So can you just start by saying your name and what your position is here?
My name is Martin Landry. I'm Professor of medicine and epidemiology in the Nuffield Department of Population Health, University of Oxford.
Great. And without giving me your entire life history, can you just give me a quick summary of how you got to where you are now?
Yes. I grew up not far from here. I grew up 20 miles west of here in a village called Brampton.
My father was the village GP. My mother was a part time anaesthetist, so medicine was all around me.
I went to school, finish it up into school again, just down the road, and then went to medical school.
I knew I wanted to be a doctor from the age of about ten or 11 and then from medical school getting ready to go to medical.
I went to medical school in University of Birmingham, right South 30th Reunion tomorrow.
A dean of medicine at Birmingham left sufficient money for every time the there
to be a 30th anniversary every year my parents went to their 30th 30 years ago.
Now my turn this time. So I recommend that to whatever Dean of Medicine wants to do with their legacies this time around.
It's a very nice tradition. So I went to Birmingham University to study medicine.
Wasn't entirely sure what I wanted to do, but increasingly got interested in in-hospital medicine and increasingly in prescribing.
How do you know which drugs to prescribe? When to prescribe, how much to prescribe?
How do you know it works? How do you know about what the side effects are, what to look out for, and so on?
And from that you quickly get into clinical trials because that's how you find out.
Can you just give me an idea of what the what the state of prescribing was at that time?
Well, you know, we did it perfectly. No, say the prescribing in the time.
I mean, I had a brilliant clinical pharmacology lecturer in Birmingham called Professor Martin Kendall,
whose approach to teaching was it was ahead of its time.
It was very much, he imagined, a real life situation,
a ladies sitting in front of you in your surgery saying that she's got chest pain and you're going to prescribe well, what are you going to get?
And what? He'd ask the question, what are the ten things you're going to tell the lady about this prescription for Duchenne?
And he used to get used to these roadshows. You get so gitanas a treatment for angina.
It's a spray that you put under your tongue.
I can give you the ten things it can cause headache, but it can deal with the angina and so on and so forth.
But the way he did it was he would have these roadshows.
We never went on the road, but he put ten students each week up on the stage and asked them a series of these sorts of questions,
and those ten students knew who they were going to be in advance. They sort of knew what the questions were going to be in advance.
But it very much put that sort of combination of you had to understand how drugs worked and the sort of science of it.
You also had to understand how medicine works, and you were also under some element of pressure because they were with the big professor and,
you know, 200 medical students in front of you. It was a very, very good training for thinking about the decision.
That is a fundamental decision of medicine. Do I prescribe a treatment or don't I?
And if I do prescribe a treatment, what treatment I want to prescribe, how do I prescribe it, etc.?
So that's sort of that. That was really what got me interested into clinical pharmacology.
And after a few years of junior doctor jobs, I went back to Birmingham.
In fact, at his lecture as his clinical lecturer, he took an enormous risk on me.
I didn't have a PhD, I'd only just passed my membership of all college positions.
So the necessary exam to be a registrar. I had no publications, no papers, no no grants, no nothing.
Now, he was either had incredible foresight or took a huge gamble or was just desperate.
But whatever way it was he he took me on as his as his as registrar, as clinical lecturer, as his PhD student.
And over the subsequent four and a half years or so,
I was able to get my specialist training so I could become a consultant in clinical pharmacology in general medicine.
I was able to get a Ph.D. from Birmingham,
and I was also able to do the sort of higher education teaching qualifications that I came as part of as well.
So I wanted to do those things in five years whilst living still in West Oxfordshire with a with by then two children under the age of two.
Well I think it probably fair to say my wife had two children under the age of two.
So I'm incredibly grateful to her for her support all the way through.
But that really got me into into as I say, into the further into clinical pharmacology.
But I got to a. Well, I thought it's all about these big clinical trials.
Where are those big clinical trials being done? They're doing done in Oxford by Rory Collinson and Richard Richard Peto.
Really? And some point during that, so ten years between going to medical school and finishing up Ph.D. and and and so on.
I've increasingly started reading the results of the big clinical trials as they were coming out.
There was one from the late 1980s called the Aces to Trial, named after the paper, which was well known as groundbreaking, is really large,
really simple, very little paper work, and got incredibly impressive results and completely changed the face of cardiology.
How we treat acute heart attack within weeks.
So what? What? Just. That's just a little bit.
How was heart attack treated previously? What was the rationale?
What were the drugs being tested and what's the. Sure.
So so prior to that, if you go back to the 1960s, well before my time that whilst my father was a GP,
patients with a heart attack which were given bedrest at home come the early 1970s or so.
Then coronary care units started to be getting established to bring these patients into hospital.
When you brought them into hospital, you didn't do much more than give them bedrest.
People were often in for ten days or a fortnight,
and there wasn't much in the way of drugs that you could give people by the time it got to the mid 1980s.
We hadn't advanced a whole load from there really.
But this trial said if we thin the blood with aspirin, maybe knows aspirin, but it has an action against the platelets, stops and clumping.
And if we were to dissolve the clot, which is the cause of the heart attack,
a clot forming in the in the coronary arteries so that blood doesn't get to a particular bit of heart muscle.
We could dissolve that clot. Maybe that would actually improve your chances of survival from the acute heart attack.
Now, there were a lot of small trials that had been done perhaps up to that point,
which if you added them all together, did a meta analysis, would say, actually,
both of those treatments look like they're good treatments,
but a collection of small trials hadn't been enough to actually convince doctors that this was the right thing to do.
Not entirely surprised by that, because these are drugs.
The idea of giving to somebody a drug that dissolves blood clots together with a drug that prevents blood clots forming.
That's that sort of shouts. There's going to be bleeding and sure enough, there is bleeding.
So when you see as a pay, as a doctor, one patient and you give them those treatments,
you either see nothing happen because they get better and they and they survive and they go home from hospital,
in which case that sort of just what you expecting to happen. So nothing is a success in that sense.
Or they have these they can have a massive catastrophic bleed and require blood transfusion or even die from bleeding.
So as a doctor, seeing one patient,
you don't you can't tell the benefits because all that the benefit is is just the person continues to recover and survive.
But you do see the harms in the harms are quite nasty.
So it's not a surprise that doctors weren't to my mind that doctors weren't entirely comfortable with giving these treatments.
Well, Richard, Peter and Roy Collins did was say, well, okay, this looked promising.
Let's do a really big trial of I think was 18,000 people or so and randomise them toss a coin between getting to coin age or placebo and also
between getting aspirin or placebo and do it so that some people get both and some people get neither and some people get one or the other.
And when they did that, they found that the streptococci still in the blood.
And so dissolving the clot reduced the risk of heart attack and the aspirin sending the blood reduced the risk of heart attack.
And if you get in both together, they both reduce the risk of heart attack and you almost halve the risk of dying following an acute heart attack.
And that was so clear that then practice changed within the following six months.
And if you look at sales of the drugs or prescribing or whatever of our doctor surveys from about that time,
this one study changed from huge uncertainty and a promising treatment that nobody was using into essentially it was definitive,
almost to the point that you were considered a not very good doctor if you weren't following that evidence.
So the key thing about that study was its size.
It was size, it was randomised this coin toss and it was really simple to do on the front page of the protocol.
It said by far the greatest contributor to success of this trial will be how easy it is for
front line busy doctors and nurses to actually enter this their patients into this study,
hence the workload. Has to be as absolutely minimal the extra workload.
So it has to be practical because I mean, I was around those times perhaps a couple of years after.
I mean, I was seeing exactly those patients. We were not getting much sleep, we didn't have much time.
And the idea of doing these extra, extra things on top, it was fine if it was, you know,
one page of questions, but if it had been a book or whatever, it would have just never, never got done.
However, how much one was paid or shouted about it or whatever else.
So the simplicity was also a really key driving point.
