When we doubt the guidance

This spring I went to a conference and it stressed me out. I was on edge the entire time. Maybe one in 10 people were wearing a mask. And we were in a major Canadian city. A city that was not low transmission. In fact, that month, Canada was deep in its sixth COVID wave, a bad one. Hospitals were nearly full and doctors were frantic.

At the conference, people seemed to be reassured by two things. 1) The province had dropped its mask mandate, and 2) everyone attending had to do an antigen test to get their conference badge. Now, I know the flaws here. I know the mask guidance doesn't actually match the outbreak data. I know you can test negative on your antigen test and still have COVID and be contagious. Or you can get infected and become contagious right after you take your test and you’ve already collected your badge. Does no one remember Kim Kardashian’s private island birthday?

However, other people don't know what I know. Normally, that would make me sound like a jerk. I realize that. But this is a public health crisis. My education is in public health. I'm allowed to say it this one time. Other people don't know what I know. These other people are highly educated - engineers, venture capitalists, major philanthropists, software developers. Heck, even astrophysicists. These are people who know how to look at data.

They are not looking at the data, though. They're looking at the guidance. They trust in the guidelines and they're following them. They're treating the guidelines as hard rules. The problem is these kinds of public health guidelines aren't best practices, and they aren't hard rules. They're the minimum achievable standards. The minimum standards that local officials think that they can get everyone to adhere to. They're not what you do if you want to be as safe as possible. Educated people read the guidelines and do their good faith best. But they're basing that good faith on what is frankly bad public health advice.

One of the things I did at the conference: every time I met another global health person, I asked them a question: what’s up with the CDC guidance on masking and quarantine? No one could defend it on public health grounds. Nobody thinks that CDC is giving good advice or communicating well.

This leads me to a question. People who have my education, or work background - public health people. What's our job here as professionals? What's our job and what's our moral responsibility?

In the United States, the CDC guidance in spring 2022 is both confusing and of poor quality. As public health professionals, is it our job to clarify the CDC guidance so people can understand how to follow it? Because people can't follow what they don't understand. If public health professionals step forward and clarify the CDC instructions, at least the population can follow those instructions consistently.

Or is it the job of public health experts to criticize and question the CDC guidance?

Dear Pandemic, a website that I've liked a lot has taken the CDC translation approach. They've got plenty of public health experts with better expertise than me. Economist Emily Oster is doing the same thing. She's explaining CDC guidelines. So is the Johns Hopkins School of Public Health, which was ranked #1 school of public health in the country -again- this year.

And, of course, it's the approach that I took in my 2020 talk at TEDx SMU. There’s a safety factor, and there’s an avoiding hubris factor to simply referencing the experts. When you quote the CDC, you're citing the most recognized official guidance. Serious people have come together to think seriously and then they've come up with their best instructions - their best information. Who am I to second guess that? One random person with a master’s degree? That’s the hubris factor. What’s the difference between second guessing CDC guidance and an anti-vaxxer? No one gets to invent their own science based on intuition.

If you stick to interpreting and sharing the official guidance and the official guidance is wrong, it's not on you. You listened to the experts. That’s the personal and emotional safety factor. Harm is done, and you were part of it, but you didn’t cause the harm. If you strike out on your own interpreting things and cause harm, that’s 100% on you. You caused that.

What I tell myself when I think about my TEDx SMU talk, by the way, is that COVID was so new. There's no way I could develop granular expertise fast enough to have my own take on things. I am not an epidemiologist or an infectious disease expert. My focus is on health systems and delivery. I didn’t try to become an expert in time for the talk. Instead, I looked at what the WHO was saying and I looked at what CDC was saying. I put that together with the things that I know about international health and inequity, and I created a talk.

The parts that were based on my own expertise, the international health equity parts - I stand by those. The parts that were based on WHO and on CDC; those are frankly less good. I'm still grappling with exactly what that means and what my culpability is.

I guess that's my way of saying I remember the debacle of the advice about masks. I remember the initial “don't take the masks away from health care providers,” like we just forgot that masks are easy to manufacture and if people bought more supply would increase.

In my opinion, if I - and dozens of other public health communicators - had really thought through the earliest mask guidance, things would be different now. We just assumed the CDC and WHO knew what they were doing.  If we’d seriously thought about it, like Zeynep Tufekci did, we would have realized the guidance was wrong. We would have been able to tell people to start masking sooner. Thus saving lives and preventing infections.

This brings us to today. Almost every public health professional and health care provider I know thinks this CDC five-day isolation period is just plain wrong. We think this community levels approach of measuring transmission severity according to hospital occupancy is wrong. We think the masking advice is wrong.

If you're inside put a mask on. Please.

People are talking about this on Twitter, which is technically in public. But should we be? Should we be saying this in public? Should I be writing this in this newsletter? Well, I don't have a ton of subscribers. I can say this in this newsletter.

But honestly, I don't know. I don't know the role of criticism here. I understand the limits of my own education and my own analysis skills. It feels ludicrous to question CDC. That’s a part of this, but not really the important part.

This is the important part: if communities lose faith in CDC guidance, I really doubt they'll decide to be more stringent. If they lose faith in CDC guidance, they will probably take more risk, not less. They'll stop masking at all. They'll stop isolating ever. They'll throw it all out the window. At least the inadequate CDC guidance does something.

What if we question it and we're left with nothing? I don't know what the answer is here. So many sources I trust are quoting and citing CDC without questioning it and without suggesting we should be more stringent than called for. Who am I to choose otherwise? I’ll say this, though. That conference I attended in April – an absolutely staggering number of people got COVID there.