The Role of Non-Expert Specialist, Part 1

How our hierarchical information institutions lost their way

This piece got too long for a single newsletter, so I’m going to have to finish it next week. This is something I’m thinking about a lot these days for a host of reasons. I believe that a formally hierarchical form of information trust is fading into the past and something else is coming to replace it.

Part 1 is about how the pitfalls of institutional information. Part 2 will be about the replacement.

• When Institutions Trip and Fall

• The Speed of Trust: A Public Health Dilemma

• Looney Tunes: Drip Along Daffy

When Institutions Trip and Fall

It was early March when the first identified community outbreak of COVID-19 was discovered in a nursing home about 3 miles from my church.

At the time I remembered how a month before, Seattle had found someone with COVID, tested all his contacts, and isolated him for a little over 2 weeks, limiting contact to such a point that they fed him with robots. When he was released February 4th, there was only one other known positive case in Washington and 11 cases in the US. Everything looked like it was fine. We had a plan and that plan was keeping us safe.

But as February advanced, things seemed to be strangely off. While the initial COVID response seemed laudable, there were stories about flawed test kits from the CDC hampering our ability to track the virus and news that the FDA wasn’t letting labs develop their own tests.

The CDC recommended against testing people without symptoms. And even patients with symptoms weren’t getting tested. Dr. Helen Y. Chu, a professor who was running a research project on the flu became suspicious that many of her participants had COVID because they were testing negative for the flu, but Federal and state officials would not permit her to test her samples for COVID because that would be against the ethical guidelines of her study. The FDA refused to allow the use of the test her team developed because they were a research laboratory and not a clinical laboratory.

By the time the nursing home story broke, it was clear that this thing was all over the city. It also became clear that there was an odd separation between the attitudes and rhetoric from public health institutions (like the CDC and FDA) and the ones coming from smart people who know things. People like Trevor Bedford, a virologist I found because an anonymous microbiologist who trades silly jokes with my online friends.

Trevor Bedford @trvrb

@CDCgov We also urgently need @US_FDA to allow Laboratory Developed Tests (LDTs) and to extend Emergency Use Authorization (EUA) to non-CDC labs https://t.co/l7oapusHMG

Scott Gottlieb, MD @ScottGottliebMD

Through creation of a path for authorizing laboratory developed tests under the EUA we can greatly increase our U.S. screening capacity, by leveraging the vast capabilities and expertise of academic labs. A test for #coronavirus can also be added to standard panels like BioFire. https://t.co/ADx45VDAqb

As we moved from February to March, community outbreak was clear and we started seeing the effects of the virus. Even then, it took another month before the CDC would change its recommendations on masks. You would have gotten a good head-start on the official guidance by reading Scott Alexander’s “Face Masks: Much More Than You Wanted to Know”, an epic 4500 word post digging though the data on masks and (this part is important) thinking about it. Alexander made a few assumptions and a few educated guesses, he understood how scientific papers are written, what they can say and what they can’t say, and then he interpreted the data. He’s not a public health official, a virologist, or an epidemiologist. But he understood what was going on before anyone had to tell him. He figured out the truth for himself.

In fact, a great deal of the best down-to-earth information in this pandemic has come not from high visibility institutional sources, but from non-official ones. My go-to source for COVID data has been the COVID Tracking Project, a volunteer-run project that bloomed when Alexis Madrigal of The Atlantic realized that the CDC wasn’t going to be getting a usable COVID data dashboard up any time soon. Most of my sources for information related to COVID, vaccines, transmissibility, or risk factors come from individuals who I trust to highlight the best information and ignore the rest of it. I have all but given up on trusting any formal news source to consistently highlight the most reliable information over sensational conjecture.

Why is that? I’ve asked myself this question a lot and I’m trying to formalize in my own mind what has happened, why I keep finding better, more reliable information from “non-official” sources. This is still a theory in incubation, but I think it speaks toward the emergence of a new form of institutional trust and informational reliability.

The Speed of Trust: A Public Health Dilemma

I first want to mention that, despite my frustrations with public health organizations like the FDA, the CDC, and the WHO, I think they have an important role to play in our national and global vision of how to manage a pandemic. This is not the last pandemic we will face as a species and there’s a good chance it’s not the last pandemic of my lifetime. We need to spend some time thinking about the future responses.

There are, I think, two big problems with institutional public health response during a pandemic. The first one is the importance of agility and speed in responding to a crisis.

The CDC’s and FDA’s response to the need for COVID testing in February was the perfect example of a system ill suited to responding to a pandemic crisis. It’s not a controversial position to point out that the CDC and FDA are slow organizations, deeply bureaucratic, cautious to a fault.

There are some benefits to this. They are very protective of scientific definitions of certainty. They dislike saying that things are certain until they can get their p-values all squared away and proven and replicated and re-proven with low levels of risk and high levels of certainty with every “t” crossed and “i” dotted.

This is a good thing when people aren’t dying. It’s a bad thing when they are. The CDC and FDA both showed a great deal of reticence to move quickly on this crisis and it cost a lot of lives. The thing that helped most of all was when Dr. Chu did an end run around the institutions. The best thing that happened in the early part of this crisis was when someone blatantly disregarded the official recommendations.

The second problem that our institutions face is a problem of trust. In this problem, I see an almost generational issue that many in public health don’t see or are unwilling to address.

