Transcript of Module 2 Public Hearing on 11 October 2023
(10.00 am)
Lady Hallett: Ms Cecil.
Ms Cecil: Indeed, my Lady. May I please call Professor Kamlesh Khunti.
1. Professor Kamlesh Khunti
PROFESSOR KAMLESH KHUNTI (affirmed).
Questions From Counsel to the Inquiry
Ms Cecil: Thank you, Professor. You may take your seat.
Can I ask you to confirm your full name, please?
Professor Kamlesh Khunti: Kamlesh Khunti.
Counsel Inquiry: Thank you.
Thank you, Professor Khunti, for assisting the Inquiry today. If you can keep your voice up, and we also have a stenographer so we may need to take things slightly more slowly. If I ask you to pause or indeed to stop for a moment, it will be my fault because we’re going too fast.
Professor Khunti, you have produced a witness statement for the Inquiry, that’s dated 14 August 2023, at INQ000252609, and it runs to some 16 pages. Is that correct?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: Thank you.
It’s prefaced with a declaration of truth at the outset and signed on the final page.
Professor Kamlesh Khunti: That’s right.
Counsel Inquiry: Thank you.
Professor Khunti, if I can just take you briefly to your professional background, as you set out within your statement, you are a professor of primary care in diabetes and vascular medicine, and the co-director for the Leicester Diabetes Centre, that’s based at the University of Leicester; is that right?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: You also occupy other hats and other roles. As we can see, you’re also the director of the UK National Institute for Health Research, in applied research collaboration, that’s in the East Midlands, and also the director of the Centre for Ethnic Health Research and director of the Real World Evidence Unit?
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: You are prolific in your output, in that you’ve published some – well, well over 1,200 articles; is that right?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: You have specific expertise in diabetes but also in healthcare disparities and ethnicity?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: Thank you.
With respect to the Covid-19 pandemic response, you were a participant in SAGE?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: And that ran from 24 September 2020 to 10 February 2022?
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: But importantly for the purposes of your evidence today, you were also the chair of the SAGE ethnicity subgroup; is that right?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: That was created on 28 August of 2020, with you as its inaugural chair –
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: – and ran through until 23 March 2021 with you as chair?
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: Also with regard to the pandemic you took upon yourself chairmanship of the National Long Covid Research Working Group?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: We will go on to explore how and when that was formed in due course. But for the purposes of today’s evidence, there are four primary areas I wish to traverse with you, and that is, firstly, the evolving understanding of the link between ethnicity and outcomes in relation to Covid-19; secondly, Long Covid, and your role in relation to that working group; thirdly, and we will take it a little bit more shortly, communications and the need for culturally appropriate communications, and your expertise there; and then, finally, just picking up on data and where the limitations lie.
If I may turn to the first topic, and that is the risk, essentially, of Covid-19 for ethnic minorities and its relationship with outcomes.
Perhaps so that we can contextualise this from the very beginning, what is the meaning of “ethnicity” in the way that you use it?
Professor Kamlesh Khunti: Ethnicity is quite a heterogeneous term, it’s where people, a group of people or individuals identify themselves being from certain cultures, backgrounds, religions, colour or various other habits. It’s a very multidimensional term and, as I’ve said in my statement, there’s no theoretical framework, ethnicity means different things to different people and it means different things at different times to different people as well.
Counsel Inquiry: Indeed, what you do flag within your statement is that that has hampered research to date because of that lack, essentially, of theoretical framework for the meaning of ethnicity?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: Thank you.
Professor Kamlesh Khunti: May I, before we start, just say my sincere condolences to the bereaved families.
Counsel Inquiry: Of course. Thank you, Professor.
Professor, you were one of the first to highlight possible increased risk of Covid-19 in ethnic minorities; is that fair to say?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: Indeed, one of the ways that it first came to attention was by use of Twitter and the use of a tweet.
If I can just call that up, please, that’s INQ000223026. This is a tweet that you put out, as we can see:
“Dear all - just had a message from a colleague that they are seeing many young south Asians being admitted with severe #COVID19. Can people share their experiences quickly.”
Looking here we see it’s time marked and stamped, it’s at 1.56 pm on 1 April 2020.
In relation to that, what prompted you to send that tweet?
Professor Kamlesh Khunti: Well, because I do work in ethnic minority health, I had some friends who were working in intensive care units in hospitals, I’m a general practitioner myself, and they phoned me and said, “Kamlesh, we’re seeing a lot of ethnic minorities at a young age being admitted to intensive care units with Covid”. Prior to that we hadn’t heard about this, because most of the Covid had happened in heterogeneous populations, China, Italy, et cetera, so this is the first time that we’d heard about this signal. So that’s why I put this out, to say: is anyone aware of this? And I did have a lot of trolls who came back to say that I shouldn’t be panicking people about this, yeah.
Counsel Inquiry: Twitter is not always the kindest of places.
Professor Kamlesh Khunti: No.
Counsel Inquiry: Can I just pick up on word that you used there, and it’s the use of the word “signal”. Can you just assist us, what does that mean?
Professor Kamlesh Khunti: Signal is something that we may see that we need to be aware of being alert about. That means for the first time we’ve seen this alert, we don’t know whether this is true or not, whether there’s an artefact, it’s because of the populations that are being admitted to certain areas – because it happened more in London and the West Midlands initially, there were more people being admitted, and there’s obviously a lot more ethnic minorities in London and West Midlands. So we just have to be careful and not say this is a direct causal pathway.
Counsel Inquiry: So signals are effectively about potential causal pathways. You also used the word “artefact”.
Professor Kamlesh Khunti: Yes.
Counsel Inquiry: Put in very simple layman’s terms, is that the situation where, albeit it might look as though something is causative, it’s actually not?
Professor Kamlesh Khunti: Absolutely, yes.
Counsel Inquiry: You followed that tweet up with a further tweet on 4 April, a few days later, and in this tweet you highlighted some research from the Intensive Care National Audit and Research Centre; is that right?
Professor Kamlesh Khunti: That’s correct, yes.
Basically this showed for the first time that there were about 30% to 35% of people being admitted into the intensive care unit who were from ethnic minority backgrounds. The population statistics suggest it’s about 16%, so it’s double the number of people who were being admitted to intensive care unit.
Counsel Inquiry: So some of the first data you were seeing was showing a disproportionate level of hospital admissions –
Professor Kamlesh Khunti: Absolutely.
Counsel Inquiry: – and into intensive care units?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: Thank you.
What did you do as a consequence of this?
Professor Kamlesh Khunti: So I’ve – spoke to a number of colleagues. I spoke to people who are working in the ethnicity area, members of the South Asian Health Foundation, and then I spoke to Professor Sir Nilesh Samani, who is based in Leicester, who I know very well, and we discussed this, and we thought this was something worth alerting the CMO about.
Counsel Inquiry: Indeed, just to pause you there, later that day you did – both of you in fact, copied in to the same email, contacted Sir Chris Whitty.
Professor Kamlesh Khunti: That’s correct, yes.
Lady Hallett: Sorry, I missed the date, Ms Cecil.
Ms Cecil: 4 April.
Lady Hallett: 4 April, thank you.
Ms Cecil: Indeed, if we can bring that up, please, INQ000223048.
We see a copy of the email. Of course we start at the bottom –
Professor Kamlesh Khunti: Yes.
Counsel Inquiry: – in terms of the email train, we see firstly an email from Professor Samani, copying you in, explaining that his attention has been brought to the ICNARC audit report, and then that that may require further exploration, and that you and your team, and indeed his team, who have interest and experience in that, would be very happy to help if needed.
You then follow that up, and we see that at the top, and we see your email here. In the second sentence you explain that:
“In particular recent systemic review data show that the multimorbidities with the worst outcomes seem to be cardiovascular disease, diabetes and hypertension and surprisingly not COPD.”
What’s COPD?
Professor Kamlesh Khunti: Chronic obstructive pulmonary disease, so it’s a chronic lung condition.
Counsel Inquiry: Why was that a surprise?
Professor Kamlesh Khunti: Because when the virus first came round we thought it was a respiratory virus, like the flu virus, it affects more people who have respiratory diseases, asthma, COPD. It did affect people with COPD, but we were surprised that a lot more people with diabetes and cardiovascular disease were affected with this.
