of it isn't so much anti science, is it, as naivety.

There's we see this every day with people talking about the Lancet online, and any other number of scientific publications. They get a particular thing, they take a particular snippet of it that out of context seems to support their particular view, and they run with that.

And I think a lot of the time, it's not so much that they're aggressively anti science, that they know they're lying. They think they found like a smoking gun that supports their point of view, but they don't really know how to understand the wider scientific context that this was placed in. And I think that's a really interesting discussion that we need to have as well.

Richard: That is absolutely true. Fragments of evidence are taken and then expanded. Into generalized statements, one particular paper or one pre print is taken and then a whole story comes from that. And it's very, you hear that on a lot of radio programs with, quite opinionated presenters with large audiences who will do just that.

And they think they're being scientific because they've discovered this scientific paper that says even if you've been vaccinated you can still get infected and they take that piece of evidence to then say, Oh, vaccination doesn't work. Vaccines are a complete waste of time because they don't stop transmission.

And then you suddenly get a story around anti vaccination. Which, is really dangerous. But there's, there seems to be no way to stop that. And this is where it does then become quite interesting. If you think about on the politics side. It's great to live in democracies.

It's wonderful to have freedom of speech. But there's a cost. And the cost is that you get this nonsense that then gets transmitted. It's very difficult to shut that down. And the other, another dimension of this, just to reflect on your point a bit further, Gavin, is that I think it does come down to the sort of personal ideology of a member of the public.

If you think that the most important thing is your freedom to do what you want then everything's about personal responsibility. And you should, you basically have no restrictions, no masks, no social distancing. You can choose to have a vaccine or not choose to have a vaccine. It's all down to your personal responsibility.

Whereas if you're at the other end of the political spectrum, it's the opposite of that. So this is, this is again very, from a public health point of view and a science point of view, it's very hard to manage those kinds of extremes in the in the public discourse. And we haven't cracked it.

Jessamy: I suppose just picking up on that, from a sort of politician's point of view, who are aware of the fuller body of evidence, there's a lot of value signaling. We've seen it in this country and in others. And I'm never sure what values they're really signaling to, whether it's about wearing a mask or not.

But it is this sort of idea of, individualism and that you can. do as you want. That seems to be the main basis, but there are also other values that they're signaling to. But ultimately, I've, you feel they should be more responsible about that value signaling when we're in the middle of a pandemic.

Richard: No, that's right. Just to me. And I think that, if you drill down to the to what's a really difficult question that we're going to have to face at some point. We're facing it now, actually, but you'll, you rarely see it discussed. I entertained, a year ago, I entertained hopes that we would have zero COVID.

But once Delta came along, it was clear that zero COVID was going to be impossible. So we will end up with a virus that's endemic. But the degree to which we have to adjust to that endemic virus is going to depend upon how many deaths we are happy to endure in our society. And that is a question that we haven't really faced up to yet.

At the moment, Over a week's period, we've been 700, 800 deaths. Are we happy with that? 100 deaths a day. Are we happy? Is that a figure that we will I use the word happy not I don't mean happy. What I mean is that acceptable? Is that an acceptable cost? Or is it higher than that or lower than that?

And we do have to answer that because, so we've got the current levels of restrictions we have. So there are changes in our behavior. We do wear masks in the supermarkets and so on. We are working from home. So do we To relax that and have a higher number of deaths, let's say it goes up to 500 a day.

And then we can go out and do more and we all go to the office and travel in the way we once used to, perhaps. But are we willing to, are we willing to accept that? Or actually, do we want to lower the, this is a discussion we're going to have at some point. And our health system is at the front end of that, because it's got to address how many deaths is it willing to cope with.

So this is a very tricky. This is very tricky, because what science has done is to make explicit a set of moral choices we will make in society, which we've never had. We've never had to do before, we've had influenza for years and we've never really faced up to that kind of choice.

Whereas now we're, we are going to have to face up to it directly. 

Jessamy: Do you think we will or will somebody in government make a decision and the rest of us will either be thrilled that it's open, or not that it's not, because in the ideal we would have a societal conversation about it. But as you say, we've never done anything like that before.

Are you hopeful we could do? 

Richard: I am hopeful. I am hopeful. You still are getting the numbers of cases and deaths and hospitalizations and so on reported on a daily basis. There is a very vigorous discussion about the extent of the restrictions that we have. So the conversation is taking place.

