Dr B. J. C. Perera
Specialist Consultant Paediatrician
Many outbreaks and epidemics such as HIV/AIDS, Ebola, as well as our past experience with vaccines and various types of treatment modalities for infectious diseases, have taught us many lessons. It is critical for us to use some of these most valuable lessons to build an effective and acceptable response to the Covid-19 pandemic caused by the SARS-CoV-2 microbe.
First and foremost, those epidemics have taught us that interventions must be based on sound and proven science. Just as in many instances of experience with an entirely new infectious disease, we face many uncertainties about the epidemiology, clinical presentation, and natural history of a new virus. SARS-CoV-2 science is therefore evolving quickly, but in a state of continuing flux, which adds to the complexity of decision making, communication, and development and sustainability of public trust. Yet for all that, Covid-19 presents an important opportunity for smart deployment of our hard-won knowledge.
HIV/AIDS has taught us the value and importance of involving affected communities in planning and implementation of research and care. Both HIV and Ebola have shown that accurate and timely local information are required to enable and guide tailored interventions; public health and medical experts should heed the slogan “Know your epidemic” and target interventions accordingly. The much-bandied notion of ‘one size fits all’ is perhaps of little use in this situation.
Of course, Covid-19 presents new challenges. The epidemiology of a pandemic respiratory virus changes rapidly, and responses must be nimble. Given that everyone is susceptible to this novel coronavirus for which we lack effective biologic interventions, the response has required large-scale behaviour change, including social distancing, scrupulous hand washing and wearing of face masks in public, which were proposed rapidly under emergency circumstances. These measures could have had greater impact, however, if they had been adopted earlier and more widely; rapid actions that require community trust and buying-in. There are examples of public health successes against Covid-19. Hong Kong, which has a much higher population density than New York City, had fewer than 100 Covid-related deaths, thanks in part to swift and widespread uptake of masking, augmented by easily accessible testing. Germany introduced large-scale Covid-19 testing combined with locally led responses and strong national leadership. Globally, individual and community-level responses required substantial sacrifices that had major economic effects. In stark contrast, the USA response however, has been hampered by denial, missteps, delays in scaling up testing, inconsistent messaging, and politicization of public health responses. A vile combination of some of these led to uncontrollable community transmission in many parts of the United States of America.
But this pandemic presents an opportunity to build bridges between scientists and the public. Trust must be earned. Experience with HIV/AIDS demonstrated that scientist–community collaboration was feasible and improved the scientific process. AIDS advocates pressured scientists to act more quickly, to be more transparent, and to communicate clearly about scientific rationale and methods. The result was shorter timelines for scientific investigation, regulatory review, and even implementation of effective interventions. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, provided an outstanding model for building bridges with the public. His willingness to listen to advocates’ concerns about AIDS research was instrumental in making clinical research on HIV/AIDS consultative and collaborative.
In facing Ebola, the Partnership for Research on Ebola Vaccines in Liberia (PREVAIL) trial demonstrated that substantial investment and adaptive approaches to community education and social mobilization could address myths about Ebola, motivate participation, and achieve high retention in vaccine trials, all secured in spite of widespread mistrust of government, low literacy, stigma associated with Ebola, and poor clinical infrastructure in the affected communities.
With Covid-19, community engagement must be on an even larger scale and must be adaptive and led by trusted scientists and public health experts. In the United States, Fauci has again led the way, confidently and authoritatively providing clear, fact-based communication about Covid-19. His voice must continue to be heard, especially since the U.S. pandemic response has become so politicized.
Scientists and public health professionals must convey the critical need for well-designed research, surveillance, and rigorously implemented clinical trials to identify safe, effective interventions, including pre-exposure and post-exposure preventive treatments, and vaccines. Objective markers of response are needed to assess efficacy, including SARS-CoV-2 shedding as a measure of infectivity, in addition to clinical end points. Given the plethora of treatment and vaccine trials, many tens of thousands of study participants are needed. Community engagement is needed to address mistrust of research and reluctance to participate in clinical trials. Health care providers, scientists, community leaders, and policymakers can, and in fact must, work in tandem to encourage participation.
With Covid-19, we have the public attention, due entirely to the actual nature of the pandemic. That alone is not quite enough. Now we need to earn their trust by doing things according to the best science available, as efficiently as we can, and by clearly communicating our rationale, methods, and results. The buzz word is ‘TRANSPARENCY’. We have very limited preclinical data on SARS-CoV-2 to guide drug development and immunologic strategies. It is our duty as scientists to avoid supporting unproven interventions, blend opinion with evidence, or make strong proclamations based only on valid science, which are then picked up by the media.
