2. Professor Anthony Costello

PROFESSOR ANTHONY COSTELLO (affirmed).

Questions From Lead Counsel to the Inquiry

Mr Keith: Good morning, Professor. I’m sorry you’ve been kept waiting. Could you commence, please, your evidence by giving your full name.

Professor Anthony Costello: Anthony Costello.

Lead Inquiry: Professor, thank you for the provision of a witness statement. You have provided a statement INQ000281260, dated 25 September 2023. You’ve signed it at the conclusion and you’ve provided the usual declaration to the effect that the contents are true.

May I start, please, with your professional qualifications. You are professor of global health and sustainable development at the UCL Institute for Global Health; is that correct?

Professor Anthony Costello: That’s correct.

Lead Inquiry: The institute implements and evaluates solutions to global health problems through research and teaching; is that true?

Professor Anthony Costello: That’s correct.

Lead Inquiry: You were, until 2018, director of maternal, child and adolescent health at the World Health Organisation, which is of course in Geneva, and I think during that time you spent 18 months or so as part of the core emergency team dealing with the global Zika epidemic outbreak; is that correct?

Professor Anthony Costello: That is correct, yeah.

Lead Inquiry: You are currently chair of the Lancet Countdown for climate and health action, again based at UCL, but you’re also, for our purposes, most significantly a founder member of Independent SAGE?

Professor Anthony Costello: Correct.

Lead Inquiry: What was or is Independent SAGE?

Professor Anthony Costello: Independent SAGE was set up specifically to educate and answer questions from the public to engage especially about the public health details of the whole pandemic.

It really got going in April 2020. I had been somewhat shocked by the 12 March press conference. I had been following things closely up to then, but of course we didn’t know anything about the membership of SAGE or any of the decisions at that point. And after the 12 March press conference I wrote my concerns down about almost everything that had been said there, because I disagreed with many of the points, I put it into a tweet, which went viral. I was then asked to write articles, which I did, in various national newspapers, laying out my concerns about the lack of a public health approach, and the idea of letting a very serious new virus spread across a population struck me as being the wrong approach.

Lead Inquiry: Why was your undoubtedly extremely worthy and impressive group, Independent SAGE, calling itself Independent SAGE? It wasn’t, was it, the government’s Scientific Advisory Group for Emergencies, that was SAGE. You weren’t SAGE. To what extent did you believe that the government’s advisory group, SAGE, wasn’t sufficiently independent?

Professor Anthony Costello: Well, the use of the phrase “SAGE” is not – is very commonplace. At WHO I was involved in both the – a little bit with the SAGE for – scientific advisory group of experts for immunisation, and I helped set up a SAGE for maternal, newborn and child health, so the use of the word “SAGE” – to distinguish ourselves from official SAGE there were two phrases used initially, “alternative” or “independent”, and it was decided to choose the word “independent”. I didn’t think that was particularly controversial or confusing, but I think some people did.

Lead Inquiry: So are you saying there were other bodies in the WHO, for example, which were specifically called SAGE, so SAGE is an acronym which is in common use?

Professor Anthony Costello: Very common use, yeah. Not just in WHO.

Lead Inquiry: Because this SAGE was the government Scientific Advisory Group for Emergencies?

Professor Anthony Costello: Yeah.

Lead Inquiry: All right. To what extent were the scientists on SAGE, in your view, or the group SAGE not sufficiently independent such that you were required to call yourself the Independent SAGE?

Professor Anthony Costello: “Independent SAGE”, not “the”, but –

Lead Inquiry: Why did you call yourselves Independent SAGE?

Professor Anthony Costello: Well, just to show that we were separate from the government set of advisers. Because when we did discover their membership, we felt – and we may come on to this later – that the composition was failing in some ways because it didn’t represent – there was no independent public health person, there was no black/minority ethnic group member, the distribution of gender and expertise we felt was wrong. There were very good people on that SAGE, but it was lopsided. And that’s why we chose a group of people who did cover a lot of those bases, and some very eminent people from public health and covering a range of disciplines, including two members who were actually on the SAGE SPI-B, the behaviour group.

Lead Inquiry: We’ll come back to the composition –

Professor Anthony Costello: Yeah, sure.

Lead Inquiry: – of the government SAGE in a moment.

Do you accept, because you acknowledge that the calling of your group Independent SAGE may have caused some degree of concern or confusion perhaps, that there is no question over the independence of those many scientists who gave their time freely and with great devotion to SAGE and the subcommittees? They were independent scientists?

