4. Dr Richard Horton

DR RICHARD HORTON (affirmed).

Questions From Lead Counsel to the Inquiry

Mr Keith: Could you give the Inquiry your full name, please.

Dr Richard Horton: My full name is Richard Charles Horton.

Lead Inquiry: Dr Horton, thank you for attending this morning and for the provision of your witness statement dated 27 April 2023, INQ000148421, which you have signed and appended a statement of truth on the last page.

Dr Richard Horton: Correct.

Lead Inquiry: Dr Horton, you are the editor-in-chief of The Lancet, an very well known UK-based medical journal, you’re an honourary professor at the London School of Hygiene and Tropical Medicine and also of University College London and the University of Oslo, you worked for many years at the London Royal Free Hospital before joining The Lancet in 1990, and you became the editor-in-chief in 1995. Is that all correct?

Dr Richard Horton: That is correct.

Lead Inquiry: You have also served in various roles with the World Health Organisation. You co-chaired a scientific advisory group, you chaired the board of the Health Metrics Network and you’ve sat on a number of advisory boards for its research strategy division and for its European region division.

For the particular interest of this Inquiry, you’ve written a book called The COVID-19 Catastrophe: What’s Gone Wrong and – even more relevantly for this module – How to Stop it Happening Again.

Dr Richard Horton: Correct.

Lead Inquiry: The Lancet has a number of different parts, does it not? It has a number of journals within it; is that correct?

Dr Richard Horton: Yes, we have 24 journals and we have offices in multiple countries around the world.

Lead Inquiry: Do each of those journals deal with particular parts of the medical world but including infectious diseases and global health?

Dr Richard Horton: That’s right. The weekly Lancet – it’s our 200th anniversary this year – covers all aspects of medicine, public health and global health, and then we have speciality journals that are, as you say, focused on particular diseases such as infectious disease, oncology, diabetes and so on.

Lead Inquiry: Whilst you give evidence, Dr Horton – I didn’t warn you, it’s my fault – could you please try to go as slow –

Dr Richard Horton: I apologise.

Lead Inquiry: – as you are physically capable.

Dr Richard Horton: I apologise.

Lead Inquiry: That way we won’t – either of us – speed up.

Evidence has been given in this Inquiry, Dr Horton, about the Global Health Security Index in which, as is well known, and is now well established in the evidence, the United Kingdom did rather well.

Evidence has been received in particular from Professor Woolhouse, whom you’ll know, and also the academic Dr Kirchhelle, about some of the learnings or some of the lessons that might be drawn from the obvious feature that, whilst the United Kingdom was rated very highly in the GHSI index, when it came to actual performance we may arguably have been thought to have done rather less well.

Could you just set out, please, your views as to why you think the indicative performance in that index was not translated into actual performance?

Dr Richard Horton: Certainly. Just before answering your question, I would just like to pay my respects and acknowledge members of bereaved families who are attending today and offer, on behalf of my colleagues at The Lancet, my condolences for the loss and suffering that you have endured during the pandemic.

In response to your question –

Lead Inquiry: And go slowly.

Dr Richard Horton: And go slowly – we have tried in the past several decades, as a medical community, to predict resilience. The Global Health Security Index with Johns Hopkins University is one such exercise. The World Health Organisation has its own initiative. We’ve also tried to make correlations based on the strength of national health systems. What became clear during this pandemic is that none of those measures were effective in predicting response.

In some ways in retrospect that is not surprising. If you take the one you mentioned, the Global Health Security Index, it’s an excellent document in setting out the technical capacities of a public health system in the face of a pandemic: six broad categories, 37 indicators, almost 200 separate questions interrogating the competence of a pandemic preparedness and response system; but what it omits is the human dimension.

Lead Inquiry: Pause there. By that, do you mean the realities of the impact of a pathogenic outbreak on members of the population, or do you mean the response of the particular health system in the country under examination?

Dr Richard Horton: How our political leaders, our health leaders frame the threat, how we assess the threat, and how we respond to the threat. Those dimensions cannot be easily captured or quantified in a measure such as the health security index.

Lead Inquiry: Is that because, as Dr Kirchhelle might suggest, those indices are too technologically based and fail to reflect adequately the reality of how any human system will respond in the face of a crisis?