Counsel Inquiry: As we’ve heard and indeed we’ll deal with slightly later, those diseases are particularly prevalent or disproportionately so in certain ethnic minority populations?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: You go on there to explain about anecdotal reports and then data, and you explain further there may be many reasons for that, and you flag socioeconomic, cultural or pathophysiological?
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: You got a response from Sir Professor Whitty, didn’t you? That response was received on 5 April. He explains that the “issue is (rightly) rising up the agenda”. With regard to the signal that you mentioned as being possible, he considered that it was sufficient to be looked at by groups with expertise, and he also flags the work that is ongoing from PHE, ICU data and Biobank, various other pieces of research that are being undertaken, and he explains that he “will put out a themed NIHR call”. What is that?
Professor Kamlesh Khunti: So this is National Institute for Health and Care Research, it’s the main funding body for applied research, and basic science research as well. And I was really surprised because he took action very, very quickly, the following day, so really admirable that he did this, that there were some actionable points that he came up with immediately, and a call did come out for doing further research in this area.
Counsel Inquiry: Indeed. And certainly there is some correspondence further down that also relates to – the email that we have here actually is the last email in the chain, so slightly later in time, but there were emails from Professor Sir Chris Whitty in relation to it being an important point?
Professor Kamlesh Khunti: That’s right.
Counsel Inquiry: At that stage it wasn’t clear whether it was an artefact of geography or a true signal?
Professor Kamlesh Khunti: Absolutely, yes.
Counsel Inquiry: Thank you.
Now, following on from that, you wrote the first editorial on the topic; is that right?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: It was published in the British Medical Journal?
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: Raising the question: “Is ethnicity linked to incidence or outcomes of covid-19?”
You urged, at that stage, the UK to explore the potential signal urgently and that there was a need for effectively greater research looking at the potential causative links –
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: – pathways.
You particularly flagged concerns being raised because the first ten doctors in the UK to die from Covid-19 were from ethnic minorities; is that right?
Professor Kamlesh Khunti: That’s correct. That did raise eyebrows when we saw that in the news on a regular basis, yes.
Counsel Inquiry: Then, of course, you also had the data that we’ve already referred to?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: The Office for National Statistics we’ve heard a little bit from already in relation to ethnicity, but they published in May of 2020 their first article or report in relation to deaths by ethnic group; is that right?
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: That’s a document that you’re familiar with?
Professor Kamlesh Khunti: Yes.
Counsel Inquiry: Indeed we’ve heard already from Professor Sir Ian Diamond that you have been in contact with him and worked with him at various stages; is that right?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: In relation to that article and the statistics that were produced, the provisional analysis showed the risk of death involving Covid-19 among some ethnic groups was significantly higher than that within the white ethnicity population?
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: When taking into account age in that analysis – so this is right at the beginning of the pandemic, what was known as at May of 2020 – black males were 4.2 times more likely to die from a Covid-19-related death and black females 4.3 times more likely than white ethnicity males and females?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: At that point it was also noted, and this will become relevant for later in terms of the progression of the pandemic, that people of Bangladeshi and Pakistani Indian and mixed ethnicities also had a statistically significant higher – raised risk of death, but that those risk factors or the extent of the disproportionality dropped once one had taken into account age but also other sociodemographic characteristics, including self-reported health and disability, and this relied on collation of data including the 2011 census?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: That reduced, then, to males and females of black ethnicity being 1.9 times more likely than those of white ethnicity and Bangladeshi and Pakistani ethnic minority men being 1.8 times more likely to have a Covid-19-related death.
So at this point in terms of the ONS statistics, is it right to say that it was already flagging up issues in relation to comorbidities that existed within ethnic minority populations and geographic issues, but that the disparity simply could not be explained by those?
Professor Kamlesh Khunti: That’s right. So basically it was 4 times the risk, and once you take into account the deprivation, the previous health, comorbidities, it reduces risk by 50%. So 50% was accounted for by those factors.
Counsel Inquiry: That was followed thereafter in June, again dealing with what was known at the outset as the pandemic progressed, by the first of the Public Health England reports?
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: In relation to that PHE report, certainly there were concerns initially that a truncated report had been published; is that right?
Professor Kamlesh Khunti: This is from a BMJ article written by Professor Raj Bhopal, because he had peer reviewed the article, and we wrote in the BMJ stating that he had seen a fuller report and he felt that it was his duty to inform the public that there were bits of the report missing.
Counsel Inquiry: What bits of the report were missing?
Professor Kamlesh Khunti: From what we understand, it was the recommendations that may have been missing.
Counsel Inquiry: Recommendations. Were there also aspects of stakeholder engagement that were missing?
Professor Kamlesh Khunti: The stakeholder was – I think, from my recollection, is the second report.
Counsel Inquiry: Second report?
Professor Kamlesh Khunti: That’s right, yes.
Counsel Inquiry: That caused a considerable degree of controversy; is that fair to say?
Professor Kamlesh Khunti: That’s correct, yes, it did, yes.
Counsel Inquiry: And that consequently resulted in a fuller report being published?
Professor Kamlesh Khunti: Yes.
Counsel Inquiry: You analysed that report; is that right?
Professor Kamlesh Khunti: That’s right, yes. We didn’t peer review it, it – once it was published we and many others looked at it to see the content and the depth of the report.
Counsel Inquiry: Indeed. In relation to that, were issues flagged in relation to structural racism and discrimination?
Professor Kamlesh Khunti: That’s right.
Counsel Inquiry: As a link?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: And socioeconomic circumstance?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: Now, given the link between or potential link between structural racism and discrimination and those poor health outcomes, as noted in that PHE report, are you aware of any other work that looked at those issues?
Professor Kamlesh Khunti: There’s been a number of studies. The issue with structural discrimination and discrimination is how you measure it. It’s very, very difficult to measure. So qualitative interviews where people are asked about it will – you can get a lot of information from.
There’s a systemic review that’s been done about the disproportionate outcomes in people from ethnic minority backgrounds, and that identified I think just a few papers that had talked about discrimination, and again they highlight that it’s very difficult to measure.
But from the qualitative evidence we have from the British Medical Association, from the nurses associations, there may have been some elements of structural discrimination, for example getting PPE given to – from the – healthcare workers particularly from ethnic minorities.
Counsel Inquiry: And we’ve heard earlier evidence that ethnic minorities are overrepresented within the healthcare workforce?
Professor Kamlesh Khunti: That’s right, about 20% of the healthcare workforce, or 1.2 to 1.5 million people within the National Health Service, are from ethnic minority backgrounds, yes.
Counsel Inquiry: Thank you.
In relation to that PHE report you wrote of some of the limitations, as you saw it, of those reports. The first aspect is that albeit that they were welcome, because they did shine a light, it was nonetheless a missed opportunity to address significant inequalities in ethnic minority communities. How did you see it as a missed opportunity?
Professor Kamlesh Khunti: Well, first of all, the report is very comprehensive and it was very laudable, the amount of work they did, you know, speaking to 4,000 individuals, speaking to a number of stakeholders, so it’s a vast amount of work they’d done. The reason we thought it was a missed opportunity, because they did have I think six recommendations, is that they didn’t have the recommendations, although they’d identified them, of the wider source of determinants.
So, first of all, how to protect these populations, and the wider social determinants of how to ensure that housing is adequate, it’s not overcrowded housing, the occupations that people were at higher risk, they weren’t protected, the educational elements, communication, how it was to be done, who was going to do it. All of that wasn’t there in huge detail.
Although they’d identified all the drivers, the recommendations or drivers – the detailed recommendations on drivers were missing.
Counsel Inquiry: Were missing. And there were significant gaps in your view; is that right?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: Now, picking up in June of 2020, which is of course when the PHE reports – well, first report – was released, you’re aware that ethnicity was discussed at one of the SAGE meetings in June, it was SAGE 40, the 40th meeting on 4 June?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: And at that point it was accepted within that meeting that the evidence suggested a significantly higher likelihood of, firstly, testing positive, secondly, admission to critical care, and thirdly, the prospects of death for ethnic minorities?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: In particular, that related to black and South Asian groups?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: At that point, as you’ve already identified, the risk factors or the causative links were assessed as being due to a complex interconnected range of factors, including socioeconomic deprivation, involvement in high risk occupations, geography, household size and comorbidities. Did that chime with what you were seeing?
Professor Kamlesh Khunti: Exactly, and that’s exactly what the initial report by ONS and the Public Health England report also shone a light to as well.
