How SARS-CoV2 Outbreaks Work

Many people have said many things about SARS-CoV2. And many of those things have been wrong. I doubt there is a not a person alive who has not been wrong about something. I am not afraid of being wrong, so I have at times been vocal about my thoughts on the virus, even sometimes speaking ahead of the evidence when I saw a pattern emerging.

I will lead with something I got wrong: I thought weather would have more of an effect than it does. In my defense, at the time I thought this, I had been convinced by the consensus belief that the virus spreads mainly through surface contamination. Given the studies that demonstrated the effect of temperature and humidity on the survival of the virus on surfaces, I expected that hot weather would have a dramatic effect on how much surface contamination was occurring. Of course, we are now fairly confident that the main mechanism of spread is close contact with the air around an infected person. Surface contamination appears to play a minor role (if any at all – it’s not clear to me).

The irony in basing my theory about weather on the belief in surface contamination is that I was right about how the virus was spreading from the beginning. I very early on expressed my belief that the virus was in the air. I thought this explained the disasters in Wuhan and Italy – neither place was maintaining any kind of infection control protocols at first, allowing infected patients to intermingle with other patients, lying in hallways, and so on. But the insistence that the virus was not in the air was so strong and backed by so many expert voices that I backed off in my belief about the virus traveling through the air. This led to my wrong belief that weather would have a major impact (weather clearly has some impact – and probably delayed major outbreaks in California and the US South for months).

Getting to the meat of this argument, I have analyzed a lot of information from many countries all over the world and have drawn some conclusions about how this virus works and in particular how the outbreaks work and the measures to control it. I may be wrong – there may be something I am missing that provides an alternative explanation. I have been wrong before. If I am wrong, I would be thankful if someone shows me how I am wrong.

Without further delay, here it goes.

The virus appears to have two potential phases of outbreak:

Phase 1: Whack-A-Mole

Phase 2: You Are Screwed


The Whack-A-Mole phase occurs when the virus first arrives in a country’s borders. Testing, tracing, and isolation (TTI) of contacts is the Whack-A-Mole game. After examining many countries around the world, I have come to the conclusion that TTI is *highly* effective. Countries all over Asia, Australia & New Zealand, half of Europe, and even the US state of Hawaii, have proven that you can keep the virus at bay by identifying outbreaks and isolating those exposed.

More on this later, but there appears to be a divide on how countries are playing Whack-A-Mole. The EU countries and Australia & New Zealand have convinced themselves that lockdowns are a necessary part of this game, while the Asian countries have largely ignored lockdowns, realizing that Whack-A-Mole is effective without them.

You Are Screwed

This phase begins when community spread in your country reaches a level that overwhelms your manpower to perform TTI. There are too many moles and not enough whackers. When you reach this phase: YOU ARE SCREWED. Contrary to conventional wisdom, I have seen *no* evidence that any of the extreme measures taken in many countries have actually stopped the virus from spreading once community transmission is high. NOTE: The United States deserves special credit here for cancelling the Whack-A-Mole phase and proceeding straight to the You Are Screwed phase. You cannot play Whack-A-Mole without tests.

These two phases can be seen across the world. Just honing in on Europe, there is a split between the countries. Half the major Western European countries successfully played Whack-A-Mole. The other half failed. The result is clear: the half that succeeded have little or no excess mortality. The half that failed have high to very high excess mortality. Australia and New Zealand succeeded in Whack-A-Mole. Both of them mostly kept the virus out and isolated, which made their game easy to play. Some of this is good execution on their part, and some is geographic isolation that minimized exposure before everyone knew what was going on. In Asia, Taiwan mostly kept the virus out. Other countries, like South Korea and Japan, played Whack-A-Mole successfully. South Korea perhaps played the most Whack-A-Mole. They had serious outbreaks early on that threatened to overwhelm them. But they also had a good system in place from past experience and they were eventually able to Whack enough moles to contain the virus.

Containment Measures

A lot of different containment measures have been used, and in a lot of different circumstances. Basic measures, like banning large gatherings, encouraging working from home, and encouraging social distancing, were adopted by virtually everyone. Beyond that, the variety of interventions is quite wide. Asian countries mainly went for universal masking with some level of shutting down schools for older children (high school, college). Most avoided stay at home orders and the general shutting down in Europe. Some of them, like Thailand and India, went for a full shut down. In Europe, the measures were much more uniform. Nearly every major Western European country went for some sort of full shut down, often including restaurants, schools, and stay at home orders. Sweden is the famous outlier here, opting instead to let the virus run its natural course with only basic measures enacted. More on Sweden later. In Europe and the Americas, masking was discouraged at first, then an about face was made and masking was encouraged or required in many places. In the United States, measures varied widely by state, but most states eventually shut down and issued stay at home orders at some point.

Based on an analysis of data from all of these countries, I have come to the below conclusions about each intervention.

Testing, Tracing, and Isolation

The Big Kahuna. TTI clearly works. In fact, TTI appears to work phenomenally – far beyond expectations. Why? Probably because of the strange clustered way this virus spreads. It seems that so many carriers and situations result in little or no spread, but certain situations result in large clusters. If you can find those clusters and isolate everyone before they begin creating more clusters, you cut off the lifeblood of the virus. It seems like a daunting task, but is apparently not so daunting due to the dynamics of this virus’s spread.

Across the world, there is only one commonality between the countries that managed to keep the virus out – they all successfully played Whack-A-Mole. Some of them locked down. Some of them closed schools. Some just wore masks. There is wide variation in the measures adopted in each of these countries. But the intervention they share in common is TTI.

Has anyone noticed that virtually all of Asia has opened back up (if they shut down at all) and has the virus under control? This is testing, tracing, and isolation. Japan was called “the next disaster” by those who argued for stay at home orders. It never happened. You can find quite a few articles talking about the “Japanese miracle” – how they took very little measures – other than telling people to wear masks, avoid the 3 C’s, and…tested, traced, and isolated cases. Or, as Japan refers to it – breaking up clusters of infections. Japanese tracers went to work quickly and they are the reason Japan has succeeded. They are the reason all of Asia has succeeded.

Speaking of Asia, everyone remembers where this outbreak started, right? China has opened back up and even had several new pockets of infections. Do they appear scared? Do they appear on the verge of shutting anything back down? No, because they understand they have the tools to stop the virus. If you are vigilant, you can stop it before it gets out of control. They learned that.

If you want the ultimate example of the power of TTI, look no further than the Dharavi slum in Mumbai. As the city around it burned with infections, Dharavi remained relatively unscathed. With one million people in a 2.5 km2 area and people sharing public toilets, this is the last place you would want to be during a pandemic. And yet, Dharavi has been modestly successful. How? Stay at home orders are a fantasy. Social distancing is a fantasy. They succeeded because local doctors organized the world’s most dedicated grassroots testing, tracing, and isolation program. They went door to door testing and locating sick people. And it worked. It may not work forever – they have to remain ever vigilant and never let up – and that is difficult with infections all around you and such cramped conditions. But if you want to see how successful Whack-A-Mole can be, just know that you can even play this game in Dharavi.

Basic Measures

The basic measures like cancelling large events and working from home are probably highly effective, but it’s difficult to say for sure because everyone enacted them. But we know from the study of “super spreading” events that these measures decrease the number of those potential events. Case studies from South Korea show how widely the virus can spread in an office environment, so working from home is likely a key intervention. There are many case studies of large gatherings where the virus spread widely, so again it’s clear cancelling these events is important.

Stay at Home Orders

Now I will make almost everyone angry. I see no evidence that stay at home orders were very effective. Belief in stay at home orders has become a religious test. I think partly this is due to the large consensus that formed around stay at home orders in the scientific community (without evidence) and the opposition to such orders by Trump and Trump followers. Together, this has created an instinctive response from many people that immediately accuses anyone who challenges stay at home orders of being “crazy” or a “flat Earther”. Ironically, belief in stay at home orders is the ultimate flat Earth mentality because it demonstrates an inability to properly read data and critically think about that data. For most, it probably just represents political ideology and parroting consensus.

Why does it look like stay at home orders are not that effective?
First, what happened to the spike in cases that was supposed to happen in Europe when countries began rolling back their measures? It did not happen. I have not heard a plausible explanation for this – I saw some articles saying “hmmmm” and then everyone moved on. But this is a big red flag. Because the most plausible explanation for this is that 1) these places reached herd immunity, and 2) the measures enacted were not that effective, so unraveling them did not result in the expected spike in cases. I have seen no other plausible explanation. Some might argue that masks picked up the slack for these measures. That is not the case based on the data, and if it were, it would still mean that masks could have been worn instead of stay at home orders, which carried a heavy burden. Either way, stay at home orders look like a huge mistake.

Second, many Asian countries do not have stay at home orders and are doing just fine. They do not seem to need stay at home orders to control the virus, so why does everyone assume stay at home orders are a key to the strategy that kept it out of other countries?

Third, when the Financial Times analyzed lockdowns, they found they only work if they were “done early”. This should be a huge red flag. Why? Well, what is the logical explanation for why a lockdown would work “early” but not later? I have not heard one. Such a reason exists for TTI – there are manpower limitations. If the spread overwhelms the manpower, it fails. That makes sense. But I cannot make sense of this idea of lockdowns working early but not late. It does not sound plausible to me.

Instead, lockdowns appear to be the ultimate mistake of seeing correlation and assuming causation. Success in Europe gave rise to assumptions that the most controversial and most hotly contested measures worked. There is enormous pressure to validate lockdowns, given their massive cost. But lockdowns are merely along for the ride. The reason lockdowns “work” early and not late is that what is really working is Whack-A-Mole – TTI. Lockdowns might make it a little easier to play Whack-A-Mole, but the data seems to indicate they do not do a whole lot. My reading of the data indicates that lockdowns “worked” if used early because TTI works. And when used late lockdowns “stopped” the outbreaks because they were issued in the weeks before reaching herd immunity. Lockdowns are merely a spurious correlation of TTI in the early phases and a spurious correlation with herd immunity in late outbreaks.

I live in the state of Illinois, and when we came out of our lockdowns, we saw very little bump in cases. We have now opened restaurants and bars and seen a small bump up in cases. Nothing Earth shattering – or on any scale that justifies lockdowns.

Fourth, lockdowns clearly failed in many places, but no one wants to talk about it. In Illinois, lockdowns were issued fairly early. But the peak of the virus occurred *8 weeks* after the lockdown started. That’s way too long to make any sense. In other countries, such as India or Peru, lockdowns failed completely. Why? Because they failed *everywhere*. But India and Peru lack the resources to effectively contact trace. And Illinois does not lack those resources, but lacked the tests necessary to do it (lack of tests was truly the original sin in the United States).

Side notes relating to contact tracing: the Indian city of Bangalore seems to have done much better than Delhi or Mumbai so far. I read an article that said Bangalore had traced 47 contacts for every positive test and Delhi had only traced 1 contact for every positive test. The results in each city follow from that. Canada is also an interesting case. Quebec was hit hard, but Toronto appears relatively unscathed. I wondered why, and was unsurprised when I found an article talking about Toronto’s contact tracing program and experience from SARS.

What is strange about stay at home orders is they were originally promoted as “flattening the curve”. They appear to have done this – albeit modestly. The chart of deaths in the state of Illinois looks flatter/smoother than a chart of Sweden. But somewhere along the line we began pretending we could stop the virus. We talked about “the hammer and the dance”. But it turns out the hammer was made of glass. I am not sure why this was invented – was it because the models that projected massive deaths were proving to be wrong, so we needed a new justification for these drastic interventions? Did we realize 2.2 million people in the US were *not* going to die, so we decided to shift the justification for stay at home orders to stopping the virus in its tracks – a proposition with no historical support?

Closing Indoor Seating in Restaurants and Bars (and churches)

It is likely this has a moderate effect. We have seen super spreading cases in restaurants, bars, and churches. When Illinois opened these things back up, there was a modest increase in cases. There is not much to say about this – other than they are precisely the kind of situation we know can spread the virus.

Closing Schools

There is no evidence this did much. Many Asian countries had data from the original SARS that said closing schools did not help. Based on this data, they kept them open and there were no major problems. Sweden kept their schools open below high school age for this same reason. They do not seem to have had major problems. Several studies from different countries (Ireland, France, Australia) find little evidence of any kind of spread in schools. The R0 value in a school environment appears to be below 1.0 – quite a bit below, possibly. Given the data, closing schools was a mistake. Some scientists in Norway have already owned this mistake and said they would not do it again.

