Luke Skywalker and Darth Vader. Rocky Balboa and Apollo Creed. Thor and Loki. No protagonist is complete without a nemesis. The nemesis allows for conflict, and therefore a more compelling story. A less intuitive context however in which to look for a nemesis is public health. And yet, in an EHFG 2020 session on informed decision-making in times of limited evidence, Trish Greenhalgh of the University of Oxford posed the intriguing question:
Could COVID-19 be evidence-based medicine’s nemesis?
Pandemics are complex, and feature both intrinsic uncertainty and paradox. Therefore, evidence-based medicine might not be the most suitable approach to tackling them; the questions that a pandemic raises cannot always be captured in a PICO-format, and waiting for the results of a randomised controlled trial may simply take too long. Instead, it might be wise to adopt a more pragmatic way of responding, one which leaves room for policy development based on observational evidence and real-world evaluations of policy actions.
The science and art of giving good policy advice during this pandemic is hard. Not only is evidence lacking, but socio-economic, political and cultural realities also need to be taken into account. And decisions have to be made fast, as delaying interventions and precautionary measures may cost lives. Helpful advice to advisors centres around three concepts: trust, transparency and communication.
When evidence is limited, trust is everything. Precisely in a crisis, when decisions must be made quickly, openness about scientific knowledge – and knowledge gaps – is crucial. Experiences, both positive and negative, need to be shared.
The only way to get trust is transparency. Don’t be afraid to say what you know – and to stick to it – but equally or even more important is to not be afraid to say what you don’t know. Admitting you were wrong is nothing to be ashamed of.
Accordingly, clear communication is vital. When polled, the majority of the participants in the session agreed that for the sake of transparency, no information should be withheld from the public. However, there was no consensus on who should be in charge of communication: Politicians? Advisors? Scientists? Regardless of who is in charge, it is important to consult communication specialists on how to convey knowledge to the public, in order to inform while gaining and maintaining trust.
But back to the matter of the nemesis. Should we abandon evidence-based medicine when it comes to COVID-19? No. Darth Vader redeems himself (let us forget for a moment that he does not survive his redemption). Rocky and Apollo become friends. Thor and Loki form an unlikely alliance. And a pragmatic pandemic response does not have to replace evidence-based medicine, both can go hand in hand. We can act on the knowledge we already have – being transparent about its flaws – while also continuing to generate more and better evidence. Like this, we can defeat that great public health nemesis COVID-19.
 PICO framework: Population – Intervention – Comparison – Outcome