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SARS‐CoV ‐2 pandemics: The lack of critical reflection addressing short‐ and long‐term challenges

2020; Wiley; Volume: 35; Issue: 3 Linguagem: Inglês

10.1002/hpm.2977

1099-1751

Tiago Correia,

Viral Infections and Outbreaks Research

WHO has finally declared the SARS-CoV-2 outbreak to be a pandemic, and new research and interventions are appearing on a daily basis. Nonetheless, it would not be going too far to say that the situation is far from being under control. Europe is now the epicenter of the contagion. Contagion has been spreading fast in the Middle East. In Asia, there are increased efforts to keep the trend toward the flattening of new cases. Contagion is more recent in North and South America, but an exponential curve seems to have begun. Then again, Africa is still a large question mark. On the one hand, this is because many African nations have close relationships with countries that have been severely affected by SARS-CoV-2, because they have limited health care resources, and because the quality of monitoring is unreliable.1 On the other hand, it is because we are still in doubt as to how warmer weather will affect the transmission and survival of this coronavirus2 and because most of these countries have young demographics. The numbers continue to show that the severity of COVID-19 is much more significant over the age of 60 years.3 In March 2020, there have been facts on which consensus varies considerably. They show that it is still not possible to predict how this pandemic will evolve. The greatest consensus is that the SARS-CoV-2 virus is more contagious, but less deadly than other coronaviruses (ie, SARS-CoV-1 and MERS-CoV).4 Therefore, the risk is not necessarily linked to the effects it causes in its hosts, but rather to how easily community spread takes place.5 And, it is well known that, if no countermeasures are adopted, the virus will spread uncontrollably. There is less of a consensus on basic research. For example, how fast is genetic mutation of SARS-CoV-2 in transmission between humans and what are the consequences of the fact that there are already different strains of SARS-CoV-2 in circulation?6, 7 To what extent is there a risk of relapse or reinfection in SARS-CoV-2?8 What is the relationship between SARS-CoV-2 and other comorbidities and associated medications?9 What is the real estimate of how lethal COVID-19 is?10 In times of emergency in which people expect clear answers from science, we have to remember that the current lack of consensus is a sign of normality. After all, we are dealing with something new to the human immune system and scientific knowledge. I therefore have to underscore contrast with political management of this pandemic. Unlike the debate on basic research, the discourse of governments and international institutions has been of relative certainty about the ability to anticipate the evolution of the disease and the efficacy of measures to contain it. We know that these certainties are far from the truth, first and foremost because of the scientific doubts mentioned above. We should be worried about the lack of critical reflection on the short- and long-term planning and management of COVID-19. I want to highlight the need for three critical points of reflection in the management of this pandemic. The first is the fact that there has been no assessment of how far the message to the public should go in saying that we are sure about what steps to take next (when we are not) or whether it should clearly admit that action needs to be defined in close association with the advances and setbacks in basic research. Some people might criticize the second option and say that it makes the political message less consistent and effective. My response is that the consistency and effectiveness of the political message should focus mainly on communication of the science and that, if this is done, it will be easier for the public to deal with adjustments in political responses. When I say improving communication of science, I am talking about strategies for making easier (a) the interpretation of basic scientific research, (b) changes in behavior, (c) mental resilience in times of crisis, and (d) fact checking and fighting fake news. None of these is new in the management of epidemics.11-13 The second point that we need to think about is how to flatten the contagion curve. The main option that has been considered (until a vaccine is discovered) is imposing lock-downs on the population at large. International consensus on this approach springs from the immediate efficacy of the measures originally adopted in Singapore, Hong Kong, Taiwan, and South Korea.14 Worldwide the bet has been on articulate social distancing with complementary measures such as preventive screening, and quarantine and/or isolation. There are not enough arguments about alternative approaches or the adverse effects of general lock-downs, however. Where other approaches are concerned, one was initially attempted in the United Kingdom ("keep calm and carry on") but was soon dropped due to international criticism and serious mistakes in political communication on the part of Prime Minister Johnson. I am not advocating this approach nor do I think that it is risk-free. I recognize that there was not enough discussion as to its suitability for Western countries, whose aging demographic pyramid theoretically exacerbates the disease and places greater pressure on health systems. In simple terms, this approach that is also adopted in some other countries including the US, Japan or Sweden consists on focusing of health resources on the segments of the population most vulnerable to the serious effects of COVID-19 and relegating the less vulnerable strata public to widely known hygiene management (eg, washing hands, social distancing). Regarding the harmful effects of general lock-downs, the pressure on globalized and industrialized community life is becoming clear in many countries. It cannot withstand the asphyxiation of the mobility of people, goods, and capital for very long. This means the collapse of the economy and therefore political regimes and people's way of life, which depends on complex, distant supply and consumer networks. Given that it is fairly clear that, if these measures are lifted contagion will rise again, it is no surprise that, in the name of economic (and political) functioning, workers in certain business sectors will have to be exposed to greater risks of contagion. Question: what is the thinking on this issue in Asia and the other countries in the world? Furthermore, unlike the Asian countries, Western countries did not adopt consistent social distancing, quarantine, or isolation measures. Schools were closed, but the parents were still going to work. Maritime and land ports were closed, but the airports remained open. At one point, screening included people who had had contact with infected patients, at another point it excluded people traveling from countries affected by COVID-19. I would also like to say that Asia's successful strategy has to be linked to the countries' geographical characteristics. With the exception of China, they are island territories or have borders with only one country. So, how successful would the consistency, anticipation, and speed of political action in Singapore, Hong Kong, Taiwan, or South Korea be in the Schengen area for example? Europe will certainly learn from mistakes made. It is already fairly clear that concerted political action between member states came late and did not apply to all the fields that it should have: restrictions on mobility between countries and rules on the distribution of infrastructure and financial, human, technical, and technological resources. Finally, we know that action by politicians and health systems focusing almost exclusively on managing one disease will have negative effects on the management of other diseases, which do not just go away.15 Regardless of how highly contagious SARS-CoV-2 is, what about management of cancer, HIV, diabetes, obesity, mental health, and pregnancy? The third critical point of reflection to be addressed is how much we were caught unawares by this pandemic. Despite the Chinese authorities moving fast to report internationally the beginning of the outbreak16 it is alarming to see how little political responses to containing SARS-CoV-2 in 2020 have evolved in relation to the difficulty in containing H5N1 in 2005, H1N1 in 2009, and SARS-CoV-1 in 2002: reacting only when the infection unexpectedly crosses a border, washing hands, wearing masks, and praying for a vaccine to be discovered. After contagion has exploded, we cannot expect interpersonal contact management to be the most effective way of fighting it when the whole of international politics failed first.17 In other words, epidemics are not managed; they are anticipated and, if possible, avoided. After we get through the SARS-CoV-2 pandemic, we must take the opportunity to learn lessons for the future about why this coronavirus was transmitted to humans and spread like wildfire between countries. The revision of this text was provided by the Fundação para a Ciência e a Tecnologia through the Strategic Financing of the R&D Unit UID/SOC/03126/2019.