Official Report: Minutes of Evidence

The Chairperson (Mr Gildernew): I welcome our distinguished guests. Thank you for making time to be with us this morning. We value your expertise and knowledge.

I ask members who are on the phone to mute their phone, if possible, if you are not speaking. That will prevent some of the feedback that we have been picking up in the room. If members unmute and indicate that they want in, I will bring them in and everyone else should remain on mute.

I welcome Professor Sian Griffiths, emeritus professor at the Chinese University of Hong Kong, where she was the director of public health and primary care. Sian co-chaired the Hong Kong Government's inquiry into the SARS epidemic in 2003. Since returning to Britain, she has been visiting professor at Imperial College London, an associate non-executive advisory board member of Public Health England and chair of the Public Health England global health committee.

Martin McKee is professor of European public health at the London School of Hygiene & Tropical Medicine and research director of the European Observatory on Health Systems and Policies, which is a partnership of universities, national and regional governments and international agencies. Professor McKee was born in Belfast and studied medicine at Queen's University, Belfast. He is a past president of the European Public Health Association.

Professor Anthony Costello is professor of global health and sustainable development at University College London and an honorary fellow of the Faculty of Public Health. Having studied medicine at Cambridge, he specialised in paediatrics and neonatology and pioneered innovations in maternal care. He is a former director of the World Health Organization (WHO), where he helped to lead the global strategy for women, children and adolescents' health.

I invite each member of the panel to make their opening remarks before we have a round-table discussion. We will start with Professor Griffiths for a look back at lessons from the SARS pandemic.

Professor Sian Griffiths (Chinese University of Hong Kong): Good morning, and thank you for inviting me to talk to you today. SARS, as you will remember, was also a coronavirus, but only identified part way through the epidemic. The epidemic was first reported in Asia in February 2003, although it became clear that the virus had been circulating for some months in mainland China beforehand. Over the course of the next few months, the illness spread to more than two dozen countries in North America, South America, Europe and Asia, before the global outbreak of 2003 was contained. In Hong Kong, SARS infected at least 1,755 residents and killed 299 people, and it resulted in a fall in the GDP of 2·63%.

The story has many echoes with COVID. Not only are both diseases coronaviruses, but there had been rumours of a severe chest infection in mainland China for several months before the first case was admitted to a Hong Kong hospital with atypical pneumonia. During the first phase, its unusual nature was recognised because it infected healthcare workers at one of the two medical schools in Hong Kong. That signalled that it was a new disease and that it had epidemic potential. The disease spread into the community, which meant that it was no longer contained. It also spread into local care homes for the elderly. People will see that there is a familiar story emerging. The origins of SARS, as were suggested for COVID, were identified as coming from illegal trade in the wet markets in China, and SARS was probably spread through the sale of wild civet cats with a reservoir in the bat population.

I repeat the story of SARS because it helps to understand the success of Hong Kong in addressing COVID-19.

Our inquiry in 2003 was established with an international panel to review how well the Government and the health system had done in containing the outbreak. There had been criticism in the media of the Government and the health authorities all the way through the handling of the disease. As a committee, we took the approach of identifying lessons to shape a future response to a pandemic. We were anxious that we did not undertake a witch hunt, but we did not shy away from assessing the decisions that were made in the light of the knowledge at that time, not what was known later. That was a useful way to approach the situation.

In our inquiry, we made a series of recommendations, including the need to strengthen surveillance, to organise the public health system more effectively and to ensure the capacity and ability to mount a surge response in the hospital system to respond to future epidemics. We also stressed the need for a global network to ensure that information was shared and research was open and collaborative, not competitive. We stressed the need for transparency and communication with the public. I have attached a paper that summarises that in more detail, if members are interested.

If you look at the COVID response, you see some improvements on SARS, but not everywhere and not well enough. For example, some of the positive things are that the overall response to COVID-19 has shown a greater willingness to share experience and data and the World Health Organization has played a very important role. There has been impressive collaboration between scientists, not only in different countries but in different sectors across public health organisations, academia and industry, which was not seen during SARS. There is an emphasis on evidence and research to provide guidance on how the pandemic should be handled.

Some things have improved since SARS, but there are still some glaring problems, which include the lack of capacity to test and the failure to provide protective equipment. Those problems seem to be far worse in some situations such as care homes and resource-poor environments. Once again, there has been a failure to respond to the public health advice that we needed to prepare for the inevitable global pandemic.

I will move back, quickly, to the experience of East Asia, this time. I would argue that the jurisdictions that experienced SARS more acutely seem to have been better prepared, particularly Hong Kong, which has seen only four deaths amongst 1,050 cases. The features that characterised their approach are a focus on active containment — I underline active containment — supported by high levels of testing. Given its geographical location in China, Hong Kong obviously expected cases. They instituted border controls and port of entry screening before the first case was identified, which is critical. There are still strict controls on who can enter Hong Kong. You might be interested to know that all returning residents have to have a swab test before they can leave the airport as they come back into the country. Anyone testing positive has to go to hospital, and those travelling with them have to go to a quarantine centre. Residents have to complete a 14-day self-quarantine with strict surveillance, including the use of electronic wrist bands paired with a mobile app. I have it on first-hand experience from one of my colleagues that the phone-based GPS checks take place every day, with random video chats every two to three days, and random home visits are made.

This is what we are talking about when we talk about quarantine at the border. We have seen how that approach, underlined with testing and quarantine, both in Hong Kong and South Korea, has been used to suppress a second spike of disease transmission. Any time that a new test is positive

again.

Why has Hong Kong been successful and what can we learn? The fact that Hong Kong acted early, as soon as they understood the threat, was very important. They have been rigorous in their identification and isolation of cases. Testing has been key to implementing policy, underpinned by a strong surveillance system and the use of the app. Hong Kong was quick to identify the second wave, and, in South Korea, the third wave, and again in Hong Kong. [Inaudible.]

The communication with the public has been commended. [Inaudible.]

For example, mask wearing does not need to be made mandatory as everybody does it. Hygiene practice levels are high, and social-distancing measures are accepted.

flexible as the numbers have waned. As an clinician, I think that the research community has been extremely active in sharing their lessons. Overall, Hong Kong has provided a good example of active containment and of gradually restarting society post-lockdown.

I will finish by saying that the lessons that we could derive from the inquiry are the need for clarity, collaboration, communication, coordination and capacity. Those, supported by information and communication, really underpin the Hong Kong response. Again, I emphasise that the facility to test is essential. I hope that that has been helpful and that Northern Ireland may be able to heed some of the lessons in relieving lockdown.

The Chairperson (Mr Gildernew): Thank you, Professor Griffiths. Yes, that has been hugely helpful, and I think that all of us in the room and on the phone will recognise many of the elements and how closely the issues match across from the previous SARS outbreak.

I will go now to our second guest, Professor McKee. Are you there, Martin?

Professor Martin McKee (London School of Hygiene & Tropical Medicine): I am. Good morning.

The Chairperson (Mr Gildernew): Good morning, Martin. You are very welcome to our Committee. Thank you for coming along. Can you go ahead now, please, and give us your presentation?

