These united States of America

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On July 4th, 1776 the Continental Congress formally stated that 13 American colonies were breaking from Great Britain and laid down the principles on which a new country would be based. Now that we’re sitting in the middle of a pandemic, it’s reasonable to reflect on that document created some 244 years ago. Because if there ever was a time where we all needed to be United but in fact were united, it’s the summer of 2020. So let’s dig into this document through the lens of the Pandemic.

These united States

If you read the first line of the Declaration of Independence something jumps out:  “The unanimous Declaration of the thirteen united States of America…” Think about that for a second. Notice how the “u” isn’t capitalized. In fact, when you look at the actual document, it’s even more interesting than that:

Notice how the words “of the thirteen united” are all in lower case. The idea of being united is definitely downplayed.

The Civil War

In Ken Burns’ documentary, The Civil War, one of the clear stars is an eccentric civil war historian by the name of Shelby Foote. In the documentary, one of his most poignant lines is:

“Before the war, it was said ‘the United States are’—grammatically it was spoken that way and thought of as a collection of independent states. And after the war it was always ‘the United States is,’ as we say today without being self-conscious at all. And that sums up what the war accomplished. It made us an ‘is.'”

So our modern notion of being the United States with a capital “U” didn’t begin until after our country was yanked apart and put back together through the crucible of war. It was at that point that a collection of rogue states became a real United nation.

We are united by the Pandemic

I remember back in March when the world began shutting down, I told my kids that this was their “World War II” moment. That time when our country and the world would come together to defeat a common foe and that great sacrifice would be required to see us through to victory. Yet sitting here on July 4th, somehow that never really happened. In fact, while it took a civil war to bind us together, it seems like it’s taken a pandemic to pull us apart.

We’ve lost that capital “U” in these past few months. Whether it’s the idea of wearing a face mask or social distancing or shutting down or staying open, we all have different ideas. For some, that’s evidence of all of the things that are wrong with our country. For others, it highlights what made “us” into an “is”. Meaning, it defines the ideas of freedom on which this country was based.

Can We Get that Capital “U” Back?

No matter on which side of the pandemic debates you fall, it’s fair to say that many of us have allowed them to divide us. So how can we get that capital “U” back? How can we get United? Perhaps by understanding that division and differing opinions are what earns us that “U”.

Through this blog, I’ve tried to bring up the medical issues and follow the data where that leads. That often leads to contrarian conclusions that oppose the prevailing narrative. Many readers like that, but for some that opposing view causes intense anger. However, isn’t that also the core of what these United States represent? A movie president once said:

“America isn’t easy. America is advanced citizenship. You’ve gotta want it bad, cause it’s gonna put up a fight. It’s gonna say ‘You want free speech? Let’s see you acknowledge a man whose words make your blood boil, and who’s standing center stage and advocating at the top of his lungs that which you would spend a lifetime opposing at the top of yours.’ You want to claim this land as the land of the free? Then the symbol of your country cannot just be a flag. The symbol also has to be one of its citizens exercising his right to burn that flag in protest. Now show me that, defend that, celebrate that in your classrooms. Then you can stand up and sing about the land of the free.”

So we don’t earn back that capital “U” by making everyone tow the party line. In fact, we earn it back by allowing as many differing opinions as there are. By allowing anyone to have any opinion, even if it doesn’t agree with ours and especially if it doesn’t agree with ours.   

Science and Medicine are All About Challenging the Narrative

We have allowed science and medicine to become politicized. In order for that to work, we must all pretend that specific topics in science and medicine are settled. After all, science can’t be used as a blunt instrument if it’s all wishy-washy and constantly questioning itself. No, it can only be used that way if its conclusions are rock solid and never change. But that, of course, is fiction.

The definition of the scientific method is:

“a method of procedure that has characterized natural science since the 17th century, consisting in systematic observation, measurement, and experiment, and the formulation, testing, and modification of hypotheses.
criticism is the backbone of the scientific method

Note that the data leads to a hypothesis (a best guess). Then one tests that “best guess” and that leads to a new theory. Also, note that it’s the job of every physician or scientist to question the status quo. That’s how science works. These are the ideas of the greatest enlightened thinkers in history like Aristotle, Descartes, Galileo, and Newton.

Hence, in many ways, our country, which was founded on the ideas of the enlightenment that were popular in the 1700’s, is all about challenging the existing narrative. It is only through those challenges that our country can thrive. That’s the way we get back our capital “U.

The upshot? The pandemic is a medical and scientific problem. Any and all narratives MUST be challenged. Every point of view MUST be permitted. Our country was founded on this bedrock of enlightenment thinking. So the next time you think about excoriating someone for not towing the pandemic party line, think about Descartes, the Declaration, and the Civil War. For us to earn back that capital “U” we must not only tolerate opinions that don’t agree with ours we MUST also CELEBRATE them. 

