Lancet editor says inequality and COVID-19 have converged to create a "syndemic"

Dr. Richard Horton, editor of The Lancet, says we face a crisis that is biological as well as social

By Matthew Rozsa

Staff Writer

Published February 6, 2021 2:00PM (EST)

"The COVID-19 Catastrophe: What's Gone Wrong and How to Stop It Happening Again" by Richard Horton (Photo illustration by Salon/Getty Images/Polity)
"The COVID-19 Catastrophe: What's Gone Wrong and How to Stop It Happening Again" by Richard Horton (Photo illustration by Salon/Getty Images/Polity)

In his new book "The COVID-19 Catastrophe: What's Gone Wrong and How to Stop It Happening Again," Dr. Richard Horton does more than trace the history of the COVID-19 pandemic and explain how we should listen to scientific experts in confronting this global scourge.

He does this, of course, but Horton is more ambitious than that. As editor-in-chief of "The Lancet" — one of the world's oldest, most famous and most prestigious medical journals — Horton has overseen the publication of countless articles on a variety of medical subjects. Hence, one can sense in his book a desire to apply the full breadth of his knowledge and experience to this problem. His conclusion is both fascinating and extremely relevant, even urgent.

As Horton explains, the COVID-19 pandemic was unnecessarily worsened by deeper social problems, from economic policies that left millions upon millions of people especially vulnerable to Western governments who made political assumptions about the virus that proved to be gravely mistaken. Speaking with Salon, Horton discussed everything from President Donald Trump's failure to address the pandemic (as well as President Joe Biden's early successes) to an intriguing thought experiment on what would have happened if the governments the world could have simply paid people to stay home.

As always, this interview has been lightly edited for clarity and context.

How would you sum up the main thesis of your book?

What I'm trying to do is to look back over the past 12 months and draw conclusions and learn lessons, in a sense to provide a preliminary verdict on the world's response to the pandemic. But second, and in some ways more importantly, to look forward and to try and put the pandemic into perspective and answer questions about what kind of society we want to live in and how do we get to that society. 

Let's talk about Donald Trump's response to the pandemic. How would you characterize that?

On dear! Donald Trump exemplifies the kind of leadership that really dragged America into the international shadows in his response. There wasn't a political leader, except perhaps for President [Jair] Bolsonaro in Brazil, who was so dismissive of the science, so dismissive of expert advisors around him, so reckless in his pronouncements, so inconsistent in his advice to the public, and seemingly so unwilling to mount any kind of coordinated national response. It really was remarkable to observe the United States of America, the world's only scientific superpower, fail utterly to bring the talent and knowledge of its scientific and medical community to bear on this pandemic. And it's a failure that will hold the US for decades to come.

How would you contrast that with the early policies we've seen from Joe Biden in responding to the pandemic?

President Biden very quickly assembled an expert team to counsel his administration, people on that team who had great expertise in public health, and of course, of managing previous infectious disease outbreaks such as AIDS. I'm thinking about Dr. Eric Goosby. He was certainly correct to retain Dr. Anthony Fauci as a principal advisor, and my impression is that he shows due deference and respect to the science while at the same time showing firm political leadership and then the intention to put in place the kind of national response that President Trump seemed to find so difficult. There is a sobriety about President Biden which may not produce exciting politics, but certainly delivers reassuring competence at a moment of national crisis. 

In your book, you described certain countries as having better responses than others. Which ones would you cite as the gold standard? I'm thinking of New Zealand, as one example.

