Public health is not like medicine: It doesn't have to generate evidence

Public health need not prove itself with randomized trials -- is this idea true?

During the pandemic, the same person who says “this observational study of <insert cancer drug> can’t prove it works because of residual confounding” is happy to say, “this observational study of community masking proves it works.” Bizarre, right?

If anything the unmeasured confounders are larger with a socio/political/virtue-signaling practice (which masking has become) than a drug. But the truth is neither study is credible evidence. Both should be rejected.

I was recently speaking to someone who offered the argument that Public Health is different than Medicine. You have to act based on incomplete evidence and you can’t always wait for a trial. Naturally, we don’t always have good evidence in Public Health, but that can’t paralyze us.

First: let me assure you. The same is true in medicine. Each day there are thousands of decisions that are made entirely devoid of evidence. We always have to act based on incomplete information and rarely have a perfect trial for the patient in front of us. So the premise is wrong.

Second: the issue is not acting without data. We all forgive the initial events of March 2020. The issue is NOT EVEN TRYING TO GENERATING DATA IN THREE YEARS WHILE YOU TALK AS IF THE SCIENCE IS SETTLED. How do you explain this?

In medicine, when we give therapies without RCT support, at least we know our limitations. We spend time with patients counseling them about the pros and cons. We don’t straight up lie to patients, and say this drug will lower your risk of death 85% (without good data that is true). Kiss them on the forehead and say “shhhh question time is over”, “why don’t you trust me. TrUSt DoCTorS. We don’t want the mis-information police to come get you.”

No, we are honest about what we don’t know. And furthermore, as much as possible, we design and conduct RCTs to reduce our uncertainty. Some of us are more conservative than others, and refrain, in so far as is possible, from prescribing unproven costly drug combinations knowing the unknown risks may exceed unknown benefits. But even the most exuberant prescribers tell patients, “I gotta be honest with you, I don’t know for sure this will work”

And yet, public health is actively engaged in a campaign of lies. Cochrane reviewed masking RCTs and it is profoundly negative. In response has been a steady stream of excuses that frankly are inconsistent with how we interpret evidence.

In Public Health, the US government (CDC and NIAID) and WHO literally ran ZERO trials of community masking— for 3 years— while recommending it AGAINST pre-pandemic guidance based on NO NEW data, and then incorporated it into future guidelines. All they while they denied the data from dozens of RCTs. If you did that to a patient, they would remove your license.

Furthermore, if anything, Public Health has a greater obligation to generate data than the cancer doctor. Our interventions are done with the consent of the person, often someone dying. Each day, they feel their body weaken. Our patients are willing to take risks, after all they know what happens if you do nothing.

Public health is for average people. Many are healthy. We impose upon these people and promise them we can make them better off. We need the very best evidence before boosting a 20 year old man who had 3 doses and covid twice, and yet we get worse evidence than a drug for a terminally ill penta-refractory cancer patient. It’s entirely backwards.

The truth is public health only has a lower evidence standard because it has been in a vicious cycle of neglect. No one cares about it, so there are no research dollars. Without money, experts get used to making things up, and don’t run trials. Without money, the field can’t recruit the best talent. Because of both lack of talent and funds, the push for better standards escapes them. Had it not been for this particular virus leaking out of the la— I mean wet market— we would not have thought of public health for another 20 years.

Does public health need to generate evidence? Yes, the obligation lies with them, and if they don’t do so after 3 years, they have failed the people they sought to serve. As time moves on, and the lies become more apparent, don’t be surprised if the people come to dismantle and defund their institutions. Reduce them to rubble. Even then, with nothing, I am sure, they will still be making things up.