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nopie  1yr ago (vinayprasadmdmph.substack.com)   Edited 1yr ago   3298 thread views

Cochrane review is out and masks have weak evidence that they are not effective

vinayprasadmdmph.substack.com

This one is against rationalists because when Scott wrote his review that masks could be effective many of us trusted it.

I don't blame Scott for failing this one because doing review of hundreds of studies is hard and one person can hardly do it. But this clearly shows that rationalist way of thinking has no special formula, they can be easily mistaken and fall by accepting general consensus just like any other person.

I was impressed when Scott did his review about masks. I trusted it because there was no other clear evidence available. Cochrane hadn't done its review yet and NICE guidelines were silent on the issue. We vaguely knew from previous studies that masks are not effective, The WHO had said so. Suddenly everyone flipped and it was not because the evidence had changed. We simply wanted to believe that masks work and we mocked those who said “no evidence that masks help”.

Even with the belief that masks work, I never wanted mask mandates. I preferred recommendations only, so that no one was penalized or prohibited entry, travel etc if one doesn't want to wear mask. Scott unwillingly had been a catalyst for governments to introduce mask mandates and all this heavy handed approach has been for nothing.

Now we are back to square one, the evidence about masks is weak and it does not support their use even in hospital settings. We can all reflect now what happened in between during these 2 or 3 years. When I realized that Scott's review is clearly insufficient as evidence, I asked some doctors if they have any better evidence that masks work. Instead of getting answer I was told not to be silly, parachutes don't need RCTs and accused me of being covid denier for nor reason. Many so-called experts were making the same mistake as Scott by looking at the issue too emotionally. It is time to get back to reality and admit that it was a mistake and we should have judged the issue with more rational mind.

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Isn't "properly fitted N95s work" just another way of saying "mask mandates don't work"?

I thought the topic was "do masks work?" not "do mask mandates work?". These are very different questions, and can be broken down further with questions like "do N95 masks worn by untrained people work?" and "do fit-tested N95 masks work?", without even delving into the details of how we want to define "work", presumably some measure of reducing the incidence of COVID-19 in the mask wearers, although looking at reducing the incidence of COVID-19 in people around the mask wearers is also an interesting question.

The summary of the study that I referenced suggests the study answered the question of "does having masks vaguely nearby that you wear inconsistently reduce the incidence of COVID-19 in mask wearers?" and got the utterly unsurprising answer of "no". Maybe that's a realistic view of what behavior under mask mandates looks like, but that information doesn't really give us any hints on the answers to questions like "does training our medical personnel and requiring them to wear fit-tested N95s at all times reduce the transmission of COVID-19 in our medical facility?" or "does an individual choosing to wear an N95 while on transit / in airports reduce the chance they'll get COVID-19?".

The fact that many people are unable to take prescription drugs frequently or consistently enough for them to be effective at treating their illnesses is not usually considered an argument against telling them to do so.

What happened is more like the government mandated an ineffective drug, censored anyone for pointing out it was ineffective, and once evidence came out that the drug doesn't work, people started defending the policy by saying there's a completely different drug that the government could have mandated, which would be effective (but it needs to be taken in precise 3 hour 37 minute intervals, and being off by one minute renders the drug ineffective).

Do you think I or 'meh' are defending the policy of mask mandates?

I am defending the policy of mask mandates, in the abstract, if it includes "do rapid and large challenge trials of N95s + ways of ensuring proper use in early 2020". I'm not defending "tell everyone to wear cloth masks", which doesn't seem to have done anything, and which is the meaning you are using.

If it was found in RCT trials that the drug does not treat the illness in the treatment group (whatever the reason), it would not get approved.

Most of the reason for that is drugs are expensive, use of a drug is based on belief it works and as such it crowds out other useful treatments, and have high rates of side effects. There's a reason a pharmaceutical to treat a disease requires rigorous testing before FDA approval but 'Ngoko Bean Extract For Psoriasis' doesn't if Ngoko beans are edible. This makes 'not being approved' much less strong as a reason to not wear masks even though, again, the mask mandate didn't do much.

