Trust in Science, Public Health, and Politics: Lessons from COVID-19

Shortly after COVID-19 was recognized as a worldwide catastrophe, my much better half asked me how long I thought this would this last.  Based on my then 45 years of biomedical research experience I replied, “Three years.”  I was wrong.  That was more than five years ago, when the refrigerated makeshift morgues were parked on the streets of New York City.  While the pandemic has slackened considerably, SARS-CoV-2 is still with us and new variants continue to emerge, with the latest causing “razor blade throat.”  The scariest development would be a new SARS-CoV-2 that is as lethal as MERS-CoV.  MERS had a fatality rate of 35% but it was not very transmissible and cases still occur.

As a comparison, smallpox had a fatality rate of 30%.  Those of us of a certain age received the smallpox shot in elementary school and this continued into the 1970s.  I remember getting the Sabin polio vaccine about the same time with my family and hundreds of others lined up in my elementary school to eat a sugar cube with a blue or purple spot on it.  The medicine went down very well.  And it worked.  Polio has been eliminated in the United States, and elimination of polio worldwide can be accomplished if vaccination is extended to everyone.  The last naturally acquired case of smallpox occurred in 1977 and the disease was declared eradicated in 1980.  From the WHO on 8 May 1980:

Having considered the development and results of the global program on smallpox eradication initiated by WHO in 1958 and intensified since 1967…the world and its peoples have won freedom from smallpox, which was a most devastating disease sweeping in epidemic form through many countries since earliest time, leaving death, blindness and disfigurement in its wake and which only a decade ago was rampant in Africa, Asia and South America.

I remember this well.  Biomedical science and public health were celebrated, as they should have been because this was truly an astounding accomplishment.  But expectations that infectious disease would soon be a thing of the past were premature.  The first clinical report of AIDS appeared on 5 June 1981.  Forty years later COVID-19 appeared.  AIDS is now a manageable chronic condition for the majority of those infected with HIV in the Global North who are treated with HAART.  Effective vaccines against HIV remain on the scientific horizon, perhaps beyond it.  In the absence of HIV vaccines, we have PrEP, but as with many effective interventions its availability is restricted to those who can pay.  Business is business, but this Neoliberal dream is no way to do public health.

Vaccines for COVID-19 are famously available.  The stimulus for this essay was a question from a conservative friend who asked me why CDC decided to change the definition of vaccine after the pandemic began.  I had read something of this but had not really paid attention to the issue.  Still, it is a good question, and I began digging.  I did not expect to find much, but I did find something I should have known.

As with most things COVID, this item appeared first in a political context through the actions of Representative Thomas Massie of Kentucky:

Massie shared an image containing three definitions for the word “vaccination” with his 326,000 followers on Sunday. One was labeled “pre-2015” and described vaccination as: “Injection of a killed or weakened infectious organism in order to prevent disease.” Another was dated 2015-2021 and said: “The act of introducing a vaccine into the body to produce immunity to a specific disease.” The third was from September 2021, calling vaccination: “The act of introducing a vaccine into the body to produce protection from a specific disease.”

The basic facts can also be found here and here and in many other contemporary articles.  They all agree with the following changes in the official definition of vaccine:

• Pre-2015: Injection of a killed or weakened infectious organism in order to prevent disease.
• 2015-2021: The act of introducing a vaccine into the body to produce immunity to a specific disease.
• September 2021: The act of introducing a vaccine into the body to produce protection from a specific disease.

The King5.com link (Seattle NBC affiliate) states it is true that:

CDC changed its definition of vaccine from “a product that stimulates a person’s immune system to produce immunity to a specific disease, protecting the person from that disease” to “a preparation that is used to stimulate the body’s immune response against diseases.”

Several experts in infectious disease responded that the definition of vaccine has changed at the margin, but these have not “impacted the overall definition…and that the previous definition could be interpreted to mean that vaccines were 100% effective, which has never been the case for any vaccine, so the current definition is more transparent.”  The changes were said to be semantic and clarifying instead of substantial.

This is where my colleagues – these scientific experts – miss the point completely.  No one has ever believed that vaccines are 100% effective, going back to the ancient practice of variolation that induced immunity to smallpox.  Variolation (covered here [1] in our discussion of Simon Schama’s Foreign Bodies: Pandemics, Vaccines and the Health of Nations) would have produced an antibody response in every person scarified with knives and needles dipped into exudate from active smallpox lesions, but in some cases the vaccinated subsequently came down with smallpox anyway.  Their immune response did not provide protection – immunity – to the disease.  This is not uncommon, both in the clinic and in the laboratory, where an antibody response can be measured but it is not strong enough to prevent disease or for the antibodies to be used in research.