Wearing Masks

I believe the evidence indicates that mask wearing is highly effective for protecting yourself and those around you in most situations. At first I thought mask wearing might actually bring transmission below 1.0. After the data started coming in, I changed my stance. I do not see any evidence that masks can stop the virus. Masks probably fail for similar reasons that lockdowns fail: the people and situations that are at high risk of infection are not amenable to mask wearing. Perhaps over an 8 hour work shift, wearing a mask does not make much difference because virus will still make it outside the masks of those infected, circulate in the air, then back into the air breathed in by others, even through their masks. I am not really sure all the dynamics, but I am fairly confident from the data that masks are not a panacea. In the United States, lots of places are wearing masks. But only those places that had major early outbreaks are seeing infections fall while wearing masks. It is much more likely those places have some degree of herd immunity, which is the main reason infections are falling, not masks. If you lack herd immunity, masks do not stop the virus from spreading.

Another way to tell: ask yourself if any Asian country would be willing to shut down their contact tracing programs and rely solely on masks. Not a chance. The reverse is probably also true, but not to the same degree. If they had to drop one of the two, it would be masks. If people were only wearing masks in those countries with no contact tracing, I have no doubt that infections would begin to grow again.

Herd Immunity

The problem with all the interventions above (aside from TTI), are that I have seen no evidence that *any* combination of them has brought transmission down below 1.0 *anywhere*. The evidence is just not there. Thus, they are just flattening the curve. If that is the case, then you will eventually move toward herd immunity.

As demonstrated by a couple papers out recently, herd immunity is likely much lower than we think. Marc Lipsitch discussed these papers here:

The Gomes paper in particular is excellent, and it is a scandal that paper was rejected for political reasons.

From what I can see, every country in Europe that instituted lockdowns to “stop” major outbreaks did *not* succeed. They reached herd immunity and began to decline.

Sweden as Myth Slayer

I got a feeling very early on that one reason the attacks on Sweden were so aggressive and toxic was that Sweden was in a position to serve as a control for extreme lockdown measures taken elsewhere in Europe. If the Swedes only took basic measures and came out in a similar place as everyone else, it would undermine the case for those extreme measures. Reading media coverage of Sweden, one would get the impression that Anders Tegnell is worse than Donald Trump. Ironically, I believe Sweden is the only Western country where the outbreak response was guided 100% by scientists, with no political interference. Sweden, who up until this outbreak has been a darling of the American Left, and who has a structure that gives full control to their scientists, somehow became the most hated player. Could it be that – like many outside science noted, such as Glenn Greenwald – that our scientists and science have become politicized?

I am not going to go into detail analyzing Sweden’s outbreak and whether they have reached herd immunity because that was done here:

In summary of that analysis: 1) Stockholm reached herd immunity in late April, 2) Deaths have clearly declined due to that herd immunity, 3) the rest of the country is behind Stockholm, but getting there, and 4) Deaths have declined even more dramatically than infections because most of the elderly, vulnerable people in nursing homes have been exposed and either recovered or died. The newer batch of infections is younger and healthier.

This pattern of infections late in the outbreak having a lower death rate has repeated everywhere that I have seen – with Italian doctors puzzling over why the virus seems so tame now. It’s not the virus – it’s the people being infected. They are less vulnerable and less likely to have a serious infection.

If you accept the reality staring us in the face that Sweden reached herd immunity in Stockholm, a lot of funny things about the virus that do not make sense suddenly make sense. It now makes sense that European countries coming out of lockdowns saw little increase in cases. It now makes sense that European countries that took lots of different measures had similar experiences and similar mortality rates. It now makes sense that lockdowns “worked early” and not late because it was not the lockdowns working late – or early. So many dominoes fall into place that it becomes an example of Occam’s Razor. The simplest explanation is indeed right: herd immunity was reached in those places with major outbreaks.

Are Asian Countries Doing it Right?

We are quite sure that wearing a mask substantially decreases the amount of virus an infected person will project into the air around them. We are also fairly certain that masks protect a person from infection – to some degree. Asian countries tend to have a culture of mask wearing when they are sick and they are wearing masks right now. We also have evidence that some people with asymptomatic infections or minimal exposure develop a robust T-Cell immune response. Is opening society and behaving normally, while wearing masks, actually the most effective thing we can do? Does wearing a mask increase the proportion of people who will have minimal exposure to the virus and develop only a T-Cell immune response? Is the best process actually one that has people go about their business while wearing a mask to minimize their risk, while either using contact tracing to keep infections down or pursuing herd immunity if they are already too high? I don’t know the answer to this, but it’s an interesting question.


Some Thoughts on Dunning-Kruger (Study design) – 4/24/2019

1) Study 1 chose the subject of humor. Humor is subjective, changes over time, and changes based on a person’s age. This is not a small problem. It makes study 1 close to useless. To their credit, Dunning/Kruger recognize this and mention that interrater variability was indeed high. But why was humor chosen to begin with? This study was a waste of resources.

2) Study 2 asks people to say how many questions they think they got right. This question will never generate a significantly different result than the generic ability question. Because it’s just a restatement of that question. Indeed, the results confirm this – if anything ALL participants across the board expressed slightly lower confidence but otherwise gave a similar answer. This question tells you nothing because nothing has happened between taking the test and answering this question that would give anyone a feeling they should lower their confidence – regardless of their score. It does NOT tell you whether the incompetent are miscalibrated due to their own performance rather than their estimate of others.

3) Study 3, Phase 1: Grammar is not “clear and decisive” like they assert. Grammar rules vary and change. Not nearly as much as humor, so it’s not fatal to this study, but it’s not as ironclad as they assert (I know they focused on ASWE, but that is unlikely to be meaningful to test takers who think of grammar more generically). General note: tests of logic and grammar are likely to produce feelings of high confidence in test takers because those things are strongly associated with a person’s sense of intelligence. I could go into this more, but the ego demands people see themselves as at least average – this is a reason for the “above-average effect”.

In this study, they were again asked to rate how they performed. Again, like in study 2, this question was useless. And again, it tracked almost exact to their original perception. Of course it did. They were also asked to rate how they did relative to their peers after the test. And *again*, this is nothing more than re-asking the original question. Why would you expect a different answer just because you took a test in between when you do not yet know how you scored on the test? These questions seem designed with the assumption that merely by taking the test, people should realize how wrong they are. But how is that supposed to happen if they have not been shown how wrong they are? It cannot – at least not on this type of test.

4) Study 3, Phase 2: This design takes the previous mistakes and supercharges them. It asks participants to “grade” the exams of others. Without any knowledge their own answers are wrong, just how do the authors expect the graders to recognize the correct answer? This is again nothing more than the obvious logic that if I answer ‘A’, you answer ‘B’, the correct answer is ‘B’, but no one has told me that, I will of course still think ‘A’ is correct and mark your answer of ‘B’ as wrong. Just seeing that someone else answered ‘B’ is not going to change my answer from ‘A’. I already saw ‘B’ and determined (incorrectly) that it was wrong. Why would I see it again and decide it is right just because my peer did so? Perhaps if ALL the papers gave the answer ‘B’ I would start to lose confidence, but this is unlikely to happen and unlikely to be a recognized pattern by the grader.

So I do not believe this answers Prediction 3 at all. There is no behavior they observed here. The authors expect incompetent people to pick up that their competent peers are correct through some unknown force in the universe. The logic here really appears to be that they expect someone to change their answer every time someone else gives a different one. For a host of reasons, this does not happen. Again, the additional question asking people to re-grade themselves after grading others is useless. It tells you nothing. It is only a restatement that they have been wrong all along. There is NO intervening event that would change their mind.

The discussion in this section even acknowledges that their overall theory has problems, made glaring by the underestimation of the top quintile scorers. They try to explain this away, but I do not think they succeed. They do demonstrate one interesting result. After grading the bottom quintile do not change their perceptions by a significant margin. But the top quintile do increase their perception significantly. They make a lot of this, but I think the explanation is really simple.

I could do a longer discussion on this, but the plain fact is the study shows that NO ONE has any clue how their peers will perform. As a result, EVERYONE judges their own rank to be within a very narrow band. EVERYONE has confidence in their answers. Seeing the answers of their peers, the top quintile’s confidence encourages them to raise their self-assessment. While the bottom quintile did not get confirmation from the peers’ answers, they will nevertheless remain confident in their own and their scores will stay similar.

The key point is that the driving force is that EVERYONE is confident in their answers and NO ONE knows how their peers will perform. Even the highest performers are likely confident in their WRONG answers. The results seen here are nothing more than a statistical tautology. It is not surprising that people will be confident in their answers and that confidence will not be shaken simply because their peers disagree. In fact, we teach people they should not give up on their answers just because the crowd disagrees. Absent proof they are wrong, the typical reaction is to remain confident.

5) Study 4. This study is interesting because its findings contradict the way that Dunning/Kruger is often deployed to criticize people. The study put a selected group of participants through a “training” session on the topic. Unsurprisingly, the bottom two quintiles lowered their estimates of their abilities and test score after training. While the top raised theirs a bit. Is anyone surprised by this? The authors theorize that this proves that teaching them competence makes them more able to recognize their faults. Gives them better “meta-cognition”.

This seems wrong to me. A more simple explanation is that EVERYONE gives an estimate in a certain narrow range. The authors broke them out of that range by DEMONSTRATING to them they are wrong. The training showed them that many of their answers were in fact wrong. And interestingly, Dunning/Kruger is often deployed to shout down people who question “experts”. The idea being they think they are better than the experts because of some unique psychological trait that goes along with being stupid.

But the data in Study 4 shows clearly that *when confronted with evidence they are wrong, people adjust their self-confidence*. According to the Study 4 data, if people who question scientists (anti-vaxxers, for instance) were suffering from some “Dunning/Kruger” effect, they would adjust their confidence in themselves when confronted with evidence they are wrong. Yet, this does not happen. The reality is the effect is bogus and anti-vaxxers challenge scientists not because they are stupid, but for other reasons (mistrust being a big one). But it feels so much better to call people stupid and have a study to back it up.

Dunning/Kruger is widely deployed to say that people are stupid and will NEVER realize it because they are too stupid to realize it. The study does not actually say this, and the study itself refutes this idea. The “stupid” people in the study adjust their self-perception quite dramatically when confronted with their “stupidity”.

On a more general note, all 4 of the studies seem designed in a way that they could NEVER generate a null result. And their results are open to many interpretations. Dunning/Kruger then choose the interpretation that matches their hypothesis without refuting other interpretations that make more sense.

As I said, the one glaring piece of data that cannot be denied is that EVERYONE judges their own ranking within peers not with any rational basis, but using psychological and social heuristics that narrow the range of responses to a small subset of the total range. No one will rank their ability on general tests of intelligence below average because to do so would be to believe you are stupid as a general proposition. Talk about ego crushing. A person could not live like that. So, the bottom half of the scale is now gone as an option. Typically, the responses cluster at somewhere just above average. It appears that the highest performers do in fact recognize they are higher performers, so their self-assessment is somewhat higher, though lower than their actual ability. This is no doubt limited by the self-doubt that people are subject to. Once they see the responses of their peers, they realize more confidence is warranted and adjust their own scores up. (The same is true of self-assessment of their raw score. Everyone will believe they are a bit above average – especially on a test of general knowledge that they have not prepared for.)

But there is no psychological phenomenon that causes dumb people to rate themselves higher. It’s simply an artifact of them being objectively dumber while at the same time being just as clueless as everyone else about how their peers perform. When higher scorers see their peers’ answers, their confidence is bolstered. While lower performers are not affected by peer answers (at least not enough to change their scores substantially), they do respond to being shown they are wrong. But in the study, the lack of response to peer answers by low performers is not evidence of some unique phenomenon. It is simply that people (wisely) do not discard their answers just because someone else answered differently – they have to be shown they are wrong. But, contrary to how Dunning/Kruger is usually deployed – when shown they are wrong, they do adjust their perception!

The idea that people should change their scores when confronted by group disagreement, otherwise they are dumb, is very strange indeed. In fact, human progress likely depends on people rejecting this idea. The greatest thinkers have often had to fight through massive group disagreement. We should all be grateful they did not change their mind just because the majority disagreed.

