On the fallacies and pitfalls that have hampered our response, and how we can learn from them to do better in the future
I am a person who works at a health department. I agree with all these points -- as do many in my office. But we are so hamstrung by the lack of any power or ability to do things. For political reasons, we cannot provide any support essential workers. For political reasons, we cannot keep the schools closed. For political reasons, we cannot contradict the CDC.
I read this whole article and I feel ashamed and sad to be part of this fucked-up response - but the only other option is not being part of this response, so.
I think there's been a repeated "you can't handle the truth" approach to public health communications which has really contributed to public skepticism. See: "masks don't help" when it could have been "Some people need masks more right now, and we're not sure..." I'm so frustrated by the ... I'll say misinformation .. around the amount of vaccine doses and when they'd be available. V-E (vaccines for everyone) day was never coming until May or so, I'm not sure why this wasn't made more clear. Also, there's something I've called data idolatry before. Yes, RCTs are the only way to be sure about a scientific fact, but in life, you often have to make the best call you can with the (incomplete) data you have. It might very well be a good call to postpone second doses in order to get single shots in arms before new variants arise. We don't have conclusive data on this yet, but we have pretty good data, and we shouldn't dismiss it.
OK, I haven't read the article yet. But when the coronavirus first appeared, I wrote on Facebook that it was "almost perfectly designed to exploit the ways America is messed up". Like you, I had a list of five. I look forward to reading your article to see whether we have the same list.
- Large number of people without health insurance, who will avoid the healthcare system.
- A culture that emphasizes individual rights over the common good will have trouble getting people to comply with the rules to curb the spread of a disease that transmits from people without symptoms.
- healthcare culture of focusing on cure rather than prevention.
- uncoordinated government structure - federal vs states and divisions between different government departments. I thought there was little hope, for example, of proper management of borders given the differing priorities of different government departments.
- a President who never leads by example or by asking people for sacrifice.
I still think the fundamental attribution error is one of the most useful things I learned about in college and I've thought about it a lot during the pandemic, especially in the context of grandma-killing rhetoric. Not exactly the same, but an imputation of very bad motives to ordinary people committing the unforgivable sin of wanting to see their loved ones.
My mother is an epidemiologist and I learned a lot about public health intervention from her, but my trust in official channels of expertise in this pandemic is utterly gone, even though I'm myself a credentialed member of their class (university professor). There are a few different reasons for this, but the three most basic: 1) Being told not to wear masks (I'm in New York) and it made no sense to me but I thought well, I'm not the expert here. 2) Total absence of harm reduction messaging. I do some work on the history of the AIDS crisis and the rhetoric and scolding was eerily similar, despite the absence of the sexual element. In fact, the trope of the careless disease spreader goes back at least to medieval times. To make people guilty for breathing in the presence of others... that's really hard to come back from. Which is connected to 3), the acknowledgement in your article that sociality is a human need and itself an essential component of health. I think we made a fundamental error in not focusing on just how basic a need we were asking people not to indulge.
The people we think of as pandemic deniers aren't necessarily stupid. They may have different assessments of risk, different values, and they may know - which is correct- that 'elites' are lying to them. That is apart from the horrible and of course completely culpable contribution Trump made to all this.
But there's other cognitive issues too: that a successful intervention would seem overkill in retrospect, and that familiarity doesn't read as danger, and that cause-effect relationships are often distant and out of sight. The cognitive load of generating decisions so contrary to fundamental processing structures in our brains is costly. Thinking more compassionately instead of treating people like naughty children might have helped.
I guess I'm pulling out specifics where this article is more concerned with trends... but I don't think I can overstate the effect that being yelled at in all caps by the Surgeon General had, on all public health messaging I received after that. https://www.nytimes.com/2020/02/29/health/coronavirus-n95-face-masks.html
(Some context: I still don't quite understood who is a political appointee and who is not; and I most strongly associate the Surgeon General's "brand" with the extremely warranted, frightening messages that got added to cigarette boxes from when I was a kid... which means there was a certain amount of recognition and trust, maybe even gratitude, that I brought to my understanding of what their role would be, in decision-making about my health and the health of those around me.)