It did occur to me that my flat statement that no one has ever believed that vaccines are 100% effective would be disputed by the experts.  This was addressed during the early years of the COVID-19 pandemic in Vaccination terminology: A revised glossary of key terms including lay person’s definitions (paywall).  This paper is an academic exercise with utility summarized in these Layperson’s Definitions from their extensive Table 2 of 44 terms associated with vaccinology, including:

• Effectiveness: A measure to describe how good a vaccine is at preventing a disease when distributed for use in the general public.
• Efficacy: A measure to describe how good a vaccine is at preventing a disease under test conditions, for example a clinical trial.
• Herd immunity: This happens when enough people are vaccinated or have immunity from a disease, thereby reducing the chances of someone who is not vaccinated from becoming infected.
• Immunization: The process where an individual becomes protected against a disease caused by a bacterium/virus.
• Immunity: The ability to fight off an infection caused by a harmful bacterium/virus.
• Pandemic: A disease occurrence worldwide affecting a large number of people.
• Vaccine failure: This occurs when the person develops the disease, even though they have been already vaccinated for it.
• Waning: A decline or weakened immunity over time.

That the public understands these terms should be a surprise to no one.  Virtually every parent knows that vaccination will not always work.  Breakthrough infections happen, but rarely with vaccines that are effective.  Virtually every parent also knows that there is an infinitesimal chance that a vaccine might have deleterious consequences for any given child but that not getting vaccinated against disease is a much bigger risk for their children and society – or they previously  “knew,” and therein lies much of our current distemper regarding public health.

To summarize: The biomedical, public health, and political response to COVID-19 was to go virtually all-in on two novel vaccines, but these prevented neither the disease nor its transmission.  It has been shown, after the fact, that vaccination reduced mortality and morbidity and saved an indeterminate number of lives.  It will be impossible to determine how many have died of COVID-19, but according to The Lancet, as many as 18,000,000 deaths were connected to the pandemic during its first two years.

These facts are inconsistent with the layperson’s conception of an effective vaccine.  And for whatever reason, the scientific and medical communities cannot seem to understand the quite natural reaction to promises not kept.  This has led to an increasing level of mistrust of the scientific and medical establishments among laypersons, who were told that if you get the vaccine you will not get COVID-19.  This was manifestly not true.  And at the same time CDC changed the definition of vaccine so that it was at odds with the public conception of and experience with vaccines. [2]  You do not have to be a conspiracy theorist to notice the coincidence.

Thus, a major casualty of our response to COVID-19 has been trust in biomedical science, clinical medicine, and public health.  It follows that this has given current political leadership an excuse to attack the establishments of each.  It did not have to be this way.  What is to be done?

The first thing to be done is to revive the public’s trust.  This has been covered in an interesting article: Rethinking Trust and Public Health Compliance: Introducing a Trust Continuum for Policy and Practice (open access).  This contribution is academic but commonsensical and useful, with one group of academics engaging with another group in a serious manner.  From the Abstract, lightly edited:

Trust in government has emerged as one of the strongest predictors of national performance (mostly undefined here) in fighting COVID-19.  This commentary aims to take stock of the vast literature on trust and compliance with public health measures that has emerged during the pandemic to synthesize policy-relevant recommendations about: 1) How to conceptualize trust; 2) Whether trust is always deserved; and 3) How governments can earn appropriate levels of trust…we develop a framework that conceptualizes trust as falling along a continuum ranging from extreme distrust to blind trust with the ideal point- “informed” or “basic” trust-falling in the mid-point of the continuum.  We illustrate the continuum with examples and provide recommendations regarding how governments can build more nuanced disease responses that account for individuals and sub-groups at different rungs on the continuum while (re)building trust.  We conclude that trust-building is a long-term project that must continue in non-crisis times.

This conceptualization of trust is the important point.  Whether trust is deserved depends on the behavior of those who believe they should be trusted.  And the only mechanism by which any government can earn trust is for it to be honest.  I.F. Stone comes to mind here, though.  Ditto for scientists, who during the pandemic forfeited trust by not emphasizing that the Operation Warp Speed vaccines were an experiment.  As the authors rightly point out, trust is not a binary concept.  Rather it exists on a continuum schematized but full of good sense in their Exhibit 1:

We clearly should exist as a polity and society somewhere in the central rows.  But we are polarized at either end of the current political divide, with the notional Right and Left [3] sneering at one another through a darkened glass, each filled with ill intent exacerbated by their overconfident faith in their tribal elites.  Coercion and corrosion are characteristics at both ends of their spectrum, which is not nearly as broad as they believe.

