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So can you start by saying your name and your position?

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Yeah. Hi. My name's Carl Hennigan.

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I am professor of evidence based medicine in the Department of Primary Care Health Sciences at the University of Oxford.

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I also work as an urgent care general practitioner in the NHS and I do that in evenings and weekend.

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Did you say urgent care or sorry? Urgent care. Right, yes.

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So in the thought. Yeah. The out-of-hours setting.

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Yes. The work that goes on in the evenings and the weekend. Yeah.

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Okay. And without telling me your entire life story, because we don't quite have time for that.

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Yeah. Can you just talk me through your career to date from where you first got interested in medicine?

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Yeah, so I actually studied medicine at the University of Oxford.

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I came here in 1994. So coming up for nearly three decades have been at Oxford and stayed there ever since.

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And what happened? While I was a medical student, I met a certain chap called David Thacker,

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who was the first ever professor of evidence based medicine and the director of the Centre for IBM.

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And he had a profound impact on my whole career and what happened next,

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just because of the way of thinking about decision making that you can integrate best

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available evidence with your clinical experience and expertise and patient values.

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You take that together. That's what evidence based medicine is how it informs decision making.

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I then went on to train as a general practitioner and then ended up in an academic career pathway that led to me being

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appointed as the sort of director of the Centre for Evidence based Medicine and Clinical Reader Knebworth in 2010.

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And subsequent to that, I become a professor of evidence based medicine here.

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But while that's been going on, I still maintain an active career as a clinician by working as a general practitioner.

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And I work in the out-of-hours setting where we do generally visits and urgent care visits, for instance, into care homes.

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And I like the out-of-hours because it fits with my sort of chaotic lifestyle.

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So I can work it round and it works with my family. And so I tend to work evenings and weekends, and in the daytime I do.

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About 50% of my time is research and about 50% of my time is teaching and building capacity and supervising.

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Hmm. Very good. So let's just unpack evidence based medicine.

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I mean, I think when I first heard of it, I guess for a lot of people, there'd be a kind of moment of surprise.

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Yeah. What do you mean? All these years, doctors have been treating us without evidence.

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So have it. How did the. The term arise? What was different about evidence?

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Yeah. Is everybody think that all of healthcare is built on evidence,

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but actually there's been a long history and tradition of so-called quackery in health care.

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Everybody wants the silver bullet, the magic bullet to that ails and that cures, if you like.

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But it was probably about the late eighties when the concept of evidence based medicine came to the fore.

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Because what was happening then is lots of medicine with practised on low quality evidence, all on opinions.

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I know what to do best.

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And one of the key changes was with the use of high quality evidence, particularly for drugs and vaccines, the use of randomised controlled trials.

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Now just to say in the current COVID pandemic,

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everybody will understand the impact and you'll probably interview people who've done the recovery trial,

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which looked at 13 treatments like dexamethasone.

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A large national multi-centre trial provide high quality evidence about decision making, and that's a superb example of evidence based medicine.

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But if you go back to the eighties and nineties, there were very few randomised controlled trials that impacted on health care and so there was a huge

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growth into can we develop high quality evidence and that was the start of evidence based practice.

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And there are an important aspect. How do you determine what is high quality evidence, what are the potential biases,

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what are the competing interests in the conflict that might distort the evidence base?

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You put all that together. My job is to try and understand how you take the evidence from the bench, if you like, to actual patient care in decisions.

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And there's a huge amount of evidence out there. At any one point there's probably about 40,000 randomised controlled trials each year.

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There are about 2 million articles index on PubMed, so it's like looking for the needle in the haystack if you like.

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What the high quality evidence that impacts on patient care.

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Now tell me about systematic review. Yeah. Yeah. So that also came.

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So there's a very in about the mid nineties, Oxford was very much at the centre of the development of evidence based medicine.

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David Sackett moved from Canada to Oxford to establish the first centre for

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IBM in Chalmers was based on the road developed the Cochrane Collaboration,

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which started up in North Oxford, actually as a group of about 70 people who were interested in systematic reviews.

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And the point about systematic reviews is you really saying, look, when you have a clinical question,

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what we don't want you to do is cherry pick the bits of evidence that suit your answers.

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You're basically saying, let's collate. All of the evidence at certain level.

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So for instance for all the randomised controlled trials and then look at the aggregate effect,

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what do they say when we systematically review the evidence and it means you have a clear question,

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you try and find all the evidence relevant to that question, you appraise the quality,

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what's the high quality and the low quality and then you sympathise it normally with what's called a meta analysis or and we look at that,

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it's called a forest plot. And when you do that that generally is the highest level of evidence that informs decision making.

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Now one of the key components also of evidence based practice and that's been interested in the COVID pandemic,

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is then how do you communicate that to inform decision making?

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There's been a big change probably in the three decades I've been involved in medicine from what we call a, you know, a doctor centric viewpoint.

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The doctor knows best to actually more of patient centred of medicine.

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We want to inform the decisions so that actually you participate in that decision.

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May ultimately it's our decision and therefore communicating the better patients.

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Yeah, definitely so, yeah. Our decision of patients. I'm a patient myself.

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I want to be informed all the time.

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So that is about informing the benefits and the harms and coming to a decision about what's the best treatment for you now.

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And that's where the patient values come in, because we may look at certain treatments and look at them differently and some people

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presenting with the same information will make different views about what to do next.

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And that's okay because the key is, have you been fully informed?

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Can you inform the decision you're about to make? And that's why I find IBN is fascinating, but actually it's still in its infancy,

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much if you go to the departments, they're like physiology and anatomy.

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They've been around for hundreds of years. The concept of evidence based medicine is about three decades old, really.

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However, over time, people have been coming to these decisions about what type of evidence should we use to inform decisions?

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And is. So you've talked about. Randomised controlled trials and obviously systematic reviews that kind of winnow those to get the answer from.

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Are there other kinds of evidence? It's not the only one. No, it's not.

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So it's a misnomer to think so. The key is it's the best available evidence to answer the question.

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So, for instance, we have a whole part of our centre of looked at qualitative research.

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You know, it's not just sometimes you might want to ask questions like, why do people not take vaccines as prescribed?

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And that's a why question. Well, then you have to go and interview and you have to talk to them like this and go.

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Can you talk to me about why you make these decisions, what the barrier is, what a facilitator.

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So it means it's appropriate to the question. Sometimes when we look at harms, the only evidence available is observational data,

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because you can't intervene when there's some harmful issue at hand.

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And the best example of that will be smoking.

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The one of the most famous studies ever done in Oxford was Richard Doe study, which was a 50 year cohort of doctors and their smoking habits.

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When that was started in the fifties. 80% of doctors smoke.

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The idea that 80% of doctors now would be ridiculous, but actually were followed up for 50 years.

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And that exposure, if you were a smoker of 20 cigarettes a day, on average, you would live ten years less than somebody with never smoked.

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And that was an important finding because it wasn't until the sort of 74

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showing when actually warnings came on cigarette packets that this is harmful.

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So the key is people say there's only randomised trials and that's all you make decision that's that's incorrect.

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It's matching the evidence to the type of question you have at hand.

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And then we have other studies like diagnostic studies. So we have to have the evidence base for diagnosis as well.

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Is this test accurate? Do they actually pick out those with the disease or not?

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And that's incredibly important to do. And people recognise that within the COVID pandemic is we've had this huge amount of testing,

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whether it's PCR testing or lateral flow testing, and we ask the questions all the time about the accuracy of these testing.

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Do they actually derive benefit? Do they pick out those people truly have COVID or not of be the case?

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And then there's another aspect of evidence based practice and even.

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Mm hmm. So what were the questions before we got to. Before we had to go with what were the main questions that you were interested in?

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We've had a huge amount of questions over time. I mean, if you have to in your centre.

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So there's about there's about 25 people in the centre.

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We've got about 130 to 140 MSI students who would do a part time evidence based health care program and about 40 students.

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So that's why it's had to do a lot of teaching and supervising.

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And the questions they bring to me are all with what I call I have a light bulb moment when somebody comes in the room and says,

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I have this question, I think, yeah, that's a really interesting, important question.

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And if we knew the answer, we'd be able to improve practice tomorrow.

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And I think that's the important. There are a lot more uncertainty for new consider in health care.

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Then there also the other aspects where we may have done something and there's been harm over time.

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So some of the work we've done, I've been approached by patients. We looked into the harms of metal hips or trans vaginal surgical mesh,

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and recently a treatment used in the sixties and seventies called Perimeter Earth, which was a hormone pregnancy test.

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So we do all that type of work. And then here we do generally work that looks at primary care in the community.

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Preventive treatment, those treatments are used and we have a vast array of evidence at any one time.

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But we tend to focus on the that the evidence, like the systematic reviews that inform the guidelines, that will change patient care,

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where if many people will be in the basic sciences in Oxford, translating, developing vaccines,

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developing new drugs and taking them forward into the pipeline, we don't do that.

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We do the applied health sciences, if you like, and we're trying to say, right, faced with this evidence, what's the decision going to be now?

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And that's and you can think about it because I said there's so many new trials published every year, 40,000.

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It's like a it's like a moving wheel, if you like, on the hamster on the wheel.

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And the key is what we're always looking to do is if we understood the answer to this, would it actually make a difference to patient care?

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And that's communicated to doctors that that's well,

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actually so so what happens now is the systematic review will go into guidelines and then you've got places people like nice.

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And if you think about it again, Nice has only been in operation since 1999 and so they're only three decades in.

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And one of the interesting issues I gave a talk to know within the pandemic about what's next.

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And they run into this problem of they've got thousands of guide and pieces of technical information and guide.

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And so they've got to keep up to date with new information.

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And they struggling with that because how do you maintain this knowledge base and then ultimately inform individuals in practice?

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But what we teach about is the idea that you have to pull information towards you when you have a question as a clinician,

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and you have to have the skills to be able to find the right evidence and in finding the right evidence to be

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able to appraise the quality and understand the effect size to bring that knowledge to patients in front of you.

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Some things are ingrained in the system, like what to do in a heart attack.

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The evidence is very well established. You no need to question that.

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But many areas, as it evolve, like cancer care, people come to me and ask all sorts of questions.

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There's the new chemotherapy for breast cancer. What do you think?

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And, you know, and the answer is, well, I have to look at the evidence and the story in my mind with evidence.

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So what we teach is the skills of how do you access that information in evidence and in accessing it?

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How can you pull it towards you and then improve the quality? And that's that's important skills for doctors.

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But I think it's been interesting in the COVID pandemic, increasingly, I think the public has an appetite for evidence based practice.

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They are increasingly saying, hold on a minute, I'm going to question this.

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I want to understand if we're going to intervene in this way, where's the evidence?

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And I found that quite invigorating, actually. The public has almost tipped itself into trying to say we want to be evidence based.

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Whether that will continue will be interesting to see. But I think there's a bit of a movement from more so the public becoming more and more aware.

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And I think they've become more aware because of the Internet. They can go in in a way you couldn't do two decades ago.

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Yeah. You couldn't go and say, I'm going to look this help.

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I'm going to. And so I think they will increasingly will be knowledgeable patients who prod and push doctors to say,

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well, I've been reading a bit of evidence when that happened to me. I think that's fantastic.

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But if you have to be now aware and ready for that in modern society, and I think that will continue to evolve over time.

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Right. So I think we finally got to COVID. Asking everybody, can you remember where you were or what you were doing when you first heard about it?

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Oh, yeah. So I first heard about it in January, you know, and it was then murmurings and it was probably January and February.

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And I remember in early February doing two things. I wrote an article for the BMJ opinion about I looked at the excess mortality.

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So one of the things is a clinical epidemiologist. We're interested in the data and the numbers and the Office for National Statistics,

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which probably everybody is aware of now, produces great data and it produces data on things like deaths.

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And he does that every week and it's been doing that for years. And we look at that.

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He's interested in excess mortality. And I wrote an article about Where Are We Now?

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And, and it was interesting because what was happening in early February, we had what we call normally.

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So you have a five year average and you either have in excess or not in excess.

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And actually with trend under at that moment in time, we'd had a very mild winter coming in.

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And my point was to say, actually, it's what you really look to understand what's going on.

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You have objective markers and death is a very is ultimately the objective marker.

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Now we can have some arguments about the causation, but ultimately when a death is recorded, it is recorded in this country in a way that,

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you know, within five days you have to go to A to certify the death that gets pulled into the earth.

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And each week they produce an amazing amount of data. That is the sort of age group, the location, the facts and all.

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That's really helpful. So I wrote that piece and then I remember I did a podcast with the BMJ about corona viruses and what are they?

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And I was just a very interesting time because at that point I think nobody really knew very much about these features, epidemiology, viruses.

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And there were very few people, I'd say a few hundred in the world who were interested in this area.

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And we've been interested in it because in the last pandemic, going back to 209,

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which is the swine flu pandemic, which we did a lot of work in that on the antiviral drug like Tamiflu.

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Yes. And we'd spent four and a half years looking at systematically reviewing the evidence on Tamiflu.

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And one of the key areas which we changed the method was we found that about 60% of the evidence had never been published.

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And that's called publication bias. And we went and got from the manufacturer manufacturers.

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The Clinical study of study reports, which are huge documents, but they're the documents that underlie all what happens in the trial.

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And we used them and it took a few years to produce that systematic review.

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So it's interesting, many of the interesting people who were the big names you'll hear like the chief scientific officer,

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like Patrick Vallance with the head of GSK at the time. And GSK produced the name of it and the name of it with one of the drugs that we looked at.