I felt wounded, honestly: first by a tone meant to convey how stupid my impulse was, to want to protect my family from a virus that had enough obvious priors/analogues even by February 29th to warrant mask use. Then by collapsing my very sane and normal impulse into a kind of panic reduction by gaslight; presumably (but not obviously) meant to address price gouging and hoarding. And finally by invoking frontline workers' need for PPE... all but the worst of us would prioritize their huge needs over our own modest ones... and it only served to underline that we were probably correct in assessing those needs. Yeesh. I still can't shake it, an entire year later!
Zeynep, further to this, from your wonderful Atlantic piece:
"The difference lay not in the level of evidence and scientific support for either theory—which, if anything, quickly tilted in favor of airborne transmission, and not fomites, being crucial—but in the fact that fomite transmission had been a key part of the medical canon, and airborne transmission had not."
In addition to your Popperian observation of weak evidence that matches the paradigm case out-competing strong evidence that does not, there is also the value of various adaptations as signals, not just as counter-measures.
Institutional consumers of public health advice, in the absence of clear Federal or state mandates, were left to signal to consumers that visiting their establishments was safe. Hand sanitizer is cheap and visible, while HEPA-compliant HVAC systems are expensive and invisible. The fact that the former is ineffective and the latter effective does not solve the merchant's primary problem, which is not limiting viral spread but rather not going out of business. (To this day, there is a stall in my farmers market, open on 4 sides and bathed in glorious UV rain or shine, that makes me sanitize my hands before entering.)
More speculatively, I wonder if there is a heuristic for people involving precaution, especially where it is engaged around questions of cleanliness and purity, where evidence to start a practice is easier to internalize than evidence to stop it?
Alternatively, I wonder if there is a heuristic that overweights early signals and underweights later ones, as humans build implicit mental models, analogous to the way parents of babies take much longer to realize their children have stopped liking certain foods, than they did to react to the moment when their children started liking it.
Zeynep, First of all, thank you for your coverage during the pandemic. You have been right so often since the beginning, and it blows my mind that you are not in some higher up position in the government public health response or the CDC. America would have been better off this way. At this point, I typically check in on what you have written and Fauci when I'm making decisions on how to proceed based on new information. Along those lines, I would greatly appreciate if you could write a future article on your thoughts on pregnancy and getting vaccinated. (Although I'm sure this is such a loaded topic...)
There are a lot of points that I think are right on in this article. Public health officials have failed to help individual citizens focus on ways that they can mitigate risk (ie- socializing outdoors safely and staying mentally healthy), and not focusing enough on providing evidence based guidelines to businesses and schools on ventilation. How is it that at this point of the pandemic, it is basically mandated that hand sanitizer be readily available in every corner of a store, but most stores keep their doors and windows closed even if they could be easily opened? An incredible failure in the public health messaging for sure...
I'm so beaten down right now that I just keep re-reading your point that life will get better with vaccines. It's so obvious that the vaccine dramatically reduces transmission and yet...FEAR MONGERING IN EVERY HEADLINE. Widespread PTSD is sure to be the next phase of this pandemic.
Thanks again, and looking forward to reading more of your work.
Perhaps the above is an updating of the colloquial concept of ‘public-health’?
Taleb quotes Popper in Black Swan:
“Genuine philosophical problems are always rooted outside philosophy and they die if these roots decay.”
That is sorta your role?; you’re one of the few American-based philosophers who can reason in an informed and fruitful way about some of the hyper-dynamics at place. Wonderful!
Targeting these fallacies makes sense; there is an opportunity for us to do a better job illustrating them; we put a lot of effort into making dynamic graphics for network television, and yet it’s hard to see the dynamics you explain. So, something like, better versions of nicky case’s work (but static stuff too) with opportunities for conversation and reflection.
As a writer, you cue us in to more tangible illustrations of the fallacies considered. Let’s do this visually. We need the public health officials working more closely with storytellers better accustomed to the tools of the times. It may help to SEE these fallacies side by side. A few core visual ways; adapted as templates for specific communities.