The point here is that when someone has psoriasis why does he need to get the approved medicine if Ngoko bean bean extract could be used instead without prescription? The reality is that we don't know if Ngoko bean extract (and thousands of other remedies offered by snake oil peddlers) works for psoriasis. Obtaining this information can be costly and I can see why no one wants to study Ngoko beans if they cannot be patented.

However, psoriasis is mostly auto-immune disease and if topical treatments do not work, specific monoclonal antibodies can be tried. They are not cheap but that's because the technology to make them is quite complicated.

Yeah, we don't know if ngoko beans work, but we do know they don't hurt, so "using them when it isn't approved" isn't as bad.

No, we don't know if ngoko bean extract don't cause harm. They could easily make psoriasis actually worse.

It is unbelievable today but merely 50 years ago cigarettes were recommended for treating asthma and were sold by pharmacists. Today we know that cigarette smoke actually harm airways and make asthma attacks worse.

The likelihood that ngoko bean extract (ngoko beans don't exist, so let's go with black bean extract) harms you is much much lower than the probability some random normal pharmaceutical like ivermectin harms you, which in turn is much lower than the probability a random never-approved-for-any-indication pharmaceutical harms you. This is because lots of people at black beans as food, already. And masks are less likely to hurt you than black bean extract. This is why wearing a mask without RCTs isn't the same as taking a random pill without RCts.

The likelihood of risk from black bean extract may be lower but not entirely zero. The medicine indicated for psoriasis have high chance of benefit, therefore some potential of harm is usually accepted. But if you don't know if the treatment has any effect, then even small harms are unnecessary.

And it is not a right way to think that black bean extract cannot harm because people have used them in food for so long. The mucosal immunity in the gut works differently from the one on the skin, so we cannot exclude that it is can harm the skin. Yesterday, I got a warning from oculist to not recommend chamomile extract for washing eyes because it can cause allergies in some people. Chamomile tea is fine and people have used chamomile extract to clean eyes for long time as well and yet it probably does nothing and can harm.

Psoriasis patient is not the same as a healthy person. We don't know how he/she would react to untested treatment. The fact that it is plant derived means little because many modern medicines are originally derived from plants. Even antibiotics came from moulds.

Masks can harm, in the UK there was a case when doctors misheard each other due to masks distorting speech and overdosed medicine and patient died. If the benefit of masks is not proven, such harms are unacceptable.

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Consider this analogy: laws mandating wearing of seatbelts in cars don't prevent 100% of automotive fatalities. Sometimes this is because people aren't wearing their seatbelts properly. Sometimes this is because people just ignore the law and don't wear them. Sometimes this is because the specific type of accident caused trauma that seatbelts can't mitigate.

Would you therefore conclude "seatbelt mandates don't work"? Would you think it reasonable for the highway department (or whomever) to stop encouraging the wearing of seatbelts because they're not 100% effective?

Consider this analogy: laws mandating wearing of seatbelts in cars don't prevent 100% of automotive fatalities. Sometimes this is because people aren't wearing their seatbelts properly.

This analogy is inaccurate in the context of the conversation. A more accurate analogy would be one where the mandated seatbelts are made out of toilet paper, and break at the slightest stress.

An N95 mandate would something closer to "seatbelts, but people don't wear them properly", but that's not the mandate we got, and it's not even clear it's realistic to get a significant amount of the population to wear them properly, unlike seatbelts.

We haven't done RCTs with seatbelts, but I can easily imagine them being very positive in favour of seatbelts even in case of some occasional non-adherence in the intervention group.

We haven't done RCTs with seatbelts

I know a bunch of crash test dummies that would like to have a word with you.

We now have talking test dummies :D

Yes! Mask mandates, as implemented, clearly didn't work. But this does not mean masks, if used properly, don't work - yet that's how everyone is interpreting it, including the other reply to your comment.

I don't think this is how he's talking about it, but he can defend himself.