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And he his company supplied us with the full study report.

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And I contacted him at that moment in time. So there was a group of people that we were aware coming in, and I think so it was that February.

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But I think I think it's fair to say in that February that there was a certain element of is this going

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to be a bit like the fourth one outbreak where there was a lot of noise and actually it petered out.

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And I think, you know, where it all started to change was when you sort of thought the the significant outbreaks in northern Italy.

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And I think that Northern Italy moment, which was about three or four weeks preceding where we were in in the UK,

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was a significant game changer in sort of what's going to come next.

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And I think there are interesting features about the outbreak in northern Italy that actually

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could explain a lot of interesting issues about what happened in that period in time.

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But I think then it moved on very rapidly. For me.

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Interestingly, I worked, uh, the week preceding lockdown.

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I think that was about the 16 to 17 the weekend before we started to go into lockdown.

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I remember I work the weekend at an urgent care GP and that involved me doing visits and that's a very interesting position to be a physician.

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When visits that we get, call them will go out and I'll go out to a care home and you'll go to a care home and on the door it will be like,

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we've got COVID in this care home.

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And that gives you a very you know, it makes you it makes you think and reflect about everything you're about to do.

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The will tell you not to go into these places and you're going, Oh, I'm thinking I booked the shift today.

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Was that a good idea? But actually the problem was at that moment in time,

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and this is one of the contributors to I think what I consider the panic measures

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is we didn't have any personal protective equipment and neither did the care home.

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And there didn't seem to be any planning place.

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And that lack of equipment meant that there was a real big hole in the floor plan,

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that somehow something was missing because when faced with an unknown,

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you do want to be in that position at that moment in time to say, look, I need to take precautions.

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And actually, many of my colleagues were in a position that we just didn't have the equipment.

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And I think that was, for me, a real position where I said, we've got a problem.

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And in that problem, there were two issues. There seemed to be a huge knowledge deficit.

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As I said, there were just lots of issues that people weren't aware of.

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And secondly, there wasn't a very clear plan about the action of what to do next.

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And about 72 hours later on a Tuesday, I got a fever cough and, uh, took care of it, and so did my wife.

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And when the world country went into lockdown, we were already in our 14 days quarantine at that moment in time.

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And, you know, and so a lot of the issues and thought processes were coming together for what the position I took next and what I thought,

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what the major need was for us to use our skills to produce things like the evidence with service,

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but also many features that had been in the last two years have been trying to improve the decision making and through informing the decision,

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because I think a lot of people and journalists, particularly politicians, the public, have had to come to what is a respiratory pathogen?

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What does it mean? How do they act? What can you do to make a difference and how should you go about that?

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So that's sort of the journey in, if you like.

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And and I guess, you know, very profound thinking about in that moment in time where we were in what was happening.

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Mm hm. Why? Is it?

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I was going to say, why is it so difficult? Is it is it is it is it actually very difficult to get certainty over a new disease like that?

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Yeah. Look, there are many areas of health care where there's more uncertainty than you consider.

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Particularly in terms of prevention, you know, treating people with high blood pressure.

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The majority of people who have drug treatment for high blood pressure will never benefit from that treatment.

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And so in certain areas, there's much more uncertainty now at the outset of a new pathogen.

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And there are 13 questions that you want to start asking about the behaviour of the virus and try to understand that very quickly.

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So for instance, one of the key attributes of a virus, if it's pandemic and pandemic theory,

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suggest that all members of society should be equally affected.

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So if you go back to the 1918 influenza outbreak, the Spanish flu, you see that actually young people were actually infected and many of those died.

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And so when you have that so for instance, if you see children and young people dying,

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you know, you've got a new pathogen and it has a severity that actually is a real problem.

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But actually, it was very quickly aware and we looked at the data and said, actually, there's a very significant problem here with age.

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That the mortality as you get older significantly goes up and actually in young people are virtually unaffected.

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In particular in terms of mortality, which is not the same for all respiratory viruses.

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So there are influenza attacks on the fires and particularly on the ones viruses like RSV really detrimental to the ones.

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We send a lot of those children into hospital.

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But this virus, 75% of the deaths were in over 75 and those under 75 were actually those with co-morbidities.

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And in subsequent, the data came out about 90, 95%, either in two categories.

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Well, that's operating much more like a seasonal pathogen.

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And that's one of the key elements that we're due to direct your interventions to.

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Who do you have to look after? What should you do? And these are the important questions that emerge very quickly.

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But early on, there was much more of a need to inform the public, the media and the policy.

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And so in the first 6 to 8 weeks, I remember I came back to work.

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I had about two weeks of feeling unwell until about another two weeks,

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and I was back in action by the fall towards the end of April and within a month.

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What had happened is by the time I go back to urgent care, it was like it was completely different.

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The plan, it got into place, but it took about a month to get into place.

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But what was interesting was the the the difference between I call it in my back garden, I've got this COVID where I work from home.

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And while everybody's in lockdown, if you go back end of April, May,

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it was incredibly nice weather in that period of time and there was a sense of everybody was in lockdown and there was information being produced.

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Much of it was not just uncertain.

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Some of it was taking viewpoints about worst case scenario or and we were just saying, look, the job here is to try and be really objective.

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And interesting, when I went back to work, it was quite it was quite therapeutic to go into work, to be honest.

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And but what was really interesting is how quiet was in the world.

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And actually it was what was what concerned me at that point is it was also very quiet in urgent care in a way that I've never seen before.

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Because we had that message protect the NHS and I think people were taking that too far because they were fearful.

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And we've had this problem with people with ongoing issues where they started to present late and where it was worth,

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where it's normally present much earlier. And I think that's one of the big issues in terms of we jumped into this lockdown,

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never been tried, never been tested, and all of those considered was something that wasn't viable.

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And I think there's going to be ongoing debate for the next hundred years about what the values are of lockdowns and restrictions.

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And there's going to be people on either side continue to make arguments about what was the right thing to do.

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But I spent about six or eight weeks, got very quickly drawn into it.

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We have a lot of connections in the media and actually spent about eight weeks and did a weekly seminar for about 40 to 50 journalists,

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just about what the old figures mean, how to interpret them.

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And so they come out on Tuesday and at 1:00 Science Media Centre would have a briefing and we present the data and said,

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Here's what you might want to think about and look out. And so it was an exercise of working with the media to try and inform.

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What was going on and how you might interpret the data.

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So what was going on with lots of older people dying and a lot of them in care homes?

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Yeah. So that was, you know, and pointing that out. So for instance, we went into the lockdown and what was interesting,

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if you look at the data is the outbreaks in care homes continue to go up for about another two weeks and about 30% of the deaths were in care homes.

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And so generally, if you if you look at that, you think, well, that's where we should be put in 30% of resources.

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That's still a big issue for us to argue and point out what I call the Department of the obvious.

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There's a problem here and that there isn't much high quality evidence to inform what happens in care home.

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But there is a lot of observational data. For instance, the number of staffing reduces the mortality.

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Those homes that have clinical examinations on a daily basis have lower mortality.

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The size of the home can make a difference. And in America they have these green have homes where there are only about ten or 12 people and but they

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have better staff ratios and they don't have this problem where you've got these super sized care homes.

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So if they have an outbreak, they can't manage it. There are there was an interest in issues with the elderly, which we've looked into,

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because one of the problems when you're elderly, if you get this concept called immunofluorescence.

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That basically your immune system starts to slowly wear down.

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So it just doesn't become as reactive. And we've noticed this for some time because one of the key things about the very elderly is, for instance,

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if they have a urinary tract infection, while a young person will just say, I've got burning, stinging and a fever and a manual.

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But actually, if you look at the evidence in elderly people,

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they may prevent with something like of legs, confusion, they don't have the tradition over.

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Yeah. Falling over. And that's because they may have had the infection on board for a week or two.

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And actually they're getting seriously on well, but they don't make the same immune response, which is the fever.

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And that's the same probably in the care home population that actually when you go in there,

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you see that actually you can end up with a lot of really unwell people, but no one's actually noticed it yet.

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And then you've got staff going from one to the other, so it's practically impossible to manage that outbreak.

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With the current systems we have in place. And today we've still not sorted out that care home issue.

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And we're not sorted out social care. It's a big issue.

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And as the population ages, you basically have more of a problem with respiratory pathogens.

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And so I see people go, well, this is not the common cold and the common cold is not a problem.

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And I go, Yeah, that's correct. But actually, if you take a virus like rhinovirus and put it in a care home, it's devastating.

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So in the wrong population. Yeah, but in the wrong population with immunosuppressants, poor health, you are vulnerable.

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It can be devastating in that environment and I don't think we've learned how

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to consider this issue of risk and a lot of it's got lost in the pandemic,

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but I think that's a good example of what we did.

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One of the things we did early on as well with a lot of statisticians.

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I'm a clinical epidemiologist and we just love looking at the data.

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And we all had a lot of spare time because we're stuck in a cabin and home and we can talk to each other and know what's going on.

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And very early on, it was very apparent, for instance, the way the data was reported was being I don't think it was people doing on purpose.

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I just think they didn't understand what the data was.

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So what happens is the way the data gets reported through NHS England and Public Health England on a Tuesday, they always dump in a lot of data,

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but the data would come in from care home, from hospital and they'd say there've been 1600 deaths today,

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but that was the date of reporting of death, not the day they actually occurred.

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So we did the simple things and actually NHS England were the first to come on this.

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And so these distribute back about two weeks and they actually look much more like a normal

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distribution then you thing deaths have gone up fourfold today and we're going know they're actually

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coming down and and so we had this out where we was making statements going that's the coming

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down and the media report they're going up four fold and people were latching onto that.

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And so we were just trying to clearly correct the data so you could inform the decisions.

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And we've continued to do that throughout, and I think that's been helpful.

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But the idea that you produce data is is incredibly important, that it's accurate.

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Now it's a bit like throwing darts at a board.

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There's a bull's eye. An accuracy means you're near the bull's eye.

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But what we get with a lot of data is it's precise.

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So the darts might be very near together to each other, but it might be some way from the bull's eye.

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So this concept of accuracy versus precision, and we get lots of precision in the modern world because we get load the data, big data.

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But often accuracy is missing. In the job is to hone in on that information and try and go right.

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What's happening in care homes. And and the second area, for instance, where there were lots of problems and still are hospital acquired infections.

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And that's been an interesting area and I think we've looked into that.

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So we continue to look in areas.

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But one of the things we also did early on, which is develop the Oxford COVID evidence, is to just put this information out.

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And how do you how did that operate? Well, we have a website, the CBN website, and actually I established in help established in 1995,

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I mean, I'd only just about started turning the Internet on it those days.

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And I remember we populated a website with evidence and facts and how to do it.

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And I've been involved in developing ever since. And we've always I've always had this.

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Job. Of all part,

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my job is to communicate what the evidence is and what it means and actually were just look for gaps in the evidence based like nobody had.

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What's the evidence for social distancing? What's the evidence for masking what?

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What's the impact of temperature and humidity? What is case fatality rate mean?

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What's the infection fatality rate? The term that would be bandied around for the first time.

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And and what was different with this time is normally when that happens, it might be one article, but the whole papers were full of it.

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One. And there are just lots of misinterpretations.

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I say people taking the information and running with it and going, Oh, you know, we might be talking about the case fatality rate verses.

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Know, what you're really interested in is some other measure and using data from China which doesn't match what we're seeing here.

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And I think we just felt that actually we should produce and write and put our information in evidence to just inform the debate.

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And actually had a huge traction really early on because it was just it also amalgamate other people's studies.

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So is it all your own work on that? No, no, no. So we our job is one of the keys within systematic reviews is they can take six months to a year.

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Or if I said use clinical study report, you're talking four years.

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But actually we have skills of rapid review where what we do is restrict some bit from the methods so we can speed up the process and the bit.

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Three Restrict don't add in too much bias. And if we do that, we can produce reviews in about 5 to 7 days.

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And so that's our rapid review methodology. And I think over time, people are looking to automate that process.

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But I think the next ten, 20 years will see more of an appetite for this is the evidence.

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How do we summarise it and then provide you with the latest update?

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And so we used all of our skills to produce rapid reviews.

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And the people I work with are probably some of the best in the world at doing this, and I think it's probably in Oxford.

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We actually do have this long tradition of epidemiology going right back to Richard Dole's age to send over

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IBM Cochrane and evolving methods for how do you apply health care information and evidence to decisions.

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And that's where we are now. We're still working on how do you get this optimised way of getting evidence to inform decisions?

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And it's difficult because there's lots of evidence out there that can be contradicting or harmful.

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And there were papers that were being retracted. There were all sorts of drugs being bandied around.

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You should use these drugs and you're going, well, we don't we don't do it the speed and pace.

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And we're going back to the days of opinion overriding the evidence.

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And I think that was hugely challenging early on.

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I mean, in terms of the the kinds of restrictions that, you know, lockdown and mask and all that kind of thing.

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I mean, do you think it was would be fair to say that that things had to be decided so fast that there

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simply wasn't time to reach the standard of evidence that you would that would have been desirable?

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Yeah. You know, if you spoke to me 20 years ago as a clinician, I'd say when I went into a moment of health care crisis in decision,

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I'd say you've got to make decisions really quick and efficiently and fast.

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And as a wise a physician, I'll go into many situations now where it looks really quite ominous for the individual.

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And now I tend to take a step back and just slow down my thinking, my analysis.

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And all the trainees want to act really quickly and say, Oh my God, the person's going to die.

