Fighting an epidemic of misinformation

The importance of science and learning in dealing with coronavirus

An artistic illustration of a coronavirus

Ever since the modern science of epidemiology emerged in the 19th century, misinformation has never been far behind. John Snow, one of the founding fathers of the field, accurately mapped various cholera outbreaks in London based on his theory of germ transmission through contaminated water pumps. Yet despite accumulating evidence to support his disease modelling, which was published and distributed in pamphlets, it was never accepted until decades after his death – with the ‘miasmists’ instead holding sway that foul air was the culprit. 

An old map of cholera outbreaks in London circa 1854

Original map made by John Snow in 1854. Cholera cases are highlighted in black. (Image credit: John Snow / Public domain)

Original map made by John Snow in 1854. Cholera cases are highlighted in black. (Image credit: John Snow / Public domain)

Over 150 years on, we’re in the midst of a pandemic of a novel coronavirus, where misinformation and misrepresentation is perhaps more prevalent than it has ever been. This ranges from the completely outlandish and utterly unfounded, to well-meaning assertions or overclaiming on matters of genuine and ongoing contention – and everything in-between.

Sometimes a deliberate attempt is made to side-track or skew the process of learning.
Dr David Nabarro, WHO Special Envoy on Covid-19

An example of the former is the false theory that the construction of 5G infrastructure is in any way linked to the spread of coronavirus or worsening of the resulting COVID-19 disease – which has absolutely no evidence to support it. Meanwhile, questions over the benefit of face masks for members of the public, as well as the related issue of the distance that the airborne virus can transmit from, rumbles on. Even more problematic to navigate are assertions about the efficacy of certain potential treatments, such as the anti-malarial chloroquine and its related compound, hydroxychloroquine. Reputable institutions are still conducting proper trials of these and other candidates, but to assert that they should have a central role in the pandemic at this stage is misrepresenting the facts – even if those assertions come from the President of the United States or the opinions of a single outspoken doctor.

Battling the infodemic

“With any outbreak and particularly with COVID-19, you’ve got ‘known unknowns’ and you’ve got ‘unknown unknowns’,” says Dr David Nabarro, who is Co-Director of Imperial’s Institute of Global Health Innovation and Special Envoy on COVID-19 to the World Health Organisation (WHO). “Sometimes information or guidance turns out to be not valid, despite good intentions. What you then do, on the basis of new information – the result of known unknowns and unknown unknowns becoming visible – is adapt quite sharply in order to continue trying to do good. Then there’s a different situation, where a deliberate attempt is made to side-track or skew the process of learning, which you could call disinformation. I think it’s important to make the distinction.” 

Dr David Nabarro sitting on a panel for the World Health Organisation

Dr David Nabarro (Image credit: UN Ebola Response)

Dr David Nabarro (Image credit: UN Ebola Response)

This underlines a key part of the problem – that the public is effectively presented with various sources of information, through different digital media platforms, sometimes from anonymous sources and other times from figures claiming to have some degree of authority or credibility. It can be difficult to discern fact from fiction. And most worryingly this happens with alarming regularity, and spurious claims can gain incredible traction with huge swathes of the public in matter of days, even hours.

The upshot is that evidence-based science is more important than ever. In the absence of a vaccine or validated antiviral treatments, information and public health measures are the only tools we have at our disposal to stop transmission of the virus, prevent deaths and keep our health systems running.

Yet the methodical, considered approach which underpins robust research can be difficult to fully enact at a time like this, when the situation on the ground is rapidly changing and data are constantly being updated.

“Science is about having a hypothesis, putting it to the test and if it’s found not to be valid in light of experience, then you revise your hypothesis,” Dr Nabarro says. “That is the nature of discoveries, the scientific process. We never prove anything, we’re always focusing on finding things that don’t fit to our hypothesis or our models and adapting our models. That is the process of learning, which had been going on super rapidly in this outbreak.”

Fortunately, experience of previous fast-moving pandemics helps enormously.

Gearing up for Disease X

Droplets of pink and blue ink under the microscope

Imperial’s expertise in the field of disease and outbreak planning is genuinely world-leading. Researchers from the College have previously worked on outbreaks and pandemics, including SARS, bird flu, swine flu, MERS and Ebola.

Expertise is now chiefly delivered through the MRC Centre for Global Infectious Disease Analysis (MRC GIDA) and Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA), both based in the School of Public Health, but also various groups across the College.

