A Case Study in Pseudoscience
February 16, 2021
Contains ideas some people may find distressing.
The science is clear! Masks save lives/don't work! But which is it, and even more importantly how can we know? To answer this wildly contentious question - one which so many on either side are utterly convinced is entirely settled - we first have to understand why this topic has not yet even been adequately debated, much less resolved beyond dispute. Join me, if you dare, on a disturbing journey through a scientific story from the United Kingdom in 2020, a tale that centres upon the world's second oldest university, Oxford...
First, however, a polite warning. This is a hot button issue, and therefore one with a high risk of triggering cognitive dissonance in those who have committed to a specific side... But if we care about the sciences, we cannot simply consent to keeping our mouths shut rather than debating the ambiguities of a live research question, regardless of how much of a minefield it becomes. In so much as the truth about this topic is currently known, the only two certain claims I can ascertain are that there is not enough good quality evidence to settle the debate definitively, and there is no longer even anything that might be called a debate, since both sides are now intractably locked into their beliefs. This kind of situation is a paradigm case of what I have called pseudoscience, the collapse of even the possibility of productive scientific work occurring.
Our story begins relatively early last year, as thousands of armchair epidemiologists took to social media to declare what was or wasn’t true on a great many topics that were far more complicated than anyone seemed to realise. A great deal of that complexity comes from the fact explored last week, namely that the sciences are discourses, series of conversations via written texts. This has the unfortunate consequence that the act of interpreting the evidence is seldom as simple (as the armchair epidemiologists apparently believed) as sifting out the ‘good evidence’ and discounting the ‘bad evidence’ - and doubly so since the evidence that is rejected in such a procedure is very frequently cast out as a result of confirmation bias rather than for any sound reason.
Not long after the social media platforms began to descend even further into a verbal war zone, severe disagreements broke out in the United Kingdom between medical researchers and practitioners about a newly proposed medical intervention for COVID-19, namely community masking. It's important to make a distinction here: use of personal protective equipment in hospitals is radically different from asking the population as a whole to deploy face masks; there are disagreements about the former as well as the latter, but since our interest in this case study is not in resolving these disputes but rather in examining them, it will be helpful to recall that the question that was being debated in the UK was not 'are face masks ever effective?' but whether we should require the general population to wear face masks to help stop the spread of the SARS-CoV2 virus. It was over this discussion specifically that medical scientific practice almost entirely collapsed in the UK.
The crisis point can be traced to a pivotal moment in June. Two months earlier, Trisha Greenhalgh of Oxford University and half a dozen other medical professionals had argued in a piece for the British Medical Journal that while “direct, experimental evidence for benefit is not clear cut”, we should follow the precautionary principle and recommend face masks for the public all the same. Intriguingly (and this will be important later), they also made the following remarks:
...trials have shown that people are unlikely to wear them properly or consistently, which is important since prevention depends on people not repeatedly touching their mask, and on all or most people wearing them most of the time.... the trials cited above have also shown that wearing a mask might make people feel safe and hence disregard other important public health advice such as hand washing and social distancing...[these] arguments may have been internally valid in the trials that produced them, but we have no evidence that they are externally valid in the context of covid-19. “The public” here are not volunteers in someone else’s experiment in a flu outbreak—they are people the world over who are trying to stay alive in a deadly pandemic. They may be highly motivated to learn techniques for most effective mask use.
In June, Professor Greenhalgh and her colleagues returned to follow up on their original piece. There had been enormous swathes of comments in the meantime, and heated arguments about the risks that might potentially be involved, not to mention how this proposal could be justified in terms of the precautionary principle, which cautions doctors not to use unproven interventions about which there is a potential risk of harm. Surprisingly, in responding to their critics the authors did not engage with any of the concerns that had been raised. Rather, they declared the myriad objections colleagues had presented as “straw men” (misusing the term, incidentally) and announced that the UK ought to do what they had suggested anyway. A week later, the UK government mandated community masking by law, with escalating fines for non-compliance. This led the Centre for Evidence-based Medicine (like Greenhalgh, also based at Oxford University) to run an unprecedented opinion piece denouncing the decision as politically motivated and scientifically unsound. From that point on, the outbreak of pseudoscience corrupted the discourse and little productive discussion on this topic has yet re-emerged.