From my own observations, there are those who work in what I’m going to instantly regret calling “consumer facing public health” who have a vision of their job that is based in a world that existed in 1987 but no longer exists. These people are incredibly accomplished and incredibly smart. They have the highest credentials and the longest resumes. They have the education and experience that you would want from someone at the top of their profession.

And they think “normal people” are incredibly stupid.

Now, to be fair, “normal” people often look quite stupid to anyone with deep knowledge of any field or trade. The high school drop-out car mechanic rolls his eyes when the PhD candidate with soft hands can’t figure out why his brakes are squealing. The programmer sneers at someone who doesn’t know how encryption works. When people outside our area of expertise suddenly dip their toes into our water, we can immediately see the folly that we avoided by taking “Topic 101” and learning what the common pitfalls are in our field. The deeper we get into a topic, the dumber the outside observer seems to us.

This is natural and normal and, I believe, actually quite healthy. It’s good to have a near-instant indicator that you are talking to someone who has no idea what they are talking about in a field. It’s good to know when a newbie has entered the ring.

The problem is when your field is entirely focused on trying to control the actions of other people.

One of the biggest goals of public health is trying to get people to do something that the experts believe is good for them. The people driving public health announcements are incredibly smart, ambitious, and accomplished, and have been since they were 12 years old. They feel smarter than most people, even people they work with. They are certainly smarter than whoever is watching them on TV because, if that person were so smart, they would be on the TV instead of watching it.

This presumption has been their downfall.

If you’re in the business of convincing people, you run the risk of losing some grasp on the truth. You end up entering this world in which the questions you ask are not “what is the truth and how do I effectively communicate that” but instead “how do I get people to act the way I want them to act”.

This is all exacerbates by the fact that these messages are crafted by a committee and sent out as a press release. All the smart experts got together in a room (or on a Zoom) and have gone through the details of how they want people to act. They’ve decided what they want people to know in order to get them to act that way. They’ve crafted their language to be technically accurate while avoiding information that reveals complexity. This method of information dissemination is dangerously sclerotic. It’s passable if you are crafting your message for a five-minute daily update on the evening news in which “experts say” is all you need to establish trust in the audience.

But we’re far past that point.

This is why the CDC and Surgeon General famously recommended against using masks. They did not think it was sufficient to say “we need masks for first responders” and rely on the public’s sense of civic responsibility. They believed people are selfish and therefore the best way to conserve masks is to say they aren’t effective.

But the tone is under-rated here. Think back to the car mechanic and imagine he’s talking to a medical doctor. The mechanic could talk down to the doctor just try to push her into green-lighting the repair. Or the mechanic may be happy to give her as much information as is necessary for her to feel like she’s making the decision herself based on the best information. And, when the tables are turned and the mechanic comes in to look at that lump, the doctor has the same set of choices to make. This is question of respect and dignity, of two equals recognizing their different capabilities and deferring to each other.

A lot of people don’t feel like public health officials respect them. They feel like they are being talked down to and given half-truths that are meant to manipulate them into making the choice that the public health official has unilaterally determined is the correct one.

Even worse is that, when health officials do make these recommendation, the carefully crafted rhetoric becomes a disadvantage. If you look at the details of the language they use, they’re not lying per se. They’re using the language of uncertainty to create an impression that is almost certainly incorrect.

Dylan Morris @dylanhmorris

Thinking about this important thread from @michaelmina_lab this evening. When communicating with the public, scientists rightly don't want to give false hope, and so they emphasize unknowns. That's admirable. But it can go too far, and become misleading

Michael Mina @michaelmina_lab

Important This virus is not happening in a vacuum where no information existed previously On Immunity, On testing, On serology, On transmission, On masks, On treatments... We must stop this narrative that we know nothing of this virus until we learn it anew - again. 1/

But then time marches on, that impression is contradicted by further evidence, and people feel like they have been lied to. At that point, the trust is broken and it’s much harder to convince people the next time we need them to act a certain way.

This is the problem of modern public health. The public needs reliable, actionable information quickly but need to be treated with respect, as if they can reasonably ingest complex information and use it to come to a healthy conclusion about how to go about their lives.

I believe this is possible. There are many public health officials who do act this way, but are undermined by an incentive structure of news and information dissemination that prefers wild headlines and emphasizing fringe cases over reasonable expectations and critical thinking.

The next part of this series will be about how we are slowly developing a new form of trust based on a decentralized form of information gathering as the hierarchical form becomes secondary.

Looney Tunes: Drip Along Daffy

This is a quintessential Looney Tunes short. The first third of the short sets the scene of the lawless western town is a series of hilarious rapid-fire visual gags. Then we meet Drip Along Daffy (and Porky as his Comic Relief) who promises to clean up the town and leaps into the nearest saloon looking for trouble. Trouble he finds in the mountainous form of Nasty Canasta (rustler, bandit, square dance caller) who humiliates Daffy in a drinking contest before they head out for a main-street shootout showdown.

The short gives us plenty of fun visual humor, Daffy’s speedy and often absurd dialogue, and a lot of playful pokes at the western genre. I love the timing and the narrative flow, which will zip right through some scenes and then spend enormous time on a single elaborate gag (like the drinking contest). Is it “uneven”? Sure, but that’s part of the fun. It feels like the animators are playing and just having fun themselves and we get to participate in that.