More specifically, the fight against HIV demonstrated the need for a combination of interventions to reduce new infections and revealed the false dichotomy between treatment and prevention. HIV treatment has the powerful secondary benefit of preventing transmission by means of viral suppression, and some HIV medications have high efficacy for primary prevention. Initial efforts to prevent HIV infection focused on behavioural interventions, even as the biomedical pipeline was being developed. Eventually, we saw treatment breakthroughs, and now we have more than 30 antiretroviral drugs. Neither this portfolio nor HIV prophylaxis would exist if we had stopped after the initial studies. Investment in HIV drugs has led to major reductions in new infections, better quality of life for people with HIV, and lower mortality. Mind you, all these important gains being secured even without an effective vaccine.
HIV has also taught us that the timing of an intervention during the disease course may be critical to its therapeutic impact. Delaying treatment because of the magnitude of immunocompromise led to unnecessary illness and deaths. This principle is key in addressing Covid-19, given the potential contribution of a hyperimmune response to the severity and duration of illness. Early intervention is needed to prevent acquisition of Covid-19 or disease progression before multi-organ involvement occurs.
We need multiple strategies for preventing and treating Covid-19, including some forms of preventive treatments, and vaccines. It is highly unlikely that such therapeutic and preventive strategies would be successful at the very first attempt. Scrupulous scientific analysis of proposed therapeutic interventions and vaccines would be the key. It is absolutely crucial to realise that, like HIV, Covid-19 will continue to require non-pharmacologic public health strategies, even after a partially effective drug or vaccine is identified. The rationale for testing repurposed drugs needs to be clearly articulated and based on their potential activity against SARS-CoV-2 and on available safety data. For example, the drug remdesivir was originally evaluated for Ebola and has now shown partial efficacy for moderate-to-severe Covid-19 infection. Data from in vitro studies led hydroxychloroquine and chloroquine to be selected as candidates for preventive treatments and for treatment of established Covid-2 cases. This secured political support, media attention, and heightened expectations and even misconceptions. The first trials, however, were small and poorly controlled, and the results received disproportionate media attention. The problem was compounded by the publication and subsequent retraction of a study showing potential harm or lack of benefit from hydroxychloroquine, which led to further confusion and undermining of public trust in science.
Thus, the scientific community’s priority, as past experience suggests, should be to pursue hypothesis-based and data-driven strategies with sufficient imagination and resources to test new approaches for Covid-19 prevention and treatment. Clinical trials should be coordinated and implemented well, and the results should be scrutinized and interpreted clearly as well as objectively. We need to prepare the general public for a discovery process that is iterative and seldom linear. Interventions should not be strictly compartmentalized into biomedical and behavioural categories since decisions about testing, masking, quarantine, and use of preventive or therapeutic interventions, all have social and behavioural components. Scientific and public health efforts therefore require multi-disciplinary teams and intense collaboration.
Yet for all this, Covid-19 presents opportunities commensurate with its challenges, including the chance to build on our collective experience with high-priority, high-impact, high-quality science conducted in an efficient and coordinated manner. Throughout the process, we must build and sustain public trust by communicating clearly about our evolving understanding of this life-threatening disease. Medical professionals and health scientists should work tirelessly and hand-in-hand, to be transparent and secure unmitigated public trust. Policy decisions of the government should invariably take into account the health perspectives presented by professionals and medical scientists. The implementing authorities entrusted with all forms of prevention, quarantine and isolation of areas, should work within humane standpoints and with sustained empathy. It is paramount to realise that the only way out of this conundrum is to secure absolute and unadulterated public faith and belief in the authorities by being transparent, committed and intensely public-spirited, on the part of everyone involved with this pandemic, including the legislators, healthcare professionals, the implementers and the law enforcement authorities. It would most definitely be counter-productive to ‘wield the stick’. It is also not the time or the place for political bickering, finger pointing and assumption of ‘holier-than-thou’ attitudes. Willing and unstinting public cooperation can only be secured if the general populace has implicit trust in the authorities concerned. For their part, everybody involved in this battle against this little blight, should feel honoured and privileged to declare that it is the least they could do for our populace in this blessed land.