An interesting aspect of the CEBM’s rebuttal was that it was entirely couched in terms of how the research had been conducted up until the year before, and the lack of strong supporting evidence - including mentioning the calls that had been made for further research on the efficacy of different kinds of face mask after previous epidemics that had never been followed up. Even if the CEBM's response was marred by the kind of righteous outrage that also corrupted discussion on social media, it is clear that (at the very least) they understood the role of the discourse in validating scientific claims, and saw the risks involved in pretending there was no prior understanding on the topic that might have made certain advocates of community masking more cautious than they were. In the sciences, scepticism can be both a blessing and a curse, but the absence of adequate scepticism - or the refusal to listen to it - almost always heralds mistakes, and sometimes disastrous errors. It is why allowing disagreements is essential to the work of the sciences, and every attempt to prevent such arguments from taking place fosters pseudoscience.
It is worth pausing briefly to point out that when I claim the medical discourse in the UK devolved into pseudoscience over this issue (and a parallel argument can almost certainly be constructed for the US, but I have spent less time examining the discourse there) I am not making any kind of claim about the truth of the competing claims about community masking. From the UK perspective, one side came to the table with a hypothesis that this intervention would be effective at preventing the spread of a respiratory virus, acknowledged the evidence they had at the time was inconclusive, recognised some of the specific risks involved in pursuing this intervention but claimed that - as a precaution - we ought to adopt the community masking anyway.
The positive argument made for the intervention was essentially ‘it might save lives and we might avoid the known harms so we must do it’. Yet as a purely logical matter, this is poor reasoning, and as a medical question the precautionary principle could not plausibly be applied on this basis (as some pointed out at the time, it cautions the exact opposite of what was done). Thus right from the outset, the necessary discussion on the topic was on dangerous ground. But this certainly does not exclude the possible benefits of community masking; rather, what was indicated was an urgent need for trials to establish the balance of benefits to risks. In ignoring the ambiguous state of knowledge regarding the potential harms, the discourse failed and we entered the condition of pseudoscience.
If we had remained in a state of productive scientific discourse, what should have happened next was commissioning studies to gather evidence to resolve the ambiguities. Yet this did not happen, and still has not happened, and it is incorrect, as British evidence-based medicine practitioner Margaret McCartney shrewdly observed, to claim that the evidence could not be gathered because it would be unethical to do so:
Another argument is that large scale trials, say of face mask use in schools, are impossible, because of the belief that every child would need a guardian to consent, making recruitment practically impossible. But this is deeply problematic. This suggests that the government can choose and implement any policy, without requiring any individual consent, as long as it is not called a trial. For as long as this double standard is allowed to persist, giving less powerful results and unnecessary uncertainty, people may come to avoidable harm. Nor does valuable information come only from randomised controlled trials. Complex interventions require multiple disciplines and types of research for assessment. But where are they? [Emphasis added]
Furthermore, it is rather strange that Greenhalgh and her colleagues specifically identified a key risk associated with mask use (touching an infected mask - see the quotation above), but set this aside by claiming that the public would be “highly motivated to learn techniques for most effective mask use.” Yet the British government provided negligible guidance on effective mask use to the public. Considerable expense was put towards promoting the idea on television and other media that the British public should wear masks, but almost none at all on what good mask technique ought to consist of. Notes on the government website, however, did provide numerous important warnings - about not re-wearing used masks, about storing used masks in plastic bags etc. - none of which I have seen practiced by anyone but myself in months and months of government-enforced mask wearing. Nor were any studies conducted to even check the quality of the mask technique that was occurring in the community! Once the law was passed to mandate face masks, even those concerns openly acknowledged by the medical professionals who had called for community masking in the UK were simply ignored.
If you had suggested to me in 2019 that the British government was going to mandate a medical intervention on weak evidence and then commission no studies to verify either the efficacy or the safety of that intervention I would have at the least raised an eyebrow, and at the worst asked what you were smoking. Yet this is precisely what happened. The entire affair has caused me quite considerable distress, not because I know the truth of the matter (community actions are far more complex research subjects than most people seem to realise), but because I would never have believed in 2019 that it would take just eight weeks to disrupt the capacity for the medical networks of the United Kingdom to act as scientists, nor that anyone would propose to use the force of law to compel everyone into a medical intervention the case for which had never even been adequately debated, let alone investigated. It is doubly amazing to me that anyone can use phrases like “following the science” or, worse, “the science is clear!” in a situation where the truth is that the required scientific work has not yet been adequately conducted.