Counsel Inquiry: As said at the outset, you went on to become the chair of the SAGE Ethnicity Subgroup. That was set up on 5 August. How did that come about?
Professor Kamlesh Khunti: So I had an email from GO-Science that they wanted to speak to me and we had a Zoom or an MS Teams meeting, and that’s when Sir Patrick Vallance came along with the GO-Science team and mentioned to me that they’d seen the signal and they were asking me if I would be willing to chair this subgroup.
Counsel Inquiry: You cannot assist us with why that subgroup was not formed earlier; is that right?
Professor Kamlesh Khunti: I think that people were trying to find evidence for this, and, as you say, we need validation from various datasets, so ONS signal was the first lot, then the PHE data came out. I mean, if you look at the PHE data, you know – we may be talking about data later, but the Public Health England report, they didn’t have anything on occupation, they didn’t have data on occupation, so we don’t know whether that would have reduced(?) the risk. So until then I think they weren’t – the data weren’t as robust. And following the Public Health England report, I think they decided they needed a chair for the Ethnicity Subgroup.
Counsel Inquiry: So you took on that role?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: And that subcommittee reported directly to SAGE?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: In terms of the issues to be focused on, they were, as one would expect, a focus on ethnicity, and some of the broader social determinants –
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: – in relation to ethnicity.
In terms of the advice to be provided, was it a case of it being commissioned from you, or was it advice that you provided on a freestanding basis?
Professor Kamlesh Khunti: It was advice on a freestanding basis, completely, yes.
Counsel Inquiry: The meetings were not officially minuted; is that right?
Professor Kamlesh Khunti: We did have minutes of the meetings, for all the meetings.
Counsel Inquiry: Sorry, I should be clearer in my question. There was no formal requirement for those meetings to be minuted, albeit that high-level minutes were taken?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: Indeed the Inquiry has access to those, so I don’t propose to take us through any of those today.
In relation to foreseeability of impact on ethnicity minorities, minority groups and potential disparities, you’ve explained that initially it was seen as a respiratory virus and therefore perhaps those issues weren’t considered in the same way they might have been had it been seen as actually what it was.
But was it foreseeable that there would be a disproportionate impact on ethnic minorities?
Professor Kamlesh Khunti: Potentially. I think that, looking back on it, potential we could have thought about it because of the pre-pandemic disparities, and I think they have been discussed previously at the Inquiry, among ethnic minority groups, particularly in terms of deprivation, health, housing, schooling, et cetera.
Counsel Inquiry: Moving to the autumn period briefly, you had some level of involvement with the minister who was placed in charge of considering the issues of ethnicity, that’s the Right Honourable Kemi Badenoch MP?
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: What involvement did you have, firstly, with her?
Professor Kamlesh Khunti: I think there were two meetings that I seem to have found. The Cabinet Office contacted me that the Right Honourable Kemi Badenoch wanted to speak to me, and this was in October and another one in December. The October one was a general discussion of what the SAGE group were doing. I don’t have any firm recollection, but it was – would have been a high-level discussion of what SAGE is looking at. I think the 16 December one was a teaching session that we did for cross-governmental departments.
Counsel Inquiry: And I understand you did two teaching sessions?
Professor Kamlesh Khunti: That’s correct, one was on the drivers of risk and one was on housing – no, sorry, vaccinations and housing.
Counsel Inquiry: Kemi Badenoch’s team went on to produce four quarterly reports to the Prime Minister between June 2020 and December 2021?
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: Did you or the Ethnicity Subgroup contribute to any of those reports?
Professor Kamlesh Khunti: We were asked to review them and we had to review them at pace. We did give some comments on them. I was asked by one of the officers to see if I would give a quote to the report, but thinking it through the SAGE committee, we felt that was inappropriate because SAGE was an independent research and science body.
Counsel Inquiry: So was the view to keep that separate, effectively, the SAGE workings and those individuals, and then government –
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: – produced reports?
Professor Kamlesh Khunti: Because they already had advisers who were acknowledging and supporting the report.
Counsel Inquiry: And the work that had been done in relation to those quarterly reports had been done by the Equalities team, as opposed to the Ethnicity Subgroup that you chaired?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: Thank you.
So by September of 2020, aspects in relation to causative links were known in relation to occupation, housing, instability, socioeconomic status, comorbidities and the other –
Professor Kamlesh Khunti: Occupations, yeah.
Counsel Inquiry: Did you and the SAGE Ethnicity Subgroup have regard to those factors in advising on policy in response?
Professor Kamlesh Khunti: We had a paper that was quite a comprehensive paper, it was on drivers of the increased risk among ethnic minority groups, yes.
Counsel Inquiry: Indeed, perhaps we can take you to that now. It’s at INQ000273842.
I’m going to deal with it briefly, if I may, whilst just perhaps prefacing it before it’s brought up on the screen.
It’s a very lengthy report. It sets out in detail where you and the Ethnicity Subgroup see the drivers as being.
Perhaps if we could just go to page 110, please. It’s appendix 7. This is the paper.
In relation to that – I’m very sorry, I thought it was at page 110.
(Pause)
Counsel Inquiry: Go to page 114, please. There is a very useful visual aid.
Professor Kamlesh Khunti: 113.
Counsel Inquiry: 113, please.
Professor Kamlesh Khunti: Yes.
Counsel Inquiry: To 113.
There is a very useful visual aid that sets out the subgroup’s workings. It builds on a paper that’s been adapted by another academic in relation to these issues; is that right?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: I’m afraid it’s a little difficult to see on the screen because of the size of the fonts.
If I can just take you to what is seen as number 1, effectively what we see is a diagram, at the top it explains “Shaped by structural racism and other power structures”; is that the context in which this is placed?
Professor Kamlesh Khunti: That’s right, yeah.
Counsel Inquiry: Then what we see is a green box that deals with dimensions of ethnicity.
A line to that to the left, we see the differential exposure and vulnerability and the drivers, and I’m going to come to that in a moment, and then the output to the far left. Is that right?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: So, taking each one of those briefly in turn, we have pathway 1, it’s the second white box down from the top, and the first issue in relation to understanding ethnicity is differential exposure.
What are the issues that arise there in relation to certain ethnic minority groups?
Professor Kamlesh Khunti: So this is what we’ve just been talking about in terms of the risk of a higher exposure among ethnic minority populations, so this is things like occupations, they are more likely to work in occupations that are in direct contact patient-facing roles and in low-paid occupations. Housing, living in high-density housing, so small houses with a large number of occupants, living in multigenerational houses, which is where we state that there’s three or more generations living together. There’s also people who are at – have poor health, so they may have other health conditions, as we’ve talked about, diabetes, cardiovascular disease, et cetera. So these are all the issues that may put them at higher exposure.
Counsel Inquiry: First –
Professor Kamlesh Khunti: And healthcare workers is obviously another one.
Counsel Inquiry: So this is the first aspect, is exposure to the virus, so there is a potentially disproportionate level of exposure for ethnic minority individuals because of those factors. That then may or may not result – as we see, if we take it across, and then go down, may or may not result in Covid infection.
That then goes into driver 2, which is differential susceptibility to infection.
In summary, is it the case that minority ethnic groups may be at greater risk, in your view, of infection because of differences in immune response, nutritional status and other –
Professor Kamlesh Khunti: Other conditions, and obesity is another big risk factor for ethnic minority populations as well, yes.
Counsel Inquiry: We’ve heard a little bit about obesity already in that respect.
Professor Kamlesh Khunti: Yeah.
Counsel Inquiry: We then see that once one has the infection, there is then potentially a differential vulnerability to the disease; is that right?
Professor Kamlesh Khunti: That’s right, yes. Some of these overlap –
Counsel Inquiry: Indeed.
Professor Kamlesh Khunti: – as well, as you can see. So this could be because they have higher stress levels, they may be living in areas that have poor air quality, et cetera.
Counsel Inquiry: Okay. That results then in the differential consequences of the disease, of an infection of Covid-19; is that right?
Professor Kamlesh Khunti: Yeah, so basically, here, if they become ill they have more disability, there’s job losses, poorer health, perpetuating this cycle of worse outcomes for them, yes.
Counsel Inquiry: Just dealing with the disease consequence in and of itself at the moment in terms of the health outcome, what you identify here are issues such as comorbidity and then access to healthcare –
Professor Kamlesh Khunti: Yes.
Counsel Inquiry: – quality of healthcare?
