Fool.com's Healthcare and Cannabis Bureau Chief Corinne Cardina interviewed Richard Horton on Motley Fool Live on Oct. 9. Horton runs the British medical journal The Lancet and has been at the forefront of publishing data about the coronavirus pandemic. He also recently published a book called The COVID-19 Catastrophe. Here, he shares what we know, and have yet to learn, about COVID-19, his thoughts on the different vaccine candidates in development, and what the future of global health looks like.
Corinne Cardina: I am Corinne Cardina, I'm the Bureau Chief of Healthcare and Cannabis on Fool.com. We are so excited to have Richard Horton here on Fool Live, who is the editor-in-chief of The Lancet, a premier British medical journal, and the author of The COVID-19 Catastrophe. So we're excited to talk about that. How are you, Richard?
Richard Horton: I'm good, very good here in London. About to go into another lockdown, we suspect, next week. How are you, Corinne?
Cardina: I'm good. Well, at least it's Friday afternoon for you, so I'm getting a little bit of a look into my future as I start my day. Well, that's not good news. It's sad to see things going in the wrong direction.
Horton: Yeah. It's the nature of this thing. You push it down, and then you relax. We had eat out to help out at the end of August. So everybody went out, they enjoyed the sunshine, they had a good time, and guess what? The virus came back, and now we're reaping what we sowed.
Cardina: Yeah, absolutely. Before we get started, I do want to let our viewers know that we're testing out a question-and-answer service. It's called Slido. We use it at the Fool. Internally, we love it. We think you'll love it. So you can open it up on your browser, or there's also an app, and the code for this hour is MFLIVE. You can submit questions, up the other people's questions that you want to see answered. Richard may not stick around to answer them, but we do have Fool.com writer, Keith Speights, who is going to jump on, and we can tackle those questions together at the end. Richard, let's talk about your book. I've got it right here.
Horton: Okay. Very good.
Cardina: It's incredible, it's so timely, I really recommend it. It's on the shorter side, 127 pages, but every sentence, every page, it's really a gut punch. I've actually read it twice now, and it's really interesting to revisit those early days in the pandemic, in context of where we are now. When it was happening, it felt very out of control, very confusing. So to read your book, which really puts the facts in an organized history, it's helped my comprehension of the whole pandemic and how we got to here. You wrote it in lockdown, what inspired you to write this book?
Horton: Well, Corinne, I think what inspired me was a sense of mounting frustration because we were privileged at the end of January to publish five papers from Chinese doctors and scientists that really sets out the story of the origin of this pandemic. Really, everything they wrote has been played out over the last 10 months. If you go back and read those papers, and remember the last week of January, those papers talk about the fact that this is a new disease, tipping patients into hospital, into intensive care with very severe illness, multi-organ failure, high numbers dying, the desperate need for personal protective equipment, testing and isolation procedures, and the risk of a global pandemic. Yet in February and early March, the world did virtually nothing. I was getting to the end of March when countries were literally just beginning to wake up to the fact that they have a crisis on their hands, and I was thinking, "This is madness. We've wasted six or seven weeks when we could've got ourselves ready." Certainly, in my country and, I'm afraid, in most Western countries that did nothing in those early stages, it seems a terrible thing to say, but I do believe it's true based on what we knew in January, many thousands, tens of thousands of those deaths were preventable if we had acted earlier. I think it was that sense in frustration, even anger, that just made me think, "Hang on, we need to get the story right here because we can't allow politicians to rewrite the history of this pandemic down the line."
Cardina: Absolutely. When you wrote your book and it went to press in May, the World Health Organization was reporting 337,000 deaths globally, 94,000 of which were in the US. Of course, since then, sadly, the death total has more than doubled, reaching more than one million globally, and your writing, it really seeks to put the human faces back on these very mind-boggling statistics, and not to you, as you wrote: erase the biographies of the dead. Why is it so important to make an effort to really grapple with the overwhelming scale of this tragedy, even while it continues to unfold?
