There is a haze surrounding COVID-19 in the media at a time when the public looks to us to help them understand what scientists are saying. The imperative is that journalists need to rapidly cultivate greater clarity about:
- How science works
- How scientists can differ in translating certainties/uncertainties in the evolving science of COVID 19 into public health guidance
- The language journalists can use to narrow the disconnect between uncertainty in science and uncertainty in popular understanding.
1. How science actually works
The quest to understand the nature of things propels science. Knowledge not being finite, its pursuit is limitless. Science, therefore, is a never-ending process that builds on itself. Science is cautious, exploratory, tentative.
With new questions, new technologies, and new avenues of exploration, it is always possible to develop more precise explanations for what happens around us. The only thing science is certain about is uncertainty.
Contrast this with the popular notion of science as perhaps the only thing people can be certain about. Consider popular statements such as “we need scientific proof” or “that’s just an opinion, not science.” This popular perception of science is derived from ‘settled science,’ the science, for instance, that tells us that a molecule of water consists of two atoms of Hydrogen and an atom of Oxygen.
Establishing the facts takes time and that’s typical of the deliberate pace at which science moves. Centuries passed before scientists established beyond doubt that the earth was round, not flat, or that a certain bacterium caused the disease we know as Tuberculosis.
But people may ask, isn’t science moving much faster these days? It took science a far lesser time – a few years – to settle beyond doubt that a certain Human Immunodeficiency Virus led to what we know as AIDS.
It was simply a matter of months before a certain coronavirus was discovered to cause SARS and it took scientists just a few weeks to identify the germ causing the current pandemic to be SARS CoV2.
What this means is simply that the methods scientists use to identify which germ causes which disease – a very narrow domain within the field of medical science – is grounded in certainty. But that’s not even a fraction of what science does.
Assessing risks of infection or disease, evaluating the efficacy of a drug or a preventive measure in preventing the spread of infections, studying the impact of behavior change interventions to influence the social determinants of disease or stigma… the list is endless and each research question demands its own rigorous methods of investigation, in order to minimize the ambiguity of the eventual results.
Science tries it’s best not to jump to conclusions. That’s why how part of a piece of research – the methods section – is among the most scrutinized in the peer-review process. (And unfortunately, a less scrutinized section by media persons)
A scientist declares her level of confidence in the findings of her study, based on the methods she deployed. By declaring the limitations of her study, one can weigh the quality of gravity of the evidence in the study better.
Uncertainty in science is no grey area but comprises specific and certain methods and measurements that capture a range or margin of error in research findings. Scientists declare these methods and measurements to communicate the level of confidence they have in their findings.
Increasingly, therefore, the phrase certainty of the evidence is increasingly replacing the phrase quality of the evidence, as being a more precise expression of how confident researchers feel about their findings. Researchers assess the certainty of their evidence and declare it, to enable the readers to decide exactly how reliable the results of their study are.
Since the pandemic began, an enormous number of studies about COVID 19 have been published, among them several whose methods and findings do not stand up to scientific scrutiny. https://www.cidrap.umn.edu/news-perspective/2020/06/controversy-covid-19-mask-study-spotlights-messiness-science-during Journalists need to be able to tell good studies from bad, including those whose findings are fabricated or falsified.
Journalists need to invest more time in:
a) understanding which types of studies can best inform public health guidance and which ones are less able to do so
b) how the evidence from studies is ranked on the basis of certainty — to enable scientists to nuance their recommendations and
c) how scientists express that degree of certainty.
To come up with public health guidance based on evidence, researchers select all available comparable studies of the same topic and weed out those that don’t match up to quality standards to arrive at a smaller number that is methodologically robust. They systematically review the findings from these studies and grade their quality, based on how certain or not, they judge each finding to be. They then make public health recommendations on the basis of that quality. An increasingly popular tool in the health sciences that transparently ranks the quality of evidence to inform public health recommendations is GRADE (Grading of Recommendations, Assessment, Development, and Evaluations). The WHO follows GRADE to come up with recommendations.
