When it comes to navigating the pandemic, many proudly proclaim: "Follow The Science." It's a popular and feel-good message. To me, #FollowTheScience means that science is essential to making good and rational decisions and implies that science makes policy decisions clear. The first half of that sentence is right. The second half is dangerously wrong. I think we must address what science is and is not.
Of course, science is necessary to navigate the pandemic. Science -- in the form of randomized trials -- allows us to separate therapies that work (dexamethasone) from those that do not (hydroxychloroquine). Science has allowed us to develop two mRNA vaccines, which may yet free us from this plague. The rapid development of a vaccine on this timespan is a great success of science, or as the "The Onion" reports, "Nation Can't Believe They Spent So Long Overlooking Obvious Solution Of mRNA Instructions For Spike Protein Encapsulated In Lipid Nanoparticle."
At the same time, science will never be sufficient to guide choices and trade-offs. Science cannot make value judgments. Science does not determine policy. Policy is a human endeavor that combines science with values and priorities. In other words, science can help quantify the increased risk (or lack thereof) of school reopening on SARS-Cov-2 spread, and help quantify the educational losses from continued closure, but science cannot tell you whether to open or close schools. Making the decision requires values, principles, a vision of the type of society we want to be. How much do we care about the kids that rely on public school? Is it enough to offset a theoretical (but unsubstantiated) risk of viral spread? On this topic, I agree with others that we have chosen poorly.
When it comes to COVID-19 policy, we have faced and continue to face immense trade-offs. Every restriction we place may slow viral spread, but may carry dozens of unforeseen countervailing consequences. Scientists can help define these trade-offs, but scientists have no special ability to speak about values on behalf of all citizens. In other words, science is necessary but not sufficient to deal with COVID-19. Thinking otherwise is a dangerous view that steals political power from people and gives it to scientists under false pretenses.
There are several other misconceptions about science in the age of COVID-19. Let me discuss a few.
1. Credentialism is not science. Science is not the degrees someone has or where they trained. Is their view justified or is it unsupported? I joke that when someone disagrees with you about COVID-19 policy, you ask if they have an MD, MPH, PhD, faculty appointment, policy expertise, and infectious disease background. But if they agree with you, none of that matters. They are a self-taught savant and amateur expert!
2. Science is not dogmatic; it demands testable, falsifiable hypotheses. The hallmark of science is that when there are competing ideas, we can agree on studies that will decide who is correct. Believing in things that cannot be falsified or tested is religion. Science is everything else. I worry we have a lot of religion when it comes to COVID-19.
3. Science is never censoring. Over the course of the pandemic, YouTube removed videos by university professors with unpopular views, and Facebook and Twitter have labeled some posts as false or inaccurate. Even if we disagree with these speakers, this is dangerous. Science is the idea that we must confront, discuss, debate, and refute ideas. Using brute force, the power of the platform, to proclaim the truth is antithetical to our creed.
The simple fact is that most heretical ideas will turn out to be false, but some may be true. Academic freedom is the idea that we allow many people to be wrong, so that some may be right. That doesn't mean we blindly accept everything folks say, in fact, it means the opposite, we must interrogate and challenge them, but we must create an environment where folks can argue their case, even if initially unpopular.
4. Science is not a popularity contest of consensus. In an era of petitions, it seems as if science is the belief that most scientists hold. This is incorrect. Science is a process to make sense of the world, and folks in the minority may well be vindicated. In fact, throughout history, there have been many moments in medicine where the majority was wrong.
5. Science is applying criticism impartially, equally, fairly. Let's say there are two studies about masks. One is a randomized trial with a wide confidence interval, the other is a retrospective observational study with myriad deficiencies. It is completely fine to fault the RCT for having results that are compatible with a broad range of outcomes, and I did, but one cannot celebrate the observational study as "proving masks work" simply because its conclusion aligns with one's worldview. In other words, we have to apply critical appraisal fairly. If we try to convince others that weak or faulty evidence proves something works, we are not scientists, but magicians.
6. Observational studies on hot topics are a self-fulfilling prophecy. For popular and debated questions, such as the benefit of hydroxychloroquine, vitamin D, and other interventions, retrospective observational studies are guaranteed to give you what you wish. I don't mean any specific study will be positive or negative, but some studies will be positive and some will be negative.
Consider this: there are thousands of datasets, and tens of thousands of investigators and these folks carry strong biases in both directions (that an intervention helps or is useless), and there is enough flexibility in analysis, that it is guaranteed with enough time, we will get observational studies showing that these practices help or hurt. The only way out of the maze is randomization. Randomized trials are desperately needed on hot topics, as these constrain multiple testing, and limit analytic flexibility through pre-specified protocols.
7. What works, in theory, does not always work in practice. There is an entire branch of science called Implementation science, which studies the gap between what works in ideal settings and what works given the messy realities of the real world. Some scientists fault the public for not heeding public health recommendations, but these folks miss the point. How you communicate your message and the sustainability and uptake of your message are part of the intervention itself, and you must be judged by what is achieved. Public policy is a pragmatic science. It is what happens when science meets real life.
Science is a tool. It is quite possibly the best tool human beings have ever devised, but just like any tool, it has limits. It cannot tell you how to adjudicate trade-offs. It is not merely what the majority believe. It requires open-mindedness and humility. It may not offer insights where bias and multiple hypothesis testing dominate. It requires one to constantly question one's assumptions, to devise experiments that may surprise. It is necessary to battle a pandemic, but it is not sufficient. We can and should embrace science, but we cannot follow it. It is up to us to make the hard choices. Not scientists.