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Well, we've got more time than you think. I think I think you always have a bit more time than you think.

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Apart from a few odd situations. And I think in those situations, I think it's so obvious to everybody, isn't it?

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I mean, you know, there are times when someone is bleeding to death.

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You've got to work really quick. But actually, in many situations, you've got much more time than anything.

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Someone has had a cardiac arrest. Minutes matter, you know, I mean, in this instance, when.

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So in in March. Transmissions seem to be pretty fast.

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Yeah. So I think I think having here's where we're going to get the division of people.

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I think there was a problem with preparedness. Oh, clearly.

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Oh, yeah. And so that problem of preparedness, lack of preparedness, meant that it almost made the decision inevitable.

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Yeah. So you could say in a perfect world, if the NHS had been totally prepared,

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had got all the PPE and had you in and got a plan, then you could have acted differently.

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But given that they didn't. Yeah. So I think that's the issue. So first time round you would go.

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But you know, actually what happened is certain countries like Sweden decided to take a different tact.

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Now, obviously, there was a big domino effect of countries taking this viewpoint.

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So I think it was incredibly hard for anybody to go go against that in the first lockdown.

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But Sweden did. And it's interesting, if you if you look at the first lockdown,

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when you start to analyse the data is people that are already modifying their behaviour quite considerably.

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You can go on Google and they can tell you about the activity on transport people in the workplace and actually dropped off a stone already.

378
00:38:14,960 --> 00:38:17,780
And in fact, if you look at the data,

379
00:38:18,020 --> 00:38:26,180
the deaths peaked on about April the eighth and we tracked back is the infections peaked about a week before we went into lockdown.

380
00:38:27,050 --> 00:38:31,200
And I think people have learnt over time is to watch the bell shaped curve.

381
00:38:31,220 --> 00:38:35,900
There's a chap called William Farr that you can go back in history and look up Falls Law.

382
00:38:36,530 --> 00:38:40,730
Firth You know, basically infections roughly rise and fall in a symmetrical pattern.

383
00:38:41,480 --> 00:38:45,590
And so you get this bell shaped curve. And that's exactly what we continue to see.

384
00:38:45,590 --> 00:38:50,060
Now, we're actually just about on the cusp of the bell shape right now.

385
00:38:50,990 --> 00:38:54,230
And what happens when you get to the top of the bell shape, everybody starts to panic.

386
00:38:55,230 --> 00:39:02,770
But I think the fact that the biggest one for me with not even having a stockpile of PPE, you just can't go.

387
00:39:02,790 --> 00:39:07,139
You can't carry on because you're not aware of at that moment in time what's the predominant mode

388
00:39:07,140 --> 00:39:12,050
of transmission and how is it going to be affected in that with number one major problem for me?

389
00:39:12,210 --> 00:39:18,900
Just one. Well, if you haven't got that in place, you have to actually say press pause on the bottom.

390
00:39:19,770 --> 00:39:26,040
So I think that's why I think and I think why that happens is is I think, you know,

391
00:39:26,760 --> 00:39:31,770
is influenza has been on the government register for the last two decades.

392
00:39:31,770 --> 00:39:38,670
It's thought they were climate change might even say to both climate change given the potential catastrophe it can cause.

393
00:39:39,120 --> 00:39:47,190
But somehow what happens is probably in in about ten years time, as we filter along, everything starts to get pushed in the fore and disappears.

394
00:39:47,490 --> 00:39:57,420
And it doesn't quite become a predominant issue. And so we this is a major issue about institutional knowledge and losing these all perspectives.

395
00:39:57,420 --> 00:40:00,930
And somebody said, well, why are we spending 250 million on something we never use?

396
00:40:01,800 --> 00:40:05,040
And you go, Yeah, because one day we might need the shelf.

397
00:40:05,400 --> 00:40:10,559
And I think and then second with that is simple things like this is just economically.

398
00:40:10,560 --> 00:40:13,710
I can't fathom why some of this stuff is not on shored.

399
00:40:14,430 --> 00:40:18,270
So we were having to buy it from around the world. So the price was going through the roof.

400
00:40:18,270 --> 00:40:21,870
We spent huge amounts of money and now we're paying the consequences of that,

401
00:40:22,350 --> 00:40:26,070
that actually people didn't realise that actually you need a facility to be able to.

402
00:40:26,280 --> 00:40:30,600
If you're not going to stockpile it, you have to have a facility that can go up and down very quickly.

403
00:40:31,050 --> 00:40:34,800
And I still don't think that message has got through. I call that health security.

404
00:40:34,830 --> 00:40:39,840
You have to be able to maintain the levels of sustainable PPE in a pandemic like this.

405
00:40:39,840 --> 00:40:48,270
You can't buy in at the cost we pay. And you could see the widespread panic that the restriction in fact, I was talking about it yesterday.

406
00:40:48,690 --> 00:40:54,329
Shelves bare of toilet roll, pasta disappearing, all of the flour disappearing.

407
00:40:54,330 --> 00:40:57,959
And I'm like, that must be a big stockpile of this somewhere in people's houses.

408
00:40:57,960 --> 00:41:07,110
But that there was a real sort of panic and anxiety across wider society that probably lasted for a couple of months.

409
00:41:07,110 --> 00:41:09,390
But some people still is still there today.

410
00:41:10,470 --> 00:41:17,780
So I think I think the interesting issue is where are we nearly now thinking of restrictions and lockdowns?

411
00:41:17,790 --> 00:41:25,710
And I think it's interesting where we are, and I think people will look back for many decades to analyse was it a good or bad thing?

412
00:41:27,120 --> 00:41:34,919
But what you've got is a natural control experiment in Sweden where they didn't restrict what they relied on.

413
00:41:34,920 --> 00:41:38,210
They did have. So they have access. I don't have the figures. Yeah.

414
00:41:38,220 --> 00:41:40,890
Yeah. So, yeah. So yeah. So they did. Yeah.

415
00:41:40,980 --> 00:41:49,810
But what they didn't do is have so what happened is with the modelling is it predicted to be half a million deaths in an unmitigated scenario here in.

416
00:41:50,280 --> 00:41:55,770
Yeah. And basically said you have to go for suppression and you'll get that down to 20,000 people.

417
00:41:55,800 --> 00:42:03,240
Well that was wrong as well because what the models don't count for is people, individual behaviour change.

418
00:42:04,330 --> 00:42:10,840
And what the difference is in Sweden is people modify their behaviour according to the risk.

419
00:42:11,340 --> 00:42:14,140
I actually think people are really good at modifying their behaviour.

420
00:42:14,590 --> 00:42:21,700
The question is do you need the government to regulate it or can individuals be informed and then say actually if you look at the size of an outbreak,

421
00:42:21,700 --> 00:42:29,170
it's about eight weeks where you get excess death. And that happened March, April, and it happened in January, February 2021.

422
00:42:29,500 --> 00:42:33,160
So it did happen again. I mean, yeah, but it was only about six or eight weeks.

423
00:42:34,180 --> 00:42:46,090
Now, the key is is is this is the key discussion going forward is what happened in 2020 was the belief that actually the model with the Chinese model.

424
00:42:47,260 --> 00:42:50,740
That actually you could follow a model of depression,

425
00:42:51,550 --> 00:42:59,410
that you could basically take your virus and get it down to below about a thousand to keep it there with things like effective test and trace.

426
00:43:00,610 --> 00:43:07,300
And for many of the people who are epidemiologists, virus experts will just go, we don't quite understand that.

427
00:43:07,990 --> 00:43:12,700
There's a reason you call it going viral. The incredibly difficult to manage.

428
00:43:12,700 --> 00:43:15,520
You know, you can do it in the short term, but over the long term.

429
00:43:16,240 --> 00:43:21,560
What's the mechanism and what do you push and what are the consequences of all the strategies is no.

430
00:43:22,000 --> 00:43:30,610
But I think what and this is an important aspect within the concept to BBM and aware of this discussion, everybody's looking for the silver bullet.

431
00:43:31,510 --> 00:43:37,600
There's a simple way to manage this and there's a simple way to prevent this and the simple treatment.

432
00:43:38,110 --> 00:43:42,940
And actually, everyone is much more complex and much more uncertain about what's going to happen next.

433
00:43:43,330 --> 00:43:47,350
So let's talk let's talk about transmission, because that's one of the things you say.

434
00:43:47,920 --> 00:43:52,750
There was a lot of uncertainty about how the virus was transmitted early on.

435
00:43:52,960 --> 00:43:57,880
So what what studies did you do? So, again, again, a transmission.

436
00:43:57,880 --> 00:44:04,070
Incredibly interesting issue. And I think what was interesting, if you go in the history of the UK,

437
00:44:04,070 --> 00:44:10,510
you had a lot of really high quality research until about the nineties in terms of respiratory pathogens.

438
00:44:10,510 --> 00:44:13,870
We used to have a monthly common cold unit in the UK.

439
00:44:13,870 --> 00:44:18,240
Oh yes. They used to give you a young man. Yeah, yeah, yeah, we called you.

440
00:44:18,250 --> 00:44:23,560
But yeah. Human challenge to these two young AMI people and see what happened next.

441
00:44:24,220 --> 00:44:30,070
And then actually probably what ended much of that was the sort of AIDS HIV because

442
00:44:30,070 --> 00:44:35,469
a lot of the focus shifted and that's what happens in research priorities shift,

443
00:44:35,470 --> 00:44:42,610
in the money shift. And then the predominant strategy was vaccination because the predominant mode was influenza.

444
00:44:43,750 --> 00:44:48,120
But the first thing to say is to say how many respiratory pathogens are out there?

445
00:44:48,130 --> 00:44:51,700
Well, when I'm a GP there's about 40. I know of that.

446
00:44:51,700 --> 00:44:59,410
I could say these affect individuals who come through the door, but about 40% of what people have got, we've no idea what they are.

447
00:45:00,190 --> 00:45:03,970
And it could be hundreds more that have not been discovered yet.

448
00:45:05,170 --> 00:45:09,399
So I think the firstly so there's a lot of different respiratory pathogens at any one time.

449
00:45:09,400 --> 00:45:12,790
They're all interacting all the time and that is really interesting.

450
00:45:13,270 --> 00:45:22,240
So, so this idea of influenza morphed into there's only one virus that really matters, but actually there are still all these other ones out there.

451
00:45:22,330 --> 00:45:26,140
And now we know there are like coronaviruses and we knew about it.

452
00:45:26,260 --> 00:45:29,260
We knew there were corona, but there were other. Yeah, yeah, yeah.

453
00:45:29,350 --> 00:45:32,860
So, you know, there are four common ones that been circulating.

454
00:45:33,370 --> 00:45:38,620
Then you've got the ones like sa one and uh so you got them in the background.

455
00:45:38,920 --> 00:45:43,120
But we've had four common ones that basically affect children, infect adults,

456
00:45:43,120 --> 00:45:51,340
and everybody who's basically probably over the age of about two or three had probably had a circulating common corona virus already.

457
00:45:52,720 --> 00:45:55,690
But actually transmission is about ultimately understanding.

458
00:45:55,690 --> 00:46:03,190
Transmission then helps you inform how you might intervene because that's ultimately you want to know how these transmitted.

459
00:46:03,610 --> 00:46:09,010
So for instance, you go back to the common cold. So for instance, in something like rhinovirus,

460
00:46:09,490 --> 00:46:13,569
they did things like put it on people's hands and actually get them to shake hands with

461
00:46:13,570 --> 00:46:17,290
each other and then see if the other person and then split them into barracks and said,

462
00:46:17,500 --> 00:46:21,909
did they get infected? And they showed it was direct contact. Now we can't do them.

463
00:46:21,910 --> 00:46:27,820
We've sort of lost that human challenge to the although they have done the human challenge studies within the vaccine development.

464
00:46:28,030 --> 00:46:35,259
So, you know, actually, although it sounds on ethical human challenges, studies are at the top of pyramid to understand transmission.

465
00:46:35,260 --> 00:46:41,409
We do it with malaria. Yeah. However, we got asked by the World Health Organisation,

466
00:46:41,410 --> 00:46:48,250
it was about September of 2020 and said they'd done a thought, a review and said This is where we are.

467
00:46:48,250 --> 00:46:54,549
But there was so much evidence emerging in a way that never emerged before for a respiratory pathogen.

468
00:46:54,550 --> 00:46:58,570
With about 2000 studies a week being published on Corona virus,

469
00:46:58,570 --> 00:47:04,240
it was incredibly hard to keep up to date with what was going on and emerging and what was happening.

470
00:47:04,240 --> 00:47:08,889
Everything was getting picked up that said, Oh, it's airborne, it's fomite is this?

471
00:47:08,890 --> 00:47:12,490
It's in the sewage, it's everywhere, you know? And it's like, how do you make sense of the.

472
00:47:13,090 --> 00:47:18,430
So we started to do systematic reviews on the mode of transmission.

473
00:47:19,590 --> 00:47:25,980
And we're still in the midst of doing that, and I still think we will get to some certainty.

474
00:47:27,300 --> 00:47:31,530
Oral faecal close contact. Vertical transmission.

475
00:47:31,740 --> 00:47:37,290
Mother to the foetus. Airborne of a third fomite.

476
00:47:38,070 --> 00:47:44,250
We've looked at asymptomatic transmission. We've looked at transmission in immunosuppressed people.

477
00:47:44,760 --> 00:47:51,479
And we've just done our latest update. We've looked at included 591 studies in Across Them review.

