Public inquiry into UK’s response to covid-19BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2052 (Published 22 May 2020) Cite this as: BMJ 2020;369:m2052
All rapid responses
A distinguished Australian contact writes to me:
“Since January, the virus has gone through at least six major gene changes that boosted its ability to infect and evade the human immune system
“The US and Britain are the two major virus mutation hotbeds at the moment, say scientists.
“Even more reason we should be focusing on innate and not acquired immunity...
“This means increasing the strength of our defence mechanisms with particular attention to vitamins C, D and the mineral Zinc.“
This, one might have thought is entirely basic. While the development of vaccines is necessarily lengthy, speculative, hit or miss, expensive etc., making sure citizens are up with their supplements should really be common sense, but has been turned into something controversial. Why were our health officials not saying this in February (if this is not too backward looking)? Why do they not say it all the time? Why do they not put effort into making these substances available to everyone? This would not admittedly be good news for the pharmaceutical industry. 
 Godlee et al, ‘ COVID-19: Call for a rapid forward looking review of the UK’s preparedness for a second wave’, 23 June 2020, https://www.bmj.com/content/369/bmj.m2052/rr-2
Competing interests: AgeofAutism.com, an on-line daily journal, concerns itself with the potential environmental sources for the proliferation of autism, neurological impairment, immune dysfunction and chronic disease. I receive no payment as UK Editor
The authors puzzle me.
They call for a review. Yet they say it is not about looking back nor about attributing blame.
If it a review, it means you look back. You view again. You determine what went wrong and why it went wrong.
Only then can you decide: what errors to avoid.
Let us call a spade a spade.
Competing interests: No competing interests
Open letter to the leaders of all UK political parties
Dear Leaders of UK political parties,
Several countries are now experiencing COVID-19 flare-ups. While the future shape of the pandemic in the UK is hard to predict, the available evidence indicates that local flare ups are increasingly likely and a second wave a real risk. Many elements of the infrastructure needed to contain the virus are beginning to be put in place, but substantial challenges remain. The job now is not only to deal urgently with the wide-ranging impacts of the first phase of the pandemic, but to ensure that the country is adequately prepared to contain a second phase.
You may have seen the recent BMJ editorial calling for a transparent rapid review of where we are and what needs to be done to prevent and prepare for a second wave (https://www.bmj.com/content/369/bmj.m2052). We believe that such a review is crucial and needs to happen soon if the public is to have confidence that the virus can be contained.
The review should not be about looking back or attributing blame. Rather it should be a rapid and forward-looking assessment of national preparedness, based on an examination of the complex and interrelated policy areas listed below . These are too broad for any one of the existing select committees. That is why a cross-party commission was suggested, establishing a constructive, non-partisan, four nations approach that could rapidly produce practical recommendations for action, based on what we have all learnt, and without itself becoming a distraction for those at the front line, or in government. These recommendations should not require primary legislation or major organisational change. The approach would also help the public understand how and by whom they will be implemented. We believe this will be essential if the UK is to get ahead of the curve.
We are aware of YouGov polls showing that a majority of the public now support an ‘Inquiry’. We also know that the Prime Minister and Secretary of State for Health and Social Care have received a petition from the COVID-19 Bereaved Families for Justice group, requesting a full public inquiry. The group have also called for an urgent interim inquiry, which shares the same fundamental approach and objective as our suggested rapid review: that it should be forward-looking, practical, responsive to what the public at large want to see happen, and focussed on evaluating national preparedness in the lead up to winter, with the aim of saving lives.
We are not wedded to any particular design of inquiry or review, but as outlined in the editorial, we believe it should be quick, broad, ambitious, able to command widespread public and stakeholder trust, and needs to happen now. It should focus on those areas of weakness where action is needed urgently to prevent further loss of life and restore the economy as fully and as quickly as possible. We believe the list below includes those areas.
As stakeholders and leaders of the UK’s medical, nursing and public health professions, we urge you to establish such a review. We think there’s a strong case for an immediate assessment of national preparedness, with the first results available no later than August, and that all its work should be completed by the end of October. We don’t underestimate the complexities of establishing this in the required timeframe. We stand by ready to help in whatever way we can.