The concern I am raising here is rather independent of what transpires to be the truth about community masking if and when scientific discourse is restored. Even if future evidence did eventually validate the hypothesis, it would not change the fact that the British government acted improperly by enforcing penalties by law for non-compliance with an intervention they apparently had no intention of confirming was effective, nor indeed of ruling out the possible health risks suggested by earlier mask studies - perhaps most significantly that cloth face masks, improperly used, might increase the rate of infection (as the CEBM commentary points out, and as Greenhalgh and colleagues acknowledged was a risk). There was more than enough evidence in April to formulate a hypothesis, but nowhere near enough to settle the issue unequivocally - as indicated by the fact evidence-based medical practitioners in both England and Scotland publicly spoke out against both the lack of good evidence and the abject failure of the British government to commission any new studies to gather it.
I can think of no better name for this depressing collapse of the medical discourse in the UK than pseudoscience. This condition destroys the ability of the sciences to operate by undermining our capacity to disagree, which is fundamental to the pursuit of scientific truth. What's more, once this situation occurs, the problem is no longer constrained to the topic that initiated it, and alas creates ample opportunities for unscrupulous people to manipulate the truth for personal profit while the scientific networks are effectively disabled. Thus in November 2020, the British Medical Journal's Executive Editor Kamran Abbasi issued an unprecedented editorial about the suppression of scientific research in the UK's most respected medical forum declaring:
Science is being suppressed for political and financial gain. Covid-19 has unleashed state corruption on a grand scale, and it is harmful to public health. Politicians and industry are responsible for this opportunistic embezzlement. So too are scientists and health experts. The pandemic has revealed how the medical-political complex can be manipulated in an emergency—a time when it is even more important to safeguard science.
This is not some off-the-cuff remark by an armchair epidemiologist on social media, this is the Executive Editor of a major British journal issuing an editorial for the express purpose of lambasting the British government for "state corruption on a grand scale" and "opportunistic embezzlement", this latter point relating to the news story (reported in October by the BMJ) that the government had handed out contracts without tender for face masks and other protective equipment, some of which was not even fit for purpose. (I note for context that Abassi appears to have remained agnostic about community masking - although not about Facebook censorship over the issue). How curious that this serious breakdown in scientific discourse did not even warrant a mention in any British news source! But then, each of the channels, each of the newspapers had already picked a side on the face mask issue, so they simply ignored and discredited any and all contrary viewpoints... thus the journalists followed the scientists into pseudoscience too, if they did not in fact lead them into it.
Logically, if the US medical community had not descended onto this crooked path immediately beforehand, we would be hard pressed to explain how this could have happened in the UK at all (it is exceptionally unusual to argue to undertake a precautionary measure while admitting the evidence for it is still inconclusive, for obvious reasons). However, since I have not examined these earlier discussions in any great depth, I leave it open whether there might be some other explanation besides the most obvious one, namely that the UK's pseudoscience outbreak was caused by a metaphorical infection of human thought that spread from the other side of the Atlantic where political partisanship had already destroyed any possibility of clear scientific thinking at a time when it was most needed.
Hence the epidemic of armchair epidemiologists who dealt with every contrasting perspective by the expedient means of summarily discounting the views of anyone who disagreed with them. Yet for their chosen position to be in any way credible, these partisans still have to explain why they have needed to discredit so many people who are well-versed in the medical sciences. As this UK case study hopefully makes clear, whichever stance is taken in 'masks save lives/don't work', at least one senior academic at the prestigious Oxford University, plus hundreds more academics at other faculties around the world, will be on the other side. How far are you willing to go in your crusade of denouncements and discreditings just to uphold a specific interpretation of the still-ambiguous evidence as being both clear and irrefutable? Will you say that their political beliefs misled them, while yours miraculously had no effect on your truth-finding powers...?
Accepting this as an outbreak of pseudoscience, on the other hand, provides both an explanation for this otherwise incomprehensible lack of collective discernment, and a potential solution as well: restore debate over the key disagreements, and either conduct the required research or entirely withdraw the legal requirement for community masking in the UK (or wherever you happen to live). Without embracing dissent, there can be no legitimate scientific position on community masking at all, only the counter-productive war of bias-against-bias I have named pseudoscience. The sooner we accept this, the fewer lives we will lose to these two infections - the deadly SARS-CoV2, and the even deadlier outbreak of pseudoscience it has fostered.
