'Global COVID-19 herd immunity will take two or three years'

‘Lancet’ editor Richard Horton tells ‘Post’: This is a moment for humanity to come together with one purpose – that is the only way we are going to get through this.

'The Lancet' editor-in-chief Richard Horton. (photo credit: COURTESY THE LANCET)
'The Lancet' editor-in-chief Richard Horton.
(photo credit: COURTESY THE LANCET)
When Richard Horton became editor-in-chief of The Lancet 25 years ago, he never could have imagined the coronavirus pandemic. Now, he told The Jerusalem Post, he is living through “a tornado” – an “existential moment for humanity.”
He said that the pandemic has “held up a mirror to our society. And I looked into that mirror.”
The Lancet began as an independent, international weekly general medical journal in 1823. Now a family of journals, it strives “to make science widely available so that medicine can serve, and transform society, and positively impact the lives of people,” according to its website.
Born in London and earning his degree in physiology and medicine from the University of Birmingham, he is receiving an honorary doctorate from the University of Haifa. The 58-year-old Horton shared his thoughts with the Post on what it has been like covering the crisis, on vaccination and the politics of the pandemic.
Some answers were shortened or edited for clarity and conciseness.
 
What has been like editing the Lancet during a pandemic?
It has been a tornado; it has turned everyone’s lives upside down. We are not frontline health workers, but it felt like being on the frontline of knowledge.
It is difficult to remember that we knew nothing about this virus in January. We published our first paper on it on January 24, and on December 8 we published a paper supporting the Oxford [AstraZeneca] vaccine. That is 321 days between knowing nothing and having a vaccine. Between those two dates we have amassed this unprecedented amount of knowledge.
I have never seen the global scientific community respond to an emergency like I have seen them respond this year. It has been an incredible tribute to scientists in every country of the world who have mobilized in the face of this threat.
It has been a tough and terrible year. But it has also been an inspiring year to see the way people have pivoted to prioritize this pandemic.
 
How do you balance getting people information fast during a pandemic and accuracy?
I think this has been one of the interesting changes this year: Normally we publish for a very specialist audience of physicians and medical scientists. This year, our audience has dramatically expanded to include the public, policy makers and politicians, who are desperately hungry for new information. That has been a good thing. In order to build public trust for mandates and restrictions on freedoms, the public has to be able to see how strong the evidence is, how certain the evidence is.
Science has opened up in 2020 in a way it has never opened up before. Scientists are often a closed community. This year, all that has changed – and sometimes it has been uncomfortable. But I think for the most part, it has been a very good experience to have science become part of mainstream public culture.
 
You have also leaped into the politics of the pandemic throughout this crisis, condemning everyone from British Prime Minister Boris Johnson to US President Donald Trump. Here in Israel, too, there have been clashes between the professionals and the politicians. What do you think the impact of this is on the public?
I think whenever there is polarization, that does jeopardize public trust. So, if we just go back to the beginning of the pandemic, when everyone was uncertain and governments locked down their countries – and scientists were mostly in agreement with that – the public mostly adhered to that [locking down] and everyone felt like they were in it together. In the beginning of the pandemic, we saw in many countries moments of national unity.
But then as we got into May and June, some notable individuals started breaking the rules, and it became clear that politicians had not acted as they should have done. Then there were dissenting scientists who did not agree with certain mandates such as masks or social distancing, or prominent voices who came out strongly against restrictions.
As you always get in democratic countries, there was a cacophony of voices disagreeing with each other. The result is that public confidence starts to break down – and that is where we are now.
Fortunately, we do have vaccines. But those vaccines will take most of 2021 to roll out and achieve herd immunity. The vaccine is not going to be a magic bullet immediately. So, we are going to still have to live with a certain amount of restrictions in our lives. It is going to be really important to build trust again as we go into the New Year.
 
Did anyone, any country do it well?
New Zealand, of course. You could say New Zealand is a bad example, because it is a small country – an island. But at the same time, Prime Minister Jacinda Ardern understood from the beginning that she had to act decisively. She looked at what happened in Italy and knew that delaying [taking action] could lead to greater death. That was a very effective political response.
If you look at the total number of deaths, it is ironic that the Western Pacific region of the world has the lowest total number, and yet that was where the origin of the pandemic came from.
Look at South Korea, China, Hong Kong and Taiwan. Although they have had second and third waves, in terms of overall cases they have done better because they have a history of epidemics. They were ready in a way that the Western world was not. We were prepared for an influenza pandemic and they were prepared for another SARS [severe acute respiratory syndrome] pandemic.
 

You have been a severe political critic of Israel. How has Israel handled the pandemic from your perspective?

I do not think you have done any better or worse than we have done [in the United Kingdom].
I think democratic countries have struggled. Democratic countries are used to a level of freedom and liberty that China is not used to. In the face of the threat of a pandemic, it is much more difficult for a democratic government to shut down society.
Another reason we have seen democracies really struggle with this pandemic is our style of politics that encourages debate – which is the wrong response you need in a pandemic. In a pandemic, you need people in agreement, cooperating, national solidarity and unity – we have not seen that in pretty much any democracy. You have the extreme of Trump in the US on one side and disagreements in Germany on the other – and Israel is in the middle of that.
The pandemic has shown the weaknesses of democracies.
 
