THE INDEPENDENT SAGE’S PRELIMINARY EVIDENCE

Below is a transcript from the first meeting of the Independent SAGE on the 4th May, 2020. Some parts have been edited to ensure clarity. Some elements of the discussions concerning technical matters have been edited out.

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David King
Colleagues, good day. Welcome to this first meeting of the Independent Science Advisory group on COVID-19 and the epidemic. I am simply now going, having welcomed you, to ask each of you to give your name and your affiliation. We don’t all know each other, and it would be good to meet up in that way. And I’m going to start with Anthony.

Anthony Costello
Hi, I’m Anthony Costello professor of global health at UCLA. I was previously at the World Health Organisation.

David King
Deenan.

Deenan Pillay
Deenan Pillay, Professor of Biology at University College London.

David King
Karl.

Karl Friston
I’m Karl Friston. I’m a professor of neuroscience at University College London.

David King
Susan.

Susan Michie
Susan Michie, professor of health psychology also from University College London.

David King
Alyson.

Allyson Pollock
Alyson Pollock, Professor of Public Health at Newcastle University,

David King
I’ve got two Alison’s. Alison Pittard.

Alison Pittard
I’m Dr. Allison Pittard. I’m Dean of the Faculty of intensive care medicine. I’m also a consultant in anaesthesia in intensive care

David King
Zubaida.

Zubaida Haque
I’m Zubaida Haque and I’m the Deputy Director of the Runnymede trust

David King
And Martin.

Martin McKee
Martin McKee, Professor of European public health at the London School of Hygiene and Tropical Medicine.

David King
Gabriel Scally.

Gabriel Scally
Gabriel Scally, public health doctor and current president of the epidemiology and public health section of the Royal Society of medicine.

David King
And Christina. Christina, you’re on mute…. Kamlesh, welcome. Could you introduce yourself and give us your affiliation?

Kamlesh Khunti
Kamlesh Knunti, Professor of primary care diabetes and vascular medicine at University of Leicester.

David King
I think we’ve almost done it. We’ve lost Christina Pagel and she is the mathematician and Professor of operational research at UCL. I’m hoping that she’ll come on shortly. So, I think the object of the exercise is that we are going to discuss the pandemic, from where we are today. Out forward to the point where effectively we’ve got rid of the virus in the UK and have lifted the lockdown. So, we’re not doing a re-analysis of where we’ve got to so far, except insofar as it impacts on how we get out of it. We’re certainly not here to analyse the decisions that were made. As we move forward out of the pandemic, of course, the first thing is going to be to look at the business of getting out of the lockdown. And that is the first item on the agenda. And as I look at the group of experts I have here I’m going to ask you to raise a hand when you want to come in. But I will also call on experts who I think should comment and I think Karl Friston, maybe you would like to come in on this one first.

Karl Friston
Thank you. So I’m coming at this from the perspective of modelling. And I think by and large, the modelling just endorses common sense, or at least consensus that we see in the media. One thing, though, that it does bring to the table is a quantitative sense of what might happen and the mechanics and the different processes involved. And the thing that I’ve taken from what I’ve read and indeed our own modelling, is a distinction between the short term the long term and I think this speaks to a distinction that I know Anthony wants to speak to, which is the difference between strategies of the sword exemplified by WHO, and what I would phrase as more policies currently being considered by Her Majesty’s Government. And the difference, I think, is important in relation to the short and the long term, exactly as framing the problem. So from the point of view of the modelling, there seems to be two different kinds of second waves. The first wave could be better thought of as a flare up or a rebound. That is an integral part of the current outbreak that we’re witnessing. And then there’s a longer term in say several months potential for a classic second wave of the sort we saw in 1918, Spanish flu, and the mechanisms seem very, very different. So the, the first, the rebound, the flare up that could confront us within the next few weeks seems to be very sensitive to social distancing and lockdown policies. Whereas the mechanism behind the second wave proper, in the autumn, seems to be much more related to the loss of immunity. And in turn, that will depend very much more on strategic approaches to suppression, that in turn depend upon tracing and tracking and other strategic tools that we have at hand. So, from my perspective, if one wanted to model the consequences of any moves that we make, it will be very useful to partition, or separate considerations of current policies in relation to lockdown and social distancing our behaviour as it gets into the game and influences the epidemiology at hand and the longer term strategic responses that rest upon the suppression and potential elimination to a certain extent of the virus. So, practically, what I would like to hear more about is if there is an explicit distinction between policies that can be articulated in quantitative terms, say for example, we will move from an amber to a red form of social distancing, when the estimated prevalence of infection in the population is 3%. So hard, crisp, clear operational policies that we can all witness and indeed, possibly even broadcast after the weather forecast on the news every night so that, as a community, we know exactly quantitatively where we’re going, how those policies are being enacted. If that were possible, that would be extremely useful from a modelling point of view because we can then make forecasts again, very much like a weather forecast. Yeah. forecasting 5-10 days into the future, preparing like we will do for floods or adverse weather events. So we know what’s coming. And we all know why the government is doing that. So that’s a discussion, I think about policies. I think the lots of concrete and simple things that one can offer, and to articulate those policies that are predicated on the modelling. And then the other discussion, I think, is about strategy, you know, to what extent is it going to be necessary to testing and tracking? And how will that leverage the opportunity, the window of opportunity that we have over the forthcoming months, where there are sufficiently low numbers of cases out there for pacing and tracking to actually work and to defer or indeed even actually eliminate the second wave under the assumption that a vaccine comes online within 12 to 18 months. So from my point of view, those are some of the pragmatic issues at hand and I repeat, it’s somewhat sort of technical point of view, in the sense that knowing what is going to happen, having well defined policies is incredibly useful for the modelling, which in turn is incredibly useful for sharing with people and resolving their uncertainty or at least quantifying their uncertainty about what might happen to us, you know, over the next two days or weeks.

David King
Well, thank you very much, Carl. That’s a great introduction. I think the question of testing and tracking is something we should come back to in a moment and discuss in more detail perhaps the other points you raise a very important I think, in particular, the one about broadcasting the state of play with the weather perhaps every evening. I think these are critically important parts of bringing a pandemic under control, and being open and honest with the public as you do this, so that you’re taking them along with you and you’re getting that trust. I think the division as well, we need to bear in mind between the short and long term that you’ve raised. And of course, most of us are aware of the fact that as we move towards lockdown at every stage, we want to see that the R0 for this epidemic is kept well below one. Otherwise, we’re going to prolong the outbreak. One of the factors I think we need to take into account is, I believe this group should be showing how we could emerge as quickly as possible from this virus, and how we can also manage to keep the death rate down. Right. These to me are the two priorities. And neither of those priorities clashes with the economic requirement, because the sooner we’re out of this, the sooner we can get economic recovery underway. So could Anthony would you like to actually comment on the size of the business of ending the lockdown?

Anthony Costello
Well, can I just ask Karl a question first? Because clearly, there are a number of things that get quite confused. So the first is in this first phase of the epidemic, how many people have been effectively susceptible or exposed and I know you’ve done some modelling on that. And then of course, we want to know what percentage have probably been infected. And then of those that are infected, we obviously want to know how many of them have become immune and for how long, which you probably can’t answer. And then of course, we want to know what percentage of those that have been infected have actually died. And I’ve got some figures that I could show just the latest from Johns Hopkins actually about cases and deaths in the UK but I wondered if you want to just answer because I know your model came up with a figure of the effective susceptible population.

Karl Friston
Yeah. And that’s an excellent question and also speaks to the framing of what we’re going to do in terms of minimising deaths, by coming out of lockdown as quickly and as gracefully as possible. So intuitively, one can frame the immediate issue as how would a firemen respond to a fire. And there are two sort of scenarios one can consider: you think you put the fire out and the firemen go home. And yet there are little embers that will flare up again if they leave prematurely. So this would be the flare up analogy. That’s one way of looking at it. In fact, the maths doesn’t quite look like that. It looks as if we’ve actually witnessed a firework or an explosion and all that can be burned has been burned in the sense that if the potential for a flare up is there, then it would require a certain proportion of the population to be susceptible and to be able to be infected. So it crucially depends that sort of divide between are we dealing with a fire that has been partially put out and we have to keep on returning, quashing the embers to prevent a second flare up? Or have we actually witnessed what has happened and now we have entered this window of opportunity where the explosion has happened? And there’s going to be now a replenishing of combustible material as we lose immunity. So that in say, 5, 6, 12 months time depending upon the rate at which we lose immunity, there is sufficient stuff for the latent virus or the the latent embers to reignite again in several months.

Allyson Pollock
Explain why you think we’re going to lose immunity and where that data comes from. Could you explain the evidence base for losing immunity? Why wouldn’t completely have residual immunity and also some of the papers and data where that comes from?

Karl Friston
Right. So my reading of this is that there is no evidence at the present time, and of course, almost self evident. We have to wait to see what happens. So I think one can say definitively, that should be a prime focus of the strategy. So, but just to sort of back up a little bit and, you know, coming back to Anthony’s question, and the key question is, so there are two key issues: how much immunity has already been inherited from the first wave that we’ve established? And we don’t know that and we really do need to know that or, you know, to put it sort of more practically, I would need to know those numbers in order to answer Anthony’s question and to address David’s question. And so that’s what we need to know, which puts real pressure on the antibody testing, the serological testing, and much less pressure on identifying those people who have been currently infected using safe vehicle swabs. So that’s, yeah, that seems to be very, very important that, you know, if there are now coming online antibody tests that have high specificity and sensitivity, we really need to get the data from those. To answer the first question, how much immunity have we inherited? And then the next question, which is implicit in answering this question was what proportion of the population are players? How relevant are they? So we talked about susceptible people, which implies there are non susceptible people. So we need to know how many people proportion of the population have host factors that render them not susceptible. And that means, in turn, that specifies the level of herd immunity, that would preclude any further flare up. So all of these things need to be known now and we don’t know them now. But in principle, if one could get, say 5000 randomly sampled people from the property tested with antibodies, I think we’d have a very, very good handle on that. So everybody, from my perspective is waiting for that.

Allyson Pollock
But there are studies now on serum prevalence and immunity in California and in Iran and other countries, which is also suggesting the infection fatality rate shows much lower than we were thinking. So are those studies being added in that actually, there’s a much higher prevalence of infection than we thought? And that means that there’s a much lower infection, death rate fatality ratio than we thought.

Karl Friston
Yeah, absolutely. These data are very provisional. And if you, I don’t personally, but I have friends in California who follow the Twitter feeds and the debates. So these early data are provisional. They’re the kind of data we need and they are used to showcase your importance. In fact, people’s reaction to these data highlight the importance of just knowing those numbers. If the current data coming out of Santa Clara or indeed New York, there isn’t a good study in New York, we’re waiting for data from studies in Munich. If the trend, these beta pointed to is correct, then, you know, the numbers suggests that there’s much greater herd immunity, and perhaps we should demystify herd immunity, would just mean the number of people who will have had it and are less likely to experience symptoms if they’re exposed again, the next few weeks. How many people have actually had the infection, whether or not they’ve had symptoms? And it looks as though it may be much much greater than you need. Say with 30%, now, if half the population was resistant, so that the effectiveness of the susceptible population size was half of the size of the UK population, then 30% of people who have had it represents herd immunity, which actually precludes any flower. It’s very difficult when you model these things to actually produce a short term second wave or a fluctuation which is a response to a premature relaxing of lockdown. That’s why I suspect most people are hoping the data will point but these data needs to be much more definitive.

David King
I have a group of people who want to come in. I’m taking them in order. Alison, and then Kamlesh then Martin.

Alison Pittard
I just wanted to put the lockdown into the clinical perspective because the main reason for the government implementing the lockdown was to protect the NHS and particularly critical care which is my area of expertise. And I think whatever anyone’s views are the lockdown has worked extremely well in terms of allowing the NHS to cope. One of the ways or in fact, the only way that critical care has been able to manage the big surge in patience is by expanding our capacity and by staff working above and beyond and other non critical care staff helping us. And one of the concerns that we have now going forward is yes, we’ve got to work out how we start to move back into a more sustainable way of working with the NHS is that staff health and well being and resilience is absolutely vital. And whatever we model and whether we’re talking about an explosion or a fan, I really like that analogy, and there’s also always going to be a backlash in terms of the numbers in hospital and you know, needing contact with (inaudible) in critical care. And so we’ve got to bear them, they can’t sustain the current level of activity indefinitely. And we need to make sure that the modelling takes the staff into account so that we can make sure that we can continue to treat patients going forward both COVID patients (inaudible) we’re going to have dual streams so that we can make sure that both patients and staff are protected.