Dr Richard Horton: Precisely; they’re necessary but they are insufficient. It is only when you are tested by a pandemic that you really see whether your system operates effectively.

Lead Inquiry: I think there is a well known boxer who said, “Everyone has a plan until they get punched in the mouth”. These indices examine plans for countries, they examine systems and anticipated eventualities. Do they, in your opinion, fail to take into account the actual reality of the baseline health systems in each country, or how the governors and the response systems will actually respond in the face of a crisis?

Dr Richard Horton: The second part, they fail to take account of the way human beings respond in the face of a crisis. They do adequately document the capacities such as levels of immunisation, laboratory capacities, supply chains, infection control mechanisms; all that is very well documented in these indices. It is the: how do we frame the pandemic? What was the threat? We may come on to this. The focus has been on influenza, but for two decades we’ve known that that was not necessarily the major or certainly the only threat that we faced.

Lead Inquiry: Was it well known that there had been, of course, an epidemic and then arguably a pandemic relating to SARS and to MERS and that the Far East in particular had responded, one might think, quite well in terms of putting into place structures and procedures for dealing with those emerging epidemics?

Dr Richard Horton: Yes. Until 2002, we thought that coronavirus – by “we” I mean the medical community – thought that coronaviruses were a relatively benign category of virus, and we were truly astonished in 2002 when SARS CoV-1 emerged.

I brought along this report. It is a workshop summary from the Institute of Medicine, from the United States, 350 pages’ worth of analysis –

Lead Inquiry: Dated?

Dr Richard Horton: 2004 – which reviews our experience from the first SARS outbreak, and it documents our astonishment that –

Lead Inquiry: Just pause there, when you say “our experience”, do you mean the Western world or America –

Dr Richard Horton: Global experience.

Lead Inquiry: Globally?

Dr Richard Horton: This is a global report, but commissioned by the US Institute of Medicine.

It documents our astonishment about the changed pathogenicity of coronaviruses, so that they’re now targeting humans, and it warns the world community that it needs to understand these, this category of viruses, develop better diagnostics, better treatments, vaccines, and really put coronaviruses on the map as a serious human threat.

Now, that was in 2004. We have MERS in 2012 and ongoing, and, with hindsight, we clearly did not elevate the threat – despite being warned clearly about the threat, did not elevate that threat into our National Risk Register.

Lead Inquiry: Do you have a view, as the learned editor of The Lancet, as to why, notwithstanding the degree of knowledge in the public, scientific and academic worlds, that knowledge wasn’t translated into governmental planning? And by governmental, I don’t just mean the United Kingdom, but generally it would seem across the western world.

Dr Richard Horton: It’s very hard to understand why, and I think – I mean, I had this book on my shelf for 20 years, and yet we were publishing papers that were talking almost only about influenza as a threat. So I think there was a general groupthink in the medical and public health community that really focused on influenza as the threat.

However, if you were working in China or an Asia-Pacific country, I think there was a different perception. I think this was a Western groupthink, and certainly colleagues I have in China were very well aware that coronaviruses were a major threat.

Lead Inquiry: Did the combination of an arguable lack of focus on non-influenza threats, as well as the high ranking in the GHSI and other indices, engender, do you think, a complacency on the part of the West?

Dr Richard Horton: I think we were complacent, for several reasons. First, I think that we were overconfident in our National Health Service and public health service to cope with a pandemic. We’re very proud of our NHS, but the reality is, as – we had a commission published in 2021 with the London School of Economics – some of the chronic weaknesses in the NHS left us very vulnerable, and I think we underestimated those weaknesses.

I think we were mistrustful of evidence coming from China. I think that was a – you know, there was a degree of Sinophobia in the international order, which meant that we didn’t take signals from China as seriously as we should, and – and this might be arguable – but I think at the time, in January 2020, we had a sense of our national sovereignty that might have made us feel stronger as a nation to weather a shock, which was clearly misplaced.

Lead Inquiry: I’m not going to ask you any more questions on that topic, Dr Horton.

Your statement makes obvious and sensible reference to the importance of simulations and exercises, and the Inquiry has heard a great deal of evidence about the extent to which there were exercises and the extent to which lessons and recommendations from those exercises were implemented. But can you express a view as to the general importance of simulations and exercises in readying a state, and particularly the United Kingdom, in preparing it for whatever eventualities may ensue? How important, in the general scheme of things, is the exercise and simulation process?