Horton: Yeah. People like me are part to the problem because we publish these research papers, which are full of figures, and tables, and statistics. Yet during March and April, I was receiving terrifying messages, DMs on Twitter, from people who are on the frontline trying to deal with this. Honestly, the messages were bloodcurdling. They describe themselves as lambs to the slaughter, they have no PPE, and they were seeing patients around them who were put at terrible, terrible risks. We do need to remember that every single life that was lost, there's a family and group of friends around that life. One of the issues that I try and raise is this notion of an ethics of memory. We have a duty to remember these lives of people whose lives, they must not be needlessly lost. We must remember the lessons so that we protect lives in the future.
Cardina: Absolutely. A little bit more about the role of a medical journal, like The Lancet during the global pandemic. Of course, you and your colleagues have shouldered a tremendous responsibility in providing accurate and reliable analysis in a situation that was changing so rapidly, impacting pretty much all human stakeholders. In your book, you mentioned that you published some really heart-wrenching communications you received from citizens. I'm sure that was just the tip of the iceberg. People writing in, telling you about what they were experiencing, their fears. What has that been like?
Horton: Well, it was awful, to be very frank with you, Corinne. Every morning, I would get up and I would look at my Twitter feed and it would be full with thousands of messages from people who are just in agony about the situation, mostly health workers who were trying to deal with this. But since then, I've been in touch. We have a group in the United Kingdom called the Bereaved Families of COVID-19 who have self-organized and we've been desperately trying to get to meet politicians so that they can tell their stories and try and emphasize to our political leaders how important it is to learn the lessons. Because unfortunately, we haven't learned the lessons, which is why we're seeing in the United Kingdom, but it's also in France, in Spain, the virus is bouncing back in the second wave. In America, you've got some real hot spots in different states across the country, in college campuses across the nation. So this is affecting some of our most vulnerable populations. It's affecting the oldest old. It's affecting people with chronic disease. There's a shadow pandemic against women and children, who often been confined in homes, where there a huge risk of domestic violence, and that's something we don't talk enough about actually, the risk to women and children from intimate partner violence. We've got a lot of learning to do about who's vulnerable. We need to put these vulnerable people center of our political stage and talk about them, and our key workers, the people who actually make our society run. I mean, that's not me. I'm able to sit at home protected, but people who keep food in our stores, people who keep our mass transit working, people who keep our healthcare working, people who keep our streets clean. They're the ones who have been at most risk.
Cardina: Yeah, absolutely. Speaking of what we're still learning, what do we know about COVID-19 at this point and what is the scientific community still working to find out?
Horton: Well, that's a great question because one of the difficulties we've had in the last 10 months is that the science of this virus and this disease has been moving very fast. That actually is one of the reasons why it's been difficult to get a clear, simple message. Let me just take a couple of examples. At the very beginning of the pandemic, we thought that this virus was transmitted through droplets from your mouth through your nose, gravity would take them down, they would land on a surface, and the risk was picking up the virus from the surface. Now we think very differently. The risk from picking the virus up on the surface where its pull-in is actually quite low and there's a much greater risk of what's called aerosol spread, where the virus isn't subject to gravity but it literally just hangs in the air. Because it hangs in the air, if you're in a crowded room or a crowded store, then if you're not wearing a mask, your risk of picking that virus up is much higher. So we shifted now. It's important still to wash your hands, but it's also now important to wear a mask. Of course, as we've seen in the White House, that's been amply proven. So that's changed. Another example, we didn't appreciate back in February, March, April, the importance of what we call asymptomatic spread. The idea that people have absolutely no symptoms, and yet they have the virus and putting loads of it out into the atmosphere. Even more reason, again, to be very careful about social mixing, to wear that mask, to keep your distance where you can because you don't know around you. You don't even know yourself. You don't know yourself whether you've gotten the virus. So our understanding has really shifted. Now in terms of the future, the most important thing we need to learn is about the immunity. If you've had this virus, how long will your immunity last? Is it two or three months? Is it 12 months? Or is it longer than that? Because that's going to determine, if somebody has become infected, how quickly they can reenter society, but it's also going to determine how we deal with the vaccine, if and when we get a vaccine. Because if we do get a vaccine, how long will that immunity last? Is the immunity the same for everybody? Will it be the same for you? You're younger than I am, I can see that. It's more likely that your immunity will be stronger than my immunity, and somebody who's in their 70s and 80s, it's likely their immunity will be even less, but we don't know for sure. So there's a lot of still we have to know.