As long as we pretend that this issue is resolved beyond further dispute, rather than trapped in a limbo where such resolution is impossible to reach, the more people will die who did not need to. Not because some people wouldn't wear masks, but because we have collectively destroyed the ability of the sciences to do what they do best: to investigate ambiguous situations and explore all the possible explanations for the evidence gathered thus far. The science is clear? No, it almost never is. But our guilt in undermining the work of the sciences is all too clear, and for this I fear we should all feel greatly ashamed.
Comments welcome, but please don't comment angry! If this piece enrages you, please wait a short while before replying.
I've read this as thoroughly as time permits which is to say not remotely as thoroughly as it deserves. If I understand your argument it is that not only has insufficient science been done to determine the issue of community masking but that the government have actively suppressed attempts to do such science. They have made a determination, based on their own preferences, and delivered it Fait Accompli?
Posted by: Matt Mower | February 16, 2021 at 11:16 AM
Um, 10 seconds review of Google found ...
And surely dozens of others. Not to mention ...
I think there is plenty to question and debate, but in the middle of a pandemic, urgent action is required to save lives, and in that case you error on the side of most likely science, you don't wait for settled science. Furthermore, some "debates" are just political attacks meant to sow confusion, not honest attempts to exercise actual science. There is no debate on whether Idaho exists, and anyone who insists on debating it is just trying to create a "he said / she said" political argument.
For "Idaho", read: HIV causes AIDS, Trump lost the election, the American Civil War was fought over slavery, American school shootings actually happen, the Holocaust actually happened, etc. We have to come up with a unifying and easy to reference term to label "arguments created for the sake of sowing hatred or confusion". Of course, which arguments are these kinds of arguments is an argument, which is why they are so insidious. Refusing to engage in such arguments is not simply an attack on free speech or science.
Posted by: Yehuda berlinger | February 18, 2021 at 01:01 PM
Hi Matt and Yehuda,
Matt - I really don't know how it was that Greenhaigh et al's case was taken up by the government, but I know that after they took it up, they didn't do any of the things that their original paper implied. Reading between the lines, the admissions in that first paper were the result of input from their peers, and were included on that basis. As such, ever since the decision was made to adopt community masking in the UK, the topic was treated as closed. As this piece explains, this was wildly shy of responsible scientific behaviour - much less "following the science", which has been Boris' wildly dishonest mantra...
Yehuda - Last year, I spent 120 hours researching community masking (although some of that time was also researching influenza-like infections and the polymerase chain reaction); I believe I have read everything that was published up until November 2020, and most of the key publications since (I am still waiting on the results of one major study, the Guinea-Bissau research, due this Summer). It is certainly possible that community masking could be conducted in a way that would be effective (the lab studies hint at this possibility), but it's also possible that it could make matters worse (the field studies warn of this risk), and the body of research so far does not allow this issue to be resolved definitively, as this piece states.
Now the fact that you begin your rebuttal by saying "Um, 10 seconds review of Google found..." tells me two things: (1) that you come to this piece having already made your decision as to the truth about community masking and (2) you think there is some epistemic weight to the top search results on Google. I would definitely discourage you in respect of (2); on (1) that's your own business. As for the specific papers you found, I've seen all of these, and quite a lot more, many of which get very low search engine rankings on Google.
Now I can't know that I haven't made a mistake doing my research, of course... but uncovering any mistake I may have made will involve much deeper engagement with this topic than a quick search on Google, especially since whatever the truth on community masking may transpire to be, it will not change the essence of this essay one jot. If you actively wanted to investigate this topic further, I would be glad to share my paper trail and how I ran my research programme (I started by looking at the disagreeing sides and the papers each was citing, and then expanded the references from there) - but if I am correct that you have already made your decision on the efficacy of community masking, there really would be no point, would there? For you, the matter is already closed.
"I think there is plenty to question and debate, but in the middle of a pandemic, urgent action is required to save lives, and in that case you error on the side of most likely science, you don't wait for settled science. "
If you (or anyone else) wants to rush to a conclusion based upon an incomplete evidence base, you can certainly do that; it's a perfectly human thing to do, and we've all done it for something I'm sure. What we ought not to do, however, is use the legislature to impel everyone to do what we have decided and then perform absolutely no research to verify that this was the right course of action. That's what the British government did. And it is an unforgivable disgrace.