So that that chart, that so much trial came out was a medical student, there was a series of other studies.
It was somewhat like it bit different over the over the subsequent ten years.
But when I saw that paper, everybody was saying, well, look at the results.
And yeah, the results are really impressive and have a big effect.
And, you know, everybody look the results over and over and over again. And I've been tested on them more times than you could imagine.
But I looked at it and I thought, Isn't it interesting that I looked at it?
Yeah. They also said something about the John Carter of the John Ratcliffe Hospital, Oxford,
and I thought there's some there's two or three people sitting in a portacabin outside the john in the car park of the John Ratcliffe Hospital,
who one day came to work and they said, you know, what's needed is a study this big.
Okay. And number two, we're going to do it. And number three, they then went on to do it.
And I was wrong about the portacabin. And it turns out that they were in a disused X-ray room and in the John Ratcliffe Hospital,
which I think they weren't they'd commandeered and weren't supposed to be in.
But the rest of the story is pretty much how I imagined it.
Pretty much true. So it was the what I suddenly got interested in was how does that actually happen?
It's not yet. The result is really impressive and the result matters.
But I was interested to go behind sort of behind the scenes.
It's sort of I guess there are people who see a wonderful West End performance, which is incredible, but they go behind the scenes and they think,
I wonder how the, you know, the puppeteer actually works or, you know, what did the stage designer have in his mind when he put that together?
How did the producer think I could assemble all these people and pull this off?
And it was I guess it was that sort of that sort of intrigue which got me into it.
So you were interested in the boxes and the barcodes and. Yeah, yeah, yeah, yeah.
How did you you know, you had exactly the boxes, the barcodes, the, you know, don't ask more questions.
You knew then you have to and so on. So when I came to this, we're now through to the late, very late 1990s.
I was finishing off my by this time my clinical lectureship in Birmingham.
I was finishing off my PhD in Birmingham and whatever, partly because my PhD was on why people with kidney disease get heart disease.
And I've been speaking to Colin Agents who is here in Oxford about that because it was an area he had an interest in.
So I sort of knew him a bit, but it became clear that the right thing to do if I wanted to pursue my interest in these really big clinical trials,
was go and work for the people who pretty much invented them.
I don't like me for saying that, but pretty much invented these sort of large, simple, so-called simple randomised trials.
People used to call them large and simple. I think the aim is that the simplicity is what is how it feels on the ground.
The complexities all dealt with so that the people on the ground don't have to worry about it.
And that's what one really learns. I mean, again, it's like a, you know, a great theatre performance.
There's huge energy and activity going on before it happens, during it afterwards and whatever behind the scenes.
But as the audience, all you see is, is, is, is, is the the simplicity, the beauty, if you like.
So was a job advertised all that you fancy?
Can we do it? Yeah. So the job was advertised. Actually, I'm just gonna take the microphone off a moment,
and I'm going to read you a piece of paper just because I need to get it from the other side.
Okay. Yeah.
So I've got a piece of paper in my, in my, in front of me now dated the 11th of November 1999,
from calling the agents here in Oxford to probably Collins and Richard Peter really Dr. Martin Landry.
And it goes sort of starts with an introduction and about what my background was and so on.
They said, I think it would be useful to get him down to meet us.
When you were both around, could I go ahead and organise a meeting in December and underneath it is is in Richard Peters.
Individual handwriting is okay as long as it doesn't get taken as a definite a job offer are paid.
So I showed that I took that out and showed that to Richard. Not no.
Not long after I got my knighthood last year said you might not remember this yet.
So then there was a job advertised for people, for someone to come and play a sort of junior clinical role on one of the big trials,
which Rory had been planning on cholesterol lowering the heart protection study.
So I joined for the last year of that they actually the memory I think they
interviewed four people they they pointed to one was Professor Louise Bowman,
who is also here and and then me.
And so we started within a month of each other. And the reason I have worked very closely for the last 22 years or whatever it is,
it was a very, very good time to join the unit's clinical trial service unit.
The reason for that is that the heart protection study was studying whether simvastatin a statin would not only
lower cholesterol but would reduce the risk of cardiovascular disease in a whole range of different sorts of people,
people who had or hadn't had a heart attack and people who had or hadn't had a stroke and so on.
And in particular, perhaps one of the most important questions was, was this a treatment with lowering cholesterol,
something you only did to people with high cholesterol or something you could also do with
people who got medium cholesterol or what we thought of at the time as low cholesterol.
And when the results came out, it turned out that didn't really matter which sort of people you took.
Lowering their cholesterol was a good thing to do. This was this study was in its final year or so for like ten or 15 months.
When Louise and I joined, they had a there's a process in clinical trials called clinical events adjudication.
This is basically a form gets filled in saying by the research to the to the participants.
So very nice to see you. Can you tell me, have you ever had a heart attack since we last saw you?
A stroke since we last show you and so on and so forth.
And then on the basis that question, if you take a yes box, then somebody said, well, that's interesting, but that's not exactly definitive.
So we now need to go and get all the hospital notes from whichever hospital this person is in, photocopy them, anonymize them and all that.
Send them into the coordinating centres to sue.
And somebody needs to go through those and by standard criteria say this meets our definition or the trial's definition of a heart attack and so on.
Now by this stage for memory, they had something like 18,000 of these reports.
From memory, they hadn't done many more than 1003 thousand of the people in the trial had died.
So we had death certificates and all the details on that, too. I didn't see any of those and they all need to be done in duplicates.
So Louise and I were essentially appointed to clear that backlog,
and we spent months and many, many hours going through each of those each of those reports.
But what it meant was we really saw the sort of the progression of a trial.
We saw some of that back in back stage activity, but we saw this trial come to fruition.
We then saw in November, November 2001, when the results were announced, the extraordinary impact they had.
And again, people put their trust in me and then us.
So because the results were being announced at the American Heart Association's big annual
meeting in front of tens of thousands of cardiologists in in Los Angeles to see the data.
And we had Internet, but we certainly didn't have any sort of team Zoom or any other form of sort of remote broadcasting and so on,
Rory and Jane Armitage and others, we're going to present the results in this meeting.
And they were they're going to cover the US media, which included the US science and and pharma media and so on,
which is really important to get the message out. Louise and I went for the sort of the weekend of preparations for this.
Then we were told we had to come back to the UK to present them to the media.
So the UK, the leader leading the stories for the interviews with Fergus Walsh and all those.
Suddenly it was it was me and Louise up in front of the cameras announcing these incredible results.
To which we had contributed one year's hard work, but one year's work out of this entire story.
But it really struck me that for, you know, this has been Rory's big project at the time.
And for him to then say, look, actually, you will take will,
will will that those two relatively junior characters actually from the media and from the story and everything else in the
UK because we need to do the US and you couldn't in those days be in both places at once is very different in that today.
That was again a huge opportunity and then people wanted to hear about themselves.
All the academic meetings, all the professional meetings, scientific meetings all around the world,
all sorts of societies of atherosclerosis and cardiovascular disease and whatever, some of which are well known, some of which are less well known.
There were dozens and dozens of these meetings.
And again, Rory and Jane would go and do the really important ones, quite rightly, that, you know, as an example,
I was sent off to Ecuador for two to meetings Ecuador, Quito and Guayaquil, then Caracas, then Bogota and then Puerto Rico.
We did Japan, I mean, but again, it was this trust that was put in us,
but also the experience of how do you present what was quite complex data and distil it down into a message that the clinical audience could really,
really grasp, because the aim of what we do isn't to get a publication.
The publication is a stepping stone along the way is not just to get a regulatory approval that's a stepping stone along the way.
So the FDA approves the drug or whatever or nice approved to pay for it or something.
You've got to get it all the way through the clinical guidelines and actual frontline doctors being prepared to prescribe it and yeah,
patients being prepared to take it. So you've actually got to think about all of those steps you have.
