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This is an extract from Chapter 18 of Salim S. Abdool Karim’s book, ‘Standing Up for Science: A Voice of Reason’, entitled, ‘Leading the MAC–attaining sufficient consensus’. It deals with the process followed to incorporate different member opinions in the work of the MAC, as well as the change in the composition of the MAC.

I took the view that the MAC needed to produce the best advice it could, and to do this, we needed to ensure that we drew on the knowledge of the best people available. I also felt that giving space to a diversity of views in the MAC was particularly important, given the lack of hard evidence available in the early stages of the outbreak. The irony of calls to ‘Follow the science’… was not lost on us, considering how little science there actually was at our disposal at the beginning of the pandemic. It was in our interests to canvass different views – so as to ensure the decisions adopted were as robust as possible.

Together with the MAC secretariat, I worked on a process for drafting and finalising an advisory that would be as democratic as possible, given the time constraints we faced. After a draft prepared by the relevant TWG or MAC member had been presented and debated in the MAC, the secretariat and I would incorporate the points made during the debate to ensure it reflected the common view. This took hours and often involved contacting individual members to clarify their comments. When I felt that certain views could not be accommodated in an advisory, I would often phone the individual who had suggested the point to discuss the matter, and we would jointly discuss ways in which it might be incorporated in the advisory or somewhere else. The final version of the advisory would then be re-tabled at the next meeting so that if anyone differed with my interpretation of the discussions and the common points of view, they could make their opinions known then or within a comment window of 24 hours. Very rarely would there be problems or errors in the final version, but in the event that there were, we could issue an update.

I adopted the concept of ‘sufficient consensus’, which I borrowed from the 1990 CODESA (Convention for a Democratic South Africa) negotiations and applied it to our discussions to ensure that the outcomes reflected what most people were thinking and articulating. Still, ensuring that everyone had an opportunity to air their views came with a downside: meetings would sometimes go well over the allotted time.

All of us were extremely busy people and the pressure on us was high, particularly when infection rates were rising, and we had to work to unrealistically tight timelines to map out actions to slow down the spread of the virus. MAC members did have sharply differing views on certain issues; especially when we were time-pressured or, perhaps, it just felt that way. I tried as hard as possible to avoid a situation in which we were split down the middle and a vote was required. In my experience, there is nothing like a partisan vote to harden positions on either side. To a large extent, we succeeded in achieving sufficient consensus. We had only one near vote—about my continuance as chair—and that was not over a scientific matter. I generally tried to find the areas we could agree on and worked from there.

When a new discussion point comes up, I try to avoid polarising points to begin with. This allows everyone to start on some form of common ground and then slowly start to introduce points where they differ through the discussion. In this process, I felt that it was important to acknowledge the essence of all views and, where possible, reflect aspects of those views in the final advisory that went to the Department of Health.

On the whole, this approach served us well and we always managed to find a way to move forward. While some members might have felt my approach was too accommodating, others might have felt that I should have more openly supported a position about which they felt strongly. As chair of the MAC, it was my responsibility to get us to a point where we could provide our best advice, and my credibility as fair chair had to be above reproach.

Six months after the original MAC was formed, while there was a dip in Covid-19 cases, we were faced with a different type of curveball. On 14 September 2020, Minister Mkhize changed the composition of the MAC. The new committee was more balanced in terms of expertise; while it had fewer biomedical experts, it included people with knowledge and experience in ethics, nursing and social science. I remember sitting on the couch next to Quarraisha when she got her email that evening thanking her for her service and saying that she would no longer be serving on the MAC. Naturally, the seemingly overnight shift garnered a great deal of media coverage. The media’s focus was less on the composition of the new MAC and more on who was no longer on it – as well as speculating about what had led to the changes.

A popular media depiction was that some MAC members had been dropped due to their vocal criticism of government. In reality, the explanation was simple. All members whose salary came from the Department of Health—including employees of the NICD, NHLS, MRC, etcetera—were removed. It was inappropriate to have those employed directly or indirectly by the Department of Health on the committee in the first place as it meant that employees of the Department of Health were advising their own department. In some instances, departmental employees were both providers and recipients of the MAC’s advice on an issue. Some of the changes in the MAC’s composition aimed to reduce duplication in expertise to allow for a wide range of skills and experience on the committee. In the new configuration, the number of MAC members was cut by about half. I was to co-chair the new committee with Professor Marian Jacobs, a former dean of UCT medical school, former chair of the MRC board and someone known to be an exceptional leader in the world of medicine. Working alongside Jacobs made leading the MAC easier and the reduction in the size of the MAC enabled greater participation, though we missed the wise contributions from those who were no longer on the committee. I particularly missed having Quarraisha’s wise counsel on the reconstituted MAC.

Along with our reduced membership, two other MACs were created.

One was a committee to deal with COVID-19 vaccines, chaired by Barry Schoub, and the other, a multi-sectoral committee on social and behavioural change, chaired by Bishop Malusi Mpulwana. Now that the emergency of the first COVID-19 wave was over, the Department of Health needed a lot more guidance on Covid-19 vaccines and on longer term behavioural and social change in anticipation of future waves.

By the time the MAC was reconstituted in September 2020, the first epidemic wave had passed and science was, for the most part, holding its own against the array of competing real-world interests. But there were rougher seas ahead: a second surge, fiercer than the first, would see us reaching infection rates of over 10 000 per day, necessitating the introduction of new national restrictions. Initially predicted to happen after Christmas 2020 and New Year festivities, the resurgence came earlier, starting its climb in late November. At the time, it was believed to be driven by pandemic fatigue in general but also by teens and young adults who were celebrating en masse the end of a disjointed and frustrating academic year. That earlier-than-expected spike was bad enough, but in mid-December we received worse news, which partially explained our predicament: a new highly transmissible variant, then known as N501Y.v2 (later called Beta), had been detected in South Africa and was making its way steadily across the country.

It was up to the MAC to come up with guidance in the uncharted territory of new COVID-19 challenges, including variants. That was our job—and we managed to do that. Every advisory—all 119 of them produced by the MAC during my time as MAC chair or co-chair—was supported by the members of the MAC. As far as I can recall, no one had ever rejected an advisory, even if they held strong opposing views during the discussions. This reflected on the maturity of the MAC members and their willingness to find a path forward, even if it was not exactly what they wanted. This willingness to compromise on less important issues in order to make progress on the critically important issues enabled the MAC to generate, on average, two advisories a week during my tenure. My task as its leader was to steer the process that enabled the MAC to achieve this. But the steering was not always being done in calm waters…

Salim S. Abdool Karim is a South African clinical infectious diseases epidemiologist who is widely recognised for his scientific contributions to AIDS and COVID-19. He is the author of ‘Standing Up for Science: A Voice of Reason’.

By Editor