Covid inquiry report: We planned for failure
BMJ 2024; 386 doi: https://doi.org/10.1136/bmj.q1633 (Published 23 July 2024) Cite this as: BMJ 2024;386:q1633
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Dear Editor,
Professor Johnson’s response [1] to “Covid inquiry report: We planned for failure” [2] is a sore reminder of some of the main determinants behind UK’s poor performance at managing COVID19 pandemic. The failure to see that re-opening schools does not equal re-opening schools “safely” unveils the true reasoning of those who have always criticised school closure. They did not mind children getting infected. Actually, they wanted children to get infected.
Professor Johnson’s 2020 article in the Spectator [3] shows zero-evidence idealism that “protecting children from coronavirus risk does not remove that risk altogether, but rather passes it to more vulnerable members of the population” and that “if all under-19 caught Covid-19, we would be on the way to achieving herd immunity.”
We are in year 4 of SARSCoV2 pandemic and is now clear that:
- there is no such a thing as herd immunity to SARSCoV2, with an average of 4 waves per year and associated peaks of hospitalisations and deaths, including children.
- yearly paediatric mortality of COVID19 is notably higher than that of flu and chickenpox together [4]. Of note, flu and chickenpox vaccination is now offered to all children, whilst COVID19 vaccination is not.
- long covid and other long-term sequelae of SARSCoV2 infection (e.g. diabetes) can affect children of all ages. Current ONS data (March 2024) show that 111,816 children (aged 3-17 yrs) had Long Covid, of whom over 20,000 reported that their ability to undertake day-to-day activities had been very much limited. [5]
Schools are like any other crowded indoor poorly ventilated space: there is no invisible shield that stops SARSCoV2 outside the school and makes it magically safe. A policy of schools with zero mitigations during a pandemic of an airborne respiratory virus was and still is a recipe for repeated re-infections in children, teachers, their families and a cascading chain of infection to their contacts.
Yes, children may get infected while they are not in school, e.g. at a birthday party or at home from their relatives. However, the schools are only responsible for what happens in the schools. For example, the fact that children may eat unhealthy food or are exposed to tobacco smoking while at home does not mean that schools should give up providing children with healthy food or being smoking-free.
Everybody wants the children to be in school. But why shouldn’t schools be safe so try and reduce the spread of any respiratory infection?
1. Johnson O. Learning lessons from pandemic school closures. Published Online First: 25 July 2024.
2. Pagel C. Covid inquiry report: We planned for failure. BMJ. 2024;386:q1633. doi: 10.1136/bmj.q1633
3. O. Johnson "Is it really necessary for schools to be closed?" Spectator online 16th June 2020
https://www.spectator.co.uk/article/is-it-really-necessary-for-schools-t...
4. National Child Mortality Database. Infection related deaths of children and young people in England. December 14, 2023.
https://www.ncmd.info/publications/child-death-infection/
5. Office for National Statistics. Self-reported coronavirus (COVID-19) infections and associated symptoms, England and Scotland: November 2023 to March 2024. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/....
Competing interests: No competing interests
Dear Editor
In his response [1], Professor Johnson questions whether Independent SAGE’s (supposed) “advocacy for school closures” is consistent with my stated concern for those who fell through the gaps during the UK’s pandemic strategy [2]. His criticisms are misleading and misrepresent Independent SAGE’s position.
A key point of my piece [2] (and the Inquiry Report) was that thinking through potential public health measures to suppress spread of a pandemic during emergency planning would have allowed for better implementation of such measures in 2020. With respect to schools, this should have reduced the impact of closures on vulnerable communities and reduced the duration of any closure.
After Independent SAGE formed in May 2020, one of our first concerns was education. Our report from the end of May 2020 [3] did not advocate for school closures . We did – in the face of a new disease with an unvaccinated and highly susceptible population – advocate for reopening with strong local test, trace, isolate and support systems and other measures (such as smaller class sizes, class bubbles, ventilation) in place, and when local prevalence was low [3, section 4]. We also advocated, given declining prevalence, that it would be sensible to wait a few weeks to allow infrastructure to be in place (e.g. contract tracing was only just being set up) and to further reduce the background prevalence. We advocated following WHO guidance [3 , section 6.4] and learning from other countries [3, Table 2].
