Features
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.
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There’s an ill more dangerous and pervasive than the Coronavirus that’s currently sweeping Sri Lanka. That is the fear to express one’s convictions. Across the public sector of the country in particular many persons holding high office are stringently regulating and controlling the voices of their consciences and this bodes ill for all and the country.
The corrupting impact of fear was discussed in this column a couple of weeks ago when dealing with the military coup in Myanmar. It stands to the enduring credit of ousted Myanmarese Head of Government Aung San Suu Kyi that she, perhaps for the first time in the history of modern political thought, singled out fear, and not power, as the principal cause of corruption within the individual; powerful or otherwise.
To be sure, power corrupts but the corrupting impact of fear is graver and more devastating. For instance, the fear in a person holding ministerial office or in a senior public sector official, that he would lose position and power as a result of speaking out his convictions and sincere beliefs on matters of the first importance, would lead to a country’s ills going unaddressed and uncorrected.
Besides, the individual concerned would be devaluing himself in the eyes of all irrevocably and revealing himself to be a person who would be willing to compromise his moral integrity for petty worldly gain or a ‘mess of pottage’. This happens all the while in Lankan public life. Some of those who have wielded and are wielding immense power in Sri Lanka leave very much to be desired from these standards.
It could be said that fear has prevented Sri Lanka from growing in every vital respect over the decades and has earned for itself the notoriety of being a directionless country.
All these ills and more are contained in the current controversy in Sri Lanka over the disposal of the bodies of Covid victims, for example. The Sri Lankan polity has no choice but to abide by scientific advice on this question. Since authorities of the standing of even the WHO have declared that the burial of the bodies of those dying of Covid could not prove to be injurious to the wider public, the Sri Lankan health authorities could go ahead and sanction the burying of the bodies concerned. What’s preventing the local authorities from taking this course since they claim to be on the side of science? Who or what are they fearing? This is the issue that’s crying out to be probed and answered.
Considering the need for absolute truthfulness and honesty on the part of all relevant persons and quarters in matters such as these, the latter have no choice but to resign from their positions if they are prevented from following the dictates of their consciences. If they are firmly convinced that burials could bring no harm, they are obliged to take up the position that burials should be allowed.
If any ‘higher authority’ is preventing them from allowing burials, our ministers and officials are conscience-bound to renounce their positions in protest, rather than behave compromisingly and engage in ‘double think’ and ‘double talk’. By adopting the latter course they are helping none but keeping the country in a state of chronic uncertainty, which is a handy recipe for social instabiliy and division.
In the Sri Lankan context, the failure on the part of the quarters that matter to follow scientific advice on the burials question could result in the aggravation of Islamophobia, or hatred of the practitioners of Islam, in the country. Sri Lanka could do without this latter phobia and hatred on account of its implications for national stability and development. The 30 year war against separatist forces was all about the prevention by military means of ‘nation-breaking’. The disastrous results for Sri Lanka from this war are continuing to weigh it down and are part of the international offensive against Sri Lanka in the UNHCR.
However, Islamophobia is an almost world wide phenomenon. It was greatly strengthened during Donald Trump’s presidential tenure in the US. While in office Trump resorted to the divisive ruling strategy of quite a few populist authoritarian rulers of the South. Essentially, the manoeuvre is to divide and rule by pandering to the racial prejudices of majority communities.
It has happened continually in Sri Lanka. In the initial post-independence years and for several decades after, it was a case of some populist politicians of the South whipping-up anti-Tamil sentiments. Some Tamil politicians did likewise in respect of the majority community. No doubt, both such quarters have done Sri Lanka immeasurable harm. By failing to follow scientific advice on the burial question and by not doing what is right, Sri Lanka’s current authorities are opening themselves to the charge that they are pandering to religious extremists among the majority community.
The murderous, destructive course of action adopted by some extremist sections among Muslim communities world wide, including of course Sri Lanka, has not earned the condemnation it deserves from moderate Muslims who make-up the preponderant majority in the Muslim community. It is up to moderate opinion in the latter collectivity to come out more strongly and persuasively against religious extremists in their midst. It will prove to have a cementing and unifying impact among communities.
It is not sufficiently appreciated by governments in the global South in particular that by voicing for religious and racial unity and by working consistently towards it, they would be strengthening democratic development, which is an essential condition for a country’s growth in all senses.
A ‘divided house’ is doomed to fall; this is the lesson of history. ‘National security’ cannot be had without human security and peaceful living among communities is central to the latter. There cannot be any ‘double talk’ or ‘politically correct’ opinions on this question. Truth and falsehood are the only valid categories of thought and speech.
