May 25, 2017
In Blog News
Dedicated to Richard Horton:
Prof. Richard Horton is a dignified man who holds one of the top jobs in the world of science: editor-in-chief of renowned British medical journal The Lancet. But when he shows a picture of a poster he received in 2014 – with his face alongside those of Nazi war criminals and terrorists – his elegance and serenity are replaced by genuine emotional distress.
“It was pretty painful,” recounts Horton, 56. “We lived in London, where my daughter goes to a school where there’s a strong Jewish community. We had parents coming into our house – I wasn’t there – and shouting at my wife, accusing her of being anti-Semitic because of me. My daughter would come home from school saying to me, ‘Dad, why do you hate Jews?’ She was 14 then. It was getting crazy. The irony is that my wife’s father is Jewish, and his mother escaped from Russia during the pogroms to Ellis Island. It was totally ridiculous.”
The furor Horton is describing came after his journal published “An Open Letter for the People of Gaza” during the war between Israel and Hamas in the summer of 2014. In the letter, 24 physicians from Italy, Britain and Norway came out against what they labeled Israel’s war crimes, calling upon the world “to take a stand” and warning that if not, “We are also complicit in the destruction of the lives and homes of 1.8 million people in Gaza.”
The letter noted that the “massacre in Gaza spares no one, and includes the disabled and sick in hospitals, children playing on the beach or on the roof top, with a large majority of non-combatants.”
The Lancet not only published the letter but also offered readers the possibility of adding their signatures to it – which tens of thousands did.
The extraordinary publication of the letter quickly became an ugly brawl between Israel’s supporters and its opponents, and to a certain extent backfired on the journal, which faced boycott threats and calls to fire Horton.
But the story took a Hollywood movie-esque turn when Prof. Karl Skorecki, a doctor from Rambam Medical Center in Haifa, invited Horton to Israel, in an effort to let him form his own impressions about the Israeli health system, and to witness the complexities of the Israeli-Palestinian conflict up close.
Earlier this month, nearly three years on, Horton was in Israel to present Israeli President Reuven Rivlin with a copy of a special edition of The Lancet, which is dedicated entirely to the Israeli health care system. He even delivered an impassioned speech about the Israeli health system during the presentation. The change in Horton’s stance could not have been more dramatic.
How did all this happen? When Horton begins recounting his tale, it is evident the wounds are still open. He asks to begin “Right at the beginning” – that is, years before Operation Protective Edge in Gaza – when he first became acquainted with the Middle East.
“I first came through Ben-Gurion airport in 2007 to go to Bethlehem. I was being encouraged by some people in the U.K. to write about Palestine and Israel,” he relates. “And I was very nervous about getting involved, because I didn’t know anything about it, and it seemed like political suicide. So I resisted and we didn’t do anything in The Lancet. But then I thought I should come, if we wanted to do something about it.”
With time, Horton began to feel at home in the occupied territories, and the relationships he developed there grew stronger.
He was taken on “a weeklong tour of villages around the West Bank and Gaza, met people in the health care system, and started to understand a little bit about their challenges. We decided to do a series about life in the territories. That took two years, and it was published in 2009. We decided to hold an annual meeting with young Palestinian researchers from the West Bank, Gaza and the Palestinian diaspora to present their research. This March, we held the eighth meeting, in Bir Zeit. There are such travel restrictions that not everybody could come. Sometimes we do it in Beirut, or Amman. We founded the Lancet Palestine Health Alliance. That was a wonderful collaboration – and then came Operation Protective Edge.”
During the 2014 war, relates Horton, the reports coming in from the field caused him great distress. “The conflict started and I was seeing the number of deaths going up every day. I’ve been to Gaza, and I know how difficult it is there. The first thing that hits you when you go through the checkpoint is that it’s basically a land of children: all you see is children playing in the street. They have to have three shifts to go to school. I found myself getting really upset. I know that thousands of rockets were being sent from Gaza. But I got very emotional about Gaza. And then we got this letter sent from these people. We published it in July 2014.”
What happened after you published the letter?
“We got thousands of people signing up on our website to support the letter. But we also got people saying, ‘What are you doing? This is anti-Israel, anti-Semitic – you clearly hate Jews.’ I didn’t expect it, I didn’t see it coming. It wasn’t just from Israel, it was from everywhere, especially America. … When we published some of the Palestinians’ abstracts in the past, we’d been criticized about balance, but nothing like this.”
How harsh was it?