And we're seeing that in all countries of the world now. The slight worry I have is that We have seen, not so much in the UK, but we certainly have seen it in European countries, such as Austria and Germany, the conversation evolves into violence. And there will come a point, perhaps, where societies could fracture if the conversation is not made more explicit in the political arena.

If you try and push the subject underground and you don't address it directly, you could end up with, some serious social disorder issues. So I think politicians do have to face up to this more, more directly, and I am cautiously optimistic. It's not a, it's not a discussion that can be avoided, especially with the new variant now, which is causing everybody to have such a gloomy outlook for the next few months.

Jessamy: And looking forward to the next few months, there's a pandemic treaty on the table. What would that look like and what would it aim to do? 

Richard: Yes, so the World Health Assembly special session this week has been looking at that question and I think I think we have to accept that the international health regulations revised in 2005 failed.

They failed because WHO doesn't have the capacity to monitor the world situation in every single country and guarantee that countries are going to have the capacities for pandemic preparedness. We also know that the way we assess global health security, which put the United States and the United Kingdom as the most secure nations, is fundamentally flawed since we're Two of the worst performing nations, so we need a different approach and the treaty does offer us a moment of departure where we can rethink the way we prepare for a future pandemic.

My slight concern about this though is that we're trying to design a treaty when we still haven't fully understood what we're trying to design a treaty to do because we haven't really come to a settled view about what the causes of the pandemic were, what's made the pandemic worse, and what preparedness really means.

And even all of the, the major committees and panels that have met to talk about this. I don't think they've got it fully right yet. We've been arguing at the Lancet over some time about the fact that you have to think about this as a syndemic, not a pandemic. And if you accept that premise, then pandemic preparedness isn't just about detecting and responding to a virus.

It's also about the general health of your population and it's about an issue of social justice in terms of the social gradients, the inequalities in your population. But then there's another dimension too, which is the whole field of One Health. We, those of us who, who trained in, in, in medicine, we trained in human medicine.

We didn't really train in animal medicine. And then you've got vets who trained in animal medicine and not human medicine. But the fact is, you need to have a confluence. Because if we're really going to prevent zoonotic spillover events in the future, you're not going to do that through just human medicine or animal medicine, you need this one health approach which really integrates the two.

And I don't think we've, there's been no serious discussion about that. So I think there's still a lot of processing of what this pandemic's been all about before you can start writing a treaty. And I fully support the notion of a treaty or convention. The danger is that we try and write it so quickly that we miss crucial elements out and we'll end up getting it wrong, which is so classic.

A terrible event occurs, you rush in to try and write a piece of legislation and you mess it up. And the danger is we do exactly that now. 

Gavin: I was going to say this year contained a lot of evidence that even when we have an overwhelming amount of evidence and we know exactly how to solve things that actually international treaties are not easy at all in the form of COP26.

Richard: Yes, COP26, it's I have some, I do have genuine conflicting feelings about that. We, it's good to talk about something that's not to do with COVID for a moment. 

Gavin: I thought I'd push us, just to a few minutes off COVID. 

Richard: We published our Lancet countdown just before COP26 to try and press the issue of health, and I think it was a great report.

COP26, it didn't meet its hoped for objectives of keeping 1. 5 degrees fully in sight. That's true. But if you take a perspective that this is an incremental annual process that we're in here and there will be COP 27 in Egypt next year, and countries are going to continue to be under pressure to make further commitments and our job in the scientific and medical communities is keep bringing the evidence to bear on this so politicians can't escape those decisions.

COP26 as a single event didn't meet our expectations, fully agree with that. But COP26 as part of a process over the next five to ten years, It made some progress. And, there is an arrogance in the West that we expect India and China just to give up coal and give up fossil fuels and fit in with us.

We've had 300 years of exploiting the planet and causing this problem, and now we're expecting countries that are trying to develop to do to basically give up their opportunity of developing. That's just another form of colonial imperial domination. It's just that we don't call it that.

There needs to be a little bit more humility, I think, in the way that we're approaching this. Yeah, COP26 had some aspects of failure, but let's keep going. Let's stay optimistic. Let's keep with the program and be back there in Sharm El Sheikh next November, December, and see what more we can do.

Gavin: Thanks so much for listening to this episode of The Lancet Voice. You can subscribe to The Lancet Voice wherever you usually get your podcasts, and we'll be with you again in mid January 2022. For our third season of health stories from around the world. See you then.