Cardina: Yeah, absolutely. The implications to the vaccine are huge. I think there's also probably some questions around the mutation of the virus and how that will impact a vaccine. Are we going to have to change the vaccine annually and get a different one, that kind of top of mind?
Horton: Absolutely. Is it going to be like influenza or not? At the moment, we do know that this virus does mutate. There are different forms of it. Different forms are associated with the different severity of disease. But it's too early at the moment to be sure whether a vaccine that's produced will be able to cover all strains or whether the virus will mutate overtime and escape the protection of the vaccine because we're only 10 months into the pandemic. Let's say we get a vaccine later this year. It's going to take us probably another 12-18 months before we can be sure whether that vaccine will protect us in the long-term.
Cardina: Yeah, absolutely. Thinking more about the vaccine, there are several, almost 10, if not 10, intriguing late-stage vaccine candidates. What kind of safety and efficacy evidence will you and others at The Lancet be looking for when you're evaluating the data on these trials?
Horton: Yeah. you're absolutely right. There are about 9 or 10 vaccines, different categories of vaccine in these late-stage trials. These trials are going on in countries around the world where the virus is still raging. What we have been looking for are two parts to this. First of all, as you say, efficacy. Does the vaccine work? So far the evidence we've got is we've got nine or so vaccines that definitely stimulate a strong immune response. That's excellent. But now we have to see that it actually protects against infection, or if you get the disease, it reduces the risk of a severe outcome or even death from the disease. Now, the question is, how much protection can the vaccine give you? It's not going to be 100% effective, Corinne. No vaccine is 100% effective. What's the minimum that we would need? Most people will say that if we have a vaccine that's 50% effective, that's good enough. That's what I'm looking for. I'm looking for a vaccine that has a minimum effectiveness of about 50%. If we have that, that will make a big impact. On safety, now that's a tougher question because safety is something that you often only see. You can only assess that accurately in the long-term. So what I'm unlikely going to be able to say is that, so far, based on the trial in a limited period, the vaccine is safe, and then we will have it licensed. The regulator will pass it, but then we're going to have to keep a very close eye on the long-term follow-up of people who have taken the vaccine to make sure that nothing unusual, surprising jumps out. So 50% efficacy and keep a close eye on safety. That's why I'm worried about president Trump's comment that we'll have a vaccine by the end of October because based on my knowledge of where we are with the vaccine trials, it's just cannot be possible that we will have a vaccine that will be available for public use by the end of October. I just don't see that.
Cardina: Yeah. It's important not to erode the public's trust in the vaccine because we need people to take the vaccine in order for the outcome to be what it is intended to be.
Horton: Well, you're right. Actually, I have a few worries about that because in China and in Russia, their vaccines, they are actually being rolled out to give to people, not members of the public, but members of the military. My concern is, and this is on the basis of having not done these big trials, so they're gambling and that gamble that they're taking may pay off. But if it doesn't pay off and there is a problem with one of those vaccines, that will have a global impact because I think in the public's mind, that could easily lead to a distrust, even a destruction in the credibility of the science, and that would be a terrifying disaster.
Cardina: Absolutely. We've gotten a question that I think is really relevant to this conversation from one of our viewers. Someone asked, what do you think the biggest misconception is about a COVID vaccine?
Horton: The biggest misconception I think is that it's going to be a magic bullet. If we have a vaccine, it will turn the pandemic off just like that and we can all go back to our normal lives. The sad truth is that that is not the case. Let me take you back to 2002, 2003 when there was another SARS virus that came out of the woodwork in China again and got distributed to half a dozen countries around the world. By the middle of 2003, it disappeared and we've never seen it again. It vanished. This virus is not that virus. This virus is now in every population, every community around the world, and we have to live with it. A vaccine will be an important tool in building up population immunity, but the virus is still going to be among us. The idea that we can erase, or eliminate, or eradicate the virus from society just is not true. I think that's one of the more dangerous myths. We have to come to terms. The way I would put it is a kind of peaceful coexistence with the virus. We have to live side-by-side with the virus. We have to renegotiate our relationship with the virus. If we understand that we have to do that, I think we will be much better placed to be planning our futures.
