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UK Covid-19 Inquiry - Module 1: The resilience and preparedness of the United Kingdom
Chapter 4 An Effective Strategy
In the words of the report:
Superficially, this looks clear and in logical order.
Let’s start with the 2011 preparedness plan. The Inquiry correctly identifies the focus on a single pathogen (influenza) as one reason for its irrelevance. We would qualify that as the main reason, together with the underlying box thinking.
The UK 2011 plan was inspired by the US HHS Pandemic plan, which contained several “Critical assumptions.”
Specific assumptions for antiviral drugs include: “Treatment with a neuraminidase inhibitor (oseltamivir [Tamiflu®] or zanamivir [Relenza®]) will be effective in decreasing risk of pneumonia, will decrease hospitalization by about half (as shown for interpandemic influenza), and will also decrease mortality.”
The Hallett report fails to mention that the plan's essence was based on the mass use of antivirals (stockpiled at great public expense) to “hold the fort” until influenza pandemic vaccines became available. In the 2009 influenza pandemic, neither was needed and subsequently, when the evidence base for both interventions was shown to be biased and wholly inadequate, no notice was taken despite extensive media coverage.
The pervasive problem with all of these plans is the false confidence that interventions will benefit those who adhere to them. Antivirals have no impact on hospitalisations or mortality unless you look at the infamous industry-funded Kaiser meta-analysis.
In 2016, the UK carried out a National Pandemic Flu Exercise to assess its preparedness and response to pandemic influenza, which was close to the UK’s reasonable worst-case planning scenario.
The evaluation of the exercise highlighted the strengths of existing plans and UK command and control emergency response structures and identified areas where resilience could be further enhanced. Beyond overconfidence, a second fatal flaw in preparedness plans is the arrogance all is well. Inexperienced ministers are looked down on by a system that pretends it is prepared. Groupthink coalesces to provide reassuring messages failing to acknowledge the uncertainties and the lack of evidence to inform decision making. Consequently, ministers, lacking experience and expertise at the time, are kept in the dark by the reassurance of their advisors.
The Inquiry stated, “It is obvious, on the face of the 2011 Strategy, that the UK had devoted its efforts to preparing for an influenza pandemic. Professor Dame Sally Davies, Chief Medical Officer for England from June 2010 to October 2019, could not recall a debate about including non-influenza pandemics in the 2011 Strategy.”
The UK’s approach to pandemic and inter-pandemic influenza preparedness psychologically locked the whole world on a single agent but also implied that “normality” was the inter-pandemic time between inevitable further pandemics, which, according to the then-WHO definition, meant widespread death and destruction.
As we pointed out repeatedly, attention to a single pathogen in the best cases (i.e. where there was no commercial intent) indicates the inadequacy and ignorance of those at the helm, specifically Dame Sally Davies and her predecessor Sir Liam Donaldson and in the US Senator Hillary Clinton pushing a bill to protect the US against “the flu”, another interesting and distorting use of the F word.
In the 2011 plan, chapter 4 (which you can read from page 34 of the 70-page document), the Key Elements of the Pandemic Response are listed as follows:
You will note the article “the” in front of the word “virus”. In addition, paragraph 4.15 refers to public face mask-wearing.
Despite the uncertainty surrounding the use of masks and some of the other remedies, the DHSC made no effort to commission large, well-designed trials that could diminish that uncertainty. As we all know, the 2011 plan was thrown out of the window post haste when the government was confronted with mass panic in the spring of 2020.
Paragraph 4.81 highlights the contradiction in the “groupthink” advice.
Contrast this with Sir Mark Walport’s statements to the press:
“There is sufficient evidence to conclude that early, stringent implementation of packages of complementary NPIs was unequivocally effective in limiting Sars-CoV-2 infections.”
Walport’s review in the Royal Society of Medicine stated, "Lockdowns and face masks ‘unequivocally’ cut spread of Covid.”
Statements of ‘Sufficient evidence to conclude’ and ‘unequivocally’ contradict any need to improve the evidence base for these measures. It's a shame the Inquiry, with all its resources at hand, didn’t pay attention to the irreconcilable statements arising from the group thinkers.
The argument that it is difficult to obtain “good quality data” is a distractor. EBM is hard and requires rigour and, more importantly, funding to address the uncertainties. Pandemics sit outside the norms of how we develop evidence, largely because those at the helm have no idea how rational evidence-based healthcare works.
In paragraph 4.27 paragraph, High Consequence Infectious Diseases (HCIDS) are further raised.
