UK Inquiry Module 1: Resilience and preparedness

[gosub]

Johnson’s messages handed to Covid-19 inquiry after Government court defeat

The Cabinet Office had sought to withhold documents it regarded as irrelevant to the inquiry’s work.

www.standard.co.uk

 

[elbows]

Yesterday the inquiry heard from an expert, Dr Claas Kirchhelle, who has a focus on certain aspects of public health history (‘bugs and drugs’) and analysis. Some of his quotes have been used already in the inquiry to question other witnesses about flaws in the system, the effects of austerity etc.

One line of questioning in this module has been whether this country failed to incirporate behavioural science into its planning and response enough. In my opinion this really needs to be accompanied by another question, whether the focus of the behavioural science used was far too narrow and biased, aimed in one particular direction with a particular ‘keep calm and carry on’ purpose. Well this witness managed to touch directly on this during questioning:

Pages 81-82 of https://covid19.public-inquiry.uk/w...4/C-19-Inquiry-10-July-23-Module-1-Day-17.pdf

A: There's a marked increase in interest in behavioural theory from around 2000 onwards. This is not just in the UK, this is also at the WHO level where there is a consistent focus on non-medical interventions but also focusing on vaccine uptake in the population.
Now, it's a very interesting historical coincidence that this new emphasis that is placed on behavioural science, which primarily uses social cues to nudge people in the right direction -- there's also a nudge unit founded in the Cabinet Office during this time -- it coincides with the election of a government which emphasises individual responsibility and market-efficient responses. Behavioural science at this time is closely integrated with market psychology, and it's a core part also of the Hine review of 2009 that more use could be made of it.
The UK's advice gremia, they start taking up on this from around 2005 onwards and start using behavioural scientists to draft, for example, business as usual messages for the UK Government, so to say, "Continue to go to work, the situation is under control".

(the 2009 Hine review was the swine flu pandemic review)

What is interesting what is missing from the behavioural science advice, that is response or representation from social sciences disciplines, which are more structural, so which try and understand the structural determinants of behaviour versus individual psychological determinants of behaviour, and obviously from 2015 onwards a large part of the research on social priming that underlies these hopes for behaviourist interventions at the scientific level experiences a crisis, the so-called replication crisis, where some of the assumptions about effects that can be scaled up to a population size are not replicable in repeat experiments, so the scientific advice and the state of science changes quite significantly during this time.
Q: Right. Does that mean that, in your opinion, enough emphasis was placed upon behavioural science in pandemic planning and in what we're going to look at briefly now, in the exercises that were performed?
A: I think clearly no, because the emphasis here is on assumptions of the behaviour in a universal individual, with not enough regard to cultural and structurally determined aspects of behaviour. So how would ethnic minorities respond to public health interventions --

And a bit later on page 84:

I think that what's quite remarkable about the tabletop exercises is that they assume homogeneity of the UK population which is being managed in response to an exercise. There are always calls for more research on how populations would respond to triage, to mass burials, et cetera, but there is very little -- remarkably little -- consideration given to the fact that the UK has become a substantially more diverse population in this time, that people with different cultural backgrounds, different experiences, will have different responses and expectations of what health services deliver.

I've been rather selective there in order to just zoom in on my own area of particular focus, but you can see that he brought those things up in order to make a different point. It would probably be better to view the questions and further background info that came before the first bit I quoted, but it was a bit too long for me to quote here properly at this time.

I'm not sure how much the inquiry will read into the implications of the things I put in bold and expand on them in future. I would suggest that the establishments focus on behavioural science was supposed to support the traditional 'cold calculations' UK approach to pandemics, was supposed to support the 'keep calm and carry on' approach where it was assumed the public would put up with huge levels of death, and the sorts of population triage that Hunt touched on some weeks ago. I suspect that if it were not for the public and journalists noticing what other countries responses to this pandemic were, if it were not for this being a virus we 'werent already conditioned to accept', ie not a flu pandemic, then the UK establishment would have carried on with the traditional approach, rather than lockdows etc, for far longer.

 

[elbows]

That witness did not buy into the groupthink excuse. And some things they said also play into my claim that we would have done badly in a severe influenza pandemic too. For example:

Pages 100-103:

Q: As a historian, what is your view of groupthink and have you seen it present in some of the groups that you've looked into?
A: I think at the scientific level there is no evidence whatsoever of groupthink. There's such a diverse planning landscape, and we see it with the WHO in 2018 putting Disease X formally onto pandemic planning landscapes. We see it with the planning for all kinds of high-consequence infectious diseases. We see it with the fact that the UK had a SARS plan, it had a MERS plan, there was planning across multiple pathogens. The fact that it still remained an influenza-based framework --

A: -- I agree here with Jenny Harries' assessment, is that influenza was the most realistic disease to plan for.
Q: Why was that?
A: We have the most robust data of pandemics based on influenza and they occur regularly. It's not just 1918, the UK had a pandemic in the 1950s, in the 1960s, there was a major scare in the 1970s, another major scare in the 1990s, and a major scare -- or an actual pandemic in 2009. So it's realistic to see influenza as the most likely respiratory pathogen that can occur and that can spread.
There were obviously failures to update the plan for new knowledge emerging around asymptomatic transmission and aerosolised transmission, but it doesn't mean that this amounts to groupthink. And I come back to the point I made earlier in my hearing, that a legal document is not necessarily representative of a very diverse ecosystem of thinking about pandemics. Again, we only need to look to popular culture, where actually there's a huge amount of pandemic scenarios already embedded, with board games with multiple pathogens, and all of these things around.
So my point here is influenza is a realistic framework to base pandemic planning around, it's there regularly. Moving forward it might be useful to perhaps have more generic names and prepare more generically for airborne pathogens, but I don't subscribe historically to the argument that groupthink delayed preparedness.
In 2019, December, we have the first phase one clinical trial of a MERS coronavirus vaccine, starting in Oxford and then in Saudi Arabia. This is physical evidence that groupthink was not present. The UK was preparing for multiple high-consequence infectious diseases with pandemic potential.

Q: But going forwards there needs to be a flex, doesn't there, there needs to be an ability to adapt whatever preparedness follows from this Inquiry and in the days forwards, there has to be an element of adaptability?
A: Yes. I mean, while writing the report I asked myself the one counterfactual question: would the UK have performed better had it been the classic influenza pandemic that hit the country in 2020? And I think there were serious doubts about the ability to handle that. The PPE levels had fallen precariously low. The resourcing at the local level was not there. The communication pathways had not been addressed, et cetera.
So yes, we dealt with Covid-19 as a novel pathogen. Would the UK have performed so much better had it been a classic, still novel, influenza strain? I have my doubts.