David King
Can I just come in with Alison and before we move on? I think you’ve raised a very, very important point. In other countries such as Greece, they turned this on its head and they said, what do we need to manage to keep this pandemic under control? And the conclusion was massive increase in staffing in the care systems in hospitals, doctors and nurses and so on, increasing the capacity so that we can deliver optimal control. So, there are two ways of looking at this. One is to say what have we got? And the other is to say, what do we need? This is an enormous crisis. What do we need seems to be a better way of looking at this.

Alison Pittard
In terms of critical care that the problem is without stf, we don’t have critical care. And doctors, nurses and all the allied health professions that make up the critical care service are highly trained and specialised. So we can’t just create them overnight. And I was absolutely delighted when the government said. So the government has given us an extra hundred training posts this year. So we will now be able to have 249 trainee intensive care medicine doctors joining us, who will be able to support us but we’re not getting any more nurses. And so we already start off in England with a very low number of critical care beds per hundred thousand population as compared to the rest of Europe. So we’re not starting from a good point. We can’t turn that around overnight. But a commitment to reviewing critical care services in the longer term would certainly help to answer the question of what you know what have we got and what can we do to make this sustainable?

David King
Thank you. I’m going to turn now to Kamlesh.

Kamlesh Khunti
Thanks so much. It was just a question. Karl? I was really surprised when you mentioned that the immunity may be limited just like Allyson Pollock. I haven’t heard of that at all. Secondly, from some of the modelling I’ve looked at, I was under the impression that about 50% of the UK population may already have been affected. And from my limited knowledge, again about herd immunity, I thought that it was quite important that we need to get to around 80% before we get to a reasonably safe level.

Karl Friston
Yes, I mean, I didn’t appreciate that 50% was the consensus. 50% of people have already been affected. If that’s the case that’s exceedingly optimistic. So 80% of the susceptible population would guarantee that any flare was precluded. If you run the numbers on the current data under certain models, then it would not be surprising that say 30% or 20% of the population was actually resistant, you know, a trivial but probably false example here would be, say children who had a (inaudible), and therefore, they’re not in the game. So, there are going to be people are not part of the susceptible or the affected population size, which brings up 60% down to something like 50% so I can certainly model a scenario where if we are at 50%, and indeed that is actually very, very close to what the simple models would predict at this stage, then it would be extremely difficult to actually have a flare up under the assumption that we have these operationalized social distancing policies. I think that’s relevant for the previous point as well, because the mechanism, from the maths point of view of all of this social distancing, is just to slow things down, so that one can prepare more appropriately, and to take the pressure off of the healthcare services that we’ve just heard about. So I think the analogy here would be like a flood. If you remember the floods around Christmas, there is nothing that can be done in terms of holding back the water. But what one can do is moderate nuance and control the rate in which those waters transcend from the clouds to the sea, and the damage they do on route. I think that’s the game that we are in. But just to conclude, if 50% is the number that’s very encouraging.

David King
So let me just interrupt the proceedings by saying several of you clearly have an urgent thing to raise which is very relevant to this discussion. Others may have other points to raise. I’m just wondering, if you just put one finger up, maybe it’s not so urgent. If you put your hand up, it’s more urgent. So Martin, you have your hand up. I’ve got Martin, Deenan and Christina, in that order. And I think Antony wants to come in as well.

Martin McKee
I really don’t think we have any idea how many people have been infected. The Santa Clara study was mentioned earlier. But there are really very significant problems with that study. And some people have argued that it shouldn’t actually have been published, given the difficulties with it. And even if it was, it doesn’t tell us anything about what’s happening here. I think 50% is extremely optimistic. The figures I’ve seen from New York talk about 25% where the epidemic has been much more intensive. So I think what this highlights is that we’ve been focusing very much on a number of tests to be done without being clear about what we’re trying to find out, and it is unfortunate that we’ve got to this position. Work is being done, for example, the 250,000 people that have been sampled the work that (inaudible) is doing and so on, which will give us the information we need, but I still think we’re flying very much in the dark in all of this.

David King
Okay, can I just run through the people whose hands are waving? I’m getting to Deenan. Are you on this point?

Deenan Pillay
Yeah, just a couple of very brief things. First of all, I do want to warn against using terms that can quickly become used outside of scientific circles and just look at how herd immunity was misinterpreted and so on. So, terms such as resistance and so forth, are biological terms which may or may not actually translate into, into what we see. So I do want to just urge caution there. And of course, what we’ve already said is there’s a large amount of unknown. And I think just talking, carrying on talking about different studies that are showing different levels of zero prevalence in populations. You know, we could talk forever about that. But in reality, my sense is that the overriding amount of data, whatever the caveats of antibody tests that are being done around the world, is a relatively small proportion of individuals that have been exposed to the virus. That’s my general feeling. But I mean, you know, we could just talk forever about that. The second thing that I just want to raise pertaining to modelling and so on that Karl talked about right at the beginning, that we need to be careful about is thinking about a vaccine. And of course, it is the mantra here that we need to somehow survive until a vaccine becomes available. But of course, Not only is there an uncertainty around that, but even when a vaccine becomes available, that vaccine does not infer 100% protection in everyone that is given it, like there’s all the variables such as the duration of prevention, the uptake, and so forth. So I would like to also suggest that when we’re talking about how the future looks and guiding that, scientifically, we actually thinking for a long term pandemic, with ups and downs and endemic infection that will come up and down for maybe years to come with perhaps interventions such as maybe vaccines, maybe partially uptaken, and so forth. But I do think we should frame things in that context, when we’re thinking about during this call and future meetings, thinking about the future strategy. Thank you.

David King
Christina, you’ve been very patient.

Christina Pagel
Just to say that the 50% figure comes from the Oxford modelling study, which I don’t think is consensus. Where they’ve done testing around the world, it’s somewhere between 5 and 20%. I think 20% is your figure. And if we’re thinking about advising the future, and looking back at the recent surge here that we’ve had, I think we do need to plan for a reasonable worst case. So it’s not kind of hoping that it’s 50% but planning for what if it’s not. What if it’s 50%? What if it’s 10% even? And how do we plan for that?

David King
Okay. Anthony?

Anthony Costello
(showing images of graphs) I mean, rather than herd immunity, death is a slightly more measurable outcome. And this is the latest today from Johns Hopkins just showing the step where we added in the community deaths about a week ago, but of course, showing we’re up towards 30,000. But the Financial Times have estimated the numbers of deaths still not counted from ONS, the Office of National Statistics data, which would push us up to about 48,000 deaths. So although we have done well, in terms of the NHS managing the surge, I don’t think we would say we’ve done well in comparison to other countries in terms of managing this first stage of the epidemic. The second one is this. This is the case, new cases each day. Now of course, this is difficult to interpret because we’re testing more, and therefore it could be that it is coming down. But at the moment, we’re around about 5000 cases. And the question is, if we’re going to lift the lockdown, at what level of cases would it be safe, in addition to the R0 number that we could lift the lockdown safely, or are we just going to see this comeback fairly rapidly if there isn’t that much herd immunity. But the other one I wanted to show you is this. So this is just a slide about the mindset really in it. There are two ways that we can really think and it comes back to Karl’s point about shorter longer term. And to Deenan’s point about this virus having many different effects and we have to be careful about the language we use. So on the right is the UK approach and the five principles so the NHS must be able to cope, we should see a sustained and consistent fall in daily death rates. We need manageable levels of infection, have enough tests and PPE and try and ensure we don’t have a second peak. It still feels to me like a managed spread option that this is a pandemic, we can’t stop it. We have to let it spread through our population but in a managed way. And then on the left, I’ve got the WHO principles which read to me very differently. And it’s it. So the first is to mention the public health falls, not the it’s all about how we can organise our public health services, particularly to train deploy them to prevent and that is, of course, our primary care people like our general practices and we have a great system in the UK, and also how our local authority public health teams can get engaged in this rather than a sort of, centralised managed thing from, say, Public Health England. The second is how you’ve got to find every case. I mean, WHO set this daily for the past two months that you know, you really got to go after every case. And for that you need testing capacity and also availability. So people in communities can get access to a test rather than drive for two hours to some, you know, airport and that you need a very good isolation policy and a clear plan to quarantine the sick people, the moderately sick, so they’re not passing it on. And also the contacts so you know, where you’re going to put the contacts and for how long for is it 14 days? Or is it seven days said? So we need that. But the final thing is really important. Are we refocusing the whole of government on suppression or are we managing the spread and I’m still not clear exactly what the UK policy is, because it was very clearly managing the spread on March the 12th. When we had you know, the ‘we must all get it and get herd immunity’ and ‘let it spread through the population’, the herd immunity idea. Are we considering coming back to a suppression policy? And how far can we go with that? It seems like Matt Hancock, Jeremy Hunt, and others are really pushing that. And I’m just not quite clear where the UK Government sits between these two.

David King
I think that’s a very fair question if we decide to put questions to the government to ask them. I think I saw first of all Zubaida and secondly, Gerald, coming in.

Zubaida Haque
I’ve got a slightly different question going back to the number of deaths in relation to COVID-19. And I think I’m a bit more concerned about how we’re measuring things because we’ve been talking entirely about just measuring deaths in relation to COVID-19 and critical illnesses in relation to COVID-19. But I’ve got two questions which may or may not be directly relevant. One is this: how much higher is the mortality that is unrelated to COVID-19? This year compared to last year? And I’m asking that because we’re just measuring COVID-19 deaths. I want to be sure that there aren’t other deaths happening because of the disproportionate focus on COVID-19. That’s my first question. And my second question, I suppose is related, which is we’re saying and I mean, it’s right, to some extent that the NHS is coping very well. And that was the intention to a great extent, but is it just coping very well right now because we’ve postponed all the cancer treatments because we’ve postponed all the other urgent care, the surgeries and can that be sustained in three months time? And in six months time? Given that this pandemic is not going to disappear in those months.

David King
Thank you very much. And I move to Gabriel.

Gabriel Scally
I just wanted to come back to the criteria for lifting lockdown, which was your question to us today. And I was very struck by the difference between the six criteria as outlined by the director general WHO on the 13th of April, and the five tests that were outlined by the government, UK government on the 17th of April. And there are quite significant differences between the two of them, some of which we’re going to go on to discuss other items on the agenda. But I do think a useful thing to do would be to try and look at potential harmonisation of those sets of criteria so that we have a practical guide that people can understand and they know exactly what sort of things we should be aiming for before lifting the restrictions or as the restrictions are gradually lifted, because I do think they are not necessarily oppositional. But do you think they could potentially be very complementary to each other if they were melded together? Thank you.

David King
Thank you. I’ve been asked by the producer to tell you actually there is feedback occurring. So it is important, it turns out to put yourselves on mute if you’re not talking. I I’ve got Christina, who is on mute, if Christina could come in,

Christina Pagel
Um just to silence to carry on from what he was saying about the importance of patients who don’t have COVID, and the NHS has coped through large by just stopping most of its other activity and I think when we come out of lockdown and having reduced the burden of COVID on the NHS, one of the key things is going to be how do we now move back to normal practice? We can’t suspend that for a year. And a lot of the people who most need the NHS are also those who are most vulnerable to COVID. So can we do some modelling? Can we think about how we provision and maybe some hospitals only treat COVID patients and some the hospitals can treat other people, but that is a really key thing that we have to deal with right now.

David King
Thank you. I’ve got Kamlesh.

