An Official Inquiry into the Covid-19 Pandemic Response – It’s Time and it’s Vital

The Government has acknowledged the need for a formal review of the Covid-19 pandemic response. In this blog we explain how it is now time to announce the process and timetable for such an official inquiry. We note that all sudden mass fatality events with 10+ deaths since 1936 in Aotearoa NZ have resulted in an official inquiry. Ensuring an inquiry has lasting usefulness will depend on the depth and scope of the terms of reference, taking a forward-looking and depoliticised approach. Effective follow-up of recommendations through legislation, active implementation, and enforcement by Government will also be required. Below is a short video summary of this blog (see here for a longer video.)

Aotearoa New Zealand (NZ) has collectively managed the Covid-19 pandemic much better than most OECD countries. It achieved one of the lowest Covid-19 mortality rates and negative “excess mortality”.^{1 2} NZ accomplished this while experiencing relatively lower GDP reductions and disruptions to employment than most other OECD countries.³ The successful use of the elimination strategy in the earlier stages of the pandemic^{4 5} allowed for relatively high Covid-19 vaccination coverage to be achieved before the switch was made to a suppression/mitigation strategy at a time of widespread transmission.

But the country’s Covid-19 response has fallen short in a number of ways, with examples documented in the media, in government-funded reviews of selected issues, in academic studies, in various court cases, and in an inquiry by the Waitangi Tribunal.⁶ These critiques were only of select components of the response or about particular issues. There is a need for a detailed and comprehensive review at a Royal Commission of Inquiry level. The Government has acknowledged the need for a “formal, proper status structured review” of the Covid-19 pandemic response, “once any winter outbreak of Omicron has eased”.⁷ But there has been no move to put a review in place. We argue that it is important a start is made while memories are clear and lessons can be learnt.

A list of our suggested priority areas for an inquiry is in the Appendix. In all these domains there is a particular need to consider the equity issues (especially for Māori, Pasifika, low-income New Zealanders and those with disabilities and chronic conditions) and unintended consequences of the response. The economic (in the wider sense) issues also need specific attention, given the billions of dollars spent by the government on the response, the more intensive impact of specific sectors such as tourism and the opportunity costs.

The inquiry should be forward-looking and depoliticised as much as possible

So that the inquiry focuses on finding the most useful lessons, it should have a forward-looking focus and be depoliticised as much as possible. As such, we suggest that it should report back to Parliament after the 2023 election. The terms of reference could also be framed in terms of “identifying lessons for addressing future (potentially much more severe) pandemics” as opposed to any apportioning blame for past decisions. Indeed, findings from the inquiry could help with bolstering preparations for both future natural pandemics (eg, from influenza and coronaviruses) but also bioengineered pandemics⁸ (for which NZ is relatively well placed to survive compared to other island nations^{9 10}). Findings could potentially contribute to improved preparedness for other major public health threats such as climate disruption and natural disasters.

Some official inquiries in NZ have helped advance health in the past

In recent work by two of us,¹¹ we found that of the “sudden mass fatality events” with 10+ deaths in NZ, 79% (42/53) had been examined in official inquiries. This was for 53 non-war disasters in the period 1900 to 2019, with most deaths occurring in the first 24-hour period. Furthermore, we found that inquiries were held for all such disasters with 10+ deaths after the year 1936. Of note was evidence of learnings from these disasters and their associated inquiries in the case of risk reduction for shipping, air travel, and fires in large buildings (see also a study with a statistical analysis of NZ disasters¹²).

Nevertheless, we also described how the lessons from some disaster inquiries were forgotten – with a number of repeated disasters related to mining, volcanic events, and earthquakes. These failings may have related to the limited depth to the inquiries, insufficient follow-up legislation, and insufficient implementation and enforcement. Some of these problems are detailed in an analysis of the 1931 Hawke’s Bay earthquake and the failure to learn from preceding NZ earthquakes.¹³

Others have also described how inquiries into disaster events in NZ have been useful. For example, the progressive legislative responses to the Seacliff fire, the Ballantyne’s fire, the Aramoana mass shooting, the Cave Creek platform collapse, the Pike River mine explosion and both the Hawke’s Bay and Canterbury earthquakes.¹⁴

While Covid deaths in NZ have largely been spread over the six months from March to August this year, there were over 10 deaths per day for nearly all that period. For more slow moving disasters such as the “tobacco epidemic”, an inquiry by the Māori Affairs Select Committee resulted in NZ’s world-leading Smokefree 2025 Goal¹⁵ which the current Government is proposing upcoming legislation to achieve.

