Intellectual Honesty in the Post Truth World

What’s the big deal?

I think that one of the most dishonest things one can do in the realm of Science and Medicine is ignore data that you wish was different, because it contradicts views that you firmly believed and espoused. Whatever your political leaning, you may be one of the 75% of Americans, who in a recent Gallup poll could not affirm that they believed the media never intentionally misled the public. The Post Truth world is tough to navigate if you value more than simply receiving constant gratification and reinforcement of your beliefs.

Enter the recent Cochran Library analysis of the utility of masks and hand hygiene as a means to limit the community spread of respiratory illnesses including COVID. Any of the long time readers here will know I have been a strong proponent of high quality masks, primarily for self protection. I was never in favor of masks for the very young, (see CDC recommendations to mask 2 year olds) a group which had very little risk of serious disease, real possibilities of social development harm, and little chance of wearing masks correctly. The Cochran review is a massive meta analysis of all the published work on mask and hand hygiene to control community spread of disease. I am including the authors summary below, but I will give you my summary of the summary. This very comprehensive analysis of all the published scientific works addressing the issue found NO convincing evidence that masks made any difference in the community level transmission of respiratory viruses, including COVID. They found that there is likely a small reduction in respiratory virus transmission with good hand hygiene versus none, but that effect is smaller when the outcome was the more rigorous end point of specific viral identification.

Physical interventions to interrupt or reduce the spread of respiratory viruses. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006207.pub6/epdf/full

Main results: We included 11 new RCTs and cluster-RCTs (610,872 participants) in this update, bringing the total number of RCTs to 78. Six of the new trials were conducted during the COVID-19 pandemic; two from Mexico, and one each from Denmark, Bangladesh, England, and Norway. We identified four ongoing studies, of which one is completed, but unreported, evaluating masks concurrent with the COVID-19 pandemic. Many studies were conducted during non-epidemic influenza periods. Several were conducted during the 2009 H1N1 influenza pandemic, and others in epidemic influenza seasons up to 2016. Therefore, many studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighborhood in a high-income country. Adherence with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included 12 trials (10 cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and 10 in the community). Wearing masks in the community probably makes little or no difference to the outcome of influenza-like illness (ILI)/COVID-19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate-certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory-confirmed influenza/SARS-CoV-2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate-certainty evidence). Harms were rarely measured and poorly reported (very low-certainty evidence). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). We are very uncertain on the effects of N95/P2 respirators compared with medical/surgical masks on the outcome of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; 3 trials, 7779 participants; very low-certainty evidence). N95/P2 respirators compared with medical/ surgical masks may be effective for ILI (RR 0.82, 95% CI 0.66 to 1.03; 5 trials, 8407 participants; low-certainty evidence). Evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate-certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies (very low-certainty evidence). One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non-inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID-19 patients. Hand hygiene compared to control Nineteen trials compared hand hygiene interventions with controls with sufficient data to include in meta-analyses. Settings included schools, childcare centres and homes. Comparing hand hygiene interventions with controls (i.e. no intervention), there was a 14% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.86, 95% CI 0.81 to 0.90; 9 trials, 52,105 participants; moderate-certainty evidence), suggesting a probable benefit. In absolute terms this benefit would result in a reduction from 380 events per 1000 people to 327 per 1000 people (95% CI 308 to 342). When considering the more strictly defined outcomes of ILI and laboratory confirmed influenza, the estimates of effect for ILI (RR 0.94, 95% CI 0.81 to 1.09; 11 trials, 34,503 participants; low-certainty evidence), and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials, 8332 participants; low-certainty evidence), suggest the intervention made little or no difference. We pooled 19 trials (71, 210 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. Pooled data showed that hand hygiene may be beneficial with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.83 to 0.94; low-certainty evidence), but with high heterogeneity. In absolute terms this benefit would result in a reduction from 200 events per 1000 people to 178 per 1000 people (95% CI 166 to 188). Few trials measured and reported harms (very low-certainty evidence). We found no RCTs on gowns and gloves, face shields, or screening at entry ports.