Kamlesh Khunti
Thanks very much. So we are already seeing excess deaths. We saw some (inaudible) a few weeks ago from the UK data today. So some data from Wales showed that there was a 30% increase in access deaths compared to comparative data from previous years adjusting for the time periods. There’s also data from that’s just been published last week in Italy showing that there’s a number of people come into hospital with heart attacks was reduced by 30%. Now what’s happening, people don’t stop having heart attacks during a pandemic. So it must be that the mortality is possibly occurring at home because they’re not accessing the services. We also need to look at what happens after we’re out of this, because there’s been good data that’s shown that after natural disasters, you get much more increased mortality further down the line because everything stopped as you’ve just mentioned. So we are not running services as we would normally, we’re not doing blood tests, we’re not reviewing patients. And people in particular with chronic diseases such as diabetes, heart disease, cardiovascular disease, first of all, they’re not having regular monitoring. Then, secondly, they also have increased anxiety levels that does put them at risk. The amount of adherence to medications goes down and up with some of this stuff. I think we really need to ensure that we are still supporting our patients at this time. And we continue supporting them even more aggressively when they’re out of this.

David King
So can I just come back to Kamlesh? This is once again the point that I was making before. So does that mean that there needs to be further investment in staff, in capabilities to manage a pandemic situation alongside keeping all those operations going?

Kamlesh Khunti
Absolutely. I think, from what we’ve seen, the pandemic situation in terms of hospital services have been inundated, but they’ve done very well compared to many of the other countries. When we’re out of this, mainly it’s going to be primary care that’s going to be hit because that’s where 95% of the populations are looked after, in terms of chronic diseases. And this is where we will need more staff, not just the general practitioners, but we know that people like nurses, pharmacists, they can all help in terms of risk factor reduction for all those patients with chronic diseases. There’s also an issue about depression, anxiety levels that are going up within our patients. And again, services will need to be met for those as well.

David King
Alison?

Alison Pittard
I’m going to let Susan come in because she’s been desperate to come in.

Susan Michie
I haven’t been desperate to come in, but I have been trying to get in for a while.

David King
Sorry, Susan.

Susan Michie
First of all, I’m very pleased that you’ve included a social and behavioural scientist in this group. And sorry, I have to leave just before one. I wanted to raise the issue of adherence by the population to government guidance. And this is relevant both for modelling and I don’t know what assumptions have been made in the modelling, but also by thinking about policy options, and I think people were very surprised at how adherent the British population have been to government guidance so far. And I think a lot of that has been down to the collective solidarity that has been built up as people have been rising to the challenges, which for some people in some living conditions has been extremely challenging indeed, And going forward in terms of lifting the lockdown, it’s going to be a very different situation, because in the lockdown, similar measures were being carried out across the whole population by large, but what we’re going to be seeing is different measures for different sections of the population. And so this has the potential for undermining the collective solidarity that’s been so important for the trust for adherence for helping each other and if it’s not handled well, risks potential division between groups. Risks, perceived inequality and injustice and unfairness, which can lead to resentment and anger and people getting alienated from the collective and from what’s being asked of them. So I think, really a lot of thought has to be given to how this is going to be managed and managed in such a way that all sections of the population are being looked after and their needs are being met. And because in the lockdown, as we know, the measures meant that those who already disadvantaged were even more disadvantaged. So already an unequal society has become more unequal. And this has potential to be even greater, along many different lines of disadvantage in the society. So, I’m raising this and not just in relation to maximising the rate at which we can stop transmission and drive the pandemic out, but also in the context of what kind of society will we be left with as we come out of the pandemic.

David King
I’ve got Alison Pittard breaking to come in. But just if I could come back to you, Susan, what would the key recommendations be? To manage what you’ve just said? I think we’re all concerned about it. Can you just help us to put in some recommendations there?

Susan Michie
I think one will be ensuring financial security for everybody when there’s very differential access to going back to incomes and kinds of financial loss. And although a lot of measures have been put in place, there’s still many millions in financial insecurity. And for example, if we’re expecting people to isolate in terms of the contact tracing. Those people need to have financial security. So there’s a material basis. There’s also an issue about messaging. And different groups of people will need to be thought about very differently in terms of the kinds of messages that will help to mobilise and really commitment to keeping going and adhering to what will continue to be difficult issues. And I think the third thing is about paying more attention to the community. Communities have been very impressive the way they’ve come together is incredible. Examples of people helping each other and strengthening communities, but this needs to be kept going and communities need to be mobilised even more intensely for the longer term. And if the cohesiveness is to be retained, so I’d say three things. One is the material basis of ensuring that people’s needs are being met. Secondly, much more nuanced messaging, for example, about the over rather than under 70 year olds, and thirdly, much more bottom up community orientated strategy, which requires rebuilding quite a bit of the infrastructure that has been lost over the last 10 years.

David King
That’s very helpful. Thank you, Susan. Allison Pittard, and then I’m going to Zubaida.

Alison Pittard
So, I just wanted to come back on what Kamlesh was saying: two things. Yes, we will need well, Ideally, we’d have more staff and certainly within as I said before critical care. One of the ways that we have managed is by our critical care teams being supported by non critical care staff, because they’ve not been doing their normal routine work that’s been put on hold during the pandemic, but as they move back to try and get business back to usual or set some semblance of normality, that support is going to reduce. So I think we need to look at what we can deliver the available model rather than put services under pressure. But one of one of the things that we could do is look at more efficient models delivering samples. And one example of that is the the faculty is about to publish some guidance on a different model of care looking at the gap between Ward and critical care because we know some patients who don’t need critical care have to go there because they can’t be managed on a ward either because they’re that little bit sicker than the ward can can deal with all they need more interventions. And so by moving stuff around and creating services to look after these people, it frees up capacity. The other thing that we could do to free up capacity in secondary care or in acute hospital settings, is to look at what happens to patients when they’ve been critically ill. And this is COVID and non COVID patients. It can take 12 to 18 months to get over being critically ill irrespective of what brings you into hospital. And that’s not only physical, but that’s psychological problems as well. And many patients will stay in secondary care longer than is required, because they don’t have adequate support outside in primary care. And that’s from physiotherapy, that psychological support over the whole rehabilitation and life after critical illness. And again, that’s a workstream that the faculty had already started on in July and we’re going to publish a provisional statement.

Alison Pittard
Okay. So perhaps, if we’re going to look at investing in anywhere, investing in new models or new services utilising stuff that we already have, because then this thing lies much more quickly and actually has an impact and, you know, more quickly than trying to develop more new stuff.

David King
Thank you, Zubaida? And you Allyson Pollock after this.

Zubaida Haque
Thank you for that, Alison. I think I really want to echo what Susan has been saying about how during COVID-19 and after COVID- 19 we have to pay much more attention to how COVID-19 has bought into sharp relief, the racial inequalities as well as the socio economic inequalities that have existed. And they have bought them into sharp relief and to some extent, talk to a great extent, arguably, they might explain some of the disproportionate COVID-19 critical illness figures as well as death among ethnic minority groups. But I want to particularly bring in that point that Susan raised about in terms of recommendations, what the government needs to be thinking about, as Susan’s absolutely right, the government has focused and to a great extent, you know, understandably, on employees as well as self employed, but there is a vast number of people within the labour market that fall in between those areas. We’ve already got some anecdotal data at Runnymede trust from surveys, that ethnic minorities have been disproportionately economically hit by COVID-19. Now the other aspect of ethnic minorities is while they’re a heterogeneous group, generally speaking, they are at the lower end of the poverty spectrum. They’re much more likely to be poor and much more likely to be in insecure jobs, in precarious jobs, and they’re much more likely to live in poor condition and overcrowded housing. Now, what that means right now is if those people are at the brink of poverty or have lost jobs, do they have a sufficient safety net? At the moment an economic safety net, and the anecdotal evidence at the moment is they haven’t that the government hasn’t really considered them. We also know at Runnymede trust having worked with the women’s budget group, we’ve worked with JC BWI, the joint Council for welfare of immigrants and so on. That there are immigrant groups, migrant groups, that there are women’s groups, and then there are ethnic minorities who are not able to access Universal Credit, either because there’s no recourse to public funds, or that they are able to access Universal Credit, but because of the way Universal Credit benefits are at the moment, because of the benefit caps, because of the five week wait to access benefits, because of the two child policy limit, which means that bigger families, which are disproportionately among ethnic minority families, they can’t get enough money. And so, what this means in terms of COVID-19 is the question for those people. Are they being forced into work? Are they having to go against social distancing policies? Because for them, it means that they know it for them. It’s a choice of not having enough food or to put food on the table or not.

David King
Thank you very much. I think I’ve got Allyson Pollock now.

Allyson Pollock
Thank you, just to build on what Susan and Zabaida were saying, Philip Halston, the US UN Special Rapporteur on extreme poverty, and more recently, Michael Marmot has drawn attention to the extraordinary and growing and widening inequalities and poverty that are going on. And the fact that we’re approaching 40% of our children living below the poverty line. So children in particular, have been badly affected as well in this lockdown, like right to education. School is much more just than about education. So in a way, colour does shine a spotlight on these growing and widening inequalities and much of the discourses neglected. As You and Susan rightly say, the most vulnerable in society, we’re all vulnerable, but they’re really truly vulnerable in society. And I think we should be picking this up. And, you know, referencing Michael Marmot and Philip Halston, because unless we tackle this with a systematic plan, we’re not going to get very far. And we’ll just see what could happen as after 2008 is a continuing widening of the inequalities and poverty because of austerity. And that leads me really into two points that I want to make with reference to the previous conversation. One is we know that COVID and the lockdown has had great collateral damage, particularly on older people, vulnerable groups, children with learning difficulties and people with disabilities. And we see the tip of the iceberg in the excess deaths. I do think it’s a great pity that the government uses the daily death toll, you know the death counts and the testing counts as a propaganda tool, because these data are unreliable when they’re reported daily, they’re inaccurate and they’re under reporting all the other excess deaths. And really, they should have the official statisticians, the Office of National Statistics do a great job, very rigorous, and they should be reporting once a week, or once a fortnight, we don’t need this daily death toll. It’s being used as a propaganda tool, and the testing data are inaccurate and incoherent. So I just want to make this point for the public that it’s really important that we understand where the official statistics are, where they’re gathered, and how they can be misused by the government. But the second point, I think, relates to the whole issue, again, around the excess deaths is what are the collateral damage of COVID and in the NHS, we know we were told we were to protect the NHS. Well, all of my life. I’ve been told the NHS was there to protect me. So this is an extraordinary position to put me into. I’ve got to protect the NHS and I got to stay at home to protect and save lives. And of course, the reason why we’re in this position is because for 30 years, we’ve had a decimation of public services, and especially the NHS, with marketization, privatisation, Foundation Trust that can now generate up to half their income from private patients, and a whole diversion of money through the private finance initiative and the contracting and commissioning. And yet the government has been able to stop contracting and commissioning, just like that when it wanted to, because it could see it was inefficient. So really, the government needs to revisit its public sector policies and we focused a lot on hospitals and (inaudible) which is right. But we need to focus on all the other parts, the bits that have stopped the community mental health services, the community health services, and above all the 400,000 people who are in nursing homes have been completely left outside of the system. And this is an opportunity for a really radical relook at why public service as a matter, we the government should be putting his hand up and saying why it’s got it wrong, where it’s got it wrong, and why we need to rebuild it and not continue the policy of privatising and contracting out. And that will also mean that we’ve got to look at an employment strategy and an industrial strategy and think about how we’re going to redeploy staff who are furloughed and unemployed, and really build up the sectors that need it. Many of the deaths in the nursing homes were preventable and avoidable. And people dying alone without relatives is inhumane and barbaric. But not only that, we could have put in many more staffing if the government had decided to requisition those homes early. It could have doubled the nursing staff and tripled them and it could have redeployed staff from quiet bits of the NHS. So, what I’m saying is that really, the other part of the system that we will be coming to is the whole carving out and loss of the local community, which is what Susan’s been talking about. Local Government is really reduced to a bin service and a contract enhanced service. Local government needs to be empowered and enhanced. So it can take on the public health roles, the educational roles, the things that have been decimated and destroyed with billions of pounds worth of cuts over the last 10-20 years. And we really need to rebuild that, if we are serious about the community and community involvement, we need to rebuild that capacity that includes the public health capacity for contact tracing, and I’m really worried that the government’s solution now is centralising and privatising with the news that (inaudible) is going to run the contact tracing centres with the news that we bought the lights running testing cert services. This is extremely worrying. The government needs to wake up and realise the value and the importance of public services and public ownership and public control. I’m sorry, I’m going on about this, but we are in this position. The lockdown has been necessitated, because we actually decimated our public services. So we limited our options and choices, which is why we are where we are now.