Professor Anthony Costello: Oh, absolutely – well, no, that’s not quite true actually.

Lead Inquiry: Well, the CMO isn’t, obviously, nor is the Government Chief Scientific Adviser.

Professor Anthony Costello: Actually nearly two-thirds of the members of SAGE were not classified as independent scientists.

So let me give you an example. The first day I went to WHO, I was told I was no longer an independent scientist, because I –

Lead Inquiry: Professor, I’m sorry to interrupt.

Professor Anthony Costello: Sure.

Lead Inquiry: We must keep this within some bounds.

Professor Anthony Costello: Okay.

Lead Inquiry: Are you suggesting that the majority of the scientists who attended SAGE were not functionally independent? So obviously we have – there were government scientists like the CMO and the Chief Scientific Adviser and representatives of the NHS, PHE, BIT –

Professor Anthony Costello: That was the majority, yeah.

Lead Inquiry: All right. The other scientists, the scientists from places like Imperial and the London School –

Professor Anthony Costello: Yeah, they were independent.

Lead Inquiry: They were all independent?

Professor Anthony Costello: Yeah.

Lead Inquiry: And insofar as any scientist came from a non-government entity, they were also independent –

Professor Anthony Costello: Correct.

Lead Inquiry: All right.

Do you accept that with the publication of some materials by Independent SAGE, however valuable and however worthy, that some degree of confusion was caused in the outside world as to whether or not you were speaking on behalf of the government and SAGE or a different body?

Professor Anthony Costello: I don’t really accept that. I don’t think – we aimed to communicate with the public and we spoke to media, and it was fairly clear from our emphasis on a number of things that SAGE were not emphasising, particularly, the desire to set up a proper system to isolate people and to suppress the virus, that we were putting forward a very different view.

Lead Inquiry: Could we have INQ000230014, please. This is a document produced by Sir Patrick Vallance. It’s an “Independent SAGE Report”. It happens to be report 29. It’s dated 8 January 2021. It’s called “A ‘Safe Schools’ policy for re-opening education as soon as possible and mitigating the harms of closure”, and it says at the bottom:

“Submitted to the UK Government and the People of Great Britain & Northern Ireland by Sir David King former Chief Scientific Adviser, UK Government, Chair of Independent SAGE.”

For those not intimately familiar with the workings of SAGE and Independent SAGE, a report appearing like that may well impress itself as emanating from government, wouldn’t you agree?

Professor Anthony Costello: Well, Sir David King made it very clear from the beginning that he would submit all of our reports to Sir Patrick Vallance and to SAGE, so that there was communication going on. I don’t think many people would have read these footnotes to gain the impression you obtained, but we were sending an Independent SAGE report to the government.

Lead Inquiry: One of the main drivers for SAGE, according to your witness statement, was the perceived lack of transparency over the SAGE process. It’s right, isn’t it, that before Friday, 29 May, SAGE had not published the minutes of the many – the 34 meetings, in fact, that it had held hitherto?

Professor Anthony Costello: That’s correct.

Lead Inquiry: Had SAGE or the government published the list of members of SAGE before the time at which it started publishing the minutes? So was there a rolling out, if you like, of information? When did SAGE explain the membership?

Professor Anthony Costello: As I recall, it was leaked by The Guardian at the end of April, but officially they only released it on the very first day or our very first meeting, when they released the names, and also – because we had been calling for that in preceding articles and – et cetera, and so that’s when they finally released it, the first day of our public meeting.

Lead Inquiry: Was that 4 May, in fact?

Professor Anthony Costello: I think so, yeah.

Lead Inquiry: So that we are absolutely clear, there was plainly a lacuna of information because nobody knew who was on SAGE and its minutes weren’t being published, and so Independent SAGE’s first meeting took place at a time when no one knew that information?

Professor Anthony Costello: Correct.

Lead Inquiry: I think Independent SAGE then ran weekly online public meetings. Online, as I say. It produced short reports, developed by a very wide range of experts from epidemiology, primary care, virology, immunology, public health and so on; is that right?

Professor Anthony Costello: Yeah.

Lead Inquiry: As you have said, you provided all your reports and recommendations to the government, but in particular the CMO and the –

Professor Anthony Costello: Correct.

Lead Inquiry: – GCSA.