If the aim of doing a trial that says cholesterol lowering works regardless of your cholesterol,
if you've had a heart attack, is when you've got the answer. The answer is to make sure that that turns into practice.
So it's a huge, you know, learning experience at that time, you know, and I'm grateful to the opportunity that we were given.
So that's taken us. Let's take this to 2000.
So and then from then on, we're into the sorts of trials that gradually I was running and I was designing with Colin,
agent, with Louise, with Jane Armitage, with Richard Haynes and so on over the last 20 years.
Just give me a couple examples of things that we we don't have time to go into.
So, so I'll give you example.
So in I did my PhD in VI patients with kidney disease I get heart disease call invasion was also interested in that area understanding.
Yes. So observing it is one thing doing something about it is different that needed a trial.
So we did a trial of lowering cholesterol in 9009 and a half thousand people with kidney disease.
It was the biggest trial in kidney disease ever done at the time,
probably since is at least three times bigger than the next trial that was even running at the time.
It was the first time that this unit had done a trial, which was both international and with long term,
with sort of chronic daily daily tablets and therapy.
And Colin and I designed that trial from the ground up, including thinking about actually, how do you make it work?
How do you make sure that the procedures are being done in a clinic in in the southern states are the same
as the features that are being done in Malaysia or New Zealand and how did you get the data and so on.
And a lot of that was around how do you use technology.
So web, this was modern web where you could actually enter stuff and you can order stuff.
You know, the sort of things that we use all the time now was only just being born at that point.
Could you use that to do the trials? So that was a lot of what that was.
Another one was a trial of a drug called niacin.
It's a vitamin B vitamin.
It's on the side of your cornflake packet in small doses, in big doses, know probably 100 times bigger also in gram doses than it lowers cholesterol.
And for 50 years, it's been considered to be a treatment for lowering cholesterol to prevent heart disease.
So we did a trial and we found that one.
It didn't lower the risk of heart disease. And two, it caused people to go into hospital more often with bleeding and infection.
Nobody had known that in 50 years. And now. It doesn't get used for that reason.
So yeah, those are two examples of these big cardiovascular trials.
And even now we're doing some on, you know, once or twice yearly injections to lower cholesterol,
which it would be a much more convenient way for many people, either in addition or instead of a statin.
And just now, we've we're announcing results about a new treatment for people with kidney disease,
which lowers their risk of heart of heart attack and particularly slows their decline in kidney function.
You know, the big thing if you've got kidney disease is you really want to delay or avoid dialysis.
And this treatment appears to certainly delay that.
So there's been a series, a series of these trials over the last 20 years that have been sort of the backbone of my clinical trials work.
So clinical trials have have got bigger and bigger and bigger, but they've also got more bureaucratic.
And I understand you've been quite critical of some of the hurdles that you're
forced to leap over by government regulations in different parts of the world.
Yes. So I've just given you examples of the work and just think of them as examples of what can happen.
Those trials, each of them is roughly ten fold cheaper and as I've indicated, often bigger,
not always and just as reliable, if not more than how industry would do them, but ten fold cheap enough drugs.
If the trial is ten fold cheaper, you can do more trials, you can include a greater range of patients and so on and so forth.
You can actually bring more interesting drugs through to to that stage, because if a trial costs you $1,000,000,000,
you an awful lot of interesting drugs get killed off even before they ever hit a patient.
So the if one looks at it in in context that ices to trial it might be for much of one of the
students being double Richard and Rory was essentially two pieces of paper one at the beginning,
one at the end. And that was essentially all they were all there was to that trial.
If you look at many trials now, there are thousands of dozens of pages of case report form,
and there are hundreds of standard operating procedures and documentation and whatever else that goes with it,
largely adding little value, but really being driven by the rules and regulations.
So in the late 1980s and through to about mid 1990s, a set of rules were developed called good clinical practice.
The old joke goes that they're not good, they're not clinical and they're not practical.
Unfortunately, the old joke joke is still current, so nothing much has changed in those 25 years,
but they take a very rigid view of how the world works.
So they were written in the days when a sort of carbon copy in a fax machine with state of the art technology.
So you've got a top copy in a bottom copy and they should really match.
And then you send the bottom copy in the post or your fax it or something to
somebody else who then types it in the machine because they typed it into machines.
Somebody else has to type it into the machine to check that you've got the two answers.
And because you're not sure that the top coffee matches the bottom copy, you send monitors out to site to check that those two things really do match.
And because you're not sure that the monitors have done a good job,
you send more monitors to check that the monitors have done the monitoring correctly.
And so you layer and lower and lower this stuff on,
which makes this story is the difference between what you're saying now and what the ICE trial did.
Because the drugs that we were testing in the ICC trial, they were testing in the ICC trial, it were already approved.
No, no. They say this is not about I mean, of course,
there are differences in different types of trials and chemotherapy treatment is a completely different beast to,
you know, studying antioxidant vitamins to see whether they prevent heart attack.
They don't. We done that one. So you will of course, you have to tailor to the clinical issues and what you know about the drug and so on.
But so much of the process is just process and paperwork without actually really focusing on what matters.
If you've got two randomised groups, we did a bit about how trials work, which would be obvious to some and less obvious to others.
But essentially you take a group, a large enough group of patients and for each patient you toss a coin,
you get the drug tails, you get something else. Let's call it placebo for now.
And then you know that come the end of the study, whatever happens to those people,
the differences between those who came down hard and those who came down tails, there were two things that could have happened.
One is the drug cause. That difference reduced the risk of health.
To tackle whatever it might be or increase the risk of going into hospital with bleeding.
The second is chance. Well, we have statistical tests to tell us whether something is likely to be purely due to the play of chance.
So we can sort of deal with that issue. And that issue becomes a lot easier to deal with the bigger your study.
You know, if you've got very small numbers, you get imbalances purely by the play, by the play of chance.
But if you got very big numbers, then actually that all washes out.
But it also tells you that how accurate does any one data point to need to be in that context?
So if I take 10,000 people, toss a coin started versus placebo to see what happens to them.
If I decide if I sort of mis code or just miss the fact that one person got a heart attack in one of the arms versus the other,
there's probably 400 heart attacks in one arm and 300 in the other arm.
Missing one heart attack is just noise in the system. Now, I've just I've literally just come from cardiology this morning,
missing one heart attack this morning, face to face with one patient is absolutely critical.
So that's a different situation. But that's not what we're doing.
We're not trying to diagnose heart attack when we do these trials.
We're trying to assess whether the strategy of giving a statin versus not cypher zebo actually makes a difference.
So all that's that you don't need ultimate precision in order to get an incredibly precise answer.
So the rules are written in ways which don't don't recognise and completely misunderstand that they want every data point to be absolutely precise.
Now, if you said to me you can have perfectly precise data individuals, every data point is correct and it costs you no more.
In terms of anything than slightly imprecise data, I'd say, well, yeah, precise data would be better,
but if you if I have to now trade that off for a now, I get a smaller study and I get a more select group of people.
I only get men and women and I don't get people from other ethnic groups and so on and so forth.
I've suddenly lost a huge amount of information.
Or if I only get a shorter study because getting that position while someone's in hospital might be feasible,
but for five years afterwards might be infeasible. Awful.
If you think of some treatments now you're thinking about what happens to these people in 20 years time.
It's impossible to still keep getting that level of precision all the way through.
But it's not only impossible, it's unnecessary. And that's the thing.
It's not a question of reducing the quality or reducing the standard is a question of actually understanding what you're trying to do.
And you're trying to work out whether there's a separation between two groups of people who one lot who by chance were giving the start in one lot,
who by chance were given placebo.
And whether that has made it made a difference and it's not really it doesn't really matter whether it's 399 versus 501 or it's 400 versus 500.
Makes no difference to the to the physician.