As you know, the ‘research debt’ problem is acute in Machine Learning; folks have some early ideas on how to address the matter. Worth a (-nother?) glance. https://distill.pub/2017/research-debt/
Forgive me Zeynep, but this all seems so intellectualized; which seems appropriate, but I’ll politely suggest that the emotional realm is quite important regarding public response, coping and the action issues.
We are all having to sit with a lot of discomfort. Updating and better distributing our tools for being with emotions and following their relation to thought, seems pertinent. Your point about awareness matters here.
Ex. ‘I am feeling ____”, . ..why? Because I am worried that ____ will occur”.
We know a lot about how cognitive load, acute and prolonged stress, and trauma, affect thinking, behavior and learning. We have to bring these insights to bear upon our current encounters.
Meditation, mindfulness, our heuristics around social emotional learning, matter here; and not in a hand wavy-way. Being in nature. Islands of competence etc.
I want to also emphasize your nod to the time boundary; which seems important.
Part of your audience seems to be the explicitly mentioned ‘officials’ and ‘media outlets’; perhaps we could expand this to include product managers?
Dewey and Addams always emphasized how democracy being embedded in social practice was crucial.
First, wonderful article.
Second, messaging is hard, especially for public health officials. Often arbitrary standards are the best they can do. I am reminded that in the jewish tradition, on Passover you are forbidden from eating leavened bread. So why not corn tortillas - there are no yeasts that can naturally leaven corn flour? Don't confuse the simple. Much easier to say "just eat Matzo".
If you are a public health official, is it better to say "stay six feet apart" or "don't get too close"?
Is it better to say "if you are socializing outdoors, wear your mask anyway" or "it depends on the wind's direction and velocity and how close you are to each other"?
Of course, our public health messaging could have been much better, but if we foster risk adverse public institutions then we should not expect sophisticated messaging.
The day this newsletter and the article came out was the same day I received my second dose of vaccine. As many sources had warned me, my immune system kicked into overdrive with an industrial-strength migraine headache, chills, and the inability to sequence thoughts enough to write meaningful comments here. 48 hours later, I’ve returned to normal.
While I appreciate the fascinating discussions about Scientific Method and public health rhetoric that have dominated the comments, there’s more than that going on that’s differently important.
I survived my zombie state with some degree of sanity not because of Scientific Method, but because of tribal knowledge. Had I not read or heard anecdotes of how awful it can feel when the immune system is working so hard, I would have been terrified that I had contracted some other deadly disease. As it was, I was only discomforted, not panicked. The public health information gave me a partial list of some possible symptoms; tribal knowledge was more phenomenological, telling me what it *felt* like, and that was paramount.
It’s clearly necessary to distinguish the valuable tribal knowledge from the recommendations of ingesting or injecting bleach, or popping hydroxychloroquine. There’s an interesting dividing line between worthwhile and damaging advice. But figuring out what to accept as possibly trustworthy and what to dismiss is not simple. For future pandemics it will remain as necessary.
Thanks for your wonderful article, Zeynep. As a student of rhetoric, I really appreciated this analysis, and especially the points you made in the section on "Rules in Place of Mechanisms and Intuitions."
The failures of the public health rhetoric is a clear example of the growing chasm between experts and non-experts, or even people who think of themselves as educated and how we educated folks think of uneducated folks. The world is more complex than an 8th grade reading level! It's dangerous to write about an extremely nuanced issue while imagining a public audience that you assume can't understand any nuance.
Throughout the pandemic, I've been frustrated and confused by close family members basing their behavior on rules and what kinds of public spaces were allowed to open rather than on knowledge of how the virus spreads (e.g., "restaurants are open now so it must be safe to eat inside a restaurant," or a holiday meal where everyone ate inside together but were careful to avoid sharing serving utensils). I know that I'm privileged to have postgraduate training, but from my perspective, being able to visualize how the virus spreads has made it much simpler to mitigate my family's risk without completely sacrificing our social needs.
Thank you for your thoughts throughout the pandemic. One of my favorite articles that I read is the interview that you did with Eric Topol -- "The Remarkable Value of Thinking Broadly: A COVID -19 Trifecta."