Professor McKee: Thank you very much. I would like to endorse everything that Sian said. I also have an interest in

with colleagues there. I think that one of the lessons from that is that, in South East Asia, there was a clear recognition from the very beginning that they were dealing with disease. They were dealing with SARS and not with influenza, and I think that in Europe

there was an issue where [Inaudible.]

I am getting an echo.

The Chairperson (Mr Gildernew): There is a slight echo, Martin. Are you maybe a bit close? We are often asking people to hold the phone closer, but maybe it is a wee bit too close.

Professor McKee: I will try that. Is that better?

The Chairperson (Mr Gildernew): Yes, that is better.

Professor McKee: I would like to pick up three areas that I think are important in going forward. The first is that we really do need very robust information systems in place and we have problems throughout the United Kingdom in doing this. We need to know the level of immunity in the population. We have just got new evidence from Spain and France in the past 24 hours suggesting that the levels of immunity are somewhat lower than we would have hoped for. It is about 5% of the general population, and maybe a bit higher in the Paris and Madrid regions at maybe up to 10%, so that is a concern. We also have to have really good information on testing and on accurate and timely mortality data. I think that there has been a problem with the fixation on the number of tests that have been done without thinking through fully why the tests are being done and what the information is that we need. The reason for this is that we do need to be able to estimate accurately the reproduction number, the R value that everybody is now talking about.

As we go forward, we need that because, for every measure that we take to ease the lockdown, I would argue that those making decisions should be able to say that if we do this, we estimate that it will increase the R value by 0·2 or 0·1 or whatever. We should be confident that that will still keep the overall value below 1, because, even if it is only over 1 by a tiny bit, it will have a huge impact, and the epidemic will grow rather than shrink. That may mean that you do things that will potentially take you above 1 but that you do other things to mitigate them. That may take you into face coverings and so on. The other reason why we need the data is that we desperately need to be able to identify resurgences. We need to identify new outbreaks. So, the first thing is that we really need to improve the quality of the data, and, compared with many other European countries, we still have a long way to go.

The second issue may be of less interest to your Committee, but I think that we should not lose sight of it. We now recognise that this is a complex, multi-system disease, and we have not fully got on top of how best to treat it. We have a worry that a lot of this work is going on in silos. In an earlier existence, a very long time ago, I worked as a medical registrar, in the Royal and in the City Hospital, in internal medicine and cardiology.

There is a tendency to work in silos. I am not commenting on Northern Ireland; I am talking about the UK-wide situation. It is very important that we try to get everybody together from the different specialties and various sciences to understand how we go forward with the information that we already have. We do not have a magic bullet. We will need some combination of treatment, which is likely to include, if we can get it to work, an antiviral agent to kill the virus. Secondly, we need to protect the target tissues. There is emerging evidence that we might be able to reduce the impact on the lining of the blood vessels — the epithelial cells. Then, thirdly, we need to be able to do something to mitigate the hyperimmune response, which is often what kills people. That is the second area. The third area that we need to do more work on is looking at what needs to be in place and getting a whole system map. It should set out how, if we are to do contact tracing — test, trace and isolate — we decide who needs to be part of this. We need to decide which organisations, which bits of local and central government, and which private sector organisations need to be involved.

When we have a map of all the functions that need to be in place, from having a register of the population and correct address system to measuring the quality and accuracy of the test and the follow-up, we need to ask who is responsible for each of those functions. We need to say which organisation and which bits of government and other services — perhaps it will be clinical leads, the health service, the Public Health Agency (PHA) or whoever — are responsible. Then, we set that out on the map. However, above all, we need clear lines of accountability. For every line, we need to ask: who has to talk to whom, how do they communicate and can they talk to each other at a local level or do they have to go to Stormont, Westminster or wherever? Once we have done that, we can overcome some of the silos and some of the problems that we have faced so far. Those are my three points — that is it.

The Chairperson (Mr Gildernew): OK. Thank you very much, Martin. That was very useful.

Our third witness is Professor Anthony Costello. You are very welcome to this morning's session. Thank you for giving your time to provide us with your experience and knowledge. Will you go ahead, Anthony, and give your presentation?

Professor Anthony Costello (University College London): I will try not to repeat what Sian and Martin have said. I will just say that, in January, I was doing some work with the WHO. I became aware of this disease in early January, soon after it had been declared by China on 31 December. The WHO set up its own management team the next day and put out information on 5 January. By the middle of the month, it was clear that there was human-to-human transmission. There was also evidence of it spreading to Thailand. When the WHO in China managed to get into Wuhan around 20 January, it realised that the death rate was much higher than word had been spread about.

By 27 January, I had sent a direct message via Twitter to one of Tedros's closest advisers, simply saying, "Please declare a public health emergency of international concern. Otherwise, you will be scapegoated because the

have not declared it". Of course, that was not the WHO's fault, because of the [Inaudible.]

However, the WHO did, at its next meeting, on 30 January, declare a public health emergency of international concern. By that time, there was talk of 250,000 cases in Wuhan, and it had spread already to 17 countries. Tedros flew to China to see the president. In fact, the WHO did not get its independent group into China until 16 February. So, I am rather defensive of the WHO, which, as an organisation, has been rather scapegoated by politicians. Its advice on day one was that you need to find, test, trace, isolate and practise social distancing, and, crucially, you must do it at speed.

Throughout February, I could not really work out what the UK Government were doing or what the Scientific Advisory Group for Emergencies (SAGE) was saying. Then, on 12 March, I was really horrified to hear that the UK policy was to stop the practice of find, test, trace and isolate; to introduce no lockdown; and to go for a herd immunity policy, which seemed to me to be completely irresponsible, especially as Korea, at that time, had already suppressed its epidemic because it had started an aggressive testing policy three weeks earlier, and it ended up with 250 deaths. Greece, for example, which did relatively little testing, introduced a full lockdown before it had a single death, and it has ended up with about 140 deaths.

Subsequently, we move forward to 23 March, when we went into lockdown, reversing the earlier decision, but we suffered an enormous explosion in cases and deaths because of the delay. There was growing concern from me and many others who commented. Two weeks ago, Sir David King, the former Chief Scientific Adviser, said that he was concerned about the transparency and independence of SAGE, so he decided to set up an independent group. I was approached, as was Martin, and there are 13 members at the moment. I think that you have our report.

Finally, Professor David Spiegelhalter has said, correctly, that it is difficult to draw up league tables of deaths across Europe, on the grounds that there are different age structures, socioeconomic structures and the like, so comparing Ireland with Italy would be dangerous. However, you can look at the rate per million. The data available show that, at the moment, we have, I believe, 32,000 deaths, but the real number is, in fact, likely to be over 60,000, as the 'Financial Times' has reported — it projects the number of community, care home and unreported cases to the present day. The number of cases presented at the press briefings is around 4,000 a day, yet John Edmunds, who is on SAGE, told the Select Committee last week that he thinks that there are 20,000 cases a day. We need to think of that. If you turned that into the rate per million of the population, it would be 841 in the UK, 93 in Germany, 51 in Finland, 15 in Greece, five in South Korea, five in Japan, four in Australia and New Zealand. So, our death rate is probably 200 times that of Australia and New Zealand, and that brings me to my final point.