I said earlier on that the reason I when we first came here, we were employed essentially to clear that backlog of clinical trial adjudication.
These piles and piles of documents that had to be coded as to, yes,
they definitely had a heart attack or didn't accord its own criteria after we'd been through
that and after we presented the results and it had a big impact all around the world and so on,
and prescribing patterns change and everybody now knew what a statin was, which they didn't at the time.
That was a common issue. After we'd done all that, we went back and we looked and said, What if Louise and Martin hadn't done all that work?
What if we just taken the patients report when the when the nurse said, Tell me, have you had a heart attack since I last saw you?
They said, Yes, we believed it was yes. And if you said no, we believed it.
No, we got almost precisely the same answer.
We were out by the second or third decimal point on the risk ratio, the confidence interval, the p value, whatever.
So statistically, we got essentially the same answer regulatory wise in terms of would get someone to give it a label,
give it a, an indication we allowed it to be prescribed and got the same answer clinically.
We got the same answer if we'd just taken the patient's words which are not precise, it's not a precise diagnosis,
we'd have got the same answer we'd have known that started work for substantially less cost much quicker.
And because of that, we could have done the study even bigger or even more diverse, or even longer or even better in a variety of ways.
Because now scale becomes becomes possible when you say, well, a big study is just like a tiny study, how do you do it?
Exactly the same things many, many more times over that becomes infeasible and therefore you actually misinformation.
So if you think of it from a regulator's point of view, I'm not a regulator. I work with lots then their job really.
It is not to regulate trials.
They need to do some of that because there are the trials need to do a job, but their job really is to improve the health of the nation.
So they need better evidence to allow them to make better decisions about whether to licence a drug or not.
So actually what they want is trials that give them better evidence,
not trials that fill some sort of slightly obsessive version of what the truth might be.
If I win that, all that story forwards and say, you look at look at today.
Well, there's health care information all around us. The NHS Digital will collect information on every hospital admission, every diagnosis,
every operation and all that for business planning reasons and reimbursement reasons and all those sorts of things.
And with the right consents and tactical operations and all those other things in place,
which is a non-trivial undertaking with those things in place,
you can use you can do trials where you randomise patients to a treatment versus not,
and you can link through to those data and you can use all those routine data that are already out there.
They're being collected for free. Where do they come from?
Well, they came from somebody typing in the answers from the clinical notes which were written when each patient was in hospital.
And you can use that.
And again, you'll find that there's a little bit of mismatch between that and whichever page of the the hospital notes you look at.
Believe me, different pages will have different different pieces of information on them,
some of them contradictory, but they won't be exactly the data.
And in then it's just digital and the paper records will be exactly aligned.
But if you do, if you link to the NHS digital data, you will get exactly the same answers as if you looked at the routine data.
But again, you can do it bigger. You can do it when patients move around the country and they move away from
my hospital into somewhere else where they're never seen in hospital again.
You know, the huge difference between somebody, nothing has happened to somebody.
And we have no idea whether something has happened to anybody because both of those
look like sort of missing pieces of information and we can do it for much longer.
So again, that sort of is bringing us forward to we can use we don't have to be absolutely precise in order to get a very precise answer and actually
a better answer and a more useful answer in more contexts and in more ways than one would've done if I'd only done it mechanically.
And yeah, we have done trial, we have done studies where we've said, What happens if you just do it the old fashioned way?
You know, have you had a heart attack since I last saw you? Or we go to NHS Digital and say,
Tell me whether any of these people have had a heart attack with vaccinations and they give you exactly the same answer.
So the rules are not written in that way.
They don't emphasise the principles, they emphasise the operational details.
And the way the world works today is so different from 1995, how we talk to each other,
how we communicate, you know, the the smartphones and and the like,
how data is collected and manage the relationships between patients in their and their and and the medical profession is wildly different.
And if you think about where most patients spend most of their time, it's thankfully nowhere near any doctor.
Even long term diseases like diabetes, most people with diabetes spend most of their time, if you like, out in the world,
living their everyday life, doing whatever they do without having to go into hospitals, without going to the GP or to diabetes.
Of course they come to those met periodically. So these there are new opportunities to actually bring trials to the patient rather than making
the you're trying to insist that the patient somehow comes to this magical clinical trial site,
but they're only possible if the rules are based on principles and the principles are so easy.
Number one, get a reliable result, actually.
Recap. Number one, ask a question that you care about the answer.
Number two, answer it. In the meantime, you need to make sure you look after the rights and wellbeing of the patients who are in the trial.
So in a sense, think about it as you go to look after the people who in the trial and you can look after the results because they will,
one way or another influence many, many more people who are not in the trial.
I would add to those rules and say we need actually doing things efficiently is
actually we should be driving to avoid wastage because we can't afford wastage.
Costs go up, we do less trials, we get less evidence, we do worse medicine,
doing things in a way that does involve the communities that people come from,
that both the clinical communities that people come from and the the communities that patients come from.
And of course, many people don't think of themselves as patients most of the time. Think about vaccines.
Most people are vaccinated. There's sort of nothing wrong with them. They have vaccine.
To stop something that might happen either in the short term or in the long term.
So I think there are many ways in which we could have much better rules which actually explain what the principles are,
actually what we're trying to achieve. What does good look like?
But then allow people to, if you like, innovate and find solutions that are fit for the for the particular context,
which is what you needed to do, which is very difficult when you are doing it.
So we really need to get on to it, I think, find out how we're doing. Right.
Okay. So can you remember? I know you can't because I've heard the story before, but let's tell it again how you first heard about that.
There was something going on in China that looked as if it might get serious.
And and how long did it take you before you realised this was something actually you were going to have to get involved with?
But I do remember seeing some very early, I guess,
tweets or whatever from Jeremy Fowler and a few others in early January of that year along the lines of, Yeah, this doesn't look good.
I am the cardiovascular doctor. I don't do infectious disease, I don't do overseas, you know, emerging outbreaks, you know,
sales and those and all those things are there are other people who do those and do them very well.
So it wasn't my area.
And so it was sort of, if you like, mentally a problem for somebody else to sort out that wasn't do didn't have a direct impact on me.
Of course, as we all knew, ties in the same position probably as most other people in the UK or elsewhere.
Of course we saw them move to Iran and then to northern Italy and by the time
we got to northern Italy it was beginning to feel a little bit close to home.
Yeah, not least because those two countries are not obviously connected.
So you're suddenly seeing this thing. This is this is entirely amateur for my perspective.
You're studying this thing pop up, clearly spread in a number of different places.
So this was this isn't just like it sort of, you know, gradually migrating down the corridor.
It's actually it's clearly getting on jet planes.
It was it was as things in February started to sort of really become more obvious again in the north of Italy.
And late February 28th of February,
I was on a train on the way back from somewhere in the north of England where I
had a meeting with NHS Digital about clinical trials and data analyst stuff,
and I was imagining Jeremy Pharaoh I was doing work with him at the time about or for him about clinical trials and the guidelines I emailed out.
Jemmy Fallon said at the bottom of the piece, at some point, is anybody is anybody thinking about randomisation?
I said, at some point people are going to start wanting to.
So treatments and vaccines and whatever it people and we really need to know if they if they work or they don't and if we don't randomise,
we'll never find out. And that would be that that could be a disaster.
And I'd also say, look, it's exactly at the time when there are no treatments,
there is a widespread disease with a bad outcome is exactly the time when randomisation is the right way forward.
And also it's a time when regulators and others are prepared to do some innovation.
Because I have to I wasn't sure that I ever get a response, but I got one about 5 minutes later saying, speak to Peter Horby and Richard Peter.
So the following week, so something like the 4th of March or so, Peter and I met with Richard, Peter,
in which his office said have some we'd met Peter and I'd had I I'd had a about in total about 20 minutes of discussion split
over about three conversations on the telephone and had met him once up to that point over the last couple of couple of years.