Dr Richard Horton: The simulations are crucial for identifying possible weaknesses, and indeed it was the failure to respond to the signals from those simulations that I believe contributed to the UK’s early misadventures in response to the pandemic.

The Exercise Cygnus, for example, clearly documented areas of weakness around surge capacity, triage management, regional and local planning, social care, and even schools. All areas that, of course, subsequently became major concerns during Covid-19.

That simulation took place in 2016. It seems that we did not take note of those vulnerabilities and act on those. There’s not much point in doing the simulation if you’re not acting on it. I can’t explain why we didn’t, but the simulation was critical in identifying those vulnerabilities.

Lead Inquiry: The degree to which it was implemented is a matter for my Lady, but may we take it from what you’ve said – and it’s obvious from your last answer – that exercises are always essential, they are a vital component in the system of preparedness?

Dr Richard Horton: Vital because they’re testing the resilience of your system, and resilience is the word that overshadows all of our discussion.

Lead Inquiry: Going back to the international indices, Dr Horton, to what extent did the United Kingdom’s rankings in those indices take account of the reality that, as you would say, when the Covid pandemic struck, the United Kingdom in particular was in fact struck by two epidemics? You describe it as a syndemic. Firstly, what do you mean by a syndemic and, secondly, to what extent did those indices reflect that reality, as you see it?

Dr Richard Horton: The concept of a syndemic was first written about by an American anthropologist called Merrill Singer in the 1990s, and it’s important because it’s connecting the biological with the social: two biological epidemics interacting to make each worse. It’s not just the co-existence, it’s the fact that they each make the other worse.

Lead Inquiry: What are the two biological –

Dr Richard Horton: Well, in this particular case it is the virus and chronic diseases within our population, obesity, heart disease, renal disease, cancer and so forth.

The intersection of those two epidemics overlaid on patterns of social inequality meant that we had this very, very toxic, potent mix of risk profile which – and it’s important, the notion of a syndemic, because it affects your management and your prevention.

Management because you’re not only dealing with a virus, you also have to deal with a pattern of disease in your society that makes certain groups of people highly vulnerable. And not only the disease but the patterns of inequality: certain people who are in more deprived communities will be at greater risk than others.

And it’s important for prevention, because you won’t have true resilience from a future pandemic shock if you’ve only focused on the virus. You have to think about the overall health of the population and you have to think about reducing inequalities.

So in the future, pandemic prevention will partly be about identifying and responding to a viral threat, but it will also and equally be important to think about the overall health of the population and patterns of inequality.

Lead Inquiry: If I may attempt to summarise it yet further, is it therefore the duty of government not just to take account of those social disparities, the vulnerabilities, the inequalities, because an intervening viral pandemic will hit them harder, but they must plan for that, prepare for it, and mitigate the risk and the reality that such sectors of society will be hardest hit as a result of a virus which draws no distinction in terms of victims but of course hits those who are vulnerable the hardest?

Dr Richard Horton: Absolutely. A pandemic preparedness and response plan needs to think about the pandemic as a syndemic; and if we don’t, we will not be truly resilient to a future threat. It’s absolutely – it’s such a fundamental point, I think, in the misunderstanding of what Covid-19 has been about and what we need to do to prevent its effects in the future, similar effects in the future.

Lead Inquiry: There is obviously a close relationship between state of resilience, therefore, and proper planning?

Dr Richard Horton: Correct.

Lead Inquiry: But in regard to both, vulnerability and inequality has to be first and foremost because they are the ones who are most likely to be affected by a future health emergency or a pathogenic outbreak?

Dr Richard Horton: That’s right. This was not an equal opportunity virus. This was a virus that struck different groups of people at different levels of risk, and the way we – I mean, these are other dimensions of public policy, but in the specific realm of pandemic prevention we should be giving greater attention to those who are living with chronic disease and to those who are living in more deprived communities if we’re thinking about pandemic prevention, yes.

Lead Inquiry: You would argue that that must go beyond making appropriate clinical arrangements for dealing with those persons who are infected by a virus, but who suffer fro co-morbidities, to addressing the comorbidities themselves?

Dr Richard Horton: Yes, and this is where I think we were particularly vulnerable here, because we have – we do have an excellent national health system which is able to address people who present with particular diseases, but what we have not got is an effective public health system that is able to focus on health promotion and health – and disease prevention, and it’s that disabling of the public health system that left us particularly vulnerable to Covid-19.