Three months into this epidemic, we, certainly in England, have failed completely to set up an integrated, local find, test, trace and isolate policy. If you are ill, you see your GP, and your GP is able to diagnose and organise tests. It is a notifiable disease, so you can use the local public health team, the outbreak management team or the health protection team. Yes, we would need some contact tracing support, but that should be built into a local public health response. We do not have that. We are appointing new tsars every day. We are using Serco for contact tracing and Deloitte for testing. We are also using Boston Consulting Group. The whole thing is completely not joined up.

If there is a note of impatience in my voice and less diplomacy than usual when speaking to a Committee, it is because I believe that we are heading into a second wave much more quickly than we need to be. I am very worried that we are starting to lift lockdown measures at a time when, although our R value may be below 1 in the community, it is certainly not below 1 in care homes and hospitals. We still probably have 20,000 cases a day, and that may mean 300,000-plus contacts every day. We are not in a position to suppress this virus. We have simply being trying to manage it in a half-hearted way in England. I am so pleased that Northern Ireland is taking a different view and has adopted the WHO principle, rather than the Public Health England (PHE) principles or those of the Government in Westminster. I will stop there. I have been controversial enough.

The Chairperson (Mr Gildernew): OK, thank you, Anthony and all our contributors.

I agree that this is a particularly dangerous time because of the care home situation. The high number of cases and deaths in that sector is hugely worrying. At this time, what are the key things that this Committee should be focusing on? What are the key questions that we should be asking? That is addressed to anyone on the panel.

Professor Griffiths: I agree that you really need to ensure that you have a strong, local public health coordinated response, which both Martin and Anthony highlighted. As part of that, you need to make sure that you have the testing capacity to carry out contact tracing in the community as the lockdown is lifted.

The Chairperson (Mr Gildernew): Thank you, Sian.

Professor McKee: I fully agree with that. I think that there needs to be a real strengthening of the data. I am aware that there have been some problems with the statistics in Northern Ireland and that the UK Statistics Authority raised some concerns, but making sure that the data are timely and are presented in a way that is fully transparent is crucial because that underpins everything else.

Professor Costello: One of the issues about being local and joined-up is that the person who has symptoms is frightened. If they can have a test, they want to know the result quickly. In about a week, China got its lab test time down from four days to three hours. It got the time from onset of symptoms to test result down from 12 days to three days. That is what we need. When people think that they have it, whether they phone 111 or report symptoms to their GP, we need them to get a test quickly. In my view, swabs should be collected at the general practice surgeries that have hot spaces for infection control, which is most of them. The practice should send off the swabs and get the results back the same day or within a maximum of 24 hours. At that stage, somebody — it could be one the 750,000 volunteers who are clinically trained or maybe someone from other resources — does the contact tracing. Of course, people will trust their GP with information because they know that GPs keep things confidential. Then, you need a proper isolation policy, a proper quarantine. At the moment, in England, it seems that we just tell people to self-isolate for seven days, which is not correct. The WHO says that it should be 14 days.

Of course, you need to differentiate. People who are sick need to go to hospital. If they are unwell and do not need to be in a hospital but cannot cope at home, they may need to be in a community facility. You will have vulnerable people — those with mental health problems or drug addiction — who also need to be looked after outside the home. In multi-generational households, you may need to separate younger contacts from elderly contacts, so you may need to requisition hotels.

All of this was done in Asian countries, but I have not heard of it being done in England except when we had our first few imported patients, when we put them into special facilities and looked after them. If we do not have a proper quarantine policy, we will not stop local/home-based infection, and we will carry on with a level of cases that is too high.

The Chairperson (Mr Gildernew): Thank you, all. My second question relates to the SAGE independent report. It identified, as has widely been recognised, Ireland as a single epidemiological unit for the purpose of dealing with this outbreak and this type of pandemic. Sian mentioned collaboration. From your experience, what would the measures under a joined-up policy across the island look like?

Professor McKee: The island of Ireland is already treated as one for animal health, so it seems odd that it is not treated as one for human health. Islands always have an advantage. We see it in New Zealand, for example, where they have been able to impose certain restrictions and keep their death rate down to double figures or very, very low numbers. There is a clear argument for having consistency of policy.

As we move forward, there is a problem that is still unresolved.

Westminster Government move to a required period of quarantine of people coming from abroad.

when I heard that they would exempt the Republic of Ireland. Of course, anyone can come in on a plane from New York to Dublin and then just jump on a plane or find another way to go across to Great Britain. There are the same issues with France. I have never quite understood. They are talking about some agreement with France, but, obviously, people can move across borders into France from elsewhere. Therefore, it seems logical to treat the two large islands of the British Isles as separate sanitary units. As I said, it is done for animals. I cannot see a public health argument about it. Obviously, being from Northern Ireland, I am not naive, and I realise that there may be a political problem. However, if we are following the science, the science is clearly set up in that direction.

Professor Costello: I have a couple of quick points. The first is that, in our independent SAGE report, we have turned to one of the world's most impressive and exciting mathematical modellers in another area of neurobiology, Professor Karl Friston. He started modelling the COVID-19 epidemic a month or two ago. He said that, although the calculation of R-value has been given great prominence, there are alternative approaches that would complement that approach. The R-value is, basically, a calculation of the spread of infection about two weeks earlier; so, it is a historical model. He has done a thing called dynamic causal modelling, which is a way of looking forward. He has done this for

data sets in America. So, for example, you could say, "In Northern Ireland, if we had not evolved social distancing and

if you can

on local

, would that be more effective than, say, a centralised

approach?". There may be other questions that you can ask. The combination of those two is very important.

One of the other things is that, on 12 March, when we gave up testing, tracing and the like across the country, we were treating it as one epidemic. Of course, at that time, many hundreds of local authorities had

recorded cases, so there was no reason to stop the contact tracing in those kind of authorities. I do not know the figures for Northern Ireland, but I imagine that you had pretty few contact cases and deaths at that time. I agree with Martin that treating Northern Ireland as more about the island advantage that you have with the South would be a very sensible policy to pursue.

The Chairperson (Mr Gildernew): Sian, do you want to come in on that issue?

Professor Griffiths: I support the one-island approach, from the arguments that have been made.

The Chairperson (Mr Gildernew): I will take Paula, Gerry, Pam and Colin in that order, in the room, and then I will go to the phones in the order in which people indicated to me that they wished to ask a question. That was Alex, Órlaithí and Pat.

Ms Bradshaw: Good morning, panel. It is great to have you here this morning. The latest figures in Northern Ireland show that about two thirds of our deaths are amongst people 80 years old and above. How do they compare globally? What should we be doing better to protect our vulnerable elderly? [Inaudible.]

Professor McKee: I would need to check the exact comparisons, but that is broadly similar to what we are seeing elsewhere. There is a clear association with age, but there is also an association with gender, with men being more likely to die than women, and with ethnicity, for reasons that are still poorly understood.

What can be done? I have been critical from the beginning of the way we were looking at care homes in particular. I should give you some background. In my previous research, in the 1990s, I did a lot of work looking at prisons in Russia — the former Soviet Union — and, subsequently, at mining communities in sub-Saharan Africa. Those are what we call institutional amplifiers. We were looking at TB and HIV. Once the disease gets into one of those institutional amplifiers, it spreads rapidly, because there is movement in and out. In prisons, there is staff, obviously, but, in the mining communities, people were going from South Africa back to Mozambique, Lesotho, Swaziland and so on. They amplify the infection in the communities, and then they take it back and spread it into the community.

