The Wry Observer’s Covid-19 update (173): The Joint Select Committee Report: Coronavirus – the lessons learned to date

The joint Select Committee report emerged while we were travelling back from Burgundy, where there has been a calm acceptance of inside masks and vaccination proof, but as it was too late for yesterday’s newspapers to comment its dissection in the press really only began today.  The Daily Sceptics site has produced a digest; its author has read the report, so says there is no need for Daily Sceptics readers to read it, as it is very long. You can find it at https://committees.parliament.uk/publications/7496/documents/78687/default/

I disagree.  The devil is in the detail.  I am particularly annoyed that my own evidence, submitted fairly early last year, has been either lost or ignored.  I have looked carefully at the list of submissions and can see only one that comes from a clinician who is, or was (to allow for retirees like me) involved in acute patient care.  This is a gross oversight.  Management of very sick patients is not a matter for politicians, epidemiologists or public health doctors.  Without a clinical perspective the report is frankly worthless.  It’s all very well discussing what should or could have been done to prevent infection if there’s nothing much about how either to stop infection progressing to severe illness or how to treat that illness.

It doesn’t help that the report continues to conflate SARS-CoV-2 and Covid-19.

To be fair, summary conclusion 18 does refer to treatment:

“Treatments for covid are another area where the UK’s response was genuinely worldleading. The RECOVERY Trial had, by mid-August 2021, recruited just over 42,000 volunteers worldwide to mount randomised trials of covid-19 treatments. Establishing the effectiveness of dexamethasone and the ineffectiveness of hydrochloroquine were vital contributions to the worldwide battle against covid-19 and estimated to have saved over a million lives globally.”

I will return to this.

Although the report acknowledges that foresight is not available in pandemic planning it excoriates the UK’s initial approach to the pandemic, based on the assumption that SARS-CoV-2 was likely to behave like “ordinary” flu.  There’s an oxymoron if ever there was.  Many clinicians and commentators, including myself, thought that SARS-CoV-2 was just another flu to start with.  It was not until April that the characteristics of Covid-19 and possible causes of the serious syndrome became clear. So I think it is unfair to criticise government, or the scientists, when the criticism is based on a retrospective analysis. It’s very easy to see your mistakes when you have the benefit of hindsight.  Yes, the government got it wrong, but no-one in the free world got it right until there were enough cases to make a judgement. That apart, the evidence that lockdowns made a major difference to transmission is minimal. Taking into account the multiple entry points (in the UK, the seed cases were not from China but from Italy, France and Spain), the discharge of hospital patients to care homes without screening and the reality of intra-hospital transmission) I do not believe that the prevarication over lockdown played a major part.  Furthermore as I have argued previously it was not a lockdown, only a partial one, given the numerous exceptions for key workers and healthcare staff. The evidence from the Antipodes shows that while you may reduce overall numbers by lockdowns you cannot make a watertight defence.  Cases will sneak in, and when lockdown comes off, unless you have a ruthless exclusion policy so that no-one with SARS-CoV-2 can get past, you will simply relight the smouldering embers.

Paragraph 46 says:

“The NHS went to extraordinary lengths to ensure that there was enough critical care capacity for people hospitalised with covid-19.”

Indeed it did, but it failed totally to introduce any strategy for early diagnosis, such as the community use of pulse oximetry to track deterioration.  It simply assumed that people would get infected, develop Covid-19 and become very sick.  As it happened the extra beds turned out to be unnecessary, developed as they were on wildly pessimistic projections – which was just as well as they could never have been staffed.  While ventilator capacity was dramatically increased, it took time to understand the lung pathology and realise that better results were obtained by continuous positive airway pressure (CPAP) and that ventilation might increase lung damage.

Para 55 states:

“Ventilation, spacing and isolation facilities in most areas of hospitals were not compliant with recommendations in Health Building Notes (HBN) and Health Technical Memoranda (HTM). No practical solutions were available to address this.”

I have raised the question of hospital airflow (or lack of it) before. Unquestionably this was the major cause of nosocomial infection.  It is an indictment of hospital design and dates back decades.

This section notes the NHS runs close to capacity all the time, so a major event like Covid-19 will inevitably cause a major problem.  Certainly true – but the cause of this goes back years, and is the result of successive governments trying to balance safety with expenditure required to maintain reserve capacity for emergencies, ie keeping large numbers of beds empty “just in case”.  In case of what?  That’s an argument that will go on forever.

The report refers to the instigation of a “full lockdown” Heading for para 96).  But as I have said, what happened was no such thing.

There has been a great deal of discussion about the failure to consider suggestions from outside sources, but as para 127 makes clear, such consideration was undertaken, and influenced decision-making:

“Dominic Cummings told our inquiry that Downing Street held a meeting on 20 September 2020 for the Prime Minister to hear both sides of the argument. He explained that Professor John Edmunds put forward the view that the Government should impose another lockdown while Professors Gupta and Heneghan put forward an opposing view. Professor Gupta and Professor Heneghan have subsequently written to us to highlight their view regarding that meeting, including, in their view, that a number of claims that Dominic Cummings made about their presentation to the Prime Minister were incorrect. Following that meeting, Mr Cummings explained that the Prime Minister was not persuaded about the need to impose another national lockdown.”

So the government did weigh the arguments.

There follows an account of the appearance of the more infectious alpha variant.  Here the report acknowledged the problem of trying to know the unknown:

“But these decisions were taken before the existence of the Alpha variant was known. So the justification for an earlier lockdown is greatly influenced by information that was not available at the time. It serves to illustrate that, in a pandemic whose course is unknown, some decisions will be taken which turn out to have been wrong, but which it was not possible to know at the time.” (para 138).