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36 thoughts on “These united States of America

  1. Joy

    New message coming from our Leader next week – We Need To Live With It

  2. Robert E. Dahl

    There are some things that must be challenged and ultimately opposed, such as the making of wearing masks into an ideological argument rather than evidence of “promoting the general welfare.”

    Wearing masks or not wearing masks is not about free speech as it is erroneously being framed. It should be like the law of wearing seat belts which is for the “general welfare” of the public.

    Unfortunately, in this toxic political environment, the lines are being drawn in the sand about the wrong behaviors.

    Not all behaviors of dubious reasons are to be celebrated.

    By the way, to what “party line” are you referring?

    I am a grateful beneficiary of your company’s expertise in helping to heal knees. Regenexx is the best, and I have sung your praises far and wide.

    While you have all the right in the world to blog your opinions on subjects other than what you know best, I keep hoping you will “mind the store,” and write about what you all do the very best.

    1. Chris Centeno, MD Post author

      Robert, about two weeks ago I put it to a reader vote whether I should continue to blog about COVID topics. Read the comments here which constitute the vote tally: It was >90% in favor of continuing to ask the tough questions about this topic. As you may have read here in numerous blogs, I wear a mask everywhere they tell me to, as that’s my personality. Meaning if it makes someone else comfortable that I have a mask on, it’s very little to ask of me. In addition, I being a healthcare worker, I and my staff all wear N-95 masks all day in the clinic.
      While the science does support that N-95 make work, the science right now DOES NOT support that surgical mask and cloth mask use will help decrease the spread of this disease. I have reviewed the scientific literature on that topic many times over the past few months.

  3. Jenna

    Brilliant!! I love how you’ve woven together the concepts of the pandemic, the freedom we have fought for as a Nation, and the ultimate goal of coming together to re-establish the capital “U”!! Our history wasn’t perfect and neither was our response to the pandemic, but the important thing is that we learn from our shortcomings and move forward in a common mission as a Nation. We have made incredible forward progress over 244 years!! And even now Americans have come together to manufacture ventilators & PPE, work on anti-virals and possible vaccines, along with the essential workers from all walks of life who have bravely shown up on the frontline of this pandemic to keep our country viable during this challenging time. That’s American ingenuity and American exceptionalism!! If we keep looking for the good we will certainly find it, and we can make our capital “U” stronger than ever before!! God Bless America!! 🌟

  4. Frank Romeo

    Interesting, but tolerating all dissent without limits is inherently destructive. We want the capital U in United but cannot be tolerant of people advocating chaos and the destruction of the USA. To end it’s existence without a viable alternative. Yes Chas, you can be free, in the libertarian sense but all must contribute positively. No Army, no police, no laws means the rule by the most violent, like the Lord of the Flys. Free to advocate, but you must convince a majority to agree and you must follow natural law and the 10 Commandments or some God centered laws. No murder, no theft, no excessive envy and so on. As an example slavery was accepted around the world in every society until until western culture realized it as an abomination. Treat everyone as you wish to be treated. America is a great experiment freedom to express yourself, property ownership, freedom to achieve happiness. Free to analyze the pandemic and decide for yourself how best to handle it, scientifically.

  5. Don Johnson

    Good comments, Chris, along with Frank’s counter in the comments. I am a Canadian, married to an American, with dual citizens as kids and grandkids. I appreciate both systems, but especially admire the American concept of “we the people” self-governing under the rule of law. In Canada, our concept is from the top down – the Crown grants us freedoms. Your concept is from the bottom up, the people enjoy liberty and cede authority to representatives. It works better, in my opinion, but it is always under attack. This year is putting exceptional pressure on liberty (and freedom, up here). Hoping we make it out of this mess in one piece!

    And FWIW, yes, keep investigating the claims of both sides of the Covid debate (or all ten sides, as it may be!)

  6. Terrence O'Neill

    The same point was made in one episode of the TV series West Wing, where a very divergent opinion was allowed, about the same point… wish I could remember more detail about Toby explaining that to the commie advocate.
    It’s called Freedom of Speech.

  7. Brian Gates

    Better divided forever than united in error. The US was founded on the principle of individual rights, but in our lifetimes that radical idea has been lost. We should enjoy the unfettered pursuit of health, but today most people accept health authoritarianism. Next time someone starts a free country they need to put an explicit wall of separation between health and state in the founding documents.

  8. Kay

    Mr. Brian Gates may find these quotes from Dr. Benjamin Rush MD interesting:

    1) “Unless we put medical freedom into the Constitution, the time will come when medicine will organize into an undercover dictatorship to restrict the art of healing to one class of Men while denying equal privileges to others, will constitute the Bastille of medical science; the Constitution of the Republic should make a Special privilege for medical freedoms as well as religious freedom.”

    2) “Controversy is only dreaded by the advocates of error.”