478
00:47:51,480 --> 00:47:55,830
So it's been a huge effort. Look at some of your papers and maybe you did make the observation at the beginning

479
00:47:55,830 --> 00:47:59,590
of a couple of them that in general the quality of the studies was poor,

480
00:47:59,820 --> 00:48:04,040
very poor. So if you put a lot of poor studies together, how do you get a good answer?

481
00:48:04,060 --> 00:48:09,140
You don't, you don't. You don't. And I think early on there was a rush.

482
00:48:09,150 --> 00:48:13,220
It was like a gold rush for to produce evidence on on COVID.

483
00:48:13,830 --> 00:48:17,459
And so, for instance, one of the simple things we said, so, for instance,

484
00:48:17,460 --> 00:48:23,340
if you're going to do a study that claims airborne transmission, then you should do some airborne sampling.

485
00:48:24,030 --> 00:48:27,929
And there are studies that say we didn't do any sampling, but it's transmitted through the air.

486
00:48:27,930 --> 00:48:31,530
And you're like, Well, okay, so we've got to create some quality measures.

487
00:48:31,560 --> 00:48:34,590
What defines a good quality study and is that. Yes.

488
00:48:34,650 --> 00:48:38,880
So, yeah, I read those papers as well. I mean, there are those who argue that.

489
00:48:39,730 --> 00:48:45,280
Sampling virus from the air is an incredibly difficult thing to do in any kind of reliable way.

490
00:48:45,550 --> 00:48:51,280
And there are other kinds of evidence. Yeah, I guess more circumstantial kinds of evidence.

491
00:48:51,580 --> 00:48:54,680
Yeah. Yeah. Airborne transmission look likely.

492
00:48:54,700 --> 00:48:58,840
Yeah. So, you know, actually. But there are 27 studies now that have tried to do it.

493
00:48:59,020 --> 00:49:01,420
So actually early on we said there's only four or five.

494
00:49:01,750 --> 00:49:06,489
But actually what we found in at the back end of of this is actually people are starting to do better,

495
00:49:06,490 --> 00:49:10,450
higher quality studies because they get the more serious scientists thinking about this.

496
00:49:10,870 --> 00:49:16,890
But you're right, it it it reminds me of a lot of the problems that occurred early on in beam in randomised trials.

497
00:49:17,290 --> 00:49:23,410
They said there's no way, no reporting standards. So people like Doug Goldman, who is a famous statistician in Oxford,

498
00:49:23,740 --> 00:49:27,850
started movements like consort and Equator and said, We're going to bring reporting standards.

499
00:49:27,850 --> 00:49:29,139
How do you report this stuff?

500
00:49:29,140 --> 00:49:36,130
Because you can't pull it together if it's not reported in a similar way because people would just miss outcomes because they didn't like the answer.

501
00:49:37,000 --> 00:49:45,130
So you're right, there's been a huge problem, but we've been working to create standards for how to determine, uh, transmission.

502
00:49:45,250 --> 00:49:49,310
And we've just published it an update, and it's only peer review now.

503
00:49:49,330 --> 00:49:56,379
We presented it via conferences. We've got a network around the world of people who look at this, and it's clear to us,

504
00:49:56,380 --> 00:50:00,910
if you want to make a transmission claim, there are a couple of things you do have to do.

505
00:50:00,920 --> 00:50:02,590
You do have to have viral culture.

506
00:50:03,620 --> 00:50:11,659
And that means you can say, for instance, if I shake your hand and then we go into your hand and then swipe your hand,

507
00:50:11,660 --> 00:50:19,520
we're going to take that and put it into what's called very thick cells and try and grow that and see if we can get an actual virus.

508
00:50:19,550 --> 00:50:23,480
We can also then do genomic sequencing to make sure it's the same sequence, and then you go,

509
00:50:23,480 --> 00:50:27,620
Yeah, actually we've established transmission, and that's probably the best way to do it.

510
00:50:28,190 --> 00:50:31,790
Now there are surrogate laborious and time consuming.

511
00:50:32,210 --> 00:50:37,670
Yeah, but yeah, but that's like saying recovery trial of 20,000 people.

512
00:50:37,970 --> 00:50:42,500
Why didn't you just do a trial of ten people and say, well, dexamethasone works.

513
00:50:42,670 --> 00:50:44,760
Hmm. Can you imagine what that you know.

514
00:50:44,840 --> 00:50:49,860
Sorry, that's the I think that's all you're doing is giving them some medicine and finding out what the answer is.

515
00:50:49,860 --> 00:50:53,750
It's all this. You know, the individuals will be the collecting of the data.

516
00:50:53,780 --> 00:51:03,110
Yeah, but this is incredibly important. If you want to make a definitive statement, X is transmitted through Y with certainty.

517
00:51:03,860 --> 00:51:07,250
You need to have high quality evidence to be able to make that statement.

518
00:51:07,610 --> 00:51:14,300
You only need to do it about twice. You need to do it once and then replicate it and say, Look, this is what we're looking for.

519
00:51:14,720 --> 00:51:18,960
And I think this is goes to the core of the difference in evidence based approach.

520
00:51:18,980 --> 00:51:22,970
Anybody down here can say, I've got a bit of information, here's how I interpret it.

521
00:51:23,660 --> 00:51:29,810
And, you know, and that's okay. But what's happening is that become statement of fact because of the way it's treated in the media.

522
00:51:30,170 --> 00:51:38,329
Our job is to say, if you're going to say something this way, then actually here's the type of evidence that informed that decision.

523
00:51:38,330 --> 00:51:48,020
And I think this is crucial to the whole debate because that science and science requires I'm building something that is a hypothesis that you tested.

524
00:51:48,470 --> 00:51:53,990
And only only when you can't you can't refute that null hypothesis.

525
00:51:54,230 --> 00:51:58,060
Do you say this is transmitted in this way? So sorry.

526
00:51:58,070 --> 00:52:05,270
How do looking at all the studies you look back so far, what do you think the likeliest form of transmission is?

527
00:52:05,300 --> 00:52:12,230
Yeah, I still think we're in a situation where it's a combination of contact, droplet close contact, but.

528
00:52:12,450 --> 00:52:15,910
But it also means we can't refute anything because of the quality.

529
00:52:15,920 --> 00:52:21,560
And in certain situations like in this room, if we shut the windows and the doors,

530
00:52:21,860 --> 00:52:26,360
there's more likely in a closed environment it'll permeate a bit further.

531
00:52:27,200 --> 00:52:32,690
But actually that's airborne. Well, that would be but that would be in a specific premotor environment.

532
00:52:33,020 --> 00:52:41,990
So I think, again, the term airborne is not helpful because I think the term airborne is is collates with it's everywhere.

533
00:52:43,070 --> 00:52:46,670
So airborne means it's open air in the in the atmosphere.

534
00:52:46,670 --> 00:52:51,230
It doesn't it's everywhere when you're out, find it. So I think the terms are not helpful.

535
00:52:51,590 --> 00:52:59,780
And I think people should be if the science is very careful about making generic statements about it's airborne.

536
00:53:00,290 --> 00:53:07,160
Because I think what we need to do is be very clear in this situation, in this circumstance, this is how it might be transmitted.

537
00:53:07,240 --> 00:53:15,080
What it. Yes. So what you've got to do in terms of having a policy, what you need to know is how far apart people need to be not to catch it.

538
00:53:15,320 --> 00:53:23,060
Yeah, but like say for instance, ultimately, even irrespective of how it's transmitted, that should inform the interventions you will do.

539
00:53:23,270 --> 00:53:28,160
And then you should formally test those interventions and you should touch them with randomised controlled trials.

540
00:53:28,910 --> 00:53:31,309
But for somehow we get that for drugs and vaccines,

541
00:53:31,310 --> 00:53:37,520
but we don't get it for non-pharmaceutical interventions there's been only two randomised controlled trials of masks.

542
00:53:38,390 --> 00:53:39,410
That being proper?

543
00:53:39,420 --> 00:53:50,090
So far I'm aware of a third one that's testing FFP, maths versus surgical math in a clinical population in Canada, and that will report sometime soon.

544
00:53:52,240 --> 00:53:55,630
What for me is a failure of this of this pandemic.

545
00:53:55,900 --> 00:54:00,870
There are lots of questions we could have tried to answer. With that situation.

546
00:54:01,740 --> 00:54:05,550
And bingo. Well, well, well, well.

547
00:54:05,730 --> 00:54:09,900
Equipoise means you're uncertain about whether it works or not.

548
00:54:09,900 --> 00:54:13,410
If you don't have equipoise, you don't need a randomised trial. You're very clear.

549
00:54:13,830 --> 00:54:21,390
Now here's a key learning point. When you find people who disagree about what to do next, it's generally a failure of the evidence base.

550
00:54:21,780 --> 00:54:24,360
There isn't a high quality to inform what's going to happen next.

551
00:54:24,750 --> 00:54:33,090
Therefore, we can have an opinion either side of the argument make it political and keep disagreeing, and we will keep disagreeing generally.

552
00:54:33,120 --> 00:54:38,730
The answer for me in that situation is as a clinician is to is to reduce the uncertainty.

553
00:54:39,540 --> 00:54:43,739
Now, this is an interesting point in evidence based practice.

554
00:54:43,740 --> 00:54:52,380
I suspect within 2 to 3 decades we'll have done what we've done for drugs and vaccines with non-pharmaceutical interventions will get it.

555
00:54:52,770 --> 00:55:00,510
We have to test these things. We just can't go on spending billions of pounds for interventions where there is uncertainty.

556
00:55:01,930 --> 00:55:07,899
And I think and I think that will be an interesting area for history to look back on and go look

557
00:55:07,900 --> 00:55:13,210
at all the failings we've made when we thought we understood what was the right thing to do.

558
00:55:13,660 --> 00:55:17,470
And it's I mean, if I were to say precautionary principle, would that make you go off?

559
00:55:17,840 --> 00:55:25,149
Well, what I think is interesting, what does the cautionary principle mean is, again,

560
00:55:25,150 --> 00:55:30,790
it's been one of those things people have taken away and wrong with what the precautionary principle generally refers to.

561
00:55:30,790 --> 00:55:33,100
If there's a known exposure in the environment,

562
00:55:33,220 --> 00:55:40,780
that may be harmful and the precautionary principle says remove that from the environment until you can prove it safe.

563
00:55:41,470 --> 00:55:44,750
So there may be some toxin or some fertiliser there.

564
00:55:46,000 --> 00:55:49,310
It doesn't mean you go and intervene in some way.

565
00:55:49,330 --> 00:55:53,160
There are very few areas where we actually mandate an intervention.

566
00:55:54,180 --> 00:55:57,920
And that's why I think if they're also like seatbelts generally,

567
00:55:57,930 --> 00:56:03,600
that they're about removing things, smoking from the environment, smoking in workplaces.

568
00:56:03,840 --> 00:56:07,170
But all of them have a very good exposure for home.

569
00:56:07,830 --> 00:56:15,950
Very rarely do we intervene. And the only good example I can think of is seatbelts, crash helmets in, crash helmets in motorbike.

570
00:56:15,960 --> 00:56:17,910
So we make people do certain things.

571
00:56:18,480 --> 00:56:24,930
But to be honest, the precautionary principle is they never get on the motorbike in the first place because it's so harmful.

572
00:56:24,930 --> 00:56:28,139
It's light way up there in terms of the harmful events.

573
00:56:28,140 --> 00:56:37,650
But we let people take that risk, don't we? But actually, when we decide to do that, there has to be very clear evidence of harm and with seatbelts.

574
00:56:37,650 --> 00:56:45,410
It was actually quite some time to build up the evidence base to actually say, actually, we've got to make this mandatory.

575
00:56:45,420 --> 00:56:53,940
And it's interesting. Before that, we had all this advertising marketing campaigns simply about every trip and all that.

576
00:56:53,960 --> 00:57:01,060
The people that are older in the room remember the. And I think when you decide to intervene, you have to.

577
00:57:01,330 --> 00:57:07,450
It's not precautionary principle. We have very clear evidence of harm that will be negated.

578
00:57:07,930 --> 00:57:14,520
And a seatbelt is actually an all or nothing event. If you do not get ejected from the car with a seatbelt.

579
00:57:15,520 --> 00:57:19,120
And also the homes are virtually zero.

580
00:57:20,620 --> 00:57:28,000
So I think precautionary principle has been used in a sort of way that doesn't make sense to me.

581
00:57:28,920 --> 00:57:33,990
And again, this is there are two things that are radically different about this pandemic.

582
00:57:34,350 --> 00:57:38,520
One is the use of PCR, which we've done work in that area as well.

583
00:57:39,440 --> 00:57:50,950
And social media. And I think the social media 24 hour news bubble has created a sort of these ways of coalescing of the were

584
00:57:50,950 --> 00:57:57,360
doing it because of the precautionary principle and then what we lacked is critical thinking in that moment.

585
00:57:57,370 --> 00:58:02,810
Oh, yeah, that's why we do it. And then we suddenly sort of say, well, when do we intervene?

586
00:58:02,830 --> 00:58:11,230
And we say, yes, they do have a safety valve, but actually it's about generally removing known exposure to precautionary principle.

587
00:58:11,410 --> 00:58:15,990
Which makes sense, doesn't it? You know, you might have I've got a certain type of drink.

588
00:58:16,000 --> 00:58:22,990
It might have one of the carcinogens we've got remove it. Because actually until you can prove it safe, we're not having it in society.

589
00:58:24,080 --> 00:58:29,900
So the coaching principle is about removal and not exposing people to known home.