Lead Inquiry: In the latter half of your statement, you set out some separate discrete points of learning or thoughts that you’ve had following, of course, the –

Lady Hallett: Sorry, are you moving to a different?

Mr Keith: Yes.

Lady Hallett: Could I just ask, Dr Horton.

Dr Richard Horton: Yes.

Lady Hallett: When you say the “disabling of the public health system”, in summary can you say what you meant by that?

Dr Richard Horton: The chronic underfunding of public health. And also the – we have a very centralised public health system in the UK – in England, perhaps I should focus on here, in contrast to some other countries which have a much more decentralised public health system.

So, for example, in Germany in the early part of the pandemic they were able to – because they have a decentralised public health laboratory system, they were able to get early data on the distribution of the virus across the country, which enabled them to plan and respond to the pandemic with greater detail and faster than we could. We didn’t have a test and trace system at all across the country.

So I think it’s that lack of investment in public health, both in terms of health protection and health promotion, that left us vulnerable.

Lady Hallett: Thank you.

Mr Keith: Picking up on some of the points that you make towards the conclusion of your statement, you say in paragraph 12, we needn’t bring it up on the screen, but it’s in paragraph 12, that:

“COVID-19 underlined the value and importance of genomic surveillance systems and these should be prioritised in strengthening our national capacities for operational readiness.”

Dr Horton, it is, I think, obvious that once academics and medics in China informed ProMED, the international surveillance body, and informed the regional office of the World Health Organisation in the first days of January and the last couple of days of December 2019, that that knowledge of the coming epidemic, then only an epidemic, was well known.

Why does there need to be further attention given or greater attention given to enhancing our genomic surveillance systems, if – the reality of the last pandemic showed that actually knowledge of the coming wave was well distributed and well known, why do we need more surveillance?

Dr Richard Horton: Well, I would argue more by accident than design, in terms of those early days. Remember, the initial response by local government officials in Wuhan was to suppress information, not to report information. The initial signal, you are right, came through ProMED, but it did not come through official channels of the Chinese government to WHO.

I have spoken to the person who was leading the WHO office in China. He had no direct contact from Chinese authorities in those early days about the outbreak in Wuhan. So the channels didn’t work.

Lead Inquiry: They worked belatedly?

Dr Richard Horton: Well, they worked by accident. Not even belatedly. He – the WHO officials had to – they saw the ProMED posting and then they were the ones who went to the Chinese authorities and said, “Hey, what’s going on?” So the information flow was in the opposite direction.

So we desperately need an awareness and a system, a global system to – genomic surveillance certainly, but also to detect pneumonias of unexplained origin. And it’s relevant to the UK – because one could say: well, this is all about China, what’s that got to do with the UK? The reality is that the UK’s national health security depends upon global health security. We are not safe as a population unless the rest of the world is safe. So that puts a responsibility on us to engage with the rest of the world to make sure that the rest of the world is safe.

I mean, over half of countries today do not have the necessary capacities as set out in the International Health Regulations to prevent or respond effectively to a pandemic. 55% of countries. That means that if there is a spillover of a virus, whether it’s from an animal to a human or it’s from a research-related laboratory leak, the fact is that in over half the countries of the world that spillover could easily escalate into an epidemic and then a pandemic. So we have an interest in making sure that those countries are able to respond effectively.

If we take spillovers, which is the most likely source of a future pandemic virus, we need to take a One Health approach to pandemic prevention. That means thinking about how human health interacts with animal health and the environment, and at the moment One Health – the concept of One Health is something of a Cinderella in global policymaking, we’re only beginning to realise its importance.

And then, you know, there has been a lot of discussion about the origins of Covid, and I’ll only say that –

Lead Inquiry: Let’s not go there, Dr Horton.

Dr Richard Horton: Let’s not go – well, it’s only relevant to this point, to your question, and that is: of the biosafety level 4 laboratories in the world that might be dealing with potentially dangerous pathogens, there is no international oversight of those laboratories. It is in our interests to make sure that we are an energetic and muscular proponent of stronger international regulation of biosafety level 4 laboratories, for national health security in the UK. I stop there.