What's the point of discussing some abstract perfect usage of a mask type most people didn't even have, given the policies that were implemented and the censorship of dissent? When people say "masks don't work", they clearly mean the masks they were forced to wear.

the point of discussing mask usage in genereal is to ... figure out policy for the future? Or just figure out personal risk tolerance from the future? Concretely - should my/your elderly parents occasionally wear N95s in e.g. airports, to reduce general disease risk? From my longer comment:

The latter is ... arguable, actually - imagine a case where N95s were mandated/heavily encouraged specifically for vulnerable populations (old, immunocompromised, other health conditions), along with early studies making sure they were useful & how to use them effectively, without lockdowns or mask mandates for most.

And from the review itself:

Routine long‐term implementation of some of the interventions covered in this review may be problematic, particularly maintaining strict hygiene and barrier routines for long periods of time. This would probably only be feasible in highly motivated environments, such as hospitals. Many of the trial authors commented on the major logistical burdens that barrier routines imposed at the community level. However, the threat of a looming epidemic may provide stimulus for their inception.

When people say "masks don't work", they clearly mean the masks they were forced to wear.

I think when people say "masks don't work", they mean "masks don't work". See the OP substack citing the evidence against N95s as "devastating".

You cannot separate “telling people to wear masks work” from “wearing masks work” in the intervention. It is the real life we are talking about.

The argument that maybe the results would be better if we apply efforts to improve the compliance is a real one and was raised by the Cochrane group reviewers. Their answer was that no one has studied it, so we don't know and cannot claim that it would have helped.

I was just learning about different contraceptive methods. Their reported results of effectiveness are not some best case values but real life results from studies. https://en.wikipedia.org/wiki/Pearl_Index Even that is being criticised that in studies people get better counselling and training and may not represent the real life values. I find interesting that fertility rhythm method has very high theoretical effectiveness (slightly worse than condoms – https://en.wikipedia.org/wiki/Comparison_of_birth_control_methods) and yet it is heavily criticized by all experts in the field. It is always more easier to take a pill than measure temperature daily plus all other behavioural aspects.

Some argue that it still makes sense for their elderly relative to wear mask to protect themselves. Maybe, but I don't know your elderly relative. The statistical chances are that they are as much non-compliant as any other member of the population. Telling all hundred or thousand of them (how many readers do we have?) to wear a mask will statistically yield the same result as in those studies.

I find interesting that fertility rhythm method has very high theoretical effectiveness (slightly worse than condoms – https://en.wikipedia.org/wiki/Comparison_of_birth_control_methods) and yet it is heavily criticized by all experts in the field.

Interesting analogy -- 'withdrawal' might be a good parallel with masking, in that it actually works not bad if you can pull it off (out) but field results are poor due to, uh, implementation difficulties.

For this reason people are usually told "withdrawal is like 99% ineffective" -- which isn't really true, but serves the public health goal.

Leads one to speculate that the public health goal is quite different in the case of masking.

You cannot separate “telling people to wear masks work” from “wearing masks work” in the intervention. It is the real life we are talking about.

Then you just go back to the seat belt problem. Seat belts existed since the early 1960s but usage rates were abysmal for 25 years. Someone studying the effect of seat belts in 1985 would have found their efficacy lacking for the simple reason that few people used them. Seat belts had been required equipment in cars for some time but given that so few people were using them so long after their introduction, the Federal government could have been forgiven for scrapping the requirement altogether as ineffective. Instead, this is around the time state governments started requiring seat belt use among all front seat occupants. As the 1980s became the 1990s and more states started adopting such laws, auto fatalities, which had been more or less stagnant for decades, halved between the late 1980s and the present. Part of the problem could be that in a lot of places these so-called "mask mandates" were so inconsistently enforced and widely ignored that the actual effect was that of no mandate whatsoever, and that the real solution is stricter enforcement. This isn't necessarily a policy I would advocate for, but simply stating noncompliance is proof that the underlying implication is wrong is disingenuous, to say the least.

Most cars didn't have seatbelts then. Some of those cars are still running and it is legal to drive them without seatbelts.