 

[Thesaint]

I personally wonder what would happen had it been flu instead, and I suspect we may have been a bit luckier if only because upcoming flu strains are known about in advance and the vulnerable often are vaccinated in advance, but with covid there was far less pre-warning as it came 'out of the blue'.

I also wonder if this happened 20 (or maybe only 10) years ago, we have no idea that secretive China were locking down, so would have even less warning, until the 1st wave had already passed.

Lastly, it seems the pressure of the 'copycat effect' of countries copying China causing a herd instinct copying/panic didn't seem factored into any plans here or anywhere else.

 

[rubbershoes]

I haven't been watching any of this. Can someone who has tell me if the lead counsel to the enquiry Hugo Keith is doing a good job

 

[elbows]

I personally wonder what would happen had it been flu instead, and I suspect we may have been a bit luckier if only because upcoming flu strains are known about in advance and the vulnerable often are vaccinated in advance, but with covid there was far less pre-warning as it came 'out of the blue'.

I also wonder if this happened 20 (or maybe only 10) years ago, we have no idea that secretive China were locking down, so would have even less warning, until the 1st wave had already passed.

Lastly, it seems the pressure of the 'copycat effect' of countries copying China causing a herd instinct copying/panic didn't seem factored into any plans here or anywhere else.

Seasonal flu strains are predicted in advance by studying the evolution of strains, and by seeing what happens in regions which experience winter at the opposite time of year to us.

Pandemic flu strains dont offer the same opportunities. To create a pandemic in the first place they have to be 'novel', different enough to existing seasonal strains to make our existing immunity, and existing vaccines, ineffective.

Only if we were correctly able to identify a flu strain in animals quite far in advance of that strain spreading well in humans, might we be able to have a traditional flu vaccine ready in time. Or, if work on more generalised flu vaccines that arent so strain-specific advances int he years to come and offers us a more universal solution.

There are still a number of reasons why the reaction to a new flu pandemic might not resemble this covid pandemic. These include:

If flu antivirals offer some protection or treatment pathway. Even if they arent brilliant, these offer governments a way to reassure people and to be seen to be doing something.

If the hospitalisation rate, age profile of the most vulnerable etc etc seems within the bounds of what our systems can cope with.

Other societal attitudes and expectations, and patterns of response seen globally. The last pandemic has upset the apple cart in terms of what cold calculations the establishment think people will put up with, but there is only so far I can run with this idea, I cannot make strong predictions about the next one. It is unfortunate that so many people got burnt out by the pandemic, and wont engage with these sorts of topics in the way they would at the height of lockdowns. For example a society might want to have more frank and honest discussions about what level of funding and spare capacity we put into health services, what level of 'population triage' (leaving some people to die in a pandemic) is deemed acceptable, etc etc. But this sort of stuff does also tie back into an earlier point - if authorities are able to point to medical, pharmaceutical interventions that can help, this is expected to have an impact on what other, non-pharmaceutical responses people think are necessary. There were people here who were understandably looking to buy into reassurances in the early months, given half the chance. If I run with that idea then it would not surprise me if the presence of antivirals that could do something, anything, would be good enough for some people, even if such treatments still left plenty of people vulnerable. Our governments traditional comfort zone in the past certainly involved throwing large quantities of tamiflu at people, including using it as a prophylactic during swine flu despite other countries scratching their heads about that untested use of that drug for that purpose. Even if I turn down my level of cynicism a bit I'd still say that traditionally the UK establishment loves that sort of thing, they find it a much easier sell to get people to 'keep calm and carry on' if they can claim to have some medical weapons in their arsenal, never mind quite how effective those medicines are.

 

[elbows]

I haven't been watching any of this. Can someone who has tell me if the lead counsel to the enquiry Hugo Keith is doing a good job

I dont know if anyone other than me is actually watching it round these parts.

Broadly I'd say that module 2 will be a better test, this first module only covers the period up to January 2020, some months before the shit really hit the fan. Module 2 is where there will be a lot more attention and lots more opportunities for evidence that makes individuals look bad and be questioned aggressively will take place.

At this stage it is hard for me to distinguish between any faults specific to Hugo Keith and the broader approach of the inquiry. The questions they are asking are clearly based on what written evidence was submitted to the inquiry for this module, and it also seems clear that they then formulated a set of angles that they would seek to explore over this modules 6 weeks of evidence sessions. Many of the themes seem like the right ones, but I have identified some areas where the line of questioning is somewhat simplistic and pre-defined. I've not seen much evidence of them being nimble and exploring new territory when a particular witness touches on a theme that wasnt one of the ones the inquiry decided on in advance. Nor has Hugo Keith tended to modify his own words even when a witness or two contradicts one of his well trodden themes, eg his tendency to keep going on about flu being symptomatic, which I already moaned about here. I have my own areas of interest which are the ones I've tended to quote in this thread, and I dont expect the inquiry to ultimately settle on the same overarching narrative as me, there will be an overlap but I'll be surprised if they ultimately build quite the same story of population triage, cold calculations etc as I am doing.

 

[Thesaint]

Seasonal flu strains are predicted in advance by studying the evolution of strains, and by seeing what happens in regions which experience winter at the opposite time of year to us.

Pandemic flu strains dont offer the same opportunities. To create a pandemic in the first place they have to be 'novel', different enough to existing seasonal strains to make our existing immunity, and existing vaccines, ineffective.

Only if we were correctly able to identify a flu strain in animals quite far in advance of that strain spreading well in humans, might we be able to have a traditional flu vaccine ready in time. Or, if work on more generalised flu vaccines that arent so strain-specific advances int he years to come and offers us a more universal solution.

There are still a number of reasons why the reaction to a new flu pandemic might not resemble this covid pandemic. These include:

If flu antivirals offer some protection or treatment pathway. Even if they arent brilliant, these offer governments a way to reassure people and to be seen to be doing something.

If the hospitalisation rate, age profile of the most vulnerable etc etc seems within the bounds of what our systems can cope with.