The founding members of J-IDEA

J-IDEA launch (October 2019.) Left to right, back row to front row: Professor Timothy Hallett; Professor Edward Gregg; Professor Helen Ward; Professor Majid Ezzati; Professor Neil Ferguson; Fady Jameel; Hassan Jameel; Dr Katharina Hauck; Professor Alice Gast; Mohammed Jameel

J-IDEA launch (October 2019.) Left to right, back row to front row: Professor Timothy Hallett; Professor Edward Gregg; Professor Helen Ward; Professor Majid Ezzati; Professor Neil Ferguson; Fady Jameel; Hassan Jameel; Dr Katharina Hauck; Professor Alice Gast; Mohammed Jameel

In 2018, the WHO added a new item to its watchlist of threats, the ominously and portentously named ‘Disease X’ which ‘represents the knowledge that a serious international epidemic could be caused by a pathogen currently unknown to cause human disease’.

We don’t know when it will come, but we know it will come

Dr Nabarro has held leadership roles on outbreak and pandemic response and planning at both the United Nations and the WHO - dating back to 2005 as UN System Senior Coordinator for Avian and Human Influenza. He said of Disease X:

“Among a community of us, the inevitability of a major pandemic was definitely there. Our line was ‘we don’t know when it will come but we know it will come’. However, that perception was not necessarily felt by everybody.  Although a pandemic would always appear in analyses of global risks, there was a big uncertainly about its timing and its nature.  That has made it hard for governments to invest significantly in preparedness. There seems to have been a reduction in the expectation of a pandemic in some quarters in more recent years.  This is for a mix of reasons, but there has been a general sense that science would be able to get on top of any disease threats that might emerge.”

In December 2018, Imperial and the Coalition for Epidemic Preparedness Innovations formed a partnership to help protect against Disease X.

Then in late 2019, J-IDEA was setup to rapidly respond to emergencies such as pandemics, extreme climate events, and natural and humanitarian disasters. Just weeks after J-IDEA launched, reports of the first cases of a novel coronavirus emerged from Asia.

Modelling isn’t a case of just pressing a button, it requires quite a lot of scientific input
Professor Azra Ghani, Chair in Infectious Disease Epidemiology

Since January, the MRC-GIDA and J-IDEA teams have responded rapidly to the emerging coronavirus threat as the Imperial College COVID-19 Response Team – led by Professor Neil Ferguson alongside other world-leading professors including Christl Donnelly, Azra Ghani and Steven Riley, and later joined by Nick Grassly, Timothy Hallett and Katharina Hauck.

Professor Ghani, who is Chair in Infectious Disease Epidemiology, says: “It started when we saw the first cases emerging from China. Early on we were thinking about what information we could get and that actually required an awful lot of scraping data from various websites, including the Ministry of Health website in China and regional websites [in the country]. We got together a very large team to do that. Once cases started to emerge outside of China, we kept track of these, looking at when they flew from China and returned home, to get some sense of when they must have been infected and the time between being infected and developing symptoms.”

(Listen above to Professor Azra Ghani (Chair in infectious disease epidemiology at Imperial) giving insights into how mathematical models are providing vital insights into the nature of the outbreak.)

Epidemiological disease modelling is perhaps the central supporting pillar that allows public health officials to plan societal interventions. Imperial’s teams have developed and refined the computer code that underpins their epidemiological models over several years, through previous epidemics. That work has been published widely and validated externally. The models have also be used in pandemic planning and simulation scenarios. Nevertheless, when a pandemic of the magnitude of coronavirus hits, there is still considerable work to be done and new data to incorporate.

Professor Ghani explains: “Early on in the pandemic, there was an agreement amongst funders and academic journals, which led to a huge amount of information being put up on websites and it is challenging even for those of us in this field of academic research to search through these. The only way we can really approach it is to have a very large team of people, including PhD and postdoctoral researchers – performing data entry or reading a paper and summarising it, trying to give us the best possible sense of all the scientific information that’s out there.

“A lot of the tools are there, but what we find is that every little aspect of a new disease is slightly different: the data will have a slightly different format or the statistics that we need to use must be very slightly modified. So whilst we have a lot of this machinery ready to go, it isn’t really a case of just pressing a button, it requires quite a lot of scientific input.”