And that was that was that was the limit of of our of our knowledge of each other.
So we met in which his office and started talking about what a trial should look like over the next four or five days.
So that took us over the weekend. It wasn't clear W.H.O. were trying to do so.
I mean, they obviously did in the end, but they were trying to do something. Should the UK be in with that and so on and so forth.
And then it got and then it got to and I asked you, could we provide an IT system for the trial because you've got some data collection.
So I did a little bit of discussion talking around various people in the Parliament about how we might go about that.
Come the Monday I was on the famous number 18 bus with Jeremy heading between Marylebone and and the Wellcome Trust,
a ten minute journey and the stories of the horrors that were happening in northern Italy were all over the serious newspapers.
The stories of what the tabloids considered. B the horrors of running out of lavatory.
Well will over the front of the red tops seriously that that that those were the new stories of the day.
And and I had also had heard from colleagues in northern Italy and so on just how horrendous it was,
people being taken off ventilators, not put on ventilators,
having three refrigerated lorries in the hospital carparks because they didn't have the space in the mortuary,
all this sort of thing, I mean, really sounded to me was horrendous.
And Jeremy said, look, I think London's going to be like this in two weeks. It's coming here.
And this we are on a crowded bus. And he asked me about, you know, what the discussion for the trial.
He said, look, we've got to get this guy up and running within two weeks. We agreed that in the 10 minutes bus ride and I got two welcome.
And the first call I made actually was to two or three Collins as head of department.
I said, look, we've, you know, we talked about the it I spoke to Richard and whatever else,
but I really think we've actually got to go completely in this post I'm back know there's no point being half and half
and I said my judgement is we should just go for this because I don't think anybody else will be able to deliver.
And I said, oh and by the way there wasn't any money.
So at that point I said, Look, I think having spoke to Jeremy, given the situation I think we should go for this is his department,
not mine, but I think we should sort of essentially underwrite this.
I said, I'm pretty confident that if we if we get going, the money will follow at some point.
I just can't tell you today I've got the grant and I've got the money.
And, you know, we to have to do this in a different order. We haven't got time.
And he agreed. Now, I turned out on Monday to answer your question on money,
the Peter who put in for grants to study treatments for COVID in China way back in the February.
But grant to Nigel is it taken in job for six weeks whatever it was to turn this through
by which time there wasn't any cobra in China because of the lockdown had worked.
That first lockdown worked very well. And so they said, yes, you can have the money, but you must study to do it in the UK.
And so actually the grant did come through for a slightly different route.
But yeah, we were prepared to do this, you know, at risk.
We had to move at risk and that was what was obvious to me. And so yeah, ninth and 10th of, of that march we broke the protocol.
I had a copy of the study protocol, this large, simple trial on my desk.
I had a copy of a paper Richard and Rory and Selim Yusuf had written from 1984, which says Why we need some large, simple trials.
It was all about heart disease. But if you substituted the word heart disease for COVID, the signal slotted into place.
And I looked at one of my usual protocols for one of my usual cardiovascular five year trials, and I thought, that's not the way to do it.
We've got to do it simply because this is this is going to be really difficult at the coalface.
And the trick is absolutely going to be can we minimise the additional effort for the frontline staff?
Otherwise we'll never happen. And number two, the second trick is we've got to get it in now before the NHS works out.
It's sort of standard protocol to whatever who gets assessed in A&E, how do they get trials, what treatments do they get, all that sort of thing.
We had to get it in so doing. The trial was part of just what they did in in this context.
So the big question is how did you know what drugs to try?
So this was, yes, a trial of treatments is not to do with prevention.
This is to do this is to treat. So my answer one question is, why did we choose this particular context?
I mean, we could have done a trial of prevention. We could have done a trial of an in doctors and nurses who are looking after patients with COVID.
They're at high risk of getting us another version of prevention. We could have done a trial in the community to prevent people getting into hospital,
but it seemed to me that the number one problem we were facing and Italy was facing was there were a lot of people dying.
The hospitals were overwhelmed and there were a lot of people dying and a lot of people needing ventilators.
And so, you know, when the house is on fire, the first thing you try to do is put out the house, put out the fire.
And, you know, of course you want to do prevention and all those other things they did.
Yeah. And that's where in particular the vaccines come in. But we never knew whether we're ever going to get a vaccine, let alone when.
So it seemed to me that the major challenge was we've got patients who are declaring themselves sick because they're sick enough to get into hospital.
So diagnosis and the problem and we know what the outcome is, one in three, one in four were dying.
You've got to do some. About that before we do anything else. And that's that's why we focussed on the treatment side.
We had some help. W.H.O. had done some shortlisting of drugs they come up with.
I say short if they prioritise but they the list was 100 drugs long or something.
Nervtag, which Peter was on, had also done some prioritisation and with particularly with regards dexamethasone,
there had been a a trial sort of protocol in case of pandemic flu, which has been a trial or was going to be a trial of steroids.
So what's the argument for using steroids in an infectious. Well,
the argument for use for using them is that the inflammatory response to the virus is
so it becomes so great that the inflammatory response itself starts to cause damage.
So you start to get secretions and so on,
and then you get a gas exchange in the lungs and then you become hypoxic and then you need a ventilator and so on.
The argument against using them is that steroids suppress the immune system at a time
when you're trying to fight an infection for which there were no other treatments.
It seemed to me that if you don't know what you're doing, you're better off randomising or finding out.
Finding out there are others.
It has to be said, who had very strong views in in one direction or another.
And in fact, once we got the dexamethasone up and running,
there were a group of eminent professors in London who wrote to the MHRA, the chief medical officer,
US and various others saying You shouldn't even be studying steroids,
you should be studying dexamethasone because it is dangerous to suppress the immune system in people fighting infection.
We had to by that time argue very strongly with the MHRA that actually nobody knew.
We needed to find out that this was the quickest way of finding out gravity.
So yes, we started with hydroxychloroquine. That was an easy choice and it was everywhere.
Everybody was saying wonderful, but that's a malaria drug.
So why would anybody think that? Where is it a malaria drug? Into a aetiology drug.
But in the laboratory. If you if you if you put hydroxychloroquine on on infected cell cells with almost any virus, then they look unhappy.
So in the laboratory for a whole range of viruses, hydroxychloroquine has been touted as an antiviral.
No one's ever yet found a viral disease for which is useful.
To the best of my knowledge, Peter's more the expert on on the choice of drugs than me.
But yeah, there were. And then there was a paper that would come out in The Lancet,
a series of about 15 or 18 people who'd been given hydroxychloroquine as if the most known antibiotic.
And this was proclaimed as wonderful treatment. Now, actually, in that paper, half the data was missing.
It was too small and it wasn't roundabout, and it wasn't it was a a really poor paper.
And actually the world was dominated by some pretty poor papers in those early days, probably ever since.
So, you know, and Trump was claiming that this is a miracle cure.
The French were very minded to use it. Bolsonaro in Brazil was saying this is a must for treatment.
It happened in India. All over the world. People were using it. The UK had a stockpile of it.
And the question was, should they use it?
We we said to them, no, the thing to do is randomise this randomised and find out quickly whether it's the right thing to do or not.
Otherwise, if you use it, you'll run out at some point and you never know whether you need more or actually
you didn't use any at all that it happened with a drug called Tocilizumab in Italy.
They do so much of it that they had run out so that they couldn't even use it for, Oh, we're running low.
They're treating people with arthritis, which is where it's normally used.
And at the end of having burnt through quite a lot of money, but also this huge stockpile of tocilizumab,
they had no idea whether they need to buy more or whether they just wasted a whole load of drug.
We said, look, randomised, randomised, randomised all the way to make randomisation part of your public health strategy,
you do R&D it seems like on the fly while you while whilst you're fighting the pandemic,
you won't regret it actually learning which ones work and which ones don't.