590
00:58:31,260 --> 00:58:36,940
No about intervening when you go into further into. So you just.

591
00:58:37,160 --> 00:58:41,600
You just threw in PCR. Yeah. So. Well, again, anything.

592
00:58:42,380 --> 00:58:48,530
Yeah. So going back, you see, in May 2009, it was very interested in the 2009 pandemic.

593
00:58:48,770 --> 00:58:50,810
There was a bit of PCR testing, but not a lot.

594
00:58:51,020 --> 00:58:59,480
And also many of the trials were starting to use PCR testing, but then we use an antibody tested and then suddenly overnight.

595
00:58:59,510 --> 00:59:05,720
Just clarify that. So. PCR testing tells you that the virus there and antibody testing tells you that has been the virus.

596
00:59:05,930 --> 00:59:13,520
Yeah, correct. Correct. So generally, if you have an antibody rise, you say if you had a fourfold antibody rise, you'd say you'd have the infection.

597
00:59:13,730 --> 00:59:17,900
And that was generally the way of establishing the group that had the infection.

598
00:59:17,930 --> 00:59:21,530
So you do a trial and say, how many people have had a fourfold antibody, right?

599
00:59:21,890 --> 00:59:27,920
But then what came along with PCR testing and that used to be a slow so it wasn't helpful.

600
00:59:27,920 --> 00:59:32,750
But then they had this real time PCR that suddenly could produce results in hours.

601
00:59:34,580 --> 00:59:39,649
And then subsequent to that, we've had lateral flow testing, which was in a minute, but we'll come up with the real time PCR.

602
00:59:39,650 --> 00:59:51,120
And what was interesting about this. Is one of the things we do a lot of and I do a lot of it in my career is when I have knowledge deficit,

603
00:59:51,270 --> 00:59:57,410
I start to teach myself about some of these issues and then I realise it's not just me with the knowledge deficit,

604
00:59:57,420 --> 01:00:00,680
there are a huge amount of people out there really don't import this fruit.

605
01:00:01,830 --> 01:00:07,530
And actually we was interested again in the relationship of PCR testing.

606
01:00:08,160 --> 01:00:13,379
What does it mean when you take in virus that may be 30,000 pages long and you

607
01:00:13,380 --> 01:00:17,730
take it down to a little fragment of about 20 base pairs in the test for that.

608
01:00:19,140 --> 01:00:22,280
And you then say you're positive. Yes. No.

609
01:00:24,180 --> 01:00:27,329
Now, both clinical tests work in a way of saying yes no.

610
01:00:27,330 --> 01:00:33,989
But actually underpinning that is a threshold for like take your blood pressure, you get to a certain point, and above that you're hypertensive.

611
01:00:33,990 --> 01:00:40,080
And below that, you know, therapy, an inflammatory marker above a certain level, it's abnormal.

612
01:00:40,080 --> 01:00:45,120
Below that it's normal. But with this test, it was yes, no. So that's the first thing that interested us.

613
01:00:45,120 --> 01:00:48,690
But that actually there's an amplification cycle called the cycle threshold.

614
01:00:49,290 --> 01:00:56,910
So what you can take is one little bit of one little bit of paper and you can have that in a sample and you start amplifying it.

615
01:00:58,170 --> 01:01:04,700
And the left that is in the original sample. The heart of the test has to work, and so it has to do more cycles because it's doubling.

616
01:01:05,250 --> 01:01:08,700
And so basically, you can go to this cycle threshold, about 45,

617
01:01:08,700 --> 01:01:15,060
which will pick up about one copy per mill on an individual that is beyond the needle in the haystack.

618
01:01:15,540 --> 01:01:20,230
But in some people, it will get to about 20 and they'll say, well, you've got a billion copies per mill.

619
01:01:20,490 --> 01:01:23,640
Well, that's a huge difference. But we treated them exactly the same.

620
01:01:25,020 --> 01:01:30,030
And we had this service where we were just trying to look at this evidence.

621
01:01:30,030 --> 01:01:37,110
And we noticed there were a number of studies coming out on the relationship of PCR testing to viral culture,

622
01:01:37,650 --> 01:01:41,549
and actually these studies had no problem doing the viral culture.

623
01:01:41,550 --> 01:01:50,550
It's really interesting. But actually we started to build this relationship that actually the more virus you had on the left a lot onboard,

624
01:01:50,550 --> 01:01:56,490
the more likely you were to be infectious and the less virus you have them, the less likely to be infectious.

625
01:01:57,270 --> 01:02:04,560
And that still is something police policy. WIV We're interested in becoming clearer because I'm where clinicians now use the test in this way.

626
01:02:04,920 --> 01:02:10,050
A cycle threshold below further means the probability of being infectious is much higher.

627
01:02:10,560 --> 01:02:15,719
The so-called threshold above further probability you being in fact you see virtually zero

628
01:02:15,720 --> 01:02:21,540
apart from a couple of situations if you're immunosuppressed or in the very short window when

629
01:02:21,540 --> 01:02:29,009
you're about to start being infected but actually meet that test it costly or laborious to

630
01:02:29,010 --> 01:02:33,450
do now because what you want to do is establish the principles and then you can use PCR,

631
01:02:33,450 --> 01:02:37,720
which we consider is a high quality test, but actually most tests will allow you.

632
01:02:38,160 --> 01:02:44,910
So I wouldn't give you the answer. Yeah, in particular because what I'm saying to you is if you've got the if you establish thresholds.

633
01:02:45,540 --> 01:02:50,070
So what I'm saying is if you have a yes no, you can't tell you who's infectious or not.

634
01:02:50,280 --> 01:02:56,640
But if you put a threshold in like a cycle threshold of 30, you've got a much better chance of being infectious.

635
01:02:57,150 --> 01:03:03,389
Yeah, I understand that. But in order to set the test for the cycle threshold is not the same as the PCR test.

636
01:03:03,390 --> 01:03:06,580
Just gives you the. Yes, no. Well, it depends. You see, some do and some don't.

637
01:03:06,600 --> 01:03:08,360
This is where we keep asking questions.

638
01:03:08,360 --> 01:03:14,550
So some give a qualitative answer where they'll just get to the end and they'll say a limited detection is 45 and positive.

639
01:03:15,030 --> 01:03:21,410
But many of the tests. Do give you a cycle threshold and can provide that quantitative result.

640
01:03:22,400 --> 01:03:24,770
And some countries in the world, like Belgium,

641
01:03:24,770 --> 01:03:30,560
are now standardising their reference laboratories and starting to provide that quite the focal threshold.

642
01:03:31,370 --> 01:03:38,570
And what this is, is the movement from analytical accuracy, what happens in the lab to developing clinical accuracy.

643
01:03:39,450 --> 01:03:43,440
Basically, Eben, how do you actually use this test in clinical practice?

644
01:03:43,770 --> 01:03:47,730
So we've rolled out speed. Now we have to think smarter about what does it mean.

645
01:03:48,270 --> 01:03:53,639
Now, our evidence suggests when we've looked at it and we've asked for the information, we've got the evidence.

646
01:03:53,640 --> 01:04:02,610
And in the countries around the UK that about 40% of people when they test positive vs know when they're a yes are not infectious.

647
01:04:03,480 --> 01:04:06,510
And there are two reasons that you actually might got the test and you've cleared it.

648
01:04:07,490 --> 01:04:11,630
And the irony fragments can keep being played for up to 6 to 8 weeks.

649
01:04:12,020 --> 01:04:20,030
In fact, we've got somebody at 180 days. Remember the Florence three that was Latin, stuck in Florence for about seven or eight weeks,

650
01:04:20,030 --> 01:04:23,599
got married because they were only going to be let free if they tested negative.

651
01:04:23,600 --> 01:04:27,679
And every week they get tested and they were positive. But we're completely.

652
01:04:27,680 --> 01:04:33,320
Well, that's contamination. They've cleared the virus, but they still testing positive.

653
01:04:33,620 --> 01:04:39,020
This is basic. Even that actually has to be brought to the fore of the myth down.

654
01:04:40,070 --> 01:04:43,070
And if you do that, it helps you think smarter about.

655
01:04:43,080 --> 01:04:45,559
So when you say there are 10,000 people in hospital,

656
01:04:45,560 --> 01:04:49,490
what you really want to know is how many of them are actually infectious and how many are not infectious.

657
01:04:50,240 --> 01:04:52,760
And that can help you make a better decision, not worry as much,

658
01:04:52,760 --> 01:04:57,080
because if that number go to 20,000, people start to panic and then instigate policies.

659
01:04:57,710 --> 01:05:02,780
So these are just create accurate information. The whole of Ibadan relies on accurate information.

660
01:05:02,780 --> 01:05:06,620
You cannot make a good decision without accurate information.

661
01:05:07,520 --> 01:05:11,390
And I think over time, over the 30 years I've been involved in it,

662
01:05:12,050 --> 01:05:18,920
the idea that people have opinions about what's the right thing to do and produce poor quality data is pervaded.

663
01:05:18,920 --> 01:05:23,260
Poor quality decision making. And so we've done the systematic review.

664
01:05:23,260 --> 01:05:27,700
We've looked 84 times. It's been published in clinical infectious diseases.

665
01:05:27,700 --> 01:05:36,250
It's been highly cited, highly accessed and started to have an impact on decision making and how people are going to think going forward.

666
01:05:36,760 --> 01:05:42,640
And so I think we'll see changes over time. The thing with evidence based best practice is we get there in the end.

667
01:05:43,360 --> 01:05:46,629
It just takes a long time. Yes. Yes, that's that that's the point.

668
01:05:46,630 --> 01:05:47,470
It takes a long time.

669
01:05:47,470 --> 01:05:55,720
But the political decision making has or the policy decision it took about 14 years to get from smoking is bad to changing the policy,

670
01:05:55,930 --> 01:05:59,260
and that's the biggest harm. Obviously, we'll get there in the end.

671
01:05:59,530 --> 01:06:07,659
Our job is to just keep putting out the information. Now, that can be controversial when you're in the midst of, well, who's going to get to that?

672
01:06:07,660 --> 01:06:10,090
And you talked about political views earlier. Yeah.

673
01:06:11,560 --> 01:06:22,510
I mean, a lot of the statements that you've made have been picked up by ostensibly political groups who simply object to the well,

674
01:06:22,840 --> 01:06:27,010
you could call them libertarian groups who object to government control of any of any kind.

675
01:06:28,150 --> 01:06:29,920
I mean, how do you feel about that?

676
01:06:30,460 --> 01:06:37,560
Well, I guess I guess the first thing is to say my views have been right at the heart of government, because in September 2020, it was right.

677
01:06:37,630 --> 01:06:40,960
The Cabinet Office helping them inform the decisions in the debate.

678
01:06:41,380 --> 01:06:46,990
I continue to work widely with policy people on political levels and inform the debate.

679
01:06:47,910 --> 01:06:52,770
And interestingly, evidence based medicine has always been controversial.

680
01:06:54,400 --> 01:07:01,719
And and and one of the things I'm very careful to do is to not tell people what to do is

681
01:07:01,720 --> 01:07:06,400
to inform the debate and say this is generally how you would respond in this situation.

682
01:07:06,430 --> 01:07:09,160
We can all have opinions from, you know, a political viewpoint.

683
01:07:09,970 --> 01:07:16,030
And I think there has been a sense that there's a sort of right and left or right and wrong.

684
01:07:16,480 --> 01:07:21,820
And I think we live in that world at the moment. And I think that's what the social media divide is creating.

685
01:07:22,600 --> 01:07:27,220
Come out of Brexit, come out from this, and it's very polarised.

686
01:07:27,940 --> 01:07:33,170
There's a lockdown around Anti-lockdown group and and there's been a,

687
01:07:33,520 --> 01:07:37,710
a group of people in Oxford that includes myself and people like to actually walk through

688
01:07:37,720 --> 01:07:43,540
it who is incredibly smart person probably theoretical epidemiologists know more about.

689
01:07:43,630 --> 01:07:51,520
I talk to her yeah viruses and and incredibly interesting and I talk to her more or less every week for the pandemic.

690
01:07:52,030 --> 01:07:56,530
Cause I'm just interested in the knowledge and understanding what's going on.

691
01:07:56,950 --> 01:08:04,659
There are things we did that I didn't understand, and I think it's my job is to point out when there's uncertainties and point out and go,

692
01:08:04,660 --> 01:08:08,080
well, look, if we're going to do that, here's what's the answer.

693
01:08:08,090 --> 01:08:11,710
So, for instance, zero COVID is a very good what's the end game?

694
01:08:12,190 --> 01:08:18,490
What do you consider is this is not like a path where you just turn off the top and actually everything will just empirically disappear.

695
01:08:19,120 --> 01:08:23,309
Actually, what the problem is, is you may be storing up huge problems for the future.

696
01:08:23,310 --> 01:08:27,549
And hey, Preston, what's happening? You push it into winter, you push more and more problems.

697
01:08:27,550 --> 01:08:31,210
And so we still going to have the fallout for years to come.

698
01:08:32,020 --> 01:08:37,870
We still haven't thought the care home issue. So all of these strategies don't sort out count.

699
01:08:37,870 --> 01:08:40,210
They don't fall to hospital acquired infections.

700
01:08:41,700 --> 01:08:47,610
There's huge problems like right now with excess deaths in the home that are not covered that we're not talking about.

701
01:08:48,690 --> 01:08:59,000
So I think I think it's been interesting, the groups of people where they are and I think there's been over time a shift,

702
01:08:59,010 --> 01:09:05,350
if that's fair to say, in the dynamic of people thinking. A lot of people have been scared.