    Who was he? One of the signatories on the Declaration of Independence. Fourth column, second signature from the top- Declaration of Independence. While some conveniently say the first quote is misattributed to Rush, that it “seems” anachronistic to late 18th century America, much of Rush’s contributions and philosophies were anachronistic, not to America, but to medicine, and are so today, exactly what he warned about. An example would be his work citing common laborers, injured or sick, recovered easily compared to the privileged class of that day who perished more easily. Expecting a real lady to jog? Blasphemy!

    The second quote cited certainly fits Dr. Centeno and to use a quote by Dr. Centeno concerning Rush: “You can’t make this stuff up.”

  9. Stef

    America has been a plutocracy since day one, everything else is walt disney an americains love walt disney. Like Tocqueville sum up: for americain it is all about INTEREST. There is an americain flag every 3 houses in the usa. Everybody lives in their own usa. It was all a matter of time before walt disney delusions would come crashing with reality. Enjoy the last gasps of the Unites States…

  10. Dorian L Valles

    “Rouge” states? You mean “rogue” states, right? Unless you mean “red” like…

    1. Chris Centeno, MD Post author

      Thanks, fixed…

  11. Bill Griffin

    Fantastic! I agree completely and I wish more of us would do the same. We have to be tolerant of others and their opinions and we must assess both sides of any question. It is only through that that we can come to reasonably valid conclusions. Towing any party line is the mark of the intellectually stupid.

  12. Kent Lester

    I believe you are ignoring a key aspect of the scientific method: Its main goal is not to develop diversity of thought but to determine truth, as much as that is possible. Yes, every hypothesis should be allowed, but then tested rigorously. And when a scientific hypothesis is proven unsound, or fails rigorous testing, IT IS ABANDONED, or at the very least reexamined from the ground up to determine the falsehoods. Americans seem to think that all opinions are equal, simply because we have the equal right to express them. But some opinions are more accurate than others. Until Americans can return to their founder’s tradition of discourse and compromise, we will never improve or grow. Until we have the humility to admit when we are wrong, we will never evolve toward what is right and factual. The current, best evidence shows that masks reduce transmission of Covid, that this disease is highly contagious, leading to exponential growth. So, we Americans need to swallow our pride and go with the best consensus currently available while continuing to strive for more accuracy. That means everyone wearing masks and distancing. I seriously doubt we would have won WWII if every citizen had felt the freedom to flaunt the draft, the allotments, food, gas, and tire stamps, the calls to action in factories, and the need to COME TOGETHER for the greater good. Simply put, people refusing to wear masks are making things worse in the most un-American way, by flaunting their individual freedoms over the general welfare of the nation. Remember, those 13 united states, (uncapitalized) had to agree to a host of compromises, in order to BECOME united.

    1. Chris Centeno, MD Post author

      Kent, you need to review the scientific data on masks. I have done that a few times. To make a claim that masks are highly effective you have to be able to review the data yourself, not read news articles. I need you to provide scientific citations to prove your point (published in scientific journals).

  13. Klaus Buechner

    When I was not yet retired I had many opportunities to improve my financial situation and move from Canada to the US. I declined because I believe that Canada has found the right balance between freedom/entrepreneurship and social cohesion/balance. In the US personal liberty and opportunity is paramount; while in Canada we recognize the concept of “community rights” and protect the rights of all types of minorities.

    How these two neighbouring countries dealt with this pandemic is a case study of some of these differences.
    1) In the US the response became totally politicized and dysfunctional; whereas in Canada all political parties basically sang from the same song sheet following the best medical advice.
    2) Both countries had let the strategic pandemic inventories atrophy. The response in the US was finger-pointing; whereas in Canada everybody pulled together to address the issues.
    3) Canadians generally followed the recommendations from politicians and medical experts; whereas the response by many in the US was “Make me if you can!”
    4) The single payer health care system in Canada rose to the occasion seamlessly; whereas the hybrid public/private system in the US needed a lot of political help/persuation.

    The end result is that Canada is down to a few hundred new cases per day compared to >50,000 in the US. All the Canadian statistics are running much lower that equivalent US stats on a per capita basis. That is why Canada is included in the European travel bubble and the US is not.

  14. Graham Terry

    I am originally from UK this second ammendmant about barring arms against the British people love the guns but they are shooting themselves now so that ammendmant needs to be corrected

  15. Lance Wolrab

    You can’t make this stuff up. Not sure how this blog handles hyperlinks, so you’ll need to fix a little text, but seriously, you just can’t make this up: published May 20, 2020. Or just search with 19-0994_article as your search term.