Lord Victor Adebowale
Derek Alderson, President, Royal College of Surgeons
Wendy Burn, President, Royal College of Psychiatrists
Jeanette Dickson, President, Royal College of Radiologists
Fiona Godlee, Editor in Chief, The BMJ
Andrew Goddard, President, Royal College of Physicians
Michael Griffin, President, Royal College of Surgeons of Edinburgh
Katherine Henderson, President, Royal College of Emergency Medicine
Richard Horton, Editor in Chief, The Lancet
Martin Marshall, President, Royal College of General Practitioners
Jo Martin, President, Royal College of Pathologists
Edward Morris, President, Royal College of Obstetricians and Gynaecologists
Chaand Nagpaul, Chairman of Council, BMA
Maggie Rae, President, Faculty of Public Health
Anne Marie Rafferty, President, Royal College of Nursing
Jackie Taylor, President, Royal College of Physicians and Surgeons of Glasgow
Conflicts of interest: None declared
Corresponding author: Fiona Godlee, Editor in Chief, The BMJ, London WC1H 9JR
Policy areas needing rapid attention:
Governance including parliamentary scrutiny and involvement of regional and local structures and leaders
Procurement of goods and services
Coordination of existing structures, in a way designed to optimise the establishment of effective public health and communicable disease control infrastructure, the resilience of the NHS as a whole, and the shielding of vulnerable individuals and communities
The disproportionate burden on BAME individuals and communities
International collaboration especially to mitigate any new difficulties in pandemic management due to Brexit
Competing interests: No competing interests
Dr Bamji seems nearer the target than anyone else.
When the ministers and their officers (not the Special Advisers) look at their own faces in the mirror in the morning, do they see a sign of shame? Embarrassment for failing to act with speed? Surely some people might be still living, if Her Majesty’s ministers had been prompt?
I put it to them that they do not need to resign. Five words would suffice:
I failed the British Public.
Then he (she) can publish a longer statement.
Competing interests: Might get caught by the VIRUS.
We agree with the authors that any delay in finding workable solutions to the challenges of COVID-19 must be avoided. As they point out, there is a disproportionate burden on ethnic minority populations (1). An easily forgotten group in this category includes those with uncertain immigration status. In particular, we at Medical Justice are concerned for those held in immigration removal centres (IRCs) for administrative reasons prior to potential removal to their country of origin.
Experts warned that the institutionalised setting of an IRC could function as an “epidemiological pump”, and recommended urgent measures to prevent the spread of infection (2). However, 653 people remain detained under immigration powers - 313 in IRCs, and the rest in prisons (3).
The Home Office has not released many of our clients, even though 39% of those still detained are classed as “Adults and Risk”, and have risk factors for severe COVID-19 infection (4). Only a handful of COVID-19 tests have been carried out (4). Prohibition of visits has further isolated detainees; the impact of this on the wellbeing of detainees including those with serious mental health issues and support needs is yet to be fully understood. Meanwhile the Home Office has appealed to the judiciary to limit the granting of bail to immigration detainees, citing among other reasons the lack of suitable accommodation after release (5). Such accommodation should be provided as a priority; it is a vital part of the Public health response, and detention is not an acceptable alternative.
As for international collaboration, we can certainly learn from our neighbours, many of whom were ahead of us in the epidemic curve. For example, Spain emptied its detention centres completely in response to the COVID-19 pandemic (6). The UK should follow suit before avoidable death in immigration detention occurs.
It is important to recognise that immigration detention is inherently harmful to health, and we regard it as part of the “deeply dysfunctional system” that the authors refer to. Well-documented health and mental health risks of immigration detention predate the pandemic (7), but COVID-19 has added an unjustified additional risk to the health of detainees and staff. We hope that this small but vulnerable group of immigration detainees is not overlooked in any future public inquiry, especially in light of the fact that none are serving a criminal sentence – their detention is optional. Most of them cannot be deported due to the global lockdown so the risk to their health, and that of the staff, is entirely avoidable.
1. Covid-19: Known risk factors fail to explain the increased risk of death among people from ethnic minorities. https://doi.org/10.1136/bmj.m1873 (Published 11 May 2020)
2. Coker R 2020 Report on Coronavirus and Immigration detentionhttps://detentionaction.org.uk/wp-content/uploads/2020/03/Report-on-Dete...
3. Statistics relating to COVID-19 and the immigration system, https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
4. Supplementary written evidence submitted by Mitie Care and Custody Limited (COR0137) https://committees.parliament.uk/writtenevidence/5308/pdf/
7. Welfare in detention of vulnerable persons review: progress report https://www.gov.uk/government/publications/welfare-in-detention-of-vulne...