If I had to summarize what this study means, it would be this: People are not a good judge of their ability relative to peers. All people will judge their ability within a narrow range, regardless of their actual ranking, because they have NO information to work with and resort to psychological/social heuristics to assess their ranking. The highest performers, who likely have some training in the field and therefore should be more confident, will indeed express more confidence in their ranking, tempered by a general hesitancy to overestimate.

As an aside, I think how people estimate their ranking in relation to peers is quite similar to how estimates are done in software development. We attempt to use information on past performance to produce future estimates, but the utility of that is questionable/marginal. It seems the only way to really get a handle on such estimating is to limit the scope of work as much as possible so that when estimates fail, they do not fail by large increments. The estimates themselves largely rely on heuristics that are more art than science (“tell me how long it will take you, then double it”). Experts admit that software estimation is to some extent guessing because we lack the information necessary to make estimates with any precision. Same with self-perception among peers. Of course, there are other factors at play, but lack of information is a big one.

Here is a funny exercise: while I don’t trust the numbers from the humor study too much, the chart is just too perfect. Take away anything below 50 and above 80. This is justified because no one will give responses in those ranges for social/psychological reasons. Now expand those values back to a scale from 0-100 and overlay the actual scores. My guess is the two data points now look pretty similar. It doesn’t work for the other studies though because those studies mainly find everyone giving the same perception, except for the highest performers. But it is a logical way to look at that data and make real sense of it, if you believe the results from study 1. People psychologically block out 0-50 and 80-100, so the real scale is 50-80. Once you realize that, you can make a chart that looks like people are *REALLY* good at assessing their own humor. I wouldn’t rely on the data from that study, though.

I’m sure you think I’m just a know it all – whatever, it doesn’t really bother me. But there has been plenty of criticism of Dunning/Kruger and follow up studies that put big dents in its armor. There is a much more involved discussion here:

David Dunning even appears in the comments to dispute a few points and there is some good back and forth.

Having said all this, I am not asserting there is not something like a “Dunning/Kruger” effect in some people. It’s always possible. But I see no evidence in their study that proves what they say, and more pedestrian psycho-social explanations fit their data a lot better. And I think “Dunning/Kruger” has become a meme and been relatively unquestioned because it tells such a pleasing story for the people in the top quintile. “Everyone else is a bunch of overconfident idiots!” Oh so seductive fallacious reasoning. And the problem with deploying it so widely, as it is by many, is that its acceptance seems to be confirmation bias writ large and its use strikes me as exceedingly arrogant (and fallacious).

Twitter Response to Rosewind on 4/22/19

1. Rosewind keeps asserting they amended the protocol because they did not find any reported cases of POTS/CRPS. This is a blatant lie and serious allegation of misconduct without any evidence. They knew ahead of time they would not find any reported cases – otherwise why would they need to see the CSRs? No one seriously thought there were reported cases that were just hidden by fraud. They suspected the cases were undiagnosed. Given this, as the original protocol says, they expected to receive patient level narratives where they could make a diagnosis of each patient. They were surprised they did not receive that information and the data available in the CSRs was so poor they wrote a separate journal article about it. Since they did not get the data they needed, they had to amend their protocol to analyze the much lower quality data that was available. This is what the amendment is about. Not the crap allegations of misconduct Rosewind keeps making. Her claims are reprehensible and without any evidence.

2. She likes to troll about “post hoc explaratory harms analysis” like it by definition is invalid. She sounds like a Republican politician making fun of scientific studies because they have funny names. This was what they were forced to do because THE DATA SUBMITTED TO REGULATORY AGENCIES IS SO POOR. A real scientist would be concerned that the quality of data regulators hold is so poor that no independent analysis can actually be undertaken. This means the regulatory agencies themselves could not possibly have undertaken any analysis. This is scary and many real scientists have expressed great concern over this. Again, this was so alarming it was worthy of a journal paper itself in the BMJ.

3. Sure, they did not prove it caused POTS and CRPS because AS A RESULT OF THE POOR DATA, THEY HAD TO PERFORM A LESS DESIRABLE ANALYSIS THAT COULD NOT PROVE CAUSATION. They reiterated their call to get access to the patient narratives. If everyone is so sure they will not prove anything, WHY WON’T THE COMPANIES PROVIDE THEM THE DATA THEY NEED? IF THIS GROUP OF PEOPLE IS SO CONFIDENT, WHY DON’T YOU CALL FOR THE COMPANIES TO PROVIDE THEM THE DATA? Finally, while they did not prove causation, they were very open about that fact and continue to qualify their statements. It is clear Gotzsche (and Jefferson) strongly believe the data they are seeing is real harm, but their statements in the paper are qualified appropriately. In fact, they are so qualified that this group is amplifying their qualifying statements in an attempt to diminish the findings. This is a dishonest tactic.

4. This paper is a tour de force in meta-analysis. It’s funny that this group was so mad when these authors criticized the Cochrane review on HPV vaccines, yet they criticize this paper with no remorse or sense of irony. It’s obvious what is going on there is simply this group’s reflexive defense of the HPV vaccine. It is clear this paper is far more comprehensive than the Cochrane review and represents an order of magnitude more effort and skill. This is not surprising given that the authors of this paper are responsible for a great deal of *how meta-analysis is performed worldwide*.

Further, leading experts in evidence based medicine, including Gotzsche, Ioannidis, Chalmers, and many, many more, have long lamented the potential for meta-analysis to simply be a laundry list of checkboxes and to instill confidence in data where it is not warranted. These pioneers of meta-analysis are recognizing that meta-analysis can have serious limitations and that purely checking off the boxes is not enough. The post hoc analysis in this review goes beyond mere checking of boxes and looks to see if something is being missed. The problem is no one wants them to look, and that is a serious issue in science today around vaccines. It is no secret that scientists are self-censoring around vaccines and quality papers have been rejected due to a climate of fear. The treatment of Gotzsche and this paper only serves to amplify that fear to astronomical levels.

We are talking about a widely respected researcher – a pioneer in the field of EBM – who did not want to be involved in this issue. He was dragged in by vaccine advocates and when he disagreed with them they undertook a campaign of character assassination that has resulted in loss of his career. The amount of fear this will cause is off the charts. No one will dare wade into this issue with any critical assessment. Anyone who says otherwise is delusional.

I always thought that scientists were supposed to be better than this. That they were not like the other side – the “anti-vaxxers” who make unsupported claims. But scientists are human and they fall to the same human instincts. Opposition by anti-vaxx groups has bred a like-minded opposite mindset among some scientists. They follow ends justify the means thought patterns. They started out years ago with websites devoted to “skepticism” and they made a lot of noise about logical fallacies and the importance of logical thinking. But read their articles today and they are littered with logical fallacies. They no longer care how much sense they make, but rather whether they are “defeating the enemy”.

I see a parallel in politics in the US. For years, Bob Somerby warned that liberals were becoming just like conservatives – that they were losing their respect for the truth. They were becoming more willing to play political games. Somerby warned this would lead to disaster because conservatives control the board (money). This has played out. At first I reacted negatively to his assertions. I couldn’t believe that “my tribe” could be just as bad (in many ways they are still not). But over time the evidence was so glaring.

With experience in life, I have sought out people I believe have unimpeachable integrity. People who are willing to risk everything for their principles. One of those people is Peter Gotzsche. Another one is Glenn Greenwald, who seems to be somewhat of a parallel to Gotzsche in politics, though not the same. Greenwald has been ostracized by many and called a Russian spy simply because he has been critical of the Mueller investigation. That is a bizarre and ridiculous claim. It’s hard to find someone more liberal than Greenwald. He criticized it because 1) he thought it was doomed to disappoint and would be a major political setback, empowering Trump, and 2) he fears for good reason that powerful forces in the US government are trying to turn Russia back into another bogeyman and war target – for profit and political gain, of course.

On Thought Policing

One key difference of philosophy in the HPV vaccine debate is the often stated belief that we must not report certain things about HPV vaccines for fear that anti-vaccine activists will misinterpret or otherwise abuse the information. Examples of this mindset are widespread and epidemic.

I want to be clear what this line of thinking is: thought policing. Sure, I will get denials from the people making these statements, but I’m sorry, this is thought policing. It seeks to control the thoughts of others through withholding information you feel may give them thoughts you feel are harmful. This is of course antithetical to democracy and a free society, and is a central feature of authoritarian systems.I could write a book length exposition on how thought policing like this is inherently bad, but I will instead just note that it is fundamentally opposed to democracy and free society because it deprives people of the information they need to exercise their freedom and their right to choose their leaders. The denial of information is the denial of freedom. It is also fundamentally wrong because it substitutes the judgment of the group keeping the secret for the judgment of those being denied the secret. Of course, the thought goes, we are scientists and we know better than these people. But this is also the thought pattern of every authoritarian system. The Communist Party knows better, the King knows better, etc, etc. The keeper of the information always thinks he knows better than others.

Aside from authoritarian societies, it is also notable that thought policing is a key tactic of the pharmaceutical industry. By conducting poor science and withholding information it does have, the public is deprived of information. The denial of this information controls the thoughts of the public. If the data on SSRIs causing suicides is kept secret, the public will never think these drugs are dangerous and will thus never take any action against them.

The Cochrane Board has practiced thought policing in the wake of their expulsion of Peter Gøtzsche. They have refused to release any information or explain their actions in an attempt to control what Cochrane members thought about the Board’s actions. They even became angry when Gøtzsche exposed their attempts at thought policing by posting the relevant documents on his website.

The Practical Issue with Thought Policing

Everyone who advocates or practices thought policing is always sure their motives are pure. So, I will make a more practical argument about thought policing: it does not work. In fact, it cannot possibly work because it violates fundamental tenets of human nature. People do not like being lied to or having information withheld from them. Because as I mentioned above, information is freedom and withholding information is withholding freedom. If you take away my access to information, you take away my freedom.

But let me back up: when I said thought policing does not work, I fudged a bit – otherwise so many groups would not practice thought policing. The truth is thought policing can work – for a time. And that time represents the amount of time you can keep the thought policing secret. In authoritarian regimes, this amount of time can be long, as governments can use their absolute control over information and also physical force to keep people in the dark. But history occurs on a long time scale and even authoritarian regimes eventually fall.

Pharmaceutical companies practice a lot of thought policing. And over time, that policing is becoming more and more apparent. The result is what happens when thought policing is revealed: loss of trust. Attempts to control information arouse suspicion – for obvious reasons. And this brings me to our present situation, where a seemingly growing anti-vaccination movement threatens public health. One thing that strikes me about those who argue with anti-vaccine activists is the lack of focus and the lack of real attempt to resolve the problem. Possibly because the problem is deeply ingrained and difficult to solve, thus we fall back on simplistic explanations (this tends to happen across politics as well, think poverty in the US). Before I finish with thought policing, I want to take an important and related detour and discuss pseudo-skepticism.

Pseudo-Skeptics: Industry’s Best Friend

This brings me to a common advocate for thought policing: what I call the pseudo-skeptic movement. These are sites like Skeptical Raptor, Science Based Medicine, and a seemingly never ending list of copycat and affiliated sites that tend to link back to each other on many issues. The people who write on these sites, and the people who read them and comment, seem very obsessed with letting the world know how skeptical they are and how smart they are. If you talk to them, scarcely a minute will pass before they throw out an accusation of a logical fallacy, often incorrectly. Without any apparent sense of irony, some of these people have published books on being a skeptic and/or logical fallacies.

Much of what you read on these sites is accurate. It would be hard not to be, given the subjects. Really, how hard is it to prove that water diluted with another substance so small it is undetectable is not a cure for cancer? This is not exactly rocket science these people are criticizing here. This is stuff so basic it makes you wonder how anyone with some understanding of science can believe it. But the biggest issue is that no one is learning anything here. These websites are not changing anyone’s mind. Homeopaths are not going on there and thinking, “Oh wow, I was wrong. Thank you Science Based Medicine.” They do not even try to convert people, since many posts are filled with insults aimed at their targets. No, these sites are just examples of preaching to the choir. And they seem designed to make their proprietors look smart and their readers feel smart along with them. It’s like a self-help site for scientists or those who fancy themselves scientific minded. Kind of pathetic, but I guess harmless.