    Not to be outdone, our own CDC also has:

    Like the doc I wear a mask knowing it is minimally useful and more to make others feel good. I worked in a nuclear measurements lab handling solid radiological materials for sample processing while on active duty in the Air Force. The masks people commonly wear are utterly worthless against a micron sized virus, and I’d wager to say even an N-95 mask is not worn to provide adequate filtering by the majority of people wearing them. We were fitted, trained, and tested to ensure our masks worked. Nuclear safety is founded on the exact same principles we see promoted to limit the spread of this virus – time, distance & shielding. Manage the length of your potential time of exposure. We did that. Distance yourself from potential sources. We’re promoting that to a ridiculous degree. Shielding – this is where we are assuming a perforated condom will prevent pregnancies and STDs. It can’t. But no one, even our healthcare workers, are going to wear PPE sufficient to prevent exposing others to their sickness because you need a full face respirator with submicron particulate filters if you expect to catch the aerosol coming from your cough or sneeze. Wearing this level of PPE is taxing physically. Ask anyone who has been through chem/bio training. While the specs on an N-95 mask filter material say it CAN do this, in real world use, it can’t and doesn’t because it will never sufficiently seal against a normal human’s face, and if you really think any less than a full face silicone mask seals against male facial hair well, you’re just kidding yourself, and you’ve not been through real PPE training as I and so many of my brothers and sisters in arms have been.

    I’m glad wearing a mask makes some people feel good. I couldn’t care less.

    1. Chris Centeno, MD Post author

      You are 100% correct! Real mask tests with N95 respirators that were properly fit would be required to help reduce the spread, not a fashion mask accessory sold on Amazon!

  16. Catherine LaCroix

    Excellent article! Thank you so much for all you constantly do in your work, your research and your educational communications to enlighten us. I really appreciate your commitment and try to read and absorb most all you blog/write or share in your live seminars on Facebook.
    I will be back in your offices today, July 9, to see Dr Hyzy for a procedure. Looking forward to excellent results.
    Thank you!

  17. Joe LaValle

    Concerning the efficacy of face masks in reducing the spread of COVID19, have you reviewed the following studies:

    >> Face Masks Against COVID-19: An Evidence Review, 4/10/20 — published by UCSF — many co-authors, reviewing available evidence on the efficacy of faces masks and concluding the use of face masks reduces the spread of COVID19.
    >> Respiratory Virus Shedding in Exhaled Breath and the Efficay off Face Masks — updated 5/27/20, published in Nature Medicine. The study was done in a Hong Kong hospital in 2013 and concluded surgical face masks were effective in reducing the amount of coronavirus respiratory droplets and aerosols emitted.

    I’ve seen earlier published studies showing a reduction in flu transmission among families who wore surgical masks vs. those who did not when housing a family member diagnosed with influenza.

    Then there’s the circumstantial evidence that countries with a strong tradition of mask wearing – like Japan, Hong Kong and S Korea have done remarkably better than the US in controlling and suppressing COVID19 infections. Even in the packed subway and train environment of Tokyo, infections are very low – as nearly every rider dons surgical masks on the train. (My Japanese American wife also believes universal inoculations with the BCG vaccine plays a role).

    Finally, the vast majority of epidemiologists — medical professionals who should know the most about transmissibility — are endorsing face masks as a preventative measure.

    1. Chris Centeno, MD Post author

      Joe, the first one isn’t a peer-reviewed article, just an opinion piece. However, please get me the link. Get me the reference for the second (a link to pubmed will do). I have reviewed this literature (about 25 studies by now in 4-5 separate blogs) and the data that mask-wearing reduces COVID spread would be graded as “Very Weak”. See , , and a few more. I’ll likely do another here this weekend, so look out for that post. On epidemiologists, they of course would have a severe bias here as that department just went from obscurity to the top of the medical school heap. Hence, bucking the trends on mask use would not be good for one’s academic career right now. You may also wanty to take a look at the comment here by the nuclear specist from the military. His experience is the same as mine, REAL mask use is at least an N-96 respirator that goes through rigorous testing based on OSHA/NIOSH standards to make sure it works (we have those tests in our office). That’s a FAR cry from a fashion mask bought off amazon.

  18. Kent Lester

    Reply to Chris:
    You said: “. . . To make a claim that masks are highly effective you have to be able to review the data yourself, not read news articles. I need you to provide scientific citations . . .”

    First, I did not say (all) masks were highly effective, so you are arguing against a statement you made, not me. I said that masks REDUCE the spread of Covid, which is true. I have read the scientific peer reviewed studies, and most show some level of mitigating effect by masks, although their effectiveness varies tremendously based on the type of mask, user behavior, and many other factors which make even the most stringent peer reviewed study marginally definitive, at best. Here’s the crux of the matter:

    I come to this pandemic from an unusual direction, as a ten year student of complexity science. Unfortunately, most people, medical experts included, tend to want “definitive” yes or no results, before giving advice. (blame it on our litigious medical industry) In physics, the bastion of peer reviewed reductionist science, physical laws can be “reduced” and isolated sufficiently to arrive at a definitive result. No so in medicine, which is why so many medical studies contradict one another. The test outcomes are highly dependent on the skills of the test taker at isolating the study material from the “noise” of many, many other effects.

