This is How We Should Have Responded to COVID-19

Since March 2020 there has been an almost continuous refrain that the UK was not prepared for the COVID-19 pandemic – across the mainstream media, at the UK Covid Inquiry and most recently by Dominic Cummings in a Spectator interview. So much so that it seems to have become an accepted ‘truth’ regardless of the actual facts. Nevertheless there are facts, even in the postmodern dystopian world we now live in.

Firstly, we did have a detailed UK Influenza Pandemic Preparedness Strategy published in 2011 and it was explicit in saying that it could be adapted to respond to other respiratory virus pandemics, and gave as an example the first Severe Acute Respiratory Syndrome virus (SARS). Secondly, there was further national guidance in 2013 and 2017 to update the strategy. Thirdly, this national guidance helped all four nations and each local health board or authority to develop their own pandemic plans which were regularly reviewed and updated. Fourthly, we had many systematic reviews of the evidence for non-pharmaceutical interventions (NPIs) to minimise transmission, one published only a few months before the COVID-19 pandemic started. And finally, the UK scored second in a global assessment of countries’ pandemic preparedness in 2019.

So, the ‘unprepared’ mantra was not the whole truth and arguably we were comparatively well prepared. However, in the event all this preparation did prove to be useless – but only because we decided to abandon it all in March 2020. We binned our pandemic plans and ignored the careful reviews of the evidence and the experience gained responding to previous pandemics. No doubt the UK strategy will be updated, but whatever is produced could be just as easily discarded next time. So what can be done?

Perhaps what we need is something more accessible, something that reflects the ethical and democratic foundations of our country, and, given how important this is for the whole of society, something that is shared widely – well beyond public health departments, the office of the Chief Medical Officer (CMO), the Scientific Advisory Group for Emergencies (SAGE) and the NHS. Core principles on how we should respond to a pandemic that are shared, understood and agreed with the public, perhaps through their representatives in Parliament, might give us some scientific, ethical and governance guardrails. They might help to improve and protect accountability and also stand a better chance of surviving beyond a few weeks when the next pandemic hits.

If so, what might such principles contain? Here we offer some suggestions with commentary on how they were applied, or not, during the Covid-19 pandemic, grouped under four headings – epidemiological, medical, ethical, and democratic. Many of these principles don’t appear in the UK Strategy, or those of the four nations or local pandemic plans … and for very understandable reasons. Prior to 2020 they were taken for granted, they were so obvious that they did not need stating, they were the principles and codes that the public health specialty and the medical profession had followed for decades if not centuries, they were the way we conducted ourselves in our liberal democratic society. The Covid-19 pandemic response changed all that – we now clearly need to restate our commitment to core, indeed fundamental, principles.

Epidemiological principles

The first task in epidemiology is to assess the scale and severity of a new disease or health problem, examine how it varies by time, place and person (age, sex, occupation etc.), and compare it with other diseases. This helps to ensure that any response is proportionate and identifies those at greater and lower risk, as well generating hypotheses about potential causes.

In the context of a respiratory viral pandemic, data on case and infection fatality ratios are paramount. These were available early in the COVID-19 pandemic and before the first UK lockdown. Instead of these data being reported accurately, compared to previous pandemic data and carefully explained to the population (for example here), public messaging was alarmist and seemed designed to instil fear not reassure, and made little reference to those at lower risk (see Laura Dodsworth’s 2021 book A State of Fear). In a future pandemic the public should expect such data, the media should demand them, the CMO should have a responsibility to identify and collate them, and government responses should be calibrated based upon them.

Then to ensure accurate monitoring of the developing pandemic within the country and valid comparison to earlier pandemics the standard definitions for confirmed cases, hospitalisations and deaths should be employed. This did not happen in the COVID-19 pandemic with new definitions adopted, definitions that for all three exaggerated the statistics. This was compounded by inappropriate widespread testing using a PCR test insufficiently specific and using inappropriate cycle thresholds.

There was a further concern that arose during the pandemic response on the epidemiological front: the use and impact of modelling studies. Whilst such studies can be helpful they cannot be interpreted without understanding their underlying inputs, assumptions and methods. They are ‘what if’ studies – for example, what if we assume that the number of cases will grow exponentially without any seasonal effect, what if we assume no existing immunity in the population from other coronaviruses, etc. The Imperial College modelling study published in March 2020 seems to have had a significant impact on the push for the first lockdown, but it had not been peer-reviewed and seems to have been insufficiently debated and challenged; of course, it is now widely considered to have been flawed. Modelling studies are not reality, they are not facts, they are not evidence, they are better viewed as ‘what if’ scenarios and their assumptions and results should be rigorously challenged. Their presentation to politicians without critical analysis and careful interpretation amounts to professional negligence.