The first report that you published was titled “Covid-19: what are the options for the UK?” and I think that was published on 12 May 2020.

Perhaps we could have that up, if it’s in the system. INQ000249693. Thank you very much. If you could go, please, to page 5.

Recommendation 1:

“The government should take all necessary measures to control the virus through suppression and not simply managing its spread. … We detect ambivalence in the government’s strategic response, with some advisers promoting the idea of simply ‘flattening the curve’ or ensuring the NHS is not overwhelmed.”

Now, the date of this report, 12 May, was plainly after the lockdown had commenced. But I want to ask you to what extent did Independent SAGE nevertheless believe that the government was still applying a particular type of strategic response?

So even though the lockdown had started, did Independent SAGE believe that there was a driver or a particular approach driving the government’s strategic overall response?

Professor Anthony Costello: Yes, because the minutes of their very first effective meeting, it was actually their second meeting, on January 28th, came up with the idea that they were going to follow a pandemic influenza strategy, and that they were going to simply model all of the interventions that the modellers subsequently did, except for suppression of the virus. And this went against WHO advice at the time and it went against all the practices of the East Asian states that managed to reduce their death rates to five times lower than our death rates.

So we felt that this was the wrong approach, particularly as two elements of pandemic science show us what was considered to be the right approach to a coronavirus outbreak back – after SARS-1, papers published in 2004 and 2006, including actually three members of SAGE, showing that for a coronavirus outbreak you need to pursue a very different strategy from pandemic influenza.

Lead Inquiry: Now, there’s a number of points in there. Could we perhaps just delineate them.

Firstly, East Asian states had, you’ve explained, undergone the experience of SARS-1, and some other states, of course, had gone through MERS as well, the Middle East Respiratory Syndrome?

Professor Anthony Costello: Correct.

Lead Inquiry: In general terms, did they therefore have the knowledge, the system to be able to respond efficiently and quickly to the outbreak of a viral pandemic?

Professor Anthony Costello: In SARS-1?

Lead Inquiry: No, we’re now coming forward to coronaviruses.

Professor Anthony Costello: Yeah, absolutely. I mean, there is this confusion between the words eradication, elimination and suppression.

Lead Inquiry: Can we come back to that –

Professor Anthony Costello: Okay.

Lead Inquiry: – conceptual debate a little later.

Professor Anthony Costello: Yeah.

Lead Inquiry: I’m just asking you about the East Asian states.

Was it fundamentally on account of their earlier experiences that they were in a better position to be able to respond to the viral epidemic that was coronavirus?

Professor Anthony Costello: Well, I, you know, Patrick Vallance and others have put forward the view that they had a much better infrastructure. I think the infrastructure was more in the mind than in reality. They knew that they had to act very fast, and that’s exactly what the World Health Organisation was saying at the time, and therefore they put in place a rapid organisation to get a test, a rapid organisation to mobilise community healthcare workers, so that you could do contact tracing at scale, but most important, and I think this is really important to emphasise, the really key thing to getting a pandemic under control is isolation. If you can isolate a case and its contacts, the household contacts, then you can suppress that pandemic, as long as its transmission rate is not so high or its incubation period is not so short.

Now, for influenza, we know that exactly that’s the problem, and therefore the strategy to just simply reduce the spread and mitigate is the only real option. But for coronavirus, it’s quite different. That’s what those two papers, after SARS-1, written by British scientists, showed very clearly.

Lead Inquiry: Are there, therefore, two vital aspects of a scaled-up, efficient testing system: firstly, it enables the country to know what the spread of the virus is, because if you test and the tests are accurate, you know what you’re dealing with; and secondly, if it is combined with an absolutely reliable contact tracing and isolation system, then it will break the chain of transmission of the virus?

Professor Anthony Costello: That’s exactly what happened in the East Asian states: they suppressed the virus within about six weeks and they did not have national lockdowns, with the exception of Taiwan, and they did not suffer any of the enormous economic damage that we suffered, because they suppressed their epidemics very quickly.

And it’s also not true that you would then have to maintain horrible lockdowns for a long time, as they were implying. In fact all they had then was an effective surveillance system that enabled them to spot new outbreaks and suppress them locally very quickly. So they hit their hotspots very quickly. In Korea, two hotspots, around the same time when we could have started, we had two hotspots in England, in the West Midlands and North London – and also in Glasgow for Scotland, but if we had hit those with limited numbers of tests – and we’ve heard millions of tests being requested. If you look at Korea, at the end of February, when they started to get their epidemic falling, they only got up to 18,000 tests per day. Why? Because they were targeting that all at hotspot areas.