As noted in Rethinking Trust and Public Health Compliance, trust can and should be viewed as a “virtuous circle in which greater trust leads to better governance and citizens who are more satisfied with the government’s performance, thereby generating increased trust.”  Neoliberalism along with the current reprise of the Gilded Age militates against the possibility of this virtuous circle.  Biomedical science has followed the same neoliberal path, as described in this remarkable passage that describes our past five years nearly perfectly:

Implicit in the focus on “trust,” however, is the notion that trust in actors and authority figures is deserved.  During the COVID-19 pandemic, public health leaders appeared shocked and dismayed that the public would resist efforts aimed at protecting them from an emerging viral threat, perhaps taking compliance to be logical, science-based, or not requiring explanation.  If only people trusted their political leaders, scientists, or doctors, millions of lives could have been saved.

Quite so.  But all scientists in good standing should have cringed every time a leader of the scientific establishment said, “Trust the science” and its corollary “I represent science” during the early phase of COVID-19.  Instead, most of us nodded in assent.  No one should accept an argument from authority from anyone.  Legitimate scientists who asked questions such as “Whose science and for what purpose?” were ignored, or worse.  As it happened, vaccines that were produced under an Emergency Use Authorization did not work as the people have come to rightfully expect.  The imperative for Big Pharma to be first with the latest technology (which was not experimental) and make a lot of money in the process won out over approaches that would have worked in the emergency, and did work until countries such as China and New Zealand fell into line with the rest of the world.

When I was asked how long I thought the pandemic would last – three years – I expected the scientific establishment to get to work as they had from the very beginning of the HIV/AIDS epidemic.  It took more than ten years for HAART to become widely available, but the spread of HIV was contained rapidly among those who followed authoritative guidelines that were initially resisted by some in the community and in the establishment.  There was every reason to believe that given the advances in modern molecular biology and virology in the forty years (at least four or five generations as progress in biomedical science is reckoned) between AIDS and COVID-19, a concentrated effort would lead to successful management of the pandemic, if not a cure of or treatment for the disease.  In any case cure/treatment would come later, after the world’s public health establishment figured out how to control the spread of SARS-CoV-2.

We have discussed this before, and there is no need to revisit the details.  But one fact about coronaviruses has bothered me from the early days of the pandemic.  When talk of the mRNA vaccines for COVID-19 had reached critical mass in 2020, my colleague and friend who died of complications of long COVID last November told me in no uncertain terms that vaccines would never be the solution to the pandemic.  I asked her why.  She was a veterinarian with whom I had worked for fifteen years.  She was right about everything and this time it was the nature of coronavirus pathobiology.  According to the scheme from Exhibit 1 above, I gave her my complete informed trust.  As she explained, avian biologists have known of deadly infectious coronaviruses for more than ninety (90!) years.  For nearly as long, veterinarians and poultry scientists have known that vaccines against coronaviruses have a short half-life.  They simply do not work very well for very long.  Therefore, infection control is essential, especially for chickens raised in CAFOs (another matter altogether).

So, why was it assumed by the biomedical establishment that human coronaviruses would be any different?  I have no answer other than ignorance suffused with hubris.  This establishment seems to have forgotten what is true for one animal and one type of virus is likely to be true for another closely related animal and similar virus (the first retroviral human oncogene was discovered in research on chicken cancer more than one hundred years ago).  A review recently published in the out-of-the-way but very good journal Avian Pathology (1972) covers the relevant pathobiology of vertebrate coronaviruses through the lens of the avian biology: Lessons learnt on infectious bronchitis virus lineage GI-23 (paywall).  From the Abstract:

Infectious bronchitis virus (IBV) is the first coronavirus discovered in the world in the early 1930s and despite decades of extensive immunoprophylaxis efforts, it remains a major health concern to poultry producers worldwide. Rapid evolution due to large poultry population sizes coupled with high mutation and recombination events and the reliance of the antiviral immune response on specific antibodies against the epitopes of the S1 glycoprotein, render the control of IBV extremely challenging. The numerous and rapidly evolving genetic and antigenic IBV types are currently classified based on the whole S1 gene sequence, into 36 lineages clustered in eight genotypes…The hallmarks of IBV Variant 2-like strain infections are high virulence and remarkable nephrotropism and nephropathogenicity; however, the molecular mechanisms of these traits remain to be elucidated.

Let us modify/paraphrase this as follows:

Despite decades of extensive immunoprophylaxis efforts, this human coronavirus remains a major health concern.  Rapid evolution due to large human population sizes coupled with high mutation and recombination events and the reliance of the antiviral immune response on specific antibodies against the epitopes of the S1 glycoprotein, render the control of this coronavirus extremely challenging.