GRADE Certainty Ratings and what they mean in plain language
|High||The authors have a lot of confidence that the true effect is similar to the estimated/declared effect|
|Moderate||The authors believe that the true effect is probably close to the estimated effect|
|Low||The true effect might be markedly different from the estimated effect|
|Very low||The true effect is probably markedly different from the estimated effect|
The certainty of the evidence is also ranked according to additional features in the studies. For example, the evidence gets rated down for risk of bias or imprecision, etc. and gets rated up for the large size of the effect, and so on. Researchers also submit that there is a degree of subjectivity in the ratings.
When questions arise faster than science can answer them, in the face of mounting urgency for guidance what do researchers do? They declare that their guidance may change in the light of more evidence.
Most of the WHO’s recommendations come with that transparent caveat. Cochrane, a website that shares systematic reviews to promote evidence-based medicine, has introduced a Rapid Review process for COVID 19 studies to “answer the time-sensitive needs of health decision-makers as fast as possible, while simultaneously ensuring that the scientific imperative of methodological rigor is satisfied .“
2. How scientists can differ in translating certainties/uncertainties in the evolving science of COVID 19 into public health guidance.
Since the pandemic began – around the end of 2019, researchers have established that the coronavirus SARS CoV 2 is the causative agent of COVID19. Public health guidance is evolving as the availability and certainty of evidence becomes greater and is continuing to shape answers to questions such as how far apart should people stay from each other to prevent giving each other the virus? Does inhaling steam help ward off infection? Will we get a vaccine by August 15? How much longer will the pandemic continue?
The task of the journalists in interpreting these uncertainties becomes more complex as institutions responsible for issuing public health guidance make their own recommendations guided not only GRADE, but by empirical evidence, resource-sensitive considerations, and as some say common sense.
For instance, WHO’s advice on the use of masks in the context of COVID-19 published on April 6, stated that current information suggested that the two main routes of transmission of the COVID-19 virus were respiratory droplets and contact. The droplets of respiratory secretions from a person infected with SARS CoV2 contain the virus and are expelled while coughing or sneezing. A person within 1 meter of the infected person would be at risk of exposure. The virus could also remain infective within the droplets that land on surfaces making the immediate environment of an infected individual a source of contact transmission.
The WHO mentioned that previous studies showed that the use of a medical mask by people infected with coronaviruses could prevent the spread of infectious droplets from them to someone else and prevent potential contamination of the environment by these droplets. But they added that there was “limited evidence that wearing a medical mask by healthy individuals in the households or among contacts of a sick patient, or among attendees of mass gatherings may be beneficial as a preventive measure and that …. there is currently no evidence that wearing a mask (whether medical or other types) by healthy persons in the wider community setting, including universal community masking, can prevent them from infection with respiratory viruses, including COVID-19.”
Some factors that caused the subtle shift from limited to no evidence and weighed in on this recommendation were the critical risks associated with mask-wearing, that would actually increase not decrease the risk of infection, such as touching the face more often to adjust the mask, after touching potentially contaminated surfaces. The advisory was clearly titled “interim guidance” but these details were largely lost on the media.
The WHO guidance notwithstanding, many countries implemented mask-wearing in public settings. In order to get better evidence on the protection afforded by masks, WHO funded a systematic review of more recent studies. On June 1st, the systematic review and GRADE of evidence from 172 studies were published in The Lancet and https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31142-9/fulltext, indicated that wearing masks in public, could afford protection against infection by coronaviruses responsible for the COVID19 pandemic and the previous epidemics of Severe Acute Respiratory Syndrome (SARS) and the Middle Eastern Respiratory Syndrome (MERS).
The researchers add this caveat: “Robust randomized trials are needed to better inform the evidence for these interventions, but this systematic appraisal of current best available evidence might inform interim guidance.”
Studies that have looked at how journalists report science to observe that the caveats mentioned by the researchers rarely if ever, find a place in news reports.
See this mainstream report on the subject.
Airborne or aerosol transmission?
The Lancet article of June 1 states that “It has not been solved if SARS-CoV-2 might spread through aerosols from respiratory droplets; so far, air sampling has found virus RNA in some studies but not in others.” The study quoted
“ However, finding RNA virus is not necessarily indicative of replication-competent and infection-competent (viable) viruses that could be transmissible. The distance from a patient that the virus is infective, and the optimum person-to-person physical distance, is uncertain.”