David King
Thank you, Alison. Oh, we’ve now lost one of our people. I was going to turn to her and ask her if she had comments before she had to go. So I’m going to go back in order of the hands that I saw going up. Next is, Gosh, so you’ve all moved now on my screen. It’s very confusing. I was getting used to where I could find you, was Gabriel.

Gabriel Scally
Hi. Yes, thank you. So just one point about the data. Alison made a good point about data here. And I’m sure, like many people, I find some of the data and the publicly quoted data quite confusing at times. And what is interesting is the variation around the UK as well. I’ve been looking particularly at the Northern Ireland data, and there were some talks about the excess mortality issue earlier. And I think that’s an extremely important issue. And one of the key sets of statistics, for example, in the last week’s data that was made available in Northern Ireland, comparing that particular week, which was the week I think, to the 24th of April, that the mortality had increased by 65% over the average of the previous five years, and only a portion of those were actually deaths registered with COVID. And an even smaller proportion of those were the deaths as declared by the Department of Health. So there is a real issue, I think about the data. And I think some recommendations about the data set would be very, very useful. And particularly taking into account the disparity that there is in data sets between the countries of the European community and the UK. In terms of what is included in data. I don’t think these are satisfactory. And I do know that the UK statistics authority applied last week to write extremely strong terms to the Department of Health in Northern Ireland, about their performance and statistics, although some of the other agencies in Northland have done well. But I was wondering, so David, we’ve had a most useful discussion for just over an hour now. And given the time we have left I was wondering, would you think about moving on to some of the other issues which you’d given us in our draft agenda?

David King
Certainly, I’m happy to move on. I’m just going to ask the remaining to Martin and Deenan and if you could be reasonably quick.

Martin McKee
Well, I may have personal views on many of the issues that Allison raised. But I think it’s really important to remember, we are a scientific advisory group. And we have a problem. Now, there are many things that are wrong with society that we obviously will need to look out in the future. And you know, my own work, certainly, shone a light on the impact of austerity. So you know, I take the points, I accept many of those points, but we now need to actually see what we do now to get out of this. And we’ve already said we’ve got a lot of problems with the data. I would strongly recommend that we look at age standardised excess mortality from all causes at the minute because it’s the one thing that we can be certain about. And when we look at the European comparative data which we can get from the Europeans database, we see that England is like 40 standard deviations away from where it would normally be is much, much higher relatively than any other country in Europe that is reported there, they don’t actually report the data from from every country. I think we also need to keep an eye on this, we need to have the measures that we have adopted to keep the R0 lower than one, because the exponential nature of the spread means that it would just go even a tiny bit above that, then the epidemic gets out of control. And that means that we do need to have the lockdown, we need to have the restrictions in place. No, of course, as Susan has said, and as Zabaida has said, we also need to accompany that with measures that will mitigate the impact on vulnerable groups. And we need to recognise that the burden falls disproportionately on some than others. We have data from New York, for example, showing that people in more affluent areas are much more likely to be able to work from home than there was in poorer areas. But I think we need to focus on what we can actually do now, which to my mind has to start off with getting much, much better data. Because at the minute, we have problems with data on mortality, problems with data on serial prevalence, problems on data with the incidence of the cases and so on. And, you know, we’re quite a long way and nice to still be having all these questions where we’re discussing, what is the zero prevalence in the community?

David King
I think we’ve now touched on a very important recommendation, which is raising the quality and level of the data. But I think it would be useful if perhaps several of you could get together and produce a short paper on that just as advice to go through. I’ve got Deenan next.

Deenan Pillay
And yeah, thank you, David. Briefly before I get to my main point, I couldn’t agree more with what Martin and others have said with regard to the paucity and inadequacy of the current data. Having said that, we are only three to four months from the discovery of this virus. And for most infections, it takes many, many years of many different sorts of studies and follow up studies and laboratory studies and clinical studies and ethnological studies to understand the dynamic. So, you know, I think we need to push for that, but I’m aware of a number of studies ongoing. What I wanted to do was to actually help by taking taking the discussion into, you know, what would be a strategy, a next strategy for as we come out of lockdown, and of course, a number of you have talked about a whole range of things such as community based sustainability, the ability to deal with local inequalities. And I think there’s three characteristics it seems to have in the next stage. One is of course, there needs to be a sustainability of our response in terms of the testing and tracking and contact tracing, as I said earlier, this may go on year after year. This is not just an urgency for the now. And the second is, is just focusing on diagnostics. And as a biologist, I’ve spent a fair bit of time thinking about and discussing diagnostics, and remembering that whatever one makes of the various figures that are bandied around about number of tests, which of course to many of us is a meaningless total. But we are now depending on these big lighthouse laboratories around the UK, and testing facilities, and of course, those facilities are staffed with those who have stopped working in laboratories elsewhere and so forth. And machines have made it to labs from other universities and so on. And as we come out of this, you know, I’m very unclear about the sustainability of that. And therefore, there has to be the development of a local based primary care, social care, locality based approach to this whole process of being able to continue to monitor infections to to understand and to support quarantines where it’s necessary and to deal with some of those inequalities that we’ve talked about. And it is worrying to continually hear about the outsourcing of different functions, because I do know that when cabinet ministers and others responsible for different areas are talking about their area, whether it’s testing or this, often they’ll say, Well, I can only talk about one thing, it’s someone else’s responsibility to talk about something else. And in fact, it is that integrated system that we may be in a position to start to guide evidence based, but something that really quickly needs to be embedded within our existing structure. And finally, it is just amazing that primary care has been nowhere within the discussion so far yet, of course is central to any sustainable sustainability as well as the way that we work between COVID and non COVID. But nevertheless integrated and impactful diseases complex as spoken about that. Thank you.

David King
Deenan, thank you again, many points to go into our recommendations. I think I just lost track. Who was next? Christina?

Christina Pagel
I just wanted to comment on where we go next from lockdown and I totally do but people have been saying and Martin’s point that we have to keep R0 below one. I think if our baseline number of infections is very low, you probably have one or reasonably close to one if just below it. And we know that lockdown has worked, the latest estimate of R0 was probably around 0.7 now, in other countries it’s come down. The question is more elements of lockdown to keep it low? And this is where I think other countries are starting to come out and can we learn from each other? Understand what are the key components of suppressing it? What can we live with? What’s sustainable? People are now pressing for: Can we do local experiments? How do we come out of lockdown in areas where COVID hasn’t been as prevalent? And the only question for me there is how do you keep people local? So how do you really say, I don’t know let’s say a certain area of England comes out of lockdown earlier, how do you keep people local? How do you stop people travelling between areas, but certainly as different countries are trying different strategies, this is a time for us to learn from each other.

David King
Very good, and I’ve got I think it’s first Anthony and then Zubaida and then Alison P.

Anthony Costello
And just to endorse what several people have said about the importance of the local response, as Kamlesh said, 85% of all care in this country is done in primary care. And over the past two months, almost all reported, has been a total transformation of the way in which primary care is delivered. And I don’t think we’re going to go back to how it was delivered before this, you know, GPS, and public health services have to be delivered in a different way and to do this sustainably we’ve got to focus on that. Most people in this country have registered with a GP, and if you’ve got a local outbreak management team, and health protection teams already in place, they should be the people delivering this, they should be the people involved in all of this. Setting up a separate system is, as Deenan said, completely unsustainable, and gonna lead to tremendous confusion. So I think Public Health England has got to get their forces, the people that they have on the ground linking into primary care as the fundamental strategy for solving how we go forward. And just the second point I’d like to make is there was a blog by Paul Romer, the Nobel Prize winning economist about a month ago, where he showed that you can solve the problem by fine test trace and isolate every case because that’s the most effective form of social distancing. As (inaudible) was said in the past, that that is one part of social distancing. But it’s the most effective because you’re trying to lock down the people that you really want to lock down, which are the people with the infection, or those who are their contacts who may be asymptomatic and also spreading the infection. And of course, the other two sources where our zero is probably not below one, which are hospitals and care homes. So you really need to focus down on what you want to do. And then you start to address in the short term, some of the problems that Zubaida and Alison and Susan were referring to, which are all the the collateral damage, all the people in marginal jobs, who are losing benefits, who are not getting Universal Credit and all the rest, because then we can get things going again. My big fear at the moment is unless, if the herd immunity is right, and Carl is right, we’re not going to have a big second surge, and we’ll be okay. But we don’t know that. And until we really know that, my fear at the moment is that we’re going to lift the lockdown, we’re going to have too many cases around and it will quickly spread into parts of the country that it hasn’t got to yet; the smaller towns and whatever. And then we’ve only got a choice between another national lockdown, a scenario of repeated national lockdowns, which would hit the economy massively, and cause mass unemployment, tip us into not a recession but possibly a depression. So somehow we’ve got to get a sustainable local fine test and treat sick setup that will work to keep it all damped down so that we can then move on. The countries like Korea, Taiwan, Hong Kong, Greece, Denmark, that have locked it down early, are able, it seems to kind of keep a lid on it and then we hope we get a vaccine. But are we in a position where because we’ve let it run like Italy and Spain and the United States, can we put the cap back on can we get it back to a fine test trace, isolate, quarantine and socially distance, so that we can then hopefully have a at least a period of stability in the economy before In fact, (inaudible). And that’s the great dilemma. And I actually don’t know what the answer is there. And obviously we all hope that the herd immunity and the tests are going to show better than expected, but I share some of Deenan’s concerns about that.

David King
If I could just come in. If we’re looking at both national and global situations, how do we emerge from all of this? And this is the last point before we move on to another point. How do we emerge from this both in Britain but also internationally, so that we get back to something like normal international travel etc. And it must surely depend on a detailed and quantitative process of testing and tracing, so that we know as we remove ourselves from this pandemic that there’s no longer any virus anywhere. Now one part of it, maybe if we get immunity widespread. But of course, that is not a point to rely on. I think in some countries where there’s been virtually no controls, and I’m talking, for example, about Brazil, where controls have been rather sporadic. It may be that it will lead to widespread immunity. But that’s certainly not going to be the case everywhere. So those countries like Greece that have operated well and South Korea, become vulnerable if the virus still continues elsewhere. So I think it behoves every country to ramp up testing and tracing so that finally we eliminate the virus completely. We can go to an R0 number that takes us constantly towards zero, but to get to zero, we actually need testing and tracing. Isn’t that as a given?

Anthony Costello
Can we get back to complete elimination? I don’t think people are arguing that you can totally eliminate this virus now. Is that correct? Maybe Deenan would know. I mean, certainly that’s what some of the modelers feeding into SAGE would say that, you know, you it only be eliminated or you have to live with it with a vaccine or whatever. Getting rid of it in a target across a global pandemic is probably impossible, but you can damp it down. Deenan?

Deenan Pillay
Well, if I can, sorry for jumping in, but, I think it’s going to be very difficult in the absence of a vaccine that is taken by the vast majority of the population and is 100% efficacious. In the absence of that, of course, the characteristics of this virus, where maybe just left less than 50% of transmissions may occur before symptoms start, where there’s variability. See where maybe 50% of the population who get the infection, may be asymptomatic or so mildly symptomatic that they wouldn’t notice. In those sorts of circumstances, I think it is going to be very difficult to eliminate the virus from the population.

Allyson Pollock
Can I just add, there was a paper today from the University of Minnesota, which was just doing different scenarios, but it reckoned that the epidemic would probably last in many countries 18 to 24 months. And so then we just need to have different strategies, but they’re not advocating lockdown, but just different ways of dealing with it. So I thought that’s an interesting paper and I don’t know whether anybody else has seen that one from the University of Minnesota.

David King
Any Comments? I’ve got Gabriel and Zubaida.