I think that if you actually look to East Asian countries, we can see now that countries such as China, Taiwan, Singapore, to an extent Vietnam, certainly New Zealand and even laterally Australia, were about to mount decisive responses and understand that the only way to address this virus through a strategy of what one might call "zero COVID." One has to act in a way that squeezes this virus out of every possible community. Now it's never going to be possible to eradicate this coronavirus. It's not going to be like smallpox, but it is possible to eliminate the virus, in a word to 'suppress' it so much, that you do not have community transmission. And that needs to be the objective in the U.S., the United Kingdom and across Europe. And at the moment, unfortunately, we have failed to learn the lessons from the successes of East Asian countries. We're pinning all of our hopes on the vaccine. A vaccine will be important, but a vaccine is not a magic bullet, and it does not alleviate us from the fact that we need to pursue a policy of zero COVID. 

Now I want to pivot to your book's discussion of austerity economics, which you describe as making this crisis worse than it needed to be. Can you elaborate on that?

Yes. This pandemic, we have viewed I think as a threat from a virus, but actually it's not a pandemic where the virus is the only threat. The pandemic also hit societies that were very poorly prepared for the virus, and they were poorly prepared in two ways. Firstly, the very high levels of chronic ill health amongst many Western societies — particularly chronic ill health from overweight and obesity, diabetes, high blood pressure, very common disorders — and secondly, we were vulnerable because of the deep inequalities in our society. And the decades of austerity has deepened those inequalities in our society. And indeed it was the people who were poorer, who lived in less good housing, who were working on the front lines, who are living in the gig economy, who didn't have the luxury of being able to choose to work from home but had to put themselves at significant risk by going out to work every day — I think what we've seen is that that austerity, which worsened inequality, created the conditions for an exquisitely vulnerable society when a virus hits.

So that's why I don't call this a pandemic. I call it a "syndemic." It's a synthesis of epidemics, which together — the biological and the social — together has caused this global emergency.

In a sense then could you argue that the failure on the international level to effectively respond to the pandemic is an indictment of capitalism

I would say that it's an indictment of the past 40 years of a version of capitalism. Since the days of Ronald Reagan and Margaret Thatcher, we have pursued a very intensive form of capitalism that has come to be called neo-liberalism. And that intensified capitalism elevates the market as the supreme arbiter for all social problems. And what we've seen is that in the good times, having efficient just-in-time societies and supply chains might work well, but when a pandemic hits, what you need is not efficient market based societies, but what you need is resilient societies. In other words, societies that are able to absorb shocks, and one of the reasons why many Western countries have performed so badly is that their societies were not able to absorb these shocks. So I think one could say that this pandemic has held a mirror up to the way we've lived our lives for the past 40 years. 

And we've looked into this mirror and seen that the kinds of societies we live in are not fit for purpose for the threats that we face today. Because we will have another pandemic. There will be one. We don't know when it will happen. It might not be next month or next year, or even next decade, but it will happen, and we need to be ready. And that means we need to change the direction of travel in the way we construct our societies so that they are resilient, so that they can absorb these shocks, and that means that death of neo-liberalism.

I would like to ask a hypothetical question. Let us say the governments of the world would have been able to simply pay people to stay at home, and redirected all of the resources necessary to fighting this pandemic. Would this have been contained more quickly and effectively than with the patchwork of policies that we've seen internationally instead?

I think it's a very interesting thought experiment because I don't think it's outlandish. I think that it would have been a highly desirable outcome. We've already said that East Asian countries pursued a very tough lockdown in the first wave and were very effective at squeezing the virus out of their communities. One of the myths of this pandemic is the trade-off that is alleged between health and the economy. People say, 'Well, we have to think about livelihoods as well as lives, but if we pursue the objective of health, then we will end up sacrificing our economies.' That's plainly not true. What we've seen is that those countries that did put a premium on saving lives actually have seen an economic bounce back.

I'm thinking here of China, as an example. It's not a trade-off between health and the economy. In order to get back on track with economic growth, you need to put health first. And what we in the West have done is not understand that lesson. And as a result, we're constantly cycling back and forth between lockdowns, release, resurgence of the epidemic, lockdowns, release, resurgence, in this endless cycle, which is doing far greater harm to our economy and at the same time driving up mortality. We have the worst of both worlds.