And that was an argument we had to keep banging on about over and over again and still do as well as people who thought dexamethasone was dangerous.
But there were probably some who thought, Well, if you think it works, we should just give it to everybody.
There were some it was it was, it was less the lobby in favour of oh, just them, the drug,
it can't do anything which was very strongly a sort of hydroxychloroquine thing.
Right. Less strongly a dexamethasone thing I would say, although some I believe when we set up the trial we said, well,
if you have a really big belief that this particular patient needs dexamethasone or must have dexamethasone, then.
Don't randomise them into that bit of the trial randomised into the race.
But then it wasn't because the job was not the right thing to do, but most people most of the time.
So we don't actually know what we're doing. One of the wonderful things we face, that's a long phrase.
One of the unusual things about COVID was it was perfectly legitimate for doctors to say, we don't know what we're doing.
We don't know how to treat this. That's very unusual in my field of cardiology.
Of all the international guidelines published by the American Heart Association,
European Society of Cardiology, and so on, if you look at all those guidelines,
Rockliff, who is now FDA commissioner a few years ago,
did a review of all those guidelines and says which of these are based on good evidence from randomised trials?
15% were based on good evidence from randomised trials, 85% were not.
Now a few of those things that are not were things like is smoking, is smoking harmful for the heart?
You don't do randomised trials of that, doesn't need a randomised trial and so on.
So it's a bit extreme. But the point is that even in a evidence based speciality like cardiology,
which is probably at the top of the tree along with some types of cancer, huge amounts of treatment decisions are based on.
We sort of don't know. We don't know. We've got experimental evidence, theoretical evidence, some experience, whatever.
But bottom line, we don't actually know. Think about the niacin example I gave earlier.
Seems it lowers cholesterol. It's a vitamin. It's been around 50 years.
Nobody's ever noticed it causing anything other than Flushing. Why not?
Well, as it turns out, it's actually makes people go. Of course, if people are going to hospital with, in fact, nasty infection and bleeding.
So this assumption that we know what we're doing is sort of touching but misplaced in some ways.
I don't want to put patients off in COVID.
It was perfectly legitimate to say we just don't know what the right treatments are.
There are no trials. We don't know what we're doing. So how did you go about recruiting the patients for the trial?
So, so, so, so just in brief, the early bit because it has been talked about in a number of before.
Number one, we had to get the trial up and running as quickly as possible.
That took us nine days, which as opposed to normally nine months, 18 months.
My first worry was, how do we get started? My second my second worry was how do we get it into every hospital or as many hospitals we can?
I thought initially if we could get into 60 hospital GP doing well, but when we set up trials here, it can take us,
you know, we might do, I don't know what it is, five or ten hospitals a month if we're lucky or something.
It takes a long time working around hospital, my hospital, getting the paperwork sorted out and all the rest and making sure you've sent
those little barcodes and labels to the right address and all those other things.
And I thought we had that long. And Lucy Fletcher, who's an experienced trauma as you're from here and and others in her team, did a wonderful job.
They got every hospital in the country set up within about within about eight weeks.
So about within within four weeks we had three course of those hospitals already set up, including many, many hospital.
They all every hospital but many of this hospital had never done clinical trials, never done these sorts of clinical trials before.
And, of course, a trial at those hospitals in diverse parts of the country.
Did you have to go up to get authority to go down to the hospitals?
Yeah. Well, you have to you have to get ethics approval and regulatory approval and so on and so forth.
We did so. We did. We got a letter from the chief chief medical officer and the director of.
So the Chief Medical Officer for each bit of the UK. So each nation plus the medical director of the NHS to write a letter which basically said that
the trial is to be deemed as part of standard of care and not an optional extra or on the side.
And we strongly encourage you to take part. And that letter was extraordinarily useful.
So it is easy to get with that. But yes, I mean, I would say I would say yes, in in that circumstance.
I mean, it takes some takes some effort, it takes some persuasion.
You've got to put your case and whatever else. But yes,
I think it was and that letter mattered a lot because suddenly this was now part of the day job at a time
when hospitals were working out how the [INAUDIBLE] they were going to cope with an unprecedented crisis,
how they were going to deal with staff numbers, how they're going to do with wards, how they get more ICU beds,
or whether they're going to contribute to the Nightingale Ward, hospitals, all that stuff as well.
That letter was very, very helpful. So that was a big part of it and.
To train the doctors who are in these hospitals. So we did all the training online with short ten minute videos for different bits.
If you want to take consent, you look at this page, if you want to fill in this form, you look at that bit and so on.
We made the trial open to as many staff as we could.
We realised that you couldn't just have one member of staff who was the only person in the hospital trained to do the trial.
We had to make sure that you had the frontline doctors who are junior doctors, many of them, that they could also take part in the trial.
We ended up with nigh on 10,000 doctors, nurses, pharmacists, our back office, R&D staff, whatever, all who have contributed in some way to the trial.
They were all listed in the in the authorship list, in the appendix to all the papers.
We had to make them silly. Question But did you need an NHS to do that?
If we hadn't have the NHS, would it have been possible?
It doesn't sound like a stupid question. It's not a question of they often ask, but often friends in the United States DNA, the NHS helps enormously.
Having data helps enormously. But it would be possible.
I think it would be possible to do the same mechanism if you didn't actually have a whole NHS and if you didn't actually have the data that we have.
If you look at in the United States, for example,
Kaiser Permanente is one of the big health insurance systems out there and I come with exactly how many patients they have,
but I think it's probably more than the size of Scotland. You know, it's you know, it's a vast number.
There's no reason why this sort of clinical trial couldn't have been done within one of those sort of health care systems.
And in fact, actually, throughout the last few years, I've had many conversations with with leaders in the US about why they couldn't do it,
why they didn't do it, why they couldn't do it, and how can they copy it now?
In fact, even just this week, Rob, Caleb and two other senior leaders from FDA have written an opinion piece in
JAMA exactly about the US needs to learn from recovery for clinical trials,
what they call it at the point of care. In other words, at the front line too, I think it's the first time we mentioned recovery.
So this trial was called recovery. Yes. Which stood for randomised evaluation of COVID therapies, I think.
Yeah. Peter came up with the acronym. You need an interesting you have to have somebody who can think of the name and that's than me.
So yeah, I think we've done consensus about testing existing drugs and we've done funding, we've done that and we've done that.
So yes, so we you get the drugs from so for drugs like dexamethasone and hydroxychloroquine, the NHS has them anyway.
So what we said was you might describe these anyway.
So rather than prescribes and randomised and they would if you like, for regular NHS stock for some of the drugs.
So Tocilizumab was donated by Roche. This was sort of six weeks or so into the study when the study was going well.
They and I think that was a very good relationship and I think it's actually a sort of model that one would want to copy.
It's not a question of, Oh, this is an industry trial or this is an academic trial, this is a genuine collaboration.
We have with Oxford University is the sponsor of the trial. That's a sort of regulatory term responsible for the trial.
Under all the rules, we're studying lots of drugs. But Roche have a drug that looked interesting.
It was recommended, recommended as sort of prioritised, as worthy of study.
They gave it to us. They didn't give us any money. That's fine.
That we put it plugged it into the trial. We do the trial.
We produce produced the data, we publish the data.
We talk to the regulators and others and health policy people and so on.
And whoever wants to know to explain the data, we also return it back to Roche and then Roche are able to use it for their own internal purposes,
develop new treatments, whatever they want to do, but they're also able to use it to apply to regulators for a an extension to the drug licence.
So it's not just for rheumatology, it's now for COVID as well.
And that's fine. Actually, it's a very good, if you like, independent test of a particular treatment that happens to be come from industry.
All treatments come from industry. Ultimately. The second one was the it was Regeneron.
That was the second big example was Regeneron who donated antibodies.