Gabriel Scally
There’s one item I wanted to raise, please, if I may, and in the context of going forward and protecting ourselves. And it’s very relevant to the discussion about whether the virus will go away or not. And that is about border controls and port health issues. And I think this is really interesting because there are countries that appear to have taken major advantage of their island status like New Zealand and Taiwan, or virtual Island status like South Korea, and very successfully dealt with the virus. And here we are sitting in Britain, adjacent to Ireland, two islands with an opportunity to take maximum advantage of that island status. And it seems to me that has not entered into discussion to any significant extent. According to the Pew Institute in the US, nine out of 10 of the world’s population live in countries where there are border controls in place on public health grounds in respect of this virus, yet Britain and Ireland maintain their open borders policy. And that seems to me as we go into a situation where we’re thinking of lifting restrictions, places us in sudden jeopardy. Looking at the experience of China and the experience of South Korea, when they got down to zero cases of domestic transmission, they were still getting cases from imported cases, from people, particularly citizens of their own countries returning to the relevant country. And it seems to me that the issue of Port health is extraordinarily important. After all, that’s taking us back to classical public health strategies and the classical response to the arrival of dangerous pathogens on our shores. Therefore, I would strongly suggest that we look at the issue of Port health and what might be done in future and look at the experience from other countries. And the contribution of improving and tightening our port health to make use of this island advantage, to explore what a contribution that could make. I think that needs to be done on both Island approach and certainly in Ireland – an all island approach, and there is work that is needed to harmonise the situation. For example, in in the UK, including the north of Ireland, the standard recommendation in terms of isolation in many cases is for seven days. Just across the bridge from the UK, just across the river into County Donegal in the Republic of Ireland, the recommendation is 14 days. This in terms of going forward, it seems to me to be nonsensical, and that there should be an attempt at getting a consensus. And there is plenty of evidence about now about length of transmissibility of the virus and recovery times, etc. And we should be looking, I think, at this issue of Port health, and how we can prevent cases coming in whilst facilitating transport of goods across because we need to import food. And that’s an absolute requirement. But we should be looking at our ports, our airports, and our eurotunnel stops, train stops , from the point of view of what port health regulations and what port health choices we’ve got in terms of protecting us from importing cases as we get down to a small number of cases ourselves.

David King
Zubaida, I’m going to come to you in a moment. But does anyone have a comment on the seven verses 14 days? Allyson P.

Allyson Pollock
Well, just a group of us wrote to the Secretary of State to ask him why he wasn’t following WHO guidance on the 14 days, because it’s highly likely that people are returning to work too early and maybe transmitting the virus. So there’s very clear WHO guidance and we are not adhering to their guidance, the reply was this was based on their scientific evidence for the best science advice, but they didn’t provide us with the basis for that, or the studies that underpins that. So that’s another big disappointment. And we have put that letter and the government’s reply is actually on my website if anybody wants to see it, but my own view is that it should be 14 days at least. In China, they’re suggesting for some of their people, it’s a much longer period because of the evidence that you might be shedding the virus for longer. But again, Deenan might have a view on that, as our biologists view.

David King
So let me just quickly come in and say in Greece, needless to say, it is 14 days. And the Greeks have allowed all Greek citizens to go back to Greece, including the 16,000 students from Britain. And they are put into hotels for two weeks in isolation before they’re allowed to join their families. And I guess that’s the situation in Ireland as well.

Gabriel Scally
No, no, I’m afraid, it isn’t. And as you know, people can fly in very easily into Ireland, transiting via the US. And people are in the Republic of Ireland, people are greeted, and there is a rudimentary public health control there, but nothing like the sort of measures that have been used with great success elsewhere. And the border, of course, between the North and South of Ireland is entirely porous as well. So I think those issues really do require further explanation and exploration. Thank you.

David King
Excellent. Zubaida, you want to come in?

Zubaida Haque
So I mean, it’s sort of tangentially linked, which is, of course, we know, for instance, that COVID-19 has hit, I think minorities, disproportionately harder than other groups. We also know from recent data that COVID-19 is hitting deprived areas much harder than non deprived areas. Now, to a great extent, none of that is surprising given what we know about the research, and how poverty and deprivation and overcrowding and so on is highly correlated to poor health. But I do think there is a recommendation to be made to the government about that analysis, and lots of the analysis in relation to ethnic minority groups and what are the contributing factors to ethnic minorities disproportionately bearing the brunt of COVID-19 and why it’s happening in deprived areas has come from outside of government. I mean, the government has constantly been on the backfoot. With this, they’ve been behind the curve. And I think at some point, they need to get slightly ahead of the curve, where they start to better understand why is it happening much more in deprived areas? Why is it happening among ethnic minorities? Now of course with ethnic minorities, they, the government now have a review. We haven’t seen the terms of the reference of the review. And I think that needs to be raised because that is of concern, because we don’t know in the review, whether they’re just going to focus on biological aspects of race rather than the socio cultural socio economic aspects of racial inequalities that are related to COVID-19. But in deprived areas, it clearly is transmitting at a much faster rate for all the obvious reasons, which is you know, overcrowding, high population density. You know, people have been forced into work because they’re much more they’re living on the breadline and so on. And I do think we need to make a recommendation to the government about doing some quick analysis and in terms of exits from lockdown, thinking about whether we need a much faster exit from lockdown in those areas where there are less green spaces. Whether it’s overcrowding issues and so on.

David King
Thank you. I got Allyson P next, but I just wonder whether I could bring in Kamlesh. He wants to make a point on this.

Kamlesh Khunti
In terms of the BMA populations, that’s a bit as mentioned, it’s much more complex than just looking at the socio economic and cultural aspects. They’re definitely part of it. But some of our work and others work has shown that may be also related to other conditions, chronic conditions that these people have. What’s been shown is that the people who are having severe disease and dying from it are more likely to have cardiovascular disease, hypertension, diabetes, these are all factors that are at higher prevalence in these populations. So I think that is very, very difficult to disentangle very easily. In terms of the research elements, we’ve just had a phone call just now, NIHR, our National Institute for Health Research just got a call out to look at why minority ethnic populations are at increased risk. And they are going to be funding a number of projects. And this will be on aspects of the medical models and all sorts of socio economic and cultural aspects as well. So, we really welcome that.

Zubaida Haque
Do you mind if I come back to you about that? Can I ask? Because, of course one of the most extraordinary things about or actually tragic things about the high proportions of critical illness and deaths among ethnic minorities in relation to COVID-19 is the slightly younger age of those groups actually a much younger age, which given their age, you would expect far fewer deaths, far fewer critical illnesses, is that not right?

Kamlesh Khunti
Not right now. What we’ve seen from data from colleagues who are working in intensive care is that they’re probably five to 10 years younger. But we also know that all of these chronic conditions that are mentioned are cardiovascular disease, diabetes, they occurred at a younger age of this population as well.

David King
Thank you. That’s very helpful. Allyson Pollock.

Allyson Pollock
Thank you. I just want to build on what Gabriel was talking about, about how do we get out of the lockdown, really. And the idea of travel restrictions and port controls, which have always been part of infectious disease control. There’s nothing new there. Except we stopped doing it. We’re still not doing it, in the UK. We haven’t got quarantine measures so people can walk in and out. And there’s no contact tracing or checking up. But I also want to bring back you raised the issue of track and trace. Now, if we think about it, I’m going back to the analogy that we had in our introduction, I think from Carl who talks about fires burning really, firecrackers and fires. But if you think about it across the country, we’ve got thousands of outbreaks or little fires burning at different stages and different sizes. You would not call them if you were living in Herefordshire or Hertfordshire, you would not ask Westminster to send their fire brigades, you would want to have locally responsive fire brigade teams. And then you would have surge capacity. If the fire gets out of control. You would draw extra support from neighbouring teams and you would build that up. That’s been really the principle of public health. You put your structures in your local health bodies or your local health authorities, and you build that capacity, but that also needs real time data. Now the directors of Public Health and local authorities are saying that the government is determined to centralise this. They’re determined to build a parallel and private system that centralises everything, we are not getting access to the local real time data we need. They’re not giving us the resources. And so what we need to have in every area is a return to building the local community capacity and services. And that includes hospitals and local areas, the pathology labs and universities in the NHS that are not being fragmented by the purchaser provider split. It means putting the testing locally, and the capacity to do the testing, as well as the contact tracing and building the teams locally. That needs a huge resource, Public Health Resource, but not nearly as much as the amount that we’ve just wasted on ventilators that don’t work, on tests that don’t work from China and even the Nightingale hospitals. What we need is community monitoring and community resource drawing on all the different parts of the health system, which have been completely fragmented by the health and social care act 2012. So public health sits in local authorities but it has no power to do communicable disease control. And then the bit of communicable disease, and public health was moved out into Public Health England, but they only operate through nine regional centres. They cannot operate at the level of the district authority. And that’s where you need the action to be in local health bodies and local health authorities and only in that way can you begin to lift the measures in local areas, because in many areas now, there are no cases or very few cases. So actually, you could have the community involved in the local decision making about how far you go with lifting some of the national measures locally, and then when you may need to adjust and put some more back in place, but this needs local responsiveness. It does not need the government which is using NHS X, which is a new body, to build a parallel system built on multiple multinational and corporate providers, as in their app, and their testing and the data, they’re sucking it all up. We must have this locally and build the trust of our community. And that’s how you do contact tracing and testing in public health. And you also have to know your community when you’re doing this.

David King
What I’m drawing out of that in terms of advice is strengthening local communities, strengthening healthcare sectors in those areas. Perhaps mayors and local councils, cities coming into play in the entire process.

Allyson Pollock
Yeah. And I think Gabriel is very well equipped as a regional director of public health to also comment on what’s required.

David King
So I’ve got Martin and then Gabriel coming in.

Martin McKee
I keep coming back to this point that we are a scientific advisory group, all of these things issues about the political arrangements and so on are fine for later. These are things that are not going to get changed now. So what do we actually need to do now? Can I make three concrete suggestions, one of them involves taking a blank sheet of paper and filling it in. On the first sheet of paper, we should have a clear list of the information that we want to know, which is about the zero prevalence, which is about mortality or other things, and then have a strategy for getting that information, looking at what sources of data we will use to collect it. So what do we need to know? How can we find it out? That’s the first one. The second issue that we haven’t really talked about much and it relates to a piece that we did with colleagues in the British Medical Journal recently, is to make sure that we bring all the different medical specialties together to really be sure that we actually know that we’re getting the best treatment. This is a complex multi system disease, and what some of the manifestations we talked about ethnic minority populations and so on. There may be biological factors that are certainly social factors. But we actually need to make sure that the immunologist, the cardiologist, the respiratory physicians, and everybody else, and the basic scientists are working together to be really clear that we know what this condition is, and how we actually optimise the treatment, because I’m not sure that we have necessarily got everything right. And the third thing, which touches on some of the points that Allison said, but you know, we can’t change it overnight is to have a sheet of paper where we write out using a systems diagram, what we want to do in terms of testing and tracing, what all the functions are that are needed for that. Do we need a population register? Do we need a quality control system? Do we need a monitoring bit? And have all of these functions written down and then work out who can actually do them and who can do them best. Now that addresses the question of whether Deloitte are the right people to do it, or whether the local government is but at least we need to say what are all the functions and how they interact? So three sheets of paper with those three things written down on them, and then I think we could move on from that.

David King
Is it possible we could emerge with those three sheets of paper? And if so, could you lead on that?

Martin McKee
Well, I’m certainly happy to put the headings down. But you know, it’s not that simple.

David King
I’m sorry, I’m now going to Gabriel.