As you know, there was a debate on what was said when, in response to Prime Minister's Questions at Westminster yesterday. To have had, at any time, advice that people in care homes were not at risk would have been very strange in the light of what we know about the virus's ability to spread, particularly because we saw exactly that happening on cruise liners at the beginning. That is another form — a particularly upmarket form — of an institutional amplifier. We cannot get away from the issue around care homes.

We also need to step back a little bit. Of course, it has been a problem in Italy and Spain, but it has not been so much of a problem everywhere else. One of these factors — and this will come to the fore in any possible inquiry looking at the United Kingdom — has been that we have a relatively low level of hospital capacity, and there was a push to get people out of hospital to save the NHS. It was an honourable objective, but it meant that people were being taken out of hospital and put into care homes, feeding the infection there, and, more broadly, in the community at a time when the testing regime was not well established.

There is a biological vulnerability. Older people are definitely more vulnerable, for a series of reasons, but, coupled with that, a lot of older people are in settings in which they are particularly at risk of institutional amplification.

Ms Bradshaw: I have a second question. You have not mentioned the V-word: the vaccine. You all spoke about the need for worldwide collaboration on a vaccine. What is your understanding of where we are with finding a vaccine?

Professor McKee: Sir John Bell was talking about that on this morning's 'Today' programme. Over 1,000 people have been recruited in the Oxford trial, and there seems to be no major side effects. As you know, there are questions about whether the antibodies that will be created — hopefully, with the vaccine — will be protective or whether there will be a mutation of the virus.

There are a number of features of this coronavirus, compared with other coronaviruses, that give us cause to be quite optimistic. Those features include the nature of the spike that we keep talking about and the way in which it is exposed and not protected by

and things like that, as well as the fact that, although it is mutating, it seems to be mutating relatively slowly compared with some others. However, it would be remarkable to get a vaccine out within this calendar year. That would be an incredible achievement.

One of the difficulties, of course — this was the problem with SARS — was that you need to have enough of the virus circulating in the community for people to be at risk of getting it. Of course, we are doing all the things like social distancing to reduce that risk, otherwise you will not know whether the group that gets the vaccine and the control group, actually are a different element. That is a huge challenge, and that is leading some in the US to talk about a

study, whereby young, otherwise healthy people might be given the vaccine. That is quite controversial, as you might imagine.

There has been superhuman effort; there has been a lot of progress so far, but we also need to be clear that we probably will get a vaccine but we cannot be absolutely confident that we will.

Ms Bradshaw: Thank you.

Professor Griffiths: I just want to point out that, once we get the vaccine, getting a policy for getting it produced in large quantities, distributed to the right people etc, will take quite a lot of effort as well.

Professor Costello: I am a little bit more worried about the prospect of a vaccine than I was; I hope that I am wrong. Martin is right: there may be things about this virus that are encouraging. At the moment, however, as was said earlier, the serology tests that we have show that, in Spain, 5% of the population has antibodies;

I heard, may have 6%; Geneva 9%. So, let us say that only 10% of

antibodies in this stage of the virus. If that reflects everybody who was infected getting antibodies, then that means that the infection fatality rate is high. In other words, we will have had 60,000-plus deaths from a virus that only

10% of the population. You can do the sums; if it went to 60% or 80%, it would be a much, much higher death rate if it spread through the population.

If, on the other hand, only a very few people get the antibody response — there are a lot of asymptomatic or mildly symptomatic people who do not have antibodies — that suggests that creating that immune response is quite difficult. That may be more negative from the point of view of developing a vaccine. Then you have the problem that, even if you develop a vaccine by, say, the end of the year, it could, in some sense, take another one or two years to get it manufactured and to all the population of the world. So we may be living with this virus for several years, and we should be making plans for that.

The Chairperson (Mr Gildernew): Thank you, panel, that is very interesting.

Mr Carroll: Thanks, panel, for your presentations. Sian, in your paper to the Committee, you mention Governments failing to heed public health advice. That is something that I and lots of people would certainly concur with in the case of the British Government and the Executive here. Anthony mentioned that there were warnings in early January about the development of the virus. Some epidemiologists and scientists were warning, even before then, about the possibility of viral infections developing and spreading.

I am also aware that at the time of the SARS outbreak, the WHO developed a collaborative research project in 11 laboratories in nine countries to tackle that disease. You said that we needed a coordinated approach. Does the panel think that now is the time to expand existing bodies or create new bodies or public health organisations to deal with not only this crisis but any new viruses that may develop in future?

The Chairperson (Mr Gildernew): Do you want to pick up on that one, Sian?

Professor Griffiths: Yes, of course. We need to think about public health organisations at different levels. We have already made the case for having strong public health at a local level as an effective way of dealing with this crisis. The global role played by the WHO should not be underestimated. We need to make sure that our existing organisations, such as the WHO, are strongly supported. We all know that in the US, Mr Trump has been less than complimentary.

He has threatened to withdraw funding, and he has very much been a destabilising influence on the power of WHO

line towards China. I think that we just have to depoliticise that and think about the importance of the WHO in making sure that it can help to coordinate across the lower and middle-income countries and not just think of ourselves.

After the event, we need to think about whether the WHO needs strengthening in some way. I would welcome that. Rather than think of a new organisation, we should use what we have. We should strengthen our local, our national and our global organisations.

Professor McKee: Of course, we absolutely need the global organisations. I realise that I am probably getting into the lion's den by even raising this, but we have the European Centre for Disease Prevention and Control in Stockholm, and it has played a very important role. There are going to be enormous difficulties in the future. We already have a situation where Switzerland, which is outside the single market, has been struggling to develop a working relationship. As we know, until the end of the transition period, the UK [Inaudible.]

There has been a lot of debate back and forward about missing emails and all sorts of things. Looking ahead, for the island of Ireland, this is going to be a challenge that somebody is going to need to grapple with to work out how you in Northern Ireland can try to find a way of continuing to benefit from these relationships.

Professor Costello: The World Health Organization's regional offices have a technical role and a political role, and I believe that the technical role is very important, particularly where Martin's suggestion about having centres for disease control around the world in different regions is concerned.

For the last 30 years, the WHO has been progressively underfunded because the assessed contributions from countries have remained frozen as a result of an initiative that came initially from President Reagan. You now have the President of the United States threatening to withdraw all the funds from it. Just to give you an idea of how it is begging, in an early February report, Dr Tedros put out a call for $675 million to help the WHO to protect countries around the world. That is actually a very small sum. I texted him a month later, on 4 March, to ask him how it was going. I said, "I see you have commitments of $120 million". He said, "Commitments, yes. Do you know how much I have received?". I said no, and he told me that it was $1·2 million. So, two months into a pandemic, the World Health Organization, which has an annual budget no larger than

University in London, had received $1·2 million from all the countries in the world to help it to fight the pandemic. I think that that is an utter disgrace, and I will quote Richard Horton, the editor of 'The Lancet', who said that the President of the United States's move to cut funding to the WHO was "a crime against humanity".