Except they are not harmless. Because on the difficult issues that require real skepticism, these sites contain bogus information and often attack real skeptics. They show no actual sign of skepticism. And their posts on these issues are absolutely shot through with logical fallacies (even posts on pedestrian topics contain fallacies, but at least the content is accurate). The amount of groupthink going on at these sites is at astronomical levels. And it is truly an example of the unwisdom and generally bad behavior people can display when they know they are a majority. Unsurprisingly, I noticed some of the people cheering the Cochrane meltdown on Twitter are regulars on these sites. And while it is difficult to know whether these people get their authoritarian tendencies and willingness to trash the reputation and career of independent scientists from these sites or they come up with that all on their own, I think this at minimum is good evidence how much these sites harm public discourse.

John Horgan was right when he stood in front of these self-styled skeptics at a conference and told them they are a bunch of posers. (I recently discovered his blog and have found it a great resource of true skepticism. Some gold level quotes in there.) Yes, what the world needs most critically now is someone who will explain to me why Bigfoot is not real…said no one ever. “Thanks for setting the record straight on Bigfoot Mr. Skeptic, but what about SSRIs? Do they work?” “Oh yeah, they work, and Big Pharma is your best friend. That’s straight talk from a real skeptic. And anyone who says otherwise is an unscientific loser.” I feel sorry for readers of these sites because many are probably duped into believing they are reading real skepticism, but unable to recognize the fake nature of the skepticism on display. They then become unwitting participates in the defense of industry against real science. Similar to how many anti-vaccine activists are probably unwittingly spreading their false messages.

SIDE NOTE: Many of these authors wear accusations of being industry shills as a ‘badge of honor’. Perhaps they would be better served by thinking critically about why so many people might get the impression they are on industry payroll. Who am I kidding, critical thinking is for losers! If they are not being paid by industry, then they are doing this for free, and that is an even sadder situation. If you are gonna make yourself look like an ass and shill for the Man, at least get some coin! The only thing I can imagine worse than selling out to be an industry shill is doing it for free.

The Pseudo-Skeptic Gambit

One favorite tactic these sites employ is the invention of new “logical fallacies”. I put it in quotes because while the definitions they give do seem to describe fallacies, they deploy these terms not to point out actual fallacies, but to shut down debate. Ironically enough, their repeated labeling of others’ statement as logical fallacies is itself a logical fallacy. If I wanted to behave like a moron, like they do, I would give this fallacy the name “pseudo-skeptic gambit”.

This brings me to an example in action: their invention and use of the term “Galileo Gambit”. According to the definition, this applies to people who assert they are right just because their arguments upset the mainstream. Except, rarely does anyone actually make this kind of ridiculous argument. Instead, when confronted with Bandwagon Fallacy arguments that the “scientific consensus says X”, people tend to respond by emphasizing the scientific consensus can be wrong, and give examples. The pseudo-skeptics will then claim this “implies” they are right because the consensus disagrees, and thus, boom, Galileo Gambit. But this is wrong. It implies no such thing. It implies they could be right (and they think they are right). The distinction is subtle, but important. Because if that response is by definition implying they have to be right, then they cannot even make an important argument because it is logically fallacious. But in fact, it is not a fallacy to point out crowds/consensus can and have been wrong in the past. So, no such implication exists, but they assert it does because it allows them to deploy the claim of Galileo Gambit to shut down discussion. And in this case, the claim of Galileo Gambit is in fact a disguised example of the Bandwagon Fallacy. The pseudo-skeptics use bandwagon arguments, which are countered by legitimate claims that bandwagons can be wrong. Then they counter by reiterating the bandwagon argument, but disguised as something else. It’s a neat trick – dishonest, but neat. I give it an ‘A’ for creativity and an ‘F’ for logic.

BONUS POINTS: Have fun reading all the ways “Gish Gallop” is deployed to shut down debate and avoid addressing arguments. I have my suspicion many of these terms are used because they think it sounds clever and they have become like secret cult handshakes. I would not be surprised to learn the next innovation on these sites is the use of grunts to dismiss arguments.

Defending Drugs that Cause Autism, While Insulting Parents of Autistic Children

I could give many examples of the lack of skepticism and reflexive defense of industry, and I might do so in a follow up post. But here is one example. This post discusses a study finding that SSRI use during pregnancy increases the risk of autism. The study discussed here, along with other studies, tend to find a relative risk somewhere in the range of 2.0. This study found a RR of 1.87. Is Dr. Novella concerned about this? Apparently not much, as the purpose of this post is to make sure everyone knows this is not a big deal. And to pull this off, he wants you to know the media is misleading people by saying the risk is doubled. What’s more important is that the absolute risk only goes from 1% to 2%. I don’t know about you, but where I come from, the doubling of a catastrophic medical outcome from 1% to 2% is serious. Some rough, back of the envelope math demonstrates the severity. I quickly found a reliable (rough) source that said 500,000 women would struggle with depression during pregnancy in the US in a given year. And that roughly 1/3 of those women would take antidepressants. So, that is 165,000 women. If the normal autism rate is 1%, that means 1650 children will be born with autism from those women (ignoring twins for simplicity). But assuming the lowest rate of 1.87% for those on antidepressants, 3086 children will be born with autism, or 1436 additional children with autism.

This is also why it matters that non-skeptics like Steven Novella believe antidepressants work. As real skeptics know, they do not work, or they harm as many people as they help (if not more). So Novella’s reliance on false science encourages him to excuse massive iatrogenic harm. Even if you believe that current studies are good science, which is preposterous, those studies show a very small effect. For every handful of women who are helped by antidepressants while pregnant, you would harm at least one child. If you asked those women to make that choice, I doubt any of them would choose to risk the harm. But none of them have been given that choice – the vast majority of women know nothing about this risk.

Even worse for Novella is how this intersects with his supposed interest in anti-vaccination campaigns. How many of the parents of these additional autistic children will join anti-vaccine movements? It is surely not zero. And while Novella encourages continued use of the drugs that possibly caused autism in their children, he will be sure to let them know they are the worst person in the world. Excuse my language, but what a gigantic asshole. If Novella actually thought critically about what leads people to become anti-vaccination believers, he might consider that useless drugs that double the rate of autism are a huge problem. (Hint: having an autistic child is a risk factor for becoming anti-vaccination).

The Birth of Anti-Vaccine Ideology

What interests me, but does not seem to interest pseudo-skeptics too much, is why people become anti-vaccine and how this movement got so large. Yes, we all know the story of Andrew Wakefield. But that is the what and maybe the how. I want to know the why. Why did people believe this stuff and why do they believe it now? Why do people believe Jenny McCarthy over vaccine experts? Well, of course, there will always be some people that believe this stuff. But that number naturally seems small, and the anti-vaccine movement is notable because it runs across demographic boundaries. You would expect uneducated people to make up a large portion of anti-vaccine believers. But highly educated upper middle class and upper class people make up an interesting proportion as well.

One answer to this question is quite simple. While anti-vaccine people tend to have varying backstories, they almost universally share a common trait: mistrust of the government science agencies and the drug industry. That mistrust has been earned. So much so that to a large extent, the people who trust them are the crazy ones. Governments and scientists operate on trust. It is their lifeblood. In a free society, it is all they have. If people do not trust government or scientists, then who do they trust? Well, they often wander on the margins until someone they believe they can trust emerges. Someone who checks off a lot of boxes, first and foremost, they must confirm the reasons that person distrusts the usual authorities. “You are being lied to…” is the truthful hook, followed by what may or may not be truthful information, “…and here is the truth.”

More deeply, where does mistrust in scientific authorities come from? It often starts (or intensifies) with harm. People who are harmed (or think they were harmed), whether by medicine or other causes, will often look for explanations for how they were harmed and why. Some of these people will already mistrust authorities, others will become distrustful as they learn more. Some of these people will find anti-vaccine messages attractive. While others will gravitate toward more reliable information. But nearly universally, harm tends to either form mistrust or galvanize already existing mistrust. Because experiences of harm are deeply personal, whatever explanation people find for their harm, they will tend to cling to that explanation very passionately and very strongly, whether it is correct or not. This is one reason why anti-vaccination sentiment is often so strong. And it is a reason why we should have honest and open information available to people when they are harmed. If people cannot trust mainstream authorities, they will look for someone they can trust, to provide them what they think is authoritative information.

What Do We Do With Anti-Vaxx People?

This takes me to an important point: how should we handle anti-vaccine believers? Should we ignore them? Insult them? That seems to be the current strategy of the pseudo-skeptic crowd. I am wondering what they hope to accomplish with this strategy, or do they just follow it because it makes them feel good about themselves? Because this is not just a foolish strategy, it is counter-productive. Insulting people is sure to increase their sense of alienation and righteousness. Ignoring them allows them to talk amongst themselves without exposure to outside information – a process sure to produce strange ideas. And maybe that is okay, because then we can write articles about how bad those ideas are, and we can feel superior all over again.

Or should we engage these people? Should we encourage them to listen to scientists with integrity, people like Peter Gøtzsche? Scientists they might be willing to trust. Instead of doing the wise thing and engaging these people, pseudo-skeptics label anyone willing to engage these people as “anti-vaccine” themselves. “Person X spoke to person Y, and person Y is an anti-vaxxer! Person X is therefore also an anti-vaxxer.” Six degrees of separation is a game, not a scientific method, yet this tactic is widespread on pseudo-skeptic websites.

These games of six degrees of separation and guilt by association are not just wrong, they have a high cost. When those who have lost trust in scientists see other scientists making baseless allegations of being “anti-vaxx” against scientists with integrity, it further entrenches their distrust. “If you don’t trust me now, let’s see how you feel after I baselessly attack this scientist over here whose integrity has never been in question! For the crime of speaking to you.” That seems like a winning strategy…or perhaps not.

So again, should we encourage scientists with integrity to speak to these groups. Or should we ignore them and wait around until a charlatan emerges who will give them bad information in a convincing manner? Or should we acknowledge their mistrust is real and let someone with good intentions speak to them? And do not say speaking to them gives them legitimacy. It does not. Their legitimacy derives in part from refusal to engage them. The more you treat them as outcasts, the more hardened they become in their beliefs, and the more members they gain from newly mistrusting people. The insults and lack of engagement have led us to where we are now. Perhaps most importantly is the total refusal to acknowledge their lack of trust is well founded and seek to repair trust. To the pseudo-skeptic crowd, science and industry can be best friends forever, and we should all be thankful for this benevolent arrangement. One wonders if pseudo-skeptics have an even basic understanding of capitalism or human nature.

The Consequences of Thought Policing

Remember those parents of children born with autism, some of whom would be caused by antidepressant use they were not told about? Well, some number of them will go looking for explanations. And people always need explanations. People need meaning in their lives. They need to know why their child has autism, even if there is no good answer. Should we let these people wander until they discover anti-vaccine ideas? Or should we tell them that antidepressants might have caused their child’s autism. Well, we should tell them, but fair warning, it might be too late. We should tell them before we give them these drugs while they are pregnant. If we do not, and they are denied informed consent, and they have an autistic child, then we tell them the truth – there will certainly be feelings of burned trust. But if we refuse to tell them even then, when they find the truth or alternative, untruthful explanations, it will be a raging inferno of trust burning.

This is the whole problem caused by the current HPV vaccines. There are many parents out there, and their doctors, who believe the vaccine has caused their children harm. And there are indications there are problems with the safety data. Legitimate scientists are looking into this and being called “anti-vaccine” for their efforts. If these harms are real and there was truly no way to know until now, I am sure many of these parents would be upset, but understanding. But the revelations that studies were designed in ways to hide harms and the behavior of shouting down those questioning what is going on is sure to burn trust with these parents, regardless of the scientific outcome.

Pseudo-Skeptics Attack Important Journalism

Circling back to pseudo-skeptics, this is a great place to bring in another example: the reaction on these sites to the Slate article exposing the intentional design flaws in Gardasil clinical trials. Skeptical Raptor posted a piece on this that is a master class in pseudo-skeptic writing. Titled “HPV vaccine clinical trials being attacked by anti-vaccine religion again”, we are already off to a promising start this post is going to be filled with logic. By the third paragraph, we already get a baseless personal attack against the author of the article.

