Publisher Elsevier threw a lavish party at the British Library last October to mark the 200th anniversary of its most illustrious title. Leading lights of medicine, academia and business joined a champagne toast to The Lancet, a medical journal with near household name status, founded in 1823.
Much of that status is down to editor Richard Horton, who took on the role 29 years ago when the publication was in a parlous state. Now, he leads a journal appreciated both for its scientific papers and the sometimes controversial campaigning on global health issues he has championed.
Having come successfully through cancer treatment, following a diagnosis of advanced melanoma in 2018, Horton’s commitment is as strong as ever. “We are going to continue to use The Lancet as a platform for advocacy,” he says. “We’re going to continue to see health as political.”
In an era of culture wars, Horton’s activism — on issues from global inequality and the Iraq war to the UK government’s immigration policy and pandemic response — is not universally popular, particularly with commentators on the political right. “Richard Horton is destroying The Lancet with politics,” claimed an article last year in online publication Unherd.
The reality is quite the opposite, argues 62-year-old Horton, from his modestly furnished office on the 10th floor of a modern block in the City of London. The Lancet and 23 specialist offspring set up during his editorship, such as Lancet Oncology and Lancet Infectious Diseases, have become a lucrative source of revenue and profit for Elsevier and its parent company Relx, he notes.
Relx does not disclose figures for specific journals but reported £2.9bn revenues in 2022 for all scientific, technical and medical products, with an operating profit of £1.1bn.
Academics have long complained about the high prices charged by journal publishers, either as subscriptions by readers or publication fees by authors. But profits give editorial freedom, says Horton. “The more money we make as a journal, the greater the freedom I have to do and say what I want. If I was running a business that was only marginally successful, I would not have that freedom.”
In 2006 The Lancet published an estimate that 655,000 Iraqi civilians had died in the war following the 2003 US-led invasion, sparking claims that the toll was exaggerated for political reasons. Another big row followed the publication of a letter in 2014 highly critical of Israel’s conduct in Gaza.
Looking back at those episodes, Horton says he “probably would have been fired if we were less successful”. “But our publishers could see we were successful and gave us the latitude to take risks. Sometimes Elsevier is criticised for being a for-profit commercial publisher but that’s a deep misunderstanding of what a publishing business gives us. They have been fantastically supportive and defended our editorial freedom over the years.”
Horton says the closest he came to being fired was an episode in 2003, when The Lancet ran a scathing editorial criticising the way AstraZeneca, the Anglo-Swedish drug company, was marketing its newly approved statin Crestor.
By chance the issue appeared on the same day as AZ’s annual shareholder meeting — and led to a significant fall in its share price. Tom McKillop, then AZ chief executive, called up Crispin Davis, his opposite number at Reed Elsevier. “[Davis] got in touch [with me] and asked: ‘Why are you trying to manipulate AstraZeneca’s share price?’,” Horton recalls. Davis quickly accepted Horton’s assurance that he had no such intention. “That was the only time I felt like I might not have my job tomorrow, but the moment passed.”
An episode often mentioned by Horton’s critics is The Lancet’s decision in 1998 to publish a study by Andrew Wakefield that raised safety fears about the measles, mumps and rubella vaccine. The concerns turned out to be unfounded but have fuelled antivax sentiments ever since. The paper was not fully retracted until 2010 when the UK General Medical Council found Wakefield had been dishonest.
“Publishing the paper was clearly a mistake,” Horton acknowledges. “I underestimated the potential for an edifice of vaccine misinformation to be constructed on the basis of this one paper. I didn’t expect Wakefield to mount a campaign against the MMR vaccine and recommend the vaccine should be withdrawn. He weaponised that paper into an incredibly damaging campaign but we gave him the foundation to do so.”
Scientific journals should be open to publishing “new, challenging and controversial findings, while thinking through how to manage the risk”, he adds.
Generally, however, The Lancet reflects mainstream scientific opinion. During the Covid pandemic it followed other leading journals such as Science and Nature in maintaining that the virus was most likely to have infected humans through a natural transmission from an animal — frustrating those who believe it originated from a Chinese viral research centre.
Horton joined The Lancet in 1990 after medical training at Birmingham university and London’s Royal Free Hospital. Looking back at his appointment as editor in 1995, at the age of 33, he recalls a journal “in trouble. As a business it was collapsing and we had just fired a previous editor. Several of the editorial staff had resigned because they disagreed with his stance.”
His first priority was “to modernise all of our editorial systems, which were really Dickensian.” Changing from an entirely paper-based procedure to a modern electronic workflow took about five years but greatly increased the journal’s efficiency. “When that job had been done I was, to be honest, bored and wondering what to do next”.
Inspiration came from meeting two individuals: Eldryd Parry, a pioneer of medical education in Africa, and Jennifer Bryce, a campaigner for reducing child mortality in the developing world. “Eldryd and Jennifer showed me that a journal can be an activist instrument for social change to improve global health,” Horton says.
In 2004 the Lancet launched what were first called series and then, from 2009, commissions. The aim was “to bring the best people in the world together to summarise all of the evidence and sometimes create new evidence on a neglected topic in medicine or global health — and then use that evidence as a platform for strong political advocacy”, he says.
“For me it was an epiphany because it gave a unique role for The Lancet. No other scientific journal was doing that,” Horton continues. “It excited me and it excited our staff. It’s a model we’ve cloned across 24 journals — the original weekly Lancet and the other 23 journals that we’ve set up under the Lancet umbrella.”
Altogether The Lancet titles have published the findings of around 100 commissions, including a collaboration with the FT in 2021 on growing up in a digital world. The first one concluded that climate change was the biggest threat to global health in the 21st century. “That got an enormous amount of coverage, which is strange to think about now because climate is covered in the news almost daily, but it wasn’t in 2009,” Horton says.
A relatively new issue that Horton faces is AI. It is “a double-edged sword in scientific research and medical publishing,” he says. “On the one hand it could hugely simplify research synthesis and systematic reviews — now an exceptionally laborious and rather dull exercise. However our peer review systems could not at the moment detect an AI-generated fake research paper, so we have a great problem. Because the system depends on trust, it is highly vulnerable to manipulation and exploitation.” The Lancet has set up systems to detect faked papers, he says, and they themselves will be improved through the use of AI technology.
In terms of how Horton’s personal experience of cancer has affected his editorship, he says “it has sharpened my work”. “I have cut back on my international travel, which means I’m in London most of the time, so I’m much more engaged in the work of The Lancet . . . I feel very committed to its values and its people, and I plan to continue as long as I can.”
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