However, Times Now (India) July 6th, carries a sensational headline “Every breath you take: How worried should you be about airborne COVID-19 transmission?” The article says that “The World Health Organisation is underplaying the airborne transmission potential of COVID-19, according to 239 scientists from across 32 countries. The scientists have penned an open letter, set to be published later this week, calling for the world’s foremost medical body to revise its recommendations and acknowledge that the virus may spread via aerosols, particles smaller than respiratory droplets.”
The New York Times piece on the same subject is a bit more restrained and provides some discussion on factors that along with the certainty of evidence drives scientists to make their recommendations.
The New York Times article says: “ But the infection prevention and control committee, in particular, experts said, is bound by a rigid and overly medicalized view of scientific evidence, is slow and risk-averse in updating its guidance and allows a few conservative voices to shout down dissent……Even its staunchest supporters said the committee should diversify its expertise and relax its criteria for proof, especially in a fast-moving outbreak.
Many experts said the WHO should embrace what some called a “precautionary principle” and others called “needs and values” — the idea that even without definitive evidence, the agency should assume the worst of the virus, apply common sense and recommend the best protection possible.
“There is no incontrovertible proof that SARS-CoV-2 travels or is transmitted significantly by aerosols, but there is absolutely no evidence that it’s not,” said Dr. Trish Greenhalgh, a primary care doctor at the University of Oxford in Britain.
“So at the moment we have to make a decision in the face of uncertainty, and my goodness, it’s going to be a disastrous decision if we get it wrong,” she said. “So why not just mask up for a few weeks, just in case?”
After all, the W.H.O. seems willing to accept without much evidence the idea that the virus may be transmitted from surfaces, she and other researchers noted, even as other health agencies have stepped back emphasizing this route.
“I agree that fomite transmission is not directly demonstrated for this virus,” Dr. Allegranzi, the W.H.O.’s technical lead on infection control, said, referring to objects that may be infectious. “But it is well known that other coronaviruses and respiratory viruses are transmitted, and demonstrated to be transmitted, by contact with fomite.”
The agency also must consider the needs of all its member nations, including those with limited resources, and make sure its recommendations are tempered by “availability, feasibility, compliance, resource implications,” she said.
Systematic reviews take time. Given the urgency for public health guidance amidst a fast-paced pandemic that is taking lives, scientists are currently fast-tracking the process into rapid reviews to swiftly assess the certainty of the evidence and come up with recommendations.
Researchers balance the loss of lives against temporary compromises in the time-consuming rigor that science demands and uphold ethics by openly declaring the varying certainties of the evidence available, each time they make a recommendation.
When journalists inform the public about the transparent ways in which evidence is assessed and declared, it can make a critical improvement to the way the public understands why the change in public health guidance around COVID 19 is actually science trying its best to remain true to itself.
More often than not, each change in guidance is a step forward. Given time, science will correct itself, meantime, journalists need to help the public develop a mature understanding of the processes, inspiring informed debate rather than rush to provide definitive answers to questions when the answers are still elusive.
Journalism around COVID 19 is an opportunity for us to set higher standards in the way we report science and crucial opening for us to raise public comprehension about how to read science news.
3. What language can journalists use to bridge the disconnect between uncertainty in science and uncertainty in popular understanding?
The column on the right lists some expressions journalists commonly used to portray uncertainties in science, whilst writing for the general public. Most of them carry the negative connotation that uncertainty in science is a shortcoming, when in fact, how well science recognizes, measures, and discloses uncertainty is an indicator of its strength. Journalists need to make that fundamental distinction clear to their audiences to promote better awareness about what science actually tries to tell us.
Portraying the transparently declared uncertainties in studies as confusion, lowers the credibility of honest research, leaving the public with little choices as to who to believe, particularly in the COVID 19 context. Journalists also need to nuance optimism and pessimism when reporting on ‘discoveries’/’ cures’ /and the results of clinical trials.
With some effort, journalists can ensure that nothing is lost in translating into simple language, the various grades of the certainty of evidence to describe findings from systematic reviews. Here is a table of different combinations of the size of the effect and the certainty of evidence and suggested language for journalists to convey what they mean to the public.