I love Paul Fenyves’ essays. He is a practicing internist and that makes him a pragmatist. Like all great internists, he understands risk and benefit, and the times in medicine you need to push hard, and when you must accept things as they are.
The only thing I mildly disagree with him on in this essay is masking kids. My sense is that if you ran 10 cluster RCTs of kids masking: for flu, influenza, RSV, you name it, you will have null results every time. The actual effect is 0. Why do I feel that way: that’s the nature of behavioral interventions and kids. But, his point is also fair: best case scenario the gain is modest. What should that mean for policy?
Hope you enjoy
Vinay Prasad MD MPH
Know Thy Patient
By Paul Fenyves, Cornell University
Throughout the pandemic, the CDC has been out of step with the American patient. This is a call for the CDC to become more aligned with the people it serves.
We all have a “medical personality” — our unique approach to healthcare marked by our worries, our risk tolerance, and our inclination to do more or less.
Both doctors and patients bring their medical personality into the exam room. Good doctors tailor their care to better match their patient’s medical personality. The intensity of medical care, whether to be aggressive or “less-is-more”, should be adjusted within reason to match the patient’s needs and desires.
Some doctors are unable to match the intensity of care to fit the patient. They add a third blood pressure medication without realizing the patient barely takes the first two. Ultimately, the patient becomes frustrated and finds another doctor.
Applying this exam room philosophy to our country’s pandemic response, national public health did not sufficiently align with the American patient, frequently making recommendations that were far too intense for the average American.
I suspect that this “intensity mismatch” led many Americans to ignore the advice of public health. Had we asked for less of the American patient, we might have gotten more in return – more respect for and acceptance of public health recommendations. Two examples:
Childhood Masking: We continue to debate the efficacy of childhood masking. There is no randomized controlled trial to answer this question (and importantly to estimate the effect size), but we do have RCTs in adults showing a modest reduction in transmission.
And like all of you, I have a gut feeling, which was informed by my experiences. For two years, I masked up and shared small exam rooms with coughing Covid patients and never got sick. When I did finally contract Covid in April 2022, I got it the way I get all my respiratory infections: from my kids.
Despite this, my gut also tells me that covering kid’s faces for years on end would negatively impact their social and emotional development. Of course, I’m not ready to run a five year study to prove this. Many Americans seem to share this concern.
For the sake of argument, let’s assume that childhood masking modestly reduces transmission. Was it prudent for the CDC to recommend continuous school masking through February 2022?
We saw that many Americans were opposed to masking kids. And we also saw that many European nations did not mask their school children at all, so the “standard of care” was quite broad.
When you have a broad standard of care, and a patient who is asking for a less intense approach, you should not offer the most aggressive intervention.
Rather than dismiss those concerned as “anti-maskers,” public health might have split the difference, only recommending childhood masks for a few weeks during the times of highest community spread. I suspect most Americans would have obliged, and we could have enjoyed most of the upside with much less downside. By asking for less, we might have gotten more.
Currently, there are some calls to bring back school masking in order to prevent hospitals from becoming overwhelmed by other pediatric respiratory illnesses, namely RSV and influenza. So far, this proposal is not getting much traction even in most pro-mask cities. I suspect this is because just about everyone is done with masks. By overdosing the intervention, the CDC has turned away even many of its adherents.
Pediatric Covid Vaccinations: The American people are not enthusiastic about getting their children vaccinated against Covid. At the time of writing, less than a third of kids 5-11 have completed the primary series, and for kids 2-4 it’s below 5%.
Again, there is a broad standard of care: Germany recommends just a single dose of mRNA vaccine for kids 5-11. Norway makes vaccines available to kids 5-11 without making a recommendation. Denmark only offers vaccines to kids who are at high risk.
In contrast, the CDC recommends all kids five and up get the initial two doses plus a bivalent booster.
Again, we have the American people asking for a less aggressive approach, but the CDC recommending the most aggressive approach. Do we really want the American people to develop a habit of ignoring the CDC’s vaccine recommendations as being “too aggressive?”
Already we are seeing suggestions that Covid vaccine hesitancy might be spilling over into other more essential vaccines. Why not communicate which vaccines are optional and which are critical? By asking for less, we might get more.
Those of us in medicine have all seen doctors who are unable to dial down the intensity to match the patient’s preference. Doctors who add a second cholesterol medication when the patient barely takes the first.
During the Covid pandemic, the CDC has been such a doctor. This is dangerous. When patients become frustrated with a doctor who is unable to meet them where they’re at, they go find a different one.
Please don’t needlessly turn away the American patient.
Dr. Fenyves, wonderful essay, and while this is the first I have heard it framed as "intensity mismatch", this certainly resonates without how I have chosen providers for myself and children and how my wife approaches her patients as a surgeon.
However, I am not convinced that Intensity Mismatch is why people have started to ignore the CDC.
The public was initially very receptive to the CDC guidance as evidenced by the strong uptake of the original series of vaccines and having one of the highest masking rates among Western countries.
The public stopped listening to the CDC because their claims have been falsified. Everyone who got vaccinated got Covid anyway. Kids in schools without masks had no different outcome than kids in masks. Every single highly vaccinated country in the world saw all-cause mortality increase after vaccinations. South Korea, once considered the model of how to fight the pandemic, with their GPS contact tracing, rolling lockdowns, mask devotion, vaccination rates, and CCTV surveillance state, now how the highest excess mortality in the world, after all-cause mortality jumped to +100% this past spring.
The CDC lost trust because it made it made incredible claims, and it turned out they were wrong, and not once has admitted error, or shown the slightest bit of humility. Instead, the agency doubles down and gaslights (see the recent fact checks on "we never said the vaccines would halt transmission").
If we saw chicken pox explode after the varicella vaccine was introduced in the 90's, you wouldn't be surprised that people stopped giving their kids the varicella vaccine.
We can't be surprised that only 10% of the public is seeking dose 4 or 5 after covid blew up in Vermont, Denmark, Japan, Israel, etc after vaccinating the public.
Had the CDC moderated intensity from the start, their credibility wouldn't be in ruins, but I am not sure this approach can help now. I'm honestly not sure what can be done, though starting with Dr. Prasad's Oct 31 piece "Pandemic accountability" is a good start.
Interesting analysis. I agree with D'Ambrosio that this may be in part an intensity mismatch but is far, far more the fact that the CDC has routinely just outright lied (or skewed the data to accomplish the same thing -- think Arizona school study) and people got wise to them pretty quickly. Publishing in non-peer reviewed MMWR is not helpful because many of those articles are instantly uncredible when the data is examined -- it has become just a shill piece container. (As a many decade subscriber, makes me sad.)
Also, I have to underscore Vinay's pooh-pooh of your mask thoughts. I would love to see credible mask literature (and please do not give me Boston schools, Arizona schools, Bangladesh -- all studies easily refutable from their own data/methodologies) that shows that there is actually a credible effect from masking adults, much less children. Even mask studies in the OR show virtually no advantages. I have hundreds of articles filed that show the reverse (null value to masking for viruses) -- especially in any situation other than a mannequin in a sterile room. I have seen essentially none that can make the counterpoint. Will you please post the references?