You have been going through your own health crisis during COVID, being treated for stage IIIb melanoma. Can you talk about how that has influenced your perspective on the pandemic?
Seeing health workers who were really all on the frontlines of this pandemic [changed my perspective]. In the early part of the pandemic, they did not have PPE [personal protective equipment]; they had no support. They were in a terrible predicament, like lambs to the slaughter, having to treat patients with no protection whatsoever. Of course, that is not where we are now.
In every phase, but especially in those first three or four months, I think health workers were doing some of the most heroic work of anyone in society.
 
What other challenges did you see?
You were not allowed to go to the hospital without a letter of appointment. Every other [branch of] medicine shut down but COVID-19. Patients with heart disease, cancer patients disappeared.
This pandemic will leave a shadow, because in six or 12 months, the patients who did not go to the doctor for heart disease and cancer will create a huge avalanche of illness.
I think Israel has something to teach us here. I have been to Haifa so many times, and one of the lessons from visiting Rambam Medical Center is their ability to understand the importance of resilience. One of the consequences of having bombs thrown at you from Southern Lebanon is that you built a system that can cope with that.
Have you been to the car park [underground hospital]? If a bomb was lobbed over, they can shut the hospital and go down to the car park and turn it into a hospital, with beds and ventilation units. Now that is resilience.
[In October, the IDF opened its first coronavirus ward at Rambam’s underground parking lot.]
 
You wrote a book: “The COVID-19 Catastrophe: What’s Gone Wrong and How to Stop It Happening Again.” It is less than 130 pages long, but from what I read it has a lot of strong messages. Why did you write it?
I wrote it because I was sitting here literally being submerged by new research into every aspect of the pandemic and trying to make sense of this moment. This might be the most important moment in my entire life – living through the middle of a pandemic is not going to happen in every lifetime. The last one was in 1918 and before that was in the 17th Century.
This is an existential moment for humanity, to pause and think what this moment actually means. As I said in the book, COVID-19 is inviting us to look at the kind of society we have created and see if that society truly lives up to the principles we claim to value. It held up a mirror to our society – and I looked into that mirror. And I see that we have a very unequal, very unjust society.
 
In what way?
The people who kept society going in the middle of this pandemic were the people on the frontlines: healthcare workers, people in the food stores making sure people did not starve, people driving buses, teachers. These essential workers were keeping society running.
These are groups of people who are usually never seen or ever heard [about] in our society. I hope they are going to move to the center of the political stage.
In my book, I wanted to tell the story of the pandemic and to try to learn some of the lessons, so we do not forget them for the future.
Now, let us look forward. Vaccines are here and more are coming. Is the vaccine a magic bullet?
I am very optimistic, but now it is about managing expectations. We have several vaccines, and we will have more. It is not a challenge of medicine but a challenge of implementation. We need to manufacture them, distribute them, and persuade people to receive the vaccines. We have to ensure public confidence in the vaccine.
And we have to recognize that this is not a problem for Israel or the UK. It is a global emergency, and the virus does not respect national borders. You can immunize the entire Israeli population, but this will not help Israel. We need to immunize all countries of the world.
To reach herd immunity, about two-thirds of the world population – four billion to five billion people – need to be vaccinated. Each person has to have two doses – that is 10 billion doses of the vaccine. This has never been done before.
We can be confident in the safety and efficacy of the vaccines. But the pandemic will not be solved by next Easter or next summer. It will take the whole of 2021 and well into 2022, if you think of the global challenge.
 
Rather than what we know about the vaccine, what don’t we know?
We do not know how long it lasts, the duration of its protection.
We also know that the virus is changing – it has mutated, which is completely normal. The good thing is that it does not mutate as fast as influenza. But still it mutates. We will need to be very vigilant about whether it escapes the immunity provided by the vaccine.
 
What do you think the biggest misconception is about the corona vaccine?
I think the biggest misconception is that it is a magic bullet: that this is the solution, a solution that means right now people do not have to implement any changes in their behavior. I worry because people know the vaccine is coming and they have stopped wearing masks, stopped physically distancing, stopped avoiding mass gatherings.
People want to see their families, but the more social mixing they do, the greater the spread of the virus is going to be. The greater spread, the more hospitalizations. The more people who are in the hospital, the more deaths there will be.
It is very important that people do not relax their vigilance until the vaccine has achieved herd immunity. According to my timescale, it will take two or three years to roll out this program to all the countries of the world. It is a very difficult message.
 
Two or three years?
Yes. Each country has to be as concerned about every other country as much as itself, and that requires unbelievable levels of global cooperation. This also makes me optimistic – because the only way we are going to succeed here is by putting all enmities and arguments to one side and to cooperate in ways we have never cooperated before.
This is a moment for humanity to come together with one purpose. That is the only way we are going to get through this.
 
Will you get inoculated?
Oh gosh, yes.
 
If all goes well, eventually this pandemic might be behind us. What are the lessons we can learn from COVID-19?
This virus has exposed some of the most profound weaknesses in our society. It has also shown some of the strengths that human beings have. It has shown the best of us and the worst of us.
I hope we can forge a future where we put the weak and the vulnerable at the center of our political stage and recognize that social justice is not just a piece of political rhetoric. Rather, social justice is the foundation for protecting our society.
Unless you have social justice societies, low levels of inequality and high levels of health, we are very vulnerable to the next pandemic.