We are told “the author of the original article is simply an amateur about science, clinical trials, and statistics. The author was trying to create doubt about the Gardasil vaccine based on misunderstanding, at best.” This caused me to immediately open Google and do a search, something I am sure Skeptical Raptor’s readers rarely do. The author is a journalist with an MS in biology, an MA in journalism, is a former ghostwriter for pharma, and has authored two published studies. Skeptical Raptor might want to actually do some checking before making baseless smears. Who am I kidding! His readers do not check anything! Let the smears fly my raptor friend!

Let’s take Skeptical Raptor’s claims in order (he makes three). First, I will note the driving force behind the entire article seems to be: thought policing. Skeptical Raptor first uses a lot of space telling us about HPV and how bad it is. This is useful information in some context, though completely useless at telling us whether Slate’s article is accurate. In fact, this information is placed here to encourage thought policing. It is an emotional argument that HPV is so bad, to even ask the questions Slate is asking is not acceptable. Special award in emotional argumentation goes to the line telling men HPV can result in amputation of the penis. Thank you for that. But what about the clinical trial design?

The first claim is that the author bases his article on a “misunderstanding”. And also apparently that Skeptical Raptor can read minds and “[t]he author was trying to create doubt about the Gardasil vaccine”. I will let others judge the mind reading claim about the author – hey, maybe Skeptical Raptor has a post about whether mind reading is real? But let’s see what is the big misunderstanding. Well, the first evidence is…a big discussion on whether the reports of POTS and other autoimmune disorders are real. What does that have to do with the article’s main claim? Nothing, really. How did we get sidetracked here? Well, Skeptical Raptor says that he thinks the author “bases his claim on a review, that was initiated at the request of Denmark”. Except that is false. The author’s claim is not based on that review at all. His interest might have been motivated or piqued by that review (although again, seems to require mind reading), but it has nothing to do with his claim, which is sourced from the internal EMA document the author obtained from the EMA. It seems to me Skeptical Raptor does not want to discuss the EMA document, and instead wants to discuss something less solid. What you see here is that the reports about POTS and CRPS are more uncertain and there is much debate about them. So Skeptical Raptor is shifting the debate to one over those claims instead of the claims made in the article. By the end of it, he hopes you will have forgotten the original claim he is supposed to be debunking. Sure enough, the original claim does not seem to resurface, or at least what does resurface has nothing to do with the actual point of the Slate article.

On to the second claim: that we have lots of post marketing data, and therefore, why should anyone care about the actual clinical trials that got the vaccines approved? First, note this is again a thought policing argument. Nothing to see here, move along! But even better, he contradicts his own writing elsewhere in the post. In the course of criticizing reports of POTS and CRPS with HPV vaccines, he hauls out his “hierarchy of evidence” chart. Super simplistic, bordering on misleading, he notes that claims of POTS and CRPS are based on studies fairly low on this chart. But what happened to his chart when he poo poos randomized clinical trials in favor of inferior post-marketing studies? Like the adverse effects themselves, it is just gone.

His third and final claim is “the author relies on anecdotal evidence, which has zero value in scientific understanding. This is a serious issue that should have cause Slate to back off from the article.” This kind of argument makes me wonder if Skeptical Raptor figuratively knows how to tie his own shoes when it comes to science. The author of course did not rely on “anecdotal evidence” to make his arguments. He relied on actual stories to demonstrate that 1) those people experienced potential side effects, 2) those side effects were serious and similar to POTS/CRPS, 3) they were not part of data recorded as side effects and tabulated for regulators, and 4) they were not included due to the flawed design the regulators originally challenged. Thus, this data is not anecdotal. It is not being used to make a claim about the amount of harm caused by the vaccine. It is only used to demonstrate how the trial design excluded potential harms from reported data. And for this purpose, it is not anecdotal, but 100% proof the claim is true. These claims are facts, not anecdotes. They are not used in a way that would make them anecdotes. And this point is either lost on Skeptical Raptor or he does not care to be honest about the way these cases were used.

EDIT: Pseudo-skeptics on Twitter are using my use of the word “stories” to claim they are in fact anecdotes. So, I will clarify even further. The stories are not anecdotes because they are not used to prove the author’s claim. The author’s claim is proven by the documents. The documents show the trial design was flawed, regulators objected, and then meekly relented. Case closed. The stories are there to make people care. It is one thing to report a bunch of dry words about flawed study design. But the stories demonstrate the effect of that flawed design in action. They demonstrate that claims the trials do not show POTS/CRPS are flawed because here are these people who suffer from similar symptoms, and due to that study design, their symptoms are not in the data. We know from the documents that people with these harms are possibly excluded from the harm data and here are some examples of people whose harms are actually excluded. That is not anecdotal.

So, to conclude, Skeptical Raptor makes three arguments, if you can call them that. And all of them are appropriately called bullshit. Bullshit thought policing arguments reflective of massive bias on the part of the author.

I could continue on in this same vein. One point I want to make is that I believe the evidence shows that in the same manner charlatans emerged to lead people with mistrust of pharma and government in the anti-vaccine movements, fake skeptics emerged to lead those who claim to adhere to science. Pseudo-skepticism has become a church just like anti-vaccination. And just like most churches, the High Priests do not always follow the stated rules, and the members do not often seem to notice.

BREAKING UPDATE: The top post on Skeptical Raptor right now is his dismissive look at a study on behavior changes observed in sheep given injections with aluminum adjuvants. Without commenting on the study itself, his opening paragraphs indicate the analysis that follows is little more than a four year old sticking his fingers in his ears and yelling “Nah nah nah nah nah, I can’t hear you.” This is not how skeptics or scientists behave.

ANOTHER UPDATE: Just read the critique. Unimpressive, but also unsurprising.

Concluding Thoughts

I will conclude by saying that pseudo-skeptics and others who are currently cheering the Cochrane disaster often peddle arguments in favor of thought policing. Such arguments are authoritarian in nature, antithetical to freedom and democracy, and counter-productive because they produce resistance and loss of trust – the very driving forces behind anti-vaccination and other anti-science movements. Withholding information, rather than helping, adds fuel to the fire. We should resist calls to “watch what we say” and “be careful with our arguments” because it is thought policing nonsense that only further sows distrust of science.

Authoritarianism at Cochrane

The Cochrane Board has not said a lot about their expulsion of Peter Gøtzsche. Perhaps because when they do speak, they tend to make things worse. The latest example is this summary of webinars they hosted to discuss the issue. I want to focus on the bullet points at the beginning of the document, as they represent a troubling mindset followed by the current board and specifically its chairs (and the CEO):

The Trustees make collective decisions, democratically, by a majority vote, according to our governing document (the “Articles of Association”). “Decisions do not usually have to be unanimous … but once the trustees have made a decision, they must all comply with it, including any who disagree…. Ultimately, you may feel that you have to resign in order to distance yourself from the decision.”

The board is quoting from the UK Charity Commission guidance for trustees. You can read that here. The quote is from section 6.2, titled “Avoid mistakes – be prepared to challenge assumptions”. This quote is taken out of context and treated as if resigning is normal. I will go into more in a bit, but a situation where a trustee resigns from a charity due to disagreement with a board decision is NOT NORMAL. It indicates something is fundamentally broken with the board. The Cochrane Board appears to have no sense of irony because this quote is lifted from a section instructing trustees they must challenge decisions and make sure decisions are not being driven by one person. That is precisely what has happened here and one reason why the board members who resigned objected. In other words, they followed the guidance of the Charity Commission to the letter. The Commission’s advice to resign is advice for what a trustee must do to further the interests of the charity if the decision making process is fundamentally broken. Finally, note also the directive to “comply” with decisions does not mean you have to publicly defend decisions, as the Cochrane Board has implied or stated. You only have to recognize that it passed and take any actions necessary to comply. Much like a legislator who votes against a law must comply with the law when it passes, but is still free to criticize the law and the process that led to its passage.

Individuals become Trustees either by election or appointment. However, the moment they join the Board they are expected to act not in the interests of those who voted for them, or their own perceived constituents, but “in the best interests of the Charity” above all. Trustees do not represent those who voted for them. “You must avoid putting yourself in a position where your duty to your charity conflicts with your personal interests or loyalty to any other person or body.”

This is one of the most troubling statements. It represents not just a fundamental misunderstanding of representation, but an authoritarian mindset. It is not correct to say that board members do not represent the interests of those who voted for them or their perceived constituents. In fact, this is fundamental to any elected position. Every elected person everywhere necessarily represents the interests of their constituents. Of course, they do not represent their personal interests, but rather their view of how the charity should be governed. Even appointed members represent the views of the person who appointed them, which is why appointed members are so dangerous, particularly for a charity like Cochrane, because they centralize power with whoever is appointing them. By definition voters and appointers will pick people who represent their views. There is nothing you can do to change this – it is fundamental to government and human nature.

The former Steering Group was an entirely elected Board, whose members were elected from a variety of constituencies. Even then, the Board members were supposed only to act in the interests of the Charity as a whole.

As already stated, members act in the interests of the charity as a whole by representing the interests and philosophy of their constituents.

Charity Boards in which all members are elected are becoming increasingly rare and this format is no longer seen as optimal in terms of good governance.

As usual for this Board, this statement is misleading. I will not go into details here, but a charity with Cochrane’s history and structure should probably not have any unelected board members. You can see the end result of appointed members right now. Concentration of power in the central executive staff. Many charities are moving to a system where some or all trustees are appointed by an independent group because voting members are sometimes the donors to the charity and that allows too much control over the charity’s work. Or the opposite problem occurs: the charity is founded by a small group who maintain control and donors do not want that small group having too much influence over decisions. Generally there is a tension between the donors to the charity and those who control the charity, so a common solution is to have a third party pick board members. In the case of a collaboration like Cochrane, members are a diverse group around the world, and electing board members makes the most sense.

Trustees must:

  • always act in the best interests of the charity – they must not let their personal interests, views or prejudices affect their conduct as a trustee;
  • act reasonably and responsibly in all matters relating to the charity – acting with as much care as if they were dealing with their own affairs, taking advice if they need it;
  • only use the charity’s income and property for the purposes set out in our Articles of Association
  • make decisions in line with good practice and the rules set by our Articles of Association (including excluding any trustee who has a conflict of interest from discussions or decision-making on the matter).

The principles of good governance are embraced by many organisations, including all Cochrane’s major funders. They not only expect but require Cochrane to have in place strong governance mechanisms.

Not much to say about these statements, other than the current Board does not follow them. But I want to go more in depth on the first two statements above.

Taken together, these statements indicate not just an inability to grasp basic concepts of democratic leadership, but an embrace of authoritarian methods of leadership. Democratic systems promote transparency and encourage the airing of dissenting voices. When the voters hear dissenting opinions, it helps create a sense that all viewpoints were heard and strengthens the belief that the best decision was made, or at least the process was fair. Debates in parliaments and the US Congress are held in the open. Judges routinely publish dissenting opinions when they disagree with the majority of their colleagues. These principles are fundamental to an open system of governance.

Authoritarian systems silence dissenting voices because they fear if dissenting voices are heard, people will lose confidence in the decisions of the authority. They seek to control information because information is power. By withholding information about the decision making process, they minimize questions about their decision. The only information people receive is that which the authority wants them to receive.

The Cochrane Board has sought to control information on the Gøtzsche expulsion since the beginning. One member instructed the minority members they were to publicly support the decision of the majority. That is an authoritarian position. The Board has further used the concept of privacy to maintain control over information. That is an increasingly common trick when democratic leaders do not want to be transparent. The Board could have easily released more information while taking steps to maintain the very minimal privacy interests involved, but their real reasoning had nothing to do with privacy. That was merely an excuse for controlling information about the process. (EDIT: Perhaps not surprising, the privacy excuse is what pharma uses to justify hiding clinical trial data. The Cochrane Board and pharma seem made for each other.)

Even sillier, the Board has then used Gøtzsche’s transparency on his own website as some further vague evidence against him. The legal principle here is simple: when you are the subject of a public smear campaign, you are entitled to release information to defend yourself, particularly when the privacy interests here are so remote and you are no longer bound by them. The only privacy interests here are the names of Gøtzsche’s accusers, and rarely does any legal system shield accusers’ names from the public. Further, that this information has been made public is entirely the fault of the Cochrane Board. Their expulsion directly led to the exposure of this information. When Gøtzsche was expelled, he no longer owed a duty to maintain privacy in these matters, particularly when his rights are so adversely affected. Note that before he was expelled Gøtzsche did keep these matters private. Only when he came under attack and no longer had an obligation did he reveal any of these details, as he is entitled. If privacy were really a concern of the Cochrane Board, there are many ways they could have handled the matter differently while protecting privacy. Instead, they started a process that anyone could see would lead to exposure of the persons involved.

