We need to secure unmitigated public trust and cooperation

COVID-19:

Dr B. J. C. Perera

Specialist Consultant Paediatrician

Many outbreaks and epidemics such as HIV/AIDS, Ebola, as well as our past experience with vaccines and various types of treatment modalities for infectious diseases, have taught us many lessons. It is critical for us to use some of these most valuable lessons to build an effective and acceptable response to the Covid-19 pandemic caused by the SARS-CoV-2 microbe.

First and foremost, those epidemics have taught us that interventions must be based on sound and proven science. Just as in many instances of experience with an entirely new infectious disease, we face many uncertainties about the epidemiology, clinical presentation, and natural history of a new virus. SARS-CoV-2 science is therefore evolving quickly, but in a state of continuing flux, which adds to the complexity of decision making, communication, and development and sustainability of public trust. Yet for all that, Covid-19 presents an important opportunity for smart deployment of our hard-won knowledge.

HIV/AIDS has taught us the value and importance of involving affected communities in planning and implementation of research and care. Both HIV and Ebola have shown that accurate and timely local information are required to enable and guide tailored interventions; public health and medical experts should heed the slogan “Know your epidemic” and target interventions accordingly. The much-bandied notion of ‘one size fits all’ is perhaps of little use in this situation.

Of course, Covid-19 presents new challenges. The epidemiology of a pandemic respiratory virus changes rapidly, and responses must be nimble. Given that everyone is susceptible to this novel coronavirus for which we lack effective biologic interventions, the response has required large-scale behaviour change, including social distancing, scrupulous hand washing and wearing of face masks in public, which were proposed rapidly under emergency circumstances. These measures could have had greater impact, however, if they had been adopted earlier and more widely; rapid actions that require community trust and buying-in. There are examples of public health successes against Covid-19. Hong Kong, which has a much higher population density than New York City, had fewer than 100 Covid-related deaths, thanks in part to swift and widespread uptake of masking, augmented by easily accessible testing. Germany introduced large-scale Covid-19 testing combined with locally led responses and strong national leadership. Globally, individual and community-level responses required substantial sacrifices that had major economic effects. In stark contrast, the USA response however, has been hampered by denial, missteps, delays in scaling up testing, inconsistent messaging, and politicization of public health responses. A vile combination of some of these led to uncontrollable community transmission in many parts of the United States of America.

But this pandemic presents an opportunity to build bridges between scientists and the public. Trust must be earned. Experience with HIV/AIDS demonstrated that scientist–community collaboration was feasible and improved the scientific process. AIDS advocates pressured scientists to act more quickly, to be more transparent, and to communicate clearly about scientific rationale and methods. The result was shorter timelines for scientific investigation, regulatory review, and even implementation of effective interventions. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, provided an outstanding model for building bridges with the public. His willingness to listen to advocates’ concerns about AIDS research was instrumental in making clinical research on HIV/AIDS consultative and collaborative.

In facing Ebola, the Partnership for Research on Ebola Vaccines in Liberia (PREVAIL) trial demonstrated that substantial investment and adaptive approaches to community education and social mobilization could address myths about Ebola, motivate participation, and achieve high retention in vaccine trials, all secured in spite of widespread mistrust of government, low literacy, stigma associated with Ebola, and poor clinical infrastructure in the affected communities.

With Covid-19, community engagement must be on an even larger scale and must be adaptive and led by trusted scientists and public health experts. In the United States, Fauci has again led the way, confidently and authoritatively providing clear, fact-based communication about Covid-19. His voice must continue to be heard, especially since the U.S. pandemic response has become so politicized.

Scientists and public health professionals must convey the critical need for well-designed research, surveillance, and rigorously implemented clinical trials to identify safe, effective interventions, including pre-exposure and post-exposure preventive treatments, and vaccines. Objective markers of response are needed to assess efficacy, including SARS-CoV-2 shedding as a measure of infectivity, in addition to clinical end points. Given the plethora of treatment and vaccine trials, many tens of thousands of study participants are needed. Community engagement is needed to address mistrust of research and reluctance to participate in clinical trials. Health care providers, scientists, community leaders, and policymakers can, and in fact must, work in tandem to encourage participation.