The Chairperson (Mr Gildernew): Thank you, Anthony. That is certainly a stark and very worrying figure for the scale of the response to the global pandemic.

Mrs Cameron: Thank you, panel, for your attendance. It is very much appreciated. You mentioned some of the early data that is coming back on immunity levels from other parts of the world. What is your opinion on how each wave of the virus will differ? Is it possible that there may be five or six waves before we have a vaccine?

The Chairperson (Mr Gildernew): Thank you, Pam. Do some of our panel wish to pick up on that first?

Professor Costello: It is very difficult to predict, because viruses behave in different ways that we do not fully understand. You cannot predict it. I suspect that we will not get huge waves like we have now, although we could, but some will say that because people are already sensitised to social distancing, in a sense, they will carry on doing that regardless of government policy. The likelihood is that you will have a high level of endemic rather than epidemic, so there would be a lower

lasting a longer time, but I could be completely wrong. I do not know what Martin thinks.

Professor McKee: I just do not know. The danger is that, again, going back to my earlier criticism of treating this as pandemic influenza, we know that there is a seasonality in pandemic influenza that there may not be with this, although there are still some really important questions. There is some seasonality with other coronaviruses but not all of them. I think that we are very much in the dark. We still need to understand much better what is happening in Africa, but, on the other hand, it is what we can see in the tropics

on the equator is extremely worrying. The gaps in our knowledge are still very substantial.

Professor Griffiths: In the Far East, they counted imported changes, so for Hong Kong and mainland China,

all the students were going back, so they were taking back infections from the US and Europe, and, in both situations, particularly for Hong Kong, they then had to really ramp up the testing, quarantine and isolation in the way that I described. That was the second wave, and they managed to get through that. They have had no cases for a while, except for a single case that has just emerged. They respond very quickly, so they are not getting waves; they are getting small, isolated outbreaks. It is the same for South Korea, where the clubs have opened up. What they found was that one case infected about 50 people, and they have been doing huge contact tracing that is focused on that [Inaudible.]

Mrs Cameron: Thank you for that. On the back of that question, what should our economic recovery look like? How would staggered working operate? Along with that, what are your views on face coverings or masks?

The Chairperson (Mr Gildernew): Who on the panel would like to pick up on that?

Professor Griffiths: I will pick up on masks or face coverings or whatever they are being called. The argument is that it is a precautionary principle. We think that they may contribute to protecting other people who come into close contact with you as

is released. In general, there is a recommendation to wear a face covering. It can be cloth that can then be washed at 60°C and reused, particularly when you go out of the house. The big danger is using up valuable personal protective equipment (PPE), and there are ways around that. Masks, as I said, are absolutely common in Asia not just this situation but any situation where someone has an upper respiratory infection.

Professor McKee: I will just jump in again. I fully agree with that, and, maybe all three of us will agree, although there will obviously be different views elsewhere. I think that people have misunderstood this. As Sian said, we are talking about face coverings. I would avoid the use of the word "masks", because that creates confusion with PPE. Nobody is talking about taking away surgical masks or respirators from health and social care workers. These coverings are just something that will interrupt the flow of breath from you. The reason why I changed my mind and am in favour of them now is that

an awful lot of the evidence that people looked at was for influenza. This is a different disease. This is spread when people are either asymptomatic or pre-symptomatic as well as when they are symptomatic. Therefore, just wearing a mask when you are infected and you know that you have symptoms is not going to help.

Secondly, the studies that have been done have often looked at the protection of the person who is wearing the face covering, whereas this is very much about source control.

This is about protecting other people. That implies that you want everybody to wear them, because what happens is this: people spread droplets, which get into the air, dry out and become an aerosol, which then floats around in a way in which droplets do not, because droplets fall to the ground. Just having that covering, which prevents the droplets getting out by catching them, can make a difference. There is nice work from Hong Kong looking at that, and it does seem to show that face coverings seem to be more effective with coronaviruses than they are with either influenza or the other common cold virus, the rhinovirus. I am therefore definitely in favour of them.

Professor Costello: The first question was about the economic effects. As we have seen, the stock markets have rebounded very quickly in the past month, because they are hopeful of a V-shaped recession, and they are predicting that everything is going to get back to normal in two or three months, a bit like after SARS-COV-1 and MERS.

I think that they are making a big mistake. This is a doctor talking, not an economist. We have seen massive central bank interventions. Most of the big stock market companies whose share price is going up are the major tech companies. I have serious concerns that this is going to last for at least two years, however. The oil industry, the aviation industry, hotels, hospitality, restaurants, international trade, cruise liners and universities are all in financial difficulties. We are heading into a deep recession, and some respected economists, such as Professor Nouriel Roubini in the States, believe that we should be heading into a depression by next year. The best that we can hope for is not a V-shaped recession but a bath-shaped one, or even a very, very prolonged suppression of our economy. I hope that I am wrong and that I am talking nonsense.

Professor McKee: Anthony, I will jump in to tell you that the stock market has fallen substantially this morning. About an hour ago, it was down about 2·5%, so I think that people are paying heed to that.

I should say that quite a lot of work being done. Colleagues of mine in the United States have looked at the economic impact of pandemic influenza of 1918-19. There, each of the cities closed down and opened up at different stages, and that work makes very clear that those cities that closed down earliest, and stayed closed for longest, had recovered much better by 1924-25. The argument is that it is an either/or. We published a paper in 'Nature Medicine' that looked at some of the evidence. I am happy to circulate it.

Another thing that came out very strongly is that the Government's approach to furloughing is very good, because it means that, when we are able to recover, we will still have people in jobs. We are protecting particularly the small and medium-sized enterprises that are at risk of failing. The Government could do more, and there is a lot of talk about how they have spent a great deal, but, in comparative terms, the German and other Governments have spent a considerable amount more, by GDP, than the UK has. That is not to knock what has already been done. It is very important to make sure that we have businesses that are maintained and held over. It is a bit like putting people on a life-support machine, allowing them to remain alive so that, when the virus is eventually defeated, they recover. Looking at the economy in the same way is very important.

The Chairperson (Mr Gildernew): Thank you, panel.

Mr McGrath: I thank the panel for giving us that information. You have the benefit of understanding all of this, but many of the public do not. They are just following instructions, but there are many out there who would like to follow the instructions in possession of a bit more knowledge. There is a task of explaining things to people.

Sian, I will not ask you a question, but I note that you said that, after SARS hit, we needed to prepare for the "inevitable global pandemic." When this all passes, we will have to review why, if we were expecting a global pandemic, we were not prepared for it.

I will ask one question of Martin and one of Anthony. Martin, can you give us a layman's definition of the R value? We kind of know what it is: it is the number of people you will pass the infection to. How do you determine it? How do you work out what the R value is, and what impact does that then have? If you can keep the explanation to a level at which I can understand it, you will be doing pretty well at a layman's definition. [Laughter.]

I was going to ask you, Anthony, whether it is your view that the cessation of testing on 12 March caused more deaths, but I think that you have answered that. Again, that is something that will come out afterwards, and the British Government will have to respond. The stopping of testing could have caused a spike in transmission and an increase in the numbers of deaths. We talked about the containment stage and the delay stage here. At that point, we asked our Chief Medical Officer (CMO) about testing. The response was almost, "Testing is not a silver bullet. You do not need to worry about it". That view changed about two or three weeks later. Do you think that our Chief Medical Officer should have been more concerned about testing, say, five or six weeks ago?