Other societal attitudes and expectations, and patterns of response seen globally. The last pandemic has upset the apple cart in terms of what cold calculations the establishment think people will put up with, but there is only so far I can run with this idea, I cannot make strong predictions about the next one. It is unfortunate that so many people got burnt out by the pandemic, and wont engage with these sorts of topics in the way they would at the height of lockdowns. For example a society might want to have more frank and honest discussions about what level of funding and spare capacity we put into health services, what level of 'population triage' (leaving some people to die in a pandemic) is deemed acceptable, etc etc. But this sort of stuff does also tie back into an earlier point - if authorities are able to point to medical, pharmaceutical interventions that can help, this is expected to have an impact on what other, non-pharmaceutical responses people think are necessary. There were people here who were understandably looking to buy into reassurances in the early months, given half the chance. If I run with that idea then it would not surprise me if the presence of antivirals that could do something, anything, would be good enough for some people, even if such treatments still left plenty of people vulnerable. Our governments traditional comfort zone in the past certainly involved throwing large quantities of tamiflu at people, including using it as a prophylactic during swine flu despite other countries scratching their heads about that untested use of that drug for that purpose. Even if I turn down my level of cynicism a bit I'd still say that traditionally the UK establishment loves that sort of thing, they find it a much easier sell to get people to 'keep calm and carry on' if they can claim to have some medical weapons in their arsenal, never mind quite how effective those medicines are.

I do wonder if say Spanish flu came around in 2020 would our improved technology and monitoring seen it coming and given some warning and it being a more known thing changed the approach.

There is a very british idea of "stay calm and carry on", but out media counters this easily by going nuts ove anything, and their reaction to ICLs predictions may have decided government policy anyway. This tendency to go nuts would have equally applied to Spanish flu in 2020 I suspect, so maybe whatever technology advantage you mention we have over flu will limited impact on policy!

As for people engaging in this subject yes people are burned out on it, and have other worries now but during the pandemic much public debate was notable because of its absence, and even now risks being decending into the culture wars and party politics still. A frank and honest debate of how much resources a country should dedicate to freak 'black swan' events isn't going to be easy, especially when busy firefighting the problems of the day. Dealing with the subject of how many people do you accept dying is impossible for most.

An inquiry taking as long as it will may allow the dust to settle and be part of that debate one day but I'm skeptical it will be any time soon after either, and doubtful any macro lessons will be learned as a result.

 

[CNT36]

I do wonder if say Spanish flu came around in 2020 would our improved technology and monitoring seen it coming and given some warning and it being a more known thing changed the approach.

The technology and monitoring has improved but the will to put the resources into them has not. Iirc it would be relatively cheap to identify 80% of potential crossover viruses with pandemic potential with it getting more expensive to nail that last 20%. Either is significantly cheaper than locking down a country let alone a significant poryion of the world after the fact.

 

[Thesaint]

The technology and monitoring has improved but the will to put the resources into them has not. Iirc it would be relatively cheap to identify 80% of potential crossover viruses with pandemic potential with it getting more expensive to nail that last 20%. Either is significantly cheaper than locking down a country let alone a significant poryion of the world after the fact.

The underlying dilemma of how much resourcing you put into a rare event, that you know will come but have no idea in what form or when exactly, is an age old one though! Hindsight etc.

It's like San Francisco and Naples are vulnerable to earthquakes or eruptions respectively, but how well planned will they be for either when it finally happens? Probably not that well.

As you say that 20% is ever harder to plan for, and even if you did the even harder 5% will still catch us out.

Full lockdown was ruinously expensive but trying to justify preparation resourcing for an unknown event is again a time old dilemma. I can imagine we have plenty of faster access to PPE now, but in 50-100 years time less likely

 

[elbows]

I haven't been watching any of this. Can someone who has tell me if the lead counsel to the enquiry Hugo Keith is doing a good job

By the way there are some inconsequential ways that he gets on my nerves, probably related to poshness.

For example he used the word lacuna a while ago and was obviously pleased with this choice of language, going on to use it again numerous times when questioning later witnesses.

Speaking of people getting on my nerves, Gove is this afternoons scheduled witness.

 

[rubbershoes]

By the way there are some inconsequential ways that he gets on my nerves, probably related to poshness.

For example he used the word lacuna a while ago and was obviously pleased with this choice of language, going on to use it again numerous times when questioning later witnesses.

Speaking of people getting on my nerves, Gove is this afternoons scheduled witness.

I only ask about him as he was a close friend years ago. Haven't had any contact for decades though.

 

[elbows]

The most obviouslly annoying parts of Goves testimony were when he stuck to the typical UK government politicians line that the hard brexit planning only made us better prepared for the pandemic, not wishing to acknowledge the areas of pandemic planning that were hampered by resources being redirected to that brexit stuff. It certainly sounds like its true that the hard brexit planning helped in a few areas such as supply chains, mostly because the planning demonstrated what a giant shitshow a hard brexit would be, forcing government to practice dealing with that level of clusterfuck disaster. His attempts to gloss over the downsides probably wont carry much weight given the number of other witnessesd who spoke about resources being redirected at the expense of pandemic planning/implementing recommendations that came from pandemic flu exercise Cygnus.

During other lines of questioning he was fairly sensible, although I dont need to quote most of this since it overlaps with what other witnesses said. There are one or two exceptions which I will quote shortly.

He also embarrassed himself after a break, because he had left a youtube feed of the inquiry running on his phone in his pocket. That feed is on a 3 minute delay, so after the sitting resumed voices from minutes earlier eventually started to emerge.

 

[elbows]

Gove was certainly useful (but too kind) when it came to behavioural science. Following on from what I quoted about that the other day, the inquirys counsel continued to stick to their dull 'should more use have been made of behavioural science?' line of questioning rather than adapting it to take account of the fact that it was more a question of the narrow starting point, agenda and nature of behavioural science.

Pages 134-137 of https://covid19.public-inquiry.uk/w...5/C-19-Inquiry-13-July-23-Module-1-Day-20.pdf

Q: You will know that the Inquiry has heard from Matt Hancock, who talked about flawed assumptions being in place which affected the way in which planning went forwards.
This week we heard from Dr Kirchhelle, who suggested to my Lady that it was imperative going forwards for behavioural science and social science to form an important place in any planning of how we are going to be able to fight the next pandemic coming down the line, and the importance of appreciating the effect of how that pandemic is not only going to affect different people in different ways, but what society is likely to do by way of reaction to rules being imposed and matters of that nature.
Do you agree that behavioural science and social science has an important place in planning?