Professor Kamlesh Khunti: Yeah. And the access to healthcare may be a driver from the right side of the dimension, this is about language and culture and not identifying the disease, not properly being able to express the disease, not being aware of the disease and the consequences.
So all of those on the right-hand side also are drivers across all the pathway, yeah.
Counsel Inquiry: Indeed. Then what we see there is the potential enhanced risk then of mortality, of death essentially, that flows through that particular driver.
Then, as we continue down, the differential social consequences in relation to follow-on impacts from that disease?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: Thank you.
You do also touch upon, within this, differential consequences of control measures. I’m not going to go into that with any detail with you today, we’ll talk a little bit about communications later.
But, in short, those are the identified pathways by the Ethnicity Subgroup; is that right?
Professor Kamlesh Khunti: Yeah. I mean, this is a theoretical framework that we put the pathways through, yes.
Counsel Inquiry: Just drilling down very briefly and flagging them up. You’ve already dealt with occupation. Household circumstance, that became very important, is that right, when it comes to looking at subsequent issues in relation to the second wave?
Professor Kamlesh Khunti: That’s right. So there was a separate paper that we did, as I said, the Ethnicity Subgroup, and here we wanted to validate the data about multigenerational households. And I think we must have had – we had the best data in the world, and we had five database studies that all concurred to the same conclusion, that multigenerational households, people with three or more occupants, was associated with worse infection, worse disease and worse mortality.
Counsel Inquiry: Perhaps if I can just pick up on that, then, in relation to the first wave and the second wave. In the first wave all ethnic minority groups were at that elevated risk, particularly acute within back populations; is that right?
Professor Kamlesh Khunti: That’s right, yes.
Counsel Inquiry: But that changed when it came to the second wave, where one saw a decrease in relation to mortality, deaths, for black ethnic minority populations but a greater disproportionate effect in relation to Bangladeshi and Pakistani, South Asian groups; is that right?
Professor Kamlesh Khunti: That’s correct. So overall, once – so basically it showed that lockdown worked. For nearly – most of the ethnic groups, including the white group, you saw a reduction in infection and mortality. But there was a higher risk in Bangladeshis and Pakistanis, and we looked at what the drivers were – and this is using the ONS data – and the drivers were likely to be what we’ve already said, the occupations that ethnic minorities are in, the housing density –
Counsel Inquiry: If I can pause you for one moment, when you say occupations, what types of work?
Professor Kamlesh Khunti: So occupation is people-facing roles, taxi drivers, restaurants, healthcare workers, et cetera. And people who were on zero-hours contracts, so they weren’t able to get time out, and so potentially they weren’t reporting their symptoms.
Counsel Inquiry: Just picking up on the people with zero-hours contracts, in terms of financial stability, did you see that as having any role?
Professor Kamlesh Khunti: That was one of the reasons that we put forward, that that would have definitely been one of the reasons, and some of the qualitative interviews have previously shown that as well.
Counsel Inquiry: I think one of the recommendations that you made at that point was for the provision of proper statutory pay for –
Professor Kamlesh Khunti: Absolutely, yes.
Counsel Inquiry: Sick pay?
Professor Kamlesh Khunti: And similarly we made recommendations on housing, that if people are in multigenerational housing there should be provision made of housing given for isolation if one member of the house was infected.
Counsel Inquiry: Thank you.
Then just to pick up on one final aspect in relation to the drivers, can I just be clear with you in relation to genetic considerations. Do you consider it likely that genetics play a role?
Professor Kamlesh Khunti: Well, most of the data shows that there are some, what we call SNPs, genetic signals, but there is no conclusive evidence to show that this is driven by genetics. It does seem to be driven mainly by the social determinants.
And we’ve done some additional work subsequently showing that if we take 25% of the most deprived populations out of deprivation, we halve the risk of Covid infections and mortality. If we take 50% of the most deprived population out of deprivation, including ethnic minorities, we near enough eliminate the risk that we’ve seen. So a lot of this we feel is due to the social determinants.
Counsel Inquiry: Just picking up on deprivation and the use of the 2011 census, because of course that informs the ONS statistics –
Professor Kamlesh Khunti: That’s right.
Counsel Inquiry: – it’s your view, is that right, that as a consequence of that, socioeconomic circumstance and deprivation is likely to be under-reported in relation to the role that it plays, because of changes since 2011?
Professor Kamlesh Khunti: That’s correct. So now we have the 2021 surveys that – they would be better placed. We’ve also seen in the surveys that the proportion of ethnic minorities has increased in England. In terms of whether they’re in more deprived areas I’m not aware of, but it’s likely health(?) changes, yes.
Counsel Inquiry: Thank you.
One final aspect, and that relates to biological factors. When you refer to biological factors, what you are referring to are comorbidities such as diabetes and other forms of disease; is that right?
Professor Kamlesh Khunti: That’s correct, diabetes, cardiovascular disease, obesity. There’s some possibility of associations with psychological aspects as well.
Counsel Inquiry: Indeed. And that’s why I just wanted to be very clear about that, that’s what you mean by biological –
Professor Kamlesh Khunti: Yes.
Counsel Inquiry: – it’s not genetic, it’s those comorbidities?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: Thank you.
Now, if I may pick up, then, on what that meant for the Covid-19 response, in terms of the government’s response, do you consider that it was successful in addressing those disparities or could things, other things, have been done?
Professor Kamlesh Khunti: So the four quarter reports mention a number of areas that the government addressed the disparities, this is the Race Disparity Unit four quarterly reports. There are a number of things that could be done. In terms of the detail, again, in some of them is lacking. There’s data on pilot areas that were funded to do evaluations of what worked, what didn’t work. Mention about communications on – for ethnic minority populations. And again they mention a number of things that were done. But to me there were other ways that this could have been done. We have the best data systems in the world, and we’re the envy of the world with the data we have. What we needed was real-time data, real-time data on people being affected in different areas, because we always say local is best, we could have acted on this locally. Leicester local public health did a tremendous effort but they were lacking in data. So if we had data given to us in real time about where the highest risks are, we could have worked with our community champions within those areas, our community leaders in those areas, the pharmacists, the GPs, as we did in Leicester, to reduce that risk.
Similarly, the test, trace, isolation programme, again we didn’t have any data coming to us to say where is – are the bottlenecks, which areas are working well, which are not working well. And again, if this data came on a regular basis, in real time, the local public health messaging could have been done.
In the reports, you know, there are mentions about the culturally-adapted information that was given out there. Now, giving out a culturally-adapted leaflet doesn’t mean that that’s going to have a major effect. You need to do a lot more than that. You need to work with that community. And there are discussions about the community champions programmes that were funded, but again we’re not sure how these were funded, which areas were funded.
And the key one is the evaluations. You know, 40 million, over £40 million was given out. These are the kinds of things that we should be evaluating robustly, because we have the data. If you put an intervention in Leicester and don’t put it in Blackburn, I can tell within a short period of time with the data that we have whether that intervention’s worked or not.
Counsel Inquiry: Thank you. So is that one of your primary concerns, is working out what happened, effectively, with those community champions, grants and research projects and that data?
Professor Kamlesh Khunti: There are soft evaluations that have been done for one of them, but others we’re not aware of what the findings are and how we can implement them. For example, we should be implementing them now. Covid is still here, we’re seeing an increased risk, but we’re not hearing anything about those messages.
And when I say regarding the communication and language, Leicester has over 80 languages, London has over 300 languages, what we need to do is the local people will know the best about what their needs are, and it really needs to be localised in terms of the response.
Counsel Inquiry: Thank you.
Lady Hallett: Can I just ask – I’m sorry to interrupt –
Ms Cecil: Of course, not at all.
Lady Hallett: – who had the data that you needed?
Professor Kamlesh Khunti: I’m not sure if the government had the data. If that was one of the asks, I’m sure Sir Ian Diamond would have provided that data, which he’s done for a number of things. As I say, ONS have done an absolute sterling job in getting data to us quickly.
Lady Hallett: It’s just that you began this passage in relation to saying we have one of the best data systems in the world, so I assumed by that you meant that we were collecting the data but –
Professor Kamlesh Khunti: It wasn’t coming to us, that’s right.
Lady Hallett: So it wasn’t being shared with you?
Professor Kamlesh Khunti: That’s right.
Lady Hallett: But you don’t know where it was?
Professor Kamlesh Khunti: No.
Lady Hallett: Right.