703
01:09:06,640 --> 01:09:13,270
And I think most people have been on a journey to think differently because I think early on and a lot of the media were very much like,

704
01:09:13,300 --> 01:09:16,510
oh, by November 2020, we'll be back to normal.

705
01:09:17,560 --> 01:09:23,650
And I would sit with people and we'd have a meeting with the cabinet and say that you've no chance of that.

706
01:09:24,130 --> 01:09:27,210
It's just it's not going to happen. You need to prepare for the winter.

707
01:09:27,220 --> 01:09:31,240
What's the plan for care homes, for instance? What's the plan for the low quality infections?

708
01:09:31,750 --> 01:09:33,670
What you're going to do with schools?

709
01:09:33,710 --> 01:09:40,280
You know, and I'm simple policies to them and said, well, you know, actually school holidays provide a natural social distance event.

710
01:09:40,340 --> 01:09:44,799
You could try in areas, not do it, just pilot ones.

711
01:09:44,800 --> 01:09:48,210
If you increase the Christmas holiday period, how does that buy you more time?

712
01:09:48,220 --> 01:09:52,060
What does it do? But you would pilot these things and try and we'd learn.

713
01:09:52,060 --> 01:09:56,140
But but actually we had very clear views of zero care.

714
01:09:56,380 --> 01:09:59,860
Then we were going to have certain interventions that were going to change the nature of it.

715
01:09:59,860 --> 01:10:09,909
So we're going to have MPI rules that fix all of these things, square boxes in schools where the kids would stay in social bubbles and all this.

716
01:10:09,910 --> 01:10:13,360
And I just looked at them and thought, you know, none of these have an evidence base.

717
01:10:13,360 --> 01:10:18,070
And actually many of the people out there would look at it and go, they don't even feel like common sense to me.

718
01:10:19,210 --> 01:10:23,730
The idea that after 10:00 viruses leave the pub or something just doesn't make sense.

719
01:10:24,610 --> 01:10:28,970
And so. I would put forward questions.

720
01:10:29,000 --> 01:10:34,270
A lot of the media come for me. About 80% of the work I do with the media never gets out there or gets published.

721
01:10:34,280 --> 01:10:38,180
I just help them think through the stories or what they may think or write.

722
01:10:38,600 --> 01:10:47,960
And so over time, I've created a relationship with the media and with policy that I hope people come to me because they go,

723
01:10:48,410 --> 01:10:52,640
Well, it's going to present a sort of fair opinion about where we are.

724
01:10:53,530 --> 01:11:03,359
I do not believe that any clinician's job is to overstate or overemphasise when they think, well, actually we'll just present a worst case scenario.

725
01:11:03,360 --> 01:11:07,120
I still don't quite understand how that helps anybody. And I mean,

726
01:11:07,120 --> 01:11:10,659
one of the things statements that you've made and you and Senator have made and

727
01:11:10,660 --> 01:11:17,080
the bank part of this is about the harms of the non-pharmaceutical interventions.

728
01:11:17,590 --> 01:11:24,050
Yeah, I do. Those homes have an evidence base. I think that evidence base is continuing to emerge, isn't it?

729
01:11:24,070 --> 01:11:25,030
And it will continue.

730
01:11:25,060 --> 01:11:32,110
So, for instance, when you start to say, for instance, now you're starting to see you restrict and close schools and keep children off schools,

731
01:11:32,110 --> 01:11:35,710
and then you starting to see the burden of a mental health anxiety.

732
01:11:36,040 --> 01:11:43,180
But then you start to see things like language development. And particularly I think we'll find certain age groups are more effective than others.

733
01:11:44,110 --> 01:11:46,180
And that's a huge problem.

734
01:11:46,480 --> 01:11:55,299
I think we've still seen many of the collateral damage and I think we're seeing accumulating in terms of co-morbidities and increasing alcohol,

735
01:11:55,300 --> 01:11:58,840
obesity, poor management of diseases.

736
01:11:59,050 --> 01:12:01,270
Hypertension is coming through the system.

737
01:12:01,990 --> 01:12:08,530
I think we'll be living with some of these issues for 5 to 10 years until we start to really get a grip of the whole problem.

738
01:12:09,370 --> 01:12:19,240
But I think when you define to intervene a position of equipoise, there are potential benefits and potential harm.

739
01:12:19,900 --> 01:12:24,700
There are no interventions I know of where they're just all benefit.

740
01:12:26,750 --> 01:12:33,660
Now if someone is going to say they'll probably all, but generally they are you know, maybe the seatbelt is worn, you know.

741
01:12:33,680 --> 01:12:38,060
Actually, even if you have a seat belt, you might have a low impact and duty. So some harm at low impact.

742
01:12:38,540 --> 01:12:43,430
But actually, you have to remember, there's always going to be homes.

743
01:12:44,150 --> 01:12:48,470
And the key is understanding the net benefit to home ratio of any intervention.

744
01:12:48,620 --> 01:12:55,310
And then how do you weigh up? Well, you see what people would do in a five year old's death against a child's health difficulties.

745
01:12:55,400 --> 01:12:59,360
Well, it's interesting, isn't it? Normally what you do is you ask people what they would like to do.

746
01:12:59,390 --> 01:13:02,900
I haven't until you 85 and I know what she wants to do.

747
01:13:03,170 --> 01:13:07,459
She would just say, I want to meet my grandchildren. And then only that's what you do.

748
01:13:07,460 --> 01:13:11,270
And she says, I'm prepared to take the risk because I've only got a couple of years.

749
01:13:11,540 --> 01:13:14,780
I can't put it off to 2024.

750
01:13:15,050 --> 01:13:20,180
So it's an individual risk. Why do we take that risk or benefit away from that?

751
01:13:20,180 --> 01:13:22,070
Basically saying 85,

752
01:13:22,580 --> 01:13:30,950
it's more benefit to me to see my grandchildren and the quality of life that provides than go that so that I might live another six months.

753
01:13:31,430 --> 01:13:39,140
So it's about informing. And each, as I said, each individual can come to different decisions about what they want to do, and that's okay.

754
01:13:39,290 --> 01:13:42,500
But when you decide to mandate on everybody, that's a problem.

755
01:13:42,680 --> 01:13:47,600
But that was the decision to mandate was because of, as you said yourself,

756
01:13:48,290 --> 01:13:52,250
because looking at what's happened in Italy, in the hospitals being overwhelmed.

757
01:13:52,460 --> 01:13:53,300
But I'll give you a good.

758
01:13:53,630 --> 01:14:01,550
So that I think that well, I think I'm completely with you on what you weigh but the worry of the hospitals being unable to cope,

759
01:14:01,790 --> 01:14:05,030
probably because they were under-resourced. Yeah. So that's fine.

760
01:14:05,780 --> 01:14:11,330
That's fine. But I think what happens now is every time you get to near peak infection, that re-emerges.

761
01:14:11,720 --> 01:14:16,340
So we could argue and I could argue and we wrote about this is that England has 100,000.

762
01:14:17,600 --> 01:14:26,780
I don't care. But if it's one of the lowest numbers in Europe and Germany has somewhere like 3 to 4 times as many beds.

763
01:14:26,780 --> 01:14:32,780
So they do have this problem. Although what we have is you could argue that what you need in winter and this

764
01:14:32,780 --> 01:14:37,639
has been a persistent problem for the 20 years I've been in health care. I wrote about this before is the winter crisis.

765
01:14:37,640 --> 01:14:42,370
When I came in 2000, it was it was unbelievable how bad it was.

766
01:14:42,380 --> 01:14:48,530
But generally what you need is for to deal with respiratory pathogens is about a 20% flex in your bed care number.

767
01:14:49,340 --> 01:14:55,430
And so, for instance, if you look at the number of admissions for respiratory diseases pre-COVID,

768
01:14:55,670 --> 01:14:59,720
they doubled between August and December and actually January.

769
01:14:59,990 --> 01:15:04,310
We normally have about 5000 excess deaths in January compared to August.

770
01:15:04,760 --> 01:15:11,479
And so going in, we've always had this problem of people have gone in to see grandma with a respiratory infection in January.

771
01:15:11,480 --> 01:15:17,450
Their deaths go up and that is one of the consequences of the way the winter seasonal effect works.

772
01:15:18,590 --> 01:15:22,700
So we've got a problem. But the problem that the answer is not to look down.

773
01:15:22,880 --> 01:15:26,120
The answer is to say, how do you ensure you've got extra capacity?

774
01:15:26,720 --> 01:15:30,860
Well, everybody goes in a supermarket, will know at Christmas they can deal with the extra capacity,

775
01:15:31,040 --> 01:15:36,500
the higher some seasonal workers, they put on more checkout, they bring in more stock and they prepare for it.

776
01:15:36,920 --> 01:15:42,200
But we go, no, no, no, we're not going to prepare for this natural variation in demand.

777
01:15:42,440 --> 01:15:45,440
We're just going to pretend it's not there. And if it occurs, we'll lockdown.

778
01:15:46,070 --> 01:15:46,820
Now, it's interesting.

779
01:15:47,000 --> 01:15:52,639
Wherever you've been in the world and somebody could do this piece of work, it could look at the media headlines where they've all gone.

780
01:15:52,640 --> 01:15:56,570
We're going to be we and we're going to go beyond capacity.

781
01:15:56,570 --> 01:16:03,370
Our hospitals are going to be completely overwhelmed. What if you come back four weeks later and you go, it didn't happen.

782
01:16:04,150 --> 01:16:07,270
And that's because of the Final Four. You're right in the peak of infections.

783
01:16:07,270 --> 01:16:11,110
And just as soon as you get there, they just drop off as quick as they've come in.

784
01:16:11,950 --> 01:16:15,610
And the explanation for that are just really interesting.

785
01:16:15,650 --> 01:16:20,670
But I do think you've got to trust the law that exist.

786
01:16:21,340 --> 01:16:26,409
But one is on the way up. Everybody panics, and that's why they give rise to these exponential curves.

787
01:16:26,410 --> 01:16:30,520
It's like, I think it's a bit like you're on the motorway and when you're on the motorway,

788
01:16:30,520 --> 01:16:35,680
you've come on the slip road and start speeding up, don't you? And what we watch is the data.

789
01:16:35,690 --> 01:16:43,450
So you start of 2040, you don't blink. But as you get to near the speed limit, you're acceleration slows down, doesn't it?

790
01:16:43,480 --> 01:16:50,450
And you can watch that acceleration. So you go 64, 65, 66, and once that starts happening, you know,

791
01:16:50,470 --> 01:16:56,110
you come into the peak and you're going to get to 70 and then you can flow down in a final way to come off the motorway.

792
01:16:56,560 --> 01:17:01,270
So if you watch the data really carefully, you can see when it's slowing down.

793
01:17:01,840 --> 01:17:06,880
And I've watched that movement multiple times. And that's exactly the point when everybody starts panicking.

794
01:17:08,590 --> 01:17:14,230
What the mathematical models try to say to you is actually there's no speed limit and you've got no brakes.

795
01:17:15,670 --> 01:17:20,200
And therefore this car is so dangerous, you need to do something like pull them.

796
01:17:20,200 --> 01:17:25,420
Right. But actually the river speed limit and you can watch the data very carefully.

797
01:17:25,430 --> 01:17:30,730
And that's what we do. And we did it day to day to watch not what we think it's going to be in a moment.

798
01:17:30,820 --> 01:17:33,820
Just ask a question. What does the acceleration look like?

799
01:17:34,120 --> 01:17:37,660
That's giving us a combination of immunity and behaviour change.

800
01:17:38,230 --> 01:17:41,070
It's a combination of all three. There are some things I think.

801
01:17:41,080 --> 01:17:48,250
Yeah, like now you look at it and you go, well look, the immunity, natural immunity that kicks in is I mean,

802
01:17:48,250 --> 01:17:52,540
the I would say there's been over 50 million people have been infected in England this year.

803
01:17:53,080 --> 01:17:57,010
So at some point your natural immunity kicks in. It doesn't protect you forever.

804
01:17:57,040 --> 01:18:02,829
I mean, with everyone, it seems to be even less. Yeah. But again. But again, you see, this is the bit where everybody's going.

805
01:18:02,830 --> 01:18:07,630
We've got genomic sequencing, we've got variants, and we've got this new scary thing called variants.

806
01:18:07,930 --> 01:18:13,740
But if you go back to the AMC Common Cold Unit, they did these experiments in Human Challenge Studies 25,

807
01:18:13,750 --> 01:18:18,220
30 years ago and showed exactly this with coronaviruses and rhinoviruses.

808
01:18:18,490 --> 01:18:21,130
About 50% of the people got reinfected at one year.

809
01:18:21,880 --> 01:18:28,420
And that's because, yeah, there's a natural variation in these viruses, but there's also a natural waning in your immune system.

810
01:18:29,170 --> 01:18:35,620
And so one of the arguments you've got is the idea that what we really do in societies keep topping up our immunity,

811
01:18:36,730 --> 01:18:43,890
that actually these viruses are all in competition all the time, and that interaction means that we go about our daily lives.

812
01:18:43,900 --> 01:18:49,790
But actually, if you give yourself a big break. That actually that's harmful and deleterious to.

813
01:18:51,010 --> 01:18:57,850
And you can think of that because many viruses are bad for you if you don't get them in childhood and get them another world for the first time,

814
01:18:57,850 --> 01:19:01,090
you get the cytokine storm. Really bad news for you.