A: Oh, completely, but one of the reasons why ministers were told that there was a risk in lockdown and that toleration of lockdown would be limited was because of the behavioural science consensus with which we were presented. That's not to say that the people who were presenting were anything other than entirely rigorous and thoughtful in the way in which they assessed the evidence and presented it to us, but it's simply the case that the behavioural science assumptions turned out to be less, what's the word, accurate about the durability and the willingness of the public to accept restrictions on liberty.
Of course none of us would want to impose these restrictions, but it was an example, as it were, of a scientific consensus, framed on the basis of what was known, then changing over time as new evidence and new facts force the existing theory to adapt.
When -- you know, it became a cliché during the pandemic when people said we needed to "follow the science", what some sometimes forgot is that science itself changes and evolves as models improve because new evidence arrives.

Q: Does that suggest that the advice that was being provided to the government then on behavioural science and behavioural reactions to the imposition of rules and regulations, that that was out of date?
A: Well, I think it was the best available evidence at the time. So, again, all of us have to recognise that when it comes to behavioural science it is different from, as it were, physics, chemistry and mathematics, where there can be a greater degree of precision in the expectation of what is going to happen if you -- you know, if you introduce one element into water or if you apply a certain degree of force to mass then certain things are likely to follow. Behavioural science, by its very nature, is based on observation but it is also the case that human beings in our infinite, what's the word, unpredictability will sometimes react to new crises in ways that people cannot predict accurately.
So behavioural science, like economics, is informed by past evidence and is shaped by expertise, but it cannot predict with certainty in the way that the hard physical sciences can. So it became out of date, as we saw how people changed, but I would not want to criticise the people who put forward that evidence because they were acting in good faith, that was the best available evidence, it was just that new facts meant that we saw that it wasn't as accurate a predictor as we might have hoped.

Q: Is there a need, do you think, for there to be a greater challenge to behavioural science before the advice gets to ministers? In other words, if there was a wider pool of scientists from whom that advice was sought, there might be challenge inside the system which would bring about perhaps a more accurate depiction of what the reality is.
A: I think that is fair, but I think it is also politicians who are sometimes at fault. Because we ask our advisers for the facts, and, as I've mentioned, sometimes it is -- what we're really asking for is a prediction, and expert advisers can offer their best advice, we seek certainty but it's often elusive, and it would be better if politicians and decision-makers were to say, "Tell me about the debate, what is the lead option within the academic community here, but what also are the alternatives?"
So most people think that a lockdown would be very difficult, but are there some who argue that the tolerance for it would be greater? Similarly, most people assume that this virus emerged in the wet market, but some suggest it might be a lab leak. Where is the evidence? We need to have a certain degree of tolerance for the fact that we can't have certainty.

 

[elbows]

I groaned at the name Gove gave to a very sensible position:

Pages 156-158:

A: Yeah, well, I'd put it slightly differently, which is that: no matter how much thought might have been given to some of the lessons learned from no-deal planning, there was a broader question as well -- which the Health Secretary alluded to -- which is that our approach towards pandemic flu planning was that, and that of many other countries, was that it was almost impossible to so control our borders as to prevent the disease spreading, it was about the mitigation of the disease once it was here.
Q: Yes. Okay. With respect, that's a slightly different point.
A: Indeed.
Q: As it turned out, we know that the control of borders or issues relating to borders were relevant.
A: Oh, they absolutely were.
Q: Yes --
A: But I think --
Q: -- so a failure?

A: But I think for the Inquiry -- again, it's not for me to say, but I do think that for the Inquiry one of the interesting questions -- and again I think Matt Hancock mentioned this -- is, you know, he outlined what one might call the Hancock doctrine, which is that rather than simply dealing with the consequences of a pandemic one should seek to prevent it arriving in the first place.
Q: Yes.
A: And I think that that is a lively debate and I have a lot of sympathy with the position he put forward.

Q: Yes. And if that's the way forward, then getting the border situation and the co-ordination of people and all the matters I've just been through
A: -- Completely.
Q: -- is absolutely key and --
A: Completely.
Q: -- therefore was a systemic failure at the time?
A: Well, it was -- there are live counterexamples of countries that closed their borders, New Zealand being the most prominent, and again I'm sure the Inquiry will want to look at what the strengths and weaknesses of that approach were -
Q: Yes.
A: -- because again, lockdown and border closure inevitably impose economic and social costs --
Q: Okay.
A: -- even as they can be very powerful tools in preventing or slowing the spread of a disease.
Q: Yes. So having the option was essential?
A: (Witness nods)

 

[elbows]

The main evidence sessions for module 1 wrapped up yesterday. Today they are hearing from some bereaved family groups, then its on to closing statements from core participants and then thats it.

I'll be doing quotes from a few more witnesses of recent days soon, and then later I will try to go back and quote some of the ones from earlier weeks that I didnt get a chance to quote at the time, but I'm not sure exactly when I will get a chance to do that.

 

[elbows]

Yesterdays transcript was missing when I looked for it earlier, so I shallr eturn to evidence from last Thursday, when Gove spoke but there were a couple of other witnesses with interesting things to say:

https://covid19.public-inquiry.uk/wp-content/uploads/2023/07/13182335/C-19-Inquiry-13-July-23-Module-1-Day-20.pdf

Nigel Edwards, chief executive of the Nuffield Trust:

Page 42:

Q: Without going into the operational aspects of the hospital estate, and again focusing just on the degree of pre-planning that there was, was there a particular area, the supply of oxygen, in fact, in relation to which there appeared to be a marked absence of planning?
A: The requirement for high flow oxygen as a method for treating Covid-19 certainly came as a surprise, both clinically and also to state departments, who discovered that, in a number of cases, both the size of the pipework to supply oxygen and the machinery that's used to condense oxygen to keep the supply going were inadequate for the scale of the task that was -- that they were required to respond to.
They responded very well, but they had to make very major engineering and structural changes to be able to accommodate that.