I am aware that masking opponents have said some bizarre things. But the truth of any claim is never determined by establishing the insanity of some of its opponents' claims, and any attempt to walk this path becomes rapidly problematic. From my vantage point, both sides in the public non-debate have said some truly bizarre things. But I do not discount either claim on this basis. To do so would be irresponsible. My interest is the state of the research and the surrounding discourse, not the general insanity of humans, which was never in doubt.
This piece traces the research discourse on community masking in the UK, and its descent into what I call 'pseudoscience'. The conclusions I make here do not obviously seem to depend upon what is eventually determined about community masking once the research community as a whole returns to conducting scientific work collectively (which I hope and trust it eventually will). What is at task here is what was done in the UK and why. If you, or anyone else, come at this piece from the position of 'the likely interpretation of the evidence is that community masking works therefore the British government were right not to conduct any research on the efficacy of community masking after enforcing it by law', then I must point out that this is an extremely bizarre position to take up, and asserting crisis-conditions only makes it more strange, not less!
Do you not think it an odd kind of scientific position where what must be done is avoiding conducting the research that might establish the truth of the matter...? I believe this unfathomable doctrine of intentional ignorance is the one that bests deserve the name 'pseudoscience'.
Thanks for your comments,
Posted by: Chris | February 20, 2021 at 11:40 AM
Awesome paper, congratulations
Situation is exactly the same here in France and I fully understand and support your idea. It would be interesting to examine the psychology of those people in charge scientifically and politically, in a situation of stress due to a major crisis. They are not great entrepreneurs or great generals, able to conduct smart analysis and take clear action under the big stress of an unexpected and uncertain situation.
Posted by: Sébastien Chaume | February 22, 2021 at 11:21 AM
Thanks, and I agree that we have to be open to science telling us otherwise.
I think we have non-science people shouting against science (the insanity, as you say), and the counter reacting government shouting their message louder than these insane people, which makes them a bit insane, too.
Which is a shame, because science should not be based on who shouts loudest.
No, I haven't made up my mind, but what I am hearing (from the shouting) is that masking should be stronger, if anything.
Posted by: Yehuda Berlinger | February 23, 2021 at 06:42 AM
Hi Sébastien and Yehuda,
Thanks for continuing this discussion.
Yehuda: The issue is a mess, and that's why I felt it would be helpful to look at a specific incident of how the issue has been discussed in the scientific community, and the problems that this exposes.
Have you seen the ECDC report? This is the most recent summary to be published:
Here's the overall statement of findings from the report:
"The evidence regarding the effectiveness of medical face masks for the prevention of COVID-19 in the community is compatible with a small to moderate protective effect, but there are still significant uncertainties about the size of this effect. Evidence for the effectiveness of non-medical face masks, face shields/visors and respirators in the community is scarce and of very low certainty. Additional high-quality studies are needed to assess the relevance of the use of medical face masks in the COVID-19 pandemic."
That's consistent with what I found in my investigations; there is evidence that masks can provide a prophylactic effect, but the evidence is still scarce and needs some robust high-quality studies. Any country - such as the UK - that mandates masks and does not conduct research as to effectiveness cannot reasonably claim, as our prime minster likes to put it, to be "following the science". Rather, they are refusing to engage in scientific activity at all. :(
I hope the situation is not as hopeless where you are!
Sébastien: I don't know whether to be heartened or depressed by the news that the situation in France is similar to that in the UK! And I agree with your assessment that the skills required to become elected as political leader of a nation do not in fact prepare you to deal with these situations where the ambiguities are enormous and the risks significant.
My overall impression, though, is that the method of having a think tank of scientific advisers attached to government is problematic because the power of scientific work is a product of cybernetic connectivity between researchers who must be free to disagree and argue their positions. Since political rhetoric requires taking up a position and staunchly standing behind it there is a serious problem when we try to integrate the sciences with politics - a theme that your fellow French citizen Bruno Latour warned us about a few years back. Alas, very few people seemed to pay much attention to that part of Latour's work, and although I did (it influenced my work in Chaos Ethics) even I did not anticipate the scale of the problem this issue could represent in a time of declared crisis.
Many thanks for your continued support!
Posted by: Chris | February 24, 2021 at 08:08 AM
An Update on Face Mask Research
It has been over a year since mask mandates were enacted in the UK... SAGE, the 'expert panel' assembled to advise the British government over the course of the SARS-CoV-2 situation has in this time commissioned zero research on the efficacy of face masks in the UK, and neither have they (as far as I can tell) reviewed any of the new evidence that has come in over the last year.