Those in authority everywhere claiming to be democratic need to adopt a scientific outlook on this issue as well. Studies conducted on plural societies in South Asia, for example, reveal that the promotion of friendly, cordial ties among communities invariably brings about healing among estranged groups and produces social peace. This is the truth that is waiting to be acted upon.
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By Sanjeewa Jayaweera
It was on 3rd January 1972 that our family arrived in Karachi from Moscow. Our departure from Moscow had been delayed for a few weeks due to the military confrontation between Pakistan and India. It ended on 16th December 1971. After that, international flights were not permitted for some time.
The contrast between Moscow and Karachi was unbelievable. First and foremost, Moscow’s temperature was near minus 40 degrees centigrade, while in Karachi, it was sunny and a warm 28 degrees centigrade. However, what struck us most was the extreme warmth with which the airport authorities greeted our family. As my father was a diplomat, we were quickly ushered to the airport’s VIP Lounge. We were in transit on our way to Rawalpindi, the airport serving the capital of Islamabad.
We quickly realized that the word “we are from Sri Lanka” opened all doors just as saying “open sesame” gained entry to Aladdin’s cave! The broad smile, extreme courtesy, and genuine warmth we received from the Pakistani people were unbelievable.
This was all to do with Mrs Sirima Bandaranaike’s decision to allow Pakistani aircraft to land in Colombo to refuel on the way to Dhaka in East Pakistan during the military confrontation between Pakistan and India. It was a brave decision by Mrs Bandaranaike (Mrs B), and the successive governments and Sri Lanka people are still enjoying the fruits of it. Pakistan has been a steadfast and loyal supporter of our country. They have come to our assistance time and again in times of great need when many have turned their back on us. They have indeed been an “all-weather” friend of our country.
Getting back to 1972, I was an early beneficiary of Pakistani people’s love for Sri Lankans. I failed the entrance exam to gain entry to the only English medium school in Islamabad! However, when I met the Principal, along with my father, he said, “Sanjeewa, although you failed the entrance exam, I will this time make an exception as Sri Lankans are our dear friends.” After that, the joke around the family dinner table was that I owed my education in Pakistan to Mrs B!
At school, my brother and I were extended a warm welcome and always greeted “our good friends from Sri Lanka.” I felt when playing cricket for our college; our runs were cheered more loudly than of others.
One particular incident that I remember well was when the Embassy received a telex from the Foreign inistry. It requested that our High Commissioner seek an immediate meeting with the Prime Minister of Pakistan, Mr Zulifikar Ali Bhutto (ZB), and convey a message from Mrs B. The message requested that an urgent shipment of rice be dispatched to Sri Lanka as there would be an imminent rice shortage. As the Ambassador was not in the station, the responsibility devolved on my father.
It usually takes about a week or more to get an audience with the Prime Minister (PM) of a foreign country due to their busy schedule. However, given the urgency, my father spoke to the Foreign Ministry’s Permanent Sectary, who fortunately was our neighbour and sought an urgent appointment. My father received a call from the PM’s secretary around 10 P.M asking him to come over to the PM’s residence. My father met ZB around midnight. ZB was about to retire to bed and, as such, was in his pyjamas and gown enjoying a cigar! He had greeted my father and had asked, “Mr Jayaweera, what can we do for great friend Madam Bandaranaike?. My father conveyed the message from Colombo and quietly mentioned that there would be riots in the country if there is no rice!
ZB had immediately got the Food Commissioner of Pakistan on the line and said, “I want a shipload of rice to be in Colombo within the next 72 hours!” The Food Commissioner reverted within a few minutes, saying that nothing was available and the last export shipment had left the port only a few hours ago to another country. ZB had instructed to turn the ship around and send it to Colombo. This despite protests from the Food Commissioner about terms and conditions of the Letter of Credit prohibiting non-delivery. Sri Lanka got its delivery of rice!
The next was the visit of Mrs B to Pakistan. On arrival in Rawalpindi airport, she was given a hero’s welcome, which Pakistan had previously only offered to President Gaddafi of Libya, who financially backed Pakistan with his oil money. That day, I missed school and accompanied my parents to the airport. On our way, we witnessed thousands of people had gathered by the roadside to welcome Mrs B.
When we walked to the airport’s tarmac, thousands of people were standing in temporary stands waving Sri Lanka and Pakistan flags and chanting “Sri Lanka Pakistan Zindabad.” The noise emanating from the crowd was as loud and passionate as the cheering that the Pakistani cricket team received during a test match. It was electric!
I believe she was only the second head of state given the privilege of addressing both assemblies of Parliament. The other being Gaddafi. There was genuine affection from Mrs B amongst the people of Pakistan.