815
01:19:01,360 --> 01:19:05,950
So actually what we do in childhood, and I say this as a GP is you start from ground zero.

816
01:19:06,980 --> 01:19:10,190
And I think within a lifetime, you're going to get about 200 viruses.

817
01:19:11,400 --> 01:19:17,070
But first, you know, we don't know. In a bad year, a child might have 5 to 7.

818
01:19:18,350 --> 01:19:22,730
And you as a parent are going to have a bad time, too, because you only get more viruses while your parents.

819
01:19:22,880 --> 01:19:25,990
And by the way, when you're a grandparent, you start to run in trouble again.

820
01:19:26,000 --> 01:19:30,649
But actually, it's really interesting to look at some. I mean, I think we should study these.

821
01:19:30,650 --> 01:19:34,580
There are some natural groups who have probably topped up immunity all the time.

822
01:19:34,790 --> 01:19:39,890
Primary school teachers, my sister's one. She continually gets cold, but she never gets seriously ill.

823
01:19:39,980 --> 01:19:47,090
Well, and she had to have fixed the 70 year I am feeling with weekends and you know and that natural.

824
01:19:47,240 --> 01:19:51,170
So one of the arguments was if you're interfering with if you're starting to create

825
01:19:51,170 --> 01:19:55,610
immune gaps and now the worries are what about the RSV and the influenza coming back?

826
01:19:55,730 --> 01:20:01,280
We've got this increasing susceptible population that actually will create more harm.

827
01:20:01,790 --> 01:20:09,140
Now, at this moment in time, people are watching Australia looking all they've got influenza and COVID autoimmune problems.

828
01:20:09,270 --> 01:20:17,900
That's the worry now going into winter. And I think these are interesting issues to look out to say, can you intervene in that?

829
01:20:19,580 --> 01:20:24,049
Generally, the laws of nature would say, well, if we've grown up in this way,

830
01:20:24,050 --> 01:20:29,010
in this symbiotic relationship, there must be benefits for us and there must be some potential harms.

831
01:20:29,020 --> 01:20:36,530
I agree. The interesting issue for me is I think, is what makes you fit for that viral challenge?

832
01:20:37,740 --> 01:20:43,200
We've got an older population, we've got more multimorbidity than we've ever seen and more obesity.

833
01:20:43,950 --> 01:20:47,609
So actually we've got we stood up and that's where we are in the world.

834
01:20:47,610 --> 01:20:51,420
And we haven't even thought about, well, what does it mean to have an ageing population?

835
01:20:52,050 --> 01:20:59,580
Because in the seventies you wouldn't have had the 75% of death in over 75 because they didn't exist in the same way.

836
01:20:59,970 --> 01:21:03,840
So you might have had this outbreak and then you've got there's been a funny virus circulating,

837
01:21:04,320 --> 01:21:09,780
so nobody's even thought about the challenges of having that increasing ageing population.

838
01:21:09,780 --> 01:21:14,430
And if it continues to grow, the viruses will continue to present more challenges.

839
01:21:16,250 --> 01:21:18,650
But does that mean you should lock down every time that occurs?

840
01:21:20,330 --> 01:21:28,700
I think there's a growing realisation that now the collateral effects, the economic consequences mean it's sort of off the table.

841
01:21:30,480 --> 01:21:35,850
But I'm not sure it's off the table forever, because I think some people have an appetite for restrictions.

842
01:21:38,050 --> 01:21:41,980
And some people are still in a mode where they think it's the right thing to do.

843
01:21:42,780 --> 01:21:47,690
I will continue to question the. Right.

844
01:21:47,840 --> 01:21:51,620
So I've just got some more questions about what actually know there is.

845
01:21:52,610 --> 01:21:58,160
Yeah, there is the question when you say some people. So I know there are people even within this department who disagree with you.

846
01:21:58,880 --> 01:22:10,230
How difficult is that people to deal with. Science is built on testing hypothesis and and and I actually there are two distinct things.

847
01:22:10,250 --> 01:22:18,440
I welcome people who provide criticism because it makes you think harder, work harder, and try and keep testing your hypothesis.

848
01:22:18,710 --> 01:22:25,460
It won't ultimately be me that says here's what how this is transmitted or here's how to do the test.

849
01:22:25,460 --> 01:22:30,590
It will be the evidence and the quality of the evidence, and that will inform the decision making.

850
01:22:31,100 --> 01:22:34,550
What's been difficult throughout this pandemic, though,

851
01:22:34,940 --> 01:22:43,670
is I think with the social media work and the frenzy and fear and the anxiety is with people up in making things personal.

852
01:22:45,050 --> 01:22:50,480
And that's not to say that this department just out there, this is an issue that that is now a problem in the world.

853
01:22:51,230 --> 01:22:58,370
If I don't like the message, I'm going after the messenger and I am not brought up in that way.

854
01:22:58,940 --> 01:23:05,260
I'm brought up in a family where, you know, is is the most important thing is not so much to say say.

855
01:23:06,510 --> 01:23:14,280
But never make it personal. Make it about the issue. Make it about what it means, the evidence, and how are you going to test it, how you go about it.

856
01:23:14,670 --> 01:23:23,129
But I think we live in very dangerous times because I think social media has created a frenzy and a way of trying to say,

857
01:23:23,130 --> 01:23:29,040
well, what we need to do is paint you into a firm corner, and then that will get rid of you and your viewpoint.

858
01:23:30,220 --> 01:23:35,560
But I think I'm okay with it. I mean I mean, you know, you've still got funding for your research.

859
01:23:35,560 --> 01:23:37,300
You haven't you've not been ostracised.

860
01:23:38,260 --> 01:23:45,280
I suspect there are people who don't want to work me or people in certain places who would not not want to support my work.

861
01:23:45,280 --> 01:23:55,239
But that's okay. It's more about them than me. I personally, the work we do, uh, I build my skill base.

862
01:23:55,240 --> 01:24:00,850
I can do the work. It slows me down on my own. You know, I don't need a team of 30 people,

863
01:24:00,850 --> 01:24:08,860
but I've got some really amazing collaborators and generally we've worked for decades together and these people are so good at

864
01:24:08,860 --> 01:24:16,060
what they do and we've been thinking about these issues for a long time and we'll be thinking for a long time going forward.

865
01:24:16,450 --> 01:24:22,419
There's been a lot of people who dipped in and will now dip out of this pandemic they saw as an opportunity to get involved.

866
01:24:22,420 --> 01:24:29,180
It's it's the only show in town. And they'll disappear and we'll still be publishing the evidence.

867
01:24:29,180 --> 01:24:32,870
And actually, I think what's helpful now is sort of everything's calmed down a bit.

868
01:24:34,280 --> 01:24:37,070
People are less fearful, less anxious, but in the middle of it.

869
01:24:37,370 --> 01:24:45,860
It was a bit like any challenge to the public messaging is not not you know, not acceptable and you need to be silenced.

870
01:24:46,040 --> 01:24:51,110
And we've had that. I've had that. And to be honest here, that was challenging in the middle of that.

871
01:24:51,140 --> 01:24:59,000
Very challenging. But I think I think is I think we'll see a reinvigoration of the need to have academic freedom.

872
01:24:59,660 --> 01:25:07,770
We all don't have to agree. We do have to agree, though, when the evidence is high quality and very clear about what to do next.

873
01:25:08,130 --> 01:25:12,840
And that's the most important thing about informing decisions, not what I think.

874
01:25:13,230 --> 01:25:16,110
What does the evidence tell you about making this decision?

875
01:25:17,370 --> 01:25:24,060
This is an important issue for policy because what I think a lot of people think politicians want to hear and policy makers is.

876
01:25:25,500 --> 01:25:30,930
You tell them what to do. They know that people in their lives is very opinionated.

877
01:25:31,260 --> 01:25:34,430
What they want to do. You say, Can I have a chat with you?

878
01:25:34,440 --> 01:25:42,120
Can you help me understand this? I have former prime ministers, current prime ministers talking to me, asking those questions.

879
01:25:42,240 --> 01:25:49,200
And the and and I think that carried on because I'm very clear about what we do and don't know.

880
01:25:49,500 --> 01:25:53,760
I won't step out of the market and go, I'm going to give you some outlandish to run with.

881
01:25:53,760 --> 01:26:03,230
I just go, this is what we know. Here's what you think about PCR testing, superb quality innovation though this is in this,

882
01:26:03,240 --> 01:26:10,590
but actually we could improve how we did it if we understood how to use PCR to make decisions about these infections and if we understood that better,

883
01:26:11,070 --> 01:26:14,270
we could move forward. You decide what we should do next?

884
01:26:14,750 --> 01:26:23,990
And I think that's because I also think and I think what's happening in this modern era, if people are sort of moving out of science into politics.

885
01:26:25,150 --> 01:26:30,459
And, you know, in evidence based medicine, it's a really clear,

886
01:26:30,460 --> 01:26:35,950
rational approach to the thinking, which is not been unusual for us to be controversial.

887
01:26:39,010 --> 01:26:44,620
I do. I mean, you've been a media commentator before this before all this started.

888
01:26:44,950 --> 01:26:48,069
Yeah, yeah, yeah, yeah. I have.

889
01:26:48,070 --> 01:26:54,610
And people have come to us over time. Probably the first thing we did was the metal hit scandal.

890
01:26:54,820 --> 01:26:59,470
Then we did a lot about in the Olympics about sports products and trans vaginal mesh areas where

891
01:27:00,100 --> 01:27:04,240
there were issues going on and there have been some controversial areas have been involved.

892
01:27:04,250 --> 01:27:11,469
And we did a review on the use of transgender hormone drugs for children, which was, you know, a very controversial area.

893
01:27:11,470 --> 01:27:15,370
And all we tried to say is what does the evidence say about what to do next?

894
01:27:15,520 --> 01:27:17,170
Oh, my gosh, that was so controversial.

895
01:27:17,740 --> 01:27:22,990
And generally we said, you know, in this normal situation, if we're going to use this treatment, we do it in a trial.

896
01:27:23,560 --> 01:27:27,460
So it should be research, no such thing. And that was hugely controversial.

897
01:27:28,060 --> 01:27:33,290
And and interestingly, over the time of the pandemic, I still have lots of relationships now with the media.

898
01:27:33,290 --> 01:27:38,110
In fact, this morning I was doing talk radio this morning TV and did an interview this morning.

899
01:27:39,160 --> 01:27:43,540
Should we be worried? It's a question. You know, right now cases are going up.

900
01:27:43,540 --> 01:27:44,380
Should we be worried?

901
01:27:44,920 --> 01:27:52,569
And it's interesting, a lot of people say to me, well, I wouldn't do the media maybe because message will get distorted or get twisted.

902
01:27:52,570 --> 01:27:55,780
Okay, go. Well, look, if the message is going to get there at whatever you do.

903
01:27:57,390 --> 01:28:00,530
The question is, do you want to be part of helping inform them?

904
01:28:01,140 --> 01:28:07,590
And going forward and I think over time is if it's about building a relationship in trust.

905
01:28:08,910 --> 01:28:13,709
So a lot of them might just come to me and say, can I ask you a question? There's no no benefit for me.

906
01:28:13,710 --> 01:28:16,050
But I think there's a benefit to wider society.

907
01:28:16,560 --> 01:28:22,320
If they put a report out or a publication that says, well, actually, here's what the death certificate data says.

908
01:28:22,350 --> 01:28:28,679
No, not what I think it might do. And I think that's I found that quite rewarding.

909
01:28:28,680 --> 01:28:32,220
But it also means you've got to be on top of your game. You've got to understand what's going on.

910
01:28:32,790 --> 01:28:35,790
You've got to understand the information and the evidence at any one point.

911
01:28:36,480 --> 01:28:41,360
And so if somebody comes to you and says. Are you worried about the data rise in infections?

912
01:28:41,380 --> 01:28:44,450
You have to go. Okay. Well, what would make people worried? Okay.

913
01:28:44,470 --> 01:28:48,370
Well, hospital admissions. Well, what about the intensive care admissions?

914
01:28:48,370 --> 01:28:51,760
If they were going up, that would we worried that we're going up? That would be worrying.

915
01:28:51,770 --> 01:28:57,790
So I look at all the data and I'll go, well, actually, when I look at it, although cases are going up,

916
01:28:57,790 --> 01:29:02,620
actually the death of actually come down and intensive care numbers have gone up.

917
01:29:03,040 --> 01:29:08,950
So actually, I wouldn't be that worried, but actually I'm giving you the information that can help you make a better decision.

918
01:29:09,280 --> 01:29:13,689
And yet and I think working in the media has been quite an interesting challenge.

919
01:29:13,690 --> 01:29:21,390
And you have to be thoughtful about what you say. Cause words in words can be taken out of context really quickly.

920
01:29:22,410 --> 01:29:26,160
But I think there's a lot of benefits to working in the media.

921
01:29:26,340 --> 01:29:32,550
Mm hmm. I mean, presumably you want the public to be informed and that they're not going to read your papers?

922
01:29:32,640 --> 01:29:37,440
Well, ultimately, we've done we've had projects even based in schools, and we've tried to get this off the ground.

923
01:29:37,440 --> 01:29:44,530
It's not quite work to actually work with big. Spanner in the works, if you like.

924
01:29:44,530 --> 01:29:52,130
But ultimately, I think these sorts of issues should be taught in schools and it's increasingly a little bit hidden.

925
01:29:52,480 --> 01:29:55,540
But if you don't do biology often, it's not in there for biology.

926
01:29:55,540 --> 01:30:00,160
Will talk about clinical trials, regulation and what's a drug trial and so forth.