Competing interests: No competing interests
There should be an inquiry into the response to Covid-19, but not now. There are still too many unknowns, both epidemiological and clinical, for an inquiry to be able to draw any sensible conclusions. In response to the five points suggested for scrutiny I suggest:
1. A major exclusion from discussions has been that of clinicians at the sharp end. The problem with Covid-19 is that it may kill people; local government leaders are unlikely to be able to contribute anything sensible to the clinical discussion of how to stop it killing people.
2. Any review of procurement must be set in context with the similar problems faced by other countries. Furthermore,as it becomes increasingly clear that mechanical ventilation is unhelpful in many cases (because it will not restore blood oxygen levels if the alveolar epithelium is significantly damaged) the whole purpose of setting up ventilator-equipped Nightingale hospitals must be reviewed.
3. I don't think that structural disconnect between health and social services altered the spread. What mattered was the SARS-CoV-2 was far more infectious than believed. The care home "epidemic" may well have been caused by the central directive to empty hospitals without testing patients before discharge; the only benefit of involving more agencies would have been to increase the pool of those whose working principle, when confronted with a plan, is to work out what could possibly go wrong with it.
4. It is apparent that any ethnic predisposition to Covid-19 may have a genetic basis, and attempts to present the subject in sociological terms is unscientific and runs the risk of serious predisposing factors being overlooked. What purpose is served by bringing in representatives from "the communities involved" other than to pay lip service to political correctness? Unless the proposed representatives have a firm grasp of statistics, epidemiology, genetics and risk factor correlation their presence would be a hindrance.
5. Brexit is irrelevant.
What is actually required is not some multi-function set of panels looking at peripheral issues, which will end up, as with all inquiries, stuffed with the wrong people, but an immediate development of treatment to stop Covid-19 from being a serious clinical problem. There is growing evidence (and the fact that it is growing so rapidly underlines my contention that an inquiry now is a waste of time, because the Science is constantly changing) that the serious multisystem disease seen is a function of (1) deep viral exposure and (2) a subsequent cytokine storm. The first has been partly addressed by PPE; the second has hardly been addressed at all.
There are two stages for this second part.
First, the development of risk-indicating tests. The required tests are already available; oxygen saturation measurement (as Dr Rammya Mathew suggested in a previous column (1), and as I have been arguing for weeks, availability of pulse oximeters enables this), and tests in deteriorating patients that point to cytokine overactivity and thrombotic risk such as serum ferritin and D-dimer.
Second, the development of cytokine storm management. In those who have abnormal tests showing they are developing a cytokine storm, the use of cytokine blockers, low molecular weight heparin in treatment not prophylactic doses, and steroids (in high dose, given early) must be instituted. Early. Current thinking that one should reserve these for late cases is analagous to treating cancer only when it gets to stage 4; it then does not work. Neither does dribbling in too little. Likewise treating with antiviral agents may reduce the ongoing storm but will do nothing to mitigate a storm that is already present. Which is the more important - the storm or the virus? My money is on the storm.
These are the measures that need to be in place before a second peak. Then patients may get SARS-CoV-2 but not die from Covid-19. A second wave is unstoppable if, as in Singapore, it transpires that large numbers of infected people are asymptomatic. That is why what matters is treating the severely ill with things that work. Deciding that is a matter for clinicians, not epidemiologists, public health doctors, social service or community groups or a public inquiry.
In conclusion Stephen Glover points out that in the 1968 influenza epidemic (which killed twice as many people as Covid-19 has yet done) there was no panic. He asks why (2). That might be an interesting subject for an inquiry.
It is now six weeks since I first wrote about the likelihood of severe Covid-19 being due to a cytokine storm. Clinicians with experience of dealing with this have not been consulted, as far as I am aware. I have had no response to my repeated attempts to highlight this with the powers that be - not even acknowledgement of receipt of my communications. If I am proved correct (and I concede that The Science may yet come up with alternative mechanisms for severe illness), I wonder how many lives would not have been lost.
1. Mathew R. Innovation during the pandemic. BMJ, 12th May 2020. https://doi.org/10.1136/bmj.m1855
2. Glover S. News spreads faster than the virus. The Oldie, June 2020, 63
Competing interests: No competing interests