Gabriel Scally
I very much agree with Martin on those three headings. And I don’t think it is simple. But it is absolutely correct that this has to be done. The data, I think we’re in general agreement that we need data specification and then a plan for getting that data, and comparable data as well and being able to compare ourselves systematically with the experience of other countries. Because I think one of the things that has been missing so far has been the science of observation, observing what is being done and what has happened as a result in other countries. I do feel very strongly that that is something that should be corrected even at this stage, in fact that this stage will be extraordinarily valuable. The issue of Martin’s third piece of paper about the tracing, contracting and setting it what how it can be done is not a simple matter where as he says, because and that’s really why no one actually does know how it is going to be done, even though there’s a general consensus that we need to improve testing in the community. There still isn’t an adequate definition of that. And one of the problems about is an English problem, I think, I think Scotland Wales and Northern Ireland are both in a better position because of the smaller population and, and geography and infrastructure to be able to bring a rational approach to bear on the practical science of delivering services in this sense public health services to the population. England has dismantled its regional structures. I used to be a Regional Director of Public Health and Saturn a government office for a region and unfortunately, those are not their forests anymore. So, there is a requirement to look at what structures are available to us to do this test going on for quite some time and hopefully spilling over into being able to deliver a rapid and effective immunisation programme when there is a vaccine available to us. And those structures are complex because of the lack of coterminosity that often exists now between what is left.It requires intelligent design and that is indeed a good function and a request some degree of Management Science to be introduced to make sure that it is going to function adequately requires to be performance monitored and performance managed. And all of those are no easy task, but it does need to be done. Thank you.

David King
I just want to distinguish between where we are now and how we emerged from where we are now. And then presumably, when it’s all blown over, whether that’s in one or two or three years time, we will come back to lessons learned. And I think it’s from the lessons learned that many of these proposals, for example that Alison Pollock is talking about, would really come into play, but at the moment, we’ve got to move on from where we are. I’m not saying that means we simply go with the facilities we have today, we have to maximise how we can get those facilities up to deliver what needs to be done.

Allyson Pollock
I hate to interrupt but actually, you know what the government is doing now determines where we’re going to be in three years time, which is why it’s so very important we think about it now, because the structures and systems really do matter. And the government is making big choices at this moment about where it’s going, for example, on NHS x, the hitech act that’s been rolled out. So the government is making those choices without our involvement. And that will mean that three years down the line, it will be too late. So I suppose I disagree. We need to say where we need to be going now. Sorry.

David King
I think I’ve got Anthony to come in.

Anthony Costello
So yes, we are a scientific advisory group of experts. But I like to challenge the definition of science. I mean, one of the huge problems with the existing SAGE and why we’re here is because they ignored population science, public health Science. It’s all very well, you know, mathematical modelling is extremely important, and virology and clinical academics. But the big problem is that to solve the immediate problem of fine trace, test, isolate, setting up a parallel system is not going to work and it’s not going to be sustainable. Yes, we can bring in maybe some private sector support to help with contact tracing, but it’s got to plug in to our local systems of primary care. And it’s got to plug into our local systems of public health, our district public health teams, and I’ve been slightly horrified because I’ve been doing more global stuff in the last few years to find how weak we’ve been on that. And I just think we’re not tapping into the resources that we have. Somebody alerted me actually to mutual aid in this country and I looked up their website on it. And there are something like nearly 5000 groups up and running to support people around the country. We know from and I’ve been involved in community development research where you use groups to bring about change. And we’ve looked at big impacts on diabetes and for example, Bangladeshi populations where group interventions are much more successful at reducing the prevalence of these underlying conditions than the many other things. And the other issue, which is perhaps not in the immediate term, but in the medium term is there was a report for a Nestor called the biomedical bubble published two years ago. And they pointed out that when you look at all the research funds going into health; 94% are spent on drugs, clinical treatments, and bio science and 2% is spent on public health. And that’s the mess that we find ourselves in now; that stuff that’s community or population is constantly downgraded. And I’ve selected two very senior public health people in this country, who are actually appalled at what’s been going on in the last couple of months. But they’re, you know, because they’re in jobs, and they need grants, and they need honours and all the rest of it. I’m not prepared to speak out about this. Because it is difficult, and it’s easy for me because if I get fired by UCLA, I’ve got a pension, you know, but it is more difficult for a lot of people to say these things. And I’ve been bombarded by really great messages from juniors in the front line, who are saying, look, we’re the public health people, we’re trying to do stuff in our districts, but we’re actually having to volunteer, and that’s the final thing. 750,000 people that have volunteered to help this initiative and we should have mechanisms, political mechanisms or local authority mechanisms to make use of those people because it can be incredibly valuable to support the collective effort as we go forward. So for a fine trace, isolate, if we’re going to get control of this and suppress it, we have to work with our existing local services, primary care for public health.

David King
I’m just going to intervene to say how I define science. I define it as a key NPI. I go back to the original definition from the Latin, which is knowledge, all of knowledge, it covers the whole range. And if you don’t put that all together, I know you can make dreadful mistakes. So of course, this is why we’ve got a good group of public health people in front of me now. I think the time is rolling on. I’m admiring everybody’s capacity for sitting on and on. But I do think I better push with the agenda. And I’m wondering whether Christina would like to come in. You sent in a comment, not actually on the agenda about the impacts of severe COVID-19 disease, on people, recovery and so on. Do you want to make a comment?

Christina Pagel
My comment was really about now that, you know, we’ve experienced the first surge as many countries, we can learn from it for planning for the next one. And one of those is beyond the need to adequately resource and staff intensive care. But what does that mean for hospitals? And things that we’ve experienced that we can definitely improve next time are how do we manage oxygen supplies hospitals at peak? How do we plan for things that happen like 30% of COVID patients in ICU develop kidney failure, and that has caused a real strain on actually doing the availability And renal fluids to support them. How do we manage rehabilitation? People post ICU which I know Allyson’s already spoken about. And it turns out as BMJ wrote an article on it two days ago, it’s not just a respiratory disease that has other impacts on organs. How do we now plan and manage for that? And we’ve given ourselves probably several months to try and plan for that and how we plan our services. I think this is the time to learn from that.

David King
Christina, thank you. Because I think that is a point that we need to include in our report. I think maybe it is not something you hear fully covered. Is anything more to be said? Or sorry, I’ve got Zubaida.

Zubaida Haque
I’m sorry. Actually, it was a building on your point earlier Dave about how this isn’t just about science. This isn’t just about health. I mean, obviously COVID-19, like health and saving lives is the priority, but the social and economic aspects of this are hugely critical. And thank you for bringing people like myself in. I mean, one of the things that we haven’t discussed, but which is quite crucial, of course, is for instance, what happens during lockdown. Now we know from the women’s sectors, from refuges and so on, that domestic violence has gone through the roof since being locked down. But what you don’t have from the government is that analysis, the social trade offs of lockdown. Now I do understand, I completely understand that, you know, lockdown has to happen for a reason, it has to be certain length and so on, but not to undertake any analysis, not to be on the front foot about the social trade offs of lockdown. What it means for people to be in overcrowded housing, what it means for vulnerable women, for vulnerable children to be in that lockdown and what the government should be doing. Now they’ve put some money aside, you know, for domestic abuse services, but it’s not going to be enough. And we already know from the women’s sectors, that actually, there’s going to be a lot more vulnerable women asking for refuge services during the exit of lockdown, rather than now. And the question will be, has the government been putting aside enough refuge places and so on? So I do think that analysis needs to be done by the government as well. And that’s a priority. This isn’t just about health. This is also about the social crisis as well.

David King
I like that because you’ve come forward with a very clear piece of policy advice to meet this crisis. I’ve got Martin and then Kamlesh.

Martin McKee
Religious to follow on from what Zubaida has said and maybe people aren’t aware, we did actually publish an analysis of all of these wider social consequences in the British Medical Journal this week, which looks at the impact on areas like domestic abuse, on transport, on education, on physical activity, and so on. And there’s a rather nice infographic pulled together by the editors in the British Medical Journal, which sets out all the interconnections, which I think while maybe not comprehensive, does provide a good basis for thinking through all of those things, plus some references to literature and how they can be mitigated.

David King
I think it would be useful, Zubaida, if you could work with Martin and just produce a short paragraph on this as advice going forward? Deenan, yeah, I have got you.

Deenan Pillay
Yeah, just briefly on that. It is remarkable, how little or how homogeneous or how homogeneity has been assumed in all of the advice coming from the government, for instance, around how to deal within households. Now, clearly, and one of the issues with regard to disadvantaged and BAME populations is perhaps different structures of households and how you actually quarantine within a household that’s multi generational. I mean, correct me if I’m wrong, but there’s been absolutely nothing that has come out with regard to how to nuance that information. And I think as we, again, as a recommendation, David, I think, you know, given that there’s been an absence of that sort of recommendation, how do you actually quarantine that? How is that done? How to quarantine in a way as well that that minimises the risk in terms of, of gender based violence. And so for domestic violence, I think that would be given that we have an expertise within this group, it would be good.

Anthony Costello
Sorry to interrupt. I know we’ve only got 10 minutes. I think that’s a really important issue. And there are people here that could talk to the quarantine issue, because I’m not clear whether there’s a very coherent quarantine policy may be Allison, Martin and others know better, but we really need that because, you know, in China, they put sickness into hospitals, they put mildly into other facilities, they, they put contacts into hotels, there are various policies. I know that colds modelling showed that actually, we’re promoting infection in households. I think you showed that and that we weren’t doing household social distancing at all well.

David King
Can I just ask that Deenan leads on producing a paragraph on this?

Deenan Pillay
As a virologist, I’m very happy to try.

David King
You’ve got some colleagues in this group who you could contact. Martin wants to come in.

Martin McKee
I wanted to pick up on Anthony’s point and reintroduce the concept of institutional amplifiers. This goes back to well work that we and others have done in Russian prisoners with tuberculosis mining communities in Sub Saharan Africa with HIV, and TB, where you bring people together at work prisons as well, anywhere that brings people together can act as an amplifier of infection and then spread it out into the communities. We’ve seen it with cruise liners, we’ve seen it with care homes. And what worries me is I suspect that we’re probably seeing it with hospitals too. And going back to Anthony’s point, I think it’s notable that in countries like Singapore after SARS, they redesigned hospitals, so they could have two pathways through the hospital, which would keep the patients apart. And that was a lesson that we didn’t learn.

David King
I think this is also a very important point. And so each of you is now raising points that I’m now turning to and saying could you produce a short paragraph. (inaudible)

Allyson Pollock
It’s just to add to what Deenan was saying about the importance of general practitioners and community monitoring to go with contact tracing. Even if you don’t have enough testing facilities, the clinical observation is really key. And the government again, missed a trick because some countries (inaudible) to people who are isolating and that includes a thermometer, and an oxygen saturation, metre, and even a blood pressure measurement. And they’re accompanying that by phoning people up two or three times a day to check on their symptoms. And many of the people who have died at home in the community, we don’t know the circumstances of which they’ve died. And the extent to which community monitoring support would actually have enabled people to be looked after more at home and then when they need to go into hospital. So that’s another area that the government could have spent money on. And all you do is you retake these packs back in and you recycle them. I just want to add that she’s absolutely right. Not everybody can self isolate. Not everybody can go into quarantine. And that’s, again, why it’s so important to know your local communities. And that, again, depends on local public health and community groups and all the rest of it and having very good information. I mean, at the moment, the directors of public health aren’t even getting seven digit postcodes to map where the cases are in their community. It’s quite extraordinary the data drought within local authorities and for directors of public health.

David King
Thank you, Allyson. And now I’m going to Alison Pittard.

Alison Pittard
I think we have a fantastic opportunity here to reflect on from the health acute health sector perspective as to where we started off – our experience so far, and where we are going forward in terms of how we manage COVID and non COVID cases within hospitals, and make sure that we remain resilient. And I think that looking at how we can perhaps transform services in terms of moving things around. So we can take the pressure off certain areas that may be under excess pressure if we have more peaks in demand in the coming months and years. So I think looking at rather than reinventing the wheel and taking on new pieces of work, is looking at work that’s already underway, or being implemented and trying to fast track that because they’re the sorts of things where all the work has already been done. It’s waiting to be either published or waiting for a work stream to finish and that will be a quick fix. That would actually give some resilience to the acute care sector.

David King
Thank you very much. I’m seeing a pause with no hands up. So I’m going to move to the next congress.

Kamlesh Khunti
Just for recommendations, we talked about recommendations about population level, about screening, about post discharge patients, but we mustn’t forget our workforce as well. I think that’s an important recommendation to make.

David King
What recommendation do we make about the well being of the workforce in hospitals?

Kamlesh Khunti
The data that came up from Wuhan showed that 50% of the workforce had depression, anxiety, post traumatic distress syndrome, once they came out of this, and I think we mustn’t forget them to prepare for that. Manage that as appropriately as we need to prepare for that now in for the short and medium term as well. Thank you.