The Imperial team has published regular reports detailing the latest outputs from their epidemiological models. As one of the most prominent academic teams on the UK government’s Scientific Advisory Group for Emergencies (SAGE) and Science and Technology Committee, these have had a significant influence on policy.

The figure shows a line graph with the y axis representing critical care beds occupied per 100,000 of population and the x axis a timescale from March 2020 to March 2021.   Several bell-shaped curves with peaks are shown in different colours representing different suppression strategies (modelled to be implemented at the end of March) and a straight red line across the length of the graph showing critical care bed capacity.   A black line shows the unmitigated epidemic which very quickly rises, surpassing the critical care capacity from early April. The orange line shows a containment strategy incorporating case isolation, household quarantine and population-wide social distancing, and surpasses critical care capacity from May.   The green line shows a more stringent suppression strategy incorporating closure of schools and universities, case isolation and population-wide social distancing which remains below and within the red line of critical care bed capacity. A second series of curves shows what happens once interventions are relaxed from September 2020 as infections begin to rise, with critical care capacity exceeded on the orange and green lines (with the black line showing herd immunity developed).

Suppression strategy scenarios for GB showing ICU bed requirements. The black line shows the unmitigated epidemic. Green shows a suppression strategy incorporating closure of schools and universities, case isolation and population-wide social distancing beginning in late March 2020. The orange line shows a containment strategy incorporating case isolation, household quarantine and population-wide social distancing. The red line is the estimated surge ICU bed capacity in GB. The blue shading shows the 5-month period in which these interventions are assumed to remain in place. (B) shows the same data as in panel (A) but zoomed in on the lower levels of the graph. An equivalent figure for the US is shown in the Appendix. (Credit: Neil M Ferguson, Daniel Laydon, Gemma Nedjati-Gilani et al. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. Imperial College London (16-03-2020), doi: https://doi.org/10.25561/77482.)

Suppression strategy scenarios for GB showing ICU bed requirements. The black line shows the unmitigated epidemic. Green shows a suppression strategy incorporating closure of schools and universities, case isolation and population-wide social distancing beginning in late March 2020. The orange line shows a containment strategy incorporating case isolation, household quarantine and population-wide social distancing. The red line is the estimated surge ICU bed capacity in GB. The blue shading shows the 5-month period in which these interventions are assumed to remain in place. (B) shows the same data as in panel (A) but zoomed in on the lower levels of the graph. An equivalent figure for the US is shown in the Appendix. (Credit: Neil M Ferguson, Daniel Laydon, Gemma Nedjati-Gilani et al. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. Imperial College London (16-03-2020), doi: https://doi.org/10.25561/77482.)

A landmark report published on the 16 March detailed the latest results of the model, showing that extensive social distance and quarantine measures would be required to supress transmission, retain vital capacity in intensive care units and keep the number of fatalities to around 20,000. Without these strict measures the NHS would have been totally overwhelmed, with fatalities between 200,000 and 500,000, according to the models.

The team continues to publish reports as new data become available for analysis – attempting to strike a balance between the rigorous, methodical scientific method and the pressing public and government need for new information.

As well as publishing rapid response reports, the Imperial College COVID-19 Response Team has continued to work on deep analysis, publishing in peer-reviewed journals.

The incubation of misinformation during lockdown

Cells in motion under the microscope

With the implementation of lockdown in the UK and the full extent of the necessary social suppression measures being felt, this seemed to coincide with, and perhaps fuel, a new wave of misinformation. Around two weeks into lockdown, reports of attacks on 5G towers in the UK began to surface, spurred by some of those unfounded conspiracy theories.

Imperial’s models also came in for more scrutiny from the mainstream media, as well as the radical fringes. Some commentators sought to downplay the severity of the pandemic, portraying Imperial’s models as ‘doomsday scenarios’ and the resulting lockdown measures as unnecessary. Despite the fact that the models are in broad agreement with those used in other countries.

'5G' on the screen of a smartphone, and a coronavirus icon in the background

False theories about the virus abound, such as that the construction of 5G infrastructure is in any way linked to the spread of coronavirus or worsening of the resulting COVID-19 disease

False theories about the virus abound, such as that the construction of 5G infrastructure is in any way linked to the spread of coronavirus or worsening of the resulting COVID-19 disease

On 26 March, Professor Ferguson gave evidence, via video link, to the UK’s Science and Technology Committee. With the suppression measures the team recommended now firmly in place and being enforced and largely abided by, he reiterated that the NHS should have the capacity to cope and that deaths should not be higher than 20,000, if measures continue to be abided by.