Cardina: A quote that, I don't remember who said it, maybe you do, but in the book, it says that if you've seen one pandemic, you've seen one pandemic. That really stuck with me. Who said that?
Horton: It's a guy called Adam Kucharski. He's a mathematical modeler at the London School of Hygiene and Tropical Medicine and he studied lots of epidemics, and they're all different. You can draw some lessons, general lessons, but by and large, when you get down to the detail, everyone is different.
Cardina: Yeah, absolutely. Talking about all the different vaccine candidates that we'll have data coming up soon, I'm curious about and I think our readers are curious, too, or viewers. We've gotten a couple of questions. When you look at the vaccines that are in phase 3, are there any that are taking a particular approach that you think is most compelling, whether it's mRNA, DNA, weakened virus? Any thoughts on that?
Horton: That's a hotly debated subject. Some of the, shall we say, fancier vaccines, that's the mRNA vaccines, I mean, they are technologically the most advanced, but some people believe that may be the good old-fashioned approach might be less exciting, technically, the science may not be as advanced, but actually they might work more effectively. That's the inactivated viral vaccines. That's a big, big debate. Is it the smart science that's going to win or is it the tried and tested rather old-fashioned, decades old approach? Another debate is over what's called the adenoviral vectors. One way of getting immunity is you basically stick parts of the coronavirus onto another virus, what's called an adenovirus, and if you give those two adjunct together, then the adenovirus is very effective at getting the coronavirus into the human body. Now the debate is, what sort of adenovirus should you have? The Oxford Group have used a chimpanzee adenovirus, the Russian group have used a human adenovirus, and the Russian team has been very vocal about saying that the human adenovirus is going to be a much more effective vector means of getting the coronavirus antigen into the human body. We don't know. These are speculations at the moment, and it's going to take us until the end of the year to find out the answer.
Cardina: Yeah, absolutely. Lots of unanswered questions still. Talking about the speed of innovation, we've talked a little bit about this, but 10 months into the pandemic, we've got almost 10 vaccine candidates in phase 3. It's really astounding. Looking at the history, China published the genetic code on January 12, two weeks after the first biopsy was taken from a COVID-19 patient. We actually saw a company, Inovio Pharmaceuticals (NASDAQ:INO), said it created a coronavirus vaccine candidate within three hours of that code being released. Have you ever seen anything like this speed of innovation before? How have these circumstances evolved differently from earlier outbreaks? We touched on the SARS virus in 2002, 2003. There's the Ebola virus in 2013 and '14. I'd love to hear about the innovation in historical context.
Horton: Well, Corinne, I've been at this journal for 30 years, this is my 30th year at The Lancet, and I can honestly tell you I've never seen the kind of cooperation between the private sector and the public sector and the speed that we've seen science move as I've seen this past 10 months. Normally, it takes about seven to eight years to produce a vaccine from the time when you actually have the viral or bacterial particle. Here, as you say, we haven't just got these nine or 10 vaccines in phase 3 trials, we have 140 other vaccines that are in pre-clinical or phase I or phase II trials. So we've got this vast number of vaccines, and this is important because the likelihood is that the very first vaccines we get, if we do get one at the end of this year, they're not going to be the best vaccines. So we're going to see some of the 130 or 140 other vaccines that are still in development. Some of those are going to be better than the first vaccines that we get. Actually, just as we have waves of the viral pandemic, we're going to have waves of vaccines. That first wave of vaccines will be so-so; the second and third waves of vaccines, they'll be much, much better. The science is moving quickly, spectacularly actually, and I think by the end of 2021, we're going to be in an even better place than we are now.
Cardina: Absolutely. We're Fool.com, so we are a lot of investors. A lot of people are considering investing in one or many companies that are working on a COVID-19 vaccine. What would you say to people who are putting their money behind one or more of these companies?
Horton: Well, that's probably above my pay grade.
Cardina: I know I'm asking a scientist about investing. I'm sorry.