Examples of past NZ inquiries into infectious disease outbreaks and pandemics

Previous inquiries have considered disease outbreaks on NZ troop ships in the South African War¹⁶ and the First World War.^{17 18} A Commission of Inquiry into infectious diseases deaths at Trentham military camp in 1915 resulted in a large number of improvements to military camps.¹⁹ There was also an official inquiry into the 1918-19 influenza pandemic that contributed to a major advance in health legislation with the Health Act of 1920 and associated health system restructure.^{20 21} More recently there was an inquiry into the Havelock North’s outbreak from campylobacteriosis in 2016.²² This led to major changes in water quality regulation – even though the number of deaths in this outbreak (at least three²³) was only a tiny fraction of the death toll from many other disasters.

Conclusions

The Government has recognised the need for an official inquiry into the NZ response to the Covid-19 pandemic – and it is now time to initiate this process. All mass fatality events with 10+ deaths since 1936 in NZ have resulted in an official inquiry and even the Havelock North campylobacteriosis outbreak (with several deaths) had a major inquiry. Some of the issues in ensuring an inquiry has lasting usefulness include the depth and scope of the terms of reference, the nature of follow-up legislation, and the continued implementation and enforcement by governments of any recommendations.

*Author details: All authors are with the Department of Public Health. Please address any media inquiries to Prof Wilson (Email: nick.wilson@otago.ac.nz; mobile 021 2045 523).

Featured image: Photograph of 440 students at Wellington College to symbolically represent the worst day for deaths from the 1918 influenza pandemic in NZ – a pandemic that was followed by a valuable official inquiry in 1919. Photo by Luke Pilkinton-Ching, University of Otago

APPENDIX

Our suggested priority domains for an inquiry into the Covid-19 response to cover, are as follows:

• The adequacy of pre-pandemic preparations including approaches for selecting response strategies and interventions.
• The adequacy of border controls and isolation and quarantine systems and the Covid-19 response during the elimination phase.
• The adequacy of the vaccination programme.
• The Covid-19 response during the Delta outbreak in 2021.
• The Covid-19 response to Omicron in 2022.
• The impact of the Covid-19 health and economic response in terms of addressing all types of inequalities, particularly Te Tiriti responsibilities.
• The initial and ongoing impact of the Covid-19 response on the delivery of preventive services (eg, childhood vaccinations, screening programmes), routine healthcare services, and provision of education to children.
• Comparisons and benchmarking with other nations which responded to Covid-19 effectively (health and economically), and what NZ can learn from these different response measures.
• Structural changes that might be needed for managing more severe future pandemics (eg, fit-for-purpose pre-established quarantine facilities at the border as in some other jurisdictions).
• Additional pandemic tools that can be refined in advance for further use eg, systems for managing physical distancing and mask use (eg, a successor to the Alert Level/Traffic Lights systems).
• Implications for the design of ongoing surveillance systems (eg, wastewater testing) and supportive technologies (eg, genomic testing).
• Government systems for hazard scanning, risk assessment, and risk management decision-making.
• Government systems for capturing expert advice and formulation, and reviewing response strategies.
• Systems for rapid operational research during pandemics and other emergencies.
• Approaches for public communications to motivate adherence with control measures, maintain trust/social licences, and for combating misinformation and disinformation.
• Institutional arrangements for all aspects of pandemic preparedness, management, and recovery and systems for optimal all-of-government operations.
• Multilateral arrangements for enhancing pandemic preparedness and responses, including regional collaboration with Australia, the Pacific, and the Asian region as well as with WHO and other international partners.