That makes sense. I would now like to pivot to specifically the Chinese government's response to the pandemic and how it compares to that from the United States and the United Kingdom. I personally feel that there has been a tendency to vilify China. I'm curious how you would contrast the government's responses strictly in terms of COVID-19 and protecting their populations.

I think we have to be very nuanced about our judgments of China. I worked very closely with a group of Chinese scientists and doctors who were on the frontline at the outbreak in Wuhan last year, and I can honestly say that the world owes them a debt of gratitude for the way they fought this outbreak when it first took place, for the fact that they sequenced the genome of this virus and posted it in early January for the world to be able to use, for the fact that they wrote up the first case descriptions, which we published in the last week of January, so that the world could get an accurate understanding of the threat that we were facing, the fact that they signalled to the world the dangers of person-to-person transmission. And finally, they raised the alarm about the risk of a global pandemic.

This work was done in China. So when I see and hear Western political leaders vilifying China in the way that they do, I think that there is a dimension of Sinophobia, even racism, against the Chinese. Now that's not to say that the Chinese government doesn't have some very important questions to answer about the very early stages of what took place in Wuhan and how that information was handled by the local authorities there, how it was transmitted to the government in Beijing and how they evaluated that evidence. I hope that the current WHO team that is in Wuhan and is investigating these early stages of the outbreak, I really hope that the Chinese authorities give them the freedom to investigate.

But when you compare the way China acted, which was decisively and quickly in those early stages, and I compare the way my government in the United Kingdom or President Trump's government acted in those weeks in January and February and early March, I'm afraid that showed the dangerous incompetence of our democracies, and actually points to a potentially very dangerous flaw in our democracies, that we were not able to apply our scientific knowledge and translate it into political decision-making that protected the lives of our people. And that is a terrible, terrible failure of the democratic system. 

My final question is — and this is something that you broach in your book, so I was hoping you could elaborate on it here — what specific mistakes did US and UK policymakers make when it came to working, or more specifically not working, with Chinese scientific experts in dealing with the pandemic? 

One of the advantages about an authoritarian political regime, which China is, is that there's a relatively small number of people who have a great deal of influence and power, and in the world of medicine and public health, we know those individuals very, very well indeed. Now when the first news of the outbreak became known, it seems to me that government advisors in the US, UK and elsewhere should either directly or through their embassies in Beijing have got in touch with these individuals. We all know them. Your leading experts in America know personally George Gao, director of the Chinese CDC, or Chen Wang, President of the Chinese Academy of Medical Sciences, or the Ministry of Health's Ma Xiaowei, or the former minister of health who has a very well-known international laboratory in Shanghei, Chen Zhu.

These people are very well known to us in the West. Why didn't we get in touch with them and ask them what actually was happening? Was this a real global danger? And again, there's a failure of statecraft here, which I do find very difficult to understand. In those weeks in January, those early weeks in January, we were in touch with all of those individuals asking them what was happening in Wuhan, and we built up a picture by the end of January of this real emergency that was taking place in the country and that was on the edge of breaking out into the rest of the world.

Now, if we, as a medical journal, could see that just through our own network. I don't understand how with the great power and reach and network of governments, that message was not somehow funneled into all the offices of presidents and prime ministers. And this failure of statecraft is what I believe there needs to be a reckoning for. The information was available in January last year, and somehow we were unable to grasp it and to translate it into policy. And the result is that literally hundreds of thousands of our fellow citizens have died. Needless deaths. They did not need to die, and they died because their governments were inept.

The second edition of Dr. Horton's book,  "The COVID-19 Catastrophe: What's Gone Wrong and How to Stop It Happening Again," was just released by Polity Press in January 2021. 


By Matthew Rozsa

Matthew Rozsa is a staff writer at Salon. He received a Master's Degree in History from Rutgers-Newark in 2012 and was awarded a science journalism fellowship from the Metcalf Institute in 2022.

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