Some portrayed that as a radical revision, citing the 500,000 fatalities figure included in the March 16 report (along with the 20,000 figure). It perhaps stems from a lack of understanding that models can produce a variety of different output predictions based on the parameters and assumptions of the model – which in this case included various levels of social distancing and quarantine measures.

It’s perhaps understandable, and in some cases excusable, that there is confusion and misinformation, after all this is an unprecedented and complex pandemic and many of us have had to get to grips with entirely new concepts and scientific lexicon: ‘flattening the curve’; basic reproduction number (R0); incubation times; and herd immunity, among many others.

Building trust within communities going forward

A busy city street at twilight in the rain

There is a strong likelihood that we are all going to have to live with and adapt to the reality of COVID for some time to come – perhaps even years. After the initial spikes have peaked and transmission is under control, there will continue be sporadic outbreaks.

This will require a new style of public health, almost akin to a neighbourhood watch scheme
Dr David Nabarro, WHO Special Envoy on Covid-19

The development of a vaccine will have an important role to play and several teams, including a group at Imperial are actively working towards that goal. Yet that will take some time to roll out on a large scale, and Dr Nabarro says that the role of communities will continue be absolutely essential in preventing larger flare-ups.

“The only way to deal with this is to find outbreaks of the disease as they start and to really close them down by prompt action in communities. If you can do that, then life can go on, but this will require a new style of public health, almost akin to a neighbourhood watch scheme. That requires a really informed population.”

A female scientist using a centrifuge

Imperial's Department of Infectious Disease is one of several research groups around the world currently working to create a viable vaccine. (Image credit: Thomas Angus, Imperial College London)

Imperial's Department of Infectious Disease is one of several research groups around the world currently working to create a viable vaccine. (Image credit: Thomas Angus, Imperial College London)

Important lessons were learned during the Ebola outbreak of 2014 in West Africa, as well as during subsequent flare-ups. There was widespread mistrust of government, and also a belief in some quarters that Ebola didn’t really exist, that it was a hoax by the government to gain aid money or that people were being taken to treatment centres for organ harvesting. There was also an issue around traditional burial and funeral rites, which were contributing to ongoing disease transmission. Dr Nabarro served as UN Special Envoy on Ebola at the time.

“We had to not only encourage people to trust those responsible for outbreak control but we had to learn to trust them too. This meant sharing the challenge with community leaders. We found that once they understood what we were saying and why, they were able to convey it to their people and implement behaviour changes in their way. We’re finding the same in Kenya with COVID – religious leaders are playing a vital role in sharing the message about transmission. Similarly in Egypt and other parts of the Middle East the mosques are so important.”

Addressing misinformation through engagement and education

A droplet of blue ink under the microscope

In the current pandemic, Imperial researchers have themselves also been examining aspects of trust, engagement and misinformation, notably through the work of the Patient Experience Research Centre (PERC) – a multidisciplinary group of clinicians, public health specialists and social scientists combining strengths in quantitative and qualitative research methods.

We feel this is an important step in building trust between researchers, public health responders and local people.
Professor Helen Ward, Director of the PERC

As part of Imperial's response to COVID-19, the PERC has been exploring people’s views, experiences and behavioural responses to the outbreak in the UK and elsewhere. The team has launched an online community involvement initiative to gather insight from members of the public, aiming to establish a network for ongoing community engagement.

Online surveys revealed that information overload and conflicting guidance are among the biggest concerns for the public during the current coronavirus outbreak.

Director of the PERC, Professor Helen Ward, said: "Building on our existing relationships with the public and patient groups we have been running online engagement activities to help guide our research and identify the needs of different communities. We feel this is an important step in building trust between researchers, public health responders and local people.”

Professor Helen Ward

Professor Helen Ward (Image:Jody Kingzett )

Professor Helen Ward (Image:Jody Kingzett )

Interestingly, almost half of respondents surveyed (47%) wanted to hear about the latest research on the virus, and 45% wanted a dedicated internet portal where they could access the latest information and trusted guidance.

As a way of responding to this, J-IDEA has published a free course on COVID-19 on Coursera called Science Matters: Let's Talk about COVID-19.  On the course, world-class experts explain the theory behind the analyses of COVID-19 and its spread, and how to interpret new information using core principles of public health, epidemiology, medicine, health economics and social science.

