Melissa Sweet writes:
“Red teams” of people from outside usual advisory and decision-making structures should be employed to test planning and responses to future pandemics and other emergencies.
These teams would include content experts as well as non-experts who do not know the specific topic in any detail but who are skilled at analytical and critical thinking more generally.
This is one of a number of recommendations from the first report of the UK COVID inquiry that may also be of interest for Australian efforts to better prepare for emergencies.
The report recommends that the governments of the UK, Scotland, Wales and Northern Ireland should each use red teams in the Civil Service to scrutinise and challenge the principles, evidence, policies and advice relating to preparedness for and resilience to whole-system civil emergencies. The red teams should be brought in from outside of government and the Civil Service.
The independence of red teams from institutional structures affords them a fresh perspective, enabling them objectively to review the thinking of others and identify cognitive biases that can lead to errors of judgement, says the report.
They are less susceptible to any ‘groupthink’, optimism bias, received wisdom or assumed orthodoxy that can grow within institutions over time.
As well, their independence makes them better placed to ask difficult questions and challenge biases, without the defensiveness or fear of personal or professional repercussions that can exist among colleagues working within the same institution.
The report notes that red teams are not a new idea within government or industry, and are perhaps most well established within the military and defence establishment, with the Ministry of Defence having published guidance about their use as far back as 2010.
It says governments and their institutions should be open to potentially unconventional thinking. The use of red teams should also stimulate a change in culture, as it will be known that decisions may have to be justified in a ‘red teaming’ exercise.
Access to a wide range of high-quality, competing advice and regular, external, independent input will make the system better equipped to prepare for and build resilience to a pandemic in the future, says the report.
The report notes that prior to the COVID-19 pandemic, the UK Government might have been assured that the UK was well prepared – for example, by the World Health Organization or the UK’s ranking on the 2019 Global Health Security Index.
“However, if it had been asked ‘prepared for what?’, the only answer would have been ‘prepared to implement the 2011 Strategy’ – with all its underlying flaws and consequences. This would have revealed that the primary aim of the strategy was not to prevent or mitigate the emergency but to manage the casualties and fatalities that would result.”
Croakey is interested to hear from readers about whether red teams are used in Australian bureaucracies, noting that this approach seems quite different from the reliance on private consultancies of so many government departments.
Examining structures
The report is the first volume from an inquiry into the UK Government’s handling of the pandemic, led by a retired British judge, the Baroness Hallett DBE. This volume examines the state of the UK’s central structures and procedures for pandemic emergency preparedness, resilience and response.
The Baroness wrote in her introduction that “no inquiry with such a wide scope has ever proceeded with such speed or rigour, or obtained so much relevant documentation in such a relatively limited amount of time”.
“It is right to say that few countries have established formal legal inquiries investigating the many aspects of the COVID-19 pandemic, let alone inquiries of this scale. A number of countries, such as Sweden, Norway, Denmark and Australia, have instead instituted independent commissions led by experts in epidemiology, public health, economics and public policy.
“Such research commissions may be quicker and cheaper than a UK statutory inquiry, but they are not necessarily legal processes with the force of the law behind them.
“Most do not have the powers to compel the production of evidence or the giving of sworn testimony by political and administrative leaders; they are not open to public scrutiny in the same way as this Inquiry; they do not allow bereaved people and other interested groups to participate meaningfully in the process as legal core participants; and they do not have anything like the same scope or depth.”
While the context in UK and Australia are different in many ways, there is much in the report that will be of interest and use for those working to ensure Australia better equipped to deal with future pandemics and other emergencies.
“It is not a question of ‘if’ another pandemic will strike but ‘when’,” wrote the Baroness.
“The evidence is overwhelmingly to the effect that another pandemic – potentially one that is even more transmissible and lethal – is likely to occur in the near to medium future. Unless the lessons are learned, and fundamental change is implemented, that effort and cost will have been in vain when it comes to the next pandemic.”
The Inquiry is investigating the handling of the pandemic in England, Wales, Scotland and Northern Ireland. A separate inquiry is taking place in Scotland, which will evaluate areas where policy was devolved to the Scottish Government.
Other recommendations of note
The report recommends the UK Government create an independent body with expertise in whole-system civil emergencies to provide independent strategic advice to the UK government and devolved administrations.
This body should provide political leaders with a critical, objective and impartial opinion on the state of preparedness and resilience and how this may be improved.
“Political leaders will require courage to think strategically about how best to approach the risks that the UK will face in the future,” says the report. “This new body would help them in that pursuit.”
It would also have an important role in ensuring the public is consulted, engaged with and informed about how governments intend to respond in the event of an emergency.
“Members of the public are the ones who will suffer in a whole-system civil emergency and as a result of the response to it. If the public is better informed about what the risks are, as well as the potential consequences of not mitigating the risks, it will more likely accept the allocation of precious resources on an appropriate ‘insurance policy’,” says the report.
The report also recommends that the UK government and devolved administrations should together hold a UK-wide pandemic response exercise at least every three years, “conducted in an environment of curiosity and openness”.
