“But what is really going on?” Why the best scientific answers regarding COVID are so hard to accept

As a medical trainee, nearly every friend, family member, or neighbor who knows my career focus will ask me what I think about COVID and its trajectory. My answer, well rehearsed at this point, is filled with cautionary phrases: “but this rapidly evolving”, “at this point”, “this could mean X or it could mean Y”. But after months of hearing these answers, the public is growing more and more impatient. Understandably, every decent scientist from Dr. Fauci down has been giving similar responses.

“Yeah, yeah, yeah…but what is really going on? Just give me a straight answer!” My closest friend accuses me of hedging my bets.

To the majority of the public’s questions about COVID, the only right answer is still “we don’t know”. This is not a condemnation of public health or its scientists, but an exploration of the pace of science vs the pace of a pandemic.

Before dissecting this further, it is helpful to review the scientific method. My simplified version is summarized as:

1. Hypothesis

2. Experiment

3. Measurement

4. Analysis

5. Repeat steps 1-4 over and over and over….

6. Draw conclusions

7. Verification with peer review and experiment reproduction

In basic sciences and clinical medicine, this is not a quick process. To develop a new drug and get FDA approval by passing these 7 steps, takes an average of 12.5 years and over $1,000,000,000. A staggeringly high number of published scientific conclusions are not able to be verified, leading us to enter a period known as the Reproducibility Crisis. Part of this dilemma is explained by economic and political factors, but part of it an inevitable hurdle of experimentation compounded by the vastly complex and variable nature of human physiology. This explains why definitive answers to seemingly important medical questions have eluded us: How detrimental is dietary cholesterol? Why do certain medications work for some people but not others? Why are autoimmune diseases on the rise?

Transitioning from decision making in clinical medicine to public health is exponentially more difficult. Clinical medicine is getting stuck at step 7: Verification, but public health is often challenged by step 3: Measurement. Some of public health’s most fundamental and important statistics are cause of death and number of deaths. Even the major public health institutions around the world give huge ranges that often contradict each other. (I highly recommend reading Epic Measures which chronicles Dr. Chris Murray’s lifelong journey to answer these questions. His team has also produced some of the most useful COVID models that we have available.)

But in the case of the COVID outbreak, it took less than 4 months to grow from a single recognized case to reaching over 3,000,000 reported cases worldwide. It took even less time for the global economy to crash and for unemployment to grow at a pace never before seen. The pace of the pandemic is orders of magnitude faster than the pace of science and public health.

Simply put, the public needs answers faster than the scientific community will be able to produce them. Without experimentally verified conclusions and answers, what are we left with? Models. It is inevitable that we will have to act, and “reopen”, based on models and not answers. This makes nearly every scientist weary due to the unstable nature of models. An oft cited quote by legendary statistician George E. P. Box: “All models are wrong, some are useful”. And Peter Attia said it best, “We shouldn’t look at models to give us the ‘answers’…Instead we should look to the models to show us how to change the answers”

We should continue to accelerate the pace of science and these vital calculations. But this time, the scientific community will not be able to provide the silver bullet for COVID. In 2020, COVID:1 and science: 0. The best we can hope for is incremental discoveries, evidence-based estimations, and a rapidly adaptive response to grow from “we don’t know” to “we don’t really know but…” This slow, steady progress will hopefully allow us to even the score in 2021 and beyond.