Meanwhile, UK Research and Innovation with the support of the UK Government’s Chief Scientific Adviser and Chief Medical Adviser have developed a portal website, providing authoritative and up-to-date explanations of the scientific evidence behind the COVID-19 pandemic. It also includes links to published and pre-published scientific papers. Imperial’s Professor Neil Ferguson and Professor Ajit Lalvani are contributing editors to the website, while Dr Rhia Kundu, Dr Lucy Okell and Dr Timesh Pillay are listed as research contributors.

Standing up for science

Bubbles in blue liquid under the microscope

The fast evolving science of the current coronavirus pandemic and the established science of climate change and the environment intersect at numerous points of interest – from the consequences of increasing proximity between humans and animals in terms of cross-species virus jumps to the alleviation of carbon emissions and air pollution from grounded flights and quiets roads during lockdown.

There are also some interesting parallels in terms of misinformation. Most obvious is the apparent tendency in some quarters to downplay the severity or even the very existence of the pandemic in the same way some have downplayed the veracity of climate change. Both are looming threats supported by a great body of evidence, but which for many people still feel quite remote and nebulous from their own day-to-day lives.

In many cases it’s the same actors peddling misinformation and disinformation about both coronavirus and climate change.

Misunderstanding about modelling is also a common strand at play here, and something climate scientists have been struggling to grapple with for many years – specifically the fact that models can produce a range of possible outcomes depending on inputs such as mitigation measures. That doesn’t mean models lack credibility and doesn’t mean there aren’t overarching certainties – such as the inevitability of health services being crippled without suppression measures or catastrophic consequences for ecosystems unless we limit global warming to an increase of 1.5 degrees or less from current levels.

Climate change banners at a rally in Germany. One sign says 'Climate is changing, why aren't you? Greenpeace'

A climate change strike demonstration in the centre of Berlin (Image: In Green / Shutterstock)

A climate change strike demonstration in the centre of Berlin (Image: In Green / Shutterstock)

Dr Nabarro previously served as Special Adviser to the UN on Sustainable Development and Climate Change. He says:

“There’s a question around how a scientist portrays herself or himself as authoritative but at the same time being both authentic and accountable. We’re all accountable for what advice we give. I think these are constant issues for scientists. One of the things you have to do when you’re accountable is to be clear when you don’t know something, be clear why you don’t know, and be clear what might change your position. Linked to that you have to be authentic, and try and find a way to connect with your listeners, not to treat them with any kind of disrespect. These are all things that I am looking at with great interest in the current pandemic as governments and communities do their best to try to implement the guidance of the WHO in very different settings.”

There is perhaps some hope in all of this though. The Imperial team has already published evidence that interventions in 11 European countries to counter the coronavirus pandemic, including school closures and national lockdowns, are working effectively and, that up to 120,000 deaths may have already been averted.

If we can demonstrate a successful, coordinated and transparent response in getting the initial coronavirus peak under control and the importance of behaviour change based on sound evidence it may help to restore more faith in the scientific process among those who are inclined to question it. That will stand us in good stead for future existential crises, such as climate change or indeed the next disease pandemic, when it inevitably comes.

Dr Ajay Gambhir

Dr Ajay Gambhir (Image credit: Thomas Angus, Imperial College London)

Dr Ajay Gambhir (Image credit: Thomas Angus, Imperial College London)

Dr Ajay Gambhir from Imperial’s Grantham Institute – Climate Change and the Environment explored these themes in a recent commentary about the pandemic.

He said: “The central importance of behaviour change has been brought to the fore. The ability of people and societies to respond to threats affecting their wellbeing – as is being demonstrated across the world – is a potentially powerful response mechanism. If we can heed the importance of science, behaviour change and resilient planning this would place humanity on a firmer footing to tackle the multiple challenges that we will face this century – including climate change.”

In the meantime, we will all have to learn to live with this disease and adapt, just as we have had to do in the past.

Dr Nabarro says: “After we learned about cholera from John Snow, we had to adapt our lives so we weren’t reliant on dirty water sources and didn’t have regular cholera outbreaks. Or 25 years ago after we learned that HIV was carried through sex and had to adapt intimacy so it was still possible despite the threat of HIV – I think humanity is amazingly resilient, so we’ll learn to live with this virus, but it’s going to be really tough at the beginning.”


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