Logic / Fear

I am a doctor and I do not support the widespread use of cloth masks in public, and strongly oppose a government mandate to this effect. Many of you are already looking for the biggest thing you can pick up, so before the rocks and chairs are in the air, I will try to go through this logically.

This is literally blog #7, and I am going to actually put this one out there. I haven't published the past half dozen because right now it is politically incorrect to offer a different perspective, and I have been afraid of the backlash. That right there should say something. I am now going to be brave enough to stand up for what I believe and overcome the fear of the inevitable misunderstanding and hatred. Also, my frustrations are going to clearly come through in this. They are not directed at any person but emanate from the way our interactions over social media have destroyed our ability to work together.

I am a doctor and I do not support the widespread use of cloth masks in public, and strongly oppose a government mandate to this effect.

Many of you are already looking for the biggest thing you can pick up, so before the rocks and chairs are in the air, I will try to go through this logically.

From the very beginning, I have not supported the disruption of normal life to fight a virus. I still do not. That does not mean I believe it's a hoax or a bioweapon. It doesn't mean I don't care about other people, or that I refuse even the slightest inconvenience to myself for the betterment of others. It is because I believe that more harm will come from the disruption -- even temporary -- of normal life than from the virus itself, and that we could have implemented more effective practices and policies that allow better mitigation of the threat with far fewer iatrogenic consequences. And we have got to do a better job with both the restarting and subsequent continuation of society as we know it.

We actually have an opportunity here to make things better instead of worse. Mandating the ubiquitous wearing of masks will make it worse, not better. Intelligent application of the tools at our disposal based on genuine science (not mathematical models) with an understanding of the of real-world application is a much better tactic. I suggest we try out this novel concept.

Our approach to the wearing of masks is looking to be identical to our approach to the use of quarantines, testing, and contact tracing: ubiquitous application of a facsimile.

We saw evidence suggesting that quarantines worked to mitigate this virus, so we decided we would put everyone in quarantine. Hey if a little works a little, let's try a lot! We didn't really think about the fact that there are important details about quarantines that are required to make them effective and that we couldn't actually do these things. It still looked and felt the same, so we ignored the realities and went all-in. Furthermore, we didn't take the time to effectively quarantine our most vulnerable, and we didn't do a whole lot to mitigate the irreparable harm that all of this was doing to the vast majority of people, instead lashing out at anyone who complained and accusing them of thinking only about themselves.

Now we are looking back at the way the virus got on and -- despite the fact that we have no control group to compare it to and the natural history is shaped just like every prior respiratory virus pattern -- we are congratulating ourselves on curbing the spread and using that as rationalization to kinda ignore the damage we did. And we are afraid to go back to normal life, with some even suggesting this should become the new norm.

And then there is testing. This whole subject sticks in my craw because there is constant insistence that we listen to experts and for the love of all that is holy I am an expert here. And when I tell you that there are limitations to testing you should at least offer up a few brain cells and hear me out. There are times when testing is very helpful, but there are important details that are required to make it effective and we shouldn't ignore the realities again and just go all-in, especially when -- like quarantines -- you can do a lot of harm if you do it wrong.

There is an unfortunate reality of testing for this disease which includes what we can actually do about it -- or more specifically what we can't -- that severely limits the real-world utilization. The first rule of laboratory medicine: don't order a test unless you are going to do something different because of the results. We have no specific COVID19 treatments of any kind, so testing has a very limited role. I am very sorry this fact doesn't make you comfortable, but it is what it is.

Before you belt out the battle cries "asymptomatic carriers!" and "contact tracing!" let me finish with testing:

The test we should be doing widely but stopped -- one of our biggest scientific mistakes in all of this -- is the test for influenza. We should be doing that test because (1) we actually have treatments, so we can do something different based on the results, and (2) we could be scientifically measuring the actual impact of all of our attempts at pseudo-quarantines on the spread of a virus where we have tremendous past data and the two diseases spread in exactly the same way. In short, we blew our chance to have a near-perfect control and a real scientific study instead of more facsimiles (mathematical models).

So now people want to screen asymptomatic carriers to eliminate what is widely regarded as the major source of transmission (and I am going to leave out all of the arguments against this concept, because I don't think you will accept this no matter what). When I tell you that's just not possible, the reaction seems to be to somehow make it possible. Well here is the reality we face: It's not possible. (And yes, on this, I am an expert). But... you are going to cry... this is precisely the scenario where we would do something different! So we have to have it! And others did it!