Lead Inquiry: This Tribunal has considerable powers, Dr Horton; I’m afraid the regulation of the international order of controlled detection, surveillance and border closures is probably beyond its remit.

All the things you’ve mentioned are all, therefore, concerned, aren’t they, with the emanation of threat as opposed to the United Kingdom’s domestic response to the threat once it presents itself; is that a fair summary?

Dr Richard Horton: It is. I would argue, though, that we do have a responsibility to engage globally in the interests of the UK population. That’s really, in summary, my point. I want us to be a strong, energetic advocate in the international community in ways that I think we’ve been less so in recent years.

Lead Inquiry: Well, if I may say so on behalf of my Lady, your call has been heard.

Dr Richard Horton: Okay.

Lead Inquiry: What can be done about it is perhaps another matter.

Dr Richard Horton: Okay.

Lead Inquiry: You then turn to the question of whether or not the United Kingdom has sufficient research structures or mechanisms for collating and identifying pathogenicity and transmissibility, that is to say the building blocks of particular pathogens.

The evidence so far and the evidence yet to come, and therefore we mustn’t pre-judge it, would suggest, because there has been evidence about how quickly the United Kingdom was able to produce a diagnostic testing device and to find suitable effective antivirals, and of course it’s a matter – it’s well known that it punched well above its weight in terms of vaccine discovery and supply.

Dr Richard Horton: Absolutely.

Lead Inquiry: Does that not all rather indicate that the scientific and research base in relation to pathogens and the risks of future diseases is very well established?

Dr Richard Horton: I would say that’s one of our – has been one of our great strengths in terms of pandemic preparedness: the quality and the robustness of the science base, certainly.

However, in relation, if we just rewind back to your very opening question about why did the UK perhaps not perform as well as predicted by these health security indices, it’s not just the science base, it’s the scientists and the scientific advice that we then give to government, and there was, I would submit, clear failures in the quality of the scientific advice that we gave to government.

Lead Inquiry: Do you mean post January 2020 in terms of the response or the pre-existing position in terms of the risk assessment process?

Dr Richard Horton: No, I’m talking about those early weeks in January 2020.

Lead Inquiry: All right. We’re not going to go there because that’s a matter for Module 2.

Dr Richard Horton: Okay.

Lead Inquiry: But what about the risk assessment process? In your statement you say elsewhere that there is, as with many – as with all governments, perhaps, and all types of administration, that there’s a danger that, in the field of identifying and judging risk, each part of the system may have a tendency to assume that somebody else in the system is going to be the final arbiter of the nature of that risk and draw the appropriate lesson and raise the appropriate warning, and therefore everyone looks to each other and nothing gets done.

Dr Richard Horton: Yes.

Lead Inquiry: Is that the nub of it?

Dr Richard Horton: It is. We have – and I’m not making any comments about individuals, but in terms of the offices, we have a Chief Scientific Adviser, a Chief Medical Officer, NERVTAG, SAGE, which is – SAGE is a – is not really a committee because different people cycle in, they cycle off. This is a very, very good system designed to pass the buck to another group, and in a crisis situation I think one might consider that a more command and control approach might work better.

In Germany, for example – again I choose Germany as my comparator because they did very well in the early phase of –

Lady Hallett: Are we on to response?

Mr Keith: I think Dr Horton is drawing comparison with the German scientific advisory committees for the purposes of expressing a view on the efficacy of our risk assessment procedures.

Dr Richard Horton: Yes.

Lady Hallett: That’s what I thought we were doing, but just from the way you introduced it –

Dr Richard Horton: Sorry.

Lady Hallett: – I thought you were going into response.

Dr Richard Horton: I was just going to say that the way the German system operated was that the government invested responsibility in the Robert Koch Institute and the president of the Robert Koch Institute, who then assembled a team around him to give advice.

Our system is more decentralised and I think that that fragmentation means that, in terms of assessing the risk, we don’t do as well at being decisive at a moment of peril.

Mr Keith: But from what you’ve said earlier you would say, I think, that that imperfection in the system is of equal importance in terms of pre-emergency drawing up – identification, drawing up and response to risk as it is when the emergency strikes and you have to respond?

Dr Richard Horton: Well, clearly that’s so, because I would say that we’ve had 20 years of documented evidence about the growing danger of coronaviruses, and yet that evidence made no headway into UK planning for a pandemic.