Professor McKee: I will not comment on what Michael McBride said or did not say, but you have picked up on a very important question. As a number of people have said, calculating the R value is not straightforward. In an ideal world, you would have almost daily testing of people and be able to see who met whom and how they passed it on. There is some work being done in a research setting that is looking at the degree of spread, using very minor genetic variations in the viruses. For example, in the United States, they have been able to say that, in some states, spread was caused by just one person coming in either from Europe or Asia, because the virus could be differentiated, and it then spread within communities.

The R value is being calculated in a number of ways. Colleagues of mine at the London School of Hygiene & Tropical Medicine have been doing some work using surveys, taking the infection data and combining it with data on how many contacts people were having, and working out the R value from there. It is therefore an estimate. Clearly, without a high level of testing, you will be guessing to some extent. Modelling data is usually used to try to calculate it. It is a case of, "If we are getting this, the R value will have to be that". It is not a straightforward issue, however. As Anthony said earlier, even within any society, it will be different. For example, it will be different in care homes from in the general population.

You asked me to explain the R value to you in very simple terms. I am not sure that I can do that. Many people have tried to. You can say, "Well, what is it?". You captured it perfectly well by saying that it is the number of people to whom it is transmitted. However, you are taking a whole lot of different bits of information, combining them and then back-calculating from that.

You mentioned the idea that something might be a silver bullet. I really would like to put that one to sleep very firmly. Nothing will be a silver bullet for this. When I talked about medical treatment, I said that you will need a combination of treatments against the virus to protect the tissues that are being infected and to deal with the immune response. It will not be like penicillin was for streptococcal infection or something like that; rather, it will be a combination of measures. We really need testing up and running, however. The more testing that we have, the more information that we have and the more confident that we can be that we have the R value. I have not really answered your question, I realise.

Mr McGrath: You have done well enough.

The Chairperson (Mr Gildernew): You tried very hard, Martin.

Professor Costello: We removed "find, test, trace" and had no lockdown on 12 March, when we were hitting the exponential part of the curve, which means that things are happening very, very fast. For example, if we had 20,000 cases, and the number was doubling every two days, we would have 1·2 million cases 14 days later. Without question, the decisions taken that day must have influenced the size of the epidemic, and therefore the number of deaths. However, I have said all along that this should be a no-blame audit for now. We should not be pinpointing individuals. The Scientific Advisory Group for Emergencies had a lot of very good people on it, who were giving of their time and advice as best they could. There was a misjudgement based on pandemic influenza, as Martin said. There was some British exceptionalism: that we knew best. We should have been in contact with the international people much more, particularly in Hong Kong, Singapore and the like.

The worst thing, in my view, was that there were no independent public health voices in SAGE. Had we had Sian or Martin in there, the decisions that were made would have been challenged much more. A couple of days ago, Jeremy Hunt said that this is:

There may be some truth in that, but what worries me a lot about the CMO, the deputy CMO, and advisers is that they are civil servants, and they must not be used as human shields for politicians, because they are limited in what they can say, by virtue of being civil servants. The Northern Ireland Chief Medical Officer, as I understand it, was allowed to attend SAGE meetings and listen but not allowed to ask any questions. I would therefore not be putting blame on specific people at all, for this was a systemic failure in Britain, and we need to look at the reasons why that happened.

Professor Griffiths: I support Anthony in that. It is really important, at this point and until we get through the pandemic, that we do not apportion blame. In the SARS inquiry, what we tried to do was to say, "This decision was made at this time, because these were the conditions and this was what was known". Doing that enabled us to unpick some of the feelings that were there, which are very natural, but we need to do the analysis post hoc and then move forward rather than have a blame culture.

The Chairperson (Mr Gildernew): OK. Thank you. We will go to the phones. Are you there, Alex?

Mr Easton: Thank you so much for your presentation. I found it interesting. I have a couple of quick questions. You mentioned the pandemic in Hong Kong and the animal markets. Do those animal markets in China need to closed down permanently. If so, how can we do that, because it is China that we are talking about?

You mentioned herd immunity, Anthony. We were told at the very beginning of this that we should not go into lockdown too soon because there needed to be enough time for herd immunity to increase. You also said that the death levels are probably a lot higher than what we know. How can we get to the bottom of the actual figures?

My last question is for Martin, and it is about the low level of immunity across Europe. He talked about it being between 5% and 10%. Why is that the case?

Professor Griffiths: I will deal with the question about wet markets. There is a bit of confusion sometimes in the way in which we use language. Wet markets are just fresh markets to which people in many parts of the world go to get fresh vegetables. The real risk in the coronavirus spread has been the wild animal trade, which is often illegal but takes place in wet markets. At the time of SARS, the wild animal trade was in civet cats. This time around no one is absolutely clear, so we do not want to make any pronouncements, but, in those situations, the coronavirus has been found in bats. It is not necessarily that bats are being sold but that they have infected other animals, and the virus then jumps from those other animals to man. That zoonotic transmission is enhanced by dirty conditions — unhygienic conditions — in wet markets and illegal trade. That is something that the Governments in the relevant jurisdictions need to be looking at. We have seen a lot of change in Hong Kong when it comes to hygiene, particularly around the sale of chickens, because of bird flu etc. It is the wild animal trade that needs much more rigorous regulation, however.

The Chairperson (Mr Gildernew): The other part of Alex's question was about the immunity level being low across Europe.

Professor McKee: That takes us back to the issue that we do not know how many people who are infected go on to develop the antibodies. There is some evidence that people who have had very mild symptoms may not, as I think Anthony mentioned earlier, so that could be one factor. The other factor is almost certainly that countries have imposed physical social distancing, and, as a result, have interrupted transmission. Anthony mentioned how we could have been up in the millions of cases very easily. The fact that we are not shows how effective the measures were that were taken have been. The pandemic has been controlled, to some extent. In other parts of the world, such as the Amazonian part of Brazil, it is completely out of control, and we can see that there is a real danger there.

That brings us back to the point that there are big gaps in our knowledge, but it does suggest that the idea of herd immunity, which many of us think was never a particularly good one, was even less of a good idea. In fact, Dr Tedros, the director general of the WHO, and Mike Ryan, who advises him, were scathing — Mike, in particular — about that in the WHO press conference the other day.

Mr Easton: My last question was about the death levels. Is it possible to get to the bottom of the figures? [Inaudible.]

Professor Costello: I am sorry, but I missed that. Was that about the level of deaths?

Mr Easton: Yes, you were saying that they were considerably higher than we know. I tend to agree, and I am wondering how we can get to the bottom of the figures.

Professor Costello: As you know, the data presented in the daily press conferences until recently were largely made up just from reports from hospitals, which, of course, are quite easy to collect. The Office for National Statistics (ONS) collects data much more rigorously. However, it is usually two to three weeks behind because people have to report cases from care homes and from the community and they need to be registered. It can sometimes be a month or more before you will get the final death toll.