Govt.’s choice is dialogue over confrontation
By Jehan Perera
Preparing for the forthcoming UN Human Rights Council cannot be easy for a government elected on a nationalist platform that was very critical of international intervention. When the government declared its intention to withdraw from Sri Lanka’s co-sponsorship of the October 2015 resolution No. 30/1 last February, it may have been hoping that this would be the end of the matter. However, this is not to be. The UN Human Rights High Commissioner’s report that will be taken up at the forthcoming UNHRC session in March contains a slate of proposals that are severely punitive in nature and will need to be mitigated. These include targeted economic sanctions, travel bans and even the involvement of the International Criminal Court.
Since UN Secretary General Ban Ki-Moon’s visit in May 2009 just a few days after the three-decade long war came to its bloody termination, Sri Lanka has been a regular part of the UNHRC’s formal discussion and sometimes even taking the centre stage. Three resolutions were passed on Sri Lanka under acrimonious circumstances, with Sri Lanka winning the very first one, but losing the next two. As the country became internationally known for its opposition to revisiting the past, sanctions and hostile propaganda against it began to mount. It was only after the then Sri Lankan government in 2015 agreed to co-sponsor a fresh resolution did the clouds begin to dispel.
Clearly in preparation for the forthcoming UNHRC session in Geneva in March, the government has finally delivered on a promise it made a year ago at the same venue. In February 2020 Foreign Minister Dinesh Gunawardena sought to prepare the ground for Sri Lanka’s withdrawal from co-sponsorship of UN Human Rights Council resolution No 30/1 of 2015. His speech in Geneva highlighted two important issues. The first, and most important to Sri Lanka’s future, was that the government did not wish to break its relationships with the UN system and its mechanisms. He said, “Sri Lanka will continue to remain engaged with, and seek as required, the assistance of the UN and its agencies including the regular human rights mandates/bodies and mechanisms in capacity building and technical assistance, in keeping with domestic priorities and policies.”
Second, the Foreign Minister concluding his speech at the UNHRC session in Geneva saying “No one has the well-being of the multi-ethnic, multi-lingual, multi-religious and multi-cultural people of Sri Lanka closer to their heart, than the Government of Sri Lanka. It is this motivation that guides our commitment and resolve to move towards comprehensive reconciliation and an era of stable peace and prosperity for our people.” On that occasion the government pledged to set up a commission of inquiry to inquire into the findings of previous commissions of inquiry. The government’s action of appointing a sitting Supreme Court judge as the chairperson of a three-member presidential commission of inquiry into the findings and recommendations of earlier commissions and official bodies can be seen as the start point of its response to the UNHRC.
The government’s setting up of a Commission of Inquiry has yet to find a positive response from the international and national human rights community and may not find it at all. The national legal commentator Kishali Pinto Jayawardene has written that “the tasks encompassed within its mandate have already been performed by the Lessons Learnt and Reconciliation Commission (LLRC, 2011) under the term of this President’s brother, himself the country’s Executive President at the time, Mahinda Rajapaksa.” Amnesty International has stated that “Sri Lanka has a litany of such failed COIs that Amnesty International has extensively documented.” It goes on to quote from the UN High Commissioner for Human Rights that “Domestic processes have consistently failed to deliver accountability in the past and I am not convinced the appointment of yet another Commission of Inquiry will advance this agenda. As a result, victims remain denied justice and Sri Lankans from all communities have no guarantee that past patterns of human rights violations will not recur.”
It appears that the government intends its appointment of the COI to meet the demand for accountability in regard to past human rights violations. Its mandate includes to “Find out whether preceding Commissions of Inquiry and Committees which have been appointed to investigate into human rights violations, have revealed any human rights violations, serious violations of the international humanitarian law and other such serious offences.” In the past the government has not been prepared to accept that such violations took place in a way that is deserving of so much of international scrutiny. Time and again the point has been made in Sri Lanka that there are no clean wars fought anywhere in the world.
International organisations that stands for the principles of international human rights will necessarily be acting according to their mandates. These include seeking the intervention of international judicial mechanisms or seeking to promote hybrid international and national joint mechanisms within countries in which the legal structures have not been successful in ensuring justice. The latter was on the cards in regard to Resolution 30/1 from which the government withdrew its co-sponsorship. The previous government leaders who agreed to this resolution had to publicly deny any such intention in view of overwhelming political and public opposition to such a hybrid mechanism. The present government has made it clear that it will not accept international or hybrid mechanisms.