Pages 45-46:

Q: It is obvious, and the evidence plainly establishes, that such preparedness as there was was focused on the possibility of an influenza pandemic as opposed to a different type of catastrophic pathogenic outbreak.
To what extent did your researchers see the consequences of that focus as they looked at the general state of health of the social care sector? Did they see evidence that non-influenza outbreak had been planned for to any degree at all?
A: No. Most of the focus had been on planning for an influenza-type outbreak, and the significance of that was that a number of the proposals for how to deal with that did not take into account the airborne nature of transmission for Covid-19.
Q: Did some of the employees and the managers in the social care sector to whom your researchers spoke express any view on the extent to which, both pre and post pandemic, the United Kingdom had availed itself sufficiently of learning or knowledge or experience from other countries who had had to deal with pandemic outbreaks in earlier times?
A: We couldn't find direct evidence for that.

Pages 48-49:

Q: Do different considerations apply to whether or not a system is capable of recovering from a shock as opposed to dealing with the initial shock of a pandemic?
A: Our research internationally suggests that the ability to recover from a shock is very closely related to the overall level of capacity and pre-existing resilience in the system, so those countries which had higher levels of beds and staffing, more hospitals, better provided home care services, have recovered significantly better than those, like the UK, that do not.

Q: Was the Nuffield Trust -- or is it able to reach a view as to general levels of resilience, firstly in the NHS and secondly in the social care sector, over the years preceding the pandemic? Is there a chart or a line or a broad degree of progress that you can identify?
A: If we start with bed capacity and the demand associated with that, the number of beds in the NHS has remained relatively static during the period leading up to the pandemic. The NHS has a very low number of beds per capita compared with other high income countries.
It tends to run them at a much higher rate of occupancy, which of course means that its ability to absorb shocks or increases in demand is much lower. And although the number of beds has remained static, the population has both grown and aged over this period. So while demand has been going up by 2% a year, the beds have remained static, and the number of nurses have gone up by 0.2% over this period, which means that the system -- the hospital system is highly constrained.

 

[elbows]

When it came to evidence from Marcus Bell of the Equalities Hub, I didnt really know where to start with quotes, its a big topic that I will probably have to look at elsewhere in future.

But I will note that at one point the lead counsel strayed into areas that are more appropriate to cover in module 2. But I'll quote this stuff that he was quoting from the witnesses written statement anyway:

Pages 18-19:

May we just move down this document, please, and go to the final paragraph:
"Experience of working with the centre
"- There was too big a focus on presenteeism in the early days of the pandemic regardless of the risks.
This meant a number of key people all became infected at the same time.

"Conversely, this approach excluded the No. 10 disability SpAd from key decisions. As a result, mistakes were made - eg not having a BSL interpreter at the daily briefings.
"- It was felt that equalities interests weren't properly represented in early meetings."
And:
"- There were mixed views on working with the Covid-19 Taskforce."

 

[elbows]

Richard Horton, Editor in chief of the Lancet since the mid 1990s was a very interesting witness. He and the lead counsel did stray into module 2 areas quite readily and was hauled back by the chair on those occasions, so I'll have to wait for more on that. He wrote a book about the pandemic which I feel the need to read.

Pages 65-67:

A: we have tried in the past several decades, as a medical community, to predict resilience. The Global Health Security Index with Johns Hopkins University is one such exercise. The World Health Organisation has its own initiative. We've also tried to make correlations based on the strength of national health systems. What became clear during this pandemic is that none of those measures were effective in predicting response. In some ways in retrospect that is not surprising. If you take the one you mentioned, the Global Health Security Index, it's an excellent document in setting out the technical capacities of a public health system in the face of a pandemic: six broad categories, 37 indicators, almost 200 separate questions interrogating the competence of a pandemic preparedness and response system; but what it omits is the human dimension.
Q: By that, do you mean the realities of the impact of a pathogenic outbreak on members of the population, or do you mean the response of the particular health system in the country under examination?
A: How our political leaders, our health leaders frame the threat, how we assess the threat, and how we respond to the threat. Those dimensions cannot be easily captured or quantified in a measure such as the health security index.

Q: Is that because, as Dr Kirchhelle might suggest, those indices are too technologically based and fail to reflect adequately the reality of how any human system will respond in the face of a crisis?
A: Precisely; they're necessary but they are insufficient. It is only when you are tested by a pandemic that you really see whether your system operates effectively.
Q: I think there is a well known boxer who said, "Everyone has a plan until they get punched in the mouth". These indices examine plans for countries, they examine systems and anticipated eventualities. Do they, in your opinion, fail to take into account the actual reality of the baseline health systems in each country, or how the governors and the response systems will actually respond in the face of a crisis?
A: The second part, they fail to take account of the way human beings respond in the face of a crisis. They do adequately document the capacities such as levels of immunisation, laboratory capacities, supply chains, infection control mechanisms; all that is very well documented in these indices. It is the: how do we frame the pandemic? What was the threat? We may come on to this. The focus has been on influenza, but for two decades we've known that that was not necessarily the major or certainly the only threat that we faced.

Q: Was it well known that there had been, of course, an epidemic and then arguably a pandemic relating to SARS and to MERS and that the Far East in particular had responded, one might think, quite well in terms of putting into place structures and procedures for dealing with those emerging epidemics?
Yes. Until 2002, we thought that coronavirus -- by "we" I mean the medical community -- thought that coronaviruses were a relatively benign category of virus, and we were truly astonished in 2002 when SARS CoV-1 emerged.

 

[elbows]

Richard Horton, pages 68-70:

Q: Do you have a view, as the learned editor of The Lancet, as to why, notwithstanding the degree of knowledge in the public, scientific and academic worlds, that knowledge wasn't translated into governmental planning? And by governmental, I don't just mean the United Kingdom, but generally it would seem across the western world.
A: It's very hard to understand why, and I think -- I mean, I had this book on my shelf for 20 years, and yet we were publishing papers that were talking almost only about influenza as a threat. So I think there was a general groupthink in the medical and public health community that really focused on influenza as the threat.
However, if you were working in China or an Asia-Pacific country, I think there was a different perception. I think this was a Western groupthink, and certainly colleagues I have in China were very well aware that coronaviruses were a major threat.

Q: Did the combination of an arguable lack of focus on non-influenza threats, as well as the high ranking in the GHSI and other indices, engender, do you think, a complacency on the part of the West?
A: I think we were complacent, for several reasons. First, I think that we were overconfident in our National Health Service and public health service to cope with a pandemic. We're very proud of our NHS, but the reality is, as -- we had a commission published in 2021 with the London School of Economics -- some of the chronic weaknesses in the NHS left us very vulnerable, and I think we underestimated those weaknesses.
I think we were mistrustful of evidence coming from China. I think that was a -- you know, there was a degree of Sinophobia in the international order, which meant that we didn't take signals from China as seriously as we should, and -- and this might be arguable -- but I think at the time, in January 2020, we had a sense of our national sovereignty that might have made us feel stronger as a nation to weather a shock, which was clearly misplaced.

