Year : 2020 | Volume
: 64 | Issue : 6 | Page : 87--89
Science, policy, people, and public health: What Is COVID-19 teaching us?
Anand Krishnan1, Rajib Dasgupta2,
1 Professor, Centre of Community Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi
|How to cite this article:|
Krishnan A, Dasgupta R. Science, policy, people, and public health: What Is COVID-19 teaching us?.Indian J Public Health 2020;64:87-89
|How to cite this URL:|
Krishnan A, Dasgupta R. Science, policy, people, and public health: What Is COVID-19 teaching us?. Indian J Public Health [serial online] 2020 [cited 2020 Aug 5 ];64:87-89
Available from: http://www.ijph.in/text.asp?2020/64/6/87/285633
In the ideal scheme of things, scientists generate evidence and policymakers use it for decision-making – a collaborative effort with clear demarcation of roles with a science–policy interface that enables them to communicate with each other. Serious failures of this interface globally and in many countries have led to disastrous public health outcomes in the current COVID-19 epidemic. The preparedness and response of reputed institutions, such as the National Health Service in the UK and the Centers for Disease Control and Prevention (CDC) in the US, have also been questioned., Many of these failures are due to shortcomings of governments, but there have also been failures by scientific institutions and advisors. That so many countries with highly capable science advisory ecosystems were unable to act wisely and early should be a concern for all of us.
One aspect where we, as a scientific fraternity, have failed is in the communication of the science behind the approach to COVID-19 prevention and control. A hallmark of this pandemic has been the rapid sharing of scientific information on an unprecedented scale. Most academic journals, societies, institutes, and companies decided to make research and data on COVID-19 freely available. Many good journals put new evidence in the public domain without a peer-review process, a sine qua non of science, and sanctity of evidence. Shared rapidly by scientists and the public alike these were disseminated and debated on social media platforms and news channels. Simplistic interpretation of complex scientific principles and facts frequently resulted in confusion and panic in the minds of public and policymakers. The scientific community often came across as a divided house. Scientists are comfortable with uncertainties and differences of opinion; these drive them to explore and seek. The problem arises when such disagreements spill over into the public domain. People and policymakers are comfortable with singularity of message that the scientist community may not be able to give, owing to differences in interpretation as well as uncertainty. What should a policymaker do in such cases?
In a pandemic such as the COVID-19 policymakers want to be seen to be doing something and something fast. Scientists can step back when there is no definitive evidence for a course of action, but lack of evidence does not mean lack of effectiveness. Scientists do not work in public glare, are not answerable to the public, and are usually not time-constrained; policy makers have none of these luxuries. While scientists recommend from a technical point of view, public health policies have immense political, economic, social, and diplomatic ramifications.
Given that even routinely evidence-based public health decision-making faces serious barriers, how do we promote it in times of crisis? We need to practice it when there is no crisis and set up necessary mechanisms and institutions that are tried and trusted and inspire faith during emergencies; examples include Public Health England and National Institute for Health and Care Excellence, UK. Most developing countries including India lack such institutional mechanisms. Time-sensitiveness and consensus generation are key challenges in public health emergencies. A transparent, participatory, and delegated decision-making process is the best alternative to evidence-based decision-making in times of crisis.
The COVID-19 crisis brought together scientists, administrators and policy makers to make decisions in a race against time, responding to it not just as a disease but also as a larger humanitarian crisis. This entails a quick cyclical knowledge-to-action (KTA) process, and must include knowledge generated through science, as well as local (community-based), or indigenous knowledge. Four processes enable this KTA cycle: socialization (sharing of individual tacit knowledge through collaborative methods such as meetings), externalization (codifying the tacit knowledge into tools and resources), internalization (learning by doing, through simulations or exercises), and a combination of these three. Have we as public health practitioners responded to this challenge adequately?
Traditional public health advocates “shoe-leather epidemiology” (field epidemiology or applied epidemiology) and entails investigations initiated in response to, for which the investigative team does much of its work in the field (outside the office or laboratory), to provide information as quickly as possible for the processes of selecting and implementing interventions. These often entail rapid or “dirty” methods in contrast to its more sophisticated cousin – “academic epidemiology” – that has come to be the hallmark of the schools of public health. While the immediate driver of shoe-leather epidemiology is service (public health surveillance, responding to outbreaks, and improving health), academic epidemiology is driven by the pursuit of discovery (identifying etiology, risk factors, causality, and disease modeling). Academic epidemiology is typically biomedical in its paradigm; working with data collected in relatively controlled circumstances, and its timeline is rarely urgent. William H. Foege, who played a key role in the successful eradication of smallpox, coined the term “consequential epidemiology” to bridge this gap. The framing of consequential epidemiology takes into account contextual constraints, public pressures, and community interests and seeks to design interventions that require technical competence blended with good judgment and community engagement, the challenge being to transition from “quick and dirty” to “quick and appropriate.”