In the preamble to the establishment of the COI the government has made some very constructive statements that open up the space for dialogue on issues of accountability, human rights and reconciliation. It states that “the policy of the Government of Sri Lanka is to continue to work with the United Nations and its Agencies to achieve accountability and human resource development for achieving sustainable peace and reconciliation, even though Sri Lanka withdrew from the co-sponsorship of the aforesaid resolutions” and further goes on to say that “the Government of Sri Lanka is committed to ensure that, other issues remain to be resolved through democratic and legal processes and to make institutional reforms where necessary to ensure justice and reconciliation.”
As the representative of a sovereign state, the government cannot be compelled to either accept international mechanisms or to prosecute those it does not wish to prosecute. At the same time its willingness to discuss the issues of accountability, justice and reconciliation as outlined in the preamble can be considered positively. The concept of transitional justice on which Resolution No 30/1 was built consists of the four pillars of truth, accountability, reparations and institutional reform. There is international debate on whether these four pillars should be implemented simultaneously or whether it is acceptable that they be implemented sequentially depending on the country context.
The government has already commenced the reparations process by establishing the Office for Reparations and to allocate a monthly sum of Rs 6000 to all those who have obtained Certificates of Absence (of their relatives) from the Office of Missing Persons. This process of compensation can be speeded up, widened and improved. It is also reported that the government is willing to consider the plight of suspected members of the LTTE who have been in detention without trial, and in some cases without even being indicted, for more than 10 years. The sooner action is taken the better. The government can also seek the assistance of the international community, and India in particular, to develop the war affected parts of the country on the lines of the Marshall Plan that the United States utilized to rebuild war destroyed parts of Europe. Member countries of the UNHRC need to be convinced that the government’s actions will take forward the national reconciliation process to vote to close the chapter on UNHRC resolution 30/1 in March 2021.
Album to celebrate 30 years
Rajiv Sebastian had mega plans to celebrate 30 years, in showbiz, and the plans included concerts, both local and foreign. But, with the pandemic, the singer had to put everything on hold.
However, in order to remember this great occasion, the singer has done an album, made up of 12 songs, featuring several well known artistes, including Sunil of the Gypsies.
All the songs have been composed, very specially for this album.
Among the highlights will be a duet, featuring Rajiv and the Derena DreamStar winner, Andrea Fallen.
Andrea, I’m told, will also be featured, doing a solo spot, on the album.
Rajiv and his band The Clan handle the Friday night scene at The Cinnamon Grand Breeze Bar, from 07.30 pm, onwards.
LET’S DO IT … in the new normal
The local showbiz scene is certainly brightening up – of course, in the ‘new normal’ format (and we hope so!)
Going back to the old format would be disastrous, especially as the country is experiencing a surge in Covid-19 cases, and the Western Province is said to be high on the list of new cases.
But…life has to go on, and with the necessary precautions taken, we can certainly enjoy what the ‘new normal’ has to offer us…by way of entertainment.
Bassist Benjy, who leads the band Aquarius, is happy that is hard work is finally bringing the band the desired results – where work is concerned.
Although new to the entertainment scene, Aquarius had lots of good things coming their way, but the pandemic ruined it all – not only for Aquarius but also for everyone connected with showbiz.
However, there are positive signs, on the horizon, and Benjy indicated to us that he is enthusiastically looking forward to making it a happening scene – wherever they perform.
And, this Friday night (January 29th), Aquarius will be doing their thing at The Show By O, Mount Lavinia – a beach front venue.
Benjy says he is planning out something extra special for this particular night.
“This is our very first outing, as a band, at The Show By O, so we want to make it memorable for all those who turn up this Friday.”
The legendary bassist, who lights up the stage, whenever he booms into action, is looking forward to seeing music lovers, and all those who missed out on being entertained for quite a while, at the Mount Lavinia venue, this Friday.
“I assure you, it will be a night to be remembered.”
Benjy and Aquarius will also be doing their thing, every Saturday evening, at the Darley rd. Pub & Restaurant, Colombo 10.
In fact, they were featured at this particular venue, late last year, but the second wave of Covid-19 ended their gigs.
Also new to the scene – very new, I would say – is Ishini and her band, The Branch.
Of course, Ishini is a singer of repute, having performed with Mirage, but as Ishini and The Branch, they are brand new!
Nevertheless, they were featured at certain five-star venues, during the past few weeks…of their existence.
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