Ms Cecil: Thank you, I was going to pick up on that myself, so that’s –
Lady Hallett: Oh, sorry.
Ms Cecil: No, not at all, that’s helpful.
And you’ve explained about the need for real-time data and that gap and lacuna there.
One of the other aspects that you just touched upon, and perhaps we’ll go there next, in fact, because you have explained the need already for culturally-sensitive and appropriate government communications, is to pick up on communications.
You were involved with the Centre for Ethnic Health Research; is that right?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: You made various recommendations and infographics in relation to culturally-sensitive and adapted communications.
If I could ask that that be called up, please, it’s INQ000223040, and if we can go firstly to page 27 and then move to look at 28 and 29.
Just while it’s coming up, the first page, here we are, this is your recommendation as to how to engage and involve ethnic minority communities; is that right?
Professor Kamlesh Khunti: That’s correct. Yes, this is from the Centre for Ethnic Health Research and the South Asian Health Foundation.
Counsel Inquiry: What we see here is, at the very top: use of culturally-tailored messaging, different languages and formats, some aspects in relation to vaccine hesitancy and, perhaps more generally and of general application, the use of community and faith centres as part of that response?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: Perhaps one of the starkest things here is actually the picture that’s in the centre of the page, because of course that reflects different ethnic minorities, clearly. Would that be correct?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: Presumably that’s the purpose of it.
But we also see, in advice to government, professionals, policymakers and scientists, the use of interpreters, accurate ethnicity coding, you address PPE, all of those sorts of issues.
If we go over the page to page 27, what we then see is an infographic that’s been designed for ethnic minority communities specifically; is that right?
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: Building on, effectively, the infographic we saw previously.
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: So, again, representative pictorial descriptions in the middle, and then very clear pictures as to what to do:
“Stay at home and away from others if ill.”
In the top left-hand corner.
“Get tested …”
A picture of somebody with a test.
Vaccine, speak to your GP, take part in research studies.
So what you have is something that is, at the very least, albeit this one’s in English, you have the pictorial representations?
Professor Kamlesh Khunti: That’s right. I’m not sure if you got the exhibits but we had these in four, five languages as well.
Counsel Inquiry: Indeed. I don’t have all of those exhibits, I’m afraid, but certainly I was going to pick up on that, and that’s how they’ve been produced.
Professor Kamlesh Khunti: And the thing about this is this is not just translation and back translation, a lot of people say we did some translation and back translation, that’s not how cultural competency works, we have to sit with that population, that ethnic minority population, go through the nuances of what this means to them. And it does take time. And that’s what we did with all these infographics. For example, the word “BMI”, you and I will know what BMI is, ethnic minorities don’t know what BMI is, there is no word for BMI in South Asian languages.
Counsel Inquiry: And I understand the same applies to the word “virus”?
Professor Kamlesh Khunti: That – absolutely, yes.
Counsel Inquiry: It’s obviously a key word, certainly in our understanding of Covid-19.
Just picking up on culturally-appropriate messaging and communications, that’s quite separate to targeting interventions or communications, isn’t it?
Professor Kamlesh Khunti: That’s absolutely – yes, it is.
Counsel Inquiry: In relation to targeting, there are concerns that tailored public health messaging aimed at very specific subgroups of the population can result in greater stigmatisation, racialisation and those sorts of issues; is that right?
Professor Kamlesh Khunti: If you pick on one minority ethnic group and – whether it’s culturally tailored or not, they will be singled out as a high risk, and that will marginalise them, that will stigmatise them, that will create distrust in that population. So it’s how that’s been done. And what we were saying is: this message is for everyone. The messaging during the pandemic should have gone to everyone at the same time. But then, in a nuanced way, made it appropriate for that population.
Counsel Inquiry: Indeed.
Professor Kamlesh Khunti: So they know that: everyone’s getting this, but we’re just getting it so that we can understand it better.
Counsel Inquiry: Indeed. That’s the distinction, essentially, that the messaging in general terms is the same across all populations but is then tailored specifically in terms of those communication aids?
Professor Kamlesh Khunti: That’s correct. I mean, we had an example of that in Leicester. We had a bus in an area where we had high vaccination rates and this bus turned up with a billboard about vaccinations and it was totally inappropriate to have a billboard there when we already had high vaccination rates there.
Lady Hallett: So what was the impact of that?
Professor Kamlesh Khunti: Well, the local communities felt stigmatised. They were: why are we – you know, we’ve worked very hard – the GPs said: we’ve worked very hard to get the patients vaccinated, but the people who are – why are the billboards still coming? Because the vaccination rates are already high in that area, because the local community worked really, really hard, and they thought that enough possibly wasn’t being done by that community.
Lady Hallett: They didn’t see the message and say, “Ah, but we’re ahead of the game here”?
Professor Kamlesh Khunti: Well, different people will take it differently, as you can imagine.
Ms Cecil: Were similar billboards in other areas of Leicester?
Professor Kamlesh Khunti: As far as I’m aware, yes.
Counsel Inquiry: Thank you.
Thank you, those are all the questions I have on communications. If I can touch very briefly now on additional involvement within the Covid-19 response.
You were also involved in Independent SAGE; is that right?
Professor Kamlesh Khunti: That is correct, yes.
Counsel Inquiry: Your role there was as a primary care researcher. As you’ve already explained, you are a GP by professional background, and indeed you remain, as I understand it, a practising GP and clinician?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: And that was the reason why you were invited to join in?
Professor Kamlesh Khunti: That’s my impression, yes.
Counsel Inquiry: In terms of your input into Independent SAGE, was that based on your role as a clinician?
Professor Kamlesh Khunti: As a clinician I think the ethnic minority work that I’d done was also important to them as well.
Counsel Inquiry: What were the distinctions in the type of work that you were doing for Independent SAGE as opposed to your role in the SAGE subcommittee for ethnicity?
Professor Kamlesh Khunti: I think Independent SAGE was discussing various aspects on a regular basis and then the main aim was to get it out to the public, while within SAGE the issues were about looking at the problem, looking at the science, getting the group together to look at the science, and then give robust evidence to the government in terms of the interventions that need to be put in place.
Counsel Inquiry: Did you see any disadvantages in the role of Independent SAGE?
Professor Kamlesh Khunti: I didn’t see any disadvantages at all. In fact, when I was asked by Sir Patrick Vallance to join the SAGE, I did mention to him that I was part of Independent SAGE and he was – there wasn’t any reason for me to stop Independent SAGE at that stage, yeah.
Counsel Inquiry: Thank you. And indeed you carried on in Independent SAGE until May 2021; is that right?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: The reason that you left was because of a lack of time, essentially?
Professor Kamlesh Khunti: Absolutely, yes.
Counsel Inquiry: And we’ve already heard a lot about the types of work that you were already engaged in, in the pandemic response.
The final area in that regard is in relation to Long Covid, and you have explained that were the chair of the National Long Covid Research Working Group, often referred to in documents as just the “Research Working Group” for short?
Professor Kamlesh Khunti: Yes.
Counsel Inquiry: That group first met on 11 March 2021 and continues to meet in fact; is that right?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: I’ve just been asked, Professor Khunti, can you just keep your voice up, please.
Professor Kamlesh Khunti: Okay, will do.
Counsel Inquiry: No, not at all.
With regard to that working group, just to place it in context, there are representatives from the nine major Long Covid epidemiological studies in the UK, and indeed we’re going to be hearing from two of those individuals – and I understand they’re colleagues that are well known to you –
Professor Kamlesh Khunti: Yes.
Counsel Inquiry: – Professor Brightling and Dr Evans, on Friday, and so as a consequence of that I’m not going to take you through the clinical aspects of Long Covid or those sorts of issues –
Professor Kamlesh Khunti: Sure.
Counsel Inquiry: – because we’ll be hearing from them.
But what I do wish to just touch upon you with is why that group was formed, and can you just explain very briefly how that came about?
Professor Kamlesh Khunti: So I think this was following an email exchange we had, and there is an email in the evidence from Chris Whitty to myself, Professor Sir Ian Diamond and Nish Chaturvedi, about a lot of work that’s going on, to see if we can co-ordinate this work together. So I emailed the epidemiological groups that were funded from NIHR, the UKRI, and ONS obviously was doing the work, and they all agreed to be part of this group.
Counsel Inquiry: Indeed. And if I can just – for those that are following the email is at INQ000072959. That’s the email from Professor Sir Chris Whitty to you and Professor Sir Ian Diamond.