The Board went even further than this control of information and urged the minority members to resign. They repeatedly highlight that this is part of the advice from the UK Charity Commission, without noting that advice is a last resort. When a Board member resigns in protest, it indicates a potentially serious issue with governance. When four resign in protest, it indicates the governance process is fundamentally broken. The situation is even worse when elected board members resign because, contra the Board’s authoritarian beliefs, those members have a constituency. They have members who share their view for the direction of the charity. When they resign, those members are disenfranchised. Resigning in a democratic system is a drastic measure.

Imagine if every time a bill was passed in the United States Congress the majority votes urged all the minority votes to resign. This does not happen. And yet, US Senators and Representatives owe their allegiance to the country first, not their voting constituents, just as Cochrane Trustees owe their allegiance to the charity first. The Cochrane Board would argue the minority Congressmen are obligated to publicly defend every bill they vote against if it passes. Of course, this is absurd. We know that members of Congress represent their voting constituency. They do so by advocating for their vision of how the country should operate. They comply with decisions made by the Congress, but there is no requirement to defend those decisions. And no one expects or even wants a Congressman to resign after every lost vote. If Congressmen resigned en masse, it would indicate a fundamental problem in government. Similarly, elected Cochrane Trustees represent their voting constituencies by advocating for their vision of how the charity should operate. They are not obligated to defend Board decisions, only to follow them. If they resign en masse, it indicates a fundamental problem in governance. It is not normal.

I must also note how this suggestion to resign resembles the way communist parties operate. When one faction gains control of the party, competing factions are asked to resign or forced out of the party. Do we want a scientific organization like Cochrane operating in the same manner as communist leaders?

The Board’s authoritarian disposition and their push for more power to be centralized at Cochrane should scare every member, particularly the collaborating centers, who the Board clearly no longer sees as collaborators, but as subordinates. The Board and executive staff have unilaterally decided that collaboration is no longer how Cochrane functions and they are aggressively enforcing that silent coup. They have removed a dissenting voice in an absurd process and used that process to purge the Board of all other dissenting votes. Now they audaciously move forward with a plan to stack the Board with more like minded members and refuse any attempts to obtain accountability for their actions. They have told members and centers concerned over their actions to stuff a sock in it and get over it. Clearly, there will be no backing down or admission of error by this Board. Members and centers must take drastic action to force the Board and executive staff to resign. The time for half measures is over. This Board will not approve any investigation into its actions. Authoritarians never do.

Should We Trust Authority or Evidence?

Twitter user @Rosewind2007 recently tweeted this. This is a great example of people who revere “authority” over evidence. Take a look at the two excerpts. Notice anything? Neither one includes actual evidence. But we are asked to make a judgment about which one is correct. Why? Because the person who posted it makes judgments based on the speaker and not the evidence. Thomas Grant is obviously right and Peter Gøtzsche is obviously wrong, evidence need not be consulted. If Gøtzsche says something at odds with what Grant says, obviously Gøtzsche is wrong. Unfortunately, I do not reason that way. I like to look at evidence.

Why does Grant “wholly reject” Gøtzsche’s allegations? Apparently because 1) Mark Wilson and Martin Burton have superhuman integrity and he divined this during a personal interview with each, and 2) everyone interprets what happens in a meeting slightly differently, so we should expect some difference in the interpretation of minutes. Those are already some thin arguments, how good do they hold up? Not so good.

First, note the repeated use of colorful language, both in describing Wilson and Burton’s motives and in describing the allegations. In describing their actions and motives, the language reaches a level of adoration not often seen in legal documents. The allegations are said to be “a very serious allegation” two times. What is the relevance of this? This raises the burden of proof. Grant is describing the allegations as criminal allegations and justifying his judgment on them by shifting to a criminal burden of proof (beyond a reasonable doubt), whereas the claims against Gøtzsche were looked at from a civil perspective (more likely than not). This allows Grant to start from a position of innocence, ignore the evidence, and then dismiss the allegations because there is not enough evidence to reach a guilty decision under a criminal standard. This is never explicitly stated, but that appears to be the purpose of this colorful language.

Let us tackle the allegation that Wilson “tampered with” the minutes for their March 21 meeting in Lisbon. The key point here is (6) in Grant’s document: “The precise details of PGs’ objections to the minutes are immaterial. During fluid discussions people have different perceptions and recollections.” This is the entire basis Grant uses for dismissing the allegation (that and the obvious integrity oozing from Wilson’s pores). It sounds convincing: sure, I can see that people have differing opinions on what is discussed at meetings and it’s interpretation.

How can Gøtzsche possibly allege that he knows the minutes were intentionally wrong? What does his report submitted to Grant say? “…the minutes [] look very much like a precise, verbatim transcript of what was said…This is correctly quoted in the minutes [] but the start of my reply was omitted…It can be verified by listening to the recording and by calling upon witnesses…” Say what? The minutes are not a recording of “perceptions” and “recollections”, but a near verbatim transcript? It would seem the impression Grant gives is misleading. There is an audio recording and Gøtzsche has witnesses and Grant has neither listened to the recording nor interviewed the witnesses? How could Grant omit this information, other than for misleading reasons? This is critical information that shreds Grant’s argument into pieces. If the minutes were nearly verbatim and most of the missing information had an adverse effect on Gøtzsche, one must assume this was intentional, or the world’s greatest coincidence. Presented with all the evidence, we now see the misleading way Grant has selectively quoted Gøtzsche and presented a limited set of evidence. Grant quotes Gøtzsche’s statement that he “assumes” Wilson tampered with the meeting minutes. In the context, we are led to believe the assumption is based on no evidence. But digging into that context, we see the assumption is quite logical, based on strong evidence.

Grant uses his argument about “perceptions” and “recollections” to avoid looking at relevant evidence. But when exposed to that evidence, it is clear why Grant’s construction is wrong. And that Grant’s failure to obtain and listen to the audio is an indictment of his judgment and neutrality. Nothing Grant says squares with the evidence when you read Gøtzsche’s report – a report sent to Grant and allegedly read by him. The most notable consequence of Grant’s argument is that in practice, no one could ever be found to have tampered with meeting notes under his criteria, regardless of evidence, as he asks you to ignore the evidence in favor of vague generalities. If you follow Grant’s assertions, the rules of the game are rigged.

Turning to the allegations against Burton, again we see the same pattern here. Again the dismissal of the allegations seems to be based on Grant’s adoration for Burton and a general claim that perceptions and recollections differ. Does it hold up here? First, let us again take a moment to appreciate Grant’s mind reading powers and general adoration of Burton. In only half a page, he manages to drop in the following judgments that require mind reading or adoration: “…it was MB’s sincere attempt..”, “…a eminent figure…”, “…was created with honest and sincere purpose…”, and “MB’s statement…was sincerely and reasonably made.” With that silliness out of the way, are there any arguments beyond the general ones already noted? No.

With that in mind, let us examine Gøtzsche’s report. On the first allegation – Burton’s summary of the meeting between Gøtzsche and Wilson, Grant’s argument about perceptions and recollections has a little bit of relevance. A little. However, Gøtzsche paints a very detailed case that Burton’s description of the events between Wilson and Gøtzsche is misleading. And misleading in favor of Wilson and against Gøtzsche. I would not convict someone of criminal intent based on this alone, but it sure looks more likely than not that this is not a fair retelling of the events. So at minimum, Burton’s description of these events violates his duties as a trustee. His retelling minimizes negative information about Wilson and deprives Gøtzsche of fair treatment. As an example, Burton’s account makes it seem as if both Wilson and Gøtzsche exchanged “strong words” and got heated, when witnesses say it was only Wilson who used strong words and only Wilson who lost his temper. The exchange was so dramatic that another member of the board who witnessed it brought it up during the board meeting.

The next allegation is even more serious. Gøtzsche alleges that at a board only meeting in Geneva, the board discussed the special restrictions that were placed on him and decided no one should be subject to special restrictions – only the Cochrane policies everyone else must follow. Burton’s description of this meeting is not just differing in “perceptions” and “recollections” from Gøtzsche’s – it is contradictory. Burton writes that to his recollection no such agreement was made at the meeting, and that most of the other trustees are not aware of the special restrictions and thus never could have voted to release him from them. But Gøtzsche states in his report that he made all the members of the board aware of the special restrictions at the meeting and they discussed those restrictions while he was out of the room waiting at the door, since they involved him personally. Gøtzsche further states that he discussed the meeting with another board member who remembers as he does and is prepared to testify to the same facts. And the meeting minutes themselves indicate some discussion on this issue took place. Yet Burton and the other board chair deny any of this happening.

Gøtzsche states that he had prepared remarks on this issue ahead of time and he read from them, after board co-chair Lisa Bero attempted to exclude him from the room without a chance to defend himself. Eventually he was allowed to speak and after doing so waited outside the room for approximately ten minutes. This kind of detail would be astonishing to fabricate and easily contradicted by other board members, yet Gøtzsche has at least one witness ready to testify to his version of events, while the board co-chairs offer no evidence. Gøtzsche adds that at least three board members confirmed he was released from the special restrictions, with one telling him the vote was nearly unanimous – no doubt the co-chairs were dissenting votes, possibly the only ones. He offers to produce the names of the other board members from his notes if needed, though he does not divulge them in the report for privacy reasons.

It is impossible for anyone to reasonably believe the co-chairs simply forgot this event took place. It was a serious discussion about another member of the board, involving a long standing issue, and there was quite a bit of conflict over it. Indeed, the meeting minutes confirm some discussion took place. And vaguely (and perhaps intentionally misleadingly) note that Gøtzsche agreed to follow the Spokesperson Policy (which everyone already does anyway). Since everyone is bound by this policy, this sentence only makes sense as the resolution to the issue of special restrictions.

One other note in this same area of the document: item 139.4. Why would it be right to stop discussion of the CEO’s aggressive physical behavior toward a board member? Is that not relevant information the rest of the board should hear and discuss? The board is specifically tasked with oversight of the CEO. I can understand not taking action on the behavior, but failing to discuss it at all? And praising the board chair for shutting down discussion? How does that make any sense? Well, it makes sense in a world where Burton and Wilson are men of raw, pure integrity, with superhuman judgment unrivaled by mere mortals. The world of Grant’s document.

These are just a couple examples of the duplicity of the board co-chairs and CEO of Cochrane, and the misleading arguments put forth in the report by Grant. As a general matter, when one party is disinterested in the evidence and insists his client is so trustworthy that to question his behavior is offensive and the other party offers all relevant documents and audio recordings for you to examine, I have but one question. Whom do you believe? I believe the evidence.

And what does this say about how Cochrane leadership conducts business when Gøtzsche knew he needed to bring witnesses to meetings and make recordings to protect himself? Is it a sign of good governance when you need to wear a wire in your meetings with leadership?

Is Cochrane Violating Nordic Cochrane’s Trademarks?

The title might sound like an odd question to some, but it is a quite serious legal question. Cochrane’s existence as a collaboration has led to difficult legal questions about who owns various Cochrane trademarks. Cochrane and the Nordic Cochrane Centre came into existence around the same time. Both were independent organizations working as collaborators. Cochrane has trademark rights to the names ‘Cochrane‘ and ‘The Cochrane Collaboration‘, and they have registered those marks (although the registration for the latter expired in 2017). But Nordic Cochrane has registered trademarks for the names ‘Nordic Cochrane Centre‘ and ‘Nordic Cochrane Centre for Evidence-based Medicine‘. And they will have enforceable trademarks for similar names they have used. I have not seen any documents that transfer legal ownership of these trademarks to Cochrane itself. If those documents exist, I would like for someone to bring them to my attention.

Absent any transfers, it appears to me that Nordic Cochrane owns the trademarks on its name(s). By seizing Nordic Cochrane’s website and posting its own messages, and continuing to maintain that website, Cochrane appears to be in violation of the Nordic Centre’s marks. They are currently publishing information to the public and representing the source of that information as Nordic Cochrane. This is not trivial. If they do not own those trademarks, they are deliberately publishing information under someone else’s mark – misleading the public about the source of the documents they have published.