Lead Inquiry: Another important and significant feature of your statement is at paragraph 18, where you say this:

“… the [United Kingdom] Government must make strengthening trust one of its principal instruments for pandemic prevention.”

Doctor, trust is obviously a vital part of response, which is why we’re not going to look at it in detail now, the need on the part of the population to have trust in its government so that when the government tells it how to respond and how to protect itself it will do so.

Why is trust relevant, though, to pandemic prevention?

Dr Richard Horton: So I think this is new understanding that’s come during the pandemic, so I – I appreciate we’re in Module 1 here, so tell me if I’m straying out of bounds, but what we have learnt during this pandemic is that trust in government, interpersonal trust, are two variables that are crucial in their influence of infection mortality rates. We didn’t have that understanding before the pandemic in quite the way we do now.

I think that’s another contributor to why the Global Health Security Index has not been a good measure, because it doesn’t measure trust, it measures technical capacities. But these more nuanced dimensions of the way the public interacts with itself and with government, these are decisive factors which shape the outcome to a pandemic.

Lead Inquiry: So are you in essence saying, if I’ve understood you correctly, when a pandemic or a pathogenic outbreak strikes, mortality rates and the ability of a population to respond and to survive depends to some extent on the trust it has in its government so that it will do as it’s told in order to protect itself, but that that trust can’t be born in a day, it must be nurtured, prepared for, planned for and encouraged so that when the pandemic strikes it’s in place?

Dr Richard Horton: That’s absolutely right. It needs – trust needs to be an essential element of pandemic prevention, preparedness and response, and that goes from – all the way from believing the government in terms of whether a lockdown is implemented to vaccine uptake and the safety of vaccines which have very rapidly been developed.

If the trust is not in place, it doesn’t matter how good your preparedness and response plan is, it isn’t going to work.

Lead Inquiry: But it is a necessary part, therefore, of preparedness?

Dr Richard Horton: Absolutely central.

Lead Inquiry: Right.

My Lady, those are all the questions that I have for Dr Horton. Thank you, Dr Horton.

The Witness: Thank you.

Mr Keith: There are two topics, my Lady, on which you have provisionally granted permission and ten minutes of questioning from Covid Bereaved Families for Justice UK.

Lady Hallett: Ms Munroe.

Questions From Ms Munroe KC

Ms Munroe: Thank you, my Lady.

Good afternoon, Dr Horton.

Dr Richard Horton: Hello.

Ms Munroe KC: My name is Allison Munroe and I ask questions on behalf of the Covid Bereaved Families for Justice UK and, as has been said, there are two discrete topics that I’d like to ask you about.

The first, in fact, has been touched upon already. It’s about the focus on influenza rather than other pathogens, including a coronavirus.

In your paragraph 5 of your statement, you considered that point in particular, and you referred to SARS as having provided “fair warning about the dangers of non-influenza epidemics”, and then you go on to express a view that:

“The threat of a newly emerging coronavirus should have been more conspicuous in the risk estimations and the pandemic planning scenarios.”

Now, Dr Horton, you’ve referred to that report from the US Institute of Medicine from 2004, that’s been with you for almost 20 years, documenting the growing danger of a coronavirus.

Was the scientific information and learning from SARS, which could have informed our planning scenarios, was it well recognised in other scientific literature, other than that journal from the US Institute of Medicine, in that period, the run-up to January 2020? And was it something that was accessible to those who give scientific advice?

Dr Richard Horton: Oh, unquestionably the SARS outbreak in 2002/03 spurred on a huge interest and research activity into coronaviruses, because suddenly we were aware that these were not a benign group of viruses circulating in our communities, causing mild respiratory illnesses, coughs and runny noses; actually they could cause multisystem disease, tipping people into intensive care with high fatality rates. This was utterly new 20 years ago.

That shock led to a surge of new research into coronaviruses, and it only redoubled when MERS in 2012 came on the scene.

So, yes, in the literature, which was entirely accessible, both in the general medical literature and the specialist literature, there’s an enormous discussion about the dangers of SARS CoV and MERS – and zoonotic infections in general, infections that jump from animals to humans. We recognised and have recognised for many decades that the biggest threat as a species we face from disease, infectious disease, comes from the jumping of a virus from an animal to a human. We knew that, and we knew that it wasn’t just influenza. It’s a whole range of different viruses, from coronaviruses to Ebola, and others.