    In absence of definitive proofs in medicine, we must take a different approach, especially in times of crisis, when there is not time or opportunity for definitive tests. I call this strategy “probability behavior;” choosing the most effective guess from a choice of many imperfect options.

    Back to masks: Most studies show at least some effectiveness from any and all masks, with N95 masks far exceeding the other choices. So, if you’re supplying a simple recommendation to the public, you can’t say, “masks are optional because we’re not ABSOLUTELY sure yours works.” Instead, we must pick the imperfect strategy that we think will come the closest to being effective, and right now, that means WEARING MASKS, preferably un-valved N95’s but any mask is better than no mask. I feel pretty safe in saying that if everyone were required to wear masks, you’d see a statistically significant reduction in transmissibility, and a far better chance at reopening our economy. The latest news from Texas and Florida should show that loose mask policy doesn’t work. Meanwhile, countries like New Zealand and Iceland have virtually conquered the disease by using stringent “best probability” behaviors. They didn’t wait for definitive test results.

    1. Chris Centeno, MD Post author

      Kent, there is no high-level evidence that masks reduce the spread of COVID. For something to be “true” from a scientific standpoint, there would need to be multiple randomized controlled trials of mask use and SARS-CoV2 transmission rates. NONE have been done to date.
      In medicine, there are dozens of variables that can’t be controlled, so that’s why physics won’t get us there to answer this question. On an imperfect strategy, that’s fine as a strategy, but that means you can NOT make the statement that we know that masks work to reduce the spread of COVID. You could say: “Honestly, we really don’t know for sure, but we think if you wear masks this could help.”
      Given the myriad of variables involved in Texas and Florida, there is no way to conclude that masks work or don’t work.
      Yes, tiny countries can easily conquer this pandemic. Large countries can if you take a totalitarian approach, but regrettably, our system isn’t set up for such an approach. For example, if you don’t toe the line in Taiwan you can lose your citizenship and be deported. That’s never going to happen here, no matter who is in charge. We hopefully will spend heavily now on a pandemic response team and approach, which we do need in place for round 2 or the next pandemic to hit.

  19. Kent Lester

    Chris, you said: “You could say: “Honestly, we really don’t know for sure, but we think if you wear masks this could help.” Actually, I’d be perfectly fine with that wording. My question is, as a medical professional, why aren’t you saying that? Unfortunately, since our government failed to act quickly and responsibly early, we now only have imperfect solutions at our disposal. But the attitudes of cynics seems to be, if the solution and proof isn’t perfect, then it’s not worth doing at all. As humans, we all desire absolute answers, but reality is far closer to a game of Texas hold’em poker than it is a church, where everything is “known” and right or wrong. Professional poker players would never make money if they only bet when they “knew” the odds were in their favor. And yet, educated guesses with incomplete information can make a lot of them rich, nonetheless.

    The sad truth is, now that the US messed up the early days of the pandemic, our best hope for re-opening the economy without a runaway pandemic is to insist on masks for everyone. Perhaps if the administration would use the war powers act to vastly increase production and availability of N95 and N96 masks, then we could improve the odds significantly. And remember this about scientific studies: absence of proof does not equate to proof of absence.

    And actually, there are numerous studies going on right now concerning the best strategies for Covid control. The entire world is participating. It’s called the actual results. It’s not peer reviewed or tightly controlled, but the tests make up for that by their sheer numbers. (the entire planet) We can study the control procedures of each country in the world, and see the actual results of those procedures. The countries with the lowest numbers are the ones that either started tight controls early, or rely heavily on masks. That’s the study I depend on to make an educated guess because the sheer number of participants drowns out a lot of the “noise.”

    Yes, America can remain stubbornly free in this pandemic, but the result is a much higher infection rate than almost any other country in the world. Somehow, freedom to “die stupidly” does not make my top list of American freedoms. Americans have no problem being “forced” to take a driving test in order to have the freedom to operate a vehicle, but they balk at the “horrible” burden of having to wear a mask for a few months to help save their elderly relatives and other vulnerable Americans. We need persons of influence to promote solutions, regardless of their imperfections, because the alternative is to sit back and do nothing but complain and tolerate the bad results.

    I am a man of science and this attitude makes no scientific sense to me at all. Obviously, I trust your knowledge and medical expertise, which is why I read your blogs. I just have doubts about your pandemic focus. Why not concentrate on the studies that show the best control procedures, the best mask results, and sanitation strategies, and recommend them to your followers?