“There were calls from the medical community in America, particularly the cardiology and diabetes communities, to boycott The Lancet. There were petitions going around to boycott us. A lot of American physicians signed the petition: They were not going to send research papers, review for us, write for us; they wouldn’t have anything to do with us. Not only that, they would not have anything to do with our publishers, Elsevier. They started writing letters to our publisher and me, calling for my dismissal.”
Health is a political issue
The moving spirits behind the letter were Dr. Paola Manduca and Dr. Swee Ang, who were subsequently revealed to have previously disseminated a neo-Nazi video and anti-Semitic conspiracy theories. They denied the accusations. Against the 24 original signatories of their letter, 500 doctors – mostly Americans, some of them Nobel Prize laureates – countered and signed a letter stating their support for Israel and demanding that The Lancet retract.
Did you really never think this might happen?
“No. To me it was a humanitarian issue. There was an imbalance of firepower. Knowing Gazans, I knew they had no chance. I read reports about families that lost two or three members at a time. The letter was a cry of anguish from our readers about it. The result was massive polarization. The most serious charge is that we’re anti-Semites – there’s nothing worse than that.”
Three weeks after publishing the letter, a battered and bruised Horton received an email from Prof. Skorecki, the director of medical and research development at Rambam and professor of medicine at the Technion – Israel Institute of Technology, Haifa.
“I thought, this is another letter accusing me. But it says: ‘I wish to invite you as a guest.’ I thought, doesn’t everybody in Israel hate me? What on earth is he doing inviting me to Rambam? He asked me to come and talk about my decision to publish the letter and learn about Rambam as an academic institution.”
Did you think it might be a trap?
Horton looks surprised by the question. “I didn’t even think about it. There was so much sincerity that I wanted to go. I do love the region. It was a fantastic opportunity. I wrote to Karl and said yes. I came in October 2014, and they asked me to give a talk about the politics in medical journals.
“I defended the idea of getting involved, because health is political: The great reforms in the 19th century in Britain, fighting against social depravity, Dickens, Obamacare – it’s all about politics. However, I did say I regretted the polarization that publishing this letter created.”
How were you received in Israel?
“People wanted me to retract the letter. I don’t think people believed me. They thought I was just saying that. To prove that I meant it, I said, ‘Let’s work together to produce a series about the health system in Israel and the health of Israelis, which we will publish in The Lancet, just as we did for Palestinians.’ They said yes.”
And did they believe you?
“Many people were very skeptical. They thought I was saying it to get out of a bad corner.”
In the end, though, Horton succeeded in convincing the Israelis that his interest was genuine. And in a subsequent editorial of The Lancet he declared: “This schism helped no one and I certainly regret that result. I have seen for myself that what was written in the letter does not describe the full reality.”
What reaction are you getting from the other side now? In a way, you’ve won the Israelis’ trust but turned your back on the writers of the letter and their supporters.
“This is complicated. We’re just doctors, not politicians. We can’t change the world. My Palestinian friends were very nervous – they believe in the boycott [BDS], and I don’t. I’ve said to them the whole time that I don’t believe in the academic and cultural boycott of Israel – it’s self-defeating. At The Lancet we don’t boycott anybody. Boycotts divide people, stop them listening and learning, end discussions, and perpetuate prejudice and hate. It’s a terrible self-inflicted wound by the Palestinians and those who support it.
“Where do you begin and end a boycott? Every country does things we don’t like. It is far better to sit down and listen and argue and discuss. If we can build trust and confidence in colleagues in Israel and Palestine, we can build a bridge based upon trust and peace. If you could do that in health, why not in education and the economy?”
A unique health model
You’ve just published your special issue, “Health in Israel: Progress and Challenges in a Region of Conflict,” which you worked on for two years. From what you learned, what’s the most important thing other countries could adopt from our health system?
“There’s loads of things. This is one of the reasons I was keen on the series, because there are a lot of lessons other countries can learn. One is the kupat holim [health maintenance organizations]. In most European countries, we don’t have anything like that. Not in the U.K. or France, nor in America.
“We [in Britain] have a monopoly provider. The problem with monopoly providers is there’s no competition, so it’s very inefficient and there is a lot of waste. Here, you have the commitment to universal care coverage through the 1994 National Health Insurance Law – you’ve got the basic protection, and the [HMOs] allow you to have managed competition. But they don’t compete aggressively like the private sector. They’re like public sector institutions: it’s a very unusual system – they’re competing but they’re not competing. They work together pretty harmoniously and they have the same goal. You get solidarity in the health system and competition to drive up quality and efficiency. It’s a very interesting model, and I haven’t seen anything quite like it in other countries.”