Monoclonal antibodies stick on the virus and nobody knew whether they would work.
By the time you get to hospital is interesting the thoughts about what the disease had changed by this point.
This is thought six months in or something because the dexamethasone or anybody said, oh, no, it's an inflammatory disease.
You don't need antiviral treatments, the virus isn't relevant, so it's completely switched their minds.
So yeah. With these antibodies work in patients in.
Hospitals. So they also gave us the drug.
Why is it a genuine one versus whatever other ones were about?
Well, it was the Vaccines Taskforce led by Kate Bingham,
who actually was charged with doing the sort of prioritisation and and selection of which of the many antibodies were to be used,
why they came on the vaccines versus something else, I have no idea.
But they did a very good job at considering the different treatments that are available.
So if you think just think about like it, does it actually stick to the version of viruses going around at the moment,
but also how, how, how many people is it been used in so far and how much stock actually is there?
Because, you know, if there's only enough for a few hundred people, well, that's no good to anybody.
And yet more recently, other other companies have done similar.
So GSK, for example, have given us SOTROVIMAB, which is another antibody which we're studying at the moment.
So we we slightly skipped over the the results. Let's go back to that.
So you've got the whole thing up and running really quickly. Oh, when did you first have something you could report?
Well, the first results came out in in June of that year.
So within so I said nine days to get the first patient in in less than 100 days, we had 12,000 patients.
And the first two results, the first one to raise its head was hydroxychloroquine, which it was quite clear.
The doctor told us we should look at the data.
It was quite clear that this was a treatment that didn't have any benefit, any chance of benefits.
It might even be harmful, but it certainly had no benefits.
We announced that in I think it's something like the 6th of June that had the impact that I expected, number one, and I personally had been hopeful,
which is that hydroxychloroquine largely stopped being used not only in the UK but around the world, not exclusively.
Some people carried on. They would do but a number to the predictable backlash,
which is there were a number of people who are or have been very, very strong hydroxychloroquine advocates.
It is interesting that people hold on to almost beliefs, if you like, and some treatments just get a sort of a momentum behind them,
as if by sheer willpower, a drug can suddenly can a virus and be good for patients.
All the drugs we've studied, I've hope they work. I've had reason to think that they might work.
But then you do the test, you do the trial to find out whether they actually work, how well they work, and in whom they work.
And this one doesn't work. That's the result is a good job.
We got a clear result. A promising drug is not is not it turns out not to be a useful drug.
That's the and that's the end of that story. But it didn't stop some fairly vociferous comments and feedback from some quarters.
As I say from yeah, for 90% of it it was a lot of people extremely grateful to actually know the answer to what was an important question.
And then the second one was the dexamethasone,
which we pitched on you pretty much at the same time within a few days or whatever, what the result was.
But we then because of that result, we then had to spend a week really making sure that we got it right.
When we first looked at the data,
here was a result that had a very clear clinically and statistically significant reduction in mortality for for the sickest people,
people on ventilators and people on oxygen. And at that stage, no treatments available, no vaccine in sight.
We were still in the first lockdown here in the UK. Other parts of the world were really struggling.
We didn't know quite how bad Africa was going to get and so on and so forth.
And so we had this result for a drug that costs £5 even less in some parts of the world is on the essential medicines list,
is in every pharmacy, in pretty much every hospital in the world.
And we have this result that says it saves lives. And you know that the moment you open your mouth, the world changes.
So we did have to spend a week really digging into the data and making absolutely certain that the that we understood the data,
that we got the data right, we got the messages right. We knew what we had to make sure that we got it straight.
And then on the 16th of June, we announced it at the lunchtime on a press conference through the Science Media Centre.
We wanted to make sure that this got out as a science and health story.
First, not a political story.
We were asked if we would look we would say at first at ten Downing Street and we say, well, we're happy to come to ten Downing Street,
but we're going to announce it to the science media first because we really want to make sure that we got it.
Doctors need to know the site, the science story. They need to know the clinical story.
They need to know the data that's much more important than the sort of the politics and whatever else.
So, yeah, we announced it at lunchtime and by the time it was then we got another invite from number ten saying, Please come to the daily briefing.
There's two of us. They said, Well, we can only take one.
So I've been to number ten once before for something completely unrelated and low key picked out.
So we decided we'd send Peter in my time. And so one of the artefacts that is going to go in is, is my tie, which was,
which is also since appeared at Buckingham Palace three times when Peter went to get his knighthood.
When I went to get my knighthood and when Richard Heinz went to get his MBA.
So this tie, not not the one I'm wearing right now.
No, it's too precious these days. It doesn't come out.
And so, yeah.
So Peter announced the results again with, with, uh, Boris Johnson.
There's one of those 5:00 briefings. By the time he did so,
the NHS had issued a statement to every hospital saying Dexamethasone is now to be considered standard of care in patients who are on oxygen,
on ventilators. So nine days to get the study started. Less than 100 days to get the first results.
3 hours to get it into policy. And that isn't just chance.
That's part of the when you ask a good question, you will to answer it robustly,
you want to answer it in a way that will change practice, that will change the world, if you like.
It's a very it's a very unique set of circumstances.
But that was always our objective was to get an answer that it was just clear cut what you should do.
We did that with hydroxychloroquine and we did that with steroids.
And over the subsequent few weeks, W.H.O., NIH, FDA, EMA, all these other people all accepted the results.
And it was and it was adopted very rapidly. And is there an estimate of how many people's lives?
Well, yeah. At the time the estimate came out, which was the following march, I wasn't terribly comfortable with it.
But I think it must be true by now, which is that at least 2 million lives worldwide have been saved as a consequence.
Impossible to know, because you can't count. You can't count how many people nothing happens to, if you like.
They survived. But I think that's a that's a reasonable estimate.
We've had three further treatments tocilizumab the genuine antibody in people who don't
already have their own antibodies and baricitinib another arthritis drug since then.
So we with over all we've studied included 48,000 people to date.
We've got, I think it's ten or possibly 11 results by now for clear treatments that can be used in the sickest patients in particular circumstances.
Six others that shouldn't be used. But that's good to know. And you have changed the way people have thought about trials.
The feedback from frontline doctors, frontline patients has been remarkable in for the doctors.
This was at last. Many of them had never done trials before.
This is a chance to help generate an answer, find a solution to this crisis,
rather than merely having to sort of suffering struggle their way through it.
We had hospitals, as I say, who've never done trials before.
Somewhere in South Tees, you know, nearly a thousand patients in one hospital,
that one hospital put almost as many patients into the trial as entire trials in the United States.
And one of the lessons has been in the United States is and this is a sort of analysis by Janet Woodcock,
who was acting chief commissioner of the FDA at the time, is now chief deputy commissioner.
She's analysis in all all the registered trials registries of ongoing clinical trials.
It's not 2700 to 800 clinical trials of COVID.
And she went through them, and 95% of them, in her view, never had a chance of answering the question.
They were either not randomised or they were too small. And that I think is a lesson in that we don't need lots and lots more trials.
We need more. The trials. And you have to ask yourself what the why is that come about?
And in large part, that's because the academic credit for leading a trial that never produces an answer is substantially greater
than the academic trial credit for contributing a very small part to a trial that changes the answer.
Put it very crudely, if you think that recovery may have saved a million lives and I told you a little earlier that
there might be 10,000 NHS staff of one sort or another who've contributed in one way or another,
big or small or whatever. You divide one number by the other number.
That's the contribution, the average contribution in terms of lives saved of each of those people.
And you compare that with those 95% of 2700 trials on average is so well over 2000 trials
where people have played a leading role in something that either has never got anywhere,
would never had a hope of getting anywhere. And I think we have to think about in academia, in our reward structures.
And so we have to think very, very differently. Peter and I have always been very clear.
Peter and I have got lots of credit, lots of accolades and lots of attention, if you like.
