A large chunk of coronavirus science is missing. Not the vaccines, which are coming along nicely and might conceivably be rolled out from next spring. Nor treatments, about which we are gleaning valuable new insights regularly. The Recovery trial run by Oxford university proved that dexamethasone, a cheap steroid, boosts the survival chances of the sickest; the Solidarity megatrial co-ordinated by the World Health Organization indicates remdesivir does not.
The missing science, unhappily, covers virtually everything else, including all the measures we have hurriedly adopted since the pandemic began. “We really lack evidence on very basic things, such as hand hygiene and mask-wearing,” says Susan Michie, professor of health psychology at University College London and a member of both Sage, the UK government’s official advisory group, and Independent Sage, set up as a transparent alternative to its somewhat secretive namesake.
Professor Michie is one of several academics championing a new global collaboration called Bessi — behavioural, environmental, social and systems interventions — that pushes this neglected science into the spotlight. It aims to do for “non-pharmaceutical interventions” what the Recovery and Solidarity trials did for coronavirus medicines: build a framework for gathering reliable evidence so that both policymakers and the public can be confident about which measures work, and how well, in a pandemic.
Among the topics targeted for study are individual behaviours, such as social-distancing, washing hands and wearing masks; systems like test-trace-isolate; and environmental factors, including indoor ventilation. Lockdowns or “circuit breakers” come under the “systems” heading: Prof Michie stresses the complexity of judging what counts as success here, given that they cut transmission but also carry considerable economic, health and social costs.
Paul Glasziou, a fellow Bessi founder and professor of evidence-based practice at Bond University in Queensland, Australia, recently pointed out there are more than 1,500 registered or reported clinical trials on drugs to treat Covid-19 but just eight for other types of interventions. “It’s really staggering,” he told the British Medical Journal in a podcast this month, of the disparity. “We need to fix the problem now, otherwise we’re going to waste the rest of the pandemic guessing our way through it.”
Masks make a fascinating case study in the loose way that evidence accretes around non-drug measures. With public health experts initially reluctant to recommend N95 respirators because of potential shortages, attention turned to simple face coverings.
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Overloaded epidemiologists did not have time to run clinical trials to see if they worked. Instead, mass gatherings, such as the Black Lives Matter protests and political rallies, as well as the staggered introduction of masks in Germany, became living observational studies, shading in evidence gaps just enough to suggest effectiveness but insufficiently to disarm critics. That has been a consistent theme in pandemic management: a thin evidence base for an intervention quickly becomes a contested space in which misinformation competes with emerging public health advice.
Behavioural insights are key to reining in transmission. For example, a functional test-trace-and-isolate system works best if the infected stay out of circulation. In the UK, just 18 per cent of people who develop symptoms of Covid-19 self-isolate. Surveys suggest that, despite wanting to comply, many, particularly those on low incomes, break the rules to go to work or perform caring duties. Finding out what prompts people to breach isolation can point to ways of increasing compliance, such as providing financial and care support.
The 10pm curfew for pubs and restaurants in England, Wales and Scotland also shows that common sense can be a perilous substitute for evidence. Given that some transmission has been traced to hospitality venues, ministers hoped earlier closing times would lead to less drinking and more careful distancing.
In London, it prompted revellers to tumble into the streets and on to public transport at exactly the same time, sometimes to carry on carousing in private homes. “It’s mad,” Prof Michie says of the curfew, adding that behavioural scientists were not consulted. “People are used to finishing their evening at 11pm or 11.30pm. They’re not going to go bed at 10pm with a cup of cocoa.”
Just as we would prefer our doctors not to guess which coronavirus medicine to dispense, this second wave in the pandemic offers an opportunity to gather evidence about which behavioural, environmental and social interventions offer the most gain for the least pain. If we must live in a “new normal”, we should at least think methodically about how to build it.
The writer is a science commentator
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