Abraar Karan considers the nature of expertise during a pandemic and argues that the notion of “the expert” is largely misplaced
As the covid-19 pandemic spreads, one question has come up repeatedly: who do we trust? Trust is the glue to an epidemic response actually working. If people don’t know who or what to believe, mounting a sustained, coordinated effort is largely impossible.
In the Ebola response, trust meant the difference between being able to contact-trace infected individuals effectively or transmission chains disappearing altogether.
Today, with covid-19, trust will once again determine if we succeed or fail. Take social distancing, for example. Why would anyone do something at great personal cost if they don’t actually trust that it will benefit society, and protect more vulnerable people? To an extent, this comes down to trust in public leadership.
The same is true in our efforts to conserve hospital capacity for those who will truly need it. If I tell my low risk patients over the phone that they are safe to stay at home and wait out their symptoms until we have widespread community level testing available, they will only do so if they trust me. If they don’t, they will go straight to an emergency department where they may infect many others inadvertently.
Who do we trust?
Despite trust being obviously critical, who to trust is understandably less obvious. With social media, the generation of ideas has become democratised, allowing both people who know what they are talking about, and those who don’t, to gain sizeable followings relatively quickly.
Moreover, the gatekeepers who decide which ideas become legitimised, including editors at major newspapers, don’t always have the technical expertise to tease out a real expert from a so called “armchair” one, which has become evident in recent times. The same goes for who media channels decide to put in front of the camera. At times with covid-19, it has been people who hold prestigious titles but who may not know what is actually going on at the ground level, or those who are speaking far outside their area of expertise.
This has become quite challenging. One wrong idea that gains traction because it is touted as truth by a celebrity or public figure can set back days of public health gains. The recent trial using azithromycin/hydroxychloroquine to treat covid-19 is a prime example of this. While the results deserve further investigation, the study itself is small and not designed in a way that should be changing clinical practice unless a doctor is completely out of safely tested options.
Who is an expert?
When thinking about who to trust, most people naturally are looking to “the experts.” I spent the past year leading the American Medical Association’s Journal of Ethics on a pandemic response themed journal issue. I was able to speak with and learn from many senior experts in pandemics during this process. They came from nearly every specialty and subject area—in fact, there were far more than we even had space to include. If I learnt anything in this role, it was that the idea of a single expert in a pandemic is folly. On Twitter, there have been ongoing debates by experts, non-experts, semi-experts, and everything in between about who is right, who has the right to speak, and who the expert is. This mixed messaging and in-fighting among those working on the covid-19 response leaves the public even more confused.
The whole notion of “the expert” to me is largely misplaced. There are many experts in different subjects—infectious disease, epidemiology, virology, law, ethics, economics, medicine, anthropology, emergency response, communications—and most who have expertise in one area do not in other areas. And that is fine. That is exactly why pandemics require interdisciplinary collaboration. Problems arise when people overstep where their expertise ends, or when they use expertise in their subject to try and silence others who have expertise in different areas. I have seen both happen, unfortunately.
Rather than asking who is the expert, you should really be asking what the question is that you want answered. If you want to know about covid-19 epidemiology, ask an infectious disease epidemiologist who understands what it takes to build a credible model. If you want to learn about covid-19 clinical management, ask an infectious disease or critical care doctor who has cared for an infected patient. If you want to understand the basic science, ask a virologist who has studied covid-19 in the lab.
Instead of arguing about who is and isn’t an expert, I think that one of our duties at this time is to create expertise, not hoard it. In a New York Times interview with pandemics expert Bruce Aylward, he describes how in China, the government actually repurposed workers to help with the covid-19 response. A receptionist was taught how to properly don/doff protective gear, and was soon leading the effort in hospitals. This is what we need: for every person to believe that they can make a difference in their community, without exception, and to then do it.
We need people who are experts in personal and community hygiene; in enforcing social distancing; in isolating and quarantining appropriately; in communicating public health messages to those who may speak a different language or who are disabled. Very soon in the US, we will need people to become experts in tracing contacts of the sick as we strategise and operationalise our community level response. There are so many needs right now. And remember—all it takes is one person ignoring their personal role for a new outbreak to start. If we sit back waiting for the “experts” to save the day, we have already lost. It will not be the brilliance of experts, but the brilliance of everyday people doing their part that the world will remember when it looks back at how covid-19 was stopped.
If there is one thing you can trust without question: you have a part to play, and the world needs you, now.
Abraar Karan is a physician at Brigham and Women’s Hospital/Harvard Medical School, a columnist at The BMJ, and is working on the population level covid-19 response in Massachusetts state. Twitter @AbraarKaran
Competing interests: None declared.