    1. Chris Centeno, MD Post author

      Kent, I say that every day with my actions. I’m a healthcare worker who wears an N-95 respirator every day in clinic. I make all of my staff do the same-NO exceptions. Every patient that walks into my clinic MUST wear a mask-NO EXCEPTIONS. I wear a cloth mask when I’m out and about in ALL of the areas they tell me to. On the latter, do I believe that the cloth mask is helping me or anyone else? Nope, I’ve reviewed that literature. So why do I wear it? 1. I’m supposed to 2. It may make someone else feel more comfortable.
      Now, the next step in this analysis is whether scientists and physicians should by lying to the public trying to get them to do wear masks because we “know” from a scientific standpoint that they work. For me, the answer is a firm “No”. We should level with everyone on the lack of evidence and if public health officials want to make it mandatory, then they have the power to do that. That issue will play out in the courts as well, as that’s how our country is built and that’s OK too.
      The scientific method is about isolating variables. When you have many variables like: [the country shutdown A,C,C,D,F, and F activities], [there was social distancing of X compliance and L distance (this one you can thankfully get off cell phones)], [there was mask-wearing of Y compliance and of G,H,I,J mask types], and [there was hand washing of M compliance]… How would we know the compliance of mask-wearing? How would we know who wore which types? How would we know who wore them well or poorly? How would we know the actual compliance of handwashing? For how long? As you can see, our “experiment” is already a mess of gargantuan proportions…

  20. Kent Lester

    Chris, I think you’re making my argument for me, better than I could. Your own message seems confusing and at odds with itself. If you’re interested in telling the public the “truth” about the ineffectiveness of cloth masks, why do you insist that you and your staff wear “worthless” and untested cloth masks? If you secretly think they may be better than nothing and worth wearing, why not emphasize that in your blogs?

    If you know from scientific studies that N95 masks are far more effective than cloth masks, why are you wearing a cloth mask in public? Why not an N95?

    You have a powerful tool in the form of your blog to promote control issues, and yes, please be honest and use your own words to say, “we don’t know for sure, but wearing masks may help.” Why focus all your energies on highlighting the inherent lack of clarity on the mask issue? Creating reasonable doubt, is an oft used tactic by lawyers who know their client is guilty, but want to “win” nonetheless. The tactic has little to do with honesty.

    Why should the US tolerate one of the worst pandemic performances in the world, in the guise of “freedom and truth.” Didn’t we used to be the “get it done” nation?

    You correctly point out the vast complexity of drafting a definitive test for the influence of masks, due to variability in mask quality, behaviors of the test participants, other preventive factors in play at the time, etc. etc. You already know from reading these studies that isolating the single influence of a mask to get a reliable test result, is practically impossible, and yet you quote those very tests to “prove” that masks aren’t effective, while still wearing them in your office. How does that make sense?

    Inability to isolate the test question from other factors is what I mean when I refer to “noise” in a reductive scientific test. In your opinion, how would you craft a mask test that would give an accurate answer to the question, “do masks reduce transmission of Covid and by how much?” I’m not sure it can be done. But as I said, lack of definitive proof has absolutely no influence on the ACTUAL effectiveness of masks. They either work or they don’t. This is why I fall back on the actual results from different countries. The sheer volume of study participants serves to drown out the noise, and yield statistically meaningful information.

    The bottom line is this: our speakers of influence can continue to question the absolute effectiveness of our tests, and ignore the realities of actual results in countries that have used masks, but get ready to resign yourself to a country incapable of “getting it done” anymore. Personally, I’d prefer to reside in a country that actually gets results, like New Zealand. Unfortunately, they don’t want us stubborn and willingly ignorant Americans mucking up the works in their country, so I’m out of luck. :-)

    I don’t want to be negative here, because that accomplishes nothing. But I will say, during the last decade that I have been studying complexity science, I’ve had to learn humility about the certainty of my existing worldview. Many of my preconceived assumptions have been dashed on the rocks of knowledge. It’s been a humbling experience, but one I would never want to avoid.

    1. Chris Centeno, MD Post author

      See above. Tomorrow’s blog will be on this issue. I have graded all of the research we have, so you’ll find that interesting.

  21. Kent Lester

    Chris, oops, correction. After rereading your post I did notice that you insist on N95 masks for you and staff in the office, so my bad. However, I’m still confused by your choice of a cloth mask in “public.”

    I do think its possible for our authorities to be accurate and say, “we don’t have absolute proof of a mask’s effectiveness, but we have a pretty good suspicion that some of them work, so we will err on the side of caution and require their use in public for the benefit of all.”

    1. Chris Centeno, MD Post author

      I wear a cloth mask because I’m expected to and it may help others feel more comfortable. Believe me, if tomorrow the health authorities said “never mind-no more masks needed” I wouldn’t wear one.