One piece that I have been very focused on, during the pandemic, is how data is gathered, what the definitions are, how it is reported at a county, state, federal level, and if those data match. There are many articles in The COVID Tracking Project Blogs, on how they do not, as well as an article from KHN in September, describing how each state was determining whether to report antigen tests/if they did. There is still no federal standardization of data reporting. Each state can report PCR pos/neg, or PCR pos/neg + Antigen pos/neg or PCR pos/neg + Antigen pos. Not every state deduplicates people that have already been tested, hence, in some state 1 person can equal 5 cases. This reporting of "cases" became especially problematic, when the 150 million Abbott Binax Now started to arrive in mid-September. The Government Accountability Office Report from January 28, 2021 details out the lack of a plan on testing, and how there are no federal reporting standardization, and how the data should not be used to compare and contract, as the data are not equal.
The WH Coronavirus Task Force, led by Dr. Birx, put out this inconsistent data, never scaled it as testing changed, and then made dire warnings about how "All Americans must change their behavior now", all through November and December. Had this task force/Birx realized that the data was inconsistent and not scaled, the picture would have been very different. It continues to this day with Dr. Walensky's warning, yesterday, as quoted in a STAT News piece that the last 3 days of cases are a "somber warning". The Director of the CDC did not realize that a winter storm that knocked out almost all of Texas, and other states, was creating a data artifact, and then making judgements and communicating them as facts -- that's a problem, for me. This challenge of the data artifact is even listed in the Community Profile Report that HHS/CDC/ASPR puts out daily, with data notes. When things like this happen . . . does she not understand statistics/data, or is the messaging for another reason?
Regarding the school metrics that the CDC put out, if one goes back and calculates the "Blue" metric, the last time the U.S. hit that metric, at a total was March 19-20, and that was on 1/70th of the testing that we do, today. For yellow, the last time it was hit was in June, on 1/7th of the testing.
I went through the 3,006 U.S. Counties, Territories, Municipalities, a week ago, 241 (8 blue, 233 yellow) would have been achieved, of those yellow counties, 203 of the 233 counties had a population of 50k or less, only 2 had populations of 500k - 1.0 million, Honolulu County, HI, and Washington County, OR. None had a population of over 1.0 million. Of those meeting the Blue Standard, only Hawaii County, HI had a population over 100k at 202k. The 7 remaining counties had a population of 46k or less.
Add in the difference in reporting, and for example, any state/county that reports PCR pos/neg only, is always going to have an advantage for "reopening" based on cases per 100k, simply because they do not report antigen tests. Doesn't mean the spread is less, just means the reporting is different. But, that isn't how the CDC/HHS is calculating it, they have applied a standardized opening metric to non-standardized data.
When hearing messages and metrics that the CDC/Dr. Walensky has put forward, coupled with Dr. Fauci on December 24th, referencing how many more people were going to be need to vaccinated to reach herd immunity, as that is what he, now, thought people were "ready to hear", based on his gut instinct, and new science -- however, no scientific reporting/research was referenced, that leaves me with questions of judgement and intent.
There has never been a push to establish serological testing for all, to see who may have already been exposed to COVID-19, to calculate what levels of exposure/natural immunity might exist. I know the CDC has done studies, they are with many caveats, and the sampling leaves a lot to be desired. People are not being tested prior to vaccination, to establish whether the 2 dose regimen is appropriate, Francis Collins wrote about this in his NIH DIrector's Blog on 2/23/21.
Couple this, with as your coauthor, Michael Mina, from the NY Times opinion piece, had written in the Lancet this past week, that 50-75% of the PCR positives are not infectious/transmissible virus. The Ct values, are too high. His preprint with James Hay, that they put out in October and updated in February, could have made such a difference, had the Federal Government adopted an approach to record these Ct values and/or delta values, to establish where the virus was most infectious. There are many quotes all over the CDC Conference Call notes/pages, that most that are seeking samples want the samples of Ct values of around 28 with a maximum of 33. The FDA as of 12/10/20, in their frequently asked questions, said that "currently there is no consensus as to whether or not particular Ct values correlate with a person being or not being infectious or risk level for disease severity". Yet, the scientists on the CDC Conference calls ask for samples at Ct values at a max of 33, and a preferred 28 -- why would that be? Hence, leaves a lot of questions of what we are trying to determine, diagnosis for an individual, that they may have had COVID-19, that they are infectious, now, and should quarantine/leave work, or are we using this as a public health measure to see where the spread may have been? So many unclear answers from the public health authorities.