Following on from that, you set up that group; is that right?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: As you’ve just explained. Did you have the – were you under the impression that you reported to the CMO, to Professor Sir Chris Whitty?
Professor Kamlesh Khunti: He’d asked us to set this group up, so whether it’s reporting or – he certainly was interested in what was going on, and he wanted to know what was going on on a regular basis. So I think we initially said it was reporting but it was really what we were doing is sharing what we were doing with Professor Sir Chris Whitty on a regular basis. Initially it was two-weekly, now it’s four-weekly.
Counsel Inquiry: Indeed, and one of the things that he asked you to consider was to co-ordinate on a definition, as we can see from this email, “case definitions”. Why was that? And the reason I ask that question is because there were already definitions from the World Health Organisation, as you know, and indeed NICE.
Professor Kamlesh Khunti: Yeah, so the definitions have been very different, and if you look at the data for Long Covid they vary, some say four weeks, some say eight weeks, some say 12 weeks, so I think in terms of definitions we did take the NICE definition, and it was just to ensure that everyone was working in a similar manner as far as the definitions go. We weren’t going to redefine the definition unless there was any evidence to do that, but our role was not to redefine the definition.
Counsel Inquiry: Thank you.
Now, just in terms of the working group and the output, the product of it, if I can just call up INQ000073726.
It’s an email from you to Chris Whitty, and what you have explained there is that you have been having the fortnightly Long Covid meetings, they have been enormously useful and productive, you explain that one of the initiatives that has resulted is a collection of Long Covid research papers similar to the Covid-19 research collection held by UCL, which we may hear some of later in the evidence.
But the point of your email was really to ask if he was agreeable to him(sic) using his name in relation to that research collection; is that right?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: And he replies shortly thereafter, and we see at the top there that he says:
“I think it would be sensible not to put the ‘CMO’ bit in as it might at some point get people asking about clearances (from one side) [presumably that’s the government side], independence from Gvt (on the other [side]) and thinking that I ‘endorse’ papers.”
How did that chime with what you had understood his role to have been at that point?
Professor Kamlesh Khunti: We weren’t sure whether we were there to just inform him or report to him, but the reporting is very, very separate. The funded studies have to report to the funders, independent of anyone, so they’d be conducting the studies independently of the CMO –
Counsel Inquiry: Yes.
Professor Kamlesh Khunti: – and reporting to the funders. So, in hindsight, he’s absolutely right: we’re not reporting to him, we’re informing him.
Counsel Inquiry: Indeed. And indeed there’s a subsequent email from one of Chris Whitty’s – the individuals in his office, on 2 November, and that’s at INQ000074244.
What we have there is – it’s from, as I say, an official within DHSC, but working – private secretary to Professor Sir Chris Whitty, and what that does is it flags this in relation to a subsequent aspect in terms of publication and the use of the CMO’s name.
And what we see here is that there’s a description, Nature:
“The group is planning to publish the attached commentary in Nature …”
That’s a journal, isn’t it?
Professor Kamlesh Khunti: That’s right, yes.
Counsel Inquiry: And you have asked whether Professor Sir Chris Whitty “would be happy to have the below line included”, and what we see there is that it essentially says:
“Researchers on these studies have formed the National Long COVID working group, reporting to the Chief Medical Officer for England, to share key findings and promote …”
Understanding and so on?
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: Now, in relation to that, that was being flagged, and you can see underneath it says:
“From my understanding of the Group, ‘reporting to’ is possibly a bit strong and slightly overstates your involvement …”
And they make a proposed modification?
Professor Kamlesh Khunti: So reporting would mean that he would have a say in what we do, which he absolutely doesn’t, and we inform him, as I said, with the minutes on a two-weekly or a four-weekly – and he always acknowledges that, it’s been helpful for him as the CMO.
Counsel Inquiry: Did you form any impression that he was seeking to keep the working group effectively at arm’s length?
Professor Kamlesh Khunti: Well, because it’s not funded by the CMO, it’s funded by NIHR, UKRI, so he wouldn’t have a say in any of the workings of the group, or the individual studies.
Counsel Inquiry: That perhaps brings me on to the next point, which is: why was the working group not set up as a subgroup of SAGE? Can you assist us with that?
Professor Kamlesh Khunti: Yes, sure. So if you look at all the evidence that’s been provided so far, there was a paper to SAGE, I think led by Nish Chaturvedi, in July of 2021, of a number of groups that had looked at Long Covid, and the report stated that they were conducting epidemiological studies. The SAGE’s response would be: if there is something concrete there that we can help to improve outcomes, that we can do something about, then they would take that forward as a recommendation to the government.
Until now, most of the studies are still evaluating, even Chris Brightling in his report said we’re in the infancy of Long Covid, so the research is still being done. What we don’t know is the exact causes, exact disease trajectories, and there are not currently any treatments for it at all. So at the moment we’re still in the research phase of Long Covid.
Counsel Inquiry: That perhaps explains why it operates differently –
Professor Kamlesh Khunti: Absolutely.
Counsel Inquiry: – in your view?
Professor Kamlesh Khunti: That’s right.
Counsel Inquiry: I have been asked to ask: do you think that that reflects a lack of importance given to Long Covid, because it’s not a formal subgroup of SAGE?
Professor Kamlesh Khunti: Absolutely not. If there wasn’t importance put to it they wouldn’t have discussed it at SAGE, but it has been discussed. And I think everything else that was going on within SAGE was to reduce Long Covid, because they’d obviously established Long Covid was an issue. The only way currently that the evidence that we had, and even now we have, is to reduce the risk of getting Covid in the first place. And that was through everything that we’ve discussed at SAGE about reduced risk, population-level risk of people getting Covid, and that’s through NPIs (non-pharmaceutical interventions) and vaccinations, and those were large areas of work that SAGE was doing. So if we reduce the population level of people getting Covid, then the risk of Long Covid would be lower as well.
Counsel Inquiry: You’ve covered it to some extent in your answer, but just to be clear, in your view, does the fact that it’s a working group impact at all upon the advice that was then taken on board by SAGE in terms of its importance and …
Professor Kamlesh Khunti: Well, when we were still in our infancy, April 2021, it was quite early on still and the studies were just being set up there, some of the studies are still not finished, so we don’t have results from many of the studies, so it would have been too early to report to SAGE with the results.
Counsel Inquiry: Thank you.
If I can just pause for a moment, you’ve answered a number of the areas and so I’m just going to truncate those.
Just dealing very briefly – because, as I say, we will be hearing on Friday from Professor Brightling and his colleagues in relation to that, and Dr Evans – in terms of your understanding, am I right that the incidence of Long Covid, albeit not termed as such at that point, was aware and apparent throughout late spring and early summer of 2020?
Professor Kamlesh Khunti: That’s when the reports started mainly coming out, mainly from the patient groups and then from the researchers themselves, yes.
Counsel Inquiry: And indeed in August 2020 guidance was published in the BMJ in relation to management of that condition?
Professor Kamlesh Khunti: That’s correct, yes.
Counsel Inquiry: Thank you. We will be hearing a little bit more about your short report that the working group produced in due course, so I don’t propose to take you through those today. We’ve heard a little bit already, and indeed from Professor Sir Ian Diamond, that the ONS worked with you in relation to statistics. Can you recall when that was?
Professor Kamlesh Khunti: Statistics in relation to Long Covid?
Counsel Inquiry: Long Covid, my apologies.
Professor Kamlesh Khunti: So I think that was in the SAGE minutes of November 2020.
Counsel Inquiry: Indeed, it was – I believe it’s SAGE 69, if it assists – on 19 November.
Professor Kamlesh Khunti: That’s correct.
Counsel Inquiry: It’s really just to get a broad understanding.
Professor Kamlesh Khunti: So I was representing the Ethnicity Subgroup within the main SAGE meetings, but because I’d done some work in the area of Long Covid I was asked to work with ONS, and that’s when they were starting the CIS, the Covid Infection Survey, and they were going to add the Long Covid questions to that, and it was just to work with the team regarding the questions that were going to be asked and how the study was going to be set up.
Counsel Inquiry: Thank you.
With regard to your involvement in SAGE, and advice provided, were there discussions about advice to be provided to government decision-makers and policymakers in relation to Long Covid, to your recollection?
Professor Kamlesh Khunti: Not that I’m aware of, no.