I don’t see any reason why we couldn’t have done the same. I don’t see any reason why we couldn’t have mobilised people to have a national contact tracing system – way different from the later one that we set up that was never going to work.

Lead Inquiry: Before we look, and it will be after lunch now, at the detail of what actually happened, and whether or not it was possible and whether or not a test – a full, scaled-up testing, contact, isolation system was called for and whether it was put into place, just on this question of the flu, the genesis of the thinking as to the relevancy of past flu pandemics, the UK Government strategy, you are aware, had been based to a large extent upon a 2011 document called the pandemic flu strategy?

Professor Anthony Costello: Yeah.

Lead Inquiry: Could you just explain why testing is available and so important if you’re dealing with a virus that has a long – longer latent period, that is to say the gap between when you become infected and when you might begin to infect other people, and a flu which may have a much shorter latent period and in relation to which testing, according to the strategy, is of much less assistance? Why is that? What is that point?

Professor Anthony Costello: Well, if you’ve got a flu virus that’s – let’s say it’s transmitting with an R value of 10, which a lot –

Lead Inquiry: Just pause there, meaning that one person infects –

Professor Anthony Costello: Could infect –

Lead Inquiry: – ten other people in an unimmunised population.

Professor Anthony Costello: Exactly. And that that has an incubation period of one to two days.

Lead Inquiry: Pause there. What is an incubation period?

Professor Anthony Costello: It’s the time between being infected and developing the disease.

Lead Inquiry: Symptoms?

Professor Anthony Costello: Yeah. And so therefore you’ve got almost no time to do it, you’ve got no time to get your test in, and it’s already spread. So there are certain diseases and that’s what the paper written by Roy Anderson, Neil Ferguson and others that I quote, with that nice diagram, shows, that for influenza you really cannot do it, as you cannot for HIV, because the other factor is how many infections are asymptomatic. So with HIV, 95% plus of infections are asymptomatic, so you don’t know that you’ve got the virus until it happens.

But with SARS, the reproduction rate was about – was under 3, it was thought, in January 2020. So one person would infect about three people, let’s say.

Lead Inquiry: Just to pause you. When you say SARS, you –

Professor Anthony Costello: Well, SARS-1 –

Lead Inquiry: Do you mean SARS-2 –

Professor Anthony Costello: I beg your pardon, SARS-2.

Lead Inquiry: – coronavirus?

Professor Anthony Costello: SARS-1 was somewhere between 3 and 6. It – you know, it changed over time, I think. SARS-2 was at that stage – the data coming out of China and also in the papers published in The Lancet on January 24th – I think the figure was 2.8. But of course it was, you know, still rudimentary, so there was quite some confidence intervals there that you would need to take account of.

But let’s assume it’s 3, you’ve got 1 to 3, you’ve got an incubation period that we then knew to be probably around the five-day mark, and a serial interval – that’s the interval between one person having symptoms and passing it to the next person and them having symptoms – was somewhere between eight to ten days.

Lead Inquiry: So just pausing you there, there was a window in which –

Professor Anthony Costello: A much wider window –

Lead Inquiry: – testing could take place –

Professor Anthony Costello: Yeah.

Lead Inquiry: – which would enable the government to know the extent of the virus and, if combined with a proper isolation and tracing contact, quarantining system, could have enabled –

Professor Anthony Costello: You could go further and say you don’t actually, in the early stages, even need a test. If somebody is symptomatic, you have to close it down. So you need to have boots on the ground. Shoe leather epidemiology, we talk about in public health.

Mr Keith: Well, that’s a very good place to pause, thank you, Professor, for lunch.

Lady Hallett: It’s not an expression I have come across before, I have to say.

2 o’clock, please.

I’m sorry we have to break but –

Mr Keith: My Lady, may I just mention that there is legal argument scheduled before you for 2 o’clock, so could we impress upon the Professor to be ready again at 2.30.

The Witness: Oh.

Lady Hallett: Sorry, I had forgotten.

(1.02 pm)

(The short adjournment)

(2.00 pm)

Lady Hallett: Mr Keith.

Mr Keith: If it pleases you, my Lady, oral submissions will be made first by Mr Hill on behalf of Sir Patrick Vallance.