I think the public health authorities forgot that a relationship involves two people. If, for example, they don't respect the person they are talking to (the public), they most likely will not get the same respect back. I know that they were/are in the position, to then "blame the public" for their behavior, but is that solving the problem? Why were they not looking at age and income stratified risk, why were they not putting a focus on protecting the nursing homes/LTCFs as (35-40% of the deaths have come from the 1% of people that reside here. Why were they not supporting them with staff, PPE, and instead threatening to fine them (based on positivity rates that are not standardized) per the CMS/HHS guidelines?
These are the questions I ask myself, as I try to wade through the information that is put before us.
Thank you for your thoughtful pieces, I learn so much, and many times causes me to dig/investigate further.
Thank you so much for your work on this, Professor. I'll just throw a little personal anecdote into the mix, for what it's worth. When the pandemic first broke out, late in 2019, I was teaching in International and English Language Programs at University of Washington (the UW IELP program has since been shuttered, for budgetary reasons, and I myself have now retired). I was teaching a Special Program with a focus on science, technology, and engineering, for an all-Chinese group from the PRC. Class opened on January 3rd, 2020, by which time it was already possible to get enough information to know that something big and scary, but not unexpected, was happening. My students and I drilled down deep on multiple sources--mainstream media, including an article or two by you; technical articles, mostly open-source pre-prints; official pronouncements from WHO; politically-motivated misguidance from you know who, etc. etc.--and treated them ALL with a healthy dose of skepticism. It helps a lot that I already had some experience teaching global public health, had mentored and been mentored, working in a program where we took hits from SARS, MERS, Ebola, HIV/AIDS, you name it, all of them in the 20+ yrs I worked there. In this latest crisis, we exercised critical thinking, in the broadest sense, not in the limited and mechanistic form that it is so often presented, but where context is in the foreground, as you discussed just the other day. Just for example: when the WHO said there was no evidence for human-to-human transmission, let's just say we took that with more than a grain of salt! What's that saying? "Absence of evidence is not evidence of absence!" When the advice was NOT to mask (right!), we masked up. The messaging on that was a debacle, and your work called it out. Thank you again! When the debate was all about the size of the droplets and the definition of an aerosol, we exercised the precautionary principle and assumed the worst. Only took like more than 6 months for the science on that to really catch on. Everything we did was done in the first 3 weeks of the breakout! We did it by studying the problem, talking about it, making up our own minds about what practical measures to take, and how to sift the flood of information and misinformation. As you have pointed out, scientific literacy is so fundamental, but it doesn't exist apart from socio/cultural/political awareness. If a person can developed a modicum of that, even on the fly, they can make well-informed judgments in fast-moving and fluid circumstances like these. The failure of much of the modern educational establishment to cultivate those habits of mind is itself of epic proportions, but these are habits of mind that really need to be instilled from day one. I always tell my students, young adults, university-bound, when we are working on 'critical thinking': "Look, it's too late!" And they get it.
I'm in the habit of only talking about things I don't like within an argument, so bear that in mind as you read this:
Here you talk about various government agencies doing what normal non-substack non-twitter people would call "lying". All these problems stem from an assumption that truth is some sort of optional and usually sub-optimal thing to be avoided when desired, necessary or just 'cause.
This doesn't seem to be a problem for you; you mention only that it produced less than great outcomes in this situation, and that seems to be your only complaint. It's very, very common for people on the left to criticize people on the right for not "trusting science", but it's so normal for science to lie at this point that you don't even think it's worth mentioning that this is what's happening.
