Public health is not like medicine: It doesn't have to generate evidence
Public health need not prove itself with randomized trials -- is this idea true?
During the pandemic, the same person who says “this observational study of <insert cancer drug> can’t prove it works because of residual confounding” is happy to say, “this observational study of community masking proves it works.” Bizarre, right?
If anything the unmeasured confounders are larger with a socio/political/virtue-signaling practice (which masking has become) than a drug. But the truth is neither study is credible evidence. Both should be rejected.
I was recently speaking to someone who offered the argument that Public Health is different than Medicine. You have to act based on incomplete evidence and you can’t always wait for a trial. Naturally, we don’t always have good evidence in Public Health, but that can’t paralyze us.
First: let me assure you. The same is true in medicine. Each day there are thousands of decisions that are made entirely devoid of evidence. We always have to act based on incomplete information and rarely have a perfect trial for the patient in front of us. So the premise is wrong.
Second: the issue is not acting without data. We all forgive the initial events of March 2020. The issue is NOT EVEN TRYING TO GENERATING DATA IN THREE YEARS WHILE YOU TALK AS IF THE SCIENCE IS SETTLED. How do you explain this?
In medicine, when we give therapies without RCT support, at least we know our limitations. We spend time with patients counseling them about the pros and cons. We don’t straight up lie to patients, and say this drug will lower your risk of death 85% (without good data that is true). Kiss them on the forehead and say “shhhh question time is over”, “why don’t you trust me. TrUSt DoCTorS. We don’t want the mis-information police to come get you.”
No, we are honest about what we don’t know. And furthermore, as much as possible, we design and conduct RCTs to reduce our uncertainty. Some of us are more conservative than others, and refrain, in so far as is possible, from prescribing unproven costly drug combinations knowing the unknown risks may exceed unknown benefits. But even the most exuberant prescribers tell patients, “I gotta be honest with you, I don’t know for sure this will work”
And yet, public health is actively engaged in a campaign of lies. Cochrane reviewed masking RCTs and it is profoundly negative. In response has been a steady stream of excuses that frankly are inconsistent with how we interpret evidence.
In Public Health, the US government (CDC and NIAID) and WHO literally ran ZERO trials of community masking— for 3 years— while recommending it AGAINST pre-pandemic guidance based on NO NEW data, and then incorporated it into future guidelines. All they while they denied the data from dozens of RCTs. If you did that to a patient, they would remove your license.
Furthermore, if anything, Public Health has a greater obligation to generate data than the cancer doctor. Our interventions are done with the consent of the person, often someone dying. Each day, they feel their body weaken. Our patients are willing to take risks, after all they know what happens if you do nothing.
Public health is for average people. Many are healthy. We impose upon these people and promise them we can make them better off. We need the very best evidence before boosting a 20 year old man who had 3 doses and covid twice, and yet we get worse evidence than a drug for a terminally ill penta-refractory cancer patient. It’s entirely backwards.
The truth is public health only has a lower evidence standard because it has been in a vicious cycle of neglect. No one cares about it, so there are no research dollars. Without money, experts get used to making things up, and don’t run trials. Without money, the field can’t recruit the best talent. Because of both lack of talent and funds, the push for better standards escapes them. Had it not been for this particular virus leaking out of the la— I mean wet market— we would not have thought of public health for another 20 years.
Does public health need to generate evidence? Yes, the obligation lies with them, and if they don’t do so after 3 years, they have failed the people they sought to serve. As time moves on, and the lies become more apparent, don’t be surprised if the people come to dismantle and defund their institutions. Reduce them to rubble. Even then, with nothing, I am sure, they will still be making things up.
It's hard to argue with people who are gaslighting you and have been doing so for 3 years. Their goal is not the same as yours: it's to justify their position because it works for them, not to engage in a relentless pursuit of the truth. This is why arguing with gaslights rarely ends well. Most of the time they don't even realize they are gaslighting: they just find themselves defending their positions like the Black Knight in Monty Python and the Holy Grail, when it has become beyond absurd to do so.
The problem is that in academia and public health, the incentives have become perverse. They aren't trying to conduct science, to learn and understand how things work in a reproducible way.
The goal is to publish and say lots of things. No one appears concerned with making accurate claims. No one is even checking if you are correct. There is zero accountability when you are wrong. No one appears concerned with trying to be accurate, admitting when they are wrong, and discovering how to improve their accuracy.
It's crazy to me.
In the private sector, typically when you are wrong, you pay a price. You lose the promotion if not the job. If you make a model that shows it takes 10 factories to meet the demand for 1 million widgets, and when you model is executed it only makes 500,000 widgets, you lose your job. If you are a sales executive and promise a 50% increase in sales and only deliver 20%, you are fired.
In public health, Donna Ginther can say that Kansas counties that masked had a 100% decrease in Covid cases in an embarrassing study where simple replication of the claims done at time of publication showed a .3% absolute difference - yet she maintains her position as Distinguished Professor of Economics and director of the Institute for Policy & Social Research at the University of Kansas.
Your Local Epidemiologist Katelyn Jetelina can claim: "believe it or not, we continue to see a beautiful correlation between country-level vaccination rates and case rates/deaths"  citing an article from Der Spiegel  which if she had bothered to double check was already out of date by the time she reported on it, as cases in her highly vaccinated countries she praised like Denmark and Portugal exploded. Despite being it brought to her attention , she doesn't ever go back and examine how she got this wrong.
She remarks in a conversation with Dr. "19-tweets-to-explain-why-he's-ready-to-have-dinner-outdoors-without-a-mask" Watcher in December on how she knows masks work  "I keep thinking of 'why does my surgeon wear a mask when I am in surgery' you know, it must do something, it has to work". She reads all of her comments but ignores polite corrections showing her mistakes .
She continues to be acknowledged as an expert.
Even if you weren't fired in private sector for being so consistently wrong, you would at least be "window seated".
Epi Ellie gets to write a paper on the importance Boston School Masks not disclosing the authors successfully ran a Change.org petition to bring masks back to Boston Schools and wrote editorials begging to bring back masks , failed to realize several schools they counted as "Mask" got exceptions to drop masks , and when asked to explain all the confounders (like the fact the group counted as No Mask already had a higher baseline of cases when they were mandated to mask) argued "trust me, I have a PhD" . The paper is not withdrawn, her job is intact. How?
What is most frustrating about all of this, is that these people are very intelligent. They believe they have the best intentions, they believe what they are doing is right. Katelyn Jetelina appears to be a very compassionate and hard working person.
As individuals I don't blame them. All of these people are incentivized to produce essays, studies, and commentaries without respect to being right or wrong. Thats a systemic problem of how "we", collectively, have organized the pursuit of science. It's absolutely broken.
There needs to be soul searching in "The Science" to understand how it is possible to generate 75 studies that find cloth masks make a huge difference in virus transmission. We know with near certainty this cannot be true, yet pooled together, ~1200 PhDs managed to find, over and over, that cloth masks worked. That is an indictment of how bad we are at sciencing.
 https://twitter.com/EpiEllie/status/1429102872470433795 , https://www.bostonglobe.com/2022/02/11/opinion/its-too-soon-lift-school-mask-mandate/