Susan richard horton, editor of the medical journal the lancet, you published a book, and you wrote the virus that caused covid19 is not going away. It will be with us for a long time to come. The best we can hope for is peaceful coexistence. What does that look like . Dr. Horton it means negotiating a relationship with the virus, if i can put it like that. When covid19 hit, countries locked down. The only way to cut viral transmission was to stay at home, stop social mixing, implement physical distancing and so on. That is fine in the short term. It can extinguish the outbreak, but it is not a longterm solution. It is not possible to live life like that. By peaceful coexistence, i mean we have to renegotiate our relationship with the virus, which means we need to leave our homes, go to work, send children to school. We have to do it in a way that minimizes the risks to those who are most at risk of covid19. That means we have to live sidebyside with this virus as we live sidebyside with many other pathogens like influenza. Susan bring me uptodate on the status in the u. K. And in western europe. Dr. Horton the status and the u. K. Is having to have one of the worst in terms of mortality, one of the worst outcomes of the pandemic of any european country i think belgium is worse we are now in a good phase where the numbers of deaths have been reduced dramatically. There is Still Community transmission, but we are seeing the evolution of the pandemic affecting a different demographic, part of our population. In the early days of the pandemic, tragically the virus was hitting all of the people older people, people from black and asian minority communities, People Living in nursing care homes. They bore the brunt of the pandemic and had high mortality. What we are now seeing is the infection is more in younger people. Of course younger people, the risks of severe disease and death are far less. The nature of the epidemic has shifted. We are seeing something similar in many other european countries. There are several countries in particular, spain and france, where we are seeing the outbreak shoot up again. It is not really a second wave. It is surging. Having suppressed the outbreak, it is coming back because people are mixing again and going back to work. It is a mixed picture. Some countries are doing well. Others less well. The challenge is managing quarantine. Every week it seems one country is out of risk and another is in risk. It is a fluid situation. Susan is it too early to look at the various ways those countries approached the virus and take learnings from it . Dr. Horton i dont think it is too early. There are still aspects of this pandemic that we dont understand, so i dont think we can be 100 definitive. We can say certain things now. We understand the modes of transmission better. At the beginning of the pandemic we did not appreciate as much as we do now that people who are a symptomatic may often have the infection. That is a particular challenge. If you are not having symptoms, you could be in particular danger of passing on the virus if you are circulating widely in the community. We did not appreciate that the droplet spread of the virus could be in very tiny droplets. Coming out of the mouth, gravity will take it downwards. Out of the range of people walking past you in the streets or in the store. We now know there are these micro droplets which can hang in the air. That is one of the reasons why we are more certain than we were that mask wearing is important. These droplets hang in the air. Wearing a mask can be a way of preventing getting those ingested. I would say that. Susan there is three aspects. Widely available, inexpensive and quick Testing Process. The remediation therapies and vaccine development. Let me start with the Testing Process. There are so many people working on this from around the world. From what you are able to see, is there progress being made on quick and inexpensive testing . Dr. Horton very rapid progress. Other parts of the pandemic, you would take a sample, and you would have to send it to a laboratory where it would be an involved scientific Testing Process which would take several days to come back. That was not fast enough in order to do the test tracing approach successfully. We are now getting testing which can we dont actually have any available but i think we will soon, where you can almost get instant results. Literally you do the swab and you can take it to a machine and get a result almost instantaneously. That is going to be important because if the test tracing is going to work, it needs to have a very rapid turnaround within 24 hours in order to get those contacts. That is real progress. By the end of the year we will have these very rapid tests more widely available because those will allow us to do mass testing of the population. That is what we are going to need in the winter months, when we will have two problems. We are going to have the virus and also to have to contend with influenza. Susan as you and i have this, the lancet is being cited across the globe. The study you published today on russian vaccine progress. Dr. Horton this russian vaccine is caught in a geopolitical struggle. If we strip that away and look at the science, the results of the study published today are encouraging, but it is small and it will be premature to draw any definitive conclusions. What the russian scientists did was study the component vaccines based upon the adenovirus. They gave it to 76 volunteers. Very small study. If i compare it with the oxford vaccine study published a few weeks ago, it was over 1000 volunteers. This is a small study. What they found in those 76 volunteers was the vaccine produced strong immune response, which you want to see, the right kind of immune response, and as far as we can tell, safe with no severe adverse reactions. Now what we need to do, go on and do very large scale randomized trials where we can test the vaccine to see if it works in preventing infection and disease. Those