Reading the conclusions in this section of the report it is apparent that there is an understanding that government found it difficult to challenge the advice of its own scientists.  This chimes with my contention that they were consulting the wrong people. But para 160 actually underlines my sentiment:

“In bringing together many of the UK’s most accomplished scientists, SAGE became

a very UK body. In future, it should include more representation and a wider range

of disciplines, from other countries.”

Accomplished they may be, but in the wrong fields.

I broadly agree with the section on testing (chapter 4).  Neither would I dispute the report’s comments on the issue of care homes in the following chapter.  It is interesting to read that Dominic Cummings thought that the Secretary of State’s announcement of a 100,000 target for testing was “incredibly stupid”.  The report clearly indicates its disagreement:

“… we consider that the impact of the Secretary of State’s target to have been an appropriate one to galvanise the rapid change the system needed. However, as such a personal and unilateral approach was needed—and appears not to have been supported by other parts of Government—it is concerning to contemplate what would have happened without this unorthodox initiative.” (para 184)

As for the ethnic minority issue (chapter 6), I have discussed this at length in previous posts.  I have no doubt that transmission of SARS-CoV-2 was influenced by social circumstances (large families living together, cultural contacts etc) but that the development of Covid-19 was a genetic issue.  Ant reader of Cron and Behrens’ textbook would be hard-pressed to disagree despite the very firm conclusions of the SAGE ethnicity subgroup (which did not include any clinicians with an understanding of cytokine storms) that genetic factors could not explain the high numbers..  The evidence for cytokine storms from other causes being related to chromosomal abnormalities is very strong.  But I suppose that if you haven’t read the textbook you might not know – though I did try repeatedly to get government advisors to go through it. How many did?  A number?  As one manager once told me with a grin, zero is a number.  One does have to wonder, though, whether the disproportionate mortality in those with learning disabilities was at least in part the result of an attitude that such people were less worthy of being saved.

The vaccination programme is praised, and in my view rightly so.  It was almost incredible that a vaccine should be developed so fast, although the technology to do this was already developed, and therefore merely needed tweaking.  The way in which this was done is a model for any future need.  Could it have been done any more quickly?  I doubt it.

The trials of treatments section is where I struggle hardest.  Para 387 says:

“One of the strongest, and most easily overlooked, components of the UK’s response to covid-19 has been in its forward position in trialling treatments against the disease. The RECOVERY Trial had, by mid-August 2021, recruited just over 42,000 volunteers worldwide to mount randomised trials of covid-19 treatments.587 Professor Peter Horby told our inquiry, “It is probably true to say that the UK has, of any country, been the most successful in running clinical trials for the treatment of Covid-19[…] we are, by far, the biggest trial in the world.”588 As a result of these mass-participation randomised clinical trials, treatments like dexamethasone were found to make a major contribution to reducing the severity and duration of covid-19 among patients receiving respiratory support. Professor Chris Whitty, Chief Medical officer for England, for example, told the Science and Technology Committee in November 2020, that “On dexamethasone, the UK can feel proud that this is something we did for the whole world very fast. That will reduce mortality”.589 Establishing the effectiveness of dexamethasone was a vital contribution to the worldwide battle against covid-19 and is estimated to have saved over a million lives globally.”

In late April and early May 2020 I proposed the use of high-dose steroids (and interleukin antagonists such as tocilizumab) for the treatment of severe Covid-19.  This was on the basis that such treatments were already established for the management of a cytokine storm; and that I had had personal experience of treating one such.  Any trial would merely confirm what was already known, and indeed was in use in some units in the United States – and the outcome of the RECOVERY trial was exactly what one would have expected.  It was completely unnecessary.  The delay occasioned by waiting for the result was of several months.  Dexamethasone (or an equivalent high-dose steroid) if deployed when I has suggested, would have saved many more lives (I estimated that over 20,000 might have been lost to the delay in the UK alone).

As I have said several times in previous blogs my attempts to get this point across to the decision-makers met with a black hole.

The section is unbelievably brief.  It fails even to mention tocilizumab, which supports my contention that no-one on the committees had heard of, let alone read, Cron and Behrens, in which tocilizumab is mentioned no less than 12 times.  I might add that Kawasaki disease, a children’s inflammatory condition well-known to rheumatologists and which resembles one of the types of Covid-19 seen in children, is treated with steroids and another interleukin antagonist, anakinra, which so far does not appear to have been trialled.  Given that tocilizumab is belatedly being used widely for Covid-19, and that anakinra is much cheaper, this seems to be a major omission, especially as its use for Covid-19 is causing problems for rheumatology patients whose supplies are being compromised. I repeat, yet again – we may or may not be able to stop SARS-CoV-2 infections, but what matters is whether we can diagnose them early, whether we can predict progression to Covid-19 and if they do (and importantly such patients are the ones that die) that they get prompt treatment.

So I think the report has missed a trick, or several.  There are many holes in it, and some of these are because, like the government, the Select Committees have failed to call evidence from the right people.  My own was lost.  I know of several rheumatologists whose experience of immune diseases is practical as well as theoretical, and have referenced them in previous blogs.  I have suggested to government, its advisors and the Health Select Committee, that if they don’t want to take well-meant (but soundly based) advice from a retired consultant with a good track record of research analysis that they could at least take it from highly intelligent and well-informed consultants still in clinical practice.  Well, they haven’t, and this report is the worse for it.  Roll on the independent inquiry!