This settled knowledge should have been in the forefront of the response to COVID-19.  As an aside, so much for the herd immunity understood by laypersons and championed by the current Director of the National Institutes of Health and a member of the completely new Advisory Committee on Immunization Practices (ACIP).  Without durable immunity to the pathogen, it is difficult to imagine how accelerating herd immunity through mass infection of those for whom COVID-19 was merely an inconvenience (untrue as it turns out) would work.

Although Avian Pathology will not be high on the list of journals read by most physicians and biomedical scientists, a quick search of PubMed using “coronavirus” as the query returns much of the early IBV literature, but not the original report from 1931: “An apparently new respiratory disease of baby chicks” in the Journal of the American Veterinary Medical Association, 78: 413-422.  Nevertheless, this paper is not difficult to find.  The Summary is visible at the link:

The very sudden and almost precipitous occurrence of an acute and quite fatal respiratory disease among baby chicks furnished the occasion for a brief though special study of the condition, the results of which supply the information given in this discussion.  We have refrained from specifically naming the disease under discussion. It materially differs, in one phase or another, from any of the established respiratory diseases of poultry.  On the other hand, it has some characteristics of catarrhal roup, laryngotracheitis, and perhaps more things in common with infectious bronchitis of adult fowls.  Therefore, if we were pressed for a definite name we would be inclined to entitle it: infectious bronchitis of baby chicks.

There is a lot about SARS-CoV-2 that we still do not understand, including its origin as spillover from a zoonotic source or as an escape from the virology laboratory in Wuhan.  The Proximal Origin of SARS-CoV-2 was published in March 2020 in Nature Medicine.  This letter has an interesting history, as recounted by Ryan Grim (informed trust again).  I remain agnostic about the origin of SARS-CoV-2, but nearly fifty years in the laboratory makes me believe that it could have escaped from one.  This is not to say the virus was manufactured in the laboratory!  On the other hand, scientists have known at least since the early 1950s that durable immunity to coronaviruses is “problematic” at best.  Therefore, the most logical approach to controlling a pathogenic human coronavirus is anything but a vaccine, wherever the virus originated.

So, where do we go from here regarding “trust”?  For scientists, the road will be long.  We should remember that much of the current distrust is our doing over the past forty years, at least.  But “science for the sake of useful knowledge” got us to the point where we understand how life works and much of what goes wrong when it doesn’t.  We must return to this work-in-progress view of disinterested science during a reconstruction that I will not live to see.

For our political predicament, we should remember that a week is a long time in politics.  But until the decision in Citizens United is rendered null and void, I see little hope.  Money is not speech.  And contrary to a fundamental tenet of Neoliberalism, consumer is not the same as citizen.  Still, the American political world is full of surprises on occasion when it is not just one thing after another courtesy of the Uniparty.

Notes

In memory of MAK, DVM.

[1] The origin of vaccination lies in variolation, which is a simple procedure in which pus or encrusted “pocks” from a smallpox lesion are introduced into the lightly incised skin of the patient after which the wound is bandaged.  This usually results in a mild form of the disease (fever and a relative few pustules localized near the site of variolation) after which the patient is generally immune to smallpox.

[2] The public knows that a vaccine eradicated smallpox and current vaccines prevent, with necessary caveats well understood by the people, the following serious illnesses: polio, measles, mumps, rubella, whooping cough, tetanus, bacterial meningitis, cervical and other cancers caused by human papilloma virus (HPV), rotavirus infection, respiratory syncytial virus infection, chicken pox and recurrent shingles in adults.  I would rather have not had five of the illnesses on this list.  Periodic vaccine denialism that culminated in the MMR-autism hoax has been covered well and is not considered here.  That the current leadership of the US Department of Health and Services is reviving vaccine denialism through the several means at its disposal is a fact.  This will continue until it is stopped, however that can be done.  However, the damage to scientific research and public health is likely to endure.

[3] “Notional” is the keyword in the distinction here between Right and Left.  Precise definitions of each are not possible here.  Suffice it to say there is often nothing conservative behind the exertions of the current Right, and at the same time there is nothing socialist, much less social democratic, behind the bleatings of the current performative, self-reverential Left.  Left Is Not Woke and never will be.  A different, more expansive version is We Have Never Been Woke: The Cultural Contradictions of a New Elite.  And contrary to the reigning Uniparty trope, aside from the 1920 Presidential campaign of Eugene V. Debs, who received 3.4% of the vote while serving a sentence in the Atlanta federal prison for seditious speeches against President Woodrow Wilson and The Great War, there has never existed in the United States something called a serious “radical left” that hides in the shadows of the hive mind of the Uniparty.