trials have begun in moscow. Susan the worldwide pickup of your report suggests how much people are hanging on the hope of a successful vaccine. You have struck a cautionary note about reliance on vaccines. What you talk more . Dr. Horton a vaccine is an important tool to help us control the pandemic and to protect us. It is important to stress it will not be a magic bullet. Vaccines have transformed life for species around the planet. But no vaccine is 100 effective or safe or will be used by 100 of people on the planet. That means it will have an important part to play. We will have to continue to negotiate this relationship with the virus. Even with a vaccine we are still going to have to be careful about social mixing, physical distancing, mask wearing and possibly also about the large Mass Gatherings as we call them, which are sadly, we have not been able to partake in. I want to be optimistic about the vaccine. I believe we will have one. I want to be cautious about saying it will be our savior because i dont believe it will be. Susan it sounds like the world will not be back to normal for quite a long time. Dr. Horton i think this is one of those changes in human history. To be fair we have known Something Like this has been coming for about 30 years or so. These types of infections, where a virus jumps from an animal to a human being, they have been documented as increasing in frequency the last 30 years. It has been the question of when, not if. What that means is we are going to have to figure out a way to get past the acute phase. We will it will take some years low. There are two ways to help reduce the risk. One is a vaccine. That is only part of the solution. The other is of course the idea that came on on early on. In the longterm it is very important. That is what is called herd immunity. The more people who build up immunity to the virus, that will reduce the possibility of there being these academic or pandemic outbreaks. That is not going to happen this year or next year. It will take several years for that to take place. We have to be in this for the long haul. Susan i want to go back to the geopolitics. From where you sit with so much information, how concerned are you about the weaponization of a successful vaccine . Dr. Horton i am anxious about this because this is a global emergency. It requires a global solution. That means countries and president s and prime ministers have to find ways to work together. It feels as if the science is being so politicized, when we published the first papers on the pandemic at the end of january this year from china, and we see the president of the United States calling this a china virus. It is no more a china virus than any other virus is. That is like saying in america you call it an american virus or my country, a british virus. It is a nonsensical statement. By saying it is a china virus, or as today in the press conference that launched the russian vaccine study that took place in moscow, where those who are presenting preventative presented as a force against the west, criticizing the vaccines, that the russian this is not the way to solve a global emergency. We seem to be putting country against country, scientist against scientist, and this is going to hamper any attempt we have to control the pandemic. We need leadership where our politicians work together, not against one another. I am very troubled by this. Susan let me go to the third leg of the stool, a treatment, clinical treatments of people who have caught the virus. There is a lot of policy about steroid use and the success of readily available steroids and treating the people in this patient in this disease. Also we hear about remdesivir and its continuing success. On that front, treatment, what are you seeing . Dr. Horton incredible. We did not even know this virus existed at the beginning of this year. But i really think we have to have so much gratitude for the scientists around the world to have found ways to work together, to test these treatments out in large numbers of people. I think we have learned an incredible amount. One of the reasons why the mortality rates have gone down the last few months in countries that have been hit hard, not the only reason but one reason is we know better about how to manage patients with this disease. It is important to say this is a nasty disease. Patients who present with covid19, they have multiple organ failures of the heart, the liver, belongs, the kidneys. They generally are in intensive care because they need intensive care. When you are faced with a patient like that, just keeping them alive is the goal. Now we have treatments that not just keep them alive but could really slow and turned back the pace and aggression of the disease. The issue is still whether it is it is really a huge the reduction of mortality in patients with severe that is a major step forward. Also we know that in fact there are trials ongoing that i believe will deliver further benefits in the coming months. Susan you have been at this field for 30 years. You think back to the earlier pandemics, ebola, sars, they have come into being. Your publications response to it, you say it feels like a lifetime. Can you comment about the speed with which the Scientific Community is responding to this compared with the recent past . Dr. Horton there has been so much criticism of china and the World Health Organization. I understand why. Because this virus has turned all of our lives and our childrens lives upside down. It is understandable we are angry about it. If you look at the timeline, this has been the fastest that International Organizations and countries like china have ever responded. If i take you back to the early 2000s when the first sars outbreak took place, a virus that is related to the coronavirus, the outbreak in 2002 took place also in china. The chinese response was to deny the outbreak, to cover it up and hope it would go away. It took months for the World Health Organization to force china to come clean