So immediately I'm struck by two conclusions here, the first being that I need to carefully evaluate everything science says with a strong prior towards them lying to me if it suits their immediate needs. The second is that I need to carefully evaluate everything Zeynep says about science, since she's apparently fine with going along with a lie so long as it might produce good results; at the very least she won't be so provincial as to call someone on lying as if it might be wrong.
This section misses its own point so hard it's almost unimaginable.
Harm Reduction in practice is a bunch of people screaming at those who will only accept "perfect" solutions at any level of cost to the to the good that they should be willing to compromise to reduce risk where it's not possible to eliminate it. You do capture this bit.
You then go on to miss the big implication - you talk about things like kids being able to play at parks instead of having to hide it; these things might have had a small but real effect, it's true. But how in the world do you not mention that we could have had working vaccines in May or June if we were willing to accept a small risk on a super-proven technology (vaccine production). Or if we were willing to do challenge trials?
The things you choose to talk about might have worked or might not have; people might have been content with the slight increased freedoms mentioned and obeyed in other ways, and this obedience may or may not have had a large effect. Let's be generous - would we have seen 20,000 lives saved? 40,000?
Meanwhile we are hemorrhaging hundreds of thousands of lives because harm reduction philosophy isn't being pursued by the FDA in the slightest; we must take a year to produce and test a vaccine. We are in a world where we might plausibly need completely new vaccines to combat virus mutations, and the FDA/WHO very plausibly might make you wait another year to gain access to vaccines that are probably in existence right now, fully functional and waiting for use.
Why ignore the huge and definite benefit harm reduction philosophy promises in this case to focus on a small, uncertain benefit?
The balance between knowledge and Action
See above; same problem. Why ignore vaccines here? Why not mention the one place a better balance would be sure to produce massive benefits?
It seems like so much of the moralizing and absolutist messaging stems from the fact that US public health systems -- the basic testing, contact tracing, and quarantining-- were totally inadequate. In some areas, half of the patients reached by contact tracers give any contacts at all. Those who are told to quarantine or isolate are asked to do so voluntarily, without aid or checks to ensure compliance. Meanwhile every country that beat this virus had a managed quarantine and isolation program. In Australia, they did call and check to make sure you were isolating at home. International travelers must spend two weeks in quarantine. China built thousands of field hospital beds to isolate even mild cases. Yet at the height of the epidemic in New York, a New Yorker could get on a plane and fly anywhere else in the country without any testing, quarantining, or tracing involved, spreading the virus across America. If you were exposed and had to go to work or lived in overcrowded housing, there wasn't much help coming for you. Is it any wonder that when the basic measures of testing and tracing weren't working, health officials could only urge people to stay home harder, and wear a mask harder?
Good article. A few thoughts on vaccines and why they have not been greeted by dancing in the streets.....
- A lot of the population doesn’t believe the virus is serious, and some have behaved as though nothing is going on. Why would these people rejoice about a vaccine?
- Whoever delivers a message in America is likely to be disbelieved by 40% of the people. Trump told us we’d have mass vaccination by the end of 2020. I instinctively didn’t believe him. It turns out he was exaggerating, but not terribly. The roll-out has been far quicker than expected. But who wants to give the Trump administration credit for supporting the development of the vaccines?
- Poor messaging by Biden. He reacted to Trump’s pretense that the virus is nothing serious by saying relentlessly how awful things are going to be. This is not what people want to hear. We’ve had a long, hard year. Tell us that if we stick with this a bit longer, success is on the horizon. When you’ve been losing a game, and the game starts to turn in your favour, you don’t take your foot off the gas and let your opponent back in the game. But you also shouldn’t dwell on the negative. (The only messaging I've seen that got this right was a commercial for the Ford Motor Company. How strange is that?)
- Media desire to look for the negative. We are vaccinating 1.4 million per day. That is fantastic. We are far ahead of most countries in the world. But if you read certain sections of the media, the sole focus is on the “inequity” of who gets vaccinated before whom. Distribution has been far from perfect. But with an infectious disease, each person vaccinated helps the whole community.
- Complacency. Most of the population has little memory of times when infectious disease imperiled whole societies. We just expect these things to be fixed.