This is a definitive case of the state of pseudoscience discussed above - the disruption or denial of the scientific cybernetic network's power to solve problems through the slow and careful accumulation and interpretation of evidence. The British Prime Minister, Boris Johnson, has declared that the government's credo is "follow the science". But this position is ludicrous and risible. The Johnson government - aided by our utterly ineffectual opposition party - have, in fact, collaborated to all but destroy scientific discourse in the UK.
I would like to update the state of the evidence on face masks, and not-so-briefly discuss the implications of that research, since at this point I contend that there is only one interpretation of the evidence base that can plausibly explain all the research results acquired so far. Every alternative interpretation now has problems explaining one or more aspects of the evidence base, and should logically be rejected, always assuming logic is something we still value.
Before I start, I would like to state what my position on the topic was during Summer 2020, when I first tried to discuss this topic on social media. At this point, there were already two folk science camps, which I will call the Pro-Maskers, whose rhetorical battle cry was "Masks save lives!", a claim that is somewhat true but rather misleading, and the Anti-Maskers, whose rhetorical war cry is "Masks don't work!", a claim that is rather misleading but also somewhat true. I call these positions 'folk science', because whatever the rhetoric asserted, neither camp could truly offer a scientific conclusion at that time.
All scientific claims are ambiguous until resolved through the application of both research and the discourse (and thus disagreement) that goes with it; in the absence of this, there is only 'folk science', which are not unscientific positions (although they can trigger the state of pseudoscience when wielded politically) but merely weak scientific positions embedded in a popular community of discourse. It is arguably the purpose of scientific practice to strive to distinguish between competing folk science explanations by acquiring and interpreting research evidence, and as such folk science is an important part of the work of the sciences. What it should never become, however, is a surrogate for scientific practice itself.
Knowing that folk science is only the starting point for research problems, I rejected the positions of both camps in the Summer of 2020 as far too hasty. The evidence base then was exceptionally weak, and only two major studies had been commissioned at the time, the DANMASK-19 study (completed in November 2020), and the Guinea-Bissau mask study (due in August this year). Indeed, the evidence base during Summer 2020 was such that the only position a scientifically minded person could reasonably take is the one that every respiratory virus face mask study up to the end of 2019 had taken: further research is needed.
So I took up a position as follows:
- We needed to do research on the efficacy of face masks, and the conditions on the ground were ideally suited for this research, since face masks are widely deployed but there was no clear evidence of their efficacy and therefore it could not be claimed to be unethical to run A-B trials (unlike requiring everyone to wear face masks and not gathering evidence, which would under any pre-2020 ethics framework be seriously unethical, and arguably illegal).
- I did not deny that certain face masks, properly used, could have a prophylactic (protective) effect; however, it was not clear under which circumstances they would be protective, nor whether they could provide any benefit with SARS-CoV-2 in a community context, rather than in a clinical setting (e.g. a hospital).
- The 'source control hypothesis' supported by the folk science of the Pro-Maskers depended either on producing direct evidence of its plausibility, or upon theoretical support that could only come by demonstrating that the micro-droplet route of transmission for SARS-COV-2 was more significant in terms of infections than the aerosol route, since the kinds of masks being suggested for deployment (especially in the context of cloth masks) could be effective against micro-droplet transmission but not against aerosol transmission.
I believe in taking up these positions I was being a responsible scientist, or at least a good friend to the sciences. I cannot honestly see how anyone could argue against this claim, at the very least.
How did the Pro-Masker camp reach its conclusion that face masks were effective against SARS-COV-2 transmission? It was not on zero evidence, but as the piece above traced it was on weak evidence, of which there were three elements:
- Lab studies on micro-droplet transmission showing a reduction in SARS-COV-2 markers when a surgical face mask or cloth mask was inserted into a contaminated air stream.
- Computer models showing that if the face masks were effective in reducing the risk of infection (which the lab studies didn't demonstrate, but which indicated a possibility requiring further investigation) then face masks would save lives (this appears to be the source of the Pro-Masker war cry).
- Infection rate studies on the introduction of mask mandates. These did demonstrate an effect of some kind - the clearest by far being the Canadian studies, because mask mandates were brought in at a separate time to other interventions. The quoted effect size was 40 (which is very large).