“It is not apparent to the Inquiry why the strategies for high consequence infectious diseases and pandemics were so different and disconnected from each other. They ought to have been considered together. If they had, then systems that were routine for high consequence infectious diseases (such as test, trace and isolate) would have been scalable and ready to control the spread of a novel virus with pandemic potential.”
The Inquiry presumes the answer lies elsewhere. If only we had done XXX. Yet, where is the evidence that test, trace and isolate works to control the spread of an agent and at what health economic cost, given it ended up costing £37 billion. More so, how does the plan apply when the pathogen is immediately downgraded from an HCID?
So what does Lady Hallett propose now? The irony is that the only person cited in the report advocating trials is the arch modeller, Sir John Edmunds. Well, that's good for him, but he’s forgetting that his models will now have to be premised on RCT evidence and not made up based on assumptions.
“The Inquiry acknowledges that improving the evidence base for such public health measures is not straightforward and requires much more thought within the scientific community.” Turning to the same old group of people won't solve the problem of having too little evidence to inform decision-making.
Here are the two recommendations:
and
None of these ideas are new. For example, “hibernation” was the mechanism by which pre-pandemic influenza vaccines were developed 20 years ago and then underwent reconfiguration, limited testing and emergency registration on 27 September 2009.
There is no mention of “inter-pandemic” evidence development, health economics, or an assessment of the interventions in the pandemic and their role in future pandemics. The chapter is supposed to be about an “effective strategy.” Yet, Box thinking continues.
This post was written by two old geezers who will not charge you £190,000 a day.
1886: When everybody thinks alike there is hardly any incentive to think at all
(Anonymous)
1905: When everybody thinks alike, nobody will think at all
(Anonymous)
1910: Where all think alike, you will find also a central office where all the thinking is done
(Jonathan P. Dolliver)
1915: Where all think alike, no one thinks very much
(Walter Lippmann)
1918: When all think alike no one thinks very much
(Anonymous)
1919: When everybody thinks alike nobody thinks at all
(Edward Krehbiel; He disclaimed credit in 1922)
1934: Where all think alike, no one thinks very much.
(Attributed to Walter Lippmann)
1935: Where everybody thinks alike nobody thinks much
(Anonymous)
1942: When everyone thinks alike, no one thinks.
(Attributed to Reader’s Digest)
1949: When everyone thinks alike, ‘everyone’ is likely to be wrong
(Humphrey B. Neill)
1955: With everyone thinking alike, no one thinks at all
(Juvenile probation officer)
1959: When everyone is thinking alike, no one is doing any thinking!
(Attributed to Walter Lippmann)
1964: If everyone is thinking alike, then no one is thinking at all
(Attributed to John F. Kennedy)
1976: When everyone thinks alike, nobody thinks
(Attributed to Walter Lippmann)
1977: When all think alike, none thinks very much
(Attributed to Ronald Gould)
1979: No one is thinking if everyone is thinking alike
(Principle ascribed to Benjamin Franklin)
1979: If everyone is thinking alike, no one is thinking
(Principle ascribed to George Patton)
1988: If everybody’s thinking alike we’re not thinking
(Attributed to Sue Myrick)
1989: When all think alike, then no one is thinking.
(Attributed to Walter Lippmann)
1990: If everyone is thinking alike then somebody isn’t thinking
(Attributed to George Patton)
1995: If everyone is thinking alike then no one is thinking
(Attributed to Benjamin Franklin)
1997: No one’s thinking if everyone is thinking alike
(Attributed to George Patton)
2024: The advice was often undermined by ‘groupthink’. "[Groupthink] is a phenomenon by which people in a group tend to think about the same things in the same way.”
(Attributed to The Rt Hon the Baroness Hallett DBE.)
[6.39], UK Covid-19 Inquiry, Module 1 report: The resilience and preparedness of the United Kingdom
Two points
1. On the focus on influenza. NERVTAG was set up as a horizon-scanning body in, I think, 2016 (before I joined) and was regularly looking for evidence of SARS-1 outbreaks and receiving reports on MERS and the occasional case of camel-human transmission.
2. The HCID category always seems to have been based on the risk of Ebola and similar viruses that might be introduced from the Global South by an infected individual who would require strict barrier nursing and medical care and aggessive contact tracing. Influenza and similar winter respiratory viruses were never thought likely to fall into that category. The rapid exclusion of the Covid virus is another indicator of the gap between the perception of risk by at least some of the scientific advisers and the public messaging. It was fully endorsed by NERVTAG which probably had more expertise than SAGE at that point.