Volume 374| Issue 6568| 5 Nov 2021
A new lane for science
Enola K. Proctor and Elvin Geng
A recent Science editorial on the social and political headwinds that have blunted, obfuscated, and confused public behavior in the United States’ COVID-19 response cautioned both politicians who appoint themselves scientists and scientists—including virologists and epidemiologists—to stay in their lanes. The warning raises an important question: Should science add another lane?
Despite the remarkable development of safe and effective vaccines, only about two-thirds of Americans have received their first dose. Even nonmedical actions (social distancing and masking) supported by rigorous evidence are met with widespread indifference, resistance, and rage. Unfortunately, this number is the rule rather than the exception. Broadly, Americans receive about 55% of clinical interventions known to benefit their health.
To address this failing, science needs to add another lane—one called implementation research. Implementation scientists move beyond medication and device development and study how to facilitate their use by clinics, front-line health care providers, patients, communities, and policy- makers. Public health failures that could have been avoided, as well as successes attributable to this science, illustrate the importance of this work. The use of beta-blockers after myocardial infarction was proven to reduce mortality in a 1982 trial, but 15 years later, only 34% of Americans hospitalized with a heart attack were discharged with a prescription for these drugs, and the practice was not universally adopted until 2007. In HIV prevention research, numerous randomized trials in Africa found that adult male circumcision reduces HIV transmission. However, its use remained low despite the World Health
Organization’s endorsement and massive donor-funded work to scale up surgical capacity. A recent randomized trial in Tanzania showed that the engagement of pastors—who are influential community opinion leaders—boosted the acceptability and uptake of circumcision in men, demonstrating the value of social influence in implementation.
Similar research on how to expand the use of proven COVID-19 interventions is underway but must be scaled up substantially to address pressing questions: What strategies lead to vaccine acceptability, feasibility, fidelity, equity, scale-up, and spread? What social marketing messages are most effective? Who are the best opinion leaders? How can health systems overcome delays in identifying mildly ill outpatients eligible for monoclonal antibodies? Data are emerging about how to equip vaccine champions with the resources necessary to train others, build coalitions, and optimize organizations to administer vaccines as widely as possible. But more must be done, especially given the current politicized pandemic response and frayed social fabric.
Society needs a lane of science that studies rapid uptake of proven interventions. Questions pursued in implementation research require cross-disciplinary collaborations among scientists who understand communication, marketing, anthropology, economics, and social psychology—disciplines that have not historically interacted with one another.
Three steps would contribute to a better pandemic response now and in the years ahead. The US National Institutes of Health (NIH) should create an Office of Implementation Research with funding that institutes must compete for, modeled on the Office of AIDS Research. The office would study emerging interventions and address obstacles to their use. Insights would guide health delivery, making learning-while-doing a standard. The office should support innovations that track rates of intervention use (vaccination and effective therapeutics) and capture the strategies leading to their uptake. And the NIH should support networks for implementation research, similar to the AIDS Clinical Trials Group. At least 10% of the NIH budget should be dedicated to this work. If this seems expensive, consider the costs of not taking these steps: Effective interventions that are not used optimally will fail to reap value from existing investments.
COVID-19 has shown the world that “knowing what to do” does not ensure “doing what we know.” It demonstrates that intervention discovery is the start, not the end, of the scientific journey. There is no better time for science to establish a new lane, one devoted to ensuring that our nation’s health discoveries are used to improve population health. The headwinds demand nothing less.