Horton: I'm a scientist for a reason, which means that I'm not very good on investment. Listen, the thing to do is you've got to be able to trust the subject experts who are running that start-up. You've got to be sure that they really understand the science. If you get the sense that these people really do get the virology, the study of the virus, they understand the molecular biology of the disease, that's the test for me. Well, I'll give you an example. When we have the Russian vaccine paper submitted to us, I don't know Russia very well. I haven't visited Russia as much as I have visited China. But I needed to be sure, I need to be able to trust that that paper was an accurate and reliable description of what they've done. So I needed to be sure about the scientists. If I could begin to trust them, if I could trust that they were doing serious work, good work of an international recognized standard, then I felt that it was safe and worthwhile publishing that paper. As we went through the peer-review process, as we began to build up confidence in what they were doing, then I felt that we had sufficient information. So make sure they're good scientists, get their work peer-reviewed by other experts in the field, consult widely, and then I think maybe that would be the basis for an investment decision.
Cardina: Yeah. To be cliche, bet on the jockey, not the horse. Make sure you know the jockey knows that they're talking about.
Horton: Absolutely, absolutely.
Cardina: Great. As we look beyond getting the first approvals for a vaccine, the next challenges become manufacturing the vaccine, distributing the vaccine. We've touched on getting people to take the vaccine, but a lot of noise is being made about certain types of vaccines and keeping them cold, which would pose a problem for your neighborhood pharmacy doling these out. They don't necessarily have the right refrigeration, questions about distribution. I'm curious if you have any insights there?
Horton: Yeah. This has been a source of great concern, and organizations like the Bill & Melinda Gates Foundation have invested heavily in trying to understand technologies that can eliminate the need for, as you described, the cold chain so that vaccines can be given more widely, especially in countries where the cold chain is hard to deliver. So in continents such as Sub-Saharan Africa, or even remote parts of Latin America, the Middle East, and Asia. This is a challenge. I think when it comes to the distribution side, I do have another concern, which is, at the moment, it's the richest countries with the biggest political clout that are able to buy out vaccine, supplies as and when they want to. That includes my country, that includes your country. Although that's good for us, we've got to think, what's the fairest way? This is a global emergency, and we need a global response. So the question I hope that we could ask one another is, not what's just best for me, but what's best for the world. So how do we make sure that the vaccine is distributed fairly to those people most in need? Because truth to tell, Corinne, you and I are not actually the first people who need the vaccine because I suspect you're not a frontline worker. It's the people who are going to be exposed. It's going to be those people who are on the frontlines of healthcare, food stores, transportation and so on. They should get it first. People who are over 70 years old, they should get it first. People who have chronic illnesses, they should get it first. In my country, machination minority ethnic communities have been particularly at risk, they should get it first. Maybe the same in America with African-American communities. We need to figure out how we distribute the vaccine to those most in need. That's not a scientific challenge so much; that's going to be up to our politicians to do the right thing.
Cardina: Yeah, absolutely. We keep seeing headlines for Canada, the US, the UK, secures doses for a vaccine that's not even approved yet and it's millions of dollars. Who's buying these up for, like you said, Sub-Saharan Africa, Latin America? No one.
Horton: It's not a smart use of public money. If I was an American taxpayer and my country's spending literally hundreds of millions, betting on a vaccine that we don't even know is going to work, I don't think I'd be very happy about my tax dollars being spent that way actually.
Cardina: Yeah. That's a great point as well.
Horton: It's like playing roulette. Putting your tax dollars on a particular number and then spinning the wheel, I'm not sure that's what taxpayers expect of their government.
Cardina: Great point. Your book ends by unfortunately looking to the next pandemic. A lot of people do not want to think about that while we are still dealing with this one that is raging. But why are you so sure that this is not the last time that we'll face this kind of situation? Is there anything that regular folks can do to be more aware in the face of this new normal? Your book, you talk about optimism bias. Should we all be a little more weary that the leaders in the world are not necessarily going to take care of us?
Horton: Well, let me be guilty of optimism bias for a moment.
Cardina: We all are.
Horton: I am actually optimistic about the future.
