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Public Health’s Truth Problem

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eye on the news

Public Health’s Truth Problem

Throughout the pandemic, medical and scientific institutions have disseminated dubious advice, flawed studies, and even outright falsehoods. January 19, 2022
Covid-19
Health Care
Politics and law

Throughout the pandemic, public-health officials have omitted uncomfortable truths, made misleading statements, and advanced demonstrably false assertions. In the information era, where what one says is easily accessible and anyone may read primary literature, these falsehoods will be increasingly recognized and severely damage the field’s credibility. No doubt, officials and organizations promulgating them had a range of motivations—including honorable ones, such as wanting to encourage salutary choices. Yet the subsequent loss of institutional trust may result in harm that far outweighs any short-term policy objectives.

Consider some messages the field has promoted to the public over the last two years and their shaky relationship with the truth.

Any mask is better than no mask. Last week, CDC director Rochelle Walensky asserted that “any mask is better than no mask.” This statement was factually incorrect when she said it. The only published cluster randomized trial of community cloth masking during Covid-19—performed in rural Bangladesh—found that surgical masks reduced the spread of Covid-19 among villages assigned to wear them, while cloth masks were no better than no masks at all regarding the primary endpoint of blood-test-confirmed Covid-19. In an umbrella review of masking that I coauthored, we found no good evidence to support cloth masking. Two days after Walensky’s statement, the CDC conceded that cloth masking was inferior to other masks. Notably, however, this is still misleading because cloth masking is not just less effective—it is entirely ineffective.

You should wear an N95 mask. Now the CDC has endorsed the use of N95 or equivalent masks in community settings, which it presents as the superior choice. Here, too, the evidence is misleading. First, a masking policy involves more than just the filtration properties of the material; it should consider both filtration and human behavior. Will people wear the mask appropriately? Will there be gaps around the nose? Will they cheat to scratch or drink? Will it cause discomfort and lead to discontinuation? Will they feel invulnerable and seek out higher risk settings? Simply put, the CDC does not know that advising the public to wear N95 is good policy. It could have run a cluster randomized trial, as was done for cloth and surgical masks in Bangladesh; it did not. In fact, the agency has run no randomized trials of masking this entire pandemic.

The virus changes, but our policies remain the same. Masking—even if it works—is not a permanent solution. It cannot work when you stop doing it. Recently, in a striking admission, Anthony Fauci confirmed not only that the virus will not be eliminated, but also that it will eventually infect us all. Even vaccination is not enough to entirely halt omicron breakthroughs. Thus, even if N95 masking delays the time to infection, we will eventually be infected. The question becomes: Is it worth it? We aren’t getting any younger, and at some point we will have to trust our immune systems (helped by vaccination) to fight off the virus. Is it worth it for a young person to delay exposure with an inconvenient and intrusive mask?

Kids suffer no harm from not seeing faces. On August 12, 2021, after more than a year in which daycare providers routinely wore masks while caring for infants, the American Academy of Pediatrics tweeted: “Babies and young children study faces, so you may worry that having masked caregivers would harm children’s language development. There are no studies to support this concern. Young children will use other clues like gestures and tone of voice. Being around adults wearing masks doesn’t delay babies’ speech or language development.”

The tweet was misleading. It appears meant to defuse a legitimate concern that kids not seeing faces may have a long-term deleterious impact. The truth is, we don’t know. We are running an unprecedented experiment on our youth. We have never concealed faces from children in daycare for so many hours a day for so many years. Thus, we cannot be certain of the full effects. If we do not know—and we don’t—then we should not be offering false reassurance. Notably, peer nations such as the U.K., recognizing this concern, have consistently refused to ask daycare providers to mask.

Vaccine policy must be one-size-fits-all. For some reason, the U.S. seems committed to a one-size-fits-all vaccine policy despite abundant evidence to the contrary. This has led us astray in several respects.

First, consider boosters. The case for population-wide boosters, including for young, healthy adults, is tenuous and was contentious even among senior scientists. Marion Gruber and Phil Krause—the director and deputy director of the FDA—reportedly resigned over White House pressure to approve boosters for all. An initial advisory action approved boosters for older and vulnerable populations but was reluctant to grant a blanket approval for adults aged 18 and above. Slowly, booster approval expanded to 18 and up, and now to 12 and up.

But substantial uncertainty persists that boosting a 20-year-old man will redound to his net health benefit. After two doses of mRNA vaccination, he will have a markedly reduced chance of hospitalization or death. He will also face a nonzero risk of myocarditis from a dose three. While a third dose may provide short-term protection against symptomatic disease, his disease would likely be mild anyway. We do not know with confidence that such a person should receive a booster. Recently, in light of these concerns, Paul Offit, director of the Vaccine Communication Center of Children’s Hospital of Philadelphia, advised his own son not to receive a booster. Current policy is built on the claim that we know that it is in the best interest of a young person to receive a booster shot. We don’t.

Recently, the government made an unusual regulatory change. It had initially recommended boosters six months after the initial vaccination series for Moderna, but it has accelerated this timetable to five months. The FDA admitted that this decision was based on data submitted for the Pfizer vaccine after the initial Pfizer series. Thus the FDA used data from a different manufacturer, at a different dose, to make vaccine policy. This is a highly unusual series of events—standardizing recommendations when no evidence supports such standardization.

Covid-19 vaccination in healthy children is the topic of considerable global disagreement. Currently, the United Kingdom’s experts have not yet advised healthy children to receive the vaccine. Yet the United States has (though uptake remains poor). Recently, the CDC published an alarming study suggesting that children who get Covid-19 may develop diabetes at higher rates than normal. Yet the study was grievously flawed. It did not adjust for risk factors—being poor or overweight—that predispose to both diabetes and Covid-19. It also failed to note that the absolute risks were astonishingly low. One can’t help but wonder if the CDC promulgated a highly imperfect study to push vaccination in this age group.

Falsehoods and half-truths have consequences. Publishing flawed science to raise irrational fear, making false statements about the efficacy of treatments, and extrapolating data from one vaccine to another all constitute bad scientific practice. In normal times, scientists would not tolerate such behavior. Yet, repeatedly, federal agencies and respected organizations push recommendations that are deeply uncertain, rely on fearmongering, or provide hollow reassurances. The right answer would be to acknowledge the massive residual uncertainty surrounding these issues and embark on studies to reduce it.

We need public-health institutions in times of crisis. But if they won’t tell the truth, they don’t deserve the public’s trust. If we meet future health threats as a more polarized society, these institutions will deserve their share of the blame.

Photo by LOIC VENANCE/AFP via Getty Images

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