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.