The 'Financial Times' has looked at the patterns in care homes and at community deaths and made a reasonable projection based on them. So, according to the 'Financial Times', just over 60,000 people will have died right up to today, based on its mixture of what is being reported from hospitals and by the ONS, and a projection forward. The figures presented in the daily press conference are largely from hospitals and some care homes because up until about three weeks ago [Inaudible.]

Professor McKee: May I jump in quickly on that? In our independent SAGE report, we were very clear that we should be looking at the seasonally adjusted excess mortality, because even if that includes some cases that are not due to COVID-19 directly but which may be indirectly caused by COVID-19 — people not going to hospital for heart attacks, for example — it is still the best measure. If we look across Europe, as 'The Economist' has done, you can see that, in Germany, the cases that are attributed to COVID-19 make up 97% of the excess mortality. In France, it is 93%, but, in the UK, it is only 64%. The Netherlands does even worse at 51%. I think that link to the issue of testing strongly suggests that a lot of the excess mortality in the UK is almost certainly due to COVID-19 but is not being attributed to it.

Ms Flynn: My question to the panel is — I apologise, but there is an echo coming back at me — what practical measures could be put in place across the island in the short, medium or long term to battle the virus?

The Chairperson (Mr Gildernew): Thank you, Órlaithí. Panel, before you answer, can you stay on for another few minutes to give members a little bit of extra time? What way are you fixed?

Professor Griffiths: OK.

Professor McKee: No problem.

Professor Costello: I am OK, but not for too long.

The Chairperson (Mr Gildernew): I appreciate that. We will come back to you with a second question, Órlaithí. I appreciate the panel making that extra effort.

To refresh, Órlaithí's question was: what measures could we look at across the island to deal with the pandemic in the short, medium and long term?

Professor McKee: Everything that we do to move ahead should be with a clear intention of keeping the R count below 1, recognising all the limitations that we discussed about how you actually measure that. You have to have coordination. I know that there has been some debate in the Republic of Ireland about clusters of cases around the border. I have not been able to look in sufficient detail to know what exactly is going on there. It is just to have clear coordination.

The European Commission's document on lifting the lockdown is very clear about the need for coordination. It contains a number of analogous examples, such as the town of Gorizia on the Italian/Slovenian border, where the border goes down the middle of the main square, which is a little bit like being in Pettigo. It is nonsense to have one set of rules in one jurisdiction and another set in another, particularly where people are walking across a bridge or a border every day.

The principle is that we need to break the transmission chain, and that means a combination of distancing, testing, tracing and isolating.

Professor Costello: The reason that I emphasise what the WHO, and everyone else, emphasises — find, test, trace and isolate — is that we want to suppress the virus, not just manage it. We want to save lives by preventing cases, and, most importantly, we want to get the economy going again, because the economic impacts of COVID-19 are enormous. A depression would be a catastrophe for [Inaudible.]

We need to get a sustainable find, test, trace and isolate policy, and by that I mean one that brings in the strengths of our islands: the primary care system, the public health service and joined-up, committed, professional people. That is why I have been very critical of the situation in England where it has been

and a lot of local authorities have been very confused about what they are supposed to be doing. If we can get that sustainable service, and I think that Northern Ireland and Southern Ireland will have done well in this regard, you can be like the Asian states that Sian mentioned.

or from community transmission starting up, but if you get right to

you can jump on those quite quickly, and that is what Korea is doing with the latest outbreak in a club. That is what China is doing. All the states are keeping an eagle eye with a surveillance system. We have to lower the number of our cases before we lift the lockdown. [Inaudible.]

Ms Flynn: The Department told us that

the testing strategy, the development has continued since the start of the pandemic, but particularly through the month of April due to the increase in capacity. Could capacity or demand in the market be used as viable reasons for having a slow evolving testing approach as opposed to a

called for consistently?

Professor McKee: Chair, there is an echo on the line. Could you summarise and repeat the question? It was difficult to follow.

The Chairperson (Mr Gildernew): To summarise, the Department here said that there were alternative strategies to test, trace and isolate throughout the month of April and that there was a delay in rolling out those strategies. Is that the case, or is test, trace and isolate the gold standard? I think that that was the question.

Professor Costello: epidemiology.

what the alternatives were, but it should be absolutely standard.

Professor McKee: In a recent paper by the London School of Hygiene & Tropical Medicine, two or three members of the SAGE committee analysed the impact of all the models and the different types of approach, such as mass testing, manual local testing and contact tracing. They found that the manual local testing approach was best at reducing the R rate and that the mass testing run by an independent company did not reduce the R rate. The evidence that we have from the testing supports that view. Certainly, based on WHO evidence — and I must pay tribute to Mike Ryan and his colleagues, because those people spend their whole lives hunting viruses. Mike Ryan is a tribute to Irish good sense. He has been extremely articulate in promoting the WHO principles.

The Chairperson (Mr Gildernew): Thank you. With regard to mass testing and manual local testing, is that the tracing techniques that are employed?

Professor Costello: Yes. Basically, we have a joined-up system. I passionately believe that this must involve primary care, GPs, and public health. If you need additional help, in the intense part of it, you bring in the contact tracers. However, you do not make that separate, because once you fragment

it is not going to [Inaudible.]

Ultimately, you want to

all cases and contact. That is the best form of social distancing. Then you isolate 10% of the country and 90% get back to work. National lockdown is a disaster [Inaudible.]

That is why it is so important to get the details right and get it locally

and sustainable.

Professor McKee: It goes back to the third point that I made in my initial presentation: somebody needs to sit down with a very large sheet of paper and put on it all the elements that need to come together and be clear about who does that. One of the concerns about what has happened in England is that — I do not want to look backwards, because that is not helpful at this stage — but there has been a tendency, each time there has been a problem, to find a large outsourcing or consultancy company to go to and say, "Solve our problem for us". Of course, such companies tend to take very simplistic solutions. That is not what is needed. This is a complex problem that really will benefit from knowledge and from established links — for example, such as we used to have in England between regional and district health authorities, but which have now gone.

As I say, I do not want to go backwards on this, but the idea that you can go to a

stand-alone programme for testing is the same mistake that we have been making in development in

for decades, where you think that you have just one solution and you do not

local context.

Mr Sheehan: Thanks to the panel for the presentation. One of the frustrations that many of us here have is that we cannot interrogate the scientific evidence or advice. For example, when we asked why community testing and contact tracing was stopped here on 12 March, we were told that it was guided by an expert scientist working in the field or that it was based on expert scientific analysis and sound public health considerations. Those of us who are not scientists have been watching this virus that started out in China. We have seen a tsunami progressing across the planet. In contrast to the lack of transparency here, we see advice from the WHO. We also see international best practice in places such as Hong Kong and South Korea.

My question has a couple of parts. Do you agree that the decision on 12 March was based on the best public health considerations? There is also the question of what was done across the water and whether it should also have been done here. We discovered during Brexit debates over quite a number of years that, in many ways, we were an afterthought and that no consideration was really given to the unique circumstances here on the island of Ireland.

There is one other issue that I want to bring up. I acknowledge the argument that, where there is widespread community transmission of the virus, testing and tracing may be difficult. However, if we look to South Korea — there was a very interesting documentary on Channel 4 last night, which you were part of, Anthony — we see that they initially thought that they had the virus under control, but then there was a major outbreak in the city of Daegu, a city of two million people, and they realised that they were being overwhelmed by the rate of community transmission. They did not stop testing and tracing in the whole country. They suspended it in Daegu and continued it in the rest of the country. Was there not an argument for that approach to be taken on 12 March?