So this has been a central debate in the global health community over 20 years about those threats and what we do about them.

Ms Munroe KC: Thank you very much, Dr Horton.

Still on the topic of focusing on influenza pandemics, again this was touched upon earlier in your evidence, this concept of Western groupthink.

Do you know of any Western countries or countries in the Global North that implemented any learning from SARS and indeed MERS in respect of training and surge capacity, for example?

Dr Richard Horton: No, I think we – I can’t identify any country that actually implemented a plan with a coronavirus as a significant potential threat. That was – I think there was a Western focus on influenza, which was not matched by countries that had been on the sharp end of SARS-CoV-2 in the early 2000s.

Ms Munroe KC: Thank you.

Moving on, then, to the second discrete topic, professional education for healthcare workers. Professor Heymann, of course, back in the first week of the Inquiry gave evidence, and in his report he describes a number of measures that were adopted by a number of countries in East Asia in the wake of SARS.

My Lady, we don’t need to bring it up, but for reference its INQ000195846, at paragraph 64, page 15.

Just reading a little part of that paragraph, he says this:

“Many countries in Asia (eg Singapore, Japan, Republic of Korea … Taiwan and Hong Kong …) had strengthened preparedness after the SARS outbreaks in 2003. Preparedness activities in these countries included cross-government pandemic containment, simulation exercises; teaching and practising outbreak containment skills with healthcare workers through the implementation of formal training and hospital surge capacity exercises; strengthening infection control measures at health facilities including the construction of state of the art patient isolation facilities at hospitals; and strengthening disease detection networks.”

So those are the areas that he sort of looked at in terms of training and education, and in your statement at paragraph 19 you say this:

“A revolution in nursing and medical education is a necessary part of preparing for the next pandemic.”

So my question, Dr Horton, honing in on that, the learning and practising aspect of education, in your view should such training – as well as perhaps other aspects of the training that Dr Heymann has mentioned – be provided to healthcare workers in the UK as part of that revolution in education that you describe in your paragraph 19?

Dr Richard Horton: So let me try and offer two parts – two answers.

First, may I add to Professor Heymann’s list the preparing of the public for a potential pandemic. So what all of those countries did, have done, very effectively is they have prepared the public – this goes to the point on trust – they have prepared the public for a potential future pandemic. So if and when one comes, issues around physical distancing, quarantine, mask wearing, travel advisories, the public is aware of these issues, they don’t suddenly get dropped on them with surprise. They know in advance that these are potential interventions the government might take.

Indeed prior to the pandemic if one travelled widely in Asia one would see people wearing masks, for example, routinely in the streets, busy streets, in shops, on metros.

So this became embedded in the public culture. A precautionary approach to the potential danger of a pandemic, which governments were able to …

Now, to answer your main question, put simply, threats to UK health and health security are going to come from outside the UK, which means that our doctors, our nurses, our health workers do need to be aware and apprised of those threats and in readiness to respond to those threats.

I think that our health workers did an absolutely brilliant job during this pandemic. I don’t take anything away from their response. However, it was done as an emergency, in something of a panic, and I was receiving messages during those early months and the system was close to meltdown, because we were not ready, and our health workers had not been adequately trained and prepared for the dangers of a pandemic, how to redeploy staff to focus on people in critical illness, how to build surge capacity in intensive care in a moment. Those plans had to be implemented instantly and there was very little planning for that.

So I think this educational revolution is to relocate the UK in a global community and a community – a global community at risk. It needs us to have a far more expansive view of what constitutes national health and a national health service.

Ms Munroe: Thank you very much, Dr Horton.

Thank you, my Lady, those are my questions.

Lady Hallett: A very good line to finish on.

Thank you, Ms Munroe.

Mr Keith: My Lady, that concludes the evidence of Dr Horton and the evidence for this morning.

Lady Hallett: Thank you very much indeed for your help, Dr Horton, your thoughtfulness.

The Witness: Thank you. Thank you very much.

Lady Hallett: I shall return at 1.45.

(12.42 pm)

(The short adjournment)

(1.45 pm)

(The short adjournment)

(1.45 pm)

Ms Blackwell: My Lady, good afternoon. May I call the Secretary of State for Levelling Up, Housing and Communities, the Right Honourable Michael Gove.