 

[elbows]

Richard Horton, pages 72-73:

A: The concept of a syndemic was first written about by an American anthropologist called Merrill Singer in the 1990s, and it's important because it's connecting the biological with the social: two biological epidemics interacting to make each worse. It's not just the co-existence, it's the fact that they each make the other worse.
Q: What are the two biological --
A: Well, in this particular case it is the virus and chronic diseases within our population, obesity, heart disease, renal disease, cancer and so forth.
The intersection of those two epidemics overlaid on patterns of social inequality meant that we had this very, very toxic, potent mix of risk profile which -- and it's important, the notion of a syndemic, because it affects your management and your prevention.
Management because you're not only dealing with a virus, you also have to deal with a pattern of disease in your society that makes certain groups of people highly vulnerable. And not only the disease but the patterns of inequality: certain people who are in more deprived communities will be at greater risk than others.
And it's important for prevention, because you won't have true resilience from a future pandemic shock if you've only focused on the virus. You have to think about the overall health of the population and you have to think about reducing inequalities.
So in the future, pandemic prevention will partly be about identifying and responding to a viral threat, but it will also and equally be important to think about the overall health of the population and patterns of inequality.

Pages 74-75:

Q: But in regard to both, vulnerability and inequality has to be first and foremost because they are the ones who are most likely to be affected by a future health emergency or a pathogenic outbreak?
A: That's right. This was not an equal opportunity virus. This was a virus that struck different groups of people at different levels of risk, and the way we -- I mean, these are other dimensions of public policy, but in the specific realm of pandemic prevention we should be giving greater attention to those who are living with chronic disease and to those who are living in more deprived communities if we're thinking about pandemic prevention, yes.
Q: You would argue that that must go beyond making appropriate clinical arrangements for dealing with those persons who are infected by a virus, but who suffer fro co-morbidities, to addressing the comorbidities themselves?
Yes, and this is where I think we were particularly vulnerable here, because we have -- we do have an excellent national health system which is able to address people who present with particular diseases, but what we have not got is an effective public health system that is able to focus on health promotion and health -- and disease prevention, and it's that disabling of the public health system that left us particularly vulnerable to Covid-19.

 

[elbows]

Richard Horton, pages 76-78:

Q: Dr Horton, it is, I think, obvious that once academics and medics in China informed ProMED, the international surveillance body, and informed the regional office of the World Health Organisation in the first days of January and the last couple of days of December 2019, that that knowledge of the coming epidemic, then only an epidemic, was well known. Why does there need to be further attention given or greater attention given to enhancing our genomic surveillance systems, if -- the reality of the last pandemic showed that actually knowledge of the coming wave was well distributed and well known, why do we need more surveillance?
A: Well, I would argue more by accident than design, in terms of those early days. Remember, the initial response by local government officials in Wuhan was to suppress information, not to report information. The initial signal, you are right, came through ProMED, but it did not come through official channels of the Chinese government to WHO.
I have spoken to the person who was leading the WHO office in China. He had no direct contact from Chinese authorities in those early days about the outbreak in Wuhan. So the channels didn't work.

Q: They worked belatedly?
A: Well, they worked by accident. Not even belatedly.
He -- the WHO officials had to -- they saw the ProMED posting and then they were the ones who went to the Chinese authorities and said, "Hey, what's going on?" So the information flow was in the opposite direction.
So we desperately need an awareness and a system, a global system to -- genomic surveillance certainly, but also to detect pneumonias of unexplained origin. And it's relevant to the UK -- because one could say: well, this is all about China, what's that got to do with the UK? The reality is that the UK's national health security depends upon global health security. We are not safe as a population unless the rest of the world is safe. So that puts a responsibility on us to engage with the rest of the world to make sure that the rest of the world is safe.

Pages 78-79:

A: If we take spillovers, which is the most likely source of a future pandemic virus, we need to take a One Health approach to pandemic prevention. That means thinking about how human health interacts with animal health and the environment, and at the moment One Health -- the concept of One Health is something of a Cinderella in global policymaking, we're only beginning to realise its importance.
And then, you know, there has been a lot of discussion about the origins of Covid, and I'll only say that --
Q: Let's not go there, Dr Horton.
A: Let's not go -- well, it's only relevant to this point, to your question, and that is: of the biosafety level 4 laboratories in the world that might be dealing with potentially dangerous pathogens, there is no international oversight of those laboratories. It is in our interests to make sure that we are an energetic and muscular proponent of stronger international regulation of biosafety level 4 laboratories, for national health security in the UK. I stop there.
Q: This Tribunal has considerable powers, Dr Horton; I'm afraid the regulation of the international order of controlled detection, surveillance and border closures is probably beyond its remit.

 

[elbows]

Richard Horton, pages 81-83:

A: I would say that's one of our -- has been one of our great strengths in terms of pandemic preparedness: the quality and the robustness of the science base, certainly.
However, in relation, if we just rewind back to your very opening question about why did the UK perhaps not perform as well as predicted by these health security indices, it's not just the science base, it's the scientists and the scientific advice that we then give to government, and there was, I would submit, clear failures in the quality of the scientific advice that we gave to government.
Q: Do you mean post January 2020 in terms of the response or the pre-existing position in terms of the risk assessment process?
No, I'm talking about those early weeks in January 2020.
Q: All right. We're not going to go there because that's a matter for Module 2.
A: Okay.
Q: But what about the risk assessment process? In your statement you say elsewhere that there is, as with many -- as with all governments, perhaps, and all types of administration, that there's a danger that, in the field of identifying and judging risk, each part of the system may have a tendency to assume that somebody else in the system is going to be the final arbiter of the nature of that risk and draw the appropriate lesson and
raise the appropriate warning, and therefore everyone looks to each other and nothing gets done.
A: Yes.