Critics of the mask mandate evidence, including Oxford University's Centre for Evidence-Based Medicine, pointed out that there are very poor controls in studies of these kind, making it difficult to prove a causal connection. Medical research usually solves these disputes by resort to random-controlled trials (RCTs), but only two (mentioned above) were commissioned anywhere in the world - already a sign of how widespread the state of pseudoscience had become. It was my view that the failure of any mask mandate study to control for footfall (by far the most parsimonious explanation available) was a serious flaw in every one of these studies. So I called for more research. That, in fact, is what any responsible scientist should have done in that situation.
The DANMASK-19 study set as its hypothesis the same effect size suggested by the mask mandate studies. It was the largest RCT trial of face masks ever conducted. When the research was completed in Autumn 2020, it was rejected by three journals each of which, in terms of scientific practice, acted improperly in so doing. Since this study was scrupulously constructed by experienced researchers, I very much doubt there were methodological reasons for these rejections. It seems far more likely that these journals had adopted political positions based upon the Pro-Masker folk science and did not want to publish any study that went against their commitments. The study was eventually published, although a line was added to its text saying that this research did not test the source control hypothesis. The authors mentioned regarding this point that they could not even imagine an experiment that could test this hypothesis - which is something of a warning flag in itself. The study results, having tested solely surgical masks in a community setting, showed no statistically significant effect. Community masking was not effective.
At this point, what should have happened was a re-evaluation of the evidence. This did not happen, alas, largely because of the sheer political power of the Pro-Masker camp at this time. In fact, at this point we could arguably eliminate the 'source control hypothesis' based on the evidence available at that time, with a fair degree of confidence. This is because we had strong evidence that the effect size was not what the mask mandate studies suggested, and furthermore we knew from the computer modelling that if the effect size of community masking was statistically significant, the infection rates in countries or states which had adopted this intervention would have deviated measurably from those that did not. The evidence did not in fact show this. Although the infection rate data was weak evidence (like the mask mandates) because they were prone to confounding factors, examination of the rates of infection could not demonstrate any significant effect and still has not.
Did the DANMASK-19 study end the 'source control hypothesis' as a legitimate scientific option? No, not at all. But it set a limit on the effect size that could be associated with it, and arguably this revelation should have constituted a scientific reason to end mask mandates at that point until such evidence could be gathered to justify its continuation, since at that point, there was no such evidence and (crucially) none coming, since the Pro-Maskers had commissioned nothing, and in many cases had actively argued that calling for more research was unscientific (a very odd position, only explicable in terms of the state of pseudoscience having become entrenched).
Were it not for the political imbalance between the Pro-Maskers (who enjoyed the unalloyed support of major tech companies - Google, Facebook, Twitter etc.) - not to mention the Trusted News Initiative formed to combat Donald Trump's "fake news" (i.e. BBC, Reuters... and of course Google, Facebook etc.) - this development would have required either immediate further investigative studies (which really should already have been done) or the discontinuation of the mask mandates. Of course, what actually happened was neither.
But the scientific research community, despite being driven nearly underground by political pressures, did not stop investigating. And naturally, since the Pro-Maskers commissioned nothing, nothing came to strengthen their position.
A key piece of research landed in early 2021. Julian Tang, Linsey Marr, Yuguo Li, and Stephanie Dancer investigated the question of micro-droplets versus aerosol transmission and took a deep dive into the literature on this topic to uncover how this split was originally defined, and what the implications of that decision were on contemporary research. You can read a neat summary of their findings in this British Medical Journal editorial from April 2021:
...but to save you time, here are the key points:
In other words, the only viable masks that can provide adequate protection against SARS-COV-2 are properly fitted masks, such as FFP3 masks, which come with a filter. (This filter will be important in a moment.) Does the evidence support this? Yes, it does. As Jacqui Wise reported on key research for the BMJ "the introduction of FFP3 respirators provided 100% protection (confidence interval 31.3%, 100%) protection against direct, ward based covid [sic] infection."
Now this is actually a point in favour of the "Masks save lives" claim - the correct kind of mask, used correctly (a non-trivial point) can save lives. But it is now completely ludicrous to suggest that any kind of mask can save lives. The studies mentioned above demonstrate that neither surgical masks nor cloth face masks are effective for personal protection, and also that the 'source control hypothesis' is highly likely to be irrelevant if the only masks that can be deployed as effective personal protection are those with filters, since the wearer of such a mask could not possibly protect others around them as their outgoing breath is not being filtered. This should have been more than enough to end the mask mandates, all things being equal, but alas, I greatly fear that nothing and no-one is equal any more.