This should test the UK-wide, cross-government, national and local response to a pandemic at all stages, from the initial outbreak to multiple waves over a number of years.
While such exercises are difficult and costly to design and run, and risk distracting ministers and officials from more urgent matters of the day, their potential advantages outweigh the disadvantages.
Exercises should involve ministers and senior officials from the devolved administrations, as well as the NHS, social care and public health leaders, representatives of local resilience forums, voluntary, community and social enterprises, and directors of public health.
The report also recommends publication of findings and lessons from civil emergency exercises by the governments of the UK, Scotland, Wales and Northern Ireland, as well as an action plan setting out specific steps to respond to the report’s findings.
These exercise reports, action plans, and emergency plans and guidance from across the UK should be compiled in a single, UK-wide online archive, accessible to all involved in emergency preparedness, resilience and response.
The report also recommends that the governments of the UK, Scotland, Wales and Northern Ireland should each produce and publish reports to their respective legislatures at least every three years on whole-system civil emergency preparedness and resilience.
Belated attention to vulnerable people
The report many times highlights the neglect of vulnerable groups in pandemic planning and responses.
It calls for governments to consult with the voluntary, community and social enterprise sector and local public health experts on how best to protect vulnerable people in the event of a whole-system civil emergency.
On entering the pandemic, most plans did not define groups of vulnerable people, and those that did took a narrow definition of vulnerability based only on clinical conditions.
When making assessments of vulnerability, there was too much focus on clinical vulnerability and not enough on wider social and economic factors, one expert told the inquiry.
The report describes a failure to identify those who were vulnerable; to consider, stress-test and put in place effective plans to mitigate the social and economic impacts of the pandemic and the potential responses to it; and to involve voluntary organisations that were well placed to advise on how to help vulnerable people.
“These failures left the most vulnerable people in society exposed to the effects of a pandemic,” it said.
Key flaws in risk assessments
The report identifies five major flaws in risk assessment in the UK that had a material impact on preparedness for and resilience to whole-system civil emergencies such as pandemics.
- Too much reliance was placed on a single scenario – pandemic influenza – and on the likelihood of that scenario occurring. As a result, risk was assessed too narrowly in a way that excluded other types of pandemic.
- Planning was focused on dealing with the impact of the disease, rather than preventing its spread. As a consequence, the levels of illness and fatalities of a pandemic were assumed to be inevitable and there was no consideration of the potential mitigation and suppression of the disease.
- Interconnected risks and a ‘domino effect’ were not adequately taken into account. There was a failure to appreciate how a whole-system civil emergency caused by a pandemic had the potential to spiral, as a result not only of the pandemic but also of the response to it.
- There was a failure to appreciate long-term risks and their effect on vulnerable people. This included a failure to appreciate that people may be vulnerable because of poor health and poverty, as well as those who may be vulnerable to the response to the pandemic.
- There was insufficient connection between the assessment of risk and the strategy and plan for dealing with it. This led to a failure to focus on the technology, skills, infrastructure and resources that would be needed to prevent or respond to a pandemic, such as testing, tracing and isolation.
Lessons from the US
Meanwhile, an article in The New England Journal of Medicine, Déjà Vu All Over Again — Refusing to Learn the Lessons of COVID-19, highlights that as well as learning from history, it’s also important to understand how the political and policy context has changed in the wake of polarisation, misinformation and kickback against public health measures.
They say the US Federal Government’s response to the spread of H5N1 avian influenza among farm animals as well as to agricultural workers suggests that, rather than heeding the lessons from COVID-19, elected officials and other key decision makers may be relying on a dangerous type of revisionism that could lead to more deaths, should H5N1 cause a pandemic.
“The H5N1 threat is also emerging in a social, political, and fiscal environment that is less conducive to public health efforts than the environment in early 2020,” they say.
Over the past few years, many states have rushed to restrain health officials’ authority, thereby limiting their ability to respond to public health emergencies.
Reflecting the widespread backlash against masking, for example, states such as Iowa and Tennessee have enacted laws prohibiting schools from requiring masking in most circumstances; other states have limited state or local health officials’ capacity to restrict religious gatherings or impose other types of public health orders.
In some states, judicial decisions have also constricted the ability of state or local officials to respond to a pandemic. For example, in James v. Heinrich, the Supreme Court of Wisconsin held that local health officials lack the authority to close schools.
With fewer tools at the public health community’s disposal, the researchers say a new pandemic could potentially spread even faster than COVID-19 did, overwhelming hospitals and morgues more quickly, putting more stress on healthcare workers, and causing more deaths — even if the causative virus isn’t more lethal than SARS-CoV-2.
“Most troubling, we believe, is the apparent inability of politicians and pundits to understand that a new pandemic may look different from the previous one, threatening different populations and presenting different trade-offs.”
Certain key community-level mitigation measures, such as school closures, are now likely to face political, legal, and popular resistance.
“The United States must be ready for the challenges ahead, even as government agencies and political leaders seem unprepared for the emergence of a new infectious disease or the re-emergence of an old foe, such as influenza,” the authors conclude.
See Croakey’s extensive archive of articles on COVID-19