RCT could be easily made by manufacturing a car with two models that are different only by presence of a seatbelt and randomly shipping to different dealers. If the car had a seatbelt, a dealer is obliged to explain a buyer how to use it properly. The car could have a mechanism installed that warns if the seatbelt is not in use and the dealer warns that defeating this measure will void the warranty. The compliance rate would be at least 50%. Then you just collect statistics from road accidents and related injuries. I am sure very soon this experiment would be stopped by an ethics committee because the seatbelt group would have huge difference that further studies would be unethical.

Maybe people who study road safety used a similar setup by comparing one model with a seatbelt to a different model without a seatbelt. It has some bias as assignment is not random and both groups can be different, for example, one model can be chosen by more careful drivers etc. It is very hard to control for all these factors afterwards. But even then they saw such a massive difference in injuries that could be explained only by seatbelt use, that it was made mandatory. It is easy to make mandatory rules in driving because most things in driving are mandatory, you have to stop at red light etc.

But the absence of RCTs and irrefutable evidence could be a minus because it was harder to explain people why seatbelts are protective. Many people said that seatbelts will protect you in minor accidents but in major crashes they would make you more likely to die. That's why we need a good evidence that seatbelts have a total protective effect from deaths although they won't protect in all possible cases. It would have improved adherence even without policing.

Someone studying the effect of seat belts in 1985 would have found their efficacy lacking for the simple reason that few people used them.

Nope. They'd find typical usage would (on average) result in people surviving the car crashes, and the non-usage in dying. We don't have anything like that justifying even an N95 mandate.

No, his claim is if you studied P(death | accident, car with seat belt) / P(death | accident) you wouldn't find an effect unless the sample size was massive because P(wears seat belt| car with seat belt) is very low, so P(death | accident, car with seat belt) = .1 * P(death | accident, wearing seat belt) + .9 * P(death | accident) which is .92 * P(death | accident), even if seat belts reduce crash risk by 80%!

We don't, but that's not what the study looked at.

The point is that we're dealing with a Motte and Bailey argument here,

Yes. The bailey is "of course masks work, you're banned for spreading misinformation", and the motte is "of course properly fitted masks, of a type that no one wore, work".

It's especially bizarre to see given that the same people are claiming to be (legitimately, IMO) upset at Fauci and Co. for misrepresenting/misinterpreting/misusing science and statistics to argue for mask mandates.

How is it bizarre? I maintain that it's obvious when people say "masks don't work" they meant the masks they were actually forced to wear. What are they misrepresenting? How is it not the pro-maskers who are not misusing the science instead?

Standard pattern of Motte-versus-Motte warfare: my motte is to deny you your bailey, and my bailey is to also deny you your motte (and, automatically, your position is symmetrical).

Sound medieval warfare tactics.

"you're banned for spreading misinformation" is downplaying things. In the real world, where mask mandates were sometimes enforced, the bailey sometimes became "of course masks work, and the police will beat the shit out of you if you disagree."

I've stalked people since the reddit site and remember the arguments they used to make. There were plenty of people making those arguments "here" in 2021, and there needs to be some process to address old arguments without allowing a temporal motte and bailey.

I don't recall anyone on /r/themotte saying 'you should be banned for misinformation if you say masks don't work'. My old comments were of the form 'should have had RCTs to figure out how to make masks that work early'.

Why should we limit ourselves to the conversation that is happening here?

but lots of people are absolutely making the M&B argument I'm citing.

Again, they can defend themselves, but I think you're misinterpreting people.

Is this supposed to be a serious question?

Yes.

Because yelling about what some people who aren't here did isn't productive or interesting

Neither is discussing the effectiveness of a policy that was never implemented, and which would arguably be unenforceable, but this is exactly what you seem to want to do for some reason.

and often veers into "Boo outgroup!" which the rules of this place explicitly prohibit.

Pointing out a policy did not work, isn't "boo outgroup".

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Exactly this. Don't even try to think seriously about articles that claim that masks work despite evidence that says they don't. It is a big fail for rationalists to even think in this way.

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