We specifically noted the inequalities inherent in the impact of school closures [3, section 2.8] and suggested measures of supporting schools in more deprived areas to open safely and hold outdoor summer camps specifically to support not just student education but also students’ social needs [3, sections 2.9, 5.1] . We advocated for the state to provide online opportunities for students to learn if they had no access at home to WiFi, laptops or safe spaces [3, section 6] and free meals for children who might be going hungry [3, 6.3]. We also advocated for consideration of clinically vulnerable teachers and children living in clinically vulnerable households.
In August 2020, we updated our report to lay out a detailed 5 point plan for safe September opening of schools [4]. These points included: reducing prevalence in the community; strong surveillance and mitigation measures (including ventilation) within schools to reduce outbreaks; ensuring support and resources for children in more deprived communities.
In early September 2020, we updated our plans again following the reopening of schools in Scotland in August [5]. Again, we advocated for safe reopening: with rapid testing, contact tracing, masks, ventilation, and smaller class sizes. We advocated for government-provided resources (computers, WiFi, study spaces) to those without, in case they had to self-isolate. We warned that testing infrastructure was being stressed (it was to later break down in England in mid September 2020), that ventilation was poor and social distancing hard to maintain. Nonetheless, we concluded that “The overall incidence of infections in children remains very low and, as yet, there is little evidence that reopening schools has contributed to an overall increase in infection. For now, schools are safe for pupils and it is right that pupils remain in schools”.
In October 2020, we criticised the Department for Education for failing in its duty to provide remote education and called for greater provision of resource and evaluation of impact [6].
Independent SAGE consistently advocated for safe open schools, with robust public health infrastructure in place, including support for those in more deprived communities. There exist, of course, different perspectives on the UK’s Covid-19 schools policy.
References
1 Johnson O. Learning lessons from pandemic school closures. Published Online First: 25 July 2024.
2 Pagel C. Covid inquiry report: We planned for failure. BMJ. 2024;386:q1633. doi: 10.1136/bmj.q1633
3 Final report on returning to schools | 28 May 2020 Independent SAGE. 2020. https://www.independentsage.org/wp-content/uploads/2020/06/Independent-S... (accessed 25 July 2024)
4 Consultation report on return to schools | 14 Aug 2020 Independent SAGE. 2020. https://www.independentsage.org/consultation_schools_aug2020/ (accessed 25 July 2024)
5 Learning the lessons from reopening schools in Scotland | 4 Sept 2020 Independent SAGE. 2020. https://www.independentsage.org/wp-content/uploads/2020/09/Schools-reope... (accessed 25 July 2024)
6 Statement on cuts to laptop allocation for disadvantaged pupils | 26 Oct 2020 Independent SAGE. 2020. https://www.independentsage.org/statement-on-cuts-to-laptop-allocation-f... (accessed 25 July 2024)
Competing interests: I am the author of the original piece and a member of Independent SAGE
Dear Editor
I was interested to see Professor Pagel of Independent SAGE complaining that "a huge amount of crucial policy was made on the hoof". This desire for established methods feels ironic given that she represented a group which in May 2020 argued [1] for the extended closure of schools partly based on novel and then unpublished "advanced mathematical techniques". These models generated "a worst-case prediction, under which we would expect a second peak of about 100 deaths per day" [2, Figure 6], which inaccuracy calls into question their use in such a crucial scenario.
Further, it feels hard to square this advocacy for school closures with her current comments that lockdown meant "those who struggled to ... learn from home ... fell through the gaps because no effort was made to think through potential policies". Those of us who questioned extended school closures at the time, for example by arguing that they "undermined the principle of universal education, and significant attainment gaps will have grown between the haves and have nots" [3] were met with considerable hostility online, including from members of Independent SAGE itself.
In my view, learning the lessons of the pandemic requires all those who played a role in it to reflect on their positions. The question of whether Independent SAGE were right to argue that children should not receive in-person education at what was to prove the lowest prevalence level of the entire pandemic [4] should not be an exception to this.
[1] Independent SAGE "Final report on returning to schools" 28th May 2020 https://www.independentsage.org/final_schools_may2020/
[2] BMJ Glob Health 2020 Dec;5(12):e003978. doi:10.1136/bmjgh-2020-003978 https://gh.bmj.com/content/5/12/e003978
[3] O. Johnson "Is it really necessary for schools to be closed?" Spectator online 16th June 2020 https://www.spectator.co.uk/article/is-it-really-necessary-for-schools-t...