Is there anything else?
“Another aspect that’s amazing is the way you link your research with patient care – it’s unusual. Organizations like the Technion, linking engineering, discovery and patient care. In my country, it’s not normal for academic medicine to work with private sector companies. It’s becoming more common, but it’s not popular because the private sector is seen as somewhat bad. You have researchers working side by side with the industries. And they set up companies, their own companies, that explore and exploit the technologies they’re developing. We don’t have any culture like that in Britain.
“The third element, which is now very politically sensitive in my country, is the issue of immigration. After Brexit, we’re going through a phase where many are anti-immigrant and xenophobic. Here in Israel, you have a history of waves of immigration not weakening the country but strengthening it. You’ve been able to absorb and transform it for the betterment of the country. In Europe, we need to learn the benefits of immigration. Your health system absorbed the immigrants – patients coming in hundreds of thousands, and also health professionals from abroad.”
Horton adds that he has witnessed something people outside of Israel don’t understand: “I see an exquisite concern for the inequality between Arabs and Jews. Though Israel is characterized as a Jewish state, it’s diverse and pluralistic. In Europe, the fear of immigration creates rising levels of anti-Semitism, anti-Muslim attitudes. People who are ‘other’ with a capital O are seen as a threat.”
A few weeks ago, the U.S. House of Representatives passed a health care bill that would eliminate extensive parts of the Affordable Care Act (Obamacare), and could cause 24 million Americans to lose their health insurance. Does The Lancet have a position on this?
“We’ve just published a series about health care in the United States. We have been looking not specifically at the new bill, but at the health system. The main predicament of the American health system is the growing inequality. This is the theme that drove the election campaign and Trump to power. One of the reasons why the Affordable Care Act was struggling was the rise in premiums and deductibles. This has led to poorer people, who officially have coverage, not being able to afford health care. This issue of inequality is one that, unfortunately, the American health care system can’t deal with. There’s no universal coverage.”
Did Obama fail to reduce the inequality?
“The good thing about the Affordable Care Act is that it tries to set a minimum standard. It reduces the risk of inequality. If this goes away, the current bill before the Senate doesn’t protect the minimum standard. If you don’t have coverage for preexisting conditions, you’re going to exacerbate inequality. This is an out-of-pocket expenditure, with catastrophic financial implications. They get plunged into poverty because of medical expenses. If you look at the causes of poverty in America, one of the most common is paying medical bills.”
What will happen now the act is in danger of being repealed?
“There’s a real potential crisis in America if the Affordable Care Act is withdrawn, and the new bill cancels the preexisting conditions. They’re not giving enough money to cover the difference. It will increase inequality even more. It’s a terrible spiral. It’s going to divide America even more. It could drive civil disruptions. Health care is like a social glue … [it] builds solidarity, community.
“Health care also changes the way people think about a country. We have a paper about Israel treating casualties from the civil war in Syria. This is not what people think of Israel or the Israel Defense Forces. People think about young Palestinians lying on the ground, and an IDF soldier shooting them in the head. Telling this story is really important, to explain how people in the IDF Medical Corps put their lives at risk to help Syrians.”
A money-making operation
The Lancet was founded in Britain nearly 200 years ago. Alongside The New England Journal of Medicine and JAMA – The Journal of the American Medical Association, it is one of the most respected medical journals in the world. Since 2015, Horton – a medical doctor by training – has been editor-in-chief, after serving as editor in North America since 1993. Horton also writes medical articles for The Observer, The Times Literary Supplement and The New York Review of Books.
After many years in key roles in the field, how much influence do you think pharmaceutical companies have on medical journals?
“We are worried about the influence of industry on the papers we publish. Most of the research is sponsored by the drug industry. They are involved in every stage: design, conduct, analysis and probably publication – they have read the paper and given comments. The opportunity for exaggeration and spin is huge.”
And how are you combating this?
“That’s where we come in, take out the exaggeration and stop the spin. The companies try to add it back in. We fight through the proxy of the paper – what we get in the end depends on the journal. At The Lancet and The New England Journal of Medicine, we can be quite powerful because people want to publish with us. We say to authors, ‘If you don’t change this, we won’t publish.’ This is usually enough. I would say that we win more times than they do. But sometimes they win.”