Nope, they didn't. And furthermore, you aren't going to do the other stuff like contact tracing without consent and forced quarantines, so once again, there are important details required to make this process effective, so don't implement yet another ineffective facsimile.

It's not possible because what we wish we had -- an instantaneous, inexpensive, perfectly performing test to detect dangerous asymptomatic carriers -- it doesn't exist. The test for asymptomatic people is the one where you ram the swab up into your sinus (which is not comfortable, by the way) and it is not easy to perform, easy to tolerate, rapid, inexpensive, nor perfect. The idea that we would test everyone on some regular basis is completely ludicrous. The fact that it is impossible to test every school kid in our little city even once -- that's 15,000 kids (and 1.5 million dollars) -- should be obvious. On a weekly basis? Seriously?

Thermometers have been the first line and most effective testing method in every successful model. A change in our society where we are expected to stay home when we have a fever or just don't feel well would be more effective in mitigating the spread of diseases than anything we have implemented over the past few months. (Resting heart rate remains a powerful tool we continue to ignore, but I hope to do something about that...)

There is a place for laboratory testing, such as where my father was just tested as a screen before being moved from his current home in assisted living to a memory care unit for dementia. By the way, the move was precipitated by the stress of isolation; I am not suggesting there was anything that could have been done differently, but damage is damage.

The only thing I am going to say about contact tracing is that you are getting ready to see industry try to position themselves to be able profit on the ability to track your movements, and the government is going to try to make legislation about technology that they don't really understand. (We are working on a better solution and it's tied to that resting heart-rate thing... stay tuned).

And now we arrive at masks. This one seems obvious, right? It's not a big deal, just put on a damn mask and keep everyone else safe. If this is a problem, then you really don't care about others.

Once again, it seems obvious, but it's not.

Masks are just like quarantines: an ineffective one is worse than none at all. Now I am having enough trouble explaining to some people how big a mess we made when we shut down the world, so explaining the negatives of mandating the ubiquitous wearing of masks is a tall order. But like everything else in life, these things are intertwined.

Frist, these cloth masks are ineffective. We know they are ineffective, and that's why we have never mandated them for influenza and other respiratory viruses -- even in doctor's offices and hospitals -- when these viruses kill tens of thousands of people every year. Believing they are more effective than they are leads to a very-real false sense of security, especially in vulnerable people. Am I saying that wearing a cloth mask will not in some way reduce the spread of respiratory viruses? No, what I am saying is that wearing willy-nilly cloth masks is not effective -- you need a properly designed and fitted mask to actually be effective -- and vulnerable people need to be effectively protected. Instead of having the entire world adapt to an ineffective practice that can make vulnerable people feel unrealistically comfortable and potentially lead to their getting sick and dying, I suggest we better protect the folks who need it.

People like cancer patients and others who are immunocompromised need to be protected no matter what. They need effective (N95) masks that work regardless of whatever the people around them are doing, because someone could have a raging fever from influenza and wear an ineffective cloth mask and wander about spreading that shit to everyone. It boggles my mind that the use of bandanas or home-made -- even industry made -- untested cloth masks is reassuring. And we are resisting the use of thermometers...

Now, if you are otherwise healthy but it makes you feel better wearing a mask, have at it, but I still don't like it. (That, by the way, is me allowing you to do what you want to do, even though I don't think it's a good idea). Whether anyone cares to admit it or not, the routine wearing of (ineffective) masks in day-to-day life perpetuates fear over logic. If an uncovered face elicits a reaction in you, that's a real thing. That's fear. It's also anger and resentment, and all of this is misplaced, but masks have been turned into a symbol. The wearing of a mask -- despite the real-world dangers that I have tried to explain -- is now equated with caring about your fellow man, and not wearing one clearly demonstrates you don't give a happy crap about anyone but yourself.

This mentality has got to stop. Life has to go on. Shutting down society was never the right plan, we didn't really change the natural course of this virus, and we will be a long time digging out. We have to stop applying ineffective measures to the whole world and instead cooperatively apply effective measures in the places where they will do the most good. Like reopening schools but with systems that allow our older and immunocompromised folks to effectively participate from the security of home, while kids -- who we have harmed far more than we have helped -- get to be kids with a genuine future.

I refuse to sit quietly and watch as we continue to try to force each other to do ineffective stuff instead of doing the right things for the right people at the right times. If we are going to create a new normal, then it needs to be one where logic reigns over fear.