[4] Office for National Statistics "Coronavirus (COVID-19) Infection Survey headline results, UK" (Dataset) 24th March 2023
https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/...
Competing interests: No competing interests
Dear Editor,
I was the pandemic lead in 2008 for NHS East Lancashire, England, and I confirm that plans then focussed on managing the mortality outcomes as well as for mass vaccination and distribution of antivirals. These were for influenza and we were told by the Health Protection Agency (latterly to become Public Health England), that it was deemed impossible to prevent the spread of a respiratory virus such as 'flu. We were only given the predicted number of deaths for our area, and had to plan refrigeration equipment for the bodies and public information to match. National planning happened in a silo, but was signed off by politicians, who took the professional advice given about the futility of spread at face value. MERS and SARS1 later showed that prevention of spread was possible but PHE advised that the regimented nature of those societies with compliant populations, limited the applicability of those strictures to our western individualistic society. I had a number of discussions with senior people within PHE in order to establish the limits of our interventions, and why we could not follow east Asian methods. I believe these were checked with politicians, but cannot confirm that.
As the Chief Medical Officer and Director of Public Health of Gibraltar during the SARS-2 CoV pandemic, it became clear that the same error had been made there ("quality assured" by PHE). We had to rely on a diet of emerging new reports, research and empirical experience to pivot our response to the new virus. Our small size meant we responded quickly and at one time had the highest per capita swabbing rate in the world. It is a pity that others could not have learned from our experience. The vaccine was delayed by two whole months, from the initial date promised by the PM, Boris Johnson, and it was partly due to that delay that mortality came to the territory.
We indeed need to learn from our experiences, and have public buy-in to choices, no matter how unpalatable or unthinkable, before the next pandemic.
Competing interests: No competing interests
Public engagement in defining triage before future pandemics
Dear Editor,
The covid-19 inquiry has discussed many areas of the pandemic response and listed where improvements need to be made.
One neglected area is triage and rationing. This is a difficult area as it has to be done fairly and transparently in order to ensure trust. Additionally it is where doctors' clinical decisions can be in conflict with their feelings and consciences whilst facing pressure from desperate families. It can be the root of the moral injury which is so associated with burn-out and other mental health problems. Clear support and guidance, rather than vague advice or simplistic algorithms, is important.
On reviewing the literature for this in March 2020 there was little good quality commentary - several bodies had made guidelines - notably the Italian body for anaesthetics (SIAARTI) in response to their well documented early experience of limited resources in the first wave of covid-19 [1]. There was an outstanding document from thorough community work in New York which had examined triage in face of a theoretical influenza pandemic which merited more attention than it got [2]. It discusses the processes involved in arriving at a silo system of triage which could be adapted to UK.
Junior doctors were distressed by political statements that rationing was not occurring when access to some ITUs appeared to have an age cut off without truly accounting for fitness. Several have recounted this to me personally so I fear it was commonplace.
The NICE algorithm for deciding on ITU care access during covid-19 was simplistic, omitting any discussion of rationing, avoiding the difficulties [3]. There was an excellent discussion article by the BMA which thoroughly went through the cognitive and ethical traps but it did not seem to lead to as much discussion or action as it ought to have done.
To prepare adequately for a future pandemic we must discuss triage and rationing openly. This must involve different parts of the health system - community and care homes, hospital and public health. Involvement of the general public is essential. This will only happen if central government or a national body takes this forward.
1. SIAARTI Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva 2020. Subsequently written up Clinical ethics recommendations for the allocation of intensive care treatments in exceptional, resource-limited circumstances: the Italian perspective during the COVID-19 epidemic. Vergano et al. Critical Care.2020 24:165. https://doi.org/10.1186/s13054-020-02891-w
2. NY PDF ventilator allocation guidelines 2015. https://www.health.ny.gov/regulations/task_force/reports_publications/do...
https://www.health.ny.gov/press/releases/2015/2015-11-25_ventilator_allo...
3. NG 159 Critical care algorithm.pdf, accessed March 2020 on NICE website. Replaced by NG 191 in which I cannot find a similar algorithm (file saved and available by emailing me)
Competing interests: No competing interests