Cardina: Oh, good.
Horton: The reason why I'm optimistic about the future is history. If you look back at past pandemics, the fact of the matter is, as terrible as the pandemic is, as many people who suffered tragedies as there are, societies bounce back. Every single time, they bounce back. They actually bounce back higher than before the pandemic. The reason for that is there's a sudden burst of creativity; intellectual, entrepreneurial, artistic creativity. Lessons are learned by the public and by government, and governments, having had such a hit, suddenly pay more attention to some of the more vulnerable people in society and make sure that their populations are better protected. So I think, as we look forward, not this year, Corinne, but maybe not even next year, but over the next five, or six, or seven years, our society is going to bounce back and it will be stronger, it will be smarter, it will be kinder. That's a good thing to look forward to. It's important that that happens, which I believe it will, because, to come back to your point, the one thing we can be 100% sure about is that we will have another pandemic in the future. It's inevitable because it's about the way we live our lives. We're living our lives in such a way, around the world, where animals are coming closer to human beings. This particular coronavirus jumps from an animal to a human being somewhere in Wuhan, and the result of that was the pandemic. As we urbanize more, we're moving to cities, as we're damaging and destroying even our environments more, that's forcing animals out of their environments, bringing them into contact with human beings, that is having the effect of increasing the risk of these moments where viruses jump species. We call them zoonotic infections. The frequency of these jumping moments is increasing. Over the last 40 years, we've had six or seven epidemics outbreaks of the zoonotic infection. We don't seem to be changing the way we live in the world; it's only intensifying. So over the coming decades, I'm afraid we're going to have more of these episodes.
Cardina: Yeah. I think you're absolutely right, unfortunately. Looking ahead, is there any particular research or studies coming out from The Lancet that you're really excited about? Maybe nothing specific, if you can't tell us free publication. But topics, anything we should keep our eyes filled for?
Horton: Well, I'd like to tell you about something we're publishing next week, in fact. So I'll give you a little heads-up. I won't give you the full answer, but just a heads-up because this is not just the pandemic of a single virus. If you look at what's happened, this has been the intersection of a virus hitting a human population, and the people who have suffered the most are people who have pre-existing disease, people who have pre-existing heart disease, pre-existing lung disease, people who have high blood pressure, people who have diabetes, people who are severely overweight. The health of the population is a very important determinant of how you react to this virus. Added onto that is how poor you are or what place on what we call the social gradient you are. So if you're living in poorer, more vulnerable positions in society, you are at greater risk. Next week, we're publishing the world's biggest study ever into the burden of disease around the world. It comes from the University of Washington in Seattle. It's called the Global Burden of Disease Study. It's going to tell you precisely how much at risk the world's population is to a pandemic like this. I won't tell you the answer to that, but if you wait until next Friday, you'll see.
Cardina: Excellent. I look forward to that. It's interesting. It's just like with a natural disaster, right? You have a hurricane that comes, and a location that has less infrastructure is going to experience more disaster as a result. There's a lot of tie-ins. This is a natural disaster in a way absolutely.
Horton: That's a perfect metaphor, and I may just steal that from you next week when we launch this.
Cardina: Please do. I want to close with a quote from the book that you quoted from someone else. I'm sorry, I'm not quoting you directly.
Cardina: It's by Laurie Garrett from The Coming Plague, which, in 1994, it was published: "While the human race battles itself fighting over evermore crowded turf and scarcer resources, the advantage moves to the microbes court. They are our predators and they will be victorious if we, Homo sapiens, do not learn how to live in a rational global village that affords the microbes few opportunities. It's either that or we brace ourselves for the coming plague." There's your call to action, everybody. It's a little bit terrifying, but I just thought it was super relevant. But thank you for your time, Richard, and as you state in the book: stay safe, stay strong.
Horton: Exactly. Corinne, thank you for your time and you, too, I appreciate the opportunity.
Cardina: Great. Well, good luck with the coming lockdown. I hope that you will be getting started on your next book in this lockdown.
Horton: Thank you very much. Take care.
Cardina: Thank you. Keep in touch.
Richard Horton: Bye.
Corinne Cardina: Bye.