  22. Joe LaValle

    You requested links to the 2 article headings I sent earlier — here they are:
    >> Face Masks against Covid19 – an Evidence Review —
    >> Respiratory Virus Shedding in Exhaled Breath
    This study is currently under peer review — interestingly, its findings suggest surgical masks are more effective at preventing the dispersion of coronaviruses aerosols than influenza aerosols — significant if the study holds up under peer review, as many of the studies you reference as evidence against the efficacy of masks were based on studies of influenza transmissibility.
    Also — I scanned a number of the studies you cited as evidence against mask efficacy and found the conclusions of said studies far more ambiguous than you.
    For example, your 6/21 blog cites a study by Dbouk and Drikakis as evidence against masks — but the study authors conclude “we show that the use of masks (surgical) will reduce the airborne droplet transmission and will also protect the wearer from the droplets expelled from other subjects”.
    Your uses of the MacIntyre CR study — “A cluster randomized trial of cloth masks compared with medical masks” — showing the the relative non-efficacy of cloth masks in a Hanoi hospital trial is also a bit misleading. It does show “medical masks” were 13 times better than cloth masks at preventing influenza infections — but the “medical masks” used in the study were surgical masks — not N95 masks. But you used this study as a lead-in to commentary on why surgical masks were ineffective – but the study you cite shows them to be 13 times more effective than 2 ply cotton masks. You also reference a Toronto hospital SARS study — but that study found “risks were lower for both surgical and N95 masks” for nurses treating SARS patients and “risk was reduced by consistent use of surgical masks”. N95 masks were superior — but the nurses were performing high risk activities like intubation and suctioning and surgical masks still provided a limited level of protection. Also — I’m not sure of the relevance in comparing surgical mask efficacy in a surgical setting in preventing wound infection vs. preventing the spread of airborne easily transmissible viral illnesses. And one of the surgical setting trials credited OR airflow that directed air away from the patient as the likely cause of the reduction in surgical wound infections. Even the NIOSH study shows some small benefit in cloth masks relative to reducing a wearers airborne spread of viral particles. And the Rengasamy study, “Simple respiratory protection…” — which, like the first study I originally sent is a review of existing studies and not a separate trial, was not a complete refutation of the efficacy of face coverings. It instead concluded “facemask use demonstrated mixed results, but a randomized clinical trial suggests that it is effective”. Finally, the Aiello study — a 6 week look at university students comparing groups of frequent hand-washing, frequent hand-washing plus facemask usage and a control group concluded “facemasks and hand hygiene combined may reduce the rate of influenza like illness and confirmed influenza in community settings. I did not review each study you referenced — or read them all in great detail — I skimmed the ones I did review and focused on the abstracts and the conclusions. But the results on facemask efficacy seems to be a bit more nuanced than your several blogs suggest.

    1. Chris Centeno, MD Post author

      Joe, please see yesterday’s blog. All of these studies you referenced need to be first graded for applicability to our current situation and the overall quality of the evidence produced.
      Your first unpublished study couldn’t be graded as it appears to be a review of all of the lower-level data out there on COVID or non-COVID papers. I reviewed the second paper in the journal Nature for the blog yesterday but ultimately didn’t include it as it didn’t study the SARS-CoV2 virus. If I had, it would have been graded as a low level somewhere between level 7 and 8 (1-2 being solid evidence). See
      All study concussions are ambiguous if they’re lower-level evidence. Reviewers rarely let you make firm conclusions unless you have a study design that can support your conclusions, which these studies didn’t.
      As I wrote in yesterday’s blog, I will grade all of these non-SARS-CoV2 studies on that same scale at some point. For example, the hospital study showed that “medical masks” (which I believe it never defined so if you can find that statement in the paper let me know) were better than cloth masks. First, being relatively better doesn’t say anything about the efficacy of “medical masks”. Second, that’s a low-level study, to begin with with a huge number of variables that weren’t controlled. Hence, the conclusions will always be weak.
      On the Macintyre study, again, a low-level study design yields weak conclusions. However, taking that study for what it says, doesn’t translate to what you’re wearing a mask for every day in this pandemic. For example, having intubated patients, that activity is nothing like walking through Target. Meaning, you don’t have other shoppers trying to spit or cough in your face with your face inches from theirs.
      NIOSH didn’t measure “viral particles”. They didn’t measure “infectivity”. They didn’t use the SARS-CoV2 virus.
      On Rengasamy, they concluded, “Results obtained in the study show that common fabric materials MAY provide MARGINAL protection against nanoparticles including those in the size ranges of virus-containing particles in exhaled breath.” This is also a low-level water droplet test stand study (see yesterday’s blog) that didn’t use the SARS-CoV2 virus or any virus or even measure infectivity.
      On Aiello, this is what they said, “Both intervention groups compared to the control showed cumulative reductions in rates of influenza over the study period, although results did not reach statistical significance. ” Hence, they couldn’t show a stat sig drop in infections.