Can you give us an example of a distortion that could occur?
“When you have a new drug, the first study is often small and with a small number of patients. The danger of that is you have a bigger chance of a positive result that turns out to be wrong. From our point of view, it’s a first study, it’s exciting, it’s a new drug, it might be positive. So what do we do? Do we reject the paper because we’re not 100 percent sure? Do we peer review it the best we can and take a risk? We publish the paper because it’s exciting and new, but we honestly don’t know what’s going to happen next.”
What protects patients from the use of an unready technology that might not really be effective, but which has been positively written about in a leading journal like The Lancet?
“Twenty-five years ago, you [a doctor] could read a paper in The Lancet and you could go and ask for the drug in your hospital the following day and prescribe it. Thankfully, that can’t happen today, not in Britain. Most doctors know you shouldn’t change your practice on the basis of one paper. A hospital can’t just go and get a supply of the drugs. In America, it’s more dangerous – it’s still more like the Wild West. Private practitioners can see the papers and order the drug. The protections for patients are weaker in a system like in the United States.”
Horton believes Britain’s National Health Service, by contrast, is sometimes too slow to react. “The danger in our system is that it takes too long to get innovations into practice. I don’t want to say we have the best system – there’s a balance. In Israel, your dialogue about health is very focused on innovation. Because of the [HMOs] and the managed competition, you can’t just do something tomorrow. There’s a bureaucracy that protects you.”
Last year, you wrote about the crisis in scientific publishing: that despite technological advances, “the state of scientific publishing today has never been more precarious.” You mentioned the mega-journals, “where they can publish hundreds, maybe even thousands of articles,” and a disconnect between the publications and the community they aim to serve. Can you tell us how you are tackling these problems?
“What is science for? If we go back and look at Diderot’s great encyclopedia in the 17th century, in the introduction it talks about publishing knowledge for the advantages of society. You don’t publish for your CV, for your next grant or for your tenure. The reason why knowledge was being brought together was for specific social purposes. We’ve lost that in science. Unfortunately, we created an academic system that is more about the academy and the career of the scientist than it is about the public and the translation of the research for the benefit of society.”
That’s a very harsh observation.
“Right, to my great regret. In the last 400 years, science has lost its soul, its purpose and its meaning. Academic publishing is part of it. We, too, have lost our purpose and our meaning. We have to add moral purpose into science. Why should the public support scientific research unless it’s getting a return back? Scientists want freedom to study – and I understand that – but the pendulum has swung too far toward the scientists and we have to bring it back toward the public.”
Do you have an example?
“When there’s a disease like SARS or a new flu, it’s really important to sequence the genome, to introduce a vaccine. If you’re in Thailand or Vietnam, there’s enormous pressure to allow samples to go to labs in the United States and make them available to vaccine manufacturers, who are set to make a huge profit.
“The countries don’t get any benefit – they will have to pay for the vaccine. The system steals intellectual property from these countries. In the life sciences, there are basic discoveries that get commercialized and the profit goes to the industry. If you want to have innovative medicine, companies have to invest. I don’t want to be naive, but there has to be a balance between what the public invests and what they are allowed to take as profit.”
As an example, Horton offers one particular area in which the pharmaceutical companies have no interest in investing in research and development: resistance to antibiotics.
“Drug companies pulled out from investing in development of antibiotics. The problem with an infectious disease is it’s a one-off, it’s solved in one go. The incentive to invest in antibiotics is zero. The public isn’t interested because they don’t get these diseases in high-income countries, and the companies make choices according to market share.”
How are you managing to prevent the horror scenario: publication of falsified information?
“Research misconduct is the biggest threat to the public’s trust in science. If someone wants to cheat, we have no system of detecting that. We depend on people doing the right thing. This is a crisis – it has to do with incentives. In China, if you publish in The Lancet, you’ll get money and promotion. So the system is threatened by it. Peer review is bad for detecting fraud. We have to ask: could this be a forgery? There are certain markers. If there are many authors around the world, the chance of cheating is low. We have a mental index – and we peer review it to death, three or four reviewers. If we’re worried – 10 peers.”
Do you think the health care system in the United States is dysfunctional because of corruption?
“I don’t see it as corruption. I would say that America is the place where you can make a fortune. But to be in that place, there’s a ferocious free market that unleashes powerful forces into society – and one of them is the very powerful pharmaceutical industry.”
Dafna Maor co-wrote this story.