When new data arises which contradicts what you believed to be true, you have several options. The intellectually dishonest approaches are to either, completely ignore it and pretend it doesn’t exist, or dismiss it out of hand with a sniff, that it must have been produced by members of the other tribe, and there must be something wrong with it. The scientific path of course is to first evaluate the information and form a true judgement of it’s likely validity, and understand exactly what it is saying. If you are unable to find objections to the study, then the next step is seeing whether elements of your prior conclusions can be modified and still be consistent with the new data. And that of course is where I find myself. I accept that this exhaustive review of all the scientific evidence does not show any significant effect of masks on spread of COVID and other respiratory viruses at a community level. Does that mean that wearing a mask correctly will not reduce an individual’s risk of acquiring disease?—absolutely not. Properly fitting masks can easily be shown in the laboratory to dramatically reduce the inhalation of particles the size of viruses. The whole problem with the thesis that masks would reduce community level spread is that the community is not a lab with a short term experiment, and human beings are not the mannikins used in such experiments. There are many reasons masks fail to reduce community spread. The mask needs to be a serious mask, not a piece of cloth, or a gator pulled up over your face as the CDC suggested for far too long. Many people never got the hang of wearing even a good N95 mask correctly, and reused masks many times over. The used, virus saturated mask was frequently removed and stuffed into a pocket—now a little viral swamp waiting for your hand, cellphone or keys. Restaurants were the most glaring example of absurdity. People tended to identify “safe” pods of folks, with what they believed were members practicing exacting mask etiquette. Why did we do these things? Because we are human beings. The Cochran Analysis says nothing about the ability of a properly worn N95 mask, to reduce an individual wearer’s risk of infection. Until I see evidence to the contrary, I continue to believe that some people, who are able to wear a fresh mask correctly can reduce their risk of disease. Realistically this would be people who have limited short term exposures to crowded indoor spaces, wear the mask properly fitted 100% of the time during exposure, wash their hands properly every time they remove a mask, and don’t reuse them. A tough regimen to be sure.

We wore masks for different reasons. Some people, like me, believed they would decrease the risk of infection, but I’m no manikin, and despite my medical training I ate in restaurants and was guilty of mask infractions. Some people wore them because they they were told it would reduce the risk of other people catching the virus—turns out there was never any evidence for that, and as far as we can tell it wasn’t true. An enormous number of people wore masks because they were forced to by mask mandates. Now it seems clear that there was never any real scientific evidence that masks would limit the spread of the virus in the community, yet governmental authorities assured everyone they were following the Science when they forced people to wear masks. You may say, “Well they had expert opinion guiding them…or…. What’s the big deal, so you had to wear a mask for no reason”. To these I would counter that expert opinion has been used to burn people alive for insisting that the earth revolves around the sun, and the shape of the skull revealed why one race was superior to another. There was plenty of scientific data available before the Pandemic which did not show a positive effect from masks. The big deal part of the equation would be the expenditure of many billions of dollars for masks, and the environmental damage from their manufacture, transport (all those incinerated dinosaurs) or sloppy disposal. I will leave it to others with knowledge of the field to assess the potential developmental damage done to young children, but yes, that’s part of the big deal. Finally, I will just say people don’t like being ordered to do things without good reason. There are women in Iran risking their lives, and being murdered, for refusing to wear a head scarf—what indeed is the big deal? People loose faith in their government when it does capricious things, and misrepresents somebody’s opinion as Scientific Truth, which is then used to bludgeon people into compliance. You might think there’s little utility in reviewing this; it’s water under the bridge, with almost nobody wearing masks and few remaining mandates. On the contrary, the last few decades suggests strongly that new pandemics of respiratory disease are likely. We should try hard to make sure there is a lesson learned here about both human nature, and the reasonable limits of governmental authority in a free society. Expert opinion can certainly be a basis for strong Public Health recommendations. When it veers into the realm of government fiat punishable by fine, business closure, denial of religious worship, or jail, we have entered the danger zone.

The sky tonight is clear in Telluride with a nice display of Jupiter and Venus close together. Apparently all sinister interlopers in our atmosphere have been blown to unrecoverable smithereens. As I get set for some bedtime reading I am reassured by the absence of any train tracks within 30 miles of our home. Let’s all keep the people of Ohio in our thoughts.