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Richard Horton is editor of The Lancet, the world’s leading medical journal. In January this year, it was the first to publish papers warning of the threat of a pandemic caused by the new coronavirus. At that time, the name itself was unknown to most laypeople. Less than a year later, it's clear that the danger which scientists foresaw in the virus has come to pass, and Horton himself admits that now he is more listened to, and the journal, a specialised scientific publication, has gained a broader profile. His editorials have been highly critical of the management of the Covid-19 pandemic in Spain.

Horton is an honorary professor at the University College of London, a fellow of the Academy of Medical Sciences, and chairs the board of the Health Metrics Network, a global health partnership based in Geneva that is dedicated to improving health information systems. He lives in London with his wife and daughter and is also critical of the public health performance of the Boris Johnson government. In fact, he places Britain's coronavirus management at approximately the same level as that of Spain. 

What has Pedro Sánchez's Spanish government done wrong?
The country came out of lockdown and de-escalated but it didn't have a plan. The government didn't build up a proper testing and tracing system. That made it impossible to keep the prevalence of the virus low. The aim should have been for the virus to remain low in July and August, something the UK didn't do either.

The public in Spain didn't have trust in the government and therefore many didn't keep to the rules

And so what is the problem then?
So you have this tough political situation in which there's no real consensus at various levels. I think the public didn't have trust in the government and therefore the adherence to the rules hasn't been good, but ultimately the failure is one of political leadership. The government was overconfident about returning to normal. Pedro Sánchez was on record as saying you would return to normal. There was no way you could do that! Nobody is going to return to normal while the virus is still circulating.

Spain needs a national health agency

You talk about having a plan, but what comes to us from the ministry is that they do PCR tests and have hired people to do tracing. What exactly do you mean?
Spain needs a national health agency. You can take the example of Germany and its Robert Koch Institute, an agency dedicated to research and ultimately responsible for disease control and prevention. It is, in this case, subordinate to the Merkel government's health ministry, but it is exclusively dedicated to this, the control and monitoring of this type of infection. They are the ones who have managed the pandemic in Germany, they defined how, and so they moved forward with that clear direction.

Do you think that Spain is hiding or playing with contagion figures?
It’s not that they hide data but that they haven’t invested enough in obtaining reliable data. The problem is that there is not enough information and the system is in deficit. And it's not just the responsibility of the Sánchez government, a lot of this began with the crisis of 2008. After the economic crash, they followed policies of austerity and millions of euros were cut from health care. When the pandemic came they were just not prepared.

The Lancet published five articles on the coronavirus at the end of January, but in Spain they were ignored

Let’s look at the more recent past. Your magazine was the first to publish the threat of this new virus in January. Did any governments read it?
Some did, but not everyone ignored it as much as Spain did. In The Lancet we published five articles about the coronavirus at the end of January but in Spain no one did anything. The history of the coronavirus is a history of political errors. If they had started testing many problems would have been avoided. In January we published papers describing what Covid-19 was and what could happen, it was anticipated that we were facing a possible pandemic. In Spain in February there was nothing but denial, even when they already had their first death. They also allowed people to continue holding major events such as football matches or the International Women's Day rally. The government wasted six weeks when they could have been strengthening the health system and putting in more beds.

So how do you rate the management by the administration's epidemiologists?
I haven't talked to Fernando Simón or anyone, I don't know them. The problem, in general terms, is that not all experts are on the same side either, and when scientists have disputes they lose people's trust. As with politicians.

If we look at the Covid-19 case numbers across Europe, leaving out Russia which has the most cases, then next comes Spain: is Spain the shame of Europe?
Not on its own, there are also the United Kingdom and Belgium, and to a lesser extent Italy and France. We need to calmly investigate the reasons why this has happened, we need to learn the lessons, plan for our future over the next three or four years. You need to deal with the pandemic in the short-term but have a plan for the long-term. Yes, there has been a catastrophic political failure in Spain, but also in these other countries that I mention. But they have to go beyond, and figure out a plan for the country's revival.

The coronavirus isn't unpredictable - but the political response can be

Is the coronavirus unpredictable?
The virus is not unpredictable at all - quite the reverse. What is unpredictable is the political response, which has not been consistent enough. There are countries that have done well, one of the factors has been national solidarity, with consensus between political parties and a strong bond of trust between the public and the government. Look at New Zealand, South Korea, Vietnam or Japan ...