927
01:30:00,970 --> 01:30:07,990
But actually, ultimately, everybody faces health care decisions. They even might have consent even at the age of 13 or 14.

928
01:30:07,990 --> 01:30:13,540
You've got to make decisions about all sorts of things, about HPV vaccination, very young.

929
01:30:13,540 --> 01:30:21,700
You might be thinking about all sorts of treatment. So I ultimately think we should be teaching about risk prevention,

930
01:30:22,090 --> 01:30:29,140
consent and informed decision in school for everybody ready for the world where they'll face these decisions.

931
01:30:29,710 --> 01:30:34,070
Because what happens is one day you wake up. And suddenly you might be 50.

932
01:30:34,340 --> 01:30:38,060
And somebody said, Well, we're going to do your blood pressure. Can you come in and like, well, what's that for?

933
01:30:38,270 --> 01:30:45,679
I'm a you know, now for men and women are probably with the fact that you engage much more with health care than men,

934
01:30:45,680 --> 01:30:47,660
but you get these very difficult questions.

935
01:30:48,140 --> 01:30:54,030
We cardiovascular risk is in the next ten years, it's going to be 8% chance of having a cardiovascular event.

936
01:30:54,040 --> 01:30:55,070
And you mean what's that about?

937
01:30:55,790 --> 01:31:02,540
So we have all these features that are thrust upon us and actually the require you to be pretty skilled in terms of risk prediction,

938
01:31:02,540 --> 01:31:06,709
prevention, understanding, impact, bias, all of these features.

939
01:31:06,710 --> 01:31:11,990
And I think what's happened in the Kobe pandemic is they've been forced on you in a way that people have now said,

940
01:31:11,990 --> 01:31:16,100
hold on a minute, I didn't ask for this. What actually is informing need?

941
01:31:17,020 --> 01:31:22,330
And on the bit that's been for me, I've had huge support in the public.

942
01:31:22,570 --> 01:31:31,540
I can't I can't quite say how positive it's been, whether it's I get letters, get emails on occasion, people send me things.

943
01:31:33,460 --> 01:31:38,610
My window cleaner wants to talk to me every time he comes round and said, Can I have 15 minutes of your time?

944
01:31:38,620 --> 01:31:44,140
Want to talk about COVID, please? And I'll give them 50 minutes. You know, and the public has been amazing.

945
01:31:44,230 --> 01:31:51,250
And I think the public has an appetite for understanding interventions, what it means to them.

946
01:31:54,510 --> 01:32:04,610
So you talked about your hut. Mm. So my next bit of question is what was working through the pandemic restrictions like for you?

947
01:32:04,620 --> 01:32:07,770
I mean, how easy was it to carry on doing what you were doing?

948
01:32:08,130 --> 01:32:16,260
I think, um, so I think, yeah. So I've got this hot in my back garden, which has got two computer screens and I plug my laptop in on a daily basis.

949
01:32:16,770 --> 01:32:24,060
And I have to say, I've never been as busy. I was probably working minimum 12 hours a day.

950
01:32:25,840 --> 01:32:31,139
And and that's because a combination of we were doing the review, the evidence service.

951
01:32:31,140 --> 01:32:35,040
But then I get media people saying, can we talk to you? Then we will write an article.

952
01:32:35,400 --> 01:32:41,700
We had a splurge of articles in certain journals which we knew like wrote a whole series in The Spectator,

953
01:32:42,300 --> 01:32:48,510
which had a big policy impact of all the politicians and journalists that had an inverse stop note with it.

954
01:32:48,840 --> 01:32:55,649
Well, you know, what I could find was. Yeah, so we write in spiked at the moment at the moment we move around I tend to move around

955
01:32:55,650 --> 01:33:00,510
will come back to spectator and I think it's just go through cycles with the media.

956
01:33:00,510 --> 01:33:08,190
You know it's not it's not I we we life and work gets in the way.

957
01:33:08,790 --> 01:33:15,389
You know, it's hard work to do everything and publish a piece and then and so, you know, we were having to take a day,

958
01:33:15,390 --> 01:33:21,629
a week out and we sort of work out for the evening on Friday morning and then finish it on a Saturday.

959
01:33:21,630 --> 01:33:23,760
And that was like for about for a month.

960
01:33:24,480 --> 01:33:30,540
And in the background we was also doing for about four months is a statistician here called Jason Oke, who is amazing.

961
01:33:31,260 --> 01:33:37,139
And for about four months we were producing the daily update for the media on the death on the day of reporting.

962
01:33:37,140 --> 01:33:41,490
And we put that out every day so, so never been busier.

963
01:33:41,490 --> 01:33:52,590
And and I think, I mean, combination wise as well is the urgent care setting in general practice is suffering from a lack of doctors as well.

964
01:33:52,590 --> 01:33:56,729
And so they're also calling out for people to come and work all the time.

965
01:33:56,730 --> 01:33:59,879
And so, you know, in the middle of Christmas, we we're in deep trouble.

966
01:33:59,880 --> 01:34:05,020
And so there's lots of shifts that need to cover. So never been busier.

967
01:34:05,070 --> 01:34:12,240
I think, you know, we've had this huge shift to online working we some of it's good.

968
01:34:13,270 --> 01:34:22,210
Some of it is not so good. I think we're more efficient in business meetings, but we're lacking that sort of in the corridor brainstorming moment.

969
01:34:23,350 --> 01:34:25,740
And I think there will be some good stuff.

970
01:34:25,750 --> 01:34:35,330
But I think for me I haven't still even come up for breath in about two and a half years and it's very difficult even.

971
01:34:35,760 --> 01:34:42,760
I was away last week. I'm still with work about 20 hours a week.

972
01:34:42,820 --> 01:34:50,140
Otherwise, I still did a media request and did that and don't know why I do it, but I do because it's just that.

973
01:34:50,500 --> 01:34:59,020
And I think there's still a lot to work through. And I think what you'll probably find with most researchers who are at that level,

974
01:34:59,200 --> 01:35:04,329
you just really can't let go of things because it's an evolving thought process.

975
01:35:04,330 --> 01:35:07,720
You can't go, so I'm going to park it for a month and then come back to it.

976
01:35:08,590 --> 01:35:17,649
You know, it's a thought of passion that you have for these are the issues and and here's here's how you might look at that.

977
01:35:17,650 --> 01:35:21,970
And I found that that's what defines, I think, academics in their own right.

978
01:35:22,690 --> 01:35:30,490
They only tell you, oh, 9:00 at night, I'm talking to work about why and I don't even know why, but we're still interested in these issues.

979
01:35:31,720 --> 01:35:40,440
What about coming back to the office with me where you were involved at all in the departments because of safety precautions and how.

980
01:35:40,440 --> 01:35:43,060
Well, you know, I tended to stay away.

981
01:35:43,270 --> 01:35:50,559
You know, there's you know, there's enough people living in the university to to be able to evolve and put together this sort of department.

982
01:35:50,560 --> 01:35:56,290
So I'm I think, you know, I think it will take time for people to return to normal.

983
01:35:56,290 --> 01:36:03,490
We're not there yet and probably be another year in the in that situation.

984
01:36:04,600 --> 01:36:08,470
I guess the thing we did in the middle is we did that thing where we got a dog as well.

985
01:36:08,740 --> 01:36:14,410
I guess both my girls have left the university and we got the dog and that's making it harder for me to return.

986
01:36:14,410 --> 01:36:20,830
And we've got to find a way of getting them into the department because I think that's been a real plus time interview.

987
01:36:20,830 --> 01:36:23,920
Somebody in her office with a dog. Yeah, not in this department.

988
01:36:23,950 --> 01:36:28,479
Well, I think I'm a big a big I mean, that's the most important learning point.

989
01:36:28,480 --> 01:36:32,950
Wherever you are, if you've got to even stay in the moment, you've still got to look after yourself.

990
01:36:32,950 --> 01:36:36,340
You've got to be out there. So, you know, I'm working long days, but I'm still out.

991
01:36:36,580 --> 01:36:41,140
I walk that out for an hour, I look after myself. And I think you've got to do the things.

992
01:36:42,060 --> 01:36:48,510
Where you just take that bit of time out to keep keep yourself fine, if you will.

993
01:36:50,070 --> 01:36:53,399
I don't know where the future will lie in terms of where we go next,

994
01:36:53,400 --> 01:37:00,930
but I think there will be significant changes as a result because I think more people want to work from home and a hybrid well from this point on.

995
01:37:01,320 --> 01:37:06,180
And I think that will have a significant impact. And that's how you able to behave in a way.

996
01:37:06,180 --> 01:37:14,040
That's one of the key things where we talked about it. Where can you change what happens next with minimal impact on society?

997
01:37:15,210 --> 01:37:19,350
Well, actually, asking people to work from home for a couple of weeks is not a big problem because,

998
01:37:19,350 --> 01:37:25,920
you know, we've just seen it happen with the rail strike. So there's the way you should be thinking about when you do restrictions,

999
01:37:26,400 --> 01:37:30,690
what can you do that actually doesn't really alter the fabric of everybody's life?

1000
01:37:30,710 --> 01:37:34,830
We'll get to the bit of effect. So I think slowing down what's going to happen next.

1001
01:37:35,930 --> 01:37:40,280
Schools, for instance, could give you an extra week on holiday and get them to do their exams from home.

1002
01:37:40,340 --> 01:37:47,120
Well, that wouldn't be a big deal. So are you looking for those little bits that can just subtly gain you a bit of time?

1003
01:37:47,840 --> 01:37:51,140
And I think that's where we should be smarter going forward in the future.

1004
01:37:51,990 --> 01:37:56,020
Mm. Yeah.

1005
01:37:56,030 --> 01:38:00,640
I think I got the last one, so. I think it can be a long answer.

1006
01:38:00,660 --> 01:38:08,100
We've got time. Mm hmm. Has the experience of working through COVID changed your attitude to your approach to your work?

1007
01:38:08,100 --> 01:38:10,530
And how would you like to see things change in the future?

1008
01:38:11,310 --> 01:38:20,910
You know, I think I think having it certainly changed it for me, my position in terms of media profile and out there.

1009
01:38:21,300 --> 01:38:25,950
I mean, I couldn't imagine it would have happened in this way and it still happens today.

1010
01:38:25,980 --> 01:38:31,590
It's been interesting to me and a lot of people come and go in that media journey and profile and policy journey.

1011
01:38:31,950 --> 01:38:40,380
But actually, for me, I'm still there. And I think that I'll stick to the evidence based approach with I'm going to write more.

1012
01:38:41,160 --> 01:38:45,780
We took a particular position. You know, I've published enough.

1013
01:38:45,960 --> 01:38:52,230
I still published in journals, but actually the days of writing an editorial that have impact, I think have gone.

1014
01:38:53,580 --> 01:39:00,560
But actually, if you write a piece in the newspaper and suddenly a million people read it, you can have a significant impact.

1015
01:39:00,570 --> 01:39:05,790
And in a way that is radically different to anything I've done in the editorial world.

1016
01:39:06,360 --> 01:39:14,190
And I think I've enjoyed the challenge of trying to write to the public or write to a wider audience is not either.

1017
01:39:15,120 --> 01:39:20,370
You'll get your people who won't like what you say when you do that, and you have to have your flak jacket on ready.

1018
01:39:20,940 --> 01:39:26,970
But actually, that, I think, is where the future lies, is for scientists to be more.

1019
01:39:28,010 --> 01:39:33,980
Communicating with the wider public, put their ideas out there and try and justify them.

1020
01:39:34,490 --> 01:39:40,280
And if we do that well, I think there'll be a better, healthier society.

1021
01:39:41,750 --> 01:39:46,489
And so I'll keep doing that. And I think in terms of the workload,

1022
01:39:46,490 --> 01:39:52,670
I think with the team I'm very mindful we're an outcome orientated unit and I think we will be more hybrid in the future.

1023
01:39:54,650 --> 01:40:01,730
Are our courses are going more online because we one of the things we didn't talk about is our master's in evidence based healthcare.

1024
01:40:02,120 --> 01:40:05,870
We have to completely flip it to an online strategy. 14 days.

1025
01:40:07,190 --> 01:40:11,210
That's pretty stressful as well. And but the team did an amazing job.

1026
01:40:11,700 --> 01:40:18,290
But now we've used it. We've just got approval from Education Policy Committee to increase the number of

1027
01:40:18,410 --> 01:40:24,110
courses that can be taken online so students don't have to come here as much.

1028
01:40:24,110 --> 01:40:29,330
And we think that's a sensible strategy in the middle of winter. It will be difficult to travel if you're well.

1029
01:40:30,260 --> 01:40:34,860
But also next week, we're all in a summer school for all the students, as about 45 coming next week.

1030
01:40:34,940 --> 01:40:41,750
So we're changing the strategy. We think they still want that in the corridor moment and there's a big appetite for that to come to Oxford.

1031
01:40:41,960 --> 01:40:51,320
But they may change the nature of when they do and what suits them. So the flip side is, I still think there's a lot of issues to work through.

1032
01:40:52,340 --> 01:40:58,910
There's a lot of things to think through in terms of the backlog now of homes, you know,

1033
01:40:59,330 --> 01:41:04,260
whether it's cancer care and diagnostics, whether it's mental health, whether it's social care.

1034
01:41:04,280 --> 01:41:11,060
We've got huge problems. And I think they're going to require a lot of astute thinking going forward.

1035
01:41:13,420 --> 01:41:16,630
Pete. What? Hate.