  23. Joe LaValle

    Chris — you asked if I could provide details on the “medical masks” used in the MacIntyre study that showed medical masks provided a 13x efficacy in preventing influenza/respiratory infections in hospital workers vs. the same workers who wore a simple homemade cotton mask. Here is the description, lifted from the study: “Masks used in the study were locally manufactured medical (three layer, made of non-woven material) or cloth masks (two layer, made of cotton) commonly used in Vietnamese hospitals.” So – 3 ply surgical masks reduced the transmission of influenza like illnesses by a factor of 13x vs simple 2 layer cotton masks. Here’s the rub — 3 ply medical masks (labeled as “surgical masks”) are readily available on Amazon and other sites at costs of around $0.50 each. A study you cited as proof surgical masks have no efficacy seems to indicate that they do provide a moderate level of protection – and it was ingress protection, not egress protection – that was referenced. I agree that many of the studies I researched were not robust enough to be definitive – but these were studies you had initially referenced in your blog as proof positive that masks were ineffective. I just googled a few to get a better picture and interpreted the study conclusions to be far more nuanced as to the protection masks provide. Again – these were studies you initially cited as verification masks don’t work, so it’s a little disingenuous to now suggest they are low level and unreliable, although some may well be. As to waiting for results of peer reviewed RCT’s measuring mask efficacy in reduction of wearer exhaled viral droplets or aerosols — vs. using past studies on influenza or current engineering studies on the filtering capability of various mask material for covid-size particles – it would seem foolish to wait when most studies — even the ones you referenced – show some level of protection, however modest, when everyone wears a mask – preferably surgical – to reduce covid 19 spread.

    1. Chris Centeno, MD Post author

      Joe, unsure why the study would use locally manufactured masks? A typical practice in studies to ensure reproducibility would be to say that the workers used “X surgical masks” provided by Y company with ID code Z. That means that someone else can buy the same mask and get the same results or not. So the issue is that this study apparently tested one homegrown mask type, not one that can be readily purchased.
      in medicine, there is no need to prove a negative. Every intervention is assumed to be ineffective until proven effective. So the burden of proof is on the intervention. Meaning if the studies are low level, then the data can only support weak conclusions and don’t reach to the point of efficacy.

  24. Kent Lester

    Chris, you said: “I wear a cloth mask because I’m expected to and it may help others feel more comfortable. Believe me, if tomorrow the health authorities said “never mind-no more masks needed” I wouldn’t wear one.”

    Interesting. What if the authorities say, “there is real word evidence that wearing masks consistently, reduces the spread of Covid.”

    Would you then turn around and change your tune and strongly recommend your followers wear one? In other words, are you equally flexible to the authorities’ recommendations when they go against your initial stance?

    You said: “in medicine, there is no need to prove a negative. Every intervention is assumed to be ineffective until proven effective. So the burden of proof is on the intervention.”

    This statement is a legal stance, born of the unfortunate litigious nature of the medical industry. No doctor gets sued for REFUSING to do an experimental and unproven procedure. Only for the opposite, if the experiment fails. In general medicine, doctors have time to wait for studies to state that, “our peer reviewed study says that this procedure is safe, effective, etc. etc.” Then the doctor’s butt is covered in court when overzealous attorneys try to pin the randomness of life on the doctor. It’s an unfortunate situation for doctors and certainly explains the over-reliance on studies, for “permission” to proceed. You may be particularly sensitive to the “legality bias” due to the fact that you deal in cutting edge technology that exposes you to the legal whims of overzealous attorneys.

    However, Covid is a triage situation. We can’t afford to wait for the plodding nature of the industry to “prove” that masks are effective. We need to make bold, experimental moves before this pandemic gets out of hand. And there’s quite a bit of anecdotal and real world evidence that countries who insist on stringent mask use have significantly reduced transmission rates. The US is quickly becoming the world example of what NOT to do in a pandemic.

    Simply doing a cost-benefit analysis should convince you that masks should be encouraged, not questioned.

    If I’m wrong about masks helping to protect Covid from the public, the worst that can happen is my followers will be irritated at having wasted time and money on a useless PPE.

    If you’re wrong that mask wear is an unnecessary hindrance and should be voluntary, the worst that can happen will be death for some of your followers and others who come in contact with them.

    That cost-benefit graph alone, should be reason enough to err on the side of caution.

    1. Chris Centeno, MD Post author

      I wear a mask because that’s the recommendation. I have no problem saying that everyone should obey whatever local regulations apply on masks. For example, I would give the same recommendation to all of my followers that I give my kids. if they say you should have a mask on, wear a mask. Now that’s different from whether we actually have solid evidence that mask-wearing helps. We don’t. Hence public health authorities should be honest with a statement like, “We don’t really have hard evidence that mask-wearing will stop or slow the spread of CIOVID, but we want you to wear a mask because we think it might help”.
      On medicine, the med-legal system has nothing to do with why every treatment or intervention is assumed to be ineffective until it’s proven effective. That’s just Evidence-Based Medicine.
      All science is to be questioned. Unless it’s questioned, there is no scientific method.

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