Q: Is that the nub of it?
A: It is. We have -- and I'm not making any comments about individuals, but in terms of the offices, we have a Chief Scientific Adviser, a Chief Medical Officer, NERVTAG, SAGE, which is -- SAGE is a -- is not really a committee because different people cycle in, they cycle off. This is a very, very good system designed to pass the buck to another group, and in a crisis situation I think one might consider that a more command and control approach might work better.
In Germany, for example -- again I choose Germany as my comparator because they did very well in the early phase of --
……..(some quibbling about whether this is in the scope of module 1)......
I was just going to say that the way the German system operated was that the government invested responsibility in the Robert Koch Institute and the president of the Robert Koch Institute, who then assembled a team around him to give advice. Our system is more decentralised and I think that that fragmentation means that, in terms of assessing the risk, we don't do as well at being decisive at a moment of peril.

 

[elbows]

And then we had a bereaved families group counsel asking Richard Horton some questions:

Pages 87-88:

Q: Was the scientific information and learning from SARS, which could have informed our planning scenarios, was it well recognised in other scientific literature, other than that journal from the US Institute of
Medicine, in that period, the run-up to January 2020? And was it something that was accessible to those who give scientific advice?
A: Oh, unquestionably the SARS outbreak in 2002/03 spurred on a huge interest and research activity into coronaviruses, because suddenly we were aware that these were not a benign group of viruses circulating in our communities, causing mild respiratory illnesses, coughs and runny noses; actually they could cause multisystem disease, tipping people into intensive care with high fatality rates. This was utterly new 20 years ago.
That shock led to a surge of new research into coronaviruses, and it only redoubled when MERS in 2012 came on the scene.
So, yes, in the literature, which was entirely accessible, both in the general medical literature and the specialist literature, there's an enormous discussion about the dangers of SARS CoV and MERS -- and zoonotic infections in general, infections that jump from animals to humans. We recognised and have recognised for many decades that the biggest threat as a species we face from disease, infectious disease, comes from the jumping of a virus from an animal to a human. We knew that, and we knew that it wasn't just influenza. It's a whole range of different viruses, from coronaviruses to Ebola, and others. So this has been a central debate in the global health community over 20 years about those threats and what we do about them.

Page 88:

Q: Still on the topic of focusing on influenza pandemics, again this was touched upon earlier in your evidence, this concept of Western groupthink.
Do you know of any Western countries or countries in the Global North that implemented any learning from SARS and indeed MERS in respect of training and surge capacity, for example?
A: No, I think we -- I can't identify any country that actually implemented a plan with a coronavirus as a significant potential threat. That was -- I think there was a Western focus on influenza, which was not matched by countries that had been on the sharp end of SARS-CoV-2 in the early 2000s.

I am a bit disappointed, given that unlike other countries in 'the West' and 'the Global North', Canada actually had a SARS problem including hospital transmission back during that outbreak, that the opportunity wasnt taken to consider whether they learnt from the original SARS, and if not why not.

Pages 89-92:

(initially quoting from earlier evidence from a different witness, Professor Heymann)
Q”: Many countries in Asia (eg Singapore, Japan, Republic of Korea ... Taiwan and Hong Kong ...) had strengthened preparedness after the SARS outbreaks in 2003. Preparedness activities in these countries included cross-government pandemic containment, simulation exercises; teaching and practising outbreak containment skills with healthcare workers through the implementation of formal training and hospital surge capacity exercises; strengthening infection control measures at health facilities including the construction of state of the art patient isolation facilities at hospitals; and strengthening disease detection networks."
So those are the areas that he sort of looked at in terms of training and education, and in your statement at paragraph 19 you say this:
"A revolution in nursing and medical education is a necessary part of preparing for the next pandemic." So my question, Dr Horton, honing in on that, the learning and practising aspect of education, in your view should such training -- as well as perhaps other aspects of the training that Dr Heymann has mentioned -- be provided to healthcare workers in the UK as part of that revolution in education that you describe in your paragraph 19?

A: So let me try and offer two parts -- two answers.
First, may I add to Professor Heymann's list the preparing of the public for a potential pandemic. So what all of those countries did, have done, very effectively is they have prepared the public -- this goes to the point on trust -- they have prepared the public for a potential future pandemic. So if and when one comes, issues around physical distancing, quarantine, mask wearing, travel advisories, the public is aware of these issues, they don't suddenly get dropped on them with surprise. They know in advance that these are potential interventions the government might take. Indeed prior to the pandemic if one travelled widely in Asia one would see people wearing masks, for example, routinely in the streets, busy streets, in shops, on metros.
So this became embedded in the public culture. A precautionary approach to the potential danger of a pandemic, which governments were able to ...

Now, to answer your main question, put simply, threats to UK health and health security are going to come from outside the UK, which means that our doctors, our nurses, our health workers do need to be aware and apprised of those threats and in readiness to respond to those threats.
I think that our health workers did an absolutely brilliant job during this pandemic. I don't take anything away from their response. However, it was done as an emergency, in something of a panic, and I was receiving messages during those early months and the system was close to meltdown, because we were not ready, and our health workers had not been adequately trained and prepared for the dangers of a pandemic, how to redeploy staff to focus on people in critical illness, how to build surge capacity in intensive care in a moment. Those plans had to be implemented instantly and there was very little planning for that.
So I think this educational revolution is to relocate the UK in a global community and a community -- a global community at risk. It needs us to have a far more expansive view of what constitutes national health and a national health service.

 

[elbows]

Yesterdays transcript became available so I can now quote some areas of interest from those witnesses.

https://covid19.public-inquiry.uk/wp-content/uploads/2023/07/18130015/C-19-Inquiry-17-July-23-Module-1-Day-21-1.pdf

First we have Professor Philip Banfield, chief of the BMA UK Council.

I dont really know how much the second module will expose the ugly realities of ethics, population triage etc, but I did note that passing reference was made to the BMA giving advice to government in this area...

Pages 59-60:

Q: Have you been able to look back and see to what extent the BMA was involved at all in any of the exercises of which we've heard evidence?
A: Yes, we've had instances where elected members have been part of the exercise or have been involved with commenting -- especially for Exercise Cygnus, we gave ethics advice.

Pages 61-62:

Q: So how did you get to know what the recommendations had been of the various exercises, and therefore be in a position to know anything about the extent to which those recommendations had not been implemented?
A: Well, the early ones, because there was a review, for example, of the 2009 swine flu pandemic by Deirdre Hine, so -- and she made a number of recommendations, particularly about making sure that services were joined-up, that -- you know, were still exposed during other exercises like Alice.
Q: Was that because you became aware of the later exercises and were therefore able to see the extent to which recommendations from Dame Deirdre Hine's review had not been put into place?
A: Yes. And in particular there was an ongoing discussion with the ethics department, because the ethics department was giving expertise to the discussion around mass casualties and population triage.