Not all of it good. But we have and we are sort of the frontmen for the recovery trial.
But the contribution of so many people has been is what is what made it possible.
So 48,000 patients who've taken part in the trial in really difficult circumstances for them,
10,000 doctors and nurses who were completely overwhelmed emotionally, time pressure, everything else.
And then I don't know what it is, 50 people or something wobbly here in Oxford in the clinical trials unit over time,
probably 25 at any one time who've contributed.
It's a much bigger and broader teamwork than just who'll be in LANDRO again,
if I think about it purely from sort of Oxford University or an academic perspective,
I think that this would I know that this would have been impossible,
impossible without the 20 years of experience of working out how to do clinical trials, number one, actually understanding the fundamental principles.
There wasn't a protocol, a standard operating procedure or whatever that could prepare anybody for trying to do a trial in the middle of a pandemic.
You had to understand the the basic principles of good design, of good ethics and so on and so forth.
In order to work out how you designed a trial that would not only answer the question,
but also that anybody could take part in seems true across all the sort of technical elements.
So the sorts of people who built a computer system for the trial in nine days have been here for,
I'm guessing, 20 years or so, long term sustainable funding.
The people who were the trial managers, the people who were the data managers managing data,
shuttling backwards and forwards between different computers here, or with NHS, digital or whatever else.
All of these different types of people, the people who test the computers,
those long term, that long term experience of technical staff is fundamental.
I think that there's a there's something that we all have to reflect on,
which is actually how do we ensure that these people are sustained, their careers are rewarding, that we can retain them?
And, you know, a significant chunk of that is a threat in terms of salaries,
in my view, academia, academic salaries are not the same as industry salaries.
Those technical people are not on an academic pathway.
If I interviewed on any one of those for a new job, I wouldn't be interested in how many people they published,
how many students they supervised, or how much grants they got come in coming in.
In fact, I wouldn't want them to do any of those things. Number one, they're probably not very good at them.
Number two, I want them to do the things they are really good at, which is programming computers,
managing data, sorting out ethics applications and the sorts of things.
So I think one of the things that was was so true of recovery was in on the ninth and 10th of March, I had a series of phone calls.
I'd ring people up and I say, Covid's coming, we've got this trial.
I really think you could do with some help. Do you think you could do your bit?
Oh, by the way, I need an answer by the end of this conversation.
I don't mind whether it's yes or no. I really don't mind. But the time pressure was such that I need to know.
And they all said yes, but it was big. Because those people were there and able to help, of course, other things.
It wasn't a question of dropping other stuff. Other stuff was being dropped because nothing else much was going to be happening.
So that's a slightly different scenario. But the reality is that those people here with their experience in there and and and their expertise.
And so I think as we looking ahead, we have to think about as a university.
It's not just Oxford University. It's true for across academia.
How does one get that sustained long term investment in the skills of the technical people that allow the academic people to then flourish?
Very good. That's usually where I end up. But I've just got a few things that if we can just skip through and we've only got 5 minutes left,
which are really about the the impact of the pandemic on you personally.
Well, the questions that I usually ask, I'll put them all at once, and then you can take them in whatever role do you like.
How did it change the way you worked? I mean, presumably where you home based or did you come in?
Did you feel personally threatened by the virus? And how did it how close did it come to you as an as an infection?
And were you continuing to do clinical work in the hospital? And so were you having to go in and get ground up and do all that stuff?
So I the first week or so of the planning, we had weekly we had daily meetings of the sort of growing recovery team.
And by the time we got to the Thursday, I said, We can't do this anymore.
We're about to be thrown out. We really can't be meeting like this.
And from then on, we were everything was remote and we all went home.
Some people didn't meet each other ever for over a year.
So some people had never worked before before with each other before,
never knew each other before and didn't actually meet each other physically for well over a year.
So, yes, I did most of this from my desk at the bottom of the staircase in west Oxfordshire in the village I grew up in.
In terms of my personal feelings, my clinical works, my clinical work,
I was never at the front line, so I was never gowned up in all those things I did do.
I dropped my clinics and got somebody else to cover them for about a month in the middle of this when it got when it was extreme but otherwise not.
I didn't get I wasn't and that was I'm lucky and I recognise that in a sense it was as a sort of irf would say,
you know, my wall was flying a desk and yes, I was taken out of that version of the front line.
I go to a different version of the front line, which was the sort of ee political stress.
I don't just mean I don't actually mean, you know, party politics or whatever.
But there were big political issues all the way through policy issues and so on in health and in in finance across the whole piece.
And so I did see a huge amount, amount of that.
So I had my own version of stress. And how did you deal with that?
Well, my my children are all adults, but they all came home and all three of them came home.
My wife was at home. And I guess we sort of and of course, you can go anywhere.
The dog got a lot of walking because that was the only thing you were allowed to do.
But personally, I personally felt okay.
I mean, I worried about the virus I had. I was admitted to intensive care unit with pneumonia 15 years ago or so.
Completely different. Uh, but I did know what being a patient on it, you.
You felt like I didn't get ventilated, but I did know what I felt like.
And I had been a junior doctor doing 56 hour shifts back in Birmingham in the early 1990s.
So I knew what it was like. Yeah. Being completely knackered at the front line for for the doctors.
But it did seem to me that and the other thing that the thought kept going through my mind was that we learned about history going backwards,
looking backwards. So we know how the story ended. Think about the Second World War.
You know that, you know, in the middle of the blitz in 19 1940, 1941, you know how that story is going to end when you're actually there at the time.
You don't know how it's going to end. You don't know when it's going to end and you don't know if you're going to be there to see it.
Personally, I never was too worried about whether I would be there to see it, but I thought this year we just didn't know what the future looked like.
And actually keeping that mind set was useful to actually think, you know, this is actually natural.
This is understandable because I think many people were sort of thinking, well, you know, just give it another few weeks.
And, you know, it was quite obvious to me that we were we were we were we were living this forward.
And that's how history actually works to the people who live through history.
If you live it, you live it forwards and you don't quite know where it's going to end and you don't quite know how it's going to end.
You don't quite know whether you're going to be there. It's a it was a particular view or mindset that I had.
So, I mean, the biggest stresses were were were issues around when were larger issues around things like hydroxychloroquine.
We came under a lot of pressure to stop the trial early of issues like dexamethasone.
We got a lot of pressure not to do the trial after we published results of hydroxychloroquine.
You know, we got a lot of limited quarters, we got a lot of really quite adverse correspondence and so on,
you know, complaints and, you know, nasty letters to high up people and all this sort of stuff.
I was never thankfully actually directly threatened.
I know colleagues who were pretty, pretty unpleasant.
Uh, we studied drugs to find out what the right answer was.
That was all I was interested in doing. The thing I was very pleased that we did, which we haven't mentioned,
was that we took a view on day one that this had to be we had to be completely transparent and completely open.
And so we put everything that we could on the public website.
How many people have been recruited? All the protocols, all the ethics and letters, everything else, all on the on there.
And also that we were very proactive and open on the sort of media front to, you know,
taking all those interviews, to, you know, taking opportunities to explain why we needed a trial is hard.
You know, help me, doctor. And the doctor says, well, when you toss a coin is a sort of odd sort of you know, it's an odd set up.
But actually, it turns out that for some of those treatments,
tossing a coin was an awful lot better than giving them hydroxychloroquine or convalescent plasma or a number of other things.
You know, give it prescribing something is not is not necessarily doing somebody good.
And yeah, some of these treatments are called considered to be prescribed, but on a compassionate use basis,
and I've never quite understood that it's compassionate to give something. You got no idea whether it's any good or not, it.
So being transparent, you're making sure we got this story out there was important.
And as a result, I mean, people do know what a trial is now. Yeah.
And I think we have opened up that area and opened up a lot of people minds.
And.