From the outside, do you perceive the differences in Covid management between the governments in Madrid and Catalonia?
No, you can see that overall people aren't all trying to go in the same direction. But in the end, if transmission is happening in one area or another it is because of the amount of social mixing that is taking place. The virus only gets transmitted from person to person, and there must be clear communication to people on the rules for how they must protect themselves and their families. If the messages aren't clear, then some people won't follow the rules, and problems will multiply, in Catalonia, Madrid or wherever.

Catalonia should be placed in lockdown

Looking at the latest data, 50% of the admissions to ICUs in Catalonia are currently for Covid: do we have to go into lockdown?
Yes. Not like March, not for three months. But a two-week lockdown staying at home, except schools, would have a circuit breaker effect, cutting the virus transmission lines and would buy you about four weeks of opportunity to reduce the epidemic and give the government the opportunity to build up the test-trace-isolate system. Where you're seeing a rise in infection with an R number greater than 1, the response should be an immediate circuit breaker. I said two but it could be three weeks. This would bring the R below 1, reduce the prevalence of the virus and buy time for more testing.

It's difficult to make the public understand this. Just before the bars and restaurants were closed, we were told they would re-open nightclubs. And now we suddenly have to go into lockdown?
That's why I mentioned before about the importance of being consistent and giving very clear messages. You mustn't do things that cause people to lose trust in what governments are saying.

And how do you make people understand if they fear being financially ruined?
It has been shown that, in other countries that have got the virus under control, they have done so by prioritizing getting out of the coronavirus crisis, and after that economic growth has been faster. Look at the example of China, it looks like it has a v-shaped economic recovery.

We must, at all costs, avoid a third wave

And in the immediate future, what likes ahead of us right now?
We are heading into winter, always a difficult time for the health system and viral risks, and we have an additional threat. And it is really important that we now do everything we can to protect the health system. It's very clear that countries like yours and mine need to spend the next 4-6 weeks building up these responses so that as we go into winter we can protect our health services and protect those who are most at risk: vulnerable groups, schools, workers, make sure everyone has masks ... We must, at all costs, avoid a third wave.

The words of the Spanish minister promising a vaccine at the end of December are simply false

The Spanish health minister, Salvador Illa, said that Spain is going to receive more than 3 million doses of vaccines in December. What would you conclude from that?
I would conclude that the minister is trying to be optimistic, but one of the problems we have learned from this pandemic is that if you don’t tell the truth to the public, you will lose their trust and too often European political leaders have over-promised and under-delivered. This is not a good place to be, because you lose the trust of your public. So to say that an average member of the Spanish population will have a vaccine at the end of December is simply false. And he knows it perfectly well. 

So what is happening with the vaccine development?
There are many stages still to go through before there’s going to be a vaccine available, so I think the earliest that we are likely to see a vaccine available for the general public will be the spring of next year, in 2021. First you have to have the trial results and then regulators have to check that it is safe. Then you have to produce hundreds of millions of doses and then choose who can get the vaccine because not everyone will be able to be vaccinated at once. The first will probably be health care workers.

The first vaccine should be available in spring of 2021 

Do we know the candidate to be the first vaccine?
We can look at China or Russia, where even though clinical trials are not over, they are already giving it to people, they are risking a lot. At the moment, there are a total of nine vaccines that are in the final testing phase but there are 140 more underway. Next spring, we should have the first one which will have positive effects against Covid-19, but in the next two or three years there will be improved vaccines which we get access to. Keep in mind that a vaccine is not a magic bullet, it will not eliminate the virus. To give you an idea, the only virus that has been able to be eliminated throughout history is smallpox. Therefore, we have to learn to live with this virus around us.

Since January this year, the human species has entered a new era 

We have to start getting used to it...
We are now living in a different moment in human history, since early January, it's a new era for our species. A mirror has been held up to our society and we have seen all the problems and weaknesses that we have accepted as a society, all this has been cruelly exposed. Austerity, old people's homes, health care cuts. So our responsibility and duty is to do something to change this and never to allow anything like this to happen again. 

We're not good at remembering...
We have to remember. And we have to talk about the wider dimensions. This isn't just a pandemic, I've described it as a syndemic - a synthesis of epidemics, three problems at once: the coronavirus, chronic illnesses like obesity or heart disease, and thirdly, inequality, which combines with the first two.

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