 

[elbows]

And now a few other things, again from Philip Banfield:

Page 64:

Q: Are you aware of the extent to which persons on the inside of government were debating the consequences of there being a pandemic which had a high degree of aerosol transmission? Do you know whether that is something that was being addressed?
A: No. There was no discussion and the general feeling is that there was a disconnect between anything that was going on in central government and the local public health teams.

Page 66:

A: The split of public health from NHS into Public Health England, which took health protection and some of health improvement into government, effectively, split, then, the health improvement and the public health assessment of the care needs and the health needs of the local population. By doing that, it split the resource, because you now had the local health protection function diluted. The terms and conditions were different in local authorities than in government. So you started to have more medically-focused personnel centrally, more non-medical locally, and you started to lose some of the resilience and expertise in managing local outbreaks.
So, for example, where that expertise was retained, an example would be Ceredigion in Wales, they managed to contain and had very low rates of Covid for a lot of the pandemic.

 

[elbows]

I still consider hospital infection control to be of even more importance than is generally understood, and here we get into some of that territory during the evidence of Philip Banfield, including failings that are still ongoing now.

We only had 8 airborne High Consequences Infectious Disease beds in England! This sort of thing severely limited our ambitions, and in my opinion is one of the differences between countries that did well like South Korea and ourselves. I often think of early images of their medical response to Covid cases involving full biohazard suits and respirators, and negative pressure rooms, compared to the complete opposite for us, where for way too long we didnt even bother testing hospital patients unless they had travelled from China.

Pages 75-76:

Q: So, in essence, it's not really a question of planning, it's a question of ensuring that inequalities are reduced and the health of the population, in particular those who suffer from ill health, is improved, so that we are all better off for the next pandemic?
A: I mean, that's partially true, but when it comes to, for example, inequalities within our healthcare and social care workforce, we are still in a situation where the recommendation is for fluid-resistant surgical masks, which of course are not protective against aerosols at all. So that advice is affecting disproportionately those with inequalities.
And ventilation within our NHS estate and social care isn't -- hasn't been addressed either.
So the risk assessments and the assessment of hazards is still being poorly done, and it affects certain members of both our patients and our staff disproportionately.

Pages 78-79:

Q: Dr Michael Prentice from NHS England -- again, no need to bring up his statement. He has provided a statement, hasn't given evidence to the Inquiry, but for reference, my Lady, it's INQ000177805, paragraph 181.
He talks about the number of airborne high-consequence infectious disease units located in the country, and he says in that paragraph airborne HCID units are located at Guy's and Saint Thomas' NHS Trust, adult and paediatric services; secondly, Royal Free London NHS Foundation Trust with a paediatric service provided by Imperial College Healthcare and St Mary's. Then Liverpool University Hospitals NHS Foundation Trust, with a paediatric service provided at Alder Hey Children's Hospital, and, finally, Newcastle upon Tyne Hospitals NHS Foundation Trust, both adult and paediatric services. Each centre routinely provides two beds, eight in total, for airborne HCID. Specific service specifications outline the care pathway and unit requirements.

Q: Was the BMA aware that there were only four units in England for airborne HCIDs, with two beds each?
A: Yes
Q: Well, firstly, those figures, those are the bald facts and figures from both the National Risk Register and the number of HCID units; would you agree that eight beds for an airborne HCID is woefully inadequate to contain 2,000 cases?
A: Yes, I would.

Pages 80-82:

A: When it comes to the Covid pandemic, the issue of capacity and the need to create effective isolation either within single rooms or then cohorting was very quickly appreciated by the medical profession, because we were getting feedback from China and from colleagues in Italy, and there was a sudden realisation within the medical community of what was coming our way, and it was all hands to the pump trying to plan where our intensive care beds would be, because we had half the number of beds of the European average, a quarter of the intensive care beds that Germany had for example, and I've never seen doctors so worried about how they were going to cope with the influx of seriously sick patients to the extent that, you know, we had intensive care consultants doing physics calculations of oxygen flow through pipes to see whether we could get more oxygen round the hospitals.
We knew that this was unprepared for, we had no idea what was coming our way, we were suddenly in a position where not only patients were going to die but our colleagues and ourselves were in a position where we might die because we felt so unprepared. And, as was referred to earlier, the surveys that we did with the medical profession continued in that vein for some time into the pandemic.
Q: That sudden realisation by the medical profession of what you were faced with, could that and should that have been planned for and prepared though?
A: Sorry?
Q: Could that and should that have been planned for and prepared for?
A: Yes, and we feel that the disconnect between central government and the realities of the shop floor was one of the recommendations that was consistently not addressed during any of the exercises.

 

[elbows]

I'm only doing one short quote from Dr Jennifer Dixon, chief executive of Health Foundation who gave evidence yesterday.

Page 92:

Q: So although NHS spending then was protected, and although there were increases in real terms year by year, because of the particular demands of the NHS, the need to modernise, the need to keep up with the demand from the population, the amounts of the increase could not be enough to match those demands?
A: No, they were not.
And if I may, just to give a comparison, if we had spent per capita in 2019 the same as France, the NHS would be receiving an extra £40 billion per year, and if we'd compared ourselves with Germany we'd be spending another £70 billion a year. That's on a roughly £150 billion budget.

 

[elbows]

Its over. She hopes to publish her report on this module by next summer.

There are over 500 more documents relevant to this module that havent been published yet that permission has now been given to publish.

And there are 135 witness statements where the person did not give oral evidence to this module! These will also be published and I will wade through a bunch of them eventually.

I cannot do the evidence sessions of the bereaved for justice witnesses justice with my quotes so I wont even try. I cant really summarise all the core participants closing statements properly either, although there are a couple of things I want to quote from one or two of those in the coming days.

Public hearings for module 2 are due to begin on October 5th.

 

[elbows]

They are doing a preliminary hearing for module 4 today, a module that covers vaccines and theraputics. Depending on when the main public evidence sessions for that module take place, I might not be able to cover that module properly.

Meanwhile I never got round to doing the remaining quotes from module 1 that I never got a chance to do at the time. I still aim to find time to do this at some point before Module 2 sessions begin in October.