Allyson Pollock
I like to add to that social care. And this I know (inaudible) but the importance that many the 1.6 million social care workers met a quarter of them are on Zero Hour contracts. They’ve got no statutory sick pay, there really needs to be a revolution in social care. I mean, I’ve argued for a national health and social care service and there’s quite a movement for that. And I think that needs to be something that the government needs to seriously think about and take into account, especially if it’s going to provide more deaths in nursing homes.

David King
Thank you, Allyson. I’m going back to Gabriel Scally.

Gabriel Scally
I absolutely agree with the importance of psychological well being as we move forward with this crisis. And we can look at examples that we have had in the fairly recent past, in this country. I know from my work as a Regional Director of Public Health, when I was very much involved in the foot and mouth outbreak because there were public health aspects to the disposal of the carcass load and various other issues. And being Regional Director of Public Health at the southwest of England, which was so badly hit by that there were enormous problems of mental health issues amongst the farming community in the areas affected people who lost their livelihoods, their herds built up over decades extremely important, and also people who were involved in the tourism industry, who lost their businesses as well because of that, and those problems continued for some time. So we have got good examples of some of the issues and I think there will also be issues of human health arising from the effects of the lockdowns specifically. I would expect agoraphobia for example, and I would be expecting obsessive compulsive disorders to be magnified. So I think a whole psychological strand of work going forward based on our knowledge of what has happened is very important. And staff are extremely important to go back sorry to foot and mouth again. But knowing of the problems of post traumatic stress disorder, traumatic disorders amongst both the farmers and indeed, some of the professional staff who were involved in that whole exercise, it’s quite clear that we are going to have big problems, and they’re the sort of problems we should be preparing for now. Thank you.

Zach
Hey, David, sorry, Zack here. Can I interrupt quickly? A couple of people have expressed in the chat that they need to leave now. Perhaps you could take a moment to allow those who need to go to go.

David King
Thank you. Who has to leave now? It’s going to be Martin, Kamlesh and Zubaida. Can I take you in perhaps that order? Martin, any final comments before you have to leave us?

Martin McKee
I think I’ve made my points. I think that the three pages, you know, what do we need to know? Gather all the clinical aspects, so we make sure that we get the treatment right. And having a whole system’s approach to all the things we want to do in terms of conduct tracing and testing. If we had those, I think that would be a concrete outcome. And I think there are lots of other issues, but I suspect that they’re going to have to be dealt with further down the track, we really do need to remember that when we’re thinking about proposing major legislative change, nothing is going to happen in the foreseeable future for all sorts of reasons. So it’s just not on the table. We may want to think about it, dream about it, whatever, but it’s not going to happen.

David King
Thank you. Very important, and thank you for your contribution.

Allyson Pollock
I disagree with that, Martin. I think things happen if there’s enough political will and enough political movement, and if people really want to see change, it can happen and October might be a good period for having new legislation for the NHS or health and social care. So I completely disagree with that, Martin.

David King
This is where of course disagreement is allowed. Can I come in with Kamlesh?

Kamlesh Khunti
Just wanted to say thank you very much and really enjoyed it. And thank you for making me a part of this.

David King
Thank you for joining us. It’s been really valuable. Zubaida.

Zubaida Haque
Yes, thank you. I want to echo that as well. It’s been incredibly valuable. And I feel incredibly privileged to be part of this group. Thank you very much. I just want to sort of reiterate two very important points. One is that I want to go back to the fact that, you know, right now, the government needs to think much more about an economic safety net for vulnerable groups. Those are the groups out there at the brink of poverty who don’t fall neatly into employees are self employed. And even if they apply for Universal Credit, there are constraints because there’s simply not enough money there. And that needs to be ramped up, including child benefit. So that’s the first recommendation that I really would like to make. The second one I think is, is that the government needs to scrap the no recourse to public funds. That is trapping so many people, those are people who I don’t know if you know, but basically, if they don’t have leave to remain, or they have limited leave to remain, they can work. They can’t access any public funds, they can’t access any benefits. They can’t access Universal Credit, you know, council tax, or rebates or anything, they can’t access any of that.

David King
Nor can they leave the country.

Zubaida Haque
Nor can they leave the country. And so those groups are extremely vulnerable, and the government needs to scrap that right now. So I’m just focusing on two recommendations that I’d like to put forward. But thank you for having me.

David King
Thank you. All three of you. It has been, I think, quite enlightening. I’m very privileged to be chairing this group. And Christina.

Christina Pagel
I need to leave as well, just to say one more thing. Firstly, thank you for inviting me. And secondly, that although we need to clearly work to support critical care and acute care, we need to prevent and so that’s why I think tracing and tracking and quarantine are so important. And really protect the key workers who have public facing every day so not just healthcare staff or care home staff, but shop workers, bus drivers, anyone who interacts a lot with the public needs to be protected. And we think about strategies to achieve that. Thank you. Bye.

David King
Thank you very much. Anthony,.

Anthony Costello
I was just going to ask Karl; If we assume that, let’s say 10% of the population has been effectively susceptible, all right, or or even 15%. And let’s assume that the herd immunity is not that good. Let’s say that you know, only about we can only rely on a fairly short spell, let’s be a bit pessimistic, it may be wrong. What advice would you give to the government now? And which criteria would you most look at about lifting the lockdown? There’s going to be increasing pressure. We’ve done what six weeks is it? Six weeks so far? China and a lot of these others lifted them the quieter parts, about seven or eight weeks. And Wuha I think was at about 11 weeks and we may be, London, you know, maybe looking at that experience, we need to go for another three or four weeks in places like that if we’re going to really lock down or not, would you go on R0? Would you go on new cases? Or would you at, you know, bearing in mind a more pessimistic scenario of how many have been covered and risks of second search? How would you advise that? Or is that an impossible question?

Karl Friston
I think it’s a great, technical and a very pragmatic question, and I think it has some clear answers. So first of all, anything that you’re advising to be done has to be demonstrably doable, and that has to be evidence based. So you need to have a generative model of what has happened so far, that includes societal, governmental, institutional health care responses, and then search for the evidence or the models that have the greatest evidence. And it looks as though it’s a fairly simple policy. I think we should reiterate your big point about the short and the long term, the WHO and the governmental criteria, and the kind of policy that seems to explain what countries are actually doing. And once you’ve got one generative model, you can actually assimilate data from China, and actually think more specifically about the United States. Those data actually speak to something that you were talking about before about quarantining and leveraging the fact that we are insular. In fact, the United States presents a very interesting problem in terms of transport of people who could potentially reinfect each other from a state that is infected to a state that is not infected. And I was amazed by the number of people that, on a daily basis, move from one state to another, it’s about, you know, between point five and 1%. So there’s a big question there. Do you lock down between State movement? And also speaking to this, you know, I think the issue which I wasn’t aware of and I found Allison’s plural treatment of it very compelling. I just say, if anybody’s going to go and talk about this. I think those two are the kind of face I would find convincing and compelling. But the issue of local responses, and this notion of the way that you model society’s response in mathematically, it is a model of self organisation and you can ask, you know, does a model where you empower statewide or local responses, have more evidence or produce better outcomes and if you have a federal national centralised response and the evidence at hand to date from collected data from specific states on new cases and new deaths suggests that a local statewide response is much better than a federal response. So it’s not Trump who decides it’s the local governor. So if you just roll out projects the model under a very simple social distancing policy that says that there exists a threshold below which you move from an amber state of social distancing to a complete lockdown, a red state of social distancing, if that exists, what it what is that threshold as estimated from the data for each country, and when you do that, it’s about 3%. For the UK. Interestingly, and this was all from the task set as last weekend. And so we didn’t do a comparative analysis of South Korea, but we did compare Germany and England. And it’s very interesting you think that Germany in virtue of its commitment, And foresight in terms of testing and tracking and rigorous adherence to social distancing would be, that would be the explanation for the relatively low death rate. In fact, it’s not. In fact, the evidence suggests England, the UK has gotten that parameter slightly lower. So the slightly more allergic to the prevalence of infection in the community, which suggests that we’re going to come to a lockdown later, as you say, about two to three weeks later than we would have done had we been Germany. And so the question, what should that criterion be? You’ve got to move forward or backwards in time. So if you choose the thing that preempts what’s going to happen in two weeks time, this is like a control theoretic problem. If you want to control some quantity, some outcome say deaths, for example, or demands of critical care, that is an evolving dynamic process. Then you have the control theoretic approaches. To go back to the first indicators of that, so it’s not the outcomes or deaths. It’s not even the number of new cases as identified by swabs. But if you can use the model to estimate the prevalence of infection, which is if you like the starter event, then that’s the criteria. And that’s what we’ve been using to actually model differential responses both in compact analyses between countries, but also in terms of evaluating different policies that could be adapted in the future. So it comes back to where we started in terms of, you know, having a well defined crisp, transparent, quantitative policy that an engineer would understand. And if an engineer would understand it, then the general public would understand it. I think a lot of the uncertainty then will be resolved.

Anthony Costello
You’re suggesting from your models that local government responses are going to be better. There’s something planned at the centre.

Karl Friston
Yeah. So if you take that model, if you define the self organised, adaptive is very much like a thermostat, you know, you, you put in place a process that becomes part of the epidemiology itself. So you don’t let me forget, I want to make a comment about R0, which I think technically is an important comment to make. But if you actually put that into the model itself, then you can estimate this parameter and you can start to ask, well, is this parameter best driven by local estimates of prevalence? Is it best driven by primary care? Or does it have to be centralized, best driven by an apple, knowing how the app harvests the data and the geographical fine gradience of it? So all these become basically hypotheses about this policy is better versus that policy. Once you have a hypothesis, then you can look for the evidence for that hypothesis, relative to another hypothesis in communities that already underwent this. I’m coming back to I think Gabriel’s point of view on learning from what other countries have already done, literally or practically simply becomes evaluating the evidence for this policy hypothesis relative to that policy hypothesis, given the data from those countries and then building those into prospective models that we can apply to our own data given that we’re a few weeks or a month behind. The R0 is interesting, it’s completely irrelevant. R0 is the basic reproduction rate ratio for a susceptible population. That’s completely irrelevant in terms of predicting what will happen if we relax lockdown. Now, what we need is the effective reproduction ratio which is just R. And the differences that R pertains to the actual community, the population at hand, how they will respond to it and how your neighbourhood will respond to it tomorrow. It’s got nothing to do with some idealised susceptible population. So, in fact, R0 is as the name says on the tin, it’s R at the beginning of time, at time zero, what we need to know is what is R now. The maths, as I read it, actually puts R very, very, very small and has to be small while we’re in lockdown. The other thing is, it’s not a biological constant. It’s not a physical thing that causes people to get infected and symptomatic, it’s a statistical summary of a long term process or where you are in some curve. If anyone was actually using R0, first of all they’re using the wrong statistic. And second, I wonder whether the media’s propensity to cast things and explanations in terms of R – the reproductive ratio, and indeed some people’s modelling initiative is the right thing to do. What you need to do is to model what causes the R. How many people are you in contact with at home? How effective is your social distancing? What’s the transmission spent? Does it depend on temperature? Is it going to couple to seasonal flu? All of the actual medical, societal and practical aspects of, you know, what we actually do? These are the proper parameters of the model, not R.

David King
Karl, I think that’s exceptionally valuable. I’m going to point to Karl and perhaps Anthony to distil something out of that as a recommendation. I just think it was critically important. I have noticed, I think Alison Pittard has had her hand up for a long time.

Alison Pittard
I just wanted to echo what Karl had said and sort of put it into the acute health care perspective. I think if this local control and then there’s a feeling of ownership and you’re much more likely to get buy in. And I think that is really important going forward. And I think the rag rating of situations is really useful. And as an example, the faculty collaborated with the college Royal College of anaesthetists to try and look at how we can start to reintroduce some operations and things but, and we’ve had sort of developed an evidence base. But what we don’t want to do is to have a top down approach because every hospital around the country is in a very different place depending on the geography. And so what we’ve established is red, amber and green situations, which will then allow individual hospitals to decide where they are in that rating, which will then give them the control over when to start re-instituting things. And I do think that the elements of ownership control are really important.

