Four months since the world’s most stringent lockdown was imposed with four hours’ notice on over a billion unprepared people with the promise, buttressed by scientific jargon and graphs of curves, that this extreme action would flatten the curve of infection down to zero by mid-May, we remain mired in the grip of multiple epidemics unfolding with different trajectories across our cities and towns. As I try to make sense of why things have gone so awry, one thought which troubles me the most is an honest appraisal of the contribution of science, whether in this country or globally. After all, I belong to that community. Never before has science been so much in the spotlight in global and national affairs and yet, it seems to me, we have not quite covered ourselves in glory. In particular, we have failed in our obligation to acknowledge the uncertainties in our observations, the limitations of our methods and the importance of other traditions of knowledge.
The history of this pandemic is littered with premature, and often inaccurate, scientific predictions ranging from the estimates of the numbers of people who will die unless nations impose a lockdown to the effectiveness of drug treatments. Crowning these scientific disciplines is the field of modelling, for it was its estimates of mountains of dead bodies which fuelled the panic and led to the unprecedented restrictions on public life around the world. None of these early models, however, explicitly acknowledged the huge assumptions that were made, for example that mortality was distributed evenly across the population (incorrect, because it is heavily concentrated in the elderly) or that everyone who is not infected is vulnerable (likely to be incorrect as evidence of innate immunity mounts). The assumption that the virus would rampage uniformly in all populations, which was a naïve one to begin with, for both the social conditions and human biology which influence the transmission of infectious diseases vary enormously across contexts, can be safely junked.
While it is fair to defend modelling science as just one tool intended to predict an uncertain future and guide governments, such models must never be interpreted as if they occur in a vacuum, agnostic to their historical, social, cultural and economic context. This responsibility falls squarely on the shoulders of the scientific community, as much as policy makers. The latest example of the myopic perspective which dominates modelling enterprises is the unpublished but publicly accessible paper authored by scientists from two Ivy League US universities which recommends the closure of red-light areas in India to dramatically reduce the number of COVID-19 deaths. The paper has, rightly, prompted fury and spurred JVR Prasada Rao, former Health Secretary and UN Secretary-General’s Special Envoy on AIDS, to write a letter, co-authored with India’s leading activists and researchers, expressing outrage at the study’s research methods and ethics. Perhaps the most egregious concern is the ludicrously naïve observation that sex workers, already amongst the most discriminated groups on the margins of society, could simply be redeployed to other vocations to stave off the hunger and violence that would befall them when the red light areas are shut.
Indeed, this kind of tunnel vision has characterised scientific proclamations from the outset of the pandemic, with little attention to their societal implications which would require a thorough assessment of the impact of policies on the most vulnerable. The fact that many lives will be lost as a result of the lockdowns is now emerging across the world, with recent reports from UNICEF documenting tens of millions of children whose routine vaccinations have been disrupted and from Oxfam that “up to 12,000 people could die from hunger every day globally — 2,000 more than died from COVID-19 each day in April”. Most of these deaths will occur in the poorest communities. It is perhaps not surprising that some scientists vociferously called for governments to act swiftly to impose lockdowns. After all, most of my community, and the government officials who conjure and implement these policies, enjoy salaried jobs which can seamlessly pivot to on-line platforms which we can operate with ease from our spacious homes in which being locked down can evolve into a rather congenial opportunity to master culinary skills and not have to commute to work. It will not surprise me if the reputation of scientists, already tainted in some quarters as being elitist, will be further muddied by our role in this pandemic.
And so here we are, after months of being tantalised by headlines of billions of dollars allocated to fund dramatic scientific discoveries, implementing strategies we have known about for decades: The humble front-line worker burrowing systematically through the community to identify cases, trace their contacts, isolate them at home, and restrict movements in areas where clusters emerge. It is instructive that Massachusetts in the US, home to the world’s leading medical school and teaching hospitals, has deployed Partners in Health, a NGO which has previously worked in the poorest countries helping contain epidemics such as Ebola through community based first-responders, to guide the state’s pandemic control programme. The success stories in India, from Kerala to Dharavi, also bear the hallmarks of such a strategy.
What marks the current pandemic out as being unlike any other public health emergency that precedes it is its global stage, with the cacophony of debates and disputes between scientists played out in full public view on digital platforms. It comes as no surprise that waves of panic and anger sweep the world, as populations which were led to believe that scientific commandments were written in stone and that government leaders were responding accordingly, are coming to grips with the truth that there is much that we don’t understand about the virus and the responsibility of containment has been devolved to the ordinary citizen and the local authorities. Which is, ironically, what it should have been from the start.
While science-informed policies are an aspiration, we also need to appreciate their limitations and assumptions to ensure that such policies do not lead to avoidable harms and promise unrealistic results. I hope the scientific community can emerge from this experience with more humility, to acknowledge that we don’t have all the answers all the time, that other disciplines such as the humanities are just as important, that our recommendations are often founded on an incomplete understanding of the problem, that these will change as new knowledge emerges, and that it is in keeping with our tradition to admit when we are wrong and use these opportunities to refine our methods. Above all, we must be cautious when recommending any policy actions to ensure they always take into account the perspectives of the vulnerable who will be most seriously affected.
This article first appeared in the print edition on July 30, 2020 under the title ‘The limits of science’. Patel is the Pershing Square Professor of Global Health at Harvard Medical School
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