There are even more complex questions surrounding the Nordic Cochrane logo. Assuming Cochrane owns the main graphic, Cochrane encouraged the centres to incorporate its graphic into their own logo. Each centre’s logo is almost surely a trademark owned by that centre. The question becomes: what license was given by Cochrane to incorporate the logo image in the centre’s own logo? Does Cochrane have the right to revoke the use of the image? This seems a difficult question. I do not have access to case law search engines to research the matter. My instinct would be that when a party encourages another to incorporate their image into their trademark, they have given a perpetual license for that use, mainly for reasons of fairness. There does not seem to be a good legal answer to these questions. This is why IP lawyers strongly discourage collaborations from an IP standpoint. The legal issues are a mess. The only way around this is to provide very clear contractual and ownership arrangements from the beginning, but it appears none of this was done in the case of Cochrane.

Finally, I said above “assuming” Cochrane owns the main graphic used in the logo. But this is not clear to me based on Cochrane’s history. I do not have enough information to determine whether Cochrane exclusively owns this image, or whether the founding centres have an ownership stake. That would depend on how the work for the graphic was contracted.

If anyone has any documents relating to this or any case law on point, please let me know, as I would be interested in reading them. And if no such documents exist, how much legal advice do you think the Cochrane board is getting before making these decisions?

Some Thoughts on the Cochrane Mess

The Way I See It

  1. There is no denying at this point that the board had predetermined they were going to expel Gotzsche at the meeting. They made allegations against him and hired a lawyer to produce a report. That report said they had no reason to discipline him. They did so anyway, while shifting their rationale. Even if you agree with his expulsion, if you cannot acknowledge this fact, you have no credibility at all. Of course, the board denies this because it says a lot about the process. But it is undeniable given the facts.
  2. The board is either lying about getting legal advice on all its actions or they are getting terrible legal advice. There are many legally questionable moves, perhaps none more glaring than the vote itself. Gotzsche had a dispute with the CEO and both chairs of the board. He made serious allegations of misconduct against the CEO and the chair. The lawyer’s report makes clear that both co-chairs had serious conflicts. The chairs then arranged and led a meeting where they tried to convince other members of the board to expel Gotzsche. They then called a vote, denying Gotzsche a vote and allowing at least one of them to vote. If this ends up in court, oh boy is the court going to have fun with that. ‘Let me get this straight. You had a dispute with the plaintiff, so you excluded him from the room for six hours while you pressured the other board members to vote to expel him, then you called a vote to expel him and did not allow him to vote while voting yourself? Sounds fine to me!’ Hopefully you can see the sarcasm in that last sentence. I cannot bring myself to believe that any lawyer would be terrible enough to advise that was appropriate or legal.Then again, maybe Cochrane’s in house lawyer is not so good. Because the external lawyer’s report notes that Cochrane’s in house lawyer thought one of Gotzsche’s actions was a “flagrant” violation of the spokesperson policy, while the external lawyer disagreed and any lawyer with basic skill can see it is not a difficult interpretation.

    Another example is the modification of Nordic Cochrane’s website without their permission. This was a blatant violation of the collaboration agreement between the centre and Cochrane. The message sent was: we have total authority and will do as we please, while ignoring the collaboration agreement. If a lawyer authorized that move, they might want to think about another line of work.

    The board expelled Gotzsche from Cochrane and purported to remove him as director of the Nordic Centre. But as is clear in the Collaboration Agreement, they do not have this authority. Gotzsche called their bluff. Their only recourse was to follow the dispute resolution process in the Collaboration Agreement. Rather than do that, they blatantly ignored the Agreement and seized Nordic Cochrane’s website.

    In my opinion, the remaining Cochrane Centres have a decision to make regarding the board’s seizure of Nordic Cochrane’s website. Do they want to acquiesce to this naked power grab? The board has signaled that if it has a disagreement with a Centre, it does not believe it is bound by the Collaboration Agreement it signed. The board will act with whatever physical tools it has at its disposal to carry out its wishes. The Centres did not sign up for that and neither did the Centres’ funders. If a centre gets into a dispute with the board, are you prepared to have the board seize your website and deface it with statements from the board about your ‘insubordination’?

  3. The board has been misleading and/or dishonest throughout the entire process. Aside from the things already mentioned, the board has been misleading in various statements. In their original statement on the expulsion, the board accused the four resigning members of “actively disseminat[ing] an incomplete and misleading account of events.” This was false and slanderous and I cannot believe a lawyer would have authorized it. When called on it, they changed the text to a vague accusation that “others” were doing so. They noted the edit to the document without indicating what was edited, so a reader who had not read the first version would not know it contained a baseless smear of their colleagues.At the end of the board’s statement on the expulsion, it talks of “zero tolerance” and makes a vague nod toward the #metoo movement. They state there was repeated “seriously bad behavior” toward “staff members” and they had no choice to act. I have a hard time believing a lawyer approved this reckless statement. Some people got the impression Gotzsche had sexually harassed staff. This is not surprising, given the language. Many others thought he had harassed staff in a physically threatening manner based on this language. When one is familiar with the situation, the deception of this statement becomes clear. The “harassment” Gotzsche is accused of is simple disagreement with the CEO and other members of the board. And in that disagreement, the board’s own hired lawyer sided with Gotzsche on the allegations against him. Gotzsche also made allegations of misconduct against the CEO and the board chair. And that is the behavior deemed to be harassment. The “seriously bad behavior” is disagreeing with those who had the power to expel him and objecting to their behavior. So, when looked at through the facts on the ground, this appears to be the expulsion of a whistleblower arranged by those he accused of misconduct. I imagine a court will have something to say about this. It is telling that the CEO and some board members made allegations of misconduct against Gotzsche, and in response Gotzsche made allegations of misconduct against them. And the board treated Gotzsche’s allegations as harassment, while deeming their own allegations above board.
    The board’s statement also included this sentence: “The report completely exonerated the member of the Senior Management Team but did not exonerate the other individual.” This is so misleading as to be false. And I assume they relied on the confidential nature of the report to conceal this deception. Now that Dr. Gotzsche has posted the report, everyone can see that Dr. Gotzsche was completely exonerated on the main issue: the accusations of violating the spokesperson policy. The only issue where Gotzsche is found at fault is violating the “Functions of Centre” document, and the lawyer declares that document does not appear to properly describe the functions of a Cochrane centre accurately, and therefore it would be inappropriate to discipline Gotzsche for violating this document. The implication is that all Cochrane centres are likely in violation of this document (in fact, a document on Cochrane’s website indicates that no centre has ever performed all the required functions), so the lawyer recommends making this document more complete. The reality is the lawyer fundamentally misinterpreted the purpose of this document, perhaps because he is not familiar with the history of Cochrane and the work of the centres, or perhaps because he was interpreting something a bit vague in favor of his client.This document is not an exhaustive list of what the centres are allowed to do, as the lawyer seems to argue. As he says, if that is the purpose of the list, it is incomplete. Instead, the more logical interpretation is that this list sets out the activities the centres are expected to do on behalf of Cochrane as a whole. It says nothing about other activities the centre deems in its own interest. If you adopt this interpretation, then the document is complete and appropriate, but it also means Gotzsche violated nothing. Under this interpretation, a centre would only violate the document if it did not perform the functions listed. And indeed, you must adopt this interpretation, given the historical autonomy of the centres, the existence of the collaboration agreements themselves, and that Cochrane centres are independently funded. If the government of Denmark wished to support the work of Cochrane and not specifically Nordic Cochrane, they would give their money to Cochrane itself. I do not think a funder of one of the centres would wish to be completely subject to the whims and priorities of Cochrane leadership. That is not how Cochrane works and never has been.

    Though it is somewhat vague, a closer reading of the collaboration agreement reinforces that Cochrane Centres have the autonomy to pursue their own activities, so long as they do not conflict with the goals and mission of Cochrane. First, the structure of the document is not that of a sub-unit, but of collaborating units. The title of the document implies autonomy. And the general organization of the document is such that it lists responsibilities each party has to the other, but nowhere does it say those responsibilities are the extent of the allowed activity of either party.

    The 2016 version of this document states the following at the end of the preamble: “The Parties are therefore establishing this Collaboration Agreement…to strengthen their existing cooperation by defining their mutual responsibilities with the purpose of sustaining and developing the activities and impact of the Xxxxxx Cochrane Centre in contributing to Cochrane’s mission and strategic goals.” That is not a statement that Cochrane Centres are limited in the functions to what Cochrane central needs. It only says the Centre works toward Cochrane’s mission and strategic goals.

    One of the responsibilities listed for a Cochrane Centre Director is: “Try to secure sufficient funding and in-kind support to allow the Cochrane Centre to deliver the functions set out for Centres and its own activity plans“. That is an explicit statement that Centres have their own activity plans, and those plans are distinct from the functions the Centre provides for Cochrane.

    In the “Dispute Resolution” section is the following text: “In the event that the performance or activities of the Director or his/her Centre in relation to Cochrane activities falls outside the expectations, functions and policies for Centres…” That is an explicit recognition the board only has control over the director in relation to Cochrane activities and implicitly means there are other activities of the Centre over which the board has no control. The board only has authority to ensure the Centre is delivering the required functions to Cochrane. Beyond that, the board has no authority over the Centre.

    This is also why the document does not give the board the authority to remove a Centre Director. Because the document recognizes the Centres are independent entities with their own priorities and so long as they are meeting their priorities to Cochrane, they are meeting the terms of this agreement. As independent entities, the board only has remedies available when the Centre is not meeting its obligations to Cochrane. Thus, their remedies are limited to taking steps to remedy the breach – and those steps do not include removal of a director. If the situation becomes unworkable, they are permitted to deregister, relocate, or dissolve the Centre. All three of these options really just mean kicking the Centre out of Cochrane. They have no ability to modify the organizational structure of the Centre because it is independent.

    There is more evidence in the draft document on the website from November 2015 titled “Centres, Branches & Networks: Structure & Function Review”. This document contains an admission that Centres have their own agendas they control: “These clear functional priorities do not, however, mean that Centres are limited in their role, as the review recognizes the distinct background, expertise and areas of interest of existing and future Centres.”

  4. The lawyer’s review was not independent at all. This is expected, given the dynamics of the situation, and the lawyer chosen is clearly sharp, based on some of the things I read in the review. He knows the board’s intention is to expel Gotzsche. So he goes to great pains to 1) provide a fig leaf to his client, and 2) completely distance himself from what they plan to do. It is clear he wants no part of any disciplinary action here.The lack of independence can be seen throughout the document. Throughout the document he attributes motivations to the Cochrane CEO and board chair that he cannot possibly know. And those motivations are always positive ones. “…they were very well-intentioned”. “I am satisfied that the Proposal advanced by MB was in good faith.” “I am satisfied that MB is wholly impartial.” “During my interview with him I was impressed with MB’s obvious integrity and impartiality.” “I should say here that over well in excess of four hours of interviews with MW I was impressed by his fairness, objectivity and open demeanour.” “…MW has shown restraint and professionalism throughout.” Except when he did not – in that case, where MW shouted at Gotzsche and called him a liar “I treat this as a minor issue.” Ha ha. It goes on and on.These are not the statements of an independent investigator. The complaints made by Gotzsche about the CEO and co-chair were never going to be investigated with much effort. And it is clear they were not. In almost all cases, the investigator seems to have talked to no one involved aside from the CEO and co-chair, and he dismissed many claims by saying he does not believe people of such integrity would do something like that. Okay. It would be impartial to say you have seen no evidence to substantiate the allegation, but the assertive statements that the allegations are false are clearly biased statements. As are silly statements saying that “eminent” professors are not likely to lose their independence. Of course, we know eminent professors lose their independence all the time for various reasons – including their financial association with drug companies. Similarly, he rejects an allegation that meeting minutes were tampered with partly based on the fact they were sent to the co-chairs before approval. Surely, the co-chairs would have objected to incorrect minutes he says. Well, if the co-chairs have been antagonistic to Gotzsche and siding with the CEO during this conflict, does that point actually hold any water? No, it does not.When reading the lawyer’s dismissal of the complaints against MW and MB, I was reminded of the famous case where the police arrested a suspect but then let him go without looking at any further evidence because they deemed him to have obvious integrity and fairness when they interviewed him. And though they had video of him losing his temper, they deemed that a minor issue in light of his obvious integrity. And if you are wondering, I am making this up because of course police, or any independent investigators, do not follow this kind of process.