David King
I couldn’t agree more. I just wondered if I could insert a comment after Gabriel’s comments on the foot and mouth disease epidemic when I was effectively in the driving seat on managing that. In my work, I focused very solidly on getting the epidemic over as quickly as possible with the least number of animals culled. And in that process, I completely took my eye off what we were doing to farmers. It was only after it was all under control, I learned about the large number of suicides amongst farmers, and what the impact was on the families in the farming communities. So there’s a lesson learned from keeping an eye on two elements of the thing without taking that into account. I’ve got Deenan keen to come in. And then I’ve got Allyson Pollock.

Deenan Pillay
Thanks, David. So yeah, no Karl it is really, really interesting. And I’m trying to pull together these direct and indirect effects of the pandemic, because we’ve talked about the obvious indirect ones which are the excess mortality for non COVID related disease, all the data that are coming out and will come out over time, but also a whole range of other you know, psychological effects. And I guess, Karl, in the model, you’re using almost like an endpoint, the elimination of the infection. And I wonder if you use something like qualities as an endpoint or the cost per quarter, which says something more global around, you know, the broader health of the population, which obviously takes into account not only these indirect ways, but also the way in which we respond. So for instance, we would assume that a locality based, you know, response to the release of the lockdown will take away some of the pressure from more acute care and so forth. And whether it’s possible to then, you know, modify the model, to talk in those more global ways. And I think that would speak to what is sustainable and the best for the health of the population rather than the, as David said, just the narrow let’s eliminate the infection.

Karl Friston
Some excellent points there. So one concept, I think is useful to bear in mind is the notion of an endemic equilibrium. So the endpoint that we’re talking about mathematically, is not the elimination. I think there’s a conversation between David and Anthony earlier on, you know, is it ever going to be the case the virus goes away? So just mathematically in the models, that’s not the endpoint, the endpoint is literally the steady state that the system ends up in an endemic equilibrium. And so for example, if you ignore seasonal variations, and you assume that we’re going to lose immunity, on a personal basis with the time constants of 32 months, then the endemic equilibrium for the UK would be between say 10 or 40 deaths per day of COVID, which is much less than number of people who are killed by traffic accidents, for example. So that would be the point where it’s not a big thing anymore, you’re more likely to get killed crossing the road. And we don’t want to develop vaccines against cars. And we don’t want to have social distancing from our vehicles or our trains. And so that’s the kind of endpoint ones going for. The question about can you put the broader issues into the model, and thereby start to elaborate, high dimensional cost functions that try to sort of accommodate different agendas and the sort of the primary, secondary and tertiary consequences and try to differentiate them as an excellent point. Yes, absolutely. Yeah. This is not my direct field of expertise. But you know, there are models like the Glee model in the United States that have exceedingly detailed fine grained spatial, temporal gridding of what could happen putting a lot of information about translocation between airports. The models that I’ve been working with, actually have days lost from work as part of this. So I think the sort of stand back comment here is that the kinds of models that are being used to assimilate data in order to provide different evidence for different models or hypotheses, and I use that phrase deliberately, because if you’ve got the right kind of model, you can use it to test hypotheses, ideas, heuristics, intuitions, recommendations, they all become hypotheses, that in principle can be evaluated in terms of the evidence for that hypothesis in the data to hand. And that means you need to have a modelling initiative that can handle those sorts of data. So you need to have modelling that goes beyond the SEIR models and actually has the number of days you are here. And if you are here, what implication does that have for load on primary care? You’re putting all of these factors into the model which takes us beyond epidemiological modelling in and of itself and becomes much more of an economics model. But as I think three, at least three people have said it in one way or another, you’re outside the silo of a virologist, of an epidemiologist, of a neuroscientist or a psychologist, you’ve got to take everything that matters into account. Otherwise, your hypothesis, and first of all, they’re not being informed by all the data at hand. But more importantly, they’re not speaking to the imperatives that matter. And then there’s the deeper questions, which imperatives matter? At the moment, we’ve alluded that problem simply by saying; this is how countries appear to behave. So I could tell you how New York values human life against a day lost at work, I can work that out on the basis of how they have responded. So you can do something called reverse reinforcement learning, so you can work out what relative values do they put on a human life relative to a day lost at work on the basis of their behaviour? Clearly was not going to do that because it would be ungentlemanly. But it does speak to the question, then, you know, what are you going to define as being an optimal outcome? So operationally, it’s just the endemic equilibrium. But of course, there are different ways of getting there. I presume, it then comes down to consensus amongst groups like this, in terms of the relative costs that you might want to consider in terms of what is a good and what is a bad outcome?

David King
I think we would all agree, wouldn’t we, that a systemic approach to a problem like this is absolutely vital, critical to get the right players in to provide the advice or action. I sense that we’re all agreeing that we need to see that there’s much more control given to local communities to manage this epidemic. I think that has come through what many of you have been saying? I’m just trying to draw some general conclusions out before we all dropped with exhaustion. And I suppose I do just want to throw in for a moment. I don’t want to spend time on this. The question of vaccines. It obviously would help enormously if there was an evolution of vaccines, if the manufacturing capacity was built up in advance of the development of the first vaccine so that it can be rolled out quickly. But the question is: is it possible that the system is relying too much on the emergence of a vaccine in this way? Yes, Deenan.

Deenan Pillay
Excellent question. And I think it’s self evident that all the years of pandemic planning that there’s been since merged, and there’s been a very at a global level, there’s been a quite an impressive coalition of policymakers, funders and so forth. It seems to me, the biggest advance that has been provided is on speeding up that new vaccine development, rather than for instance, providing the UK or many other countries within a public health infrastructure that will work. That’s not that’s not denigrating the vaccine issue. I’m saying that that’s one of the I think one of the successes given how quickly vaccines have come. But I think an implication of that historical focus on vaccines as the way out and many eminent people, you know, Jeremy Ferrara, a very good colleague and very respected member of global health leader, has himself said, it’s the science that will lead us out of this. It’s the vaccine. And, and I worry about that, I worry as well, because when a scientist stands up in the press and says, and there’s a lot of press about this, that a vaccine will be ready in September, that will say something to the scientists, you know, who is the first in human study. It does not mean when we’re all going to go to our primary care centres and get our jab. So, I do fear as I said earlier, I do fear that the vaccine is the backdrop to literally every conversation government is having at the moment, and so it would be good if this group could, however much I’m looking forward to good vaccines and many different candidates, I do think we need to consider what would be the situation for a partially effective vaccine? A vaccine that maybe didn’t have full uptake, some safety profile issue that maybe came out after the very rapid licencing. All of those things that could happen could have a huge adverse effect on how behaviourism we’re all familiar with the politicisation of immunisation and so on. So, of course, that’s also their indirect cost. So that’s a summary of my thoughts. So, I’d love us to all feel as if we’re going to depend on the vaccine, I just feel that we should maybe consider, you know, what if a vaccine is not as effective as we’re hoping and how we deal with that.

David King
Thank you, Deenan. And I think Gabriel wants to come in.

Gabriel Scally
Yeah, I agree with that so much. I get a little bit dismayed when I say the bonding enthusiasm for the vaccine is the solution to all our problems. And I worry about it a little bit when I read some of the stuff that’s begun to emerge. Interestingly enough, I was looking at the issue of convalescent serum therapy recently, and I was surprised to find that when they started collecting the serum from people who had been positive, tested positive, they’d find a significant proportion of those survivors of the virus, who didn’t really have antibodies circulating and who serum was of no value to them. So I think it’ll be very interesting to see how that plays out. And the public health, practical public health response is to whilst acknowledging and being grateful for optimism, we should plan for the worst scenario which would be that we don’t end up with an effective vaccine certainly for several years, and that we have to rely on other methods to try and keep our communities operational and working and keeping people safe. And that means putting in place really good public health measures and practices at a local or regional underneath of the government level. And that means an alteration in the system.

David King
Thank you. Is that the same point, Allyson Pollock?

Allyson Pollock
Just to reinforce that we have some very good vaccines that work and the government’s were very concerned about (inaudible) children. So that’s another, you know, damage of COVID because our health services aren’t working and we need to get them up and working again. And the only other point I’m going to make is that it’s all very well to have a vaccine which may not be as effective as we want, but then there will be other pandemics, epidemics, other viruses and Corona may well mutate to another one. So I think all the points are we must plan to have a system that can cope, the next time that we have another epidemic or the next wave of this epidemic.

David King
I couldn’t agree more. I think that is a very important factor. So I’m afraid I’m going to throw one more thing at you. Which is the question of masks. We haven’t really discussed that. I have noted that as Greece emerges from its lockdown starting today, face masks will have to be worn by everybody outdoors and going shopping, etc. I know that when Austria introduced the regulation legal process that everyone was required to wear face masks, the incidents seem to drop. What do people feel about face masks?

Anthony Costello
Actually, I’m probably the least qualified and we’ve lost two of our people because I know that Martin McKee changed his mind after doing a review. And I think Susan’s also done a lot of work on this, I’m sure Allyson will have something to say. I mean, we know you wear a mask to protect other people. And there’s no doubt about that. But the question is, does it protect you, if you’re, you know, on a tube train or on a bus or something, or in a choir? Because we know that people singing or in schools can, you know, maybe spread it more effectively than we think. And I just have one thought, which I got from a very eminent public health person who told me, she said, this comes from your nose, washing your hands, yes, that’s important, but you don’t put a condom on your finger which is a way of saying, cover your mouth. You know, I’m sitting in rural York. And I’ll go out for a walk without a mask. But frankly, if I was in London, I would definitely wear some kind of covering on the tube or on a bus. And the evidence is not that strong, but it’s absence of evidence rather than evidence of absence of effect, I think. But I might be wrong. I might be talking rubbish here.

David King
So we know that a lot of the evidence is obtained from the normal flu virus. And this is a very different beast. But I think given that we’re not an expert group in this area. I may have asked the wrong question at the wrong moment. And maybe we should move on it. Is there any other point? Before we do? come to an end. But I see Deenan is gonna raise a new point.

Deenan Pillay
All I want to say about masks is that while we’ve been ‘On Air’ as it were, the Royal Society group that is looking at a whole range have issued some guidance on masks. So I’m looking forward to reading what that eminent group of individuals have said.

David King
Good. I just want to say something to what Anthony said. He mentioned choirs and masks. I’m not sure that a choir can sing when it’s wearing masks.

Allyson Pollock
Or be heard. Could I just ask you, David? I think the R0, I was thinking about these three kinds of lies, lies, damned lies, and statistics – Mark Twain. And we’ve already covered the problem of the daily toll of deaths and tests that the government’s putting out and the need for official statistics and the statistician but I’d add to that, this whole R0, it’s being used all the time on a daily basis by our you know, CMO or CSO. And I really think it’s something that is confusing for most people. And it would be really good to do something, you know, to put something out on this Karl. I think it’s really useful your explanation.

David King
Thank you. Thank you, Allyson. Absolutely, it would be quite important if we can get that distinction out in a report to the government. And then I’ve got Gabriel with possibly the last comment. I don’t know.

Gabriel Scally
Well, thank thank you very much. I just had one final thought on masks. And that was we shouldn’t forget about people for whom the wearing of masks in public causes problems. And for people with hearing disabilities, who rely upon being able to see people’s mouths and their lips move, it really would be an enormous and enormous difficulty for them. But I’m not an expert in this area, and I look forward to seeing the consensus emerge. But finally, I just wanted to say what a pleasure it’s been to take part in this excellent meeting. It has been a rare privilege. Thank you. Thank you very much sir David for convening it. I look forward to working with colleagues, and helping to eliminate some of these really interesting issues that we’ve touched on today. Thank you very much.

David King
Well, can I just finish by saying thank you to all of you. Anthony helped me considerably pull this together. I think Karl, wonderful contribution. It was really so important to have you here. Deenan, I think we just learned so much from you. And then as was said, the two Allison’s together. You guys need to get together and produce again, a short recommendation on the importance of care in the community. In this process, so thank you so much. I always enjoy these because I come from outside your field. And it’s always a steep learning curve and I enjoyed it immensely. Thank you.

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