Medical principles

Science and medicine only develop through open debate and a willingness to consider alternative views, even if they are contrary to the current orthodoxy. This did not happen during the COVID-19 pandemic, as the oft repeated term ‘The Science’ demonstrates. There is no such thing: there is rarely a consensus and science is never settled, we only ever have the current disputed theories which remain until better ones come along. Any pandemic response should be open to challenge and wide debate so that we are not limited to the knowledge and experience of only a few prominent scientific and medical government advisors. The thoughtful and detailed letters addressed to the Medicines and Healthcare Products Regulatory Agency (MHRA) and Joint Committee on Vaccination and Immunisation (JCVI) from often in excess of 100 doctors and scientists on the merits or otherwise of Covid vaccination of children were a case in point, and were ignored or summarily dismissed. Public health messages to the population certainly need to be clear and if possible consistent to maximise understanding, but this does not preclude an open and vigorous debate within the medical and scientific community, something that is essential if we are to develop an optimal response.

In 1979 Archie Cochrane, widely regarded as the father of evidence-based medicine, made his famous comment that: “It is surely a great criticism of our profession that we have not organised a critical summary, by speciality or subspeciality, adapted periodically, of all relevant randomised controlled trials.” The international Cochrane Collaboration, named after him and designed to address this criticism, produced a series of systematic reviews on the effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses such as school and business closures, social distancing measures and restrictions on large gatherings. Despite the limited evidence for effectiveness and the relatively poor quality of the evidence from these reviews and similar conclusions from a WHO review published in September 2019, almost all these measures were applied to the whole population from March 2020, including a ‘lockdown’ of healthy people.

We copied the response of a totalitarian state despite a lack of evidence and despite the fact that these same systematic reviews drew attention to the widespread harms that would be caused by implementing these measures across the whole population. These harms are beginning to be appreciated across multiple areas – in terms of mortality and physical health particularly of older people, the social development of young children, the mental health and education of young people, businesses across the country as well as jobs, the economy and the benefits system.

An evidence-based approach also required a thorough review of the evidence on the benefits and harms for the prevention and treatment of COVID-19 in individuals. The limited data on the effectiveness of the novel gene technology ‘vaccines’ (and see Clare Craig’s 2025 book Spiked – A Shot in the Dark) and on their side-effects, with no data at all on long term harms, pointed clearly towards their use only in those at higher risk with full disclosure on what was known and what was not. In the event, of course, they were recommended and pushed on most of the population including those at insignificant risk. Furthermore, ‘safe and effective’ was far from a full disclosure of the evidence on benefits and risks.

By contrast, the use of re-purposed drugs such as ivermectin with known anti-viral and anti-inflammatory effects, extensive evidence on effectiveness and a well-documented safety profile, was actively discouraged.

In all these areas, doctors should be acting as advocates for their patients, informing them as best they can and helping them to make decisions on their treatment and care, as required by the General Medical Council’s guidance ‘Good Medical Practice‘. However, as already discussed, the informing was cursory and partial, and the contact often non-existent or via leaflet or video-call.

If they are to regain public trust the medical profession and public health authorities must do better next time, and patients and the public must demand better information and better discussion and engagement with medical staff to help them make decisions.

Ethical principles – informed consent for individuals

The Greek philosopher and physician Hippocrates developed his Oath around 400 BC. It urged doctors to act with beneficence – that is, to help their patients and prevent harm – and non-maleficence – that is to do no harm themselves or primum non nocere. The term appropriateness brings these two concepts together – an appropriate treatment is one that has been chosen because its benefits outweigh its harms in the particular patient.

As outlined above, evidence-based medicine involves the careful assessment of the evidence, ideally from randomised controlled trials, to quantify these benefits and harms. Whilst the patient advocacy role of doctors involves them in informing and supporting their patients to make informed decisions on their treatment and care.

Although this process sounds simple and straightforward, it is not. It seems to be taken more seriously in surgical practice, after notable legal cases, but less so in medical practice with the prescribing of drugs and vaccines. Certainly in the pandemic consenting practices for vaccination were cursory, to the point of being non-existent – public information heralding the ‘safe and effective’ vaccines was at best partial, and coercion was widespread via national advertising that deliberately sought to shame and manipulate, via vaccine mandates, and via bans from venues without proof of vaccination (or negative Covid antigen tests).