I always remember the indefatigable efforts of Mr Abdul Haffez Kardar, a cabinet minister and the President of the Pakistan Cricket Board. From around 1973 onwards, he passionately championed Sri Lanka’s cause to be admitted as a full member of the International Cricket Council (ICC) and granted test status. Every year, he would propose at the ICC’s annual meeting, but England and Australia’s veto kept us out until 1981.
I always felt that our Cricket Board made a mistake by not inviting Pakistan to play our inaugural test match. We should have appreciated Mr Kardar and Pakistan’s efforts. In 1974 the Pakistan board invited our team for a tour involving three test matches and a few first-class games. Most of those who played in our first test match was part of that tour, and no doubt gained significant exposure playing against a highly talented Pakistani team.
Several Pakistani greats were part of the Pakistan and India team that played a match soon after the Central Bank bomb in Colombo to prove that it was safe to play cricket in Colombo. It was a magnificent gesture by both Pakistan and India. Our greatest cricket triumph was in Pakistan when we won the World Cup in 1996. I am sure the players and those who watched the match on TV will remember the passionate support our team received that night from the Pakistani crowd. It was like playing at home!
I also recall reading about how the Pakistani government air freighted several Multi Barrell artillery guns and ammunition to Sri Lanka when the A rmy camp in Jaffna was under severe threat from the LTTE. This was even more important than the shipload of rice that ZB sent. This was crucial as most other countries refused to sell arms to our country during the war.
Time and again, Pakistan has steadfastly supported our country’s cause at the UNHCR. No doubt this year, too, their diplomats will work tirelessly to assist our country.
We extend a warm welcome to Mr Imran Khan, the Prime Minister of Pakistan. He is a truly inspirational individual who was undoubtedly an excellent cricketer. Since retirement from cricket, he has decided to get involved in politics, and after several years of patiently building up his support base, he won the last parliamentary elections. I hope that just as much as he galvanized Sri Lankan cricketers, his political journey would act as a catalyst for people like Kumar Sangakkara and Mahela Jayawardene to get involved in politics. Cricket has been called a “gentleman’s game.” Whilst politics is far from it!.
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Believe me, seeing certain videos, on social media, depicting action, on the dance floor, at some of these entertainment venues, got me wondering whether this Coronavirus pandemic is REAL!
To those having a good time, at these particular venues, and, I guess, the management, as well, what the world is experiencing now doesn’t seem to be their concerned.
Obviously, such irresponsible behaviour could create more problems for those who are battling to halt the spread of Covid-19, and the new viriant of Covid, in our part of the world.
The videos, on display, on social media, show certain venues, packed to capacity – with hardly anyone wearing a mask, and social distancing…only a dream..
How can one think of social distancing while gyrating, on a dance floor, that is over crowded!
If this trend continues, it wouldn’t be a surprise if Coronavirus makes its presence felt…at such venues.
And, then, what happens to the entertainment scene, and those involved in this field, especially the musicians? No work, whatsoever!
Lots of countries have closed nightclubs, and venues, where people gather, in order to curtail the spread of this deadly virus that has already claimed the lives of thousands.
Thailand did it and the country is still having lots of restrictions, where entertainment is concerned, and that is probably the reason why Thailand has been able to control the spread of the Coronavirus.
With a population of over 69 million, they have had (so far), a little over 25,000 cases, and 83 deaths, while we, with a population of around 21 million, have over 80,000 cases, and more than 450 deaths.
I’m not saying we should do away with entertainment – totally – but we need to follow a format, connected with the ‘new normal,’ where masks and social distancing are mandatory requirements at these venues. And, dancing, I believe, should be banned, at least temporarily, as one can’t maintain the required social distance, while on the dance floor, especially after drinks.
Police spokesman DIG Ajith Rohana keeps emphasising, on TV, radio, and in the newspapers, the need to adhere to the health regulations, now in force, and that those who fail to do so would be penalised.
He has also stated that plainclothes officers would move around to apprehend such offenders.
Perhaps, he should instruct his officers to pay surprise visits to some of these entertainment venues.
He would certainly have more than a bus load of offenders to be whisked off for PCR/Rapid Antigen tests!
I need to quote what Dr. H.T. Wickremasinghe said in his article, published in The Island of Tuesday, February 16th, 2021:
“…let me conclude, while emphasising the need to continue our general public health measures, such as wearing masks, social distancing, and avoiding crowded gatherings, to reduce the risk of contact with an infected person.
“There is no science to beat common sense.”
But…do some of our folks have this thing called COMMON SENSE!