The COVID-19 situation underscores the importance of combining good science with prudent judgment to meet the needs of large populations, while maximizing scientific quality in the face of applicable limitations and competing interests. Consequential epidemiology thus demands “complementary nontechnical competencies” beyond conventional epidemiologic methods to respond to the social, economic and political challenges of health and healthcare, embedding research and intervention within a variety of complementary disciplinary approaches. COVID-19 is an imperative that calls for global and synergistic approaches in public health to enable politics to work to the best interest of people, recognizing that physical ailments parallel material and psychological suffering–working with and between the disciplines of epidemiology, social science, and humanities with constant explanation, adaptation, and scientific readjustment., Underscoring the inseparability of medicine (read, public health) from politics, Virchow famously articulated, “Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: The politician, the practical anthropologist, must find the means for their actual solution.”
The Government of India has launched the Atmanirbhar Bharat Abhiyan (Self-reliant India Mission) as a revival package to mitigate the devastation caused by COVID-19. What should the public health package be? COVID-19 is neither the first pandemic nor will it be the last one. The single most important step should be to significantly invest in institutions and individuals to build national and subnational capacities in disease surveillance, prevention, and control. It is time for a complete revamp of the National Centre for Disease Control to live up to its name. We need an effective national public health agency that can provide leadership and technical capacity to resolve contemporary complexities (also remarked in the context of the US CDC). It should significantly expand the Epidemic Intelligence Services training to create a large cadre of competent professionals and work synergistically with state-level agencies and laboratories. There is a need to strengthen public health governance at district/state and central levels by the establishment of public health cadres. The science–policy interface requires improving communication between scientists and policymakers and administrators. The country should build upon the existing strengths, enlarging vaccine development and production capacities and should establish vaccine delivery platforms beyond mothers and children. Central in all these pursuits is a transparent and open data sharing policy for public health practitioners and researchers to access available data and be able to delineate the contours of the epidemic and plan an effective response. Finally, the pandemic showed up major deficiencies in India's health sector emergency preparedness, especially the role of the private sector which simply did not rise to the occasion. We cannot afford this to happen the next time around.
This pandemic is not yet over; it has provided us with an opportunity to introspect and chart the way forward. Many of these aspects have been addressed by authors in this special issue combining science with realpolitik as befits any good public health discussion, a dialog we hope you will join in….
It seemed to be a rather ambitious idea to prepare a COVID-19 Special Issue of the Indian Journal of Public Health (IJPH) in 3 weeks and then collaborate with the publisher to complete the production process and post it online in another 3 weeks. Assured of the IPHA/IJPH leadership's complete support and editorial freedom, and given our own sense of adventure, we took up this challenge. With an open call of about 2 weeks, we received nearly 450 submissions (from India and abroad); about a hundred were peer reviewed and 26 made it finally. There were difficult (and often harsh) choices to make, more so on account of limits to original research on the subject at this point plus that the timeline of this issue did not leave room for multiple revisions. The key elements that the selected articles sought to capture are expertise, evidence, originality, and usefulness.
This Special Issue particularly benefitted from the contribution and wisdom of key figures in the fields of interdisciplinary public health and epidemiology as well as other specialties such as pharmacology, digital health, and virology. We are fortunate and grateful that they acceded to our request to contribute commentaries and technical reviews in a very short time. These have blended well to enable readers to have a 360° view of the COVID-19 situation – a uniqueness of this issue. We sincerely hope that this combination of invited and peer-reviewed articles adequately meets the aim of IPHA to collate and present evidence on contemporary aspects of COVID-19 to promote evidence-based decision-making among academicians and practitioners of public health.
All this was made possible by the very generous contribution of a hundred-plus peer reviewers and support from the IJPH Editorial Board members. The IPHA and IJPH leadership provided unstinted facilitation throughout the process. Dr. Shreya Jha played a key role in the entire process and provided endless support in all the activities.
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