Counsel Inquiry: Thank you.
In fact, it appears that the first detailed discussion on Long Covid doesn’t take place until February 2021. Can you help us with why it may be that it took so long?
Professor Kamlesh Khunti: I think most of this, as I’ve said, is because there wasn’t any evidence there that one could change anything in terms of Long Covid. Long Covid was this new disease, we still don’t know much about Long Covid, as you’ll hear from Chris Brightling, so at this phase it was mainly trying to get informed from the studies that had been done, which are still – many of them are still not complete.
Counsel Inquiry: Thank you.
You have had the opportunity of reading the report, haven’t you, and just in general high-level terms, do you agree with the report of Professors Brightling and Dr Evans?
Professor Kamlesh Khunti: Yes, completely agree, yes.
Counsel Inquiry: You completely agree, thank you.
Professor Kamlesh Khunti: There’s areas about funding I think he mentions, which we’ve discussed at Long Covid meetings as well, and we do agree further funding is required, but there are NIHR calls(?) that people can go to, to continue doing this work, if they wanted to extend their work.
Counsel Inquiry: I have just three very short points, if I may, and then I’ll be handing over, my Lady.
The first relates to the collection of data in relation to Long Covid. Effectively at the outset of the pandemic, as we’ve heard, data was not being collected. In terms of that, are there any recommendations that you would make with regard to population-level data collation?
Professor Kamlesh Khunti: I think longer-term we’ve learnt a lot from this pandemic, there are a number of areas that we can look at, but in terms of Long Covid, I think we need to start planning for this very early. And the studies like CIS and REACT, these are what we call, now, hibernating studies, we’re not doing them, but they could easily be set up – if another pandemic came, they could very quickly be set up.
Counsel Inquiry: Essentially used as sleeping studies to be activated; is that right?
Professor Kamlesh Khunti: That’s right.
Counsel Inquiry: Thank you.
Then in terms of coding issues, a further tweet from you, because you appear to use social media in this way, INQ000280199, you tweeted that:
“Longcovid is poorly coded in primary care records but there are other ways.”
Again, in relation to collation of data.
What other ways do you see?
Professor Kamlesh Khunti: So the coding structures came very quickly, I think there were 18 codes that were set up for Long Covid within the GP systems. The tweet was in relation to a paper that was published a month before from OpenSAFELY, that’s in the British Journal of General Practice, that showed that only 0.04% of practices at population level had a code for Long Covid. By that time we’d had a number of people with Long Covid, but only 0.04% were shown on the GP computer systems, and it was variable, 25% of practices did not have a code at all. So it showed that there is an issue with coding of Long Covid.
The other areas are that if patients are going to Long Covid clinics, for example, if they came back to the practice, that’s one way of putting Long Covid codes in. Otherwise we have to do them prospectively. I think because the diagnosis is so difficult of Long Covid – unless you’re a researcher, we’re doing that on a regular basis – in clinical practice Long Covid is a difficult diagnosis for a busy general practitioner. There are training elements already inputting for that though.
Counsel Inquiry: We’ve heard a little bit about that, and obviously we can surmise, and you’ve covered the implications for that within your statement in relation to assessing that.
Finally, just in relation to ethnicity and sex, it appears that data concerning ethnicity at the moment is less consistent in relation to having a causal link or that enhanced risk of Long Covid, is that right?
Professor Kamlesh Khunti: Yes, there are – so there are some studies that have shown that ethnic minorities may have Long Covid when we look at the large datasets. When we look at prospective studies where people are asked about Long Covid, we seem to see less Long Covid, but again I think there maybe some nuances here. We’ve seen ethnic minorities get worse disease, we’d expect them to get more Long Covid, but this may be the language that’s used, and I don’t think there’s work that’s been done in terms of the language of Long Covid with ethnic minorities, and that’s an area of work that certainly needs to be done.
Counsel Inquiry: So we still have a gap there?
Professor Kamlesh Khunti: Absolutely.
Counsel Inquiry: Can you just assist with women, because women appear to be disproportionately impacted in terms of the initial outputs for some of these research studies. Do you know why that is?
Professor Kamlesh Khunti: I don’t, sorry.
Ms Cecil: Not at all. We’ll be hearing, as I say, from Professor Brightling and Dr Evans in any event in due course.
My Lady, those are my questions. There have been applications that have been granted by two core participants, the first is FEHMO and the second is the Long Covid groups.
Lady Hallett: I think I’m just going to check. Professor, do you mind if we take a break? I’m sorry, Mr Thomas. It’s just I have been watching our stenographer.
Are you okay if we take a break now and come back afterwards?
The Witness: Sure.
Lady Hallett: Good, thank you very much. In which case I shall be back at 11.30.
(11.13 am)
(A short break)
(11.30 am)
Lady Hallett: Mr Thomas.
Questions From Professor Thomas KC
Professor Thomas: Hello, Professor, I represent the Federation of Ethnic Minority Healthcare Organisations, FEHMO.
I’ve only got a few questions for you. One of my questions has already been asked, but let me come on to the three questions that I do have.
My Lady, I’m starting from question 2.
Lady Hallett: Thank you.
Professor Thomas: The Chair asked you earlier a question, she said:
“… who had the data that you needed?”
Your response was you weren’t sure and you said:
“I’m not sure if the government had the data. If … one of the asks, I’m sure Sir Ian Diamond would have provided that data …”
“[The data] wasn’t coming to us …”
My question is this: so bearing that in mind, what was the source of the data in the period leading up to March/April 2020 that connected certain underlying clinical conditions with increased vulnerability to Covid-19?
Professor Kamlesh Khunti: Okay, so in terms of the data, there were a number of data points that were available to researchers, and obviously they were available to the Office of National Statistics. In terms of the government, I’m not sure what data were available to them.
Professor Thomas KC: Okay.
Professor Kamlesh Khunti: Unless they commissioned the other groups to do the work.
Professor Thomas KC: Yes. But you’re clear in your analysis – well, let me ask you in a non-leading way: did the analysis of that data that you did have, that suggested a heightened vulnerability to Covid-19 based on race and ethnicity?
Professor Kamlesh Khunti: Absolutely, yes. And as I mentioned before, it’s the ONS data and the Public Health England data also suggested that, and then subsequently a number of other independent researchers have also identified that risk as well.
Professor Thomas KC: Okay, thank you.
Let me move on to my next question. If there was a growing expert view in between March/April 2020 that there was indeed a heightened risk to Covid based on race and ethnicity, can you say who the main voices who were making this call, who were – you know, “This is a potential problem”, who were the main voices?
Professor Kamlesh Khunti: So, as I said, the first signal that we mentioned earlier was that I was the first one to point that risk out. And, as I said, this – you know, it was in a cautionary way, that “We’re seeing more people from ethnic minority backgrounds being admitted to hospital”, and we’d not heard of this.
And then after that I think the first lot of data we were relying on was the ICNARC data, which is the intensive care unit data that’s collected nationally from a number of centres. And we were tweeting this on a regular basis saying there is still this risk, and then more patients were admitted, and saying disproportionately ethnic minorities are more represented in intensive care unit database.
So we were the first ones to make these, all these signals available to people. And then I think that’s when ONS started looking at the data.
Professor Thomas KC: Yes. Can I just follow on from that, if I may. So you were signalling this, did you consider the level of any such risk to be actionable, you wanted it acted upon?
Professor Kamlesh Khunti: Before we act on anything we need a definite confirmation that there is a causal risk there, and we hadn’t identified – we knew that there were more patients admitted to the hospital – and I am talking here of May/June time, and that’s when ONS did their first lot of analysis showing and confirming this risk.
Professor Thomas KC: Right.
Let me move on to my last area. Are you aware of any targeted interventions that were formulated to address the probability of heightened risk of Covid based on race and ethnicity?
I’ll repeat the question if you want me to.
Professor Kamlesh Khunti: Please, yeah.
Professor Thomas KC: Are you aware of any targeted intervention that was formulated to address the probability of heightened risk to Covid-19 based on race and ethnicity?
Professor Kamlesh Khunti: So if you look at the four quarterly reports from the Race Disparity Unit, you do see that there were targeted interventions throughout those four reports, and they were at various levels, including the communications that we’ve talked about, the vaccinations and more data-driven work that could be done.