It is worth mentioning here that the Pro-Masker camp committed a significant error in judgement by suggesting that community masking had no side effects, and therefore had no associated risks. The greatest risk in fact was arguably the one that I wrote about in the above piece - that fighting over face masks (the least important of the non-pharmaceutical interventions) would prevent adequate discussion of long-term lockdowns (by far the most damaging of the non-pharmaceutical interventions, based on the evidence accumulating since January 2021). In this regard, the WHO reported that 1.2 million people died 'as a secondary consequence' of COVID-19 in 2020 i.e. as a result of the disruptions caused by the various interventions deployed against SARS-COV-2. What a shameful and depressing disaster this has been!
Despite the presumption of a lack of harms associated with face masks, the literature on the negative side effects of community masking has become substantial. Kai Kisielinski, Paul Giboni, Andreas Prescher, Bernd Klosterhalfen, David Graessel, Stefan Funken, Oliver Kempski, and Oliver Hirsch report that:
There has also been an RCT on face masks deployed for use by children conducted by Harald Walach, Ronald Weikl, Juliane Prentice; et al, that reports:
So it turns out that "Masks don't work!" is misleading since in fact "Masks save lives" if you are deploying suitable fitted masks to health care workers in a clinical setting. But face masks can cause significant health harm in other contexts, especially when used with children, and in these wider contexts "Masks save lives" is completely unsupported by any evidence at all. On the whole, I'd say neither of those two folk science positions has been very helpful in dealing with the problems and complexities of the community masking problem, but in not commissioning any new research at all the Pro-Maskers gave up any claim to scientific legitimacy - let alone "following the science".
At this point, the Anti-Maskers might try to claim victory and declare they had "the science". But nobody has "the science"... "the science" is just another name for Magical Science, which is far more a mythos of faith in technology than any aspect of scientific practice (it is almost precisely what I called 'cyberfetish' in Chaos Ethics). Despite how it sometimes feels, it simply does not matter whose assertions align with the conclusions reached after analysing the research if our interest is who had the scientific high ground: you are not 'right' because you reached your conclusion prematurely, you are only 'right' in terms of scientific practice if you asked for more research. That was the only correct position anyone could take up on face masks last year: conduct more research. If you did not ask for this - regardless of the specifics of the position you took up - you were to some degree 'anti-scientific'; you supported the state of pseudoscience instead of scientific practice.
In this regard, my heart sank when the British Medical Association suggested to the British government the need to extend masking after so-called "Freedom Day" on 19th July 2021. Not because they were wrong, although I think it quite clear at this point that their position is not well supported by the evidence, but because of what it says about the nation of Isaac Newton, Mary Anning, Charles Darwin, and Ada Lovelace, about how far we have fallen from the ideals of scientific practice. We no longer believe in research as a method of securing the truth. We have abandoned the core principles of scientific practice.
I have spent a year investigating face masks. There is only one study left to arrive at this point, the Guinea-Bissau study on cloth masks. But even without this study, there is sufficient evidence at this time to conclude that mandatory community face masks should be discontinued. We ought to remove any legal requirement to wear a face mask outside of a clinical context, and leave it as a matter of individual conscience whether to wear a mask or not.
But whatever position you take up on face masks, I will fight to the death to defend your freedom of belief in respect of this or any other issue. Yet if you propose to enforce your beliefs upon others against their will, I must oppose you, and anyone else who turns against equality and democracy in this way.
I will not stop you wearing a face mask, if that is what you wish, although if you wish to do this to protect yourself from SARS-COV-2 you should make sure you have a properly fitted FFP3 mask, since nothing else has been demonstrated to be effective. Whatever you decide to do, please do not ask me to betray my scientific commitments by expecting me to wear one for your benefit. The evidence at this time overwhelmingly suggests that my wearing a mask is not measurably to your benefit at all, it is solely to my detriment. Please afford to me the freedom to choose which medical interventions can be applied to me, a freedom that only a few scant years ago we all held dear, back in the dim and distant year of 2019, before the Enlightenment came to its crashing and dismal end, and scientific discourse was driven underground.
With my thanks to every scientist who pursued research on these topics at a time when to conduct such research was to put your own career in jeopardy. You are all scientific heroes in my eyes.
Posted by: Chris | July 17, 2021 at 10:10 AM