about what was going on. What happened this time . The first patient that we are aware of what was admitted to hospital was on the first of december, 2019. And one month later, the Chinese Government informed the World Health Organization there was an outbreak of an unknown virus and severe disease. One month after that, the World Health Organization had sounded the most important alarm signal it can, declaring a Public Health concern. It took eight months with the recent Ebola Outbreak for the w. H. O. To call this, and ebola is much nastier. It took them eight months. On this occasion it took one month. China and the w. H. O. Outperformed themselves from any previous pandemic. Although we have questions to ask of the Chinese Government, we have reasons to be concerned about some of w. H. O. s response and the government responses, such as mine and the american government, we also need to recognize parts of the response were really very quick. Susan i want to dig into that a little bit. I would like to spend some minutes on the lancet itself. Lots of laypeople were saying, tell me what the lancet is and what its vision is. Dr. Horton the lancet was founded by a 27yearold young surgeon called thomas whackly in 1823. He founded it to do two things. He called it the lancet for two reasons. A lancet was a surgical implement. It was there to cut out the diseased parts of the body that was causing illness. The idea was the general should cut out the corruption he saw in medicine in the 19th century. It had a political objective. And it was also going to be a scientific journal. That is another meaning of the word, lancet. It is an arch that lets light into a building. So these twin ideas, whichever was going to throw light on knowledge and at the same time fighting corruption and informing medicine, these are the two ideas that founded the journal. We try to reinvent those ideas for a new generation. We try to publish the best science that we can find and at the same time act as advocates for health as an important issue in our societies and communities. Susan how are you funded . Dr. Horton we are a magazine. We are just like the New York Times or the economist. We rely on subscriptions. We rely on advertising. We rely on pharmaceutical companies that buy reprints from the journal of studies we have published. We have a kind of mixed model of how we are funded. We are very similar to any other magazine or newspaper. Susan what do you know about your readers and how they use the material you publish . Dr. Horton dr. Horton we publish for physicians, but our readership goes beyond. I started to read it when i was a medical student. I hope we still have the idea we are reaching out to doctors and providing them every week with information that can shape the practice and thinking, keeping them up to date. We have deliberately tried to do this in recent years, reached out to a broader audience of people who work in public policy. Because health is such a Critical Force in our culture, society. It is a politicized subject. Because of debates about the Affordable Care act. We want to be advocates for the best science that can help inform policymakers and politicians about what they do. No politician or policymaker will read a 20 Page Research paper in the lancet. What we can do through editorials or podcasts or videos is we can translate the research into ideas and prose that will be understandable by the layperson. That is what we hope for. We hope to be a scientific journal. We also want to have that other role of the lancet, trying to reform society, make society fairer, healthier and kinder. Susan the lancet published the very first study of the coronavirus from the chinese all the way back in january . Dr. Horton january 24. Susan can you give us a sense of when this hit your Editorial Group conversations that were happening about publication . Dr. Horton we have been working in china the past 10 or 11 years. We became aware there was this outbreak of virus in wuhan. We contacted our colleagues in the Chinese Ministry of health, the National Health commission. And in the China Centers for Disease Control and prevention. And we asked them, what is going on . Can we help . By that, what we meant was, can we help by publishing any work you have to show the International Community . This is where some of the criticism of china has been unfair. The chinese have been accused of covering up the outbreak. Far from it. When we first made contact, we had editors who wrote in beijing. When we first made contact with the Chinese Government and offered a hand to help tell the International Community about what was going on, they said yes. Very quickly gathered the data they had been assembling in december and january and wrote up four or five research papers, which we were able to publish at the end of january. It is strange to go back and report these things we did not know but this was the first descriptions of how severe the infection was, putting patients into intensive care with a high mortality. We have published papers showing human to human transmission. We did not know those human to human transmission publishing papers showing what you know, characterization, that this was a sars virus. Publishing that showed and the very phrase was used in january, we are at risk of a global pandemic. All of this information came from the chinese themselves. Everything that has happened in the last six months was described in those papers, and they came from china. To accuse china of covering up and not telling the world is unfair. Susan we in the states saw a report by combined intelligence agencies coming to the conclusion that local authorities in wuhan hid the extent of the virus from the national government. Can you corroborate whether that rings true . Dr. Horton i think it is a complex picture to try and understand. Let me just try and explain how it might have played out. I see how it can be seen but we will have to put oneself in the position of the authorities at the time. Yo