In terms of my answers I gave earlier, the targeted interventions were – we felt it wasn’t co-ordinated as such. They weren’t – the funded individuals, there was about 60 authorities that were given this funding, they were left to themselves to decide what to do with that rather than having a co-ordinated effort – or even having co-ordinated pilots, to say, “Let’s intervene here in this area, intervene in this way in this area”, to draw out and reduce the risk and to identify what are the best interventions that will lead to better outcomes for people from ethnic minority backgrounds.
Professor Thomas KC: Yes. I’ve finished, but just on that, do you think things were being done timely?
Professor Kamlesh Khunti: The first quarterly report was in October, and that’s when they started discussing this. I think the first lot of funding for community champions was given in January 2021. Yes. £23.75 million was given for community champions over, I think, 60 authorities. And we think that this could have been done earlier, yes.
Professor Thomas: It could have been done earlier.
My Lady, that’s all I ask, thank you.
Lady Hallett: Thank you, Mr Thomas.
Mr Metzer.
Questions From Mr Metzer KC
Mr Metzer: Thank you, my Lady.
Two topics, please, Professor Khunti.
First of all, I’m going to cite, I’m not going to go to the INQ number, but it’s INQ000280061, which is part of Sir Patrick Vallance’s dairies.
At page 205, Professor Khunti, he recorded an entry, on 6 October 2020, listing the reasons why the Great Barrington proposal, namely herd immunity and let it rip, as you will be aware, is wrong. Number 4 on that list is Long Covid.
First of all, do you agree with Patrick Vallance’s view that Long Covid was one of the reasons why letting the virus spread unchecked was wrong?
Professor Kamlesh Khunti: Absolutely. I agree with that. As I mentioned earlier, at the moment the way to reduce the risk of Long Covid is through reducing the risk of people getting Covid. And this is through, as we said, all the NPIs. And now we have the vaccines that can drive the risk. Vaccines drive the risk – reduces the risk, and there’s good evidence now that if people are vaccinated they’re less likely to get Long Covid. If they have Long Covid and they’re vaccinated, there’s also data to suggest that they get less Long Covid.
Mr Metzer KC: Thank you.
Since you’ve said yes, can you answer this subsidiary question: should Long Covid be one of the factors to take into account in assessing the need for non-pharmaceutical interventions to limit transmission?
Professor Kamlesh Khunti: Yes, absolutely. As I’ve said, that’s one of the ways, and one of the major ways, of reducing the risk of getting Covid in the first place, and we know – also know that if you have had Covid and you have Long Covid and you have Covid again, your risks are worse. So definitely, yes.
Mr Metzer KC: Thank you.
Would SAGE be responsible for informing government decision-makers about the nature of risk of Long Covid, as with other factors on Patrick Vallance’s list, such as how long immunity lasts?
Professor Kamlesh Khunti: I think that was already in many of the SAGE papers. The SPI-M modelling had looked at how long the immunity lasts, after an infection or vaccinations, and these were all taken into account when the modelling was done.
Mr Metzer KC: Thank you.
You said at paragraph 3.5 of page 13 of your report, you said:
“By August 2020, understanding was sufficient for guidance on management of ‘post-acute Covid’ (as the longer-term effects of Covid-19 were then termed) to be published in the British Medical Journal.”
Is it right that SAGE did not provide advice on Long Covid to government decision-makers by October 2020 when Sir Patrick Vallance made this note in his diary?
Professor Kamlesh Khunti: As I mentioned earlier on, there weren’t any interventions for people with Long Covid. Indeed, you’ll hear on Friday we don’t have any interventions at the moment. Really, we’re at its infancy in terms of knowing much about Long Covid. So at that stage we did not have any interventions to put into place to help people with Long Covid except to reduce the risk of Long Covid with the interventions I’ve mentioned, the NPIs and the vaccination programmes.
Mr Metzer KC: All right, well, that ties in well to my second topic that I want to go on to, on recommendations.
The Long Covid group, the two questions I want to ask you about that in relation to something you said, I think, both in evidence at paragraph 3.8 of your witness statement. You of course sat on SAGE. Can we look at the minutes of SAGE 94, on 22 July 2021, which is INQ000092856. I don’t know if that’s going to be put up.
Lady Hallett: It’s up on mine.
Mr Metzer: Not on mine, sorry.
Could we go to page 4 at paragraph 27. I want to ask you about the fourth line, which starts:
“For those children who do suffer long illness” –
Lady Hallett: You need to be near the microphone, sorry.
Mr Metzer: I’m sorry, yes. It’s on my screen, thank you.
“For those children who do suffer long illness duration, there may be a need for guidance to parents, carers and schools on how to support them.”
Would you agree that this appears to be a recommendation from SAGE?
(Pause)
Professor Kamlesh Khunti: That’s what it seems like, yes.
Mr Metzer KC: Thank you. Do you know if that guidance was prepared?
Professor Kamlesh Khunti: I’m not aware of that, sorry.
Mr Metzer KC: So you’re not able to say, if it wasn’t, why it wasn’t.?
Professor Kamlesh Khunti: As I said, I was on the SAGE for – as chair of the Ethnicity Subgroup. I did give comments on Long Covid particularly for the CIS survey. Children’s Long Covid is not my area of expertise.
Mr Metzer KC: So be it. And the last INQ I’d like to take you to, INQ000249018, which is a WHO policy brief, number 39. That’s titled “In the wake of the pandemic: preparing for long COVID”.
Can we look, first of all, at the first page and just confirm that you’re a co-author?
Professor Kamlesh Khunti: That’s right, yes.
Mr Metzer KC: Thank you. Page 4, can we go to, please, which is a correction from 22 March 2021, can we take that to indicate that the report was published by then, March 2021?
(Pause)
Professor Kamlesh Khunti: This is the first time I’ve seen this, so if this is there, yes, I do agree.
Mr Metzer KC: So you do agree that we can indicate the report must have been published by then, March 2021?
Professor Kamlesh Khunti: Yes.
Mr Metzer KC: Thank you.
The last thing I want to ask you, page 23, please, we can see there a number of recommendations for policymakers. Do you have that, Professor Khunti?
Professor Kamlesh Khunti: Yes.
Mr Metzer KC: Yes. Do you agree that these recommendations could have been put before SAGE?
Professor Kamlesh Khunti: I’m just reading those.
Mr Metzer KC: Yes, of course.
(Pause)
Professor Kamlesh Khunti: Yeah, so these are recommendations stating that we should be implementing patient registers, we should be giving guidelines on multidisciplinary services, but we didn’t have any evidence for this at all. These were all consensus recommendations that we gave, as part of this document. SAGE was looking at the acute complications, and giving advice of trying to reduce the risks associated with this, acute effects of the pandemic.
Mr Metzer KC: Yes.
Professor Kamlesh Khunti: In terms of this, there are other areas looking at this, there are already clinics that have been set up to deal with this. These were all actioned by the government in terms of having clinics for people with Long Covid. They, I think, pre-date some of the discussions on SAGE.
Mr Metzer KC: Yes. But we can see the implications for policy makes reference to –
Lady Hallett: Microphone, Mr Metzer. Sorry, it’s because it’s not appearing on your screen.
Mr Metzer: I’m very sorry, I’m bending down. I’ll bring it down with me:
“Although Long COVID is not yet fully understood health policy-makers should be preparing to address it.”
Professor Kamlesh Khunti: Yes, so this is to the policymakers, in terms of the government policymakers, and we know that they did set up the Long Covid clinics because of that.
Mr Metzer KC: Yes. So the last question I ask, therefore, is: SAGE could have made similar recommendations on the basis of information available at that time, which is early 2021; do you agree?
Professor Kamlesh Khunti: They could have done but, as I said, this wasn’t a question that was put towards SAGE to look at this evidence, because there wasn’t any evidence. Even the Long Covid clinics were set up to help people with Covid but there wasn’t any evidence, as such, for that.
Mr Metzer KC: No, just recommendations?
Professor Kamlesh Khunti: Yes.
Mr Metzer: Thank you.
Lady Hallett: Thank you, Mr Metzer.
Ms Cecil: Thank you, my Lady. That concludes the evidence, unless your Ladyship has any questions.
Lady Hallett: No, I have no questions.
Thank you very much, Professor, for all the work you have done generally and for all your help with this Inquiry. We are very grateful.
The Witness: Thank you very much.
(The witness withdrew)
Ms Cecil: My Lady, if I may just hand over to Mr Keith.
Mr Keith: My Lady, the next witness is Professor Tom Hale.