Large relative risk reductions of 70% for the Astra Zeneca ‘vaccine’ and 95% for the Pfizer ‘vaccine’ were trumpeted, but not the smaller, less convincing absolute risk reductions of around 1-2%. And there was no attempt to directly compare benefits and risks and harms, the key information a patient needs to give fully informed consent.

The wholesale abandonment of standard codes of practice for informed consent during the pandemic was truly shocking. To regain public trust the medical profession needs to take this key responsibility more seriously and particularly improve practice in relation to long term medications and vaccinations.

Democratic principles

The UK Strategy of 2011 did emphasise the importance of accurate and timely information to the public, and stressed that uncertainty and any alarmist reporting in the media could create additional pressures on health services. Despite this, the early epidemiological data on the scale and severity of the COVID-19 pandemic, a comparison with previous pandemics and clear identification of those at higher and lower risk were not shared with the public and carefully explained. The data that were given were far vaguer and the messages seemed designed to raise anxiety rather than contain it and modulate it to appropriate levels. Government advisors seem to have entirely lost sight of these crucial epidemiological data that are so essential to enable the government to calibrate its response and ensure it was proportionate. Data reflecting reality seem to have been overshadowed by modelling data reflecting potential future scenarios – fiction rather than fact influenced key decisions.

Whatever national response is being contemplated to a pandemic, there needs to be a clear separation of the medical and scientific evidence on the benefits and risks of specific interventions on the one hand, and the political value judgements and decisions on the other. Governmental advisors must present options and their benefits, risks, harms and likely costs to ministers, and in a democracy it is for ministers to decide as they are accountable to the electorate. This relationship is akin to the doctor-patient relationship – the doctor informs the patient and supports him or her to make his or her own decision but does not lead or coerce. This line may have been blurred during the COVID-19 pandemic. Moreover, government advisors seemed reluctant to identify, and where possible quantify, the risks, harms and costs that might flow from the options they put to ministers despite some, like lockdowns, being unprecedented in their severity and scope.

In turn ministers and politicians more generally have a responsibility to ensure that their advisors present them with the epidemiological data and the data on the benefits, risks and costs of recommended options. Ministers also have a responsibility to ensure that differences of opinion on how best to respond within the medical and scientific community are fully aired and discussed. This is crucial to arrive at an optimal response and to avoid groupthink. Only if ministers do these things can they take decisions on behalf of their population and give fully informed consent.

Crucially ministers have a particular responsibility to protect the basic freedoms we enjoy in a democratic society – freedom of speech, association and movement and individual bodily autonomy when it comes to medical treatments. Any infringement of such basic freedoms demands a clear, unambiguous and overwhelming justification, must be subject to challenge in Cabinet and Parliament, and must be as least restrictive as possible to achieve the aim – in extent, impact and time. This is such a fundamental issue that we perhaps need to develop a framework to guide and constrain actions: defining the types of evidence and high thresholds that are required; limiting powers in terms of their impact, duration and the number of people affected; and outlining checks and balances, with perhaps an automatic independent review afterwards. We have such a clear and rigorous framework for compulsory detention under the Mental Health Acts when one individual is affected: we need at least as rigorous a framework when the freedom of millions is at stake.

There has also been considerable criticism of how the usual democratic governance systems were subverted and avoided during the pandemic, including the use of emergency legislation by the executive without appropriate challenge within Parliament. These governance systems are essential to enable questioning and challenge by MPs and select committees with the aim of improving decision making, and to ensure a clear justification for measures taken and transparency to facilitate accountability. This did not happen during the COVID-19 pandemic as clearly outlined in The Accountability Deficit by Kingsley, Skinner and Kingsley (2023).

In all of these four areas – epidemiological, medical, ethical and democratic – principles were violated during the COVID-19 pandemic with dire consequences for health, basic freedoms, quality of life, education, business and the economy, and for democracy and society itself. Before 2020 it would have seemed unnecessary to state such core principles. Now, having set a precedent when we abandoned them, it seems absolutely essential not only to restate them but to discuss them widely and if possible to reaffirm our commitment to uphold them before another pandemic hits.

Dr Alan Mordue is a retired consultant in public health medicine and Dr Greta Mushet is a retired consultant psychiatrist and psychotherapist.