With Covid-19, we have the public attention, due entirely to the actual nature of the pandemic. That alone is not quite enough. Now we need to earn their trust by doing things according to the best science available, as efficiently as we can, and by clearly communicating our rationale, methods, and results. The buzz word is ‘TRANSPARENCY’. We have very limited preclinical data on SARS-CoV-2 to guide drug development and immunologic strategies. It is our duty as scientists to avoid supporting unproven interventions, blend opinion with evidence, or make strong proclamations based only on valid science, which are then picked up by the media.

More specifically, the fight against HIV demonstrated the need for a combination of interventions to reduce new infections and revealed the false dichotomy between treatment and prevention. HIV treatment has the powerful secondary benefit of preventing transmission by means of viral suppression, and some HIV medications have high efficacy for primary prevention. Initial efforts to prevent HIV infection focused on behavioural interventions, even as the biomedical pipeline was being developed. Eventually, we saw treatment breakthroughs, and now we have more than 30 antiretroviral drugs. Neither this portfolio nor HIV prophylaxis would exist if we had stopped after the initial studies. Investment in HIV drugs has led to major reductions in new infections, better quality of life for people with HIV, and lower mortality. Mind you, all these important gains being secured even without an effective vaccine.

HIV has also taught us that the timing of an intervention during the disease course may be critical to its therapeutic impact. Delaying treatment because of the magnitude of immunocompromise led to unnecessary illness and deaths. This principle is key in addressing Covid-19, given the potential contribution of a hyperimmune response to the severity and duration of illness. Early intervention is needed to prevent acquisition of Covid-19 or disease progression before multi-organ involvement occurs.

We need multiple strategies for preventing and treating Covid-19, including some forms of preventive treatments, and vaccines. It is highly unlikely that such therapeutic and preventive strategies would be successful at the very first attempt. Scrupulous scientific analysis of proposed therapeutic interventions and vaccines would be the key. It is absolutely crucial to realise that, like HIV, Covid-19 will continue to require non-pharmacologic public health strategies, even after a partially effective drug or vaccine is identified. The rationale for testing repurposed drugs needs to be clearly articulated and based on their potential activity against SARS-CoV-2 and on available safety data. For example, the drug remdesivir was originally evaluated for Ebola and has now shown partial efficacy for moderate-to-severe Covid-19 infection. Data from in vitro studies led hydroxychloroquine and chloroquine to be selected as candidates for preventive treatments and for treatment of established Covid-2 cases. This secured political support, media attention, and heightened expectations and even misconceptions. The first trials, however, were small and poorly controlled, and the results received disproportionate media attention. The problem was compounded by the publication and subsequent retraction of a study showing potential harm or lack of benefit from hydroxychloroquine, which led to further confusion and undermining of public trust in science.

Thus, the scientific community’s priority, as past experience suggests, should be to pursue hypothesis-based and data-driven strategies with sufficient imagination and resources to test new approaches for Covid-19 prevention and treatment. Clinical trials should be coordinated and implemented well, and the results should be scrutinized and interpreted clearly as well as objectively. We need to prepare the general public for a discovery process that is iterative and seldom linear. Interventions should not be strictly compartmentalized into biomedical and behavioural categories since decisions about testing, masking, quarantine, and use of preventive or therapeutic interventions, all have social and behavioural components. Scientific and public health efforts therefore require multi-disciplinary teams and intense collaboration.

Yet for all this, Covid-19 presents opportunities commensurate with its challenges, including the chance to build on our collective experience with high-priority, high-impact, high-quality science conducted in an efficient and coordinated manner. Throughout the process, we must build and sustain public trust by communicating clearly about our evolving understanding of this life-threatening disease. Medical professionals and health scientists should work tirelessly and hand-in-hand, to be transparent and secure unmitigated public trust. Policy decisions of the government should invariably take into account the health perspectives presented by professionals and medical scientists. The implementing authorities entrusted with all forms of prevention, quarantine and isolation of areas, should work within humane standpoints and with sustained empathy. It is paramount to realise that the only way out of this conundrum is to secure absolute and unadulterated public faith and belief in the authorities by being transparent, committed and intensely public-spirited, on the part of everyone involved with this pandemic, including the legislators, healthcare professionals, the implementers and the law enforcement authorities. It would most definitely be counter-productive to ‘wield the stick’. It is also not the time or the place for political bickering, finger pointing and assumption of ‘holier-than-thou’ attitudes. Willing and unstinting public cooperation can only be secured if the general populace has implicit trust in the authorities concerned. For their part, everybody involved in this battle against this little blight, should feel honoured and privileged to declare that it is the least they could do for our populace in this blessed land.