We are American public health practitioners. In addition to our work in the United States, we lived and worked in South Africa during the height of that country’s HIV epidemic. Contrasting America’s slapdash, inadequate response to the coronavirus pandemic with South Africa’s effective, science-based containment efforts produces a profound and painful sense of irony.
The United States has all but renounced the role of science in guiding policy at this critical time, allowing politics and misinformation to shape containment efforts, with tragic consequences. The Centers for Disease Control and Prevention (CDC) were once heralded as the world’s premier public health agency, but there is growing evidence that an overly bureaucratic approach to a rapidly-evolving pandemic and political conflicts with the White House have undermined its ability to provide effective scientific leadership at a time when we need it most.
Taking science seriously results in better policy. Scientists around the world are generating data at breakneck pace to improve our understanding of the coronavirus and the disease it causes. To sift through these findings and generate effective, actionable guidance requires a vibrant scientific community, excellent communication, and the support and trust of political leaders.
We are entering a new phase of our global response to the pandemic. Our understanding of the disease is growing rapidly, as is our capacity to treat it. A growing body of evidence suggests that implementation of Test, Track and Supported Isolation (TTSI) programs can radically reduce infection. At the same time, quarantine fatigue and the economic consequences of the epidemic are taking an immense toll, and, in the US, nation-wide protests against police brutality are exposing hundreds of thousands of Americans to infection for speaking out against racism. How much will science shape US policy in the crucial months to come?
As the coronavirus pandemic enters its seventh month, the US federal government continues to mislead Americans and ignore scientific evidence and consensus. In contrast, the South African government has not only acted swiftly and decisively, guided by a diverse group of public health scientists, many of whom were part of the movement to make HIV treatment available two decades ago. As a result, to date, while cases continue to rise, South Africa has so far avoided the devastating outbreak that was initially feared.
South African President Cyril Ramaphosa’s coronavirus task force is led by infectious disease researchers who have shaped national policy on social distancing and the country’s five-stage plan for reopening. South Africa leads the continent in testing for coronavirus, and has deployed 28,000 health workers to do contact tracing and screening. To date, South Africa has tested over 600,000 people, but a backlog of 100,000 tests suggests that TTSI efforts will falter without greater material support. While the national test positivity rate of about 7% is concerning, the epidemic is primarily focused in the Western Cape province. Preventing and containing outbreaks in densely-packed informal settlements, and safeguarding the 7.7 million South Africans who are HIV positive will require renewed efforts, funding, and vigilance. But the South African response suggests what can be accomplished when science guides policy.
South Africa learned these lessons from brutal experience. Over twenty years ago, as HIV/AIDS tore through sub-Saharan Africa, Thabo Mbeki succeeded Nelson Mandela as president of South Africa, and immediately began to call into question the scientific consensus on the disease and its treatment. Mbeki convened an advisory panel featuring prominent AIDS denialists, many with no public health or other relevant training. Mbeki’s Minister of Health, Dr Manto Tshabalala-Msimang, dismissed antiretroviral (ARV) therapies as “poison,” and promoted unscientific and unproven therapies, earning the nickname “Dr. Beetroot.”
The consequences of rejecting HIV science were grave. Rather than rapidly scale up ARV treatment, particularly to prevent mother-to-child transmission, the South African government promoted home remedies, dietary regimens, and treatment with industrial solvents.
In 2010, only half of South African infants were being tested and treated to prevent mother to child transmission, a much lower rate than many other African countries. An analysis at the Harvard T.H. Chan School of Public Health concluded that this policy failure resulted in 35,000 additional HIV-positive births, and 330,000 preventable deaths.
In 2020, it is the United States that has chosen to set aside science in the face of an epidemic. Our coronavirus response was delayed by cuts to the CDC’s monitoring capacity and our failure to pay attention to the scientists entrusted with monitoring global health, many of whom had been warning of such a pandemic for years. This delay has exposed healthcare workers to grave and unnecessary risks, and greatly increased the scope of infection. The US is now the epicenter of the global pandemic, with the highest number of deaths of any country. Yet we still have no definitive data on infection rates due to inadequate testing, driving rash, politically-motivated decisions about reopening our economy.
We must do better.
In South Africa, public health advocates and activists in South Africa overcame the government’s rejection of HIV science. In 2008, Tshabalala-Msimang was replaced as Minister by Aaron Motsoaledi, a physician who acknowledged that “If we had acted more than a decade ago, we might not have been in this situation where we are. Obviously, we did lose time.”
We cannot afford to lose more time in the fight against the coronavirus in the United States.
First, our policies must be guided by the weight of science. To do so effectively, scientists must play a critical role both in rapidly generating new evidence and sifting in real-time the complex data that emerges in pre-print papers and other sources. While leaders in medicine and policy are under tremendous pressure to act, we must resist the imperative to do so in the absence of data.
Second, to support public understanding and scientific literacy, scientists must be effective and energetic communicators. To counteract confusion and misinformation, we must generate, articulate, and amplify accurate, data-driven guidelines and recommendations. This is particularly important when evidence and guidelines evolve, as with guidelines about masks. Experts with experience in the HIV and other epidemics understand that guidance must be shared through a range of popular and influential channels – not just Twitter.
Finally, we must commit ourselves to health equity. African-American communities are three times as likely to die of the coronavirus, mirroring disproportionate use of force by police and other forms of structural violence which are at the root of nationwide protests. Public health practitioners must make it our highest priority to mitigate the grossly disproportionate impact of coronavirus in African-American communities.
We need science to guide us. There is no more time to lose.