    I do understand the lawyer was pressed for time, so perhaps a thorough investigation was not possible. But the absolute certainty with which he dismisses the allegations made by Gotzsche smacks of obvious bias and lack of independence. The report should have stated he did not find evidence to substantiate the claims, but further investigation would be prudent.

  5. Let us take some time to appreciate the nature of the complaints against Dr. Gotzsche. We will look at just the three most recent complaints. A common theme of these complaints is they are not sincere. One of the complaints was in the form of a tweet. The tweet complains about Dr. Gotzsche listing his Cochrane position when advertising a course on psychiatric drug withdrawal, and also the use of a Cochrane email address for responses. Dr. Gotzsche’s response made clear that he used Cochrane email because the event related to a Cochrane review and future work of the Nordic Centre. And listing his position at Cochrane does not violate anything anyway. But what is notable here is the clear motivation for this tweet: the person who sent this is unhappy that Dr. Gotzsche is holding this seminar. This tweet never resulted in a formal complaint, and even Cochrane’s CEO eventually conceded it did not violate the spokesperson policy.The second complaint, which was a formal complaint, is worse. This complaint was made by a physician who participated in a homicide trial as a witness for the state while Dr. Gotzsche was a witness for the defense. Notably, no complaint was made about Dr. Gotzsche until two years after the trial. And this complaint was made after Dr. Gotzsche had filed a formal case against the physician with the disciplinary court.Dr. Gotzsche’s response to the complaint sets out the egregious behavior by this doctor that prompted his disciplinary complaint. During the trial, this doctor called an opposing expert witness (not Dr. Gotzsche) a “charlatan”. The court reprimanded him for this behavior. Further, Dr. Gotzsche says the doctor improperly attempted to influence the judicial process, and the Public Prosecution Service said his actions were criminal offenses. Finally, this doctor circulated a note in court that alleged Dr. Gotzsche had become mentally ill and even cited his “professional opinion” that Dr. Gotzsche needed to be evaluated for mental illness.

    So, it is clear the complaint is motivated by anger and retaliation against Dr. Gotzsche for filing his complaint about the doctor’s own despicable behavior. It is difficult to take the concerns in the complaint seriously when they were apparently not enough to generate a complaint until Dr. Gotzsche filed a complaint against the physician, and when that physician’s behavior was so fundamentally unethical.

    The third complaint is possibly as egregious as the second. In this case Gotzsche sent a letter asking for information on the deaths of youths [NOTE: Edited to change “children” to the more accurate “youths” in several places] in a long running antipsychotic trial. The number of deaths were reported with three different amounts. And the causes of death were apparently not reported. Dr. Gotzsche was asking for that information.

    First, I will note that asking a question privately on company letterhead does not seem like a “spokesperson” role at all. What is the idea he is conveying by asking this question? That Cochrane cares about dead youths? Apparently the CEO of Cochrane feels it is essential to make sure everyone knows Cochrane takes no position on the issue of young people dying in clinical trials.

    Second, this complaint was not even about the spokesperson policy. This complaint was made on the basis that Gotzsche is “biased” and not an independent researcher, and that makes Cochrane look bad. Apparently, Fuller Torrey will not trust any Cochrane reviews after receiving an inquiry about dead youths from a member of Cochrane. Well, I am not sure Fuller Torrey has read many Cochrane reviews anyway. He is not exactly a shining example of evidence based medicine in action. But of note here is that the Cochrane CEO transformed this complaint into an issue about the spokesperson policy (and was proven wrong).

    But my larger issue with this complaint is the total lack of perspective here from Cochrane leadership. The complaint was clearly sour grapes, meant as intimidation. Aside from these sour grapes, Torrey is perhaps the leading proponent of forced treatment – the Treatment Advocacy Center he runs is dedicated to forced treatment, while Gotzsche has been leading a campaign against forced treatment. A normal, functioning complaint system at Cochrane would recognize this problem and dismiss the complaint (as it should have many others against Gotzsche). The Cochrane complaint process should not be a tool for harassment by people angry at a Cochrane director. That is all these complaints are: harassment. And this is the very thing the board accused Gotzsche of doing. In the upside down world of the Cochrane board, the actual target of a years-long campaign of harassment is the guilty party. Sorry, but when you take seriously the claims of obvious harassers, you are yourself participating in harassment. And you should expect the target of your harassment to get angry and push back. While the board’s lawyer sees all of the CEO and chair’s actions as reasonable and appropriate, they do not look that way when you realize they are threatening and harassing Gotzsche based on complaints that are obviously not made in good faith by unethical researchers Gotzsche has upset in some way. In what world does it make sense to threaten to close an entire Cochrane Centre because their director asked for information on how and why so many young people died in a study? Who wants to be a part of an organization that prioritizes the letterhead used to ask questions over answers about dead youths?

    A few common themes run through the disputes over the board’s complaints. One is the mistaken idea that affiliation denotes representation. Professionals often list their affiliations in their work. This is normal and expected. Doctors frequently list the hospital they attend, and no one assumes the doctor is representing the hospital’s views. When reporters write books, they will often identify their employer in big text, yet no one thinks the book is the message of their employer. Cochrane leadership and policy makes a big deal about having stricter rules for directors of centres, but we should be honest here: these rules were put in place to muzzle Dr. Gotzsche. They produce absurdities like Dr. Gotzsche is more restricted in how he can use Nordic Cochrane letterhead than his subordinates are. The difference with Dr. Gotzsche is the Cochrane leadership disagrees with his views and sees them as controversial. So, they apply requirements to him that are not required of other professionals, both at Cochrane and throughout the scientific community. And as already noted, the use of Nordic Cochrane letterhead is a red herring because, as Dr. Gotzsche has repeatedly stated and is indicated in the various Cochrane agreements, Nordic Cochrane is an independent entity, Dr. Gotzsche is its director, and he is empowered to decide what is Nordic Cochrane business. The problem for Cochrane central is that Nordic Cochrane shares their brand. But they have limited ability to control Nordic Cochrane’s activities by design.

    Another common thread is the special rules that were imposed on Dr. Gotzsche’s activities. This is a ridiculous overstepping of authority. Again, these rules were imposed on Dr. Gotzsche because the board disagrees with his views. No one else had special rules imposed on them, and the legality of such rules is dubious. The board’s own lawyer even says these rules were misguided. Though he of course knows they were made in good faith. The Cochrane board is always acting in good faith, except maybe when they are misleading everyone as demonstrated above. I am sure the hired lawyer would call those “minor issues”.

    Yet another aspect is the motivation behind imposing a requirement to affirmatively state Dr. Gotzsche is not speaking for Cochrane. This is asserted as an innocent requirement to avoid confusion, but no one is confused. The requirement is imposed instead to attempt to diminish Dr. Gotzsche’s authority and lessen his credibility. Have you ever seen someone affiliated with an organization specifically state before speaking that their views are not that of the organization? Rarely, if ever. Forcing Dr. Gotzsche to do this is an exceptional circumstance meant to make Dr. Gotzsche look “radical”. Everyone knows that when people speak for organizations in an official capacity, they either do so all the time based on being an explicit spokesman, or they affirmatively indicate when they are speaking on behalf of that organization. In the case of Cochrane, when documents or statements are issued through official channels or through official spokespeople, everyone knows they are the statements of Cochrane. When they are not distributed in that manner, everyone knows they are not Cochrane statements unless otherwise affirmatively stated. There is no need to affirmatively deny statements are official to avoid confusion. Instead, the motivation is clearly to diminish Dr. Gotzsche’s credibility. And this is why the rules are enforced on Dr. Gotzsche and no one else.

    Finally, possibly the worst aspect of this is the clear impression from Cochrane leaders such as the CEO, that the Cochrane centres have no autonomy and Cochrane leadership does not respect the existence of the collaboration agreements or the centres’ ability to operate autonomously. This is clear from the statements by CEO Mark Wilson throughout the documents he sent to Dr. Gotzsche. For example, Wilson says this in a letter to Gotzsche:

    the use of your name and title in the signature description at the bottom of the letter as Director of the Nordic Cochrane Centre, and the language used in the request for data (where consistent use of the words ‘we’ and ‘our’ would reasonably lead any reader to assume that the request is from the Nordic Cochrane Centre and the views expressed in the request are those of the NCC) you have failed to abide by the Cochrane Spokesperson Policy

    Gotzsche’s obvious response to this was: these are the views of the Nordic Cochrane Centre. I am its director and I am authorized to speak on its behalf. The implication from Wilson’s statement is that he see no difference between “Cochrane” and the Cochrane centers. It is as if the collaboration agreements do not exist.

A Summary of Events

When we take a step back, it is quite easy to see what has happened up to this point. Dr. Gotzsche made some people angry. Frankly, it is unsurprising that people get angry when someone reports their misconduct to medical authorities. It is also unsurprising that someone gets angry when Dr. Gotzsche asks about all the young people that died in their clinical trials. What is surprising for a scientific organization is the way Cochrane responded to these complaints. And they responded the way they did because the leadership of the organization already wanted Dr. Gotzsche out, so these dubious complaints were used as ammunition to justify what was already in motion.

Dr. Gotzsche’s work makes him “controversial”. The CEO of Cochrane is not a scientist. He comes from the business world. And in the business world, controversy is considered bad for the brand. And employees who rock the boat and do not fall in line with orders from above do not last long. Corporations are dictatorships, not democracies. The CEO brought a dictatorial mindset to Cochrane, and he believes Gotzsche is bad for the “brand”. Not being a scientist, he has no recognition that the work Gotzsche does IS the brand. The ideal of science is not sitting by idly while science is perverted by moneyed interests. The ideal is someone who thoroughly vets the science being produced and is willing to challenge corruption at great personal risk.

So, in the CEO’s mind, any appearance of the Cochrane name next to Dr. Gotzsche is bad for the brand. This led to his attempts to get Dr. Gotzsche to dissociate himself from Cochrane. Rules were imposed on Dr. Gotzsche that were not imposed on anyone else. A broad spokesperson policy was written that goes beyond what is necessary and then selectively applied to only Dr. Gotzsche. But the policy was not strict enough, and allowed Dr. Gotzsche to continue with behavior the CEO wanted to end. The CEO was surely frustrated by Cochrane’s organizational structure – that he has limited power over the centres.

The CEO made various threats against Gotzsche and the Nordic Centre, but lacked the power to force Gotzsche to do as he wished and the will and political ability to pursue the remedy that was available (actually removing Nordic Cochrane from Cochrane). So a process was setup to provide a pretext for Gotzsche’s removal from Cochrane. That process failed, but leadership went ahead with the expulsion anyway, trampling all sorts of rules and agreements in the process to get its way. And misleading Cochrane’s members about what it had done.

This was Inevitable

In my opinion, this all became inevitable with the centralization of power in Cochrane. The executive staff of Cochrane was given ultimate authority with annoying limits. And the executive staff and centres exist in some kind of quasi-corporate, quasi-collaborative arrangement. But once power was centralized, it was inevitable that Cochrane central would seek to claim more power. This always occurs. The CEO is expected to manage Cochrane’s brand and direction, while not having full control over either. Of course he will attempt to gain more control over them. And putting a non-scientist in the role virtually guarantees conflict with the centres because business people do not think and operate on the same principles as scientists. Naturally, the conflict will occur with anyone who resists, typically the most independent people.

One oddity in the whole arrangement is that Cochrane’s “brand” was largely built by the centres. At some point, it was decided the brand that was created by the centres needed to be centrally managed. And this new management had no moral authority, yet was tasked with telling the centres how best to build the brand they already built. While at the same time providing almost nothing back to the centres. I think the centres see the relationship as parasitic and one-sided, and I cannot blame them.

A corporate power structure does not work for a scientific organization like Cochrane. For one thing, corporations operate more like dictatorships than democracies. Dissenting voices are squeezed out, not respected. A corporate structure is exactly what powerful interests like pharmaceutical companies want at Cochrane. Because corporations will move quickly to remove people they deem controversial. Eventually you are left with subservient people who fill out the forms and publish the work without asking the difficult questions. Many studies are already produced in a check box manner, where companies are sure to cross off every technical requirement while producing a biased design that results in the desired outcome. Their ideal world would include a Cochrane that produces meta-analysis the same way. Check off all the boxes. Do not ask any difficult questions, just publish the free marketing materials.