The Chairperson (Mr Gildernew): Thank you, Pat. Over to our panel. Who would like to start on that?

Professor Costello: I am quite happy to have a go at that. In answer to your question, no, I do not think that it was based on the best scientific advice, because the view of the scientists on that committee were largely from modelling, virology and behavioural science and they did not have a public health voice. They did not have an independent public health voice or voices, and they did not consult scientists from Korea, Hong Kong, Singapore or China, as far as I am aware. Remember that we do not have the minutes. We do not know what was discussed in those meetings. Maybe it is with a retrospectoscope, but, in my opinion, clearly, the decision that it took was not correct.

On the question of whether Northern Ireland is an afterthought, that is a political judgement. I believe passionately in devolution when it comes to public health and in making sure that everything is geared to the local context [Inaudible.]

Professor McKee: Can I just recall what happened in 1996? We wrote about it at the time. That was when the Ulster Farmers' Union called for a separate BSE status for Northern Ireland. It was at a time of direct rule. At that time, there was a Conservative Government. Baroness Denton, in the Northern Ireland Office, argued passionately for that separate status but was overruled by her colleagues in the Government. Northern Ireland was treated the same. I do not want to get into politics, particularly because I am from Northern Ireland, but that should have reminded us that there are certainly differences. It has long been recognised that there are differences in animal health, so it is not surprising that we should think that perhaps we should look at differences in human health, too.

The Chairperson (Mr Gildernew): Thank you. I will come now to Alan.

Mr Sheehan: Chair, can I just come back in with a short question?

The Chairperson (Mr Gildernew): Go ahead, Pat.

Mr Sheehan: Can the panel comment on the uneven spread of the virus and, if there was widespread community transmission, sealing off one particular part of a region or a country and continuing with testing and tracing in other parts? The second part of that question is this: why did community testing and tracing, which had stopped, not resume immediately when the lockdown began?

Professor McKee: I will take up the first one. First of all, there is actually a precedent, because there have been significant restrictions on movement between the mainland and the Scottish islands, so it is impossible to get from Mull to Shetland and so on, unless you have a very good reason to be there. That has happened.

If we look at the situation internationally, we see that Italy is a very good example of where restrictions were imposed on movement in the four northern regions of Venice, Emilia-Romagna, Lombardy and Piedmont. When we look at the excess mortality, we see that they were the only four regions where it is now at even 50%, and in the other parts [Inaudible.]

There are 20 Italian regions. If we take that as the measure of control, we see that they controlled the epidemic in four out of the 20 regions. If we take the 12 standard regions of the UK, which are Northern Ireland, Scotland, Wales and the English regions, you can see that

in seven out of the 12. There has been much less success at limiting it. Of course, I can see that there are issues with preventing people moving from the West Midlands to the north-west, but they did it in Italy.

Professor Costello: In Korea, they had a partial lockdown in two of the 18 provinces. They did it in Singapore by locking down certain parts of their city state where there were outbreaks. Indeed, the Government are now talking about future partial lockdowns if things are getting out of control in certain areas.

On March 12, they could have had a debate about locking down London, meaning everyone within the M25, and possibly parts of the Midlands. I am in rural east Yorkshire right now, and we have had very few cases up here. Certainly at the time of lockdown, I think that there were fewer than 10 cases in the entire district of East Riding, which has about 350,000 people. It was an option, but, on the other hand, there were political considerations

when they had to do it on 23 March, that probably did require a national response.

Mr Chambers: I am aware that two of our contributors this morning serve on the independent SAGE group, so I will come at this maybe as the devil's advocate. Why was it felt necessary to form an alternative SAGE group that is seen as being in competition to the official SAGE group, which is widely regarded as having the best scientific minds in the land? Does the independent SAGE group accept that, by publicly undermining those scientific minds and efforts, it is perhaps, in fact, undermining the scientific and medical minds that are trying harder than anyone else to save lives? The official SAGE has access to all the latest data, both public and not, whereas I assume that the self-appointed alternative SAGE group has access to a significantly narrower data field. In conclusion, do all three of the panel members fully support all the actions and statements made by the World Health Organization to date on this crisis?

The Chairperson (Mr Gildernew): Thank you, Alan. Who in the panel wants to start on that?

Professor Costello: Perhaps I will start. First, science is always about debate, and in a complex situation like this, it tends to be about open discussion and transparency. That was why Sir David King was so concerned that there should be an independent SAGE, not an alternative SAGE, that would particularly focus on the weaknesses of SAGE because it did not have a public health or social science point of view. We wanted to do it in an open way to discuss many of these problems.

We do not know how [Inaudible.]

You are absolutely right that there are some fine scientific minds on the main SAGE. However, I argue that the definition of science goes beyond behavioural science, virology and mathematical modelling and that, actually, public health, with population science, is the primary science that you need to involve in this epidemic. The independent SAGE includes social scientists, people who have expertise in black and minority ethnic (BME) issues, which is a much bigger problem in England than in Northern Ireland, and many other representatives. Having that open debate will be constructive.

In our report, we have been totally constructive. We have sent it to the Chief Scientific Adviser and to the CMO, who has indicated that he approves of many of the suggestions. We have not looked back in a way that is critical. We have tried to make positive contributions.

Professor McKee: I really want to refute absolutely the idea that there is any competition. First of all, there is a degree of overlap in our membership. Some members of the official SAGE are also on the independent SAGE. Many of us, as individuals, talk to senior officials on a regular basis, and that is absolutely meant to be constructive. It is not meant in any way to undermine anybody. Actually, that is a very serious allegation to make, and I, personally, find it offensive that we would be trying to do that.

Mr Chambers: I think that I was talking about the public perception of what you are doing.

Professor McKee: I just find it spurious. Of course we are aware that there have been a number of attacks on us, which, in a number of cases, are factually inaccurate. In fact, one of the individuals concerned had to correct what they said.

No, this is not a competition. This is meant to be constructive, and there are formal mechanisms for ensuring that we share our work and what we are thinking with some of the people who are in more official positions. I just want to say that that is simply not true. Why would we?

Professor Costello: I feel quite sorry for many of the scientists on the official SAGE. Most of them are very happy to give their names, and most of them would be very happy to see all the minutes from their discussions. You will have seen how the press targeted Professor Ferguson in a way that I thought was highly inappropriate and unfair. My worry is that, when we come to a public inquiry, it will be all about shifting the weight onto the individual scientists on SAGE, and that should not be the case. We are, in fact, adding value to an extremely complex national crisis.

The Chairperson (Mr Gildernew): Thank you, panel members, very much for the length of time that you contributed to this meeting and for the evidence, experience and knowledge that you brought. When we initially agreed that we wanted to schedule this session, we asked for this type of debate. We wanted to inform and educate ourselves from the best evidence that we could find from across the world and from other pandemics so that we could play our role in scrutinising and advising the Department of Health. I think that is valid, and you all contributed hugely to that effort this morning. I thank you for your attendance and wish you all the very best in the days ahead. Go raibh maith agaibh agus slán libh.